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Review in Psychiatric Nursing

FREUD’S PSYCHOANALYSIS Personality Id Ego Superego Psychosexual Stages of Development Oral (0-18 mos) Anal (18mos.-3yrs) Phallic (3-6yrs.) Latency (6-12yrs) Genital (12Defense Mechanisms Defense Mechanisms- techniques used by the ego to keep threatening and unacceptable material out of consciousness therefore reducing anxiety. Defense mechanisms are workings of the unconscious mind. A number of phenomena are used to aid in the maintenance of repression. These are termed Ego Defense Mechanisms (the terms “Mental Mechanisms” and “Defense Mechanisms” are essentially synonymous with this). The primary functions of these mechanisms are: 1. to minimize anxiety 2. to protect the ego 3. to maintain repression Mechanism Compensation Definition Covering up of weaknesses by placing emphasis on a more comfortable area Example A boy who cannot participate in sports studies hard and gets good grades. A physically unattractive adolescent becomes an expert dancer. A youth with residual muscle damage from poliomyelitis becomes an athlete. A student develops headache before taking a exam. A man's arm becomes paralyzed after impulses to strike another. A man who has had a heart attack refuses to acknowledge illness and to follow prescribed therapy. a person having an extramarital affair gives no thought to the possibility of pregnancy. persons living near a volcano disregard the dangers involved. a disabled person plans to return to former activities without planning a realistic program of rehabilitation. Displacement Discharging pent-up feelings to a less threatening object. A man who is angry at his boss comes home and yells at his wife.


Unconscious expression of intrapsychic conflicts symbolically through physical symptoms. Unconscious to admit unacceptable behavior or idea an



Unconscious separation of painful feelings from an unacceptable idea, situation, or object. Some dissociation is helpful in keeping one portion of one's life from interfering with another (e.g., not bringing problems home from the office). However, dissociation is responsible for some symptoms of mental illness; it occurs in "hysteria" (certain somatoform and dissociative disorders) and schizophrenia, The dissociation of hysteria involves a large segment of the consciousness while that in schizophrenia is of numerous small portions. The apparent splitting of affect from content often noted in schizophrenia is usually spoken of as dissociation of affect, though isolation might be a better term.

A rape victim tells that she felt as if she were outside of her body watching what was happening.


Gratifying frustrated desires imaginary achievements.


A man who fails to get a part in the play, imagines himself chosen for the lead role. A teenager dresses like that of her idolized movie star.


Imitating the behavior of someone feared or respected. Using only logical explanations without feeling or an affective component. The individual deals with emotional conflict or internal or external stressors by the excessive use of abstract thinking or the making of generalizations to control or minimize disturbing feelings.


A wife tells her husband that a dented car is better than a wrecked car.


Unconsciously incorporating other people’s norms and values as if they were your own. Blaming someone else for one’s difficulties. Justification faulty logic. of behavior though

A young girl scolds her brother just like her mother would.

Projection Rationalization Reaction formation

A husband forgets to pay the bill and blames his wife for not reminding him. A student fails an exam and says that the teacher did not clarify the material sufficiently. A woman who dislikes her sister sends her gifts every holiday.

Acting oppositely to what the person truly feels.

Regression Repression

Return to an earlier, more comfortable level of functioning. Involuntary and unconscious forgetting of painful ideas, feelings and events. Attempting to restore unconscious guilt feelings. Channeling instinctual drives into acceptable activities. Replacement of unacceptable objects or need with one that is more acceptable. Conscious exclusion of anxiety producing feelings or ideas from awareness. An external object is made to symbolize an internal feeling or idea. Doing something to counteract or relieve guilt feelings.

A 6 year old begins to wet his pants following the birth of his baby sister. A accident victim becomes amnesic about the details of the accident, but was aware at that time. A nurse who regrets not caring for her mother when she was dying because of anger chooses to work with terminal patients. A man with excessive sexual drives becomes a successful nude painter. A woman who wants to marry a man exactly like her dead father marries someone who looks a little bit like him. A woman says she is not ready to talk about her condition.

Restitution Sublimation Substitution Suppression

Symbolization Undoing

A young woman gives flowers and chocolates to his girlfriend. A mother spanks her child and brings home a gift for him the next day.

THERAPEUTIC COMMUNICATION Technique Using Silence Accepting Definition Gives person time to think and say more. Receiving information in a nonjudgmental manner. Does not necessarily indicate agreement. Shows awareness of change or efforts. Does not imply right or wrong. Making self available and showing interest, concern and desire to understand. Clarifies that the lead is to be taken by the client Using neutral expressions to encourage the client to continue talking. Asking for relationships among events. Example

Giving recognition Offering self

Yes. Uh hmm I follow what you say I’m with you Good morning, Mr. Santos I noticed you shaved this morning. You’ve combed your hair I’ll sit with you for a while. I would like to spend some time with you. Where would you like to begin? What are you thinking about? What would you like to discuss? Go on. And then. Tell me about it. What lead up to…? What happened before? When did this happen?

Giving broad openings Offering general leads Placing the events in time or sequence

Making observations

Commenting on what is seen or heard to encourage discussion of feelings and thoughts. Helpful with withdrawn patients. of Asking for client’s views of their situation. Expressing uncertainty about the reality of client’s perceptions and conclusions, used when the nurse wants to explore other explanations. Offering a view of what is real and not, without arguing with the client. Asking for similarities and differences among feelings, behavior and events. Repeating expressed the main idea

You seem restless. I noticed you’re biting of lips. You appear tense when you… What is happening to you right now? What does the voice seem to be saying? That doesn’t sound like it. Isn’t that unusual?

Encouraging descriptions perceptions Voicing doubt

Presenting reality

Encouraging comparison Restating Reflecting

I know the voices are real to you, but I don’t hear them. You are not in heaven, you are in the hospital. Has this ever happened to you before? Is this the way u felt when..? Pt: I can’t sleep. I stay awake all night. Nurse: You have difficulty sleeping? Patient: do you think I should? Nurse: Do you think you should? Patient: My brother spends all the money and still has the nerve to ask for more Nurse: This makes you angry? Explain more about… This point seems worth looking at more closely. Tell me more about… Can you describe it more fully?

Directing feelings and ideas back to the client.

Focusing Exploring

Concentrating on a topic until its meaning is clear. Looking at certain ideas more fully. However, if the patient chooses not to elaborate, the nurse should not pry. Providing information that will help clients make better choices. Clarifying communications, help clarify own thoughts. vague clients

Giving information

Seeking clarification

Verbalizing the implied

Rephrasing or putting into concrete terms what the client implies to highlight an underlying message.

I am… My purpose on being here is… This medication is for… The rules and regulations of this ward are… What do you mean by…? What is the main point of what you just said? I’m not sure I follow you. Patient: There is nothing to do at home. Nurse: It sounds you might be bored at home. Patient: I can’t talk to you or to anyone. It’s only a waste of time. Nurse: Do you feel no one understands?

