psychiatric nursing
Content
LOBES OF BRAIN 1. FRONTAL LOBE - Language - Learning - Personality - Judgment 2. TEMPORAL LOBE - Hearing - Smell 3. PAREITAL LOBE - Touch - Taste 4. OCCIPITAL LOBE - Visual 3 STEPS TO INTERACT WITH ENVIRONMENT 1. Sensory – eyes, ears, tongue 2. Integration 3. Motor – voluntary or involuntary VOLUNTARY NERVOUS SYSTEM • also called as somatic Brain Spinal Cord Motor Nerve Synapse Muscle Fiber • Motor nerve to muscle fiber you need Acethylcholine which is an ―On switch‖.
INVOLUNTARY NERVOUS SYSTEM • also called autonomic nervous system. AUTONOMIC NERVOUS SYSTEM ———————–SYMPATHETIC ————PARASYMPATHETIC ——————-(Awake, ADRINERGIC) ——–(Relax, CHOLINERGIC) Heart Rate ———— Increase ——————– Decrease Respiratory Rate —— Increase ——————– Decrease GI ———————Decrease ——Increase (Moist mouth, Diarrhea) GU ——————– Decrease —- Increase (Urinary Frequency) Neurotransmitter—- Epinephrine, Norepinephrine —-Acethylcholine • Psych focuses in feelings or self awareness. • Beliefs determine feelings which affects behavior (manifestation of feelings) • Sigmund Freud is the father of PSYCHOANALYSIS. • What happens to childhood will affect adulthood. STRUCTURE OF PERSONALITY ID • impulsive, want to, wants pleasure. • PLEASURE PRINCIPLE. • Guiding principle is PAIN AVOIDANCE. SUPEREGO • should not • small voice of God • to stop EGO • executive decision maker. • In touch with reality principle.
ID DOMINANT PERSONALITIES Manic Anti – Social – experienced by serial killers Narcissistic SUPEREGO DOMINANT PERSONALITIES Obsessive Compulsive Anorexia Nervosa EGO – if destroyed result in impaired reality perception. Schizophrenia LIBIDO • Sexual energy responsible for survival. Oral Stage • 0 – 18 months evident. • ID is developed. *FIXATION – Person is stuck in certain developmental shape. *REGRESSION – Return to an earlier developmental stage. EGO – Developed on the 6th month. Anal Stage • 18 months – 3 years old. • Able to control bladder, bowel. • Best time for toilet training. • SUPEREGO is developed. TOILET TRAINING Good Mother———————— Bad Mother Successful —————–Dirty ———————- Clean ————————-disorganized ————— organized ————————- disobedient —————- obedient
————————- Anti-social ——————- O.C ———————– Anal expulsive ———– Anal retentive PHALLIC STAGE • 3 – 6 years old. • Experience pleasure by manipulating genitals. • Love – hate relationship. • Oedipus Complex boy loves parent of the opposite . • Imitates daddy called identification. • Castration fears. • Electra Complex girl loves parent of the opposite . • Imitates mommy called identification. • Penis envy. *Conscious – upper level of thinking. *Preconscious – tip of tongue. *Unconscious – protects us from traumatic experiences. LATENCY STAGE • 6 – 12 years old. • School age. • Separation anxiety. • Reading, Writing, Arithmetic. • Lasts for 6 years. GENITAL STAGE • 12 years old and above • Sexual reawakening. • Very important stage. PHARMA NOTES: ANTI – ANXIETY DRUGS • Valium • Librium • Ativan
• Serax • Tanxene • Miltown • Equanil • Vistaril • Atarax • Ideral • Buspar ERIC ERIKSON • There is more to life than just . • Psychosocial Theory of development. • You can develop a positive side or a negative side. • Developmental task begins at 0 – 18 months. ——————– POSITIVE ——NEGATIVE ——– FACTOR 0 – 18 mos. ———-Trust ———— Mistrust ———— Feeding 18 mos. – 3 yrs. —-Autonomy ——-Shame & Doubt —- Toilet Training 3 yrs. – 6 yrs. ——-Initiative ———- Guilt ————–Independence 6 yrs. – 12 yrs. —–Industry ———Inferiority ———— School 12 yrs. – 20 yrs. —-Identity ———Role Confusion ——— Peers 20 yrs. – 25 yrs. —-Intimacy ———–Isolation ————–Love 25 yrs. – 45 yrs. —Generativity ——–Stagnation ———–Parenting 45 yrs. – above —-Ego Integrity ——— Despair ————Reflection DRUGS WITH ANTICHOLINERGIC EFFECTS • Anti – Anxiety • Anti – Psychotic • Anti – Cholinergic • Anti – Depressants PHARMA NOTES:
MONOAMINE OXIDASE INHIBITORS (MAOI DRUGS) • Marplan • Nardil • Parnate DEFENSE MECHANISMS 1. Displacement – transfer of feelings to a less threatening object rather than the one who provoked it. 2. Denial – failure to acknowledge an unacceptable trait or situation. 3. DISOCIATION – psychological flight from the self. 4. REGRESSION – return to an earlier development state. 5. repression – unconscious forgetting. 6. RATIONALIZATION – illogical reasoning for an unacceptable trait and situation. 7. REACTION FORMATION – doing the opposite of what you have done. 8. UNDOING – doing the opposite of what you have done. 9. IDENTIFICATION – assuming trait for personal, social, occupational role. 10. PROJECTION – attribute to others one’s unacceptable trait. 11. INTROJECTION – assume another person’s trait as your own. 12. SUPPRESSION – conscious forgetting. 13. SUBLIMATION – putting destructive energies or hostile feelings towards a more productive endeavors. 14. CONVERSION – unexpressed or repressed feelings are converted to physical symptoms. 15. COMPENSATION – over achievement in one area to cover a defective part. 16. SUBSTITUTION – replace difficult goal with more accessible one. PHARMA NOTES: ANTI – PARKINSON DRUG - CAPABLES • Cogentin • Artane
• Parlodel • Akineton • Benadryl • Larodopa • Eldepryl • Symmetrel AUTONOMIC NERVOUS SYSTEM —————– SYMPATHETIC ——– PARASYMPATHETIC Pupils —————-Dilate —————-Constrict Blood Vessels ——–Constrict ————- Dilate Blood Pressure ——–Increase ———— Decrease THERAPEUTIC COMMUNICATION TECHNIQUES THERAPEUTIC 1. Offer Self 2. Silence – provide time to think 3. Making observation – what you see you say 4. Active Listening – nodding, eye contact 5. Broad Opening – how are you today? 6. General Leads – Go on, I’m listening 7. Restating – I’m sad ―You’re sad?‖ 1. Don’t worry be happy 2. Changing the topic/subject 3. Ignore the client 4. Value based judgment – never assume 5. Flattery 6. Advising 7. Giving Opinion NONTHERAPEUTIC 1. Don’t worry be happy 2. Changing the topic/subject
3. Ignore the client 4. Value based judgment – never assume 5. Flattery 6. Advising 7. Giving Opinion FEAR – protects us from something bad. ANXIETY • Vague sense of impending doom. • Triggers the sympathetic nervous system. • Assess level of anxiety of client. TYPES OF ANXIETY MILD ANXIETY • + 1 level of anxiety. • Widened perceptual field. • Restless (say you seem restless). • Enhanced learning capacity. MODERATE ANXIETY • + 2 level of anxiety. • Client pace. • Give PRN meds. SEVERE ANXIETY • + 3 level of anxiety. • Don’t know what to do/say. • Directive orders (please sit down). PANIC • + 4 level of anxiety. • May commit suicide. • Promote safety. • Never touch patient.
