PSYCHIACTRIC NURSING

3 ASPECT OF PERSONALITY By Sigmund Freud

ID EGO SUPEREGO

 Inborn  begins to develop between  Develop bet 3-6 y/o

 Instinctive drive
 Internal desires (urges)
 “I WANT” pleasure principle
 DEVIL ego
4-6 mos.  Det RIGHT and WRONG
 the “self”, “I” identity
 reality principle
 no balance of EGO  may
schizo , ocd

*There should BE BALANCE bet the 3

PSYCHOSEXUAL THEORY by Sigmund Freud

- All behaviour is SEXUALLY MOTIVATED

- The theory supports the notion that all human behavior is caused and can be explained. Sexual impulses and
desires motivate human behavior.
- Remember “ O-A-Pha-La-Ge”

PHASE AGE FOCUS

ORAL Birth – 18 mos Gratification is on MOUTH

- Nauuhaw, nagugutom
- Regression can happen
- Oral regression ( thumbsuck, nail
biting)

ANAL x 2 = 18-36 mos ANUS

- “control” is develop
PHALLIC / OEDIPAL 3-5 yrs Fascinated by PENIS or VAGINA
- Pero NO SEXUAL orgasm happen; no
malice
- “curiosity” is developed

BOeYdipal (oedipal)L complex – boy love

mom
GErlectra (Elektra) complex – girl love dad
Latency 6-11 yr old SCHOOL - competition

You see SUPERIOR and INFERIOR

Genitals 12-18 yrs old Penis/ vagina

- Aware na; may mga sex orgasm na

- Sexual education important
PSYCHOSOCIAL THEORY of DEVELOPMENT

AGE AFFECTING MAJOR FACTOR

0-18 mo TRUST vs. MISTRUST Feeding (di magain ang attention)

18 mo – 3 y/o AUTONOMY vs SHAME/DOUBT Toilet training
-Good mom (may balance)
-Bad mom (disorganized / perfectionist)
3-6 y/o INITIATIVE vs. GUILT Independence
6-12 y/o INDUSTRY vs INFERIORITY In the school
12-21 y/o IDENTITY vs ROLE CONFUSION Peer
20-39 y/o INTIMACY vs ISOLATION Love
40-64 yo GENERAVITY VS STAGNATION Parenting
- 45 above = inc risk for suicide
65 yo and above EGO INTEGRITY VS. DESPAIR Reflection

MASLOW’s HEIRARCHY OF NEEDS

4 PHASE OF NURSE-CLIENT RELATIONSHIP

A. Pre-interaction / Pre orientation

 For ther nurse
 Stage of SELF-AWARENESS  To prevent COUNTERTRANFERENCE (nurse to pt)
 Important CORE VALUE: Self-awareness

B. Orientation (initiation)
T- rust and rapport
R-eflect on words
U-se of CONTRACT (I will be your nurse in next 6 days)
S- tress confidentiality and privacy
T- herapeutic environment

*The start of TERMINATION PHASE: Good morning, full name, RN, shift, session, date start and end
 C. Working phase
Problem: EMOTIONAL ATTACHMENT
Goal: RN (explore); Patient (verbalize)
Transference – Patient to Nurse; Countertransference – Nurse to Patient

S-elf concept (encourage independence)

O-rganize SUPPORT system (how family,society?)
L- ead to plan of action
V-erbalization of FEELINGS
E-mcourage independence
R-ealistic goal setting

*most difficult phase

*longest phase

D. Termination phase
R-egression is common (kasi maghihiwalay na)
I-ncrease independence (kaya niya magisa)
P-romote slef-care (should be able to take care of self)
E-nvironmental support need

*S/sx: regression: temper tantrum, thumbsuck, apathy, fetal position

COMMUNICATION

 Exchange of info bet 2 or more person

 Sender (encodes message); Receiver (decodes)
 Successful if may FEEDBACK

ESSENTIAL for THERA-COMM BARRIER to THERA-COMM

 Genuineness  Belittling
 Respect  Interrupting/ Ignoring
 Empathy (understanding what they feel)  Giving advice
 Attentive listening (may proper feedback)  Social response (that is improper)
 Trust (rapport)  Changing the subject kasi uncomfy sa subject
 Approving/ disapproving
 Moralizing

NON VERBAL COMMUNICATION

1. Kinetics Body language

Facial expression, poise, posture, gait, movement
Reflects MOOD
2. Proxemics Distance bet sender and receiver
a. Intimate distance – up to 18 inches
b. Personal space -18 inches to 4 ft
c. Social space – 9-12 ft
d. Public space- beyond 12 ft
Remember PEPSI: P - ersonal space E - lectronic - P - ublic S - ocial space I- ntimate distance
3. Paralanguage  Vocal cues: tone
 4. Touch  Shows attempt to connect or relate
 Can be therapeutic and non-therapeutic

5. Silence  Encourage verbalization

THERAPEUTIC TECHNIQUES

1. Clarifying
 Im not sure I understand what you are trying to say

2. Exploring  Tell me more….


3. Giving broad opening / asking  Is there something you’d like to do
open ended question
4. Accepting  Yes, that must been difficult for you
 Acknowledge pt feeling

5. Acknowledging or giving
recognition

6. Asking direct questions  How does your wife feel about your hospitalization?

7. Informing  I’ll be your nurse today, from 7- 10 pm

8. Making observation

9. Reflecting  You acknowledge the FEELING of pt.

 Client: I do not want those med!
Nurse: You seem unhappy taking med
10. Restating (shorter)  Client: I cant sleep, I stay awake all night
Nurse: You cant sleep at night
11. Summarizing  Highlight important points
 “ during the last our we talked about.,..they include…
12. Using silence
13. Voicing doubt  Acknowledge feeling
 “ I find that hard to believe….”
14. Supportive Confrontation

NON THERAPEUTIC

Defending
Belittling  Feeling are invalidated
 Nurse: Don’t be concerned, everyone feels like that

False reassurance  N: Don’t worry everything will be alright

Judging  N: It’’s your own mistake

STRESS

 state of physical and emotional imbalance (Disequilibrium ) in response to threats, challenges, demand, unmet
needs and lack of resources, unsolved problems

GENERAL ADAPTATION SYNDROME (GAS) RESPONSE TO STRESS

STRESS MANAGEMENT 5 A’s

 AVOID the stressor

 ALTER the stressor (change mo ang approach sa stress)
 ACCEPT the stressor
 ADAPT to the stressor
 ADOPT a healthy lifestyle

ANXIETY DISORDERS

- Anxiety – fear of the unknown

GENERAL ANXIETY DISORDER

Level of Anxiety
Mild (+1)  Known as +1 level of anxiety
 Has inc attention span
 Widened perception (5 senses)
 Higher level of thinking
 Restless (stationary)
 Walang nangyayari sa RR, HR
 Mgt:
 “You seem restless”
 Problem solving

Moderate (+2)  + 2 level of anxiety

 DEC attention span
 Pacing back ang forth
 “NAVDA” happens
  Nausea
 Anorexia (loss appetite)
 Vomiting
 Diarrhea and urination
 Abdominal butterflies
 Mgt:
 Problem solving
 Prioritized SAFETY
 Give PRN meds – kasi baka magprogress to severe – panic

Severe (+3)  +3 level of anxiety

 Ito na ang problem
 INC HR, RR, dyspnea
 DON’T know what to do, & say  the pt. verbalizes “I DON’T
KNOW WHAT TO DO ANYMORE”
 DEC visual perception
 Mgt:
 Directives from nurse – dahil di na alam ni pt. gagawin niya si
nurse na magdedecide
 SAFETY
 PRN med

Panic (+)  + 4 level of anxiety

 Suicidal
 HARM others
 Chest pain
 Syncope
 DISPLACEMENT – defense mechanism
 Tunnel vision
 Mgt:
 Do NOT touch pt.
 DEC the environmental stimuli
 SAFETY
 NURSE – will be ang THERAPEUTIC MILEU manager’

