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
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 ● Frontal lobe - control organization of thought, body
movement, memories, emotions and moral behavior. Increase v/s Decrease v/s
o Associated with schizophrenia, attention deficit/
hyperactive disorder and dementia Decrease GI motility Increase GI motility
● Parietal lobe - interpret sensations of taste and touch
Decrease GU function
and assist is spatial orientation. Increase GU function
- urinary retention
● Temporal lobes - are centers for the sense of smell,
hearing, memory, and expression of emotions. Moist mouth Dry mouth
● Occipital lobes - assist in coordinating language
generation and visual interpretation, such as depth Genetics and Hereditary
perception.
● Alzheimer's disease - linked with defects in
Neurotransmitters ● chromosomes 14 and 21
● Biochemical theories say that neurotransmitters have
● Schizophrenia
an effect to the mental processes, behavior, cognition,
and thoughts of a patient ● Mood disorders (depression)
● Dopamine - controls complex movements,
● Autism and AD/HD
motivation, cognition, regulates emotional responses
o If low, it will cause tremors
SIGMUND FREUD
o If increased, there is a possibility to have
increased cognition, to the point you are not ● Father of Psychoanalysis
intact with reality. A patient may become
delusional: fixed problems in thoughts and ● “Your behavior today is directly or indirectly affected
cognition (Schizophrenia) by your childhood days or experiences.”
o Do not contradict the delusion of your o Repression a defense mechanism wherein
patient because it is a fixed belief and it may there is unconscious forgetting
cause anxiety ● STRUCTURE – Personality Structure
o Present reality by giving instructions to
activities that will revert them back to reality
o Do not argue but do not tolerate it, just keep Personality Structure
on mind to ignore the delusion and divert the
ID (4-5MONTHS)
delusion to reality
● Impulsive/ Instinctual drive
● Serotonin - regulation of emotions, controls food
intake, sleep and wakefulness, pain control, sexual ● I want to... PLEASURE PRINCIPLE
behaviors
o Problems in this neurotransmitter may be ● I want to... PHYSIOLOGIC NEEDS
found in depression, anorexic, bulimic
● I want to... PRIMARY PROCESS
patients
● Acetylcholine - controls sleep and wakefulness cycle ● All about I, me, and myself
(decreased in Alzheimer's) SUPEREGO
● Histamine - controls alertness, peripheral allergic ● Should not
reactions, cardiac stimulations ● Small voice of GOD
● GABA - modulates other neurotransmitters
● Set norms, standards, and values
o Modulates norepinephrine and epinephrine
o When patient is having panic anxiety there is ● MORAL PRINCIPLE
a problem with epinephrine
● Conscience
● Norepinephrine / Epinephrine - causes changes in
attention, learning and memory, mood ● Contradicts ID
EGO
Sympathetic Parasympathetic ● Executive
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 ● REALITY PRINCIPLE

● Conscious

● Competencies ● Hallucinations are sensations that seem to be real but

is only created in the mind
● Decision Maker; Problem-Solving; Critical and
Creative thinking ● Hallucination vs illusion
o Both these involve the senses, it only differs
● Balances ID and superego
in cognition
● Once this is fully developed, you are now intact to o Hallucination has no stimulus but can sense
something
reality
o Illusions have stimulus but is interpreted
wrongly
Imbalances between Personality Elements
Libido
● Sexual energy responsible for survival of human
beings
● Psychosexual Theory of Freud

ORAL STAGE
● 18 months
● Manic- usually seen in a bipolar patient. Patient
experiences hyperactivity ● Cry, suck, mouth
o Extreme exaggerated behaviors ● EGO at 6 months
● Antisocial personality disorder- personality problems
● Child cries - fed - successful
in interpersonal relationships
● Child cries – ignored - unimportant - narcissistic

FIXATION
● Occurs when a person is stuck in a certain
developmental stage

REGRESSION
● Returning to an earlier developmental stage
● Narcissistic- there is illusion of grandiosity ● Infantile behavior
● These are people who are strict law followers
ANAL STAGE
● Obsessive compulsive disorder- recurring, unwanted ● 18 months 3 years old
thoughts, ideas or sensations that make them feel
driven to do something repetitively ● SUPEREGO develops
o Those with ritualistic behaviors
o Do not try to contradict because it will only ● Toilet training
increase their anxiety, because that is their o Good Mother - Normal
coping mechanism o Bad Mother
o Do not abruptly stop it, but give schedules ▪ Clean, organized, obedient - OC (anal
for those ritualistic behavior
retentive)
● Obsessive compulsive personality disorder- are those
▪ Dirty, disorganized - Anti-social (anal
who are perfectionists
o They are perfectionists because they know expulsive)
that being unorganized is not acceptable to
the society PHALLIC STAGE

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 o Diverting sexual urges to activities that are
● Preschooler (3 6 years old)
acceptable to the society
● Parent
SUBSTITUTION
o Oedipus Complex
● Replace a goal that can't be achieved for another that
▪ Castration Fear
is more realistic.
o Electra Complex
o Unachievable to achievable
▪ Penis Envy
GENITAL STAGE
▪ Daughter to father
● 12 years old and above
REPRESSION ● Developing satisfying sexual and emotional
● UNCONSCIOUS forgetting of an anxiety provoking relationships with members of the opposite sex
concept ● Planning life's goals
● 80% of rape victims go into repression
EGO DEFENSE MECHANISMS
● There is a possibility that memories will go back
once a person undergoes psychoanalysis or because Function - To ward off anxiety
of triggers * without defense mechanisms, anxiety might overwhelm and
paralyze us and interfere with daily living
SUPRESSION
2 Features:
● CONSCIOUS forgetting of an anxiety provoking 1.1. they operate on an unconscious level (Except suppression)
situation 2. 2. they deny, falsify or distort reality to make it less
threatening
IDENTIFICATION
● Attempts to resemble or pattern the personality of a REPRESSION VS. SUPPRESSION
person being admired of REPRESSION
o Idolizing a person and copying them
(behaviors, attitudes, physical appearance) ● Unconscious forgetting of an anxiety provoking
concept
INTROJECTION
● Acceptance of another values and opinion as one's SUPRESSION
own ● Conscious forgetting of an anxiety provoking
● Thoughts and opinions of other people are taken as situation
own REGRESSION VS. FIXATION
● Claiming of other people’s stories
REGRESSION
LATENCY STAGGE ● Returning to an earlier developmental stage
● 6 to 12 years old o Inappropriate behavior during anxiety
o E.g. tantrums of an adult
● School
● Infantile behavior
● Reading, writing, arithmetic FIXATION
● Ability to care about and relate to others outside ● Occurs when a person is stuck in a certain
home developmental stage
o A stage is not satisfied
SUBLIMATION o Satisfaction of the stage is done by a person
e.g. smoking
● Placing sexual energies toward more productive
o This is different from regression and
activities mannerisms
o Unacceptable to acceptable behaviors to the
society RATIONALIZATION VS. INTELLECTUALIZATION
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RATIONALIZATION
● Self-saving with incorrect illogical explanation
o Reasoning out even with the wrong reasons
INTELLECTUALIZATION
● Excessive use of abstract thinking; technical
explanation
o Excessive rationalization
o Possibly correct but not necessary to the
current situation
o Focusing on situations that is not really the
problem
DISPLACEMENT VS. PROJECTION VS.
INTROJECTION
DISPLACEMENT
● Feelings are transferred or redirect to another person
or object that is less threatening
● Keyword: anger or feelings
● Anger redirection
PROJECTION
● Blaming; Falsely attributing to another his/her own
unacceptable feelings.
o This can be seen in paranoid patients
o “Takot sa sarili nilang multo”
o A person unconsciously transfers his/her
own negative behavior to others
o The person is aware that he/she possesses
that behavior but subconsciously blames
others for it
INTROJECTION
● Acceptance of another's values and opinions as one’s
own
● Separating and detaching idea, situation from its
emotional significance.
o Detaching from the self temporarily d/t
anxiety
ISOLATION
● Individual strips emotion when talking or responding
about it.
EGO DEFENSE MECHANISMS
Conversion
● Anxiety converted to physical symptoms
o E.g. stress is converted to headache
Compensation
● Overachievement in one area to Overpower
weaknesses or defective area.
o There should be presence of weakness,
limitation, or insecurity that will be covered
up by other achievements
Undoing
● Doing the opposite of what have done
o Trying to compensate for the wrong a person
has done
o E.g. a guy hurt a woman and then gave her
flowers after
o Restitution- you do something wrong to a
person but compensate by doing good to
people who are involved to the person
Denial
● Failure to acknowledge an unacceptable trait or
situation
● Alcoholic patients commonly use this defense
mechanism

SUBLIMATION VS. SUBSTITUTION Fantasy

● Magical thinking
SUBLIMATION
● Transfer of sexual energy to a more productive Reaction Formation
activity. ● Opposite of intention
o Unacceptable behavior to acceptable
behavior to the society
Acting out
SUBSTITUTION ● Deals with emotional conflict or stressors by
● Replaces a goal that can't be achieved for another that ACTION rather than reflection or feelings
is more realistic.
Symbolization
DISSOCIATION VS. ISOLATION ● Creates a representation to an anxiety provoking
thing or concept
DISSOCIATION
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Splitting
● “I didn't get the raise because my boss doesn't like
● Labile emotions; all bad - all good me."