• Hyperventilation (Respiratory Alkalosis) • Breathe into paper bag. NURSING DIAGNOSIS: • ineffective individual coping. • Powerlessness. • Impaired skin integrity PLANNING/IMPLEMENTATION: • decrease level of anxiety. • Decrease environmental stimuli. • Relaxation techniques. EVALUATION • effective individual coping. GENERALIZED ANXIETY DISORDER • 6 month excessive worrying. • Restless, difficulty concentration, sleep disorders, palpitations, edge of the seat, easy fatigability. PANIC ATTACKS/DISORDER • 15 – 30 minutes sympathetic nervous system escalation. • Example is AGORAPHOBIA fear of open spaces. POST TRAUMATIC STRESS DISORDER • victims becomes survivors and experience flashbacks or nightmares. MALINGERING • pretending to be sick (conscious). • Primary Gain anxiety decreases, able to escape source of anxiety. • Secondary Gain able to get attention. SOMATOFORM • no protection
• unconscious • no organic basis of being sick DIFFERENT TYPE OF SOMATOFORM 1. Conversion Disorder • cannot speak, see, hear. • Nervous system affected. 2. La Belle Indifference • do not care what happens to them. HYPOCHONDRIASIS • has minor discomfort and interprets it as major illness. • Focus on clients feelings. BODY DISMORPHIC DISORDER • Illusion of structural defect. • Favorite past time is doctor hopping. • Focus on clients feelings. PSYCHOSOMATIC • Real pains/illness • Real symptoms because of anxiety PSYCHOSOMATIC Increase Anxiety SNS Increase BP & HR Hypertension Fat Deposits Atherosclerosis Calcium Arteriosclerosis Decrease Oxygen Angina Pectoris
MI Necrosis CHF Coma PHOBIA • Irrational fear • Etiology: Knowledge of certain object • Bad experience • Immediate nursing objective: Removal of stimulus will remove anxiety • Systemic Desensitization gradually expose client to stimuli/feared object • Employ relaxation techniques SNS • GABA (Gamma Amino Butyric Acid) – stop • Epinephrine and Norepinephrine – Go ANTI-ANXIETY • Increase GABA and client becomes drowsy (no alcohol and coffee) • May develop orthostatic hypotension • Let patient sit then dangle feet and then stand • Develop anti cholinergic effects • If abruptly withdrawn to anti anxiety it may result to rebound phenomenon (1 week) may lead to seizures • Do it in gradual and in tapered dose • Anti anxiety leads to dependence AUTISM • Unresponsive and does not want to be touched • Autistic Savant: high intelligence and has a ratio of 1:100 • Assessment • Appearance – flat affect and loves constancy and ritualistic • Behavior – withdrawn • Communication – echolalia
NURSING DIANOSIS • Impaired verbal communication • Impaired social interaction • Self mutilation • Risk for injury PLANNING/IMPLEMENTATION • Maslow’s hierarchy of needs • Expressive Therapy – use of art as mode if communication EVALUATION • Enhanced communication • Improved social interaction • Safety ATTENTION DEFICIT HYPERACTIVITY DISORDER • 7 years and below onset • Duration: 6 months and above • Settings: house and school • Assessment • Appearance: dirty, clumsy, hyperactive, impatient, easily distracted and has no focus • Behavior • Communication: talkative NURSING DIAGNOSIS • Risk for injury • Impaired social interaction PLANNING/IMPLEMENTATION • Structure: place to play, sleep, eat and study • Schedule: there is always a time for everything that you do • Set limits • Safety
EVALUATION • Minimize risk for injury • Improved social interaction FRONTAL LOBE OF ADHD Decrease glucose Decrease judgment Increase impulsiveness ADHD Hyperactivity • Need a drug that brings glucose level up. • Give Ritalin a stimulant • May result in loss of appetite • Given after meals • Given 6 hours before bedtime EATING DISORDERS ANOREXIA NERVOSA —————BULIMIA NERVOSA - Eat, eat, eat ————————— Eat, eat, vomit - Less 85% expected body weight ——- Normal weight - 3 months amenorrhea ————— Irregular menstruation BULIMIA NERVOSA • Metabolic alkalosis (vomiting results to decrease hydrochloric acid) • Metabolic acidosis (diarrhea results to decrease bicarbonate) • Dental caries • Wound in knuckles MANAGEMENT • Fluid and electrolyte imbalance • Meal contract • Weight gain for client
• After eating stay with client for 1 hour and accompany when going to the comfort room PHARMA NOTES: ANTI – PSYCHOTIC DRUG • Stelazine • Serentil • Thorazine • Trilafon • Clozaril • Mellaril • Haldol • Prolixin SCHIZOPHRENIA • Ego disintegration • Impaired reality perception • Genetic vulnerability • Stress – Diathesis Model • Biological theory – increase dopamine level • Exact cause unknown ASSESSMENT • Affect: Appropriate, Inappropriate, Flat, Blunt (incomplete) • Ambivalence: pulled into 2 opposing forces Autism • Looseness, no idea, not related to one another ASSESSMENT NEGATIVE ————————POSITIVE Hypoactive ———————— Hyperactive Withdrawn ————————- Sociable Thought Blocking ——————Flight of ideas Apathy
I. ASSESS • Content of thought NURSING DIAGNOSIS • Disturbed thought process PLANNING/IMPLEMENTATION • Present reality • Provide safety EVALUATION • Improved thought process II. ASSESS • Hallucinations/Illusions NURSING DIAGNOSIS • Disturbed sensory perception PLANNING/IMPLEMENTATION • Present reality • Safety EVALUATION • Improved sensory perception III. ASSESS • Suspicious NURSING DIAGNOSIS • Risk for other directed violence PLANNING/IMPLEMENTATION • Present reality • Safety EVALUATION • Eliminate/minimize risk for other directed violence