Fosters dependency and inhibits the problem-solving process. I agree. an “Why” questions require analysis of the problem which increases anxiety. Challenging the patient to defend his/her thoughts and feelings which serves as a hindrance in the communication process. Gives the impression that the client has no right to express own opinions and feelings. .NON-THERAPEUTIC COMMUNICATION TECHNIQUES Technique Reassuring Definition Closes off the communication by giving information that is not based on facts and truth. Giving approval Rejection Talk to the doctor about this. Testing Defending Do you know what this drug is for? Dr. The hospital staff is very competent to take care of you. Communication barriers that may make the patient feel needed and valued only for the information they can give. This technique fails to explore the feelings of the patient. Encourages the client to continue doing something for the sake of the nurse’s approval rather than for own learning. Example Don’t worry. I’d rather you wouldn’t. Santos is a very good doctor. Implies that the nurse feels that the patient needs help. Disapproving That is not good. I disagree with that. Denies the client’s thoughts and feelings by implying that the nurse has the right to judge the client and the client has to please the nurse. Advising Probing I think you should… Tell me about… Let’s talk about your family and relatives. Provides no opportunity for the patient to change their views. Everything will be alright. This is a communication barrier since the patient may avoid expressing his or her own thoughts / feelings to avoid the risk of rejection. Why did you? Requesting explanation Minimizing feelings Patient: I wish I were dead. Patient may respond defensively. That is good. Nurse: Everyone gets down once in a while. Agreeing Disagreeing That’s right. You’ll feel better tomorrow.

imagination and ambition or setting goals. production of work and creation of new ideas that impacts a great number of people intimate relationships established and caring for others. mistrust Autonomy vs. Wisdom (reflection) .Making stereotypical comments Blocks off the communication process since the patient is encouraged to have empty responses. guilt Activity infant takes in food sense of control over interpersonal relationships and selfcontrol ability to move freely. ERICKSON’S PSYCHOSOCIALTHEORY Age 0-1 y/o 2-3y/o Stage Trust vs. shame and doubt Initiative vs. vs. Changing the subject Let’s discuss that later. It’s for your own good. Let’s leave that and talk about… Using denial Patient: I’m nothing Nurse: Of course you’re everybody’s something. curiosity. something. child strives hard to read and write. They try-out new roles and beliefs during their search of a sense of ego identity ability and willingness to share a mutual trust procreation of children. confusion Intimacy isolation Generativity stagnation vs. Love Care (parents) 41-above y/o Ego-integrity despair vs. Fails to address the message of the patient. Closes off the communication by failing to identify the feelings and thoughts of the patient. The nurse maybe threatened by an anxiety provoking topic thus the perceived need to change the subject. They feel whole and coherent Strength/ Factor Realistic hope (feeding) Conflict (toilet training) Purpose (independence) SO Mother 4-5 y/o 6-12 y/o Industry inferiority Identity vs. Competence (school) 13-18 y/o role Fidelity (peers) 19-25y/o 26-40 y/o vs. pursue his hobbies and be the best among the rest. acquiring language skills.

role confusion (12-18 yrs) • • • Confident of self Emotionally stable Commitment to career planning and .3 yrs.) • • • • • • • • • • Or • • • Self control and willpower • Realistic self concept and self. mistrust (0-18 mos.ADULT MANIFESTATIONS OF ERICKSON’S STAGES OF DEVELOPMENT Life stage Trust vs. indecision and alienation Vacillation between dependence or independence Superficial.) vs.• esteem • Pride and a sense of goodwill • Simple cooperativeness • Generosity tempered by withholding Or Delayed gratification when • necessary • • • • An adequate conscience • Initiative balance with restraint • Appropriate social behaviors • Curiosity and exploration • Healthy competitiveness • Sense of direction • Original and purposeful activities • Or • • • • • Sense of competence • Completion of projects • Pleasure in efforts and effectiveness Ability to cooperate and • compromise • Identification with admired others • Joy of involvement in the world and Or with others • Balance of work and play • • • • • • Adult behaviors reflecting mastery Realistic trust of self and others Confidence in others Optimism and hope Shares openly with others Relates to others effectively Adult behaviors reflecting developmental problems Suspiciousness/testing others Fear of criticism and affection Dissatisfaction and hostility Projection of blame and feelings Withdrawal from others Overly trusting of others Naïve and gullible Shares too quickly and easily Self doubt/self conscious Dependence on others for approval Feeling of being exposed/ attacked Sense of being out of control of the self and one’s life Obsessive compulsive behaviors Excessive independence or defiance. grandiosity Denial of problems Unwillingness to ask for help Impulsiveness Recklessness regarding safety for self and others Excessive guilt/embarrassment Passivity and apathy Avoidance of activities/pleasures Rumination and self pity Assuming a role as victim/self-punishment Reluctance to show emotions Underachievement of potentials Lack of follow-up on plans Little sense of guilt for actions Excessive expressions of emotion Labile emotions Excessive competitiveness/showing off Feeling of unworthiness and inadequacy Poor work history (quitting. Guilt (3-5 yrs) • • • • • • • Industry inferiority yrs.) • • • • • • Initiative vs. lack of productivity) Inadequate problem solving skills Manipulation of others/ violation of others’ rights Lack of friends of the same sex Overly high achieving/ perfectionists Reluctance to try new things for fear of failing Feeling unable to gain love of affection unless totally successful Being a workaholic Feelings of confusion.. lack of promotions. • (6-12 • • • • • • Identity vs. absenteeism. Shame and doubt (18 mos. short-term relationships with another person Autonomy vs. being fired.

isolation (18-25 or 30 years) realistic long-term goals Sense of having a place in society Establishing an intimate relationship Fidelity to friends Development of personal values Testing out adults Ability to give and receive love Commitment and mutuality with others • Collaboration in work and affiliation • Sacrificing for others • Responsible sexual behaviors • • • • • • • Or • Dramatic overconfidence • Acting out behaviors (including alcohol and drug abuse) • Flamboyant display of sex role behaviors • • • • • Or • • • • Persistent aloneness/isolation Emotional distance in all relationships Prejudices against others Lack of established vocation. creative stagnation (30-65 activity years) • Personal and professional growth • Parental and societal responsibilities Integrity vs. to death) • • • • • • • • • • • Or • Too many professional or community activities to the detriment of the family or self Feelings of self-acceptance • Sense of helplessness. hopelessness. social events) Or • Inability to reduce activities • Overtaxing strength and abilities • Feeling indispensable • Denial of death as inevitable . many career changes Seeking of intimacy through casual sexual encounters Possessiveness and jealousy Dependency on parents and/or partner Abusiveness towards loved ones Inability to try new things socially or vocationally (staying in routine/ mundane job/activities Self-centeredness/ self-indulgence Exaggerated concern for appearance and possessions Lack of interest in the welfare of others Lack of civic or professional activities/responsibilities Loss of interest in marriage and/or extramarital affairs Generativity vs. and death volunteer work. despair (65 yrs. • Productive. worth. and/or meaninglessness Sense of dignity. uselessness. constructive. worthlessness. failures and dissatisfactions Valuing one’s life • Feeling too old to start over Sharing of wisdom • Suicidal ideas or apathy Exploration of philosophy of life • Inability to occupy self with satisfying activities (hobbies.Intimacy vs. and importance • Withdrawal and loneliness Adaptation to life according to • Regression limitations • Focusing on past mistakes.

) . He is able to form effective relationships. don’t patronize Do not place patients in situations wherein they will feel inadequate or embarrassed Treat patients as individuals Provide reality testing Handle hostility therapeutically Provide psychopharmacologic treatment BASIC PRINCIPLES IN DEVELOPING THERAPEUTIC NURSE-PATIENT RELATIONSHIP Do not reinforce or argue a patients hallucinations or delusions Orient patient to time. 6. He knows himself. A mentally healthy person is free from internal conflicts. He has good control over his behavior. 8. problems and goals (self-actualization). 7. He faces problems and tries to solve them logic and reason RULES FOR PSYCHOTHERAPEUTIC MANAGEMENT Provide support. He is productive. . numbers and spatial relationships Formal operational (12. He is not at war with himself. 4. He is able to get along well with others. 5. He is able to accept criticisms and is not upset easily.PIAGET’S COGNITIVE DEVELOPMENTAL THEORY Sensorimotor Stage (0-2) senses Preoperational thought stage (2-7) Preconceptual-learning to think in mental images (2-4) Intuitive. treat patients with respect and dignity Uplift patient’s self-esteem. 2. start with one-to-one interactions Allow and encourage verbalization of feelings Be calm when talking to patients Accept patients as they are but do not accept all behaviors Keep promises Be consistent Be honest CHARACTERISTICS OF A MENTALLY HEALTHY PERSON 1. He is well adjusted.more logical and has concepts of morality. 3. his needs.egocentrism (4-7) Concrete operational stage (8-12) . He has a strong sense of self-esteem. person and place Do not touch patients without warning them Avoid whispering or laughing when patients are unable to hear all of the conversations Reinforce positive behaviors Avoid competitive activities with some patients Do not embarrass patients For withdrawn patients. He searches for an identity.

