Psychiatric Nursing Power Point

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Psychiatric Nursing

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FUNDAMENTAL CONCEPTS
MENTAL HEALTH
± Is a state of emotional, psychological, and social wellness evidenced by: Satisfying interpersonal relationships Effective behavior and coping Positive self-concept Emotional stability Self-awareness

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Factors Affecting Mental Health:
‡ Mastering the Environment ‡ Reality orientation ‡ Stress Management ‡ Maximizing One¶s Potential ‡ Autonomy and Independence ‡ Tolerating One¶s Uncertainties ‡ Self-esteem

´MRS MATSµ
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STRESS
‡ is any biopsychosocial (external or internal) experiences that one views as demanding, challenging, and threatening; ‡ Also char as: ±It is recurring. ±It is normal. ±It cannot be avoided. ±It is caused by a stressor.

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STRESSOR
± is any condition, event, or agent that increases the activity of the Sympathetic NS; ‡ Stress Adaptation Syndrome (SAS) ³A R E´
1. Stage I ± ALARM ± Activation of the SNS (or the Fightor-Flight Response) ± Increase epinephrine, NE, and cortisol. ± Client is alert with increase anxiety.
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2. Stage II ± RESISTANCE ‡ Hormone readjustment; ‡ Decrease in size and activity of the adrenal cortex; ‡ Increase use of defense mechanism; 3. Stage III ± EXHAUSTION ‡ Loss of ability to stop stress; ‡ Exaggerated defense-oriented behavior; ‡ Disorganized thinking and personality; ‡ May show signs of illusion, hallucination and delusions; ‡ Client may be stuporous or violent (PANIC)
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GRIEF
± is a powerful emotional reaction to a separation or loss from something that is/are very valuable; is SELF-LIMITING; Stages of Death and Dying (Kubler-Ross) ³DABDA´ a. Denial b. Anger c. Bargaining d. Depression e. Acceptance
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± ±

‡ DENIAL ± ³She¶s not dead! She¶s still alive!´ ‡ ANGER ± ³You¶re the reason she¶s dead!!!´ ‡ BARGAINING ± ³God, take me.. Spare her«´ ‡ DEPRESSION ± ³I¶m not hungry, I just want to be alone.´ ‡ ACCEPTANCE ± ³At least she no longer have to suffer.´ ± ³He is in the presence of our Creator.´
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‡

CONCEPT OF DEATH:
1. TODDLER ± ³No specific concept of death yet.´ ± Reacts more to pain and discomfort; ± Separation anxiety may be felt; ± Focus is on the feelings of the parents; 2. PRESCHOOL ± Death is like SLEEP; ± Or a form of PUNISHMENT; ± May use PLAY as a method of therapy;

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3. SCHOOL AGE ± Death is personified or as a final stage of life; ± May fear mutilation or punishment; ± Accept regressive or protest behavior from the client; ± Encourage verbalization of feelings;

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4. ADOLESCENT ± Have MATURE understanding of death; ± May show strong emotions about death (sadness, silence, anger, withdrawn) ± Encourage verbalization of feelings; ± Respect need for privacy and expression of grief;

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5. ADULT ± Death is disruption of lifestyle; ± Effects of death to significant others;

6. OLDER ADULT (Elderly) ± Emphasis on religious beliefs for comfort; ± Time for reflection, rest or peace;

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TRANSFERENCE
± is the unconscious transfer of special feelings from a client to the nurse or therapist.

COUNTERTRANSFERENCE
± Is the projection of the therapist¶s feelings about a significant other to the patient during therapy;

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CRISIS
‡ Is an imbalance of the internal equilibrium that results from a stressor or threat to the patient;
Client is in bad situation Problem-solving inadequate Cannot immediately neutralize the stressor CRISIS
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‡

Types of Crisis: 1. Maturational ± growth and development (identity crisis, midlife crisis) 2. Situational ± unexpected events (death, loss) 3. Social ± major disaster (landslide, typhoon)

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‡

Crisis is characterized by: 1. Self-limiting, only last for 4-6 weeks 2. Individualized - every person have their own reaction. 3. Person becomes passive and submissive. 4. Alteration in support system.
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‡

Stages of a Crisis: (DIDA) 1. Denial ± first reaction; 2. Increase tension ± the person recognizes the crisis but continues to function; 3. Disorganization ± the person is pre-occupied to solve the conflict and alters his ADL; 4. Attempts to reorganize ± by using his coping mechanism;

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CRISIS INTERVENTION
‡ Aims to restore the person to a precrisis state of functioning; ‡ Focuses on resolving the immediate crisis;

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DEFENSE MECHANISMS
REPRESSION
Unconscious and involuntary forgetting of painful ideas, events and conflicts. A nursing student who failed the recent board exam, can¶t remember any of the questions asked.

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DEFENSE MECHANISMS
SUPPRESSION
Voluntary exclusion from awareness, anxiety-producing feelings, ideas and situations. A nursing student states, ´I cannot talk about my recent board, please change the topic.µ

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DEFENSE MECHANISMS
DENIAL
Unconscious refusal to admit an unacceptable idea or behavior. Sometimes mistaken for rationalization. ´I·m not drunk« I can still drive«µ

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Alcoholics Battered wives Anorexia nervosa Drug dependents

DENIAL

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DEFENSE MECHANISMS
RATIONALIZATION
Attempts to make or prove that one·s feelings or behaviors are justifiable. A student states, ´I failed the recent board exam because there was a leakage and it doesn·t had any credibility.µ

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DEFENSE MECHANISMS
INTELLECTUALIZATION
Using only logical explanations without feelings or an affective component. An examinee explains how she passed the NLE but hardly showed any emotion regarding the leakage.

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DEFENSE MECHANISMS
IDENTIFICATION
A conscious or unconscious attempt to model oneself after a respected person. ´I want to be just like you« a very good reviewer «« nurse«. and ««« cheater.µ

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DEFENSE MECHANISMS
INTROJECTION
Unconsciously incorporating wishes, values, attitudes of others as if they were your own. While her mother is gone, a young girl disciplines her brother just like her mother would.

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DEFENSE MECHANISMS
COMPENSATION
Covering up for a weakness by overemphasizing or making up a desirable trait. An academically weak high school student was sworn as the new president of the supreme SC.

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DEFENSE MECHANISMS
REACTION FORMATION
A conscious behavior that is the exact opposite of an unconscious feeling. An older brother who dislikes his younger brother sends him gifts for every holiday.

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DEFENSE MECHANISMS
SUBLIMATION
Channeling instinctual drives into acceptable activities. A former NPA hitman, talks about the importance of life, democracy, justice, and following laws of the land.µ

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DEFENSE MECHANISMS
DISPLACEMENT
Discharging pent-up feelings to a less threatening object. After the board exam, Andy went directly to his room and smashed his reading table.

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DEFENSE MECHANISMS
UNDOING
Doing something to counteract or make up for a transgression or wrongdoing. After hitting his wife, Venicio offered jewelries and money to her.

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DEFENSE MECHANISMS
PROJECTION
Blaming someone else for one·s difficulties or placing one·s unethical desires on someone else. Involves in the development of DELUSIONS; A nursing graduate blamed a dean of a nursing school in Recto for not passing the nursing exam.
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DEFENSE MECHANISMS
CONVERSION
The unconscious expression of intrapsychic conflict symbolically through physical symptoms. A nursing student suddenly went blind after her recent nursing board exam.

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DEFENSE MECHANISMS
DISSOCIATION
The unconscious separation of painful feelings and emotions from an unacceptable idea, situation, or object. A pretty nurse tells how important to review months before the board exam«. But failed to remember her past board failures.
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DEFENSE MECHANISMS
REGRESSION
Return to earlier and more comfortable developmental level. An examinee went directly to her room and sleeps in fetal position and thumb sucks after knowing she failed the board exam««..«« for physicians.

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SELF - AWARENESS
‡ The nurse·s goal is to achieve
authentic, open, and personal communication;

‡ The nurse must be able to examine
personal feelings and reactions; reactions;

‡ A good understanding and
acceptance of self allow the nurse to acknowledge a patient·s differences and uniqueness;
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‡ QUADRANT 1
Is the open quadrant; ´known to self and othersµ

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‡ QUADRANT 2
Is the blind quadrant; ´Known only to OTHERS, unknown to self.µ

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‡ QUADRANT 3
Is the hidden quadrant; ´Known ONLY to selfµ

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‡ QUADRANT 4
Is the unknown quadrant; ´Unknown to the self and to othersµ

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1 Known to self and others

2 Known only to others

3 Known only to self

4 Known neither to self nor to others

JOHARI WINDOW
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‡ The following three principles help
explain how the self functions: 1. A change in any one quadrant affects all other quadrants. 2. The smaller quadrant 1, the poorer the communication. 3. When quadrant 1 is larger and other quadrants are smaller, ´interpersonal learning is significantly present.µ
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STEP 1 The goal of increasing selfselfawareness is ´to enlarge the area of quadrant 1 while reducing the size of the other three quadrants.µ To increase self-knowledge, it is selfnecessary to listen to the self; The individual allows genuine emotions to be experienced, and identifies and accepts personal needs;
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STEP 2 Reduce the size of quadrant 2 by LISTENING TO AND LEARNING FROM OTHERS; OTHERS; As we relate to others, we broaden SELF-PERCEPTIONS; our SELF-PERCEPTIONS; Requires active listening and openness to the feedback others provide;
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STEP 3 Reduce the size of quadrant 3 by selfself-disclosing or revealing to others important aspects of the self; SELFSELF-DISCLOSURE is both a sign of personality health and a means of achieving healthy personality;

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PSYCHOANALYTICAL MODEL (or Psychodynamic Theory)
‡ ‡ By Sigmund Freud; Emphasizes unconscious processes or psychodynamic factors as the basis for motivation and behavior;

‡

Personality is developed by early childhood;

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‡

Three Processes:

1. Id ± present at birth; wants to experience only pleasure (pleasure principle) ‡ Uses fantasies and images to seek pleasure; ‡ Compulsive and acts without morals; ‡ Ex. ³I want to eat« sleep«.. drink«

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2. Ego ± controls id impulses and mediates between id and reality; » Focuses on reality principle; » Maintains contact with reality; » Strives to meet the demands of the id while maintaining the well-being of the individual; » Altered in client with anti-social PD;

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3. Superego ± human conscience that directs and controls thoughts and feelings;

 Concerned with right and wrong;  ³Small voice of GOD within us´  Provides the ego with an inner control to help cope with the id;  Delays pleasure from id;
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ID Mania Nascissistic

EGO

SUPEREGO

Schizophrenia Depression Psychosis Anxiety

Anti-social PD OCD (increase) Anorexia n. Anti-social PD (decrease)

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PSYCHOSEXUAL DEVELOPMENT
A. Oral Stage (birth ± 18 months)
 Oral gratification;  Child learns to handle anxiety by using the oral cavity (biting and sucking activities)  Infants explore the environment or assess an object using their oral cavity.

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B. Anal Stage (18 ± 36 months)
 Child learns to control muscles, especially those that control urination and defecation;  Develops awareness of fullness of the rectum;  Takes pleasure in retaining or eliminating feces;  Acquisition of voluntary sphincter control (TOILET TRAINING)  Bowel Control ± 18 months.  Daytime Bladder Control ± 30 months.  Nocturnal Bladder Control ± 36 months.
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‡ Clues for Toilet Training:
stand alone. walk steadily. be dry of at least 2 hours. demonstrate awareness of defecating and voiding. use words and gestures regarding toilet need and training. please the PCG.

