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BASIC CONCEPTS IN

PSYCHIATRIC NURSING
MENTAL HEALTH
 Is a state of emotional, psychological,
and social wellness evidenced by
satisfying personal relationships,
effective behavior and coping, a
positive self concept, and emotional
stability.
COMPONENTS OF MENTAL
HEALTH (Johnson, 1997)
 Autonomy and Independence
 Maximizing One’s Potential
 Tolerating Life’s Uncertainties
 Self-esteem
 Mastering the Environment
 Reality Orientation
 Stress Management
COMPONENTS OF MENTAL
HEALTH – AUTONOMY AND
INDEPENDENCE
 The individual can look within for guiding
values and rules to live by.

 The opinions and wishes of others are


considered but do not dictate the person’s
decisions and behavior.

 The person can work independently or


cooperatively with others without losing his
or her autonomy
COMPONENTS OF MENTAL
HEALTH – MAXIMIZING ONE’S
POTENTIAL
 The person has an orientation toward
growth and self-actualization.

 He or she is not content with the


status quo and continually and
continually strives to grow as a person.
COMPONENTS OF MENTAL
HEALTH – TOLERATING LIFE’S
UNCERTAINTIES
 The person can face the challenges of
life’s day-to-day living with hope and a
positive outlook, despite not knowing
what lies ahead.
COMPONENTS OF MENTAL
HEALTH – SELF-ESTEEM
 The person has realistic awareness of
his or her abilities and limitations.
COMPONENTS OF MENTAL HEALTH
– MASTERING THE ENVIRONMENT
 The person can deal with and influence
the environment in a capable,
competent, and creative manner.
COMPONENTS OF MENTAL HEALTH
– REALITY ORIENTATION
 The person can distinguish the real
world from a dream, fact from fantasy,
and act accordingly.
COMPONENTS OF MENTAL HEALTH
– STRESS MANAGEMENT
 The person can tolerate life stresses,
experience feelings of anxiety or grief
appropriately, and experience failure
without devastation.

 He or she uses support from family


and friends to cope with crises,
knowing that the stress will not last
forever.
MENTAL ILL HEALTH
 A state of imbalance characterized by
disturbance in a person’s thoughts,
feelings and behavior.
MENTAL DISORDER (AMERICAN
PSYCHIATRIC ASSOCIATION, 1994)
 Is a clinically significant behavioral or
psychological syndrome or pattern that
occurs in an individual and that is
associated with present distress (i.e.,
painful symptom) or disability (i.e.,
impairment in one or more important
areas of functioning) or with a
significantly increased risk of suffering
death, pain, disability, or an important
loss of freedom.
PSYCHIATRIC NURSING
 Interpersonal process whereby the professional
nurse practitioner through the therapeutic use
of self assists a family, group, or community to
promote mental health, to prevent mental
illness and suffering, to participate in the
treatment and rehabilitation of the mentally ill,
and if necessary to find meaning in these
experiences.

 It is both a science and an art.


THE SCIENCE
IN PSYCHIATRIC NURSING
 The use of different theories in the
practice of nursing serves as the
science of Psychiatric Nursing
THE ART
IN PSYCHIATRIC NURSING
 The therapeutic use of self is
considered as the art of Psychiatric
Nursing.
THE CORE
OF PSYCHIATRIC NURSING
 The interpersonal process, that is, the
human-to-human relationship, is the
core of Psychiatric Nursing.
THE CLIENTS
IN PSYCHIATRIC NURSING
 The individual, the family, and the
community, both mentally healthy and
mentally ill, are considered as the
clientele in Psychiatric Nursing.
MENTAL HYGIENE
 It is the science that deals with
measures to promote mental health,
prevent mental illness and suffering
and facilitate rehabilitation.
SAMPLE BOARD QUESTION
NO.1
 Which of the following is a generally
accepted component of mental health?

A) Autonomy
B) Absence of anxiety
C) Ability to control others
D) Happiness
ANSWER
 Letter A

 Rationale: According to Johnson, 1997,


autonomy and independence is one of
the components of mental health.
SAMPLE BOARD QUESTION
NO.2
 A major predisposing factor of mental
illness in the home is?

A) Urbanization
B) Poverty
C) Political turmoil
D) Genetics
ANSWER
 Letter B

 Rationale: Poverty and domestic


abuses are some of the most common
causes of mental illness at home
SAMPLE BOARD QUESTION
NO.3
 The science which deals with the
measures to promote mental health and
reduce incidence of mental illness is
known as?

A) Psychiatric Nursing
B) Psychology
C) Psychiatry
D) Mental Hygiene
ANSWER
 Letter D

 Rationale: Mental Hygiene is the


science that deals with measures to
promote mental health. Psychiatric
Nursing is the interpersonal process
whereby the nurse assists the patient
to attain a state of mental health.
SAMPLE BOARD QUESTION
NO.4
 Nursing as an interpersonal process is?

A) The science of nursing


B) The art of nursing
C) The core of nursing
D) The clientele of nursing
ANSWER
 Letter C

 Rationale: The core of Psychiatric


Nursing is the human-to-human
relationship or the interpersonal
process.
SAMPLE BOARD QUESTION
NO.5
 Mental illness is?

A) Always hereditary in nature


B) Is manageable but is never treatable
C) A behavioral pattern associated with a
significantly increased risk of suffering
death, pain, disability, or an important
loss of freedom.
D) A state of emotional balance
ANSWER
 Letter C

 Rationale: Mental Illness is a clinically


significant behavioral or psychological
syndrome or pattern that occurs in an
individual and that is associated with present
distress (i.e., painful symptom) or disability
(i.e., impairment in one or more important
areas of functioning) or with a significantly
increased risk of suffering death, pain,
disability, or an important loss of freedom.
THERAPEUTIC USE OF
SELF
THERAPEUTIC USE OF SELF
 During therapeutic communication,
nurses use themselves as a
therapeutic tool to establish a
therapeutic relationship with the client,
to help the client grow, change, and
heal.

 It is the main tool used by the nurse in


the practice of Psychiatric Nursing.
THERAPEUTIC USE OF SELF
 Using one’s humanity – personality, experiences,
values, feelings, intelligence, needs, coping
skills, and perceptions – to help the client grow
and change is called THERAPEUTIC USE OF
ONE’S SELF (Northouse & Northouse, 1998).

 It is the main tool used by the nurse in the


practice of Psychiatric Nursing.

 It is the positive use of one’s self in the process


of therapy
THERAPEUTIC USE OF SELF
 Hildegaard Peplau (1952), who described this
therapeutic use of self in the nurse-client
relationship, believed that nurses must have a
clear understanding of themselves to promote
their clients’ growth and to avoid limiting
clients’ choices to those valued by the nurse.

 Therapeutic use of self requires SELF-


AWARENESS!!!
SELF-AWARENESS
 Self-awareness means an understanding of
one’s personality, emotions, sensitivity,
motivation, ethics, philosophy of life,
physical and social image, and capacities
(Campbell, 1980).

 It is the process by which the nurse gains


recognition of his or her own feelings,
beliefs, and attitudes.
SELF-AWARENESS
 The nurse needs to discover himself and what he believes
before trying to help others with different views.

 Most of the time, the nurse’s values and beliefs will conflict with
those of the client, the nurse must learn to accept these
differences among people and view each client as a worthwhile
person regardless of the client’s opinions and lifestyle.

 Therefore, understand YOURSELF before understanding


OTHERS!
SELF-AWARENESS
 The greater the nurse’s understanding of his or her own
feelings and responses, the better he or she can
communicate with and understand others.

 One tool that is useful in learning more about oneself is


the JOHARI WINDOW (Luft, 1970), which creates a “word
portrait” of a person in four areas and indicates how well
a person knows himself or herself and communicates
with others.
FOUR QUADRANTS OF THE
JOHARI WINDOW
 QUADRANT I
 Open Public Self
 Qualities one knows about
oneself and others also know

 QUADRANT II
 Blind / Unaware Self
 Qualities known only to others

 QUADRANT III
 Hidden / Private Self
 Qualities known only to oneself

 QUADRANT IV
 Unknown
 An empty quadrant to symbolize
qualities as yet undiscovered by
oneself or others
 CREATING
First Step A JOHARI WINDOW
– Appraise one’s own qualities by creating a list of
those qualities:
 One’s values
 Attitudes
 Feelings
 Strengths
 Behaviors
 Accomplishments
 Needs
 Desires
 Sad thoughts
CREATING A JOHARI WINDOW
 Second Step
– Find out how others perceive you by
interviewing others and asking them
to identify qualities they see in you,
both positive and negative.
CREATING A JOHARI WINDOW
 Third Step
– Compare lists and assign qualities to
the appropriate quadrants.
FOUR QUADRANTS OF THE
JOHARI WINDOW
 If Quadrant I is the
longest list, this
indicates the person is
open to others; a small
Quadrant I means the
person shares little
about himself or
herself with others
FOUR QUADRANTS OF THE
JOHARI WINDOW
 If Quadrants I and III
are both small, the
person demonstrates
little insight.
FOUR QUADRANTS OF THE
JOHARI WINDOW
 The goal is to work
toward moving
qualities from
Quadrants II, III and IV
into Quadrant I
(qualities known to
oneself and others),
which indicates the
person is gaining self-
knowledge and self-
awareness.
METHODS USED TO INCREASE
SELF-AWARENESS
 ROLE PLAY
– Putting yourself in the client’s situation allows you to think about his
or her thoughts, feelings and actions.
 INTROSPECTION

– Self-awareness can be accomplished through reflection, spending


time consciously focusing on how one feels and what one values or
believes.
– Keep a diary that focuses on experiences and related feelings.

 DISCUSSION
– Talk with others about your own experiences and feelings and how
they feel about similar experiences.
– Try to seek alternative points of view.

 ENLARGING ONE’S EXPERIENCE


– Being involved in new situations and experiences will uncover
qualities in yourself you might have not seen before.
CORE CONCEPTS ON
THE CARE OF THE
PSYCHOTIC PATIENT
COMMON BEHAVIORAL SIGNS
AND SYMPTOMS
 Disturbances in Perception
 Disturbances in Thinking
 Disturbances in Affect
 Disturbances in Motor Activity
 Disturbances in Memory
DISTURBANCES IN
PERCEPTION
DISTURBANCES IN PERCEPTION:
ILLUSION
 Misperception of an actual external
stimuli

 Example
– An electrical cord on the floor may
appear to be a snake!
DISTURBANCES IN PERCEPTION:
HALLUCINATION
 False sensory perception in the absence of an
external stimuli
 Perceptual experiences that do not exist in
reality

 Example
– A person may see “angels” hovering above
when nothing is there
– A person may hear voices in a room
wherein he is alone
DISTURBANCES IN
THINKING
DISTURBANCES IN THINKING:
NEOLOGISM
 Pathological coining of new words

 These are words invented by the client


– Example:
 “I am afraid of grittiz. If there are any
grittiz here, I will have to leave. Are you
a grittiz?”
DISTURBANCES IN THINKING:
CIRCUMSTANTIALITY
 Over inclusion of details.

 Example:
– Nurse: “How have you been sleeping lately?”
– Client: “Oh, I go to bed early, so I can get plenty of rest.
I like to listen to music or read before bed. Right now I
am reading a good mystery. Maybe I will write a mystery
someday. But is it isn’t helping, reading I mean. I have
been getting only 2 or 3 hours of sleep at night.”
DISTURBANCES IN THINKING:
WORD SALAD
 Incoherent mixture of words and phrases.

 This is a combination of jumbled words and


phrases that are disconnected or incoherent
and make no sense to the listener.

 Example:
– “Corn, potatoes, jump up, play games, grass,
cupboard.”
DISTURBANCES IN THINKING:
VERBIGERATION
 Meaningless repetition of words and
phrases.

 Example:
– “I want to go home, go home, go
home, go home.”
DISTURBANCES IN THINKING:
PERSEVERATION
 Persistence of a response to a previous question.

 Example:
– Nurse: “How have you been sleeping lately?”
– Client: “I think people have been following me.”
– Nurse: “Where do you live?”
– Client: “At my place people have been following me.”
– Nurse: “What do you like to do in your free time?”
– Client: “Nothing because people are following me.”
DISTURBANCES IN THINKING:
ECHOLALIA
 Pathological repetition of words of others.

 Example:
– Nurse: “Can you tell me how you are
feeling?”
– Client: “Can you tell me how you are
feeling? how you are feeling?”
DISTURBANCES IN THINKING:
FLIGHT OF IDEAS
 Shifting of one topic from one subject
to another in a somewhat related way.
 Excessive amount and rate of speech
composed of fragmented or unrelated
ideas.
DISTURBANCES IN THINKING:
LOOSENESS OF ASSOCIATION
 Shifting of a topic from one subject to another in a
completely unrelated way.
 Example:
– Nurse: ”Do you have enough money to buy that candy bar?”
– Patient: “I have a real yen for chocolate. The Japanese have all
the yen and have taken all of our money and marked it. You
know, you have to be careful of the Marxists because they are
friends with the Swiss and they have all the cheese and all the
watches and that means they have taken all the time. The worst
thing about Swiss cheese is all the holes. People have to be
careful about falling into holes.”
DISTURBANCES IN THINKING:
CLANG ASSOCIATION
 The sound of the word gives direction to the
flow of thought.

 Examples:

– “I will take a pill if I go up to the hill but not if my


name is Jill, I don’t want to kill.”

– “I want to sing ping pong that song wong kong long


today, hey way.”
DISTURBANCES IN THINKING:
DELUSION
 False belief which is inconsistent with one’s
knowledge and culture

 Examples:
– The client may claim to be engaged to a famous
movie star or related to some public figure such
as claiming to be the daughter of the President of
the Philippines

– May claim he or she has found a cure for cancer


DISTURBANCES IN
AFFECT
DISTURBANCES IN AFFECT:
INAPPROPRIATE AFFECT
 Disharmony between the stimulus and
the emotional reaction.
DISTURBANCES IN AFFECT:
BLUNTED AFFECT

 Severe reduction in
emotional reaction.

 Restricted range of
emotional feeling,
tone, or mood
DISTURBANCES IN AFFECT:
FLAT AFFECT

 Absence or near absence


of emotional reaction

 Absence of any facial


expression that would
indicate emotions or
mood
DISTURBANCES IN AFFECT:
APATHY
 Dulled emotional tone

 Feelings of indifference toward people,


activities, and events
DISTURBANCES IN AFFECT:
AMBIVALENCE
 Presence of two opposing feelings.

 Holding seemingly contradictory


beliefs of feelings about the same
person, event or situation
DISTURBANCES IN AFFECT:
DEPERSONALIZATION
 Feeling of strangeness towards oneself

– Clients feel detached from their behavior


– Although client can state his name correctly, he feels as if
his body belongs to someone else, or that his spirit is
detached from his body.
– He may feel that his limbs are detached or that the size of
his body parts is changed, or he is unable to tell where his
body leaves off and the rest of the world begins
– Patient describes the feeling of having stepped outside
their bodies and are observing themselves as detached
and foreign objects.
DISTURBANCES IN AFFECT:
DEREALIZATION
 Feeling of strangeness towards the environment

 Environmental objects become smaller or larger, or


seem unfamiliar.

 Individual feels that the outside world has changed:


– Buildings may appear to be leaning
– Everything may seem gray and dull
DISTURBANCES IN
MOTOR ACTIVITY
DISTURBANCES IN MOTOR
ACTIVITY:
ECHOPRAXIA

 The pathological
imitation of posture or
action of others.

 Imitation of the
movements and
gestures of another
person whom the client
is observing.
DISTURBANCES IN MOTOR
ACTIVITY:
WAXY FLEXIBILITY
 Maintaining the
desired position for
long periods of time
without discomfort
even when it is
awkward or
uncomfortable.
DISTURBANCES IN
MEMORY
DISTURBANCES IN MEMORY:
CONFABULATION
 Filling in of memory gaps to save face in an embarasing situation.

 It is a confused person’s tendency to make up a response to a


question when he cannot remember the answer

 Example:
– Nurse: “Do you know Gemma? (referring to one of the residents at the
patient’s home)
– Patient: “Yes, I know her. I used to play cards with her husband.”
– Actually, Gemma’s husband had been dead for many years and the
patient had never met him
DISTURBANCES IN MEMORY:
AMNESIA
 Inability to recall past events.
DISTURBANCES IN MEMORY:
ANTEROGRADE AMNESIA
 Loss of memory of the immediate past.
DISTURBANCES IN MEMORY:
RETROGRADE AMNESIA
 Loss of memory of the distant past.
DISTURBANCES IN MEMORY:
DEJA VU
 Feeling of having been to a place
which one has not yet visited.
DISTURBANCES IN MEMORY:
JAMAIS VU
 Feeling of NOT having been to a place
which one HAS VISITED.
SAMPLE BOARD QUESTION
 A patient changes topics quickly while relating
his past psychiatric history. However, the
nurse is able to follow his thoughts. The
patient’s pattern of thinking is called?

A) Looseness of association
B) Flight of ideas
C) Clang association
D) Confabulation
ANSWER
 Letter B

 Rationale: Flight of ideas is the shifting


of a topic from one subject to another
in a somewhat related way. Looseness
of association is the shifting of a topic
from one subject to another in a
completely unrelated way.
SAMPLE BOARD QUESTION
 A patient states, “The sun is shining.
Where is my sun? I love Lucy. Let us
play ball.” The patient is displaying?

A) Clang association
B) Flight of ideas
C) Derealization
D) Neologism
ANSWER
 Letter B

 Rationale: The patient is manifesting


flight of ideas
SAMPLE BOARD QUESTION
 The main function confabulation
serves in patients with dementia, is to?

A) Lessen isolation
B) Protect their self-esteem
C) Control others
D) Enhance memory recall
ANSWER
 Letter B

 Rationale: Confabulation is the filling in


of memory gaps and it serves to
protect the patient’s self-esteem
SAMPLE BOARD QUESTION
 A patient has mistakenly perceived a
coiled piece of wire as a snake. This is
an example of?

A) Illusion
B) Hallucination
C) Delusion
D) Confabulation
ANSWER
 Letter A

 Rationale: The patient misperceived an


actual external stimulus.
SAMPLE BOARD QUESTION
 All of the following are disturbances in
thinking, EXCEPT?

A) Looseness of association
B) Hallucination
C) Delusion
D) Clang association
ANSWER
 Letter B

 Rationale: Hallucination is a
disturbance in perception.
CORE CONCEPTS ON
THERAPEUTIC
COMMUNICATION
COMMUNICATION
COMMUNICATION
 It is the interchange of information
between two or more people

 It is the exchange of ideas or thoughts.


ELEMENTS OF
COMMUNICATION
 Sender
– Originator of the information
 Message
– Information being transmitted
 Receiver
– Recipient of information
 Channel
– Mode of communication
 Feedback
– Return response
 Context
– The setting of the communication
VARIABLES THAT INFLUENCE
COMMUNICATION
 Perception
– Experience of sensing, interpreting, and comprehending
the world in which the person lives

 Values
– Principles, standards of quality considered worthwhile or
desirable

 Culture
– The totality of socially transacted behavior patterns,
arts, beliefs, institutions, products of human work
characteristic of a community or population
LEVELS OF COMMUNICATION
 Intrapersonal
– Occurs when a person communicates within himself

 Interpersonal
– Takes place within dyads (groups of two persons) and in
small groups.
– The level of person-to-person communication is the heart of
of psychiatric nursing

 Public
– Communication between a person and several other people
MODELS OF COMMUNICATION
 Communication is an Act

 Communication is an Interaction

 Communication is a Transaction
COMMUNICATION IS AN ACT
 It is something that a person is doing to another person
(example: person A talks to person B)
 There is an attempt to transfer the thoughts or ideas of
one person into someone else’s head.
 It suggests that the receiver plays a passive role and
does not affect the communicator
 When misunderstandings occur, either the
communicator is faulted for failing to send the correct
message or the receiver is faulted for having allowed
something to interfere with the transmission of a
correct message.
 The model is, therefore, inadequate
COMMUNICATION IS AN
INTERACTION
 It takes into account the process of
mutual influence.

 When two people interact, they put


themselves into each other’s shoes.

 It is a circular process in which the


participants take turns at being
communicator and receiver
COMMUNICATION IS A
TRANSACTION
 It is viewed as a process of simultaneous mutual influence
rather than as a turn-taking event.
 No one is labeled either as a communicator or receiver.
 The symbolic interactionist model views human
communication on the social, interpersonal level and accounts
for the whole persons involved in the process.
 The participants are products of their social systems and
integral parts of it. Some events take place within the
participants (intrapersonal) and some take place between the
participants (interpersonal).
MODES OF COMMUNICATION
 Verbal Communication

 Non-verbal Communication
VERBAL COMMUNICATION:
THE SPOKEN WORD
 Denotation

 Connotation

 Private and Shared meanings


VERBAL COMMUNICATION:
THE SPOKEN WORD
 Denotation
– The meaning that is in general used
by most persons who share a
common language; the particular,
explicit, literal meaning of the word.
VERBAL COMMUNICATION:
THE SPOKEN WORD
 Connotation
– Usually arises from a person’s
personal experience
– Suggests or implies something in
addition to the literal meaning
VERBAL COMMUNICATION:
THE SPOKEN WORD
 Private and Shared Meanings
– For communication to take place,
meanings must be shared.
– People labeled schizophrenic may
use language in an idiosyncratic way
or may use a private, unshared
language called neologisms.
NON-VERBAL MESSAGES
 They carry more meaning than verbal
messages and involves the following:

– Body movement or kinetics

– Voice quality (pitch and range) and


non-language sounds (sobbing or
laughing)
NON-VERBAL

MESSAGES
They carry more meaning than verbal messages and involves
the following:

– Proxemics – use of personal or social space


 Intimate Distance – actual contact to 1.5 feet
 Personal Distance – 1.5 to 4 feet or 3 to 4 feet for interviews
 Social Distance – 4 to 12 feet
 Public Distance – 12 feet and beyond

– Cultural Artifacts – items in contact with interacting persons


that may act as non-verbal stimuli (i.e., clothes, cosmetics,
jewelry, cars)
CHARACTERISTICS OF
SUCCESSFUL COMMUNICATION
 1) Feedback (return response)
– If effective, may result in extension,
clarification or alteration of the original
communication

 2) Appropriateness
– The reply is fitting and relevant to the
communication; it is neither too much nor
too little
CHARACTERISTICS OF
SUCCESSFUL COMMUNICATION
 3) Efficiency
– The language used is understood

 4) Flexibility
– The absence of over-control or
under-control
ESSENTIAL INGREDIENTS TO
FACILITATE COMMUNICATION
 Respond with empathy

 Respond with respect

 Respond with genuineness

 Respond with immediacy

 Respond with warmth


THERAPEUTIC COMMUNICATION
 An interpersonal interaction between the
nurse and client during which the nurse
focuses on the client’s specific needs to
promote an effective exchange of
information

 Skilled use of therapeutic communication


techniques helps the nurse understand and
empathize with the client’s experience
GOALS OF THERAPEUTIC
COMMUNICATION
 Establish a therapeutic nurse-client relationship

 Identify the most important client concern at the


moment (the client-centered goal)

 Assess the client’s perception of the problem as it


unfolded.
– This includes detailed actions (behaviors and messages) of
the people involved and the client’s thoughts and feelings
about the situation, others, and self

 Facilitate the client’s expression of emotions


GOALS OF THERAPEUTIC
COMMUNICATION
 Teach the client and family necessary self-care
techniques

 Recognize the client’s needs

 Implement interventions designed to address the


client’s needs

 Guide the client toward identifying a plan of action


to a satisfying and socially acceptable resolution.
THERAPEUTIC
COMMUNICATION
TECHNIQUES
THERAPEUTIC COMMUNICATION
TECHNIQUES
 Accepting  Focusing
 Broad Openings  Formulating a Plan of
 Consensual validation
Action
 Encouraging Comparison
 General Leads
 Encouraging Description of
Perceptions  Giving Information
 Encouraging Expression  Giving Recognition
 Exploring  Making Observations
 Offering self
THERAPEUTIC COMMUNICATION
TECHNIQUES
 Placing Event in Time  Silence
or Sequence  Suggesting
 Presenting Reality Collaboration
 Reflecting  Summarizing
 Restating  Translating into
 Seeking Information Feelings
 Verbalizing the Implied
 Voicing Doubt
THERAPEUTIC COMMUNICATION
TECHNIQUES: ACCEPTING
 Definition
– Indicating reception

 Examples
– “Yes”
– “I follow what you said”
– Nodding

 Rationale
– An accepting response indicates the nurse has heard and followed
the train of thought.
– It does not indicate agreement but is nonjudgmental.
– Facial expression, tone of voice, and so forth also must convey
acceptance or the words will lose their meaning
THERAPEUTIC COMMUNICATION
TECHNIQUES: BROAD
OPENINGS
 Definition
– Allowing the client to take the initiative in introducing the topic

 Examples
– “Is there something you’d like to talk about?”
– “Where would you like me to begin?”

 Rationale
– Broad openings make explicit that the client has the lead in the
interaction.
– For the client who is hesitant about talking, broad openings
may stimulate him or her to take the initiative
THERAPEUTIC COMMUNICATION
TECHNIQUES: CONSENSUAL
VALIDATION
 Definition
– Searching for mutual understanding, for accord in the meaning of
the words.

 Examples
– “Tell me whether my understanding of it agrees with yours.”
– “Are you using this word to convey that . .”

 Rationale
– For verbal communication to be meaningful, it is essential that the
words being used should have the same meaning for all
participants.
– Sometimes words, phrases, or slang terms have different
meanings and can be easily misunderstood.
THERAPEUTIC COMMUNICATION
TECHNIQUES: ENCOURAGING
COMPARISON
 Definition
– Helping the client to understand by looking at similarities and
differences.

 Examples
– “Was it something like. . . ?”
– “Have you had similar experiences?”

 Rationale
– Comparing ideas, experiences, or relationships brings out many
recurring themes.
– The client benefits from making these comparisons because he or
she might recall past coping strategies that were effective or
remember the he or she has survived a similar situation
TECHNIQUES:
ENCOURAGING DESCRIPTION OF
PERCEPTIONS
 Definition
– Asking client to verbalize what he or she perceives.

 Examples
– “Tell me when you feel anxious”
– “What is happening?”
– “What does the voice seem to be saying?”

 Rationale
– To understand the client, the nurse must see things from his or her
perspective.
– Encouraging the client to describe ideas fully may relieve the
tension the client is feeling, and he or she might be less likely to
take action on ideas that are harmful or frightening.
THERAPEUTIC COMMUNICATION
TECHNIQUES: ENCOURAGING
EXPRESSION
 Definition
– Asking client to appraise the quality of his or her experience.

 Examples
– “What are your feelings in regard to. . ?”
– “Does this contribute to your distress?”

 Rationale
– The nurse asks the client to consider people and events in
light of his or her own values.
– Doing so encourages the client to make his or her own
appraisal rather than accepting the opinion of others.
THERAPEUTIC COMMUNICATION
TECHNIQUES: EXPLORING
 Definition
– Delving further into a subject or idea.

 Examples
– “Tell me more about that.”
– “Would you describe it more fully?”
– “What kind of work?”

 Rationale
– When clients deal with topics superficially, exploring can help them
examine the issue more fully.
– Any problem or concern can be better understood if explored in depth.
– If the client expresses an unwillingness to explore a subject, however,
the nurse must respect his or her wishes.
THERAPEUTIC COMMUNICATION
TECHNIQUES: FOCUSING
 Definition
– Concentrating on a single point.

 Examples
– “This point seems looking at more closely.”
– “Of all the concerns you have mentioned, which is most
troublesome?”

 Rationale
– The nurse encourages the client to concentrate his or her energies
on a single point, which may prevent a multitude of factors or
problems from overwhelming the client.
– It is also a useful technique when a client jumps from one topic to
another.
TECHNIQUES:
FORMULATING A PLAN OF
ACTION

 Definition
– Asking the client to consider kinds of behavior likely to be
appropriate in future situations.

 Examples
– “What could you do to let your anger out harmlessly?”
– “Next time this comes up, what might you do to handle it?”

 Rationale
– It may be helpful for the client to plan in advance what he or
she might do in future similar situations.
– Making definite plans increases the likelihood that the client
will cope more effectively in a similar situation
THERAPEUTIC COMMUNICATION
TECHNIQUES: GENERAL LEADS
 Definition
– Giving encouragement to continue.

 Examples
– “Go on.”
– “And then?”
– “Tell me about it.”

 Rationale
– General leads indicate that the nurse is listening and following what
the client is saying without taking away the initiative for the
interaction.
– They also encourage the client to continue if he or she is hesitant
or uncomfortable about the topic.
THERAPEUTIC COMMUNICATION
TECHNIQUES: GIVING
INFORMATION

 Definition
– Making available the facts that the client needs.

 Examples
– “My name is. . .”
– “Visiting hours are. . .”
– “My purpose in being here is. . .”

 Rationale
– Informing the client of facts increases his or her knowledge
about a topic or lets the client know what to expect.
– The nurse is functioning as a resource person
– Giving information also builds trust with the client.
THERAPEUTIC COMMUNICATION
TECHNIQUES: GIVING
RECOGNITION
 Definition
– Acknowledging, indicating awareness.

 Examples
– “Good Morning Ms. A. . .”
– “You’ve finished your list of things to do.”
– “I notice that you’ve combed your hair.”

 Rationale
– Greeting the client by name, indicating awareness of change, or
noting efforts the client has made all show that the nurse
recognizes the client as a person, as an individual.
– Such recognition does not carry the notion of value, that is, of being
“good” or “bad”.
THERAPEUTIC COMMUNICATION
TECHNIQUES:
MAKING OBSERVATIONS
 Definition
– Verbalizing what the nurse perceives.

 Examples
– “You appear tense.”
– “Are you uncomfortable when . . ?”
– “I notice that you are biting your lip.”

 Rationale
– Sometimes clients cannot verbalize or make themselves
understood.
– Or the client may not be ready to talk.
THERAPEUTIC COMMUNICATION
TECHNIQUES: OFFERING SELF
 Definition
– Making oneself available.

 Examples
– “I will sit with you awhile.”
– “I will stay here with you.”
– “I am interested in what you think.”

 Rationale
– The nurse can offer his or her presence, interest, and desire to
understand.
– It is important that this offer is unconditional, that is, the client
does not have to respond verbally to get the nurse’s attention.
THERAPEUTIC COMMUNICATION
TECHNIQUES: PLACING EVENT IN TIIME
SEQUENCE
 Definition
– Clarifying the relationship of events in time.

 Examples
– “What seemed to lead up to. . ?”
– “Was this before or after?”
– “When did this happen?”

 Rationale
– Putting events in proper sequence helps both the nurse and client to see
them in perspective.
– The client may gain insight into cause-and-effect behavior and
consequences, or perhaps some things are not related.
– The nurse may gain information about recurrent patterns or themes in
the client’s behavior relationship.
THERAPEUTIC COMMUNICATION
TECHNIQUES: PRESENTING
REALITY
 Definition
– Offering for consideration that which is real.
 Examples

– “I see no one else in the room.”


– “That sound was a car backfiring.”
– “Your mother is not here. I am a nurse.”
 Rationale

– When it is obvious that a client is misinterpreting reality, the nurse


can indicate what is real.
– The nurse does this by calmly and quietly expressing the nurse’s
perceptions of the facts not by way of arguing with the client or
belittling his or her experience.
– The intent is to indicate an alternative line of thought for the client
to consider, not to “convince” the client that he or she is wrong.
THERAPEUTIC COMMUNICATION
TECHNIQUES: REFLECTING
Definition
– Directing client actions, thoughts, and feelings back to the client.

Examples
– Client: “Do you think I should tell the doctor?”
– Nurse: “Do you think you should?”
– Client: “My brother spends all my money and then has the nerve to ask for
more.”
– Nurse: “This causes you to feel angry?”

Rationale
– Reflection encourages the client to recognize and accept his or her own
feelings.
– The nurse indicates that the client’s point of view has value, and that the
client has the right to have opinions, make decisions, and think
independently
THERAPEUTIC COMMUNICATION
TECHNIQUES: RESTATING
 Definition
– Repeating the main idea expressed.
 Examples

– Client: “I can’t sleep. I stay awake all night.”


– Nurse: “You have difficulty sleeping.”
– Client: “I am really mad. I am really upset.”
– Nurse: “You’re really mad and upset.”
 Rationale

– The nurse repeats what the client has said in approximately or nearly the
same words the client has used.
– This restatement lets the client know that he or she communicated the
idea effectively.
– This encourages the client to continue
– Or if the client has been misunderstood, he or she can clarify his or her
thoughts.
THERAPEUTIC COMMUNICATION
TECHNIQUES:
SEEKING INFORMATION
 Definition
– Seeking to make clear that which is not meaningful or that
which is vague.
 Examples
– “I am not sure that I follow.”
– “Have I heard you correctly?”
 Rationale
– The nurse should seek clarification throughout interactions
with clients.
– Doing so can help the nurse to avoid making assumptions
that understanding has occurred when it has not.
– It helps the client to articulate thoughts, feelings, and ideas
more clearly.
THERAPEUTIC COMMUNICATION
TECHNIQUES: SILENCE
 Definition
– Absence of verbal communication, which provides time for the client
to put thoughts or feelings into words, regain composure, or continue
talking.
 Examples

– Nurse says nothing but continues to maintain eye contact and


conveys interest
 Rationale

– Silence often encourages the client to verbalize provided that it is


interested and expectant.
– Silence gives the client time to organize thoughts, direct the topic of
interaction, or focus on issues that are most important.
– Much nonverbal behavior takes place during silence, and the nurse
needs to be, aware of the client and his or her own nonverbal
behavior.
THERAPEUTIC COMMUNICATION
TECHNIQUES:
SUGGESTING COLLABORATION
 Definition
– Offering to share, to strive, to work with the client for his or her
benefit.
 Examples

– “Perhaps you and I can discuss and discover the triggers for
your anxiety.”
– “Let’s go to your room and I will help you find what you are
looking for.”
 Rationale

– The nurse seeks to offer a relationship in which the client can


identify problems in living with others, grow emotionally, and
improve the ability to form satisfactory relationships.
– The nurse offers to do things with, rather than for, the client
THERAPEUTIC COMMUNICATION
TECHNIQUES: SUMMARIZING
 Definition
– Organizing and summing up that which has gone before.
 Examples

– “Have I got this straight?”


– “You’ve said that. .”
– “During the past hour, you and I have discussed..”
 Rationale

– Summarization seeks to bring out the important points of the


discussion and to increase the awareness and understanding of
both participants.
– It omits the irrelevant and organizes the pertinent aspects of the
interaction.
– It allows both client and nurse to depart with the same ideas and
provides a sense of closure at the completion of each discussion.
THERAPEUTIC COMMUNICATION
TECHNIQUES:
TRANSLATING INTO FEELINGS
 Definition
– Seeking to verbalize client’s feelings that he or she expresses
only indirectly.
 Examples
– Client: “I am dead.”
– Nurse: “Are you suggesting that you feel lifeless?”
– Client: “I am way out in the ocean.”
– Nurse: “You seem to feel lonely or deserted.”
 Rationale
– Often the client says, when taken literally, seems
meaningless or far removed from reality.
– To understand, the nurse must concentrate on what the client
might be feeling to express himself or herself this way.
THERAPEUTIC COMMUNICATION
TECHNIQUES:
VERBALIZING THE IMPLIED
 Definition
– Voicing what the client has hinted at or suggested.
 Examples

– Client: “I can’t talk to you or anyone. It is a waste of time.”


– Nurse: “Do you feel that no one understands?”
 Rationale

– Putting into words what the client has implied or said indirectly
tends to make the discussion less obscure.
– The nurse should be as direct as possible without being
unfeelingly blunt or obtuse.
– The client may have difficulty communicating directly
– The nurse should take care to express only what is fairly obvious;
otherwise the nurse may be jumping to conclusions or interpreting
the client’s communication
THERAPEUTIC COMMUNICATION
TECHNIQUES: VOICING DOUBT

 Definition
– Expressing uncertainty about the reality of
the client’s perceptions.

 Examples
– “Isn’t that unusual?”
– “Really?”
– “That is hard to believe.”
THERAPEUTIC COMMUNICATION
TECHNIQUES: VOICING DOUBT
 Rationale
– Another means of responding to distortions of reality is
to express doubt.
– Such expression permits the client to become aware
that others do not necessarily perceive events in the
same way or draw the same conclusions.
– This does not mean the client will alter his or her point
of view, but at least the nurse will encourage the client
to reconsider or reevaluate what has happened.
– The nurse neither agreed nor disagreed; however, he or
she has not let the misperceptions and distortions pass
without comment.
NON-THERAPEUTIC
COMMUNICATION
TECHNIQUES
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES
 These responses cut off
communication and make it more
difficult for the interaction to continue

 It takes practice for the nurse to avoid


making these typical comments
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES
 Advising  Giving Literal
 Agreeing Responses
 Belittling Feelings  Indicting the Existence
Expressed of an External Source
 Challenging  Interpreting
 Defending  Introducing an
 Disagreeing Unrelated Topic
 Making Stereotyped
 Disapproving
Comments
 Giving Approval
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES
 Probing  Requesting an
 Reassuring Explanation
 Rejecting  Testing
 Using Denial
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
ADVISING

 Definition
– Telling the client what to do.

 Examples
– “I think you should.”
– “Why don’t you?”

 Rationale
– Giving advice implies that only the nurse knows
what is best for the client.
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
AGREEING
 Definition
– Indicating accord with the client.

 Examples
– “That is right.”
– “I agree.”

 Rationale
– Approval indicates the client is “right” rather than “wrong.”
– This gives the client the impression that he or she is “right” because
of agreement with the nurse.
– Opinions and conclusions should be exclusively the client’s
– When the nurse agrees with the client, there is no opportunity for
the client to change his or her mind without being “wrong”
COMMUNICATION TECHNIQUES:
BELITTLING FEELINGS
EXPRESSED
 Definition
– Misjudging the degree of the client’s discomfort.
 Examples

– Client: “I have nothing to live for. . . I wish I was dead”


– Nurse: “Everybody gets down in the dumps.” OR “I have felt that way
myself.”
 Rationale

– When the nurse tries to equate the intense and overwhelming


feelings the client has expressed to “everybody” or to the nurse’s
own feelings, the nurse implies that the discomfort is temporary,
mild, self-limiting, or not very important.
– The client is focused on this or her own worries and feelings; hearing
the problems or feelings of others is not helpful.
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
CHALLENGING
 Definition
– Demanding proof from the client.

 Examples
– “But how can you be the President of the United States?”
– “If you are dead, why is your heart beating?”

 Rationale
– Often the nurse believes that if he or she can challenge the
client to prove unrealistic ideas, the client will realize there is
no “proof” and then will recognize reality.
– Actually challenging causes the client to defend the delusions
or misperceptions more strongly than before.
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
DEFENDING
 Definition
– Attempting to protect someone or something from verbal attack.

 Examples
– “This hospital has a fine reputation.”
– “I am sure your doctor has your best interests in mind.”

 Rationale
– Defending what the client has criticized implies that he or she has
no right to express impressions, opinions, or feelings.
– Testing the client that his or her criticism is unjust or unfounded
does not change the client’s feelings but only serves to block
further communication
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
DISAGREEING
 Definition
– Opposing the client’s ideas.

 Examples
– “That is wrong.”
– “I definitely disagree with. . .”
– “I do not believe that. . .”

 Rationale
– Disagreeing implies the client is “wrong”
– Consequently the client feels defensive about his or her
point of view or ideas.
NON-THERAPEUTIC COMMUNICATION
TECHNIQUES: GIVING APPROVAL
 Definition
– Sanctioning the client’s behavior or ideas.

 Examples
– “That is good.”
– “I am glad that. . ”

 Rationale
– Saying what the client thinks or feels if “good” implies that the
opposite is “bad”.
– Approval then, tends to limit the client’s freedom to think, speak, or
act in a certain way.
– This can lead to the client’s acting in a particular way just to please
the nurse.
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
GIVING LITERAL RESPONSES
 Definition
– Responding to a figurative comment as though it were a
statement of fact.

 Examples
– Client: “They are looking in my head with a television camera.”
– Nurse: “Try not to watch television.” OR “What channel?”

 Rationale
– Often the client is at a loss to describe his or her feelings, so such
comments are the best he or she can do.
– Usually it is helpful for the nurse to focus on the client’s feelings in
response to such statements.
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
INDICATING THE EXISTENCE OF
AN EXTERNAL SOURCE

 Definition
– Attributing the source of thoughts, feelings,
and behavior to others or to outside
influences.

 Examples
– “What makes you say that?”
– “What made you do that?”
– “Who told you that you were a prophet?”
COMMUNICATION TECHNIQUES:
INDICATING THE EXISTENCE OF AN
EXTERNAL SOURCE

 Rationale
– The nurse can ask, “What happened?” or
“What events led you to draw such a
conclusion?”
– But to question “What made you think that?”
implies that the client was made or compelled
to think in a certain way.
– Usually the nurse does not intend to suggest
that the source is external but that is often
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
INTERPRETING

 Definition
– Asking to make conscious that which is unconscious; telling the
client the meaning of his or her experience.

 Examples
– “What you really mean is. . .”
– “Unconsciously you are saying. . .”

 Rationale
– The client’s thoughts and feelings are his or her own, not to be
interpreted by the nurse or for hidden meaning.
– Only the client can identify or confirm the presence of feelings.
COMMUNICATION TECHNIQUES:
INTRODUCING AN UNRELATED
TOPIC
 Definition
– Changing the subject.

 Examples
– Client: “I would like to die.”
– Nurse “Did you have visitors last night?”

 Rationale
– The nurse takes the initiative for the interaction away from
the client.
– This usually happens because the nurse is uncomfortable,
does not know how to respond, or has a topic he or she would
rather discuss.
MAKING STEREOTYPED
COMMENTS
 Definition
– Offering meaningless cliches or trite comments.
 Examples

– “It is for your own good.”


– “Just keep your chin up”
– “Just have a positive attitude and you will be better in no time.”
 Rationale

– Social conversation contains many cliches and much meaningless


chit-chat.
– Such comments are of no value in the nurse-client relationship.
– Any automatic responses will lack the nurse‘s consideration or
thoughtfulness.
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
PROBING
 Definition
– Persistent questioning of the client.

 Examples
– “Now tell me about this problem. You know I have to find out.”
– “Tell me your psychiatric history.”

 Rationale
– Probing tends to make the client feel used or invaded.
– Clients have the right not to talk about issues or concerns if
they choose.
– Pushing and probing by the nurse will not encourage the client
to talk.
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
REASSURING
 Definition
– Indicating there is no reason for anxiety or other feelings of discomfort.

 Examples:
– “I would not worry about that.”
– “Everything would be alright.”
– “You are coming along just fine.”

 Rationale
– Attempts to dispel the client’s anxiety by implying that there is not
sufficient reason for concern completely devalues the client’s feelings.
– Vague reassurances without accompanying facts are meaningless to the
client.
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
REJECTING
 Definition
– Refusing to consider or showing contempt for the client’s
ideas or behaviors.

 Examples
– “Let us not discuss. . .”
– “I do not want to hear about. . .”

 Rationale
– When the nurse rejects any topic, he or she closes it off from
exploration.
– In turn, the client will feel personally rejected along with his
or her ideas.
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
REQUESTING AN EXPLANATION
 Definition
– Asking the client to provide reasons for thoughts, feelings,
behaviors, events.