• Cannot act normally in society and may harm self and others. feeling. job and interpersonal relationships. It involves rehabilitation after defect and disability have been fixed. 3. with the goal of reducing the prevalence (total number of existing cases in a year) is the aim of secondary prevention. resulting in changes in talk and behavior. Abnormal behavior causes disturbance in the person’s day-to-day activities. • Population screening • Crisis intervention services • Mental health education TERTIARY PREVENTION. Neurosis Frequently talks about his symptoms Does not lose contact with reality Personality is intact Continue to function socially and at work Hospitalization is usually not required • • • Psychosis Denies that there is something wrong with him Loses contact with reality Personality is often disorganized and deteriorates.early identification and effective treatment of an illness or disorder. CRISIS . memory. perceptions and judgment. thereby reducing the incidence (number of of new cases occurring in a specific period in time). • Often requires hospitalization PREVENTION OF MENTAL ILLNESS PRIMARY PREVENTION. When a person’s behavior is causing distress and suffering to the individual and/or others around him Abnormal changes in one’s thinking.aims to reduce the prevalence of residual defect or disability due to illness or disorder. Primary prevention aims to prevent the onset of a disease or a disorder. 2.involves the promotion of general mental health and protection against the occurrence of specific diseases. • Elimination of etiological agents • Reducing risk factors • Enhancing host resistance or interfering with disease transmission • Reducing stress factors • Counseling o Student’s counseling o Marriage counseling o Sex counseling o Genetic counseling • Special centers o Child guidance centers o Crisis intervention center o Geriatric center • Mental health education SECONDARY PREVENTION.CHARACTERISTICS OF MENTAL ILLNESS 1. Community reintegration is also part of tertiary prevention.

o Experience separation anxiety a great deal Nursing interventions: Focus on parents  Assist parent to deal with their feelings  Encourage parents’ participation in child’s care • Preschooler (3-5 yo) o Death is a kind of sleep. as well as those who are in the significant “social orbit. • • • • • • • • STAGES OF DEATH AND DYING (KUBLER-ROSS) Denial and isolation Anger Bargaining Depression Acceptance STAGES OF GRIEF Shock and disbelief Developing awareness Restitution and resolution of the loss COPING REACTION TO DEATH THROUGHOUT THE LIFE CYCLE • Toddler (1-3 yo) o No specific concept of death and thinks only in terms of the the process of coping with a loss. It is a form of punishment o Life and death can change place with one another Nursing interventions • Utilize play for expressing thoughts and feelings • Explain what is death that it is final and not sleep • Permit a choice of attending the funeral • o o o o School Age (5-12) Death is personified Child fears mutilation and punishment Anxiety is alleviated by nightmares and superstition Death is perceived as a final process Approaches: • Accept regressive or protest behavior . CRISIS INTERVENTION. o Reacts more to pain and discomfort of illness and immobilization.means of entering into the life situation of an individual.” CONCEPT OF LOSS GRIEF. family or group to alleviate the impact of a crisis including stress in order to help mobilize the resources of those directly affected.• Refers to the state of the reacting individual who finds himself in a hazardous situation in which the habitual problem solving activities are not adequate and do not lead to rapidly to the previously achieved balance state.

• Incoherence • Looseness of associations • Grossly disorganized behavior • Flat or grossly inappropriate affect Catatonic • Motor immobility (waxy flexibility or stupor) • Excessive purposeless motor activity (agitation) • Extreme negativism or mutism • Peculiar voluntary movements o Posturing • . Disorganized type • Dominant: disorganized speech and disorganized behavior and inappropriate affect.• • • • • Encourage verbalization of feelings Adolescent (12-16) Mature understanding of death May have strong emotions about death. • Preoccupied with 1 or more systematized delusions or with frequent auditory hallucinations related to a single theme. rest and peace SCHIZOPHRENIA A group of mental disorders that feature withdrawal. silent. Approaches: • • • • • • Adult Death is disruption of the life cycle Death is viewed on terms of its effect on significant others. affective problems and interrupted thought processes. or inappropriate affect present. sadness or fear. catatonia. A time of reflection. BLEULER’S FOUR A’S OF SCHIZOPHRENIA Affective Disturbances: inappropriate. • Associated features including grimacing. if present. disorganized behavior. blunted or flattened affect Autism: Preoccupation with the self without concern for external reality Associative looseness: The stringing together of unrelated topics Ambivalence: simultaneous opposite feelings Subtypes: Paranoid Type • Dominant: hallucinations and delusions • No disorganized speech. • Older adult Emphasis is on religious beliefs for comfort. withdrawn. mannerisms and other oddities of behavior. angry Worry about physical changes Support maturational crisis Encourage verbalization of feelings Respect need for privacy and personal expression for anger . • Delusions and hallucinations. are not prominent or fragmented.

2. hallucinations. 5. trying to kill and poison him. interest . student or home maker) o Markedly eccentric behavior or odd beliefs o Marked impairment in personal hygiene o Marked lack of initiative. incoherence or grossly disorganized behavior. 4. o Paranoid o Disorganized o catatonic POSITIVE SYMPTOMS OF SCHIZOPHRENIA Hallucinations Delusions TYPES OF DELUSIONS 1. He believes that he can achieve anything and everything.g. Persecutory. Ideas of reference. Abnormal thought form Bizarre behavior Develops over a short time Pathoanatomy: Hyperdopaminergic process No structural changes NEGATIVE SYMPTOMS  Alogia (poverty of speech) Affective flattening .false belief that his spouse is unfaithful and is having extramarital affairs. wealthy and a very important person. 6. 3.suspicious of people and believes that others are trying to harm him.g. hallucinations. and feels that all the world is under him. Nihilistic. o No clinical presentation dominates e. Grandiosity.• o Stereotyped movements o Prominent mannerisms o Prominent grimaces Echolalia and echopraxia Residual o No longer has active phase symptoms (e. actions and feelings are all not his own but are being controlled by some external agencies.suddenly the person starts to harbour a false belief that he is extraordinarily powerful. o Marked social isolation or withdrawal o Marked impairment in role function (wage earner. or disorganized speech and behaviors) o However. e.g. and bizarre behaviors).false belief that the world is going to end or his body parts are missing.false belief that his thoughts . delusions. delusions.the person has false idea that people around him talk about him and make fun of him. Jealousy or infidelity. persistence of some symptoms is noted. Control ( Passivity Phenomenon). or energy o Blunted or inappropriate affect Undifferentiated type o Has active phase symptoms (does have hallucinations. Prominent delusions.

depression) Paranoid or catatonic features Married Family history of mood disorders Good support systems Undulating course Positive symptoms Asocial behavior Anergia (lack of energy) Poor Younger Onset No precipitating factors Insiduous Onset Premorbid social and sexual and work history Withdrawn. autistic behavior Undifferentiated or disorganized features Single. or increase in number of dopamine receptors NEUROSTRUCTURAL THEORIES Negative symptoms are due to pathoanatomy: increased ventricular brain ratio. divorced or widowed Family history of schizophrenia Poor support systems Chronic course Negative symptoms Neurological signs and symptoms History of perinatal trauma No remission in 3 years Many relapses Etiology: BIOLOGICAL Biochemical theories Dopamine hypothesis Excessive dopaminergic activity in cortical areas are responsible for the acute positive symptoms of schizophrenia. sexual and work history Affective symptoms (esp. and decreased cerebral blood flow GENETIC THEORIES VIRAL INFECTIONS AND FETAL INSULTS PSYCHODYNAMIC THEORIES DEVELOPMENTAL THEORY Freudian Poor ego boundaries Fragile ego . increase release or turnover of dopamine.Anhedonia (lack of pleasure) Attentional impairment Avolition (poor motivation) Pathoanatomy: Nondopaminergic process Structural changes Increased ventricular brain ratio Decreased cerebral blood flow SCHIZOPHRENIC PROGNOSIS Good Later Onset Obvious precipitating factors Acute Onset Good premorbid social. brain atrophy. This maybe due to increase in the synthesis of dopamine.

