Psychiatric-nursing.doc

MENTAL HEALTH

 "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  leads to self-acceptance, self-understanding in order to understand others  Autonomy: ability to function independently and function with others  Perceptive ability  Awareness of stimuli, reality orientation.  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  Mastery of one’s environment: Awareness of the changes around him MENTAL HYGIENE  a science that deals with: Promotive, Preventive, Curative, Rehabilitative aspects of care. 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:

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PSYCHIATRIC NURSING

 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  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)  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.

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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.  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)

Researcher Socializing agent Teacher Technician Therapist Ward manager

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Levels of Interventions in Psychiatric Nursing Level Primary

PSYCHIATRIC NURSING  An interpersonal process  Concerned with all the aspects of care  Both a Science and an Art  Science – uses different theories  Art - therapeutic use of self  Clientele:  Individual, family and the community  Both mentally healthy and mentally ill

Secondary

Tertiary

Description Aimed at altering the stressors through:  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

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Examples Health education Information dissemination Counseling Crisis intervention Drug administration Alcoholics anonymous Occupational therapy

Main tool of the nurse: Therapeutic use of Self THE PSYCHIATRIC SETTING Admitting a Client in the Psychiatric Setting

Characteristics of a Good Psychiatric Nurse:  Empathy  Genuineness  Congruence  Unconditional positive regard

Areas to be assessed:  Health perception  Orientation  Metabolic pattern  Elimination pattern

Roles of the Nurse in Psychiatric Setting:  Clinician  Collaborator  Counselor  Healthy role model  Parent surrogate  Patient advocate  Reality based a.n.g./n.a.l.

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PSYCHIATRIC NURSING

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

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LEGAL ASPECTS OF PSYCHIATRIC NURSING Types of Admissions:  Voluntary  Persons admit themselves  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 Insanity as a Defense  Insanity : determined in court; legal terminology 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.” COMMON BEHAVIORAL SIGNS AND SYMPTOMS Disturbance in Perception  Illusion - misperception of an actual external stimuli  Hallucination - false sensory perception in the absence of external stimuli

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PSYCHIATRIC NURSING

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

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 somewhat related way Looseness of Association - shifting of a topic from one subject to another in a completely unrelated 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  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 Disturbances in Motor Activity  Echopraxia - the pathological imitation of posture/action of others

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 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  Confabulation - filling in of memory gaps  Amnesia - inability to recall past events  Anterograde - immediate past  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  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  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)

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PSYCHIATRIC NURSING

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  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 Elements:

FEEDBACK

Message

(Channel)

(Context) Page 4 of 32

Therapeutic Communication: a way of interacting in a purposeful manner to promote the client’s ability to express his thoughts and feelings openly. Essentials for a Therapeutic Communication:  Genuineness E G R A T  Respect  Empathy  Attentive listening  Trust (rapport)

Has this ever happened before? How do you feel when you 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 Focusing Giving broad openings or asking open-ended questions Informing

Barriers to a Therapeutic Communication  Belittling  Interrupting / ignoring  Giving advice    

Encouraging comparison Encouraging description

Making observations

Social response Changing the subject Approving / disapproving Moralizing

Offering general leads Restating Summarizing Using silence Validating

Examples: Therapeutic Technique Technique Example Accepting Yes, that must have been difficult for you. Acknowledging or giving I noticed that you've fixed your bed. recognition Asking direct questions How does your wife feel about hospitalization? Clarifying Confronting or presenting reality

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Voicing doubt

your

I'm not sure that I understand what you are trying to say. I see no bats flying in this room.

PSYCHIATRIC NURSING

take

your

(giving needed facts) I'll be your nurse for today, from 7:00 until 3:00 this afternoon. You appear to be angry. / I noticed that you're trembling. Go on. / You were saying… Client: I can't sleep, I stay awake all night. Nurse: You can't sleep at night, (restating) During the past hour, we talked about your plans for the future, they include... (to induce thought, pacing, acceptance) (confirming one's observation) “So you mean . . .” 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 “I feel that way too.” feeling Judging "It's your own mistake".

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NURSE – PATIENT RELATIONSHIP Working / Therapeutic Phase:  it is highly individualized  identification and resolution of the patient's problems  more structured than the orientation phase  the longest and most productive phase  limit setting must be employed  planning and implementation Hildegard Peplau Phases: 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  develop self-awareness  data gathering, planning for first interaction

Problems:  Transference  the development of an emotional attitude towards the nurse  positive or negative  Counter transference – experienced by the nurse / therapist Termination Phase  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

Orientation phase  when the nurse-patient interacts for the first time  establish of contract with the patient  establish of trust and rapport  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

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PSYCHIATRIC NURSING

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overeating, smoking, nail-biting

THEORIES OF HUMAN DYNAMICS Psychosexual Development : Sigmund Freud Levels of Consciousness

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.  Pleasure: elimination.  Covers the ideal age for "toilet training" (2 1/2 years)  2 concepts:  Holding on  Letting go Possible problems:  Compulsive need to be clean and orderly.  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.

