MENTAL HEALTH  Dissatisfaction with:

 "A state of well-being where a person can realize his or her own abilities to  one’s characteristics, abilities and accomplishments
cope with the normal stresses of life and work productively." (WHO)  one’s place in the world
 Balance in person’s internal life and adaptation to reality.  Ineffective:
 State of well-being in which a person is able to realize his potentials.  interpersonal relationship
 coping or adaptation to the events in one’s life
Criteria for Mental Health:
 Self-awareness
 Ability to: MENTAL ILLNESS
 recognize one’s thoughts feelings, asset potentials and weakness.  A state in which an individual shows deficit in functioning and is unable to
 experience genuine feelings as anger, happiness, resentment maintain personal relationship.
 leads to self-acceptance, self-understanding in order to understand  State of imbalance characterized by a disturbance in a person’s thoughts,
others feelings and behavior
 Autonomy: ability to function independently and function with others  Factors that increase the risk are: Crises, Abuses, Poverty
 Perceptive ability
 Awareness of stimuli, reality orientation.
 Orientation to: Time, Place, Person Historical View of Mental Illness
 Integral capacity: Ability to harmonize psychic forces (id, ego, super ego).  In the past, mental illness has been viewed as:
 Self-actuation  Demonic possession
 Ability to adopt to life changes, happy to work with others  Influence of ancestral spirits
 Satisfaction in every endeavor  Result of violating taboo or neglecting cultural, ritual, and spiritual
 Genuine cooperation condemnation
 Period of Enlightenment (1745-1886)
 Mastery of one’s environment: Awareness of the changes around him
 Lunatics were restrained in iron menacles
 Mentally ill were exhibited as diversion and entertainment for the
MENTAL HYGIENE public
 a science that deals with: Promotive, Preventive, Curative, Rehabilitative  Establishment of asylums
aspects of care.  Opening of state hospitals for mentally ill.
 Period of Scientific Study
 Psychoanalysis by Sigmund Freud
MENTAL DISORDER  Psychotropic Drugs (1950)
 A medically diagnosable illness which results in significant impairment of  Use of chlorpromazine and imipramine
one's cognitive, affective or relational abilities and is equivalent to mental  Mental illness is caused by chemical imbalance in the brain.
illness.  The Decade of the Brain (1990)
 Focused on the connections between mental illness and biological
Criteria for Mental Disorder: malfunction in the brain and the neuroendocrine-immune system.

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 1 of 32

  Biological views holds that biological defects are responsible for  Counselor
certain serious mental illness.  Healthy role model
 Parent surrogate
Diagnosis of Mental Illness  Patient advocate
 Use of the Diagnostic and Statistical Manual of Mental Illness (DSM-IV)  Reality based
 Provides diagnostic criteria for each mental disorder and a system of 5  Researcher
axes to give a comprehensive view of the client’s mental illness.  Socializing agent
 Axis I: The clinical disorder that is the focus of treatment  Teacher
 Axis II: Personality disorders and mental retardation  Technician
 Axis III: Medical conditions  Therapist
 Axis IV: Psychosocial and environmental problems  Ward manager
 Axis V: Global assessment of functioning (GAF)
Levels of Interventions in Psychiatric Nursing

PSYCHIATRIC NURSING Level Description Examples

Primary Aimed at altering the stressors  Health education
 An interpersonal process through:  Information
 Concerned with all the aspects of care  promotion of mental health dissemination
 Both a Science and an Art  lowering the rate of cases  Counseling
 Science – uses different theories Secondary Interventions that limits the severity of  Crisis intervention
 Art - therapeutic use of self a disorder thorugh:  Drug administration
 Clientele:  Case finding
 Individual, family and the community  Prompt treatment
 Both mentally healthy and mentally ill Tertiary Aimed at reducing the disability after  Alcoholics
a disorder through: anonymous
Main tool of the nurse: Therapeutic use of Self  Prevention of complication  Occupational therapy
 Active program of rehabilitation
Characteristics of a Good Psychiatric Nurse:
 Empathy
 Genuineness THE PSYCHIATRIC SETTING
 Congruence Admitting a Client in the Psychiatric Setting
 Unconditional positive regard
Areas to be assessed:
Roles of the Nurse in Psychiatric Setting:  Health perception
 Clinician  Orientation
 Collaborator  Metabolic pattern

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 2 of 32

 Elimination pattern COMMON BEHAVIORAL SIGNS AND SYMPTOMS

 Cognitive pattern: Judgment, Insight, Memory Disturbance in Perception

 Activity and exercise pattern  Illusion - misperception of an actual external stimuli
 Thought process  Hallucination - false sensory perception in the absence of external
 Sleep-rest pattern stimuli
LEGAL ASPECTS OF PSYCHIATRIC NURSING

Types of Admissions:
 Voluntary Management:
 Persons admit themselves  Acknowledge the feelings
 Client consents to all treatment  Reorient to reality
 Client can refuse treatment, including drugs, unless danger to self or  Provide distractions
others
 Involuntary  Neologism - pathological coining of new words
 Judicial process
 Circumstantiality - over inclusion of details
 Initiated when someone files a petition
 Word salad - incoherent mixture of words and phrases
 Certification of the likelihood of serious harm to self or others, or
 Flight of ideas - shifting of one topic from one subject to another in a
unable to care for self
somewhat related way
 Under 18, parents can confine with confirmation by a neutral fact
 Looseness of Association - shifting of a topic from one subject to another
finder
 Must be released at end of statutory time or put on voluntary in a completely unrelated way
status or have a hearing  Verbigeration - meaningless repetition of word or phrases
‘  Perseveration - persistence of a response to a previous question
 Echolalia - pathological repetition of words of others
Judicial Precedents  Clang association - the sound of the word gives direction to the flow of
Unless incompetent, client maintains all previous rights thought
 Delusion - false belief which is inconsistent with one's knowledge and
Insanity as a Defense culture
 Insanity : determined in court; legal terminology  Grandeur - is an exaggerated belief of identity
 Nihilistic - the client denies the existence of self or part of self
McNaughten Rule  Persecution - belief that he or she is the object of environmental
“At the time of the crime, the individual didn’t know the nature and quality of the attention and being singled out for harassment
act or didn’t know right from wrong.”  Self-depreciation - worthlessness or hopelessness
 Somatic - false belief to body function.

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 3 of 32

Disturbances of Affect  refers to acute change or disturbance in a person's: LOC, cognition,
 Inappropriate affect - disharmony between the stimuli and the emotional emotion , perception
reaction  Depression - feeling of sadness
 Blunted affect - severe reduction in emotional reaction  Derealization - feeling of strangeness towards the environment.
 Flat affect - absence or near absence of emotional reaction
 Dysthymia - persistent state of sadness
 Apathy - dulled emotional tone
 Elation (euphoria)- a feeling of high degree of confidence, boastfulness
Disturbances in Motor Activity and joy with increase motor activity.
 Echopraxia - the pathological imitation of posture/action of others  Narcolepsy - sleep disorder characterized by frequent irresistible urge to
 Waxy flexibility - maintaining the desired position for long periods of time sleep with episodes of cataplexy (sudden loss of muscle power)
without discomfort
 Akinesia - loss of movement
USE OF APPROPRIATE COMMUNICATION TECHNIQUES
 Bradykinesia - slowness of all voluntary movement including speech.
 Ataxia - loss of coordinated movement Communication: reciprocal exchange of ideas between or among persons

Disturbances in Memory Modes:

 Confabulation - filling in of memory gaps  Verbal - written/spoken
 Amnesia - inability to recall past events  Non-verbal - posture, tone of voice, facial expression
 Anterograde - immediate past
 Retrograde - distant past Types of Non-verbal communication:
 Deja vu - feeling of having been to place which one has not yet visited  Kinesis
 Jamais vu - feeling of not having been to a place which one has visited  body movement
 Dementia  eye contact
 gradual deterioration of intellectual functioning  gestures
 results in the decreased of capacity to perform ADL  Paralanguage
 voice quality
Other behavioral signs & symptoms  non-language vocalization (crying, sobbing, moaning)
 Agitation - severe anxiety associated with motor restlessness.  Proxemics – law of space relationship
 Agnosia - inability to recognize and interpret sensory stimuli.  Touch – physical act
 Akathisia - subjective feeling of muscular tension, restlessness and pacing  Cultural artifacts
repeated sitting and standing.  Meta communication
 Ambivalence - presence of two opposing feelings at the same time.  based on role expectations
 Aphasia - inability or difficulty to speak or recall words  hidden meaning of words
 Apraxia - inability to carry out specific task or activity.
 Delirium Elements:

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 4 of 32

 FEEDBACK Examples: Therapeutic Technique
Technique Example
Accepting Yes, that must have been difficult for you.