nurturing attention during the early childhood years Blocks the expression of those same affective responses during the later years Disordered social interactions. Do not “slip” medications into juices or food without talking to patients. when coupled with stressful life events can precipitate a schizophrenic process DISRUPTIVE PATIENTS  Set limits on disruptive behavior Decrease environmental stimuli Frequently observe escalating patients in order to intervene. Interactions are permitted in this situation. Patients who fear being poisoned should be allowed to open a can of food and serve themselves. SUSPICIOUS PATIENTS  Be matter-of-fact when interacting with these patients. . The nurse should clarify any misconceptions that patients have. Modify the environment to minimize objects that can be used as weapons WITHDRAWN PATIENTS  Arrange nonthreatening activities that involve these patients in “doing something”. sense. Be careful in stating what the staff will do if a patient acts out. PATIENTS WITH IMPAIRED COMMUNICATION  Provide opportunities for patients to make Be patient and do not pressure patients to make simple decisions. provide for safety by evaluating the patient’s status of hydration. however follow through once a violation occurs When using restraints. Avoid close physical contact.Inadequate ego development Love-hate relationships Arrested psychosexual development Erikson and Sullivan Absence of warm. Do not touch suspicious patients without warning. Obviously. but should not be demanded. Maintain eye contact. Some will move the chair away despite the nurses’ efforts Help patients to participate in decision making as appropriate. Staff members should not laugh or whisper around patients unless the patients can hear what is said. Sit in silence with patients who are not ready to respond. Provide patients with opportunities for nonthreatening socialization with the nurse on a one-to-one basis. Often students work with occupational or recreational therapists to provide these experiences. Catching the nurse in the act of doing this will reinforce their suspicious. nutrition. elimination. Arrange furniture in a semicircle or around a table so that patients are forced to sit with someone. and circulation. avoid social interaction due to painful childhood experiences FAMILY THEORIES Lack of loving and nurturing primary caregiver Inconsistent family behaviors Faulty communication patterns VULNERABLE STRESS MODEL Both biological and psychodynamic predisposition to schizophrenia. Provide psychosocial rehabilitation. this maybe difficult top arrange in some hospital settings. Reinforce appropriate grooming and hygiene (assist first if needed) Provide remotivation and resocialization group experiences.

and clarify following programs Monitor for command hallucinations that may increase the potential for patients to become dangerous. be available to explain. Assist with grooming and hygiene. Discourage situations in which patients talk to others about their perceptions. esteem. damage their selfpsychomotor activity. PATIENTS WITH DISORDERED PERCEPTIONS Attempt to provide distracting activities. Provide a calm environment. DISORGANIZED PATIENTS  Remove disorganized patients to a less stimulating environment. Monitor television selections. or overtax their availability. Provide safe and relatively simple activities for these patients. Have staff members available in the dayroom so that patients can talk to real people or real events Paging systems may reinforce perceptual problems and should be eliminated if possible. If you cannot sensor programs. . Provide information boards with schedules and refer to them often so patients can begin to use this as an orienting function Help protect each patient’s self esteem by intervening if a patient does something that is embarrassing. the staff should appear calm.Do not place patients in group activities that Provide opportunities for purposeful would frustrate them. discuss.

BRIEF PSYCHOTIC DISORDER Psychotic disturbance that last less than one month and are not related to a mood disorder. Symptoms are due to directly to a substance or to a medical condition. Maintain bowel and bladder function. IMMOBILITY Provide nursing care for catatonic or immobile patients in order to minimize circulatory problems and loss of muscle tone. Provide adequate diet. or a substance-induced disorder. Observe patients to prevent victimization (verbal or physical) by others. and rest. If mood episodes have occurred concurrently with delusions. Provide a safe environment and a place where patients can pace without inordinately bothering other patients Encourage participation in activities or games that do not require fine motor skills or intense concentration. exercise. OTHER PSYCHOTIC DISORDERS DELUSIONAL DISORDER Difference between delusional disorder and schizophrenia Delusions have a basis in reality The patients have never met the criteria for schizophrenia Behavior is relatively normal except in relation to their delusions. and intervene before problems arise. SCHIZOAFFECTIVE Schizophrenic symptoms are dominant but are accompanied by major depressive or manic symptoms . Delusions Hallucinations Disorganized speech Catatonic behavior SCHIZOPHRENIFORM Typical signs of schizophrenia and at least one month but no longer that six months.PATIENTS WITH ALTERED LEVELS OF ANXIETY HYPERACTIVITY Allow patients to stand for a few minutes during group meetings. a general medical condition. their total duration has been relatively brief.

neurotransmitters are norepinephrine. dizziness. skin. clothing or other objects Psychomotor retardation  Slowing of speech General slowing of body movements Decreased frequency of speech Change in sleeping patterns Increased pauses before answering Change in eating behaviors Soft or monotonous speech (dysprosody) Negligence of personal hygiene Muteness  Altered socialization Easily distracted Underachievement leading to lack of productivity on the job Withdrawn Subjective Signs: Alterations in affect Overall affective sense is one of low self-esteem Guilt Alterations in cognition Ambivalence and indecision Inability to concentrate Confusion Loss of interest and motivation Pessimism. self depreciation Self destructive thoughts and thoughts of death and dying Alterations of a physical nature Complaints of abdominal pain. self blame. chest pain. serotonin and dopamine Psychodynamic Theories Debilitating Early life experiences Intrapsychic conflict Reactions to life events These . fatigue. headache Preoccupation with the body (+) panic attacks Alterations of perceptions (+) delusions (somatic and nihilistic) (+) hallucinations Etiology: Biological theories Due to a chemical imbalance or deficiency of certain neurotransmitters in the brain. anorexia.MOOD DISORDERS MAJOR DEPRESSION  Chronic Fatigue Psychomotor retardation or pronounced reduced mental and physical activity Psychomotor agitation or pronounced agitated mental and physical activity Sleep disturbances Disturbance in appetite GI complaints Impaired libido Apathy Sadness Hopelessness Helplessness/ ruminations of inadequacy Objective signs of depression: Thoughts of Death Spontaneous crying without apparent cause Dependency Passiveness Anhedonia Lack of interest in self care Deep sense or feeling of sadness Anxiety Unconscious anger or hostility directed inward Guilt feelings Indecisiveness Lack of self-confidence Alterations in activity Psychomotor agitation Unable to sit still Pacing and engaging in hand wringing Pulling or rubbing the hair.

combining the daily dose in just one single dose at bedtime will decrease daytime sleepiness. delusions or irrational beliefs Recognize anger. Keep self help strategies simple Be honest to develop trust. PATIENTS WITH SLEEP DISTURBANCES Depressed patients want to sleep but suffer insomnia. Help patients avoid embarrassment through socially unacceptable behaviors and appearance. Encourage verbalizations Spend time with the withdrawn patient Provide opportunities for independent decision making without any pressure PATIENTS WITH LOW SELF-ESTEEM Encourage to participate in individual and group activities to experience accomplishments and receive positive feedback. For patients taking TCA. collects potentially dangerous items. appears to be in deep thought Assessment of suicidal behavior  Making final plans Suicide history Changes in social behavior Social withdrawal. Allow patients to eat food from their home if he prefers it.PSYCHOTHERAPEUTIC NURSE-PATIENT RELATIONSHIP Accept them as they are. Discouraging patients to have day naps would help in their wanting to sleep at night.reflects action of the person who has thought of suicide and maybe trying to solve a problem situation through suicide threat or gesture. suddenly feels very happy after being depressed. Provide assertiveness training. wanting to be dead.act of deliberate harm to one’s own body Suicide. Depressed patients who prefers to sleep most of the time should not be given daytime access to their rooms. PATIENTS WITH POTENTIAL FOR SELF-INJURY AND SUICIDE Self-injury. deliberate acts of ending one’s life that are a result of considerable thought and planning Suicide clusters Mild intent. include high fiber foods in the patient’s diet. gives away personal things Use of drugs and alcohol Commanding hallucinations . Activities could be substituted for daytime napping. They may be seen lying in their beds most of the time but this does not necessarily mean that they are sleeping or resting.intentional. Since constipation is a side effect of anti-depressant. Help them focus on the positive. WITHDRAWN PATIENTS Keep brief but frequent contacts. Be sincere and empathic Point out even small accomplishments and strengths to a depressed patient Reward patients who try to be independent Should not embarrass patient Never reinforce hallucinations. Has intense need for attention and recognition Done to manipulate or blackmail another Moderate intent Serious to end life but ambivalent Lethal intent Fully expected to die Method and timing are meant to be fatal Assessment of suicidal behavior  Direct warning Depressed behavior Frequent talks about death. Include these patients in group activities ANOREXIC PATIENTS Encourage to eat and spoon feed them if necessary Allow patients to choose their food Provide small frequent feedings and record intake. Monitor and record bowel elimination.