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

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”

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

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

PSYCHIATRIC NURSING

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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.  Their energies are absorbed by the concerns in school, peers, sports and other recreational activities Nursing Implication: Help the child have positive experiences. Genital Stage (12 years & up)  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  Childhood is very important in personality development.  Rejected Freud's attempt to describe personality solely on the basis of sexuality,  believed that social factors greatly affect  felt that personality continued to develop beyond five years of age. Identified 8 developmental stages throughout the whole life cycle.  Stages 1-5 - childhood and adolescent  Stages 6-8 - Adulthood

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PSYCHIATRIC NURSING

Stages: Stage 1: Period of Life

Infant, 0-18 months, (Hope)

Psychosocial Crisis

Trust vs. Mistrust

Relationship with

Maternal person

Positive Resolution

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

Stage 2: Period of Life

Toddler, 18 mos. to 3 years (Willpower) Psychosocial Crisis Autonomy vs. Shame/doubt Relationship with Paternal person Positive Resolution o Sense of self-worth o Assertion of choice and will o Environment encourages independence, leading to sense of pride Negative Resolution o Loss of self-esteem o Sense of external control may produce self-doubt in others

Stage 3: Period of Life Psychosocial Crisis Relationship with Positive Resolution

Preschool, 3 to 6 years (Purpose) Initiative vs. Guilt Family The ability to learn to initiate activities, to enjoy achievement and competence Negative Resolution o The inability to control newly developed power o Realization of potential failure leads to fear of punishment and guilt

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Negative Resolution Self-indulgence and resulting psychological impoverishment

Stage 4 Period of Life Psychosocial Crisis Relationship with Positive Resolution

Schooler, 6 to 12 yrs. (Competence) Industry vs. Inferiority Neighbors/School o Learning the value of work o Acquiring skills and tools of technology o Competence helps to order life and make things work Negative Resolution Repeated frustrations and failures lead to feelings of inadequacy and inferiority that may affect their view of life

Stage 8: Period of Life Psychosocial Crisis Relationship with Positive Resolutiono o o Negative Resolution

Cognitive Development Theory: Jean Piaget

Stage 5: Period of Life Psychosocial Crisis Relationship with Positive Resolution

Adolescent, 12 to 18 yrs, (Fidelity) Identity vs. Role confusion Peer group Experiments with various roles in developing mature individuality Negative Resolution Pressures and demands may lead to confusion about self

Stage 6: Period of Life Psychosocial Crisis Relationship with Positive Resolution

Young Adult, 18 to 54 yrs., (Love) Intimacy vs. Isolation Partners in friendship o A commitment to others o Close heterosexual relationship and procreation Negative Resolution Withdrawal from such intimacy, isolation, selfabsorption and alienation from others

Stage 7: Period of Life

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

Psychosocial Crisis

Generativity vs. Self-absorption

Relationship with

Partner

Positive Resolution

o o

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Late Adult, 54 yrs. to death, (Wisdom) Integrity vs. Despair Mankind Acceptance of one’s life Realization of the inevitability of death Feeling of dignity and meaning of existence Disappointment of one’s life and desperate fear of death

The care and concern for the next generation Widening interest in work and ideas

PSYCHIATRIC NURSING

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  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)  Thinking appears to be stabilized o ability to think of the possible consequences of actions  Logical implications

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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

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arbitrariness of social and legal conventions. The individual attempts to define moral values that are separate from group norms.

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

a.n.g./n.a.l.

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

PSYCHIATRIC NURSING

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

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

 Behavior is:  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. 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

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 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  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

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PSYCHIATRIC NURSING

 Gama-Aminobutyric Acid  An inhibitory neurotransmitter  Associated to treat anxiety and induce sleep. PSYCHOTHERAPY  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.  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 

Advantages: o decreases isolation o decreases dependence o develops coping skills o develops interpersonal learning o develops opportunities for helping others o develops ability to listen to other members

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

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o o o

improve communication improve functioning of individual members as well as the family as a whole. 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. 