DEFENSE MECHANISMS COMMONLY USED IN

● Five-year old girl dresses in her mother's shoes and
EACH RESPECTIVE DISORDERS
dress and meets daddy at the door.
● Paranoid - Projection

● Phobia - Displacement ● After his wife's death, husband has transient

complaints of chest pain and difficulty breathing- the
● Amnesia - Dissociation
symptoms his wife had before she died
● Anorexia - Suppression
● Man forgets wife's birthday after a marital fight.
● Bipolar Disorder - Reaction Formation

● Borderline - Splitting
● Businessman who is preparing to make an important
● Schizophrenia - Regression speech that day is told by his wife that morning that
she wants a divorce. Although visibly upset, he puts
● Substance Abuse-Denial this incident aside until after his speech, when he can
give the matter his total concentration.
● Depression - Introjection

● OC - Undoing ● A man cannot accept his physician's diagnosis of

● Catatonic - Repression cancer is correct and seeking a second opinion

● slamming a door instead of hitting as person, yelling

● Woman who is angry with her boss writes a short
at your spouse after an argument with your boss
story about a heroic woman.

● focusing on the details of a funeral as opposed to the

● Four-year old with new baby brother starts sucking
sadness and grief
his thumb and wanting a bottle.

● stating that you were fired because you didn't kiss up

● Patient criticizes the nurse after her family failed to
the boss, when the real reason was your poor
visit performance

● Man who is unconsciously attracted to other women ● having a bias against a particular race or culture and
teases his wife about flirting then embracing that race or culture to the extreme

● 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.”
● 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

● Student is unable to take a final exam because of a

Therapeutic Communication
terrible headache.
● After flirting with her male secretary, a woman ● Non-verbal cues are more accurate than verbal cues
brings her husband tickets to a show. o Reaction formation may be seen in these
situations
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 ● Therapeutic communication is important because it ● Continuous, dynamic process of SENDING and
can affect the progress of the patient RECEIVING MESSAGES by various verbal or non-
verbal means (words, signals, signs, symbols) utilized
● Always assert and affirm authority
in a goal- directed professional framework.
o The healthcare provider should be followed
● Offering self
and not the patient
o Offering safety, service, comfort
● For paranoid patients, always position in front of the
o “I’ll sit beside you”
patient but should have a space in between o “Do you need help?”
o Because standing on the sides may pose as a
o You want to tell the patient that you want to
threat to the patient
provide care
o Being too close or too far may also present
o Very helpful for depressed patients, this
as a threat to the patient
shows that people care for them
o Paranoid patients are hypervigilant
o E.g. Ursula, age 25, is found on the floor of
● Reality orientation the bathroom in the day treatment cleaning
o Alcoholic patients who are already in with moderate lacerations to both wrists.
Surrounded by broken glass, she sits staring
withdrawal may experience formication
blank at her bleeding wrist while staff
o Sensation that resembles that of small
members call for an ambulance. The best
insects crawling on (or under) the skin when
way the nurse should do is to approach
there is nothing there.
Ursula slowly while speaking in the calm
o Acknowledge what the patient feels
voice, calling her name and telling her that
(because they are not inventing things) to
the nurse is here to help her. This approach
reduce anxiety, explain that you understand
provides reassurance for a patient in distress
how the patients feel but don’t forget to
present the reality to the patient 3 LEVELS OF PSYCHIATRIC NURSING (Levels of
o Divert the attention to a realistic Health)
environment
Primary
● General leads
o Broad opening statements, leave the ● Objective: PROMOTION & PREVENTION
direction of the conversation to the patient
o Used when patients have difficulty in ● Client and Family Teaching (Health Teaching)
expressing or verbalizing thoughts and ● No existing illness yet
feelings
o Schizophrenic patients are disorganized, Secondary
general leads may be helpful
o May also be used in geriatric patients ● Screening, Diagnosis, and Immediate Treatment
● Silence
● Screening
o If you remain silent when a patient is talking
o Denver Development Screening Test
it indicates that you are listening
o A sign of respect to the person speaking (DDST) #1 test for PDD
o Best therapeutic communication used for Tertiary
paranoid patients, to be able to establish
trust ● Rehabilitation
o May help develop rapport

Therapeutic communication
Four phases of nurse- client relationship (NCR)

Pre-interaction/Pre-orientation (For the Nurse)

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 ● Stage of Self-Awareness 🡪 To prevent Counter ● NCP is on going
Transference ● Identification of the problem/exploration
● #1 CORE VALUE OF Psychiatric Nursing
● The #1 Psychiatric Core Value is Consistency 🡪 For
AIM: PLAN THE RELATIONSHIP
manipulative patients
● Upon admission, discharge instruction plan should ● Be consistent to patient with: BAAAM COPS
already be formulated
o You already know the chief complaint B orderline C onduct d/o
(existing problems)
A ntisocial O ral/eating disorder
o To not neglect other problems that will come
out during the working phase A lzheimer’s P aranoid
A utistic S uicidal
Orientation (initiation)
● Use therapeutic and problem- solving techniques
● Assessment of problems, needs, expectations of
o Maintain professional, therapeutic relationship
clients o Keep interaction reality- oriented- here and now
● Identify anxiety level of self and client o Provide active listening and reflection of feelings
o Use non- verbal communication to support client
● Set goals of relationship. o Recognize blocks to communication and work to
remove them
● Define responsibilities of nurse and client. Stage of
● FOCUS on client’s:
testing.
o Confronting and working through identified
● Establish boundaries of relationship. Stress problems
confidentiality. o Problems- solving skills
o Increasing independence
● Contract – 2 famous psychiatric contracts: o Help client develop alternative, adaptive coping
mechanisms
o 1. No suicide contract 🡪 Major depression o Personal biases (manifestation by counter-
= emergency transference & vice versa) are seen during
working phase
o TWO definitions of no suicide contract:

o 24 hours monitoring
Termination
o Verbalization to the nurse of all suicide
ideas ● Plan for termination of relationship early the
relationship
● Diet contract 🡪 Eating disorder
● Stage of Separation Anxiety 🡪 Signs & symptoms:
Regression: Temper tantrums, thumb sucking,
● The start of termination phase: “Good morning,
apathy, fetal position when crying
full name, RN, shift, session, date start & end.”
● Phase of prognosis 🡪 Evaluation

● Maintain boundaries
Working phase
● Anticipate problems of termination:
● Promote acceptance of each other o Increased dependency on the nurse
o Recall of previous negative experience-
o Accept client as having value and worth as a rejection, depression, abandonment, etc.
unique individual. o Regressive behaviors
o Stage of resistance o Emphasize to the patient that a discharge
instruction has been made which would help
● Counter transference phase his/ her progression
o Discharge plan is discussed in this phase
● Most difficult phase
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 ● Discuss client’s feelings and objectives achieved
Levels of awareness
● Conscious- you can immediately answer or remember
because this is still in your memory
o Composed of past experiences, logical
and governed by REALITY
PRINCIPLE; are remembered and easily
recalled or available to the individual
Mental status examination
● Subconscious- information or memory where you
need to exert effort in order to remember
o the Preconscious; composed of material that
has been deliberately pushed out of
conscious level; helps repress
unpleasant thoughts or feelings and can
examine or censor certain desires or
thinking; can be recalled with some effort
● Unconscious- memories or information that are
already repressed
o Composed of the LARGEST BODY OF
MATERIAL- the thoughts, memories and
feelings that are repressed and not available
to the conscious mind, not logical and
governed by PLEASURE PRINCIPLE –
and since it is usually painful and
unacceptable to the individual, it cannot
be deliberately brought back into awareness
unless in disguised or distorted form
(dreams)
o Information cannot be totally remembered
o Largest storage among the three
Additional notes
● Exploration is a sign of suicide
o They are giving their belongings to other
people
● If a patient has suicidal ideations, do you confront or
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
● 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)
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 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
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 ▪ 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
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 ● 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
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
are 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)
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 o Aversion Therapy/Aversion Technique o Increases reality- testing opportunities
o Gives info on how one’s personality and
BEHAVIORAL TREATMENTS behavior appear to others
1. Desensitization – gradual exposure to the feared 4. With opportunities for practicing alternative
object behaviors and methods of coping with feelings
o #1 treatment for phobia 5. Provides attention to reality and provides
2. Flooding/Implosive Therapy – sudden exposure development of insight into one’s problems by
3. Relaxation Technique – light stroking = labor expressing own experiences and listening to others in
o Purse Lip Breathing Exercise = COPD/CAL groups
(Chronic Airflow Limitation)
4. Biofeedback – mind over matter. Ex. HPN > ↓BP,
palpitations, headache
5. Guided Imagery (Child) & Visualization (Adult
PRINCIPLES OF GROUP THERAPY
Group therapy 1. Verbalization: Members express feelings and group
reinforces appropriate communication.
● Psychotherapeutic processes that occur in formally Desired outcome of group therapy includes
verbalization of feelings rather than acting them out
organized groups designed to change maladaptive or
2. Activity: Provides stimuli to verbalization and
undesirable behavior.
expression of feelings.
● Knowledge of therapeutic modalities enhances the 3. Support: Members gain support from one another
performance of nursing interventions during therapy. through interaction, sharing and communication.
8-10 patients are the optimal number of patients in a 4. Change: Members have opportunity to try out new
group. and desirable behaviors in group, supportive setting
to effect change.
● There should be 8-10 members only
PHASES OF GROUP THERAPY
● Maximum of 10, no longer therapeutic if too many
1. Initial Phase
● All members should have or experience the same ● Formation of group
problem
● Setting and clarification of goals and expectations
● Done during rehabilitation in order to gain other
coping mechanisms of other patients who have ● Initial meeting, acquaintance and interaction
overcome the problems
2. Working Phase