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C. Phallic or Oedipal Stage (3 ± 5 years old)
 Child takes pleasure in exploring and manipulating the genitalia;  Penis is the organ of interest for both sexes;  Penis envy for girls;  Fear of castration for boys due to oedipal feeling to the mother;  Attracted and wants to marry the oppositesex parent (Oedipal complex)  Physiologic homosexuality may also be seen in this stage.
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D. Latency Stage (6 ± 12 years old)

 Sexual development and energy are quiescent;  Resolution of the oedipal complex;  Sexual drive is channeled into socially appropriate activities such as school work or sports;

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E. Genital Stage (12 ± 13 years old)

 Sexual interest emerges as the person strives to develop satisfactory relationships with potential sex partners (intimacy)  Corresponding with genital maturation which result to sexual awakenings;

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PSYCHOSOCIAL MODEL
‡ ‡ or Developmental Model; Established by Erik Erickson from Freud¶s psychoanalytical model; Spans the total life cycle from birth to death; Each stage of development is an emotional crisis involving positive and negative experiences;

‡ ‡

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Life Stages
I. Trust vs Mistrust (0 ± 18 months of age)


Child develops sense of trust or mistrust of others; Shares openly and relates to others; Interpersonal skills start to develop;

 

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II. Autonomy vs Shame and Doubt
 18 months ± 3 y/o;  Child learns self-control or becomes very conscious and full of doubt;  Negativistic attitude;  Exhibits motor self-control and independence thru negativism;  Parallel play is the social skill.
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III. Initiative vs Guilt (3 ± 5 y/o)
 Child initiates spontaneous activities or develops fear of wrongdoing;  Shows appropriate social behaviors;  Curiosity and exploration;  Social Skill:

Cooperative Play

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IV. Industry vs Inferiority (6 ± 12 y/o)
 Child develops the social and physical skills necessary to negotiate and compete in life;  Acquisition of competence;  Ability to cooperate and compromise;  Identification with admired others (teachers, parents)
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V. Identity vs Role Diffusion ( 12 ± 20 y/o )
 Teenager either integrates childhood experiences into a personal identity;  May develop self-doubts about sexual or occupational roles;  Establish relationship with the opposite sex;  Fidelity with friends;  Also value importance of beauty or self-image;
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VI. Intimacy vs Isolation (18 ± 25 or 30 y/o)
 The person develops commitment to work and to other people;  Ability to give and receive love;  Responsible sexual behaviors;

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VII. Generativity vs Stagnation (30 ± 65 y/o)
 Productive, constructive, and creative activities;  Personal and professional growth;  Parental and societal responsibilities;  Ability to care;

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VIII. Integrity vs Despair (65 years old to death)
 The person reviews life for meaning, fulfillment, and contributions made to the next generations;  Sense of dignity and worth;  Explores the philosophy of life;  Have period of reminiscence;  May result to regression and withdrawn;
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Psychosocial Stage T vs MT A vs S and D Initiative vs G Ind vs Inf Identity vs RD Inti vs Iso G vs S Integrity vs D

VIRTUE
HOPE

PATHOLOGY
Psychosis Addiction Depression Impulsivity Paranoia Obs/Comp Conversion Phobia Inhibition Creative inhibition Gender-related identity disorders Schizoid Midlife crisis Despair Alienation
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WILL

PURPOSE

COMPETENCE FIDELITY LOVE CARE WISDOM

COGNITIVE - BEHAVIORAL MODEL


By Piaget;

A. SENSORIMOTOR STAGE (birth ± 18 months)
 

The child learns by IMITATION; Also by object permanence;

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B. PREOPERATIONAL STAGE ( 2 ± 7 years old)
‡ Preconceptional Phase ( 2- 4 y/o) ‡ Learns using mental images and develops symbolic language and play (symbolism) Intuitive Phase ( 4 ± 7 y/o) ‡ The child learns by separating disparate objects and events and also expands expressive language; ‡ Can give reason for belief and reactions but still pre-logical;

‡

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C. CONCRETE OPERATIONS (8 ± 12 years old)

‡ Child can systemically organize thoughts and facts about the environment; ‡ Can apply rules to things that are seen and heard; ‡ Child begins abstract thinking;

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D. FORMAL OPERATIONS (12 ± adulthood)

‡ The person can think using conceptual, abstract operations, and CAN HYPOTHESIZE and evaluate solutions to the problems;

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Maslow·s Hierarchy of Needs
A. Physiologic Needs

 The most basic;  Food, water, sleep, shelter, sexual expression, and freedom from pain;
B. Safety and Security Needs

 Includes protection, security, and freedom from harm or threatened deprivation;
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C. Love and Belongingness
 Includes enduring intimacy, friendship, and acceptance;

D. Self-esteem Needs
 The need for self respect and esteem from others;

E. Self-Actualization
 The need for beauty, truth, justice, and to meet his highest potential;  Few people ever become fully self-actualized;
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Interpersonal Theory - by Sullivan;
± Behavior motivated by need to avoid anxiety and satisfy needs;

Therapeutic Nurse-Client Relationship ± by Peplau;
± The nurse and the client must work together to assist client grow and to resolve problems;

Behavioral Model ± by Pavlov and Skinner;
± ± Behavior is learned and retained by positive reinforcements; Behaviors that are inadequate or inappropriate must be replaced by more adaptive ones;
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THERAPEUTIC COMMUNICATION
± Is an interactive process that occurs between the patient and the health professional; ± Focuses solely on the patient¶s problem; ± Establishment of trust is the foundation of a nurse-client relationship;

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Techniques of Therapeutic Communication
³C SOAP ME FEG and SURE STROL´ C ± clarification S ± silence O ± offering self A ± accepting P ± presenting reality M ± making observation E ± empathy
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F ± focusing E ± exploring G ± giving recognition and S ± suggesting collaboration U ± using broad openings R ± reflecting E ± encouraging description

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S ± sharing perceptions T ± translating into feelings R ± restating O ± offering general leads L ± listening

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CLARIFICATION ± Encourage client to make idea more understandable; ± Nurse: ³I don¶t understand what you mean. Could you explain it to me?´

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SILENCE ± Client able to think about self or his problems; ± Does not feel any pressure to speak; ± Look into the eyes and listen to the client while he is talking;

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OFFERING SELF
± ± ± ± Offer to provide comfort to client by mere presence; ³I¶ll sit with you.´ ³I¶ll walk with you.´ ³I¶m here for you.´

ACCEPTING
± by nodding and following what client says;

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PRESENTING REALITY
± ± ± Reports events and situations as they really are; Client: ³I don¶t have a chance talking to my doctor.´ Nurse: ³I saw you and your doctor talking this morning´ Client: ³These voices are bothering. They want me to jump from the window.´ Nurse: ³There are no other people here.´ OR ³I don¶t hear any voices except for ours.´

± ±

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MAKING OBSERVATION
± ± ± Verbalize what you perceive; ³I notice that you can¶t sit still.´ ³I notice that something is bothering you.´

EMPATHY
± Showing or telling what you feel in relation to the client¶s suffering. ³I know what you feel«««´ ³I know this is hard for you«««.´
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± ±

FOCUSING
± ± ± Encouraging the client to stay or focus on the topic; ³You were talking about your mother.´ ³You were saying that your«««..´

EXPLORING
± ± ± Encourage client to express feelings or ideas deeply; ³Tell me more about you and your mother.´ ³How did you respond to««..´

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GIVING RECOGNITION
± Indicate to client your awareness of him and his behaviors; ³Good morning, I noticed that you combed your hair today.´ ³I observed that you¶re behaving appropriately.´

±

±

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SUGGESTING COLLABORATION
± ± ± Offer to work with client towards a specific goal; Client: ³I fail at everything I try.´ Nurse: ³May be we can figure out something together so that you can accomplish something you want to do.´

USING BROAD OPENINGS
± ± ± Encourage client to introduce the topic of conversation; or to start a conversation; ³Where shall we begin today?´ ³What are you thinking about?´
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REFLECTING
± ± ± Direct client¶s questions or statements back to encourage expression of ideas and feelings; Client: ³Do you think I should talk to my doctor.´ Nurse: ³What do you want to talk about?´

ENCOURAGING DESCRIPTION
± ± ± Ask the client to verbalize his perception; ³What is happening to you right now?´ ³What are you doing in front of the window?´

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SHARING PERCEPTIONS
± ± nurse describes his or her understanding of the patient¶s feelings and ideas; Nurse: ³I noticed that you have an unresolved feelings towards your mother.´

TRANSLATING INTO FEELINGS
± ± ± Encourage client to verbalize feelings expressed in another way; Client: ³I will never get better.´ Nurse: ³You sound rather hopeless and helpless.´
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RESTATING
± ± ± Repeat what client has said; Client: ³I don¶t want to take my medicines.´ Nurse: ³You don¶t want to take your medicines?´

OFFERING GENERAL LEADS
± ± ± Encourage client to continue discussing the topic; ³And then?´ or ³Go on I¶m listening.´ ³Tell me more about what you just said?´

LISTENING
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Blocks to Constructive Communication
j

These are methods of communication that obstruct the process of therapeutic conversations (³Non-therapeutic´) ³BAD SCAR DROP´

j

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B ± belittling feelings A ± agreeing / disagreeing D ± denial S ± stereotypical response C ± changing topic A ± approval / disapproval R ± reassuring D ± defending R ± requesting explanation O ± offering advise P ± probing
.

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NON-THERAPEUTIC COMMUNICATION
Belittling feelings ³Everybody experiences failures and downs.´ ³I¶ve felt the same sometimes.´ ³That¶s right«.. I agree.´ ³It¶s wrong« I don¶t agree«´ Denial P ± ³I¶m nothing.´ N ± ³Of course you¶re something.´

Agreeing / Disagreeing

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Stereotypical ³Nice weather were having.´ ³I¶m fine and how are you?´ response Changing topic Approval / Disapproval Reassuring
P ± ³I want to die!´ N ± ³Did your parents visited you?´ ³I¶m glad that you«´ ³I¶d rather you wouldn¶t«´ ³Everything will be alright.´ ³Don¶t worry it¶s fine.´

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Defending

Requesting explanation Offering advise Probing

³That nurse is competent.´ ³His thinking of you all the time.´ ³Why do you think that«´ ³Why do you feel this way«´ ³Why did you do that?´ ³I think you should«´ ³Why don¶t you«´ ³Now tell me about you«.´ ³Tell me your history.´

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Phases of Therapeutic Relationship
A. ORIENTATION
± ± ± ± ± ± or Assessment or analysis; The nurse establishes trust with the client; The nurse assesses the client; Formulation of nursing diagnosis; Prioritization of the client¶s problems; The nurse and the client establish mutually agreed goals; Discussing the indications for termination;
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±

B. WORKING PHASE
± ± Pertains to planning and intervention; the nurse plans outcomes and related interventions to assist client to meet goals; The nurse facilitates the client¶s expression of problems, thoughts, and feelings; The nurse uses problem-solving approach;

±

±

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C. TERMINATION PHASE ± Pertains to evaluation; ± The nurse evaluates outcomes, reassess the problems, goals and interventions; ± Needs close attention to avoid destroying the benefits gained from the relationship;

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±

The nurse and client express feelings regarding the termination of the interactions; The nurse observes the client for negative behaviors: ‡ Regression ‡ Anger ‡ Inappropriate expressions (laughter) The nurse evaluates the entire nurse-client relationship;

±

±

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PSYCHOPHARMACOLOGY
ANTI-PSYCHOTIC DRUGS
² Or neuroleptics or major tranquilizers; ² For acute and chronic psychosis; ² For bipolar I disorder, manic phase; ² Paranoid disorder; ² Severe nausea and vomiting*; ² Severe or pathologic hiccups*;

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Classification (Traditional or Typical Classification)
1.

2. 3. 4. 5. 6.

Chlorpromazine (Thorazine) EARLIEST Fluphenazine (Prolixin) Thioridazine (Mellaril) Trifluoperazine (Stelazine) Haloperidol (Haldol) Loxapine (Loxitane)

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 Atypical Anti-psychotics:
1. 2. 3.

Clozapine* (Clozaril) Olanzapine* (Zyprexa) Risperidone* (Risperdal)

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Mechanisms of Action:
Blocks dopamine receptors in the nigrostriatal system causing pseudoparkinsonism; Inhibits dopamine receptors in the tubuloinfundibular system; Antagonizes serotonin receptors in the cerebral cortex (Risperidone)
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Typical Anti-psychotics Decrease dopamine

Atypical Anti-psychotics Decrease serotonin

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Desired Effects of Antipsychotic Drugs:
1. CNS Effects a. sedation b. emotional quieting c. slowing of psychomotor functions 2. Modification of Psychiatric Symptoms a. Resolution of ´positive symptomsµ  Hallucinations  Illusions  Delusions  Excitement  Suspiciousness
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b. Resolution of negative symptoms Accomplished by ATYPICAL antipsychotic agents 1.Attention deficit 2.Asocial behavior 3.Blunted or flat affect 4.Communication difficulties 5.Difficulty with abstraction

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SIDE EFFECTS
A.