Limit Setting

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PSYCHIATRIC NURSING

Therapist gives an advanced warning of the limit and the consequences will follow if the client does not adhere to the limit. o The consequences should occur immediately after the client has exceeded the limit o Consistency must occur with all personnel. o Purposes: o Minimizes manipulation and splitting of the staff. o Provide a framework for the client to function in and enable a client to learn to make requests. Systematic Desensitization o Clients are exposed slowly to a feared object or a thing that inhibits anxious responses and taught ways to relax. o Effective in treating phobias. Implosive therapy o 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. 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. o

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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  Increased ICP  Cardiac conditions  TB with history of hemorrhage

o o o o o

Watch out for complications: Memory loss 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:   

Unhealed fracture Retinal detachment Pregnancy

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

a.n.g./n.a.l.

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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 PSYCHIATRIC NURSING

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 Monitor I & O  Monitor for signs of increased IOP

Agranulocytosis o Assess for:  Fever  Sore throat  Lab data: WBC count Hepatotoxicity o Assess for ALT & AST

MAO INHIBITORS Indication: refractory depression

MINOR TRANQUILIZERS/ ANXIOLYTICS  Common indication: Anxiety disorders  Desired Effect: Decreased anxiety, adequate sleep Examples:  Diazepam (Valium)  Chlorazepate Dipotassium (Tranxene)  Oxazepam (Serax)  Alprazolam (Xanax)  Chlordiazepoxide (Librium) Nursing Implications:  Best taken before meals  Advise to avoid driving  Avoid alcohol and caffeine-containing foods  Administer it separately with any drug ANTIDEPRESSANTS Desired effects: increased appetite, adequate sleep Tricyclic Antidepressants Examples:  Imipramine (Tofranil)

PaN aM a

Nursing Implications:  Best taken after meals  Report headache; it indicates hypertensive crisis  Avoid tyramine containing foods like:  Avocado  Banana  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 antidepressant to another Selective Serotonin Reuptake Inhibitors

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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

a.n.g./n.a.l.

Examples:  Tranylcypromine (Parnate)  Phenelzine (Nardil)  Isocarboxazid (Marplan)

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

 

Paroxetine (Paxil) Fluvoxamine (Luvox)

Nursing Implications:  Avoid the use of:  diazepam

PSYCHIATRIC NURSING

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

Alcohol Tryptophan  Monitor PTT, PT  Never give to pregnant / lactating mothers.



ANTI-MANIC AGENT

Adaptation  A constant ongoing process that occurs along time continuum, beginning with birth and ending with death. (Smeltzer, 1992)  A continuous process of seeking harmony in an environment.



Examples:  Lithium Citrate (Cibalith – S)



Lithium Carbonate (Eskalith, Lithane, Lithobid)

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  Antipsychotic is administered during the first 2 weeks  Therapeutic level:.5-1.5 meq/L  If ineffective: Tegretol  Signs of toxicity: o Vomiting o Anorexia o Nausea o Diarrhea o Abdominal cramps o Lightheadedness (late)  Antidote: Mannitol

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

STRESS 

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)

A nonspecific response of the body to any demand made upon it. (Hans Selye, 1936)

Eustress - positive stress Distress

a.n.g./n.a.l.

PSYCHIATRIC NURSING

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 

Negative stress 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.

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

Phases  Denial  Increased Tension  Disorganization  Attempts to reorganize  Stage for full reorganization

a.n.g./n.a.l.

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

Characteristics  Highly individualized  Self-limiting: 4-6 weeks  Person affected becomes passive and submissive  Affects a person’s support system Type Description Maturational/developmental expected, predictable crisis and internally motivated

CRISIS INTERVENTION  Major Goal: o Restore the maximum level of functioning (pre-crisis state) o It is an active but temporary entry into the life situation of an individual or a family during a period of stress. o A way of entering into the situation to help them mobilize their resources and to decrease the effect of stress.

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. 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

PSYCHIATRIC NURSING

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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

Battered Wife Syndrome (BWS)  A form of cyclic domestic violence  Men: low self-esteem  Women: Dependent personality disorder

Warning signs of Child Abuse / Neglect:  Child’s excessive knowledge on sex and abusive words  Hair growth in various lengths  Inconsistent stories from the child and parent/s  Low self-esteem  Depression

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

a.n.g./n.a.l.

PSYCHIATRIC NURSING

    

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)  Required reporting of suspected cases  Report cases to the nearest authorities within 48 hours Assessment, Planning and Nursing Actions for Crisis  Primary concerns: o Physical injuries o Alleviation of psychological trauma  Nurse should display: o Sensitivity o Attitude (Nonjudgmental) o Confidentiality o Respect o Empathy

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

  

 

o 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

o

and kicked his room’s door.

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. 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. 





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. 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. Displacement a.n.g./n.a.l.

the redirection of feelings to a less threatening object

o An adolescent boy, after an argument with his father, goes to the room

PSYCHIATRIC NURSING



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.



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.



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.



Identification o An individual integrates certain aspects of someone else's personality into one's own. o A young school teacher adopts his former mentor's teaching style when 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.