Med: Anxiolytics – potentiate GABA (pagmeron nito binabalance niya ang other neurotransmitter)

DOC: Benzodiazepines, Azapirones

 “Lam” “Pam” drugs

 “rone”
 Midazolam, Alprazolam, Diazepam, Clonazepam (shortterm)
 Buspirone (for long term), Ipsapirone

Antidote: Flumazenil (Romazicon)

SE: Anticholinergic SE

 Can’t see (blurry vision)

 Can’t spit (dry mouth)
 Can’t sweat ( dec perspiration)
 Can’t pee ( urine retention)
  Can’t shit (constipation)

ANXIOLYTIC DRUG
- Given for ANXIETY and SEIZURE
a. Benzodiazepine - sedative
b. Barbiturates- sedative
c. Buspirone – do not sedate

1. BENZODIAZEPINE
 Take effect in few minutes (fast acting), BUT loose effect immediately
 Has SEDATIVE EFFECT
 Taken only in LESS than 1 month kasi highly ADDICTIVE
 “PAM” and “LAM”
a. AlprazoLAM
b. MidazoLAM
c. TemazePAM
d. ClonazePAM

SE: SEDATION – everything is LOW and SLOW  low HR, RR, sedation

 Given for ANXIETY, SEIZURE, also ALCOHOL WITHDRAWAL, SEDATION

 Increase GABA which DEC the activity of NEURONs

Note:

 Taken at BEDTIME  due to SEDATIVE EFFECT

 DON’T skip dose
 DON’T stop abruptly- taper off if magsstop
 NO ETOH
 DON’T operate machine/drive
 ANTIDOTE BEnzo: Flumazenil
ANTIDOTE Opoids: Naloxone (NArcan)
 Highly addictive and hard to come off – NOT safe for long term use

2. BARBITURATES
 Used as TRANQUILIZERS
 End in “BARBITAL”
a. Phenobarbital

SE: Low and SLOW din ang EFFECT

Note:
  Last LONGER in BODY; take LONGER to get out of body (3-5 days)  high risk for toxicity  hypotension, respi
depression, death
 GVEN for ACUTE Anxiety – same w/ benzo
 Highly addictive like benzo

3. BUSPIRONE
 Doc for Generalized anxiety ds

 NOT SEDATING  still can drive, operate machine
 It’s ATYPICAL ANXIOLYTIC
 No depressant effect
 Can continue normal life

Note:

 Will take effect 2-4 weeks (slow) for full effect and easy to quit
 Has NO withdrawal problem
 NO SEDATION
 NOT addictive, NO dependence, NO tolerance
 SAFE for LONG- TERM USE
 NOT for ACUTE ATTACKS

Education:

1. Can still have NORMAL life (drive, operate machinery)

2. Not for ACUTE attacks – taken at regular basis
CRISIS and CRISIS INTERVENTION

CRISIS – (difficult situation ) when coping mechanism are ineffective that results to disequilibrium  anger, despair,
disbeliefs, shock

TYPES OF CRISIS

Situational - caused by unexpected event (Loss of a job /

starting a new job, Death of a loved one)
Adventitious / Social - caused by natural catastrophe (earthquake, fire,
tornado)
Maturational / Developmental - caused by expected events (menarche, marriage,
pregnancy, retirement)

Duration of Crisis: 4 – 6 weeks (crisis is self-limiting)

Goal: To HELP pt. RETURN to PRE-CRISIS LEVEL

Focus: Here and Now (Gestalt Therapy) – focus on what’s present concern / problem now

Approach:

 Directive – promote problem solving

 Supportive – encourage expression

PHOBIA

- Illogical, intense, and persistent fear of specific object or social situation

- Similar ang s/sx to panic attack

AGORAphobia - Fear of place (GORA na us sa place)

SOCIALphoboa - Social and performance situation fear
SPECIFIC / SIMPLE / COMMON ACROphobia – heights
phobia ARACHNOphobia – spider
ASTRAphobia – thunder and lightning
AUTOphobia– being alone
CLAUSTROphobia – enclosed space
OPHIDIOphobia - snakes

Defense Mechanism: DISPLACEMENT and AVOIDANCE

Mgt

 CBT (cognitive behavioral therapy)

 Flooding – sudden exposure to fear obj
 Systematic Desensitization – gradual exposure sa feared obj
1. Let pt think about and talk about it

PTSD and ACUTE STRESS D/O

- Same lang
- Fear of past (war, sex assault, car accident etc)
 Acute Stress Disorder (ASD) - Mental d/o that occur within 1st month ff
traumatic event
- less than 1 mo

PTSD - persist over 1 mo

S/sx:

 severe- panic anxiety

 nightmares
 flashback (happen when gising) – AVOID reminding them the trauma; safety; explain that sx are normal

THERAPIES

Psychotheraphy  Also called talk therapy is a way to help people with a broad variety of
mental illnesses and emotional difficulties.
 Psychotherapy can help eliminate or control troubling symptoms so a
person can function better and can increase well-being and healing.

CBT - Cognitive Behavior Therapy
 CBT is a common type of psychotherapy (talk therapy).
 It helps clients reframe their thought processes in order to slowly cope
with stress & anxiety, helping to treat many disorders from PTSD & OCD,
to eating disorders like anorexia & bulimia, and even depressive
disorders.

Guided Imagery  Guided imagery is a mind-body intervention where clients concentrate on

mental images to help reduce stress, anxiety, & improve concentration.
 Done by med professional ; papapikitin at papaisipin ng good and guiding
thoughts

Group Therapy  Open forum (pero not effective if no professional)

 Goal: reduce ISOLATION and COMMUNICATE acceptance
 Problem: allow group to talk about issues
 Family therapy, Alcoholic Anonympus
Catharsis  releasing repressed emotions thru art and music

Others:
Defusing – providing education on stress and stress management
Debriefing – client is asked about their emotional reaction to an incident
Exposure therapy – confronting trauma associated thoughts rather than avoiding
Adaptive closure therapy (empty chair technique)

Therapeutic Milieu  provide a safe and secure ENVIRONMENT

 Ex: Suicidal pt  place on semi-private room, near Nurse Station
PERSONALITY DISORDER

 A personality disorder is a way of thinking, feeling, and acting that goes against what people in the culture
expect, causes distress or makes it hard to function, and lasts for a long time.
 PERSON is UNAWARE OF PROBLEM
 Personality disorders are ego-sync, which means that the person who has the disorder might not think they
have a problem

 Has 3 clusters
 Unaware that they are problem to others
 STRAINED relationship is a PROBLEM
 Risk for injury  SAFETY precautions
 Use MATTER-OF FACT approach (be true to them and SET limits)
 We must PREVENT transference and counterference

TRANSFERENCE = pt to nurse
COUNTERFERENCE = nurse to pt

WILD

WEIRD WORRIED

NARCISSISTIC PERSONALITY D/O  They believed na PERFECT sila

Mgt:
PARANOID PERSONALITY D/O
 Acts ENTITLED, arrogant, grandiose
 Relies on CONSTANT REINFORCEMENT and need for ADMIRATION =
attempt to maintain self esteem
 Mataas ang SELF-ESTEEM
 Arrogant, common in MALE; pa-victim
 Set limits
 DISTRUST and SUSPICION of others
 JEALOUS
 Has intense need to CONTRO environment
 Defense mechanism: PROJECTION
 Nursing Dx:

HISTRIONIC PERSONALITY D/O
Note:
DEPENDENT PERSONALITY D/O
BORDERLINE PERSONALITY D/O
Note:
ANTISOCIAL PERSONALITY D/O
AVOIDANT PERSONALITY D/O
SCHIZOID PERSONALITY D/O
 Risk for INJURY to self and others
 Dec ang SELF-ESTEEM  they need VALIDATION of others
 CENTER of attention
 EXAGGERATED or shallow emotional expression
 Little tolerance for FRUSTRATION and demand gratification
 OVERLY friendly and flirtatious
 SEXUALLY seductive – pede nila pakita legs nila ex. For personal gain
 common in female: attention seekers
 Extreme dependency in relationship and fear separation
 CO-DEPENDENT behavior: ex battered wife syndrome (yung di maiwan
ang lasengong asawa example)
 UNABLE to decide on their OWN
 May attachment ISSUES
 It PROGRESSES
 Fear of being ABANDONED
 Uses MANIPULATIVE BEHAVIOUR
 Love to manipulate people to get what they want
 CLING to 1 favorite staff member
(Mgt: assign DIFFERENT nurse)
 SUICIDAL (ex. Pag-iniwan mo ako magpapakamatay ako)
 SELF-mutilation happen
 common in psych facility; due to suicidal thoughts; unstable ang emotion
 LAW breakers, rule breakers (criminal)
 They lie, cheat, steal, kill
 GOOD talkers and charming “bad boy effect”
 IMPULSIVE, manipulate other for personal gain
 LACKS emphaty
 SEXUALLY experimentative
 Has DEC self-esteem (EXTREMELY SHY)  AVOID people
 SHY, timid, INFERIORITY complex
 Avoid open forum
 Over sensitive to rejection/criticism
- They are usually talented but hide it
 Had HIGH self esteem
 “ I don’t want people” – AYAW sa TAO –
 DETACH FROM SOCIAL RELATIONSHIP
 BELIEVES he can stand on HIS OWN
 NEVER had a BESTFRIEND

SCHIZOTYPAL PEROSNALITY D/o
 Avoid group and social activities; no enjoyment
 CARE more about computer and pets
 Withdrawn and alone
 SPECIAL POWERS
 MAGICAL thinker
 Weird ang thinking

CONDUCT D/O

- Antisocial sa kabataan = <18 yrs old

ANTISOCIAL D/O

- Above 18 yrs old

OBSESSIVE-COMPULSIVE PERSONALITY D/o and OBSESSIVE-COMPULSIVE DISORDER

- OBSESSION= excessive thoughts and impulses

- COMPULSION = repetitive behavior, rituals
- Malakas ang super-ego

OCPD  Unaware sa problem

 Has obsession and compulsion but UNAWARE
OCD  Aware sa problem nila
Ex. Na-lock ko ba ang pintuan – ay di ko pala nalock!  anxiety
 Has obsession and compulsion but AWARE

Mgt:

D- istract/divert the activity to productivity (2nd)

 Ex: if hugas ng hugas ng kamay divert mo sa pagwawash ng dishes
I – nitially ALLOW rituals (1st thing to do)
 Never STOP the rituals
E- ngage in verbalization of feelings (3rd)
 Group therapy
S- et limits, NOT stopping rituals (4th)

Tx:
 CBT – change behavior
 systematic desensitization = gradual exposure dun sa nagcacause ng anxiety

DISSOCIATIVE IDENTITY DISORDER

 occurs when 2 or more identities rotate control over client’s behavior

 nagawa ka ng bagong identity  amnesia, confusion, memory gap  multiple personality d/o

Mgt:

1. STAY with patient

2. GATHER data about pt (ex kung sya si kevin that time – ask mo si kevin)
3. DO NOT present all data, avoid FLOODING
4. EXPLORE stressors
5. ASK pt to relate the event  do JOURNALING
6. LOOK for effective coping
SOMATIC SYSTEM DISORDER

 Psychological d/o where clients have UNEXPLAINED physical symptoms like abd pain, weakness, chest pain, SOB
etc
 Symptoms is REAL to patient ( pero wala sya MEDICAL CAUSE)
 Dx and lab test result is NORMAL

3 SOMATOFORM D/O

 Imagined (occur in mind and manifest sa body)

CONVERSION D/O  Loss of FUNCTION of organ

 Ex: malipit na may nagaaway – tapos nahimaty si lola
 Labelle – indifference/ unconcerned of the symptoms
BODY DYSMORPHIC D/O  Loss of an ORGAN
HYPOCHONDRIASIS  With physical symptoms, no organic cause

A. MALINGERING – faking illness; lying

B. FACTITIOUS – causing an illness (gumawa ka nan g sakit) ; ex. nagpaulan
ka para lagnatin
C. FACTITIOUS DS by PROXY (Munchausen’s Syndrome) – causing illness to
others

Mgt:

1. RECOGNIZE manipulation- priority

2. REAL to pt – so iacknowledge mo and ATTEND to physical complaints
3. Consistent caregiver must be provided
4. ENCOURAGE verbalization of feelings

Meds: Antidepressants (SSRI)

EATING DISORDERS

ANOREXIA NERVOSA BULIMIA NERVOSA

>> Fear of OBESITY >> known as BINGE and PURGE SYNDRME
>> Has problem with HYPOTHALAMUS >> binge eat followed by self-induced vomit
(thirst and hunger)

Pattern  Diet, diet, diet  Eat, eat, vomit

Weight  <85% of expected body  Normal Weight

Menstruation  3 mos AMENORRHEA  IRREGULAR mens

Assessment Remember: REFUSe

1. Refuse to eat/drink
2. Excessive exercise
3. Ferfectionist (perfectionist) –
dominant ang super-ego
4. Underweight ( 15% or less than IBW)
5. Signs and Sx Malnutrition
6. Ensure safety (suicidal) – meron
silang SLOW suicide
S/sx
Remember: BAD LIP  Hoarness of voice
 B-ony prominence  Enlarge parotid glands
 A-menorrhea  Average ang weight
 D-ry hair  Russel’s sign – callus sa knuckles
 L-anugo  Tootchache – dental caries
 I-mbalance  Halitosis
 P-oor skin turgir  Met. Acidosis and Alkalosis
 Enema’s, diuretics and diet pills are
taken by this people

Mgt
1. Always Physiologic needs first!!!!
2. Fluid and electrolyte imbalance
3. After eating stay with the client for 1
hour and accompany when going to
the comfort room
4. Meal contract
 Plan meals with clients
 Set limits during meals
 Recognize manipulation (ex.
natapunan yung food – change it)
 Supervise pt during meal
5. Weight gain for the client –>
determinant factor na ok na si pt

DOC: Antidepressant: TOFRANIL

 Given sa A.N  weight gail
 Given sa B.N  dec bulimic episode
NEURODEVELOPMENTAL DISORDERS

Autism Spectrum Disorder

 A DEVELOPMENTAL disorder that impairs child’s ability to communicate and interact

 Cause: UNKNWON

S/sx:

 NO eye contact
 DON”T interact with gestures
 Like being cuddles and plays ALONE
 Respond to questions
 Display NON-VERBAL behavior
 DELAY language development
 REPETITIVE actions (ritualistic behavior) and WORDS (echolalia)

Mgt:

- ASD want consistency and routine

1. Provide safety - Increased risk for injury
2. Structured environment – provide place to study, eat, play, bath etc
3. Schedule – time for everything
- Wag itime out kasi nagtatntrum sila because of nagulong environment
4. Set limits
5. PREVENT OVERSTIMULATION
>> Limit number of visitors & choices
>> Private room away from the nurse’s station
6. Give a written schedule of daily activities NCLEX TIP
7. Aggressive behavior: distract the child & ask them to blow up a balloon

Communication

a. Eye contact first (before speaking)

b. Simple language
c. Child repeats back what was said
d. Offer praise upon task completion

Management:

a. Expressive therapy drawing, muscic etc

b. Enhanced communication
c. Improved social interaction
d. Safety

DOC: Antipsychotics: HALDOL (pampakalma nila)

ADD/ADHD

ADD- attention deficit d/o (old term)

ADHD- attention deficit hyperactivity d/o

 Low level ang DOPAMINE and NOREPINEPHRINE na tumutulong sa brain focus ( dec attention span)
 It make ADHD pt more likely to have ANXIETY and SUBSTANCE ABUSE
 Dominant ang ID (gagwin ang gusto gawin) – Mom and Rn should act as super-ego
 Onset: 7 yo and below
 Duration: 6 mo above
 Settings: detected sa house or school

Causes & Risk Factors

a. Head trauma: TBI (traumatic brain injury)

b. Children who have had a serious head injury are more likely to develop ADHD later on in age.

