Care of Clients with Maladaptive Patterns of Behavior, Acute and
Chronic
Psychiatric nursing
Mental Health
 A state of emotional, psychological and social
wellness evidenced by satisfying interpersonal
relationships, effective behavior and coping, positive
self-concept and emotional stability.
COMPONENTS OF MENTAL HEALTH
 Autonomy and Independence - can work
interdependently without losing autonomy
 Maximization of One's Potential - oriented towards
growth and self-actualization
 Tolerance of Life's Uncertainties - can face the
challenges of day-to-day living with hope & positive
look
 Self-esteem - has realistic awareness of her abilities
and limitations
 Mastery of the Environment - can deal with and
influence the environment
 Reality Orientation - can distinguish the real world
from a dream, fact from fantasy
MENTAL ILLNESS
 State of imbalance characterized by a disturbance in a
person’s thoughts, feelings and behavior
Criteria to Diagnose Mental Disorders
 Dissatisfactions with one's characteristics,
accomplishments, abilities
 Ineffective or dissatisfying relationships
 Dissatisfaction with one's place in the world
 Ineffective coping with life's events
 Lack of personal growth
PSYCHIATRIC NURSING
 Interpersonal process whereby the nurse through the
therapeutic use of self-assist an individual family,
group or community to promote mental health, to
prevent mental illness and suffering, to participate in
the treatment and rehabilitation of the mentally ill and
if necessary, to find meaning in these experiences
CORE OF PSYCHIATRIC NURSING
 Interpersonal relationship
o Transference: unacceptable behavior, feeling,
cognition or thought of a patient towards the
nurse
o Countertransference: unacceptable behavior,
feeling, cognition or thought of the nurse towards
the patient
o Pre-orientation Phase: self-awareness; know
patient’s information and history, know reason
for admission
o If you think that you cannot handle the
client you can refuse, to not experience
countertransference and for care to be
more effective
o You cannot control your emotions; you
might get attached to the patient which
would lead to ineffective care and
countertransference
o Orientation Phase: signing of contract occurs
here, setting of boundaries and roles are also
done here
o You also inform the patient of the exact
time when the contract will end
o Working Phase
o If during this phase you experience
countertransference, best action is to
inform your superior and you will be
assessed
o You are allowed to terminate the
contract here, but if other measures are
suggested you may follow it
o Terminal or termination phase
o Evaluation phase
o If plan has of management has been met
 FOCUS: Patient
o Do not ignore the feelings of the patient but
the nurse should divert it back to the
problem of the patient
o It is a policy that a nurse cannot handle
friends, family members, and people who
have a relationship to the nurse. This may
also lead to countertransference because the
nurse is already attached to the clients
o This will affect the care and judgment of the
client
Foundation
 Etiology of mental disorders remain unknown
 But there are some theories like biochemical theories
Central Nervous System
Cerebrum
 Frontal lobe - control organization of thought, body
movement, memories, emotions and moral behavior.
o Associated with schizophrenia, attention deficit/
hyperactive disorder and dementia
 Parietal lobe - interpret sensations of taste and touch
and assist is spatial orientation.
 Temporal lobes - are centers for the sense of smell,
hearing, memory, and expression of emotions.
 Occipital lobes - assist in coordinating language
generation and visual interpretation, such as depth
perception.
Neurotransmitters
 Biochemical theories say that neurotransmitters have
an effect to the mental processes, behavior, cognition,
and thoughts of a patient
  Dopamine - controls complex movements,  I want to... PHYSIOLOGIC NEEDS
motivation, cognition, regulates emotional responses  I want to... PRIMARY PROCESS
o If low, it will cause tremors  All about I, me, and myself
o If increased, there is a possibility to have SUPEREGO
increased cognition, to the point you are not  Should not
intact with reality. A patient may become  Small voice of GOD
delusional: fixed problems in thoughts and  Set norms, standards, and values
cognition (Schizophrenia)  MORAL PRINCIPLE
o Do not contradict the delusion of your  Conscience
patient because it is a fixed belief and it may  Contradicts ID
cause anxiety EGO
o Present reality by giving instructions to  Executive
activities that will revert them back to reality  REALITY PRINCIPLE
o Do not argue but do not tolerate it, just keep  Conscious
on mind to ignore the delusion and divert the  Competencies
delusion to reality
 Decision Maker; Problem-Solving; Critical and
 Serotonin - regulation of emotions, controls food Creative thinking
intake, sleep and wakefulness, pain control, sexual
 Balances ID and superego
behaviors
 Once this is fully developed, you are now intact to
o Problems in this neurotransmitter may be
reality
found in depression, anorexic, bulimic
patients Imbalances between Personality Elements
 Acetylcholine - controls sleep and wakefulness cycle
(decreased in Alzheimer's)
 Histamine - controls alertness, peripheral allergic
reactions, cardiac stimulations
 GABA - modulates other neurotransmitters
o Modulates norepinephrine and epinephrine
o When patient is having panic anxiety there is
a problem with epinephrine
 Norepinephrine / Epinephrine - causes changes in
attention, learning and memory, mood  Manic- usually seen in a bipolar patient. Patient
experiences hyperactivity
Sympathetic Parasympathetic o Extreme exaggerated behaviors
Increase v/s Decrease v/s  Antisocial personality disorder- personality problems
Decrease GI motility Increase GI motility in interpersonal relationships
Decrease GU function  Narcissistic- there is illusion of grandiosity
Increase GU function
- urinary retention
Moist mouth Dry mouth

Genetics and Hereditary

 Alzheimer's disease - linked with defects in
 chromosomes 14 and 21
 Schizophrenia
 Mood disorders (depression)
 Autism and AD/HD

SIGMUND FREUD  These are people who are strict law followers
 Father of Psychoanalysis  Obsessive compulsive disorder- recurring, unwanted
 “Your behavior today is directly or indirectly affected thoughts, ideas or sensations that make them feel
by your childhood days or experiences.” driven to do something repetitively
o Repression a defense mechanism wherein o Those with ritualistic behaviors
there is unconscious forgetting o Do not try to contradict because it will only
 STRUCTURE – Personality Structure increase their anxiety, because that is their
coping mechanism
Personality Structure o Do not abruptly stop it, but give schedules
for those ritualistic behavior
ID (4-5MONTHS)  Obsessive compulsive personality disorder- are those
 Impulsive/ Instinctual drive who are perfectionists
 I want to... PLEASURE PRINCIPLE
 o They are perfectionists because they know
that being unorganized is not acceptable to
the society
 Hallucinations are sensations that seem to be real but
is only created in the mind
 Hallucination vs illusion
o Both these involve the senses, it only differs
in cognition
o Hallucination has no stimulus but can sense
something
o Illusions have stimulus but is interpreted
wrongly
Libido
 Sexual energy responsible for survival of human
beings
 Psychosexual Theory of Freud
 There is a possibility that memories will go back
once a person undergoes psychoanalysis or because
of triggers
SUPRESSION
 CONSCIOUS forgetting of an anxiety provoking
situation
IDENTIFICATION
 Attempts to resemble or pattern the personality of a
person being admired of
o Idolizing a person and copying them
(behaviors, attitudes, physical appearance)
INTROJECTION
 Acceptance of another values and opinion as one's
own
 Thoughts and opinions of other people are taken as
own
 Claiming of other people’s stories

ORAL STAGE LATENCY STAGGE

 18 months  6 to 12 years old
 Cry, suck, mouth  School
 EGO at 6 months  Reading, writing, arithmetic
 Child cries - fed - successful  Ability to care about and relate to others outside
 Child cries – ignored - unimportant - narcissistic home

FIXATION SUBLIMATION
 Occurs when a person is stuck in a certain  Placing sexual energies toward more productive
developmental stage activities
o Unacceptable to acceptable behaviors to the
REGRESSION society
 Returning to an earlier developmental stage o Diverting sexual urges to activities that are
 Infantile behavior acceptable to the society

ANAL STAGE SUBSTITUTION

 18 months 3 years old  Replace a goal that can't be achieved for another that
 SUPEREGO develops is more realistic.
 Toilet training o Unachievable to achievable
o Good Mother - Normal
o Bad Mother GENITAL STAGE
 Clean, organized, obedient - OC (anal  12 years old and above
retentive)  Developing satisfying sexual and emotional
 Dirty, disorganized - Anti-social (anal relationships with members of the opposite sex
expulsive)  Planning life's goals

PHALLIC STAGE EGO DEFENSE MECHANISMS

 Preschooler (3 6 years old)
 Parent Function - To ward off anxiety
o Oedipus Complex * without defense mechanisms, anxiety might overwhelm and
 Castration Fear paralyze us and interfere with daily living
o Electra Complex
 Penis Envy 2 Features:
 Daughter to father 1.1. they operate on an unconscious level (Except suppression)
2. 2. they deny, falsify or distort reality to make it less
REPRESSION threatening
 UNCONSCIOUS forgetting of an anxiety provoking
REPRESSION VS. SUPPRESSION
concept
 80% of rape victims go into repression
REPRESSION
  Unconscious forgetting of an anxiety provoking
concept SUBLIMATION VS. SUBSTITUTION

SUPRESSION SUBLIMATION
 Conscious forgetting of an anxiety provoking  Transfer of sexual energy to a more productive
situation activity.
o Unacceptable behavior to acceptable
REGRESSION VS. FIXATION behavior to the society

REGRESSION SUBSTITUTION
 Returning to an earlier developmental stage  Replaces a goal that can't be achieved for another that
o Inappropriate behavior during anxiety is more realistic.
o E.g. tantrums of an adult
 Infantile behavior DISSOCIATION VS. ISOLATION
FIXATION
 Occurs when a person is stuck in a certain DISSOCIATION
developmental stage  Separating and detaching idea, situation from its
o A stage is not satisfied emotional significance.
o Satisfaction of the stage is done by a person o Detaching from the self temporarily d/t
e.g. smoking anxiety
o This is different from regression and
mannerisms ISOLATION
 Individual strips emotion when talking or responding
RATIONALIZATION VS. INTELLECTUALIZATION about it.

RATIONALIZATION
 Self-saving with incorrect illogical explanation EGO DEFENSE MECHANISMS
o Reasoning out even with the wrong reasons
INTELLECTUALIZATION Conversion
 Excessive use of abstract thinking; technical  Anxiety converted to physical symptoms
explanation o E.g. stress is converted to headache
o Excessive rationalization
o Possibly correct but not necessary to the Compensation
current situation  Overachievement in one area to Overpower
o Focusing on situations that is not really the weaknesses or defective area.
o There should be presence of weakness,
problem
limitation, or insecurity that will be covered
DISPLACEMENT VS. PROJECTION VS. up by other achievements
INTROJECTION Undoing
 Doing the opposite of what have done
DISPLACEMENT o Trying to compensate for the wrong a person
 Feelings are transferred or redirect to another person has done
or object that is less threatening o E.g. a guy hurt a woman and then gave her
 Keyword: anger or feelings flowers after
 Anger redirection o Restitution- you do something wrong to a
person but compensate by doing good to
PROJECTION people who are involved to the person
 Blaming; Falsely attributing to another his/her own Denial
unacceptable feelings.  Failure to acknowledge an unacceptable trait or
o This can be seen in paranoid patients situation
o “Takot sa sarili nilang multo”  Alcoholic patients commonly use this defense
o A person unconsciously transfers his/her mechanism
own negative behavior to others
Fantasy
o The person is aware that he/she possesses
 Magical thinking
that behavior but subconsciously blames
others for it
Reaction Formation
INTROJECTION  Opposite of intention
 Acceptance of another's values and opinions as one’s
Acting out
own
  Deals with emotional conflict or stressors by
ACTION rather than reflection or feelings
Symbolization
 Creates a representation to an anxiety provoking
thing or concept
Splitting
 Labile emotions; all bad - all good
DEFENSE MECHANISMS COMMONLY USED IN
EACH RESPECTIVE DISORDERS
 Paranoid - Projection
 Phobia - Displacement
 Amnesia - Dissociation
 Anorexia - Suppression
 Bipolar Disorder - Reaction Formation
 Borderline - Splitting
 Schizophrenia - Regression
 Substance Abuse-Denial
 Depression - Introjection
 OC - Undoing
 Catatonic - Repression
 Woman who is angry with her boss writes a short
story about a heroic woman.
 Four-year old with new baby brother starts sucking
his thumb and wanting a bottle.
 Patient criticizes the nurse after her family failed to
visit
 Man who is unconsciously attracted to other women
teases his wife about flirting
 Short man becomes assertively verbal and excels in
business.
 Recovering alcoholic constantly preaches about the
evils of drink.
 Man reacts to news of the death of a loved one “No, I
don't believe you. The doctor said he was fine.”
 Student is unable to take a final exam because of a
terrible headache.
 After flirting with her male secretary, a woman
brings her husband tickets to a show.
 “I didn't get the raise because my boss doesn't like
me."
 Five-year old girl dresses in her mother's shoes and
dress and meets daddy at the door.
 After his wife's death, husband has transient
complaints of chest pain and difficulty breathing- the
symptoms his wife had before she died
 Man forgets wife's birthday after a marital fight.
 Businessman who is preparing to make an important
speech that day is told by his wife that morning that
she wants a divorce. Although visibly upset, he puts
this incident aside until after his speech, when he can
give the matter his total concentration.
 A man cannot accept his physician's diagnosis of
cancer is correct and seeking a second opinion
 slamming a door instead of hitting as person, yelling
at your spouse after an argument with your boss
 focusing on the details of a funeral as opposed to the
sadness and grief
 stating that you were fired because you didn't kiss up
the boss, when the real reason was your poor
performance
 having a bias against a particular race or culture and
then embracing that race or culture to the extreme
 sitting in a corner and crying after hearing bad news;
throwing a temper tantrum when you don’t get your
way
 forgetting sexual abuse from your childhood due to
the trauma and anxiety
 lifting weights to release 'pent up' energy
Therapeutic Communication
 Non-verbal cues are more accurate than verbal cues
o Reaction formation may be seen in these
situations
 Therapeutic communication is important because it
can affect the progress of the patient
 Always assert and affirm authority
o The healthcare provider should be followed
and not the patient
 For paranoid patients, always position in front of the
patient but should have a space in between
o Because standing on the sides may pose as a
threat to the patient
o Being too close or too far may also present
as a threat to the patient
o Paranoid patients are hypervigilant
 Reality orientation
o Alcoholic patients who are already in
withdrawal may experience formication
o Sensation that resembles that of small
insects crawling on (or under) the skin
when there is nothing there.
o Acknowledge what the patient feels
(because they are not inventing things) to
 reduce anxiety, explain that you understand
how the patients feel but don’t forget to
present the reality to the patient
o Divert the attention to a realistic
environment
 General leads
o Broad opening statements, leave the
direction of the conversation to the patient
o Used when patients have difficulty in
expressing or verbalizing thoughts and
feelings
o Schizophrenic patients are disorganized,
general leads may be helpful
o May also be used in geriatric patients
 Silence
o If you remain silent when a patient is
talking it indicates that you are listening
o A sign of respect to the person speaking
o Best therapeutic communication used for
paranoid patients, to be able to establish
trust
o May help develop rapport
Therapeutic communication
 Continuous, dynamic process of SENDING and
RECEIVING MESSAGES by various verbal or non-
verbal means (words, signals, signs, symbols) utilized
in a goal- directed professional framework.
 Offering self
o Offering safety, service, comfort
o “I’ll sit beside you”
o “Do you need help?”
o You want to tell the patient that you want to
provide care
o Very helpful for depressed patients, this
shows that people care for them
o E.g. Ursula, age 25, is found on the floor of
the bathroom in the day treatment cleaning
with moderate lacerations to both wrists.
Surrounded by broken glass, she sits staring
blank at her bleeding wrist while staff
members call for an ambulance. The best
way the nurse should do is to approach
Ursula slowly while speaking in the calm
voice, calling her name and telling her that
the nurse is here to help her. This approach
provides reassurance for a patient in distress
3 LEVELS OF PSYCHIATRIC NURSING (Levels of
Health)
Primary
 Objective: PROMOTION & PREVENTION
 Client and Family Teaching (Health Teaching)
 No existing illness yet
Secondary
 Screening, Diagnosis, and Immediate Treatment
 Screening
o Denver Development Screening Test
(DDST) #1 test for PDD
Tertiary
 Rehabilitation
Four phases of nurse- client relationship (NCR)
Pre-interaction/Pre-orientation (For the Nurse)
 Stage of Self-Awareness  To prevent Counter
Transference
 #1 CORE VALUE OF Psychiatric Nursing
AIM: PLAN THE RELATIONSHIP
 Upon admission, discharge instruction plan should
already be formulated
o You already know the chief complaint
(existing problems)
o To not neglect other problems that will come
out during the working phase
Orientation (initiation)
 Assessment of problems, needs, expectations of
clients
 Identify anxiety level of self and client
 Set goals of relationship.
 Define responsibilities of nurse and client. Stage of
testing.
 Establish boundaries of relationship. Stress
confidentiality.
 Contract – 2 famous psychiatric contracts:
o 1. No suicide contract  Major depression
= emergency
o TWO definitions of no suicide contract:
o 24 hours monitoring
o Verbalization to the nurse of all suicide
ideas
 Diet contract  Eating disorder
 The start of termination phase: “Good morning,
full name, RN, shift, session, date start & end.”
  Discuss client’s feelings and objectives achieved
Working phase Levels of awareness