IV. ASSESS • Suicidal NURSING DIAGNOSIS • Risk for self directed violence PLANNING/IMPLEMENTATION • Present reality • Safety EVALUATION • Eliminate/minimize risk for self directed violence LOOSENESS OF ASSOCIATION • Thinking that is overgeneralized, diffuse, and vague with only a tenuous connection between one thought and the next FLIGHT OF IDEAS • Jumping from on topic to another AMBIVALENCE • Pulled between 2 strong opposing forces MAGICAL THINKING • acting like magician ECHOLALIA • Client repeats what you say ECHOPRAXIA • Client repeats what you do WORD SALAD • Just words no rhyme CLANG ASSOCIATION • Words that rhyme
NEOLOGISM • Formation of new words (needs clarification) DELUSION: PERSECUTORY • ―The NBI is out to get me‖ DELUSION: RELIGIOUS • ―I am Jesus Christ the savior‖ DELUSION: GRANDEUR • ― I am the queen of the world‖ DELUSION: IDEAS OF REFERENCE • ―The nurses are talking about me‖ CONCRETE ASSOCIATION • Also known as ―pilosopo‖ THOUGHT BLOCKING • Unable to think ———————–HALLUCINATIONS—— ILLUSIONS STIMULUS ———— ABSENT———— PRESENT VISUAL —————-ABSENT———— PRESENT AUDITORY ———– ABSENT———— PRESENT TACTILE ABSENT — ABSENT———— PRESENT • Present reality to clients experiencing hallucinations • Technique in handling clients with hallucinations • Hallucinations • Acknowledgement ―I know the voices are real to you‖ • Reality orientation ―I know the voices are real but I don’t hear them‖ • Diversion ―Lets go to the garden‖ • 10% of schizophrenic clients hear voices
PARKINSON’S DISEASE • If acethylcholine (on switch) is increased there is excessive movement resulting to decrease in dopamine (off switch) ANTI-PSYCHOTIC Decrease dopamine level Parkinson like effect Extra pyramidal side effect With akathesia Restless, inability to rest AKINESIA • Muscle rigidity DYSTONIA • Torticollis (wryneck) OCULOGYRIC CRISIS • Fixed stare OPISTHOTONUS • Arched back • Lips – smacking • Tongue – protruding • Cheeks – puffing • The 3 are irreversible and called tardive dyskinesia • Neuroleptic malignant syndrome – hyperthermia ANTI – PARKINSON Anticholinergics Dopaminergics (Decrease Ach) (Increase Dopa) Artane, Akineton Parlodel Benadryl Larodopa Cogentin Eldepryl Symmetrel
OTHER SIDE EFFECTS OF DECREASE DOPAMINE • Photosensitivity • Agranulocytosis – decrease WBC • Clients prone to infection due to decrease WBC • First sign for infection is sore throat TYPES OF SCHIZOPHRENIA DISORGANIZED SCHIZOPHRENIA - Sad but smiles (inappropriate affect) - No reaction (flat affect) - Flight of ideas (disorganized speech) - Giggling (hebephrenic giggle) - Combination of positive and negative signs and symptoms CATATONIC SCHIZOPHRENIA - Ambivalence - Waxy flexibility - Favorite word is ―No‖ - Negativism (client do not follow what you tell them to do) Nursing management: meet needs PARANOID SCHIZOPHRENIA - Suspicious - Mistrust, scared, withdrawn Nursing management: - Gain trust by 1 to 1 short interaction but frequent - Foods should be in a sealed container - Medications should be in tamper resistant foil. Violent: - Keep door open - Position near door - Don’t touch client
- Call for reinforcement - One arms length away from the client. PARANOID SCHIZOPHRENIA - No more positive symptoms just withdrawn UNDIFFIRENTIATED SCHIZOPHRENIA - Mixed classification, cant be classified PHAMRA NOTES: BI-POLAR, MANIC • Lithium: undergo first kidney test and check for blood levels • Level: .6 – 1.2 meq/L • Increase urination • Tremors, fine hand • Hydration of 3L/day • Increase • Uu (diarrhea) • Mouth dry Signs of Lithium toxicity • Nausea, vomiting, diarrhea • Increase sodium * Wait for 2 – 4 weeks before lithium therapy takes effects BIPOLAR DISORDER/MANIC PROFILE • 20 years old • Female • Stress • Obese ASSESSMENT • Decrease appetite (give finger foods) • Decrease sleep (place in a private room)
• Hyperactive • Increase sexual activity – only means of addressing anxiety so decrease level of anxiety • Risk for injury/other directed violence • Impaired social interaction (care giver role: strain and stay with client) • Self esteem decrease (to cover up their sadness there is compensation to cover defective doing) • Because there is decrease self esteem there will be increase compensation resulting to increase interference with ADL’s and harm to others • Compensation is the culprit • Management: increase self esteem to decrease compensation and decrease interference with ADL’s and harm to others HOW TO INCREASE SELF ESTEEM OF MANIC PATIENTS T- no sports (basketball, volleyball), no fine motor skills only gross motor skills A lot energies toward more productive endeavors (sublimation) S - escorted walk outdoors K – punching bag (displacement) PHARMA NOTES: ANTI – DEPRESSANTS • Asendin • Norpralamin • Tofranil • Sinequan • Anafranil • Aventyl • Vivactil • Elavil • Prozac
• Paxil • Zoloft ALCOHOL LEADS TO: • Blackout: awake but unaware • Confabulation: inventing stories to increase self esteem • Denial: ―I am not an alcoholic‖ • Dependence: cant leave with out leading to enabling where in the significant other tolerates the abuser co dependence is another term • Tolerance: gradual increase in amount of stimuli to experience the same euphoria MANAGEMENT • Detoxification: withdrawal with medical doctor supervision • Avoid alcohol therapy • Aversion therapy a more technical term for avoid alcohol therapy • Antabuse: Disulfiram makes the client never drink alcohol because it causes vomiting • Alcoholics anonymous • Interval of 12 hours after last dose of alcohol or experience nausea and vomiting and hypotension • Alcoholism may result to Vitamin B1 (Thiamine) deficiency WERNICKE’S ENCEPHALOPATHY • Problem with motor KORSAKOFF’S PSYCHOSIS • Problem with memory • 24 – 72 hours after last dose of alcohol expect: • Delirium Tremens: sympathetic nervous system • Prevent hallucinations/Illusions by placing client in a well lit room • Formication: feeling of bugs crawling under the skin
