€ © LEVEL 4 SEMESTER 2 / © INA2- Lecture Share yy Document Style Maladaptive Patterns of wna |~ Behavior - additional notes Uplosd © Tap * Matt Killingsworth * The MIND * Wandering > 47% * Concentrate on task > 53% Filipinos 90% in a conference or class talks 66% ¥_ wandering about = food/when the conference stops ¥ , sex and others ¥ * Therapeutic Communication * Techniques that facilitate and enhance communication between patient and nurse * Active listening « listening attentively to insure understanding * Broad openings < allow patient to take initiative * Accepting < indicate you heard the patient without judgement © Clarifying < make vague topics clear * Exploring < examine topic deeper * Focusing < putting attention into single topic * Reflecting < direct patient's thoughts and feelings back to patient * Restating < repeat patient's words in a different way to make it clearer— 4 Characteristics of good. * Pre-orientation > how long do you stay first day? > max 20 min * Pre-orientation < Rapport not yet developed, both strangers to each other * Orientation < Contract must be laid out * How long > 10-15 min Working Phase < Re-introduce self; Establish rapport * Can stay with px for 30-40min * Do not allow patient to leave you *Nowhyque © § cmt oat when, what v* Lucid moment < px relate to what you are saying * Termination phase how long > 20 min * Defense Mechanism * Repression ¢ unconscious mechanism employed by the ego to keep disturbing or threatening thoughts from becoming conscious * Repression € during the oedipus complex aggressive thoughts about the same sex parents are repressed * *Electra complex < female identifies/competes with the mother * Denial < blocking external events from awareness. If some situation is just too much to handle, the person just refuses to experience it. * Denial < smokers refuse to admit to themselves that smoking is bad for the health * Projection < attribute own unacceptable thoughts, feelings and motives to another person * Projection < you might hate someone, but your superego tells you that such hatred is unacceptable. You can solve the problem by believing that they hate you * Displacement < satisfying an impulse (e.g. aggression) with a substitute object * Displacement < someone who is frustrated by his or her boss at work may go home and kick the dog * Regression € this is a movement back in psychological time when one is faced with stress * Regression < a child may begin to suck their thumb again or wet the bed when they need to spend some time in the hospital * Sublimation € satisfying an impulse (e.g. aggression) with a substitute object in a socially acceptable way. * Sublimation < sport is an example of putting our emotions (e.g. aggression) into something constructive??? * Factors Affecting Mental lliness * Individual Factors < biologic make up, anxiety, worries and fears, a sense of disharmony in life, and a loss of meaning to one's life * Interpersonal Factor < ineffective communication, excessive dependency or withdrawal from relationships, and loss of emotional control * Social and cultural € lack of resources, violence, homelessness, poverty, discrimination such as racism, classism, ageism, and sexism + 3 Main Types of Temperament * Extrovert < outgoing, talkative, and energetic behavior * Introvert © more reserved and solitary behavior * Ambivert < have both characteristics* Theoretical Frameworks in Psychosocial Nursing * Psychoanalytical/Psychosexual (Sigmund Freud) < intrapsychic process (conflicts, anxiety, defense mechanism, impulses) * Behavioral Framework Focus: Learned Behavior * Paviov's Theory > Classical Conditioning * Skinners Theory > Operant Conditioning * Interpersonal Model (Sullivan and Peplau) < Focus: interpersonal Relationships * Psychosocial Theory (Eric Erickson) < Focus: Psychosocial Task * Existential Theory/Humanistic Model (Rogers) ¢ Focus: Conscious Human Experience * Biomedical Model (Mayer, Kraeplin, Frances) < Focus: Approach, Syndromes, Diagnoses, Etiologies isease ® Related Disorders * Somatoform Disorders < distinguished from other body related mental disorders which intentionally produce symptoms for some purpose or gain * Malingering < Intentional production of false or grossly exaggerated physical or psychological symptoms * Malingering < Is motivated by external incentives such as avoiding work, evading criminal prosecution, obtaining financial compensation, or obtaining drugs * Can stop the physical symptoms as soon as they have gained what they wanted * Factitious Disorder « person intentionally produces/feigns physical