 Promote acceptance of each other

o Accept client as having value and worth as a
unique individual.
o Stage of resistance
 Counter transference phase
 Most difficult phase
 NCP is on going
 Identification of the problem/exploration
 The #1 Psychiatric Core Value is Consistency  For
manipulative patients
 Be consistent to patient with: BAAAM COPS
B orderline C onduct d/o
A ntisocial O ral/eating disorder
A lzheimer’s P aranoid
A utistic S uicidal
 Conscious- you can immediately answer or remember
 Use therapeutic and problem- solving techniques because this is still in your memory
o Maintain professional, therapeutic relationship o Composed of past experiences, logical
o Keep interaction reality- oriented- here and now and governed by REALITY
o Provide active listening and reflection of feelings PRINCIPLE; are remembered and easily
o Use non- verbal communication to support client recalled or available to the individual
o Recognize blocks to communication and work to  Subconscious- information or memory where you
remove them need to exert effort in order to remember
o the Preconscious; composed of material that
 FOCUS on client’s:
o Confronting and working through identified has been deliberately pushed out of
conscious level; helps repress
problems
unpleasant thoughts or feelings and can
o Problems- solving skills
examine or censor certain desires or
o Increasing independence
thinking; can be recalled with some effort
o Help client develop alternative, adaptive coping
 Unconscious- memories or information that are
mechanisms already repressed
o Personal biases (manifestation by counter- o Composed of the LARGEST BODY OF
transference & vice versa) are seen during MATERIAL- the thoughts, memories and
working phase feelings that are repressed and not available
to the conscious mind, not logical and
governed by PLEASURE PRINCIPLE –
Termination and since it is usually painful and
unacceptable to the individual, it cannot
 Plan for termination of relationship early the be deliberately brought back into awareness
relationship unless in disguised or distorted form
 Stage of Separation Anxiety  Signs & symptoms: (dreams)
Regression: Temper tantrums, thumb sucking, o Information cannot be totally remembered
apathy, fetal position when crying o Largest storage among the three
 Phase of prognosis  Evaluation
 Maintain boundaries
 Anticipate problems of termination:
o Increased dependency on the nurse
o Recall of previous negative experience- Additional notes
rejection, depression, abandonment, etc.
o Regressive behaviors  Exploration is a sign of suicide
o Emphasize to the patient that a discharge o They are giving their belongings to other
instruction has been made which would help people
his/ her progression  If a patient has suicidal ideations, do you confront or
o Discharge plan is discussed in this phase
ask that patient?
 o Yes, because it is considered to be
therapeutic
o A no suicide attempt contract will be given,
because once a suicide happen the hospital
and staff will be held liable
o When you ask the patient if he/she will
perform suicide the patient will know that
the nurse is knowledgeable leading to delay
in the plan, do this until serotonin levels go
back to normal and depression will be
solved
o Confrontation is therapeutic to suicidal
patients. You can ask when, where, and how
can be asked but never why
 Asking questions starting with why is never
therapeutic
o Because why is an open-ended question,
leading the patient to rethink of the thoughts
and feelings that drove them to do suicide
Mental status examination
 A systematic assessment that checks if a person is
mentally sound or not
o Assessment in terms of their mental health
o No tools are available for this exam
o Not used to create a diagnosis but only to
assess
o Only used to add confirmation to a specific
mental disorder
 Clinical eye may be used in this assessment
 Histrionic personality disorder
o Characterized by a pattern of excessive
attention-seeking behaviors, usually
beginning in early childhood, including
inappropriate seduction and an excessive
desire for approval.
 Hygiene should be assessed
 Eye contact
o Does the person engage in eye contact?
o But always take into consideration of the
norms and practices about eye contact of
the patient
 Attitude
o Mannerisms (can usually be seen in
Tourette’s and autism)
o It is important to detect mannerisms
because this may be a sign of neurologic
dysfunction
o Alcohol and drug use may induce
mannerisms because these damages the
CNS
 Appearance
o Check the way a person dresses, is it
appropriate for the time and occasion?
o Can be observed in narcissists and people
with illusion of grandeur
 Speech
o Depressed patients can only answer close-
ended questions
o They cannot explain d/t decreased levels of
serotonin
o Volume of the voice may also be an
indicator depending on the client
 Mood and affect
o Affect can be seen in the client’s facial
expression
o Affect is the experience of feeling
an emotion while mood is a state
of emotion
o Affect is usually short-lived
while mood can last for hours or days
o Blunted vs. flat affect
o A person with flat affect has no or nearly
no emotional expression. He or she may not
react at all to circumstances that usually
evoke strong emotions in others. A person
with blunted affect, on the other hand, has
a significantly reduced intensity in
emotional expression
o Inappropriate vs labile affect
o Inappropriate affect is an affect that is
incongruent with the situation or with the
content of a patient's
ideas or speech. Labile affect that
characterized by rapid changes in emotion
unrelated to external events or stimuli
 Inappropriate affect is somehow
similar to the reaction formation
o Restricted affect is a term used to describe
a mild constriction in a client's
physical affect: range and/or intensity of
emotion or display of feelings
 The person does not want to really
show his/her feelings
 Speech
o There are certain forms or types of speech
that manifests in mental disorders
o Bipolar patients manifest flight of ideas
when speaking (flight of ideas where one
sentence has little connection to the second
statement) d/t hyperactive thinking
o Schizophrenia not intact with reality when
speaking (delusional)
 Loses association in spoken
statements
 Word salad (speaking of words not
related to one another)
o Neologisms can also be observed in
schizophrenic patients
 Coining or use of new words
 Invented words that is only known
by the patient
 When talking to the patient, clarify
what these words are to the client
o Echolalia, echopraxia, and palilalia
 Echolalia is the repetition of
words spoken by others,
whereas palilalia is the automatic
repetition of one's own words
  Echopraxia (also known as
echokinesis) is the involuntary
repetition or imitation of another
person's actions.
 Can be seen in autism patients
o Clanging- rhyming of words or phrases also
observed in schizophrenic patients]
o Blocking
 People with
thought blocking often interrupt
themselves abruptly mid-sentence.
 Can be observed in schizophrenic-
paranoid type
 This occurs d/t hallucinations of
the patient
 Thought
o Thought insertion can be seen in
schizophrenia
 Experiencing one's
own thoughts as someone else's
o Thought withdrawal
 Delusion that thoughts have been
taken out of the patient's mind
o Disturbed sensory perception and altered
thought process may be a nursing diagnosis
o Agnosia- loss of the ability to recognize
objects, faces, voices, or places
o Apraxia- inability to perform learned
(familiar) movements on command
 Inability to use objects properly
o Aphasia- impairment of language, affecting
the production or comprehension of speech
and the ability to read or write
Therapy for mental disorders
Electroconvulsive therapy
 ECT is passing of an electric current through
electrodes applied to one or both temples to
artificially induce a grand mal seizure for the safe and
effective treatment of depression.
 ECT’s mechanism of action is unclear at present
 For depressed patients
 Last resort for a depressed patient who can no longer
wait for the effect of an antidepressant medications or
is no longer responsive to medications
Advantages
 Quicker effects than antidepressants; Safer for
elderly; 80 % improvement rate of major depressive
episode with vegetative aspects
 Best therapy for major depression (last resort)
 Invasive
 Induction of 70-150 volts of electricity in).5-2secs.
Then, it is followed by a grand-mal
seizure lasting 30-60 secs.
o Prone to aspiration that is why atropine
sulfate is given to decrease secretions and
prevent aspiration
o Should be in supine during ECT, then after
place in a side-lying position to allow
drainage of secretions
 6-12 treatments, “every other day”
 Before ECT
o Should be on NPO
o Food is introduced when gag reflex is back
 Before ECT a major depressed client undergoes the ff
meds:
 Phenobarbitals are given as anticonvulsants and may
also decrease heart rate of patients
 SSRi (Selective Serotonin Reuptake
Inhibitor inhibitor) –2 weeks
 Antidepressants  TCA 2nd Generation
o 2-4 weeks
 MAOIs – are taken for 2 weeks
Side Effects
 After ECT, reorient the patient because antegrade
amnesia is expected after therapy
o Temporary RECENT Memory Loss
ANTEROGRADE amnesia
o Intervention: Re-orient client to 3 spheres
o Reintroducing yourself, therapy, where
patient is, time and date, secure the safety of
a patient as well
o confusion/disorientation (usually 24 hours)
o Headache  ↑02 demand, ↑cerebral
hypoxia
o Muscle spasm
o Wt. gain (stimulate thalamic/limbic 
appetite)
Contraindications
 PPPP– Post MI, Post CVA, pacemaker, pregnant
women
 People with cardiovascular problems
 Neurologic problem  Alzheimer’s, degenerative
disorder
 Brain tumor, weakness of lumbosacral spine
Legal/Pre-Nursing Responsibilities
Preparation: Similar to preparing a client for surgery
 Informed Consent – if client is coherent, if not a
guardian may sign the consent forms.
 No metallic objects
o Metals can interfere with electrical
transmissions
 No nail polish to check peripheral circulation
 No contact lenses it may adhere to the cornea
 Let the patient void first
 Wash & dry hair
 6. Give following medications BEFORE ECT:
 Atropine sulfate – anticholinergic
 PRIMARY purpose – to dry secretions and
prevent aspiration
 SECONDARY purpose – to prevent bradycardia
(vagolytic)
 Phenobarbital (Luminal), Methohexital (barbiturate
Na)- minor tranquilizer also an anticonvulsant
  Succinylcholine (Anectine) – muscle relaxant
o Given because ECT can cause muscle spasm
 Priority vs. to focus ABC; check RR 12 less; LOC
 Before ECT  supine position; after ECT  side-
lying
 Have patient VOID before giving ECT
Nursing Diagnosis
 Risk for Airway Obstruction/aspiration
 Risk for Injury
 Impaired/Altered Cognition/LOC
Nursing Intervention
 5 S in Seizure
 Safety (#1 objective)
 Side-lying (#1 Position)
 Side rails up
 Stimulus ↓ (no noise & bright lights)
 Support the head with a pillow AFTER the seizure
 FIRST & TOP priority: Ensure a patent airway.
Side-lying after removal of airway. Observe for
respiratory problems
 Remain with client until alert. VS q 5 min until
stable.
 REORIENT: Time, place (unit), person (nurse);
Reassure regarding confusion and memory loss.
Same RN before & after.
Behavior therapy
TERMINOLOGIES
 STIMULUS: Any event affecting an individual
 PROBLEM BEHAVIOR: Deficient, excessive,
condemned, unwanted behavior
 OPERANT BEHAVIOR: Activities that are
strongly influenced by events that follow them.
 TARGET BEHAVIOR: Activities that the nurse
wants to develop or accelerate in the client.
 REINFORCER: A reward positively or negatively
influences and strengthens desirable behaviors.
 POSITIVE REINFORCER: A desirable reward
produced by specific behavior (TV time after doing
homework)
 NEGATIVE REINFORCER: A negative
consequence of a behavior (Spanking child for
wetting the floor)
Classical conditioning
 (pairing of two stimuli in order to gain a new learning
behavior – by Ivan Pavlov)
 Acquisition (newly acquired behavior or the by-
product of classical conditioning)
 Extinction
 Reward and punishment in order to change the
behavior of the patient
 How frequent do we need to do this?
o Behavior changes quicker if rewards are not
given frequently, because once reward is
gone attitude may come back
o Should have a gap in between before you
give another reward
o This is to train them to maintain the good
behavior and not wait for the rewards
 If with bad behavior, punishment should be provided
right away
o Because there is a tendency that they will
not believe that the punishment is not true
 Provides a stimulus to encourage good behavior
 Appropriate therapy for phobias is systematic
desensitization
o A gradual exposure of the person to feared
objects
o E.g. fear of snakes, first show it from afar or
a stuffed toy, then progress until patient can
touch the snake
o Reinforce to the patient that not all snakes
are venomous
 If systematic desensitization is not effective, flooding
may be done
o This is the abrupt exposure to feared objects
until the patient becomes tolerant with it
OPERANT CONDITIONING
Burrhus Skinner
 used in Behavior Modification
1. Positive reinforcement (Reward Orientation)
o Token Economy – use tokens as a source of
reward.
o Used in eating disorders and depression
o Token economy is also effective for toddlers
2. Negative Reinforcement (Punishment Orientation)
o Aversion Therapy/Aversion Technique
BEHAVIORAL TREATMENTS
1. Desensitization – gradual exposure to the feared
object
o #1 treatment for phobia
2. Flooding/Implosive Therapy – sudden exposure
3. Relaxation Technique – light stroking = labor
o Purse Lip Breathing Exercise = COPD/CAL
(Chronic Airflow Limitation)
4. Biofeedback – mind over matter. Ex. HPN > ↓BP,
palpitations, headache
5. Guided Imagery (Child) & Visualization (Adult
Group therapy
 Psychotherapeutic processes that occur in formally
organized groups designed to change maladaptive or
undesirable behavior.
 Knowledge of therapeutic modalities enhances the
performance of nursing interventions during therapy.
8-10 patients are the optimal number of patients in a
group.
 There should be 8-10 members only
 Maximum of 10, no longer therapeutic if too many
  All members should have or experience the same
problem
 Done during rehabilitation in order to gain other
coping mechanisms of other patients who have
overcome the problems
TYPES OF GROUPS
1. Structured
o Goals: Pre-determined
o Format: Clear and specific
o Factual material: Presented
o Leader: Retains control
2. Unstructured
o Goals: Not pre-determined.
Responsibility for goal is shared by group and
leader
o Format: Discussion flows according to group
members’ concern
o Materials and topics are not pre-elected.
o Leader: Nondirective
o Emphasis: More on FEELINGS rather than facts
ADVANTAGE OF GROUP THERAPHY
1. Economical: Less staff used.
2. Increased feelings of closeness > Reduction on
feelings of being alone.
3. With feedback group >
o Corrects distortions of problems
o Builds self- image and self- confidence
o Increases reality- testing opportunities
o Gives info on how one’s personality and
behavior appear to others
4. With opportunities for practicing alternative
behaviors and methods of coping with feelings
5. Provides attention to reality and provides
development of insight into one’s problems by
expressing own experiences and listening to others in
groups
PRINCIPLES OF GROUP THERAPY
1. Verbalization: Members express feelings and group
reinforces appropriate communication.
Desired outcome of group therapy includes
verbalization of feelings rather than acting them out
2. Activity: Provides stimuli to verbalization and
expression of feelings.
3. Support: Members gain support from one another
through interaction, sharing and communication.
4. Change: Members have opportunity to try out new
and desirable behaviors in group, supportive setting
to effect change.
PHASES OF GROUP THERAPY
1. Initial Phase
 Formation of group
 Setting and clarification of goals and expectations
 Initial meeting, acquaintance and interaction
2. Working Phase
 Confrontation between members→ Cohesiveness
 Identification of problems→ Problem- solving
processes
 In a group therapy when one client says to another,
“Maybe you’re taking on someone else’s problems.”
this shows that they are in the working phase
3. Termination Phase
 Evaluation of goals attainment
 Support for leave- taking
 In group therapy if a client says, “Leave me alone &
get away from me.”, best action of the RN is to
maintain distance from the pt.
 Behavior indicating that goal is met after
socialization in a group therapy includes participation
of each group member telling the leader about
specific problems
Milieu therapy
 Milieu therapy or environmental therapy
o If a patient is having a religious delusion
remove images of saints, or smokes, because
it only adds to the delusion of the patient
o This does not bring the patient back to
reality
 Therapeutic milieu is an environment that is
structured and maintained as an ideal, dynamic
settings in which to work, with client
 For hyperactive patients do not place them in areas
with a lot of activities
o Place them in safe environments
 Any activity that is to be done should be supervised
by the nurse
Crisis
 Expected especially when a person is growing up
(developmental crisis)
o E.g. a girl undergoing puberty had her first
menstruation has increased anxiety because
this is her first time
o This cannot be avoided
 Midlife crisis where a person experiences ttransition
of identity and self-confidence that can occur in
middle-aged individuals, typically 45 to 65 years old
 When a person gets married, a person may also
undergo crisis because there will be a huge
adjustment
 Situational crisis involves an unexpected event that is
usually beyond the individual's control. Examples
of situational crises include natural disasters, loss of
a job, assault, and the sudden death of a loved one.
 Adventitious crisis where natural resources are
involved
o Called events of disaster. They are rare,
unexpected happenings that are not part of
 everyday life and may result from: Natural
disasters, such as floods, fires, and
earthquakes
 You are considered healthy is you are able to cope up
with the crisis in 4-6 weeks
o It should lessen in 4-6 weeks, but if it
increases you need to seek professional help
o If it resolves then recurs, its fine so long as it