PNS Effects (anticholinergic effects) PNS Effects (anti-adrenergic effects) 1. Orthostatic hypotension 2. Reflex tachycardia ² due to lower extremity vasodilatation;

B.

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´Anti-cholinergic effects are the same irregardless of what medication.µ
    

A ² urinAry retention Blurring of vision ² due to dilated pupils. Constipation Dry mouth and nasal passages Elevated heart rate (tachycardia)

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C. CNS Effects (or EPSE)
1. Akathisia it is the most common EPSE; ´inability to sit stillµ; px is restless, jittery or uneasy and may report a lot of nervous energy; Tx: Anticholinergic antiparkinson drugs (Artane, Biperiden, Cogentin)

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2. Acute Dystonic Reactions (dystonia)
² rigidity of the muscles of the tongue, face, neck or back; ² results to abnormality in posture, gait or ocular movements; Torticollis Oculogyric crisis ² rolling of eyes backward in a fixed stare; Laryngeal-pharyngeal dystonia ² Tx: IM anticholinergic antiparkinson drug (Benztropine or Cogentin)
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3. Tardive Dyskinesia (TD) ² potential permanent complication;
² refers to abnormal voluntary skeletal muscle movements usually jerky motion; ² appears after months or years of drug use but may occur sooner; ² caused by dopamine hypersensitivity and cholinergic deficit; ² ´anticholinergics may aggravate TDµ;
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² usually affects the muscles of the mouth and face: 1. Lip smacking 2. Grinding of the teeth 3. Rolling or protrusion of the tongue 4. Tics 5. Excessive facial movements ‡ Grimacing and blinking ‡ Chewing and lateral jaw movement ‡ Puffing of the cheeks; ² Tx: Bromocriptine (Parlodel); Reduction of dose; Discontinuation of the drug;
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4. Drug-induced Parkinsonism
² or pseudoparkinsonism; ² motor retardation (bradykinesia) and rigidity; ² difficulty in initiating or carrying out motor activity; ² shuffling gait; ² resting tremors of the hands and feet; ² hypersalivation; ² Tx: Dosage reduction Antiparkinson drug (Akineton)

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5. Neuroleptic Malignant Syndrome
² is a rare but life-threatening reaction to neuroleptic drugs (1% of clients) ² 3-9 days after starting anti-psychotic (Haldol) ² manifestations: a. hyperthermia ² cardinal symptom. b. rigidity c. impaired consciousness d. hypertension e. cardiac arrhythmias ² Tx:
Immediate discontinuation of the drug; Cooling blankets; Dantrolene or Bromocriptine

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6.

Other Side Effects a. Hyperglycemia b. Jaundice c. Blood dyscrasias or agranulocytosis (Clozapine) d. Orthostatic hypotension (Risperidone) e. Retinal pigmentation (Thioridazine) f. Galactorrhea and gynecomastia (Increase secretion of prolactin) g. Amenorrhea and impaired ejaculation h. Sun burn

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ANTI-PARKINSON DRUGS
’ Major cause of EPS malfunction is a

DEFICIENCY in the neurotransmitter DOPAMINE (substantia nigra) and a subsequent decrease in dopamine transmission in the basal ganglia;

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Mechanisms of Actions:
Increases dopamine by increasing its precursor. ± Levodopa ± Carbidopa-levodopa (Sinemet) Stimulates the release of dopamine. ± Amantadine (Symmetrel) Increases the action of the dopamine receptors (Dopamine agonists) ± Bromocriptine (Parlodel) ± Pergolide (Permax)
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Blocks the metabolism of dopamine by inhibiting MAO type b. ± Selegiline (Eldepryl) Anti-parkinsons with anti-cholinergic properties. ± Benztropine (Cogentin) ± Biperiden (Akineton) ± Diphenhydramine (Benadryl) ± Ethopropazine (Parsidol) ± Procyclidine (Kemadrin) ± Trihexyphenidyl (Artane)

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ANTI-PARKINSON DRUGS
A ± Artane , Amantadine B ± Biperiden, Bromocriptine C ± Cogentin D ± Diphenhydramine, Dopamine precursors (Levodopa, Sinemet) E ± Eldepryl F ± Pergolide

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ANTIDEPRESSANTS
DEPRESSION is caused by an imbalance or decreased availability of certain neurotransmitters (deficiencies of norepinephrine, serotonin, and possibly dopamine)

Norepinephrine Serotonin Dopamine

DEPRESSION

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Goals in the tx of Depression:
1. Reduce or remove all signs and

symptoms of depression ± the most important.
2. Restore occupational and

psychosocial function;
3. Reduce the incident of relapse and

recurrence;

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A.

TRICYCLIC ANTIDEPRESSANTS Blocks reuptake of norepinephrine and serotonin; Also increases receptor sensitivity to these neurotransmitter;

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Desirable Effects: ± Sedation. ± Others increase psychomotor activity. ± Improved appetite. Side Effects: 1. Anti-cholinergic side effects 2. Orthostatic hypotension

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Nursing Implications: ± Take medications at night. ± Reassure that symptoms will decrease in 2 - 4 weeks ± Increase fiber and fluid diet. ± Assess for adverse drug reactions. ± Assess for suicide potential.

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Classifications: ± Tertiary Amines ± Imipramine (Tofranil) ± Amitriptyline (Elavil) ± Clomipramine (Anafranil) ± used in OCD. ± Secondary Amines - Amoxapine (Asendin) - Nortriptyline (Aventyl) - Desipramine (Norpramin)

122

Classifications« ± Novel Cyclic Antidepressants ± Bupropion (Wellbutrin) ± Trazodone (Desyrel) ± Venlafaxine (Effexor)

123

B. SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI)
± Fewer side effects that TCA; ± ³First choice in treating depression.´ ± MOA: inhibits reuptake of serotonin in neurons which later increases the availability of serotonin in several neurons; ± Therapeutic lag time is approximately 1 ± 4 weeks;

124

Side Effects: ± GIT Symptoms ± Nausea ± Diarrhea ± Weight loss ± CNS Symptoms ± Headache ± Dizziness ± Tremors ± Nervousness ± Decreased libido and orgasms
125

Nursing Implications: ± Avoid incorporating with MAOI because of the danger of serotonin syndrome (coma, hyperreflexia, hyperthermia, death) ‡ 14 days ± stopping MAOI and starting SSRI: ‡ 5 weeks ± stopping SSRI and starting MAOI; ± Avoided during the 1st trimester of pregnancy. ± WOF: Increase activities and mood of patients because these are signs of suicidal ideations;

126

Classification: ± Fluoxetine (Prozac) ± Fluvoxamine (Luvox) ± Paroxetine (Paxel) ± Sertraline (Zoloft)

127

C. MONOAMINE OXIDASE INHIBITORS (MAOI)
± Monoamine Oxidase ± involved in the metabolic decomposition and inactivation of amines (norepinephrine, dopamine and serotonin); ± Administered to hospitalized patients or px that can be closely monitored or supervised at home; ± It takes 2 ± 4 weeks for these drugs to take effect;
128

Side Effects: ± CNS Hyperstimulation ± Hypomania ± Agitation ± Insomnia ± Restlessness and euphoria ± Acute Anxiety Attack ± Hypertensive crisis (tachycardia, palpitations, occipital headache, chest pain, elevated BP, diaphoresis, and dilated pupils; sudden epistaxis)

129

Nursing Implications:
± Take the medication EARLY IN THE DAY to avoid insomnia; ± Caution client to avoid OTC drugs because these contain AMINES and can cause HYPERTENSIVE CRISIS. Cold remedies Decongestants Antihistamines Sleeping aids Stimulants ± Instruct the px TO AVOID FOODS HIGH IN TYRAMINE (tyramine-restricted diet)
130

± Foods high in TYRAMINE: A ± aged cheese and avocado B ± bananas, beer C ± chocolate, coffee, chicken and pork liver D ± dried and preserved foods (pickles) E ± etc (yogurt, sausage) F ± fermented foods (beer, wine)

131

Classifications: ± Phenelzine (Nardil) ± Tranylcypromine (Parnate) ± Moclobemide (Manerix) ± atypical MAOI.

132

ANTI-MANIC DRUGS (Mood Stabilizers)
LITHIUM
Is used for manic phase of manic-depressive illness and refractory depression; The exact action of lithium is UNKNOWN;  Substitute for Na in neurons altering the release and attachment of certain neurotransmitters in most neurons;  Increases the reuptake of NE and serotonin; Lithium has a lag time of 7 ² 10 days;
133

Lithium is well absorbed from the GIT (via ORAL route) The typical dose for acute mania is 600 mg TID which produces a therapeutic blood dose of 0.6 ± 1.2 mEq/L; Blood levels over 1.5 mEq/L can be toxic;

134

Nursing Implications: ± WOF signs of early Li toxicity:  Vomiting ± earliest;  Diarrhea and Drowsiness  Muscular weakness  Lack of coordination  Polyuria
‡ Client may have mild exercise or activities. ‡ Advise px not to drive during Li therapy; ‡ Advise px to practice balanced diet and salt intake;

Increase Salt intake = decrease blood Li Decrease salt intake = increase blood Li
135

‡ For Li determination, blood must be drawn at least 8-12 hrs after the last dose and performed in the morning (every 3 ± 4 months of Li intake) ‡ Take Li with meals to avoid nausea and vomiting; ‡ Increase fluid intake (2500-3000 ml) per day to reduce thirst and maintain normal fluid balance;

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CARBAMAZEPINE (Tegretol)
‡

Used for px who do not respond to Li or for px Li is contraindicated; Used in px with bipolar disorders and for px with seizure disorders; Thought to inhibit the small abnormal activity in the brain; Side Effects: Nausea and vomiting Anorexia Sedation and drowsiness Agranulocytosis

‡

‡

‡

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VALPROIC ACID (Depakene)
‡

Is an anticonvulsant with antimanic property; Effective in px with bipolar disorders; Rapid acting and with less effect on cognition; Side Effects: Transient hair loss Weight gain Tremors GI Upset Thrombocytopenia
138

‡

‡

‡

ANTIANXIETY DRUGS
‡

Are also known as anxiolytics; Classified into: a. Benzodiazepines b. Sedative-Hypnotics

‡

139

Benzodiazepines
‡

are the major class of anxiolytics or minor tranquilizers; Are used in px: a. chronic anxiety b. acute anxiety or persons in crises c. presurgery d. panic attacks e. insomnia f. alcohol withdrawal syndrome g. bipolar disorders with Li therapy h. seizures
140

‡

‡

Types of Benzodiaze PAM« PAM« 1. Diazepam (Valium) 2. Lorazepam (Ativan) 3. Clonazepam (Klonopin) 4. Oxazepam (Serax) ± for elderly. 5. Alprazolam (Xanax) 6. Chlordiazepoxide (Librium) 7. Clorazepate (Tranxene) 8. Buspirone (BuSpar)

141

‡

Adverse Drug Reactions: 1. CNS Depression a. Drowsiness b. Fatigue c. Decreased coordination d. Mental impairment e. Slow reflexes f. Confusion g. Respiratory depression***
2.

