Psychiatric Nursing 2

St. Louis Review Center MENTAL HEALTH

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"A state of well-being where a person can realize his or her own abilities to cope with the normal stresses of life and work productively." (WHO) Balance in person’s internal life and adaptation to reality. State of well-being in which a person is able to realize his potentials.

Criteria for Mental Health: ⊗ Self-awareness ♦ Ability to:  recognize one’s thoughts feelings, asset potentials and weakness.  experience genuine feelings as anger, happiness, resentment

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Autonomy: ability to function independently and function with others Perceptive ability  Awareness of stimuli, reality orientation.

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leads to self-acceptance, self-understanding in order to understand others

Orientation to: Time, Place, Person

Integral capacity: Ability to harmonize psychic forces (id, ego, super ego). Self-actuation  Ability to adopt to life changes, happy to work with others  Satisfaction in every endeavor  Genuine cooperation

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A state in which an individual shows deficit in functioning and is unable to maintain personal relationship. State of imbalance characterized by a disturbance in a person’s thoughts, feelings and behavior Factors that increase the risk are: Crises, Abuses, Poverty

Historical View of Mental Illness ⊗ In the past, mental illness has been viewed as:  Demonic possession  Influence of ancestral spirits  Result of violating taboo or neglecting cultural, ritual, and spiritual condemnation ⊗ Period of Enlightenment (1745-1886)  Lunatics were restrained in iron menacles  Mentally ill were exhibited as diversion and entertainment for the public  Establishment of asylums  Opening of state hospitals for mentally ill. ⊗ Period of Scientific Study  Psychoanalysis by Sigmund Freud ⊗ Psychotropic Drugs (1950)

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Mastery of one’s environment: Awareness of the changes around him

Use of chlorpromazine and imipramine  Mental illness is caused by chemical imbalance in the brain. The Decade of the Brain (1990)  Focused on the connections between mental illness and biological malfunction in the brain and the neuroendocrine-immune system.  Biological views holds that biological defects are responsible for certain serious mental illness.

MENTAL HYGIENE

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a science that deals with: Promotive, Preventive, Curative, Rehabilitative aspects of care.

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MENTAL DISORDER A medically diagnosable illness which results in significant impairment of one's cognitive, affective or relational abilities and is equivalent to mental illness.

Criteria for Mental Disorder: ⊗ Dissatisfaction with:  one’s characteristics, abilities and accomplishments  one’s place in the world ⊗ Ineffective:  interpersonal relationship  coping or adaptation to the events in one’s life MENTAL ILLNESS

Psychiatric Nursing: Lecture Aid

Diagnosis of Mental Illness ⊗ Use of the Diagnostic and Statistical Manual of Mental Illness (DSM-IV) ⊗ Provides diagnostic criteria for each mental disorder and a system of 5 axes to give a comprehensive view of the client’s mental illness.

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Axis I: The clinical disorder that is the focus of treatment Axis II: Personality disorders and mental retardation Axis III: Medical conditions Axis IV: Psychosocial and environmental problems Axis V: Global assessment of functioning (GAF) PSYCHIATRIC NURSING

Importance: ⊗ ⊗ ⊗

An interpersonal process Concerned with all the aspects of care Both a Science and an Art

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 Science – uses different theories  Art - therapeutic use of self Clientele:  Individual, family and the community  Both mentally healthy and mentally ill

Main tool of the nurse: Therapeutic use of Self

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Characteristics of a Good Psychiatric Nurse: ⊗ Empathy ⊗ Genuineness ⊗ Congruence ⊗ Unconditional positive regard Roles of the Nurse in Psychiatric Setting:  Clinician  Collaborator  Counselor  Healthy role model  Parent surrogate  Patient advocate  Reality based  Researcher  Socializing agent  Teacher  Technician  Therapist  Ward manager

Description Aimed at altering the stressors through:

 Secondary

Tertiary

promotion of mental health  lowering the rate of cases Interventions that limits the severity of a disorder thorugh:  Case finding  Prompt treatment Aimed at reducing the disability after a disorder through:  Prevention of complication  Active program of rehabilitation

Psychiatric Nursing: Lecture Aid

Metabolic pattern Elimination pattern Cognitive pattern: Judgment, Insight, Memory Activity and exercise pattern Thought process Sleep-rest pattern

Types of Admissions: ⊗ Voluntary  Persons admit themselves

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Client consents to all treatment  Client can refuse treatment, including drugs, unless danger to self or others Involuntary  Judicial process  Initiated when someone files a petition  Certification of the likelihood of serious harm to self or others, or unable to care for self  Under 18, parents can confine with confirmation by a neutral fact finder  Must be released at end of statutory time or put on voluntary status or have a hearing

‘ Judicial Precedents Unless incompetent, client maintains all previous rights

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Examples Health education Information dissemination Counseling

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Crisis intervention Drug administration

Insanity as a Defense ⊗ Insanity : determined in court; legal terminology

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Alcoholics anonymous Occupational therapy

McNaughten Rule “At the time of the crime, the individual didn’t know the nature and quality of the act or didn’t know right from wrong.”