TYPES OF GROUPS ● Confrontation between members→ Cohesiveness

1. Structured
● Identification of problems→ Problem- solving
o Goals: Pre-determined
o Format: Clear and specific processes
o Factual material: Presented ● In a group therapy when one client says to another,
o Leader: Retains control “Maybe you’re taking on someone else’s problems.”
2. Unstructured this shows that they are in the working phase
o Goals: Not pre-determined.
Responsibility for goal is shared by group and 3. Termination Phase
leader
o Format: Discussion flows according to group ● Evaluation of goals attainment
members’ concern ● Support for leave- taking
o Materials and topics are not pre-elected.
o Leader: Nondirective ● In group therapy if a client says, “Leave me alone &
o Emphasis: More on FEELINGS rather than facts get away from me.”, best action of the RN is to
maintain distance from the pt.
ADVANTAGE OF GROUP THERAPHY
1. Economical: Less staff used. ● Behavior indicating that goal is met after
2. Increased feelings of closeness > Reduction on socialization in a group therapy includes participation
feelings of being alone. of each group member telling the leader about
3. With feedback group > specific problems
o Corrects distortions of problems
o Builds self- image and self- confidence
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Milieu therapy

● Milieu therapy or environmental therapy

o If a patient is having a religious delusion
remove images of saints, or smokes, because
Stages of grief
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
● 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."
14
 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
Additional notes
● 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
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 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
TYPES OF ANXIETY DISORDER
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.
● 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)
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 ● 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
17
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
18
 ● 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
dissociative disorder that consists of persistent or
recurrent feelings of being detached (dissociated)
from one’s body or mental processes, usually with a
feeling of being an outside observer of one’s life
(depersonalization), or of being detached from one's
surroundings (derealization).
● This is not fixed, only temporary. The patient can still
go back to reality
MULTIPLE PERSONALITY DISORDER
● A person is dominated by at least one of two or more
definitive personalities at one time
● Maintenance of at least two distinct and relatively
enduring personality states. The disorder is
accompanied by memory gaps beyond what would be
explained by ordinary forgetfulness.
● The person won’t know about the different
personalities unless they are already being treated
● Once they verbalize and is conscious of the multiple
personalities it is a sign of progress or recovery
Psychotic Disorders
SCHIZOPHRENIA
→ Severe impairment of mental & social functioning with
grossly impaired reality testing, sensory perception and
with deterioration & regression of psychosocial
functioning.
→ Schizo = Split
→ Phrenia = Mind
→ Dopamine is increased
└ Dopamine is responsible in cognitive function
└ Increased levels will lead to delusions and
hallucinations
→ #1 HALLUCINATION of Schizophrenia is Auditory.
→ Irreversible disease
└ It can be managed but not treated
└ Intake of antipsychotics drugs is lifetime
└ If intake of medications are stopped, schizophrenia
manifestations will return again
→ Ego is damaged because ego is what keeps the patient
intact in the reality
THE FOUR A’s of SCHIZOPHRENIA
ACCORDING TO BLEULER
ASSOCIATIONS, LOOSE: Jumping to different
topics WITHOUT association or relevance
AMBIVALENCE (Two opposing
thoughts/feelings toward others at the same time)
AUTISM (withdrawal from environment and
A others) → magical thinking, neologism, aloofness,
echolalia)
AFFECT, FLAT (Inappropriate or no display of
feelings)
***should be assessed to diagnose schizophrenia
***symptoms should be present for at least 6 months to
confirm schizophrenia
***At least 2 positive symptoms and 1 negative symptoms\
THEORIES
1) Increased dopamine –coming from the substancia nigra
2) Genetics
└ 65% chances- if two parents are diagnosed with
schizophrenia
└ 32.5% chances- if 1 parent is diagnosed with
schizophrenia
19
3) Drug addicts and alcoholics: High probability for
schizophrenia due to increase Delusions & hallucination
4) Pregnant woman who is a smoker may increase risk for
development of schizophrenia of her baby
CLINICAL MANIFESTATIONS OF SCHIZOPHRENIA
✔ Characterized by both (-) & (+) symptoms & social /
occupational dysfunction for at least SIX (6) months.
✔ Patient with 5 admissions in 2 yrs is considered a chronic
schizophrenia
✔ (+) POSITIVE SIGNS OF SCHIZOPHRENIA: Due
to EXCESS DOPAMINE
HILDDA PI
o Hallucination
o Illusion
o Looseness of Association
o Delusion of Grandeur
o Disorientation
o Agitation
o Paranoia
o Insomnia
✔ (-) NEGATIVE SIGNS OF SCHIZOPHRENIA: Due
to LACK OF DOPAMINE
POOR A’s
o Poor judgment
o Poor insight
o Poor self care
o Alogia [lack of speech caused by a disruption
in the thought process]
o Anhedonia [absence of sexual urges]
NURSING DIAGNOSIS FOR NEGATIVE SYMPTOMS OF
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
20
 → No longer exhibits overt symptoms, no more
interventions so that they will see that everything is
prepared safely with no harm
delusions but the signs and symptoms may comeback
2. CATATONIC due to non-compliance with drug intake

→ With stereotyped position (catatonia) with waxy → No more PO drugs, IV drugs are now given

flexibility, mutism, → Nursing care: consistency

→ #1 Cardinal Sign of Catatonia – waxy flexibility
→ Give antipsychotic –hallucination / delusion
→ Most dangerous/serious type of schizophrenia–
→ Undifferentiated type chronic schizophrenia must be
may die from dehydration
referred to a program promoting social skills due to
→ Catatonic stupor – markedly slowed movement. functional loss deficit
o Waxy Flexibility
└ decreased response to stimuli and a PRINCIPLES OF CARE FOR SCHIPHRENIA
1. Maintenance of safety:
tendency to remain in an immobile
posture → Protect from altered thought processes.
└ lack of movement for a prolonged period
of time → Respond to feelings, and not to delusions
└ occurs because the patient is regressive
→ Do not argue
o mutism
→ Catatonic hyperactivity or excitability → Validate reality

→ Nursing Responsibility: prevent injury → Remove from areas of tension

→ Eg. Appropriate action of RN to a Schizophrenic who

3. DISORGANIZED/ HEBEPHRENIC
yells loudly, talks to wall and saying “Don’t talk to
→ Characterized with inappropriate behavior: me, bastard.” includes walking towards the pt & ask
o Silly crying him who he is talking to.
o Laughing 2. Meeting of physical needs
o Regression → May have to be fed / bathe initially
o Confusion 3. Establishment and maintenance of therapeutic
o disorganized thoughts relationship
o transient hallucinations (Auditory)
→ Engage in individual therapy
→ Common in women
→ Promote trust
→ All behaviors are similar with toddlers since they are
→ Encourage expression by verbalizing the observed
anal fixated.
→ Developmental Stage FIXATION: Anal Fixation → Offer presence-Tolerate long silences
4. Implementation of appropriate family, group, social or
→ #1 Defense Mechanism: Regression & Fixation
diversional therapies