or psychological symptoms solely to gain attention * Munchausen syndrome ¢ most common term. * Munchausen syndrome by proxy ¢ occurs when a person inflicts illness or injury on someone else to gain the attention of emergency medical practitioner or to be a hero for saving a vicitm * Main Categorical Disorders * Neurosis € chronic or recurrent disorder characterized mainly by anxiety, which is experienced or expressed directly, or is altered through defense mechanism * Psychosis < loss of reality testing and impairment of mental functioning “manifested by delusions, hallucinations, confusion, and impaired memory” * Schizophrenia * Delusions ¢ exaggerated or distorted thoughts of self and others; or unrealistic belief in ability, knowledge, or ideas © 3main criteria: © certainty < held with absolute conviction* incorrigibility < not changeable by compelling counterargument or proof to the contrary * impossibility or falsity of content < implausible, bizarre or patently untrue * often manifest in consistent themes > persecutory, grandeur, somatic, reference, etc. * Hallucinations < a perception in the absence of external stimulus that has qualities of real perception * Hallucinations ¢ can occur in any sensory modality — auditory, olfactory, gustatory, tactile etc. * Alogia < poverty of speech * Anhedonia « lack of pleasure * Avolition < lack of ability to do tasks or activities that have end goal * Attentional Impairment © Affective Flattening * Basic Psychotropic Medications * psychotropic drugs ¢ Medications used to treat psychiatric disorders * psychotropic drugs < Alter chemical levels in the brain which impact thought, mood, and behavior. * Antiparkinsonisms Anti-depressants Antipsychotics Mood stabilizers Hypnotics-Sedatives * Two types * Ist gen * 2nd gen * How are these medications used to treat mental disorders? * Psychotropics treat the symptoms of mental disorders. * They cannot cure the disorder v , but they make people feel better v_so they can function v * Psychotropics usually work slowly. * Keep in mind the rule: “Start low, Go Slow." * Psychotropics work differently for different people. * Factors that can affect how medications work J * Genetics * diet (given with meals)* Other medications or supplements * Compliance to medications * Antipsychotics ¢ are used to treat schizophrenia or schizophrenia related disorders and mania. * Typical < Can cause extrapyramidal motor disabilities (some of which are quite severe) * Typical « Especially good at reducing the positive symptoms of psychosis (e.g. hallucinations, delusions) * other names > Conventional, traditional, first-generation antipsychotics © Haloperidol (haldol) * Chlorpromazine (thorazine) © Fluphenazine decanoate (Prolixin) * Antipsychotics < can cause side effects related to physical movements (extrapyramidal symptoms, EPS) * Persistent muscle spasms © Rigidity « Restlessness * Involuntary movements © Tremors © Atypical other names > Novel, second to third generation antipsychotics * Atypical < Treat both the positive and negative symptoms of psychosis; also improves cognitive functions * Atypical < Less likely to cause extrapyramidal side effects but some has higher risk for metabolic changes * Risperidone * Olanzapine * Clozapine © Quetiapine * Aripriprazole * Clozapine and Agranulocytosis * Agranulocytosis < a rare condition that occurs when the bone marrow does not make enough neutrophils, the white blaed cells needed to fight infections. * Symptoms * Sudden fever * Sore throat * Sore gums * skin abscess* Chills © mouth ulcers * weakness in the limbs * Lack of Motivation (Avolition) < Individuals with schizophrenia may ‘experience lack of interest in the world around them. They might struggle with initiating and sustaining activities or task. * Inability to Feel Pleasure (Anhedonia) < People with schizophrenia may find it difficult to experience pleasure or joy. Activities that typically bring happiness may no longer evoke positive emotions. * Limited Range of Emotions (Blunted Affect) < A reduced expression of emotions characterizes blunted affect. Facial expressions and emotional responses may appear flat or muted * Social Withdrawal (Asociality) < Individuals may exhibit a lack of interest social interactions. They might avoid socializing, preferring solitude over social events. * Difficulty Speaking (Alogia) < refers to a reduction in speech. People with schizophrenia may have trouble expressing themselves verbally due to disorganized thinking. * *CBC - agranulocytosis WBC Atypical antipsychotics < can cause major weight gain and