 Examples
– “Why do you think that?”
– “Why do you feel that way?”

 Rationale
– There is a difference between asking the client to describe what is
occurring or has taken place and asking him to explain why.
Usually a “why” question is intimidating.
– In addition, the client is unlikely to know “why” and may become
defensive trying to explain himself or herself.
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
TESTING
 Definition
– Appraising the client’s degree of insight.

 Examples
– “Do you know what kind of hospital this is?”
– “Do you still have the idea that. . ?”

 Rationale
– These types of questions force the client to try to recognize
his or her problems.
– The client’s acknowledgement that he or she does not know
these things may meet the nurse’s needs but is not helpful
for the client
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
USING DENIAL
 Definition
– Refusing to admit that a problem exists.

 Examples
– Client: “I am nothing.”
– Nurse: “Of course you are something. Everybody is something.”
– Client: “I am dead.”
– Nurse: “Do not be silly.”

 Rationale
– The nurse denies the client’s feelings or the seriousness of the
situation by dismissing his or her comments without attempting to
discover the feelings or meaning behind them.
NON-VERBAL COMMUNICATION
 This is transmitted with or without verbal
communication.
 It is essential that the nurse become aware of
her own non-verbal communication in addition
to becoming skillful in identifying the client’s
non-verbal communication.
 Non-verbal communication provides clues about
the validity of the spoken words and congruency
with the client’s behavior.
 The phrase “Actions speak louder than words” is
generally accurate.
NON-VERBAL COMMUNICATION
 A list of ways in which non-verbal
communication is conveyed to others follows:
– Tone of voice
– Voice inflection
– Facial Expression
– Silence
– Gestures
– Mannerism
– Posture
NON-VERBAL COMMUNICATION
 List of ways in which non-verbal
communication is conveyed to others:
– Eye contact
– Rate of speech
– A “hurry up” attitude
– An “I couldn’t care less” attitude
– Physical appearance
– Touch
– Space
GUIDELINES FOR
IDENTIFYING THERAPEUTIC
RESPONSES IN THE BOARD
EXAM
GUIDELINES FOR IDENTIFYING
THERAPEUTIC RESPONSES IN
THE BOARD EXAM
 Identify therapeutic and non-therapeutic phrases

 Open-ended or Closed-ended question?

 Avoid ‘why’ questions and instead use ‘what’ questions

 Avoid false reassurances

 Avoid focus on the nurse (use of the word “I”); or focus on the doctor.
Focus on the patient instead.

 Use direct questions for suicidal cases

 Avoid the ‘Authoritarian Answer’


THERAPEUTIC RESPONSES IN THE
BOARD EXAM: LOOK FOR
THERAPEUTIC PHRASES
 The following are therapeutic phrases
utilized by the nurse:

– “It seems…”
– “It sounds…”
– “I will sit with you…”
– “I will stay with you…”
– “I will check…”
– “Tell me…”
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: LOOK FOR NON-
THERAPEUTIC PHRASES

 The use of ‘labels’ is non-therapeutic

– “That’s good!”
– “That’s bad!”
– “You’re the best!”
– “You’re the worst!”
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: LOOK FOR NON-
THERAPEUTIC PHRASES

 The use of ‘absolutes’ is non-therapeutic

– “Always…”
– “Never…”
– “None…”
– “All….”
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: LOOK FOR NON-
THERAPEUTIC PHRASES

 The use of ‘commands’ is non-therapeutic

– “You need to…”


– “You must…”
– “You should…”
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: USE OF OPEN-ENDED
QUESTIONS

 “Tell me, how do you feel,” then follow it


up with “I understand how you feel. I will
stay with you for awhile.’
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: USE OF CLOSED-ENDED
QUESTIONS
 Use of Closed-ended questions is therapeutic
when dealing with:

– Manic patients
 This would discourage them from over-control of
the conversation

– Rape or Crisis Victims


 With their unstable condition, they may
misconstrue use of open-ended questions as
‘prying’.
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: USE OF ‘WHY’
QUESTIONS

 The use of the question ‘why’ is non-therapeutic


– Example:
 Client: “I was speeding along the street and did not stop
at the sign”
 Nurse: “Why were you speeding?”

 Rationale
– Responses to why questions are considered
prying, violate the client’s privacy and places the
client in a defensive position
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: USE OF ‘WHAT’
QUESTIONS

 The use of the question ‘what’ is


therapeutic

– “What is happening?”
– “What does the voice seem to be saying?”
– “What transpired after that?”
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: AVOID FALSE
REASSURANCES

 Examples:
– “I would not worry about that.”
– “Everything would be alright.”
– “You are coming along just fine.”

 Rationale
– This response blocks the fears, feelings and other thoughts
of the client. Furthermore, vague reassurances without
accompanying facts are meaningless to the client
GUIDELINES FOR IDENTIFYING
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: USE OF THE WORD ‘I’

 Example:
– Client: “Should I move from my home to
a nursing home?”
– Nurse: “If I were you, I’d go to a nursing
home, where you’ll get your meals
cooked for you”

 Rationale:
– Therapeutic Communication is always client-centered, it is
never nurse-centered.
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: USE OF THE WORD
‘YOU’

 Examples
– Client: “I am dead.”
– Nurse: “Are you suggesting that you feel lifeless?”
– Client: “I am way out in the ocean.”
– Nurse: “You seem to feel lonely or deserted.”

 Rationale:
– Therapeutic Communication is always client-
centered, it is never nurse-centered.
THERAPEUTIC RESPONSES IN THE
BOARD EXAM: USE OF DIRECT
QUESTIONS FOR SUICIDAL PATIENTS

 Nurse: “Do you have any plans of killing


yourself?”
GUIDELINES FOR IDENTIFYING
THERAPEUTIC RESPONSES IN THE
BOARD EXAM:
AVOID THE ‘AUTHORITARIAN ANSWER’

 Authoritarian Answer
– Avoid statements like “I think you
should. . I should know, I am the nurse”

 Rationale
– Giving authoritarian answers implies
that only the nurse knows what is best
for the client
WHAT TO REMEMBER IN
THERAPEUTIC COMMUNICATION
 Be empathetic and not just
sympathetic!
EMPATHY
 Is the ability of the nurse to perceive the meanings
and feelings of the client and to communicate that
understanding to the client.
 It is considered one of the essential skills a nurse
must develop
 Being able to put himself on the client’s shoes does
not mean that the nurse has had the same exact
experiences as the client
 Nevertheless, by listening and sensing the
importance of the situation to the client, the nurse
can imagine the client’s feelings about the
experience
EMPATHY
 Both the client and the nurse give a “gift of self”
when empathy occurs – the client by feeling safe
enough to share feelings, and the nurse by
listening closely enough to understand.

 Empathy has been shown to positively influence


client outcomes

 Clients tend to feel better about themselves when


the nurse is empathetic
EXAMPLE OF EMPATHY
 Client: “I am so confused! My son just visited and
wants to know where the safety deposit box key is.”
 Nurse: “You’re confused because your son asked for
he safety deposit key.” (Using reflection)
 Nurse: “Are you confused about the purpose of your
son’s visit?” (Using clarification)

 Note that from these empathetic moments, a bond


can be established to serve as the foundation for the
nurse-client relationship
SYMPATHY
 Feelings of concern or compassion one
shows for another.

 By expressing sympathy, the nurse


may project his or her personal
concerns onto the client, thus
inhibiting the client’s expression of
feelings
EXAMPLE OF SYMPATHY
 Client: “I am so confused! My son just visited and wants
to know where the safety deposit box key is.”
 Nurse: “I know how confusing sons can be. My son
confuses me, too, and I know how bad that makes you
feel.”
 Note that the nurse’s feelings of sadness or even pity
could influence the relationship and hinder the nurse’s
abilities to focus on the client’s needs.
 Sympathy often shifts the emphasis on the nurse’s
feelings, hindering the nurse’s ability to view the client’s
needs more objectively.
SAMPLE BOARD QUESTION
NO.1
 These are communication techniques that
contribute to therapeutic relationship,
EXCEPT?

A) Active listening to what the patient


says
B) Labeling the patient
C) Encouraging expression of feelings
D) Clarifying
ANSWER
 Letter B

 Rationale: Labeling the patient is non-


therapeutic.
SAMPLE BOARD QUESTION
NO.2
 Which one of the following techniques used is
an example of giving a broad opening?

A) “When did this happen to you?”


B) “Would you describe it in more detail?”
C) “Where would you like to begin?”
D) “I would like to spend time to talk with
you.”
ANSWER
 Letter C

 Rationale: Giving a broad opening


provides an opportunity to the patient
to choose the topic of the
conversation.
SAMPLE BOARD QUESTION
NO.3
 A technique that enhances communication is
illustrated by one of the following statements:

A) “Why do you feel this way?”


B) “It is for your own good.”
C) “I am sure he only meant to help you.”
D) “I would like to spend time with you.”
ANSWER
 Letter D

 Rationale: Offering one’s self facilitates


the development of rapport between
the nurse and the patient.
SAMPLE BOARD QUESTION
NO.4
 Which of the following elements refers
to the setting of the communication?

A) Sender
B) Context
C) Receiver
D) Message
ANSWER
 Letter B

 Rationale: Context refers to the setting


of the conversation.
SAMPLE BOARD QUESTION
NO.5
 Which of the following techniques of
communication is appropriate when
initiating a conversation?

A) Focusing
B) Use of silence
C) Giving broad opening
D) Reflecting
ANSWER
 Letter C

 Rationale: Giving broad opening


provides an opportunity for the patient
to choose the topic of the
conversation. Hence, it is appropriate
to use when initiating a conversation.
NURSE – PATIENT
RELATIONSHIP
NURSE-PATIENT RELATIONSHIP
 Series of interactions between the
nurse and the patient in which the
nurse assists the patient to attain
positive behavioral change
CHARACTERISTICS OF THE
NURSE-PATIENT RELATIONSHIP
 Goal-directed

 Focused on the needs of the patient

 Planned

 Time-limited

 Professional
BASIC ELEMENTS OF THE
NURSE-PATIENT RELATIONSHIP
 Trust

 Rapport

 Unconditional positive regard

 Setting limits

 Therapeutic communication
PHASES OF THE
NURSE-PATIENT RELATIONSHIP
 Pre-orientation phase

 Orientation phase

 Working phase

 Termination phase
PRE-ORIENTATION PHASE
 Begins when the nurse is assigned to a
patient

 Phase of Nurse-Patient Relationship in


which the patient is excluded as an actual
participant

 Nurse feels certain degree of anxiety


PRE-ORIENTATION PHASE
 Includes all of what the nurse thinks and
does before interacting with the patient

 Tasks include data gathering, planning for


the first interaction

 Major task is to develop self-awareness


ORIENTATION PHASE
 Begins when the nurse and the patient interacts for the
first time

 Parameters of the relationship are to be laid

 Nurse begins to know about the patient

 Tasks include establishing rapport, developing trust,


assessment (and formulation of a nursing diagnosis).

 Major task is to develop a mutually acceptable contract


WORKING PHASE
 It is highly individualized

 More structured than the orientation phase

 The longest and most productive phase of the nurse-patient


relationship

 Limit-setting is employed

 Tasks include planning and implementation

 Major task is identification and resolution of the patient’s


problems
TERMINATION PHASE
 It is a gradual weaning process

 It is a mutual agreement

 It involves feelings of anxiety, fear and loss

 It should be recognized in the orientation phase

 Tasks include evaluation

 Major task is to assist patient to review what has been learned


and to transfer his learning to his relationship with others
TERMINATION PHASE
 How to terminate?

– Gradually decrease interaction time

– Focus on future oriented topics

– Encourage expression of feelings

– Make the necessary referral


PROBLEMS AFFECTING THE
NURSE-PATIENT RELATIONSHIP -
TRANSFERENCE
 Occurs when the client displaces onto the
nurse attitudes and feelings that the client
originally experience in other relationships

 These patterns are automatic and


unconscious
PROBLEMS AFFECTING THE
NURSE-PATIENT RELATIONSHIP -
TRANSFERENCE
 Example:

– An adolescent female client working


with a nurse who is about the same age
as the teen’s parents might react to the
nurse like she reacts to her parents.
She might experience intense feelings of
rebellion or make sarcastic remarks.
PROBLEMS AFFECTING THE
NURSE-PATIENT RELATIONSHIP -
COUNTERTRANFERENCE
 Occurs when the nurse displaces onto the client
attitudes or feelings from his or her past.

 Example:
– A female nurse who has teenage children and
who is experiencing extreme frustration with an
adolescent client may respond by adopting a
parental or chastising tone.

 The nurse is countertransfering her own attitudes


and feelings toward her children onto the client.
NURSE-PATIENT RELATIONSHIP

RESISTANCE
 Development of ambivalent feelings
toward self-exploration
SAMPLE BOARD QUESTION
NO.1
 The basis for a therapeutic nurse-patient
relationship begins with the nurse’s?

A) Sincere desire to help others


B) Sincere desire to help others
C) Self-awareness and understanding
D) Sound knowledge of Psychiatric
Nursing
ANSWER
 Letter C

 Rationale: Prior to the nurse helping


others, he should first have a thorough
awareness of himself.
SAMPLE BOARD QUESTION
NO.2
 The nurse should introduce information about the
end of the nurse-patient relationship?

A) During the Orientation phase


B) As the goals of the relationship are reached
C) About one or two sessions before the last
meeting
D) When the patient is able to handle it
ANSWER
 Letter A

 Rationale: In the establishment of a


contract during the orientation phase,
information about the end of the
nurse-patient relationship must also be
included.
SAMPLE BOARD QUESTION
NO.3
 The goal of the orientation phase of the nurse-
patient relationship is?

A) assist the patient to review what he has


learned
B) plan interventions to meet patient’s goals
C) formulating nursing diagnosis
D) facilitate expression of thoughts and
feelings
ANSWER
 Letter C

 Rationale: This provides the nurse with


a sense of direction.
SAMPLE BOARD QUESTION
NO.4
 Which of the following is the most appropriate topic
during the orientation phase of nurse and patient
relationship?

A) patient’s perception of the reason of her being


hospitalized
B) identification of more effective methods of dealing
with stress
C) exploration of the patient’s inadequate coping skills
D) establishment of regular schedule for meeting
ANSWER
 Letter D

 Rationale: Establishment of a contract


is the major task of the nurse in the
Orientation phase.
SAMPLE BOARD QUESTION
NO.5
 The nurse knows that a therapeutic
relationship is possible only when?

A) Emotional difficulties are identified


B) Mutual trust is achieved
C) Patient’s self-esteem is enlarged
D) Patient is motivated to change
ANSWER
 Letter B

 Rationale: Trust is the foundation of a


therapeutic nurse-patient relationship.
PRINCIPLES OF CARE IN
PSYCHIATRIC SETTINGS
PRINCIPLES OF CARE IN
PSYCHIATRIC SETTINGS
 The nurse views the patient as a
holistic human being with
interdependent and interrelated needs.
PRINCIPLES OF CARE IN
PSYCHIATRIC SETTINGS
 The nurse accepts the patient as a
unique human being with inherent
value and worth exactly as he is.
PRINCIPLES OF CARE IN
PSYCHIATRIC SETTINGS
 The nurse should focus on the
patient’s strengths and assets and not
on his weakness and liabilities
PRINCIPLES OF CARE IN
PSYCHIATRIC SETTINGS
 The nurse views the patient’s behavior
non-judgmentally, while assisting the
patient to learn more adaptive ways of
coping
PRINCIPLES OF CARE IN
PSYCHIATRIC SETTINGS
 The nurse should explore the patient’
behavior for the need it is designed to
meet and the message it is
communicating.
PRINCIPLES OF CARE IN
PSYCHIATRIC SETTINGS
 The nurse has the potential for
establishing a nurse-patient
relationship with most if not all
patients.
PRINCIPLES OF CARE IN
PSYCHIATRIC SETTINGS
 The quality of the nurse-patient
relationship determines the degree of
change that can occur in the patient’s
behavior.
LEVELS OF
INTERVENTIONS IN
PSYCHIATRIC NURSING
PRIMARY LEVEL OF
PREVENTION
 Interventions aimed at the promotion
of mental health and lowering the rate
of cases by altering the stressors.

 Examples:
– Health education
– Information dissemination
– Counseling
SECONDARY LEVEL OF
PREVENTION
 Interventions that limit the severity of a disorder.

 Has two components:


– Case finding
– Prompt treatment

 Examples:
– Crisis intervention
– Administration of medications
TERTIARY LEVEL OF
PREVENTION
 Interventions aimed at reducing the disability
after a disorder.

 Has two components:


– Prevention of complication
– Active program of rehabilitation

 Examples:
– Alcoholics Anonymous
– Occupational therapy
SAMPLE BOARD QUESTION
NO.1
 Promotion of mental illness is best achieved by?

A) helping individuals use established successful


coping mechanisms
B) assisting individuals deal with physical
problems
C) helping individuals deal with physical problems
D) assisting individuals deal with family problems
ANSWER
 Letter A

 Rationale: Strengthening an
individual’s coping mechanism is one
of the best ways to prevent mental
illness.
SAMPLE BOARD QUESTION
NO.2
 A psychiatric nurse would be more likely
to work with people with mental disorders
in which of the following settings?

A) Shelters
B) Neighborhood centers
C) Prisons
D) All of these
ANSWER
 Letter D

 Rationale: Psychiatric nursing practice


is applicable in all healthcare settings.
SAMPLE BOARD QUESTION
NO.3
 Which is an example of secondary
prevention strategy in a psychiatric
ward.?

A) Monitoring of medication
administration
B) Monitoring of blood pressure
C) Assessing of skin problems
D) All of these
ANSWER
 Letter D

 Rationale: All the choices fall under the


category of prompt treatment
SAMPLE BOARD QUESTION
NO.4
 Helping a patient find an alternative to
her home, which had been destroyed by a
fire, is an example of what level of
prevention strategy?

A) Primary
B) Secondary
C) Tertiary
D) Any of these
ANSWER
 Letter C

 Rationale: Providing assistance during


recovery period falls under
rehabilitation, which is tertiary level of
prevention strategy
SAMPLE BOARD QUESTION
NO.5
 Health education, communication and
information dissemination are
examples of activities under?

A) Health promotion
B) Rehabilitation
C) Case finding
D) Prompt treatment
ANSWER
 Letter A

 Rationale: Health education,


communication and information
dissemination are activities, which
promotes health.
CHARACTERISTICS OF A
PSYCHIATRIC NURSE
CHARACTERISTICS OF A
PSYCHIATRIC NURSE
 Empathy
– The ability to see beyond outward behavior
and sense accurately another person’s inner
experiencing.

 Genuineness / Congruence
– Ability to use therapeutic tools appropriately

 Unconditional Positive Regard


– Respect
ROLES OF THE NURSE
IN PSYCHIATRIC
SETTINGS
ROLES OF THE NURSE IN
PSYCHIATRIC SETTINGS
 Ward Manager
– Creates a therapeutic environment.

 Socializing Agent
– Assists the patient to feel comfortable
with others

 Counselor
– Listens to the patient’s verbalizations
ROLES OF THE NURSE IN
PSYCHIATRIC SETTINGS
 Parent Surrogate
– Assists the patient in the performance of
activities of daily living.

 Patient Advocate
– Enables the patient and his relatives to know
their rights and responsibilities

 Teacher
– Assists the patient to learn more adaptive
ways of coping
ROLES OF THE NURSE IN
PSYCHIATRIC SETTINGS
 Technician
– Facilitates the performance of nursing procedures

 Therapist
– Explores the patient’s needs, problems and
concerns through varied therapeutic means

 Reality Base
– Enables the patient to distinguish objective reality
and subjective reality
ROLES OF THE NURSE IN
PSYCHIATRIC SETTINGS
 Healthy Role Model
– Acts as a symbol of health by
serving as an example of healthful
living.
THE NERVOUS SYSTEM
AND HOW IT WORKS
BRAIN
 The brain is divided
into:
Cerebrum
Cerebellum
Brain Stem
Limbic System
CEREBRUM
 The LEFT HEMISPHERE is the
center for logical reasoning and
analytic functions such as reading,
writing and mathematical tasks.
 The RIGHT HEMISPHERE is the
center for creative thinking,
intuition, and artistic abilities
CEREBRUM
CEREBRUM
 Each cerebral
hemisphere is divided
into four lobes:
Frontal
Parietal
Temporal
Occipital
FRONTAL LOBES OF CEREBRUM
 These control the:
Organization of
thought
Body movement
Memories
Emotions
Moral behavior
FRONTAL LOBES OF CEREBRUM
 The frontal lobes:
Helps regulate
arousal
Focus attention
Allow problem
solving and decision
making to occur
FRONTAL LOBES OF CEREBRUM
 Abnormalities in the
frontal lobes are
associated with:
Schizophrenia
Attention Deficit
Hyperactivity
Disorder
Dementia
PARIETAL LOBES OF CEREBRUM
 The parietal lobes are
involved with:
Interpreting
sensations of taste
and touch
Assisting in spatial
orientation
TEMPORAL LOBES OF CEREBRUM
 These function as
centers for:
Hearing
Memory
Expressions of
emotions
OCCIPITAL LOBES OF CEREBRUM
 They assist in:
Coordinating
language generation
Visual interpretation
Depth perception
CEREBELLUM
 It is the center for
coordination of
movements and
postural adjustments
CEREBELLUM
 Inhibited transmission
of a neurotransmitter,
DOPAMINE, in this area
is associated with a
lack of smooth,
coordinated
movements in
diseases such as
PARKINSON’S DISEASE
and DEMENTIA
BRAIN STEM
 This includes the
following:
Midbrain
Pons
Medulla Oblongata
MEDULLA OBLONGATA OF THE
BRAIN STEM
 This contains the vital
centers for respiration
and cardiovascular
function
PONS OF THE BRAIN STEM
 This bridges the gap
both structurally and
functionally, serving as
a primary motor
pathway
MIDBRAIN OF THE BRAIN STEM
 This includes most of the
RETICULAR ACTIVATING
SYSTEM (RAS) and the
EXTRAPYRAMIDAL
SYSTEM (EPS).
 The RAS influences
motor activity, sleep,
consciousness and
awareness.
 The EPS relays
information about
movement and
coordination from the
brain to the spinal nerves
LIMBIC SYSTEM
 This includes the
following:
Thalamus
Hypothalamus
Hippocampus
Amygdala
THALAMUS OF THE LIMBIC SYSTEM
 This regulates:
Activity
Sensation
Emotion
HYPOTHALAMUS OF THE LIMBIC
SYSTEM
 This is involved with:
Temperature
regulation
Appetite control
Endocrine function
Sexual drive
Impulse behavior
associated with
feelings of anger,
rage and excitement
HIPPOCAMPUS AND AMYGDALA OF
THE LIMBIC SYSTEM
 These structures are
involved in emotional
arousal and memory.
LIMBIC SYSTEM
 Disturbances in the
limbic system have
been implicated in a
variety of mental
illnesses, such as:
 The memory loss seen
in DEMENTIA
 The poorly controlled
emotions and impulses
seen in PSYCHOTIC or
MANIC BEHAVIOR
NEUROTRANSMISSION

 Neurons or nerve cells


communicate
information with each
other by sending
electrochemical
messages from neuron
to neuron, in a process
called
NEUROTRANSMISSION.
NEUROTRANSMISSION
 Electrochemical messages pass from:
– The dendrites
– Through the cell body
– Down the axon
– Across the gaps between cells (SYNAPSE)
– To the dendrite of the next neuron
NEUROTRANSMISSION
NEUROTRANSMITTERS
 These are chemical
substances
manufactured in the
neuron that aid in the
transmission of
information throughout
the body
NEUROTRANSMITTERS
 They either excite or
stimulate an action in
the cells (EXCITATORY)
or inhibit or stop an
action (INHIBITORY).
NEUROTRANSMITTERS
 Neurotransmitters fit
into a specific receptor
cells embedded in the
membrane of the
dendrite, just like a
certain key shape fits
into a lock
NEUROTRANSMITTERS
 After neurotransmitters are
released into the synapse and
relay the message to the
receptor cells, they are either:
 Transported back from the
synapse to the axon to be
store for later use
(REUPTAKE);
 Or are metabolized and
inactivated by enzymes,
primarily MONOAMINE
OXIDASE or MAO
MAJOR TYPES OF
NEUROTRANSMITTERS
TYPE OF MECHANISM PHYSIOLOGIC EFFECTS
NEUROTRANSMITTER OF ACTION

DOPAMINE Excitatory Controls complex movements,


motivation, cognition; regulates
emotional response.

NOREPINEPHRINE Excitatory Changes in attention, learning and


(NORADRENALINE) memory, sleep and wakefulness, mood

EPINEPHRINE Excitatory Fight-or-flight response


(ADRENALINE)
SEROTONIN Inhibitory Control of food intake, sleep and
wakefulness, temperature regulation,
pain control, sexual behaviors,
regulation of emotion.
MAJOR TYPES OF
NEUROTRANSMITTERS
TYPE OF MECHANISM OF PHYSIOLOGIC EFFECTS
NEUROTRANSMITTER ACTION

ACETYLCHOLINE Excitatory or Sleep and wakefulness cycle; signals


Inhibitory muscles to become alert

NEUROPEPTIDES Neuromodulators Enhance, prolong, inhibit, or limit the


effects of principal neurotransmitters

GLUTAMATE Excitatory Neurotoxicity results if levels are too


high
GAMMA- Inhibitory Modulates other neurotransmitters
AMINOBUTYRIC ACID
(GABA)
DOPAMINE
 It is synthesized from the amino acid
tyrosine

 It is implicated in Schizophrenia and other


psychoses, as well as movement disorders in
Parkinson’s Disease

 Antipsychotic medications work by blocking


dopamine receptors and reducing dopamine
activity
NOREPINEPHRINE
 Excess norepinephrine has been implicated in a
variety of anxiety disorders.

 Deficits in norepinephrine may affect memory


loss, social withdrawal and depression.

 Some antidepressants block the reuptake of


norepinephrine, and others inhibit MAO from
metabolizing it.
SEROTONIN
 It is derived from a dietary amino acid named
tryptophan.

 It has been found to play a role in the delusions,


hallucinations, and withdrawn behavior in
schizophrenia.

 Some antidepressants block serotonin reuptake,


thus leaving it available in the synapse for a
longer time, which results in improved mood.
HISTAMINE
 The role of histamine in mental illness
is under investigation

 Some psychotropic drugs block


histamine, resulting in weight gain,
sedation and hypotension.
ACETYLCHOLINE
 It is synthesized from dietary choline
found in red meat and vegetables.

 Persons with Alzheimer’s Disease have


a decreased number of acetylcholine-
secreting neurons
GAMMA-AMINOBUTYRIC ACID
(GABA)
 Drugs that increase GABA function,
such as benzodiazepines, are used to
treat anxiety and induce sleep
GLUTAMATE
 This is an excitatory amino acid that at
high levels can have major neurotoxic
effects.

 This has been implicated in the brain


damage caused by stroke,
hypoglycemia, sustained hypoxia or
ischemia, and some degenerative
diseases like Alzheimer’s Disease.
PSYCHOPHARMACOLOGY
PSYCHOPHARMACOLOGY
 Terms used in describing drugs and drug
therapy important for the nurse to know:

– Efficacy

– Potency

– Half-life
EFFICACY
 This refers to the maximal therapeutic
effect that can be achieved by a drug.
POTENCY
 This describes the amount of drug
needed to achieve that maximum effect

 Drugs that have a low potency require


higher dosages to achieve efficacy

 High-potency drugs achieve efficacy at


lower doses.
HALF-LIFE
 This is the amount of time it takes for half of the
drug to be removed from the bloodstream.

 Drugs with a shorter half-life may need to be


given 3 or 4 times in a day, but drugs with a
longer half-life may be given once a day.

 The amount of time needed for a drug to leave


the body completely after it has been
discontinued is about five times its half-life.
PRINCIPLES THAT GUIDE
PSYCHOPHARMACOLOGIC TREATMENT
 A medication is selected based on its
effect on the client’s target symptom,
such as delusional thinking, panic
attacks, or hallucinations.

 The effectiveness of the medication is


evaluated in large part by its ability to
diminish or eliminate the target
symptom.
PRINCIPLES THAT GUIDE
PSYCHOPHARMACOLOGIC TREATMENT
 Many psychotropic drugs must be
given in adequate dosages for a period
of time before their full effect is
realized.

– Tricyclic antidepressants can require


4 to 6 weeks to provide optimal
therapeutic benefit.
PRINCIPLES THAT GUIDE
PSYCHOPHARMACOLOGIC TREATMENT
 The dosage of a medication is often
adjusted to the lowest dosage
effective for the client

 Some higher dosages may be needed


to stabilize the client’s target
symptoms, and lower dosages can be
used to sustain those effects over
time.
PRINCIPLES THAT GUIDE
PSYCHOPHARMACOLOGIC TREATMENT
 As a rule, elderly persons require lower
dosages of a medication to produce
therapeutic effects, and it may take
longer for a drug to achieve its full
therapeutic effect.
PRINCIPLES THAT GUIDE
PSYCHOPHARMACOLOGIC TREATMENT
 Psychotropic medications are often
decreased gradually (tapering)rather than
abruptly discontinued.

 This is due to potential problems with


rebound (temporary return of symptoms),
recurrence of the original symptoms, or
withdrawal (new symptoms resulting from
discontinuation of the drug)
PRINCIPLES THAT GUIDE
PSYCHOPHARMACOLOGIC TREATMENT
 Follow-up care is essential to ensure
compliance with the medication
regimen, to make needed adjustments
in dosage, and to manage side effects.
WHAT THE NURSE NEEDS TO
KNOW ABOUT PSYCHOTROPIC
DRUGS
 How the drug works

 Its side effects

 Contraindications

 Interactions

 Nursing interventions required for helping clients


manage the medication regimen
PSYCHOTROPIC DRUG
CATEGORIES
 Antipsychotics

 Antidepressants

 Mood Stabilizers

 Anti-anxiety Drugs

 Stimulants
1) ANTIPSYCHOTIC DRUGS
ANTIPSYCHOTIC DRUGS
 These are also known as NEUROLEPTICS

 These are used to treat symptoms of


psychosis, such as delusions and
hallucinations.

 They work by blocking the receptors of


the neurotransmitter Dopamine.
ANTIPSYCHOTIC DRUGS
 Antipsychotic drugs are the primary medical treatment for
Schizophrenia and are also used in psychotic episodes of acute
mania, psychotic depression, and drug-induced psychosis.

 Persons with dementia who have psychotic symptoms


sometimes respond to low doses of antipsychotics.

 Short-term therapy with antipsychotics may be useful for


transient psychotic symptoms, such as those seen in some
persons with borderline personality disorder.
TYPICAL ANTIPSYCHOTIC DRUGS
GENERIC FORMS DAILY EXTREME
(TRADE) DOSAGE DOSAGE
NAME (mg) RANGE
(mg/day)
Chlorpromazi T, L, INJ 200 – 1600 25 – 2000
ne
(Thorazine)
Perphenazine T, L, INJ 16 – 32 4 – 64
(Trilafon)

Fluphenazine T, L, INJ 2.5 – 20 1 – 60


(Prolixin)

Thioridazine T, L 200 – 600 40 – 800


TYPICAL ANTIPSYCHOTIC DRUGS
GENERIC FORMS DAILY EXTREME
(TRADE) DOSAGE DOSAGE
NAME (mg) RANGE
(mg/day)
Trifluoperazin T, L, INJ 6 – 50 2 – 80
e (Stelazine)

Thiothixene C, L, INJ 6 – 30 6 - 60
(Navane)
Haloperidol T, L, INJ 2 – 20 1 - 100
(Haldol)
Loxapine C, L, INJ 60 – 100 30 - 250
ATYPICAL ANTIPSYCHOTIC
DRUGS
GENERIC FORMS DAILY EXTREME
(TRADE) DOSAGE DOSAGE
NAME (mg) RANGE
(mg/day)
Clozapine T 150 – 500 75 - 700
(Clozaril)
Risperdone T 2–8 1 – 16
(Risperdol)

Olanzapine T 5 – 15 5 - 20
(Zyprexa)
MECHANISM OF ACTION OF
ANTIPSYCHOTIC DRUGS
 The major action of all antipsychotics in the
nervous system is to block receptors for the
neurotransmitter dopamine.

 The typical antipsychotic drugs are potent


antagonists (blockers) of dopamine receptors
D2, D3, and D4.

 This makes them effective in treating target


symptoms but also produces many
extrapyramidal side effects.
MECHANISM OF ACTION OF
ANTIPSYCHOTIC DRUGS
 Newer, atypical antipsychotic drugs, such
as clozapine (Clozaril), are relatively weak
blockers of D2, which may account for the
lower incidence of extrapyramidal side
effects.

 Atypical antipsychotics also inhibit the


reuptake of serotonin, which makes them
more effective in treating the depressive
aspects of Schizophrenia
SIDE EFFECTS OF
ANTIPSYCHOTIC DRUGS
 Extrapyramidal Symptoms (EPS)
are serious neurologic symptoms
that are the major side effects of
antipsychotic drugs, which include:
– Acute Dystonia
– Pseudoparkinsonism
– Akathisia
– Tardive Dyskinesia
SIDE EFFECTS OF ANTIPSYCHOTIC
DRUGS – EXTRAPYRAMIDAL SYMPTOMS
(EPS)
 Blockade of D2 receptors in the midbrain region of
the brain stem is responsible for the development
of EPS
 Therapies for the neurologic side effects of acute
dystonia, pseudoparkinsonism, and akathisia are
similar and include:
– 1) Lowering the dosage of the antipsychotic
– 2) Changing to a different antipsychotic
– 3) Administering anticholinergic medication
DRUGS USED TO TREAT
EXTRAPYRAMIDAL SIDE
EFFECTS
GENERIC ORAL IM / IV DOSES DRUG CLASS
(TRADE) NAME DOSAGES (mg)
(mg)
Amantadine 100 bid or - Dopaminergic
(Symmetrel) tid Agonist
Benztropine 1- 3 bid 1–2 Anticholinergic
(Cogentin)
Beperiden 2 tid – qid 2 Anticholinergic
(Akineton)
Diazepam 5 tid 5 – 10 Benzodiazepin
(Valium) e
Diphenhydrami 25 – 50 qid 25 – 50 Antihistamine
DRUGS USED TO TREAT
EXTRAPYRAMIDAL SIDE
EFFECTS
GENERIC ORAL IM / IV DOSES DRUG CLASS
(TRADE) NAME DOSAGES (mg)
(mg)
Lorazepam 1 – 2 tid - Benzodiazepin
(Ativan) e
Procyclidine 2.5 – 5 tid - Anticholinergic
(Kemadrin)
Propranolol 10 – 20 tid; - Beta-blocker
(Inderal) up to 40 qid

Trihexaphenidyl 2 – 5 tid - Anticholinergic


(Artane)
SIDE EFFECTS OF ANTIPSYCHOTIC
DRUGS – (EPS) – ACUTE DYSTONIA
 This includes any of the following:

– Acute muscular rigidity and cramping

– A stiff or thick tongue with difficulty of


swallowing

– In severe cases, laryngospasm and


respiratory difficulties.
SIDE EFFECTS OF ANTIPSYCHOTIC
DRUGS – (EPS) – ACUTE DYSTONIA

 Spasms or stiffness in
muscle groups can
produce torticollis
(twisted head and
neck)
SIDE EFFECTS OF ANTIPSYCHOTIC
DRUGS – (EPS) – ACUTE DYSTONIA

 Spasms or stiffness in
muscle groups can
produce opisthotonus
(tightness in the entire
body with the head
back and an arched
neck)
SIDE EFFECTS OF ANTIPSYCHOTIC
DRUGS – (EPS) – ACUTE DYSTONIA

 Spasms or stiffness in
muscle groups can
produce an oculogyric
crisis (eyes rolled back
in a locked position)
TREATMENT FOR (EPS)
ACUTE DYSTONIA
 Rapid relief is brought about by
immediate treatment with
anticholinergic drugs such as:

– Intramuscular benztropine mesylate


(Cogentin)

– Intramuscular or intravenous
diphenhydramine (Benadryl)
TREATMENT FOR (EPS)
ACUTE DYSTONIA
 Recurrent dystonic reactions would
necessitate a lower dosage or a
change in the antipsychotic drug.
DRUGS – (EPS) –
PSEUDOPARKINSONISM
 Drug-induced Parkinsonism or pseudoparkinsonism
have the following symptoms:
– A stiff, stooped posture
– Masklike facies
– Decreased arm swing
– A shuffling, festinating gait (with small steps)
– Cogwheel rigidity (ratchet-like movements of joints)
– Drooling
– Tremor
– Bradycardia
– Coarse pill-rolling movements of the thumb and
fingers while at rest
TREATMENT FOR (EPS)
PSEUDOPARKINSONISM
 Pseudoparkinsonism is treated by
changing to an antipsychotic
medication that has a lower incidence
of EPS or by adding an oral
anticholinergic agent or amantadine .
SIDE EFFECTS OF ANTIPSYCHOTIC
DRUGS – (EPS) – AKATHISIA
 Akathisia is reported by the client as an intense
need to move about

 The client appears restless or anxious and


agitated, often with a rigid posture or gait and a
lack of spontaneous gestures.

 This feeling of internal restlessness and the


inability to sit still or rest often leads clients to
discontinue their antipsychotic medication.
TREATMENT FOR (EPS)
AKATHISIA
 Akathisia can be treated by a change
in antipsychotic medication or the
addition of an oral agent such as a
beta-blocker, anticholinergic, or
benzodiazepine.
SIDE EFFECTS OF ANTIPSYCHOTIC
DRUGS – (EPS) – TARDIVE DYSKINESIA
(TD)

 TD is a syndrome of permanent, involuntary movements, is


most commonly caused by the long-term use of typical
antipsychotics.

 Once it has developed, TD is irreversible.

 Symptoms of TD include:
– Involuntary movements of the tongue, facial and neck
muscles, upper and lower extremities, and truncal
musculature
– Tongue-thrusting and protrusion, lip-smacking, blinking,
grimacing and other excessive, unnecessary facial
movements
TREATMENT FOR (EPS)
TARDIVE DYSKINESIA
 Although TD is irreversible, its progression can be arrested by
decreasing or discontinuing the antipsychotic medication.
 Preventing the occurrence of TD is done by keeping maintenance
dosages as low as possible, changing medications, and
monitoring the client periodically for the initial signs of TD.
 Persons who have already developed signs of TD but who still
need to take antipshychotic medication are often given
clozapine, which has not yet been found to cause, or therefore
worsen, TD.
OTHER SIDE EFFECTS OF
ANTIPSYCHOTIC DRUGS
 Neuroleptic Malignant Syndrome
 Anticholinergic Side Effects
SIDE EFFECTS OF ANTIPSYCHOTIC
DRUGS –NEUROLEPTIC MALIGNANT
SYNDROME (NMS)
 NMS is a potentially fatal, idiosyncratic reaction to
an antipsychotic drug with the following symptoms:

– Rigidity
– High fever
– Autonomic instability such as unstable blood
pressure, diaphoresis, pallor, delirium and
elevated levels of enzymes (particularly CPK).
– Confusion
– Being mute
– Fluctuation from agitation to stupor
SIDE EFFECTS OF ANTIPSYCHOTIC
DRUGS –NEUROLEPTIC MALIGNANT
SYNDROME (NMS)
 Dehydration, poor nutrition, and
concurrent medical illness all increase the
risk for NMS.
TREATMENT FOR
NEUROLEPTIC MALIGNANT SYNDROME
(NMS)
 This includes the following:

– Immediate discontinuance of all


antipsychotic medications

– Institution of supportive medical care


such as rehydration and hypothermia,
until the client’s physical condition is
stabilized.
SIDE EFFECTS OF ANTIPSYCHOTIC
DRUGS –ANTICHOLINERGIC SIDE
EFFECTS
 Symptoms usually decrease after 3 – 4 weeks but do
not entirely remit and include the following:
– Orthostatic hypotension
– Dry mouth
– Constipation
– Urinary hesitance or retention
– Blurred near vision
– Dry eyes
– Photophobia
– Nasal congestion
– Decreased memory
TREATMENT FOR
ANTICHOLINERGIC SIDE
EFFECTS
 The client who is taking anticholinergic
agents for EPS may have increased
problems with anticholinergic side
effects, but some nutritional or over-
the-counter remedies can ease these
symptoms
CLIENT TEACHING AND MEDICATION
MANAGEMENT: ANTIPSYCHOTIC
DRUGS

 Drink sugar-free fluids and eat sugar-free hard candy


to ease the anticholinergic effects of dry mouth.

 Avoid calorie-laden beverages and candy because they


promote dental caries, contribute to weight gain, and
do little to relieve dry mouth

 Constipation can be prevented or relieved by


increasing intake of water and bulk-forming foods in
the diet and by exercising.
CLIENT TEACHING AND MEDICATION
MANAGEMENT: ANTIPSYCHOTIC
DRUGS

 Stool softeners are permissible, but laxatives should


be avoided.

 Use sunscreen to prevent burning and avoid long


periods of time in the sun. Wear protective clothing as
photosensitivity can cause a patient to burn easily.

 Rising slowly from a sitting or lying position will


prevent falls from orthostatic hypotension or dizziness
due to a drop in blood pressure. Wait to walk until any
dizziness has subsided.
CLIENT TEACHING AND MEDICATION
MANAGEMENT: ANTIPSYCHOTIC
DRUGS

 Monitor the amount of sleepiness or drowsiness you


experience. Avoid driving a car or performing other
potentially dangerous activities until your response
time and reflexes seem normal.

 If you forget a dose of antipsychotic medication, take


it if the dose is only 3 to 4 hours late. If the missed
dose is more than 4 hours late or the next dose is
due, omit the forgotten dose.
CLIENT TEACHING AND MEDICATION
MANAGEMENT: ANTIPSYCHOTIC
DRUGS

 If you have difficulty remembering


your medication, use a chart to record
doses when taken, or use a pill box
labeled with dosage times and/or days
of the week to help you remember
when to take medication.
SIDE EFFECTS OF ATYPICAL
ANTIPSYCHOTIC DRUGS – CLOZAPINE
(Clozaril)
 This drug produces fewer traditional side effects
than most typical antipsychotic drugs, but it has
the potentially fatal side effect of
agranulocytosis.

 This develops suddenly and is characterized by


fever, malaise, ulcerative sore throat, and
leukopenia.

 This side effect can occur up to 24 weeks after


the initiation of therapy
TREATMENT OF AGRANULOCYTOSIS
DUE TO CLOZAPINE (Clozaril)

 Blood samples should be taken weekly


to monitor the WBC count of patients
with agranulocytosis.

 The drug must be discontinued


immediately if the white blood cell
count drops by 50% or to less than
3,000.
2) ANTIDEPRESSANT DRUGS
ANTIDEPRESSANT DRUGS
 Antidepressant drugs are primarily
used in the treatment of:
– Major depressive illness
– Panic disorder
– Other anxiety disorders
– Bipolar depression
– Psychotic depression
ANTIDEPRESSANT DRUGS
 Although the mechanism of action is
not completely understood,
antidepressants somehow interact with
two neurotransmitters, norepinephrine
and serotonin, that regulate mood,
arousal, attention, memory processing
and appetite
ANTIDEPRESSANT DRUGS
 These are divided into four groups

– 2A) Tricyclic and the related cyclic antidepressants

– 2B) Selective serotonin reuptake inhibitors (SSRIs)

– 2C) Monoamine Oxidase inhibitors (MAOIs)

– 2D) Other antidepressants such as venlafaxine


(Effexor), bupropion (Wellbutrin), trazodone
(Desyrel), and nafozodone (Serzone)
MECHANISM OF ACTION OF
ANTIDEPRESSANT DRUGS
 The major interaction is with the
monoamine neurotransmitter systems in
the brain, particularly norepinephrine and
serotonin.