4. UNDIFFERENTIATED/ MIXED → Patients with schizophrenia need activities that do not

require interaction, so solitary activities are preferred
→ Symptoms of more than one type of schizophrenia
over team activities.
has delusions & disorganized behavior
→ The #1 drug of choice is Fluphenazine (Prolixin
*Hindi to kasama sa lecture pa po hehe
decanoate)
ERIK ERICKSON
PSYCHOSOCIAL THEORY OF DEVELOPMENT
5. RESIDUAL
21
0-18 mos. TRUST VS. MISTRUST JEAN PIAGET
COGNITIVE THEORY OF DEVELOPMENT
● attachment to mother which lays foundations for later
trust in others ASSIMILATION
● conflict: general difficulties relating to others. ● people transform incoming information so that it fits
suspicion, fear of the future within their existing schemes or thought patterns

ACCOMMODATION
18 mos-3 yrs AUTONOMY VS. SHAME/DOUBT
● people adapt their schemes to include incoming
● Gaining some basic control of self and environment
information
● Conflict: independence-fear conflict, severe feelings
PIAGET’S COGNITIVE THEORY
of self-doubt
SENSORIMOTOR STAGE
3 yrs-6 yrs INITIATIVE VS. GUILT
● development proceeds from reflex activity to
● becoming purposeful and directive
representation and sensorimotor solutions to
● conflict: aggression-fear conflict, sense of inadequacy problems
and guilt ● 0 to 18 months

PRE-OPERATIONAL STAGE
6 yrs-12 yrs INDUSTRY VS. INFERIORITY
● development proceeds from sensorimotor
● Developing social, physical and school skills,
representation to prelogical thought and. solutions to
competence
problems can use these representational skills only to
● Conflict: sense of inferiority, difficulty learning and view the world from their own perspective.
working ● Understand the meaning of symbolic gestures

12 yrs-20 yrs IDENTITY VS. ROLE DIFFUSION ● 2 to 7 years

● Making transition from childhood to adulthood,
CONCRETE OPERATIONAL
developing a sense of identity
● development proceeds from prelogical thought to
● Conflict: confusion of who one is, identity submerged
logical solutions to concrete problems
in relationships or group memberships
● understand concrete problems
21 yrs -35 yrs INTIMACY VS. ISOLATION
● cannot yet contemplate or solve abstract problems
● establishing intimate bonds of love and friendship
● 7 to 12 years
● conflict: emotional isolation
FORMAL OPERATIONAL

35 yrs-55 yrs GENERATIVITY VS. STAGNATION ● development proceeds from logical solutions to
concrete problems to logical solutions to all
● fulfilling life's goals that involve family, career and
society, developing concerns that embrace future ● classes of problems
generations
● cannot yet contemplate or solve abstract problems
● conflict: self-absorption. Inability to grow as a person
● can also reason theoretically
55 yrs-above INTEGRITY VS. DESPAIR ● 12 and above
● looking back into one’s life and accepting its
meaning HARRY STACK SULLIVAN
INTERPERSONAL THEORY
● conflict: dissatisfaction with life, denial of or despair
over prospect of death SULLIVAN'S INTERPERSONAL THEORY

22
INFANCY
ORIENTATION
● anxiety develops as a result of unmet needs by the
mother (bodily needs); needs met, the child has sense ● Major task of the nurse: to develop a mutual
of well-being acceptable contract
● 0 to 18 months
WORKING

CHILDHOOD ● Major task: identification and resolution of patient's

problem
● anxiety as a result of lack of praise/acceptance from
parents TERMINATION
● gratification leads to positive self-esteem ● Major task: to assist the patient to review what he has
● moderate anxiety leads to uncertainty and insecurity learned and transfer his learning to his relationship
with others
● severe anxiety results in self-defeating patterns of
behavior THERAPEUTIC COMMUNICATIONS

● 18 months to 6 years ORIENTATION

● Broad Opening
JUVENILE
● severe anxiety may result in a need to control or ● Recognition
restrictive, prejudicial attitudes learns to negotiate ● Giving information
own needs
● Silence
● 6 to 9 years
● Offering Self - "Do you want me to sit beside you?”
PRE-ADOLESCENCE
● capacity to attachment, love and collaboration WORKING
emerges or fails to develop ● Focusing - "Let us discuss this topic more”
● move to genuine intimacy with friend of the same sex ● Exploring - "Tell me more about it.”
● 9 to 12 years ● Encourage Evaluation - "IS this what you want?”

ADOLESCENCE ● Reflecting - same idea

● if self-system is intact, areas of concern expand to ● Restating - same statement

include values, career decisions and social concerns
● lust is added to interpersonal equation
● need for special sharing relationship shifts to opposite
sex
● new opportunities for social experimentation lead to
consolidation or self-ridicule
● 12 to adulthood
● Verbalizing Implied - "Are you going to kill
yourself?"
● Seeking Clarification – “May you please repeat that
statement”
● General lead - "Please continue.”; “And then?”
● Limit setting - "Stop"
● Interpreting - "Maybe that thing is very significant to
you.”

HILDEGARD PEPLAU TERMINATION

NURSE PATIENT RELATIONSHIP ● Summarizing – “Let us now sum up. You have stated
earlier... etc.”
PEPLAU'S NPR
● “Do you have any questions?”
PRE-INTERACTION
● “Our next therapy...”
● Major task of nurse- to develop self-awareness
23
 ● Look for changes in behavior
● Resistance is a common problem
THERAPEUTIC COMMUNICATION TECHNIQUES
● Accepting-indicating reception
● E.g., “Yes"
“I follow what you said”
Nodding
BROAD OPENINGS
● Allowing the client to take the initiative in
introducing the topic
● e.g., "is there something you'd like to talk about?”
“Where would you like to begin?”
CONSENSUAL VALIDATION
● Searching for mutual understanding, for accord in the
meaning of the words
● e.g., "Tell me whether my understanding of it agrees
with yours”
“Are you using this word to convey that…?”
ENCOURAGING COMPARISON
● Asking that similarities and differences be noted
● e.g., "was it something like...?
“Have you had similar experiences?”
ENCOURAGING DESCRIPTION OF PERCEPTIONS
● Asking the client to verbalize what he or perceives
● E.g., “Tell me when you feel anxious”
“What is happening?”
“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?”
24
 ● E.g., Client: “I’m dead”
PRESENTING REALITY
Nurse: “Are you suggesting that you feel
● Offering for consideration that which is real lifeless?”
● E.g., “I see no one else in the room”
VERBALIZING THE IMPLIED
“Your mother is not here; I am a nurse”
● Voicing what the client has hinted at or suggested

● E.g., Client: “I can’t talk to you or anyone. It’s a

REFLECTING
waste of time.”
● Directing client actions, thought, and feeling back to Nurse: “Do you feel that no one
the client understands”
● E.g., Client: “Do you think I should tell the doctor…?
VOICING DOUBT
Nurse: “Do you think you should?”
● Expressing uncertainty about the reality of the
RESTATING client’s perceptions
● Repeating the main idea expressed ● “isn’t that unusual?”
“really?”
● E.g., Client: “I can’t sleep. I stay awake all night”
“that’s hard to believe”
Nurse: “You have difficulty sleeping”
Client: “I’m really mad, and upset” NONTHERAPEUTIC COMMUNICATION
Nurse: “You’re really mad and upset” TECHNIQUES

SEEKING INFORMATION ● Advising – telling the client what to do

Agreeing – indicating accord with the client
● Seeking to make clear that which is not meaningful
or that which is vague ● E.g., “I think you should…”
“That’s right”
● “I’m not sure that I follow”
“Have I heard you correctly?” AGREEING

SILENCE ● Indicating accord with the client

● Absence of verbal communication, which provides ● “that’s eight.” “I agree”

time for the client to put thought or feelings into
words, regain composure, or continue talking BELITTLING FEELINGS EXPRESSED
● E.g., nurses say nothing but continues to maintain ● Misjudging the degree of the client’s comfort
eye contact and conveys interest
● Client: “I have nothing to live for… I wish I was
SUGGESTING COLLABORATION dead”
Nurse: “Everybody gets down in the dumps”
● Offering to share, to strive, to work with the client for
his or her benefit CHALLENGING
● E.g., “perhaps you and I can discuss and discover the ● Demanding proof from the client
triggers for your anxiety”
● “But how can you be president of the Philippines?”
SUMMARIZING
DEFENDING
● Organizing and summing up that which has gone
● Attempting to protect someone or something from
before
verbal attack
● E.g., “Have I got this straight?”
● “this hospital has a fine reputation”
TRANSLATING INTO FEELINGS
DISAGREEING
● Seeking to verbalize client’s feelings that he or she
● Opposing the client’s ideas
expresses only indirectly

25
 ● 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
26
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
27