Message
Acknowledging or giving I noticed that you've fixed your bed.
recognition
Asking direct questions How does your wife feel about your
hospitalization?
(Channel)
(Context) Clarifying

Confronting or presenting
I'm not sure that I understand what you are
trying to say.
I see no bats flying in this room.
Therapeutic Communication: a way of interacting in a purposeful manner to reality
promote the client’s ability to express his thoughts and feelings openly. Encouraging comparison Has this ever happened before?
Encouraging description How do you feel when you take your
Essentials for a Therapeutic Communication: medication?
 Genuineness
E
 Respect G R A T Encouraging evaluation Does participating in group therapy enable you
 Empathy to discuss your feelings?
Exploring Tell me more about your job. Would you
 Attentive listening
describe your responsibilities?
 Trust (rapport)
Focusing (assisting a patient to explore specific topic)
Giving broad openings or Is there something you'd like to do?
asking open-ended
Barriers to a Therapeutic Communication questions
 Belittling Informing (giving needed facts)
 Interrupting / ignoring I'll be your nurse for today, from 7:00 until 3:00
 Giving advice this afternoon.
Making observations You appear to be angry. / I noticed that you're
 Social response trembling.
 Changing the subject Offering general leads Go on. / You were saying…
 Approving / disapproving Restating Client: I can't sleep, I stay awake all night.
 Moralizing Nurse: You can't sleep at night, (restating)
Summarizing During the past hour, we talked about your plans
for the future, they include...
Using silence (to induce thought, pacing, acceptance)

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 5 of 32

Validating (confirming one's observation)  data gathering, planning for first interaction
“So you mean . . .”
Voicing doubt I find that hard to believe.
Orientation phase
Examples: Non-therapeutic Technique and Ineffective Communication  when the nurse-patient interacts for the first time
Agreeing and disagreeing “I think you did the right thing.”  establish of contract with the patient
Advice “You should.….”  establish of trust and rapport
Belittling "Don't be concerned, evervone feels like that".  learn about the patient and his initial concerns and needs
Defending "All doctors here are simply great".
 encourage the patient to feel comfortable with the meeting
False reassurance "Don't worry, everything will be all right".
 conduct initial interview
Focus on caregiver’s “I feel that way too.”
feeling  manage present emotion of the patient
Judging "It's your own mistake".  provide support and empathy of the patient’s feelings
 assure of confidentiality

NURSE – PATIENT RELATIONSHIP

Working / Therapeutic Phase:

 it is highly individualized
 identification and resolution of the patient's problems
 more structured than the orientation phase
 the longest and most productive phase
 limit setting must be employed
 planning and implementation

Hildegard Peplau Problems:

 Transference
Phases:  the development of an emotional attitude towards the nurse
 positive or negative
Pre-Interaction Phase  Counter transference – experienced by the nurse / therapist
 begins when the nurse is assigned/chooses a patient
 patient is excluded as an active participant Termination Phase
 nurse feels certain degree of anxiety  Evaluate the summary of progress
 includes all of what the nurse thinks and does before interacting with the  Reinforce change and strength of patient
patient  Give rewards for the cooperation during interaction
 develop self-awareness  Encourage expression of feelings about termination of the relationship

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 6 of 32

 Terminate the relationship without giving promises Superego

 Libido - are the instinctual drives

 Regression and fixation are common terms in this theory.
 Gave prominence to sexual feelings: defined "sex" as anything that gives
gratification

Stages:

Oral Stage (0-2 years)

 The area of gratification is the mouth
 Pleasures: sucking activities like fingers, toes or nipples
 Dissatisfaction: resurface at a later
THEORIES OF HUMAN DYNAMICS  overeating, smoking, nail-biting

Psychosexual Development : Sigmund Freud Nursing Implication:

 Provide oral stimulation by giving pacifiers
Levels of Consciousness  Breastfeeding may provide more stimulation.
 Do not discourage thumb sucking

Anal Stage (2-4 years)

 Children's attention is focused on the anal region.
 Pleasure: elimination.
 Covers the ideal age for "toilet training" (2 1/2 years)
 2 concepts:
 Holding on
 Letting go

Possible problems:
 Compulsive need to be clean and orderly.
3 Psychic Energies  Frugality and stinginess
 Greed
Id  Insistence on doing things at one's own rate at the expense of others
Ego  Rigid training

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 7 of 32

 Excessive messiness and disorderly habits.
Psychosocial Development Theory: Erik Erikson
Nursing Implication: Help children achieve bowel and bladder control without
undue emphasis on its importance.  Childhood is very important in personality development.
 Rejected Freud's attempt to describe personality solely on the basis of
sexuality,
 believed that social factors greatly affect
 felt that personality continued to develop beyond five years of age.
Phallic Stage (4-6 years)
 Pleasure: genital region.
 activities associated with stroking and manipulating their sex organs. Identified 8 developmental stages throughout the whole life cycle.
 Oedipus complex  Stages 1-5 - childhood and adolescent
 Electra complex  Stages 6-8 - Adulthood
 Concepts
 Onset of “normal homosexuality”

Nursing implications:
 Accept child's sexual interest Stages:
 Help the parents answer child's questions about birth or sexual differences.
Stage 1:
Period of Life Infant, 0-18 months, (Hope)
Latency Stage (6 to 12 years)
 Period of calmness / stable period. Psychosocial Crisis Trust vs. Mistrust
 Many of the disturbing behaviors are buried in the subconscious mind. Relationship with Maternal person
 Their energies are absorbed by the concerns in school, peers, sports and Positive Resolution o Reliance on the caregiver
other recreational activities o Development of trust in the environment
Negative Resolution o Fear, anxiety and suspicion
Nursing Implication: Help the child have positive experiences.
o Lack of care, both physical & psychological by
Genital Stage (12 years & up) caretaker leads to mistrust of environment
 Oedipal feelings are reactivated toward opposite sex
Stage 2:
 The person is on his way in establishing a satisfying life of his own
Period of Life Toddler, 18 mos. to 3 years
(Willpower)
Nursing Implication:
Psychosocial Crisis Autonomy vs. Shame/doubt
 Provide appropriate opportunities for the child to relate with opposite sex.
Relationship with Paternal person
 Allow child to verbalize feelings about new relationships.