Anticholinergic side effects

142

3. Problems of dependence, withdrawal, and tolerance; a. Dependence or addiction ± the person must take the drug to feel normal; b. Withdrawal ± physical signs and symptoms that occur when the addictive substance is reduced or withheld; c. Tolerance ± the need to increase the amount of a substance to achieve the same effects;

143

‡

Nursing Interventions: ‡ Advise the px to avoid taking alcohol and other CNS depressants with the drug. ‡ WOF of overdose ( somnolence, confusion, coma, decreased reflexes, and hypotension) ‡ Advise the px to avoid driving; ‡ Monitor VS especially breathing;

144

Sedative-Hypnotics
‡

Are also used in the treatment of anxiety, insomnia, and prevention of alcohol withdrawal syndrome; Barbiturates: ‡ Phenobarbital ‡ Secobarbital ‡ Pentobarbital Antihistamines: ‡ Diphenhydramine

‡

‡

145

THERAPEUTIC LAG TIME Anti-psychotics TCA MAOI SSRI Lithium Clomipramine

2 ± 4 weeks

1 ± 4 weeks 7 ± 10 days 2-3 months

146

ELECTROCONVULSIVE THERAPY
An electrical current (70-150 v) passes thru electrodes applied to the patient¶s temple to induce a generalized tonic-clonic seizure (or Grand Mal) and unconsciousness; Is use when other traditional therapies failed; Length of application: 0.5 - 2 secs; Length of seizure: 30 - 60 secs; The cumulative effect of ECT is approx 220 - 250 secs. Used to treat patients with depression, bipolar disorders, manic, and psychotic symptoms; The exact action of ECT remains unknown;

147

’

Nursing Interventions:
Obtain an informed consent from the patient, family, or legal representative of the patient; Teach the family and the patient about the treatment and what to expect like: ± Short-term memory loss ± resolve after 4-8 weeks; ± Disorientation ± Confusion ± Respiratory depression NPO post-midnight to prevent aspiration and vomiting; at least 8 hrs. Remove all prostheses including hairpins and dentures;
148

Administer all preop meds as indicated like: 1. AtSO4 ± to decrease oral and nasal secretions*; 2. Succinylcholine ± muscle relaxant; 3. Short-acting barbiturates* ± Does not affect seizure threshold ± Ex. Methohexital Vital signs must be monitored before and after the procedures; Tongue guard is inserted to prevent tongue injury during seizure; Monitor heart rate and rhythm, blood pressure, and EEG; 149

150

NEUROSIS
‡ is a maladaptive emotional state due to unresolved emotional conflict; NEUROSIS
Does not need hospitalization Minor reaction to stress Normal reality Can feel sufferings and wants to get well Does not deny reality

PSYCHOSIS
Needs hospitalization Major reaction to stress Impaired reality Does not know his ill Denies reality

Exploits sex for secondary gain No secondary gain is derived
151

I.

OVERVIEW ‡ ANXIETY is a subjective feeling of vague apprehension due to real or perceived threat; ‡ ‡ is a NORMAL response to stress; Or may precede new experiences;

152

II.

ETIOLOGY
1. Biological Theory a. **GABA ² decrease; b. Norepinephrine ² increase; c. Serotonin ² increase; d. Dopamine ² increase;

2.

Psychodynamic Theory ‡ Due to unresolved developmental conflicts;

153

3. Interpersonal Theory (by Sullivan) ² When expectations, approval, or needs are not met. 4. Behavioral Theory ² Anxiety is a learned response to combat stress;

154

’ Kind of Anxiety (Freud)
1. Reality Anxiety - from external real threat; 2. Neurotic Anxiety - fear that instinct will cause one to do something that will cause punishment; 3. Moral Anxiety - guilt from a wrongdoing against the conscience;

155

’

Levels of Anxiety:
1. Mild Anxiety
    associated with the tension of everyday life; the individual is alert and attentive (SNS is stimulated) perceptual field is increased; ´NO INTENSE FEELING BECAUSE SELF-CONCEPT NOT THREATENEDµ With mild muscle tension; Interventions: - Discuss source of anxiety. - Problem solving to neutralize anxiety. - Teach the client to accept anxiety as normal.
156

 

2. Moderate Anxiety ‡ the focus is on immediate concerns; ‡ ‡ ‡ ‡ ‡ ‡ narrows the perceptual field; selective inattentiveness occurs; learning and problem-solving still take place; ´self-concept may be threatenedµ (may have discomfort and irritability) may show moderate muscle tension with increase vitals, mydriasis, and sweating; Interventions: ² Decrease anxiety by ventilation of feelings, crying, or exercise.
157

3. Severe Anxiety
‡ ‡ ‡ ‡ ‡ a feeling that something bad is about to happen; With significant reduction in perceptual field; All behavior is directed at relieving the anxiety; learning and problem-solving are not possible; May show: ² Hyperventilation ² Severe muscle tension ² Rapid pacing or walking ² Shouting and trembling Interventions: ² Stay with the client. ² Decrease anxiety and pressure. ² Use kind, firm, and simple directions. ² IM anxiolytics as ordered.
158

‡

4. Panic Level of Anxiety
‡ associated with dread and terror and a sense of impending doom; ‡ the personality of the individual is disorganized; ‡ the individual is unable to communicate or function effectively; ‡ may experience loss of rational thoughts with distorted perception;

159

‡ May have: ² Fight or flight ² Freeze ² Helplessness ² Out of control (jump from windows) ² Rage, anger, and terror ‡ Interventions: ² Guide firmly or physically take control. ² IM anxiolytics as ordered. ² Restraints if needed (FOR SAFETY)

160

III. COPING WITH ANXIETY
’

Coping Mechanisms  any effort that will decrease the stress response;
  

either a constructive or destructive mechanisms; they can be task-oriented to solve the problem; or defense-oriented to protect the px·s feelings;

161

 Type of Coping: 1.Adaptive coping ² for mild anxiety;

2.Pallative coping ² for moderate anxiety; 3.Maladaptive coping ² for severe anxiety; 4.Dysfunctional coping ² for panic level of anxiety;

162

 Type of Coping:

1.Adaptive ² solve the problem.  Ex. If you have an exam««« you study or review«. You PASSED with flying colors«.

2.Pallative ² temporarily decrease the anxiety but does not solve the problem (allows the client to return to problem solving)  Ex. If you have an exam«. Go to the gym first then review««. You·ll PASS«.

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3. Maladaptive ² unsuccessful to decrease anxiety without attempting to solve the problem.  Ex. You have an exam«« Watch movies with friends first««« then cramming for review««. Result of exam«« FAILED!!! 4. Dysfunctional ² not successful in reducing the anxiety or solving the problem; minimal functioning becomes difficult;  Ex. You have an exam ««« drinking spree with buddies«.. When you wake up«« UMAGA NA«. Result of exam ««. ´Asa ka pa«. Eh di bagsak!!!µ
164

’

Common Nursing Diagnosis: 1. Ineffective individual coping*** 2. Anxiety 3. Impaired adjustment 4. Risk for injury 5. Risk for violence, self-directed or directed at others 6. Fear
165

’

Important Nursing Interventions: C ² calm environment A ² ask client to identify cause/s. L ² let client describe feelings. M ² monitor for suicide ideation. E ² expression of feelings. R ² release tension and energy (art therapy)

166

and ANXIETY ± RELATED DISORDERS
167

GENERAL ANXIETY DISORDER (GAD)
² Characterized by diffused, persistent, or unrealistic worry that rarely occurs by itself; ² Increase amount of inner energy consumed on controlling anxious feelings; ² Have used alcohol or other drugs to the point of dependence to control anxiety;

168

² Person may experience physical symptoms:
‡ ‡ ‡ ‡ ‡ ‡ ‡ Dyspnea Palpitations Chest pain Gastric distress - diarrhea Tremors Insomnia Restlessness

² Tx:
‡ Anxiolytics ‡ Psychotherapy
169

PANIC DISORDER
² The cause is usually cannot be identified; ² sudden onset, with feelings of intense apprehension, and dread; ² May be severe, recurrent, or intermittent lasting 5 ² 30 minutes; ² Fear of losing control about themselves, ´going crazy,µ heart attack, or dying; ² Client may also experience physical symptoms similar to GAD;

170

²

Treatment: a. Relaxation techniques b. Cognitive ² Behavioral Therapy c. Benzodiazepines ² Alprazolam (Xanax) d. *** Antidepressants ² Sertraline; Paroxetine;

171

OBSESSIVE-COMPULSIVE DISORDER
² Characterized by episodes of obsession (unwanted, repetitive thought) and compulsion ( unwanted, repetitive action) that influence a person·s life; ² Char by irrational, repetitive, ritualistic behaviors that the px uses in attempt to control the anxiety resulting from obsessions; ² Affects the ADL of the client;
172

² Anxiety occurs if O-C are resisted, and from being powerless to stop obsession. ² Compulsive behaviors are related to decrease or neutralize anxiety;

OBSESSION COMPULSION

Increases anxiety Decreases anxiety

173

²

Treatment: a. Behavioral techniques ‡ Desensitization ‡ Graded response ‡ Modeling of desired behaviors ‡ Cognitive therapy - to stop altered thought. b. Antidepressants ² ***Clomipramine (Anafranil); SSRI·s. c. Anxiolytics

174

PHOBIA
² An irrational fear of an object or situation that persists even though the px may recognize it as unreasonable; ² Associated with panic-level of anxiety if the object, situation, or activity cannot be avoided; ² Client will do anything just to avoid the phobic object regardless of the consequences;
175

² Types of Phobia: a. Agoraphobia ² fear of being alone in open or public places where escape might be difficult or impossible; ² Client may not leave home;

176

b. Social Phobia ² fear of situations in which one might be embarrassed or criticized, and the fear of making fool of oneself; ² includes the fear of eating in public places, public speaking, or performing in public places;

177

c. Specific Phobia ² a fear of a single object, activity, or situation such as snakes, closed spaces, and flying; ² Arachnophobia ² Aerophobia ² Acrophobia ² Aviophobia ² Claustrophobia

178

² Treatment: a. Behavioral techniques ² ***desensitization ² therapy of choice. b. Benzodiazepine Therapy

179

POSTTRAUMATIC STRESS DISORDER (PTSD)
² Grieving-like behaviors that result from a major and severe trauma like rape, assault, accident, fire, war, or natural disaster; ² Usually occurs AFTER a major traumatic events (usually after ONE month) ² Acute Stress Disorder ² anxiety during or immediate after a traumatic event (within 4 weeks or 1 month)
180

²

May show physical manifestations: a. Flashbacks b. Insomnia and nightmares c. Eating problems d. Depression and isolation e. Hypervigilance and guilt about surviving the event;

181

²

Types of PTSD: a. Acute ² less than 3 months after the event; b. Chronic ² 3 months or more after the event; c. Delayed ² at least 6 months after the event;

182

²

Treatments: a. Psychotherapy b. Pharmacotherapy 1. Benzodiazepines 2. Antidepressants ² SSRI.

183

² Nursing Interventions: P ² provide safe environment for the client. T ² try to recall the traumatic event. S ² suicide precaution. D ² don·t leave client alone.
184

DISSOCIATIVE DISORDERS
² Is characterized by splitting off or removal from conscious awareness of some information, feeling, or mental function; ² Also associated with traumatic events and severe anxiety;

185

Types of Dissociative Disorders:
a.

Dissociative Identity Disorder ‡ or multiple personality; ‡ existence of two or more fully developed distinct and unique personalities within the person; ‡ the personalities may take full control of the person one at a time;
186

‡ the personalities may or may not be aware of each other; ‡ the person is unable to recall important information; ‡ char by sudden transition from one personality to the other RELATED TO STRESS; ‡ ´dissociation is used as a method of distancing and defending self from anxiety and traumatic events;µ
187

‡ Clients with depersonalization disorder (like DID) are not admitted unless they are suicidal; ‡ GOAL: ´Integrate the personalities or memories so that they can coexist with the original personality.µ Psychotherapy Hypnosis Amobarbital sodium.
188

b.

Dissociative Amnesia ² inability to recall important personal information because it is anxiety provoking; ² memory impairment may be partial or complete; ² amnesia may be anterograde (recent information) or retrograde (past information);

189

c.

Dissociative (Psychogenic) Fugue
² Sudden travel away from home and assumes a new personality with inability to recall the past; This may occur suddenly for several hours or days; Follows severe psychosocial stress (marital quarrels, personal rejections, or natural disaster) It allows escape or flight from an intolerable situations.
190

²

²

²

² ´When the fugue state stops or lost «.. the client returns home «« UNABLE to recall the fugue state.µ ² Tx: ‡ Psychotherapy ‡ Anxiolytics ‡ SSRI

191

d.