● 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
termination phase)
SHORT TERM DYNAMIC PSYCHOTHERAPY
● Indication – persons with specific symptom or
interpersonal problem that he/she wants to work on
● Therapist directs the content
● Use of transference and dream analysis
● Weekly sessions (total number – 12 to 30)
● Successful for highly motivated individuals who have
insight and with positive relationship with the
therapist
TRANSACTIONAL ANALYSIS
● 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
COGNITIVE PSYCHOTHERAPY
● Restructuring or changing ways in which people
think about themselves
● Thought stopping
● Positive self-talk
● DE catastrophizing
● Therapists help patients identify these thoughts
BEHAVIORAL THERAPY
● Changes in maladapted behavior can occur without
insight into the underlying cause
● Based on learning theory
● Modeling
● Operant conditioning
● Self-control therapy – combination of cognitive and
behavioral approaches “talking to self”
● Systemic desensitization
● Aversion therapy
GESTALT THERAPY
● Emphasis on the “here and now”
● Only present behavior can be changed, not history
● Uncover repressed feelings and needs
● Techniques: have a person behave the opposite of the
way he/she feels, presuming that a person can then
come in contact with a submerged part of the self; in
dreams, person is asked to play roles of persons in the
28
 dream to get in touch with different repressed
● Family therapy
feelings

MILIEU THERAPY ASSUMPTION OF FAMILY THERAPY

● Total environment has an effect on the individual’s ● Client: whole family
behavior ● Concepts:
● Components o The family is the most fundamental unit of the
o Physical environment society
o Interpersonal relationships o Adaptive or maladaptive patterns of behavior are
o Atmosphere of safety, caring, and mutual respect learned from the family
o For alcoholics o Dysfunction in the family = dysfunction in the
individual
PROGRAMS FOR MILIEU SHOULD HAVE: ● Purpose
● An emphasis on group and social interaction o Improve relationships among family members
o Promote family function
● No rules and expectations mediated by peer pressure o Resolve family problems
● A view of patients’ roles as responsible human beings
OTHER TYPES OF THERAPIES
● An emphasis on patients’ rights for involvement in
setting goals SUPPORT GROUPS

● Freedom of movement and informality relationships ● For those with AIDS, Mother-Against-Drug
with staff Dependence

● Emphasis on interdisciplinary participation SELF-HELP GROUPS

● Goal-oriented, clear communication ● Alcoholic Anonymous

GROUP THERAPY RULES FOR PSYCHOTHERAPEUTIC

MANAGEMENT
● Number of people coming together, sharing a
● Provide support, treat patients with respect and
common goal, interest or concern, staying together
and developing relationships dignity
● For PTSD and alcoholics ● Do not place patients in situations wherein they will
feel inadequate or embarrassed
● Phases
● Treat patients as individuals
o Orientation
o Working ● Provide reality testing
o Termination
● Handle hostility therapeutically
CHARACTERISTICS OF GROUP THERAPY
● Provide psychopharmacologic treatment
● Universality → “you are not alone”

● Instilling hope and inspiration BEHAVIORAL THERAPIES

TREATMENT MODALITIES
● Developing social skills by interacting with one
another ● Pavlov’s Classical Conditioning: All behaviors are
● Feeling of acceptance and belonging learned

● Altruism → “giving of one’s self ● B.F. Skinner’s Operational Conditioning:

Reinforcements
FAMILY THERAPY ● Behavioral Conditioning: substance abuse
● Psychoanalytically oriented group therapy ● Token Economy: anorexia/schizo
● Psychodrama ● Systematic Desensitization: phobia

29
 ● Monitor for respiratory problems, gag reflex
ATTITUDE THERAPY
TREATMENT MODALITIES ● Reorient patient

1. Paranoid – passive friendliness ● Observe until stable

2. Withdrawn – active friendliness
3. Depressed/Anorexia – kind firmness ● Careful documentation
4. Manipulative – matter of fact
5. Assaultive – no demand ● Male erectile dysfunction
6. Anti-social – firm, consistent
OTHER THERAPIES
PSYCHOSOMATIC THERAPY ● Neurosurgery
TREATMENT MODALITIES
ANXIETY
ELECTROCONVULSIVE THERAPY
● Effective in most affective disorders PEPLAU’S LEVEL OF ANXIETY

● The induction of a grandmal seizure in the brain MILD

● Abnormal firing of neurons in the brain causes an ● Associated with the tension of day to day living
increase in neurotransmitters ● Perceptual field increased
● Number of Treatments: 6-12, 3 times a week,
● More alert than usual
about .5-2 seconds
● Unilateral or bitemporal ● Adaptive

Indications:
MODERATE
● Patients who require rapid response
● Narrowed perception
● Patients who cannot tolerate pharmacotherapy or
● Difficulty focusing
cannot be exposed to pharmacotherapy
● Patients who are depressed but have not responded to ● Selective inattention
multiple and adequate trials of medication ● Mild somatic complaints: stomachache and butterflies
in the stomach
Preparations for ECT:
● Pretreatment evaluation and clearance INTERVENTIONS FOR MILD TO MODERATE
ANXIETY
● Consent
● Assist the client in identifying anxiety
● NPO from midnight until after the treatment
● Anticipate anxiety provoking situations
● Atropine Sulfate – to decrease secretions
● Use nonverbal language to demonstrate interest
Succinylcholine (Anectine) – to promote muscle
relaxation ● Encourage the client to talk about his or her feelings
Methohexital Sodium (Brevital)- anesthetic
● Avoid closing off avenues of communication
● Empty bladder
(refraining from offering advice or changing the
● Remove jewelry, hairpins, dentures and other topic)
accessories ● Encourage problem-solving
● Check vital signs
● Explore past and present coping behaviors

Care after ECT: ● Provide outlets for working off excess energy
● O2 therapy of 100% until patient can breathe
LEVELS OF ANXIETY
unassisted
SEVERE
30
 ● Very narrowed perception ● Xanax

● Unable to focus on problem solving ● Buspar

● Increased physical discomfort

ANTI-ANXIETY DRUGS
● All behavior is aimed at relieving anxiety ● Used only in a short time (1-2 weeks)
● Direction is needed to focus attention ● Tolerance (after 7 days) and dependence (after 1
month)
PANIC
● Liver function test
● Awe, dread and terror
● Monitor side effects
● Unable to see the whole situation or reality
● Avoid machines, activities needing concentration
● Distortion of perception
● Z tract if given parenterally
● Disorganization of the personality
● Avoid mixing with alcohol, antihistamines,
● A frightening and paralyzing experience
antipsychotics

INTERVENTIONS FOR SEVERE AND PANIC LEVELS ● Don’t stop abruptly but gradually for 2-6 weeks
OF ANXIETY
● Avoid caffeine
● Maintain a calm manner
CATEGORIES OF ANXIETY DISORDERS
● Remain with the person
● Basic Anxiety Disorders
● Minimize environmental stimuli
● Somatoform Disorders
● Reinforce reality
● Dissociative Disorders
● Listen for themes in communication

● Attend to physical safety and medical needs first BASIC ANXIETY DISORDERS
● Generalized Anxiety Disorder
● Physical limits may need to be set
● Panic
● Provide opportunities for exercising
● Phobia
● Assess the person’s need for mediation or seclusion
● PTSD
ANTI-ANXIETY DRUGS
● Obsessive Compulsive
● Valium

● Librium GENERALIZED ANXIETY DISORDER

● Excessive worry and anxiety for days but not more
● Ativan
than 6 months
● Serax
● Difficulty in controlling the worry
● Tranxene
● Anxiety and worry are evident by 3 or more of the
● Miltown following:
o Restlessness, keyed up
● Equanil o Fatigue and irritability
o Decreased ability to concentrate
● Vistaril
o Muscle tension
● Atarax o Disturbed sleep

● Inderal ● Anxiety or worry causes significant impairment in

interpersonal relationship or activities of daily living

31
 ● Preoccupation with persistent intrusive thoughts,
POST TRAUMATIC STRESS DISORDER
impulses or images
● Disturbing pattern of behavior occurring after a
traumatic event that is outside the range of usual COMPULSIONS
experience
● Repetitive behaviors or mental acts that the person
Characteristics feels driven to perform in order to reduce distress or
prevent a dreaded event or situation
● Persistent re-experiencing of the trauma through
recurrent intrusive recollections of the event, through CUES:
dreams or flashbacks
● Ritualistic behavior
● Persistent avoidance of the stimuli
● Constant doubting if he/she has performed the
● Feeling of detachment of estrangement from others activity
● Chemical abuse to relieve anxiety
EXAMPLE
OBSESSIONS COMPULSIONS
S
PHOBIAS
Washing or “Wash away my Young woman
Definition cleaning sins.” Thought repeatedly washes
● Persistent, irrational fear of a specific object, activity appeared after sexual hands
or situation that leads to a desire for avoidance of the encounter with a
object of fear married man