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 8 of 32

 Positive Resolution o Sense of self-worth Negative Resolution Pressures and demands may lead to confusion about
o Assertion of choice and will self
o Environment encourages independence, leading to Stage 6:
sense of pride Period of Life Young Adult, 18 to 54 yrs., (Love)
Negative Resolution o Loss of self-esteem Psychosocial Crisis Intimacy vs. Isolation
o Sense of external control may produce self-doubt in
Relationship with Partners in friendship
others
Positive Resolution o A commitment to others
Stage 3: o Close heterosexual relationship and procreation
Period of Life Preschool, 3 to 6 years (Purpose) Negative Resolution Withdrawal from such intimacy, isolation, self-
absorption and alienation from others
Psychosocial Crisis Initiative vs. Guilt Stage 7:
Relationship with Family Period of Life Middle Adult, 24 to 54 yrs., (Care)
Positive Resolution The ability to learn to initiate activities, to enjoy Psychosocial Crisis Generativity vs. Self-absorption
achievement and competence
Negative Resolution
o The inability to control newly developed power Relationship with Partner
o Realization of potential failure leads to fear of Positive Resolution o The care and concern for the next generation
punishment and guilt o Widening interest in work and ideas
Negative Resolution Self-indulgence and resulting psychological
Stage 4 impoverishment
Period of Life Schooler, 6 to 12 yrs. (Competence) Stage 8:
Psychosocial Crisis Industry vs. Inferiority Period of Life Late Adult, 54 yrs. to death, (Wisdom)
Psychosocial Crisis Integrity vs. Despair
Relationship with Neighbors/School
Relationship with Mankind
Positive Resolution o Learning the value of work
o Acquiring skills and tools of technology Positive Resolutiono Acceptance of one’s life
o Competence helps to order life and make things o Realization of the inevitability of death
work o Feeling of dignity and meaning of existence
Negative Resolution Repeated frustrations and failures lead to feelings of Negative Resolution Disappointment of one’s life and desperate fear of
inadequacy and inferiority that may affect their view of death
life
Stage 5: Cognitive Development Theory: Jean Piaget
Period of Life Adolescent, 12 to 18 yrs, (Fidelity)
Stages:
Psychosocial Crisis Identity vs. Role confusion
Relationship with Peer group Sensorimotor (0-2 years)
Positive Resolution Experiments with various roles in developing mature  Reflex to complex
individuality
 Begins to organize visual images and control motor responses.

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 9 of 32

 Coordinates sensory impressions. Level Two (Conventional Stage 2
 Pre-verbal stage Morality)  Actions are based largely on satisfying one’s
 Children’s judgments own personal needs.
Preoperational Stage (2-7 years) are based on the norms Stage 3
 Transitional period and expectations of the  Good behavior is that which pleases others
 Egocentric and irreversible thinking group. and judgments are based on intentions.
 Words become symbols for objects – symbolic thinking  Children conform to rules to win the approval
 Formation of ideas of categorization. of others and to maintain good relationships.
 Lack of ability to go back and rethink a process or concept. Stage 4
 What is right is what is accepted.
 Mental image – the symbolic process which are evident in plays
If the social accepts rules as appropriate for all
 Construction of verbal schemas – preconcepts
group members, children will conform to them to
avoid social disapproval and censure
Concrete Operations (7 – 11 years) Level Three Stage 5
 Thinking appears to be stabilized (Post Conventional  Behavior recognizes the laws as arbitrary
o ability to think of the possible consequences of actions Morality) and changeable.
 Logical implications  The individual  For aspects of life not governed by laws,
recognizes the right and wrong are personal decisions
Formal Operations arbitrariness of social based on agreement and contracts.
(11 years to adulthood) and legal conventions. Stage 6
 Full patterns of thinking  The individual attempts  Morality is based on respect for others
 Ability to use logic and symbolic processes to define moral values rather than on personal desires.
o mathematical and scientific reasoning that are separate from  The individual conforms to both social
 Combinatorial thinking - multidimensional approach group norms. standards and to internalized ideals to
o hypothetic or hypothetico-deductive reasoning avoid self-condemnation rather than to
avoid social censure.

Moral Development Theory: Laurence Kohlberg

Other Theories
Level One Stage 1
(Preconventional Morality)  Behavior is based on the desire to avoid Behavioral Model (Ivan Pavlov, John Watson, B. F. Skinner)
 Children’s judgments severe physical punishment by a superior  Behavior is:
are based on external power.  a response to a stimulus from the environment
criteria.  Right or wrong is based on consequences to
 learned and retained by positive reinforcement
 Standards of right and him.
wrong are absolute and  Punishment = wrong act
laid down by authority. Interpersonal Model (Harry Stack Sullivan)

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 10 of 32

 Focused on the role of the environment and interpersonal relations as  Excess of this is associated with anxiety, memory loss, social
the most significant influences on a individual’s development. withdrawal and depression.
 Anxiety is communicated interpersonally.  Epinephrine – responsible in the fight or flight mechanism
 Serotonin
Human Motivational Need Model. (Abraham Maslow)  An inhibitory neurotransmitter
 Hierarchy of needs in order of importance  Derived from tryptophan
 Involved in control of food intake, sleep and wakefulness, pain
 Primary needs (physiologic) need to be met prior to dealing with higher
control, sexual behavior and emotions
level needs.  Involved in anxiety and mood disorders, schizophrenia and its
symptoms
Psychobiologic Model
 Histamine
 Focus is in mental illness as a biophysical impairment.  Primarily involved in immunity and allergic reactions
 Human behavior is influenced by genetics, biochemical alterations and  Some psychotropic drugs are block by histamine
function of brain and CNS.  Acetylcholine
 The stress response is a neuroendoctine response.  Affects sleep-wake cycle
 Associated with Alzheimer’s disease
Important structure (limbic system):  Glutamate
 Thalamus – regulates activity, sensation, emotion  An excitatory neurotransmitter
 Hypothalamus – themoregulation, appetite control, endocrine function,  At high levels, it can cause neurotoxicity.
appetite control, impulsive behavior associated with feelings of anger, rage  Associated with Alzheimer’s and Huntington’s disease
or excitement.  Gama-Aminobutyric Acid
 Hippocampus and amygdale – emotional arousal and memory  An inhibitory neurotransmitter
 Neurons – basic functioning unit of the CNS  Associated to treat anxiety and induce sleep.
 Neurotransmitters
 Chemical substances manufactured in the neuron
 Aid transmission of information throughout the body PSYCHOTHERAPY
 Dopamine
 An excitatory neurotransmitter  Is a process in which a person enters into a contract to interact with a
 Located primarily at the brain stem therapist to relieve symptoms, resolve problems in living, seek personal
 Involved in control of complex movements, motivation, cognition and growth
regulation of emotional responses
 Associated with pyschosis and Parkinson’s disease
 Catecholamines (norepinephrine and epinephrine) INDIVIDUAL THERAPY: Is a confidential relationship between client and
therapist.
 Norepinephrine
 Hypnotherapy: Involves various methods and techniques to induce a
 Attention, learning and memory, sleep and wakefulness
trance state where the patient becomes submissive to instructions