resolves
Stages of grief
Additional notes
 Denial – The first reaction is denial. In this stage,
individuals believe the diagnosis is somehow
mistaken, and cling to a false, preferable reality.
o Present the reality to the client
 Anger – When the individual recognizes that denial
cannot continue, they become frustrated, especially at
proximate individuals. Certain psychological
responses of a person undergoing this phase would
be: "Why me? It's not fair!"; "How can this happen to
me?"; "Who is to blame?"; "Why would this
happen?".
 Bargaining – The third stage involves the hope that
the individual can avoid a cause of grief. Usually, the
negotiation for an extended life is made in exchange
for a reformed lifestyle. People facing less serious
trauma can bargain or seek compromise. Examples
include the terminally ill person who "negotiates with
God" to attend a daughter's wedding, an attempt to
bargain for more time to live in exchange for a
reformed lifestyle or a phrase such as "If I could trade
their life for mine".
 Depression – "I'm so sad, why bother with
anything?"; "I'm going to die soon, so what's the
point?"; "I miss my loved one; why go on?"
During the fourth stage, the individual despairs at the
recognition of their mortality. In this state, the
individual may become silent, refuse visitors and
spend much of the time mournful and sullen.
 Acceptance – "It's going to be okay."; "I can't fight it;
I may as well prepare for it."
In this last stage, individuals embrace mortality or
inevitable future, or that of a loved one, or another
tragic event. People dying may precede the survivors
in this state, which typically comes with a calm,
retrospective view for the individual, and a stable
condition of emotions.
 It is important for nurses to guide patients not to stay
too long in denial stage
 Nurse should guide the patient through the stages
 Voluntary admission- patient wants to seek mental
help so he/she surrendered self to the facility
o Contract may be ended by the patient
o He/ she may request to be discharged
o False imprisonment, assault, battery may be
charged if the nurse does not allow the client
to be discharged and was restrained
 Involuntary- those who were escorted to the facility
because they are still in denial of their condition
o Patients in this type of admission cannot
request to be discharged
o Contact the legal guardian who brought the
client there
 Safety and security must always be prioritized when a
patient is in jeopardy
o E.g. a patient is having seizures and the IV
lines are dislodged, ensure the safety of the
client first side rails up!
 How do you consider an alcoholic patient already
okay?
 Delusion of grandeur- fixed false belief of being high
or important
 Flight of ideas are somewhat related to one another
o Very common in bipolar disorders
o Mentioning one word then connecting it to
another
o Ex. Sir Gan—gun, I want to kill somebody
 Looseness of association- sentences are not
connected with one another
o Common in schizophrenic patients
o Because they are not intact with reality
  Clanging- rhyming words
 Neologism- making of words
 Projection is used by paranoid patients
 Conversion- anxiety converted to physical symptoms
 Compensation- weakness covered by greatness
 Orient the patient to location, time, place, and person
 Narcissistic patient- always remind them of the roles
and the patient should be the one following the nurse
o Reinforce to the patient that all the activities
to be done is for her/his good
o Always set the boundaries
o Confrontation can be done since there is a
contract
MIDTERMS
Anxiety
 DEFINITION: Effective subjective response to an
imagined or real internal or external threat.
 Perceived SUBJECTIVELY by the conscious mind is
as a painful, diffuse apprehension or vague
uneasiness, but the causative conflict or threats is not
in the conscious mind or awareness.
 Low / mild level of anxiety is healthy and helps in
individual growth and development.
 So long as you are still oriented to time, space, and
situation the anxiety you are feeling is still normal
o Up to moderate level of anxiety may still be
considered normal
 There are internal and external threats
o Internal- formed in the mind
o External- due to your situation or
environment
MAJOR ASSESSMENT CRITERION FOR
MEASURING DEGREE OF ANXIETY:
 Mild: The perceptual field is wide allowing the client
to focus realistically on what is happening to him.
Alert senses, increased attentiveness, and increased
motivation.
o Expected incoming threats
o Can still focus on other things
 Moderate: Another word is selective inattention. The
perceptual field narrows and the client is able to
partially focus on what is happening if directed to do
so and can verbalize feelings of anxiety
o Cannot focus anymore on other things
 Severe: The perceptual field is significantly reduced
and the client may not be able to focus on what is
happening to him and may not be able to recognize or
verbalize anxiety. All senses affected; decreased
perceptual field; drained energy; Learning and
problem-solving not possible. Start of sympathetic
symptoms: tachycardia, palpitations, hyperventilation
(brown paper bag to prevent Respiratory Alkalosis)
and cold clammy skin.
o Patient is already disorganized
 Panic: The perceptual field is severely reduced and
the client experiences feelings of panic and dread.
Client overwhelmed and helpless; personality may
disintegrate → hallucinations and delusions.
Pathological conditions requiring immediate
intervention. Client may harm self or others.
o A patient stating, “Sometimes I feel like I’m
going crazy & losing control over myself,”
is showing symptoms of panic attack
 Perceptual field and anxiety are inversely
proportional
o Sensorium or senses are involved
o As anxiety increases sensorium decreases
o When a patient is anxious, he/she can only
see what is in front and can only hear loud
noises
 Talk to the patient in a short and direct manner, use
close-ended questions
 Always place yourself in front of the patient
 Identify the stimulus that causes anxiety and remove
it
 Do not leave the patient alone during anxiety attack
o Safety is always priority
 Still give space and do not touch the patient unless
he/she permits you to do so
POTENTIAL NURSING DIAGNOSES
 Ineffective Individual Coping
 Anxiety
NURSING INTERVENTION IMPLEMENTATON:
 Identify anxious behavior and anxiety levels and
institute measures to decrease anxiety at a level
where learning can occur.
 Provide appropriate environment where
environmental stress & stimulation are low (First
nursing action):
o Structured, NON-STIMULATING,
uncluttered
o SAFE from physical exhaustion and harm.
 STAY. Do not leave client alone. Recognize if
additional help is needed. Provide physical care if
necessary.
 Establish PERSON-TO-PERSON relationship and
maintain an accepting attitude:
o ACCEPT client. Show willingness to
LISTEN.
o Encourage, allow EXPRESSION OF
FEELINGS at client’s OWN PACE avoid
forcing verbalization.
 Administer medication as directed and needed. The
pharmacologic therapy of choice is ANXIOLYTIC-
reduces anxiety so client can participate in
psychotherapy.
 Assist to cope with anxiety more effectively. Assist
to recognize individual strengths realistically
 Encourage measures to reduce anxiety: activities:
relaxation techniques, exercises (DANCING,
 WALKING, JOGGING), hobbies, talking with
support groups, desensitization treatment program
 Provide individual or group therapy to identify
anxiety and new ways of dealing with it and develop
more effective coping interpersonal skills.
 If patient can be redirected back to the topic after he
gets anxious while the RN gives discharge teaching,
it is an indication that discharge teaching can be
resumed.
TYPES OF ANXIETY DISORDER
 Phobia
o Fear of heights- acrophobia
o Fear of fire- pyrophobia
o Fear of doctor- iatrophobia
o Fear of microorganisms- germaphobia
o Fear of death- thanatophobia
o Fear of animals- zoophobia
 Obsessive Compulsive
 Post-Traumatic Stress Disorder (PTSD)
 Generalized Anxiety Disorder (GAD)
 Panic Disorder
PHOBIA AND PANIC DISORDER
 Extreme anxiety and apprehension experienced by an
individual when confronted with feared object/
situation; commonly begins in early twenty’s (young
adult) as a result of childhood environmental factors
characterized by ORDER & RIGIDITY; use
compensatory mechanism of the psychoneurotic
pattern of behavior and development of symptoms
permits some measure of social adjustment.
 PRECIPITATING FACTOR: Pressures of decision-
making regarding life-style in early adult period
TYPES OF PHOBIA
 Agoraphobia: Fear of being alone, fear of open
spaces or PUBLIC places where help would not be
immediately available (trains, tunnels, crowds, buses)
 A client with agoraphobia who is already able to go
outside the house indicates a positive response to
therapy.
 Expected outcome for agoraphobia includes going
out to see the mailbox
 Social phobia: Fear of public speaking or situations in
which public scrutiny may occur
 Simple phobia: Fear of specific objects, animals or
situations
NURSING IMPLEMENTATION
 Recognize the client’s feelings about phobic object/
situation
o Specific precipitants are present with phobia
 Avoid confrontation and humiliation; Provide
constant support (Stay with client during an attack) if
exposure to phobic object or situation cannot be
avoided
 Do not focus on getting patient to stop being afraid
 Provide relaxation techniques
 Implement behavioral therapy: SYSTEMIC
DESENSITIZATION (the #1 treatment for
PHOBIA). Administer antidepressants as ordered
OBSESSIVE-COMPULSIVE DISORDER
 A psychiatric disorder characterized by persistent,
recurring anxiety-provoking thoughts and repetitive
acts; Unconscious control of anxiety by the use of
rituals and thoughts
o OBSESSION: Persistent, repetitive,
uncontrollable thoughts
 These are thoughts that are
recurring in the mind
 Thoughts that keeps a patient
preoccupied, thus, affects ADLs
o COMPULSION: Repetitive, uncontrollable
acts of irrational behavior that serve NO
rational purpose → rigidity, rituals,
inflexibility; the development of rituals
permits some measure of social adjustment
 Things that the patient
unconsciously does to decrease the
level of anxiety because of the
obsession
 Helps in decreasing the anxiety felt
by the patient
 ASSESSMENT FINDINGS: Ritualistic, rigid,
inflexible; with difficulty making decisions and
demonstrates striving at perfection; use verbal and
intellectual defenses
 Acknowledge positive reinforcement
NURSING IMPLEMENTATION
 Provide for physical safety (1st); meet physical needs
 Accept, allow ritualistic activity; DO NOT
INTERFERE with it; (The best time to interfere with
ritual is after client has completed it.) Accept
behavior but set limits on length and frequency of the
ritual. Offer alternative activities; support attempts to
reduce dependency on the ritual; guide decisions
o Just set a time when to perform the
ritualistic behavior (time management)
o Do not stop, because it will increase anxiety
 Provide structured environment, minimize choices
 Provide socialization, group therapy
 Administer CLOMIPRAMINE (ANAFRANIL) as
ordered
o A Tricyclic antidepressant used in phobias,
anxiety and obsessive-compulsive disorder;
SIDE-EFFECTS/ ADVERSE REACTIONS:
Tachycardia, cardiac arrest, dizziness, tremors,
seizures, CONTRAINDICATIONS: Pregnancy,
hypersensitivity; Interactions/Incompatibilities:
Hypertensive crisis, convulsions, with MAOIs
POST-TRAUMATIC STRESS SYNDROME
  A disorder following exposure to extreme traumatic
event (wars, rape, natural catastrophes) causing
intense fear, recurring distressing recollections and
nightmares
o Retained in the patient’s mind
o They are detached because they do not know
who to trust anymore. They think that
people who surround them are going to do
something bad
 ASSESSMENT: 2 Cardinal Sign: FLASHBACK &
NIGHTMARES. Images, thoughts, feelings →
intense fear and horror, sleep disturbances.
o Depression, or irritability or outburst of anger
o Exaggerated startle response; Poor impulsive
control
o Avoidance; Inability to maintain intimacy;
Hypervigilance
o The two cardinal signs should be present in order
to diagnose PTSD
 PRIORITY NURSING DIGNOSIS
o Altered Sleeping Patterns
o Altered Skin Integrity
o Ineffective Individual Coping
NURSING INTERVENTATION
o Encourage VERBALIZATION about painful
experience. Show empathy; be non-judgmental; Help
feel safe.
o To prevent level of anxiety
o Rational emotive-therapy; Allow to grieve
o Help client identify, label and express feelings safely
o If they have difficulty in sharing the experience their
level of anxiety may increase
 Enhance support systems: Self-help groups, family
psychoeducation, and socialization.
o In a rape victim, a statement like, “If I should not
have worn that red panty, it won’t happen to me”,
shows denial
o Statement of a rape patient who is beginning to
resolve trauma includes, “I’m able to tell my friends
about being raped.”
o An RN needs further teaching about caring for a post-
traumatic client when she keeps on asking the client
to describe the trauma that caused patient’s distress
after recovering from a PTSD
SOMATOFORM DISORDERS
 Body Dysmorphic Disorder
 Somatization
 Conversion Disorders
 Hypochondriasis
 Psychogenic Pain
 This are all caused by anxiety
BODY DYSMORPHIC DISORDER
 Preoccupation with an imagined defect in his or her
appearance
 A perceived distortion to the physical body
 This is not made up by the client but this is what
he/she sees
SOMATIZATION
 A client expresses emotional turmoil or conflict
through a physical system, usually with a loss or
alteration of physical functioning
 Involves a person having a significant focus on
physical symptoms, such as pain, weakness or
shortness of breath, that results in major distress
and/or problems functioning. The individual has
excessive thoughts, feelings and behaviors relating to
the physical symptoms
 When validated by laboratories it is not confirmed to
be true
CONVERSION DISORDERS
 A psychological condition in which an anxiety-
provoking impulse is converted unconsciously into
functional symptoms
 Anxiety is converted to physical symptoms
 Patients with this disorder do not fake the physical
signs and symptoms
 Physical symptoms can be confirmed through
diagnostic tests
 Does not do hospital-hopping because the doctor will
validate that the symptoms are real
HYPOCHONDRIASIS
 Presentation of unrealistic or exaggerated physical
complaints
 When a patient complains of backache and thoughts
of it as bone cancer
DISSOCIATIVE DISORDERS
 Dissociative amnesia
 Dissociative fugue
 Depersonalization
 Dissociative Identity Disorder/Multiple Identity
Disorder
 These disorders are still because of anxiety
DISSOCIATIVE AMNESIA
 Characterized by the inability to recall an extensive
amount if important personal information because of
physical or psychological trauma
 Once the patient has recovered from the crisis, the
memory of the patient will return
DISSOCIATIVE FUGUE
 The person suddenly and unexpectedly leaves home
or work and is unable to recall the past
 If the patient moves from one country to another the
patient will not be able to recall the previous life and
the previous country he has been in
 Characterized by reversible amnesia for personal
identity, including the memories, personality, and
other identifying characteristics of individuality. The
state can last days, months or longer.
DEPERSONALIZATION
 Person experiences a strange alteration in the
perception or experience of the self, often associated
with a sense of unreality
  Depersonalization/derealization disorder is a type of ***symptoms should be present for at least 6 months to
dissociative disorder that consists of persistent or confirm schizophrenia
recurrent feelings of being detached (dissociated) ***At least 2 positive symptoms and 1 negative symptoms\
from one’s body or mental processes, usually with a
feeling of being an outside observer of one’s life THEORIES
(depersonalization), or of being detached from one's 1) Increased dopamine –coming from the substancia nigra
surroundings (derealization).
2) Genetics
 This is not fixed, only temporary. The patient can still
go back to reality └ 65% chances- if two parents are diagnosed with
schizophrenia
MULTIPLE PERSONALITY DISORDER └ 32.5% chances- if 1 parent is diagnosed with
 A person is dominated by at least one of two or more schizophrenia
definitive personalities at one time 3) Drug addicts and alcoholics: High probability for
 Maintenance of at least two distinct and relatively schizophrenia due to increase Delusions & hallucination
enduring personality states. The disorder is
4) Pregnant woman who is a smoker may increase risk for
accompanied by memory gaps beyond what would be
explained by ordinary forgetfulness. development of schizophrenia of her baby
 The person won’t know about the different
personalities unless they are already being treated CLINICAL MANIFESTATIONS OF SCHIZOPHRENIA
 Once they verbalize and is conscious of the multiple  Characterized by both (-) & (+) symptoms & social /
personalities it is a sign of progress or recovery occupational dysfunction for at least SIX (6) months.
 Patient with 5 admissions in 2 yrs is considered a chronic
Psychotic Disorders schizophrenia
 (+) POSITIVE SIGNS OF SCHIZOPHRENIA: Due
SCHIZOPHRENIA to EXCESS DOPAMINE
 Severe impairment of mental & social functioning with HILDDA PI
grossly impaired reality testing, sensory perception and o Hallucination
with deterioration & regression of psychosocial o Illusion
functioning. o Looseness of Association
 Schizo = Split o Delusion of Grandeur
 Phrenia = Mind o Disorientation
 Dopamine is increased o Agitation
└ Dopamine is responsible in cognitive function o Paranoia
└ Increased levels will lead to delusions and o Insomnia
hallucinations  (-) NEGATIVE SIGNS OF SCHIZOPHRENIA: Due
 #1 HALLUCINATION of Schizophrenia is Auditory. to LACK OF DOPAMINE
 Irreversible disease POOR A’s
└ It can be managed but not treated o Poor judgment
└ Intake of antipsychotics drugs is lifetime o Poor insight
└ If intake of medications are stopped, schizophrenia o Poor self care
manifestations will return again o Alogia [lack of speech caused by a disruption
 Ego is damaged because ego is what keeps the patient in the thought process]
intact in the reality o Anhedonia [absence of sexual urges]