Specific Phobia Need for “Everything must be Arranges and

order in place” rearranges items
● Experience of high level of anxiety or fear provided
by a specific object or situation Germs or “Everything is Avoids touching all
dirt contaminated” objects. Scrubs
Treatment hands if she is
● Systematic Desensitization forced to touch any
object
Defense Mechanisms Symmetry “Secretaries who Secretary lines up
● Repression and displacement practice neatness objects in rows on
never gets fired” her desk, then
MAJOR TYPES OF PHOBIAS realigns them
repeatedly during
AGORAPHOBIA the day
● Comes from the Greek word “agora”
CARE STRATEGIES
● Meaning “market place”
● Be nonjudgmental and honest; offer empathy and
● Fear of being alone in open or public spaces
support

SOCIAL PHOBIA ● Help patient to recognize the connections between the

trauma experience and their current feelings,
● Fear of situations where one might be seen and
behaviors and problems
embarrassed or criticized
● Encourage verbalizations of feelings, especially anger
SPECIFIC PHOBIAS ● Encourage adaptive coping strategies and techniques
● Fear of a single object, situation or activity that
● Encourage patients to establish or reestablish
cannot be avoided
relationships
OBSESSIVE COMPULSIVE DISORDERS ● Explore shattered assumptions. “I’m a good person.
This is a safe world”
OBSESSIONS
32
 ● Promote discussion of possible meaning of events ● Persecutory

● Religious

● Grandeur

● Ideas of Reference
PSYCHOSOMATIC DISORDER
● True/unconscious because of hormonal and bodily DISTURBED THOUGHT PROCESS
changes ● Looseness of association
● Increase anxiety may result to asthma, stress ulcers or ● Flight of ideas
migraine
● Ambivalence
SCHIZOPHRENIA
● Magical thinking
● A major form of psychotic disorder that affects a
person’s thinking, language, emotions, social ● Echolalia/Echopraxia
behavior and ability to perceive reality ● Word salad
● At least 2 of 5 types of positive and negative
● Neologism
symptoms
● Characteristic Symptoms ● Thought blocking

● Social or occupational dysfunction ● Concrete association

o IPR
o Self-care
● Duration BLEULER’S FOUR A’s OF SCHIZOPHRENIA
o Continuous for at least 6 months ● Affective disturbances

POSITIVE AND NEGATIVE SYMPTOMS ● Autism

POSITIVE SYMPTOMS ● Associative looseness

● Hallucinations ● Ambivalence

● Delusions ● Other A’s

o Attention deficits
● Illusions
o Disturbances of activities
● Abnormal thought patterns or perceptions
SCHIZOPHRENIA
● Bizarre behavior
● Brief Psychotic Disorder – may be seen when a
NEGATIVE SYMPTOMS person exhibits clinical symptoms of illogical
thinking, incoherent speech, delusions, or
● Affective flattening disorganized behavior after psychological trauma
● Anhedonia ● Induced Psychotic Disorder – develops in a second
person as a result of a close relationship with a person
● Attention impairment who has psychosis
● Asocial behavior ● Delusional Psychotic Disorder

● Anergia ● Schizoaffective Disorder – characterized by

depression or elation as the psychosis symptoms of
● Autism
schizophrenia and MDD
● Avolition ● Schizophreniform – when a person exhibits features
of schizophrenia for more than one week but less than
DELUSIONS 6 months
33
SUBTYPES: ANTI-PSYCHOTIC
● Tara, look natin sina Stella, Mel, at Thor na nag mo-
Paranoid – most common form if the illness
Suspicious moulin rogue… sssh, alam niyo ba na ang trio na yan
na akala mo may halo ay mga closet queens pala…,
● Promote trust namen”
● Short interaction but frequent ● Taractan, Loxitane, Stelazine, Mellaril, Thorazine,
Molindone, Seroquel, Serlect, Trilafon, Haloperidol,
● Food in containers (sealed)
Clozapine, Navane
● Prepare food in front of them
● Stelazine
● Let them see preparation of drugs
● Serentil
Violent
● Thorazine
● Keep door open
● Trilafon
● Position near door and with distance of 1 arm length
(patient-nurse) ● Clorazil

● Don’t touch ● Millaril

● Maintain eye contact ● Haldol

● Risperidol
Disorganized – absence of systematized delusions; presence
of incoherence and inappropriate affect ● Prolixin
● Inappropriate, flat affect
ANTI-PSYCHOTIC DRUGS
● Hebephrenic, flight of ideas Watch for side-effects
● Increase v/s
Catatonic
● Risk for suicide ● Constipation/dry mouth

● Catatonic stupor, rigidity ● Postural hypotension

● Waxy flexibility ● Photophobia/photosensitivity

● Drowsiness

Undifferentiated ● Agranulocytosis
● Unclassified ● Extrapyramidal symptoms
o Parkinson’s syndrome
Residual o Akathisia
● No more positive symptoms but withdrawn o Akinesia
o Dystonia – oculogyric crisis, torticollis,
NURSING PROCESS opisthotonos
o Tardive dyskinesia
● Disturbed thought process o NMS
● Disturbed sensory process
UNDESIRABLE EFFECTS
● Risk for self-directed violence ● S-edation/sunlight sensitivity/sleepiness
● Risk for other directed violence ● T-ardive dyskinesia

● A-nticholinergic/agranulocytosis/akathisia
● Present safety
● N-euroleptic malignant syndrome
● Present reality
34
 ● C-ardiac effects (orthostatic hypotension) ● May occur anytime during therapy

● E-xtrapyramidal (dystonia) ● Seen during the initiation of therapy, change of

therapy, after a dosage increase or when a
PARKINSONISM combination of meds is used
● Motor retardation or akinesia characterized by mask- ● Early sign: rigidity or mental status changes
like appearance, rigidity, tremors, “pill-rolling”,
● Catatonia, tachycardia, tachypnea, labile blood
salivation
pressure, dysphagia, diaphoresis, incontinence,
● Generally occurs after 1st week of treatment or before rigidity, myoclonus, tremors, low grade fevers
second month
● Discontinue antipsychotic agent. Have
● Administer anticholinergic agent, anti-Parkinson cardiopulmonary support available; administer
medication (Akineton) skeletal muscle relaxant (e.g., dantrolene) or central
acting dopamine agonist (.e.g., bromocriptine)
AKATHISIA
NOTES ON SCHIZOPHRENIA
● Constant state of movement, characterized by
restlessness, difficulty sitting still, or strong urges to ● Distorted EGO
move about
● Disturbed thought process
● Generally occurs two weeks after treatment begins
● Disorganized personality
● Rule out anxiety or agitation before administration of
● Dopamine – increase
an anticholinergic agent
● Autism
ACUTE DYSTONIC REACTIONS
● Ambivalence
● Irregular, involuntary spastic muscle movement,
wryneck or torticollis , facial grimacing, abnormal ● Associative looseness
eye movements, backward rolling of eyes on the
sockets ● Affect – flat
● May occur anytime from a few minutes to several ● Stimulation
hours after a first dose of antipsychotic drug
● Structure
● Administer anticholinergic agent, have respiratory
support equipment available ● Socialization

● Support
TARDIVE DYSKINESIA
● Most frequent serious side effect resulting from MANIFESTATIONS
termination of the drug, during reduction in dosage, S – social isolation
or after long term high dose therapy a C – catatonic behavior
H – hallucinations
● Characterized by involuntary rhythmic, stereotyped I – incoherence
movements, tongue protrusion, cheek puffing, Z – zero/lack of interest and initiative
involuntary movements of extremities and trunk O – obvious failure in development
● Occurs in approximately 2—25% of patients taking P – peculiar behavior
H – hygiene and grooming impaired
antipsychotics for over two years R – recurrent illusions
● No treatment except discontinuation of the E – exacerbations and remissions
N – no organic factor account S/S
antipsychotic agent
I – inability to return to functioning
A – affect is inappropriate

ANTI-PARKINSONIAN DRUGS
NEUROLEPTIC MALIGNANT SYNDROME
● A potentially fatal syndrome DOPAMINERGIC DRUGS

35
 o Obese
● To live (Levodopa), you need a car (Carbidopa)
and a man (Amantadine) not your brother o Care giver role strain
(Bromocriptine) per (Pergolide) se (Selegiline)

ANTI-CHOLINERGIC MANIA VS DEPRESSION

● BACPAK (Benadryl, Artane, Cogentin, Parsidol, MANIA DEPRESSION
Akineton, Kemadrin)
Colorful, Sad and gray
OTHER TREATMENTS APPEARANCE
flamboyant
● Psychotherapy – individual, group, behavioral,
supportive or family therapy may be used depending Psychomotor Psychomotor
BEHAVIOR
on the clinical symptoms agitation retardation
● Milieu therapy – a structured environment to Pressured Monotonous
minimize environmental and physical stress and to speech speech
meet the individual needs of the patients until they COMMUNICATIO
are able to assume responsibility for themselves N Stuttering