ALZHEIMERS DISEASE • Axon (away) and Dendrites (toward) nerve • Neurofibrillary tangles • Neurotic plaques ————————–ALCOHOL — ALZHEIMERS ONSET ——————– Abrupt ——– Gradual LEVEL OF CONSCIOUSNESS – Fluctuating —-Unaffected DURATION ———– Hours to days — Progressive MEMORY ————– Short term —Short and long term 5 A’s OF ALZHEIMERS 1. Amnesia – memory loss 2. Anomia – don’t know the name 3. Agnosia – sensory problems smell, taste, sight 4. Aphasia - expressive: cant say/express - frontal lobe is affected particularly broca’s area - receptive: cant hear - temporal lobe is affected particularly wernicke’s area 5. Apraxia – cant do simple things * Reminiscing Therapy – talk about past • Patients with alzheimer’s may experience hallucinations, illusions thus becomes restless and may wander • As sun goes down client becomes restless, agitated, disoriented called sundowning • Drug of choice is Cognex and Aricept a cholinesterase inhibitor that increases Ach causing delay in disease progression SEROTONIN • Responsible for happiness • Decrease serotonin clients becomes sad give anti-depressants
SELECTIVE SEROTONIN REUPTAKE INHIBITOR Safest drug Side effects low R I to 4 weeks - Increases serotonin and affects only serotonin - Prozac, Paxil, Zoloft TRICYCLIC ANTI DEPRESSANT Two – four weeks C A - Has higher incidence of side effects - Also increases norepinephrine - Asendin, Norpralamin, Tofranil, Sinequan, Anafranil, Aventyl, Vivactil, Elavil MONO AMINE OXIDASE INHIBITORS • MAO kills serotonin • Increased MAO results to decreased serotonin the more depressed the client becomes • MAOI kills MAO and increases all neurotransmitters (serotonin, epinephrine, norepinephrine, dopamine but client becomes prone to hypertensive crisis • Avoid tyramine rich foods • Avocado, Alcohol • Beer • Chocolates, Cheese (aged) • Fermented foods • Pickles • Preserved foods • Soy sauce • There is increase incidence of side effects after 2 – 6 weeks • Marplan, Nardil, Parnate
PERSONALITY DISORDERS 1. Schizophrenia - They avoid people because there is no enjoyment 2. Avoidant - They avoid people because they are afraid of criticisms - They have talent but has no confidence 3. Anti-Social - Constantly breaks law - Project charm - They are witty and articulate - Manipulative 4. Borderline - They perceive life as an empty glass - They like splitting friends - Sudden change in mood ―labile affect‖ - Prone to suicide 5. Dependent - ―Cant live if living is without you‖ 6. Histrioinic - Constantly wants to be the center of attention - Excited, dramatic, manipulative 7. Narcissistic - ―I love myself‖ - They get jealous even with achievement of family members 8. Obsessive – Compulsive - ―I am so organized‖ 9. Paranoid - Suspicious - May lead to domestic violence ANTI – DEPRESSANT SIDE EFFECTS: Male – erectile dysfunction, prone to impotence
GRIEF PROCESS 1. Denial – shock/disbelief 2. Anger – question ―why me?‖ 3. Bargaining – if, then 4. Depression – 2 weeks or more sign and symptoms becomes major clinical depression 5. Acceptance – client acts according to situation ASSESSMENT • Decrease self actualization • Decrease self esteem • Withdrawn: stay with client • Suicidal: risk for self directed violence • Increase/decrease eat, increase/decrease sleep, hypoactive, decrease sexual urge • Be sensitive to clients needs FOR SUICIDAL OBSERVE FOR Verbal • ―I wont be a problem‖ • ―This is my last day on earth‖ • ―I’ll soon be gone‖ Non verbal • Giving away of valuables • Sudden change in mood WHEN THE CLIENT IS SUICIDAL WHAT WILL THE NURSE DO Direct: ―Do you plan to commit suicide?‖ Irregular/interval visits Endorsement period, early morning clients are most likely to commit suicide DOWNERS Alcohol Barbiturate
Opiates Narcotics Marijuana Morphine Codeine Heroine Resulting to: • Bradycardia • Bradypnea • Moist mouth • Pupils constrict • Constipation • Urinary retention • Hypotension • Coma • Weight gain • Narcotics overdose: give narcotic antagonist (Narcan, Naloxone hydrochloride) UPPERS Cocaine Hallucinogens Amphetamines Resulting to: • Tachycardia • Awake • Tachypnea • Dry mouth • Pupils dilate • Hypertension • Seizures • Weight loss
INVOLUNTARY NERVOUS SYSTEM • also called autonomic nervous system. AUTONOMIC NERVOUS SYSTEM ———————–SYMPATHETIC ————PARASYMPATHETIC ——————-(Awake, ADRINERGIC) ——–(Relax, CHOLINERGIC) Heart Rate ———— Increase ——————– Decrease Respiratory Rate —— Increase ——————– Decrease GI ———————Decrease ——Increase (Moist mouth, Diarrhea) GU ——————– Decrease —- Increase (Urinary Frequency) Neurotransmitter—- Epinephrine, Norepinephrine —-Acethylcholine • Psych focuses in feelings or self awareness. • Beliefs determine feelings which affects behavior (manifestation of feelings) • Sigmund Freud is the father of PSYCHOANALYSIS. • What happens to childhood will affect adulthood. STRUCTURE OF PERSONALITY ID • impulsive, want to, wants pleasure. • PLEASURE PRINCIPLE. • Guiding principle is PAIN AVOIDANCE. SUPEREGO • should not • small voice of God • to stop EGO • executive decision maker. • In touch with reality principle.