Depersonalization Disorder
² An altered self-perception in which one·s own reality is temporarily lost or changed; Feeling of self- detachment; The client may experience feelings of detachment but intact reality testing; To protect the client from an overwhelming stress; Tx: SSRI (Fluoxetine)
192

² ² ²

²

SOMATOFORM DISORDERS


Complains of physical symptoms or illness for which no organic or physiologic cause can be identified; Evidence is present or presumption exists that the physical symptoms are connected to psychological factors or conflicts; With prolonged periods of diagnostic work ups with negative physical findings; ³The nurse or health team must never assume that patients are not sick.´







193

BODY DYSMORPHIC DISORDER


Preoccupation with an imaginary defect in one¶s physical appearance even though the person appears normal to others; Complaints of facial or body deformities; Client may have slight physical deformity but the reaction or preoccupation is out of proportion to the degree of deformity; Usually encountered during adolescence;
194









Tendency to seek unnecessary surgery to correct the imaginary defect or minor flaws; May manifest with social impairment and altered work performance resulting from the client¶s desire to hide the imaginary defect;



195

CONVERSION DISORDER


Alteration or loss of functioning of a body part that is not related to any physical abnormalities (eg. Paralysis, blindness) Most symptoms are unconscious;



196

HYPOCHONDRIASIS
± Morbid preoccupation with fear or belief that one has a serious disease based on personal interpretation of physical health; ‡ Paralysis ‡ Anosmia ‡ Blindness ‡ Aphonia ‡ Seizures ‡ Anesthesia or paresthesia ± No physical evidence of serious disease; ± Char by unwavering conviction of his/her illness;
197

-

May show ³LA BELLE INDIFFERENCE.´
-

Lack of concern regarding the severity of the above symptoms; The client explains a severe disease calmly«

-

198

PAIN DISORDER ± Preoccupation with pain with no diagnostic findings as to the cause or intensity of pain; ± Pain that doesn¶t follow anatomical nervous system distribution; ± Have long history of several consultations with numerous doctors, use of drugs, or alcohol abuse; ± There is clear connection between a psychological stressor and onset of symptoms; ± With marked impairment in lifestyle and ADL;
199

SOMATIZATION DISORDER
± These individuals verbalize recurrent, frequent, and multiple somatic complaints for several years without physiologic cause; ± Begins before age 30; ± Clients usually see several physicians thru the years and even have exploratory and unnecessary surgeries; ± May also have social and occupational impairments;
200

± ±

These px¶s may have anxiety or depression; Or sleep disturbances, nervousness and experience suicidal ideation because of hopelessness about getting better; Common symptoms: ‡ Nausea and vomiting ‡ Dizziness ‡ Shortness of breath ‡ Dysmenorrhea ‡ Chest pain

±

201

Other Types of Somatoform Disorders:
1. MALINGERING ‡ Intentional production of false or grossly exaggerated physical or psychological symptoms to get external compensation (leave, evading prosecution, compensation) ‡ May have no real symptoms or over exaggerated minor symptoms.

202

2. FACTITIOUS DISORDER
‡ ‡ aka Munchausen¶s syndrome; When physical or psychological symptoms are intentionally produced or feigned TO GAIN ATTENTION; they may inflict injury to themselves to receive attention; Munchausen¶s by proxy ± person inflicts injury or illness on SOMEONE else to gain attention or to be a hero;
203

‡

‡

MOOD DISORDERS
j Associated with severe and painful

sadness or abnormal elation;

j Changes a person·s behavior,

cognition, motivation, and emotions; diagnosis??? DISORDERS;

j Most common psychiatric

j Also known as AFFECTIVE

204

j Two Diagnostic Categories:

1. Major Depressive Disorder (MDD) ‡ A person experiences one or more episodes of depression with no manic or hypomanic manifestations; ‡ Twice as many women than men; ‡ Onset is usually early - mid 20·s;
205

2. Bipolar Disorders ‡ A person experiences major depression with one or more manic or hypomanic episodes; ‡ Female and male ratio is the same; ‡ Onset is usually late 20·s;

206

MAJOR DEPRESSION
j Etiologies:

a. Biochemical Theory ‡ Altered or deficient levels of norepinephrine and serotonin are most often related to depression (Dopamine, Acetylcholine and GABA)

207

‡ Alterations in the functions of the hypothalamic-pituitaryadrenal system may cause depression; ‡ Alterations in the circadian rhythm (wake-sleep cycle) will cause problem with sleep patterns, arousal, activity, and hormonal secretions;

208

b. Psychodynamic or Psychoanalytical

Theory  Depression occurs as a result of a person·s ego loss in relationship to early life occurrences;  Aggressive behavior inappropriately directed at self;

209

c. Cognitive Theory



Depression results when a person perceives all stressful situations as being negative;

210

d. Interpersonal Theory



Stated that persons difficulties, coping with individuals, life events, and life changes can be stressful and may lead to depression;

211

e. Behavioral Theory



Depression develops when one feels helpless and unworthy.

f.

Sociological Theory  Stated that depression is caused by abnormal medical, social learning, stress, and response mechanism by an individual;

212

Criteria for Major Depressive Disorder: 1. **Depressed mood. 2. **Anhedonia ² inability to experience or even imagine any pleasant emotion; 3. Sleep disturbances ² insomnia or hypersomnia; 4. Possible weight loss or weight gain. 5. Fatigue or energy loss.
213

6. Reduced recognition and concentration; 7. Psychomotor agitation ² increase or decrease activities; 8. Feelings of worthlessness or guilt; 9. Recurrent death or suicidal thoughts;
’

Symptoms must persists for a minimum of 2 weeks. A person must have at least 5/9, one of which is a depressed mood and/or anhedonia.
214

’

j

Other symptoms of depression:
1. Apathy and sadness 2. Hopelessness and helplessness 3. Unworthiness and guilt 4. Anger 5. Decreased libido 6. Private verbal berating of self 7. Sudden crying without a cause 8. Dependency and Passiveness
215

Nursing Diagnosis for MDD and Bipolars:
1. Ineffective individual coping 2. Hopelessness 3. Potential for injury 4. Potential for violence 5. Powerlessness 6. Altered nutrition 7. Sleep pattern disturbances 8. Impaired verbal communication
216

Management:
A. Nurse Interventions D ² drugs E ² expression of feelings P ² patient involvement in physical activities R ² reinforce decision making E ² nEvEr reinforce hallucination or delusions S ² suicide precaution S ² safe environment

217

B. Pharmacotherapy

1. SSRI ² Fluoxetine (Prozac) 2. TCA ² Imipramine (Tofranil) 3. MAOI ² Phenelzine (Nardil)

218

BIPOLAR DISORDERS
j Approximately 2 million people

yearly suffer from bipolar disorders;
j Bipolar I disorders appear equally

common among men and women;
j In men, the first episode is usually of

manic manifestations;

219

j In women, it is depressive

symptoms that come first before the manic signs;
j Characterized by episodes of

mania and depression with periods of normal mood and activity in between;
j Also known as manic-depressive

disorder;
220

Clinical Manifestations of Mania:
Denial**, distractibility, and delusions Resistance to treatment** Hyperactivity** Anorexia** Pleasurable activity involvement Irritability and insomnia Elevated mood Flight of ideas Loud and rapid speech Anger with labile mood Grandiosity ² or inflated self-esteem ³DR. HAPI E FLAG´
221

Types of Bipolar Disorders:
1. Bipolar I Disorder

‡

Has major depression and mania;

2. Bipolar II Disorder

‡

The person has major depression and hypomanic rather than mania;

222

Hypomanic Episode
j Is almost similar to mania but with

less severe level of impairment;
j Not severe enough to cause major

problems in school, work, or home;
j Manic episodes only last at least 4

days in duration and does not warrant hospitalization;

223

A. Nursing Management
M - Maintain a safe environment. Monitor sleeping pattern. A - Always limit group activities. N - Never reinforce altered perceptions and delusions. I - Institute motor programs (running, walking) A - Avoid stimulants. Provide finger foods.

224

B. Pharmacotherapy
² Lithium carbonate ‡ WOF signs of lithium toxicity. ‡ ‡ ² ² Carbamazepine Valproic acid

Antianxiety drugs. **Antipsychotics ² for psychotic episodes during the manic phase of Bipolar I.
225

PERSONALITY DISORDERS
These are groups of psychiatric disorders that affects behavioral responses of an individual; Persons with this type of disorders are incapable of functioning effectively in the society; Patients are unaware of the adverse impacts of their behaviors;
226

DSM-IV CLASSIFICATION
Cluster A Odd/ Eccentric Aloof and emotionally distant from others; Behaviors are considered strange;
1. 2. 3.

Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder
227

Cluster B Dramatic / Erratic The individual is egocentric or selfcentered; Little ability to understand another s perspective;
1. 2. 3. 4.

Borderline Personality Disorder Histrionic Personality Disorder Antisocial Personality Disorder Narcissistic Personality Disorder

228

Cluster C Anxious / Fearful Appears overly anxious about various social and personal issues; Unusually concerned with the rules, procedures, and acceptance by others;
1. 2. 3.

Dependent Personality Disorder Avoidant Personality Disorder Obsessive-Compulsive Personality Disorder
229

CLUSTER A PERSONALITY DISORDERS
A. Paranoid Personality Disorder
’

Individual is very secretive, suspicious, and don t trust others; Conviction that other people are out to do me in Also very aloof, cold, and overly serious affect; Uses projection;
230

’

’

’

B. Schizoid Personality Disorder ’ Steadfast determination to remain distant and aloof;
’

Preferred solitary activities; Lack of desire to develop social contacts (answer using words or phrases) Fearful of intimate relationships; Tend to fantasize or daydream;

’

’

’

231

C. Schizotypal Personality Disorder
’

Usually expressed unusual ideas and magical thinking; Inability to form and maintain ageappropriate relationships; May have transient psychotic symptoms but not sufficient to be diagnosed as schizophrenia; Ex. People with ESP; can see and talk with dead people (Sixth Sense)
232

’

’

’

CLUSTER B PERSONALITY DISORDERS
A. Antisocial Personality Disorder
’

More common in males; Char by constant antisocial behaviors (robbery, theft, alcoholism, vandalism, etc.) Sustained history of irresponsibility, selfcenteredness, and impulsiveness; Lack of remorse for one s destructive actions;

’

’

’

233

’ ’

Very manipulative and exploits others; Manifests with anger that results in hostile outburst; Potential for violence; Commonly uses rationalization; Tx: Group Psychotherapy

’ ’ ’

234

B.

Borderline Personality Disorder
’

The px may be impulsive with splitting tendency and suicidal; With outburst of intense anger and rage; Emotionally labile and with unstable personality; Tendency for self-mutilation; Also are manipulative; Most commonly treated;
235

’ ’

’ ’ ’

C.

Histrionic Personality Disorder
’

Melodramatic, colorful, highly energetic, and seductive; Tendency to have shallow relationships; Self-centered character; Wants to be the center of attention; Tendency to make many demands on others for reassurance;

’

’

’

’

236

D. Narcissistic Personality Disorder ’ More common in males;
’ ’ ’

Inflated sense of self-importance; Feeling of entitlement for recognition; Feelings of worthlessness if not praised and admired by others;
With labile affect; Tx: Group Psychotherapy
237

’ ’

CLUSTER C PERSONALITY DISORDERS
A.

Dependent Personality Disorder
’

Relies on others to assume large areas of responsibilities for his life; Excessive need to be taken care of; Unassertive and passive; Fear of shame and criticism; Inability to take risks or to initiate anything; May show signs of depression and anxiety;

’

’

’

’

’

238

B. Avoidant Personality Disorder
’ Avoidance

of any situation that could result in criticisms and shame; feels discomfort in social gatherings;

’ Px ’ Px

may be shy and fearful (of rejection or disapproval) to enter into a relationship unless he/she feels secured and accepted;

’ Afraid

239

C. Obsessive-Compulsive Personality Disorder
’ Preoccupation

with orders, rules and

regulations;
’ Usually ’ Too ’ Has

perfectionist and meticulous;

busy working to have social life; difficulty in making decisions;

’ Uses

reaction formation, undoing, and displacement;

240

by: Manuel Sanchez Tu, Jr., RN, MD, USRN

241

 Morel described schizophrenia before as

dementia praecox (precocious senility);
 Bleuler later coined the term

schizophrenia which means ³split mind´ (not split personality);
 95% of clients with schizophrenia have a

lifetime disease;
 It is the most common thought disorder;

242

 SUICIDE is the most common cause of

premature death of these clients;
 Usually appears in late adolescent or

early adulthood;
 Affects men and women almost equally;

243

II. Theoretical Perspective A. Biological Theories 1. Biochemical Theory (Dopaminergic Hypotheses) ‡ Excessive dopaminergic activity in cortical areas causes acute positive symptoms of schizophrenia (³HIDES´)

244

2. Neurostructural Theory ± Patients with schizophrenia have four structural changes in the brain: a. Cerebral ventricular enlargement. b. Cerebral atrophy c. Hypoplasia of the medial limbic structures. d. Decreased cerebral blood flow specially in the prefrontal cortex.