 Both of these neurotransmitters are


released throughout the brain and help to
regulate arousal, vigilance, attention,
mood, sensory processing, and appetite.
MECHANISM OF ACTION OF
ANTIDEPRESSANT DRUGS
 Norepinephrine, serotonin, and
dopamine are removed from the
synapses after release by reuptake
into presynaptic neurons.

 After reuptake, these three


neurotransmitters are reloaded for
subsequent release or metabolized by
the enzyme Monoamine Oxidase
MECHANISM OF ACTION OF
ANTIDEPRESSANT DRUGS
 The cyclic antidepressants and venlafaxine block the
reuptake of norepinephrine primarily and serotonin to
some degree.

 The Monoamine Oxidase Inhibitors (MAOIs) interfere


with enzyme metabolism.

 The Selective Serotonin Reuptake Inhibitors (SSRIs)


block the reuptake of serotonin
2A) CYCLIC ANTIDEPRESSANT
DRUGS
CYCLIC ANTIDEPRESSANT
DRUGS – DRUG
 The cyclic antidepressants became
available in the 1950s and for years
were the first choice of drugs to treat
depression.
CYCLIC ANTIDEPRESSANTS –
DRUG ALERT!!!
 These are potentially lethal if taken in
an overdose.

 Depressed or impulsive clients who are


taking these drugs need to have
prescriptions and refills in limited
amounts to decrease the risk.
CYCLIC ANTIDEPRESSANT
DRUGS
GENERIC FORMS USUAL DAILY EXTREME
(TRADE) DOSAGE DOSAGE
NAME (mg) RANGE
(mg/day)
Imipramine T, C, INJ 150 - 200 50 - 300
(Tofranil)
Despiramine T, C 150 - 200 50 - 300
(Nopramin)

Amitryptiline T, INJ 150 - 200 50 - 300


(Elavil)
Nortryptiline C, L 75 - 100 25 - 150
CYCLIC ANTIDEPRESSANT
DRUGS
GENERIC FORMS USUAL DAILY EXTREME
(TRADE) DOSAGE DOSAGE
NAME (mg) RANGE
(mg/day)
Trimipramine C 150 - 200 50 - 300
(Surmontil)

Protriptyline T 15 - 40 10 - 60
(Vivactil)
Maprotiline T 100 - 150 50 - 200
(Ludiomil)
SIDE EFFECTS OF CYCLIC
ANTIDEPRESSANT DRUGS
 The cyclic antidepressant drugs block cholinergic
receptors, resulting in anticholinergic effects such
as:

– Dry mouth
– Constipation
– Urinary hesitancy or retention
– Dry nasal passages
– Blurred near vision
– Agitation, delirium and ileus are more severe
anticholinergic side effects that may occur in the
elderly.
SIDE EFFECTS OF CYCLIC
ANTIDEPRESSANT DRUGS
 Other common side effects include:
– Orthostatic hypotension
– Sedation
– Weight gain
– Tachycardia

 Sexual dysfunction is frequently


reported by clients taking TCAs
2B) MONOAMINE OXIDASE
INHIBITOR (MAOI)
ANTIDEPRESSANT DRUGS
MONOAMINE OXIDASE
INHIBITORS (MAOIs)
 The MAOIs were also discovered in the
1950s and were found to have a
positive effect on depressed persons.

 The MAOIs have a low incidence of


sedation and anticholinergic effects
MONOAMINE OXIDASE
INHIBITORS –
DRUG ALERT!!!
 These are potentially lethal if taken in
an overdose.

 Depressed or impulsive clients who are


taking these drugs need to have
prescriptions and refills in limited
amounts to decrease the risk.
MONOAMINE OXIDASE
INHIBITORS (MAOIs)
GENERIC FORMS USUAL DAILY EXTREME
(TRADE) NAME DOSAGE DOSAGE
(mg) RANGE
(mg/day)
Phenelzine T 45 – 60 15 - 90
(Nardil)
Tranylcypromi T 30 - 50 10 - 90
ne
(Parnate)
Isocarboxazid T 20 - 40 10 - 60
(Marplan)
SIDE EFFECTS OF MONOAMINE
OXIDASE INHIBITORS (MAOIs)
 The most common side effects of MAOIs include:
– Day-time sedation
– Insomnia
– Weight gain
– Dry mouth
– Orthostatic hypotension
– Sexual dysfunction

 Sedation and insomnia are difficult to treat and


may necessitate a change in medication
SIDE EFFECTS OF MONOAMINE
OXIDASE INHIBITORS (MAOIs)
 Of particular concern with MAOIs is the potential
for a life-threatening hypertensive crisis if the
client ingests food containing tyramine.

 The symptoms of this crisis are:


– Severe hypertension
– Hyperpyrexia
– Tachycardia
– Diaphoresis
– Tremulousness
– Cardiac Arrythmias
FOODS (CONTAINING TYRAMINE) TO
AVOID WHEN TAKING MONOAMINE
OXIDASE INHIBITORS (MAOIs)
 No mature or aged cheeses or dishes made
with cheese, such as lasagna, pizza. All cheese
is considered aged except cottage cheese,
cream cheese, ricotta cheese, and processed
cheese slices

 No aged meats such as pepperoni, salami,


mortadella, summer sausage, beef logs, and
similar products. Make sure meat and chicken
are fresh and have been properly refrigerated.
FOODS (CONTAINING TYRAMINE) TO
AVOID WHEN TAKING MONOAMINE
OXIDASE INHIBITORS (MAOIs)
 No Italian broad beans (fava) pods or banana peel.
Banana pulp and all other fruits and vegetables are
permitted

 Avoid all tap beers and microbrewery beer. Drink no


more than two cans or bottles of beer (including non-
alcoholic beer) or 4 ounces of wine per day

 No sauerkraut, soy sauce or soybean condiments, or


marmite (concentrated yeast).
INHIBITORS DRUG
INTERACTION –
DRUG ALERT!!!
 The following drugs can cause a potentially fatal drug
interaction when taken with MAOI antidepressants:

– Other MAOI antidepressants


– SSRI antidepressants
– Certain cyclic compounds
– Meperidine (Demerol)
– Buspirone (BuSpar)
– Dextromethorphan
– General anesthetic
2C) SELECTIVE SEROTONIN
REUPTAKE INHIBITOR (SSRI)
ANTIDEPRESSANT DRUGS
SELECTIVE SEROTONIN
REUPTAKE INHIBITORS (SSRIs)
 The SSRIs were first available in 1987 with the release
of fluoxetine (Prozac).

 They have replaced the cyclic drugs as the first choice


in treating depression, because they equal in efficacy
and produce fewer troublesome side effects.

 The SSRIs and clomipramine (cyclic antidepressant)


are effective in the treatment of Obsessive-
Compulsive Disorder as well.
SELECTIVE SEROTONIN
REUPTAKE INHIBITORS (SSRIs)
GENERIC FORMS USUAL DAILY EXTREME
(TRADE) DOSAGE DOSAGE
NAME (mg) RANGE
(mg/day)
Fluoxetine C, L 20 50 - 80
(Prozac)
Fluvoxamine T 150 - 200 50 - 300
(Luvox)
Paroxetine T 20 10 - 50
(Paxil)
Sertraline T 100 - 150 50 - 200
SIDE EFFECTS OF SELECTIVE
SEROTONIN REUPTAKE INHIBITORS
(SSRIs)
 Enhanced serotonin transmission can lead to several
common side effects such as:
– Anxiety
– Agitation
– Akathisia or motor restlessness (treated with a beta-
blocker such as propranolol or a benzodiazepine)
– Nausea (take medications with food)
– Insomnia which may continue to be a problem even if
the medication is taken in the morning (a sedative
hypnotic or low-dosage trazodone may be needed)
– Sexual dysfunction or a diminished sexual drive or
difficulty achieving an erection or orgasm
SIDE EFFECTS OF SELECTIVE
SEROTONIN REUPTAKE INHIBITORS
(SSRIs)
 Less common side effects include:
– Sedation particularly with paroxetine or Paxil
(indicates need for a change to another
antidepressant)
– Sweating (indicates need for change to another
antidepressant)
– Diarrhea (manage with symptomatic treatment)
– Hand tremor
– Headaches (manage with symptomatic
treatment)
DRUG INTERACTIONS FOR
SELECTIVE SEROTONIN
REUPTAKE INHIBITORS (SSRIs)
 An uncommon but potentially serious drug interaction
called serotonin or serotonergic syndrome can result
from taking a MAOI and an SSRI at the same time

 It can also occur if one of these drugs is taken too


close to the end of therapy with the other

 Therefore, one drug must clear the person’s system


before therapy with the other drug is initiated
DRUG INTERACTIONS FOR
SELECTIVE SEROTONIN
REUPTAKE INHIBITORS (SSRIs)
 Symptoms of the serotonergic syndrome include:
– Agitation
– Sweating
– Fever
– Tachycardia
– Hypotention
– Rigidity
– Hyperreflexia
– In extreme reactions, even coma and death
could occur.
2D) OTHER ANTIDEPRESSANT
COMPOUNDS
OTHER ANTIDEPRESSANT
DRUGS
GENERIC FORMS USUAL DAILY EXTREME
(TRADE) DOSAGE DOSAGE
NAME (mg) RANGE
(mg/day)
Buproprion T 200 – 300 100 – 450
(Wellbutrin)

Venlafaxine T, C 75 – 225 75 – 375


(Effexor)
Trazodone T 200 – 300 100 – 600
(Desyrel)
Nefazodone T 300 – 600 100 - 600
SIDE EFFECTS OF OTHER
ANTIDEPRESSANT DRUGS
 Sedation is caused by nefazodone, trazodone,
and mirtazapine
 Headaches are brought about by nefazodone and
trazodone
 Dry mouth and nausea are also brought about by
nefazodone
 Loss of appetite, nausea, agitation and insomnia
are caused by Bupropion and venlafaxine
 Dizziness, sweating and sedation may be brought
about by venlafaxine
SIDE EFFECTS OF OTHER
ANTIDEPRESSANT DRUGS
 Sexual dysfunction is much less common
with the novel antidepressants, with one
notable exception : trazodone can cause
priapism (a sustained and painful erection
that necessitates immediate treatment and
discontinuation of the drug)

 Priapism could result to impotence.


CLIENT TEACHING AND MEDICATION
MANAGEMENT: ANTIDEPRESSANT
DRUGS

 Minimize nausea by taking medication with food.

 To reduce insomnia, take daily doses in the morning.


If this is not effective, ask the physician if a
medication for sleep is indicated. Do not use alcohol
to induce sleep, because this will worsen insomnia.

 For diarrhea and headaches caused by the


medication, take over-the-counter medications
approved by the physician.
CLIENT TEACHING AND MEDICATION
MANAGEMENT: ANTIDEPRESSANT
DRUGS

 Initial sedation effects generally lessen with time. If they


persist, talk to the physician about modifying the dose or
changing medications

 For motor restlessness or hand tremor, ask the physician for a


medication such as propranolol (Inderal) or a benzodiazepine

 Use calorie-free beverages or sugar-free candy to relieve dry


mouth. Avoid calorie-laden beverages, because they do not
alleviate dry mouth and may add to weight gain.
CLIENT TEACHING AND MEDICATION
MANAGEMENT: ANTIDEPRESSANT
DRUGS

 Try to get a balanced diet to avoid excess weight gain.


Exercise is also beneficial.

 Increase your intake of water and bulk-forming foods


to prevent or relieve constipation. Stool softeners are
permitted. But laxatives should be avoided.

 Do not drink alcohol while taking antidepressants


CLIENT TEACHING AND MEDICATION
MANAGEMENT: ANTIDEPRESSANT
DRUGS

 If problems with sexual drive or having


an erection or orgasm occur, discuss
them with the physician rather than
altering or stopping medication. Other
antidepressants may be appropriate.

 If you miss a dose of the drug, follow


the directions given by your physician.
3) MOOD STABILIZING
DRUGS
MOOD STABILIZING DRUGS
 These are used for the following:

– To treat bipolar affective disorder by


stabilizing the client’s mood

– To avoid or minimize the highs and lows


that characterize bipolar illness

– To treat the acute phases of mania


MOOD STABILIZING DRUGS
 Lithium is the most established mood
stabilizer

 Some anticonvulsant drugs are


effective mood stabilizers such as:
– Carbamazepine (Tegretol)
– Valproic Acid (Depakene, Depakote)
MOOD STABILIZING DRUGS
 Other anticonvulsants, such as
gabapentin (Neurontin) and
lamotrigine (Lamictal), are being used
on a trial basis for mood stabilization

 Occasionally, clonazepam (Klonopin),


an anti-anxiety agent, is also used to
treat acute mania.
MECHANISM OF ACTION OF
MOOD STABILIZING DRUGS
 Lithium normalizes the reuptake of certain
neurotransmitters, such as:
– Serotonin
– Norepinephrine
– Acetylcholine
– Dopamine

 Lithium also reduces the release of norepinephrine


through competition with calcium

 Lithium produces its effects intracellularly rather than


within neuronal synapses.
MECHANISM OF ACTION OF
MOOD STABILIZING DRUGS
 Valproic Acid is known to increase levels of the
inhibitory neurotransmitter GABA.

 Both anticonvulsants, Valproic Acid and


Carbamazepine, are thought to stabilize mood
by inhibiting the kindling process – the
snowball-like effect seen when minor seizure
activity seems to build up into more frequent
and severe seizures.
MECHANISM OF ACTION OF
MOOD STABILIZING DRUGS
 In seizure management, anticonvulsants raise the level of
the threshold to prevent these minor seizures.

 It is suspected that this same kindling process may also


occur in the development of full-blown mania, with
stimulation by more frequent minor episodes.

 This explain why anticonvulsants are effective in the


treatment and prevention of mania as well.
DOSAGE OF MOOD STABILIZING
DRUGS - LITHIUM
 Lithium is available in tablets, capsules,
liquid and a sustained release form but
NO PARENTERAL FORMS ARE AVAILABLE.

 Daily dosages generally range from 900


mg to 3,600 mg.

 More importantly, the serum Lithium


level should be about 1.0 mEq/L
DOSAGE OF MOOD STABILIZING
DRUGS - LITHIUM
 Serum Lithium levels of less than 0.5 mEq/L are
rarely therapeutic, and levels of more than 1.5
mEq/L are usually considered toxic.

 The Lithium level should be monitored every 2 to


3 days while the therapeutic dosage is being
determined, then weekly.

 When the client’s condition is stable, the level


may need to be checked once a month or less
frequently.
DOSAGE OF MOOD STABILIZING
DRUGS - ANTICONVULSANTS
 Carbamazepine is available in liquid, tablet, and chewable
forms. Dosages usually range from 800 to 1,200 mg / day
and the extreme dosage is 200 to 2,000 mg / day.

 Valproic acid is available in liquid, tablet, and capsule forms


and as sprinkles, with dosages raging from 1,000 to 1,500
mg / day and the extreme dosage is 750 to 3,000 mg / day

 Serum drug levels, obtained 12 hours after the last dose of


the medication, are monitored for therapeutic levels of both
anticonvulsants.
SIDE EFFECTS OF MOOD STABILIZING
DRUGS - LITHIUM

 Common side effects of Lithium therapy include:


– Mild nausea (take medication with food) or
diarrhea
– Anorexia
– Fine hand tremors (use propranolol – a beta
blocker)
– Polydipsia
– Polyuria
– Metallic taste in the mouth
– Fatigue or lethargy
SIDE EFFECTS OF MOOD STABILIZING
DRUGS - LITHIUM

 Weight gain and acne are side effects


that occur later in lithium therapy and
both are distressing for clients.
– These are difficult to manage or
minimize and frequently lead to
noncompliance
TOXIC EFFECTS OF MOOD STABILIZING
DRUGS - LITHIUM
 These include:
– Severe diarrhea
– Vomiting
– Drowsiness
– Muscle weakness
– Lack of coordination

 Untreated, these symptoms worsen and can lead


to renal failure, coma and death.
DRUG ALERT!!! - LITHIUM
 When toxic signs occur, the drug
should be discontinued immediately.

 If Lithium levels exceed 3.0 mEq/day,


dialysis may be indicated.
SIDE EFFECTS OF MOOD STABILIZING
DRUGS - ANTICONVULSANTS
 Side effects of carbamazepine and valproic acid include:
– Drowsiness
– Sedation
– Dry mouth
– Blurred vision

 Carbamazepine may also cause rashes and othostatic


hypotension.

 Valproic Acid may cause weight gain, alopecia and hand


tremors.
CLIENT TEACHING REGARDING
MEDICATION MANAGEMENT:
MOOD STABILIZING DRUGS

 Have serum levels monitored periodically to


ensure therapeutic levels of the medication.

 Take the medication with food to minimize


nausea.

 For the fine hand tremors, ask the physician to


prescribe a beta-blocker such as propranolol
(Inderal).
CLIENT TEACHING REGARDING
MEDICATION MANAGEMENT:
MOOD STABILIZING DRUGS

 To help minimize weight gain, get a balanced


diet and get regular exercise. Expect some
weight gain.

 Minimize side effects of sedation and


drowsiness from anticonvulsant medications
by taking larger doses at bedtime and smaller
doses during the day.
CLIENT TEACHING REGARDING
MEDICATION MANAGEMENT:
MOOD STABILIZING DRUGS

 Use calorie-free beverages and sugar-free


candy to relieve dry mouth. Avoid calorie-
laden beverages, because they do not
relieve dry mouth and stimulate more weight
gain.

 If you are taking lithium, keep water intake


in a normal range and avoid heavy sweating,
because this decreases serum lithium levels
rapidly.
4) ANTIANXIETY DRUGS
(ANXIOLYTICS)
ANTIANXIETY DRUGS
These drugs are used to treat:

(ANXIOLYTICS)
– Anxiety and anxiety disorders
– Insomnia
– Obsessive-Compulsive disorder
– Depression
– Post-traumatic Stress disorder
– Alcohol withdrawal

 Benzodiazepines have proved to be the most effective in treating anxiety.

 Buspirone is a non-benzodiazepine that is often used for relief of anxiety.


MECHANISM OF ACTION –
ANTIANXIETY DRUGS (ANXIOLYTICS)
 Benzodiazepines mediate the actions of the amino
acid GABA, the major inhibitory neurotransmitter in
the brain.

 Benzodiazepines produce their effects by binding to a


specific site on the GABA receptor.

 Buspirone is believed to exert its anxiolytic effect by


acting as a partial agonist at serotonin receptors,
decreasing serotonin turnover.
ANTIANXIETY DRUGS -
BENZODIAZEPINES
GENERIC DAILY HALF LIFE SPEED OF
(TRADE) NAME DOSAGE (hours) ONSET
RANGE
(mg)
Alprazolam 0.75 – 1.5 12 – 15 Intermediate
(Xanax)
Chlordiazepoxid 15 – 100 50 – 100 Intermediate
e
(Librium)
Clonazepam 1.5 – 20 18 – 50 Intermediate
(Klonopin)
Chlorazepate 15 – 60 30 – 200 Fast
ANTIANXIETY DRUGS -
BENZODIAZEPINES
GENERIC DAILY HALF LIFE SPEED OF
(TRADE) NAME DOSAGE (hours) ONSET
RANGE
(mg)
Flurazepam 15 – 30 47 – 100 Fast
(Dalmane)
Lorazepam 2–8 10 – 20 Moderately
(Ativan) slow
Oxazepam 30 – 120 3 – 21 Moderately
(Serax) slow
Temazepam 15 – 30 9.5 – 20 Moderately
(Restoril) fast
DRUG ALERT!!! -
BENZODIAZEPINES
 Benzodiazepines strongly enhance the
effects of alcohol

 Clients should not drink alcohol when


taking benzodiazepines, or indeed any
psychotropic drug.
ANTIANXIETY DRUGS –
NON-BENZODIAZEPINES

GENERIC DAILY HALF LIFE SPEED OF


(TRADE) NAME DOSAGE (hours) ONSET
RANGE
(mg)
Buspirone 15 – 30 3 – 31 Very slow
(BuSpar)
PROBLEMS ENCOUNTERED WITH USE
OF BENZODIAZEPINES
 Benzodiazepines have a tendency to cause physical
dependence.

 Significant discontinuation symptoms occur when the


drug is stopped that often resemble the original
symptoms for which the client sought treatment.

 This is especially a problem for clients with long-term


benzodiazepine use, such as those for panic disorder of
generalized anxiety disorder.
PROBLEMS ENCOUNTERED WITH USE
OF BENZODIAZEPINES
 Benzodiazepines commonly cause psychological
dependence.

 Clients fear the return of anxiety symptoms or


believe themselves incapable of handling anxiety
without the drugs.

 This can lead to overuse or abuse of these drugs.


SIDE EFFECTS OF ANTIANXIETY DRUGS
- BENZODIAZEPINES
 These are associated with CNS depression such as:
– Drowsiness
– Sedation
– Poor coordination
– Impairment of memory or clouded sensorium

 When used for sleep, clients may complain of next-day


sedation or a hangover effect which is common among
benzodiazepines with a long half life.
SIDE EFFECTS OF ANTIANXIETY DRUGS
- NON-BENZODIAZEPINES

 Common side effects from Buspirone


include:
– Dizziness
– Sedation
– Nausea
– Headache
CLIENT TEACHING REGARDING
MEDICATION MANAGEMENT:
ANTIANXIETY (ANXIOLYTIC) DRUGS

 It is important for clients to know that antianxiety agents


are aimed at relieving symptoms, such as anxiety or
insomnia, but do not treat the underlying problems that
cause the anxiety.

 Benzodiazepines strongly potentiate the effects of alcohol


– One drink may have the effect of three drinks
– Clients should not drink while taking benzodiazepines
CLIENT TEACHING REGARDING
MEDICATION MANAGEMENT:
ANTIANXIETY (ANXIOLYTIC) DRUGS

 Clients should be aware of decreased response time,


slower reflexes, and possible sedative effects of
benzodiazepines when attempting activities such as
driving or going to work. Drowsiness and sedation
usually decrease with time.

 Benzodiazepine withdrawal can be fatal: once a


course of therapy has been started, benzodiazepines
should never be discontinued abruptly without the
supervision of the physician.
CLIENT TEACHING REGARDING
MEDICATION MANAGEMENT:
ANTIANXIETY (ANXIOLYTIC) DRUGS

 Take anxiolytic drugs only as prescribed.


Do not increase the dosage or take
extra doses even if your anxiety is
increased without consulting the
physician
5) STIMULANTS
STIMULANT DRUGS

 Stimulant drugs, specifically amphetamines, were first


used in the treatment of psychiatric disorders in the 1930s
for their pronounced effects of CNS stimulation.

 Today, the primary use is for attention deficit /


hyperactivity disorder (ADHD) in children and adolescents,
residual attention deficit disorder in adults, and narcolepsy
(attacks of unwanted but irresistible daytime sleepiness
that disrupt a person’s life).
STIMULANT DRUGS

 The primary drugs used to treat ADHD


are the CNS stimulants:

– methylphenidate (Ritalin)

– pemoline (Cylert)

– dextroamphetamine (Dexedrine)
MECHANISM OF ACTION OF
STIMULANT DRUGS

 Amphetamines and methylphenidate are often termed


indirectly acting amines because they act by causing
release of the neurotransmitters (norepinephrine,
dopamine, and serotonin) from presynaptic nerve
terminals, as opposed to having direct agonist effects
on the postsynaptic receptors.

 They also block the reuptake of these


neurotransmitters.
DOSAGES OF STIMULANT DRUGS

 For the treatment of narcolepsy in adults, both


dextroamphetamine (Dexedrine) and
methylphenydate (Ritalin) are given in divided
doses totaling 20 – 200 mg/day.

 The higher doses may be needed because adults


with narcolepsy develop tolerance to the
stimulants, requiring more medication to sustain
improvement.
DOSAGES OF STIMULANT DRUGS

 The dosages used to treat ADHD in children


vary widely depending on:

– the physician

– the age, weight and behavior of the child

– the tolerance of the family for the child’s


behavior
DOSAGES OF STIMULANT DRUGS

GENERIC (TRADE) DOSAGE


NAME

Methylphenidate Adults: 20-200 mg/day, orally, in divided doses


(Ritalin) Children: 10-60 mg/day orally, in 2-4 divided doses

Dextroamphetamine Adults: 20-200 mg/day, orally, in divided doses


(Dexedrine) Children: 5-40 mg/day orally, in 2-3 divided doses

Pemoline Children: 37.5-112.5 mg/day orally, given once a


(Cylert) day in the morning
SIDE EFFECTS OF
STIMULANT DRUGS

 The most common side effects of stimulants are:


– Anorexia
– Weight loss
– Nausea
– Irritability

 Caffeine, sugar, and chocolate should be


avoided because they may worsen these
symptoms.
SIDE EFFECTS OF STIMULANT DRUGS

 Less common side effects include:


– Dizziness
– Dry mouth
– Blurred vision
– Palpitations
SIDE EFFECTS OF
STIMULANT DRUGS

 The most common long-term problem with


stimulants is the growth and weight
suppression that occurs in some children.

 This can usually be prevented by taking


“drug holidays” on weekends, holidays, or
during summer vacation, which helps to
restore normal eating and growth patterns
CLIENT AND FAMILY TEACHING FOR
MEDICATION MANAGEMENT:
STIMULANT DRUGS

 Never leave the supply of medication in


a place the child can reach to avoid
overdose or taking additional
medication

 Take the medication at meal time to


minimize nausea and anorexia.
CLIENT AND FAMILY TEACHING FOR
MEDICATION MANAGEMENT:
STIMULANT DRUGS

 Monitor the child’s weight and height because growth


suppression can be a long-term consequence of
stimulant therapy.
– Not giving the drugs during weekends during the
summer can help resume normal growth patterns.

 Try a dosage schedule that provides a dose of


medication before beginning routine tasks of
concentration such as nightly homework.
CLIENT AND FAMILY TEACHING FOR
MEDICATION MANAGEMENT:
STIMULANT DRUGS
 Avoid beverages containing caffeine. Limit intake of
chocolate, sugar, or any other substance that increases
the child’s activity level.

 Alleviate dry mouth with calorie-free beverages or sugar-


free candy.

 Consult often with the school nurse or other person


responsible for giving medications at school.
– Medications should be given in a manner that is not
intrusive, nor should it draw undue attention to the
child.
6) SENSITIZING DRUGS
DISULFIRAM (ANTABUSE)

 Disulfiram is a sensitizing agent that


causes an adverse reaction when mixed
with alcohol in the body.

 This agent’s only use is as a deterrent


to drinking alcohol in persons receiving
treatment for alcoholism.
ADVERSE REACTION WHEN
DISULFIRAM (ANTABUSE) MIXES WITH
ALCOHOL
 Five to ten minutes after someone who is taking disulfiram
ingests alcohol, symptoms begin to appear:
– Facial and body flushing from vasodilation
– A throbbing headache
– Sweating
– Dry mouth
– Nausea and vomiting
– Dizziness and weakness
 In severe cases, severe hypotension, confusion and even death.

 Symptoms progress rapidly and last from 30 minutes to 2 hours.


MECHANISM OF ACTION OF
DISULFIRAM (ANTABUSE)

 Disulfiram inhibits the enzyme aldehyde


dehydrogenase, which is involved in the
metabolism of ethanol.
 Acetaldehyde levels are then increased
from 5 to 10 times higher than normal,
resulting in the disulfiram-alcohol
reaction
SIDE EFFECTS OF DISULFIRAM
(ANTABUSE)
 Side effects of taking Disulfiram include:
– Fatigue
– Drowsiness
– Halitosis
– Tremor
– Impotence

 It can interfere with the metabolism of other drugs the


client is taking such as: phenytoin (Dilantin), isoniazid
(INH), warfarin (Coumadin), barbiturates, and long-acting
benzodiazepines such as diazepam and chlordiazepoxide.
CLIENT EDUCATION FOR PATIENTS
TAKING DISULFIRAM (ANTABUSE)
 Many common products contain alcohol, such as:
– Shaving cream
– Aftershave lotion
– Cologne
– Deodorant
– Over-the-counter medications such as cough
preparations
 When used by the client taking disulfiram, these products
can produce the same reaction as drinking alcohol
 The client must read product labels carefully and select
items that are alcohol-free
ELECTROCONVULSIVE
THERAPY (ECT)
ELECTROCONVULSIVE THERAPY
(ECT)
 Involves application of electrodes to the
head of the client to deliver an electrical
impulse to the brain; this causes a seizure

 It is believed that the shock stimulates brain


chemistry to correct the chemical imbalance
of depression

 However, the mechanism of action of ECT is


unclear at present
FACTS ABOUT ELECTROCONVULSIVE
THERAPY (ECT)
 Voltage of electrical current that is administered to
the client
– 70 – 150 volts
 Length of electrical shock applied to the patient

– About 0.5 to 2.0 seconds


 Usual number of treatments needed to produce a
therapeutic effect
– 6 – 12 treatments
 Frequency of treatments

– There should be an interval of 48 hours for each


treatment
FACTS ABOUT ELECTROCONVULSIVE
THERAPY (ECT)
 Indicators of effectiveness of ECT
– The occurrence of generalized tonic-
clonic seizure

 Indications for ECT


– Depression, Mania, Catatonic
Schizophrenia
FACTS ABOUT ELECTROCONVULSIVE
THERAPY (ECT)
 Contraindications to ECT
– Fever
– Increased intracranial tumor
– TB with history of hemorrhage
– Cardiac condition
– Recent fracture
– Retinal detachment
– Pregnancy
FACTS ABOUT ELECTROCONVULSIVE
THERAPY (ECT)
 Need for consent prior to ECT
– Yes, consent is needed
FACTS ABOUT ELECTROCONVULSIVE
THERAPY (ECT)
 Medications given to clients prior to ECT

– Atropine sulfate
 To decrease secretions

– Anectine (Succinylcholine)
 To promote muscle relaxation

– Methohexital Sodium (Brevital)


 Serves as an anesthetic agent
FACTS ABOUT ELECTROCONVULSIVE
THERAPY (ECT)
 Common complications of ECT
– Loss of memory
– Headache
– Apnea
– Fracture
– Respiratory depression
SAMPLE BOARD QUESTION
NO.1
 Mr. Barte’s depression does not improve with
antidepressant medication, and the physician
orders electroconvulsive therapy (ECT). ECT’s
mechanism of action is?

A) Similar to that of antidepressant drugs


B) Related to an increased production of chemicals
in the brain
C) Unclear at present
D) Related to the patient’s perception of ECT as
well-deserved punishment
ANSWER
 Letter C

 Rationale: The mechanism of action of


ECT is unclear at present
SAMPLE BOARD QUESTION
NO.2
 Which of the following medications is
given to a patient before ECT, to
prevent aspiration?

A) Anectine
B) Brevital
C) Ritalin
D) Atropine sulfate
ANSWER
 Letter D

 Rationale: Atropine sulfate is given to


the patient, to decrease secretions to
prevent aspiration.
SAMPLE BOARD QUESTION
NO.3
 Which of the following statements,
indicate a common side effect of ECT,
when a patient says:

A) “I cannot sleep”
B) “I have a headache”
C) “I know you”
D) “I feel that my muscles are stiff”
ANSWER
 Letter B

 Rationale: Headache is a common


complication of ECT
SAMPLE BOARD QUESTION
NO.4
 An appropriate intervention for a
patient after ECT is to?

A) Check the consent


B) Re-orient the patient
C) Serve meals right away
D) Assist the patient to ambulate
ANSWER
 Letter B

 Rationale: Memory loss usually occurs


after ECT, so the nurse needs to re-
orient the patient
SAMPLE BOARD QUESTION
NO.5
 Which of the following complaints
should the nurse address initially with
ECT?

A) “I have a headache”
B) “I cannot breathe”
C) “I cannot remember anything”
D) “I am hungry”
ANSWER
 Letter B

 Rationale: Respiratory depression can


occur after ECT due to the muscular
relaxation effect of Anectine, so assess
for respiration.
COMMON
PSYCHOTHERAPEUTIC
INTERVENTIONS
COMMON PSYCHOTHERAPEUTIC
INTERVENTIONS
 Remotivation Therapy  Hypnotherapy
 Music Therapy  Humor Therapy
 Play Therapy  Behavior Modification
 Group Therapy  Aversion Therapy
 Milieu Therapy  Token Economy
 Family Therapy  Desensitization
 Psyhcoanalysis  Cognitive Therapy
REMOTIVATION THERAPY
 Treatment modality that promotes
expression of feelings through
interactions facilitated by discussion of
neutral topics

 Reality orientation for rehabilitative


patients only and not for actively
psychotic patients
REMOTIVATION THERAPY
 Five different steps:
– Climate of acceptance
 Welcome clients, introduce self to each other
– Creating a bridge to reality
 Orientation to topic
– Sharing the world we live in
 Discussion of the topic
– Appreciation of the works of the world
 Ask patient to reflect
– Climate of appreciation
 Express gratitude
MUSIC THERAPY
 Involves the use of music to facilitate
relaxation, expression of feelings and
outlet of tension
PLAY THERAPY
 Treatment modality which enables the
patient to experience intense emotion in
a safe environment with the use of play

 Example: For victims of child abuse, give


dolls.
GROUP THERAPY
 Treatment modality involving therapeutic
interactions of three or more patients with a
therapist to relieve emotional difficulties,
increase self-esteem, develop insight and
improve behavior in relation with others

 The minimum number of members in a group is


3, while the ideal number is 8 - 10
GROUP THERAPY
 Types of Groups:

– Therapeutic Group
 To gain insight into their problems (i.e. –
Alcoholics Anonymous)

– Socialization group
 To enhance interaction among patients

– Life Review / Reminiscing Group


 To lessen isolation
MILIEU THERAPY
 Consists of treatment by means of
controlled modification of the patients’
environment to facilitate positive
behavioral change

 Nurse identifies what each patient


needs from the therapeutic milieu,
while keeping in mind the needs of the
larger patient group
FAMILY THERAPY
 A method of psychotherapy which focuses on the total
family as an interactional system
 Best suited for families where there is domestic violence

 Goals include:
– Enhancement of communication among family members
– Mobilizing the family’s inherent strengths
– Strengthening family problem-solving behaviors
PSYCHOANALYSIS
 A method of psychotherapy which focuses on the exploration of
the unconscious, to facilitate identification of the patient’s
defenses

 Behavioral disorders are related to unresolved anxiety-


provoking childhood experiences that are repressed into the
unconscious

 Goal is to bring repressed experiences into conscious


awareness and to learn healthier means of coping with anxiety.

 Utilizes dream analysis and free association (verbalization of


thoughts without censorship)
HYPNOTHERAPY
 A therapeutic modality which involves
various methods and techniques to
induce a trans state where the patient
becomes submissive to instructions
HUMOR THERAPY
 Involves the use of humor to facilitate
expression of feelings and to enhance
interaction

 Therapeutic laughing lessens the high


levels of tension that often accompany
discussions of serious matters.
BEHAVIOR MODIFICATION
 A therapeutic intervention involving the
application of learning principles in order
to change maladaptive behavior

 It attempts to strengthen a desired


behavior or response by reinforcement,
either positive or negative.
BEHAVIOR MODIFICATION

 Positive reinforcement

– Example:

 If the desired behavior is assertiveness,


whenever the client uses assertiveness skills
in a communication group, the group leader
provides positive reinforcement by giving the
client attention and positive feedback.
BEHAVIOR MODIFICATION

 Negative reinforcement – involves removing a


stimulus immediately after a behavior occurs so
that the behavior is more likely to occur again.

 For example, if a client becomes anxious when


waiting to talk in a group, he may volunteer to
speak first to avoid the anxiety.
AVERSION THERAPY
 An example of behavior modification in which a
painful stimulus is introduced to bring about an
avoidance of another stimulus with the end view of
facilitating behavioral change

 Examples:
– A patient snaps a rubber band on the wrist when
bothered by an intrusive thought
– Covert sensitization
 Patient imagines scenes that pair undesired behavior
with unpleasant consequences of overeating.
TOKEN ECONOMY
 An example of behavior modification
technique which utilizes the principle
of rewarding desired behavior to
facilitate change
DESENSITIZATION
 Periodic exposure of the individual to a
feared object, until the undesirable
behavior disappears or is lessened
COGNITIVE THERAPY
 Short term structured therapy between the
patient and the therapist oriented towards
present problems and solutions.

 The main focus of cognitive therapy is in


depression disorders to:
– Increase activity
– Reduce unwanted behavior
– Increase pleasure
– Enhancing social skills
COGNITIVE THERAPY
 Anxiety Reduction
– Relaxation Training
– Systematic Desensitization

 Cognitive Restructuring
– Thought Stopping

 Learning New Behavior


– Token Economy
SAMPLE BOARD QUESTION
NO.1
 A nurse consults the hospital’s clinical nurse
specialist in psychiatric nursing about group
size. The nurse specialist will most likely say
that the optimal number of patients in each
group is?

A) 5
B) 10
C) 20
D) Unlimited
ANSWER
 Letter B

 Rationale: 8 – 10 patients is the


optimal number of patients in a group
SAMPLE BOARD QUESTION
NO.2
 Milieu therapy involves?

A) Gathering together a member of a disturbed


patient’s community
B) Only immediate family members are involved in
affecting behavior changes in the patient
C) Emphasis on considering patient as a biophysical
and sociocultural being
D) Scientific manipulation of the environment that
influence improvement of patient’s behavior
ANSWER
 Letter D

 Rationale: Milieu therapy involves


scientific manipulation of the
environment that can influence
improvement of the patient’s behavior
SAMPLE BOARD QUESTION
NO.3
 What is the main goal of milieu therapy?

A) Inclusion of the family in the therapy


B) Change inappropriate behavior
C) Patient-planned, patient-led activities
D) Staff-led decision-making process
ANSWER
 Letter C

 Rationale: In milieu therapy, patients


plan and lead activities rather than the
staff.
SAMPLE BOARD QUESTION
NO.4
 In family therapy sessions, the nurse
should?

A) Serve as a leader
B) Focus on the sick member
C) Neutralize blaming by setting
contract
D) Use paradoxical communication
ANSWER
 Letter C

 Rationale: A contract is essential at the


beginning of therapy to make
expectations clear.
SAMPLE BOARD QUESTION
NO.5
 Milieu activities which are initially
appropriate for schizophrenic patients
are the following, EXCEPT?

A) Basketball
B) Painting
C) Writing
D) Listening to music
ANSWER
 Letter A

 Rationale: Patients with schizophrenia


need activities that do not require
interaction, so solitary activities are
preferred over team activities.
DYNAMICS OF HUMAN
BEHAVIOR
NEED
 It is an organismic condition which
requires a certain activity
STRESS
 A broad class of experiences, in which a demanding
situation taxes a person’s coping abilities

 A non-specific response of the body to any kind of


demand made upon it (Hans Selye)

 This non-specific response is called the General


Adaptation Syndrome (GAS) or the stress syndrome

 Distress is known as unhealthy stress

 Eustress is known as healthy stress


BEHAVIOR
 Way in which an organism responds to
a stimulus
CONFLICT
 Situation that arise from the presence
of two opposing drives.
BASIC CONCEPTS ON
THE PATIENT
PERSONALITY
 The integration of those systems and
habits that represents an individual’s
characteristic adjustment to his
environment.

 Personality is expressed through


behavior
CHARACTERISTICS OF
PERSONALITY
 Distinctiveness
– Each individual is unique

 Stability and Consistency


– Personality is predictable
DETERMINANTS OF
PERSONALITY
 Psychological
– Type of climate at home

 Cultural
– Customs and traditions

 Biological
– Personality is not inherited

 Familial
– Parenting style
DIVISIONS OF THE MIND OR
LEVELS OF AWARENESS
 Freud believed that the human personality
functions at three levels of awareness:

– Conscious

– Preconscious

– Unconscious
DIVISIONS OF THE MIND /
LEVELS OF AWARENESS –
CONSCIOUS
 This refers to the perceptions, thoughts,
and emotions that exist in the person’s
awareness such as being aware of
happy feelings or thinking about a loved
one

 It is the part of the mind focused on


awareness
DIVISIONS OF THE MIND /
LEVELS OF AWARENESS –
SUBCONSCIOUS
 Preconscious thoughts and emotions are not
currently in the person’s awareness, but he or she
can recall them with some effort.

 It is the part of the mind that contains information


that can be recalled at will

 For example, an adult remembering what he or


she did, thought, or felt as a child.
DIVISIONS OF THE MIND /
LEVELS OF AWARENESS –
SUBCONSCIOUS
 This refers to the realm of thoughts and feelings that
motivate a person, even though he or she is totally
unaware of them.

 This realm includes most defense mechanisms and


some instinctual drives or motivations.

 It is the largest part of the mind; contains materials


and information that can never be recalled
PERSONALITY STRUCTURE
 Sigmund Freud conceptualized
personality structure as having three
components:

– Id
– Superego
– Ego
ID
 Is the part of one’s nature that reflects
basic or innate desires such as:
– Pleasure-seeking behavior
– Aggression
– Sexual impulses

 The id seeks instant gratification; causes


impulsive, unthinking behavior; and has
no regard for rules or social convention.
SUPEREGO
 Is the part of a person’s nature that
reflects moral and ethical concepts,
values, and parental and social
expectations

 Therefore, it is in direct opposition to


the id.
EGO
 Is the balancing or mediating force between the
id and the superego.

 It represents mature and adaptive behavior that


allows a person to function successfully in the
world.