S/sx:

 Hypercactivity “restless”
 Inattention
 Impulsiveness “excessive talking; padalos dalos ang act
 Low self-esteem & impaired social skill

Mgt

Meds: mga controlled shabu

- Best given: Once a day; after meals – prevent loss of appetite; 6 hrs prior to bedtime if BID
- Wag ibigay at bedtime (stimulant kasi)  will cause INSOMIA
 Methylphenidate
 Amphetamine (Ritalin, Adrenal)
 Dextroamphetamine Stimulants

Key Points:

 Given to treat: ADHD in children & adolescents & even narcolepsy

 Priority nursing assessment
 Monitor BP
 Monitor and report HEIGHT, WEIGHT trends with HCP
 Reveral Agent: Alprazolam ( Anxiolytics) – potentiate GABA

NEUROTRANSMITTERS

1. Dopamine/ Epinephrine/ Norephinephrine = are EXCITATORY

2. Serotonin –
>> Synapse = space bet. neuron and muscle cell
 If SEROTONIN is na-reuptake ang go to neuron and muscles cells – nagiging INHIBITORY
 Pero if nagstay sa SYNAPSE – nagiging EXCITATORY
3. GABA – Gamma-Aminobutyric acid
 GABA balance other neurotransmitter
PSYCHOTIC DISORDERS

SCHIZOPHRENIA

 A long-term mental disorder involving a deteriorating breakdown in the relation between thought, emotion, and
behavior.
 The earlier the onset, the worse the prognosis.

Causes: unknown

Possible Cause

1. Genetics
>> 1 biologic parent = 15% risk
>> 2 biologic parent = 35%
>> Identical twin = 50%
2. Neuroantomic/Neurochemical
>> Low CSF
>> Low brain tissure
>> inc dopamine
3. Immunovirologic
>> meningitis
>> encephalitis

POSITIVE SX = Psychotic sx: clear sx; visibly displayed

1. Hallucinations a. Tactile hallucination = being touch

- Hear, see things b. Auditory hallucination = hear voice
- Best action : PUT earphone/ music / tv
2. Delusions  Delusion of reference
- False belief  Delusion of control
 Delusion of grandeur
 Persecutory (paranoid) delusion
3. Thought/speech disturbance 1. Loose association=flight of ideas; rapid shift of thought w/p
logical connection
2. Neologism = made up WORDS
3. Clang Association = rhyming words
4. Word salad= mix words with no meaning
5. Concrete thinking = taking statement LITERALLY
6. Tangentiality= speaking unrelated topics that do not relate to
what was asked/ main discussion
7. Echolalia = repeat words other says
8. Perseveration= repeat same word/ phrase when answering
different questions

NEGATIVE Sx= Negative state; non-active sx; Lack of emotion and facial expression

A-ffect flat blank look (blunt affect)

A-nhedonia lack of pleasure
A-pathy and Avolition lack interest or motivation
A-logia poor speech
A-nxiety and Avoids social interaction
Psychomotor Disturbances – may problem sa movement

Remember: “PAWER”

Posturing  movement intended to impress

Apraxia no movement
Waxy Flexibility maintenance of awkward position
Echopraxia imitating movement
Rigidity stiff and inflexible

Automatism – repetitive purposeless behavior

Mood/ Affect Disturbances

Remember: “ ABA DD FIMALE”

Flat speech can’t express vocally what they feel

Inappropriate affect
Melancholia sobrang malungkot (deep sadness)
Alexithymia inability to recognize own emotion
Labile moody
Euphoria extreme happiness
Apathy lack interest / motivation
Blunt affect SUDDEN dec of emotion
Ambivalence two opposing emotion
Derealization strangeness towards one’s environment
Depersonalization strangeness to oneself

Disorganized Speech and Thought

Loose associations rapid shift of thought with NO logical connection

Flight of ideas rapid shift of thought WITH logical connection
Neologisms making up imaginary words; NEOW words
Clang associations listing RHYMING words together that make no sense
Word Salad MIXING words together that have no meaning except to the client
Concrete thinking taking a statement LITERALLY
Tangentiality speaking of unrelated topics that do not correlate to the main
discussion
Echolalia REPETITION of words they hear from someone else
Perseveration repeating the same words and phrases when answering different
questions
Verbigeration repeating phrases (nastock ka sa same phrases)
Stilted language FlOWERY words
Illusion false perception of actual external stimuli – WITH STIMULI
Hallucination false sensory perception in the absence of external stimuli – NO
STIMULI

Types:

1. Psychedelics (Visual)
2. Formication ( touch) – ex. feeling na may gumagampang
3. Auditory – command
4. Gustatory – ex. spontaneous dysguesia (wala ka nilagay pero
may nalalasahan)
5. Olfactory – ex. Phastomia ( ex naaamoy mo parin yung bomba
kahit wala na)

Synysthesia - mixing of senses (ex. natatast mo ang music)

Mgt:
Remember: “HARDER-T”
 HALLUCINATION must be recognized
 ASSESS content – in auditory hallucination and other
hallucination
 REALITY presentation
 DIVERT attention
 ENGAGE in reality based activity (ex. may naririnig is pt – put
him sa place with no stimuli)
 RE-INTEGRATE with the milieu (ex. tanggalin mo ang
nagcacause ng hallucination like radio etc)
 TALK BACK TO VOICES – para labanan niya yung voices that
commands
Delusion Fixed-false belief that is inconsistent with one’s knowledge and culture

Common types:
1. Delusion of reference: belied that TV, newpaper, music have
special meaning for him
2. Delusion of Control: belief na controlled ka by higher people
3. Delusion of Grandeur:
4. Persecutory (Paranoid) delusion: belief that others are planning
to harm you
Other types:
1. Religious Delusion: central theme ofteh center on 2nd coming of
Christ or other prophet
2. Capgras’ syndrome: theme is significant other has been
replaced by and identical impostor
3. Dorian Gray – theme is lahat nag-aage except you
4. Jealous Delusion: central theme is UNFAITHFULNESS of spouse
or lover
 5. Erotomanic delusion: belief na pt is loved intensely by the loved
object (who’s usually married, on a higher socio-economic stat,
or unattainable) – ex. asawa ako ni jungkook

Mgt
Remember: “CAVE”
 CLARIFICATION of meaning
 ACKNOWLEDGE the feeling
 VOICE doubt – pero acknowledge mo muna si pt
 ENGAGE in reality-based activities

Note: Illusions and hallucinations can be visual, tactile, auditory, gustatory, or olfactory is inconsistent with

CLASSIFICATION OF SCHIZOPHRENIA

DISORGANIZED aka Hebephrenic Essential features:

 Characterized with inappropriate behavior: Silly crying, laughing,
regression, transient hallucinations (Auditory)
 Defense Mechanism: Regression
 Anal Fixation

Goal: provide nutrition, hygiene, safety

PARANOID SCHIZOPHRENIA  Presenting sign is SUSPICIOUSNESS, ideas of persecution and

delusions.
 REMEMBER the 4 P’s:
 Projection (#1 defense mechanism),
 Proxemics ( 7 feet away from the patient – social space)
 Passive Friendliness (#1 attitude therapy: No touching, , no
whispering & laughing)
 Persecutory delusion (#1 delusion of Paranoid Schizophrenia)

Plan of care:
a. Focus on REALITY and REINFORCE it verbally
b. ACKNOWLEDGE pt feeling
- Focus on reality, and client feeling- do not explore delusion