THE PSYCHIATRIC SETTING Admitting a Client in the Psychiatric Setting Areas to be assessed:

Orientation

LEGAL ASPECTS OF PSYCHIATRIC NURSING

Levels of Interventions in Psychiatric Nursing Level Primary

Health perception

COMMON BEHAVIORAL SIGNS AND SYMPTOMS Disturbance in Perception

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Illusion - misperception of an actual external stimuli Hallucination - false sensory perception in the absence of external stimuli

Management: ⊗ Acknowledge the feelings ⊗ Reorient to reality ⊗ Provide distractions

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St. Louis Review Center

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Neologism - pathological coining of new words Circumstantiality - over inclusion of details Word salad - incoherent mixture of words and phrases Flight of ideas - shifting of one topic from one subject to another in a completely unrelated way Looseness of Association - shifting of a topic from one subject to another in a somewhat related way Verbigeration - meaningless repetition of word or phrases Perseveration - persistence of a response to a previous question Echolalia - pathological repetition of words of others Clang association - the sound of the word gives direction to the flow of thought Delusion - false belief which is inconsistent with one's knowledge and culture  Grandeur - is an exaggerated belief of identity  Nihilistic - the client denies the existence of self or part of self  Persecution - belief that he or she is the object of environmental attention and being singled out for harassment  Self-depreciation - worthlessness or hopelessness  Somatic - false belief to body function.

Disturbances of Affect

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Inappropriate affect - disharmony between the stimuli and the emotional reaction Blunted affect - severe reduction in emotional reaction Flat affect - absence or near absence of emotional reaction Apathy - dulled emotional tone

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Retrograde - distant past

Deja vu - feeling of having been to place which one has not yet visited Jamais vu - feeling of not having been to a place which one has visited Dementia • gradual deterioration of intellectual functioning • results in the decreased of capacity to perform ADL

Other behavioral signs & symptoms

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Agitation - severe anxiety associated with motor restlessness. Agnosia - inability to recognize and interpret sensory stimuli. Akathisia - subjective feeling of muscular tension, restlessness and pacing repeated sitting and standing. Ambivalence - presence of two opposing feelings at the same time. Aphasia - inability or difficulty to speak or recall words Apraxia - inability to carry out specific task or activity. Delirium

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refers to acute change or disturbance in a person's: LOC, cognition, emotion , perception

Depression - feeling of sadness Derealization - feeling of strangeness towards the environment. Dysthymia - persistent state of sadness Elation (euphoria)- a feeling of high degree of confidence, boastfulness and joy with increase motor activity. Narcolepsy - sleep disorder characterized by frequent irresistible urge to sleep with episodes of cataplexy (sudden loss of muscle power)

Disturbances in Motor Activity

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Echopraxia - the pathological imitation of posture/action of others Waxy flexibility - maintaining the desired position for long periods of time without discomfort Akinesia - loss of movement Bradykinesia - slowness of all voluntary movement including speech. Ataxia - loss of coordinated movement

Disturbances in Memory

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Confabulation - filling in of memory gaps Amnesia - inability to recall past events

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Anterograde - immediate past

Psychiatric Nursing: Lecture Aid

USE OF APPROPRIATE COMMUNICATION TECHNIQUES Communication: reciprocal exchange of ideas between or among persons Modes: ⊗ Verbal - written/spoken ⊗ Non-verbal - posture, tone of voice, facial expression Types of Non-verbal communication: ⊗ Kinesis • body movement • eye contact • gestures ⊗ Paralanguage

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• voice quality • non-language vocalization (crying, sobbing, moaning) Proxemics – law of space relationship Touch – physical act Cultural artifacts Meta communication • based on role expectations • hidden meaning of words

St. Louis Review Center Acknowledging or giving recognition Asking direct questions

I noticed that you've fixed your bed.

Clarifying

I'm not sure that I understand what you are trying to say.

Confronting or presenting reality

Essentials for a Therapeutic Communication:

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Genuineness Respect Empathy Attentive listening Trust (rapport)

Barriers to a Therapeutic Communication

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Belittling Interrupting / ignoring Giving advice Social response

I see no bats flying in this room.

Encouraging comparison Encouraging description

Has this ever happened before? How do you feel when you take your medication?

Encouraging evaluation

Does participating in group therapy enable you to discuss your feelings? Tell me more about your job. Would you describe your responsibilities? (assisting a patient to explore specific topic) Is there something you'd like to do?

Exploring

Therapeutic Communication: a way of interacting in a purposeful manner to promote the client’s ability to express his thoughts and feelings openly.

How does your wife feel about your hospitalization?