mirrors. pressured speech Flight of ideas Grandiosity. sleeping Make rounds at irregular times Assess and evaluate for changes Help patient to evaluate strengths and other ways to cope such as seeking interpersonal support or other anxiety reducing activities BIPOLAR DISORDERS  Psychomotor overexcitability or excitement Insomnia with fatigue Euphoria or elated mood Distractability Pressured speech Continuum of symptoms associated with Mania Mild (“high”)  Transient feeling of elation. pointed objects. a high feeling Moderate (Hypomania)  Clear sense of euphoria Talkativeness. toileting. interpersonal and occupational relationships  Manipulation of self esteem of others Ability to find vulnerability in others  Alteration in activity and appearance  Hyperactive and agitated Ability to shift responsibility Limit testing Alienation of family Colorful dresses Lack of sleep and poor nutrition Pacing & Flamboyant gestures . have someone to stay with them. smoking. confidence Minor alterations in habit and activity patterns Hypersexuality Impulsivity recklessness Decreased need for sleep Distractability Excessive buying. lotions.Signs and symptoms Physiological changes  Disturbance in sleep pattern Fatigue Anorexia with accompanying weight loss Constipation or diarrhea Behavioral  Loss of motivation Lack of interest Social withdrawal Flat. excessive spending Severe( “mania”/ euphoria)  Hyperactivity Talkativeness Flight of ideas Inflated self esteem Provide a safe environment in which the patient is protected and cared for until the impulses are controlled Maintain a safe unit Remove potentially harmful objects and supervise use of razors. Provide structure and assistance Take the patient seriously Provide one-one supervision Restrict to the ward Supervise eating. sad affect Mental changes Negative self concept Negative expectations of the future Impaired concentration Exaggerated view of problems Suicidal ideations and thoughts of death Care strategies  Be available to the patients. sexual indiscretions Objective behaviors Disturbances of speech Altered Social. drugs. chemicals… Use seclusion but ensure that patient is within sight and seconds away Encourage the patient to verbalize feelings and plans Obtain a “NO SUICIDE” contract Flight of ideas Manipulative or demanding behavior Destructive or combative behavior Delusions of grandeur Impaired judgment Shift in mood during the day Somatic complaints Psychomotor retardation Agitation and restlessness Decreased interest in sex Suicidal talks and acts Gives away personal things Feelings of well-being.

concise directions and comments Limit setting Reinforcement of reality Provide a homogenous group . if possible MANIPULATIVE PATIENT Manipulation refers to a coping strategy that a person employs to get one’s needs met without regard for others To cope with unmet needs for trust. direct.increased noradrenergic activity. specific approach when setting limits Enforce limits consistently Use clear. Psychotherapeutic management: Safety Clear. security and control Typical behaviors Assuming instant intimacy Using flattery Claiming Entitlement Splitting Categorizes providers as ‘good’ or ‘bad’ based on whether the staff has done what the patient wants Ignites power struggles Care strategies  Limit setting Establish boundaries Put restrictions on problematic behaviors Communicate constantly Introduce shift nurses to illustrate shift-shift teamwork Acknowledge grievances without defensiveness Use clear.Subjective behaviors: Alterations in affect Alterations of perception Etiology: Psychodynamic theories Family dynamics Mania as a defense Biological theories Imbalance between cholinergic and noradrenergic systems. specific approach when setting limits Enforce limits consistently Let the patient know that you are available and won’t abandon them Firm kindness approach Depression-increased cholinergic . mania. direct. activities.

Effort to compensate Impaired body image or functioning Regression . and cultural mores Employed by patients who needs to prove his worth Represents and unconscious bid for friendliness.Sexually provocative behavior  This behavior can be overt or covert and influenced by age. warmth. or social isolation. gender. alienation. attention to feelings of loneliness.

Sexually provocative behaviors  Flirting Excessive use of flattery Touching in sexually suggestive manner Commenting on staff’s behaviors or body parts Making sexist remarks Discussing sexual prowess .

Set boundaries Redirect personal questioning Document interactions and behaviors Develop a consistent approach Evaluate pre-existing problems that may affect behavior Set limits on behaviors Give positive reinforcements when appropriate .Sexually provocative behavior care strategies  Clarify one’s role as a nurse.


with a fingerbreadth allowance so as not to impede blood circulation. Ensure that the patient’s need for elimination. threatens. food intake.a growing tension and less ability to control it Actual violence. Important policies to consider: Restraints and seclusions must be ordered by the physician Informed consent Policies should be explained to the relatives Explain to the patient the purpose of the restraint and the seclusion Ensure a safe environment Teamwork is essential Patient should not be abandoned.anxiety associated with severe motor restlessness Potential violence. Non-verbal. comfort and safety are met Assess if the patient’s behavior is under control and no longer possess a threat to self or others . intensified facial expression. Ensure proper body position is maintained Isolate the patient with the head away from the door Give tranquilizers or sedatives prescribed by the physician Debrief family with regards to restraining and isolation.excessive psychomotor activity. shouting. fist clenching.Violent and agitated behavior Agitation. pacing about.raising voice. Designate a seclusion marshal who would clear the are of other patients and any physical obstruction State clearly the purpose and rationale of the procedure Ensure correct team positioning Ensure that when restraining the patient. suspicious. Must be monitored and evaluated regularly Nobody except the staff shall remove the restraints Care strategies:  Initial action and objective is to talk down the patient and guide away from the extraneous stimulus Give prn medication if ordered and set a contract Form a four-man restraining team Choose a restraint leader and designate the role of each member of the team Present to the patient a “show of force” by gathering sufficient personnel. threatening stances. makes demands. speaking profanities. care must be observed to avoid injury by holding on the patient’s joints Assume an oblique position in approaching the patient Approach the patient calmly and promptly Use proper body mechanics and maintain physical contact at all times. violent gestures Care strategies Check for any history of violence Observe current behavior Observe physical distance in approaching the patient Ensure space on both sides Assume an oblique position instead of direct approach Avoid aggressive posture Utilize active listening Utilize restraints or limit setting Assess patients need for seclusion or physical restraints PHYSICAL RESTRAINT AND SECLUSION Indications: Prevent imminent harm to the patient or other person Prevent serious disruption of the treatment program or serious damage to the physical environment To provide control to psychotic symptoms that are severe and causing serious psychological pain Decrease stimulation a patient receives. Use cross chest carry while other members hold the extremities Restrain the patient on 4 extremities using a double knot act of aggression towards others. to self or objects in the environment VIOLENT AND AGITATED BEHAVIOR Behavioral cues Verbal.


illness. 3. Women-lubrication Men.rubbing one’s genitals against an unconsenting individuals thighs or buttocks Sexual masochism hypoxyphilia-strangulation/oxygen deprivation Sexual sadism Voyeurism ANXIETY.erection Orgasm disorder Inability to achieve orgasm Sexual pain disorder Suffer genital pain (dyspareunia) before. • • • PARAPHILIAS Sexual instinct is expressed in ways that are socially prohibited or unacceptable and are biologically undesirable.SEXUAL DISORDERS • SEXUAL DYSFUNCTION Characterized by the inhibition of sexual appetite or psychophysiological changes that compromise the sexual response cycle THE SEXUAL RESPONSE CYCLE Desire phase Excitement phase Orgasm phase Resolution phase Types: • • Sexual desire disorder Have little or have no sexual desire or an aversion to sexual contact Sexual arousal disorders Cannot attain the physiologic requirements for sexual intercourse e. unmet needs. 7.e. 5.victim: <13 y/o.feeling of apprehension due to anticipation of danger ANXIETY2 causes: Threats of psychological integrity or well being i. 6. Types: Pedophilia.fight or flight ResistanceExhaustion. during and after intercourse Vaginismus 1.relaxation or death Exhaustion- 1. safety Selye’s GAS Stages: Alarm. 8. a. 4. 2. .adrenaline is released when threat is recognized AlarmResistance. 3.e. 2. pedophile: >_ 16 y/o or at least 5 years older Incest Exhibotionism Fetishism. threats to self esteem. 4. love and belongingness Threats to physical integrity i. guilt.g.inanimate objects Frotteurism.