Cluttering
CONCEPTS AND PRINCIPLES OF HALLUCINATION
● Possible to replace hallucination with satisfying Risk for Injury Risk for Injury
interactions (others) (self)
Nx
● Can re-learn to focus attention on real things and Suicidal
people precaution

● Hallucinations originate during extreme emotional NURSING Safety and Safety and
stress when the patient is unable to cope PRIORITY nutrition nutrition
● Hallucinations are very real to the patient Finger foods Increased in
● Patient will react as the situation is perceived NUTRITION and high in nutrients
calories
● Concrete experiences, not argument on confrontation
Lithium; ECT TCA; SSRI;
will correct sensory distortion TREATMENT
MAOOI’s; ECT
● Hallucinations are a substitute for human relations
Non- Stimulating
BIPOLAR DISORDER MILIEU stimulating
MOOD DISORDER/AFFECTIVE DISORDER environment
● A distinct period of abnormally and persistently Quiet type; Monotonous;
APPROPRIATE
elevated expansive or irritable mood lasting at least 1 non- non-
ACTIVITY
week competitive competitive
● 3 or more of the following
Matter of fact Kind firmness;
o Psychomotor overexcitability or excitement ATTITUDE
active
o Insomnia with fatigued THERAPY
friendliness
o Euphoria or elated mood
o Distractibility
o Pressured speech LITHIUM
o Flight of ideas ● Level of lithium (0.5 to 1.5 meq/L)
o Manipulative or demanding behavior
o Destructive or combative behavior ● Increase urination (polyuria)
o Delusions of grandeur
● Tremors – fine hand
● Risk
● Hydration
o Female
o 20 years old and above ● Increase peristalsis
o Stressful life
36
 ● U2 – 4 weeks effective ● 2 to 6 weeks

● Increased bowel movements ● Hypertensive crisis

● Mouth is dry ● Don’t take:

o Assess function of kidney o Avocado
o Toxicity: nausea and vomiting, diarrhea o Aged cheese
o Beer/B6 (tyramine)
PHARMACOLOGY MOMENTS o Chocolate
ANTIDEPRESSANTS o Fermented foods
o Soy sauce
ANTIDEPRESSANTS o Pickles and preserved foods
● Asendin
A. TCA
● Norpramin “knock! Knock! Who’s there? SEVANA to gagah!” --------
(Sinequam, Elavil, Vivactil, Ascendin, Norpramin,
● Tofranil Aventyl, Tofranil)
● Sinequan
B. SSRI
● Anafranil Ngongo: “Paxil ka! Paxil ka! Prozoleta ka lang, kala ko luv
mo ko! (Praxil, Prozac, Zoloft, Luvox)
● Aventil
C. MAO
● Vivactil “naman, parnate ko pa” (Nardil, Manerix, Parnate)
● Elavil
SUICIDE
● Prozac ● The intentional act of killing oneself
● Luvox Suicidal Ideation – means thinking about oneself
● Passive suicidal ideation – when a person thinks
● Paxil
about wanting to die or wishes he/she were dead but
● Zoloft has no plans to cause his/her death (e.g., reckless
driving, heavy smoking, overeating, self-mutilation,
SSRI drug abuse)

● Selective Serotonin Reuptake Inhibitor ● Active suicidal ideation – when a person thinks
about and seeks to commit suicide
● Safest
SAD PERSON’S SCALE
● Side effects are low
● S-Sex. Mean kill themselves 3x more than women
● 1 to 4 weeks though women make attempts 3x more often than
● Prozac, Paxil, Zoloft, Luvox men
● A-Age. High risk groups: 19 years or younger; 45
TCA years or older, especially the elderly 65 and above
● Tricyclic Antidepressants ● D-Depression. Studies report that 35-79% of those
● 2 to 4 weeks who attempt suicide manifested a depressive
syndrome
● Anticholinergic ● P-Previous Attempts. Of those who commit suicide,
● Amitriptyline, Nortiptyline, Doxepin Trimipramine, 65-70% have made previous attempts
Amoxapine, Anafranil, Venlafaxine ● E-ETOH. Alcohol is associated with up to 65% of
successful suicides
MAOI’s
● R-Rational Thinking Loss. People with functional
● Increases all neurotransmitters
or organic psychoses are more apt to commit suicide
than those in the general population
37
 ● 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
38

SUICIDE PRECAUTIONS
● Execute a “no suicide contract.” The client will
inform the nurse when he/she has suicidal ideations
● Ask direct questions. Find out if the person has
specific plan for suicide. Determine what method
● Be alert for cries for suicide
● Provide a safe environment and protect client from
self
● Encourage to ventilate feelings and thoughts
● Give emotional support
● Make the patient realize that the tendency to commit
suicide is due to the disturbance in the brain
chemistry and is treatable – once they know that an
episode of suicidal thinking will pass, they will likely
not act on the impulse
● Provide structured schedule and involve in activities
with others to increase self-worth and divert attention
● On discharge: help patient create “plan for Life” (list
of warning signs of suicidal ideation and actions to
take)
Always remember:
● That a suicidal person wants to crisis – during this
time the person is ambivalent about living and dying
● Suicidal person gives warning
● Persons recovering from depression are high risk for
9-15 months after recovery
● Suicidal people are extremely unhappy but not
always mentally ill
PERSONALITY BEHAVIORS
PERSONALITY PROBLEMS
● Schizoid
● Dependent
● Antisocial
● Avoidant
● Histrionic
● Borderline
PARANOID PERSONALITY DISORDER
● A pervasive pattern of distrust and suspiciousness of
others such that their motives are interpreted as
malevolent
o Suspicious (e.g., others are exploiting or
deceiving him)
o Doubt trustworthiness of others
o Fear of confiding in others
o Fear personal information will be used against
him
o Interpret remarks as demeaning or threatening
o Hold grudges toward others
o Becomes angry and threatening when they
perceive to be attacked by ithers
● Intervention: centered on building trust
SCHIZOID PERSONALITY DISORDER
● A pervasive pattern of detachment from social
relationships and a restricted range of expression of
emotions in interpersonal settings
o Lacks desire for close relationships or friends
including family
o Chooses to be alone
o Lack of sexual experiences
o Avoids activities
o Appears cold and detached
● Interventions: building trust followed by
identification and appropriate verbal expression
SCHIZOTYPAL PERSONALITY DISORDER
● A pervasive pattern of social and interpersonal
deficits marked by acute discomfort with and reduced
capacity for close relationships as well as by
cognitive or perceptual distortions and eccentricities
of behavior
o Ideas of reference
o Magical thinking or odd beliefs
o Unusual perceptual experiences, including bodily
illusions
o Peculiar thinking
o Vague, stereotypical, overelaborate speech
o Eccentric appearance or behavior
o Few close relationships
o Uncomfortable in social situations
● Interventions: improving interpersonal relationships,
social skills, and appropriate behaviors
ANTI-SOCIAL PERSONALITY DISORDER
● Characterized by deceit, manipulation, revenge and
harm to others with an absence of guilt or anxiety
o Violates rights of others
o Engages in illegal activities
o Aggressive behavior
o Lack of guilt or remorse
o Irresponsible in work and with finances
o Impulsiveness
o Recklessness
39
 o Manipulative
● Sense of entitlement
● Interventions:
● Takes advantage of others for own benefit
o Consistency
o Kind firmness in confronting behaviors and ● Lacks empathy
enforcing rules and policies
o Limit setting ● Envious of others or others are envious of him
o Decrease impulsivity
● Arrogant
o Enhance role performance
o Effective use of confrontation ● Interventions:
o Supportive confrontation on what the patient
BORDERLINE PERSONALITY DISORDER
says and what exists
● Characterized by pervasive pattern of unstable o Limit setting and consistency to decrease
interpersonal relationships; self-image and affect; and manipulation and entitlement behaviors
marked impulsivity o Remain neutral, avoid power struggles, or
o Frantic avoidance of abandonment; real or becoming defensive
imagines
o Unstable and intense interpersonal relationships HISTRIONIC PERSONALITY DISORDER
o Identity disturbances ● A pervasive pattern of excessive emotionality and
o Impulsivity attentive seeking
o Self-mutilating behavior o Overly dramatic
o Rapid mood shifts o Draws attention to self
o Chronic feelings of emptiness o Extroverted and thrives on being the center of
o Problems with anger attraction
o Transient dissociative and paranoid symptoms o Uses somatic complaints to avid responsibility
and support dependency
OTHER IMPORTANT INFORMATION o Dissociation
● Priority nursing diagnosis: high risk for injury ● Interventions: provide reinforcement in the form of
directed to self-related to self-mutilation behaviors attention, recognition or praise given for unselfish or
● Coping mechanisms used: splitting other centered behaviors
o Classifying people as either “good” or “bad”
DEPENDENT PERSONALITY DISORDER
INTERVENTIONS ● A pervasive and excessive need to be taken care of
● Use of empathy that leads to submissive and clinging behavior and
fears of separation
● Recognize the reality of the patient’s pain o Needs others to be responsible for important
areas of life
● Offer support o Problems with initiating with projects or doing
● Empower and work with the patient to understand things on his own because of little self
confidence
control and change dysfunctional behaviors o Performs unpleasant tasks to obtain support from
● Provide safe environment others
o Urgently seeks another relationship for support
● Teach social skills and care after a close relationship ends
o Preoccupied with fear of being alone to care for
● Make a list of solitary activities to combat boredom
self