THE FOUR A’s of SCHIZOPHRENIA NURSING DIAGNOSIS FOR NEGATIVE SYMPTOMS OF

ACCORDING TO BLEULER
ASSOCIATIONS, LOOSE: Jumping to different
topics WITHOUT association or relevance
AMBIVALENCE (Two opposing
thoughts/feelings toward others at the same time)
A 
AUTISM (withdrawal from environment and
others) → magical thinking, neologism, aloofness,
echolalia)
AFFECT, FLAT (Inappropriate or no display of
feelings)
***should be assessed to diagnose schizophrenia
SCHIZOPHRENIA:
1. Alteration in Thought Process
2. Alteration in Content of Thought
OTHER POSITIVE SYMPTOMS:
All this signs & symptoms can also be seen in SAM
(Schizophrenia, Alzheimer’s & Manic)
1. Neologism (creating NEW WORDS) vs. Word
Salad (incoherent mixture of words)
2. Verbigeration (meaningless repetition of action
words and phrases
 Perseveration
e.g. 1st stimulus → correct response
2nd & following stimulus → still responding to
the 1st stimuli
3. Circumstantiality (beating around the bush;
answers but delayed) vs. Tangentiality (did not
answer the stimulus/ question)
 Usually found in disorganized type of
schizophrenia
4. Clang association (use of rhymes in
sentences/words connected) vs. Echolalia/Parroting
& Echopraxia-involuntary imitation of movements
made by another.
5 TYPES OF SCHIZOPHRENIA
1. PARANOID
 Presenting sign is SUSPICIOUSNESS, ideas of
persecution and delusions
└ sees environment as hostile and threatening
 most difficult to handle because they are usually
uncooperative
 REMEMBER the 4 P’s:
o Projection (#1 defense mechanism) attributing
one’s own unacceptable feelings & thoughts to
others
o Proxemics (4 feet away from the patient)
o P Friendliness (#1 attitude therapy: No
touching, no whispering & laughing)
o Delusion of Persecution (#1 delusion of
Paranoid Schizophrenia) – thinking of being
attacked by someone else
 Developmental Stage FIXATION: ORAL PHASE
(TRUST vs. MISTRUST)
 Defense Mechanism: Projection
 Nursing Care:
1. Consistency to build trust
2. Food: PACKED OR SEALED foods except
canned goods: No metal
3. Social Isolation – no group session when
schizophrenic
4. At least 4 feet away and in front of the patient
when communicating
5. Never touch the patient
 Eg. Paranoid who is suspicious saying, “This place is
meant for bugs & prison,” In order to encourage trust,
the patient should be involved in the plan of care.
 Eg. How will you feed a malnourished paranoid
schizophrenic patient? Involve patient in all
interventions so that they will see that everything is
prepared safely with no harm
2. CATATONIC
 With stereotyped position (catatonia) with waxy
flexibility, mutism,
 #1 Cardinal Sign of Catatonia – waxy flexibility
 Most dangerous/serious type of schizophrenia–
may die from dehydration
 Catatonic stupor – markedly slowed movement.
o Waxy Flexibility
└ decreased response to stimuli and a
tendency to remain in an immobile
posture
└ lack of movement for a prolonged period
of time
└ occurs because the patient is regressive
o mutism
 Catatonic hyperactivity or excitability
 Nursing Responsibility: prevent injury
3. DISORGANIZED/ HEBEPHRENIC
 Characterized with inappropriate behavior:
o Silly crying
o Laughing
o Regression
o Confusion
o disorganized thoughts
o transient hallucinations (Auditory)
 Common in women
 All behaviors are similar with toddlers since they are
anal fixated.
 Developmental Stage FIXATION: Anal Fixation
 #1 Defense Mechanism: Regression & Fixation
4. UNDIFFERENTIATED/ MIXED
 Symptoms of more than one type of schizophrenia
has delusions & disorganized behavior
 The #1 drug of choice is Fluphenazine (Prolixin
decanoate)
5. RESIDUAL
 No longer exhibits overt symptoms, no more
delusions but the signs and symptoms may comeback
due to non-compliance with drug intake
 No more PO drugs, IV drugs are now given
 Nursing care: consistency
 Give antipsychotic –hallucination / delusion
 Undifferentiated type chronic schizophrenia must be
referred to a program promoting social skills due to
functional loss deficit
PRINCIPLES OF CARE FOR SCHIPHRENIA
1. Maintenance of safety:
 Protect from altered thought processes.
 Respond to feelings, and not to delusions
 Do not argue
 Validate reality
  Remove from areas of tension
 Eg. Appropriate action of RN to a Schizophrenic who 35 yrs-55 yrs GENERATIVITY VS. STAGNATION
yells loudly, talks to wall and saying “Don’t talk to  fulfilling life's goals that involve family, career and
society, developing concerns that embrace future
me, bastard.” includes walking towards the pt & ask
generations
him who he is talking to.  conflict: self-absorption. Inability to grow as a person
2. Meeting of physical needs
 May have to be fed / bathe initially 55 yrs-above INTEGRITY VS. DESPAIR
3. Establishment and maintenance of therapeutic  looking back into one’s life and accepting its
relationship meaning
 Engage in individual therapy  conflict: dissatisfaction with life, denial of or despair
over prospect of death
 Promote trust
 Encourage expression by verbalizing the observed JEAN PIAGET
 Offer presence-Tolerate long silences COGNITIVE THEORY OF DEVELOPMENT
4. Implementation of appropriate family, group, social or
diversional therapies ASSIMILATION
 people transform incoming information so that it fits
 Patients with schizophrenia need activities that do not
within their existing schemes or thought patterns
require interaction, so solitary activities are preferred
over team activities. ACCOMMODATION
 people adapt their schemes to include incoming
information
*Hindi to kasama sa lecture pa po hehe
ERIK ERICKSON PIAGET’S COGNITIVE THEORY
PSYCHOSOCIAL THEORY OF DEVELOPMENT
SENSORIMOTOR STAGE
0-18 mos. TRUST VS. MISTRUST  development proceeds from reflex activity to
 attachment to mother which lays foundations for later representation and sensorimotor solutions to
trust in others problems
 conflict: general difficulties relating to others.  0 to 18 months
suspicion, fear of the future
PRE-OPERATIONAL STAGE
 development proceeds from sensorimotor
18 mos-3 yrs AUTONOMY VS. SHAME/DOUBT representation to prelogical thought and. solutions to
 Gaining some basic control of self and environment problems can use these representational skills only to
 Conflict: independence-fear conflict, severe feelings view the world from their own perspective.
of self-doubt  Understand the meaning of symbolic gestures
 2 to 7 years
3 yrs-6 yrs INITIATIVE VS. GUILT
 becoming purposeful and directive CONCRETE OPERATIONAL
 conflict: aggression-fear conflict, sense of inadequacy  development proceeds from prelogical thought to
and guilt logical solutions to concrete problems
 understand concrete problems
 cannot yet contemplate or solve abstract problems
6 yrs-12 yrs INDUSTRY VS. INFERIORITY  7 to 12 years
 Developing social, physical and school skills,
competence FORMAL OPERATIONAL
 Conflict: sense of inferiority, difficulty learning and  development proceeds from logical solutions to
working concrete problems to logical solutions to all
 classes of problems
12 yrs-20 yrs IDENTITY VS. ROLE DIFFUSION  cannot yet contemplate or solve abstract problems
 Making transition from childhood to adulthood,  can also reason theoretically
developing a sense of identity  12 and above
 Conflict: confusion of who one is, identity submerged
in relationships or group memberships HARRY STACK SULLIVAN
INTERPERSONAL THEORY
21 yrs -35 yrs INTIMACY VS. ISOLATION
 establishing intimate bonds of love and friendship SULLIVAN'S INTERPERSONAL THEORY
 conflict: emotional isolation
INFANCY
  anxiety develops as a result of unmet needs by the
mother (bodily needs); needs met, the child has sense ORIENTATION
of well-being  Broad Opening
 0 to 18 months  Recognition
 Giving information
CHILDHOOD  Silence
 anxiety as a result of lack of praise/acceptance from  Offering Self - "Do you want me to sit beside you?”
parents
 gratification leads to positive self-esteem WORKING
 moderate anxiety leads to uncertainty and insecurity  Focusing - "Let us discuss this topic more”
 severe anxiety results in self-defeating patterns of  Exploring - "Tell me more about it.”
behavior  Encourage Evaluation - "IS this what you want?”
 18 months to 6 years  Reflecting - same idea
 Restating - same statement
JUVENILE  Verbalizing Implied - "Are you going to kill
 severe anxiety may result in a need to control or yourself?"
restrictive, prejudicial attitudes learns to negotiate  Seeking Clarification – “May you please repeat that
own needs statement”
 6 to 9 years  General lead - "Please continue.”; “And then?”
 Limit setting - "Stop"
PRE-ADOLESCENCE  Interpreting - "Maybe that thing is very significant to
 capacity to attachment, love and collaboration you.”
emerges or fails to develop
 move to genuine intimacy with friend of the same sex TERMINATION
 9 to 12 years  Summarizing – “Let us now sum up. You have stated
earlier... etc.”
ADOLESCENCE  “Do you have any questions?”
 if self-system is intact, areas of concern expand to  “Our next therapy...”
include values, career decisions and social concerns  Look for changes in behavior
 lust is added to interpersonal equation  Resistance is a common problem
 need for special sharing relationship shifts to opposite
sex THERAPEUTIC COMMUNICATION TECHNIQUES
 new opportunities for social experimentation lead to
consolidation or self-ridicule  Accepting-indicating reception
 12 to adulthood  E.g., “Yes"
“I follow what you said”
Nodding

BROAD OPENINGS
HILDEGARD PEPLAU  Allowing the client to take the initiative in
NURSE PATIENT RELATIONSHIP introducing the topic
 e.g., "is there something you'd like to talk about?”
PEPLAU'S NPR “Where would you like to begin?”
PRE-INTERACTION CONSENSUAL VALIDATION
 Major task of nurse- to develop self-awareness  Searching for mutual understanding, for accord in the
meaning of the words
ORIENTATION
 e.g., "Tell me whether my understanding of it agrees
 Major task of the nurse: to develop a mutual with yours”
acceptable contract “Are you using this word to convey that…?”
WORKING ENCOURAGING COMPARISON
 Major task: identification and resolution of patient's  Asking that similarities and differences be noted
problem
 e.g., "was it something like...?
“Have you had similar experiences?”
TERMINATION
 Major task: to assist the patient to review what he has ENCOURAGING DESCRIPTION OF PERCEPTIONS
learned and transfer his learning to his relationship