245

3. Genetic Theory ±Higher incidence of schizophrenia in patients with a diagnosed psychotic relative; ±Monozygotic twins have a higher incident rate compared to ordinary individuals; ±Identical twins have 50% risk; ±Fraternal twins have 15% risk;

246

4. Perinatal Risk Factors ±Prenatal exposure to influenza ±Minor malformations developing during early gestation ±Complications of pregnancy particularly during labor and delivery;

247

B. Developmental Theory
‡ The ³first stage (trust vs mistrust) is very important in the development of interpersonal relationship.´ ‡ A child deprived of nurturing, loving environment, neglected or rejected, is very vulnerable to mental disturbances; ‡ Therapeutic intervention focuses on the reestablishment of trust thru consistent, anxiety-free relationship;

248

III. DSM-IV Criteria in the Diagnosis of Schizophrenia
A. Characteristic symptoms: ‡ Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): 1. Delusions 2. Hallucinations 3. Disorganized speech (e.g., frequent derailment or incoherence) 4. Grossly disorganized or catatonic behavior 5. Negative symptoms (anergia, alogia)
249

B. Social / Occupational Dysfunction: ‡ Manifestations of psychosis will significantly affect the level of functioning of the client. C. Duration ‡ Signs of the disturbance persist for at least 6 months.

250

D. Schizoaffective and Mood Disorder Exclusion: ‡ The manifestations of psychosis are NOT secondary to other mental illness. E. Substance / General medical condition exclusion: ‡ The manifestations of psychosis are NOT secondary to substance abuse (shabu use) or medical illness (delirium, typhoid psychosis)
251

 BLEULER¶S Four A¶s
1. Affective Disturbance
a. Inappropriate ± affective response does not match the circumstances; b. Blunted ± the response to certain circumstances is weakly appropriate; c. Flat ± inability to generate any affective response; d. Labile ± emotional tone changes quickly;

252

2. Autism ± preoccupation with the self with little concern for external reality; 3. Associative looseness ± the stringing together of unrelated topics with VAGUE connections; 4. Ambivalence ± simultaneous opposite feelings;

253

 Positive vs Negative Symptoms

of Schizophrenia
1. Positive Symptoms (type I)  believed to be caused by an increase in the amount of dopamine;  Symptoms are additional of abnormal cognition and perception;  Targeted by typical anti-psychotics (Haldol, Thorazine)
254

 Examples of Positive Symptoms: ± Hallucinations and hostility ± Illusions and ideas of reference ± Delusions ± Excitement ± Suspiciousness ± Bizarre behavior ± Agitation or tension ± Grandiosity

³HIDES BAG´
255

2. Negative Symptoms (type II) ‡ Symptoms are essentially an absence or diminution of what should be ( lack of affect, lack of energy) ‡ May be related to: ±decrease amount of dopamine ±cerebral atrophy ±decreased cerebral blood flow ±increase serotonin; ‡ Targeted by ATYPICAL anti-psychotics (Clozapine, Olanzapine)
256

± Examples of Negative Symptoms:
1. Alogia ± poverty of content; lack of meaning or substance in what he say; 2. Anhedonia 3. Asocial behavior 4. Attention deficit 5. Avolition ± lack of motivation; 6. Blunted affect 7. Communication difficulties (echolalia, neologism, word salad, etc) 8. Difficulty with abstraction;

257

Objective vs Subjective Behavioral Manifestations:
A. Objective Signs 1. Alterations in personal relationships.  Poor attention span.  Poor self care or grooming.  Poor social communication.

258

2. Alterations of activity.  Psychomotor agitation  Echopraxia  Catatonic rigidity  Stereotype behaviors

259

Subjective Signs: Autism and Ambivalence Blocking Clanging association and concrete
thinking

Delusions rEtardation ± slow mental activity. Flight of ideas, mutism, and word salad. neoloGism ± invented words. Hallucination Illusions and ideas of reference
260



Delusions ± fixed, false beliefs; 1. Somatic delusions 2. Delusion of grandiosity 3. Delusion of religion 4. Delusion of nehilism (dead) 5. Delusion of reference ± other people is talking about you. 6. Delusion of influence or control 7. Delusion of persecution 8. Paranoid delusions

261



Subtypes of Schizophrenia (DSM-IV) 1. Paranoid  extreme suspiciousness  persecutory delusions  auditory hallucinations


Uses PROJECTION. ND: Potential for violence, directed to others or self.
262



2. Catatonic  Increased purposeless motor activities  Stuporous or waxy flexibility  Rigid posturing behavior  Mutism and negativism  Peculiar movements  Echolalia or echopraxia


Uses REPRESSION. ND: Impaired motor activities.



263

3. Disorganized / Hebephrenic  With child-like behaviors  Incoherent speech  Disorganized behavior  Unsystematized delusions  Inappropriate or flat affect  Abnormal social behavior


uses REGRESSION.

264

4. Undifferentiated ‡ Grossly disorganized and incoherent behavior ‡ Severe hallucinations ‡ Prominent delusions ‡ Severely impaired level of functioning. ‡ Or if the client¶s manifestations will not fall under the three categories.

265

5. Residual ‡ Absence of psychotic symptoms although the px had previous schizophrenia; ‡ Functional level moderately impaired and the client can¶t keep a permanent job;

266

’

Treatment: 1. Psychosocial Therapy


Initially focuses on the patient¶s physical safety; ³Helping px to become stronger than their symptoms´ Support the patient by abandoning maladaptive behaviors for more acceptable ones; Design a treatment plan to raise the patient¶s functional level and to educate the family on how to respond appropriately to the patient¶s behavior;







267

2. Pharmacotherapy ‡ Use of phenothiazines (Thorazine) and other neuroleptics; ‡ Adjunctive drugs such as antiparkinsons, anticholinergics, propranolol, and diphenhydramine may be used to control adverse drug reactions; 3. Combination Therapy ‡ Psychotherapy and pharmacotherapy; ‡ To build a stable psychological foundation and helping the patient accept responsibility for self care, develop social relationships, and vocational satisfaction;
268



Nursing Diagnosis: 1. Altered thought process*** 2. Sensory/perception alteration*** 3. Potential for violence, directed to self or others; 4. Ineffective individual coping 5. Personal identity disturbance 6. Impaired verbal communication 7. Self-care deficit 8. Impaired social interaction
269

’

Nursing Interventions: 1. Safety  Remove any unsafe objects from the patient¶s environment;

270

2. Environment ‡ Keep the px oriented to reality and 3 spheres; ‡ Minimize environmental stimuli; ‡ Communicate in clear, direct, and concise manner; 3. Self-esteem ‡ Assist the px with grooming if needed; ‡ Allow the px to make decisions when appropriate; ‡ Acknowledge the px¶s abilities and skills, and use them to reinforce teaching;
271

4. Social activities ‡ Give positive reinforcement when the px voluntarily interacts with others; ‡ Encourage the px to participate in group activities; 5. Ego development ‡ Validate the patient¶s perceptions that are accurate and correct all misperceptions;

272

6. Homeostasis ‡ Monitor the patient¶s vital signs; ‡ Provide period for adequate sleep and diet; ‡ Control hyperactive psychomotor activity; ‡ WOF: adverse drug reactions (EPSE) 7. Correct delusions ‡ Establish and maintain reality for the client. ‡ Teach the client to practice positive thinking and IGNORING delusions.

273

8. Correct hallucinations and illusions ‡ Help maintain reality. ‡ Engage px in reality-based activities such as card playing or occupational therapy.

274

OTHER PSYCHOTIC DISORDERS
A. Schizoaffective Disorder

± Is a psychosis characterized by both affective and schizophrenic symptoms with substantial loss of occupational and social functioning; ± Schizophrenic symptoms are dominant but are accompanied by major depressive or manic symptoms;
275

B. Delusional Disorder

± Manifest symptoms similar to schizophrenia but with substantial differences exists: 1. DELUSIONS have basis in reality. 2. Have not met the criteria of schizophrenia. 3. Behavior is relatively normal other than their delusions. 4. Duration of symptoms is brief. 5. Symptoms may be due to substance or general medical conditions.

‡

Tx:

Anti-psychotics
276

C. Brief Psychotic Disorder

± Psychotic disturbances that last less than 1 month and are not related to other mental disorders, general medical conditions, or substance abuse; ± Tx: Anti-psychotics
D. Schizophreniform Disorder

± Shows symptoms of typical schizophrenia and last at least 1 month but no longer than 6 months; ± Tx: Anti-psychotics
277

COGNITIVE DISORDERS
± Cognitive abilities are processes that allow the person to make sense of experience and to interact productively with the environment; 1. Judgment 2. Attention 3. Perception 4. Orientation 5. Reasoning 6. Memory Char by deficit in memory or cognition that significantly changes a person¶s level of functioning; Also known as Organic Brain Disorders; 278

±

±

DELIRIUM (acute brain syndrome)  Deficiency in the capacity to maintain attention;
 

With rapid onset and brief duration; Char by acute loss of conscious awareness; May lasts for hours or weeks and resolves in a few days (reversible);



279



Causes:
1. 2. 3.

4. 5.

Physical abuse Infection - sepsis Endocrine problems ± thyrotoxicosis Trauma ± massive blood loss; Abuse of substance

280

±

Signs and Symptoms: 1. Prodromal signs ‡ Restlessness ‡ Anxiety ‡ Sleep disturbance ‡ Irritability 2. **Cloudy consciousness ± cardinal sign. 3. Apathy 4. Impaired cognition and memory defects 5. Disturbances in perception 6. Disorganized thought process
281

± Nursing Diagnosis: 1. **Risk for injury related to cognitive and psychomotor deficit. 2. Self-care deficit related to inability to carry out ADL.

282

±

Nursing Interventions:

**Follow treatment plan to relieve cause of delirium. 1. Reality orientation a. Call the px by name and keep a clock and calendar in plain view. b. Use very simple words and short sentences. c. Provide a safe and quiet environment;

283

2. Monitor vital signs. 3. Set limitations on inappropriate and harmful behaviors. 4. Provide adequate nutritional and fluid intake if tolerated;

284

DEMENTIA (chronic brain syndrome)
± Char by memory impairment and insidious loss of intellectual ability; May be due to destruction of neurons in the brain; Etiology usually due to other NEUROLOGIC diseases: 1. Parkinson¶s Disease 2. Pick¶s disease 3. Huntington¶s chorea 4. Wernicke-Korsakoff¶s Syndrome 5. Alzheimer¶s Disease ****

±

±

285

’ DSM-IV Criteria for Dementia
1. Memory impairment (amnesia) 2. At least one of the ff cognitive disturbances: a. Aphasia ± language disturbance b. Apraxia ± inability to carry out motor activities despite intact motor function; c. Agnosia ± failure to recognize or identify objects despite intact sensory function; d. Disturbance in executive functioning (abstracting, planning, organizing) 3. Significant impairment in social or occupational functioning after the onset of illness.
286

Feature
Onset Course Duration Attention Orientation Memory Perception Speech Course

Delirium
Acute (night) Fluctuating Hours to days Fluctuates Impaired time Immediate or recent memory Illusions and visual hallucination Incoherent, rapid, slow Reversible

Dementia
Insidious Stable Months to years Unaffected Often impaired Recent and remote memory Absent of perceptual function Difficulty in finding words Irreversible
287

ALZHEIMER¶S DISEASE
± ± ± Is the most common type of dementia; Exact cause is UNKNOWN; Is a degenerative brain disease causing dementia that is progressive and most of the time irreversible; Usually begins after age 60 but early signs can be observed at age 40; Death may occur within five years after diagnosis (pneumonia or from other infections) More common in males;
288

±

±

±

±

Char by microscopic brain changes: 1. Senile plaques** 2. Degeneration of neurons or ³neurofibrillary tangles´ ** 3. Cerebral atrophy ** 4. Reduced level of acetylcholine:** ‡ Loss of neurons in the basal ganglia ‡ Increase action of acetylcholinesterase enzyme;
289

± A¶s of Alzheimer¶s Disease: ging mnesia gnosia phasia praxia luminum deposition myloid deposition ntibodies abnormalities cetylcholine abnormality bnormality in chromosome 21 - ricept (donepezil) 290

±

Clinical Manifestations of AD: 1. Memory loss (amnesia) and mood swings 2. Intolerance for activity 3. Depression 4. Anger 5. Helplessness and hopelessness 6. Incontinence and abnormal reflexes 7. Lack of self-care and home care 8. Altered sleep and arousal patterns 9. Numerous behavioral symptoms (hallucinations, delusions, dysphoria, apathy, agnosia, apraxia, aphasia)
291

± Nursing Diagnosis: 1. **High risk for injury 2. Altered thought process 3. Anxiety

292

±

Nursing Interventions: 1. Ensure safety:  removing toys and other dangerous objects in the vicinity;  rearranging furniture and use of pads;
2.