Nursing Diagnosis: Alteration in nutrition: Less than body

requirement Nursing
Goal: to meet the patient’s daily nutritional requirements
Nursing Interventions:
a. Do not force patient to eat foods that he refuses
- pag-ayaw kumain better to throw it nalang; wag mo itatry
for him
b. You may do any of the following:
1. Allow client to buy foods
2. Allow client to prepare his own food
3. Offer packaged foods except canned food
● Develop trust
● Involve the client in planning
● SEALED CONTAINER (for food and medicine)
● Avoid staring, whispering, and giggling
 ● Respect personal space (not less than _______)
● Maintain professional tone (use simple, direct, concise words)

Nursing Diagnosis: Non-compliance with therapy

Nursing Interventions:
a. Explain to the client the reason for administering the drug
b. Administer drugs in the same form always (if binigay mo ng
tablet at first – give it on tablet always)
c. Do not hide tablets in foods
*To inspect is drug taken – check tongue, buccal – stay with pt in
next 15-30 mins

CATATONIC SCHIZOPHRENIA  May movement disorder

Essential features:
 psychomotor disturbances
a. waxy flexibility (cerea flexibilitas) - immobility
b. Rigidity
c. Posturing
d. Negativism (severe)
e. Mutism (Mute)
 Defense Mechanism: Autism and mutism

CATATONIC CHARACTERISTICS
- Catatonic stupor – markedly slowed movement.
- Catatonic posturing- bizarre or weird positions
- Catatonic rigidity – cementation/stone-like position
- Catatonic negativism – resistance towards flexion & extension
- Catatonic hyperactivity or excitability

Priority: Fluid and Nutritional Intake – dahil high rish for DHN and
Malnutrition

UNDIFFERENTIATED or MIXED  Symptoms of more than one type of schizophrenia

SCHIZOPHRENIA  The #1 drug of choice is Fluphenazine (Prolixin decanoate)
RESIDUAL SCHIZOPHRENIA  No longer exhibits overt symptoms
 no more delusions but still has negative symptoms

ANTIPSYCHOTICS

 These are medications, also known as neuroleptics, which are used to treat the symptoms of psychosis such as
the delusions and hallucinations seen in schizophrenia, schizoaffective disorder, and the manic phase of bipolar
disorder.
 Works by blocking the receptors for the neurotransmitter: Dopamine

Common Examples

1st Generation Antipsychotics:  Typical: end in “zine” , “dol”

 Chlorpromazine (Thorazine), Haloperidol (Haldol)
 Has inc risk for EPS
 Cheaper

Notes:
a. High potency
 - HA-NA-PRO-STELA
- Haldol, Navane, Prolixin, Stelazine
b. Low potentcy
- THO – SE-TA- ME
- Thorazine, Serentil, taractan, Mellaril (limit 800mg/day) 
Pigmentary Retinopathy (blindness)

HALOPERIDOL
- Long acting
- Given IM once a month
- For pt na COMBATIVE, SUICIDAL, NELY ADMITTED = give
Haldol + Lorazepam

2nd Generation Antipsychotics:  Atypical ; ends in “ done” and “zapine”

 Clozapine (Clozaril), Risperidone (Risperdal), Quetiapine
(Seroquel) Olanzipine (Zyprexa)
 Has dec risk for EPS
 Risk for Agranulocytosis (report infxn)

Note: Atypical Antidepressant -- > Mas lesser ang SE

Trazodone- sleep aid and tx depression
 Make pt sleepy and sedated
 AVOID alcohol and other sedatives (benzo ,
antihistamine)
 Take at NIGHT
 Can cause ORTHO HPOTENSION  so slow position
change
 RARE COMPLICATION : PRIAPRISM
- If erection last >4hrs  report
Bupropion
 For DEPRESSIOn and aid to STOP smoking
 SE: insomnia; headache; weightloss
 XL (extended release) SR (sustained released) = never
crush, never chew , never cut --SWALLOW lang w/ or
w/o food
 Chewing or crushing  faster absorption  high level of
drug can be inc  SE will also INC

New Generation (Dopamine System  Also Atypical; ends in “zole”

Stabilizers)  Aripiprazole
 Dec risk for EPS; Dec risk for Agranulocytosis
 Expensive
Note:

*Decanoate

 given IM
 effect is 3-4 weeks  reduce risk sa non-compliance
 Remember: AVOID alcohol and drug-drug interaction

S/E: of Antipsychotics

1. Anticholinergic SE : CAN’T see, pee, shit, sweat

2. EPS (extra pyramidal syndrome) – no. 1 SE; temporary only
Remmenber: “PAA”
>> PSEUDOPARKINSONISM – but it’s a false parkinsonism
>> ACUTE DYSTONIA – dysphagia, drymouth, rigidity (risk for aspiration)
>> AKATHISIA- anxiety, agitated, restless

Action: Notify Physician, DO NOT discontinue the drugs

Mgt: MD will usually lower the dose or shift to another gen of drug

ANTI-EPS : “CABA”

 Congentin
 Artane
 Benadryl
 Akineton

Note: EARLY detection  early management

3. NEUROLEPTIC MALIGNANT SYNDROME – deadly

>> Hyperthermia
>> HTN Seizure  Death
>> Muscle Spasm

Action: DISCONTINUE medication

Mgt: Baclofen (muscle relaxant), Antipyretic

Prevention: Hydrate the pt para walang toxicity

4. Tardive Dyskinesia – not deadly BUT lifetime na

>> tongue protusion
>> teeth grinding
>> lip smacking

Action: Notify MD
Mgt: Valbenazine (Ingrezza) – to dec sx
Prevention: Start sa LOWEST dose
5. Other S/Sx
>> Photosensitivity – so AVOID direct sunlight, use umbrella / sunglasses, apply SPF 25 lotion
>> Arrythmias – report abnormal heart beat
>> Weight gain – lessen intake of SUGARY food and beverage
 >> Sedation – AVOID driving and OPERATING Machineries

DEFENSE MECHANISM

- Use to protect ego and decrease anxiety

- Happen to protect your EGO kasi di mo matanggap ang reality  anxiety

DISPLACEMENT  TRANSFER feeling to LESS threatening OBJECT rather than one who provoke it
 Ex. Pinagalitan ka- tas sinuntok mo ang pinto
 Seen sa may PHOBIA

DENIAL  FAILURE to acknowledge the TRUTH

 # 1 D.M of ALCOHOLIC and DIABETIC
 Mgt:
>> setting matter of fact approach

DISSOCIATION  Psychological FLIGHT from self (nagawa ng bagong identity)

“switching of another  A type of AMNESIA
identity”

REGRESSION  Returning to earlier developmental stage

 Ex: thumb-sucking; Fetal positioning; Pouting of lips; Baby talking

REPRESSION  UNCONSCIOUS forgetting of an anxiety provoking concept

SUPRESSION  CONSCIOUS forgetting

Ex: nagtanungan ng scores – and you received LOW grade -> tas sinadya mo kalimutan ang
score mo

SUBLIMATION  Placing SEXUAL energies toward a more productive endeavors

 DIVERT negative/ unacceptable desire into ACCEPTABLE way
Ex: person is aggressive  nagBOXER nalang

RATIONALIZATION  Nagdadahilan
 Illogical reasoning for socially UNACCEPTABLE TRAIT

REACTION  Doing OPPOSITE of your intention

FORMATION  PLASTIC
 D.M of DEPRESSED PT.