Focusing Giving broad openings or asking open-ended questions Informing

(giving needed facts) I'll be your nurse for today, from 7:00 until 3:00 this afternoon. Making observations You appear to be angry. / I noticed that you're trembling. Offering general leads Go on. / You were saying… Restating Client: I can't sleep, I stay awake all night. Nurse: You can't sleep at night, (restating) Summarizing During the past hour, we talked about your plans for the future, they include... Using silence (to induce thought, pacing, acceptance) Validating (confirming one's observation) “So you mean . . .” Voicing doubt I find that hard to believe. Examples: Non-therapeutic Technique and Ineffective Communication Agreeing and disagreeing “I think you did the right thing.” Advice “You should.….” Belittling "Don't be concerned, evervone feels like that". Defending "All doctors here are simply great". False reassurance "Don't worry, everything will be all right". Focus on caregiver’s feeling “I feel that way too.” Judging

"It's your own mistake".

Changing the subject NURSE – PATIENT RELATIONSHIP

Approving / disapproving Moralizing

Examples: Therapeutic Technique Technique Accepting

Psychiatric Nursing: Lecture Aid

Example Yes, that must have been difficult for you.

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St. Louis Review Center Hildegard Peplau

Pre-Interaction Phase ⊗ begins when the nurse is assigned/chooses a patient ⊗ patient is excluded as an active participant ⊗ nurse feels certain degree of anxiety ⊗ includes all of what the nurse thinks and does before interacting with the patient

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Phases:

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Evaluate the summary of progress Reinforce change and strength of patient Give rewards for the cooperation during interaction Encourage expression of feelings about termination of the relationship Terminate the relationship without giving promises

develop self-awareness data gathering, planning for first interaction THEORIES OF HUMAN DYNAMICS Psychosexual Development : Sigmund Freud

Orientation phase ⊗ when the nurse-patient interacts for the first time

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Levels of Consciousness

establish of contract with the patient establish of trust and rapport

3 Psychic Energies

learn about the patient and his initial concerns and needs encourage the patient to feel comfortable with the meeting conduct initial interview manage present emotion of the patient provide support and empathy of the patient’s feelings assure of confidentiality

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

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

Problems:

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Transference  the development of an emotional attitude towards the nurse

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positive or negative

Counter transference – experienced by the nurse / therapist

Termination Phase

Psychiatric Nursing: Lecture Aid

Stages: Oral Stage (0-2 years) ⊗ The area of gratification is the mouth ⊗ Pleasures: sucking activities like fingers, toes or nipples ⊗ Dissatisfaction: resurface at a later  overeating, smoking, nail-biting

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Nursing Implication: ⊗ Provide oral stimulation by giving pacifiers  Breastfeeding may provide more stimulation. ⊗ Do not discourage thumb sucking Anal Stage (2-4 years) ⊗ Children's attention is focused on the anal region.

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Covers the ideal age for "toilet training" (2 1/2 years) 2 concepts:  Holding on  Letting go

Nursing Implication: Help children achieve bowel and bladder control without undue emphasis on its importance.

Phallic Stage (4-6 years) ⊗ Pleasure: genital region.  activities associated with stroking and manipulating their sex organs. ⊗ ⊗

Oedipus complex Electra complex Concepts  Onset of “normal homosexuality”

Nursing implications: ⊗ Accept child's sexual interest ⊗ Help the parents answer child's questions about birth or sexual differences. Latency Stage (6 to 12 years) ⊗ Period of calmness / stable period. ⊗ Many of the disturbing behaviors are buried in the subconscious mind.

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St. Louis Review Center Oedipal feelings are reactivated toward opposite sex The person is on his way in establishing a satisfying life of his own

Nursing Implication: ⊗ Provide appropriate opportunities for the child to relate with opposite sex. ⊗ Allow child to verbalize feelings about new relationships. Psychosocial Development Theory: Erik Erikson

Pleasure: elimination.

Possible problems: ⊗ Compulsive need to be clean and orderly. ⊗ Frugality and stinginess ⊗ Greed ⊗ Insistence on doing things at one's own rate at the expense of others ⊗ Rigid training ⊗ Excessive messiness and disorderly habits.

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Their energies are absorbed by the concerns in school, peers, sports and other recreational activities

Nursing Implication: Help the child have positive experiences.

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Childhood is very important in personality development. Rejected Freud's attempt to describe personality solely on the basis of sexuality,

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believed that social factors greatly affect felt that personality continued to develop beyond five years of age.