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o 

A student who failed a subject blames his failure on poor teaching.

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.



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.



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.





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. 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?"

a.n.g./n.a.l.

PSYCHIATRIC NURSING

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.



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.



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.



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.



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.

ANXIETY  Vague sense of impending doom  Subjective response to stress  Is a state of apprehension, uneasiness, uncertainty or tension experienced by an individual in response to an unknown object or situation. Signs and symptoms: Mild  Physical - ↑PR, RR, BP, pupillary dilatation, sweating  Cognitive - Attentive and alert  Emotional - Minimal use of defenses

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Moderate  Physical - Nausea, Anorexia, Vomiting, Diarrhea, Constipation, Restlessness  Cognitive - narrowed perceptual field & selective inattention  Emotional - use of any defense mechanism available SEVERE  Physical - s/sx becomes the flow of attention  Cognitive – perceptual field is greatly narrowed, focus of attention is trivial events  Emotional – defense mechanism operate PANIC  Physical – s/sx of exhaustion ignored  Cognitive – personality disorganized  Emotional – defense mechanism fail

Generalized Anxiety Disorder (GAD)  Unrealistic, excessive anxiety and is unable to control worry.  Clients may experience: fatigue, irritability, restlessness, muscle tension, sleep disturbance Obsessive Compulsive Disorder  Is characterized by recurrent obsessions and compulsions that interfere with normal life.

Nursing Diagnoses:  Ineffective individual coping  Anxiety Nursing Management:  Calm  Administer medications  Listen  Minimize environmental stimuli ANXIETY DISORDERS

Obsession  Refers to persistent, painful intrusive thought, emotion or urge that one is unable to suppress or ignore. Compulsion  Refers to repetitious uncontrollable act and sometimes a purposeful act to prevent a certain mistake in an event or situation.

Panic Disorder  An individual may suddenly experience frightening and uncomfortable symptoms  May include terror, sense of unreality or fear of loosing control  Attack: 1 minute and 1 hour Phobic Disorder  Phobia is an irrational fear of an object, place, activity or situation.  Avoidance will allow the individual to be free from anxiety.

a.n.g./n.a.l.

Examples:  Agoraphobia - fear of open places and of being alone in public places.  Social phobia - irrational fear of criticism, humiliation or embarrassment.  Acrophobia - fear of heights  Algophobia - fear of pain  Claustrophobia - fear of enclosed place  Thanatophobia - fear of crowds  Pathophobia - fear of disease  Monophobia - fear of being alone

PSYCHIATRIC NURSING

Post-Traumatic Stress Disorder (PTSD)  Is the delayed reaction of the person who has been involved or exposed to a traumatic events.  Symptoms of this disorder are:  intense psychological distress  feeling of detachment or estrangement from others  insomnia  decreased concentration  avoidance of thoughts and feelings  recurrent distressing dreams  inability to recall an important aspect of the trauma

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Nursing Interventions  Calm and nonjudgmental approach to convey acceptance.  Use short and simple sentences or words.  Help the client develop an increase tolerance to anxiety.  Help the client to:  develop a problem-solving and coping skills of the client.  develop the ability to remain calm in anxiety-producing situations.  Approach: kind-firmness  Systematic desensitization (phobic disorders)  Clients with ritualistic behavior (obsessive-compulsive disorder) should not be prohibited or reprimanded.  Biofeedback, change of the scenery, therapeutic touch, hypnosis, massage or relaxation exercises.  Administer medications, as ordered. ANXIETY RELATED DISORDERS Somatization Disorder  Free floating anxiety disorder  Clients:  express emotional turmoil or conflict through physical symptoms.  usually seek for repeated medical attention.  may exhibit antisocial behavior and may attempt suicide.  Associated with anxiety and depression Conversion Disorder  A condition in which an anxiety-provoking impulse is converted unconsciously into functional symptoms.  Conscious counterpart of malingering  Examples: Paralysis, blindness, loss of touch or pain sensation, dyspnea, seizures or convulsions Hypochondriasis  An individual presents an unrealistic or exaggerated physical complaints.

a.n.g./n.a.l.