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 11 of 32

 Humor therapy: Use of humor to facilitate expression of feelings and to
enhance interaction
 Psychoanalysis: Focuses on the exploration of the unconscious, to
facilitate identification of the patient's defenses
GROUP THERAPY
 minimum number : 3
 Ideal number :8-10
 Advantages:
o decreases isolation
o decreases dependence
o develops coping skills
o develops interpersonal learning
o develops opportunities for helping others
o develops ability to listen to other members
 Remotivation Therapy: Promotes expression of feeling through interaction
facilitated by discussion of neutral topics
 Family therapy: A method in which family members gain:
o insight into the problems
o improve communication
o improve functioning of individual members as well as the family as a
whole.
o It focuses on the total family as an interactional system
 Milieu Therapy
 A therapeutic environment is organized to:
o encourage and assist the client to control problematic behavior
o function within the range of social norms
 Play therapy
 Effective for children suffering from maladjustment or behavior disorder.
 The child is usually placed in a play room
 Purpose - to discover the causes of the child's conflict through
observation of his play and to interpret it to the child.
a.n.g./n.a.l. PSYCHIATRIC NURSING
 Recreational therapy
 Uses activities which vitalize the patient's interest and help him or her to
relax and feel refreshed.
 Example: Playing baseball may be prescribed for as a means of
expressing hostility in a group.
 Occupational therapy: Uses any mental or physical activity prescribed or
guided to aid an individual's recovery from a disease or injury.
 Musical therapy
 Involving the music which allows the child or adolescent to express
herself or himself.
 Also effective with those who have difficulty communicating.
 Art therapy: Clients are encouraged to express their feelings or emotions
by painting, drawing or sculpture.
 Psychodrama therapy: Patients dramatizes their emotional problems in a
group setting.
 Behavior Therapy
 Is a mode of treatment that focuses on modifying observable (overt) and
quantifiable behavior
 Systematic manipulation of the environment and variables thought to be
functionally related to the behaviors.
 Limit Setting
o Therapist gives an advanced warning of the limit and the
consequences will follow if the client does not adhere to the limit.
o The consequences should occur immediately after the client has
exceeded the limit
o Consistency must occur with all personnel.
o Purposes:
o Minimizes manipulation and splitting of the staff.
o Provide a framework for the client to function in and enable a
client to learn to make requests.
 Systematic Desensitization
o Clients are exposed slowly to a feared object or a thing that inhibits
anxious responses and taught ways to relax.
o Effective in treating phobias.
 Implosive therapy
Page 12 of 32
 o The clients are exposed abruptly to intense forms of anxiety  Catatonic schizophrenia
producers, either in imagination or in real life Contraindications (not absolute)
 Cognitive Behavior therapy  Fever  Unhealed fracture
o Uses confrontation as a means of helping the clients restructure or  Increased ICP  Retinal detachment
rearrange irrational beliefs, maladaptive thinking, perception-, and  Cardiac conditions  Pregnancy
behaviors.  TB with history of hemorrhage
o Used for depression and adjustment difficulties.
 Biofeedback Before the procedure:
o Teaches the client to control or change aspects of their internal  Diagnostic procedures
environment. o X-ray
 Aversion therapy o ECG
o Uses unpleasant or noxious stimuli to change inappropriate o EEG
behavior.  Drugs given
o Examples
o Atrophine sulfate (decrease secretions)
o Antabuse to treat alcoholics
o Anectine (Succinylcholine) – relax muscles
o Showing films to drivers who are arrested for speeding or driving
o Methohexital Na (Brevital) - anesthetic
while under the influence of alcohol or drugs.
During the procedure:
 Assertiveness Training
 Observe for tonic-clonic seizure
o Clients are encouraged and taught how to appropriately relate to
After the procedure:
others
 Position
o Teaches the individual to ask for what is beneficial to both mentally
 Check vital signs
ill and mentally healthy persons.
 Token-economy: Utilizes the principle of rewarding desired behavior to  Reorient the client
facilitate change.  Watch out for complications:
o Memory loss
o Headache
ELECTROCONVULSIVE THERAPY (ECT) o Apnea
 Exact mechanism is unknown o Respiratory depression
 Requires a consent o Fracture
 Usually given at 70-150 volts for about .5-2 seconds
 Effectivity: 6-12 treatments with at least 48 hour interval BASIC CONCEPTS ON PSYCHOPHARMACOLOGY
 Indicator of effectiveness: tonic-clonic seizure
MAJOR TRANQUILIZERS/ ANTIPSYCHOTICS
 Indication: Schizophrenia and Other Psychosis
Indications of use:
 Desired effect: control of symptoms
 Depression
 Best taken after meals
 Mania

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 13 of 32

  Diazepam (Valium)  Chlorazepate Dipotassium
Examples:  Oxazepam (Serax) (Tranxene)
 Haloperidol (Haldol)  Fluphenazine (Prolixin)  Chlordiazepoxide (Librium)  Alprazolam (Xanax)
 Prochlorperazine (Compazine)  Chlorpromazine (Thorazine)
Nursing Implications:
Side effects: Nursing Action  Best taken before meals
Blurred vision Avoid driving  Advise to avoid driving
Dry mouth Give sugarless gum  Avoid alcohol and caffeine-containing foods
Tachycardia, palpitation, constipation, Monitor & report
 Administer it separately with any drug
urinary retention
Photosensitivity Don’t expose skin to sunlight
Orthostatic hypotension Monitor BP ANTIDEPRESSANTS
Advise gradual change in position Desired effects: increased appetite, adequate sleep
Extra Pyramidal Symptoms Report at once
o Pseudoparkinsonism
o pill-rolling tremors Tricyclic Antidepressants
mask-like face
o cog-wheel rigidity Examples:
o propulsive gait  Imipramine (Tofranil)  Amitriptyline (Elavil)
o Akathisia - restless leg syndrome
o Dystonia - defect in muscle tone Nursing Implications:
 Best given after meals
Adverse effect: report promptly  Effectivity: after 2-3 weeks
 Tardive dyskinesia - lip smacking  Check the BP, it causes hypotension
 Agranulocytosis  Check the heart rate, it causes cardiac arrythmias
o Assess for:  Monitor I & O
 Fever  Monitor for signs of increased IOP
 Sore throat
 Lab data: WBC count
 Hepatotoxicity
o Assess for ALT & AST MAO INHIBITORS
Indication: refractory depression
MINOR TRANQUILIZERS/ ANXIOLYTICS
 Common indication: Anxiety disorders Examples:
 Desired Effect: Decreased anxiety, adequate sleep  Tranylcypromine (Parnate)
Examples:  Phenelzine (Nardil)
PaN aM a
a.n.g./n.a.l. PSYCHIATRIC NURSING Page 14 of 32
  Isocarboxazid (Marplan) Lithane, Lithobid)

Nursing Implications: Nursing implications:

 Best taken after meals  Best taken after meals
 Report headache; it indicates hypertensive crisis  Increase intake of:
 Avoid tyramine containing foods like:  fluids (3 L /day)
 Avocado  sodium (3 gm/day)
 Banana  Avoid activities that increase perspiration
 Cheddar and aged cheese  Never give to pregnant mothers
 Soysauce  Effectivity: 10-14 days
 Preserved foods  Antipsychotic is administered during the first 2 weeks
 Effectivity: 2-3 weeks  Therapeutic level:.5-1.5 meq/L
 Monitor the BP  If ineffective: Tegretol
 There should be at least a two-week interval when shifting from one anti-  Signs of toxicity:
depressant to another o Vomiting
o Anorexia
Selective Serotonin Reuptake Inhibitors o Nausea
o Diarrhea
Examples: o Abdominal cramps
 Fluoxetine (Prozac)  Paroxetine (Paxil) o Lightheadedness (late)
 Celatopram (Celexa)  Fluvoxamine (Luvox)  Antidote: Mannitol
 Sertraline (Zoloft)
STRESS
Nursing Implications:
 Avoid the use of:  A nonspecific response of the body to any demand made upon it. (Hans
 diazepam Selye, 1936)
 Alcohol  A state produced by a change in the environment that is perceived as
 Tryptophan challenging, threatening or damaging to the person’s dynamic equilibrium.
 Monitor PTT, PT (Smeltzer, 1992)
 Never give to pregnant / lactating mothers.
Adaptation
ANTI-MANIC AGENT
 A constant ongoing process that occurs along time continuum, beginning
Examples: with birth and ending with death. (Smeltzer, 1992)
 Lithium Citrate (Cibalith – S)  Lithium Carbonate (Eskalith,  A continuous process of seeking harmony in an environment.