Identified 8 developmental stages throughout the whole life cycle. ⊗ Stages 1-5 - childhood and adolescent ⊗ Stages 6-8 - Adulthood Stages: Stage 1: Period of Life

Infant, 0-18 months, (Hope)

Psychosocial Crisis

Trust vs. Mistrust

Relationship with

Maternal person

Positive Resolution

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Negative Resolution

Stage 2: Period of Life

Reliance on the caregiver Development of trust in the environment Fear, anxiety and suspicion Lack of care, both physical & psychological by caretaker leads to mistrust of environment

Toddler, 18 mos. to 3 years (Willpower)

Psychosocial Crisis

Autonomy vs. Shame/doubt

Relationship with

Paternal person

Positive Resolution

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Sense of self-worth Assertion of choice and will Environment encourages independence, leading to sense of pride

Negative Resolution

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Loss of self-esteem Sense of external control may produce self-doubt in others

Genital Stage (12 years & up)

Psychiatric Nursing: Lecture Aid

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St. Louis Review Center Psychosocial Crisis

Intimacy vs. Isolation

Relationship with Positive Resolution

Partners in friendship o A commitment to others o Close heterosexual relationship and procreation Withdrawal from such intimacy, isolation, self-absorption and alienation from others

Negative Resolution Stage 7: Period of Life

Middle Adult, 24 to 54 yrs., (Care)

Initiative vs. Guilt

Psychosocial Crisis

Generativity vs. Self-absorption

Relationship with

Family

Relationship with

Partner

Positive Resolution

The ability to learn to initiate activities, to enjoy achievement and competence

Positive Resolution

Negative Resolution

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Negative Resolution

o The care and concern for the next generation o Widening interest in work and ideas Self-indulgence and resulting psychological impoverishment

Stage 8: Period of Life Psychosocial Crisis

Late Adult, 54 yrs. to death, (Wisdom) Integrity vs. Despair

Relationship with

Mankind

Positive Resolution

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Negative Resolution

Disappointment of one’s life and desperate fear of death

Stage 3: Period of Life

Preschool, 3 to 6 years (Purpose)

Psychosocial Crisis

The inability to control newly developed power Realization of potential failure leads to fear of punishment and guilt

Stage 4 Period of Life Psychosocial Crisis

Schooler, 6 to 12 yrs. (Competence) Industry vs. Inferiority

Relationship with

Neighbors/School

Positive Resolution

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Negative Resolution

Repeated frustrations and failures lead to feelings of inadequacy and inferiority that may affect their view of life

Learning the value of work Acquiring skills and tools of technology Competence helps to order life and make things work

Stage 5: Period of Life

Adolescent, 12 to 18 yrs, (Fidelity)

Psychosocial Crisis Relationship with

Identity vs. Role confusion Peer group

Positive Resolution

Experiments with various roles in developing mature individuality

Negative Resolution

Pressures and demands may lead to confusion about self

Cognitive Development Theory: Jean Piaget Stages: Sensorimotor (0-2 years) ⊗ Reflex to complex ⊗ Begins to organize visual images and control motor responses. ⊗ Coordinates sensory impressions. ⊗ Pre-verbal stage Preoperational Stage (2-7 years) ⊗ Transitional period ⊗ Egocentric and irreversible thinking

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Stage 6: Period of Life

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Psychiatric Nursing: Lecture Aid

Acceptance of one’s life Realization of the inevitability of death Feeling of dignity and meaning of existence

Words become symbols for objects – symbolic thinking Formation of ideas of categorization. Lack of ability to go back and rethink a process or concept. Mental image – the symbolic process which are evident in plays Construction of verbal schemas – preconcepts

Concrete Operations (7 – 11 years)

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St. Louis Review Center Thinking appears to be stabilized o ability to think of the possible consequences of actions Logical implications

Formal Operations (11 years to adulthood) ⊗ Full patterns of thinking ⊗ Ability to use logic and symbolic processes o mathematical and scientific reasoning ⊗ Combinatorial thinking - multidimensional approach o hypothetic or hypothetico-deductive reasoning

Behavioral Model (Ivan Pavlov, John Watson, B. F. Skinner)

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Behavior is:

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a response to a stimulus from the environment learned and retained by positive reinforcement

Interpersonal Model (Harry Stack Sullivan) ⊗ Focused on the role of the environment and interpersonal relations as the most significant influences on a individual’s development. ⊗ Anxiety is communicated interpersonally.

Moral Development Theory: Laurence Kohlberg Level One (Preconventional Morality) • Children’s judgments are based on external criteria. • Standards of right and wrong are absolute and laid down by authority. Level Two (Conventional Morality) • Children’s judgments are based on the norms and expectations of the group.

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Level Three (Post Conventional Morality) The individual recognizes the arbitrariness of social and legal conventions. The individual attempts to define moral values that are separate from group norms.