changes in a person's metabolism. Atypical antipsychotics < may increase the risk of getting diabetes and high cholesterol. * Common Side Effects * Drowsiness/Somnolence ~ Do not give activities that call for alertness * Dizziness when changing positions > Graduated positions, do not tindog gulpi * Rapid heartbeat/ Cardiovascular disturbances > avoidVigorous activity * Blurred vision * Sensitivity to the sun * Skin rashes * Menstrual problems for women > Pregnancy test Disorganized speech or catatonic behavior < defining symptom of schizophrenia Disorganized speech or catatonic behavior « Unpredictable or inappropriate emotional responses Disorganized speech or catatonic behavior < lack of inhibition and impulse control Disorganized speech or catatonic behavior < bizarre or purposeless behavior* disorganized behavior is not goal driven intend to behave a certain way v e., the person does * incoherent and incomprehensible speech often results in > severely impaired communication * Duration > 6 months to present * Nursing Diagnosis for Schizophrenia and Thought Disorders J * Acute Confusion * Altered Nutrition less than body requirements * Anxiety * Altered Thought processes * Chronic Confusion * Decisional Conflict * Diversional Activity Deficit * Impaired Social Interaction * Impaired verbal communication * Ineffective individual coping * Mood * APERSON MAY OCCASIONALLY feel * sad * low * anergia * tired * exhaustion * noise intolerance * slowed thinking process « makes decision making difficult * LOW PERIODS * agitation * DEPRESSED + THE OTHER END OF THE SPECTRUM. * exaggeratedly energetic behavior * "on top of the world" * EUTHYMIC MOOD * SO SO..., px is still functional, can still do problem solving * These mood alterations are NORMAL ¥ and do not interfere meaningfully » with the person's life. + Mood/Affective Disorders < are pervasive alterations in emotions that are manifested by depression, mania, or both* Mood/Affective Disorders < Most common psychiatric diagnoses associated with SUICIDE; depression is one of the risk factors for it (Suddak, 2005) * Mood/Affective Disorders < Interferes with a person's life, plaguing him or her with drastic and long term sadness, agitation, or elation. * 1950's < no treatment was available to help people with serious depression or mania. * Effective treatments for both depression and mania are now available. * Mood/Affective Disorders < involves disturbance in emotion and behavior * Mood/Affective Disorders < Criterion: once problem mood is ‘exaggerated, prolonged or interfere with normal functioning. * *grief < is a normal response to a loss that can last from 3 months to 3 years * maladaptive response v_and loss of self esteem v can lead to mood disorders. * Major Depressive Disorders ¢ Must be present everyday for 2_ weeks and result in significant distress or impair social, occupational or other important areas of functioning (APA, 2000). © Lasts atleast > 2 weeks * Major Depressive Disorder is characterized by 1 * depressed mood * loss of pleasure in nearly all activities * Symptoms ¥ * changes in appetite and weight, sleep or psychomotor activity « Feelings of worthlessness or guilt © Difficulty thinking, concentrating, or making decisions « Recurrent thoughts of death or suicidal ideation, plans, or attempts * psychotic depression < Some people have delusions and hallucinations, the combination referred to as.. * Dysthymia « Characterized by 2 years of depressed mood, with accompanying symptoms that are not severe than that of major depression * Bipolar Disorder < is diagnosed when a person's mood cycles between extremes of mania and depression * Mania < a distinct period during which mood is abnormally and persistently elevated, expansive, or irritable. * last about 1 week ¥ (unless the person is hospitalized ¥ or treated sooner v ), may be longer individuals.esteem or grandiosity, decreased need for sleep * Pressured speech < unrelenting, rapid, often loud talking without pauses * Flight of ideas € racing, often unconnected thoughts © Flight of ideas < distractibility, increased involvement in goal-directed activity or psychomotor agitation * Flight of ideas € excessive involvement in pleasure seeking activities with a high potential for painful consequences (APA, 2000) * Hypomania < period of abnormally and persistently elevated, expansive, or irritable mood lasting 4 days * Mixed episode is diagnosed when person experiences both mania and depression nearly everyday for at least 1 week > rapid cycling * Description of Bipolar Disorders for Medical Diagnosis: * Bipolar