 Freud believed that anxiety resulted from the


ego’s attempts to balance the impulsive instincts
of the id with the stringent rules of the superego.
STRUCTURES
ID
OF PERSONALITY
EGO SUPEREGO

AGE AT WHICH 0 – 1 YEAR OLD 1 – 3 YEARS OLD 3 – 6 YEARS OLD


IT IS PRESENT

DIVISION OF UNCONSCIOUS CONSCIOUS AND UNCONSCIOUS


MIND UNCONSCIOUS

DESCRIPTION NO SENSE OF INTEGRATOR OF EGO IDEAL GIVES


RIGHT OR PERSONALITY REWARDS;
WRONG CONSCIENCE
GIVES
PUNISHMENT
THEORIES OF
PERSONALITY
DEVELOPMENT
THEORIES OF PERSONALITY
DEVELOPMENT
 Freud’s Psychosexual Theory

 Erikson’s Psychosocial Theory

 Piaget’s Cognitive Theory


FREUD’S THEORY OF
PSYCHOSEXUAL
DEVELOPMENT
FREUD’S THEORY OF
PSYCHOSEXUAL DEVELOPMENT
 Freud based his theory of childhood development on
the belief that sexual energy, termed libido, was the
driving force of human behavior

 He proposed that children go through five stages of


psychosexual development”
– Oral
– Anal
– Phallic
– Latency
– Genital
FREUD’S THEORY OF
PSYCHOSEXUAL DEVELOPMENT
 Psychopathology results when a
person has difficulty making the
transition from one stage to the next,
or when a person remains stalled at a
particular stage or regresses to an
earlier stage.
ORAL STAGE
 Age
– Birth to 18 months
 Focus

– Major site of tension and gratification is the mouth, lips and


tongue, includes biting and sucking activities
– Id present at birth
– Ego develops gradually from rudimentary structure present
at birth
 Indicators of Fixation: smoking, chewing gum, voracious
eaters
ANAL STAGE
 Age
– 18 – 36 months

 Focus
– Anus and surrounding area are major source of
interest
– Acquisition of voluntary sphincter control (toilet
training)
 Indicators of Fixation: Parsimonious, punctual,
precise, obsessive-compulsive (overemphasized
cleanliness), passive-aggressive
PHALLIC OR OEDIPAL STAGE
 Age
– 3 – 5 years

 Focus
– Penis is organ of interest for both sexes.
– Masturbation is common
– Penis envy (wish to possess penis) seen in girls;
oedipal complex (wish to marry opposite-sex parent
and be rid of same-sex parent) seen in boys and girls.
 Indicators of Fixation: Exhibitionism due to fear of
castration
LATENCY STAGE
 Age
– 5 – 11 or 13 years
 Focus

– Resolution of oedipal complex


– Homosexual stage – formation of gangs (boy-boy or
girl-girl)
– Sexual drive channeled into socially appropriate
activities such as school work and sports
– Formation of the superego
 Indicators of Fixation: Chum-relationships or buddy,
Gender Identity Disorder or being uncomfortable with
gender
GENITAL STAGE
 Age
– 11 – 13 years

 Focus
– Final stage of psychosexual development
– Begins with puberty and the biologic capacity for
orgasm; involves the capacity for true intimacy
– Area of gratification includes secondary sex
characteristics, reawakening of sexual drives.
 Indicators of Fixation: Identity crisis
ERIKSON’S THEORY OF
PSYCHOSOCIAL
DEVELOPMENT
ERIKSON’S THEORY OF
PSYCHOSOCIAL DEVELOPMENT
 In each stage, the person must
complete a life task that is essential to
his or her well-being and mental health.

 These tasks allow the person to achieve


life’s virtues
ERIKSON’S THEORY OF
PSYCHOSOCIAL DEVELOPMENT
 In his view, psychosocial growth occurs in sequential
phases and each stage is dependent in completion of the
previous stage and life task

– For example, in the infant stage, trust versus mistrust,


the baby must learn to develop basic trust (the positive
outcome) such that he or she will be fed and taken
cared of. The formation of trust is essential; mistrust,
the negative outcome of this stage, will impair the
person’s development throughout his or her life.
1st Stage: TRUST VERSUS
MISTRUST (Infant)
 Age
– 0 – 12 months
 Virtue

– Hope
 Task

– Viewing the world as safe and reliable;


relationships as nurturing, stable and dependable
 Concept

– If the needs of the child are consistently met, trust


develops
2nd Stage: AUTONOMY VERUS
SHAME AND DOUBT (Toddler)
 Age
– 1 – 3 years
 Virtue
– Will
 Task
– Achieving a sense of control and free will
 Concept
– If toilet training is not hurried, autonomy
develops
3rd Stage: INITIATIVE VERSUS
GUILT (Pre-School)
 Age
– 3 – 6 years
 Virtue
– Purpose
 Task
– Beginning development of a conscience;
learning to manage conflict and anxiety
 Concept
– If the child’s sexual curiosity is handled
without anxiety, initiative develops
4th Stage: INDUSTRY VERSUS
INFERIORITY (School Age)
 Age
– 6 – 12 years
 Virtue
– Competence
 Task
– Emerging confidence in own abilities; taking
pleasure in accomplishments
 Concept
– If the child’s efforts at learning is supported,
industry develops
5th Stage: IDENTITY VERSUS
ROLE CONFUSION
(Adolescence)
 Age
– 12 – 18 years
 Virtue
– Fidelity
 Task
– Formulating a sense of self and belonging
 Concept
– If the adolescent’s vocational decision is
supported, identity develops
6th Stage: INTIMACY VERSUS
ISOLATION (Young Adult)
 Age
– 18 – 25
 Virtue
– Love
 Task
– Forming adult, loving relationships and
meaningful attachments to others
 Concept
– If the young adult’s decisions regarding love
relationships is supported, intimacy develops
7th Stage: GENERATIVITY
VERSUS STAGNATION (Middle
Adult)
 Age
– 25 – 65 years
 Virtue
– Care
 Task
– Being creative and productive; establishing
the next generation
 Concept
– If an adult enjoys support from the family,
generativity develops
8th Stage: EGO INTEGRITY
VERSUS DESPAIR (Maturity)
 Age
– 65 years and above
 Virtue
– Wisdom
 Task
– Accepting responsibility for one’s self and life
 Concept
– If the elderly has a satisfying past
recollection, integrity develops
PIAGET’S THEORY OF
COGNITIVE DEVELOPMENT
PIAGET’S THEORY OF COGNITIVE
DEVELOPMENT
 Piaget believed that human intelligence
progresses through a series of stages based
on age with the child at each successive
stage demonstrating a higher level of
functioning than at previous stages.

 He also believed that biologic changes and


maturation were responsible for cognitive
development
PIAGET’S THEORY OF
COGNITIVE DEVELOPMENT
 Four stages of cognitive development:
– Sensorimotor
– Preoperational
– Concrete Operations
– Formal Operations
SENSORIMOTOR
 Age
– 0 – 2 years
 Concepts
– The child develops a sense of self as separate
from the environment and the concept of object
permanence; that is, tangible objects don’t
cease to exist just because they are out of sight
(example: peek-a-boo)
– He or she begins to form mental images
– Development proceeds from reflex activity to
sensorimotor learning
PREOPERATIONAL STAGE
 Age
– 2 – 6 years
 Concepts

– The child develops the ability to express self with language,


understands the meaning of symbolic gestures, and begins
to classify objects
 At 2 – 4 years, development proceeds from sensory motor learning
to prelogical thought (pre-conceptual)
– The child learns language and symbols
 At 4 – 6 years, the child is able to think in terms of class (intuitive)
– The child is able to determine that individuals have roles
CONCRETE OPERATIONAL
STAGE
 Age
– 6 – 12 years
 Concepts
– Development from pre-logical to logical
concrete thought
– The child begins to apply logic to thinking,
understands spatiality and reversibility, and
is increasingly social and able to apply rules
– Thinking is still concrete
FORMAL OPERATIONAL STAGE
 Age
– 12 – Adulthood

 Concepts
– The child is able to think abstractly and is
able to apply the scientific method
– The child learns to think and reason in
abstract terms, further develops logical
thinking and reasoning, and achieves
cognitive maturity.
SAMPLE BOARD QUESTION
NO.1
 Erikson described the psychosocial tasks of
the developing person in his theoretical
model. The primary developmental task of
the young adult (age 18 – 25) is?

A) Intimacy versus isolation


B) Industry versus inferiority
C) Generativity versus stagnation
D) Trust versus mistrust
ANSWER
 Letter A

 Rationale: The primary developmental


task of the young adult is intimacy
versus isolation
SAMPLE BOARD QUESTION
NO.2
 Jen, 5 years-old has been brought to the
emergency room by their neighbor with
second degree burns at her right hand.
According to Freud, Jen is at what stage of
psychosexual development?

A) Latency
B) Oral
C) Anal
D) Phallic
ANSWER
 Letter D

 Rationale: The phallic stage of


development is from ages 3 through 6.
SAMPLE BOARD QUESTION
NO.3
 Monica, a 19-year old college student
belongs to what stage of psychosexual
development?

A) Anal
B) Latency
C) Genital
D) Phallic
ANSWER
 Letter C

 Rationale: Age 12 to adulthood is the


genital stage of development
according to Freud
SAMPLE BOARD QUESTION
NO.4
 Three-year old Messiah belongs to what
stage of development?

1) Anal
2) Phallic
3) Sensorimotor
4) Pre-operational

A) 1,3 B) 1,4 C) 2,3 D) 2,4


ANSWER
 Letter B

 Rationale: In Freud’s theory, age 1 – 3


belong to the anal stage while in
Piaget’s theory, age 2 – 7 belong to the
pre-operational stage
SAMPLE BOARD QUESTION
NO.5
 A child who belongs to the phallic stage in
Freud’s theory must develop which of the
following developmental tasks according
to Erickson?

A) Trust
B) Autonomy
C) Initiative
D) Industry
ANSWER
 Letter C

 Rationale: The phallic stage in Freud’s


theory (age 3 – 6) corresponds to the
development of the developmental
task of initiative versus guilt in
Erickson’s theory
CRISIS AND CRISIS
INTERVENTION
CRISIS
 A crisis is a turning point in an individual’s life that produces an
overwhelming emotional response

 Individuals experience a crisis when they confront some life


circumstance or stressor that they cannot effectively manage
through use of their customary coping skills

 A situation that occurs when an individual’s habitual coping


ability becomes ineffective to meet demands of the situation
CHARACTERISTICS OF A CRISIS
STATE
 Highly individualized

 Lasts for 4 – 6 weeks

 Person affected becomes passive and


submissive

 Affects a person’s support system


TYPES OF CRISES
 Maturational or Developmental Crisis

 Situational or Accidental Crisis

 Social or Adventitious Crisis


MATURATIONAL OR
DEVELOPMENTAL CRISIS
 Expected, predictable and internally
motivated events in the normal course of
life such as:
– Leaving home for the first time
– Getting married
– Having a baby
– Beginning a career
– Growth
– Parenthood
SITUATIONAL OR ACCIDENTAL
CRISIS
 Unanticipated or sudden, unexpected,
unpredictable and externally motivated
events that threaten the individual’s
integrity such as:
– Death of a loved one
– Loss of a job
– Physical and emotional illness in the
individual family or member
– Car accident
SOCIAL OR ADVENTITIOUS
CRISIS
 Includes natural disasters and acts of
nature like:
– Floods
– Earthquakes
– Hurricanes
– War
– Terrorist attacks
– Riots
– Violent crimes such as rape or murder
PHASES OF A CRISIS
 Denial
– Initial reaction
 Increased Tension

– The person recognizes the presence of a crisis and


continues to do activities of daily living
 Disorganization

– The person is pre-occupied with the crisis and is


unable to do activities of daily living
 Attempts to Reorganize

– The individual mobilizes previous coping mechanisms


CRISIS INTERVENTION
 A way of entering into the life situation
of an individual, family, group, or
community to help them mobilize their
resources and to decrease the effect of
a crisis inducing stress
GOAL OF CRISIS INTERVENTION
 To enable the patient to attain an
optimum level of functioning
TYPES OF CRISIS INTERVENTION
 Authoritative Crisis Intervention

 Facilitative Crisis Intervention


AUTHORITATIVE CRISIS
INTERVENTION
 Are designed to assess the person’s health status
and promote problem-solving such as:

– Offering the person new information, knowledge


or meaning

– Raising the person’s self awareness by providing


feedback about behavior

– Directing the person’s behavior by offering


suggestions or courses of action
FACILITATIVE CRISIS
INTERVENTION
 Aim at dealing with the person’s needs for
empathetic understanding such as:

– Encouraging the person to identify and


discuss feelings

– Serving as a sounding board for the person

– Affirming the person’s self worth


PRIMARY ROLE OF THE NURSE
IN CRISIS
 Active and directive, the nurse has to
assist the patient
SAMPLE BOARD QUESTION
NO.1
 Nurse Apple attends to patients who are in crisis. The
goal of crisis intervention is to?

A) Assist the patient explore available and appropriate


resources in the community
B) Assist the patient develop awareness of her feelings
C) Assist the patient to achieve correct cognitive
perception of the situation
D) Assist the patient to seek new and useful adaptive
mechanisms within the context of her social support
system
ANSWER
 Letter D

 Rationale: The goal of crisis


intervention is to assist the patient to
seek new and useful adaptive
mechanisms within the context of her
social support system.
SAMPLE BOARD QUESTION
NO.2
 This phase of crisis is characterized by
feelings of great anxiety and inability
to perform activities of daily living.

A) Disorganization
B) Reorganization
C) Attempt to escape the problem
D) Increased tension
ANSWER
 Letter A

 Rationale: Disorganization is the phase


of a crisis state which is characterized
by feelings of great anxiety and
inability to perform activities of daily
living.
SAMPLE BOARD QUESTION
NO.3
 Which of the following would be most helpful
during the early stages of crisis intervention

A) Help the patient to understand the crisis


B) Encourage the patient to forget the experience
C) Assess her thoughts thoroughly
D) Protect the patient from potential harm
ANSWER
 Letter A

 Rationale: In crisis intervention, a


thorough understanding of the crisis is
necessary for appropriate planning
SAMPLE BOARD QUESTION
NO.4
 The nurse’s role in crisis therapy
should be?

A) Non-directive and passive


B) Firm and confrontational
C) Active and directive
D) Calm and non-expressive
ANSWER
 Letter C

 Rationale: A patient in crisis is passive


and submissive so the nurse needs to
be active and directive to facilitate
coping.
SAMPLE BOARD QUESTION
NO.5
 Which of the following is expected of a
person in crisis?

A) Be able to adjust in a week


B) Becomes submissive and passive
C) Takes the lead in problem-solving
D) Assists the nurse in decision-making
ANSWER
 Letter B

 Rationale: A patient in crisis is passive


and submissive.
RAPE
RAPE
 Is a crime of violence and humiliation of the victim
expressed through sexual means

 Rape is the penetration of an act of sexual intercourse


with a female against her will and without her consent,
whether her will is overcome by force, fear of force,
drugs, or intoxicants

 It is also considered rape if the woman is incapable of


exercising rational judgment because of mental
deficiency or when she is below the age of consent.
RAPE
 According to Republic Act 8353, it refers
to the insertion of the penis into the
mouth, vagina, anus of a victim

 Insertion of any object into the mouth or


anus

 It is generally considered as an act of


hostility, anger or violence
ESSENTIAL ELEMENTS
NECESSARY TO DEFINE AN ACT
OF RAPE
 Use of threat / force

 Lack of consent of the victim

 Actual penetration of the penis into the


vagina
DIFFERENT KINDS OF RAPE
 Anger Rape

 Power Rape

 Sadistic Rape
ANGER RAPE
 Distinguished by physical violence and cruelty
to the victim

 Rapist believes he is the victim of an unjust


society and takes revenge on others by raping

 He uses extreme force and viciousness to


overcome the victim

 This is done as a means of retaliation


POWER RAPE
 The intent of the rapist is not to injure the victim but
to command and master another person sexually

 The rapist has an insecure self-image and feelings


of incompetence and inadequacy

 The rape is the vehicle for expressing power,


potency and might

 This is done to prove one’s masculinity


SADISTIC RAPE
 Involves brutality

 The use of bandage and torture is not an


expression of anger but necessary for the
rapist’s sexual excitement

 The assault is often eroticized and is sexually


stimulating

 This is done to express erotic feelings


WARNING SIGNS OF
RELATIONSHIP VIOLENCE
 Emotionally abuses you (insults, makes belittling comments,
acts sulky or angry when you initiate an idea or activity)

 Tell you with whom you may be friends or how you should
dress, or ties to control other elements of your life

 Talks negatively about women in general

 Gets jealous for no reason

 Drinks heavily, uses drugs, or tries to get you drunk


WARNING SIGNS OF
RELATIONSHIP VIOLENCE
 Acts in an intimidating way by invading your
personal space such as standing too close or
touching you when you do not want him to

 Cannot handle sexual or emotional frustration


without becoming angry

 Does not view you as an equal; sees himself as


smarter or socially superior
WARNING SIGNS OF
RELATIONSHIP VIOLENCE
 Guards his masculinity by acting tough

 Is angry or threatening to the point


that you have changed your life or
yourself so you won’t anger him
RAPE TRAUMA SYNDROME
 It refers to a group of signs and
symptoms experienced by a victim in
reaction to a rape
PHASES OF THE RAPE TRAUMA

SYNDROME
Acute Phase
– Characterized by shock, numbness and disbelief

 Denial Phase
– Characterized by the victim’s refusal to talk about the
event

 Heightened Anxiety
– Characterized by fear, tension, and nightmares

 Stage of Reorganization
– The victim’s life normalizes
NURSING CARE FOR RAPE
VICTIMS
 In the emergency setting, provide immediate
emotional support

 The nurse should allow the woman to proceed at her


own pace and not rush her through any interview or
examination

 Give as much control back to the victim as possible by


allowing her to make decisions, when possible, about
whom to call, what to do next, what she would like
done, etc.
NURSING CARE FOR RAPE
VICTIMS
 It is the victim’s decision about whether or
not to file charges and testify against the
perpetrator and the victim must sign
consent forms before any photographs of
hair and nail samples are taken for future
evidence

 The priority in the care of a rape victim is


the preservation of evidence
NURSING CARE FOR RAPE
VICTIMS
 Prophylactic treatment for STDs is offered

 Prophylaxis can be offered to prevent pregnancy

 In some areas, HIV testing is strongly encouraged

 Referrals to rape crisis centers are encouraged


SAMPLE BOARD QUESTION
NO.1
 The initial treatment of a rape victim can
significantly affect the psychological impact the
assault will have on the victim. The first
information elicited from a victim would be which
of the following?

A) the marital state of the victim


B) the victim’s perception of what occurred
C) whether or not the rapist was known to her
D) how she feels about having an abortion if she
becomes pregnant
ANSWER
 Letter B

 Rationale: Rape is a form of crisis. The


severity of a crisis situation depends
on the individual’s perception of the
event.
SAMPLE BOARD QUESTION
NO.2
 Rape is generally considered to be an
act of ?

A) Aggression
B) Bestiality
C) Exposure
D) Sexual passion
ANSWER
 Letter A

 Rationale: Rape is generally


considered to be an act of aggression,
hostility and violence
SAMPLE BOARD QUESTION
NO.3
 Which of the following is most
important for the emergency room
nurse to take?

A) Call the police


B) Call a psychiatrist
C) Provide emotional support
D) Offer protection from pregnancy
ANSWER
 Letter C

 Rationale: Initially, the provision of a


safe and supportive environment is
necessary
SAMPLE BOARD QUESTION
NO.4
 The overall patient goal in rape counseling is
to help the victim?

A) Forget the incident and repress her feelings


in order to be able to carry on with her life
B) Identify the rapist in court
C) Accept her part in the rape
D) Acknowledge, face, and resolve the
reaction she is experiencing
ANSWER
 Letter D

 Rationale: Rape is a form of crisis. In


crisis intervention, the patient is
considered as the primary
rehabilitator.
SAMPLE BOARD QUESTION
NO.5
 Primary prevention of rape can be best
accomplished by which of the following?

A) Initiation of emergency measures after the


rape
B) Policewoman teaching a class on rape
prevention
C) Psychiatric hospitalization for the survivor
of rape
D) A lengthy jail sentence for the rapist
ANSWER
 Letter B

 Rationale: Conducting rape prevention


classes is an example of primary level
of prevention
SPOUSE OR PARTNER
ABUSE
SPOUSE OR PARTNER ABUSE
 Is the mistreatment or misuse of one
person by another in the context of an
intimate relationship

 The abuse can be emotional or


psychological, physical, sexual or a
combination (which is common)
SPOUSE OR PARTNER ABUSE
 Emotional or psychological abuse includes:

– Name-calling
– Belittling
– Screaming
– Yelling
– Destroying property
– Making threats
– Refusing to speak to or ignoring the victim
SPOUSE OR PARTNER ABUSE
 Physical abuse includes the following:

– Shoving

– Pushing

– Severe battering and choking and may


involve broken limbs and ribs, internal
bleeding, brain damage, even homicide
SPOUSE OR PARTNER ABUSE
 Sexual abuse include the following assaults
during sexual relations such as:

– Biting nipples

– Pulling hair

– Slapping and biting

– Rape
BATTERED WIFE SYNDROME
 Cycle of domestic violence characterized by
wife-beating by the husband, humiliation and
other forms of aggression

 The most common trait of abusive men is


low self-esteem

 The most common trait of the abused


woman is dependence
CHARACTERISTICS OF ABUSIVE
HUSBANDS
 They usually come from violent
families

 They are immature, dependent and


non-assertive

 They have strong feelings of


inadequacy
PHASES OF SPOUSE OR
PARTNER ABUSE
 Tension Building Phase
– Involves minor battering incidents

 Acute Battering Phase


– More serious form of battering occurs

 Aftermath / Honeymoon Phase


– The husband becomes loving and gives
the wife hope
PRIORITY IN NURSING CARE
FOR THE ABUSED SPOUSE OR
PARTNER
 Provision of shelter
DOs IN WORKING WITH VICTIMS
OF PARTNER ABUSE
 Do ensure and maintain the client’s confidentiality

 Do listen, affirm, and say “I am sorry you have


been hurt.”

 Do express: “I am concerned for your safety.”

 Do tell the victim: “You have the right to be safe


and respected.”
DOs IN WORKING WITH VICTIMS
OF PARTNER ABUSE
 Do recommend a support group or individual
counseling

 Do identify community resources and


encourage the client to develop a safety plan

 Offer to help the client contact a shelter, the


police, or other resources
DON’Ts IN WORKING WITH
VICTIMS OF PARTNER ABUSE
 Don’t disclose client communications
without the client’s consent

 Don’t preach, moralize, or imply that you


doubt the client

 Don’t minimize the impact of the violence

 Don’t express outrage with the perpetrator


SAMPLE BOARD QUESTION
NO.1
 Seeing a patient for the first time, the nurse notices bruises on her
upper arms and asks about them. After denying any problems, the
patient starts to cry and says, “He didn’t really mean to hurt me,
but I hate the kids to see. I am so worried about them.” During the
interview, it would be most important for the nurse to determine?

A) The type and extent of abuse in the family


B) The potential of immediate danger to the patient and her
children
C) The resources available to the patient
D) Whether the patient wants to be separated from her husband
ANSWER
 Letter B

 Rationale: In domestic violence, the


priority is the patient’s safety
SAMPLE BOARD QUESTION
NO.2
 When planning her care, which of the following is the
most important to the patient?

A) The phone number of the local crisis hotline


B) Referral to a psychotherapist
C) Referral to assertiveness training classes for women
D) No referral will be needed unless the battering
occurs against or is witnessed by an adult
ANSWER
 Letter A

 Rationale: Provision of support is an


essential component of the care of
battered women.
SAMPLE BOARD QUESTION
NO.3
 In assessing a battered wife’s method
of coping, which method would the
nurse least expect to find her using?

A) Assertiveness
B) Alcohol abuse
C) Self-blame
D) Suicidal thoughts
ANSWER
 Letter A

 Rationale: Battered women are usually


dependent and non-assertive
SAMPLE BOARD QUESTION
NO.4
 Wife beaters will usually manifest?

A) Maturity
B) Low self-esteem
C) Assertiveness
D) Patience
ANSWER
 Letter B

 Rationale: Wife-beaters usually have


low self-esteem
SAMPLE BOARD QUESTION
NO.5
 Abused women are more likely to become
receptive to nursing intervention during
the ?

A) Acute phase
B) Honeymoon stage
C) Tension building phase
D) Time between the acute phase and the
tension building phase
ANSWER
 Letter D

 Rationale: During this stage, the victim


is in a state of crisis and is therefore
more receptive to suggestions.
DON’Ts IN WORKING WITH
VICTIMS OF PARTNER ABUSE
 Don’t imply that the client is responsible for the
abuse

 Don’t recommend couples’ counseling

 Don’t direct the client to leave the relationship

 Don’t take charge and do everything for the client


CHILD ABUSE
CHILD ABUSE
 Child abuse or mistreatment is
generally defined as the intentional
injury of a child
CHILD ABUSE
 It can include any of the following:

– Physical abuse or injuries


– Neglect or failure to prevent harm
– Failure to provide adequate physical or
emotional care or supervision
– Abandonment
– Sexual assault or intrusion
– Overt torture or maiming
TYPES OF CHILD ABUSE
 Physical Abuse

 Sexual Abuse

 Neglect

 Psychological Abuse
TYPES OF CHILD ABUSE –
PHYSICAL ABUSE
 Physical abuse of children often results from
unreasonably severe corporal punishment or unjustifiable
punishment such as hitting an infant for crying or soiling
his diapers

 Intentional deliberate assaults on children include:


– Burning
– Biting
– Cutting
– Poking
– Twisting limbs
– Scalding with hot water
TYPES OF CHILD ABUSE –
PHYSICAL ABUSE
 The victim often has evidence of old
injuries (e.g., scars, untreated
fractures, multiple bruises of various
ages) that the history given by parents
does not explain adequately
TYPES OF CHILD ABUSE –
SEXUAL ABUSE
 Sexual abuse involves sexual acts performed by an adult
on a child younger than 18 years of age

 Examples include:
– Incest
– Rape
– Sodomy performed directly by the person or with an
object
– Oral-genital contact
– Acts of molestations such as rubbing, fondling, or
exposing the adult’s genitals
TYPES OF CHILD ABUSE –
SEXUAL ABUSE
 Sexual abuse includes:

– Exploitation, such as:


 Making, promoting, or selling
pornography involving minors
 Coercion of minors to participate in
obscene acts
TYPES OF CHILD ABUSE –
NEGLECT
 Neglect is malicious or ignorant
withholding of physical, emotional, or
educational necessities for the child’s
well-being
TYPES OF CHILD ABUSE –
NEGLECT
 Child abuse by neglect is the most prevalent type of
maltreatment and includes:
– Refusal to seek health care or delay doing so;
– Abandonment
– Inadequate supervision
– Reckless disregard for the child’s safety
– Punitive, exploitative, or abusive emotional treatment;
– Spousal abuse in the child’s presence
– Giving the child permission to be truant (absent from
school)
– Failing to enroll the child in school
TYPES OF CHILD ABUSE –
PSYCHOLOGICAL ABUSE
 Psychological abuse (emotional abuse) includes
– Verbal assaults
 Blaming
 Screaming
 Name-calling
 Using sarcasm
– Constant family discord characterized by fighting,
yelling, and chaos
– Emotional deprivation or withholding affection,
nurturing
– Normal experiences that engender acceptance, love,
security and self-worth
CHARACTERISTICS OF ABUSIVE
PARENTS
 They come from violent families

 They were also abused by their parents

 They have inadequate parenting skills

 They are socially isolated because they don’t trust anyone

 The are emotionally immature

 They have negative attitude towards the management of


the abused
WARNING SIGNS OF ABUSED
OR NEGLECTED CHILDREN
 Serious injury such as fractures, burns, or
lacerations with no reported history of trauma

 Delay in seeking treatment for a significant injury

 Child or parent gives a history inconsistent with


severity of injury, such as a baby with contre coup
injuries to the brain (shaken baby syndrome) that
the parent claim happened when the infant rolled
off the sofa
WARNING SIGNS OF ABUSED
OR NEGLECTED CHILDREN
 Inconsistencies or changes in the child’s history
during the evaluation by either the child or the
adult

 Unusual injuries for the child’s age and level of


development, such as fractured femur on a 2
month old or a dislocated shoulder in a 2 year old
WARNING SIGNS OF ABUSED
OR NEGLECTED CHILDREN
 High incidence of urinary tract
infections; bruised, red, or swollen
genitalia; tears or bruising of rectum or
vagina

 Evidence of old injuries not yet


reported, such as scars, fractures not
treated, multiple bruises that parent
cannot explain adequately
COMMON INDICATORS OF
CHILD ABUSE
 Serious injuries in various stages of
healing
 Healthy hair in various length
 Apathy, no reaction
 Depression
 Excessive knowledge of sex
 Self-esteem is low
PRIORITIES IN CHILD ABUSE
 Republic Act 7610, the anti-child abuse law requires
reporting of suspected cases to authorities

– Remember that the nurse does not have to decide with


certainty that abuse has occurred

– Nurses are responsible for reporting suspected child


abuse with accurate and thorough documentation of
assessment data

– Report cases to barangay officers, DSWD personnel,


police within 48 hours
PRIORITIES IN CHILD ABUSE
 The first part of treatment for child
abuse or neglect is to ensure the
child’s safety and well-being

 Assistance of social service agencies


may be tapped
SAMPLE BOARD QUESTION
NO.1
 In assessing an abusive situation, the nurse
would find what information most useful?

A) The interaction between the child and his


mother
B) The time of abuse
C) Presence of other children in the family
D) Age of the mother
ANSWER
 Letter A

 Rationale: The interaction between a


child and his mother provides a clue to
the kind of relationship that the child
has with his mother
SAMPLE BOARD QUESTION
NO.2
 Which of the following actions would be
taken by hospital personnel when child
abuse is suspected?

A) Confront the mother


B) Notify the family
C) Notify the child protective service
D) Do nothing until the diagnosis is
certain
ANSWER
 Letter C

 Rationale: Hospital personnel are


required by law to report suspected
cases of child abuse.
ANXIETY
ANXIETY
 A stage of uneasiness or discomfort experienced to
varying degrees

 Is frequently coupled with doubts, fears, obsessions.

 A feeling of terror or dread; the most uncomfortable


feeling a person can experience

 An initial response to a psychic threat (Hildegard Peplau)


HILDEGARD PEPLAU’S FOUR
LEVELS OF ANXIETY
 Mild Anxiety

 Moderate Anxiety

 Severe Anxiety

 Panic Anxiety
MILD ANXIETY
 It is a positive state of heightened
awareness and sharpened senses,
allowing the person to learn new
behaviors and solve problems.

 The person can take in all available


stimuli (enlarged perceptual field)
MODERATE ANXIETY
 Involves a decreased perceptual field
(focus on immediate task only)

 The person can learn new behavior or


solve problems only with assistance

 Another person can redirect the person


to the task.
SEVERE ANXIETY
 This involves feelings of dread or terror

 The person cannot be redirected into a task;


he or she focuses only on scattered details
and has physiologic symptoms of
tachycardia, diaphoresis, and chest pain.

 People with severe anxiety often go to


emergency departments, believing they are
having a heart attack.
PANIC ANXIETY
 It involves loss of rational thought,
delusions, hallucinations, and
complete physical immobility and
muteness

 The person may bolt and run


aimlessly, often exposing himself or
herself to injury.
SIGNS AND SYMPTOMS OF
ANXIETY
SIGNS AND MILD ANXIETY MODERATE SEVERE PANIC
SYMPTOMS ANXIETY ANXIETY ANXIETY

Increased pulse Nausea Signs and Signs and


rate, respiratory Anorexia symptoms symptoms of
rate, blood become the exhaustion are
PHYSICAL Vomiting
pressure focus of ignored
Diarrhea attention
Pupillary
dilation Constipation
Sweating Restlessness

Attentive and Narrowed Perceptual field Personality is


alert patient perceptual field is greatly disorganized
COGNITIVE and selective narrowed.
inattention Focus of
attention is
trivial events
PRIORITY NURSING DIAGNOSES
FOR ANXIETY
 Ineffective individual coping

 Anxiety
PRINCIPLES OF NURSING CARE
IN ANXIETY
 Calm

 Administer medications

 Listen to the patient’s concerns

 Minimize environmental stimuli


SAMPLE BOARD QUESTION
NO.1
 The nurse is aware that the two major types of
precipitating factors in anxiety are?

A) Fear of disapproval and shame


B) Conflicts involving avoidance and shame
C) Threats to one’s biologic integrity and threats
to one’s self-esteem
D) A person’s poor health and poor financial
condition
ANSWER
 Letter C

 Rationale: The two major types of


precipitating factors to anxiety are:
threats to one’s biologic integrity and
threats to one’s self-esteem
SAMPLE BOARD QUESTION
NO.2
 When working with a person who is anxious,
what is the overall goal of nursing
intervention?

A) Remove anxiety
B) Develop the person’s awareness of anxiety
C) Protect the person from anxiety
D) Develop the person’s capacity to tolerate
mild anxiety
ANSWER
 Letter D

 Rationale: The goal of intervention in


the care of the anxious patient is to
enable him to develop his capacity to
tolerate mild anxiety
SAMPLE BOARD QUESTION
NO.3
 The nurse is caring for a patient with panic disorder and a
patient with a phobia. What is one major difference
between those two disorders?

A) Specific precipitants are present with panic disorder


B) Specific precipitants are present with phobia
C) The symptoms are different for each disorder
D) Phobias are one cause of major depressive states
ANSWER
 Letter B

 Rationale: Specific precipitants are


present with phobia
SAMPLE BOARD QUESTION
NO.4
 A man in his mid-forties complaints of severe
palpitations, sweating and intense fear when he had to
speak in public. Because his job entails lecturing in
auditoriums, what would the nurse suggest?

A) Behavior therapy with beta-adrenergic blockers


B) Quitting his job altogether
C) Telling jokes to reduce anxiety
D) Monoamine Oxidase inhibitors
ANSWER
 Letter A

 Rationale: A combination of behavioral


and somatic approaches is effective in
the management of anxiety
SAMPLE BOARD QUESTION
NO.5
 An appropriate nursing diagnosis for a
patient with anxiety is which of the
following?

A) Self-esteem disturbance
B) Ineffective individual coping
C) Unilateral neglect
D) Altered thought process
ANSWER
 Letter B

 Rationale: Anxiety is one of the


defining characteristics of ineffective
individual coping.
EGO DEFENSE
MECHANISMS
EGO DEFENSE MECHANISMS
 Freud believed that the self or ego used ego
defense mechanisms to protect the self and
cope with basic drives or emotionally painful
thoughts, feelings, or events.

 Most ego defense mechanisms operate at the


unconscious level of awareness, so people are
not aware of what they are doing and often
need help to see the reality.
EGO DEFENSE MECHANISMS
 Compensation  Rationalization
 Conversion  Reaction Formation
 Denial  Regression
 Displacement  Repression
 Dissociation  Resistance
 Fixation  Sublimation
 Identification  Substitution
 Intellectualization  Suppression
 Introjection  Undoing
 Projection
COMPENSATION
 Overachievement in one area to offset real
or perceived deficiencies in another area

 Examples:
– Napoleon complex: diminutive man
becoming an emperor
– Nurse with low self-esteem works double
shifts so her supervisor will like her
CONVERSION
 Expression of an emotional conflict through the
development of a physical symptom, usually
sensorimotor in nature.

 Example:
– A teenager forbidden to see x-rated movies is
tempted to do so by friends and develops
blindness, and the teenager is unconcerned
about the loss of sight.
DENIAL
 Failure to acknowledge an unbearable
condition; failure to admit the reality of a
situation, or how one enables the problem to
continue

 Examples:
– Diabetic eating chocolate candy
– Spending money freely when broke
– Waiting 3 days to seek help for severe
abdominal pain
DISPLACEMENT
 Ventilation of intense feelings toward
persons less threatening than the one
who aroused those feelings.

 Examples:
– A person who is mad at the boss yells
at his or her spouse
– A child who is harassed by a bully at
school mistreats a younger sibling.
DISSOCIATION
 Dealing with emotional conflict by a
temporary alteration in consciousness or
identity

 Examples:
– Amnesia that prevents recall of
yesterday’s auto accident
– An adult remembers nothing of
childhood sexual abuse
FIXATION
 Immobilization of a portion of the
personality resulting from unsuccessful
completion of tasks in a developmental
stage

 Examples:
– Never learning to delay gratification
– Lack of a clear sense of identity as an
adult
IDENTIFICATION
 Modeling actions and opinions of influential
others while searching for identity, or
aspiring to reach a personal, social, or
occupational goal.

 Example:
– Nursing student becoming a critical care
nurse because this is the specialty of an
instructor she admires.
INTELLECTUALIZATION
 Separation of the emotions of a painful
event or situation from the facts
involved; acknowledging the facts but
not the emotions.

 Example
– Person shows no emotional
expression when discussing serious
car accident.
INTROJECTION
 Accepting another person’s attitudes,
beliefs, and values as one’s own.

 Example:
– A person who dislikes guns becomes
an avid hunter, just like a best
friend.
PROJECTION
 Unconscious blaming of unacceptable
inclinations or thoughts on an external
object.

 Examples:
– Man who has thought about same-gender
sexual relationship but never had one,
beats a man who is gay.
– A person with many prejudices loudly
identifies others as bigots.
RATIONALIZATION
 Excusing own behavior to avoid guilt,
responsibility, conflict, anxiety, or loss of
self-respect

 Examples:
– Student blames failure on teacher
being mean
– Man says he beats his wife because
she does not listen to him.
REACTION FORMATION
 Acting the opposite of what one thinks
or feels.

 Examples:
– Woman who never wanted to have
children becomes a super-mom.
– Person who despises the boss tells
everyone what a great boss she is.
REGRESSION
 Moving back to a previous developmental
stage in order to feel safe or have needs met

 Examples:
– Five-year-old asks for a bottle when new
baby brother is being fed.
– Man pouts like a four-year-old if he is not
the center of his girlfriend’s attention.
REPRESSION
 Excluding emotionally painful or anxiety-
provoking thoughts and feelings from
conscious awareness

 Examples:
– Woman has no memory of the mugging
she suffered yesterday
– Woman has no memory before age 7 when
she was removed from abusive parents.
RESISTANCE
 Overt or covert antagonism toward
remembering or processing anxiety-
producing information.

 Examples:
– Nurse is too busy with tasks to spend time
talking to a dying patient
– Person attends court-ordered treatment for
alcoholism but refuses to participate.
SUBLIMATION
 Substituting a socially acceptable activity for
an impulse that is unacceptable

 Examples:
– Person who has quit smoking sucks on
hard candy when the urge to smoke arises.
– Person goes for 15-minute walk when
tempted to eat junk foods.
SUBSTITUTION
 Replacing the desired gratification with
one that is more readily available.

 Example:
– Woman who would like to have her
own children opens a day care
center.
SUPPRESSION
 Conscious exclusion of unacceptable thoughts
and feelings from conscious awareness.

 Examples:
– A student decides not to think about a parent’s
illness in order to study for a test
– A woman tells a friend she cannot think about
her son’s death right now
UNDOING
 Exhibiting acceptable behavior to make up for or
negate unacceptable behavior.

 Examples:
– A person who cheats on a spouse brings the
spouse a bouquet of roses.
– A man who is ruthless in business donates large
amounts of money to charity
SAMPLE BOARD QUESTION
NO.1
 When upset, the patient curls into a
fetal position in bed. The nurse judges
the patient to be exhibiting?

A) Fixation
B) Regression
C) Substitution
D) Symbolization
ANSWER
 Letter B

 Rationale: Regression is turning to an


earlier level of development in the face
of stress
SAMPLE BOARD QUESTION
NO.2
 Family members often feel guilty that they are
not doing enough to the patient, so their
tendency is to blame the staff, nurses and
doctors. This defensive response is ?

A) Displacement
B) Rationalization
C) Projection
D) Sublimation
ANSWER
 Letter C

 Rationale: Projection is attributing to


others one’s unconscious wishes or
fears. Usually it is seen in paranoid
patients.
SAMPLE BOARD QUESTION
NO.3
 Alcoholics commonly use a defense
mechanism known as?

A) Denial
B) Regression
C) Displacement
D) Sublimation
ANSWER
 Letter A

 Rationale: Alcoholics usually use


denial, rationalization, projection and
isolation
SAMPLE BOARD QUESTION
NO.4
 Rationalization is exemplified in one of the
following situations?

A) An applicant for a job develops fever on the day


of her personal interview
B) A student says, “I did not get good grades
because the teacher does not like me.”
C) An unfaithful husband gives a gift to his wife
after a heated argument
D) A patient says, “I do not want to think about
my problems.”
ANSWER
 Letter B

 Rationale: Rationalization is justifying


one’s action which are based on other
motives. It is usually seen among
alcoholics
SAMPLE BOARD QUESTION
NO.5
 An example of maladaptive use of defense
mechanism is?