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 15 of 32

Types of Adaptation:  Leads to potentially dangerous, self-destructive or socially unacceptable
behavior.
General Adaptation Syndrome (GAS)
 Involves the whole body in response to stress. Characteristics
 Compared to life process as it focuses on the “wear and tear of the body  Highly individualized
tissues.  Self-limiting: 4-6 weeks
 Person affected becomes passive and submissive
Phases:  Affects a person’s support system
 Alarm
o Acute phase of the syndrome
o Characterized as the “flight and fight” reaction Type Description Example
o Defensive by nature but self-limiting Maturational/developmental expected, predictable Puberty, adolescence,
o If stress is intense, it may lead to death. crisis and internally young adulthood,
 Resistance motivated marriage, or the aging
o Characterized as the state of adaptation process.
o Person moves back to homeostasis Situational/accidental Unexpected, Economic difficulty,
 Exhaustion unpredictable and illness, accident, rape,
o Result of a prolonged exposure to stress and adaptive mechanisms can externally motivated divorce or death
no longer persist.
Social crisis Due to acts of nature Natural calamities
Local Adaptation Syndrome
 Refers to inflammatory response and repair processes that occur at the
Phases
local site of tissue injury.
 Denial
Eustress - positive stress  Increased Tension
 Disorganization
Distress  Attempts to reorganize
 Negative stress  Stage for full reorganization
 Damaging stressors which may result in various physical and emotional
disorders such as: anxiety, frustration, insecurity, aimlessness
CRISIS INTERVENTION
CRISIS AND CRISIS INTERVENTION  Major Goal:
 A situation that occurs when an individual's habitual coping ability becomes o Restore the maximum level of functioning (pre-crisis state)
ineffective to meet the demands of a situation. o It is an active but temporary entry into the life situation of an individual
 As a serious interruption and disturbance of one's equilibrium or or a family during a period of stress.
homeostasis

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 16 of 32

 o A way of entering into the situation to help them mobilize their resources
and to decrease the effect of stress.

Domestic Violence Requiring Crisis Intervention:

RAPE
 Nonconsensual sexual penetration of an individual, obtained by force or
threat, or in cases in which the victim is not capable of consent.

Kinds of Rape
 Power – to prove masculinity
 Anger – means of retaliation
 Sadistic – to express erotic feelings
Child Abuse
Silent Rape Syndrome  Is an act of omission of responsibility or commission in which intentional
 Is a maladaptive reaction to rape harm is inflicted on a child.
 The victim:
 fails to disclose information about the rape Components of Omission:
 is unable to resolve feelings about the sexual assault  Child abandonment – leaving the child physically
 Results to increase anxiety and may develop a sudden phobic reaction.  Child neglect - lack of provision of those things which are necessary for the
child's growth and development
Rape Trauma Syndrome (RTS)
 Refers to a group of signs and symptoms experienced by a victim in Types of Commission:
Physical Abuse
reaction to rape
 Is an intentional physical harm inflicted on a child by a parent or other
Phases: person.
 Acute Phase – shock, numbness, disbelief
Emotional abuse - insult and undermining one's confidence
 Denial – refusal to discuss the event
 Heightened Anxiety – fear, tension, nightmares Sexual abuse - abuse in the form of sexual contact
 Stage of Reorganization
Characteristics of Abusive Parents:
 They come from violent families
Battered Wife Syndrome (BWS)  They were also abused by their parents
 A form of cyclic domestic violence  They have inadequate parenting skills
 Men: low self-esteem  They are socially isolated because they don't trust anyone
 Women: Dependent personality disorder

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 17 of 32

 They are emotionally immature o mouth or anal smears containing semen
 They have negative attitude towards the management of the abused  Intervention focuses family as a unit.
 If the victim is a child: Play and art therapy
Warning signs of Child Abuse / Neglect: DEFENSE MECHANISM
 Child’s excessive knowledge on sex and abusive words
 Hair growth in various lengths  These are automatic and usually unconscious processes or act by the
 Inconsistent stories from the child and parent/s individuals to:
 Low self-esteem o reduce or cope anxiety or fear
 Depression o resolve emotional or mental conflict
o protect one's self-esteem
 Apathy o protect one's sense of security
 Bruised or swollen genitalia; tears or bruising of rectum or vagina  Becomes pathologic when overused.
 Unusual injuries for the child’s age and development  Used by both mentally healthy and mentally ill individuals
 Serious injuries (fractures, burns, lacerations)
 Evidence of old injuries not reported
Common Defense Mechanisms Used:
 Compensation
Republic Act 7610
o An attempt to overcome a real or imagined short coming, inferiority,
(Anti Child Abuse Law)
 Required reporting of suspected cases inabilities and weaknesses.
o A blind woman becomes proficient in playing piano.
 Report cases to the nearest authorities within 48 hours
 Conversion
Assessment, Planning and Nursing Actions for Crisis
o Emotional problems are converted to physical symptoms
 Primary concerns:
o A student unprepared for a report suffered headache the day she is
o Physical injuries
supposed to deliver her report.
o Alleviation of psychological trauma
 Nurse should display:
 Denial
o Sensitivity
o Failure to acknowledge an intolerable thought, feeling, experience or
o Attitude (Nonjudgmental)
reality
o Confidentiality o A middle-aged man after being admitted to the CCU because of an AMI,
o Respect insists that he is in the hospital for just a diagnostic work-up.
o Empathy
o Dignity  Displacement
 Evidences are important: o the redirection of feelings to a less threatening object
o stained clothing o An adolescent boy, after an argument with his father, goes to the room
o fingernail scrapings and kicked his room’s door.

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 18 of 32

  Reaction – Formation
 Fantasy o Expression of feeling that is the direct opposite of one's real feeling.
o Conscious distortion of unconscious feelings or wishes o Also referred to as overcompensation.
o A boy who is being bullied by his friends wished he had the power of o A student who dislikes one of her classmates may act or show concern
Wolverine. toward her.

 Fixation  Rationalization
o An unhealthy mechanism which is an arrest of maturation at certain o An individual finds a justifiable cause and acceptable reasons just to be
stages of development. saved from an embarrassing and anxiety producing thoughts or
o A boy never overcame being fully reliant from his mother. situations.
o A basketball player claims that he missed the shot and lost the game
 Introjection because of the distractions made by the audience.
o Symbolic assimilation or taking into oneself a love/hatred object.
Derived from the word "introject" which literally means to take into or  Regression
ingest. o Is the turning back to earlier patterns of behavior in solving personal
o Common to depressed clients. conflicts.
o Commonly seen to schizophrenic patients
o A person who becomes ill in the face of disappointment has regressed
 Identification to a form of childish behavior.
o An individual integrates certain aspects of someone else's personality
into one's own.
o A young school teacher adopts his former mentor's teaching style when  Repression
conducting class sessions. o It is the involuntary or unconscious forgetting of an unpleasant ideas or
impulses.
 Intellectualization o During the nurse-patient relationships, patients often unconsciously
o An overuse of intellectual concepts by an individual to avoid expression avoid discussing those experiences producing anxiety which are
of feelings emotionally difficult to verbalize.
o A man who was asked to share a memorable experience about his
grandmother who died discussed the stages of death and dying by  Suppression
Elizabeth Kubler Ross. o Permits the individual to store away or consciously forget the
unpleasant, painful and unacceptable thoughts, desires, experiences
 Projection and impulses.
o Attributing to others one's unconscious wishes/fear. o "I'll think it about tomorrow", "I'd rather go now", "Can we change the
o Literally, this means to "throw off. topic?"
o A student who failed a subject blames his failure on poor teaching. o A boy walked out from the group and said "I have to go now", when he
was asked what was happened to their relationship with his girlfriend.