ID DOMINANT PERSONALITIES Manic Anti – Social – experienced by serial killers Narcissistic SUPEREGO DOMINANT PERSONALITIES Obsessive Compulsive Anorexia Nervosa EGO – if destroyed result in impaired reality perception. Schizophrenia LIBIDO • Sexual energy responsible for survival. Oral Stage • 0 – 18 months evident. • ID is developed. *FIXATION – Person is stuck in certain developmental shape. *REGRESSION – Return to an earlier developmental stage. EGO – Developed on the 6th month. Anal Stage • 18 months – 3 years old. • Able to control bladder, bowel. • Best time for toilet training. • SUPEREGO is developed. TOILET TRAINING Good Mother———————— Bad Mother Successful —————–Dirty ———————- Clean ————————-disorganized ————— organized ————————- disobedient —————- obedient
————————- Anti-social ——————- O.C ———————– Anal expulsive ———– Anal retentive PHALLIC STAGE • 3 – 6 years old. • Experience pleasure by manipulating genitals. • Love – hate relationship. • Oedipus Complex boy loves parent of the opposite . • Imitates daddy called identification. • Castration fears. • Electra Complex girl loves parent of the opposite . • Imitates mommy called identification. • Penis envy. *Conscious – upper level of thinking. *Preconscious – tip of tongue. *Unconscious – protects us from traumatic experiences. LATENCY STAGE • 6 – 12 years old. • School age. • Separation anxiety. • Reading, Writing, Arithmetic. • Lasts for 6 years. GENITAL STAGE • 12 years old and above • Sexual reawakening. • Very important stage. PHARMA NOTES: ANTI – ANXIETY DRUGS • Valium • Librium • Ativan
• Serax • Tanxene • Miltown • Equanil • Vistaril • Atarax • Ideral • Buspar ERIC ERIKSON • There is more to life than just . • Psychosocial Theory of development. • You can develop a positive side or a negative side. • Developmental task begins at 0 – 18 months. ——————– POSITIVE ——NEGATIVE ——– FACTOR 0 – 18 mos. ———-Trust ———— Mistrust ———— Feeding 18 mos. – 3 yrs. —-Autonomy ——-Shame & Doubt —- Toilet Training 3 yrs. – 6 yrs. ——-Initiative ———- Guilt ————–Independence 6 yrs. – 12 yrs. —–Industry ———Inferiority ———— School 12 yrs. – 20 yrs. —-Identity ———Role Confusion ——— Peers 20 yrs. – 25 yrs. —-Intimacy ———–Isolation ————–Love 25 yrs. – 45 yrs. —Generativity ——–Stagnation ———–Parenting 45 yrs. – above —-Ego Integrity ——— Despair ————Reflection DRUGS WITH ANTICHOLINERGIC EFFECTS • Anti – Anxiety • Anti – Psychotic • Anti – Cholinergic • Anti – Depressants PHARMA NOTES:
MONOAMINE OXIDASE INHIBITORS (MAOI DRUGS) • Marplan • Nardil • Parnate DEFENSE MECHANISMS 1. Displacement – transfer of feelings to a less threatening object rather than the one who provoked it. 2. Denial – failure to acknowledge an unacceptable trait or situation. 3. DISOCIATION – psychological flight from the self. 4. REGRESSION – return to an earlier development state. 5. repression – unconscious forgetting. 6. RATIONALIZATION – illogical reasoning for an unacceptable trait and situation. 7. REACTION FORMATION – doing the opposite of what you have done. 8. UNDOING – doing the opposite of what you have done. 9. IDENTIFICATION – assuming trait for personal, social, occupational role. 10. PROJECTION – attribute to others one’s unacceptable trait. 11. INTROJECTION – assume another person’s trait as your own. 12. SUPPRESSION – conscious forgetting. 13. SUBLIMATION – putting destructive energies or hostile feelings towards a more productive endeavors. 14. CONVERSION – unexpressed or repressed feelings are converted to physical symptoms. 15. COMPENSATION – over achievement in one area to cover a defective part. 16. SUBSTITUTION – replace difficult goal with more accessible one. PHARMA NOTES: ANTI – PARKINSON DRUG - CAPABLES • Cogentin • Artane
• Parlodel • Akineton • Benadryl • Larodopa • Eldepryl • Symmetrel AUTONOMIC NERVOUS SYSTEM —————– SYMPATHETIC ——– PARASYMPATHETIC Pupils —————-Dilate —————-Constrict Blood Vessels ——–Constrict ————- Dilate Blood Pressure ——–Increase ———— Decrease THERAPEUTIC COMMUNICATION TECHNIQUES THERAPEUTIC 1. Offer Self 2. Silence – provide time to think 3. Making observation – what you see you say 4. Active Listening – nodding, eye contact 5. Broad Opening – how are you today? 6. General Leads – Go on, I’m listening 7. Restating – I’m sad ―You’re sad?‖ 1. Don’t worry be happy 2. Changing the topic/subject 3. Ignore the client 4. Value based judgment – never assume 5. Flattery 6. Advising 7. Giving Opinion NONTHERAPEUTIC 1. Don’t worry be happy 2. Changing the topic/subject
3. Ignore the client 4. Value based judgment – never assume 5. Flattery 6. Advising 7. Giving Opinion FEAR – protects us from something bad. ANXIETY • Vague sense of impending doom. • Triggers the sympathetic nervous system. • Assess level of anxiety of client. TYPES OF ANXIETY MILD ANXIETY • + 1 level of anxiety. • Widened perceptual field. • Restless (say you seem restless). • Enhanced learning capacity. MODERATE ANXIETY • + 2 level of anxiety. • Client pace. • Give PRN meds. SEVERE ANXIETY • + 3 level of anxiety. • Don’t know what to do/say. • Directive orders (please sit down). PANIC • + 4 level of anxiety. • May commit suicide. • Promote safety. • Never touch patient.