A) An individual resorts to drinking when


under stress to diffuse tension
B) A former drug addict helps in the
rehabilitation of drug users.
C) A short man excels in public speaking
D) A patient blames the nurse for his family’s
unacceptable ways.
ANSWER
 Letter A

 Rationale: Drinking alcohol when under


stress makes a person at risk for
various disorders.
ANXIETY DISORDERS
ANXIETY DISORDERS
 These are emotional illnesses characterized by fear,
autonomic nervous system symptoms and
avoidance behavior
 They are diagnosed when anxiety no longer
functions as a signal of danger or a motivation for
needed change but becomes chronic and permeates
major portions of the person’s life, resulting in
maladaptive behaviors and emotional instability
 Anxiety disorders have many manifestations but
anxiety is the key feature of each
TYPES OF ANXIETY DISORDERS
 Agoraphobia
 Panic Disorder
 Specific Phobia
 Social Phobia
 Obsessive-compulsive Disorder
 Generalized anxiety Disorder
 Acute Stress Disorder
 Post-traumatic Stress Disorder
AGORAPHOBIA
 Is anxiety about or avoidance of places
or situations from which escape might
be difficult or help might be
unavoidable

 Fear of being alone in public places


SYMPTOMS OF AGORAPHOBIA
 Avoids being outside alone or at home
alone
 Avoids traveling in vehicles
 Impaired ability to work
 Difficulty meeting daily responsibilities
(e.g., grocery shopping, going to
appointments)
 Knows response is extreme
MANAGEMENT OF
AGORAPHOBIA
 Anti-anxiety medications

 Social skills training


– Teach them how to:
 Ask questions
 Give compliments
 Maintain eye contact
 Speak in a clear tone of voice
 Avoid criticism
 Avoid fidgeting
PANIC DISORDER
 Is characterized by recurrent,
unexpected panic attacks that cause
constant concern

 Panic attack is the sudden onset of


intense apprehension, fearfulness, or
terror associated with feelings of
impending doom
SYMPTOMS

OF PANIC DISORDER
A discrete episode of panic lasting 15 to 30 minutes with four or more
of the following:
– Palpitations
– Sweating
– Trembling or shaking
– Shortness of breath
– Choking or smothering sensation
– Chest pain or discomfort
– Nausea
– Derealization (sensing that things are not real) or depersonalization
(feelings of being disconnected from oneself
– Fear of dying or going crazy
– Paresthesias
– Chills or hot flashes
MANAGEMENT OF PANIC
DISORDER
 Anti-anxiety medications

 Relaxation exercises

 Deep breathing

 Cognitive behavioral techniques


COGNITIVE BEHAVIORAL
TECHNIQUES FOR PANIC
DISORDERS
 Positive Reframing

 Decatastrophizing

 Assertiveness Training
POSITIVE REFRAMING
 Turning negative messages into positive messages
 The therapist teaches the person to create positive
messages for use during panic episodes
 Instead of thinking, “My heart is pounding. I think I am
going to die” the client thinks, “I can stand this. This is
just anxiety. It will go away.”
 The client can write down these messages and keep
them readily accessible such as in an address book,
wallet or calendar
DECATASTROPHIZING
 Involves the therapist’s use of questions to more realistically
appraise the situation; the therapist may ask, “What is the worst
thing that could happen? Is that likely? Could you survive that?
Is that as bad as you imagine?”
 The client uses thought-stopping and distraction techniques to
jolt himself from focusing on negative thoughts
 Splashing the face with water, snapping a rubber band worn on
the wrist, or shouting are all techniques that can break the cycle
of negative thoughts
ASSERTIVENESS TRAINING
 Helps the person take more control over life situations
 Techniques help the person negotiate interpersonal
situations and foster self-assurance
 They involve using “I” statements to identify feelings and
to communicate concerns or needs to others.
 Examples include “I feel angry when you turn your back
while I’m talking,” “I want to have 5 minutes of your time
for an uninterrupted conversation about something
important”
SPECIFIC PHOBIA
 Is characterized by significant anxiety
provoked by a specific feared object or
situation which often leads to
avoidance behavior
SYMPTOMS OF SPECIFIC
PHOBIA
 Marked anxiety response to the object
or situation
 Avoidance or suffered endurance of
object or situation
 Significant distress or impairment of
daily routine, occupation, or social
functioning
 Adolescents and adults recognize their
fear as excessive or unreasonable.
MANAGEMENT OF SPECIFIC
PHOBIA
 Anti-anxiety medications

 Systematic Desensitization
SYSTEMATIC OR SERIAL
DESENSITIZATION
 The therapist progressively exposes the client
to the threatening object in a safe setting until
the client’s anxiety decreases
 During each exposure, the complexity and
intensity of exposure gradually increase but
each time the client’s anxiety decreases.
 The reduced anxiety serves as a positive
reinforcement until the anxiety is ultimately
eliminated
EXAMPLE OF SERIAL
DESENSITIZATION
 For a client who fears flying, the therapist would encourage
the client to hold a small model airplane while talking about
his or her experiences
 Later the client would talk about flying while holding a larger
model of an airplane
 Later exposures might include walking past an airport, sitting
in a parked airplane, and finally taking a ride in the plane
 Each session’s challenge is based on the success achieved in
the previous sessions
SOCIAL PHOBIA
 Is characterized by anxiety provoked
by certain types of social or
performance situations, which often
leads to avoidance behavior
SYMPTOMS OF SOCIAL PHOBIA
 Fear of embarrassment or inability to perform
 Avoidance or dreaded endurance of behavior or
situation
 Recognition that response is irrational or excessive
 Belief that others are judging him or her
negatively
 Significant distress or impairment in relationships,
work, or social life
 Anxiety can be severe or panic level
MANAGEMENT OF SOCIAL
PHOBIA
 Anti-anxiety medications

 Social Skills training


OBSESSIVE-COMPULSIVE
DISORDER
 Involves obsession (thoughts, impulses
or images) that cause marked anxiety
and/or compulsions (repetitive
behaviors or mental acts) that attempt
to neutralize anxiety
SYMPTOMS OF OBSESSIVE-
COMPULSIVE DISORDER
 Recurrent, persistent, unwanted, intrusive
thoughts, impulses, or images beyond worrying
about the realistic life problems
 Attempts to ignore, suppress, or neutralize
obsessions with compulsions that are mostly
ineffective
 Adults and adolescents recognize that
obsessions and compulsions are excessive and
unreasonable
OBSESSIVE-COMPULSIVE
DISORDER
OBSESSIONS COMPULSIONS

FEAR OF DIRT AND GERMS EXCESSIVE HAND WASHING

FEAR OF BURGLARY ORREPEATED CHECKING OF DOOR


ROBBERY AND WINDOW LOCKS

WORRIES ABOUT DISCARDINGCOUNTING AND RECOUNTING


SOMETHING IMPORTANT OF OBJECTS IN EVERYDAY LIFE

WORRIES THAT THINGS MUSTEXCESSIVE STRAIGHTENING,


BE SYMMETRICAL ORORDERING, OR ARRANGING OF
MATCHING THINGS
MANAGEMENT OF OBSESSIVE-
COMPULSIVE DISORDER
 Anti-anxiety medications

 Response prevention (delaying or


avoiding performance of the rituals)

 Thought Stopping
GENERALIZED ANXIETY
DISORDER
 Is characterized by at least six months
of persistent and excessive worry and
anxiety that interferes with a person’s
life
 It is also characterized by motor
tension, autonomic hyperactivity and
cognitive vigilance
SYMPTOMS OF GENERALIZED
ANXIETY DISORDER
 Apprehensive expectations more days than not for 6
months or more about several events or activities
 Uncontrollable worrying
 Significant distress or impaired social or occupational
functioning
 Three of the following symptoms:
– Restlessness
– Easily fatigued
– Difficulty concentrating or mood going blank
– Irritability
– Muscle tension
– Sleep disturbance
MANAGEMENT OF
GENERALIZED ANXIETY
DISORDER
 Anti-anxiety medications

 Anti-depressants

 Psychotherapy
ACUTE STRESS DISORDER
 Is the development of anxiety,
dissociative, and other symptoms
within 1 month of exposure to an
extremely traumatic stressor

 It lasts 2 days to 4 weeks


SYMPTOMS OF ACUTE STRESS
DISORDER
 Exposure to traumatic event causing intense fear,
helplessness, or horror
 Marked anxiety symptoms or increased arousal

 Significant distress or impaired functioning

 Persistent re-experiencing of the event

 Three of the following symptoms:

– Sense of emotional numbing or detachment


– Dissociative amnesia (inability to recall important aspect
of the event)
– Feeling dazed
– Derealization
– Depersonalization
MANAGEMENT OF ACUTE
STRESS DISORDER
 Anti-anxiety medications

 Anti-depressant medications

 Group therapy
POST-TRAUMATIC STRESS
DISORDER
 Is characterized by the re-experiencing
of an extremely traumatic event,
avoidance of stimuli associated with
the event, numbing of responsiveness,
and persistent increased arousal

 It begins within 3 months to years


after the event and may last a few
months or years
SYMPTOMS OF POST-
TRAUMATIC STRESS DISORDER
 Exposure to traumatic event involving intense fear, helplessness
or horror
 Re-experiencing (intrusive recollections or dreams, flashbacks,
physical and psychological distress over reminders of the event)
 Avoidance of memory-provoking stimuli and numbing of general
responsiveness (avoidance of thoughts, feelings, conversations,
people, places, amnesia, diminished interest or participation in
life events, feeling detached or estranged from others, restricted
affect, sense of foreboding)
SYMPTOMS OF POST-
TRAUMATIC STRESS DISORDER
 Increased arousal (sleep disturbance,
irritability or angry outbursts, difficulty
concentrating, hypervigilance,
exaggerated startle reflex)

 Significant distress or impairment


MANAGEMENT OF POST-
TRAUMATIC STRESS DISORDER
 Anti-anxiety medications

 Anti-depressant medications

 Group therapy
PRIORITY NURSING DIAGNOSIS
FOR ANXIETY DISORDERS
 Ineffective individual coping
PSYCHOPHARMACOLOGIC
MANAGEMENT OF POST-
TRAUMATIC STRESS DISORDER
 Anti-anxiety or anxiolytic drugs or
minor tranquilizers
– Diazepam (Valium)
– Oxazepam (Serax)
– Chlordiazepoxide (Librium)
– Chlorazepate Dipotassium
(Tranxene)
– Alprazolam (Xanax)
EFFECTS OF ANXIOLYTIC DRUGS
 Decreased anxiety

 Adequate sleep
WHEN TO ADMINISTER
ANXIOLYTIC DRUGS
 Best taken before meals, food in the
stomach delays absorption
SIDE EFFECTS OF ANXIOLYTIC
DRUGS
 Drowsiness

 Sedation

 Poor coordination

 Impaired memory and clouded sensorium


CLIENT TEACHING ON
ANXIOLYTIC DRUGS
 Avoid driving

 Intake of alcohol and caffeine-containing


foods alter the effect of the drug
– It potentiates the effect of alcohol

 Administer separately, it is incompatible


with any drug.
WORKING WITH CLIENTS WITH
ANXIETY AND ANXIETY
DISORDERS
 Remember that everyone suffers from stress
and anxiety occasionally that can interfere with
daily life and work
 Avoid falling into the pitfall of trying to “fix” the
client’s problems
 Discuss any uncomfortable feelings with a more
experienced nurse for suggestions on how to
deal with your feelings toward these clients
 Remember to practice techniques to manage
stress and anxiety in your life.
SITUATION
 Leonora Cielo is the nurse manager of the oncology unit
on the 33rd floor of a large urban medical center.
Recently, she has been increasingly afraid of riding in
the elevator and of being in public places. This morning
she experienced shortness of breath, palpitations,
dizziness, and trembling while in the elevator. Leonora
was examined by an emergency department physician.
SAMPLE BOARD QUESTION
NO.1
 Which of the following behaviors would
the nurse expect to observe in the patient
with agoraphobia?

A) The patient is afraid of talking to other


people
B) The patient is afraid to leave her home
C) The patient is afraid of pain
D) The patient is afraid of fire
ANSWER
 Letter B

 Rationale: Agoraphobia is fear of being


alone in a particular place where
escape is difficult
SAMPLE BOARD QUESTION
NO.2
 Leonora begins outpatient counseling sessions with a
psychiatric clinical nurse specialist. Which nursing
intervention would be most helpful in reducing
Leonora’s anxiety level?

A) Psychoanalytically oriented psychotherapy


B) Group psychotherapy
C) Systematic desensitization
D) Referral for evaluation for electroconvulsive therapy
ANSWER
 Letter C

 Rationale: Systematic desensitization


is the treatment of choice for people
with phobia
SAMPLE BOARD QUESTION
NO.3
 Because of the severity of Leonora’s anxiety, the nurse
referred her to a psychiatrist for medication evaluation.
Which psychotropic drug regimen is most likely to be
prescribed on a short-term basis?

A) Diazepam (valium) 5 mg orally three times a day


B) Benztropine mesylate (Cogentin) 2 mg orally twice a day
C) Chlorpromazine hydrochloride (Thorazine) 25 mg orally
four times a day
D) Thioridazine hydrochloride (Mellaril) 100 mg orally four
times a day
ANSWER
 Letter A

 Rationale: An anxiolytic drug is the


drug of choice
SAMPLE BOARD QUESTION
NO.4
 An appropriate nursing diagnosis for a
patient with phobia is?

A) Ineffective individual coping


B) Altered thought process
C) Sensory perceptual alteration
D) Self-esteem disturbance
ANSWER
 Letter A

 Rationale: A patient with anxiety


disorder may exhibit difficulty in
coping
SAMPLE BOARD QUESTION
NO.5
 Which of the following outcomes indicate a
positive response to therapy for a patient with
agoraphobia?

A) Patient experiences palpitation when going


out of the house
B) The symptoms occur only when triggered
C) The patient is able to visit the mailbox
D) The patient is able to entertain visitors
inside the house
ANSWER
 Letter C

 Rationale: The patient’s ability to go


outside the house indicates a positive
response to therapy.
PERSONALITY
DISORDERS
PERSONALITY
 It can be defined as an ingrained, enduring pattern of
behaving and relating to self, others, and the environment;
personality includes perceptions, attitudes, and emotions

 These behaviors and characteristics are consistent across a


broad range of situations and do not change easily

 A person is usually not consciously aware of his personality


PERSONALITY DISORDERS
 These are personality styles that are rigid and
maladaptive, causing significant personal
distress and impair social functioning.

 These are diagnosed when personality traits


become inflexible and maladaptive and
significantly interfere with how a person
functions in society or cause the person
emotional distress.
ETIOLOGICAL FACTORS
Genetic Factors
– Due to inherited traits

Temperamental Factors
– Due to emotional climate at home

Biological Factors
– Due to imbalance in hormones and neurotransmitters

Psychoanalytic Factors
– Due to fixation at certain psychosexual stage of development
DSM-IV-TR PERSONALITY
DISORDER CATEGORIES
The Diagnostic and Statistical Manual of Mental Disorders – Text Revision
of the American Psychiatric Association, in 2000, has made the following
classification of personality disorders:
– Cluster A: Individuals whose behavior appears odd or eccentric
(paranoid, schizoid, and schizotypal personality disorders)
– Cluster B: Individuals who appear dramatic, emotional, or erratic
(antisocial, borderline, histrionic, narcissistic)
– Cluster C: Individuals who appear anxious or fearful (avoidant,
dependent, obsessive-compulsive)
CLUSTER A
 Paranoid

 Schizoid

 Schizotypal
PARANOID PERSONALITY
DISORDER
 Symptoms / Characteristics
– Mistrust and suspicion of others
– Guarded or hypervigilant and generally appear alert to
any impending danger
– Restricted affect
– Mood is labile, quickly changing from quietly suspicious
to angry or hostile
– Responses become sarcastic for no apparent reason
– Uses the defense mechanism of projection, which is
blaming other people, institutions or events for their
own difficulties
PARANOID PERSONALITY
DISORDER
Nursing Interventions
Nursing Interventions
– The nurse must approach these clients in a formal,
business-like manner and refrain from chit-chat and
jokes (serious and straightforward approach)
 Involve the client in treatment planning
 Because these clients need to feel in control, it is important to
involve them in formulating plans of care.
 The nurse asks what the client would like to accomplish in
concrete terms.
 Clients are more likely to engage in the therapeutic process if
they believe they have something to gain
SCHIZOID PERSONALITY
DISORDER
 Symptoms / Characteristics
– Detached from social relationships
– They display a constricted affect and little, if any
emotion; aloof and indifferent, appearing emotionally
cold, uncaring,or unfeeling
– Report no leisure or pleasurable activities because they
rarely experience enjoyment
– Have a pervasive lack of desire for involvement with
others in all aspects of life
– They do not have or desire friends, rarely date or
marry and have little or no sexual contact
– Involve themselves more with things than people
SCHIZOID PERSONALITY
DISORDER
 Nursing Interventions
– Focus on improved functioning of
the client in the community
– Assist the client to find a case
manager – one who can help the
client obtain services and health
care, manage finances, etc.
SCHIZOTYPAL PERSONALITY
DISORDER
 Symptoms / Characteristics
– Has social and interpersonal deficits
marked by acute discomfort with
and reduced capacity for close
relationships
– Has cognitive or perceptual
distortions
– Possesses eccentric behavior
SCHIZOTYPAL PERSONALITY
DISORDER
 Symptoms / Characteristics
– Clothes are ill fitting, do not match, and may be
stained or dirty
– Cognitive distortions include ideas of reference
(events have special meaning for him), magical
thinking that he has special powers, unfounded
beliefs
– Interpersonal relationships are troublesome and
may have only one significant relationship with
a first degree relative
SCHIZOTYPAL PERSONALITY
DISORDER
 Nursing Interventions
– Development of self-care skills
– Nurse encourages client to establish
a daily routine for hygiene and
grooming
– Improve community functioning and
provide social skills training
CLUSTER B
 Antisocial

 Borderline

 Histrionic

 Narcissistic
ANTISOCIAL PERSONALITY
DISORDER
 Symptoms / Characteristics
– Violation of the rights of others
– Lack of remorse for behavior
– Shallow emotions
– Lying
– Rationalization of own behavior
– Poor judgment
– Impulsivity
– Irritability and aggressiveness
– Lack of insight
ANTISOCIAL PERSONALITY
DISORDER
 Symptoms / Characteristics
– Thrill-seeking behaviors
– Exploitation of people in
relationships
– Poor work history
– Consistent irresponsibility
ANTISOCIAL PERSONALITY
DISORDER
 Nursing Interventions
– Promote responsible behavior
 Limit setting
– State the limit in a matter-of-fact, non-
judgmental manner
– Identify consequences of exceeding the limit
– Identify expected or acceptable behavior
– Consistent adherence to rules and treatment
plan
ANTISOCIAL PERSONALITY
DISORDER
 Consistent limit setting in a matter-of-fact, non-
judgmental manner is crucial to success
 A client may approach the nurse flirtatiously and
attempt to gain personal information.
– The nurse would use limit-setting by saying, “It is not
acceptable for you to ask personal questions. If you
continue, I will terminate our interaction. We need to use
this time to work on solving your job-related problems.”
 The nurse should not become angry or respond to the
client harshly or punitively
ANTISOCIAL PERSONALITY
DISORDER
 Nursing Interventions
– Confrontation
 Point out problem behavior
 Keep client focused on self, behavior
rather than justifying it.
ANTISOCIAL PERSONALITY
DISORDER

– Confrontation is a technique designed to manage


manipulative or deceptive behavior.
– The nurse points out a client’s problematic behavior while
remaining neutral and matter-of-fact; he or she avoids
accusing the client.
– The nurse can also use confrontation to keep clients focused
on the topic and in the present
– The nurse can focus on the behavior itself rather than on
attempts by clients to justify it.
ANTISOCIAL PERSONALITY
DISORDER
 Example of use of confrontation:
– Nurse: “You’ve said you’re interested in learning to
manage angry outbursts, but you’ve missed the
last three group meetings.”
– Client: “Well, I can tell no one in the group likes
me. Why should I bother?”
– Nurse: “The group meetings are designed to help
you and the others, but you can’t work on issues if
you are not there.”
ANTISOCIAL PERSONALITY
DISORDER
 Nursing Interventions
– Helping clients solve problems and
control emotions
 Effective problem solving skills
– Identifying the problem
– Exploring alternative solutions and related
consequences
– Choosing and implementing an alternative
– Evaluating the results
 Decrease impulsivity
ANTISOCIAL PERSONALITY
DISORDER
 Nursing Interventions:
– Take time-out from a stressful situation
 Leaving the area and going to a neutral
place to regain internal control helps
clients to avid impulsive reactions and
angry outbursts, regain control of
emotions and engage in constructive
problem-solving
ANTISOCIAL PERSONALITY
DISORDER
 Nursing Interventions:
– Enhancing role performance
 Identify barriers to role fulfillment
 Decreasing and eliminating use of drugs
and alcohol
BORDERLINE PERSONALITY
DISORDER
 Symptoms / Characteristics
– Fear of abandonment, real or perceived
– Unstable and intense relationships
– Unstable self-image
– Impulsivity or recklessness
– Recurrent self-mutilating behavior or suicidal
threats or gestures
– Chronic feelings of emptiness and boredom
– Labile mood
BORDERLINE PERSONALITY
DISORDER
 Symptoms / Characteristics
– Irritability
– Polarized thinking about self and others
(“splitting”)
– Impaired judgment
– Lack of insight
– Transient psychotic symptoms such as
hallucinations demanding self-harm
BORDERLINE PERSONALITY
DISORDER
 Nursing Interventions:
– Promote client’s safety
 The nurse must always seriously consider suicidal ideation with
the presence of a plan, access to means for enacting the plan,
and self-harm behaviors and institute appropriate action
 The nurse can encourage clients to enter a no self-harm contract,
in which a client promises to not engage in self-harm and to
report to the nurse when he or she is losing control
– The nurse emphasizes that the no self-harm contract is not a
promise to the the nurse but is the client’s promise to himself
to be safe
BORDERLINE PERSONALITY
DISORDER
 Nursing Interventions:
– Helping clients to cope and control emotions
 Clients often react to situations with extreme emotional
responses without actually recognizing their feelings
 The nurse can help clients to identify their feelings and learn
to tolerate them without exaggerated responses such as
destruction of property or self-harm
– Keeping a journal often helps clients gain awareness of
feelings.
 The nurse can review journal entries as a basis for discussion
BORDERLINE PERSONALITY
DISORDER
Nursing Interventions:
– Helping clients to cope and control emotions
 Another aspect of emotional regulation is decreasing impulsivity and
learning to delay gratification
 When clients have an immediate desire or request, they must learn that it is
unreasonable to expect it to be granted without delay
 Clients can use distraction such as taking a walk or listening to music to
deal with the delay or they can think about ways to meet needs themselves
– Clients can write in their journals about their feelings when gratification
is delayed.
BORDERLINE PERSONALITY
DISORDER
 Nursing Interventions:
– Cognitive Restructuring Techniques
 These clients view everything, people
and situations, in extremes – totally
good or totally bad.
 Cognitive restructuring is a technique
useful in changing patterns of thinking
by helping clients to recognize negative
thoughts and feeling and to replace
them with positive patterns of thinking
BORDERLINE PERSONALITY
DISORDER
 Nursing Interventions:
– Cognitive Restructuring Techniques
 Thought-stopping is a technique to alter the process of
negative or self-critical thought patterns such as “I am
dumb, I am stupid, I can’t do anything right.”
– When the thoughts begin, the client may actually
say, “Stop!” in a loud voice to stop the negative
thoughts
– Later, a more subtle means such as forming a
visual image or a stop sign will be a cue to interrupt
the negative thoughts
BORDERLINE PERSONALITY
DISORDER
 Nursing Interventions:
– Cognitive Restructuring Techniques
 The client then learns to replace recurrent,
negative thoughts of worthlessness with
more positive thinking
 In positive self-talk, the client reframes
negative thoughts into positive ones: “I
made a mistake, but it is not the end of the
world. Next time, I will know what to do.”
BORDERLINE PERSONALITY
DISORDER
 Nursing Interventions:
– Cognitive Restructuring Techniques
 Decatastrophizing is a technique that involves
learning to assess situations realistically rather
than always assuming a catastrophe will happen
 The nurse asks, “So what is the worst thing that
could happen?” or “Can you think of any
exceptions to that?”
 In this way, the client must consider other points
of view and actually think about the situation
BORDERLINE PERSONALITY
DISORDER
 Nursing Interventions:
– Structure time
 Feelings of chronic boredom and emptiness, fear
of abandonment, and intolerance of being alone
are common problems that lead to self-harm
 Minimizing unstructured time by planning
activities can help clients to manage time alone
 Clients can make a written schedule that includes
appointments, shopping, reading the paper, or
going for a walk
HISTRIONIC PERSONALITY
DISORDER
 Symptoms / Characteristics
– With a pervasive pattern of excessive
emotionality and attention-seeking
– Clients are overly concerned with impressing
others with their appearance
– Dress and flirtatious behavior are not limited to
social situations or relationships but also occur
in occupational and professional settings
– Clients are extroverts
HISTRIONIC PERSONALITY
DISORDER
Symptoms / Characteristics
– Clients are emotionally expressive, gregarious, and effusive.
– They often exaggerate emotions inappropriately: “He is the
most wonderful doctor! He is so fantastic! He has changed
my life!” to describe a physician she has seen once or twice.
– In such a case, the client cannot specify why she views the
doctor so highly.
– Expressed emotions, although colorful, are insincere and
shallow
HISTRIONIC PERSONALITY
DISORDER
 Symptoms / Characteristics
– Clients experience rapid shifts in mood and emotions
and may be laughing uproaringly one moment and
sobbing the next.
– Thus their display of emotion may seem phony or
forced on observers
– Clients are uncomfortable when they are not the center
of attention and go to great lengths to gain that status
– Clients embarrass family members or friends by their
flamboyant hugging, kissing of someone newly
introduced, by sobbing over minor incidents
HISTRIONIC PERSONALITY
DISORDER
Nursing Interventions:
– The nurse gives clients feedback about their social interactions
with others including manner of dress and nonverbal behavior.
– Feedback should focus on appropriate alternatives not merely
criticism
– The nurse might say, “When you embrace and kiss other people
on first meeting them, they may interpret your behavior in a
sexual manner. It would be more acceptable to stand at least 2
feet away from them and to shake hands.”
HISTRIONIC PERSONALITY
DISORDER
 Nursing Interventions:
– Teaching social skills and role-playing those skills in a
safe, non-threatening environment can help clients to
gain confidence in their ability to interact socially
– The nurse must be specific in describing and modeling
social skills including establishing eye-contact, active
listening, and respecting personal space
– It also helps to outline topics of discussion
appropriately for casual acquaintances, closer friends
or family and the nurse only.
HISTRIONIC PERSONALITY
DISORDER
 Nursing Interventions:
– Clients may be quite sensitive to discussing self-esteem and
may respond with exaggerated emotions.
– It is important to explore personal strengths and assets and
give specific feedback about positive characteristics
– Encouraging clients to use assertive communication, such
as “I” statements, may promote self-esteem and help them
to get their needs met more appropriately.
NARCISSISTIC PERSONALITY
DISORDER
 Symptoms / Characteristics
– Has a pervasive pattern of grandiosity (in fantasy or behavior), need for
admiration, and lack of empathy for others
They believe that they are superior, special and they demand special attention

– They display an arrogant or haughty attitude
– They view their problems as the fault of others
Underlying self-esteem is almost always fragile and vulnerable

– They are hypersensitive to criticism and need constant attention, admiration
NARCISSISTIC PERSONALITY
DISORDER
 Nursing Interventions
– The nurse must use self-awareness skills to avoid the
anger and frustration that their behavior and attitude
can engender
– Clients may be rude and arrogant, unwilling to wait, and
harsh and critical of the nurse. The nurse must not
internalize such criticism or take it personally
– The goal is to gain cooperation of these clients with
other treatment as indicate
NARCISSISTIC PERSONALITY
DISORDER
 Nursing Interventions
– She sets limits to rude or verbally
abusive behavior and explains his or
her expectations from the clients.
CLUSTER C
 Avoidant

 Dependent

 Obsessive-Compulsive
AVOIDANT PERSONALITY
DISORDER
 Symptoms / Characteristics
– Has a pervasive pattern of social
discomfort and reticence, low self-esteem
and hypersensitivity to negative
evaluation
– They fear rejection, criticism, shame or
disapproval
– They remain aloof in their relationships
and feel inferior to others
AVOIDANT PERSONALITY
DISORDER

 Nursing Interventions:
– These clients require much support and
reassurance from the nurse
– The nurse can help them to explore
positive self-aspects, positive responses
from others, and possible reasons for self-
criticism
– Helping clients to practice self-
affirmations and positive self-talk may be
useful in promoting self esteem
AVOIDANT PERSONALITY
DISORDER
 Nursing Interventions:
– Other cognitive restructuring techniques such as
reframing and decatastrophizing can enhance self worth
– Positive reframing means turning negative messages
into positive messages
 Instead of thinking “I will fail”, the client thinks “I may fail but I
will keep trying until I succeed.”
– Decatastrophizing involves the nurse’s use of questions
to realistically appraise the situation
 “What is the worst thing that could happen? Is that likely?
Could you survive that? Is that as bad as you imagine?”
 The client uses thought-stopping and distraction techniques to
jolt himself out of negative thoughts
DEPENDENT PERSONALITY
DISORDER
Symptoms / Characteristics
– Has a pervasive and excessive need to be taken care of which leads
to submissive and clinging behavior and fears of separation
– Has incessant demands for attention from others, lacks self-
confidence, needs excessive reassurance and advice
– They are pre-occupied with excessive fears of being left alone to
care for themselves
– They perceive themselves as unable to function outside a
relationship with someone who can tell them what to do
DEPENDENT PERSONALITY
DISORDER
Nursing Interventions:
– The nurse must help the clients to express feelings of grief and
loss over the end of a relationship while fostering autonomy
and self reliance
– Helping clients to identify their strengths and needs is more
helpful than encouraging the overwhelming belief that the
client can’t do anything alone
– Clients may need assistance in daily functioning like planning
menus, shopping, budgeting money, etc.
– The nurse teaches problem-solving and decision-making skills
OBSESSIVE-COMPULSIVE
PERSONALITY DISORDER
 Symptoms / Characteristics
– Has a pervasive pattern of preoccupation with
perfectionism, mental and interpersonal control and
orderliness at the expense of flexibility, openness
and efficiency
– They are formal, serious and answer questions with
precision and much detail
– Clients check and recheck the details of any project
or activity
– They have problems with judgment and decision-
making – specifically actually reaching a decision
OBSESSIVE-COMPULSIVE
PERSONALITY DISORDER
 Symptoms / Characteristics
– They have low self-esteem and are always harsh,
critical, and judgmental of themselves; they believe
they “could have done better” regardless of how
well the job has been done
– They have difficulty in relationships, few friends,
and little social life
– They cannot tolerate lack of control
– They have difficulty working collaboratively,
preferring to “do it myself” so it is done correctly
OBSESSIVE-COMPULSIVE
PERSONALITY DISORDER
 Nursing Interventions:
– Nurses may be able to help clients to view
decision-making and completion of projects from a
different perspective
 Rather than striving for the goal of perfection, clients
can set a goal of completing the project or making the
decision by a specified deadline
 Helping clients to accept or to tolerate less-than-perfect
work or decisions made on time may alleviate some
difficulties at work or at home
OBSESSIVE-COMPULSIVE
PERSONALITY DISORDER
 Nursing Interventions:
– Use of cognitive restructuring techniques
like decatastrophizing may challenge
some rigid and inflexible thinking
– Encouraging clients to take risks, such as
letting someone else plan a family
activity, may improve relationships
– Practicing negotiation with family or
friends may help them to relinquish some
of their need for control
OTHER RELATED DISORDERS
 Depressive Personality Disorder

 Passive Aggressive Personality


Disorder
DEPRESSIVE PERSONALITY
DISORDER
 Symptoms / Characteristics
– Has a pervasive pattern of depressive cognitions and
behaviors in various contexts but is much less severe
than major depression
– They have a sad, gloomy, dejected affect
– They express unhappiness, cheerlessness,
hopelessness regardless of the situation
– They repress or not express anger
– Thinking is negative, pessimism for them is being
realistic
– They blame themselves or others unjustly for
situations beyond anyone’s control
DEPRESSIVE PERSONALITY
DISORDER
 Symptoms / Characteristics
– Self-esteem is quite low with feelings
of worthlessness and inadequacy
even when clients have been
successful.
– Self-criticism often leads to punitive
behavior and feelings of guilt or
remorse
DEPRESSIVE PERSONALITY
DISORDER
 Nursing Interventions
– Assess for the possibility of self-harm. If the
client expresses suicidal ideation or has urges
for self-injury, the nurse must provide safety
precautions
– Cognitive restructuring techniques such as
thought-stopping or positive self-talk can
enhance self-esteem
– Giving compliments promotes receiving
compliments, which further enhances positive
feelings
DEPRESSIVE PERSONALITY
DISORDER
Nursing Interventions
– Giving factual feedback, rather than general praise, reinforces
attempts to interact with others and gives specific, positive
information about improved behaviors.
– “Oh, you are doing so well today” is a general praise that does
not identify specific positive behaviors
– “You have talked to Mrs. Jones for 10 minutes even though it was
difficult. I know that took a lot of effort.” is specific praise that
gives the client a clear message about what specific behavior was
effective and positive
PASSIVE AGGRESSIVE
PERSONALITY DISORDER
Symptoms / Characteristics
– Has a negative attitude and pervasive pattern of passive
resistance to demands for adequate social and occupational
performance
– Loves to procrastinate and expresses anger through passivity
– The negative attitude influences thought content: clients
perceive and anticipate difficulties and disappointments
where none exists
– They believe nothing good ever lasts
– Ability to make decisions or judgments is impaired
PASSIVE AGGRESSIVE
PERSONALITY DISORDER
 Symptoms / Characteristics
– They habitually resent, oppose, and resist
demands to function at a level expected by others.
– This opposition occurs most frequently in work
situations but can also be evident in social
functioning
– They express such resistance through
procrastination, forgetfulness, stubbornness, and
intentional inefficiency especially in response to
tasks assigned by authority figures.
PASSIVE AGGRESSIVE
PERSONALITY DISORDER
 Nursing Interventions:
– The nurse can help clients examine the relationship between
feelings and subsequent actions
– For example, a client may intend to complete a project at
work but then procrastinates, forgets or becomes ill and
misses the deadline. Or the client may intend to participate
in a family outing but becomes ill, forgets, or has an
“emergency” when it is time
– By focusing on the behavior, the nurse can help the client to
see what is so annoying or troubling to others
PASSIVE AGGRESSIVE
PERSONALITY DISORDER
 Nursing Interventions:
– The nurse can also help the client to
learn appropriate ways to express
feelings directly especially negative
feelings such as anger
– Methods such as having the client write
about the feelings or role-play are
effective.
POINTS TO CONSIDER WHEN
WORKING WITH CLIENTS WITH
PERSONALITY DISORDERS
 Talking to colleagues about feelings of frustration will help you
to deal with your emotional responses so you can be more
effective with clients
 Clear, frequent communication with other health care
providers can help to diminish the client’s manipulation
 Do not take undue flattery or harsh criticism personally; it is a
result of the client’s personality disorder
 Set realistic goals and remember that behavior changes in
clients with personality disorders take a long time. Progress
can be very slow
SAMPLE BOARD QUESTION
NO.1
 The nurse is caring for a patient who is
sarcastic and critical and often expresses
feelings that are the opposite of what he is
actually feeling. This patient is exhibiting
which type of behavior?

A) Passive
B) Aggressive
C) Passive - Aggressive
D) Assertive
ANSWER
 Letter C

 Rationale: Patients with passive-


aggressive personality disorder loves
to procrastinate, expresses anger
through passivity
SAMPLE BOARD QUESTION
NO.2
 The nurse is caring for a patient diagnosed with
paranoid personality disorder in an acute care facility.
Which intervention would the nurse use to control the
patient’s suspiciousness?

A) Keeping messages clear and consistent, while


avoiding deception
B) Providing pharmacologic therapy
C) Providing social interactions with others on the unit
D) Attending to the basic daily needs of the patient on
a consistent basis
ANSWER
 Letter A

 Rationale: Consistency should be


maintained when dealing with patients
with personality disorder.
SAMPLE BOARD QUESTION
NO.3
 In caring for a patient who has antisocial
personality disorder. Which of the following
assessment findings should the nurse expect?

A) Manipulative behavior and inflated feelings


of self-worth
B) Manipulative behavior and inability to
tolerate frustration
C) Suicidal ideation and starvation
D) patterns of bulimia and starvation
ANSWER
 Letter B

 Rationale: Antisocial patients are


manipulative and have low tolerance
to frustration.
SAMPLE BOARD QUESTION
NO.4
 In caring for a patient with borderline personality
disorder, which interventions should the nurse
perform?

A) Setting limits on manipulative behavior


B) Allowing the patients to set time limits
C) Using restraints judiciously
D) Encouraging acting out behavior
ANSWER
 Letter A

 Rationale: Setting limits prevents the


patient from manipulating the nurse.
SAMPLE BOARD QUESTION
NO.5
 The nurse is performing an admission interview with the patient
who exhibits signs of narcissistic personality disorder. Which
behavior patters is most characteristic of narcissistic
personality disorder?

A) The patient has no close friends


B) The patient is reticent in social situations
C) The patient has grandiose sense of self-importance
D) The patient avoids work or school activities
ANSWER
 Letter C

 Rationale: Patients who are narcissistic


feel that they are special and they
demand special attention from others.
SAMPLE BOARD QUESTION
NO.6
 In paranoid disorder, the part of the
personality that is weak is called?

A) Id
B) Ego
C) Superego
D) “Not me”
ANSWER
 Letter B

 Rationale: The ego acts as the


integrator of the personality
SAMPLE BOARD QUESTION
NO.7
 A patient says he must wash his hands from 9:00 AM to 9:45
AM each day and therefore cannot attend 9:00 AM group
therapy sessions. Which concept does the nursing staff need to
keep in mind in planning nursing interventions for this patient?

A) Fears and tensions are often expressed in disguised form


through symbolic processes
B) Unmet needs are discharged through ritualistic behavior
C) Ritualistic behavior makes others uncomfortable
D) Depression underlies ritualistic behavior
ANSWER
 Letter A

 Rationale: The rituals performed by the


obsessive-compulsive patient is their
way of expressing fears and tensions.
SAMPLE BOARD QUESTION
NO.8
 In interacting with a patient with an
antisocial personality disorder, what
would be the most therapeutic approach?

A) Reinforce the patient’s self concept


B) Gratify the patient’s inner needs
C) Give the patient the opportunity to test
reality
D) Provide external controls
ANSWER
 Letter D

 Rationale: Providing external controls


enables the nurse to set limits on the
patient’s behavior
SAMPLE BOARD QUESTION
 A NO.9
patient uses repetitive hand washing. To help the
patient use less maladaptive means of handling stress,
the nurse could?

A) Provide varied activities on the unit, as change in


routine can break this ritualistic pattern
B) Give the patient ward assignment that do not require
perfection
C) Tell the patient changes in routine at the last minute to
avoid build up of anxiety
D) Provide an activity in which positive accomplishments
can occur so the patient can gain recognition
ANSWER
 Letter D

 Rationale: Providing positive


reinforcement for the desired behavior
can facilitate behavioral change.
SAMPLE BOARD QUESTION
NO.10
 Which is an example of limit setting as an effective nursing
intervention in ritualistic hand washing behavior?

A) “I don’t want you to wash your hands so often anymore.”


B) “If you continue to wash your hands so frequently, the skin
on your hands will break down.”
C) “You may wash your hands before the group therapy
meeting if you wish, but not during the group therapy”
D) “The doctor wrote an order that you are to stop washing
your hands so often.”
ANSWER
 Letter C

 Rationale: Allowing the obsessive-


compulsive patient to perform his
rituals decreases the patient’s anxiety.
AUTISM
AUTISM
 Is a disorder characterized by impairment in
communication skills, or the presence of
stereotyped behavior, interests and activities with
associated impairment in social interactions

 More common among boys

 Usually diagnosed at age 2

 It is treatable but not curable


MAIN PROBLEM IN AUTISM
 Impaired interpersonal functioning
MOST ACCEPTABLE CAUSE OF
AUTISM
 Biological Factors

– Brain anoxia

– Intake of drugs
MOST COMMON SIGNS AND
SYMPTOMS OF AUTISM
 Resist normal teaching method
 Silly laughing or giggling
 Echolalia
 Acts as deaf
 No fear of danger
 Insensitive to pain
 Crying tantrums
 Loves to spin objects
MOST COMMON SIGNS AND
SYMPTOMS OF AUTISM
 Resists change in the routine
 Not cuddly
 Sustained odd play
 Difficulty interacting with others
 No eye contact
 Wants blocks and not balls
 Points to anything
 Attachment to inanimate objects
COMMON PROBLEMS AND
APPROPRIATE MANAGEMENT
 Tantrums
– Involves head-banging
– Place a helmet on the head

 Communication
– All vowels
– Use of short sentences when talking to the child

 Routines
– Provide consistency
PRIORITY NURSING DIAGNOSIS
 Risk for injury
SAMPLE BOARD QUESTION
NO.1
 Autism can usually be diagnosed when
the child is about?

A) 2 years of age
B) 6 years of age
C) 6 months of age
D) 1 to 3 months of age
ANSWER
 Letter A

 Rationale: Autism is usually diagnosed


during the toddler stage
SAMPLE BOARD QUESTION
NO.2
 The treatment of choice for an autistic
child probably will include?

A) Psychoanalysis
B) Behavior modification
C) Group therapy
D) Play therapy
ANSWER
 Letter B

 Rationale: Behavior modification


enables the nurse to modify the child’s
maladaptive behavior
SAMPLE BOARD QUESTION
NO.3
 When interacting with patients who have autistic
thinking and speaking patterns, what is likely to pose
the greatest difficulty for the nurse?

A) Showing acceptance for their incomprehensible acts


and verbalization
B) Ignoring their bizarre behavior
C) Speaking in a way that patients can understand
D) Determining which of the patients needs are being
met by their autistic expression.
ANSWER
 Letter D

 Rationale: Interacting with patients with


autistic thinking requires thorough analysis
of their speech patterns, the meanings of
their expressions and the relationship of
these to their covert needs. This situation
usually poses great difficulty on the part of
the nurse.
SAMPLE BOARD QUESTION
NO.4
 In assessing the behavior of an autistic child, the
nurse notes that a symptom that characteristically
differentiates an autistic child from one with down
syndrome and that is?

A) Retardation of activity
B) Short attention span
C) Difficulty in responding to a nurturing relationship
D) Poor academic performance
ANSWER
 Letter C

 Rationale: Autistic children are usually


withdrawn
SAMPLE BOARD QUESTION
NO.5
 Primary treatment goals to facilitate
recovery of an autistic child should
include all of the following, EXCEPT?

A) Developing self-confidence
B) Accepting healthy nurturance
C) Maintaining contact with reality
D) Encouraging the child to play with a
ball
ANSWER
 Letter D

 Rationale: Autistic children want to


play with blocks but not with balls.
MENTAL RETARDATION
MENTAL RETARDATION
 The essential feature of mental retardation is below-
average functioning (IQ less than 70) accompanied by
significant limitations in areas of adaptive functioning
such as communication skills, self care, home living,
social or interpersonal skills, use of community
resources, self-direction, academic skills, work, leisure,
and health and safety manifested before the age of 18.

 It is not a mental illness

 Main problem is inadequate mental functioning


LEVELS OF MENTAL
RETARDATION
LEVEL OF MENTAL INTELLIGENCE WHAT CAN BE
RETARDATION QUOTIENT (IQ) DONE

MILD / MORON 50 / 55 TO 70 EDUCABLE

MODERATE / 35 / 40 TO 50 / 55 TRAINABLE
IMBECILE
SEVERE / IDIOT 20 / 25 TO 35 / 40 NEEDS CLOSE
SUPERVISION

PROFOUND BELOW 20 / 25 NEEDS


CUSTODIAL CARE
BASIS OF DIAGNOSIS OF
MENTAL RETARDATION
 The Intelligence Quotient should not be the only criterion
used in making a diagnosis of Mental Retardation.

 It should serve only to help in making a clinical judgment


of the patient’s adaptive behavioral capacity

 This judgment should also be based on an evaluation of


the patient’s developmental history and present
functioning, social and emotional maturity
CAUSES OF MENTAL
RETARDATION
 Congenital numerical deficiency or abnormal
arrangement of brain cells
 Birth injuries due to pelvic disproportion,
premature births or forceps delivery
 Rh blood-factor incompatibility between mother
and child
 Infectious diseases, such as German measles of
the mother during the first three months of
pregnancy
 Infectious diseases during childhood, such as
meningitis and encephalitis
CAUSES OF MENTAL
RETARDATION
 Brain injuries occurring during childhood
 Endocrine deficiencies, such as thyroid deficiency,
known to be the cause of cretinism
 Exposure to environmental deprivation, with poor
housing and poor economic and social conditions.
 Familial or hereditary causes
 Inborn errors of metabolism, such as the inability to
metabolize proteins, carbohydrates or fats.
 Genetic defects, such as abnormalities in genes and
chromosomes
PREVENTION OF MENTAL
RETARDATION
 Adequate medical care during the prenatal period
and birth
 Early detection of various disorders
 Immunization against communicable diseases
 Educating parents to understand the important
concepts of growth and development
 Educating family members and society to accept
the mentally retarded
 Better housing and living conditions
 Improved nutrition through dietary requirement
instruction and meal planning
PREVENTION OF MENTAL
RETARDATION
 Intellectual stimulation through
socialization, recreation, play and
learning activities for affected
individuals
 Genetic counseling
NURSING CARE FOR MENTALLY
RETARDED PATIENTS
 Help parents accept a diagnosis of
mental retardation

 Consider the developmental or


functional age and not the
chronological age
NURSING CARE FOR MENTALLY
RETARDED PATIENTS
 Teach parents that they should:

– Protect the child from danger

– Make the child as independent as his condition


will permit

– Teach the child small social graces and manners


which are a tremendous factor in helping to be
accepted by others
NURSING CARE FOR MENTALLY
RETARDED PATIENTS
 Teach parents that they should:

– Teach the child to refrain from holding their mouths


open as this gives them a dull appearance

– Select attractive, well-fitted clothing, hair style and


good hygiene practices

– Eliminate the child’s undesirable social traits, such as


touching their noses and ears, scratching, etc.
NURSING CARE FOR MENTALLY
RETARDED PATIENTS
 Teach parents that they should:

– Teach the child only one thing at a time

– Demonstrate what they teach, whenever possible

– Use pictures, since these are valuable visual aids


NURSING CARE FOR MENTALLY
RETARDED PATIENTS
 Teach parents that they should:

– Start teaching the child simple things, gradually


progressing to more complex learning experiences

– Remember that patience and repetition are


necessary virtues

– Avoid prolonged teaching sessions since retarded


individuals easily become fatigued
NURSING CARE FOR MENTALLY
RETARDED PATIENTS
 Teach parents that they should:

– Refrain from scolding because it blocks learning and instills fear

– Give compliments as a motivating force

– Not show fear themselves as this emotion will be transferred to


the child

– Protect the child from teasing and taunting


NURSING CARE FOR MENTALLY
RETARDED PATIENTS
 Teach parents that they should:

– Recognize a temper tantrum as a child’s attempt to meet some


underlying emotional need such as attention, affection and
security or as the expression of the child’s dislike for activity

– Recognize that these children have a tendency to express


jealousy

– Know that play activities are enjoyed and may be a teaching


experience.
PRINCIPLES OF NURSING CARE
FOR MENTALLY RETARDED
PATIENTS
 Repetition

 Role Modeling

 Restructuring the Environment


FOCUS OF EDUCATION FOR
MENTALLY RETARDED PATIENTS
 Reading

 Writing

 Basic Arithmetic
SAMPLE BOARD QUESTION
NO.1
 A child scores between 55 and 68 on a
standardized intelligent quotient (IQ)
assessment test. The nurse is aware that this
degree of intellectual impairment would be
considered?