 Asking the client to verbalize what he or perceives
with others
 E.g., “Tell me when you feel anxious”
“What is happening?”
THERAPEUTIC COMMUNICATIONS
 “What does the voice seem to be saying?”
ENCOURAGING EXPRESSION
 Asking client to appraise the quality of his or her
experience
 e.g., “what are your feelings in regard to...?”
“Does this contribute to your distress?”
EXPLORING
 Delving further into a subject or idea
 e.g., "Tell me more about that.”
“Would you describe it more fully?”
“What kind of work?”
FOCUSING
 Concentrating on a single point
 e.g., "This point seems worth looking at more
closely"
“Of all the concerns you've mentioned,
which is most troublesome?”
FORMULATING A PLAN OF ACTION
 Asking the client to consider kinds of behavior likely
to be appropriate in future situations
 e.g., "What could you do to let your anger out
harmlessly?"
“Next time this comes up, what might you
do to handle it?"
GENERAL LEADS
 Giving encouragement to continue
 e.g., "Go on”
“And then?"
"Tell me about it”
GIVING INFORMATION
 Making available the facts that the client needs
 E.g., “My name is…”
“Visiting hours are…”
“My purpose in being here is…”
GIVING RECOGNITION
 Acknowledging, indicating awareness
 E.g., “Good morning, Mrs. S…”
“You’ve finished your list of things to do.”
“I noticed that you’ve combed your hair”
MAKING OBSERVATIONS
 Verbalizing what the nurse perceives
 E.g., “You appear tense…”
“I notice that you’re biting your lips”
OFFERING SELF
 Making oneself available
 E.g., “I’ll sit with you awhile.”
“I’ll stay here with you”
“I’m interested in what you think
PLACING EVENT IN TIME OR SEQUENCE
 Clarifying the relationship of events in time
 E.g., “What seemed to lead up to…?”
“Was this before or after?”
PRESENTING REALITY
 Offering for consideration that which is real
 E.g., “I see no one else in the room”
“Your mother is not here; I am a nurse”
REFLECTING
 Directing client actions, thought, and feeling back to
the client
 E.g., Client: “Do you think I should tell the doctor…?
Nurse: “Do you think you should?”
RESTATING
 Repeating the main idea expressed
 E.g., Client: “I can’t sleep. I stay awake all night”
Nurse: “You have difficulty sleeping”
Client: “I’m really mad, and upset”
Nurse: “You’re really mad and upset”
SEEKING INFORMATION
 Seeking to make clear that which is not meaningful
or that which is vague
 “I’m not sure that I follow”
“Have I heard you correctly?”
SILENCE
 Absence of verbal communication, which provides
time for the client to put thought or feelings into
words, regain composure, or continue talking
 E.g., nurses say nothing but continues to maintain
eye contact and conveys interest
SUGGESTING COLLABORATION
 Offering to share, to strive, to work with the client for
his or her benefit
 E.g., “perhaps you and I can discuss and discover the
triggers for your anxiety”
SUMMARIZING
 Organizing and summing up that which has gone
before
 E.g., “Have I got this straight?”
TRANSLATING INTO FEELINGS
 Seeking to verbalize client’s feelings that he or she
expresses only indirectly
 E.g., Client: “I’m dead”
Nurse: “Are you suggesting that you feel
lifeless?”
VERBALIZING THE IMPLIED
 Voicing what the client has hinted at or suggested
 E.g., Client: “I can’t talk to you or anyone. It’s a
waste of time.”
Nurse: “Do you feel that no one
understands”
VOICING DOUBT
  Expressing uncertainty about the reality of the
client’s perceptions
 “isn’t that unusual?”
“really?”
“that’s hard to believe”
NONTHERAPEUTIC COMMUNICATION
TECHNIQUES
 Advising – telling the client what to do
Agreeing – indicating accord with the client
 E.g., “I think you should…”
“That’s right”
AGREEING
 Indicating accord with the client
 “that’s eight.” “I agree”
BELITTLING FEELINGS EXPRESSED
 Misjudging the degree of the client’s comfort
 Client: “I have nothing to live for… I wish I was
dead”
Nurse: “Everybody gets down in the dumps”
CHALLENGING
 Demanding proof from the client
 “But how can you be president of the Philippines?”
DEFENDING
 Attempting to protect someone or something from
verbal attack
 “this hospital has a fine reputation”
DISAGREEING
 Opposing the client’s ideas
 E.g., “that’s wrong”
DISAPPROVING
 Denouncing the client’s behavior or ideas
 “that’s bad”
“I’d rather you wouldn’t”
GIVING APPROVAL
 Sanctioning the client’s behavior or ideas
 “that’s good.” “I’m glad that…”
GIVING LITERAL RESPONSES
 Responding to a figurative comment as though it
were a statement of fact
 Client: “They’re looking in my head with television
camera”
Nurse: “Try not to watch television”
INDICATING EXISTENXE OF AN EXTERNAL
SOURCE
 “What makes you say that?”
INTERPRETING
 Asking to make the conscious that which is
unconscious
 “what you really mean is…”
INTRODUCING AN UNRELATED TOPIC
 Changing the subject
 Client: “I’d like to die.”
Nurse: “did you have visitors last night?”
MAKING STEREOTYPED COMMENTS
 Offering meaningless cliché or trite comments
 “keep your chin up”
“just have a positive outlook”
PROBING
 Persistent questioning of the client
 “now tell me about this problem. I need to know”
REASSURING
 Indicating there is no reason for anxiety
 “everything will be alright”
REJECTING
 Refusing to consider or showing contempt for the
client’s behavior, ideas
 “let’s not discuss…”
REQUESTING AN EXPLANATION
 Asking the client to provide reasons for thoughts,
feelings, behaviors, events
 “why do you think that?”
TESTING
 Appraising the client’s degree of insight
 “do you know what kind of hospital this is?”
USING DENIAL
 Refusing to admit that a problem exists
 Client: “I am nothing”
Nurse: “Of course, you’re something”
NON-THERAPEUTIC COMMUNICATIONS
 Overloading – “blah, blah, blah”
 Underloading – ignoring
 Value Judgement – use of adjectives
 False Reassurance – “Don’t worry, you will be fine
later”
 Focusing on Self – “I gave you meds so you are now
feeling good”
 Incongruence
 Internal Validation – biased judgement
 Giving Advice – “If I were you, I’ll…”
 Changing Subject
LOSS AND GREIVING
GRIEF – refers to the subjective emotions and affect that are
a normal response to the experience of loss
ANTICIPATORY GRIEVING – when people facing an
imminent loss begin to grapple with the very real possibility of
the loss or death in the near future
DISENFRANCHISED GRIEVING - grief over a loss that
is not or cannot be acknowledged openly, mourned publicly or
supported socially
COMPLICATED GRIEVING – when a person is void of
emotion, grieves for prolonged periods, has expressions of
grief that seem disproportionate to the event
LOSS
 Physiologic loss
 Safe and security loss
 Love and belongingness loss
 Self-esteem loss
 Self-actualization loss
GRIEVING PROCESS
 Denial
 Anger
 Bargaining
 Depression
 Acceptance
 Dysfunctional Grieving – grieving which extends
from 4 to 6 weeks leading to CRISIS
INTERVENTIONS
 Explore client’s perceptions and meaning of the loss
 Allow adaptive denial
 Assist client to reach out for and accept support
 Encourage client to examine patterns of coping in
past and present situation of loss
 Encourage client to care for themselves
 Offer client food without pressure to eat
 Use effective communication
CRISIS AND ITS MANAGEMENT
CRISIS
 Situation that occurs when an individual’s habitual
coping ability becomes ineffective to merit demands
of a situation
TYPES OF CRISES
 MATURATIONAL/DEVELOPMENTAL: normal
expected crisis that runs through age
 SITUATIONAL: an expected and sudden event in
life
 ADVENTITIOUS: calamities, war
CHARACTERISTICS OF A CRISIS STATE
 Highly individualized
 Lasts for 4-6 weeks
 Self-limiting
 Person affected becomes passive and submissive
 Affects a person’s support system
PHASES OF A CRISIS
 PRE-CRISIS: state if equilibrium
 INITIAL IMPACT (may last a few hours to a few
days): high level of stress, helplessness, inability to
function socially
 CRISIS (may last a brief or prolonged period of
time): inability to cope, projection, denial,
rationalization
 RESOLUTION: attempts to use problem-solving
skills
 POST CRISIS: may have OLOF or may have
symptoms of neurosis, psychosis
CRISIS MANAGEMENT
 Role of the nurse is to return the client to its pre-crisis
state by assisting and guiding them until they
achieved their OLOF
 Goal: to enable patient to attain an OLOF
 Nurse’s Primary Role: active and directive
STEPS IN CRISIS INTERVENTION
 Identify the degree of disruption the client is
experiencing
 Assess the client’s perception of event
 Formulate nursing diagnoses
 Involve the patient and family if applicable with
planning
 Implement interventions – new and old coping
mechanisms
 Evaluate – reassessment, reinforcement
TYPES OF THERAPIES
TREATMENT MODALITIES
INDIVIDUAL PSYCHOTHERPAY
 One to one relationship between therapist and client
 For dissociative, anorexia, paranoid, narcissistic
 Change is achieved by the exploration of feelings,
attitudes, thinking behavior and conflict
SEVEN SUBTYPES
CLASSICAL PSYCHOANALYSIS
 Based on Freud’s theory
 To uncover unconscious feelings and thoughts that
interfere with the client’s living a fuller life
 Free association – client is encouraged to say
anything that comes to mind, without censoring
thoughts or feelings
 Dream analysis
 Working through (transference) – process of repeated
interpretation to the person of his or her unconscious
processes has the effect of bringing about change
PSYCHOANALYTICAL PSYCHOTHERAPY
 Uses dream analysis, transference and free
association
 Therapist is much more involved and interacts with
the client more freely
 Done through intimate professional relationship
between the nurse/therapist and the client over a
 period of time (introductory, working and dreams, person is asked to play roles of persons in the
termination phase) dream to get in touch with different repressed
feelings
SHORT TERM DYNAMIC PSYCHOTHERAPY
 Indication – persons with specific symptom or MILIEU THERAPY
interpersonal problem that he/she wants to work on  Total environment has an effect on the individual’s
 Therapist directs the content behavior
 Use of transference and dream analysis  Components
 Weekly sessions (total number – 12 to 30) o Physical environment
 Successful for highly motivated individuals who have o Interpersonal relationships
insight and with positive relationship with the o Atmosphere of safety, caring, and mutual respect
therapist o For alcoholics