• Hyperventilation (Respiratory Alkalosis) • Breathe into paper bag. NURSING DIAGNOSIS: • ineffective individual coping. • Powerlessness. • Impaired skin integrity PLANNING/IMPLEMENTATION: • decrease level of anxiety. • Decrease environmental stimuli. • Relaxation techniques. EVALUATION • effective individual coping. GENERALIZED ANXIETY DISORDER • 6 month excessive worrying. • Restless, difficulty concentration, sleep disorders, palpitations, edge of the seat, easy fatigability. PANIC ATTACKS/DISORDER • 15 – 30 minutes sympathetic nervous system escalation. • Example is AGORAPHOBIA fear of open spaces. POST TRAUMATIC STRESS DISORDER • victims becomes survivors and experience flashbacks or nightmares. MALINGERING • pretending to be sick (conscious). • Primary Gain anxiety decreases, able to escape source of anxiety. • Secondary Gain able to get attention. SOMATOFORM • no protection
• unconscious • no organic basis of being sick DIFFERENT TYPE OF SOMATOFORM 1. Conversion Disorder • cannot speak, see, hear. • Nervous system affected. 2. La Belle Indifference • do not care what happens to them. HYPOCHONDRIASIS • has minor discomfort and interprets it as major illness. • Focus on clients feelings. BODY DISMORPHIC DISORDER • Illusion of structural defect. • Favorite past time is doctor hopping. • Focus on clients feelings. PSYCHOSOMATIC • Real pains/illness • Real symptoms because of anxiety PSYCHOSOMATIC Increase Anxiety SNS Increase BP & HR Hypertension Fat Deposits Atherosclerosis Calcium Arteriosclerosis Decrease Oxygen Angina Pectoris
MI Necrosis CHF Coma PHOBIA • Irrational fear • Etiology: Knowledge of certain object • Bad experience • Immediate nursing objective: Removal of stimulus will remove anxiety • Systemic Desensitization gradually expose client to stimuli/feared object • Employ relaxation techniques SNS • GABA (Gamma Amino Butyric Acid) – stop • Epinephrine and Norepinephrine – Go ANTI-ANXIETY • Increase GABA and client becomes drowsy (no alcohol and coffee) • May develop orthostatic hypotension • Let patient sit then dangle feet and then stand • Develop anti cholinergic effects • If abruptly withdrawn to anti anxiety it may result to rebound phenomenon (1 week) may lead to seizures • Do it in gradual and in tapered dose • Anti anxiety leads to dependence AUTISM • Unresponsive and does not want to be touched • Autistic Savant: high intelligence and has a ratio of 1:100 • Assessment • Appearance – flat affect and loves constancy and ritualistic • Behavior – withdrawn • Communication – echolalia
NURSING DIANOSIS • Impaired verbal communication • Impaired social interaction • Self mutilation • Risk for injury PLANNING/IMPLEMENTATION • Maslow’s hierarchy of needs • Expressive Therapy – use of art as mode if communication EVALUATION • Enhanced communication • Improved social interaction • Safety ATTENTION DEFICIT HYPERACTIVITY DISORDER • 7 years and below onset • Duration: 6 months and above • Settings: house and school • Assessment • Appearance: dirty, clumsy, hyperactive, impatient, easily distracted and has no focus • Behavior • Communication: talkative NURSING DIAGNOSIS • Risk for injury • Impaired social interaction PLANNING/IMPLEMENTATION • Structure: place to play, sleep, eat and study • Schedule: there is always a time for everything that you do • Set limits • Safety
EVALUATION • Minimize risk for injury • Improved social interaction FRONTAL LOBE OF ADHD Decrease glucose Decrease judgment Increase impulsiveness ADHD Hyperactivity • Need a drug that brings glucose level up. • Give Ritalin a stimulant • May result in loss of appetite • Given after meals • Given 6 hours before bedtime EATING DISORDERS ANOREXIA NERVOSA —————BULIMIA NERVOSA - Eat, eat, eat ————————— Eat, eat, vomit - Less 85% expected body weight ——- Normal weight - 3 months amenorrhea ————— Irregular menstruation BULIMIA NERVOSA • Metabolic alkalosis (vomiting results to decrease hydrochloric acid) • Metabolic acidosis (diarrhea results to decrease bicarbonate) • Dental caries • Wound in knuckles MANAGEMENT • Fluid and electrolyte imbalance • Meal contract • Weight gain for client
• After eating stay with client for 1 hour and accompany when going to the comfort room PHARMA NOTES: ANTI – PSYCHOTIC DRUG • Stelazine • Serentil • Thorazine • Trilafon • Clozaril • Mellaril • Haldol • Prolixin SCHIZOPHRENIA • Ego disintegration • Impaired reality perception • Genetic vulnerability • Stress – Diathesis Model • Biological theory – increase dopamine level • Exact cause unknown ASSESSMENT • Affect: Appropriate, Inappropriate, Flat, Blunt (incomplete) • Ambivalence: pulled into 2 opposing forces Autism • Looseness, no idea, not related to one another ASSESSMENT NEGATIVE ————————POSITIVE Hypoactive ———————— Hyperactive Withdrawn ————————- Sociable Thought Blocking ——————Flight of ideas Apathy
I. ASSESS • Content of thought NURSING DIAGNOSIS • Disturbed thought process PLANNING/IMPLEMENTATION • Present reality • Provide safety EVALUATION • Improved thought process II. ASSESS • Hallucinations/Illusions NURSING DIAGNOSIS • Disturbed sensory perception PLANNING/IMPLEMENTATION • Present reality • Safety EVALUATION • Improved sensory perception III. ASSESS • Suspicious NURSING DIAGNOSIS • Risk for other directed violence PLANNING/IMPLEMENTATION • Present reality • Safety EVALUATION • Eliminate/minimize risk for other directed violence