UNDOING  Doing the OPPOSITE of what you have done dahil ng GUILT
 Alam mo na may mali kang ginawa pero may ginawa ka to ease yung mali mo
Ex. Dinapa mo yung tao  pero due to guilt ikaw parin nagdala sa hospital
Ex. Ngacheat  he gives you flowers
IDENTIFICATION  Assume trait for personal, social, occupational role
 GINAGAYA mo ang tao dahil model/idol mo sya

PROJECTION  Attribute to others one’s Unacceptable trait

 NANINISI ng iba

INTROJECTION  Assume ANOTHER person trait as your own

 UNCONSCIOUS adopting kasi lagi mo kasama yung tao

CONVERSION  Strong emotional conflict which are NOT expressed are converted into physical sx

COMPENSATION  OVERACHIEVEMENT IN one area to cover defective part

INTELLECTUALIZATIO  ACKNOWLEGING THE facts BUT NO emotion

N  AVOID expressing actual emotion by using intellectual process of logic / reasoning/
analysis
 Inaacknowledge ang facts and hinahide yung true emotion niya

SUBSTITUTION  Replacing difficult goal with a MORE accessible one

 Anxiety reduced by replacing the UNACHIEVABLE goal with ACHIEVABLE goal

SPLITTING  Seeing someone as either GOOd/Bad (Black or White)

IDEALIZATION  The action of regarding or representing something as perfect or better than reality
 You present things perfect kahit di naman perfect
MOOD DISORDERS

BIPOLAR BIPOLAR 2 MANIC MAJOR D/O CYCLOTHYMIA DYSTHYMIA

1 D/O
- Bipolar-liked - Minor
d/o pero No depression
extremes - Sad for 2-3
(walng yrs
hallucination
etc)

Mania
- May Hypomania +
Hallucination +
delusion + illusion

Hypomania
- Has euphoria,
hypeactivity,
restless, inc sex
drive

NORMAL

Hypo Depression
- Excessive
loneliness,
hopelessness,
empty, anergia

Major Depression
- Hypo Dep + suicide
thoughts/attempt

DEPRESSION

 Major Depressive Disorder (MDD) also called clinical depression is when a client experiences a severe depressed
mood, loss of enjoyment in life, low energy & few other critical signs and symptoms.
 Pathophysiology: Everything is low & slow, it is thought to be from low levels of neurotransmitters within the
brain.

CAUSE: Neurotransmitters is LOW

1. Low Serotonin
2. Low Dopamine
3. Low Norepinephrine

S/sx

Diagnosis: 5 or more symptoms  5/9 sx is (+) for depression

1. Depressed mood (hopeless, empty)

2. Anhedonia (loss of joy/ interest in life)
3. Weight loss (anorexia) or Wt. Gain
 4. Psychomotor retardation or Agitation
5. Insomnia (no sleep) or hypersomnia (sleeping too much)
6. Fatigue (Anergia)
7. Feelings of worthlessness or Guilt
8. Difficulty in concentration
9. Suicidal thoughts (Recurrent)

Risk Factors

a. Stressful life event

b. Chronic illness
c. Genetics
d. Females
e. Substance abuse disorder

CRISIS = self limiting ; 4-6 wks only

1. Maturational/ Developmental crisis

- expected
- Getting married, menarche
2. Situational/ Social
- Unexpected
- Death (natural), breakup, divorce
3. Adventitious
- Extreme life events
- Murder, rape, witness a crime, act of terrorism

PEDIATRICS side note: 10-19 yrs old

a. Angry, aggressive outburst, vandalism, skip class

b. Weight loss/gain
c. Napping during day
d. Low self esteem (withdrawal)

Mgt for Depressed Client

1. Kind firmness
 Silence
 Offering self
 Engage then in social activities
 Motivate- remind client of timw when she felt better and was successful (make observation and
compliment)
2. Continuous 1 on 1 observation
3. Semi-private room (near nurse station)
 Remove harmful objects from room
 Supervise during meals
 Reassess: changes in behaviour (suicidal thoughts)
 Clear plans of future involving personal goals, fam, friends
4. Diet
 Small “frequent” meals
 High calorie foods & fluids
  Stay with client during meals
 Weekly weighing
ANTIDEPRESSANTS

1. SSRI – 1st line: safest

2. SNRI-
3. TCA- 2nd line
4. MAOI- 3rd line

*If resistant – ECT (electroconvlsive therapy)

* Antidepressant - Use in tx of major depressive illness, anxiety d/o, depressed phase of bipolar d/o and psychotic
depression

4 Rules

1. Pt will be at Inc risk of suicide

2. Slow onset, slow taper off (ang effect of antidepressant 2-4 wks; itaper mo din 2-4 wks)
3. NEVER mix
Ex. SSRI + St John’s Wort or MAOI + Antidepressant (TCA, SSRI, SNRI)  SEROTONIN SYNDROME
4. ALL antidepressant
 Dec BP  do slow position changes
 Cause change in weight (gain)

3 Major Groups and Common Examples

Tricyclic Antidepressants (TCA)

Remember: “ToSiEl” Action: prevent reuptake of NOREPHI and SEROTONIN (T- two
Examples: Imipramine (Tofranil), neutransmitter) increasing these neurotransmitter in body
Doxepin (Sinequan), Amitriptyline
(Elavil) SE:
a. Two-4 weeks ang onset and taper
TOfranil b. Check higher incidence of SE (ANTICHOLI SE)
NOrtryptiline  cardio toxic, blue urine c. Assess suicide
ELavil
SInequan Other Note
Severe complication : Cerebral EDEMA
Atropine sulfate = anticholinergic
- A preop drug for DRYING EFFECT
- Pre ECT Succinylcholine
TCA EDUCATION:
1. Use eyeglass and eyedrops
2. Give CANDY (sugarless), GUM, ICE CHIPS, WET
COTTON for drying mouth
3. Drink fluid – drying
4. Inc FIBER for constipation
Note:
- Orthostatic hypotension – slow ang position
change
(amitriptyline- amy trips on things)
- Urinary retention
(imipramine- inhibit peeing)
- Never take with MAOI
 (2 week ang wash out period)

Selective Serotonin Reuptake Inhibitors (SSRI) Action: prevent reuptake of serotonin increasing availability of
Remember: CeProXo serotonin in body
Examples: Fluoxetine (Prozac), Sertraline
(Zoloft), Citalopram (Celexa) For depression, anxiety and PTSD

SE:
a. Serotonin syndrome- inc Hr, BP, Confusion, anxiety,
tremors  seizure  death
b. Suicide risk watch out
c. Rigid muscle and restlessness (description ng
Serotonin sydrone)
d. 1-4 wks ang onset and taper off

Other Note
- Slow ONSET and Slow ang pag-TAPER
SE:
4 common SE that improved in 3 mo
1. Sex dysfunx
2. Sleeplessness –NO SEDATION but causes INSOMIA
3. Suicide risk
4. Serotonin SYNDROME
WHY: due to combination of SSRI +TCA = SEROTONIN
SYNDROME → CHOLINERGIC/ PNS EFFECTS
S/SX: Serotonin Syndrome
- Happen due to use of drug and vitamins that ic
serotonin level
- NEVER MIX SSRI with St. John, MAOI, Tramadol
 Sweaty & Hot+ Fever
o Not Cold & clammy
 Rigid muscle + Restlessness & Agitation
Tremors, Hyperreflexi, NOT decreased DTRs
 Inc Rate “Tachycardia”

Monoamine Oxidase Inhibitors (MAOI) Action: inc availability of NOREPI, SEROTONINE, DOPAMINE in
Remember: PaMaNa brain
Examples: Phenelzine (Nardil),
Tranylcypromine (Parnate), SE:
Isocarboxazid (Marplan) a. Massive HTN crisis risk
- inc headache, agitation
-DOC: PHENTOLAMINE
b. AVOID tyramine containing food  HTN crisis
>> no alcholol; wine
>> no chocolates
>> no preserved / ferment foods
>> no Avocado
>> no cheese; soy sauce; -beer, sausage, salami

c. OTC drug AVOID  HTN crisis

>> calcium
>> antacids
 >> acetaminophen
>> NSAIDS (naproxen , ibuprofen)
d. Other antidepressant AVOID  serotonin syndrome
>> X to St. Johns Wort
e. Inc suicide risk

Note:
- If med DON’T WORK after 2 weeks
1. Assess hopelessness, despair, suicide thought,
thought of self harm