I disorder < One or more manic or mixed episodes usually accompanied by major depressive episodes. * Bipolar Il disorder « One or more major depressive episodes accompanied by at least | hypomanic episodes. * Causes of Depressive Disorders * Psychobiologic theory < Various chemical and genetic factors are related to mood disorders. * Mania © can be viewed as a reaction formation to. underlying depression * Depression < anger turned inward (Psychoanalytic Theory of Freud) * Behavioral Theory ¢ depression results as a response to negative life event * Cognitive Theory < depression is a result of a negative view of self in the world * Signs & Symptoms J * Sadness * Anhedonia (lack of sexual drive) * Weight changes * Sleep pattern disturbances * Psychomotor retardation * Anergia/fatigue Feeling of worthlessness, hopelessness Impaired concentration No talk/limited talk* Suicidal ideation * Selective serotonin re-uptake inhibitors (SSRI) < the most commonly prescribed; antidepressants; can ease symptoms of moderate to severe depression. * Fluoxetine * Sertraline * Escitalopram * Nursing Management * Accepting» and non judgmental » attitude * Reinforce decision making by patients * Never reinforce hallucinations ¥ or delusions ¥ * Involve activities which they can experience success * Spend time with withdrawn patients * Make decisions for patients who are not ready to make decisions for themselves * Administer antidepressants as ordered * Bipolar Disorders © Manic * Onset > Before Age 30 * Mood 4 * Elevated * Expansive * Irritable * Speech: Loud-Rapid, Punning, Rhyming, Clanging, Vulgar * Characteristics 4 * Grandiose * Inappropriate * Delusions Distracted Decreased Need For Sleep Hyperactive Flight of Ideas * Begins suddenly escalates over several days * Depressive < Previous Manic Episodes * Mood + * Dysphoric * Depressive * DespairingCharacteristics 1 * Mania Decreased Interest in Pleasure Decreased appetite Decreased libido Insomnia Constipation Suicidal preoccupation Negative views Fatigue May be agitated or have movement retardation * Types: * Mild Elation/Hypomanic + Feeling of happiness Increased motor activity Increased sexual drives Rapid association of ideas Superficial relationships © *Stimulate salivation > gum * Acute Manic Episode Mood disturbance/tendency to argue Motor restlessness Indulgence in sex and sexual activities, poor money mgmt. Flight of ideas, delusion of grandeur Poor sleep/poor hygiene * Antidepressants < are generally used to treat the symptoms of major depressive disorder. * Common Side Effects * Nervousness, agitation or restlessness © Dizziness erectile dysfunction « Reduced sexual desire or difficulty reaching orgasm or inability to maintain an erection * Drowsiness * Insomnia oMi Weight gain or loss Headache ilizer © Lithium carbonate * Common Side Effects* Mild * Vomiting Gl problems * Dry mouth © Dizziness Slurred speech * Lethargy or excitement * Muscle weakness * Moderate © Persistent of mild symptoms * Anorexia Chronic limb movements Hyperactive deep tendon reflexes Muscle fasciculation Blurred vision * Severe * Convulsions * Syncope * Stupor to coma * Delirium * Death * Oliguria and renal failure * Circulatory failure * Valproate Na * Common Side Effects © Diarrhea * Dizziness/Drowsiness * Unsteadiness * Hair Loss * Blurred/Double Vision * Change in Menstrual Periods * Ringing In The Ears * Shakiness (Tremor) * Weight Changes * Carbamazepine * Common Side Effects * Dosage-Related * Gastrointestinal (GI) disturbances* Blurred or double vision * Vertigo * Task performance impairment * Idiosyncratic * Hepatic Failure * Agranulocytosis Aplastic Anemia Rash Steven-Johnson syndrome * Warning! Pregnancy and Lactation * Carbamazepine 4 * craniofacial abnormalities * fingernail hypoplasia * spina bifida * Valproate Na > neural tube defects * Lithium cardiovascular abnormalities (most commonly Ebstein's anomaly of the tricuspid valves) * *Pregnant women should not use these medications unless absolutely necessary (carbamazepine v , valproate Nav , Lithium v ). All women with childbearing potential should take 1_ to 4 mg of folic acid daily. * Lithium Salts * Anti-convulsant 4 * Lamotrigine * Valproate Na * Carbamazepine * Neuroleptics / * Quetiapine * Olanzapine * Risperidone * Nursing Diagnosis 4 Potential for injury Potential for injury: Self Directed or Directed at Others Altered Nutrition Less than Body Requirements Impaired Social Interactions Sleep Pattern Disturbance * Nursing Management * Reduce environmental stimuli v /assign to quiet environment v / remove hazardous objects and