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 19 of 32

 Substitution  Physical - Nausea, Anorexia, Vomiting, Diarrhea, Constipation,
o Replacing the desired unattainable goal with one that is attainable Restlessness
o A woman who failed the nursing board exam 3 times, worked as a  Cognitive - narrowed perceptual field & selective inattention
nursing aide just to be in the hospital.  Emotional - use of any defense mechanism available

 Sublimation SEVERE
o The redirection of unacceptable instinctual drive with one that is socially  Physical - s/sx becomes the flow of attention
acceptable  Cognitive – perceptual field is greatly narrowed, focus of attention is trivial
o Instead of harming his mother, a man expressed his anger by events
composing a song.  Emotional – defense mechanism operate

 Symbolization PANIC
o Less threatening object is used to represent another  Physical – s/sx of exhaustion ignored
o A woman, missing her husband finds comfort in hugging her son who  Cognitive – personality disorganized
looks like his father.  Emotional – defense mechanism fail

 Undoing Nursing Diagnoses:

o An attempt to erase an act, thought, feeling, guilt or desire  Ineffective individual coping
o A man gives her wife a bunch of roses after their argument last night.  Anxiety
Nursing Management:
 Calm
ANXIETY
 Administer medications
 Vague sense of impending doom
 Listen
 Subjective response to stress
 Minimize environmental stimuli
 Is a state of apprehension, uneasiness, uncertainty or tension experienced
ANXIETY DISORDERS
by an individual in response to an unknown object or situation.
Panic Disorder
Signs and symptoms:
 An individual may suddenly experience frightening and uncomfortable
Mild symptoms
 Physical - ↑PR, RR, BP, pupillary dilatation, sweating  May include terror, sense of unreality or fear of loosing control
 Cognitive - Attentive and alert  Attack: 1 minute and 1 hour
 Emotional - Minimal use of defenses
Phobic Disorder
 Phobia is an irrational fear of an object, place, activity or situation.
Moderate
 Avoidance will allow the individual to be free from anxiety.

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 20 of 32

Examples:  avoidance of thoughts and feelings
 Agoraphobia - fear of open places and of being alone in public places.  recurrent distressing dreams
 Social phobia - irrational fear of criticism, humiliation or embarrassment.  inability to recall an important aspect of the trauma
 Acrophobia - fear of heights
 Algophobia - fear of pain Nursing Interventions
 Claustrophobia - fear of enclosed place  Calm and nonjudgmental approach to convey acceptance.
 Thanatophobia - fear of crowds  Use short and simple sentences or words.
 Help the client develop an increase tolerance to anxiety.
 Pathophobia - fear of disease
 Help the client to:
 Monophobia - fear of being alone
 develop a problem-solving and coping skills of the client.
 develop the ability to remain calm in anxiety-producing situations.
Generalized Anxiety Disorder
(GAD)  Approach: kind-firmness
 Unrealistic, excessive anxiety and is unable to control worry.  Systematic desensitization (phobic disorders)
 Clients may experience: fatigue, irritability, restlessness, muscle tension,  Clients with ritualistic behavior (obsessive-compulsive disorder) should not
sleep disturbance be prohibited or reprimanded.
 Biofeedback, change of the scenery, therapeutic touch, hypnosis, massage
Obsessive Compulsive Disorder or relaxation exercises.
 Is characterized by recurrent obsessions and compulsions that interfere  Administer medications, as ordered.
with normal life.

Obsession ANXIETY RELATED DISORDERS

 Refers to persistent, painful intrusive thought, emotion or urge that one is
unable to suppress or ignore. Somatization Disorder
Compulsion  Free floating anxiety disorder
 Refers to repetitious uncontrollable act and sometimes a purposeful act to  Clients:
prevent a certain mistake in an event or situation.  express emotional turmoil or conflict through physical symptoms.
 usually seek for repeated medical attention.
Post-Traumatic Stress Disorder (PTSD)  may exhibit antisocial behavior and may attempt suicide.
 Is the delayed reaction of the person who has been involved or exposed to  Associated with anxiety and depression
a traumatic events.
 Symptoms of this disorder are: Conversion Disorder
 intense psychological distress  A condition in which an anxiety-provoking impulse is converted
 feeling of detachment or estrangement from others unconsciously into functional symptoms.
 insomnia  Conscious counterpart of malingering
 decreased concentration  Examples: Paralysis, blindness, loss of touch or pain sensation, dyspnea,
seizures or convulsions

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 21 of 32

  Acute discomfort in close relationships
Hypochondriasis  Cognitive or perceptual distortion
 An individual presents an unrealistic or exaggerated physical complaints.
 The person becomes, preoccupied with the fear of developing or having Dramatic-Erratic Personality Disorder (Type B)
already a disease or illness in spite of medical reassurance.  Antisocial (aggressive and manipulative)
 Pattern of disregard for the violation of the rights of others
Body Dysmorphic Disorder  Low self-esteem
 Preoccupation with an imagined defect in his or her appearance.
 Slight physical abnormality = excessive concern / anxiety  Borderline (destructive and unstable)
 Characterized by patterns of instability in relationships, self image and
Dissociative Amnesia mood
 Inability to recall extensive amount of important information  Self-mutilating behavior
 Caused by trauma  Affective instability
 Characterized by:  More common in women
 Disorientation  Narcissistic (boastful / superiority complex)
 Purposeless wandering  Grandiosity and need for constant admiration
 Impairment in ability to perform ADL  Exploitation of others for fulfillment of own desire
 Rapid recovery generally occur
Anxious or Fearful Personality Disorder (Type C)
 Avoidant (inferiority complex)
PERSONALITY DISORDERS  Social inhibition
 Are pervasive and inflexible patterns of functioning that is stable overtime,  Feelings of inadequacy and sensitivity
and leads to distress or impairment.  Low self-esteem
 Social withdrawal in spite of a desire for affection and acceptance
Types of Personality Disorders:  Dependent (submissive)
 Submissive clinging behavior related to excessive need to be cared for
Eccentric Personality Disorder (Type A)
by others
 Paranoid (Suspicious and distrustful)
 Lack of self-confidence
 Persons who display pervasive and long stand suspiciousness
 Perceive self as helpless and stupid
 More common in men
 Obsessive-Compulsive (perfectionist)
 Schizoid (Socially distant and detached)
 Preoccupied with orderliness, perfectionism, inflexibility, need to be in
 Pattern of detachment from social relationship
control
 Chooses solitary activities  Formal and serious interpersonal relationship
 Topics are inanimate objects and ideas  Judgmental of self and others
 Schizotypal (Odd and eccentric)  Passive-Aggressive
 “mild schizophrenia”

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 22 of 32

  Intentional inefficiency  Insensitive to pain
 Passive resistance to demands for adequate performance in both  No eye contact
occupational and social functioning  Giggling or silly laughing

Nursing Diagnosis: Nursing Interventions

 Ineffective individual coping  Environment: safe & consistent
 Self-esteem disturbance  Encourage the client to participate for self-care
 Speak calmly when giving instructions
 Use simple words or phrases
DISORDERS COMMONLY DIAGNOSED TO CHILDREN
 Repeat instructions as necessary.
AUTISM  Haloperidol - symptomatic relief for hyperactivity, stereotypical and self-
 Characterized by: destructive behavior
 impairment in communication skills
 presence of stereotyped behavior, interests and activities.
MENTAL RETARDATION
 associated with impairment on social interactions
 Not a mental illness.
 treatable but not curable
 Problem of inadequate mental functioning.
 more common among boys
 Onset: 18
 usually diagnosed at age 2
 IQ below 70
 Main problem: Interpersonal functioning
 Manifested by sub-average intellectual functioning in:
 Most acceptable cause: Biological factors - brain anoxia, intake of drugs  Communication
Self-care
Signs and Symptoms Home living
 Odd play Social skills
 Not cuddly Health and safety
 Echolalia
 Crying tantrums Causes
 Head towards anything  HIV/ AIDS / rubella infection
 Inanimate object attachment  Alcoholic mother
 Loves to spin objects / self  Thyroid deficiency
 Difficulty interacting with others  Excessive lead poisoning
 Wants blocks  Damage to the brain
 Acts as deaf
 Neurological / neurodevelopmental impairment
 Resists normal teaching method / routine changes
 Exact gestational age is not reached (premature)
 No fear of danger