SNRI - For depression and pain – pain like with NEUROPATHY

- Duloxetine and FIRBROMYALGIA
- Venlafaxine - DRUG: Duloxetine “DUALoxetine”
Educate:
- Help with CHRONIC PAIN and inc cleep in pt w.
Fibromyalgia

Note:

- Inc risk of SUICIDE esp TEENAGERS (monitor pt)

- SLOW onset and SLOW din ang pag-taper
- NEVER mix (don’t mix antidepressants and St. John’s WOrt)
- ALL PSYCH DRUGS  can dec BP (so slow position changes) ; wt loss
- INUUNA ang anxiolytics kasi inc ang energy pagnagantidep
- MAOI + Tyramine  HTN crisis (ANTIDOTE: phentolamine)

ECT (Elctroconvulsive Therapy)

- DONE if antidepressant has no effect

Indications

1. Severe depression
2. Tx-ressitant depression
3. Severe Mania
4. Catatonia

*Life threat priority: Monitor for aspiration and respi status

Pre-preparation for ECT

 1. Informed consent secure
2. NPO 6-8 hrs – para no risk for aspiration
3. Meds given before ECT
 Atropine  dry mouth, dec oral secretion dec risk aspiration
 Bartbiturate  has sedative effect
 Succinylcholine (Susu Ni Choline) – muscle relaxant; prevent seizure
Post-procedure

1. Side lying (lateral position)

2. S/E after procedure
 Confusion: most common
 Headache, dizziness
 Temporary memory loss : distinct sign  re-orient the pt
Mgt

 Seizures
1. Safety
2. Side lying
3. Side rails up
4. Stimulus must be decreased (no noise / light)
5. Support head with pillow AFTER seizure
 FIRST & TOP priority: Ensure a patent airway; side-lying; 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

Notes about ECT (di pa nalabas sa board)

Electric Current 70 – 150 volts

Duration of Administration 0.5 – 2 seconds

Frequency of Treatment 2 – 3 treatments weekly

Total Number of Treatments 6 – 12 ECT therapy

Side Effect: Seizure Lasts 30 secs. To 1 min. or slightly longer

( tonic – clonic / grandma seizure)

SUICIDE

Verbal Non-verbal
• I won’t be a problem anymore • Take this ring, it’s yours (giving of valuable)
• This is my last day on earth • Sudden change in mood
• I’ll soon be gone

Approach: Direct (Ex. are you going to kill yourself?)

Who will commit suicide?

“ SAD PERSON”

 Sex – Male (more successful)/ female (hesitant)

 Age – 15 –24 y/o or above 45
 Depression
 Patient with the previous attempt
 ETOH – ethanol – alcoholics
 Rirrational (Irrational)
 Social support lacking
 Organized plan greater risk
 No family sickness (wlang may sakit sa pamilya) ; terminal

Best Approach: Direct approach

Nursing Mgt: Close surveillance

Hospital area majority suicide happen at:

 Weekend (1-3 am SUNDAY)

 Weekend has less staff personnel
 Early AM everyone is asleep
 Endorsement time

BIPOLAR DISORDER

 Has 2 face
 Mania: “A mood disorder marked by hyperactive wildly optimistic state”
Depression: “The feeling of severe despondency and dejection”

Mania

 Mood is elevated, expansive, irritable to mask depression

 S/Sx

M – ood elevated D - epressed M – ore energy and mood swing

A – Grandiose delusion O – ut for suicide A –gitation
N – o need for sleep, eat W – on’t eat and sleep N- on stop talk & flight of idea
I – nappropriate behaviour N - egativistic I – nsomia
C – langing, vulgar A –ttention span lacking

 They wear extravagant

clothing – as RN gawa ka ng
something she can choose
Depression

 S/sx

Lethargy (mentally and physically)

Feeling worthless
Eat too much / less
Overwhelming sadness
Thoughts of suicide
Nursing Diagnostics

1. Risk/ Potential for injury directed to other or to self

2. Fluid volume deficit
3. Fluid and Electrolyte Imbalance

Mgt

1. Accept client; Reject the behaviour

2. Provide consistent care
3. Set limits
4. Distract and redirect energy (ubusin mo energy ni pt)
 No to competitiive sport
 Recommended: Dancing, Wlaking
5. Meet nutritional needs
 High calorie
 FINGER foods (potato chips, bread, raisin) and carry fluids
 ALL high caloric and high carb diet or ALL bakery products
6. Encourage rest: sedate PRN, short PM naps

Bipolar, Manic Medication: MOOD STABILIZING AGENT (Lithium)

 We only give ANTIPHSYCHOTICS sa Bipolar, Manic Pt if nag-mamanic sila hindi pagmay depression (Risperidone,
Haldol)
 LITHIUM is a form of salt
 Undergo the first kidney test and check for blood levels
 Therapeutic Level: 0.6 – 1.2 meq/L
 May anticholinergic SE (pero 3 lang: CAN’T see, sweat, spit) so may INC urination; may diarrhea
 WOF Toxicity: Tremors, Fine hand tremors
 HYDRATION is on normal limits (maintain normal salt and h20 intake para wlang toxicity)
 Hypothyroidism – inhibits thyroidal iodine uptake
 Effect of lithium: seen 2-4 wks
 Other drug given: VALPROIC ACID – an anticonvulsant ; for manic pt

Other Notes
BIPOLAR, MANIA DRUG

CARBAMAZEPINE - Tx trigeminal neuralgia (neurophatic pain)

Has inc risk for INFXN
Report FEVER and SORE THROAT
- TERATOGENIC drug
ORAL contraceptive is INEFFECTIVE so need ng ALTERNATIVE birth control

VALPROIC ACID - LIVER toxic – monitor JAUNDICE and LIVER LABS (alt and ast)
- Can cause LOW PLATELETS (thrombocytopenia) – bleeding risk
- DON’T discontinue ABRUPTLY
- Use manual tootbrush
- ELECTRIC razor – no to straight razor

LITHIUM - Given for long-term tx for BIPOLAR and SCHIZOAFFECTIVE (combi of schi and
bipolar) disorder
- Therapeutic range: 0.6-1.2 mEq/L
- Therapeutic affect: achived at 1 week
Note:
 TOXICITY- >1.5
- Dec in renal funx = set stage for toxicity
- Creatinine > 1.3 = BAD kidney
- Urine <30ml = kidney DISTRESS
- S/Sx: Tinnitus (otoxixity)
 INC FLUID and NA+
- Contraindication: DON’T give LITHIUM if may dhn, low sodium
- DO NOT limit NA+ and WATER intake
- High risk for toxicity: Stomach flu , diarrhea, vomiting
- Limit DIURECTICS, NO Anticholimed like Respiratory med (Ipratropium) – it will
DRY pt-
 TOXIC signs
- REPORT  excessive urination, extreme thirst, vomiting, diarrhea, neuromascular
excitability (tremor etc)
- NO 1 INTERVENTION : INC FLUID

 HOLD NSAIDS
-bad for kidneys – dec renal blood flow  innc risk for TOXICITY
- use TYLENOL instead

EXPECTED SE of LITHIUM:
1. Dry mouth and thirst
- Teach pt to use ICE CHIPS, GUMS, SUGARLES CANDY, DRINK FLUID, DO ORAL
HYGIENE
2. Drowsy and fatigue
- Avoid driving, and hazard activity
3. Weight gain
- Teach proper diet and execise
- Dec and appetite if pt has weight loss, may anorexia, mild gi upset