PSYCHIATRIC NURSING

 The person becomes, preoccupied with the fear of developing or having already a disease or illness in spite of medical reassurance. Body Dysmorphic Disorder  Preoccupation with an imagined defect in his or her appearance.  Slight physical abnormality = excessive concern / anxiety Dissociative Amnesia  Inability to recall extensive amount of important information  Caused by trauma  Characterized by:  Disorientation  Purposeless wandering  Impairment in ability to perform ADL  Rapid recovery generally occur PERSONALITY DISORDERS  Are pervasive and inflexible patterns of functioning that is stable overtime, and leads to distress or impairment. Types of Personality Disorders: Eccentric Personality Disorder (Type A)  Paranoid (Suspicious and distrustful)  Persons who display pervasive and long stand suspiciousness  More common in men  Schizoid (Socially distant and detached)  Pattern of detachment from social relationship  Chooses solitary activities  Topics are inanimate objects and ideas  Schizotypal (Odd and eccentric)  “mild schizophrenia”  Acute discomfort in close relationships  Cognitive or perceptual distortion Dramatic-Erratic Personality Disorder (Type B)

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 Antisocial (aggressive and manipulative)  Pattern of disregard for the violation of the rights of others  Low self-esteem  Borderline (destructive and unstable)  Characterized by patterns of instability in relationships, self image and mood  Self-mutilating behavior  Affective instability  More common in women  Narcissistic (boastful / superiority complex)  Grandiosity and need for constant admiration  Exploitation of others for fulfillment of own desire Anxious or Fearful Personality Disorder (Type C)  Avoidant (inferiority complex)  Social inhibition  Feelings of inadequacy and sensitivity  Low self-esteem  Social withdrawal in spite of a desire for affection and acceptance  Dependent (submissive)  Submissive clinging behavior related to excessive need to be cared for by others  Lack of self-confidence  Perceive self as helpless and stupid  Obsessive-Compulsive (perfectionist)  Preoccupied with orderliness, perfectionism, inflexibility, need to be in control  Formal and serious interpersonal relationship  Judgmental of self and others  Passive-Aggressive  Intentional inefficiency  Passive resistance to demands for adequate performance in both occupational and social functioning Nursing Diagnosis:  Ineffective individual coping  Self-esteem disturbance a.n.g./n.a.l.

PSYCHIATRIC NURSING

DISORDERS COMMONLY DIAGNOSED TO CHILDREN AUTISM  Characterized by:  impairment in communication skills  presence of stereotyped behavior, interests and activities.  associated with impairment on social interactions  treatable but not curable  more common among boys  usually diagnosed at age 2  Main problem: Interpersonal functioning  Most acceptable cause: Biological factors - brain anoxia, intake of drugs Signs and Symptoms  Odd play  Not cuddly  Echolalia  Crying tantrums  Head towards anything  Inanimate object attachment  Loves to spin objects / self  Difficulty interacting with others  Wants blocks  Acts as deaf  Resists normal teaching method / routine changes  No fear of danger  Insensitive to pain  No eye contact  Giggling or silly laughing Nursing Interventions  Environment: safe & consistent  Encourage the client to participate for self-care  Speak calmly when giving instructions

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 Use simple words or phrases  Repeat instructions as necessary.  Haloperidol - symptomatic relief for hyperactivity, stereotypical and selfdestructive behavior MENTAL RETARDATION  Not a mental illness.  Problem of inadequate mental functioning.  Onset: 18  IQ below 70  Manifested by sub-average intellectual functioning in:  Communication Self-care Home living Social skills Health and safety

a.n.g./n.a.l.

IQ 51-70

o

36-50

Severe/Idiot

20-35

Below 20

o Educable – needs assistance Poor awareness of needs of others Trainable – needs moderate supervision o Unable to learn academic skills o Poor motor development and minimal speech o Needs complete and close supervision o Has minimal capacity for sensorimotor function o Needs custodial care with a totally structured environment

Principles of Nursing Care  Protective care Education of the family  Their involvement is an important factor in the plan of care to promote progress and to minimize the stress.  Repetition  Role modeling  Restructuring  Focus of Education  Reading  Arithmetic  Writing

Causes  HIV/ AIDS / rubella infection  Alcoholic mother  Thyroid deficiency  Excessive lead poisoning  Damage to the brain  Neurological / neurodevelopmental impairment  Exact gestational age is not reached (premature)  Opiate intoxication  Nutritional deficiency (lack in Folic Acid)  Anoxia  Toxemia (pregnancy-induced hypertension)  Environmental factors  Severe RH incompatibility Levels: Level Mild/moron

Moderate/Imbecile

ATTENTION DEFICIT HYPERACTIVITY DISORDER  Common in boys  Usually diagnosed before age 7  Problems:  Inattention  Hyperactivity  Impulsivity

Implication Difficulty adapting to school

PSYCHIATRIC NURSING

Causes: Intranatal factors

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Signs and Symptoms  Obstinacy  Negativism  Egocentrism

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

 Fighting syndrome  Aggressiveness  Tolerance is low       

Anorexia Nervosa  Main sign: Morbid fear of gaining weight  Other signs:  Sensitivity to cold temperatures  Amenorrhea  Deliberate self-starvation with weight loss