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 23 of 32

 Opiate intoxication
 Nutritional deficiency (lack in Folic Acid)
ATTENTION DEFICIT HYPERACTIVITY DISORDER
 Anoxia
 Common in boys
 Toxemia (pregnancy-induced hypertension)  Usually diagnosed before age 7
 Environmental factors  Problems:
 Severe RH incompatibility  Inattention
 Hyperactivity
Levels:  Impulsivity
Level IQ Implication
Mild/moron 51-70 o Difficulty adapting to school Causes: Intranatal factors
o Educable – needs assistance
Moderate/Imbecile 36-50 Poor awareness of needs of others Signs and Symptoms
Trainable – needs moderate supervision  Obstinacy
Severe/Idiot 20-35 o Unable to learn academic skills  Negativism
o Poor motor development and minimal  Egocentrism
speech
o Needs complete and close supervision  Fighting syndrome
Below o Has minimal capacity for sensorimotor  Aggressiveness
20 function
 Tolerance is low
o Needs custodial care with a totally
structured environment
 Difficulty concentrating
 Excessive talking
Principles of Nursing Care  Fidgeting
 Protective care  Interrupt/intrudes on others
Education of the family  Child exhibits hyperactivity
 Their involvement is an important factor in the plan of care to promote  Indulges in destructive behavior
progress and to minimize the stress.  Temper tantrums
 Repetition
 Role modeling
 Restructuring Nursing Diagnosis
 Focus of Education  Potential for injury
 Reading
Principles of Nursing Care:
 Arithmetic
 Provide nutrition and safety
 Writing

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 24 of 32

 Environment:  purges after eating
structured  extreme exercise
enable appropriate reaction to the environmental stimuli  Signs of purging
 Plan a firm and consistent environment in which limits and standards are  swelling of the cheeks or jaw area
set.  cuts and calluses on the back of the hands and knuckles
 teeth that look clear
Drug of choice : Methylphenidate (Ritalin)  Peculiar signs
 depression
 loss of interests in activities
DISORDERS COMMONLY DIAGNOSED TO ADULTS

EATING DISORDERS
 More common among females.

Causes:
 Psychological factors
 Parental factors (domineering parents)
 Individual factors (conflict about growing up)
 Sociocultural factors

Anorexia Nervosa
 Main sign: Morbid fear of gaining weight
 Other signs:
 Sensitivity to cold temperatures
 Amenorrhea
 Deliberate self-starvation with weight loss
Findings: (for both)
 Denial of hunger  Weight loss of 15% or more of original body weight
 Obvious thinness but feels fat
 Amenorrhea
 Lanugo all over the body
 Loss of scalp hair  Social withdrawal and poor family and individual coping
 History of high activity and achievement in academics, athletics
 Electrolyte imbalance
Bulimia Nervosa  Depression / distorted body image
 Extreme measures to lose weight
 uses diet pills, diuretics or laxatives Nursing Diagnosis:

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 25 of 32

 Body image disturbance formerly termed as climax
 Ineffective individual coping the shortest stage in the sexual response cycle
occurs when stimulation proceeds through the plateau stage to a point
Nursing Interventions: where the body suddenly discharges accumulated sexual tension
 Establish a trusting relationship  Resolution phase
 Monitor vital signs  the final phase of sexual response
 Reinforce:  organs and body systems gradually return to the unaroused state
 dietician’s prescription to accomplish realistic weight gain
 treatment plan that establishes privileges and restrictions based on
compliance Sexual Dysfunction Disorders
 Decrease emphasis on foods, eating, weight loss or gain  Sexual Desire Disorders: have little or no sexual desire or have an
 Weigh client daily at the same time aversion to sexual contact.
 Remain with the client after meal and for 1st four hours  Sexual Arousal Disorder: Individuals cannot complete the physiologic
requirements for sexual intercourse
 Set limit on time allotted for eating
Examples
 Encourage client to express feelings  Women cannot maintain lubrication
 Promote feeling of control by  Men cannot maintain an erection
 participation in treatment  Orgasm Disorders: Inability to achieve orgasm phase
 independent decision making Example: Premature ejaculation
 Sexual Pain Disorders: Individuals suffer genital pain (dyspareunias)
Example: Vaginismius
SEXUAL DISORDERS
 Sexuality - is the result of biologic, psychological, social and experimental Paraphilia (Sexual Deviation)
factors that mold an individual's sexual development, self-concept, body  A term which generally refers to abnormal sexual behavior
image and behavior.  Lasts for 6 months leading to distress or impairment to functioning.
Phases of the Sexual Response Cycle
 Desire Examples
 the ability, interest and willingness to receive sexual stimulation
 Excitement / Arousal Anilingus tongue brushing the anus
 Result of psychological stimulation Bestiality or Zoophilia contact with the animals
 Example is fantasizing during the desire phase and foreplay which Coprophilia smearing feces on the partner
involves petting and fondling of erogenous zones or areas of the body Cunnillingus tongue brushing the vulva
that are particularly sensitive to erotic stimulation. Exhibitionism  Involves exposing one’s genitals to unsuspecting
 Plateau strangers.
 Orgasm Victims are usually women or children.

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 26 of 32

  They are stimulated by the effect of shocking the  Attitude:
victim.  Accepting
Fellatio inserting the penis into the mouth  Empathic
Fetishism inanimate / non-living objects or articles  Non-judgmental
Frotteurism  Touching or rubbing against the unsuspecting  Accept his feelings related to sexuality
people.  Have a private area to discuss fears or concerns about sexuality
 Usually occurs in crowded places where escape is  Intervene to discuss self-esteem issues, anxiety, guilt, and empathy for
into the crowd is possible. victims.
Masochism  Sexual gratification from experiencing pain  Employ limit setting.
 Involves the acts of being humiliated beaten,  Referral to the correct clinic.
restrained, or otherwise made to suffer
Necrophilia  involves the use of corpses
Partialism  inserting the penis into the other parts of the body SUBSTANCE-RELATED DISORDERS
Pedophilia  use of prepubertal children
 could be an actual sexual act or a fantasy Alcoholism
 child is generally 13 years of age or younger  Is a chronic disease or a disorder characterized by excessive alcohol intake
Sadism inflicting pain and interference in the individual’s health, interpersonal relationship and
Telephone Scatalogia  Involves telephoning someone and making lewd, economic functioning. (WHO)
obscene remarks or conversation.  Considered to be present when there is .1% or 10 ml for every 1000 ml of
 AKA sex on phone blood
Transvestism sexual excitement through wearing the clothing of a
woman Signs of use:
Urophilia urinating on the partner  .1-.2% - low coordination
Voyeurism Act of observing unsuspecting person who is naked, in  .2-.3% - presence of ataxia, tremors, irritability, stupor
the process of disrobing, or engaging in sexual activity  .3 and above - unconsciousness
Includes cyber-voyeurism
Progression:
 Pre-alcoholic Phase - starts with social drinking; tolerance begins to
Gender Identity Disorder develop
 AKA Transexualism  Prodromal Stage - alcohol becomes a need; blockout's occur; denial
 Believe that they were born as the wrong sex begins to develop
 Leads to persistent discomfort and feels inappropriate in the role of the  Crucial - cardinal symptoms of alcoholism develops (loss of control over
assigned sex. drinking)
 Chronic Phase - the person becomes intoxicated all day
Nursing Interventions:

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 27 of 32

Outcome:  serious medical complications may occur if the client is left untreated
 Brain damage
 Alcoholic hallucinosis
Korsakoff's Psychosis
 Death
 Is a form of amnesia
 characterized
Behavioral problems:  short-term memory loss
 Denial  Disorientation
 inability to learn new skills
 Dependency
 confabulation
 Demanding
 Deficiency in vitamin B complex, especially B1 and B12.
 Destructive
 Domineering Wernicke's Encephalopathy
 An inflammatory hemorrhagic degenerative condition of the brain
Alcohol Withdrawal  caused by B1 deficiency
 Occurs when an individual abruptly stops drinking after alcohol has become  Symptoms include:
a necessity of life to maintain functioning.  double vision
 Symptoms include:  involuntary and rapid eye movements
 autonomic hyperactivity  lack of muscular coordination
 grand mal seizures  decreased mental function
 psychomotor agitation and anxiety
 increased hand tremors Nursing Diagnosis: Ineffective individual coping
 sleep disturbances (insomnia and nightmares)
 illusions hallucinations Principles of Nursing Care:
 hyperthermia  Well lighted room
 tachycardia (impending delirium tremens)  Diet as tolerated
 Monitor vital signs
Alcohol Withdrawal Delirium  Administration of glucose
 AKA delirium tremens  Vitamins
 experienced within 24 to 72 hours after the last intake:
o agitation
o elevated vital signs Alcohol Detoxification:
o illusions and hallucinations  Drug of Choice: Disulfiram (Antabuse) - delays the metabolism of alcohol
o restlessness  Avoid alcohol-containing products
o hyperalertness  3 S’s of detoxification:
o incoherent speech