TRANSACTIONAL ANALYSIS PROGRAMS FOR MILIEU SHOULD HAVE:

 Eric Berne
 Each person has three ego states and change from one
to another frequently
 Parent – concepts of standards of behavior and how
things should be done.
o E.g., go and take out the garbage
 Adult – rational thinking and data analyzing part of
the personality.
o E.g., would you please take out the garbage
 Child – feelings associated with persons, things or
incidents represent the need-gratifying aspects of the
personality
o E.g., is this why you married me? To be your
garbage man?
 For group, family and individual
 Client to identify ego states for each given situation
 Rewarding of positive or negative behaviors with
strokes
 Client work through these behaviors
 An emphasis on group and social interaction
 No rules and expectations mediated by peer pressure
 A view of patients’ roles as responsible human beings
 An emphasis on patients’ rights for involvement in
setting goals
 Freedom of movement and informality relationships
with staff
 Emphasis on interdisciplinary participation
 Goal-oriented, clear communication
GROUP THERAPY
 Number of people coming together, sharing a
common goal, interest or concern, staying together
and developing relationships
 For PTSD and alcoholics
 Phases
o Orientation
o Working
o Termination

COGNITIVE PSYCHOTHERAPY CHARACTERISTICS OF GROUP THERAPY

 Restructuring or changing ways in which people  Universality → “you are not alone”
think about themselves  Instilling hope and inspiration
 Thought stopping  Developing social skills by interacting with one
 Positive self-talk another
 DE catastrophizing  Feeling of acceptance and belonging
 Therapists help patients identify these thoughts  Altruism → “giving of one’s self

BEHAVIORAL THERAPY FAMILY THERAPY

 Changes in maladapted behavior can occur without  Psychoanalytically oriented group therapy
insight into the underlying cause  Psychodrama
 Based on learning theory  Family therapy
 Modeling
 Operant conditioning ASSUMPTION OF FAMILY THERAPY
 Self-control therapy – combination of cognitive and  Client: whole family
behavioral approaches “talking to self”  Concepts:
 Systemic desensitization o The family is the most fundamental unit of the
 Aversion therapy society
o Adaptive or maladaptive patterns of behavior are
GESTALT THERAPY learned from the family
 Emphasis on the “here and now” o Dysfunction in the family = dysfunction in the
 Only present behavior can be changed, not history individual
 Uncover repressed feelings and needs  Purpose
 Techniques: have a person behave the opposite of the o Improve relationships among family members
way he/she feels, presuming that a person can then o Promote family function
come in contact with a submerged part of the self; in o Resolve family problems
 Preparations for ECT:
OTHER TYPES OF THERAPIES  Pretreatment evaluation and clearance
 Consent
SUPPORT GROUPS  NPO from midnight until after the treatment
 For those with AIDS, Mother-Against-Drug  Atropine Sulfate – to decrease secretions
Dependence Succinylcholine (Anectine) – to promote muscle
relaxation
SELF-HELP GROUPS Methohexital Sodium (Brevital)- anesthetic
 Alcoholic Anonymous  Empty bladder
 Remove jewelry, hairpins, dentures and other
RULES FOR PSYCHOTHERAPEUTIC accessories
MANAGEMENT  Check vital signs
 Provide support, treat patients with respect and
dignity Care after ECT:
 Do not place patients in situations wherein they will  O2 therapy of 100% until patient can breathe
feel inadequate or embarrassed unassisted
 Treat patients as individuals  Monitor for respiratory problems, gag reflex
 Provide reality testing  Reorient patient
 Handle hostility therapeutically  Observe until stable
 Provide psychopharmacologic treatment  Careful documentation
 Male erectile dysfunction
BEHAVIORAL THERAPIES
TREATMENT MODALITIES OTHER THERAPIES
 Neurosurgery
 Pavlov’s Classical Conditioning: All behaviors are
learned ANXIETY
 B.F. Skinner’s Operational Conditioning:
Reinforcements PEPLAU’S LEVEL OF ANXIETY
 Behavioral Conditioning: substance abuse
 Token Economy: anorexia/schizo MILD
 Systematic Desensitization: phobia  Associated with the tension of day to day living
 Perceptual field increased
ATTITUDE THERAPY  More alert than usual
TREATMENT MODALITIES  Adaptive

1. Paranoid – passive friendliness

2. Withdrawn – active friendliness
3. Depressed/Anorexia – kind firmness
4. Manipulative – matter of fact
5. Assaultive – no demand
6. Anti-social – firm, consistent
PSYCHOSOMATIC THERAPY
TREATMENT MODALITIES
ELECTROCONVULSIVE THERAPY
 Effective in most affective disorders
 The induction of a grandmal seizure in the brain
 Abnormal firing of neurons in the brain causes an
increase in neurotransmitters
 Number of Treatments: 6-12, 3 times a week,
about .5-2 seconds
 Unilateral or bitemporal
Indications:
 Patients who require rapid response
 Patients who cannot tolerate pharmacotherapy or
cannot be exposed to pharmacotherapy
 Patients who are depressed but have not responded to
multiple and adequate trials of medication
MODERATE
 Narrowed perception
 Difficulty focusing
 Selective inattention
 Mild somatic complaints: stomachache and
butterflies in the stomach
INTERVENTIONS FOR MILD TO MODERATE
ANXIETY
 Assist the client in identifying anxiety
 Anticipate anxiety provoking situations
 Use nonverbal language to demonstrate interest
 Encourage the client to talk about his or her feelings
 Avoid closing off avenues of communication
(refraining from offering advice or changing the
topic)
 Encourage problem-solving
 Explore past and present coping behaviors
 Provide outlets for working off excess energy
LEVELS OF ANXIETY
SEVERE  Generalized Anxiety Disorder
 Very narrowed perception  Panic
 Unable to focus on problem solving  Phobia
 Increased physical discomfort  PTSD
 All behavior is aimed at relieving anxiety  Obsessive Compulsive
 Direction is needed to focus attention
GENERALIZED ANXIETY DISORDER
PANIC  Excessive worry and anxiety for days but not more
 Awe, dread and terror than 6 months
 Unable to see the whole situation or reality  Difficulty in controlling the worry
 Distortion of perception  Anxiety and worry are evident by 3 or more of the
 Disorganization of the personality following:
 A frightening and paralyzing experience o Restlessness, keyed up
o Fatigue and irritability
INTERVENTIONS FOR SEVERE AND PANIC LEVELS o Decreased ability to concentrate
OF ANXIETY o Muscle tension
 Maintain a calm manner o Disturbed sleep
 Remain with the person  Anxiety or worry causes significant impairment in
 Minimize environmental stimuli interpersonal relationship or activities of daily living
 Reinforce reality
 Listen for themes in communication POST TRAUMATIC STRESS DISORDER
 Attend to physical safety and medical needs first  Disturbing pattern of behavior occurring after a
 Physical limits may need to be set traumatic event that is outside the range of usual
 Provide opportunities for exercising experience
 Assess the person’s need for mediation or seclusion
Characteristics
ANTI-ANXIETY DRUGS  Persistent re-experiencing of the trauma through
 Valium recurrent intrusive recollections of the event, through
 Librium dreams or flashbacks
 Ativan  Persistent avoidance of the stimuli
 Serax  Feeling of detachment of estrangement from others
 Tranxene  Chemical abuse to relieve anxiety
 Miltown
 Equanil PHOBIAS
 Vistaril
Definition
 Atarax
 Persistent, irrational fear of a specific object, activity
 Inderal
or situation that leads to a desire for avoidance of the
 Xanax
object of fear
 Buspar
Specific Phobia
ANTI-ANXIETY DRUGS
 Experience of high level of anxiety or fear provided
 Used only in a short time (1-2 weeks) by a specific object or situation
 Tolerance (after 7 days) and dependence (after 1
month) Treatment
 Liver function test  Systematic Desensitization
 Monitor side effects
 Avoid machines, activities needing concentration Defense Mechanisms
 Z tract if given parenterally  Repression and displacement
 Avoid mixing with alcohol, antihistamines,
antipsychotics MAJOR TYPES OF PHOBIAS
 Don’t stop abruptly but gradually for 2-6 weeks
 Avoid caffeine AGORAPHOBIA
 Comes from the Greek word “agora”
CATEGORIES OF ANXIETY DISORDERS  Meaning “market place”
 Basic Anxiety Disorders  Fear of being alone in open or public spaces
 Somatoform Disorders
 Dissociative Disorders SOCIAL PHOBIA
 Fear of situations where one might be seen and
BASIC ANXIETY DISORDERS embarrassed or criticized
  True/unconscious because of hormonal and bodily
SPECIFIC PHOBIAS changes
 Fear of a single object, situation or activity that  Increase anxiety may result to asthma, stress ulcers or
cannot be avoided migraine

OBSESSIVE COMPULSIVE DISORDERS SCHIZOPHRENIA

 A major form of psychotic disorder that affects a
OBSESSIONS person’s thinking, language, emotions, social
 Preoccupation with persistent intrusive thoughts, behavior and ability to perceive reality
impulses or images  At least 2 of 5 types of positive and negative
symptoms
COMPULSIONS  Characteristic Symptoms
 Repetitive behaviors or mental acts that the person  Social or occupational dysfunction
feels driven to perform in order to reduce distress or o IPR
prevent a dreaded event or situation o Self-care
 Duration
CUES: o Continuous for at least 6 months
 Ritualistic behavior
 Constant doubting if he/she has performed the POSITIVE AND NEGATIVE SYMPTOMS
activity
POSITIVE SYMPTOMS
EXAMPLE  Hallucinations
OBSESSIONS COMPULSIONS
S  Delusions
Washing or “Wash away my Young woman  Illusions
cleaning sins.” Thought repeatedly washes
 Abnormal thought patterns or perceptions
appeared after sexual hands
 Bizarre behavior
encounter with a
married man
NEGATIVE SYMPTOMS
Need for “Everything must be Arranges and
 Affective flattening
order in place” rearranges items
Germs or “Everything is Avoids touching all  Anhedonia
dirt contaminated” objects. Scrubs  Attention impairment
hands if she is  Asocial behavior
forced to touch any  Anergia
object  Autism
Symmetry “Secretaries who Secretary lines up  Avolition
practice neatness objects in rows on
never gets fired” her desk, then DELUSIONS
realigns them  Persecutory
repeatedly during  Religious
the day  Grandeur
 Ideas of Reference
CARE STRATEGIES
 Be nonjudgmental and honest; offer empathy and DISTURBED THOUGHT PROCESS
support  Looseness of association
 Help patient to recognize the connections between  Flight of ideas
the trauma experience and their current feelings,  Ambivalence
behaviors and problems  Magical thinking
 Encourage verbalizations of feelings, especially anger  Echolalia/Echopraxia
 Encourage adaptive coping strategies and techniques  Word salad
 Encourage patients to establish or reestablish  Neologism
relationships  Thought blocking
 Explore shattered assumptions. “I’m a good person.  Concrete association
This is a safe world”
 Promote discussion of possible meaning of events