Stage 1 • Behavior is based on the desire to avoid severe physical punishment by a superior power. • Right or wrong is based on consequences to him. • Punishment = wrong act Stage 2 • Actions are based largely on satisfying one’s own personal needs. Stage 3 • Good behavior is that which pleases others and judgments are based on intentions. • Children conform to rules to win the approval of others and to maintain good relationships. Stage 4 • What is right is what is accepted. If the social accepts rules as appropriate for all group members, children will conform to them to avoid social disapproval and censure Stage 5 • Behavior recognizes the laws as arbitrary and changeable. • For aspects of life not governed by laws, right and wrong are personal decisions based on agreement and contracts. Stage 6 • Morality is based on respect for others rather than on personal desires. • The individual conforms to both social standards and to internalized ideals to avoid self-condemnation rather than to avoid social censure. Other Theories

Psychiatric Nursing: Lecture Aid

Human Motivational Need Model. (Abraham Maslow) ⊗ Hierarchy of needs in order of importance ⊗ Primary needs (physiologic) need to be met prior to dealing with higher level needs. Psychobiologic Model ⊗ Focus is in mental illness as a biophysical impairment. ⊗ Human behavior is influenced by genetics, biochemical alterations and function of brain and CNS. ⊗ The stress response is a neuroendoctine response. Important structure (limbic system): ⊗ Thalamus – regulates activity, sensation, emotion ⊗ Hypothalamus – themoregulation, appetite control, endocrine function, appetite control, impulsive behavior associated with feelings of anger, rage or excitement. ⊗ Hippocampus and amygdale – emotional arousal and memory ⊗ Neurons – basic functioning unit of the CNS ⊗ Neurotransmitters  Chemical substances manufactured in the neuron  Aid transmission of information throughout the body ⊗ Dopamine  An excitatory neurotransmitter  Located primarily at the brain stem  Involved in control of complex movements, motivation, cognition and regulation of emotional responses  Associated with pyschosis and Parkinson’s disease ⊗ Catecholamines (norepinephrine and epinephrine) ⊗ Norepinephrine  Attention, learning and memory, sleep and wakefulness  Excess of this is associated with anxiety, memory loss, social withdrawal and depression. ⊗ Epinephrine – responsible in the fight or flight mechanism ⊗ Serotonin  An inhibitory neurotransmitter  Derived from tryptophan  Involved in control of food intake, sleep and wakefulness, pain control, sexual behavior and emotions  Involved in anxiety and mood disorders, schizophrenia and its symptoms

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Histamine  Primarily involved in immunity and allergic reactions  Some psychotropic drugs are block by histamine Acetylcholine  Affects sleep-wake cycle  Associated with Alzheimer’s disease Glutamate  An excitatory neurotransmitter  At high levels, it can cause neurotoxicity.  Associated with Alzheimer’s and Huntington’s disease Gama-Aminobutyric Acid  An inhibitory neurotransmitter  Associated to treat anxiety and induce sleep. PSYCHOTHERAPY

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Is a process in which a person enters into a contract to interact with a therapist to relieve symptoms, resolve problems in living, seek personal growth

INDIVIDUAL THERAPY: Is a confidential relationship between client and therapist.

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Hypnotherapy: Involves various methods and techniques to induce a trance state where the patient becomes submissive to instructions Humor therapy: Use of humor to facilitate expression of feelings and to enhance interaction Psychoanalysis: Focuses on the exploration of the unconscious, to facilitate identification of the patient's defenses

GROUP THERAPY • minimum number : 3 • Ideal number :8-10 •

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St. Louis Review Center o improve functioning of individual members as well as the family as a whole. o It focuses on the total family as an interactional system Milieu Therapy • A therapeutic environment is organized to: o encourage and assist the client to control problematic behavior o function within the range of social norms Play therapy • Effective for children suffering from maladjustment or behavior disorder. • The child is usually placed in a play room • Purpose - to discover the causes of the child's conflict through observation of his play and to interpret it to the child. Recreational therapy • Uses activities which vitalize the patient's interest and help him or her to relax and feel refreshed. • Example: Playing baseball may be prescribed for as a means of expressing hostility in a group. Occupational therapy: Uses any mental or physical activity prescribed or guided to aid an individual's recovery from a disease or injury. Musical therapy • Involving the music which allows the child or adolescent to express herself or himself. • Also effective with those who have difficulty communicating. Art therapy: Clients are encouraged to express their feelings or emotions by painting, drawing or sculpture. Psychodrama therapy: Patients dramatizes their emotional problems in a group setting. Behavior Therapy • Is a mode of treatment that focuses on modifying observable (overt) and quantifiable behavior • Systematic manipulation of the environment and variables thought to be functionally related to the behaviors. •

Advantages:

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decreases isolation decreases dependence develops coping skills develops interpersonal learning

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develops opportunities for helping others develops ability to listen to other members

Remotivation Therapy: Promotes expression of feeling through interaction facilitated by discussion of neutral topics Family therapy: A method in which family members gain: o insight into the problems o improve communication

Psychiatric Nursing: Lecture Aid

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Limit Setting o Therapist gives an advanced warning of the limit and the consequences will follow if the client does not adhere to the limit. o The consequences should occur immediately after the client has exceeded the limit o Consistency must occur with all personnel. o Purposes: o Minimizes manipulation and splitting of the staff. o Provide a framework for the client to function in and enable a client to learn to make requests. Systematic Desensitization

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Clients are exposed slowly to a feared object or a thing that inhibits anxious responses and taught ways to relax. o Effective in treating phobias. Implosive therapy

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The clients are exposed abruptly to intense forms of anxiety producers, either in imagination or in real life Cognitive Behavior therapy o Uses confrontation as a means of helping the clients restructure or rearrange irrational beliefs, maladaptive thinking, perception-, and behaviors.