Difficulty concentrating Excessive talking Fidgeting Interrupt/intrudes on others Child exhibits hyperactivity Indulges in destructive behavior Temper tantrums

   

Nursing Diagnosis  Potential for injury Principles of Nursing Care:  Provide nutrition and safety  Environment: structured enable appropriate reaction to the environmental stimuli  Plan a firm and consistent environment in which limits and standards are set. Drug of choice : Methylphenidate (Ritalin)

Denial of hunger Obvious thinness but feels fat Lanugo all over the body Loss of scalp hair

Bulimia Nervosa  Extreme measures to lose weight  uses diet pills, diuretics or laxatives  purges after eating  extreme exercise  Signs of purging  swelling of the cheeks or jaw area  cuts and calluses on the back of the hands and knuckles  teeth that look clear  Peculiar signs  depression  loss of interests in activities

DISORDERS COMMONLY DIAGNOSED TO ADULTS EATING DISORDERS  More common among females.

a.n.g./n.a.l.

PSYCHIATRIC NURSING

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   

Remain with the client after meal and for 1st four hours Set limit on time allotted for eating Encourage client to express feelings Promote feeling of control by  participation in treatment  independent decision making

SEXUAL DISORDERS  Sexuality - is the result of biologic, psychological, social and experimental factors that mold an individual's sexual development, self-concept, body image and behavior.

Findings: (for both)  Weight loss of 15% or more of original body weight  Amenorrhea  Social withdrawal and poor family and individual coping  History of high activity and achievement in academics, athletics  Electrolyte imbalance  Depression / distorted body image Nursing Diagnosis:  Body image disturbance  Ineffective individual coping Nursing Interventions:  Establish a trusting relationship  Monitor vital signs  Reinforce:  dietician’s prescription to accomplish realistic weight gain  treatment plan that establishes privileges and restrictions based on compliance  Decrease emphasis on foods, eating, weight loss or gain  Weigh client daily at the same time a.n.g./n.a.l.

PSYCHIATRIC NURSING

Phases of the Sexual Response Cycle  Desire  the ability, interest and willingness to receive sexual stimulation  Excitement / Arousal  Result of psychological stimulation  Example is fantasizing during the desire phase and foreplay which involves petting and fondling of erogenous zones or areas of the body that are particularly sensitive to erotic stimulation.  Plateau  Orgasm  formerly termed as climax  the shortest stage in the sexual response cycle  occurs when stimulation proceeds through the plateau stage to a point where the body suddenly discharges accumulated sexual tension  Resolution phase  the final phase of sexual response  organs and body systems gradually return to the unaroused state Sexual Dysfunction Disorders  Sexual Desire Disorders: have little or no sexual desire or have an aversion to sexual contact.  Sexual Arousal Disorder: Individuals cannot complete the physiologic requirements for sexual intercourse

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Examples  Women cannot maintain lubrication  Men cannot maintain an erection  Orgasm Disorders: Inability to achieve orgasm phase Example: Premature ejaculation  Sexual Pain Disorders: Individuals suffer genital pain (dyspareunias) Example: Vaginismius Paraphilia (Sexual Deviation)  A term which generally refers to abnormal sexual behavior  Lasts for 6 months leading to distress or impairment to functioning. Examples Anilingus Bestiality or Zoophilia Coprophilia Cunnillingus Exhibitionism

Fellatio Fetishism Frotteurism

Masochism Necrophilia Partialism Pedophilia

a.n.g./n.a.l.

tongue brushing the anus contact with the animals smearing feces on the partner tongue brushing the vulva  Involves exposing one’s genitals to unsuspecting strangers. Victims are usually women or children.  They are stimulated by the effect of shocking the victim. inserting the penis into the mouth inanimate / non-living objects or articles  Touching or rubbing against the unsuspecting people.  Usually occurs in crowded places where escape is into the crowd is possible.  Sexual gratification from experiencing pain  Involves the acts of being humiliated beaten, restrained, or otherwise made to suffer  involves the use of corpses  inserting the penis into the other parts of the body  use of prepubertal children  could be an actual sexual act or a fantasy

PSYCHIATRIC NURSING

 Sadism Telephone Scatalogia Transvestism Urophilia Voyeurism

child is generally 13 years of age or younger inflicting pain  Involves telephoning someone and making lewd, obscene remarks or conversation.  AKA sex on phone sexual excitement through wearing the clothing of a woman urinating on the partner Act of observing unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity Includes cyber-voyeurism

Gender Identity Disorder  AKA Transexualism  Believe that they were born as the wrong sex  Leads to persistent discomfort and feels inappropriate in the role of the assigned sex. Nursing Interventions:  Attitude:  Accepting  Empathic  Non-judgmental  Accept his feelings related to sexuality  Have a private area to discuss fears or concerns about sexuality  Intervene to discuss self-esteem issues, anxiety, guilt, and empathy for victims.  Employ limit setting.  Referral to the correct clinic. SUBSTANCE-RELATED DISORDERS Alcoholism