BLEULER’S FOUR A’s OF SCHIZOPHRENIA

 Affective disturbances
 Autism
 Associative looseness
PSYCHOSOMATIC DISORDER
  Ambivalence
 Other A’s  Present safety
o Attention deficits  Present reality
o Disturbances of activities
ANTI-PSYCHOTIC
SCHIZOPHRENIA  Tara, look natin sina Stella, Mel, at Thor na nag mo-
 Brief Psychotic Disorder – may be seen when a moulin rogue… sssh, alam niyo ba na ang trio na yan
person exhibits clinical symptoms of illogical na akala mo may halo ay mga closet queens pala…,
thinking, incoherent speech, delusions, or namen”
disorganized behavior after psychological trauma  Taractan, Loxitane, Stelazine, Mellaril, Thorazine,
 Induced Psychotic Disorder – develops in a second Molindone, Seroquel, Serlect, Trilafon, Haloperidol,
person as a result of a close relationship with a person Clozapine, Navane
who has psychosis
 Delusional Psychotic Disorder  Stelazine
 Schizoaffective Disorder – characterized by  Serentil
depression or elation as the psychosis symptoms of  Thorazine
schizophrenia and MDD  Trilafon
 Schizophreniform – when a person exhibits features  Clorazil
of schizophrenia for more than one week but less  Millaril
than 6 months  Haldol
 Risperidol
SUBTYPES:  Prolixin

Paranoid – most common form if the illness ANTI-PSYCHOTIC DRUGS

Suspicious Watch for side-effects
 Promote trust  Increase v/s
 Short interaction but frequent  Constipation/dry mouth
 Food in containers (sealed)  Postural hypotension
 Prepare food in front of them  Photophobia/photosensitivity
 Let them see preparation of drugs  Drowsiness
 Agranulocytosis
Violent  Extrapyramidal symptoms
 Keep door open o Parkinson’s syndrome
 Position near door and with distance of 1 arm length o Akathisia
(patient-nurse) o Akinesia
 Don’t touch o Dystonia – oculogyric crisis, torticollis,
 Maintain eye contact opisthotonos
o Tardive dyskinesia
Disorganized – absence of systematized delusions; presence
o NMS
of incoherence and inappropriate affect
 Inappropriate, flat affect
UNDESIRABLE EFFECTS
 Hebephrenic, flight of ideas
 S-edation/sunlight sensitivity/sleepiness
 T-ardive dyskinesia
Catatonic
 A-nticholinergic/agranulocytosis/akathisia
 Risk for suicide
 N-euroleptic malignant syndrome
 Catatonic stupor, rigidity
 C-ardiac effects (orthostatic hypotension)
 Waxy flexibility
 E-xtrapyramidal (dystonia)

Undifferentiated PARKINSONISM
 Unclassified  Motor retardation or akinesia characterized by mask-
like appearance, rigidity, tremors, “pill-rolling”,
Residual salivation
 No more positive symptoms but withdrawn  Generally occurs after 1st week of treatment or before
second month
NURSING PROCESS  Administer anticholinergic agent, anti-Parkinson
 Disturbed thought process medication (Akineton)
 Disturbed sensory process
AKATHISIA
 Risk for self-directed violence
 Risk for other directed violence
  Constant state of movement, characterized by
restlessness, difficulty sitting still, or strong urges to
move about
 Generally occurs two weeks after treatment begins
 Rule out anxiety or agitation before administration of
an anticholinergic agent
ACUTE DYSTONIC REACTIONS
 Irregular, involuntary spastic muscle movement,
wryneck or torticollis , facial grimacing, abnormal
eye movements, backward rolling of eyes on the
sockets
 May occur anytime from a few minutes to several
hours after a first dose of antipsychotic drug
 Administer anticholinergic agent, have respiratory
support equipment available
TARDIVE DYSKINESIA
 Most frequent serious side effect resulting from
termination of the drug, during reduction in dosage,
or after long term high dose therapy a
 Characterized by involuntary rhythmic, stereotyped
movements, tongue protrusion, cheek puffing,
involuntary movements of extremities and trunk
 Occurs in approximately 2—25% of patients taking
antipsychotics for over two years
 No treatment except discontinuation of the
antipsychotic agent
NEUROLEPTIC MALIGNANT SYNDROME
 A potentially fatal syndrome
 May occur anytime during therapy
 Seen during the initiation of therapy, change of
therapy, after a dosage increase or when a
combination of meds is used
 Early sign: rigidity or mental status changes
 Catatonia, tachycardia, tachypnea, labile blood
pressure, dysphagia, diaphoresis, incontinence,
rigidity, myoclonus, tremors, low grade fevers
 Discontinue antipsychotic agent. Have
cardiopulmonary support available; administer
skeletal muscle relaxant (e.g., dantrolene) or central
acting dopamine agonist (.e.g., bromocriptine)
NOTES ON SCHIZOPHRENIA
 Distorted EGO
 Disturbed thought process
 Disorganized personality
 Dopamine – increase
 Autism
 Ambivalence
 Associative looseness
 Affect – flat
 Stimulation
 Structure
 Socialization
 Support
MANIFESTATIONS
S – social isolation
C – catatonic behavior
H – hallucinations
I – incoherence
Z – zero/lack of interest and initiative
O – obvious failure in development
P – peculiar behavior
H – hygiene and grooming impaired
R – recurrent illusions
E – exacerbations and remissions
N – no organic factor account S/S
I – inability to return to functioning
A – affect is inappropriate
ANTI-PARKINSONIAN DRUGS
DOPAMINERGIC DRUGS
 To live (Levodopa), you need a car (Carbidopa)
and a man (Amantadine) not your brother
(Bromocriptine) per (Pergolide) se (Selegiline)
ANTI-CHOLINERGIC
 BACPAK (Benadryl, Artane, Cogentin, Parsidol,
Akineton, Kemadrin)
OTHER TREATMENTS
 Psychotherapy – individual, group, behavioral,
supportive or family therapy may be used depending
on the clinical symptoms
 Milieu therapy – a structured environment to
minimize environmental and physical stress and to
meet the individual needs of the patients until they
are able to assume responsibility for themselves
CONCEPTS AND PRINCIPLES OF HALLUCINATION
 Possible to replace hallucination with satisfying
interactions
 Can re-learn to focus attention on real things and
people
 Hallucinations originate during extreme emotional
stress when the patient is unable to cope
 Hallucinations are very real to the patient
 Patient will react as the situation is perceived
 Concrete experiences, not argument on confrontation
will correct sensory distortion
 Hallucinations are a substitute for human relations
BIPOLAR DISORDER
MOOD DISORDER/AFFECTIVE DISORDER
 A distinct period of abnormally and persistently
elevated expansive or irritable mood lasting at least 1
week
 3 or more of the following
o Psychomotor overexcitability or excitement
o Insomnia with fatigued
o Euphoria or elated mood
o Distractibility
o Pressured speech
o Flight of ideas
o Manipulative or demanding behavior
 o Destructive or combative behavior
o Delusions of grandeur ANTIDEPRESSANTS
 Risk  Asendin
o Female  Norpramin
o 20 years old and above  Tofranil
o Stressful life  Sinequan
o Obese  Anafranil
 Aventil
o Care giver role strain  Vivactil
 Elavil
 Prozac
 Luvox
 Paxil
 Zoloft

MANIA VS DEPRESSION SSRI

MANIA DEPRESSION  Selective Serotonin Reuptake Inhibitor
Colorful, Sad and gray  Safest
APPEARANCE
flamboyant  Side effects are low
Psychomotor Psychomotor  1 to 4 weeks
BEHAVIOR
agitation retardation  Prozac, Paxil, Zoloft, Luvox
Pressured Monotonous
COMMUNICATIO speech speech TCA
N Stuttering  Tricyclic Antidepressants
Cluttering  2 to 4 weeks
Risk for Injury Risk for Injury
 Anticholinergic
(others) (self)
Nx  Amitriptyline, Nortiptyline, Doxepin Trimipramine,
Suicidal
Amoxapine, Anafranil, Venlafaxine
precaution
NURSING Safety and Safety and
MAOI’s
PRIORITY nutrition nutrition
 Increases all neurotransmitters
Finger foods Increased in
 2 to 6 weeks
NUTRITION and high in nutrients
calories  Hypertensive crisis
Lithium; ECT TCA; SSRI;  Don’t take:
TREATMENT o Avocado
MAOOI’s; ECT
Non- Stimulating o Aged cheese
MILIEU stimulating o Beer/B6 (tyramine)
environment o Chocolate
Quiet type; Monotonous; o Fermented foods
APPROPRIATE o Soy sauce
non- non-
ACTIVITY
competitive competitive o Pickles and preserved foods
Matter of fact Kind firmness;
ATTITUDE
active A. TCA
THERAPY
friendliness “knock! Knock! Who’s there? SEVANA to gagah!” --------
(Sinequam, Elavil, Vivactil, Ascendin, Norpramin,
LITHIUM Aventyl, Tofranil)
 Level of lithium (0.5 to 1.5 meq/L)
 Increase urination (polyuria) B. SSRI
 Tremors – fine hand Ngongo: “Paxil ka! Paxil ka! Prozoleta ka lang, kala ko luv
 Hydration mo ko! (Praxil, Prozac, Zoloft, Luvox)
 Increase peristalsis
 U2 – 4 weeks effective C. MAO
“naman, parnate ko pa” (Nardil, Manerix, Parnate)
 Increased bowel movements
 Mouth is dry
SUICIDE
o Assess function of kidney
 The intentional act of killing oneself
o Toxicity: nausea and vomiting, diarrhea
Suicidal Ideation – means thinking about oneself
 Passive suicidal ideation – when a person thinks
PHARMACOLOGY MOMENTS about wanting to die or wishes he/she were dead but
ANTIDEPRESSANTS has no plans to cause his/her death (e.g., reckless
 driving, heavy smoking, overeating, self-mutilation,
drug abuse)
 Active suicidal ideation – when a person thinks
about and seeks to commit suicide
SAD PERSON’S SCALE
 S-Sex. Mean kill themselves 3x more than women
though women make attempts 3x more often than
men
 A-Age. High risk groups: 19 years or younger; 45
years or older, especially the elderly 65 and above
 D-Depression. Studies report that 35-79% of those
who attempt suicide manifested a depressive
syndrome
 P-Previous Attempts. Of those who commit suicide,
65-70% have made previous attempts
 E-ETOH. Alcohol is associated with up to 65% of
successful suicides
 R-Rational Thinking Loss. People with functional
or organic psychoses are more apt to commit suicide
than those in the general population
 S-Social Support Lacking. A suicidal person often
lacks significant others, meaningful employment and
religious supports
 O-Organized Plan. The presence of a specific plan
for suicide signifies a person at high risk
 N-No Spouse. Repeated studies indicate that persons
who are widowed, separated, divorced or single at
greater risk than those who are married
 S-Sickness. Chronic, debilitating and severe illness is
a risk factor
SCORING
 0-2 home with follow up care
 3-4 close follow up and possible hospitalization
 5-6 strongly consider hospitalization
 7-10 hospitalize
SITUATION:
 Charles Brown, age 52 lost his wife in a car accident
few months ago. Since that time, he has been
severely depressed and has taken to drinking to numb
the pain
 How many points according to the SAD PERSONS
SCALE?
THEORIES OF SUICIDE
PSYCHODYNAMIC THEORIES
 Describe suicide as a wish to be at peace with the
internalized significant person
 Wish to be reunited with a deceased loved object
 Suicide is an attempt to escape from an intolerable
situation or intolerable state of mind
SOCIOLOGICAL THEORIES
 Durkheim – pioneer of sociological research in the
study of suicide
 3 Principal Types:
 Egoistic suicide – occurs when a person is
insufficiently integrated into society
 Anomic suicide – occurs when a person is isolated
from others through abrupt changes in social
norms/status
 Altruistic suicide – occurs as a response to societal
demands (deaths of Buddhist monks who set
themselves on fire to protest the Vietnam war)
BIOCHEMICAL
 Low serotonin levels
PRECIPITATING FACTORS
 Social Isolation – have difficulty forming and
maintaining relationships
Norman Cousins Story:
A woman who committed suicide had written in her
diary every day during the week before her death
“Nobody called today. Nobody called today. Nobody
called today. Nobody called today. Nobody called
today…”
 Severe life’s events – divorce, death, sickness, legal
problems, interpersonal discord
 Sensitivity to Loss – may react tragically to
separation or loss of a loved one (had insecure or
unreliable childhood experiences)
ASSESSING VERBAL AND NONVERBAL CLUES
VERBAL CLUES:
 Overt Statements: “I can’t take it anymore!”; “Life
isn’t worth living anymore.”; “I wish I were dead.”;
“Everyone will be better off if I am dead.”
 Covert Statements: “It’s ok now, soon everything will
be fine”; “Things will never work out.”; “I won’t be a
problem much longer.”; “How can I give my body to
medical science?”
NONVERBAL CLUES
 Behavioral Clues: sudden behavioral changes
especially when depression is lifting and when the
person has more energy available to carry out the
plan
 Signs: giving away prized possessions, writing
farewell notes, making out a will and putting personal
affairs in order
 Somatic Clues: physiological complaints can mask
psychological pain and internalized stress
 Headaches, muscle aches, trouble sleeping, irregular
bowel habits, unusual appetite or weight loss
 Emotional Clues: social withdrawal, feelings of
hopelessness and helplessness, confusion, irritability,
and complaints of exhaustions
SUICIDE PRECAUTIONS
  Execute a “no suicide contract.” The client will o Chooses to be alone
inform the nurse when he/she has suicidal ideations o Lack of sexual experiences
 Ask direct questions. Find out if the person has o Avoids activities
specific plan for suicide. Determine what method o Appears cold and detached
 Be alert for cries for suicide  Interventions: building trust followed by
 Provide a safe environment and protect client from identification and appropriate verbal expression
self
 Encourage to ventilate feelings and thoughts SCHIZOTYPAL PERSONALITY DISORDER
 Give emotional support  A pervasive pattern of social and interpersonal
 Make the patient realize that the tendency to commit deficits marked by acute discomfort with and reduced
suicide is due to the disturbance in the brain capacity for close relationships as well as by
chemistry and is treatable – once they know that an cognitive or perceptual distortions and eccentricities
episode of suicidal thinking will pass, they will likely of behavior
not act on the impulse o Ideas of reference
 Provide structured schedule and involve in activities o Magical thinking or odd beliefs
with others to increase self-worth and divert attention o Unusual perceptual experiences, including bodily
 On discharge: help patient create “plan for Life” (list illusions
of warning signs of suicidal ideation and actions to o Peculiar thinking
take) o Vague, stereotypical, overelaborate speech
Always remember: o Eccentric appearance or behavior
 That a suicidal person wants to crisis – during this o Few close relationships
time the person is ambivalent about living and dying o Uncomfortable in social situations
 Suicidal person gives warning  Interventions: improving interpersonal relationships,
 Persons recovering from depression are high risk for social skills, and appropriate behaviors
9-15 months after recovery
 Suicidal people are extremely unhappy but not ANTI-SOCIAL PERSONALITY DISORDER
always mentally ill  Characterized by deceit, manipulation, revenge and
harm to others with an absence of guilt or anxiety
PERSONALITY BEHAVIORS o Violates rights of others
o Engages in illegal activities
PERSONALITY PROBLEMS o Aggressive behavior
 Schizoid o Lack of guilt or remorse
 Dependent
o Irresponsible in work and with finances
 Antisocial
o Impulsiveness
 Avoidant
o Recklessness
 Histrionic
o Manipulative
 Borderline
 Interventions:
o Consistency
PARANOID PERSONALITY DISORDER
o Kind firmness in confronting behaviors and
 A pervasive pattern of distrust and suspiciousness of
others such that their motives are interpreted as enforcing rules and policies
malevolent o Limit setting
o Suspicious (e.g., others are exploiting or o Decrease impulsivity
deceiving him) o Enhance role performance
o Doubt trustworthiness of others o Effective use of confrontation
o Fear of confiding in others
o Fear personal information will be used against BORDERLINE PERSONALITY DISORDER
him  Characterized by pervasive pattern of unstable
o Interpret remarks as demeaning or threatening interpersonal relationships; self-image and affect; and
o Hold grudges toward others marked impulsivity
o Frantic avoidance of abandonment; real or
o Becomes angry and threatening when they
imagines
perceive to be attacked by ithers
o Unstable and intense interpersonal relationships
 Intervention: centered on building trust
o Identity disturbances
SCHIZOID PERSONALITY DISORDER o Impulsivity
 A pervasive pattern of detachment from social o Self-mutilating behavior
relationships and a restricted range of expression of o Rapid mood shifts
emotions in interpersonal settings o Chronic feelings of emptiness
o Lacks desire for close relationships or friends o Problems with anger
including family o Transient dissociative and paranoid symptoms