A) Mild
B) Severe
C) Profound
D) Moderate
ANSWER
 Letter A

 Rationale: Mild retardation means an


I.Q. of 50 – 55 to approximately 70
SAMPLE BOARD QUESTION
NO.2
 When a child is diagnosed as being moderately
retarded, it would be most helpful for the nurse to
suggest that the parents?

A) Offer simple, repetitive tasks


B) Concentrate on teaching, competitive situations
C) Offer challenging, competitive situations
D) Provide complete directions at the beginning of the
task to be carried out
ANSWER
 Letter A

 Rationale: Simple and repetitive tasks


facilitate learning
SAMPLE BOARD QUESTION
NO.3
 Which of the following measures is of primary importance for
the parents with a young mentally retarded child at home?

A) Limit the amount of environmental stimulation to which the


child is exposed
B) Have the same parent teach the child new skills
C) Teach the child socially acceptable behaviors
D) Maintain a constant routine for daily activities
ANSWER
 Letter D

 Rationale: Consistency facilitates


adjustment of the child.
SAMPLE BOARD QUESTION
NO.4
 A six year-old girl is recently diagnosed as mildly retarded.
An important aspect in nursing care of a mildly mentally
retarded child is to?

A) Encourage her parents to concentrate on the child rather


than on the condition at this time
B) Delay extensive diagnostic studies until the child is older
C) Modify the child’s environment to promote independence
and impulse control
D) Provide one-to-one tutorial education and minimize peer
interaction
ANSWER
 Letter C

 Rationale: Restructuring the child’s


environment prevents injury and
promotes independence
SAMPLE BOARD QUESTION
NO.5
 Nursing intervention that focus on the
cognitively impaired child most emphasize
providing the child and family with support
and education that are directed toward?

A) Finding a cure
B) Optimal development
C) Identifying the problem
D) Curing major symptoms
ANSWER
 Letter B

 Rationale: The primary goal of care for


the cognitively impaired child is to
promote optimal development.
ATTENTION DEFICIT
HYPERACTIVITY DISORDER
(ADHD)
ATTENTION DEFICIT
HYPERACTIVITY DISORDER
(ADHD)
 A disorder characterized by:

– Inattentiveness
– Over-activity
– Impulsiveness

 A common disorder among boys

 Occurs before the age of 7


MAIN PROBLEMS IN ADHD
 Inattention

 Hyperactivity

 Impulsivity
COMMON ETIOLOGICAL
FACTORS
 Neurologic impairment

 Pre-natal trauma

 Early malnutrition

 Frontal lobe hypoperfusion

 Use of drugs by the mother during pregnancy


SIGNS AND SYMPTOMS OF
ADHD
 Subdivided into:

– Inattentive behaviors

– Hyperactive and Impulsive behaviors


SIGNS AND SYMPTOMS OF
ADHD - INATTENTIVE
BEHAVIORS
 Misses details
 Makes careless mistakes
 Has difficulty sustaining attention
 Does not seem to listen
 Does not follow-through on chores or homework
 Has difficulty with organization
 Avoids tasks requiring mental effort
 Often loses necessary things
 Is easily distracted by other stimuli
 Is often forgetful in daily activities
SIGNS AND SYMPTOMS OF
ADHD - HYPERACTIVE /
IMPULSIVE BEHAVIOURS
 Fidgets
 Often leaves a seat, (e.g., during a meal)
 Runs or climbs excessively
 Can not play quietly
 Is always on the go; driven
 Talks excessively
 Blurts out answers
 Interrupts
 Can’t wait for turn
 Is intrusive with siblings and playmates
PSYCHOPHARMACOLOGY FOR
ADHD
 Stimulant Drugs

– Methylphenidate (Ritalin) – drug of


choice

– Dextroamphetamine (Dexedrine)

– Amphetamine (Adderall)
STIMULANT DRUGS USED TO
TREAT ADHD
GENERIC (TRADE) DOSAGE (mg/day) NURSING
NAME CONSIDERATIONS

Methylphenidate 10 – 60 in 3 – 4Monitor for appetite


(Ritalin) divided doses suppression and growth
delays
Give regular tablets after
meals
Alert client that full drug effect
takes 2 days

Dextroamphetamine 5 – 40 in 2 – 3 dividedMonitor for insomnia


(Dexedrine) doses Give last dose in early
afternoon
Monitor for appetite
suppression
Alert client that full drug effect
takes 2 days
NURSING CARE FOR ADHD
 Ensuring the client’s safety and that of others

– Stop unsafe behavior (priority nursing


diagnosis is RISK FOR INJURY)

– Provide close supervision

– Give clear directions about acceptable and


unacceptable behavior
NURSING CARE FOR ADHD
 Improved role performance

– Give positive feedback for meeting


expectations

– Manage the environment (e.g., provide


a quiet place free of distractions for
task completion)
NURSING CARE FOR ADHD
 Simplifying instructions and directions

– Get the child’s full attention

– Break complex tasks into small steps

– Allow breaks
NURSING CARE FOR ADHD
 Structured daily routine

– Establish a daily schedule

– Minimize changes
NURSING CARE FOR ADHD
 Client / Family education and support

– Listen to parents’ feelings and


frustrations
SAMPLE BOARD QUESTION
NO.1
 A 7 year-old child has attention deficit
hyperactivity disorder. The child is most likely to
exhibit which of the following?

A) Restlessness, decreased attention span and


distractability
B) Hyperactivity, somatic complaints, and
distractability
C) Impulsiveness, anhedonia and shyness
D) Poor concentration, decreased attention span
and somatic complaints
ANSWER
 Letter A

 Rationale: ADHD is characterized by


Inattention, Hyperactivity and
Impulsivity
SAMPLE BOARD QUESTION
NO.2
 An 8 year-old boy has recently been diagnosed with
attention deficit hyperactivity disorder by his
pediatrician. He and his parents come to the pediatric
clinic together. Which of the following behaviors would
the nurse be most likely to observe from the child?

A) Lethargy
B) Preoccupation with body parts
C) Very poor skills
D) Short attention span
ANSWER
 Letter D

 Rationale: ADHD is characterized by


Inattention, Hyperactivity and
Impulsivity
SAMPLE BOARD QUESTION
NO.3
 In providing care to a school-age child with attention-deficit
hyperactivity disorder, the most effective intervention
would be to?

A) Increase environmental stimulation and peer interaction


B) Administer drug therapy (i.e., methyphenidate or Ritalin)
and use behavior modification
C) Provide parental education and diet therapy
D) Encourage delayed achievement of normal
developmental tasks
ANSWER
 Letter B

 Rationale: Ritalin is the drug of choice


for ADHD because it increases
attention span
SAMPLE BOARD QUESTION
NO.4
 Which nursing diagnosis is most applicable for a child
with ADHD?

A) Ineffective family coping related to ineffective


parenting
B) Potential for injury related to impulsivity
C) Impaired verbal communication related to mutism
D) Altered thought processes related to impaired reality
ANSWER
 Letter B

 Rationale: The priority needs of a child


with ADHD are safety and provision of
adequate nutrition
SAMPLE BOARD QUESTION
NO.5
 Which medication side effects is
typically the greatest concern of
parents with children with ADHD?

A) Dizziness
B) Headache
C) Increased appetite
D) Delayed physical growth
ANSWER
 Letter D

 Rationale: Ritalin, the drug of choice


for ADHD causes growth suppression,
insomnia and suppression of appetite.
EATING DISORDERS
EATING DISORDERS
 For many, eating symbolizes parental nurturing –
the love and care that are the prototype of and a
basis for all future intimate relationships

 For some, however, eating creates anxiety


because of its association with unsatisfactory and
unpleasant parent-child interactions.

 Clearly, food and eating have greater individual


and cultural meaning and importance than
merely an activity undertaken to sustain life.
ANOREXIA NERVOSA
ANOREXIA NERVOSA
 This is a life-threatening eating disorder characterized by:
– the client’s refusal or, inability to maintain a minimally
normal body weight
– intense fear of gaining weight or becoming fat
– significantly disturbed perception of the shape or size of
the body
– steadfast inability or refusal to acknowledge the
seriousness of the problem or even that one exists
ANOREXIA NERVOSA
 Clients with anorexia nervosa have:
– A body weight that is 85% less than
expected for their age and height
– Experienced amenorrhea for at
least three consecutive cycles
– A preoccupation with food and food-
related activities
SIGNS AND SYMPTOMS OF
ANOREXIA NERVOSA
 Fear of gaining weight or becoming fat even
when severely underweight (Main Sign)

 Body image disturbance

 Amenorrhea

 Depressive symptoms such as depressed mood,


social withdrawal, irritability, and insomnia
SIGNS AND SYMPTOMS OF
ANOREXIA NERVOSA
 Preoccupation with thoughts of food

 Feelings of ineffectiveness

 Inflexible thinking

 Strong need to control the environment


SIGNS AND SYMPTOMS OF
ANOREXIA NERVOSA
 Limited spontaneity and overly restrained
emotional expression

 Complaints of constipation and abdominal pain

 Cold intolerance

 Lethargy
SIGNS AND SYMPTOMS OF
ANOREXIA NERVOSA
 Emaciation

 Hypotension, hypothermia and bradycardia

 Hypertrophy of salivary glands


SIGNS AND SYMPTOMS OF
ANOREXIA NERVOSA
 Elevated BUN

 Electrolyte imbalances

 Leukopenia and mild anemia

 Elevated liver function studies


BULIMIA NERVOSA
 Is an eating disorder characterized by:
– Recurrent episodes (at least twice a
week for 3 months) of binge eating
(consuming a large amount of food,
far greater than most people eat at a
time, in a discrete period of usually 2
hours or less)
BULIMIA NERVOSA
 Is an eating disorder characterized by:
– Binge eating followed by inappropriate
compensatory behaviors to avoid weight gain such
as:
 Purging (compensatory behavior designed to eliminate
food by means of self-induced vomiting, misuse of
laxatives, enemas, and diuretics)
 Fasting
 Excessively exercising
SIGNS AND SYMPTOMS OF
BULIMIA NERVOSA
 Recurrent episodes of binge eating

 Compensatory behavior such as self-induced


vomiting, misuse of laxatives, diuretics, enema or
other medications, or excessive exercise

 Self-evaluation overly influenced by body shape


and weight

 Usually within normal weight range, possible


underweight or overweight
SIGNS AND SYMPTOMS OF
BULIMIA NERVOSA
 Restriction of total calorie consumption between binges,
selecting low-calorie foods while avoiding foods perceived to
be fattening are likely to trigger a binge

 Depressive and anxiety symptoms

 Possible substance use involving alcohol or stimulants

 Loss of dental enamel


SIGNS AND SYMPTOMS OF
BULIMIA NERVOSA
 Chipped, ragged, or moth eaten appearance of
the teeth

 Increased dental caries

 Menstrual irregularities

 Dependence on laxatives

 Esophageal tears
SIGNS AND SYMPTOMS OF
BULIMIA NERVOSA
 Fluid and electrolyte abnormalities

 Metabolic alkalosis (from vomiting) or


metabolic acidosis (from diarrhea)

 Mildly elevated serum amylase levels


RISK FACTORS FOR EATING DISORDERS
DISORDER BIOLOGIC DEVELOPMENTAL FAMILY RISK SOCIO-
RISK RISK FACTORS FACTORS CULTURAL
FACTORS RISK
FACTORS

Anorexia Obesity; dieting Issues of developing Family lacks Cultural ideal of


Nervosa at an early age autonomy and emotional being thin;
having control over support; media focus on
self and parental beauty,
environment; maltreatment; thinness,
developing a unique cannot deal with fitness,
identity; conflict preoccupation
dissatisfaction with with achieving
body image the ideal body

Bulimia Obesity; early Self-perceptions of Chaotic family Same with


Nervosa dieting; being overweight, with loose above, weight-
possible fat, unattractive, and boundaries; related teasing
serotonin and undesirable; parental
norepinephrine dissatisfaction with maltreatment
COMMON NURSING DIAGNOSES
RELATED TO EATING
DISORDERS
 Body image disturbance

 Self-esteem disturbance

 Ineffective individual coping


NURSING INTERVENTIONS FOR
ANOREXIA NERVOSA
Promote improved nutrition – assume a calm, matter-of-fact attitude
and positive expectation of the client, meeting minimal nutritional
goals is non-negotiable.
– Tube or IV feedings
– Weigh daily, record intake and output, observe client during
meals and bathroom activities
– Avoid discussing food, recipes, restaurants and eating
– Provide a pleasant meal time environment and adopt realistic
expectations of how much the client will eat
NURSING INTERVENTIONS FOR
ANOREXIA NERVOSA
 Promote improved nutrition
– Frequent, small meals are more acceptable
– Set time limit of about one-half hour to forestall
mealtime “marathon” (protracted meals during
which the client eats little)
– Collaborate with a dietitian
– Acknowledge and recognize efforts of clients who
meet weight gain goals but avoid praise or flattery
– Behavior modification therapy can help
NURSING INTERVENTIONS FOR
ANOREXIA NERVOSA
Promote effective individual coping
– The best way is to involve the clients in their own treatment
planning
– Give clients the opportunity to practice problem solving.
Demonstrate positive belief in client’s abilities to regain
healthy functioning and a willingness to tolerate “mistakes”
– Set firm, clear limits to provide the secure environment
needed to learn more effective coping behaviors
– Explore client’s feelings about their families, their roles in the
family and their autonomy within the family system
NURSING INTERVENTIONS FOR
BULIMIA NERVOSA
 Promoting effective coping with anxiety
– help them recognize events that
create anxiety and to avoid binging and
purging in response to anxiety

 Promoting improved fluid volume

 Promoting effective individual coping


NURSING INTERVENTIONS FOR
BULIMIA NERVOSA
 Promoting effective individual coping

– It is important for clients to identify situations or


patterns of events that precede episodes of binging
and purging.

– They need to learn effective ways of expressing


feelings and assertive techniques to diminish guilt
interactions in the future

 Promoting effective family coping


SAMPLE BOARD QUESTION
NO.1
 The nurse is monitoring a patient diagnosed with anorexia
nervosa. In addition to monitoring the patient’s eating, the
nurse should do which of the following after meals?

A) Encourage the patient to go for a walk to get some exercise


B) Prevent the patient from using the bathroom for 2 hours after
eating
C) Tell the patient to lie down for 2 hours after eating
D) Instruct the patient to get plenty of exercise
ANSWER
 Letter B

 Rationale: Preventing the patient from


using the bathroom for 2 hours after
eating, prevents the patient from
inducing vomiting
SAMPLE BOARD QUESTION
NO.2
 The nurse is caring for a patient who has
bulimia. What treatment option is most
effective?

A) Antidepressant
B) Cognitive behavior therapy
C) Anti-depressants and cognitive-behavior
therapy
D) Total parenteral nutrition and
antidepressants
ANSWER
 Letter C

 Rationale: Combination of somatic and


behavioral treatment modalities
facilitates treatment of the disorder
SAMPLE BOARD QUESTION
NO.3
 The nurse is caring for a bulimic patient and an
anorexic patient. What cognitive characteristics
would be similar for both of these patients?

A) Perfectionism and pre-occupation with food


B) Relaxed personality, but pre-occupied with food
C) No similarities
D) Pre-occupation with exercise
ANSWER
 Letter A

 Rationale: Patients with eating


disorders are usually high achievers,
perfectionists and pre-occupied with
food.
SAMPLE BOARD QUESTION
NO.4
 Psychologically, bulimic differs from an anorexic
patient through awareness that her behavior is?

A) Acceptable
B) Abnormal
C) Easy to control
D) Physically dangerous
ANSWER
 Letter B

 Rationale: Bulimic patients are usually


aware of their abnormal behavior
SAMPLE BOARD QUESTION
NO.5
 The primary objective in the treatment of
anorexia is to?

A) Enable the patient to eat and gain


weight
B) Decrease anxiety to stimulate appetite
C) Help patient to select food she likes
D) Cure her anorexia condition and eat
ANSWER
 Letter A

 Rationale: Anorexic patients usually


suppress their appetite, which makes it
difficult for the nurse to convince them
to eat.
SEXUAL DISORDERS
GENDER IDENTITY
 This is an individual’s personal or
private sense of identity as female or
male

 It develops from an interaction of


biology, identity imposed by others
and self-identity
GENDER ROLES
 Refers to learning and performing
socially accepted sex behaviors, i.e.,
taking on a feminine or masculine role

 Proponents of andogeny (flexibility in


gender roles), however, view most
characteristics and behaviors as
human qualities that should not be
limited to a specific gender
TRANSSEXUALISM
 Is a gender identity disorder in which a
person has consistently strong feelings
of being trapped in a body of a wrong
sex.
PARAPHILIAS
 A group of psychosexual disorders characterized by
unconventional sexual behaviors

 These are abnormal expressions of sexuality

 They are not, by definition, pathologic

 They only become so when severe, insistent,


coercive and harmful to the self or others
NON-COERCIVE PARAPHILIAS
 Fetishism

 Autoerotic Asphyxia

 Sexual Masochism

 Transvestitism
NON-COERCIVE PARAPHILIAS -
FETISHISM
 Sexual arousal elicited by inanimate
objects (shoes, leather, rubber) or
specific body parts (feet, hair)
NON-COERCIVE PARAPHILIAS -
AUTOEROTIC ASPHYXIA
 Constriction of the neck to enhance a
masturbation experience; often leads
to accidental death
NON-COERCIVE PARAPHILIAS -
SEXUAL MASOCHISM
 Erotic interest in receiving
psychological or physical pain, real or
fantasized
NON-COERCIVE PARAPHILIAS -
TRANSVESTITISM
 Using the apparel of the opposite sex
COERCIVE PARAPHILIAS
 Exhibitionism
 Voyeurism
 Frotteurism
 Obscene Phone Callers / Telephone
Scatologia
 Pedophilia
 Urophilia
 Coprophilia
 Sadism
COERCIVE PARAPHILIAS -
EXHIBITIONISM
 Intentional exposure of the genitals to
a stranger or unsuspecting person

 May be accompanied by arousal and


masturbation either during or after the
exposure
COERCIVE PARAPHILIAS –
VOYEURISM
 Secret observation of an unsuspecting
person (usually a woman) engaged in
a private act, e.g., undressing or
having sex.

 The voyeur often masturbates during


or after the viewing
COERCIVE PARAPHILIAS -
FROTTEURISM
 Intense sexual arousal elicited by
rubbing the genitals against a non-
consenting person
COERCIVE PARAPHILIAS –
OBSCENE PHONE CALLERS
 Calling a non-consenting person and
making sexual noises, using profanity,
attempting to seduce, or describing
sexual activity.

 The caller often masturbates during or


after the call
COERCIVE PARAPHILIAS –
PEDOPHILIA
 Sexual interest in a child

 Behavior ranges from exposure,


voyeurism, and explicit talk to
touching, oral sex and intercourse
COERCIVE PARAPHILIAS –
UROPHILIA
 Urinating on the sexual partner
COERCIVE PARAPHILIAS -
COPROPHILIA
 Smearing feces on the partner
COERCIVE PARAPHILIAS –
SADISM
 Erotic interest in inflicting physical pain
OTHER FORMS OF PARAPHILIA
 Anningulus

 Cunnillingus

 Fellatio

 Partialism
OTHER FORMS OF PARAPHILIA
ANNILINGUS
 Tongue brushing of the anus
OTHER FORMS OF PARAPHILIA
CUNNILLINGUS
 Tongue brushing of the vulva
OTHER FORMS OF PARAPHILIA
FELLATIO
 Inserting the penis into the mouth
OTHER FORMS OF PARAPHILIA
PARTIALISM
 Inserting the penis into the other parts
of the body
TYPE OF THERAPY PERFORMED
ON PATIENTS WITH PARAPHILIAS
 Behavior Modification
– A therapeutic intervention involving the
application of learning principles in order to
change maladaptive behavior
– A method of attempting to strengthen a desired
behavior or response by reinforcement , either
positive or negative
 Positive reinforcement is given to the client who
exhibits the desired behavior
 Negative reinforcement involves removing a stimulus
immediately after a (positive) behavior occurs so that
the behavior is more likely to occur again
TYPE OF THERAPY PERFORMED
ON PATIENTS WITH
PARAPHILIAS
 Aversion Therapy
– An example of behavior modification in which
a painful stimulus is introduced to bring about
avoidance of another stimulus with the end
view of facilitating behavioral change
 Token Economy
– An example of behavior modification
technique which utilizes the principle of
rewarding desired behavior to facilitate
change.
SEXUAL ADDICTION
 The frequency of sexual activity can be viewed on a
continuum, with most people falling in the middle
range

 Some have sex frequently in a way that enhances


their lives; others have sex infrequently and report
contentment and satisfaction

 A sexual pattern that falls at either extreme of the


continuum, however can signal problems.
SEXUAL ADDICTION
 Is a disorder in which the central focus of life is sex

 People with these addictions spend 50% or more of all waking hours
dealing with sex, from fantasy to acting out behavior.

 Acting out behavior is often victimless, e.g., overindulging in


masturbation, fetishism, pornography use, or commercial telephone
sex; or visiting prostitutes

 Victimizing behaviors (those with a non-consenting partner) are less


frequent and include obscene phone calls, frotteurism, voyeurism,
exhibitionism, child sexual abuse and rape
SEXUAL ADDICTION
 Sexual addiction is not simply the frequent enjoyment of
sexual behaviors; rather, it is a progressive disease in which
sex is used to numb pain.

 The pay off is the same as in any other addiction, i.e., an


intensely pleasurable, short-lived release from pain, and an
escape from the problems of daily life.

 The consequences are the same in the addict’s life and


eventually becomes unmanageable
SEXUAL ADDICTION
 Many sexual addicts grew up in homes where
they were emotionally, physically, or sexually
abused

 Most of them suffer from low self-esteem and


believe themselves unlovable.

 They have desperate need for love and they


equate sex with proof of love.
SEXUAL ADDICTION
 The components have the hallmarks of
obsessive-compulsive behavior:
– Preoccupation
 Spends hours thinking or obsessing about
sex and is so time consuming that the
person cannot fulfill work, school, or
family responsibilities
SEXUAL ADDICTION
 The components have the hallmarks of
obsessive-compulsive behavior:
– Ritualization
 The individual engages in specific
behaviors done just the “right” way and
in the same sequence at the right time.
The ritual seems to control anxiety; once
addicts begin a ritual, they cannot stop
until the cycle is completed
SEXUAL ADDICTION
 The components have the hallmarks of
obsessive-compulsive behavior:
– Compulsivity
 The individual cannot control sexual
behavior and this behavior becomes the
most important aspect of life
SEXUAL ADDICTION
 The components have the hallmarks of
obsessive-compulsive behavior:
– Shame and Despair
 At the end of the cycle, the person
experiences guilt and shame at the loss of
control. The pain of despair creates the
need to begin the cycle all over again. Like
other addicts, these individuals want to stop
their behavior, promise to stop, try to stop
and are unable to stop without treatment.
ON PATIENTS WITH SEXUAL
ADDICTION
 Behavior Modification
– A therapeutic intervention involving the
application of learning principles in order to
change maladaptive behavior
– A method of attempting to strengthen a desired
behavior or response by reinforcement , either
positive or negative
 Positive reinforcement is given to the client who
exhibits the desired behavior
 Negative reinforcement involves removing a stimulus
immediately after a (positive) behavior occurs so that
the behavior is more likely to occur again
SEXUAL DYSFUNCTIONS
 These are problems or difficulties with sexual expression classified
according to the phase of the sexual response cycle that is affected
 This does not include dissatisfaction problems

 Contributory factors actually implicate past and current factors:

– Lack of sex education


– Internalization of the teaching that sex is dirty or sinful
– Parental punishment for normal exploration of one’s genitals
– Severe trauma such as rape or child sexual abuse
SEXUAL DYSFUNCTIONS
 Contributory factors actually implicate
past and current factors:
– Negative feelings like guilt anxiety,
anger which interfere with the ability
to experience pleasure and joy
SEXUAL DYSFUNCTION
 Fear of failure in sexual performance
often becomes a vicious cycle, i.e.,
fear of failure creates actual failure,
which in turn, produces more fear.
CLASSIFICATIONS OF SEXUAL
DYSFUNCTION
 Disorders of Sexual Desire

 Arousal Disorders

 Orgasm Disorders
DISORDERS OF SEXUAL DESIRE
 Inhibited Sexual Desire
– Persistently low interest or a total lack of interest in
sexual activity
 Sexual Aversion Disorder

– Severe distaste for sexual activity or the thought of


the sexual activity, which then leads to a phobic
avoidance of sex
– The most common cause of sexual aversion disorder
is childhood sexual abuse or adult rape
 Increased Sexual Interest

– Symptomatic of the manic phase of a bipolar disorder


AROUSAL DISORDERS
 Physiologic responses and subjective sense
of excitement experienced during sexual
activity
– Female Sexual Arousal Disorder
 Lack of vaginal lubrication
– Male Sexual Arousal Disorder
 Occurs when the man has erection problems
during 25% or more of sexual interactions;
cannot attain a full erection or loses erection
prior to orgasm (impotence / erectile inhibition)
ORGASM DISORDERS
 Inhibited Female Orgasm / Frigid
– Woman is totally incapable of responding sexually
– Sexual response stops before orgasm occurs
 Pre-orgasmic

– Women who have never experienced an orgasm


 Secondarily Non-Orgasmic

– They have had orgasm in the past but are not currently
experiencing them
 Situationally Non-orgasmic

– Have orgasms in some situations but not in others


ORGASM DISORDERS
 Inhibited Male Orgasm

– Male can maintain an erection for long periods


(e.g., an hour or more) but has extreme difficulty
ejaculating

– Could be organic, e.g., spinal cord injuries,


multiple sclerosis, due to drugs or may be
psychogenic (fear of pregnancy, performance
pressure, fear of losing control, anxiety and guilt
about engaging in sexual activity)
ORGASM DISORDERS
 Rapid Ejaculation
– One of the most common dysfunction among men
– Refers to the absence of voluntary control of ejaculation
– Probably due to:
 Inability to perceive his arousal level accurately
 Lowered sensory threshold due to infrequent sexual activity
 Early conditioning as a result of hurried masturbation or
hurried sexual intercourse
 Extreme anxiety during sexual interaction, resulting in
ejaculation triggered by the SNS
SEXUAL PAIN DISORDERS
 Vaginismus

– Involuntary spasms of the outer one third of the


vaginal muscles making penetration of the
vagina painful and sometimes impossible.

– Cause is mainly psychophysiologic: as


protection against real or imagined pain;
history of sexual trauma; emotional conflict
SEXUAL PAIN DISORDERS
 Dyspareunia

– Pain during or immediately after


intercourse

– Could be due to skin irritations,


vaginal infection, estrogen deficiency,
or drugs; pelvic disorders, such as
endometriosis, scar tissue, tumors
PROBLEMS WITH SEXUAL
SATISFACTION
 These are more related to the
emotional tone of the relationship than
the physiologic response

 May be situational, due to lack of


extragenital satisfaction, related to the
relationship difficulties, due to lack of
intimacy
NURSING CARE FOR SEXUAL
DYSFUNCTIONS
Reduce anxiety and fear
– Accurate identification of feelings is the first step
– Help the client identify one anxiety-producing situation
within their sexual interactions
– The nurse and client may analyze the situation to discover
negative anticipatory thoughts that may be the source of the
anxiety.
– Review how the client has handled anxiety in the past and
evaluate the range and effectiveness of this past coping
behavior, then explore alternative coping behaviors
NURSING CARE FOR SEXUAL
DYSFUNCTIONS
 Decrease spiritual distress

– Because the origin of spiritual


distress is the lack of intimacy or
connection within a sexual
relationship, the goal of nursing care
is to help clients achieve and
maintain a level of intimacy each
partner finds comfortable
NURSING CARE FOR SEXUAL
DYSFUNCTIONS
 Promote more effective family coping
– Apart from setting specific times to share feelings, and belief,
some couples need training in more effective communication
skills.
 Teach couples to avoid the “you” language, which evokes a defensive
response and results in arguments, and encourage use of the “I”
language, which expresses personal thoughts, feelings and needs.
– Example of “You” language
 “You only have sex on your mind. You are a pervert”
– Example of “I” language
 “I am concerned because we seem to have different expectations of
how often we would like to make love.”
NURSING CARE FOR SEXUAL
DYSFUNCTIONS
 Promote comfort with personal identity

– A multidisciplinary approach is most


effective in helping transsexuals adjust to
their situation

– Family and friends need support and


counseling to reintegrate this person into
their lives as a person of the other sex
NURSING CARE FOR SEXUAL
DYSFUNCTIONS
 Promote effective role performance

– Refer sexual addicts to self-help groups


and specialized professional therapy

– Recovery is a long-term process facilitated


by individual, group, couple, family, and
family-of-origin therapy
NURSING CARE FOR SEXUAL
DYSFUNCTIONS
 Promote non-coercive sexuality
patterns

– If practiced with an adult consenting


partner requires no nursing
intervention except for client and
partner education and possible
couple negotiation about the
behavior
NURSING CARE FOR SEXUAL
DYSFUNCTIONS
 Decrease violence against the self and others

– The most important nursing education regarding


autoerotic asphyxia is community education
– Therapy for sex offenders is a specialized area that
should not be taken lightly
– Behavior modification techniques, group therapy,
hypnosis could be used
NURSING CARE FOR SEXUAL
DYSFUNCTIONS
 Decrease pain

– Thorough physical examination is


necessary to find and treat the organic
cause of the pain

– Vaginismus is treated with education,


dilators and supportive psychotherapy
NURSING CARE FOR SEXUAL
DYSFUNCTIONS
 Increase knowledge

– Teach clients sexual anatomy and


the sexual response cycle

– Encourage couples to talk with one


another about their individual
responses
SEX THERAPY
 Common components
– Information and education about sexual functions

– Experiential and Sensory Awareness


 Therapist helps clients to recognize feelings of anxiety,
anger and pleasure by tuning into bodily cues

– Insight
 Therapist attempts to learn and understand what is causing
and perpetuating the sexual problem
SEX THERAPY
 Common components
– Cognitive Restructuring
 Clients identify and re-evaluate their non-
sexual fears about sexual interaction
– Behavioral Interventions
 Focus is on changing the non-sexual behavior
that contributes to sexual problems
 Assertiveness training, communication training,
stress-reduction exercises and problem-solving
techniques
SCHIZOPHRENIA
SCHIZOPHRENIA
 The term “schizophrenia” (split mind) was coined by
Bleuler to describe a lack of integration of the
patient’s functions
 There is disharmony between the patient’s thinking,
feeling and acting.
 Schizophrenia causes distorted and bizarre thoughts,
perceptions, emotions, movements and behavior.
 It cannot be defined as a single illness; rather it is
thought of as a syndrome or disease process with
many different varieties and symptoms
SCHIZOPHRENIA
 The main problem in schizophrenia is
Altered Thought Process

 The most acceptable theory on the


cause of schizophrenia is the Biologic
Theory which says that schizophrenia
is due to increased dopamine.
CHARACTERISTICS OF PATIENTS
WITH SCHIZOPHRENIA
 Patients are usually of the asthenic or
slender, lightly muscled body type

 They tend to be introverted, deficient in their


affective response ability, self conscious,
retiring, moody and sensitive

 Thought processes are disorganized and


disturbed; emotion may be lacking or
disassociated from the content of thought
CHARACTERISTICS OF PATIENTS
WITH SCHIZOPHRENIA
 There is failure in adapting to objective reality with its
everyday problems, situations and demands and in forming
satisfactory relationships with others

 Instead of recognizing and adapting to the inevitable


frustrations and problems of living, they utilize the
mechanism of denial and withdraw from reality

 The patient’s abstract ability becomes impaired to the


extent that he cannot conceptualize or form logical
conclusions
CHARACTERISTICS OF PATIENTS
WITH SCHIZOPHRENIA
 Patient acts out in ways which would
ordinarily be subject to social restraint

 Delusions and hallucinations are


accessory symptoms which serve to
fulfill denied wishes and to free the
patient from intolerable feelings of
guilt and anxiety.
TYPES OF SCHIZOPHRENIA
 Paranoid Type

 Catatonic Type

 Disorganized Type

 Undifferentiated Type

 Residual Type
SCHIZOPHRENIA
PARANOID TYPE
 Characterized by persecutory (feeling
victimized or spied on) grandiose
delusions, hallucinations, and
occasionally, excessive religiosity
(delusional religious focus) or hostile
and aggressive behavior.
SCHIZOPHRENIA
CATATONIC TYPE
 Characterized by marked psychomotor disturbance, either
motionless or excessive motor activity.

 Motor immobility may be manifested by catalepsy (waxy


flexibility) or stupor

 Excessive motor activity is apparently purposeless and is


not influenced by external stimuli

 Other features include negativism, mutism, peculiarities of


voluntary movement, echolalia, and echopraxia
SCHIZOPHRENIA
CATATONIC TYPE
 Catatonic Stupor
– Marked decrease in reactivity to the environment
and/or reduction in spontaneous movement and
activity or mutism

 Catatonic Negativism
– Apparently motive-less resistance to all instruction or
attempts to be moved

 Catatonic Rigidity
– Maintenance of a rigid posture against efforts to be
moved
SCHIZOPHRENIA
CATATONIC TYPE
 Catatonic Excitement
– Excited motor activity, apparently
purposeless and not influenced by
external stimuli

 Catatonic Posturing
– Voluntary assumption of
inappropriate posture.
SCHIZOPHRENIA
DISORGANIZED TYPE
 Incoherence, marked loosening of
associations, or grossly disorganized
behavior

 Flat or grossly inappropriate affect

 Does not meet the criteria for the


catatonic type
SCHIZOPHRENIA
UNDIFFERENTIATED TYPE
 Characterized by mixed schizophrenic symptoms
(of other types) along with disturbances of
thought, affect and behavior

 Prominent delusions, hallucinations, incoherence


or grossly disorganized behavior

 Patients whose manifestations cannot be fitted


into one or the other types
SCHIZOPHRENIA
RESIDUAL TYPE
 Absence of prominent delusions,
hallucinations, incoherence or grossly
disorganized behavior
SCHIZOPHRENIA
RESIDUAL TYPE
 Continuing evidence of the disturbance, as indicated by
2 or more of these residual symptoms:
– Marked social isolation or withdrawal
– Marked impairment in role functioning as wage-
earner, student or homemaker
– Marked peculiar behaviors
– Marked impairment in personal hygiene and grooming
– Odd beliefs or magical thinking, influencing behavior
and inconsistent with cultural norms.
– Marked lack of initiative, interest
COMPARISON OF DIFFERENT
TYPES OF SCHIZOPHRENIA
CATATONIC TYPE DISORGANIZED PARANOID TYPE
TYPE
Onset Acute Insidious Abrupt

Distinguishing Abnormal Motor Bizarre Behavior Suspiciousness


Feature Behavior Ideas of reference

Defense Repression Regression Projection


Mechanism
Priority Nursing Impaired Motor Impaired Social Potential for injury
Diagnosis Activity Functioning directed at others

Priority Nursing Circulation Assistance with Nutrition


Care Nutrition ADL Safety
CRITERIA FOR PROGNOSIS OF
SCHIZOPHRENIA
 Favorable Prognosis
– Good socialization
– Late / acute onset
– Adequate support system
– Family history of mood disorder
CRITERIA FOR PROGNOSIS OF
SCHIZOPHRENIA
 Unfavorable Prognosis
– Poor / no socialization
– Early and insidious onset
– Few / no support system
– History of chronicity / many relapses
THEORIES OF CAUSATION OF
SCHIZOPHRENIA
 Biologic
– Genetic Theories
 Schizophrenics inherit a genetic
vulnerability for the disease
 Relatives of schizophrenics have a
greater chance of developing the disease
 Concordance rates for schizophrenia are
consistently higher for monozygotic than
for dizygotic twins
THEORIES OF CAUSATION OF
SCHIZOPHRENIA
 Biologic
– Biological Theories
 The dopamine hypothesis is the most
widely held and extensively studied
biochemical mechanism thought to
underlie schizophrenia
THEORIES OF CAUSATION OF
SCHIZOPHRENIA
 Biologic
– Brain Structure
 Ventricular size has been found to be
significantly larger in chronic
schizophrenics
THEORIES OF CAUSATION OF
SCHIZOPHRENIA
 Psychological Theories

– Information Processing Deficit

– Attention and Arousal


 Either hypo- or hyper-
THEORIES OF CAUSATION OF
SCHIZOPHRENIA
 Family Theories

– Defect in family interaction /


disordered family communication

– Family’s Emotional Tone is highly


critical, hostile or over involved
FUNDAMENTAL SIGNS AND
SYMPTOMS OF SCHIZOPHRENIA
AS IDENTIFIED BY BLEULER
 Associative Looseness

 Autism

 Apathy

 Ambivalence
SYMPTOMS OF SCHIZOPHRENIA
 The symptoms of schizophrenia are divided into
two major categories:

– Positive or hard symptoms / signs, which


include delusions, hallucinations, and grossly
disorganized thinking, speech and behavior

– Negative or soft symptoms / signs such as flat


affect, lack of volition, and social withdrawal or
discomfort
SYMPTOMS OF
SCHIZOPHRENIA
 Medication can control the positive
symptoms, but frequently the negative
symptoms persist after positive
symptoms have abated
POSITIVE OR HARD SYMPTOMS OF
SCHIZOPHRENIA
 Ambivalence  Flight of ideas

 Associative Looseness  Hallucinations

 Delusions  Ideas of Reference

 Echopraxia  Perseveration
POSITIVE OR HARD SYMPTOMS
OF SCHIZOPHRENIA –
AMBIVALENCE
 Holding seemingly contradictory
beliefs or feelings about the same
person, event or situation
POSITIVE OR HARD SYMPTOMS
OF SCHIZOPHRENIA –
ASSOCIATIVE LOOSENESS
 Fragmented or poorly related thoughts
and ideas
POSITIVE OR HARD SYMPTOMS
OF SCHIZOPHRENIA -
DELUSIONS
 Fixed false beliefs that have no basis in
reality
POSITIVE OR HARD SYMPTOMS
OF SCHIZOPHRENIA -
ECHOPRAXIA
 Imitation of the movements and
gestures of another person whom the
client is observing.
POSITIVE OR HARD SYMPTOMS
OF SCHIZOPHRENIA - FLIGHT
OF IDEAS
 Continuous flow of verbalization in
which the person jumps rapidly from
one topic to another
POSITIVE OR HARD SYMPTOMS
OF SCHIZOPHRENIA –
IDEAS OF REFERENCE
 False impressions that external events
have special meaning to the person
POSITIVE OR HARD SYMPTOMS
OF SCHIZOPHRENIA -
PERSEVERATION
 Persistent adherence to a single idea or topic; verbal repetition of a
sentence, word, or phrase; resisting attempts to change the topic
 Example:

– Nurse: “How have you been sleeping lately?”


– Client: “I think people have been following me.”
– Nurse: “Where do you live?”
– Client: “At my place people have been following me.”
– Nurse: “What do you like to do in your free time?”
– Client: “Nothing because people are following me.”
NEGATIVE OR SOFT SYMPTOMS OF
SCHIZOPHRENIA
 Alogia  Catatonia

 Anhedonia  Flat Affect

 Apathy  Lack of Volition

 Blunted Affect
NEGATIVE OR SOFT SYMPTOMS
OF SCHIZOPHRENIA - ALOGIA
 Tendency to speak very little or to
convey little substance of meaning
(poverty of content)
NEGATIVE OR SOFT SYMPTOMS
OF SCHIZOPHRENIA -
ANHEDONIA
 Feeling no joy or pleasure from life or
any activities or relationships
NEGATIVE OR SOFT SYMPTOMS
OF SCHIZOPHRENIA - APATHY
 Feelings of indifference toward people,
activities, and events
NEGATIVE OR SOFT SYMPTOMS
OF SCHIZOPHRENIA - BLUNTED
AFFECT
 Restricted range of emotional feeling,
tone, or mood
NEGATIVE OR SOFT SYMPTOMS
OF SCHIZOPHRENIA -
CATATONIA
 Psychologically induced immobility
occasionally marked by periods of
agitation or excitement; the client
seems motionless, as if in a trance
NEGATIVE OR SOFT SYMPTOMS
OF SCHIZOPHRENIA - FLAT
AFFECT
 Absence of any facial expression that
would indicate emotions or mood
NEGATIVE OR SOFT SYMPTOMS
OF SCHIZOPHRENIA - LACK OF
VOLITION
 Absence of will, ambition, or drive to
take action or accomplish tasks
GENERAL SIGNS AND
SYMPTOMS OF SCHIZOPHRENIA
1) Perceptual changes
– Perceptions may either be heightened or blunted
– May occur in all the senses, or in just one or two
1a) Illusions
 Client’s misperceives or exaggerates stimuli in the external
environment
1b) Hallucinations (hallmark of schizophrenia)
 Subjective perception of something that does not exist in the
external environment
 May be visual, olfactory, gustatory, tactile, or auditory
GENERAL SIGNS AND
SYMPTOMS OF SCHIZOPHRENIA
2) Disturbances in thought
– The thinking is nudged or unclear
– Thoughts are disconnected or
disjointed
– Connections between one thought and
another are vague
– Examples:
2a) Clang Associations
2b) Delusions
CLANG ASSOCIATIONS
 Are ideas that are related to one
another based on sound or rhyming
rather than meaning.