Mgt
  FOR AGGRESSIVE CLIENT (verbally abusive)
1. Decrease stimulation – turn off tv, other pt. leave the room
2. De-escalate – encourage expression of feeling (ASSERIVE COMMUNICATION)
3. Directive Approach – calm and non threat
4. Show of Force – ex. visibility ng 4-6 staff
 Restraint
1. MD order (is needed) – pedeng to follow
2. Informed consent – get it BEFORE magwild si pt.
3. Proper Application
>> 6-8 staff member req
>> adequate circulation must be ensures (check 10-15 mins)
>> anchor on stable part of bed (bed frame)
4. Removal of restraint: necessary na ang MD order
5. Proper Removal
>> Temporary – alternately, one at a time, for 10 min q 2 hrs
>> Permanent- alternately one at a time
 Seclusion room
1. Informed consent: taken BEFORE
2. Room: lockable and observable from the outside
3. Purpose: RESTORATIVE, NOT PUNITIVE
4. Goal: to help client regain self-control
5. Monitoring: one-on-one monitoring on the first hour
6. Environment: less stimulated environment (no visitors and phone calls allowed)

ALCOHOLISM

Alcohol  Blackout (awake but unaware)  Confabulation (inventing stories to inc self-esteem)  Denial,
Dependence, Enabling (significant other tolerates abusers known also as CO-DEPENDENCY), Tolerance increase –
substance to achieve a previous effect

Note:

Intoxication – lasing lang  Alcohol is a downer so  DEC BP, RR, HR, LOC  Coma

Withdrawal  INC BP, RR, HR, LOC, tremor, insomia  Seizure

4 STAGES OF ALCOHOL WITHDRAWAL (abrupt stop)

Early/ initial Fine tremors

Restless
Tachycardia
Diaphoresis
Hyperventilation
Nervousness
After 6-8 hrs ng di pag-inom  INC tremor, BP, HR, RR, Insomia, Agitation

After 12-24 hrs  Convulsion, Hallucination, Illusion, Nightmares

After 36-48 hrs or 72 hrs  Delirium tremens  D-E-A-T-H  death

- D – iaphoresis
 - E- levated VS
- A – gitation
- T – remors, Seixures
- H – yperexcitabiliy
 Tactile hallucination

DOC for Withrawal: Anxiolytics (Librium)

DETOXIFICATION (DRYING OUT)

- Process of assisting an individual to go thru withdrawal safely and successfully

 DISULFIRAM (Antabuse) –is for AVERSION therapy (iniiwas si person sa pagtake ng alcohol)
AVOID: vanilla, vinegar, aftershave lotion, mouthwash, polish remover, backrub ointment, cologne,
isoprophyl alcohol (NO sa lahat ng may ALCOHOL content)

S/E: “ DINA”
D- iarrhea
I – ntense headache
N- and V
A- bdominal cramps

CNS Symptoms due to DEC Vitamin B1 (Thiamine)

WERNICKE’s Syndrome KORSAKOFF’s Syndrome

Ataxia Confabulation
Confusion Hallucination
Ophthalmoplegia Amnesia
TEMPORARY CHRONIC

Mgt: Thiamine rich food

 green leafy vegetables
 nuts

Summary:

 Alcoholic Anonymous – a group therapy

DRUG ABUSE
 HALLUCINOGENS  Purpose: to cause HALLUCINATION
 Commonly used hallucinogens:
1. Cannabis Sativa (Marijuana) – bloodshot eyes ( INC blood flow to
eyeballs)
---> Appetite stimulant (kakainin siya)
---> Lysergic Acid Diethylmide
---> Long-term use  chronic hallucination
*thru SMOKE, BROWNIES

STIMULANTS  Purpose: to cause EUPHORIA

 Example:
1. Cocaine  Excoriated nostrils (isang butas na ilong)
2. Shabu (amphetamine  hypervigilance)
*thru NASAL, INHALATION 
 Sign of Abuse:
1. Hyper, Tachy, Tachy
2. Pupil Dilation
3. Rotting TEETH
4. NO appetite
 BROMOCRIPTIME – dec craving sa Cocaine

NARCOTICS (downers)  Purpose: to escape REALITY

- Nakaka-antok but  Commonly used:
you feel heaven 1. Codeine
2. Tramadol
3. Oxycodone
4. Morphine
5. Mereridine
6. Fentanyl
 Sign of Abuse
1. Hypo, Brady, Brady
2. Pupil Constriction
3. BRAD pa-abot ng injection kaya HIV ang worse complication due to
needle sharing
4.
BARBITURATE (sedative-  Purpose: to cause SEDATION
hypnotics)  Commonly used: ends with “barbitals”
1. Phenobarbitals
2. Methohexital
3. Thiopental
 Antidote: Activated charcoal
 Withrawal of Barbitals  Anxiety and Seizure

Note:
 DOWNERS “AMBON INE” UPPERS (CHA)
A- lcohol C- ocaine
M- arijuana H- allucinogens
B- arbiturates A- mphetamines
O- piates
N- arcotics

MorphINE
CodeINE
HeroINE

Morphine, Codeine, heroin INTOXICATION  give NARCAN

Morphine, Codeine, heroin WITHDRAWAL (nagIINC ang s/sx)  give METHADONE

SEXUAL DISORDERS
  Orgasm – sexual release and climax
 Arousal – stimulation
 Libido – sex drive
 Addiction – repeated and uncontrollable

PARAPHILA  Recurrent sexual fantasy

 Di sila nagaarouse and nag-oorgasm ng walang fantasy (ex. wearing
costumes)
SADISM  Inflict pain to OTHERS
MASOCHISM  Inflict pain to SELF
 Di nila maachieve ang sexual pleasure without pain
PEDOPHILIA  sexual feelings directed toward children
 child less than 13, offender is 18 y/o and above
FETISHISM  arousal to SEXUAL OBJECT
 Ex: Like using gamit na socks of women
VOYEURISM  Watching other people sex
 PEEPING TOM
EXHIBITIONISM  Exposing GENITALIA in public
 They get arousal in UNCONSENTING reaction ng tao
 PUBLIC
TELEPHONE SCATOLGIA 
FROTTEURISM  rubbing of genital to another person without consent
ZOOPHILIA/BESTIALTY  pleasure thru animals

Others:
COPROPHILIA- pleasure thru FECES
UROPHILIA- pleasure thru URINE
NECROPHILIA - pleasure thru cadaver

Mgt for Sexual Disorder

1. SELF-AWARENESS on part of nurse

2. Clarify sexual values
3. BEHAVIOR therapy
4. ACCEPT person but not the act
5. ENGAGE patient in productive activity

THEORIES

GRIEF
 - Normal lang na umabot ng 6mo-1yr/2y

STAGES OF GRIEF

Remember: DABDA

DENIAL - Shock and disbelief r/t loss

ANGER - May feel anger towards GOD or others

BARGAINING - Asking God/ fate to delay the loss

DEPRESSION - Acute awareness of loss

ACCEPTANCE - Comes to terms with loss

TYPES of GRIEF

Anticipatory Grief  experienced BEFORE actual loss

 Ex. Cancer pt. dying
Complicated Grief  Grief suppression, prolonged experience of grief / disproportionate grief
experience
 Ex. Death by suicide
Disenfranchised Grief  inability to openly acknowledge the loss/ grief of an abusive husband
Collective grief  grief of community

COGNITIVE DISORDERS

 Known as ORGANIC MENTAL DISORDERS

 Frequently manifest as DEMENTIA or DELIRIUM
 May be substance induced or caused by disease process; etiology may be UNKNOWN

ALZHEIMER’S DISEASE Key point:

 Safety – NO rugs, LOCK everything leading outside
 Communication – DISTRACT and RE-DIRECT from reality

Assessment
 Amnesia
 Agnosia
 Aphasia
 Apraxia

Mgt
1. Routine – Repeat – Reinforce
2. Saftey measure: side rail up, restraint as last resort / as ordered
3. Maintain reality orientation
4. Medication
 >> C-ognex (donecipil)
>> A-ricept (Tacrine)
>> R-eminyl (Galantamine)
>> E-xelon (Rivastagmine)

PARKINSON’S DISEASE Assessment

 Shuffling gait
 Dec arm swinging
 Pill rolling
 Tremors AT REST

Mgt
1. Med
>> levoDOPA and carbiDOPA
2. AVOID proteins

MEDICATIONS

BENZODIAZEPINE

ANTI – EPS MEDICATIONS