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 Is a chronic disease or a disorder characterized by excessive alcohol intake and interference in the individual’s health, interpersonal relationship and economic functioning. (WHO)  Considered to be present when there is .1% or 10 ml for every 1000 ml of blood Signs of use:  .1-.2% - low coordination  .2-.3% - presence of ataxia, tremors, irritability, stupor  .3 and above - unconsciousness Progression:  Pre-alcoholic Phase - starts with social drinking; tolerance begins to develop  Prodromal Stage - alcohol becomes a need; blockout's occur; denial begins to develop  Crucial - cardinal symptoms of alcoholism develops (loss of control over drinking)  Chronic Phase - the person becomes intoxicated all day Outcome:  Brain damage  Alcoholic hallucinosis  Death

Alcohol Withdrawal Delirium  AKA delirium tremens  experienced within 24 to 72 hours after the last intake: o agitation o elevated vital signs o illusions and hallucinations o restlessness o hyperalertness o incoherent speech  serious medical complications may occur if the client is left untreated Korsakoff's Psychosis  Is a form of amnesia  characterized  short-term memory loss  Disorientation  inability to learn new skills  confabulation  Deficiency in vitamin B complex, especially B1 and B12.

Behavioral problems:  Denial  Dependency  Demanding  Destructive  Domineering Alcohol Withdrawal  Occurs when an individual abruptly stops drinking after alcohol has become a necessity of life to maintain functioning.

a.n.g./n.a.l.

 Symptoms include:  autonomic hyperactivity  grand mal seizures  psychomotor agitation and anxiety  increased hand tremors  sleep disturbances (insomnia and nightmares)  illusions hallucinations  hyperthermia  tachycardia (impending delirium tremens)

PSYCHIATRIC NURSING

Wernicke's Encephalopathy  An inflammatory hemorrhagic degenerative condition of the brain  caused by B1 deficiency  Symptoms include:  double vision  involuntary and rapid eye movements

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 

lack of muscular coordination decreased mental function

 cocaine psychosis  agitation  dilation of the pupils  diaphoresis  increase VS  Classic sign: Perforated nasal septum  Can cause a sudden heart attack even in healthy young people.

Nursing Diagnosis: Ineffective individual coping Principles of Nursing Care:  Well lighted room  Diet as tolerated  Monitor vital signs  Administration of glucose  Vitamins

Cannabis-Related Disorders (Cannabinoids)

Alcohol Detoxification:  Drug of Choice: Disulfiram (Antabuse) - delays the metabolism of alcohol  Avoid alcohol-containing products  3 S’s of detoxification:  Safety  Sedation  Supplement (Multivitamins, Vitamin B-complex, Vitamin C) DRUG-RELATED DISORDERS Cocaine-Related Disorders (Stimulants)  Cocaine is a white powdered stimulant substance  Usually sniffed, snorted, smoked in a pipe or injected into a vein or subcutaneous tissue.  Poor man’s cocaine:  Shabu (sha-boo)  Signs of use:  panic attacks  insomnia  loss of appetite  impaired thinking

a.n.g./n.a.l.

Marijuana  Can act as stimulant or depressant and is often considered to be a mild hallucinogen with some sedative properties  Is not physically addicting but may lead to psychological dependence  Plant : cannabis sativa  Active component is Tetrahydocannabinol  Routes of use:  Orally (capsules, tablets, on sugar cubes)  With food  Smoked in a pipe or rolled as cigarette.  Acts within 15 minutes  Effects lasts approximately 2 to 4 hours  Physiologic symptoms include  increased appetite  excitement  drowsiness  lowered body temperature  depression  unsteady gait  reduced coordination and reflexes  inability to think clearly  impaired judgment  Classic sign: bloodshot eyes  In large doses, it may cause:  Hallucination  Suicidal ideations

PSYCHIATRIC NURSING

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

Delusions of invulnerability

Long-term Goals:  Community resources  Other coping means aside from denial  Personal responsibility for not drinking / drugs taking  Isolation  Nutrition  Group therapy

Paranoid

Prognosis: Poor Defense Mechanism: Regression Hallucinations Ideas of reference Delusion of persecution Suspiciousness Prognosis: Good Defense Mechanism: Projection