3. 4.

5. 6.

Support and meet the client¶s basic needs (food, shelter, clothing) Encourage activities of daily living. Provide sensory stimulation (reading, music) Encourage life review or reminisce. Use clear, short and concise communication.
293

± Pharmacotherapy:
1. Antipsychotics ± for psychotic symptoms; 2. Antidepressants ± SSRI¶s; Nortriptyline and Desipramine; 3. Antianxiety ± used for agitation, anxiety, and sleep disturbances; ‡ Buspirone ‡ Lorazepam ‡ Oxazepam
294

4.

Metabolic enhancers / Vasodilators - treat cognitive impairment; ‡ Hydergine Nootropic agents ± used to enhance neuronal metabolic activity; ‡ Nootrophil Donepezil (Aricept) and Tacrine (Cognex) ‡ acetylcholinesterase inhibitors; ‡ TO INCREASE ACH LEVEL; ‡ Aricept given once daily with low incidence of hepatotoxicity;
295

5.

6.

SUBSTANCE ABUSE


Causes maladaptive behaviors secondary to moodaltering substances; UPPERS DOWNERS Stimulation of SNS Depression of SNS



Substance abuse is a widespread concern with broad social ramifications and personal consequences; May lead to addiction;
296





Most commonly abused substances: 1. Alcohol 2. Opiates 3. Narcotics 4. Hallucinogens 5. Stimulants 6. Inhalants ALCOHOL - is considered as the leading abused substance; CIGARETTE ± is the most commonly abused substance by psychiatric patients;
297





Intoxication
Stimulants (Uppers) ±Shabu ±Cocaine ±Ecstasy ±Cannabis* Depressants (Downers) ±Alcohol ±Narcotics ±Opiates

Withdrawal

Stimulation of the SNS

Depression of the SNS

Depression of the SNS

Stimulation of the SNS
298

ALCOHOL ABUSE
± Alcohol is a CNS depressant that is rapidly absorbed into the bloodstream; ± Alcoholism is considered to be present when there is 0.1% or 10mL for every 1000mL of blood; ± Levels: .1 - .2% - slow coordination, slurred speech
.2 - .3% - tremors, irritability, violence .3% and above - unconsciousness
299



Effects of Alcohol Intake:
1. 2. 3. 4. 5. 6. 7. 8. 9. Aggression Blackouts Coordination problem Difficulty walking (unsteady gait) Experience slurred speech F - polyuria Gone are inhibitions ³Hanep makapag-relax´ Impaired attention, concentration, memory and judgment;

300



An overdose or excessive alcohol intake in short period of time can result to (ABCD): 1. Altered level of consciousness 2. Breathing is depressed and vomiting 3. Coma 4. Death

301

Wernicke - Korsakoff¶s Syndrome


Char by amnesia, clouding of consciousness, confabulation (falsification of memory) and peripheral neuropathy; Results from inadequate amounts of THIAMINE (B1) and NIACIN, and the neurotoxic nature of alcohol; Tx: Vitamin B1 or B-complex replacement;





302

Common Behavioral Problems: 1. Denial 2. Dependency 3. Demanding 4. Destructive 5. Domineering

303

Treatment:


Symptoms of withdrawal usually begin 4 ± 12 hours (6-8 hrs) after cessation or marked reduction of alcohol intake; May lasts up to 5 days;



304

ALCOHOL WITHDRAWAL SYNDROME
Stage I ± 6-8 hrs after last intake. ± Anxiety and anorexia ± Insomnia and tremors ± N/V and hyperactivity ± Increase pulse and BP ± Depression Stage 2  8-12 hrs after lasts intake.  Confusion  Gross tremors  Nervousness  Disorientation  Auditory and visual hallucinations  Illusions  Nightmares
305

Stage 3
± ± ± 12-48 hrs after last intake. Severe hallucinations Seizures (Dilantin)

Stage 4
± ± ± ± ± ± ± ± 3 ± 5 days after last ingestion. Confusion and delirium. Clouding of consciousness. Disorientation. Visual and tactile hallucinations. Fever and increase BP. Tremors and tachycardia. Medical emergency.
306



Alcohol withdrawal can be life-threatening, so detoxification needs to be accomplish under medical supervision; Safe withdrawal is usually accomplished by benzodiazepines: ± Lorazepam (Ativan) ± drug of choice; ± Diazepam (Valium)



307



Disulfiram (Antabuse)
± Inhibits the breakdown of acetaldehydes by an enzyme (aldehyde dehydrogenase)
Alcohol (Ethanol)

L I V E R

Alcohol dehydrogenase

Acetaldehyde + H2
Aldehyde dehydrogenase

Acetic acid

CO2 + H2O (for excretion)
308

±

³The person who drinks alcohol while taking disulfiram will become ill´: (DISULFIRAM OR ANTABUSE REACTION) 1. Sweating 2. Flushing of the neck and face 3. Tachycardia and palpitations 4. Hypotension 5. Throbbing headache 6. Nausea and vomiting 7. Dyspnea 8. Tremors 9. Weakness
309

± Disulfiram may also cause arrhythmias, MI, cardiac failure, seizures, coma, and death; ± The unpleasant effects to alcohol is intended to help stop alcohol drinking; ± Once disulfiram is started, the px must not take alcohol because of the danger of these adverse effects;
AVOID ALCOHOLIC BEVERAGES, PERFUMES AND SHAVING CREAMS with ALCOHOL.
310

FETAL ALCOHOL SYNDROME (FAS)
± Is the result of alcohol¶s inhibiting effects on fetal development during the first trimester of pregnancy; ± Pregnant women who drink alcohol run the risk of seriously harming their unborn child; ± Characteristics: 1. Microcephaly 2. Severe mental retardation 3. Stillborn
311

SEDATIVES, HYPNOTICS, and ANXIOLYTICS
 

These are CNS depressants; Intoxication symptoms: (³SIC LULI´) 1. Slurred speech and stupor 2. Impaired verbal communication 3. Coma 4. Lack of coordination 5. Unsteady gait 6. Labile mood 7. Impaired attention or memory

312



Benzodiazepines when taken orally are rarely fatal (ONLY causes lethargy and confusion) Barbiturates (Parenteral or oral) can be lethal when taken in overdose (2 ± 10 g can be fatal) 1. Coma 2. Respiratory arrest 3. Cardiac failure 4. Death
313





Withdrawal Symptoms: ± Usually occurs 6 ± 8 hrs after cessation of some benzodiazepines; ± Manifested by: 1. Autonomic hyperactivity a. Increase PR b. Increase BP c. Increase RR d. Increase in temperature 2. 3. 4. 5. 6. Hand tremors Anxiety Nausea Insomnia Psychomotor agitation

314



Detoxification from sedatives, hypnotics, and anxiolytics often manage by TAPERING the amount of drugs the client receives over a period of days or weeks; Barbiturates can cause fetal abnormalities because these can cross the placental barrier; - Infants born to mothers who take barbiturates during the last trimester of pregnancy can experience withdrawal symptoms postpartum;



315

OPIOIDS


Are popular drugs because these desensitize the person to both physiologic and psychological pain and induce a sense of euphoria and well-being; Examples: 1. Morphine* 2. Opium* 3. Meperidine (Demerol)* 4. Codeine 5. Hydrocodone 6. Methadone ± drug of choice during detoxification. 7. Heroin*
316





OPIOID INTOXICATION happen after the initial euphoric feeling: 1. Pinpoint pupils* 2. Apathy 3. Respiratory depression 4. Uncoordinated movements 5. Lethargy and listlessness 6. Attention and memory impairment 7. Slurred speech

317



NALOXONE (opioid antagonist) - is the treatment of choice for toxicity; NOT FOR DETOXIFICATION; - It reverses all the signs of opioid toxicity by blocking the neuroreceptors affected by opioids; - Immediately improves px¶s respiration and consciousness;

318



Withdrawal develops when (1) drug intake ceases or is (2) markedly decreased, or it can also be (3) precipitated by the administration of naloxone: 1. Craving 2. Restlessness and rhinorrhea 3. Anxiety with aching backs and legs 4. Nausea and vomiting 5. Dysphoria and diarrhea 6. Sweating 7. Fever 8. Insomnia 9. Lacrimation

³CRANDS FIL´

319



Heroin Withdrawal: ³STRICY´ ± Sneezing ± Tears ± Restlessness ± Irritability ± Coryza ± Yawning Methadone - is used to replace opioid during detoxification to reduce signs and symptoms of withdrawal;
320



STIMULANTS (Amphetamines, Cocaine, Ecstasy ) ± Also known as ³uppers;´ ± These drugs excite the CNS; ± The effects of these drugs, even though they are different, are the virtually same; ± These drugs have limited clinical indications and a high potential for abuse;
321

± Amphetamines are commonly used before to lose weight (ex. IONAMINE) ± Cocaine and ecstasy have NO clinical use and is highly addictive; Commonly used as a recreational drug because of intense and immediate feeling of euphoria;

322



Intoxication from stimulants develops rapidly:
1. 2. 3. 4. 5. 6. 7. 8. 9. Super active Talkative Impaired judgment ³Mabilis pumayat´ (weight loss) Unhappiness or anger Loss of appetite (anorexia) Anxiety The presence of hallucinations and illusions Euphoria

323

10. Physiologic effects: a. Tachycardia b. Elevated BP c. Dilated pupils d. Diaphoresis with chills e. Nausea f. Chest pain and Confusion g. Cardiac arrhythmias

Cocaine users may also report ³bugs´ crawling beneath the skin (FORMICATION) and foul smells; Nasal septum perforation ± is associated with chronic snorting cocaine and is due to extreme vasoconstriction which impedes blood supply to the nasal septum causing necrosis;
324

Cocaine or Stimulant Withdrawal:
 

Occurs within a few hours to several days; Manifestations: (³ D MANIPIS´) 1. Depressive symptoms 2. Marked dysphoria ± feeling of unhappiness and anger; 3. Agitation 4. Nightmares 5. Increase appetite 6. Psychosis 7. Increase suicidal ideations 8. Sleeping disturbances
325

CANNABIS (Marijuana)
± From Cannabis sativa, a hemp plant for making ropes and cloth; ± contain DELTA-9 TETRAHYDROCANNABINOL (THC) - the active substance; ± Marijuana ± upper leaves, flowering tops, and stems of the plant; ± Hashish ± is the dried resinous exudates from the leaves of the female plant; ± Cannabis most of the time is smoked like cigarettes but it can be eaten (brownies)
326

±

Therapeutic use of cannabis: 1. Lowers IOP 2. ** Relieves nausea and vomiting associated with cancer chemotherapy (dronabinol, nabilone) 3. Anorexia and weight loss of AIDS Cannabis Intoxications: - Begins to act less than 1 minute after inhalation; - Peak levels occur in 20 ± 30 minutes and lasts at least 2 - 3 hours;

±

327



Symptoms of Cannabis Intoxication:
1. Tachycardia 2. Hypotension 3. Eye redness 4. Psychotic symptoms (hallucinations) 5. Abnormal motor coordination 6. Short-term memory loss 7. Inappropriate laughter (³laughing trip´) 8. Social withdrawal 9. Increase appetite (³food trip´) 10. Disorientation, delirium, and dysphoria
328

± Treatment is usually symptomatic and overdose does not occur ( because easily excreted ) ± Withdrawal symptoms are usually not present when sudden cessation is performed;

329

HALLUCINOGENS


Also referred to as psychotomimetics or psychedelics; Are substances that distort the user¶s perception of reality and produce symptoms similar to psychosis; Used to treat chronic alcoholism and reduction of cancer pain and PLP;





330



Two basic groups: 1. Natural a. Mescaline ± peyote from cactus; b. Psilocybin ± psilocin from mushrooms; c. Cannabis ± Synthetic a. LSD ± lysergic acid diethylamide b. STP ± dimethoxy-4-methylamphetamine c. Pencyclidine (PCP) ± most potent; d. DMT ± dimethyltryptamine e. MDA - methylenedioxyamphetamine
331



Hallucinogen intoxication is marked by a variety of maladaptive behavioral or psychological changes: 1. 2. 3. 4. 5. Hallucinations Anxiety Paranoid ideation Depression and dangerous behaviors Ideas of reference

332



Toxic reactions to hallucinogens (except PCP) are primarily psychological and overdose usually will not occur;



Psychotic reactions are best managed by: 1. Isolation from external stimuli. 2. Using physical restraints if necessary for the CLIENT¶S SAFETY.