IV. ASSESS • Suicidal NURSING DIAGNOSIS • Risk for self directed violence PLANNING/IMPLEMENTATION • Present reality • Safety EVALUATION • Eliminate/minimize risk for self directed violence LOOSENESS OF ASSOCIATION • Thinking that is overgeneralized, diffuse, and vague with only a tenuous connection between one thought and the next FLIGHT OF IDEAS • Jumping from on topic to another AMBIVALENCE • Pulled between 2 strong opposing forces MAGICAL THINKING • acting like magician ECHOLALIA • Client repeats what you say ECHOPRAXIA • Client repeats what you do WORD SALAD • Just words no rhyme CLANG ASSOCIATION • Words that rhyme
NEOLOGISM • Formation of new words (needs clarification) DELUSION: PERSECUTORY • ―The NBI is out to get me‖ DELUSION: RELIGIOUS • ―I am Jesus Christ the savior‖ DELUSION: GRANDEUR • ― I am the queen of the world‖ DELUSION: IDEAS OF REFERENCE • ―The nurses are talking about me‖ CONCRETE ASSOCIATION • Also known as ―pilosopo‖ THOUGHT BLOCKING • Unable to think ———————–HALLUCINATIONS—— ILLUSIONS STIMULUS ———— ABSENT———— PRESENT VISUAL —————-ABSENT———— PRESENT AUDITORY ———– ABSENT———— PRESENT TACTILE ABSENT — ABSENT———— PRESENT • Present reality to clients experiencing hallucinations • Technique in handling clients with hallucinations • Hallucinations • Acknowledgement ―I know the voices are real to you‖ • Reality orientation ―I know the voices are real but I don’t hear them‖ • Diversion ―Lets go to the garden‖ • 10% of schizophrenic clients hear voices
PARKINSON’S DISEASE • If acethylcholine (on switch) is increased there is excessive movement resulting to decrease in dopamine (off switch) ANTI-PSYCHOTIC Decrease dopamine level Parkinson like effect Extra pyramidal side effect With akathesia Restless, inability to rest AKINESIA • Muscle rigidity DYSTONIA • Torticollis (wryneck) OCULOGYRIC CRISIS • Fixed stare OPISTHOTONUS • Arched back • Lips – smacking • Tongue – protruding • Cheeks – puffing • The 3 are irreversible and called tardive dyskinesia • Neuroleptic malignant syndrome – hyperthermia ANTI – PARKINSON Anticholinergics Dopaminergics (Decrease Ach) (Increase Dopa) Artane, Akineton Parlodel Benadryl Larodopa Cogentin Eldepryl Symmetrel
OTHER SIDE EFFECTS OF DECREASE DOPAMINE • Photosensitivity • Agranulocytosis – decrease WBC • Clients prone to infection due to decrease WBC • First sign for infection is sore throat TYPES OF SCHIZOPHRENIA DISORGANIZED SCHIZOPHRENIA - Sad but smiles (inappropriate affect) - No reaction (flat affect) - Flight of ideas (disorganized speech) - Giggling (hebephrenic giggle) - Combination of positive and negative signs and symptoms CATATONIC SCHIZOPHRENIA - Ambivalence - Waxy flexibility - Favorite word is ―No‖ - Negativism (client do not follow what you tell them to do) Nursing management: meet needs PARANOID SCHIZOPHRENIA - Suspicious - Mistrust, scared, withdrawn Nursing management: - Gain trust by 1 to 1 short interaction but frequent - Foods should be in a sealed container - Medications should be in tamper resistant foil. Violent: - Keep door open - Position near door - Don’t touch client
- Call for reinforcement - One arms length away from the client. PARANOID SCHIZOPHRENIA - No more positive symptoms just withdrawn UNDIFFIRENTIATED SCHIZOPHRENIA - Mixed classification, cant be classified PHAMRA NOTES: BI-POLAR, MANIC • Lithium: undergo first kidney test and check for blood levels • Level: .6 – 1.2 meq/L • Increase urination • Tremors, fine hand • Hydration of 3L/day • Increase • Uu (diarrhea) • Mouth dry Signs of Lithium toxicity • Nausea, vomiting, diarrhea • Increase sodium * Wait for 2 – 4 weeks before lithium therapy takes effects BIPOLAR DISORDER/MANIC PROFILE • 20 years old • Female • Stress • Obese ASSESSMENT • Decrease appetite (give finger foods) • Decrease sleep (place in a private room)
• Hyperactive • Increase sexual activity – only means of addressing anxiety so decrease level of anxiety • Risk for injury/other directed violence • Impaired social interaction (care giver role: strain and stay with client) • Self esteem decrease (to cover up their sadness there is compensation to cover defective doing) • Because there is decrease self esteem there will be increase compensation resulting to increase interference with ADL’s and harm to others • Compensation is the culprit • Management: increase self esteem to decrease compensation and decrease interference with ADL’s and harm to others HOW TO INCREASE SELF ESTEEM OF MANIC PATIENTS T- no sports (basketball, volleyball), no fine motor skills only gross motor skills A lot energies toward more productive endeavors (sublimation) S - escorted walk outdoors K – punching bag (displacement) PHARMA NOTES: ANTI – DEPRESSANTS • Asendin • Norpralamin • Tofranil • Sinequan • Anafranil • Aventyl • Vivactil • Elavil • Prozac