 Example: “I will take a pill if I go up to


the hill but not if my name is Jill, I don’t
want to kill.”
DELUSIONS
 Disturbances in the content rather than the
form of thought
 Fixed false beliefs about one’s environment or
event occurring in it
 Types of delusions
– Persecutory or Paranoid Delusions
– Grandiose Delusions
– Religious Delusions
– Somatic Delusions
– Referential Delusions or Ideas of Reference
PERSECUTORY / PARANOID
DELUSIONS
 Involves the client’s belief that “others” are planning
to harm the client or are spying, following, ridiculing,
or belittling the client in some way.
 Sometimes the client cannot define who these “others”
are.
 Examples:
– The client may think that food has been poisoned or that
rooms are bugged with listening devices
– Sometimes the “persecutor” is the government or other
powerful organization
– Occasionally, specific individuals, even family members may
be named as the “persecutor”
GRANDIOSE DELUSIONS
 Are characterized by the client’s claim to association with
famous people or celebrities, or the client’s belief that he
or she is famous or capable of great feats
 Examples:

– The client may claim to be engaged to a famous movie


star or related to some public figure such as claiming
to be the daughter of the President of the Philippines
– May claim he or she has found a cure for cancer
RELIGIOUS DELUSIONS
 Often center around the second coming of Christ or another
significant religious figure or prophet
 These religious delusions appear suddenly as part of the
client’s psychosis and are not part of his or her religious
faith or that of others
 Examples:
– Client claims to be the Messiah or some prophet sent from God
– Believes that God communicated directly to him or her
– He or she has a “special” religious mission in life or special
religious powers
SOMATIC DELUSIONS
 Are generally vague and unrealistic beliefs
about the client’s health or bodily functions

 Factual information or diagnostic testing does


not change these beliefs

 Examples
– A male client may say that he is pregnant
– A client may report decaying intestines or
worms in the brain
REFERENTIAL DELUSIONS /
IDEAS OF REFERENCE
 Involve the client’s belief that television
broadcasts, music, or newspaper articles have
special meaning for him or her

 Examples:
– The client may report that the president was
speaking directly to him on a news broadcast
or that special messages are sent through
newspaper articles
GENERAL SIGNS AND SYMPTOMS
OF SCHIZOPHRENIA
3) Changes in communication
– Clients have difficulty responding appropriately to
events and people they encounter because of their
distorted perceptions, impaired ability to sort and
assimilate these perceptions, and difficulty
communicating responses clearly
– Examples:
3a) Thought Disorganization
3b) Thought Blocking
3c) Tangential Communication
3d) Circumstantial Communication
3e) Alogia
THOUGHT DISORGANIZATION

 Responses are inappropriate to the


situation
THOUGHT BLOCKING
 Difficulties articulating a response or
stops mid-sentence as if they are stuck

 Clients may suddenly stop talking in


the middle of a sentence and remain
silent for several seconds to one
minute
TANGENTIAL THINKING
 Veering into unrelated topics and never answering
the original question
– Example:
 Nurse: “How have you been sleeping lately?”
 Client: “Oh, I try to sleep at night. I like to listen to
music to help me sleep. I really like country-western
music best. What do you like? Can I have something
to eat pretty soon? I am hungry!”
 Nurse: “Can you tell me how you have been sleeping?”
CIRCUMSTANTIAL
COMMUNICATION
 Circumstantiality may be evidenced if the client gives
unnecessary details or strays from the topic but eventually
provides the requested information
 Example:

– Nurse: “How have you been sleeping lately?”


– Client: “Oh, I go to bed early, so I can get plenty of rest. I
like to listen to music or read before bed. Right now I am
reading a good mystery. Maybe I will write a mystery
someday. But is it isn’t helping, reading I mean. I have
been getting only 2 or 3 hours of sleep at night.”
ALOGIA
 Poverty of content describes the lack of
any real meaning or substance in what
the client says

 Example:
– Nurse: “How have you been sleeping
lately?”
– Client: “Well, I guess, I do not know,
hard to tell.”
GENERAL SIGNS AND
SYMPTOMS OF SCHIZOPHRENIA
4) Disruptions in emotional responses
– Restricted or inappropriate
expression or emotion
GENERAL SIGNS AND SYMPTOMS
OF SCHIZOPHRENIA
5) Motor Behavior Changes
– Disorganized behavior and catatonia (manifested
by unusual body movement or lack of movement)
– Examples:
5a) Catatonic Excitement
– The client moves excitedly but not in response to
environmental influences
5b) Catatonic Posturing
– Clients hold bizarre postures for a period of time
5c) Stupor
– Client holds the body still and is unresponsive to the
environment
GENERAL SIGNS AND
SYMPTOMS OF SCHIZOPHRENIA
6) Self care deficits

– They neglect to bathe, change clothes or


attend to minor grooming tasks

– Some show little awareness of current fashion


styles

– Wearing clothing that makes them look out of


place is also seen
GENERAL SIGNS AND
SYMPTOMS OF SCHIZOPHRENIA
7) Activity Intolerance
– This is brought about by
ambivalence about where to sit or
what to eat
GENERAL SIGNS AND
SYMPTOMS OF SCHIZOPHRENIA
8) Altered Thought Processes

– Examples:
8a) Magical Thinking
8b) Thought Insertion
8c) Thought Withdrawal
8d) Thought Broadcasting
MAGICAL THINKING
 Belief that events can happen simply
because one wishes them to happen.
THOUGHT INSERTION
 They may state that others are placing
thoughts in their mind or in their head
against their will
THOUGHT WITHDRAWAL
 They may state that others are taking
their thoughts out of their head
THOUGHT BROADCASTING
 They may state that they believe
others can hear their thoughts

 They believe that thoughts are


transmitted to others via radio,
television or other means but not
directly by the client
GENERAL SIGNS AND
SYMPTOMS OF SCHIZOPHRENIA
9) Unusual speech patterns
– Examples:
9a) Clang Associations
9b) Neologisms
9c) Verbigeration
9d) Echolalia
9e) Stilted Language
9f) Perseveration
9g) Word Salad
CLANG ASSOCIATIONS
 Are ideas that are related to one
another based on sound or rhyming
rather than meaning.

 Example: “I will take a pill if I go up to


the hill but not if my name is Jill, I don’t
want to kill.”
NEOLOGISMS
 These are words invented by the client
– Example:
 “I am afraid of grittiz. If there are any
grittiz here, I will have to leave. Are you
a grittiz?”
VERBIGERATION
 This is the stereotyped repetition of
words or phrases that may or may not
have meaning to the listener.

– Example:
 “I want to go home, go home, go home,
go home.”
ECHOLALIA
 This is the client’s imitation or
repetition of what the nurse says.

– Example:
 Nurse: “Can you tell me how you are
feeling?”
 Client: “Can you tell me how you are
feeling? how you are feeling?”
STILTED LANGUAGE
 This is the use of words or phrases that
are flowery, excessive, and pompous

– Example:
 “Would you be so kind, as a
representative of Florence Nightingale,
as to do me the honor of providing just
a wee bit of refreshment, perhaps in the
form of some clear spring water?”
PERSEVERATION
 Persistent adherence to a single idea or topic; verbal repetition of a
sentence, word, or phrase; resisting attempts to change the topic
 Example:

– Nurse: “How have you been sleeping lately?”


– Client: “I think people have been following me.”
– Nurse: “Where do you live?”
– Client: “At my place people have been following me.”
– Nurse: “What do you like to do in your free time?”
– Client: “Nothing because people are following me.”
WORD SALAD
 This is a combination of jumbled words
and phrases that are disconnected or
incoherent and make no sense to the
listener.

– Example:
 “Corn, potatoes, jump up, play games,
grass, cupboard.”
OTHER DISORDERS RELATED
TO SCHIZOPHRENIA
1) Delusional
– Similar to schizophrenia because they hold
unusual bizarre beliefs and cannot be
reasoned with regarding these beliefs.
– Unlike schizophrenic clients, delusional clients
do not have persistent hallucinations
 Delusions have a basis reality
 Hallucinations are not a dominant feature
 Behavior is within normal range except in relation
to delusion
 Behavior does not meet criteria for schizophrenia
OTHER DISORDERS RELATED TO
SCHIZOPHRENIA
2) Psychotic disorders not elsewhere classified
2a) Schizophreniform Disorder
 The duration of all symptoms (acute and residual) is less than six
months and a return to normal functioning is possible. (Note that 6
months is the amount of time necessary to meet the diagnostic
criteria for schizophrenia)
2b) Schizoactive Disorder
 Dominant schizophrenic symptoms are accompanied at some, but
not all times by a major depressive or manic syndrome
 There is a mood disorder in the form of either depression or mania
OTHER DISORDERS RELATED TO
SCHIZOPHRENIA
2) Psychotic disorders not elsewhere classified

2c) Brief Reactive Psychosis


 Psychotic symptoms appear shortly after a stressful event
or a series of stressful events

2d) Induced Psychotic Disorder


 A delusional system develops because of a close
relationship with a person who already has a psychotic
disorder with delusions
 Also known as folie a deux, two people share a similar
delusion.
MEDICATIONS USED IN
SCHIZOPHRENIA
 Drug Classification

– Antipsychotics or neuroleptics

 Conventional antipsychotics
– These are dopamine antagonists

 Atypical antipsychotics
– Newer schizophrenic drugs which are both
dopamine and serotonine antagonists
CONVENTIONAL
ANTIPSYCHOTICS
 Chlorpromazine (Thorazine)
 Trifluoperazine (Trilafon)
 Fluphenazin (Prolixin)
 Thioridazine (Mellaril)
 Mesoridazine (Serentil)
 Thiothixene (Navane)
 Haloperidol (Haldol)
 Loxapine (Loxitane)
 Molindone (Moban)
 Perphenazine (Etrafon)
 Trifluoperazine (Stelazine)
ATYPICAL ANTIPSYCHOTICS
 Clozapine (Clozaril)
 Risperidone (Risperdol)
 Olanzapine (Zyprexa)
 Quetiapine (Seroquel)
 Ziprasidone (Geodon)
EFFECTS OF ANTIPSYCHOTICS
 Prescribed primarily for efficacy in
decreasing psychotic symptoms like
delusions, hallucinations and looseness
of association

 They do not cure schizophrenia, they


only manage the symptoms of the
disease
WHEN TO ADMINISTER
ANTIPSYCHOTIC MEDICATIONS
 Best taken after meals
SIDE EFFECTS OF
ANTIPSYCHOTIC MEDICATIONS
1) Extrapyramidal Side Effects or EPS
– Reversible movement disorders
which include:
 Dystonic Reactions
 Pseudoparkinsonism

 Akathisia

 Tardive Dyskinesia
DYSTONIC REACTIONS
 They appear early in the course of treatment and are
characterized by spasms in discrete muscle groups such as the
neck muscles (torticollis) or eye muscles (oculogyric crisis)

 These spasms may also be accompanied by protrusion of the


tongue, dysphagia and laryngeal/pharyngeal spasm that can
compromise the client’s airway

 Acute treatment consists of diphenhydramine (benadryl) given


either intramuscularly or intravenously or benzotropine
(Cogentin) given intramuscularly
DYSTONIC REACTIONS
 Nursing considerations for dystonic
reactions include:

– Administering medications as ordered

– Assessing for their effectiveness

– Reassuring client if frightened.


PSEUDOPARKINSONISM
 Includes shuffling gait, masklike facies, muscle
stiffness (continuous) or cogwheeling rigidity (rachet-
like movements of joints), drooling, and akinesia
(slowness and difficulty initiating movements.

 These symptoms appear in the first few days after


starting the medication

 Treatment of pseudoparkinsonism is achieved by both


dopaminergic drugs and anticholinergic drugs
PSEUDOPARKINSONISM
 Dopaminergic Drugs
– Amantadine (Symmetrel)
– Levodopa
– Levodopa-Carbidopa (Sinemet)
PSEUDOPARKINSONISM
 Anticholinergic Drugs
– Trihexyphenidyl (Artane)
– Biperiden Hydrochloride (Akineton)
– Benzotropine Mesylate (Cogentin)
– Diphenhydramine Hydrochloride
(Benadryl)

AKATHISIA
This is characterized by restless movement, pacing, inability to
remain still, and the client’s report of inner restlessness.

 Described by patients as “I feel as if I have ants in my pants.”

 Akathisia usually develops when the antipsychotic is started or


when the dose is increased

 Beta-blockers such as propranolol have been most effective in


treating akathisia, while benzodiazepines like diazepam have
provided some success as well.
TARDIVE DYSKINESIA

– A late appearing side-effect characterized by


abnormal involuntary movements such as lip
smacking, tongue protrusion, chewing, blinking,
grimacing, and choreiform movements of the
limbs and feet

– This is irreversible once it has appeared


TARDIVE DYSKINESIA

– Decreasing or discontinuing the medication can


arrest the progression.

– Clozapine (Clozaril) has not been found to cause


this side effect

– Nursing consideration includes proper


assessment and subsequent reporting to the
physician
SIDE EFFECTS OF
ANTIPSYCHOTIC MEDICATIONS
2) Seizures
– These are infrequent side effects of
antipshychotic medications
– The notable exception is Clozapine
– These may be associated with high
doses of the medication
– Treatment is a lowered dosage or a
different antipsychotic medication
SIDE EFFECTS OF
ANTIPSYCHOTIC MEDICATIONS
3) Seizures

– Nursing consideration includes:

 Stopping the medication;


 Notifying the physician;
 Protecting client from injury;
 Providing reassurance and privacy for client
after seizure
SIDE EFFECTS OF
ANTIPSYCHOTIC MEDICATIONS
3) Neuroleptic Malignant Syndrome

– This is a serious and frequently fatal condition seen


in those being treated with antipsychotic medications

– It is characterized by muscle rigidity, high fever,


increased muscle enzymes (particularly CPK), and
leukocytosis (increased leukocytes)

– This is treated by stopping the medication


SIDE EFFECTS OF
ANTIPSYCHOTIC MEDICATIONS
4) Neuroleptic Malignant Syndrome

– Nursing considerations include:


 Stopping the medication
 Notifying the physician immediately of
its signs and symptoms
SIDE EFFECTS OF
ANTIPSYCHOTIC MEDICATIONS
4) Agranulocytosis

– Clozapine has the potentially fatal side


effect of agranulocytosis (failure of the
bone marrow to produce adequate white
blood cells)

– This develops suddenly and is


characterized by fever, malaise, ulcerative
sore throat, and leukopenia
SIDE EFFECTS OF
ANTIPSYCHOTIC MEDICATIONS
4) Agranulocytosis

– May not be manifested immediately but can occur


as long as 18 to 24 weeks after initiation of
therapy.

– Drug must be discontinued immediately

– Weekly white blood cell counts (CBC) are


necessary
SIDE EFFECTS OF
ANTIPSYCHOTIC MEDICATIONS
4) Agranulocytosis

– Nursing considerations include


stopping the medication and
notifying the physician immediately
of its signs and symptoms
OTHER SIDE EFFECTS OF ANTIPSYCHOTIC
MEDICATIONS AND THEIR NURSING
CONSIDERATIONS
SIDE EFFECTS NURSING CONSIDERATIONS
Sedation Caution about activities requiring client
to be fully alert such as driving a car

Photosensitivity Caution client to avoid sun exposure;


advise client when in the sun, to wear
protective clothing and sun-blocking
lotion
Weight Gain Encourage balanced diet with
controlled portions and regular
exercise; focus on minimizing gain
Dry mouth Use ice chips or hard candy for relief
(anticholinergic
OTHER SIDE EFFECTS OF ANTIPSYCHOTIC
MEDICATIONS AND THEIR NURSING
CONSIDERATIONS
SIDE EFFECTS NURSING CONSIDERATIONS

Constipation Increase fluid and dietary fiber intake; client may


(anticholinergic need a stool softener if unrelieved
symptom)

Blurred vision Assess side effect, which should improve with


(anticholinergic time; report to physician if no improvement
symptom)

Urinary Retention Instruct client to report any frequency or burning


(anticholinergic with urination; report to physician if no
symptom) improvement over time
NURSING CARE FOR
SCHIZOPHRENIA
1) Promote adequate communication

– Attend seriously to the client since he


perceives nuisances of the nurse’s
behavior

– If a client complains of physical


symptoms such as stomach distress,
consider the symptoms as real until there
is evidence otherwise.
NURSING CARE FOR
SCHIZOPHRENIA
2) Promote compliance with medical regimen

– Administer prescribed medications

– Observe client behavior for therapeutic effects

– Maintaining therapeutic blood levels is important

– Monitor side effects of drugs


NURSING CARE FOR
SCHIZOPHRENIA
2) Promote compliance with medical
regimen

– Teach client about the therapeutic and


possible untoward effects of drugs

– Help client to take action to prevent


untoward effects
NURSING CARE FOR
SCHIZOPHRENIA
2) Promote compliance with medical regimen

– Evaluate client’s subjective response to the drug and attitude


towards continued use. Compliance may be affected because:
 They do not understand the administration instruction
 They are so disorganized to follow instruction
 The side effect of major tranquilizers are too uncomfortable
NURSING CARE FOR
SCHIZOPHRENIA
3) Assist with grooming and hygiene

– Intervention begins by establishing clear


expectations. Frequency and timing
should be specified in writing

– Avoid power struggles regarding


completion of tasks. If initial prompts do
not work, leave the client alone for a short
period
NURSING CARE FOR
SCHIZOPHRENIA
4) Promote organized behavior

– The first rule is to go slowly and keep


calm

– Clients with disorganized behavior


require direction and limits to make
their actions more effective and goal
directed.
NURSING CARE FOR
SCHIZOPHRENIA
5) Promote social interaction and activity

– The client’s effort to withdraw from


social contact stem from past
relationship failures and fear of
rejection
NURSING CARE FOR
SCHIZOPHRENIA
6) Social skills training

– Provide structure by clearly setting times


for group meetings, beginning and ending
each session with a statement of goals
and recapping what the group has
accomplished

– Address social skills that are essential to


functioning in the milieu
NURSING CARE FOR
SCHIZOPHRENIA
6) Social skills training

– Do not assume periods of quiet or inactivity are


due to laziness or lack of interest

– Help client find activities that are intrinsically


rewarding or some social tangible reward yet
are within their capacities
NURSING CARE FOR
SCHIZOPHRENIA
7) Promote reality-based perceptions as
hallucinations and illusions often frighten clients

– Reassure client of their safety


– Protect them from physical harm as they respond
to their altered perceptions
– Intervene quickly by giving additional doses of
phychotropic medications or placing the client in
a quiet room
NURSING CARE FOR
SCHIZOPHRENIA
7) Promote reality-based perceptions as
hallucinations and illusions often frighten clients

– Validate reality – “I know the voices are real to


you but no one else can hear them. No one
means to harm you.”

– Help clients to distinguish reality from the


hallucinatory experience
NURSING CARE FOR
SCHIZOPHRENIA
7) Promote reality-based perceptions as hallucinations
and illusions often frighten clients

– Make brief frequent contacts with the client to


interrupt the hallucinatory cycle and to maintain trust

– Encourage the client to attend to stimuli in the


environment such as conversation rather than to
internal stimuli. Example: “Greg, listen to me rather
than to the sound you hear.”
NURSING CARE FOR
SCHIZOPHRENIA
7) Promote reality-based perceptions as
hallucinations and illusions often frighten
clients

– Help the client in activities that require


cognitive or verbal involvement

– Support coping strategies that the client has


identified as personally effective in reducing
hallucinations
NURSING CARE FOR
SCHIZOPHRENIA
7) Promote reality-based perceptions as hallucinations
and illusions often frighten clients

– If needed, teach the client that the hallucination are


part of the disease process

– Help the client monitor events or interactions that


increase the hallucinations

– Protect the client and others who might be harmed


by the client’s acting on hallucinated commands.
NURSING CARE FOR
SCHIZOPHRENIA
8) Intervene with delusions

– Do not argue with their general beliefs


– Focus on the reality-based aspects of their
communications
– Protect them from acting on their delusion in a
way that might harm themselves or others
– Observe for stressors that precipitate the
delusion and help the client to avoid or
eliminate these stressors
NURSING CARE FOR
SCHIZOPHRENIA
9) Promote congruent emotional
responses

10) Promote family understanding and


involvement
SAMPLE BOARD QUESTION
NO.1
 Which of the following is not
characteristic of the patient with
paranoid schizophrenia?

A) Delusions
B) Hallucinations
C) Decreased sensitivity
D) Ideas of reference
ANSWER
 Letter C

 Rationale: Paranoid schizophrenia


patients are usually extremely
sensitive.
SAMPLE BOARD QUESTION
NO.2
 Which defense mechanism is most
characteristic of the patient with
paranoid schizophrenia?

A) Undoing
B) Projection
C) Rationalization
D) Suppression
ANSWER
 Letter B

 Rationale: Paranoid patients usually


project their mistrust to others.
SAMPLE BOARD QUESTION
NO.3
 Thiodazine (Mellaril), an antipsychotic, is
usually effective in treating all but one of the
following symptoms of schizophrenia. Which
symptom will not be affected by this drug?

A) Agitation
B) Hallucinations
C) Delusions
D) Ambivalence
ANSWER
 Letter A

 Rationale: Antipsychotics can only


decrease the positive symptoms of
schizophrenia. Agitation is a negative
symptom
SAMPLE BOARD QUESTION

NO.4
The nurse is caring for a patient with disorganized schizophrenia.
The patient is responding well to therapy but has had limited social
contact with others. Which of the following interventions is most
appropriate?

A) Discourage the patient from interacting with others because if his


efforts fail, it will be too traumatic for him
B) Encourage the patient to attend a party thrown for the residents
of the facility
C) Encourage the patient to participate in one-on-one interactions
D) Encourage the patient to place a personal advertisement in the
local newspaper but not reveal his main identity
ANSWER
 Letter C

 Rationale: Participation in one-on-one


interactions helps the patient in
establishing beginning social contact
with others.
SAMPLE BOARD QUESTION
NO.5
 A 27 year-old female has been admitted to the inpatient
psychiatric unit with diagnosis of catatonic schizophrenia. She
appears weak and pale. The nurse would expect to observe
which behavior in the patient?

A) Scratching cat-like motions of the extremities


B) Exaggerated suspiciousness, excessive food intake
C) Stuporous withdrawal, hallucinations and delusions
D) Sexual preoccupation and word salad
ANSWER
 Letter C

 Rationale: Catatonic schizophrenia is


usually manifested by stuporous
withdrawal, hallucinations, delusions,
waxy flexibility and catatonic rigidity.
MOOD DISORDERS
MOOD / AFFECTIVE DISORDERS
 A group of psychiatric diagnoses characterized by
disturbances in emotional and behavioral response
patterns ranging from elation and agitation to extreme
depression and a serious potential for suicide.

 Group of disorders characterized by a decreased or entire


loss of control over mood

 The mood disturbance may occur in different patterns of


severity, duration, alone or in combination
COMMON ETIOLOGICAL
THEORIES OF MOOD
DISORDERS
1) Genetic Theory
– If one parent has a bipolar disorder,
there is 25% chance of transmission
to the child

2) Aggression Turned Inward Theory


– Overdeveloped superego leads to
depression
COMMON ETIOLOGICAL
THEORIES OF MOOD
DISORDERS
3) Object Loss theory
– Loss of parent before age 11 increases the
risk for depression

4) Personality Organization Theory


– Obsessive-compulsive, oral-dependent,
hysterical personalities have higher
predisposition to mood disorders
COMMON ETIOLOGICAL
THEORIES OF MOOD DISORDERS
5) Cognitive Theory
– Mood disorder results from negative
views of the self, the future, and
negative interpretation of experiences

6) Learned Helplessness Theory


– Mood disorder is caused by a belief that
one has no control over his environment
COMMON ETIOLOGICAL
THEORIES OF MOOD
DISORDERS
7) Psychoanalytic Theory
– Mania is a defense against an underlying
depression
– Depression is due to a rigid superego

8) Biologic Factor
– Mania is related to increased norepinephrine
while depression is related to low
norepinephrine
COMMON PRECIPITATING
FACTORS OF MOOD DISORDERS
 Loss of a loved one
 Major life events
 Roles strain
 Decreased coping resources
 Physiological changes
DIFFERENT TYPES OF MOOD
DISORDERS
 The two main types of mood disorders are:

– Depression
 Characterized by anergia (lack of energy),
exhaustion, agitation, noise intolerance, and
slowed thinking process

– Bipolar Disorders
 Diagnosed when a person’s mood cycles
between extremes of mania and depression
SUBTYPES OF DEPRESSIONS
 Major Depression

 Dysthymic Depression

 Depression Not Otherwise Specified


MAJOR DEPRESSION
 Severe depression which lasts for at
least 2 weeks during which the person
experiences a depressed mood or loss
of pleasure in nearly all activities
 MAJOR DEPRESSION
In addition, four of the following symptoms are present:
– Changes in appetite or weight
– Changes in sleep
– Changes in psychomotor activity
– Decreased energy
– Feelings of worthlessness or guilt
– Difficulty thinking, concentrating or making decisions
– Recurrent thoughts of death or suicidal ideation, plans, or
attempts.
 These symptoms must be present every day for 2 weeks and
result in significant distress or impair social, occupational or
other important areas of functioning
DYSTHYMIC DEPRESSION
 It is less severe than major depression

 It is characterized by at least 2 years


of depressed mood for more days than
not with some additional less severe
symptoms that do not meet the
criteria for a major depressive episode
DEPRESSION NOT OTHERWISE
SPECIFIED (DNOS)
 Depression that lasts for 2 days to 2
weeks
SUBTYPES OF BIPOLAR
DISORDERS
 Manic

 Hypomanic

 Bipolar I

 Bipolar II

 Cyclothymia
MANIA
 The diagnosis of manic episode or mania requires at
least 1 week of unusual and incessantly heightened,
grandiose or agitated mood in addition to three or
more of the following symptoms:

– Exaggerated self-esteem
– Sleeplessness
– Pressured speech
– Flight of ideas
– Reduced ability to filter extraneous stimuli
MANIA
 The diagnosis of manic episode or mania requires at least 1
week of unusual and incessantly heightened, grandiose or
agitated mood in addition to three or more of the following
symptoms:

– Distractability
– Increased activities with increased energy
– Multiple, grandiose high-risk activities involving poor
judgment and severe consequences such as spending
sprees, sex with strangers, and impulsive investments
HYPOMANIC
 Less severe than mania

 Lasts for at least 4 days


BIPOLAR I
 With history of mania

 The patient exhibits:


– Manic episodes
– Periods of normal behavior
– Periods of profound depression
BIPOLAR II
 No history of mania

 The patient exhibits:


– Depression
– Normal behavior
– At least one hypomanic episode, but
NOT manic
CYCLOTHYMIA
 Characterized by two years of
numerous periods of both hypomanic
symptoms that do not meet the
criteria for bipolar disorder

 Numerous episodes of hypomania and


depressed mood that lasts for at least
two years
DIFFERENCE BETWEEN MANIA
AND DEPRESSION
MANIA DEPRESSION

Appearance Colorful Sad

Behavior Highly driven, Passivity


Hyperactive Psychomotor
retardation
Communication Talkative (Flight of Monotonous
Ideas) speech
Nursing Risk for injury Risk for injury:
Diagnosis directed at others Self-directed

Nursing Care Safety Safety


DIFFERENCE BETWEEN MANIA
AND DEPRESSION
MANIA DEPRESSION
Treatment of Lithium ECT
Choice
Milieu Therapy Non-stimulating Stimulating
Appropriate Quiet Type Monotonous
Activity Avoid competitive activity
Example: counting

Attitude Therapy Matter of fact Kind Firmness


(attitude of
casualness)
MEDICATIONS USED IN MANIA
 Drug Classification

– Antimanic Medications
 Lithium Carbonate

– Anticonvulsant Medications
 Used as mood stabilizers
LITHIUM CARBONATE
 It is a salt contained in the human body

 Its mechanism of action is not known but it is


thought to work in the synapses to hasten
destruction of catecholamines (dopamine and
norepinephrine), inhibit neurotransmitter
release, and decrease the sensitivity of post-
synaptic receptors.
EFFECTS OF LITHIUM
CARBONATE
 It decreases hyperactivity
WHEN TO TAKE LITHIUM
CARBONATE
 Best taken after meals
IMPORTANT POINTS ON LITHIUM
CARBONATE
 Lithium is not metabolized; rather, it is
reabsorbed by the proximal tubule and
excreted in the urine

 Periodic serum lithium levels are used to


monitor the client’s safety and to ensure that
the dose given has increased the serum
lithium level to treatment level or reduced it
to maintenance level.
IMPORTANT POINTS ON LITHIUM
CARBONATE
 There is a narrow range of safety among
maintenance levels (0.5 to 1.0 mEq/L),
treatment levels (0.8 to 1.5 mEq/L) and
toxicity levels (1.5 mEq/L and above)

 It is important to asses for signs of toxicity


and ensure that clients and their families
have this information prior to discharge.
SYMPTOMS AND INTERVENTIONS OF
LITHIUM TOXICITY
SERUM LITHIUM SYMPTOMS OF INTERVENTIONS
LEVEL LITHIUM
TOXICITY
1.5 – 2.0 mEq/L Nausea andWithhold next
vomiting, diarrhea,dose; call
reduced physician. Serum
coordination, lithium levels are
drowsiness, ordered and doses
slurred speech,of lithium are
muscle weakness usually suspended
for a few days or
the dose is
reduced
SYMPTOMS AND INTERVENTIONS
OF LITHIUM TOXICITY
SERUM LITHIUM LEVEL SYMPTOMS OF LITHIUM INTERVENTIONS
TOXICITY

2.0 – 3.0 mEq/L Ataxia, agitation, blurredWithhold future doses, call


vision, tinnitus, giddiness,physician, stat serum
choreoathetoid lithium level. Gastric
movements, confusion,lavage may be used to
muscle fasciculation,remove oral lithium; IV
hyperreflexia, hypertoniccontaining saline and
muscles, myoclonicelectrolytes used to ensure
twitches, pruritus,fluid and electrolyte
maculopapular rash,function and maintain renal
movement of limbs, slurredfunction.
speech, large output of
dilute urine, incontinence
of bladder of bowel, vertigo
SYMPTOMS AND INTERVENTIONS
OF LITHIUM TOXICITY
SERUM LITHIUM LEVEL SYMPTOMS OF LITHIUM INTERVENTIONS
TOXICITY

3.0 mEq/L and above Cardiac arrythmia,All of preceding


hypotension, peripheralinterventions plus lithium
vascular collapse, focal orion excretion is augmented
generalized seizures,with use of aminophylline,
reduced levels ofmannitol, or urea.
consciousness from stuporHemodialysis may also be
to coma, myoclonic jerksused to remove lithium
of muscle groups, andfrom the body.
spasticity of muscles Respiratory, circulatory,
thyroid and immune
systems are monitored
and assisted as needed.
CLIENT TEACHING FOR LITHIUM
CARBONATE
 Clients should drink adequate water (approximately
3 liters per day) and continue with the usual amount
of dietary table salt (3 grams per day).

 Having too much salt in the diet because of


unusually high salty foods or the ingestion of salt-
containing antacids can reduce receptor availability
for lithium and increase lithium excretion, so the
lithium level will be too low.
CLIENT TEACHING FOR LITHIUM
CARBONATE
 If there is too much water, lithium is diluted and the
lithium level will be too low to be therapeutic.

 Drinking too little water or losing fluid through


excessive sweating, vomiting, or diarrhea will increase
the lithium level, which may result in toxicity.
CLIENT TEACHING FOR LITHIUM
CARBONATE
 Monitoring daily weights and the balance
between intake and output and checking
for dependent edema can be helpful in
monitoring fluid balance.

 The physician should be contacted if the


client has diarrhea, fever, flu, or any
condition that leads to dehydration
CLIENT TEACHING FOR LITHIUM
CARBONATE
 It takes 10 – 14 days before therapeutic effect of
lithium becomes evident

 Antipsychotics are administered during the first two


weeks to manage the acute symptoms of mania until
lithium takes effect

 Anticonvulsants could also be used as mood stabilizers

 Mannitol is administered if lithium toxicity occurs


ANTICONVULSANTS USED AS
MOOD STABILIZERS
GENERIC (TRADE) SIDE EFFECTS NURSING
NAME OF IMPLICATIONS
ANTICONVULSANT

Carbamazepine (Tegretol) Dizziness, hypotension,Assist client to rise slowly


ataxia, sedation, blurredfrom sitting position
vision, leukopenia, rashes Monitor gait and assist as
necessary
Report rashes to
physician

Divalproex (Depakote) Ataxia, drowsiness,Monitor gait and assist as


weakness, fatigue,necessary
menstrual changes,Provide rest periods
dyspepsia, nausea,Give with food
vomiting, weight gain, hair
loss Establish balanced
nutrition
ANTICONVULSANTS USED AS
MOOD STABILIZERS
GENERIC (TRADE) SIDE EFFECTS NURSING
NAME OF IMPLICATIONS
ANTICONVULSANT

Lamotrigine (Lamictal) Dizziness, hypotension,Assist client to rise slowly


ataxia, coordination,from sitting position
sedation, headache,Monitor gait and assist as
weakness, fatigue,necessary
menstrual changes, soreProvide rest periods
throat

Topiramate (Topamax) Dizziness, hypotension,Assist client to rise slowly


anxiety, ataxia,from sitting position
incoordination, confusion,Monitor gait and assist as
sedation, slurred speech,necessary
tremor, weakness Orient client
NURSING INTERVENTIONS FOR
MANIA
 Provide for client’s physical safety and safety of those
around the client
– The nurse assess clients directly for suicidal ideation and
plans or thought of hurting others
– Clients in the manic phase have little insight into their
anger and agitation and how their behaviors affect
others. They often intrude into others’ space, take
others’ belongings without permission, or appear
aggressive in approaching others. This behavior can
threaten or anger people who then retaliate
– It is important to monitor the client’s whereabouts and
behaviors frequently.
NURSING INTERVENTIONS FOR
MANIA
 Set limits on client’s behavior when needed and
remind client to respect distances between self and
others.

– The nurse may say: “John, you are too close to my


face. Please stand back 2 feet.” or “It is
unacceptable to hug other clients. You may talk to
others, but do not touch them.”

 When setting limits, it is important to clearly identify


the unacceptable behavior and convey the expected
appropriate behavior
NURSING INTERVENTIONS FOR MANIA
 Use short simple sentences to
communicate

– Clients with mania have short


attention span, so he nurse uses clear
, simple sentences when
communicating
NURSING INTERVENTIONS FOR
MANIA
 Keep channels of communication open with clients,
regardless of speech patterns (pressured, rapid,
circumstantial, rhyming, noisy or intrusive with flight of
ideas)

– The nurse can say, “Please speak more slowly, I am


having trouble following you.”

– The nurse patiently and frequently repeats this


request during conversation because clients will
return to rapid speech
NURSING INTERVENTIONS FOR
MANIA
 Clarify the meaning of client’s
communication

– When speech includes flight of ideas, the


nurse can ask clients to explain the
relationship between topics – for example,
“What happened then?” or “Was that
before or after you got married?”
NURSING INTERVENTIONS FOR
MANIA
 Set limits regarding taking turns
speaking and listening and giving
attention to others when they need it
NURSING INTERVENTIONS FOR
MANIA
 Frequently provide finger foods that are
high in calories and protein (sandwiches,
protein bars, fortified shakes)

– Manic clients may be too “busy” to sit


down and eat, or they may have such
poor concentration that they fail to stay
interested in food for very long
NURSING INTERVENTIONS FOR
MANIA
 Promote rest and sleep by decreasing
environmental stimulation

– The nurse provides a quiet


environment without noise,
television, or other distractions.
NURSING INTERVENTIONS FOR
MANIA
 Establishing a bedtime routine, such as
tepid bath may help clients to calm
down enough to rest
NURSING INTERVENTIONS FOR
MANIA
 Protect the client’s dignity when inappropriate behavior occurs
– Clients may lose sexual inhibitions resulting in provocative and risky behaviors.
Clothing may be flashy or revealing, or clients may undress in public. They may
engage in unprotected sex with virtual strangers. Clients may ask staff members
or other clients for sex, graphically describe sexual acts, or display their genitals.
 The nurse handles such behavior in a matter-of-fact, non-judgmental
manner
– For example, “Mary, let’s go to your room and find a sweater.”
 It is important to treat clients with dignity and respect despite their
inappropriate behavior. It is not helpful to scold or chastise them.
REVIEW OF MAJOR SYMPTOMS
OF DEPRESSIVE DISORDER
 Depressed mood

 Anhedonism (decreased attention to and


enjoyment from previously pleasurable
activities)

 Unintentional weight change of 5% or more in


a month

 Change in sleep pattern


REVIEW OF MAJOR SYMPTOMS
OF DEPRESSIVE DISORDER
 Agitation or psychomotor retardation

 Tiredness

 Worthlessness or guilt inappropriate to


the situation (possibly delusional)
REVIEW OF MAJOR SYMPTOMS
OF DEPRESSIVE DISORDER
 Difficulty thinking, focusing, or making
decisions

 Hopelessness, helplessness and/or


suicidal ideation
TREATMENT MODALITIES FOR
DEPRESSIVE DISORDERS
 Electroconvulsive Therapy

 Psychopharmacology
– Cyclic antidepressants
– Monoamine oxidase inhibitors
– Selective serotonin reuptake
inhibitors
ELECTROCONVULSIVE THERAPY
(ECT)
 Involves application of electrodes to the
head of the client to deliver an electrical
impulse to the brain; this causes a seizure

 It is believed that the shock stimulates brain


chemistry to correct the chemical imbalance
of depression

 However, the mechanism of action of ECT is


unclear at present
FACTS ABOUT
ELECTROCONVULSIVE THERAPY
(ECT)
 Voltage of electrical current that is administered to
the client
– 70 – 150 volts
 Length of electrical shock applied to the patient

– About 0.5 to 2.0 seconds


 Usual number of treatments needed to produce a
therapeutic effect
– 6 – 12 treatments
 Frequency of treatments

– There should be an interval of 48 hours for each


treatment
FACTS ABOUT ELECTROCONVULSIVE
THERAPY (ECT)
 Indicators of effectiveness of ECT
– The occurrence of generalized tonic-
clonic seizure
FACTS ABOUT ELECTROCONVULSIVE
THERAPY (ECT)

 Indications for ECT


– Depression, Mania, Catatonic Schizophrenia

 Contraindications to ECT
– Fever
– Increased intracranial tumor
– TB with history of hemorrhage
– Cardiac condition
– Recent fracture
– Retinal detachment
– Pregnancy
FACTS ABOUT ELECTROCONVULSIVE
THERAPY (ECT)
 Need for consent prior to ECT
– Yes, consent is needed
FACTS ABOUT
ELECTROCONVULSIVE THERAPY
(ECT)
 Medications given to clients prior to ECT

– Atropine sulfate
 To decrease secretions

– Anectine (Succinylcholine)
 To promote muscle relaxation

– Methohexital Sodium (Brevital)


 Serves as an anesthetic agent
FACTS ABOUT
ELECTROCONVULSIVE THERAPY
(ECT)
 Common complications of ECT
– Loss of memory
– Headache
– Apnea
– Fracture
– Respiratory depression
REVIEW OF BIOLOGIC FACTOR
ON DEPRESSIVE DISORDERS
 Depression is related to low levels of
norepinephrine (particularly in brain
synapses)
PSYCHOPHARMACOLOGY FOR
DEPRESSIVE DISORDERS
 Cyclic Antidepressants

 Selective Serotonin Reuptake Inhibitors

 Monoamine Oxidase Inhibitors


MECHANISM OF ACTION
 The precise mechanism of action by which antidepressants
produce their therapeutic effects is not known, but much is
known about their action on the CNS.
 The major interaction is with the monoamine
neurotransmitter systems in the brain, particularly
norepinephrine and serotonin.
 Both of these neurotransmitters are released throughout the
brain, and help to regulate arousal, vigilance, attention,
mood, sensory processing and appetite
MECHANISM OF ACTION
 Norepinephrine and serotonin are
removed from the synapses after
release by reuptake into presynaptic
neurons.
 After reuptake, norepinephrine and
serotonin are reloaded for subsequent
release or metabolized by the enzyme
Monoamine Oxidase (MAO).
MECHANISM OF ACTION
 The Selective Serotonin Reuptake Inhibitors block the
reuptake of serotonin

 The Cyclic Antidepressants block the reuptake of


norepinephrine and serotonin to some degree

 The Monoamine Oxidase Inhibitors (MAOIs) interfere


with enzyme metabolism of norepinephrine

 These class of medications permits norepinephrine to


linger longer in synapses to increase its levels there.
TRICYCLIC ANTIDEPRESSANTS
(TCAs)
 Amitriptyline (Elavil)
 Amoxapine (Asendin)
 Doxepin (Sinequan)
 Imipramine (Tofranil)
 Despiramine (Norpramine)
 Nortriptyline (Pamelor)
EFFECTS OF TCAs
 Prevents the reuptake of
norepinephrine, increases appetite and
produces adequate sleep
WHEN TO ADMINISTER TCAs
 Best given after meals
SIDE EFFECTS OF TCAs
 The cyclic antidepressants block cholinergic receptors,
resulting in anticholinergic effects such as dry mouth,
constipation, urinary hesitancy or retention, dry nasal
passages, and blurred near vision

 More severe anticholinergic effects, such as agitation,


delirium, and ileus, may occur particularly in adults

 Hypotention, sedation, weight gain, tachycardia, and


sexual dysfunction are common side effects
IMPORTANT POINTS ON THE
USE OF TCAs
 Therapeutic effects may become evident only after 2 –
3 weeks of intake; they have a lag period before
reaching a serum level that begins to alter symptoms

 Check the blood pressure as they cause hypotension

 Check the heart rate as they cause cardiac arrythmias


IMPORTANT POINTS ON THE
USE OF TCAs
 TCAs are contraindicated in severe
impairment of liver function and in
myocardial infarction (acute recovery
phase)

 They cannot be given concurrently


with MAOIs
IMPORTANT POINTS ON THE
USE OF TCAs
 Because of their anticholinergic side effects, TCAs must
be used cautiously in patients with glaucoma, benign
prostatic hypertrophy, urinary retention or obstruction,
diabetes mellitus, hyperthyroidism, cardiovascular
disease, renal impairment or respiratory disorders

 Overdosage occurs over several days and results in


confusion, agitation, hallucinations, hyperpyrexia and
increased reflexes
MONOAMINE OXIDASE
INHIBITORS
 Isocarboxazid (Marplan)
 Phenelzine (Nardil)
 Tranylcypromine (Parnate)
EFFECTS OF MAOIs
 Functions as antidepressants resulting
into increased appetite and adequate
sleep
WHEN TO ADMINISTER MAOIs
 Best taken after meals
SIDE EFFECTS OF MAOIs
 The most common side effects of MAOIs
include daytime sedation, insomnia, weight
gain, dry mouth, orthostatic hypotension
and sexual dysfunction.

 The sedation and insomnia are difficult to


treat and may necessitate a change in
medication
SIDE EFFECTS OF MAOIs
 Of particular concern with MAOIs is the potential for a life-
threatening hypertensive crises if the client ingests food that
contains tyramine or takes sympathomimetic drugs

 Because the enzyme monoamine oxidase is necessary to break


down the tyramine in certain foods, its inhibition results to
increased serum tyramine levels, which causes severe
hypertension, hyperpyrexia, tachycardia, diaphoresis,
tremulousness, and cardiac dysrythmias
FOODS (CONTAINING
TYRAMINE) TO AVOID WHEN
TAKING MAOIs
 Mature or aged cheeses or dishes made with
cheese, such as lasagna or pizza. All cheese is
considered aged except cottage cheese, cream
cheese, ricotta cheese, and processed cheese slices

 Aged meats such as pepperoni, salami, mortadella,


summer sausage, beef logs, and similar products.
Make sure meat and chicken are fresh and have
been properly refrigerated
FOODS (CONTAINING
TYRAMINE) TO AVOID WHEN
TAKING MAOIs
 Italian broad beans (fava) pods or banana peel.
Banana pulp and all other fruits and vegetables
are permitted

 All tap beers and microbrewery beer. Drink no


more than two cans or bottles of beer (including
non-alcoholic beer) or 4 ounces of wine per day

 Sauerkraut, soy sauce or soybean condiments or


marmite (concentrated yeast)
IMPORTANT POINTS ON THE
USE OF MAOIs
 It takes 2 – 3 weeks before initial therapeutic effect
become noticeable as it also has a lag period before
they reach therapeutic levels

 Monitor the blood pressure

 There should be at least a two-week interval when


shifting from one anti-depressant to another. Because
of the lag period a washout period is recommended
between the time the MAOI is discontinued and
another class of antidepressant is started
MAOI DRUG INTERACTIONS
 The following drugs cause potentially fatal interactions with
MAOIs
– Amphetamines
– Ephedrine
– Fenfluramine
– Isoproterenol
– Meperedine
– Phenylephrine
– Phenylpropanolamine
– Pseudoephedrine
– SSRIs
– TCAs
– Tyramine
SELECTIVE SEROTONIN
REUPTAKE INHIBITORS (SSRIs)
 These are the newest category of antidepressants
that are effective for most clients

 Their action is specific to serotonin reuptake


inhibition

 These drugs produce few sedating, anticholinergic


and cardiovascular side effects, which makes
them safer for use in children and older adults
SELECTIVE SEROTONIN
REUPTAKE INHIBITORS (SSRIs)
 Because of their low side effects and relative
safety, people using SSRIs are more apt to be
compliant with the treatment regimen than
clients using more troublesome medications.