NARCISSISTIC PERSONALITY DISORDER ● Interventions: increase responsibility for self in day to

day living; assertiveness training
● Grandiose self-importance

● Fantasies of unlimited power, success or brilliance AVOIDANT PERSONALITY DISORDER

● A pervasive pattern of social inhibition, feelings of
● Believes he or she is special
inadequacy and hypersensitivity to negative
● Needs to be admired evaluation

40
 o Avoids occupations involving interpersonal
● Losses in short term memory
contact due to fears of disapproval or rejection
o Preoccupied with being criticized or rejected in ● Memory aids compensate
social situations
o Very reluctant to take risks or engage in new ● Aware of the problem, disturbed
activities due to the possibility of being
embarrassed ● Not diagnosable at this time

OBSESSIVE COMPULSIVE PERSONALITY STAGE 2 MODERATE (CONFUSION)

DISORDER ● Progressive memory loss
● A pervasive pattern of preoccupation with
● ST memory loss interferes with ADLs
orderliness, perfectionism and mental and
interpersonal control at the expense of flexibility, ● Withdrawn, denial, fear of losing their minds
openness and efficiency
o Preoccupied with details, lists, rules, ● Depression, confabulation
organization
o Perfectionist ● Problems increase when stressed
o Too busy working to have friends or leisure ● Needs home care on in-home assistance
activities
o Unable to discard worthless or worn-out objects
STAGE 3 MODERATE TO SEVERE (AMBULATORY
o Reluctant to spend and hoards money
DEMENTIA)
o Rigid and stubborn
● Loss of reasoning ability, planning and verbal
DELIRIUM communication
● Characterized by disturbance of consciousness and a ● Frustrated, withdrawn, self-absorbed
change in cognition such as impaired attention span
and disturbances in consciousness that develop over a ● Depression decreases
short period of time ● Reduced stress threshold
o Always secondary to another condition (medical
condition or substance abuse) ● Institutional care required
o Frequent among the elderly and young febrile
children STAGE 4 LATE (END STAGE)
o Fluctuations of consciousness and inoculation
throughout the day ● Family recognition disappears

● Classified as mild to severe ● Doesn’t recognize self

● Sundowning ● Nonambulatory

● Little purposeful activity

DEMENTIA
● Characterized by multiple cognitive deficits that ● Often mute, may scream spontaneously
include impairment of memory which develops ● Forgets most ADLs
slowly
o 80-90% irreversible ● Problems associated with immobility
o Reversible due to pathologic process
o Most common: Alzheimer’s Dementia ● Institutional care required

● 4 Symptoms of Dementia ● Return of primitive reflexes

o Loss of memory DELIRIUM VS DEMENTIA
o Deterioration of language function DELIRIUM DEMENTIA
o Loss of ability to think abstractly, plan, initiate,
sequence, monitor or stop complex behavior ONSET Usually sudden Usually gradual
o Loss of ability to perform ADLs

STAGES OF DEMENTIA

STAGE 1 MILD (FORGETFULNESS)

41
 Usually brief with Usually long-term and ● Gross tremors, hyperactivity, profound confusion,
COURS return to usual progressive,
loss of appetite, insomnia, weakness, disorientation,
E level of occasionally maybe
illusions, hallucinations and delusions
functioning arrested or reversed

AGE Any Elderly 3 → 12-48 hours after the last drink

GROUP ● Severe hallucinations, grand mal seizures

4 → 3-4 days after the last drink

SEXUAL DISORDERS
● Delirium tremens, confusion, agitation,
● Homosexuality
hallucinations, insomnia and tachycardia
● Heterosexuality ALCOHOLISM

● Bisexuality ● Avoid alcohol during therapy

● Masochism ● Aversion therapy

● Sadism ● Antabuse – disulfiram

● Frotteurism ● Belongings – check for alcohol, mouthwash, elixir,

etc.
● Pedophilia
● B1 deficiency
● Necrophilia
● Complication
● Voyeurism o Wernicke’s Encephalopathy (Motor)
o Korsakoff’s Psychosis (Mind)
● Transvestism
● Delirium Tremens
● Transsexualism
● Fornication
ALCOHOL
AUTISM
ALCOHOLISM
● Living in their own world
● Intergenerational Transmission
● Appearance – flat (consistent)
● Awake but unconscious
● Behavior – ritualistic, repetitive
● Blackout
● Communication – echolalia, incomprehensible
● Confabulation
NX: Impaired verbal communication
● Denial, dependence
Impaired social interaction
● Enabling, co-dependence Self-mutilation
Risk for injury
● Tolerance increases
ADHD

● Detoxification – doctor ● Attention-deficit/hyperactive disorder

● 7 years old and above

STAGES OF ALCOHOL WITHDRAWAL
● Duration: 6 months and above
1 → 8 hours after the last drink
● Requires 2 settings: home and school
● Mild tremors, tachycardia, increased BP, diaphoresis,
nervousness
● Appearance: dirty child
2 → 8-12 hours after the last drink
● Behavior: clumsy, hyperactive, impatient

42
 ● Communication: talkative, bursts out ● Peripheral edema

● Muscle weakening
● Structure
● Constipation
● Setting limits
● Low T3 and T4
● Schedule
● Hypotension
● Safety
● Bradycardia
EATING DISORDERS ● Hypokalemia
● Anorexia Nervosa
● Anemia
● Bulimia Nervosa
● Pancytopenia
● Pica
● Decreased bone density
● Compulsive Eating Behavior
SIGNS RELATED TO PURGING BEHAVIORS
ANOREXIA NERVOSA
Gastrointestinal
Symptoms: ● Parotid gland tenderness, pancreatitis, esophageal and
● Refusal to maintain body weight over a minimum gastric erosion or rupture
normal weight for age and height
Metabolic
● Intense fear of gaining weight or becoming fat, even
● Electrolyte abnormalities → hypokalemia
though underweight
● Disturbance in the way in which one’s bodyweight, Dental
shape or size is experienced
● Erosion of dental enamel of the front teeth
● In females, absence of menses of at least 3
consecutive cycles OBJECTIVES OF CARE
● Inability or refusal to acknowledge the seriousness of ● Increasing body weight to at least 90% of average
the problem weight for age and height
● Onset: 12-15; 17-21 years of age ● Reestablishing good eating behavior

● Increasing self-esteem
Etiology
● Cultural pressure
NURSING INTERVENTIONS
● Serotonin imbalance → controls appetite and the
satiety control center ● Monitor daily caloric intake, activity level, weight
and electrolyte status
● Family patterns
o Perfectionist ● Establish nutritional eating patterns
o Does not permit verbalization of feelings o Sit with client during meals
o Marital problems o Offer liquid protein supplement if unable to
complete a meal
Clinical Presentation o Observe signs of purging 1-2 hours after meals
● Low weight ● Provide accurate information on nutrition and discuss
realistic and healthy diet
● Amenorrhea
● Help the client identify emotions and develop non-
● Yellow skin
food related strategies
● Cold extremities o Convey warmth and sincerity
o Ask the client to identify feelings
43
 o Assist the client to change stereotypical beliefs
● Assist in identifying at least three positive
characteristics
● Teach patient about their illness
● Behavior modification: reward increase in weight
with meaningful privileges
● Identify patient’s non weight related interests to
reduce anxiety and refocus attention
BULIMIA NERVOSA
Symptoms
● Recurrent episodes of binge eating
● Feeling of lack of control over eating behaviors
during the eating binges
● Recurrent inappropriate compensatory behavior in
order to prevent weight gain, such as self-induced
vomiting
● Binge eating and inappropriate eating behaviors
● Persistent over concern with body shape and weight
● 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

Clinical Presentation
● Binge and purging behaviors

● Have depressive signs and symptoms

● Disturbed home life

● Major concerns
o Interpersonal relationships
o Self-concept
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

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