substances© Limit group activities © Stay v with the patient/have sufficient staff v available * Provide constructive v_activities/provide nursing measures to promote sleep ¥ /no caffeine drinks ¥ * Provide food with high protein v , high caloric v © Set limits on the manipulative behavior v /do not argue v * Antimanic ¥ drugs as ordered. LiC03 v eg. Eskalith v , Lithobid ™Y , Lithonate v , Lithotabs v , Lithane_ * Nursing Management for Antimanic Drugs © Drowsiness, dizziness, headache > do not involve patient in activities that requires alertness * Dry mouth > sugarless candy, oral hygiene, increase fluid intake © GlUpset/N&V > administer with meals © hypotension, pulse irregularities, arrhythmias > monitor v/s * Polyuria and DHN > MIO and weigh patient daily, monitor skin turgor daily © Patient/Family Education about LiCO3 * Take medication as ordered * Avoid excessive use of beverages containing caffeine * Notify MD if vomiting or diarrhea occurs * Don't skip on dietary Na intake * Drink 6 to 8 glass of water per day * Important points in LiCO3 intake * LiCO3 is started with 300mg v TID y in7 days ¥ * Blood level is checked 12 hours v after last dose, then: every week v for the 1st month v , then, every 3 - 6 months v * Therapeutic Level: * Adult > 0.6 - 1.4 mEq/L. * Elderly > 0.6 - 0.8 mEq/L * Adverse Reactions: Lithium Toxicity (equal to or greater than 2.0 EqiL) Anorexia NIV Diarrhea Drowsiness Coarse hand tremor Lethargy Tinnitus Vertigo* Lithium Intoxication (equal to or greater than 2.5mEq/L) * Decrease urine output * Decrease BP * Death * Impaired consciousness * Irregular pulse * Coma * ECG changes * Fever * Seizure * Mood Disorder < emotions are derailed for an extended period of time * Main Types: * Bipolar | < alternating manic + depressive episodes * Bipolar Il < alternating hypomanic + depressive episodes (hypomania = mild mania) * Cyclothymia < alternating hypomanic + mild depressive episodes * Unipolar Depression ¢ single or recurrent episodes with no mania * Dysthymia € chronic, low-grade depression * Suicide Precautions * Secure Room: * Windows locked © break proof glass and mirrors * plastic flatware * Now * cord phone * curtains * extension * equipment * matches or cigarettes * belts * sharps/razors © Pt Care frequent observation (possibly 1 to 1) staff communication develop therapeutic relationship written behavior contract to patient© restraints as ordered * medications as ordered * monitor and restrict visitors * High risk for suicide * past history of suicide * having a plan to commit suicide * Gender > male * Civil Status > single due to poor coping skill than married * Age > elderly * Occupation - lawyers, law enforcement * Risk for Suicide 1 Id age group * Sex (male) * Age (Generation) > Gen Y andZ * Depression * Psychiatric care * Excessive drug usage * Rational thinking is absent * Single * Organized attempt * No support © States future intent + Types of Bullying * Physical * Verbal € calling names * Social exclusion * Spreading rumors * Cyber © nasty remarks on twitter and fb * Racist < belonging to religious minority * sexual < touching private parts © *Anti Bullying Act of 2013 ¢ TREAT bullies and parents = those abused at home © Child Suicide < Act by which child voluntarily brings about his death * Suicidal Ideation € Not simply a wish to die, but may just be a means of escaping * Suicidal Gestures < a person's non lethal self injury acts * Suicidal Threats < a person's statements that may declare intent to commit suicide * Suicidal Attempt < actual implementation of a self injurious act with the expressed purpose of ending the person's life.* Common Expressions of Suicidal Individuals * I cant put up with this mess any longer Failure in an area of great investments An attempt to control * "everyone would be better even without me" © to gain respect Fantasy of getting a new start in life An attempt to make up for something wrong. * “I can't stand the pain any longer.” © Suicide viewed as getting even. * Joining a loved one in heaven * Nursing Diagnosis 1 * High Risk for Self Directed Violence * Altered Thought Process * Altered Nutrition Less than Body Requirements © Self-Esteem Disturbance * Nursing Management * Assess for J « intent to kill oneself * availability of means * lethality of means * Encourage ventilation of feelings v_and talk about his stressors * Maintain suicide precaution at all times. * Promote safety. * Listen emphatically. * Assist in problem solving. © Reinforce his desire to solve problems. * Teach members about warning signs. * Anti depressant as ordered.