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o Used for depression and adjustment difficulties. Biofeedback o Teaches the client to control or change aspects of their internal environment. Aversion therapy o Uses unpleasant or noxious stimuli to change inappropriate behavior. o Examples o Antabuse to treat alcoholics o Showing films to drivers who are arrested for speeding or driving while under the influence of alcohol or drugs. Assertiveness Training o Clients are encouraged and taught how to appropriately relate to others o Teaches the individual to ask for what is beneficial to both mentally ill and mentally healthy persons. Token-economy: Utilizes the principle of rewarding desired behavior to facilitate change.

ELECTROCONVULSIVE THERAPY (ECT) • Exact mechanism is unknown • Requires a consent • Usually given at 70-150 volts for about .5-2 seconds • Effectivity: 6-12 treatments with at least 48 hour interval • Indicator of effectiveness: tonic-clonic seizure Indications of use: • Depression • Mania • Catatonic schizophrenia Contraindications (not absolute) • Fever • Unhealed fracture • Increased ICP • Retinal detachment • Cardiac conditions • Pregnancy • TB with history of hemorrhage Before the procedure: • Diagnostic procedures o X-ray o ECG o EEG • Drugs given o Atrophine sulfate (decrease secretions) o Anectine (Succinylcholine) – relax muscles o Methohexital Na (Brevital) - anesthetic During the procedure: • Observe for tonic-clonic seizure After the procedure: • Position • Check vital signs • Reorient the client • Watch out for complications: o Memory loss

Psychiatric Nursing: Lecture Aid

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Headache Apnea Respiratory depression Fracture BASIC CONCEPTS ON PSYCHOPHARMACOLOGY

MAJOR TRANQUILIZERS/ ANTIPSYCHOTICS ⊗ Indication: Schizophrenia and Other Psychosis ⊗ Desired effect: control of symptoms ⊗ Best taken after meals Examples: • Haloperidol (Haldol) • Prochlorperazine (Compazine) Side effects: Blurred vision Dry mouth Tachycardia, palpitation, constipation, urinary retention Photosensitivity Orthostatic hypotension Extra Pyramidal Symptoms o Pseudoparkinsonism o pill-rolling tremors mask-like face o cog-wheel rigidity o propulsive gait o Akathisia - restless leg syndrome o Dystonia - defect in muscle tone

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Fluphenazine (Prolixin) Chlorpromazine (Thorazine)

Nursing Action Avoid driving Give sugarless gum Monitor & report Don’t expose skin to sunlight Monitor BP Advise gradual change in position Report at once

Adverse effect: report promptly • Tardive dyskinesia - lip smacking • Agranulocytosis o Assess for:  Fever  Sore throat  Lab data: WBC count • Hepatotoxicity o Assess for ALT & AST MINOR TRANQUILIZERS/ ANXIOLYTICS ⊗ Common indication: Anxiety disorders ⊗ Desired Effect: Decreased anxiety, adequate sleep Examples: • Diazepam (Valium) • Oxazepam (Serax)

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Chlorazepate Dipotassium (Tranxene) Alprazolam (Xanax)

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St. Louis Review Center Chlordiazepoxide (Librium)

Examples: • Fluoxetine (Prozac) • Celatopram (Celexa) • Sertraline (Zoloft)

Nursing Implications: • Best taken before meals • Advise to avoid driving • Avoid alcohol and caffeine-containing foods • Administer it separately with any drug

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Tricyclic Antidepressants

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Lithium Carbonate (Eskalith, Lithane, Lithobid)

diazepam Alcohol

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Amitriptyline (Elavil)

Nursing Implications: ⊗ Best given after meals ⊗ Effectivity: after 2-3 weeks ⊗ Check the BP, it causes hypotension ⊗ Check the heart rate, it causes cardiac arrythmias ⊗ Monitor I & O ⊗ Monitor for signs of increased IOP MAO INHIBITORS Indication: refractory depression Examples: • Tranylcypromine (Parnate) • Phenelzine (Nardil) • Isocarboxazid (Marplan) Nursing Implications: ⊗ Best taken after meals ⊗ Report headache; it indicates hypertensive crisis ⊗ Avoid tyramine containing foods like: • Avocado • Banana

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Cheddar and aged cheese • Soysauce • Preserved foods Effectivity: 2-3 weeks Monitor the BP There should be at least a two-week interval when shifting from one anti-depressant to another

Tryptophan • Monitor PTT, PT Never give to pregnant / lactating mothers.