BP. inc. individuals fails to notice what goes on in situations peripheral to the immediate focus but can notice if attention is pointed there by another observer. Involves disorganization of the personality. spleen and lymph nodes Hormone levels readjust Reduction in activity and size of adrenal cortex Lymph nodes return to normal size Weight returns to normal Decreased immune response Depletion of adrenal glands and hormone production Weight loss Enlargement of lymph nodes and dysfunction of lymphatic system Cardiac failure. Sees. And there is inability to do so even when attention is pointed to this direction by another observer. the person does not notice what goes on in a situation ( specifically communication with reference to the self). Perceptual filed is greatly reduced. grasps less but can attend to more if asked to do so. Dissociating tendencies operate to panic i. Loss of control Unable to do things even with direction Distorted perceptions Effects upon the ability on what is happening Increased awareness and alertness Attention is possible Skill in seeing relations can be used. Levels of Anxiety Mild Perception is more alert than usual Moderate Narrowed perception Difficulty focusing Selective inattention Mild physical complaints such as stomachache Severe Very narrowed perception Unable to focus on problem solving Increased physical discomfort Panic Unable to see the whole situation or reality Distortion of perception Level Mild Effects upon the ability to observe Person is alerted.Stage Alarm reaction • • • • • • Stage of resistance • • • • • • • • • Stage Exhaustion of Physical Changes Release of adrenaline=vasoconstriction. inc. HR. . hears. i. Person’s perceptual field is narrowed. that can motivate leaning and can produce growth and creativity in the individual.e. and force of cardiac contraction Increased hormone levels Enlargement of adrenal cortex Marked loss of body weight Irritation of gastric mucosa Shrinkage of thymus. HEARING IS NOT POSSIBLE He tends to focus on a specific detail and all his behavior aimed at getting relief. and grasps more than previously • Level. sees. Moderate Severe Panic Selected inattention. • Associated with the tension of everyday life.e. renal failure or death may occur • • • Psychosocial changes Increased level of alertness Increased level of anxiety Task/defense oriented behavior • • Increased/intensified use of coping mechanisms Tendency to rely on defense oriented behavior • • • • Defense oriented behaviors Disorganization of thinking Disorganization of personality Sensory stimuli maybe perceived with the appearance of illusion • Reality contact maybe reduced with the appearance of delusion or hallucinations. hears. Person becomes immobilized (emotional paralysis) Increase motor activity Decrease ability to relate to others.

Implosion. 2. Flooding. .Loss of rational thought ANXIETY DISORDERS PHOBIC DISORDERS Irrational. Accept patients and their fears with a non-critical attitude Provide and involve in activities that do not produce anxiety but will increase involvement rather than avoidance Help patients with physical safety and comfort needs Help the patient to recognize that their behavior is a method of coping with needs Assertiveness training and goal setting OBSESSIVE COMPULSIVE DISORDER Definition: Obsession. Arachnophobia (spiders)  Claustrophobia (close space) Zoophobia (animals) Agoraphobia (open space) Allurophobia (cats) Acrophobia(heights) Chromophobia (colors) Hydrophobia (water) Mysophobia (dirt) Xenophobia (strangers) Bacillophobia (germs) Etiology Psychoanalytic view Individual experiences severe diffused anxiety which is only incompletely resolved by repression and so there is displacement of the anxiety to an external focus which the individual then tries to avoid 1. excessive fear of a condition or object Degree of fear expressed is obviously unusual and out of proportion to the attending circumstances e.flooding carried out in imagination. Systematic Desensitization b.uncontrollable impulse to repeatedly perform an act Etiology: Genetic predisposition Decreased serotonin Symptoms: Ritualistic behavior Constant doubting if he\she has performed the activity Nursing Care: Allow the patient to perform the ritual to decrease the anxiety and energy level Provide structured activities to decrease the ritual to a degree that is comfortable to the patient Note: The individual recognizes the unreasonableness and absurdity of the obsessions and compulsions but is unable to control it. Treatment for phobic disorders Drug treatment. POST-TRAUMATIC STRESS DISORDER Developed usually after experiencing a traumatic event Symptoms: Events are traumatic to anyone and are unusual life events Sleep disturbances: Insomnia due to nightmares Patient may appear to re-experience the event while awake Psychic numbness: unable to move in life.g.sudden exposure of the patient to the phobic situation until he is no more fearful.persistent thought that wont go away thru logical effort Compulsion.anxiolytics Behavior Therapy a. stuck in the experience of the past Management: Psychotherapy Group therapy Anxiolytics c.

explore their personal values. Encourage adaptive coping strategies and techniques Encourage patients to establish or reestablish relationships CHRONIC ANXIETY DISORDER OR GENERALIZED ANXIETY DISORDER Anxiety is directly felt and expressed Difficulty in controlling the anxiety Often admitted to the hospital Symptoms: Excessive worry and anxiety Difficulty in controlling the worry Anxiety and worry are evident in: Restlessness  Fatigue and irritability Decreased ability to concentrate Muscle tension Disturbed sleep Nursing Care:  Provide a calm and quiet environment Ask the patient to identify what and how they feel to increase awareness of what is happening to them Encourage to describe and discuss their feelings with you to increase awareness of the connection between feelings and behaviors Help patients to identify possible causes of their feelings Listen carefully for patients’ expressions of helplessness and hopelessness. Assist patients with exploring alternative solutions and behaviors Encourage patients to test new adaptive coping behaviors through role playing or implementation. severe. especially anger. behaviors and problems. Help patients to evaluate past behaviors in the context of the trauma. not in the context of current values and standards Encourage safe verbalizations of feelings. morbid preoccupation with one’s physical and emotional health and accompanied by various somatic complaints without demonstrated organic cause  Individual is aware and exaggerates the intensity and importance of sensations that most others disregard. acknowledge any unfairness or injustices to the trauma Assure patient that what they are feeling are typical reactions to serious trauma Help patient to recognize the connections between the trauma experience and their current feelings. SOMATOFORM DISORDERS Have physical symptoms with no known organic or physiological cause Defense mechanisms used Repression Denial Displacement HYPOCHONDRIASIS Thought disorder  Characterized by persistent.Nursing Care:  Be nonjudgmental and honest. SICK BEHAVIOR extra love. assess for suicidality Plan and involve patients in activities such as going for walks and playing recreational games Discuss with patients their present and previous coping mechanisms Discuss with patients the meaning of problems and conflicts to appraise stressors. offer empathy and support. Teach patients relaxation exercises Promote use of hobbies and recreational activities. and define the scope and seriousness of their problems Use supportive confrontation and teaching. attention and sympathy Primary gain Characteristics: No pathology Secondary gain .