SCHIZOPHRENIA AND OTHER PSYCHOSES SCHIZOPHRENIA  Is a serious psychiatric disorder  One of the most profound disabling illness  Not a single disease entity but a combination of disorders  "split mind"  characterized by: o impaired communication o loss of contact into reality o deterioration from a previous level of functioning  Nursing Diagnosis: Altered thought process  Most acceptable theory: Biologic Theory Manifestations: Eugene Bleuler  Associative looseness  Autism  Apathy  Ambivalence  Auditory hallucination Types Distinguishing features Disorganized Peculiar / bizarre behavior Incoherence Stereotyping

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Nursing Interventions  Assist with ADL  Encourage activity  Present reality

PSYCHIATRIC NURSING

Catatonic

Wax flexibility Stupor Negativism – mutism, rigidity, lack of response

 Priority: safety of others  Deal with the HID  Offer sealed foods / unopened medicines  Never displace outbursts of emotions  Explain procedures in simple ways  Never argue with the patient  Priority: nutrition & circulation  Provide distraction  Encourage activity

Prognosis: Good Defense Mechanism: Repression Undifferentiated  Patients whose manifestation cannot be easily fitted into one or the other type Residual  Patients with minimal symptoms General Nursing Interventions:  Establish:  a trusting relationship and provide acceptance  a clear, consistent and open communication  Set limits  Decrease environmental stimuli  Observe for suicidal ideation  Administer medications, as ordered. Page 29 of 32

 Exhibit flight of ideas  Decreased need for help  Distractibility

MOOD DISORDERS Precipitating Factors  Loss of a loved one  Major life events  Role strain  Decreased coping resources  Physiological changes

Summary: Appearance DM Attitude therapies

Common Types of Mood Disorder  Bipolar I Disorder: May experience one or more of symptoms of manic episode  Bipolar II Disorder: May experience one or more symptoms of major depressive episode with hypomania  Major Depressive Disorder: May be coded as mild, moderate or severe with or without psychotic features.  Dysthymic Disorder  Lesser severe than major depression  No symptoms such as impaired communication, delusions and hallucinations  Cyclothymic Disorder  DNOS (Depression Not Otherwise Specified) - lasts for 2 days-2 weeks Clinical Symptoms of Major Depressive Episode  Affect flat  Weight change (gain or loss)  Energy loss  Sad feelings / Social withdrawal  Obvious sleep disturbances  Memory loss  Emotional blunting

Priority NDx Nursing Management

Depression Sad Introjection Kind firmness

Non-stimulating Never give anything that requires attention Risk for injury: Directed at others Individual therapies Lithium Diet

Monotonous Risk for injury: selfdirected Group therapy Antidepressants ECT

Suicide  thought or act of taking one’s own life  ultimate form of self-destruction  "cry for help“  reunion wish or fantasy  progressive failure to adapt feelings of anger or hostility  a way to end feelings of hopelessness and helplessness  an attempt "to save face" or seek a release to a better life Risk Factors  Sex (more female attempts suicide but more male commits suicide)  Unsuccessful previous attempt  Identification with a dead family member  Chronic  Illness (e.g. Cancer)  Depression/Dependent personality  Age (18-25 and 40)/Alcoholism)  Lethality of previous attempt/Looses

Clinical Symptoms of Manic Episode  Talkative or pressured to keep talking  Inflated self-esteem or grandiosity  Psychomotor agitation

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Activity

Mania Elated Projection Matter of fact

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 Always reorient the client (clock & calendar)  Use color instead of numbers & letters  Consistency – 1 nurse to lessen confusion

Nursing Diagnosis: Risk for injury-Self directed Nursing care:  Safe environment  Always take overt or covert threats or attempts seriously  Ventilation of feelings  Encourage activities

CONCEPTS ON DEATH AND DYING DEATH/D YING: Elizabeth Kubler-Ross Stages: Denial - "NO NOT ME" Anger - "WHY ME" Bargaining - "IF ONLY" Depression - stage of silence Acceptance - "Yes, it's me"

 Monitor closely (one-on-one, 24/7)  Empathy (show acceptance & appreciation) CONDITIONS COMMONLY DIAGNOSED IN THE ELDERLY Alzheimer’s Disease A chronic, progressive degenerative cognitive disorder. Marked by Dementia Main Pathology: presence of senile plaques - destroys neurons (decreased acethylcholline) Signs and Symptoms:  Aphasia – deterioration of language function  Apraxia – impaired motor function  Agnosia – inability to recognize objects / people  Executive functioning - loss of abstract thinking

Nursing Diagnosis: Ineffective individual coping Nursing Care:  Be physically present  Be non-judgmental  Encourage verbalization of feelings  Allow the patient to cry  Recognize your own thoughts about death and dying

3 PHASES:  Forgetfulness - difficulty of remembering appointments  Advance - difficulty of remembering past events but not recent events  Terminal - death occurs in 1 year Nursing Diagnosis: Altered thought processes Nursing Care:  Priority: safety & security

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