OTHER IMPORTANT INFORMATION
 Priority nursing diagnosis: high risk for injury
directed to self-related to self-mutilation behaviors
 Coping mechanisms used: splitting
o Classifying people as either “good” or “bad”
INTERVENTIONS
 Use of empathy
 Recognize the reality of the patient’s pain
 Offer support
 Empower and work with the patient to understand
control and change dysfunctional behaviors
 Provide safe environment
 Teach social skills
 Make a list of solitary activities to combat boredom
NARCISSISTIC PERSONALITY DISORDER
 Grandiose self-importance
 Fantasies of unlimited power, success or brilliance
 Believes he or she is special
 Needs to be admired
 Sense of entitlement
 Takes advantage of others for own benefit
 Lacks empathy
 Envious of others or others are envious of him
 Arrogant
 Interventions:
o Supportive confrontation on what the patient
says and what exists
o Limit setting and consistency to decrease
manipulation and entitlement behaviors
o Remain neutral, avoid power struggles, or
becoming defensive
HISTRIONIC PERSONALITY DISORDER
 A pervasive pattern of excessive emotionality and
attentive seeking
o Overly dramatic
o Draws attention to self
o Extroverted and thrives on being the center of
attraction
o Uses somatic complaints to avid responsibility
and support dependency
o Dissociation
 Interventions: provide reinforcement in the form of
attention, recognition or praise given for unselfish or
other centered behaviors
DEPENDENT PERSONALITY DISORDER
 A pervasive and excessive need to be taken care of
that leads to submissive and clinging behavior and
fears of separation
o Needs others to be responsible for important
areas of life
o Problems with initiating with projects or doing
things on his own because of little self
confidence
o Performs unpleasant tasks to obtain support from
others
o Urgently seeks another relationship for support
and care after a close relationship ends
o Preoccupied with fear of being alone to care for
self
 Interventions: increase responsibility for self in day
to day living; assertiveness training
AVOIDANT PERSONALITY DISORDER
 A pervasive pattern of social inhibition, feelings of
inadequacy and hypersensitivity to negative
evaluation
o Avoids occupations involving interpersonal
contact due to fears of disapproval or rejection
o Preoccupied with being criticized or rejected in
social situations
o Very reluctant to take risks or engage in new
activities due to the possibility of being
embarrassed
OBSESSIVE COMPULSIVE PERSONALITY
DISORDER
 A pervasive pattern of preoccupation with
orderliness, perfectionism and mental and
interpersonal control at the expense of flexibility,
openness and efficiency
o Preoccupied with details, lists, rules,
organization
o Perfectionist
o Too busy working to have friends or leisure
activities
o Unable to discard worthless or worn-out objects
o Reluctant to spend and hoards money
o Rigid and stubborn
DELIRIUM
 Characterized by disturbance of consciousness and a
change in cognition such as impaired attention span
and disturbances in consciousness that develop over a
short period of time
o Always secondary to another condition (medical
condition or substance abuse)
o Frequent among the elderly and young febrile
children
o Fluctuations of consciousness and inoculation
throughout the day
 Classified as mild to severe
 Sundowning
DEMENTIA
 Characterized by multiple cognitive deficits that
include impairment of memory which develops
slowly
o 80-90% irreversible
o Reversible due to pathologic process
o Most common: Alzheimer’s Dementia
 4 Symptoms of Dementia
o Loss of memory
o Deterioration of language function
o Loss of ability to think abstractly, plan, initiate,
sequence, monitor or stop complex behavior
 o Loss of ability to perform ADLs
ALCOHOL
STAGES OF DEMENTIA
ALCOHOLISM
STAGE 1 MILD (FORGETFULNESS)  Intergenerational Transmission
 Losses in short term memory  Awake but unconscious
 Memory aids compensate  Blackout
 Aware of the problem, disturbed  Confabulation
 Not diagnosable at this time  Denial, dependence
 Enabling, co-dependence
STAGE 2 MODERATE (CONFUSION)  Tolerance increases
 Progressive memory loss
 ST memory loss interferes with ADLs  Detoxification – doctor
 Withdrawn, denial, fear of losing their minds
 Depression, confabulation STAGES OF ALCOHOL WITHDRAWAL
 Problems increase when stressed
 Needs home care on in-home assistance 1 → 8 hours after the last drink
 Mild tremors, tachycardia, increased BP, diaphoresis,
STAGE 3 MODERATE TO SEVERE (AMBULATORY nervousness
DEMENTIA)
 Loss of reasoning ability, planning and verbal 2 → 8-12 hours after the last drink
communication  Gross tremors, hyperactivity, profound confusion,
 Frustrated, withdrawn, self-absorbed loss of appetite, insomnia, weakness, disorientation,
 Depression decreases illusions, hallucinations and delusions
 Reduced stress threshold
 Institutional care required 3 → 12-48 hours after the last drink
 Severe hallucinations, grand mal seizures
STAGE 4 LATE (END STAGE)
 Family recognition disappears 4 → 3-4 days after the last drink
 Doesn’t recognize self  Delirium tremens, confusion, agitation,
hallucinations, insomnia and tachycardia
 Nonambulatory
ALCOHOLISM
 Little purposeful activity
 Avoid alcohol during therapy
 Often mute, may scream spontaneously
 Aversion therapy
 Forgets most ADLs
 Antabuse – disulfiram
 Problems associated with immobility
 Belongings – check for alcohol, mouthwash, elixir,
 Institutional care required
etc.
 Return of primitive reflexes
 B1 deficiency
DELIRIUM VS DEMENTIA
 Complication
DELIRIUM DEMENTIA
o Wernicke’s Encephalopathy (Motor)
ONSET Usually sudden Usually gradual
o Korsakoff’s Psychosis (Mind)
Usually brief with Usually long-term and
COURS return to usual progressive,  Delirium Tremens
E level of occasionally maybe  Fornication
functioning arrested or reversed
AGE Any Elderly AUTISM
GROUP  Living in their own world
 Appearance – flat (consistent)
SEXUAL DISORDERS  Behavior – ritualistic, repetitive
 Homosexuality  Communication – echolalia, incomprehensible
 Heterosexuality
 Bisexuality NX: Impaired verbal communication
 Masochism Impaired social interaction
Self-mutilation
 Sadism
Risk for injury
 Frotteurism
 Pedophilia ADHD
 Necrophilia  Attention-deficit/hyperactive disorder
 Voyeurism  7 years old and above
 Transvestism  Duration: 6 months and above
 Transsexualism  Requires 2 settings: home and school
  Parotid gland tenderness, pancreatitis, esophageal and
 Appearance: dirty child gastric erosion or rupture
 Behavior: clumsy, hyperactive, impatient
 Communication: talkative, bursts out Metabolic
 Electrolyte abnormalities → hypokalemia
 Structure
 Setting limits Dental
 Schedule  Erosion of dental enamel of the front teeth
 Safety
OBJECTIVES OF CARE
EATING DISORDERS  Increasing body weight to at least 90% of average
 Anorexia Nervosa weight for age and height
 Bulimia Nervosa  Reestablishing good eating behavior
 Pica  Increasing self-esteem
 Compulsive Eating Behavior

ANOREXIA NERVOSA NURSING INTERVENTIONS

 Monitor daily caloric intake, activity level, weight
Symptoms: and electrolyte status
 Refusal to maintain body weight over a minimum  Establish nutritional eating patterns
normal weight for age and height o Sit with client during meals
 Intense fear of gaining weight or becoming fat, even o Offer liquid protein supplement if unable to
though underweight complete a meal
 Disturbance in the way in which one’s bodyweight, o Observe signs of purging 1-2 hours after meals
shape or size is experienced  Provide accurate information on nutrition and discuss
 In females, absence of menses of at least 3 realistic and healthy diet
consecutive cycles  Help the client identify emotions and develop non-
 Inability or refusal to acknowledge the seriousness of food related strategies
the problem o Convey warmth and sincerity
 Onset: 12-15; 17-21 years of age o Ask the client to identify feelings
o Assist the client to change stereotypical beliefs
Etiology  Assist in identifying at least three positive
 Cultural pressure characteristics
 Serotonin imbalance → controls appetite and the  Teach patient about their illness
satiety control center  Behavior modification: reward increase in weight
 Family patterns with meaningful privileges
o Perfectionist  Identify patient’s non weight related interests to
o Does not permit verbalization of feelings reduce anxiety and refocus attention
o Marital problems
BULIMIA NERVOSA
Clinical Presentation
 Low weight Symptoms
 Amenorrhea  Recurrent episodes of binge eating
 Yellow skin  Feeling of lack of control over eating behaviors
 Cold extremities during the eating binges
 Peripheral edema  Recurrent inappropriate compensatory behavior in
 Muscle weakening order to prevent weight gain, such as self-induced
 Constipation vomiting
 Low T3 and T4  Binge eating and inappropriate eating behaviors
 Hypotension  Persistent over concern with body shape and weight
 Bradycardia
Clinical Presentation
 Hypokalemia
 Binge and purging behaviors
 Anemia
 Have depressive signs and symptoms
 Pancytopenia
 Disturbed home life
 Decreased bone density
 Major concerns
o Interpersonal relationships
SIGNS RELATED TO PURGING BEHAVIORS
o Self-concept
Gastrointestinal o Impulsive behaviors
 Chemical dependence is also common
  Normal to slightly low
 Dental carries
 Parotid swelling
 Gastric swelling and rupture
 Calluses or scars on the hand
 Peripheral edema
 Hypokalemia, hyponatremia

Management:
 Trust
 Help patient identify feelings associated with binge-
purge behaviors
 Accept patient as a worthwhile human being
because they are often ashamed of their behavior
 Encourage patient to discuss positive qualities about
themselves
 Teach about bulimia nervosa
 Encourage to explore interpersonal relationships
 Encourage patients to adhere to meal and snack
schedules
 Encourage the patent to approach the staff if they
feel like binging or purging
 Encourage to attend group sessions
 Encourage family therapy
 Encourage participation in art, recreation and
occupational therapy
 Encourage the patient to describe their body image
at different ages of their lives