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 28 of 32

  Safety  Routes of use:
 Sedation  Orally (capsules, tablets, on sugar cubes)
 Supplement (Multivitamins, Vitamin B-complex, Vitamin C)  With food
 Smoked in a pipe or rolled as cigarette.
 Acts within 15 minutes
DRUG-RELATED DISORDERS  Effects lasts approximately 2 to 4 hours
 Physiologic symptoms include
Cocaine-Related Disorders
 increased appetite
(Stimulants)
 excitement
 Cocaine is a white powdered stimulant substance
 drowsiness
 Usually sniffed, snorted, smoked in a pipe or injected into a vein or
 lowered body temperature
subcutaneous tissue.
 depression
 Poor man’s cocaine:
 unsteady gait
 Shabu (sha-boo)
 reduced coordination and reflexes
 Signs of use:  inability to think clearly
 panic attacks  impaired judgment
 insomnia  Classic sign: bloodshot eyes
 loss of appetite
 impaired thinking  In large doses, it may cause:
 cocaine psychosis  Hallucination
 agitation  Suicidal ideations
 dilation of the pupils  Delusions of invulnerability
 diaphoresis
Long-term Goals:
 increase VS
 Community resources
 Classic sign: Perforated nasal septum
 Other coping means aside from denial
 Can cause a sudden heart attack even in healthy young people.
 Personal responsibility for not drinking / drugs taking
Cannabis-Related Disorders (Cannabinoids)  Isolation
 Nutrition
Marijuana  Group therapy
 Can act as stimulant or depressant and is often considered to be a mild
hallucinogen with some sedative properties
 Is not physically addicting but may lead to psychological dependence SCHIZOPHRENIA AND OTHER PSYCHOSES
 Plant : cannabis sativa
SCHIZOPHRENIA
 Active component is Tetrahydocannabinol

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 29 of 32

  Is a serious psychiatric disorder Catatonic Wax flexibility  Priority: nutrition &
 One of the most profound disabling illness Stupor circulation
 Not a single disease entity but a combination of disorders Negativism – mutism, rigidity,  Provide distraction
 "split mind" lack of response  Encourage activity
 characterized by:
Prognosis: Good
o impaired communication Defense Mechanism:
o loss of contact into reality Repression
o deterioration from a previous level of functioning
 Nursing Diagnosis: Altered thought process
 Most acceptable theory: Biologic Theory Undifferentiated
 Patients whose manifestation cannot be easily fitted into one or the
Manifestations: Eugene Bleuler other type
 Associative looseness Residual
 Autism  Patients with minimal symptoms
 Apathy
 Ambivalence
General Nursing Interventions:
 Auditory hallucination
 Establish:
 a trusting relationship and provide acceptance
Types Distinguishing features Nursing Interventions
 a clear, consistent and open communication
Disorganized Peculiar / bizarre behavior  Assist with ADL
Incoherence  Set limits
 Encourage activity
Stereotyping  Decrease environmental stimuli
 Present reality
 Observe for suicidal ideation
Prognosis: Poor  Administer medications, as ordered.
Defense Mechanism:
Regression MOOD DISORDERS
Paranoid Hallucinations  Priority: safety of others
Ideas of reference  Deal with the HID Precipitating Factors
Delusion of persecution  Offer sealed foods /  Loss of a loved one
Suspiciousness unopened medicines  Major life events
 Never displace outbursts of  Role strain
Prognosis: Good
Defense Mechanism:
emotions  Decreased coping resources
Projection  Explain procedures in  Physiological changes
simple ways
 Never argue with the patient Common Types of Mood Disorder

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 30 of 32

 Bipolar I Disorder: May experience one or more of symptoms of manic Attitude therapies Matter of fact Kind firmness
episode Activity Non-stimulating Monotonous
 Bipolar II Disorder: May experience one or more symptoms of major Never give anything that
depressive episode with hypomania requires attention
 Major Depressive Disorder: May be coded as mild, moderate or severe Priority NDx Risk for injury: Risk for injury: self-
with or without psychotic features. Directed at others directed
 Dysthymic Disorder Nursing Individual therapies Group therapy
 Lesser severe than major depression Management Lithium Antidepressants
 No symptoms such as impaired communication, delusions and Diet ECT
hallucinations
 Cyclothymic Disorder Suicide
 DNOS (Depression Not Otherwise Specified) - lasts for 2 days-2 weeks  thought or act of taking one’s own life
 ultimate form of self-destruction
Clinical Symptoms of Major Depressive Episode  "cry for help“
 Affect flat  reunion wish or fantasy
 Weight change (gain or loss)  progressive failure to adapt feelings of anger or hostility
 Energy loss  a way to end feelings of hopelessness and helplessness
 Sad feelings / Social withdrawal  an attempt "to save face" or seek a release to a better life
 Obvious sleep disturbances Risk Factors
 Memory loss  Sex (more female attempts suicide but more male commits suicide)
 Emotional blunting  Unsuccessful previous attempt
 Identification with a dead family member
Clinical Symptoms of Manic Episode  Chronic
 Talkative or pressured to keep talking  Illness (e.g. Cancer)
 Inflated self-esteem or grandiosity  Depression/Dependent personality
 Psychomotor agitation  Age (18-25 and 40)/Alcoholism)
 Exhibit flight of ideas  Lethality of previous attempt/Looses
 Decreased need for help
 Distractibility Nursing Diagnosis: Risk for injury-Self directed

Summary: Nursing care:

Mania Depression  Safe environment
Appearance Elated Sad  Always take overt or covert threats or attempts
DM Projection Introjection seriously

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 31 of 32

 Ventilation of feelings DEATH/D YING: Elizabeth Kubler-Ross
 Encourage activities Stages:
Denial - "NO NOT ME"
 Monitor closely (one-on-one, 24/7) Anger - "WHY ME"
Bargaining - "IF ONLY"
 Empathy (show acceptance & appreciation)
Depression - stage of silence
Acceptance - "Yes, it's me"
CONDITIONS COMMONLY DIAGNOSED IN THE ELDERLY
Nursing Diagnosis: Ineffective individual coping
Alzheimer’s Disease
A chronic, progressive degenerative cognitive disorder.
Nursing Care:
Marked by Dementia
 Be physically present
Main Pathology: presence of senile plaques - destroys neurons (decreased
acethylcholline)  Be non-judgmental
 Encourage verbalization of feelings
 Allow the patient to cry
Signs and Symptoms:  Recognize your own thoughts about death and dying
 Aphasia – deterioration of language function
 Apraxia – impaired motor function
 Agnosia – inability to recognize objects / people
 Executive functioning - loss of abstract thinking

3 PHASES:
 Forgetfulness - difficulty of remembering appointments
 Advance - difficulty of remembering past events but not recent events
 Terminal - death occurs in 1 year

Nursing Diagnosis: Altered thought processes

Nursing Care:
 Priority: safety & security
 Always reorient the client (clock & calendar)
 Use color instead of numbers & letters
 Consistency – 1 nurse to lessen confusion
---END---
CONCEPTS ON DEATH AND DYING

a.n.g./n.a.l. PSYCHIATRIC NURSING Page 32 of 32