 Insomnia decreases in 3 to 4 days, appetite


returns to a more normal state in 5 to 7 days, and
energy returns in 4 to 7 days.

 In 7 to 10 days, mood, concentration, and interest


in life improves
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
(SSRIs)
GENERIC (TRADE) NAME SIDE EFFECTS NURSING IMPLICATIONS
Fluoxetine (Prozac) Headache, nervousness,Administer in AM (if nervous) or
anxiety, sedation, tremor,PM (if drowsy)
sexual dysfunction, anorexia,Monitor for hyponatremia
constipatin, nausea, diarrhea,Encourage adequate fluids
weight loss
Report sexual difficulties to
physician

Sertraline (Zoloft) Dizziness, sedation, headache,Administer in PM if client is


insomnia, tremor, sexualdrowsy
dysfunction,diarrhea, dry mouthEncourage use of sugar free
and throat, nausea, vomiting,beverages or hard candy
sweating Drink adequate fluids
Monitor hyponatremia; report
sexual difficulties to physician

Paroxetine (Paxil) Dizziness, sedation, headache,Administer with food


insomnia, weakness, fatigue,Administer in PM if client is
constipation, dry mouth anddrowsy
throat, nausea, vomiting,Encourage use of sugar free
diarrhea, sweating hard candy or beverages
Encourage adequate fluids

Citalopram (Calexa) Drowsiness, sedation,Monitor for hyponatremia


insomnia, nausea, vomiting,Administer with food
weight gain, constipation,Administer dose at 6PM or later
diarrhea
Promote balanced nutrition and
NURSING INTERVENTIONS FOR
DEPRESSION
 Provide for safety of the client and others
– The first priority is to determine if the client with
depression is suicidal
– If a client has suicidal ideation or hears voices
commanding him to commit suicide, measures
to provide a safe environment are necessary
– The nurse asks additional questions to
determine the lethality of the intent and plan
– Suicide precautions (removal of harmful items,
increased supervision) are instituted.
NURSING INTERVENTIONS FOR
DEPRESSION
 Begin a therapeutic relationship by spending non-
demanding time with the client
– Clients may be unable to sustain a long interaction, so
several shorter visits help the nurse to asses status and
to establish a therapeutic relationship
– The nurse’s presence conveys genuine interest and
caring. Silence can convey that clients are worthwhile
even if they are not interacting.
– “My name is Sheila, I am your nurse today. I’m going to
sit with you for a few minutes. If you need anything, or
if you would like to talk, please tell me.”
– After time has elapsed, the nurse would say, “I am
going now. I will be back in an hour to see you again.”
NURSING INTERVENTIONS FOR
DEPRESSION
Promote completion of activities of daily living by assisting the
client only as necessary
– The nurse asks the client to perform a global task, “Martin, it is
time to get dressed.”
– If a client cannot respond to the global request, the nurse
breaks the task into smaller segments. Clients with depression
can become overwhelmed easily with a task that has several
steps. The nurse can use success in small, concrete steps as a
basis to increase self-esteem and to build competency for a
slightly more complex task the next time.
NURSING INTERVENTIONS FOR
DEPRESSION
 Establish adequate nutrition and hydration
– The nurse can explain that beginning to eat will help
stimulate appetite
– Food offered frequently and in small amounts can
prevent overwhelming clients with a large meal that
they feel unable to eat
– Sitting up with clients during meals can promote eating
– Monitoring food and fluid intake may be necessary until
clients are consuming adequate amounts
NURSING INTERVENTIONS FOR
DEPRESSION
 Promote rest and sleep
– This may include the short-term use of
sedatives or giving medication in the evening
if drowsiness or sedation is a side-effect.
– It is also important to encourage clients to
remain out of bed and active during the day
to facilitate sleeping at night
– It is important to monitor the number of hours
client sleep as well as if they feel refreshed on
awakening
NURSING INTERVENTIONS FOR
DEPRESSION
Encourage the client to verbalize and describe emotions
– Clients with depression are often overwhelmed by the intensity of
their emotions
– Talking about these feelings can be beneficial.
– Initially, the nurse encourages the clients to describe in detail how
they are feeling
– Sharing the burden with another person can provide some relief
– The nurse can listen attentively, encourage clients, and validate
the intensity of their experience.
NURSING INTERVENTIONS FOR
DEPRESSION
 Work with the client to manage
medications and their side effects.
SAMPLE BOARD QUESTION
NO.1
 The nurse knows that sadness typically
accompanies grief and depression. Which
affect changes indicate major depressions?

A) Fear, timidity and lack of interest around


B) Withdrawal, negative attitude, and little or
no eye contact
C) Lack of initiative, dominating personality,
and defensiveness
D) Irritability, apathy and self-doubt
ANSWER
 Letter D

 Rationale: Depression is usually


manifested by irritability, apathy, self-
doubt, sadness and psychomotor
retardation.
SAMPLE BOARD QUESTION
NO.2
 Which nursing approach would be best for a patient with
symptoms of severe depression?

A) Allow the patient time for quiet thought; remain silent


B) Ask the patient to join the nurse and the other patients
in the TV lounge
C) State that the nurse would like to go with a patient for a
short walk around the outside grounds, and assist the
patient with his or her coat
D) Give the patient a choice of recreational activities.
ANSWER
 Letter C

 Rationale: Walking is a therapeutic


activity for a patient with mood
disorder. Providing assistance to the
patient conveys a feeling of
importance.
SAMPLE BOARD QUESTION
NO.3
 Which nursing approach is important in
depression?

A) Providing motor outlets for aggressive,


hostile feelings.
B) Protecting against harm to others
C) Reducing interpersonal contacts
D) De-emphasizing preoccupation with
elimination, nourishment and sleep
ANSWER
 Letter A

 Rationale: Depressed patients usually


turn their hostile feelings towards
themselves. Providing an outlet for
these aggressive feelings will make the
patient feel less guilty.
SAMPLE BOARD QUESTION
NO.4
 When a patient with symptoms of severe depressions
says to the nurse, “I can’t talk; I have nothing to say.”
And continues being silent, what should the nurse say?

A) Say, “Alright, you do not have to talk. Let us play


cards instead.”
B) Explain that talking is an important sign of getting
well and that the patient is expected to do so
C) Be silent until the patient speaks again
D) Say, “It may be difficult for you to speak at this time,
perhaps you can do so at another time.”
ANSWER
 Letter D

 Rationale: This response will convey


that the nurse is willing to wait for the
patient’s readiness to engage in a
conversation.
SAMPLE BOARD QUESTION
NO.5
 When assessing patients who are in a depressed
episode and those who are exhibiting a manic
episode of bipolar mood disorders. Which
characteristics common to both episodes of the
disorder is the nurse likely to note?

A) Suicidal tendency
B) Underlying hostility
C) Delusions
D) Flight of ideas
ANSWER
 Letter B

 Rationale: In the depressed patient,


hostility is turned towards the self. In
the manic patient, hostility is turned
towards the environment.
SAMPLE BOARD QUESTION
NO.6
 An extremely hyperactive patient exhibiting manic behavior is
admitted to the hospital. In view of the patient’s elated state,
the nurse should arrange for the patient to be in a room

A) With another patient who is very quiet


B) That will provide a great deal of stimuli
C) That has had most of the furniture removed
D) With another patient experiencing similar behavior
ANSWER
 Letter C

 Rationale: The priority for a


hyperactive patient is safety
SAMPLE BOARD QUESTION
NO.7
 A hyperactive, manic patient might be redirected
therapeutically by?

A) Asking the patient to guide other patients in


group games
B) Encouraging the patient to tear pictures out of
magazines for a scrapbook
C) Suggesting the patient initiate social activities
on a unit with other patients
D) Encourage the patient to write a short story
ANSWER
 Letter B

 Rationale: This provides the patient an


opportunity to rechannel excess
energy into a more productive activity.
SAMPLE BOARD QUESTION
NO.8
 A patient who has a history of bipolar disorder
(manic) demonstrates grandiosity. The best
interpretation of this behavior is that the
patient is?

A) Afraid of talking to other people


B) Manifesting conceit
C) Compensating for low self-esteem
D) Deliberately attempting to intimidate
others
ANSWER
 Letter C

 Rationale: Delusions of grandeur is the


patient’s way of compensating for poor
self-esteem.
SAMPLE BOARD QUESTION
NO.9
 Which of the following food selections
is appropriate for a manic patient?

A) Cheeseburger
B) Rice toppings
C) Chicken soup
D) Potato chips
ANSWER
 Letter A

 Rationale: High calorie finger foods


which the patient can carry around as
he moves is the most appropriate
selection for a manic patient.
SAMPLE BOARD QUESTION
NO.10
 An individual who is on a psychiatric unit and has a
diagnosis of depression makes all of the following remarks
to the nurse during her hospitalization. Which one
suggests an improvement in her condition?

A) “I am making a plan to organize child care for parents


while they attend services at my church.”
B) “My room mate does not show any consideration. She is
always turning the lights on at any hour of the night.”
C) “I know who is boss and I cooperate to the best of my
ability.”
D) “Let me wash the bathroom floor.”
ANSWER
 Letter A

 Rationale: At the height of depression,


patients usually have difficulty
conceptualizing activities. The
patient’s plan to organize child care
indicates that his ability to
conceptualize is working. This
indicates recovery from depression.
SUICIDE
SUICIDE
 It is the intentional act of killing
oneself

 It is the ultimate form of self-


destruction

 It is a cry for help


SUICIDE
 Suicidal thoughts are common in
people with mood disorders, especially
depression

 In the United States, men commit


approximately 72% of suicides, which
is roughly 3 times the rate of women,
although women are 4 times more
likely than men to attempt suicide.
SUICIDE
 The higher suicide rates for men are
partly the result of the method chosen
(e.g., shooting, hanging, jumping from
a high place).

 Women are more likely to overdose on


medication
RISK FACTORS FOR SUICIDE
 Clients with psychiatric disorders who are
at increased risk for suicide include:

– Depression
– Bipolar disorder
– Schizophrenia
– Substance abuse
– Post-traumatic stress disorder
– Borderline personality disorder
RISK FACTORS FOR SUICIDE
 Environmental factors that increase suicide
risk include:

– Isolation
– Recent Loss
– Lack of social support
– Unemployment
– Critical life events
– Family history of depression or suicide
RISK FACTORS FOR SUICIDE
 A history of suicide attempts increases
risk for suicide.

– The first two years after an attempt


represent the highest risk period,
especially the first three months.
RISK FACTORS FOR SUICIDE
 Those with a relative who committed suicide are
at increased risk for suicide: the closer the
relationship, the greater the risk

– One possible explanation is that the relative’s


suicide offers a sense of “permission” or
acceptance of suicide as a method of
escaping a difficult situation
THEORETIC FOUNDATIONS OF
SUICIDE
 Psychodynamic theories

– According to Freud is a “conflict between the


instinct for life and the instinct for death

– Suicide occurs when the wish for death


predominates.

– Others view suicide as an aggression intended for


others turned inward against the self
THEORETIC FOUNDATIONS OF
SUICIDE
 Sociologic Theories
– The social and cultural contexts in which the
individual lives influence the expression of
suicidality. There are four types:

 Egoistic Suicide
– The individual’s ties to the community are too
loose or tenuous, and the individual is not
interested in maintaining his or her relationship
with the community
THEORETIC FOUNDATIONS OF
SUICIDE
 Sociologic Theories

 Anomic Suicide
– An individual experiences the aloneness
or estrangement that occurs when there
is a precipitous deterioration in one’s
relationship with the society
THEORETIC FOUNDATIONS OF
SUICIDE
 Sociologic Theories

– Fatalistic Suicide
 An individual is excessively regulated,
or there are no personal freedoms or no
hope (e.g., suicide of slaves)
THEORETIC FOUNDATIONS OF
SUICIDE
 Sociologic Theories

– Altruistic Suicide
 Rules of customs demand suicide under
certain conditions, or self–inflicted
suicide is honorable
LEVELS OF SELF-DESTRUCTIVE
BEHAVIOR
 Chronic self-destructive behavior
– Smoking, gambling, self-mutilation

 Suicidal threat
– A threat more than a casual statement
of suicidal intent and accompanied by
behavioral changes, e.g., mood
swings, temper outbursts, decline in
school or work performance
LEVELS OF SELF-DESTRUCTIVE
BEHAVIOR
 Suicidal gesture
– More serious warning signal than a threat
that may be followed by an act that is
carefully planned to attract attention
without seriously injuring the subject

 Suicidal attempt
– A strong and desperate call for help
involving a definite risk
FAMILY CHARACTERISTIC OF
SUICIDAL PATIENTS
 Poor family history or tendencies
 Early trauma
 Rigid, disorganized or dysfunctional
family system
 Disturbed parent-child relationship
 Unresolved loss
 History of abuse
COGNITIVE STYLES OF
SUICIDAL PATIENTS
 Ambivalence

– They have two conflicting desires at


the same time: to live and to die

– Ambivalence accounts for the fact that


a suicidal person often takes lethal or
near-lethal action but leaves open the
possibility for rescue.
COGNITIVE STYLES OF
SUICIDAL PATIENTS
 Communication

– Some people cannot express their needs or


feelings to others, or when they do, they do
not obtain the results they hope for.

– For them, suicide becomes a clear and


direct, if violent, form of communication
DEMOGRAPHIC VARIABLES
 Suicide rates are higher among the following:
– Single people
– Divorced, separated or widowed
– People who are confused about their sexual orientation
– People who have experienced a recent loss: divorce, loss of
job, loss of prestige, loss of social status or who are facing the
threat of criminal exposure
– Caucasians, Eskimos and native Americans
– Protestants or those who profess no religious affiliation
SUICIDAL IDEATION
 Means thinking about killing oneself

 Active suicidal ideation is when a person thinks


about and seeks ways to commit suicide

 Passive suicidal ideation is when a person thinks


about wanting to die or wishes he or she were
dead but has no plans to cause his or her death

 People with active suicidal ideation are considered


more potentially lethal
LETHALITY ASSESSMENT SCALE
 A scale used in an attempt to predict
the likelihood of suicide
LETHALITY ASSESSMENT SCALE
KEY TO SCALE DANGER TO TYPICAL
SELF INDICATORS

1 No predictable riskHas no notion of


of immediatesuicide or history
suicide of attempts, has
satisfactory social
support network,
and is in close
contact with
significant others
LETHALITY ASSESSMENT SCALE
KEY TO SCALE DANGER TO TYPICAL
SELF INDICATORS
2 Low risk ofPerson has
immediate suicide considered suicide
with low lethal
method; no history
of attempts or
recent serious
loss; has
satisfactory
support network;
no alcohol
problems;
LETHALITY ASSESSMENT SCALE
KEY TO SCALE DANGER TO TYPICAL
SELF INDICATORS

3 Moderate risk ofHas considered


immediate suicide suicide with high
lethal method but
no specific plan or
threats; or has
plan with low
lethal method,
history of low
lethal attempts,
with tumultuous
family history and
reliance on valium
or other drugs for
LETHALITY ASSESSMENT SCALE
KEY TO SCALE DANGER TO TYPICAL
SELF INDICATORS

4 High risk ofHas current high


immediate suicide lethal plan,
obtainable means,
history of previous
attempt, has a
close friend but is
unable to
communicate with
him; has a
drinking problem;
is depressed and
LETHALITY ASSESSMENT SCALE
KEY TO SCALE DANGER TO TYPICAL
SELF INDICATORS

5 Very high risk ofHas current high


immediate suicide lethal plan with
available means,
history of high
lethal suicide
attempts; is cut off
from resources; is
depressed; uses
alcohol to excess;
and is threatened
with a serious loss
such as
unemployment or
GUIDE QUESTIONS IN
LETHALITY ASSESSMENT
 Does the client have a plan? If so, what is it? Is
the plan specific?

 Are the means available to carry out this plan?


(For example, if the person plans to shoot himself,
does he have access to a gun and ammunition?)

 If the client carries out the plan, is it likely to be


lethal? (For example, a plan to take 10 aspirin
tablets is not lethal; a plan to take a 2-week
supply of a tricyclic antidepressant is.)
GUIDE QUESTIONS IN
LETHALITY ASSESSMENT
 Has the client made preparations for death such
as giving away prized possessions, writing a
suicide note, or talking to friends one last time?

 Where and when does the client intend to carry


out the plan?

 Is the intended time a special date or anniversary


that has meaning for the client?
WHAT IS THE PRIORITY
NURSING DIAGNOSIS IN
SUICIDE
 Risk for injury – Self directed
NURSING CARE FOR SUICIDAL
PATIENTS
 Provide one-on-one monitoring

 Have frequent unscheduled rounds

 Avoid use of metals and glass utensils

 Monitor for the signs of impending


suicide
MAJOR INTERVENTIONS FOR
SUICIDAL PATIENTS
 Prevention

 Listen
SAMPLE BOARD QUESTION
NO.1
 A 19 year-old patient is brought to the
emergency room because she slashed her
wrists. What is the nurse’s first concern?

A) Stabilization of physical condition


B) Determination of antecedent, causal
factors relevant to the wrist slashing
C) Reduction of anxiety
D) Obtaining a detailed nursing history
ANSWER
 Letter A

 Rationale: The priority for the patient


is her physiologic homeostasis
SAMPLE BOARD QUESTION
NO.2
 Which characteristic should the nurse recognize as
common in a person engaged in gradual self-
destructive behavior such as in obesity, drug
addition, and smoking?

A) Acceptance of death wish


B) Denial of possibility of death
C) Ability to control own behavior
D) Ignorance of the consequences of own behavior
ANSWER
 Letter B

 Rationale: Self-destructive behavior


usually is related to the patient’s
denial of the possibility of death
SAMPLE BOARD QUESTION
NO.3
 A patient relates to the nurse, “I was going to kill
myself last night.” What is the best initial
response of the nurse?

A) Say nothing. Wait for the patient’s next


comment
B) “What were you going to do this time?”
C) “Have you felt this way before?”
D) “You seem upset. I am going to be here with
you. Perhaps you will want to talk about it.”
ANSWER
 Letter D

 Rationale: This response facilitates free


expression of feelings.
SAMPLE BOARD QUESTION
NO.4
 Which feeling is the nurse likely to identify as
the antecedent of self-destructive behavior?

A) Omnipotence
B) Grandiosity
C) Low self-esteem
D) Self-satisfaction
ANSWER
 Letter C

 Rationale: Low self-esteem causes


depression. When depression begins
to lift, the patient may now have
enough energy to carry out a suicidal
plan.
SAMPLE BOARD QUESTION
NO.5
 In planning patient care, a nurse need to know
that self-destructive behavior may be
interpreted as the?

A) Directing hostile feelings toward self


B) Directing hostile feelings toward others
C) Directing hostile feelings toward an
internalized love object
D) Internalized on the fear of death
ANSWER
 Letter C

 Rationale: Suicide can be related to


directing of hostile feelings toward an
internalized love object.
SAMPLE BOARD QUESTION
NO.6
 It would be important to the nurse to
implement definite suicide precautions for
a depressed patient’s mood change
suddenly to one of ?

A) Cheerfulness
B) Psychomotor retardation
C) Agitation
D) Hostility
ANSWER
 Letter A

 Rationale: When a depressed person


suddenly becomes cheerful, it means
that the patient is recovering from
depression and is in danger of
committing suicide.
SAMPLE

BOARD QUESTION NO.7
Ursula, 25, is found sitting on the floor of a bathroom with moderate
lacerations to both wrists. With broken pieces of glass around her, she
stares blankly at her bleeding wrists while friends call for an
ambulance. How should a nurse approach Ursula initially?

A) Enter the room quietly and move beside her to assess her injuries
B) Call for back-up before entering the room and restraining her.
C) Move as much glass away and then quietly sit next to her
D) Approach her slowly and in a calm voice call her name and tell her
that the nurse is here to help her
ANSWER
 Letter D

 Rationale: This approach provides


reassurance for a patient in distress
SAMPLE BOARD QUESTION NO.8
 Ursula is taken to the hospital and admitted on emergency basis for 72 hours, as provided by
state law. Ursula says to the admitting nurse, “I am not staying here. I was a little upset
and did a stupid thing. I want to live.” Which response is most appropriate?
A) “Unfortunately, you have no right to leave at this time. You must be evaluated further.”
B) “Cutting your wrist certainly was a stupid thing to do. What are you trying to accomplish
anyway?”
C) “You have been admitted on an emergency basis and can be held by 72 hours. You have
the right to consult the lawyer about your admission.”
D) “I can see you’re upset. Why don’t you try to relax? You can explain to the physician
what upset you. If what you say is true, you’ll be released sooner.”
ANSWER
 Letter C

 Rationale: This response provides


orientation to the patient about the
present situation
SAMPLE BOARD QUESTION
NO.9
 Determining Ursula’s suicide potential during the
mental status examination involves assessing
several factors, the most significant of which is her?

A) History of previous attempts


B) Suicide plan
C) Emotional state
D) Self-esteem
ANSWER
 Letter B

 Rationale: The presence of a definite


plan increases the risk for suicide.
SAMPLE BOARD QUESTION
NO.10
 A female patient who is on a psychiatric unit is being observed
for signs of suicidal intent. Which of these behaviors by the
patient is most likely a sign of suicidal risk?

A) She continuously falls asleep after midnight


B) She has constant body aches without organic cause
C) She becomes euphoric for no apparent reason
D) She restricts her interpersonal contacts to staff who care for
her.
ANSWER
 Letter C

 Rationale: The patient’s behavior


indicates recovery from depression,
which increases the risk for suicide.
ALZHEIMER’S DISEASE
ALZHEIMER’S DISEASE
 An organic mental disorder defined as
a chronic, progressive condition that is
the major cause of degenerative
dementia seen in the elderly

 The main pathology is the presence of


senile plaques that destroys neurons
leading to decreased acetylcholine
COMPARISON OF DELIRIUM AND
DEMENTIA
INDICATOR DELIRIUM DEMENTIA
Onset Rapid Gradual and insidious

Duration Brief (hours to days) Progressive deterioration

Level of Impaired, fluctuates Not affected


Consciousness

Memory Short-term memoryShort-term then Long-term


impaired memory impaired, eventually
destroyed

Speech May be slurred,rambling,Normal in early stage,


pressured, irrelevant progressive aphasia in later
stage

Thought Temporarily disorganized Impaired thinking, eventual loss


Processes of thinking abilities

Perception Visual or tactileOften absent, but can have


hallucinations, delusions paranoia, hallucinations,
4As OF ALZHEIMER’S DISEASE
 Aphasia

– Loss of language ability

– Initially there is difficulty in finding words

– There is deterioration of language function and


exhibits palilalia (echoing sounds) and echoing
words

– Eventually, there is loss of all verbal ability


4As OF ALZHEIMER’S DISEASE
Apraxia

– Loss of purposeful movement without loss of muscle power or


coordination in general

– Ability to conceptualize or perform motor tasks deteriorates

– There is difficulty in pursuing complex tasks or become so


obsessed with an aspect of an act that they cannot complete it.

– The client loses the ability to perform self-care activities


4As OF ALZHEIMER’S DISEASE
 Agnosia

– Loss of sensory ability to recognize objects

– Initially, has difficulty recognizing everyday


objects like chairs and tables

– In the later stages, cannot recognize even loved


ones or their own body parts.
4As OF ALZHEIMER’S DISEASE
 Amnesia

– Mnemonic disturbances or memory loss

– In the initial stages, there is recent memory loss such


as forgetting food cooking on the stove

– In later stages, there is remote memory loss such as


forgetting names of children, occupation

– Eventually there is profound memory loss of both


recent and past events
STAGES OF ALZHEIMER’S
DISEASE
 Early or Forgetfulness Stage

 Second or Advanced Stage

 Final or Terminal Stage


EARLY OR FORGETFULNESS
STAGE
 Has difficulty remembering names and
appointments and may forget where
things are placed

 Have problems with spatial orientation

 Shows affect changes and seems


emotionally unstable at times
SECOND

OR ADVANCED STAGE
Cognitive deficits are present

 May last from 2 – 12 years

 Memory for past events may still exist, but the person has no recall
of recent ones.

 Orientation and concentration are affected and has increasing


difficulty comprehending everyday events

 There is restlessness at night and increased aphasia, apraxia and


agnosia

 Former social habits are forgotten


FINAL OR TERMINAL STAGE
 Lasts for several months to 5 years

 There is severe disorientation, psychotic symptoms

 Kluver-Busy-like syndrome (hyperorality, blunting of emotions,


bulimia, attempt to touch every object in sight) occurs

 Eventually becomes bedridden, emaciated and helpless

 Death results from pneumonia, malnutrition or dehydration


PREDISPOSING FACTORS IN
ALZHEIMER’S DISEASE
 Genetics
– In 10% to 20%, runs in the family
 Viral
 Aluminum
 Vitamin B12 deficiency
 Related with Down’s syndrome
 Possible defect in the immune system
 Disrupted biochemical pathways and other
metabolic (glucose) abnormalities
DRUGS THAT SLOW THE
PROGRESS OF DEMENTIA
NAME OF DOSAGE RANGE AND NURSING
CHOLINESTERASE ROUTE CONSIDERATIONS
INHIBITOR

Tacrine (Cognex) 40 – 160 mg orally perMonitor liver enzymes for


day divided into 4 doses hepatotoxic effects
Monitor for flu-like
symptoms

Donepezil (Aricept) 5 – 10 mg orally per day Monitor for nausea,


diarrhea, and insomnia
Test stools periodically for
GI bleeding

Rivastigmine (Exelon) 3 – 12 mg orally per dayMonitor for nausea,


NURSING CARE FOR
ALZHEIMER’S PATIENTS
 Promote normal motor behavior
– Living areas must be well lit and furniture left in the
same place
– Safety bars installed near toilets, showers, and tubs
– Teach safe use of walkers and wheelchairs
– Evaluate clients using tranquilizers and
antidepressants for postural hypotension
– Avoid crowds or large open spaces without
boundaries
NURSING CARE FOR
ALZHEIMER’S PATIENTS
 Maintain self-care
– Allow the client to do as much as
possible unassisted
– Remind client about daily grooming
– Remind client about grooming and
personal hygiene
– Use mouth swabs with dilute hydrogen
peroxide if client resists mouth care
– Total bed care
NURSING CARE FOR
ALZHEIMER’S PATIENTS
 Promote adequate sleep

– Allow sleepless clients to wander in a


confined area until they are tired

– Make sure room is lighted and without


shadows

– Leave a radio on to provide more stimulation


NURSING CARE FOR
ALZHEIMER’S PATIENTS
 Support knowledge processes

 Support optimal verbal expression


– Call the client by name, approach in a
clear view and give simple directions

 Support optimal role performance


– Client must be viewed as an active
family member
NURSING CARE FOR
ALZHEIMER’S PATIENTS
 Promote optimal patterns of
elimination
– Toileting routine is essential

 Promote optimal nutritional status


NURSING CARE FOR
ALZHEIMER’S PATIENTS
 Support optimal memory function

– Gently orient client

– Do not argue about verbal discrepancies. Rather,


direct client towards areas of interest that are
familiar and pleasurable

– Music therapy

– Drug therapy
NURSING CARE FOR
ALZHEIMER’S PATIENTS
 Promote optimal orientation

– Structure environment to support


cognition
– Hearing or visual aids are necessary to
prevent sensory loss or distortion
– Easy to read clocks, orientation boards
and consistent daily routine
– Do not quiz the client
NURSING CARE FOR
ALZHEIMER’S PATIENTS
 Support appropriate conduct or impulse control

– Client functions best in an environment where


stimulation is controlled and sensory overload is
prevented
– Changes must be done slowly
– Call client by name, approach in full view and
refrain from touching client
– Requests should be simple and non-demanding
NURSING CARE FOR
ALZHEIMER’S PATIENTS
 Maintain optimal attention span

– Repeat requests as needed

– Speak in simple phrases, loud enough to be heard


and reinforce meaning with non-verbal gesture

– Lower client’s anxiety level by moving slowly,


speaking clearly and providing new information
slowly
NURSING CARE FOR
ALZHEIMER’S PATIENTS
 Maintain optimal perceptual functioning
– A quiet environment with soft music prevents
sensory overload
– When speaking with the client, stand or sit so that
you are in direct view
– First giving a verbal warning, touch the client’s
shoulder or hands, and slowly and clearly explain all
procedures.
– Use touch with caution
– Sometimes a very soothing touch can overexcite the
client, who may respond by striking out
NURSING CARE FOR
ALZHEIMER’S PATIENTS
 Maintain optimal perceptual functioning
– When responding to hallucination
– Simply state that you understand that these
thoughts seem very real but that you do not
experience the same thoughts
– Do not argue or ask client to elaborate
– Give assurance that these thoughts will go
away
SAMPLE BOARD QUESTION
NO.1
 When a patient has dementia, it is most important that
the nurse plan the daily activities to?

A) Be highly structured
B) Be changed each day to meet the patient’s need for
variety
C) Be simplified as much as possible to avoid problems
with decision-making
D) Provide many opportunities for making choices to
simulate the patient’s involvement and interest
ANSWER
 Letter A

 Rationale: A highly structured


environment decreases the burden of
decision making for the patient.
SAMPLE BOARD QUESTION
NO.2
 What will the nurse most commonly note in the
clinical picture of dementia?

A) Memory loss for events of the distant past


B) Quarrelsome behavior directly related to the
extent of lack of blood supply to the brain
C) Increased resistance to change
D) Ability to perform ADL
ANSWER
 Letter C

 Rationale: Increased resistance to


change is a common manifestation of
dementia
SAMPLE BOARD QUESTION
NO.3
 An important part of the nursing care
for a patient with dementia would be?

A) Minimizing regression
B) Correcting memory loss
C) Rehabilitating toward independent
functioning
D) Preventing further deterioration
ANSWER
 Letter A

 Rationale: Nursing care for the patient


with dementia is geared toward
maintaining existing functions by
minimizing regression.
SAMPLE BOARD QUESTION
NO.4
 The patient is in the early stage of Alzheimer’s disease and
his adult son attended an appointment at the community
health center. The nurse is reading the autopsy report of a
patient who recently died. The report reveals senile plaques,
neurofibrillary tangles, and atrophy. These changes are
characteristic of which illness?

A) Meningitis
B) Delirium tremors
C) Neurosyphilis
D) Alzheimer’s disease
ANSWER
 Letter D

 Rationale: Alzheimer’s disease is


characterized by presence of senile
plaques, neurofibrillary tangles, and
atrophy of the brain.
SAMPLE BOARD QUESTION
NO.5
 While conversing with the nurse the son
states, “I am tired of hearing about how
things were 30 years ago. This statement
indicates?

A) A lack of knowledge of the disease


B) Unusual behavior in the father
C) His father’s level of anxiety
D) His father’s antagonism toward him
ANSWER
 Letter A

 Rationale: Patients with dementia


usually talk about the past
SAMPLE BOARD QUESTION
NO.6
 The nurse discusses the possibility of the patient attending day
treatment for patients with Alzheimer’s disease. The best
rationale the nurse would give for day treatment is that

A) The patient would have more structure for his day


B) The staff are excellent in the treatment they offer to the
patients
C) The patient would benefit from increased social interaction
D) This will decrease burden on the family
ANSWER
 Letter C

 Rationale: Attending day treatment


increases social interaction for the
demented patient.
SAMPLE BOARD QUESTION
NO.7
 Three of the following statements are true about
Alzheimer’s disease. Which one is inaccurate?

A) There is degeneration of the cortex and atrophy of the


cerebrum
B) Death usually occurs 1 to 10 years after onset
C) There is progressive deterioration of intellectual function
and change in personality and behavior
D) The etiology of this disease is well-known and
documented in research findings.
ANSWER
 Letter D

 Rationale: The etiology of Alzheimer’s


disease is unknown
SAMPLE BOARD QUESTION
NO.8
 Mrs. Reyes, 72, with Alzheimer’s disease, has difficulty
remembering where her room is on the unit. Which of the
following would best help her alleviate this problem?

A) Paint the door to her room light pink


B) Assign her a peer who will help her find her room
C) Print her name in large letters on the door to her room
D) Assign her a room next to the nurses’ station so the staff can
assist her as necessary
ANSWER
 Letter C

 Rationale: Printing the patient’s name


in large letters on the door to her room
provides reorientation for the patient.
SAMPLE BOARD QUESTION
NO.9
 Mang Nano, 75, was diagnosed as having
primary degenerative dementia of the
Alzheimer’s type. Alzheimer’s disease is a ?

A) Functional disorder
B) An irreversible condition
C) Generally reversible condition
D) Delirious state
ANSWER
 Letter B

 Rationale: Alzheimer’s disease, a


dementia, is irreversible
SAMPLE BOARD QUESTION
NO.10
 One of the important areas of concern for
the staff and family in the care of Mang
Nano is his safety. An appropriate nursing
diagnosis would be?

A) Impaired physical mobility


B) Altered thought process
C) Impaired verbal communication
D) Potential for injury
ANSWER
 Letter D

 Rationale: Due to cognitive and


memory deficits, a patient with
Alzheimer’s disease is at risk for injury.
SAMPLE BOARD QUESTION
NO.11
 The nurse should include in her health
teaching that Mang Nano’s progressive loss of
memory leads to inability to recognize family
members. This sign of Alzheimer’s disease is
known as?

A) Apraxia
B) Mnemonic disturbance
C) Agnosia
D) Aphasia
ANSWER
 Letter C

 Rationale: Agnosia is inability to


recognize objects and persons.
ALCOHOLISM
ALCOHOLISM
 A state of physical and psychological dependency on
alcohol manifested by an individual’s inability to refrain
from drinking or to control his consumption of alcohol

 World Health Organization definition


– A chronic disease or a disorder characterized by
excessive alcohol intake and interference in the
individual’s health, interpersonal relationship and
economic functioning

 Considered to be present when there is 0.1% or 10 ml for


every 1,000 ml of blood
DYNAMICS OF ALCOHOLISM
 Social drinking may progress to abuse

 The reliance on excessive drinking as a means of


dealing with personal tension and discomfort clearly
suggests the psychological factors play a key role in the
development of alcohol abuse.

 Alcohol being a depressant aids in the relaxing of the


individual and releases inhibitions

 Following a drinking episode, the alcohol abuser is


often overwhelmed with feelings of remorse and guilt
PHASES OF PROGRESSION OF
ALCOHOLISM
1) Pre-alcoholic Phase
– Starts with social drinking until tolerance begins
to develop
2) Prodromal Phase
– Alcohol becomes a need; blackouts occur; denial
begins to develop
3) Crucial Phase
– Cardinal symptoms of alcoholism develops (loss of
control over drinking)
4) Chronic Phase
– The person becomes intoxicated all day
ETIOLOGICAL THEORIES OF
ALCOHOLISM
1) Psychoanalytic Theories
– Due to fixation in the oral stage of development

2) Learning Theories
– Due to a learned behavior

3) Biological Theories
– Due to inherited traits

4) Socio-cultural Theories
– Due to effects of mass media
MANIFESTATIONS OF
DIFFERENT BLOOD LEVELS OF
ALCOHOL

BLOOD LEVEL MANIFESTATION

0.1% TO 0.2% Low coordination

0.2% TO 0.3% Presence of ataxia,


tremors, irritability,
stupor
EFFECTS OF ALCOHOL
 A sedative anesthetic, alcohol is
absorbed in the small intestine;
approximately 95% is broken down by
the liver, the rest is excreted through
the lungs, the kidneys and skin.

 Generally, a person can metabolize 10


ml of alcohol or 1 ounce of whiskey
every 90 minutes
EFFECTS OF ALCOHOL
 If taken in exceedingly high doses, it
can depress respiration and cause
death.

 Intoxication occurs when a person’s


blood alcohol level is 0.10% or more
EFFECTS OF ALCOHOL
 Simple intoxication lasts less than 12 hours and is usually
followed by a hangover with unpleasant symptoms
(nausea, vomiting, gastritis, headache, fatigue, sweating,
thirst, vasomotor instability) occurring approximately 4 – 6
hours after alcohol ingestion. The cause is uncertain but
the symptoms are attributed to hypoglycemia and the
accumulation of lactic acid and acetaldehyde in the blood.

 Alcoholic hallucinosis
– Auditory hallucinations reported approximately 48
hours after heavy drinking.
POSSIBLE OUTCOMES OF
ALCOHOLISM
 Brain damage

 Alcoholic hallucinosis

 Death
COMMON BEHAVIORAL
PROBLEMS OF ALCOHOLIC
PATIENTS
 Denial

 Dependency

 Demanding

 Destructive

 Domineering
COMMON DEFENSE
MECHANISMS UTILIZED BY
ALCOHOLICS
 Denial

 Rationalization

 Isolation

 Projection
STAGES OF ALCOHOL
WITHDRAWAL SYNDROME
1) Tremulousness
– Occurs during the drinking period up
to 2 hours afterward.
– There is anxiety, agitation and
irritability
– As it progresses, tremors,
tachycardia and diaphoresis are
exhibited
STAGES OF ALCOHOL
WITHDRAWAL SYNDROME
2) Hallucinations
– Begins 12 – 48 hours after the
person stops drinking
– Gastrointestinal symptoms of
nausea, vomiting, diarrhea and
anorexia are present
STAGES OF ALCOHOL
WITHDRAWAL SYNDROME
 Delirium tremens
– A condition of severe memory disturbance,
agitation, anorexia and hallucinations
– Begins a few days after drinking stops and
ends within 1 – 5 days
– There is elevated temperature, severe
diaphoresis, hypertension and tachycardia
– Behavioral symptoms include confusion
with disorientation, agitation, tremors, and
alterations in sensory perception.
COMMON WITHDRAWAL SIGNS
AND SYMPTOMS
 Hallucinations (visual and tactile)

 Increased vital signs

 Tremors

 Sweating and seizures


COMMON WITHDRAWAL
SYNDROMES EXPERIENCED BY
ALCOHOLICS
SYNDROME CAUSE ONSET ESSENTIAL OTHER SIGNS AND
FEATURE SYMPTOMS

DELIRIUM Faulty Acute Delirium Increased vital signs


TREMENS metabolism Visual and tactile
of alcohol hallucinations
Coarse tremors

KORSAKOFF’S Thiamine Chronic Memory Retrograde amnesia


PSYCHOSIS and Niacin Disturbances Anterograde amnesia
deficiency Confabulation
PHARMACOLOGIC TREATMENT
OF ALCOHOLIC PATIENTS
 Vitamin B1 (Thiamine) is often prescribed to prevent or to treat
Wernicke’s syndrome and Korsakoff’s syndrome, which are neurologic
conditions that can result from heavy alcohol use.
 Vitamin B12 (Cyanocobalamin) and folic acid are often prescribed for
clients with nutritional deficiencies
 Alcohol withdrawal is managed with a benzodiazepine anxiolytic agent,
which is used to suppress the symptoms of abstinence.
– The most commonly used benzodiazepines are lorazepam,
chlordiazepoxide and diazepam.
PHARMACOLOGIC TREATMENT
OF ALCOHOLIC PATIENTS
 Disulfiram (Antabuse) may be prescribed to help deter clients from drinking.
 If a client taking disulfiram drinks alcohol, a severe adverse reaction occurs with flushing, a
throbbing headache, sweating, nausea and vomiting.
 In severe cases, severe hypotension, confusion, coma, and even death may result

 The client must avoid a wide variety of products that contain alcohol such as cough syrup,
lotions, mouthwash, perfume, aftershave, vinegar and vanilla and other extracts.
The client must read product labels carefully because any product containing alcohol can

produce the symptoms.
DRUGS
DRUG USED FOR ALCOHOLIC
USE DOSAGE PATIENTS
NURSING
CONSIDERATIONS

Lorazepam Alcohol 2 – 4 mg every 2 – Monitor vital signs and


(Ativan) withdrawal 4 hours prn global assessments for
effectiveness; may cause
dizziness and drowsiness

Chlordiazepoxide Alcohol 50-100 mg, repeat Monitor vital signs and


(Librium) withdrawal in 2-4 hours if global assessments for
necessary, not to effectiveness; may cause
exceed 300 mg/day dizziness and drowsiness

Disulfiram Maintain 500 mg/day for 1-2 Teach client to read labels
(Antabuse) abstinence weeks, then 250 to avoid products with
from alcohol mg/day alcohol

Thiamine (Vitamin Prevent or 100 mg/day Teach client about proper


B1) treat nutrition
NURSING INTERVENTIONS FOR
ALCOHOLIC PATIENTS
1) Using confrontation strategies
– Several family members, friends, etc., can speak
calmly and slowly with minimal emotion.
– Present facts by saying, “You have alcohol on your
breath”, or “You have slurred speech”
– The next step requires them to make clear and
direct statements about consequences – “Either
you get help now or you will have to leave your
job.”
NURSING INTERVENTIONS FOR
ALCOHOLIC PATIENTS
2) Avoiding non-therapeutic
communication
– The nurse should avoid the role of
rescuer, patsy and prosecutor and
function in the role of a non-
judgmental problem solver who
points out the consequences of the
behavior.
NURSING INTERVENTIONS FOR
ALCOHOLIC PATIENTS
3) Make use of educating video tapes
and talks by recovered alcoholics

4) Referral and self-help groups


NURSING INTERVENTIONS FOR
ALCOHOLIC PATIENTS
5) Encourage lifestyle changes.
– Nurses can help clients discuss ways to
alter their destructive habits by
suggesting different coping strategies
and by encouraging clients to discover
new interests and capabilities within
themselves.
– Recognizing that relapses are always a
threat, nurses may set up contracts with
the client.
CONCEPT OF LOSS
STAGES OF GRIEF / GRIEVING
 Shock, Numbness, Disbelief
– Searching behavior

 Yearning and Protest


– Anger towards God

 Anguish, Disorganization and Despair


– Reality of the loss is accepted
STAGES OF GRIEF / GRIEVING
 Identification stage
– A family member imitates some
characteristics of the dead person

 Reorganization / Restitution
– Life normalizes
STAGES OF DEATH / DYING
 Denial
– “No, not me!”

 Anger
– “Why me?”

 Bargaining
– “If only….”
STAGES OF GRIEF / GRIEVING
 Depression
– Stage of silence

 Acceptance
– “Yes, it is me”
PRIORITY NURSING DIAGNOSIS
FOR THE GRIEVING / DYING
 Ineffective individual coping
PRIORITY NURSING DIAGNOSIS
FOR THE GRIEVING / DYING
 Be physically present

 Be non-judgmental

 Encourage verbalization of feelings

 Allow the patient to cry

 Recognize your own thoughts about death and


dying
THANK YOU !!! 