The child often has excessive gross motor activity (e.holding neck erect 6 months. Disorganized behavior Sustaining attention is very difficult.g. Course is chronic. Symptoms: • Failure to form interpersonal relationships • Impairment in communication • Bizarre responses to the environment • Extreme fascination for objects that move (e. fans.sitting with support 9 months-1 year. trains) • Fluctuating mood sudden crying or laughing • Self mutilating behaviors ATTENTION DEFICIT HYPERACTIVITY DISORDER  A disorder occurring in childhood characterized by poor attention span. excessive running-climbing.g. • • • Symptoms: Easily distracted.Doctor shopping Symptoms are under unconscious control CONVERSION DISORDER Repression Conversion Characteristics: Physical disability without pathology Motor Paralysis paresthesia Sensory Hysterical Blindness Mutism/deafness Labelle indifference.speaking few words or phrases AUTISM  Withdrawal of the child into the self and into a fantasy world of his own creation. not able to sit or do one thing for some time.indifference with his/her condition indifferenceTreatment: Psychotherapy Hypnosis Management: Acknowledge complaints Divert attention Keep the patient busy Discourage secondary gains Encourage independence MENTAL RETARDATION  Below average general intellectual functioning originating during the development period and associated with impairment in adaptive behavior. Hence is disruptive and overactive in the classroom. overactivity and impulsiveness. The child responds to multiple stimuli at the same time. Levels Mild Mental retardation Moderate Mental retardation Severe mental retardation Profound mental retardation Normal Milestones 3 months. difficulty in sitting for long. restlessness) IQ range 50-69 35-49 20-34 below 20 • • • • .walking 11/2 years.

Alterations in memory ( short and long term. Memory impairment Disturbances in sleep Disturbances in psychomotor sensory misperceptions Disorientation activity and Nursing Interventions: Manipulation of the environment to provide familiarity and to decrease the fear of a strange place is also beneficial DEMENTIA Characterized by the development of multiple cognitive deficits manifested by both memory impairment and at least one of the cognitive disturbances of aphasia. and logical reasoning Alterations in judgment Alterations in perceptions (+) visual and auditory hallucinations (+) delusions arising out of a reaction to a cognitive deficit (+) illusions ALZHEIMER’S DISEASE Age related. They often get caught by the police. Common Problems: • Truancy ( not attending school. The course is gradual in onset with an unabated decline. anxiety. personality deterioration Clear consciousness Global impairment of cerebral function Progressive course Mostly irreversible Nursing Management: Daily routine Stress Safety . COGNITIVE DISORDERS DELIRIA Characterized by a change in cognition and a disturbance of consciousness. intellect and memory. Symptoms: Cardinal symptoms: problems with orientation. thefts outside home. • Does not accept responsibility and learn from past experiences and go on repeating the same mischief again and again. concept formation. breaking things. substance abuse. attention. Delirium tends to develop over a short period of time and tends to fluctuate during the course of the day. progressive disorder of the CNS. spending time somewhere else) • Lying. Prognosis is usually poor. The behaviors are repetitive and persistent. apraxia.CONDUCT DISORDERS  Disorders where the child’s behavor is against social norms and values. Symptoms:  Reduced awareness of and attentiveness to the environment Reduced stare of consciousness Disorganized thinking Rambling. sustain or shift attention. judgement. stealing. irrelevant or incoherent speech. agnosia or disturbances in planning. setting fire. gambling poor peer group relations. They violate rules. which manifests as a reduced ability to focus. poor attention Clouding of consciousness or drowsiness Perceptual abnormalities are common (hallucinations and illusions) Fluctuating course Reversible Dementia Insidious onset Disturbed memory. differentiation. fights with others. Their conduct is worse than ordinary mischief. often running away from home. language and personality) Alterations in abstract thinking Decreased capacity for generalization. characterized by chronic cognitive dysfunction Four A’s of Alzheimer’s disease Amnesia Agnosia Aphasia Apraxia Delirium • • • • • • Acute onset Presence of disorientaion. alterations in reasoning.

flamboyant and erratic) a. Inhibited a. Narcissistic Characteristics of Personality Disorders 1. Obsessive Compulsive 4. they do not find their behaviors distressing to others.. Dependent (anxious and fearful) a. inflexible. Borderline c. These dysfunctional patterns and behaviors usually cause distress to others. including bodily illusions Peculiar thinking Vague. PARANOID PERSONALITY DISORDER  Suspicious Doubt trustworthiness of others Fear of confiding in others Fear personal information will be used against him Intervention: centered on building trust SCHIZOID PERSONALITY DISORDER Lacks desire for close relationships or friends Chooses to be alone Lack of sexual experiences Avoids activities Appears cold and detached Interventions: building trust followed by identification and appropriate verbal expression SCHIZOTYPAL PERSONALITY DISORDER  Ideas of reference Magical thinking or odd beliefs Unusual perceptual experiences. Dependent 3. It is not a mental illness 2. and appropriate behaviors ANTI-SOCIAL PERSONALITY DISORDER Violates rights of others Engages in illegal activities Aggressive behavior Lack of guilt or remorse Irresponsible in work and with finances Impulsiveness Recklessness Manipulative . most of the time. Histrionic b. However. and dysfunctional patterns of relating and behaving.Wandering PERSONALITY DISORDERS This involves lifelong. It is a maladaptive behavior 3. lifelong problem 5. It produces distress to the individual and to others. stereotypical. Classification of Personality Disorders 1. Anti-social (dramatic. Avoidant b. Schizotypal b. social skills. It is the possession of abnormal personality traits 4. Schizoid c. Paranoid 2. emotional. overelaborate speech Suspiciousness Blunted or inappropriate affect Eccentric appearance or behavior Few close relationships Uncomfortable in social situations Interpret remarks as demeaning or threatening Hold grudges toward others Becomes angry and threatening when they perceive to be attacked by others Interventions: Improving Interpersonal relationships. It causes significant impairment in social occupational functioning 6. Withdrawn (odd and eccentric) a. It is a long lasting.

maybe due to neglect. • Encourage the patient to talk about his behavior. assertiveness training AVOIDANT PERSONALITY DISORDER Avoids occupations involving interpersonal contact due to fears of disapproval or rejection Uninvolved with others unless certain of being liked Fears intimate relationships due to fear of shame or ridicule Preoccupied with being criticized or rejected in social situations Inhibited and feels inadequate in new interpersonal situations Believes self to be socially inept.dramatizes all events and draws attention to self DISORDERUses somatic complaints to avoid responsibility  Overly dramatic and support dependency Draws attention to self Dissociation Extroverted and thrives on being the center of attraction Interventions: Positive reinforcement in the form of attention. HISTRIONIC PERSONALITY DISORDER.Interventions: Consistency and firmness in confronting behaviors and enforcing rules and policies. SHORT TERM: minimize manipulation and acting out. BORDERLINE PERSONALITY DISORDER. Recognize the reality of the patient’s pain. DEPENDENT PERSONALITY DISORDER Unable to make daily decisions without much advice and reassurance Performs unpleasant tasks to obtain support  Needs others to be responsible for important from others areas of life. should offer support and should empower and work with the patient to understand control and change dysfunctional behaviors. Nursing Care of Antisocial Personality Disorders: LONG TERM: helping person to accept responsibility for and consequences of his actions. success or brilliance Believes he or she is special Needs to be admired Sense of entitlement Takes advantage of others for own benefit Lacks empathy Envious of others or others are envious of him Arrogant Interventions: supportive confrontation on what the patient sways and what exists. its limits and consequences. Provide safe environment. • Develop trust and rapport. • Provide positive reinforcement for non-manipulative behavior because thay cannot be corrected by punishment. real or Rapid mood shifts imagined Chronic feelings of emptiness Unstable and intense interpersonal relationships Problems with anger Identity disturbances Transient dissociative and paranoid symptoms Impulsivity Interventions: Use of empathy. • Discuss how manipulative behavior prevents him from establishing a close relationship. unappealing and inferior to others . over involvement or abusive DISORDERfamily. • Help the client identify more adaptive strategies. NARCISSISTIC PERSONALITY DISORDER  Grandiose self importance Fantasies of unlimited power. • Assist him to understand his positive qualities. Defense mechanism: splitting (viewing things as all good or all bad) Self-mutilating behavior  Frantic avoidance of abandonment. Limit setting and consistency to decrease manipulation and entitlement behaviors. • Provide group situations for the patient. recognition or praise are given for unselfish or other-centered behaviors. Anxious or helpless when alone because of fear Seldom disagrees with others because of fear of of being unable to care for self loss of support or approval Urgently seeks another relationship for support Problems with initiating with projects or doing and care after a close relationship ends things on his own because of little self Preoccupied with fear of being alone to care for confidence self Interventions: increase responsibility for self in day to day living.