ANTI-MANIC AGENT Examples: • Lithium Citrate (Cibalith – S) Nursing implications: ⊗ Best taken after meals ⊗ Increase intake of: • fluids (3 L /day) • sodium (3 gm/day) ⊗ Avoid activities that increase perspiration ⊗ Never give to pregnant mothers ⊗ Effectivity: 10-14 days

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Paroxetine (Paxil) Fluvoxamine (Luvox)

Nursing Implications: ⊗ Avoid the use of:

ANTIDEPRESSANTS Desired effects: increased appetite, adequate sleep

Examples: • Imipramine (Tofranil)

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⊗

Antipsychotic is administered during the first 2 weeks Therapeutic level:.5-1.5 meq/L If ineffective: Tegretol Signs of toxicity:

o o o o o o

Vomiting Anorexia Nausea Diarrhea Abdominal cramps Lightheadedness (late)

Antidote: Mannitol

Selective Serotonin Reuptake Inhibitors

Psychiatric Nursing: Lecture Aid

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STRESS • •

A nonspecific response of the body to any demand made upon it. (Hans Selye, 1936) A state produced by a change in the environment that is perceived as challenging, threatening or damaging to the person’s dynamic equilibrium. (Smeltzer, 1992)

Adaptation

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A constant ongoing process that occurs along time continuum, beginning with birth and ending with death. (Smeltzer, 1992)

• • • •

St. Louis Review Center Highly individualized Self-limiting: 4-6 weeks Person affected becomes passive and submissive Affects a person’s support system

Type Maturational/developmental crisis

Description expected, predictable and internally motivated

Situational/accidental

Unexpected, unpredictable and externally motivated

Example Puberty, adolescence, young adulthood, marriage, or the aging process. Economic difficulty, illness, accident, rape, divorce or death

Social crisis

Due to acts of nature

Natural calamities

A continuous process of seeking harmony in an environment.

Types of Adaptation: General Adaptation Syndrome (GAS) • Involves the whole body in response to stress. • Compared to life process as it focuses on the “wear and tear of the body tissues. Phases: • Alarm o Acute phase of the syndrome o Characterized as the “flight and fight” reaction o Defensive by nature but self-limiting o If stress is intense, it may lead to death. • Resistance o Characterized as the state of adaptation o Person moves back to homeostasis • Exhaustion o Result of a prolonged exposure to stress and adaptive mechanisms can no longer persist.

Phases • • • • •

CRISIS INTERVENTION • Major Goal: o Restore the maximum level of functioning (pre-crisis state)

o o

Local Adaptation Syndrome

•

Refers to inflammatory response and repair processes that occur at the local site of tissue injury.

Denial Increased Tension Disorganization Attempts to reorganize Stage for full reorganization

It is an active but temporary entry into the life situation of an individual or a family during a period of stress. A way of entering into the situation to help them mobilize their resources and to decrease the effect of stress.

Domestic Violence Requiring Crisis Intervention: RAPE

Eustress - positive stress Distress • Negative stress

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Damaging stressors which may result in various physical and emotional disorders such as: anxiety, frustration, insecurity, aimlessness

CRISIS AND CRISIS INTERVENTION • A situation that occurs when an individual's habitual coping ability becomes ineffective to meet the demands of a situation. • As a serious interruption and disturbance of one's equilibrium or homeostasis • Leads to potentially dangerous, self-destructive or socially unacceptable behavior. Characteristics

Psychiatric Nursing: Lecture Aid

•

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

Kinds of Rape • Power – to prove masculinity • Anger – means of retaliation • Sadistic – to express erotic feelings Silent Rape Syndrome • Is a maladaptive reaction to rape • The victim: • fails to disclose information about the rape • is unable to resolve feelings about the sexual assault • Results to increase anxiety and may develop a sudden phobic reaction.

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Rape Trauma Syndrome (RTS) • Refers to a group of signs and symptoms experienced by a victim in reaction to rape Phases: • Acute Phase – shock, numbness, disbelief • Denial – refusal to discuss the event • Heightened Anxiety – fear, tension, nightmares • Stage of Reorganization

Inconsistent stories from the child and parent/s Low self-esteem Depression

• • • • •

Apathy Bruised or swollen genitalia; tears or bruising of rectum or vagina Unusual injuries for the child’s age and development Serious injuries (fractures, burns, lacerations) Evidence of old injuries not reported

Republic Act 7610 (Anti Child Abuse Law)

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Battered Wife Syndrome (BWS) • A form of cyclic domestic violence • Men: low self-esteem

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Required reporting of suspected cases Report cases to the nearest authorities within 48 hours

Women: Dependent personality disorder

Child Abuse • Is an act of omission of responsibility or commission in which intentional harm is inflicted on a child.