• Paxil • Zoloft ALCOHOL LEADS TO: • Blackout: awake but unaware • Confabulation: inventing stories to increase self esteem • Denial: ―I am not an alcoholic‖ • Dependence: cant leave with out leading to enabling where in the significant other tolerates the abuser co dependence is another term • Tolerance: gradual increase in amount of stimuli to experience the same euphoria MANAGEMENT • Detoxification: withdrawal with medical doctor supervision • Avoid alcohol therapy • Aversion therapy a more technical term for avoid alcohol therapy • Antabuse: Disulfiram makes the client never drink alcohol because it causes vomiting • Alcoholics anonymous • Interval of 12 hours after last dose of alcohol or experience nausea and vomiting and hypotension • Alcoholism may result to Vitamin B1 (Thiamine) deficiency WERNICKE’S ENCEPHALOPATHY • Problem with motor KORSAKOFF’S PSYCHOSIS • Problem with memory • 24 – 72 hours after last dose of alcohol expect: • Delirium Tremens: sympathetic nervous system • Prevent hallucinations/Illusions by placing client in a well lit room • Formication: feeling of bugs crawling under the skin
ALZHEIMERS DISEASE • Axon (away) and Dendrites (toward) nerve • Neurofibrillary tangles • Neurotic plaques ————————–ALCOHOL — ALZHEIMERS ONSET ——————– Abrupt ——– Gradual LEVEL OF CONSCIOUSNESS – Fluctuating —-Unaffected DURATION ———– Hours to days — Progressive MEMORY ————– Short term —Short and long term 5 A’s OF ALZHEIMERS 1. Amnesia – memory loss 2. Anomia – don’t know the name 3. Agnosia – sensory problems smell, taste, sight 4. Aphasia - expressive: cant say/express - frontal lobe is affected particularly broca’s area - receptive: cant hear - temporal lobe is affected particularly wernicke’s area 5. Apraxia – cant do simple things * Reminiscing Therapy – talk about past • Patients with alzheimer’s may experience hallucinations, illusions thus becomes restless and may wander • As sun goes down client becomes restless, agitated, disoriented called sundowning • Drug of choice is Cognex and Aricept a cholinesterase inhibitor that increases Ach causing delay in disease progression SEROTONIN • Responsible for happiness • Decrease serotonin clients becomes sad give anti-depressants
SELECTIVE SEROTONIN REUPTAKE INHIBITOR Safest drug Side effects low R I to 4 weeks - Increases serotonin and affects only serotonin - Prozac, Paxil, Zoloft TRICYCLIC ANTI DEPRESSANT Two – four weeks C A - Has higher incidence of side effects - Also increases norepinephrine - Asendin, Norpralamin, Tofranil, Sinequan, Anafranil, Aventyl, Vivactil, Elavil MONO AMINE OXIDASE INHIBITORS • MAO kills serotonin • Increased MAO results to decreased serotonin the more depressed the client becomes • MAOI kills MAO and increases all neurotransmitters (serotonin, epinephrine, norepinephrine, dopamine but client becomes prone to hypertensive crisis • Avoid tyramine rich foods • Avocado, Alcohol • Beer • Chocolates, Cheese (aged) • Fermented foods • Pickles • Preserved foods • Soy sauce • There is increase incidence of side effects after 2 – 6 weeks • Marplan, Nardil, Parnate
PERSONALITY DISORDERS 1. Schizophrenia - They avoid people because there is no enjoyment 2. Avoidant - They avoid people because they are afraid of criticisms - They have talent but has no confidence 3. Anti-Social - Constantly breaks law - Project charm - They are witty and articulate - Manipulative 4. Borderline - They perceive life as an empty glass - They like splitting friends - Sudden change in mood ―labile affect‖ - Prone to suicide 5. Dependent - ―Cant live if living is without you‖ 6. Histrioinic - Constantly wants to be the center of attention - Excited, dramatic, manipulative 7. Narcissistic - ―I love myself‖ - They get jealous even with achievement of family members 8. Obsessive – Compulsive - ―I am so organized‖ 9. Paranoid - Suspicious - May lead to domestic violence ANTI – DEPRESSANT SIDE EFFECTS: Male – erectile dysfunction, prone to impotence
GRIEF PROCESS 1. Denial – shock/disbelief 2. Anger – question ―why me?‖ 3. Bargaining – if, then 4. Depression – 2 weeks or more sign and symptoms becomes major clinical depression 5. Acceptance – client acts according to situation ASSESSMENT • Decrease self actualization • Decrease self esteem • Withdrawn: stay with client • Suicidal: risk for self directed violence • Increase/decrease eat, increase/decrease sleep, hypoactive, decrease sexual urge • Be sensitive to clients needs FOR SUICIDAL OBSERVE FOR Verbal • ―I wont be a problem‖ • ―This is my last day on earth‖ • ―I’ll soon be gone‖ Non verbal • Giving away of valuables • Sudden change in mood WHEN THE CLIENT IS SUICIDAL WHAT WILL THE NURSE DO Direct: ―Do you plan to commit suicide?‖ Irregular/interval visits Endorsement period, early morning clients are most likely to commit suicide DOWNERS Alcohol Barbiturate
Opiates Narcotics Marijuana Morphine Codeine Heroine Resulting to: • Bradycardia • Bradypnea • Moist mouth • Pupils constrict • Constipation • Urinary retention • Hypotension • Coma • Weight gain • Narcotics overdose: give narcotic antagonist (Narcan, Naloxone hydrochloride) UPPERS Cocaine Hallucinogens Amphetamines Resulting to: • Tachycardia • Awake • Tachypnea • Dry mouth • Pupils dilate • Hypertension • Seizures • Weight loss