Tolerance 3. The drug is seen as a reinforcer 2. organization Perfectionism that interferes with task completion Too busy working to have friends or leisure activities Overconscientious and inflexible Unable to discard worthless or worn-out objects Others must do things his or her way in work or task related activity Reluctant to spend and hoards money Rigid and stubborn CHEMICAL DEPENDENCE DRUG ABUSE • • • • Reasons for taking drugs: Search for euphoria Relief from psychological pain of diverse origins Wanting to feel better than they do To avoid withdrawal symptoms Factors involved in drug abuse: 1. The motivating factors  Initiation by company  Curiosity  Pleasure  Acceptance by the group . Physical dependence 4.Very reluctant to take risks or engage in new activities due to the possibility of being embarrassed OBSESSIVE COMPULSIVE PERSONALITY DISORDER Preoccupied with details. The environment  Stress  Isolation  Peer group influence 6. lists. The abuser  The personality. rules. degree of stability and attitude of the individual 5.

palpitation. tremors and weakness Interactions Fetal alcohol Syndrome. dyspnea. flushing of the face and neck. throbbing headache. cleft palate. nausea and vomiting.microencephaly. mental retardation. cardiac defects.DEPRESSANTS ALCOHOL Physiological effects Disinhibition. and depressed sucking reflex Withdrawal and Detoxification Withdrawal:  tremulousness nervousness anxiety anorexia. altered palmar creases. increase blood pressure profuse perspiration diarrhea fever unsteady gait difficulty concentrating exaggerated startle reflex craving for alcohol and other drugs . hallucinations may occur.CNS irritability. the body not only invents sensory inputs but also has extreme Tremensmotor agitation. anomalous Syndromegenitalia. seizures (grand mal) may also be present. n/v insomnia and other sleep disturbances rapid pulse. impaired judgment and fuzzy thinking Sedation and toxicity Delirium Tremens. Nursing issues: Overdose Disulfiram (Antabuse).intake of disulfiram with alcohol creates an ill feeling in the person ( sweating.

insomnia. safe environment Control nausea and vomiting Administer anticonvulsant (for seizures or rumfit) Physical restraint if highly disturbed or hyperactive Keep potentially dangerous items out of patients access to prevent self harm • • . Welllighted rooms reduce fears and illusions • Safety.impairment in long term and short term memory with disorientation and confabulation • Alcoholic dementia.vitamin C to acidify urine to increase excretion of alcohol.Physical complications of alcoholism: Gastrointestinal • Dyspepsia • Vomiting • Acute or chronic gastritis • Peptic ulcer • Cancer Liver • Fatty degeneration of the liver • Alcoholic Hepatitis • Cirrhosis Pancreas • Acute and chronic pancreatitis Cardiovascular • Alcoholic cardiomyopathy • High risk for myocardial infarction Blood • Folic acid deficiency anemia • Decreased WBC production Muscle • Peripheral muscle weakness • Muscle wasting Skin • Spider angiomas • Acne Nutrition • Protein malnutrition • Vitamin Deficiency disorders like pellagra and beriberi Joints • Gout due to increased uric acid level Reproductive system • Sexual dysfunction in males • Failure of ovulation in females Pregnancy • Fetal Alcohol syndromefetal abnormalities like mental retardation and growth deficiency Nervous System • Alcoholic peripheral neuropathy • Wernicke’s-Korsakoff syndrome • Rum fits during withdrawal Psychiatric Complications • Pathologic intoxication • Withdrawal phenomenon • Alcoholic Hallucinosisvivid hallucinations developing shortly after cessation or reduction of alcohol use. Care of alcoholics in the acute stage of withdrawal • Provide calm. B complex for liver damage. Observe for signs of DT • Side rails up • • • • Supplementation. agitation and tremors • Assess fluid and electrolyte imbalance • Reestablish proper nutrition by giving high protein diet (if no liver damage).paranoia in chronic alcohol use • Morbid jealousy • Alcohol amnestic disorder. Provide calm. quiet environment.due to prolonged use and maybe rendered irreversible Management of alcoholism • Assessment of the patient o His drinking pattern o Work spot o Family o Environment • Physical methods o Detoxification o Disulfiram Therapy • Psychological methods o Counseling o Individual and group psychotherapy o Marital/family therapy o Behavioral modification (Aversion therapy) o Relapse prevention therapy • Rehabilitation • Alcoholic anonymous Detoxification • Administration of minor tranquilizers to control anxiety. • Alcoholic psychosis.

• Monitor VS every 15 minutes • Frequently reorient patient to reality and surroundings .

energy Tachycardia Increased blood pressure Deeper respirations Dilated pupils Nasal septum perforation Improved mood to euphoria Insomnia and amnesia Amphetamine induced psychosis .3 element of detoxification: secure environment sedation supplements BARBITURATES INHALANTS OPIOIDS AND NARCOTICS STIMULANTS COCAINE PhysiologicEffects:  Euphoria Increased mentalalertness Increased strength Anorexia Increased sexual stimulation Increased motor activity AMPHETAMINES Physiologic Effects:  Wakefulness Alertness Heightened concentration.

firm in implementing rules Expressing empathy and providing a safe environment Group treatment Assertion training Lifestyle issues Personal responsibility Conscience development Milieu Management: Drug free environment Suicide prevention Thwarting inappropriate sexual behaviors Active. meaningful schedules EATING DISORDERS ANOREXIA NERVOSA Symptoms: .HALLUCINOGENS Natural hallucinogens Mescaline Psilocybin Marijuana Synthetic Hallucinogens LSD PCP Psychotherapeutic Management: Help patient understand positive motivators that will help in establishing new goals and direction for his life Trusting relationship.

BULIMIA NERVOSA Symptoms: Recurrent episodes of binge eating Feeling of lack of control over eating behaviors during the eating binges Recurrent inappropriate compensatory behavior in order to prevent weight gain. absence of menses of at least 3 consecutive cycles Objectives of Care: Increasing self esteem Increasing body weight to at least90% of average weight for age and height Reestablishing good eating behavior Nursing Interventions: Monitor daily caloric intake Observe signs of purging Monitor activity level Weigh daily Provide accurate information on nutrition and discuss realistic and healthy diet Regularly monitor electrolyte status Convey warmth and sincerity Listen empathically Be honest Set limits Assist in identifying at least three positive characteristics Involve patient in care Teach patient about their illness Avoid long silences Behavior modification: reward increase in weight with meaningful privileges Identify patient’s non weight related interests to reduce anxiety and refocus attention. .Refusal to maintain body weight over a minimum normal weight for age and height Intense fear of gaining weight or becoming fat. oral-genital contact or penetration of a bodily orifice.refers to some act as fondling of the genital area. recreation and occupational therapy Encourage the patient to describe their body image at different ages of their lives. Abuse may involve omission or commission Sexuality abusive behavior. No consent of the victim. shape or size is experienced In females. even though underweight Disturbance in the way in which one’s bodyweight.the less likely she is to acknowledge abuse openly or seek assistance of others. Misuse of power by one to inflict pain and injury to another who is less powerful. hurt or damage. such as self induced vomiting Binge eating and inappropriate eating behaviors Persistent over concern with body shape and weight Management: Trust Help patient identify feelings associated with binge-purge behaviors Accept patient as worthwhile human beings because they are often ashamed of their behavior Encourage patient to discuss positive qualities about themselves Teach about bulimia nervosa Encourage to explore interpersonal relationships Encourage patients to adhere to meal and snack schedules Encourage the patient to approach the staff if she feels like binging or purging Encourage to attend group sessions Encourage family therapy Encourage participation in art. ABUSE • • • • • • • Definition: To take unfair or undue advantage of. to use or treat as to injure. The less powerful a person is. General considerations: No population or socioeconomic group is immune to neglect or abuse.

Nurse should be comfortable with abuse and victimization behavior before they can become therapeutic. Categories of abuse: Spouse Rape Child physical abuse and neglect Child sexual abuse • • • • .• • Lack of power or control over their own lives leads to distrust.