Assessment, Planning and Nursing Actions for Crisis • Primary concerns: o Physical injuries o Alleviation of psychological trauma • Nurse should display:

o o o o o o

Components of Omission: • Child abandonment – leaving the child physically • Child neglect - lack of provision of those things which are necessary for the child's growth and development Types of Commission: Physical Abuse

•

St. Louis Review Center

• • •

Is an intentional physical harm inflicted on a child by a parent or other person.

•

Emotional abuse - insult and undermining one's confidence Sexual abuse - abuse in the form of sexual contact 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 • They are emotionally immature • They have negative attitude towards the management of the abused Warning signs of Child Abuse / Neglect: • Child’s excessive knowledge on sex and abusive words • Hair growth in various lengths

Psychiatric Nursing: Lecture Aid

• •

Sensitivity Attitude (Nonjudgmental) Confidentiality Respect Empathy

Dignity Evidences are important: o stained clothing o fingernail scrapings o mouth or anal smears containing semen Intervention focuses family as a unit. If the victim is a child: Play and art therapy

DEFENSE MECHANISM •

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These are automatic and usually unconscious processes or act by the individuals to: o reduce or cope anxiety or fear o resolve emotional or mental conflict o protect one's self-esteem o protect one's sense of security Becomes pathologic when overused.

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•

St. Louis Review Center Used by both mentally healthy and mentally ill individuals

Common Defense Mechanisms Used: • Compensation o An attempt to overcome a real or imagined short coming, inferiority, inabilities and weaknesses. o A blind woman becomes proficient in playing piano.

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Conversion o Emotional problems are converted to physical symptoms o A student unprepared for a report suffered headache the day she is supposed to deliver her report.

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Denial o Failure to acknowledge an intolerable thought, feeling, experience or reality o A middle-aged man after being admitted to the CCU because of an AMI, insists that he is in the hospital for just a diagnostic work-up.

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Displacement o the redirection of feelings to a less threatening object

o

Fantasy o Conscious distortion of unconscious feelings or wishes o A boy who is being bullied by his friends wished he had the power of Wolverine.

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Fixation o An unhealthy mechanism which is an arrest of maturation at certain stages of development. o A boy never overcame being fully reliant from his mother.

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Introjection o Symbolic assimilation or taking into oneself a love/hatred object. Derived from the word "introject" which literally means to take into or ingest. o Common to depressed clients.

•

•

Rationalization o An individual finds a justifiable cause and acceptable reasons just to be saved from an embarrassing and anxiety producing thoughts or situations. o A basketball player claims that he missed the shot and lost the game because of the distractions made by the audience.

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Regression o Is the turning back to earlier patterns of behavior in solving personal conflicts. o Commonly seen to schizophrenic patients o A person who becomes ill in the face of disappointment has regressed to a form of childish behavior.

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Repression o It is the involuntary or unconscious forgetting of an unpleasant ideas or impulses. o During the nurse-patient relationships, patients often unconsciously avoid discussing those experiences producing anxiety which are emotionally difficult to verbalize.

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Suppression o Permits the individual to store away or consciously forget the unpleasant, painful and unacceptable thoughts, desires, experiences and impulses. o "I'll think it about tomorrow", "I'd rather go now", "Can we change the topic?" o A boy walked out from the group and said "I have to go now", when he was asked what was happened to their relationship with his girlfriend.

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Substitution o Replacing the desired unattainable goal with one that is attainable o A woman who failed the nursing board exam 3 times, worked as a nursing aide just to be in the hospital.

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Sublimation o The redirection of unacceptable instinctual drive with one that is socially acceptable o Instead of harming his mother, a man expressed his anger by composing a song.

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Symbolization o Less threatening object is used to represent another o A woman, missing her husband finds comfort in hugging her son who looks like his father.

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Undoing o An attempt to erase an act, thought, feeling, guilt or desire o A man gives her wife a bunch of roses after their argument last night.

Identification o An individual integrates certain aspects of someone else's personality into one's own.

o •

Reaction – Formation o Expression of feeling that is the direct opposite of one's real feeling. o Also referred to as overcompensation. o A student who dislikes one of her classmates may act or show concern toward her.

An adolescent boy, after an argument with his father, goes to the room and kicked his room’s door.

•

•

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A young school teacher adopts his former mentor's teaching style when conducting class sessions.

Intellectualization o An overuse of intellectual concepts by an individual to avoid expression of feelings o A man who was asked to share a memorable experience about his grandmother who died discussed the stages of death and dying by Elizabeth Kubler Ross. Projection o Attributing to others one's unconscious wishes/fear. o Literally, this means to "throw off. o A student who failed a subject blames his failure on poor teaching.

Psychiatric Nursing: Lecture Aid

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