333

INHALANTS


Are diverse groups of drugs that are inhaled for their effects: 1. Anesthetics 2. Nitrates 3. Organic solvents a. Gasoline b. Glue c. Paint thinner d. Spray paint Inhalants can cause significant brain damage, PNS damage, and liver disease;
334





Inhalants may cause acute toxicity: 1. Respiratory depression 2. Anoxia 3. Vagal stimulation 4. Arrhythmias 5. Death ( due to bronchospasm, cardiac arrest, suffocation, or aspiration)

335



Treatment consist of supporting respiratory and cardiac functions until the substance is removed from the body; There are no withdrawal or detoxification procedures for inhalants;



336

EFFECTS OF SUBSTANCE ABUSE
1. 2. 3. 4. 5.

6.

Decrease number of social friends. Reduction of leisure activities. Erosion of spiritual values and moral standards. Abnormal physical functions. Mounting family tension and mental deterioration. Sexual and occupational problems.

337

EATING DISORDERS
ANOREXIA NERVOSA
± is a disorder characterized by compulsive resistance to eat and maintain body weight; ± Common in adolescent and young adult 12 ± 18 years of age; ± With a mortality rate of 15 ± 20%; ± Majority of cases are females; ± Clients usually die of severe malnutrition; 338

± Most of them are experiencing DENIAL (unconscious refusal to admit their disease) ± May be triggered by: ‡ adolescent crisis ‡ unconscious fear of growing up ‡ excessive concern and fear of obesity ‡ elevated feelings for self-control

339

±

Manifestations of Anorexia Nervosa:
1. 2. 3. 4. Hypothermia, and hypotension Anemia with bradycardia/tachycardia. Nutritional deficiency (malnutrition) Obvious weight loss ( 15% or more of original body weight ) *** 5. Resistance to eat (fear of eating) 6. Electrolyte imbalance (hypoK and hypoNa) 7. Keep high performance in school and sports 8. Social withdrawal with poor individual coping 9. Increase in size of salivary gland (hypertrophy) 10. Amenorrhea (absence of at least 3 consecutive menstrual cycle)

340

-

Nursing Diagnosis: 1. Altered nutrition: less than body requirements 2. Disturbed body image 3. Ineffective individual coping 4. Ineffective family coping 5. Fluid and Electrolyte imbalance

341

BULIMIA
± A syndrome char by recurrent binge eating with lack of control and followed by purging (vomiting, use of laxatives or diuretics, or vigorous exercise) ± May also manifest with pica (or eating nonnutritious foods such as plaster, paint, clay, or sand) ± Common among adolescent and young adults 17-23 years old; ± More common among women;
342

± Tend to be episodic with remissions and relapse; ± Most clients know their illness; ± Is predispose to have depression; ± May have discord with family relationship; ± There is a profound history of obesity in the family;

343

± Manifestations: 1. Body and weight conscious. 2. Unusual, extroverted, and impulsive individuals. 3. Lability in weight (due to binge-eating and long hours of fasting) 4. Induced purging after binge-eating. 5. Multiple dental staining 6. I - Electrolyte imbalance (hyponatremia, hypokalemia, and hypochlorinemia) 7. Engages in vigorous exercises. 8. Signs of depression.

344

ANOREXIA NERVOSA Diet« diet« diet«. Denial > 15% weight loss Amenorrhea Hypertrophy of Salivary G. Severe malnutrition Lanugo formation Course is continuous ³I¶m fat«.´ (mirror) SUPEREGO

BULIMIA Eat..eat..vomit« exercise.. Know«. Hide «.. Fluctuating body weight Irregular menstruation Teeth erosion Metabolic alkalosis (vomit) Metabolic acidosis (diarrhea) Course is episodic Weight conscious ID

Fear of obesity

345

-

Nursing Diagnosis: 1. Altered nutrition: less than body requirements 2. Ineffective family coping 3. Ineffective individual coping 4. Personal identity disturbance

346

Nursing Interventions for Eating Disorders: 1. 2. 3. 4. Weigh client daily. Encourage verbalization of feelings. Increase self-esteem. Go observe for signs of purging and depression. 5. Help clients reestablish proper eating behavior. 6. Monitor caloric intake. 7. Electrolyte monitoring regularly.
347

SEXUAL DISORDERS
± These are disorders that are related to human sexuality due to psychophysiological causes; ± Types: 1. Alteration in gender identity 2. Alteration in sexual orientation 3. Alteration in sexual behavior 4. Alteration in sexual functioning 5. Painful sexual disorders
348

ALTERATION IN GENDER IDENTITY
1. Transsexualism ± Persistent discomfort about one¶s sex assignment; ± Caused by confused learning about gender roles; ± Feeling of being trapped in the wrong body; ± With intense feeling or preoccupation about transsexual surgery;

349

2. Gender Identity Disorder of Childhood ± Persistent and intense distress at one¶s sexual identity; ± Client insists that he/she is an opposite sex; ± Assertion that he/she will grow up to have transsexual surgery; 3. Nontranssexual Cross Gender Disorder ± Persistent discomfort about one¶s sex but with no preoccupation with getting rid of the genitalia;
350

ALTERATION IN SEXUAL ORIENTATION
1. Ego-Dystonic Homosexuality ‡ Weak heterosexual arousal with desire to have heterosexual relationship; ‡ Client experience inappropriate homosexual arousal pattern;

351

ALTERATION IN SEXUAL BEHAVIOR
1. Sexual Acting Out ± With disturbed conduct or poor impulse control; ± Have extramarital affairs and promiscuous individuals; ± With high sexual drive; ± Presence of inadequate coping and interpersonal skills;

352

2. Paraphilia ± Sexual urges or fantasies that are directed toward nonhuman objects, pain to self, partner, or children, or other nonconsenting individuals; ± This may be asymptomatic; ± Behavior often followed by guilt, shame, low self-esteem, or anxiety; ± Not due to other mental disorder;

353

Fetishism Transvestism Exhibitionism Pedophilia Voyeurism

substitution of an inanimate object for the genitals wearing clothes of the opposite sex to achieve sexual pleasure Haha lam na =) attraction to children less than 13 y/o as sex objects sexual gratification obtained by watching the sexual plays of others sexual gratification obtained by inflicting pain and punishment to the partner sexual pleasure from enduring physical and psychological pain
354

Sadism Masochism

Frotteurism

sexual pleasure obtained by touching or rubbing against a non-consenting person. sexual gratification obtained from corpse. sexual gratification from or during telephone conversation. intense sexual arousal or desire for animals oral and anal intercourse between males;
355

Necrophilia Telephone scatologia

Zoophilia Sodomy

ALTERATION IN SEXUAL FUNCTIONING
1. Sexual Dysfunction ± individual is unsatisfied in his sexual function; 2. Hypoactive sexual desire ± absence of sexual fantasies and desires; 3. Sexual aversion ± avoidance of genital sexual contact with a partner;

356

4. Sexual arousal disorder ± Failure to attain and maintain erection in males; ± Lack of lubrication in females; ± Persistent or recurrent lack of subjective sense of sexual excitement and pleasure;

357

PAINFUL SEXUAL DISORDERS
1. Vaginismus ± an involuntary vaginal spasm at penetration;  Protection against anticipated pain associated with sexual trauma, intense guilt, or high religion offense; 2. Dyspareunia ± painful sexual intercourse;

358

NURSING DIAGNOSIS
1. 2. 3. 4. 5. Altered sexuality patterns Ineffective individual coping Altered family process Anxiety Potential for violence: self-induced or to others.

359

NURSING INTERVENTIONS:
1. Sexuality belief and values discussion. 2. Encourage to discuss feelings of guilt, remorse, anger, and loneliness. 3. X ± explain to the client the institution of suicidal precaution.

360

OVERVIEW OF SUICIDE
‡ is the 9th leading cause of death in the US; ‡ Among the three leading causes of death for those aged 15-34 years old; ‡ Females are higher to COMMIT suicide; ‡ Men are 4x higher to COMPLETE SUICIDE than females;
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SUICIDE
 Or self-inflicted death;  outcome of a person¶s inability to deal

with catastrophic stress (depression) ‡ Suicide most often is the result of depression, diagnosed or not;
 Suicide may occur in children,

adolescent, or adult populations;
362



Suicidal ideation ± includes a person¶s thoughts regarding suicide; Suicidal gestures ± non-lethal self-injury acts like: 1. Cutting of skin areas 2. Burning of skin 3. Ingestion of poisonous substances or drugs




Suicidal gestures may be considered as ³ATTENTION-SEEKING´ measures and MAY NOT LEAD to serious attempts or completion;
363

‡ Suicidal threats ± are person¶s verbal statements that may declare their intent to commit suicide; Threats OFTEN PRECEDE an actual suicide attempt; ‡ Suicide attempt ± is the actual implementation of a self-injurious act with the purpose of ending a person¶s life; ‡ The death by suicide of a psychiatric client is of particular importance to the nurse because of opportunities for assessment and interventions;

364

‡

(HIGH) Risk Factors for Completed Suicide:
1. Caucasian and Native Americans 2. Living alone ± single, divorced, widow/er 3. Age 40-60 and older 4. Male sex 5. Prior suicide attempts ± 50-85% 6. Substance use (alcoholism, drugs) 7. Hopelessness and helplessness 8. Unemployed or financial problems 9. General medical illness ± terminal cancer 10. Severe anhedonia

365

‡

Assessment of Suicidal Patients:
 It is important for the nurse to be able to

assess the suicidal potential of mentally ill clients because of higher risk in committing suicide;

1. Plan
‡ The more developed the plan, the greater risk of suicide; ‡ Impulsive suicide attempts can also result in death but generally are less often lethal because of lack of planning;

366

2. Method
‡ Some methods of suicide are more lethal than others; ‡ One important factor in determining the lethality of a method is the time between initiation and the delivery of the lethal impact of the method; ‡ Ex. GSW is more lethal than drowning or suffocation;

367

‡

Types of Methods: 1. Gunshot 2. Jumping from high places 3. Hanging 4. Drowning 5. Carbon monoxide poisoning 6. Overdose with certain drugs (alcohol, barbiturates, and other CNS depressants, ASA, valium) 7. Wrist cutting 8. Ingestion of poisonous substances

368

3. Rescue
‡ A person who deliberately attempts to deceive would-be rescuers has a high lethal potential; ‡ The more detailed the plan, the more lethal and accessible the method; ‡ The more effort to block rescuers, the greater the chance for a successful suicide;

369

± Nursing Diagnosis: ‡ Ineffective individual coping ‡ Potential for violence: self-directed ‡ Fear ‡ Anxiety

370

‡

Nursing Interventions:
1. Assess and evaluate client for suicidal risk to develop a reasonable plan of care. 2. Suspect suicidal ideation in most depressed clients. 3. Inquire directly about the frequency and content of suicidal ideations. ± The nurse will not provoke suicide. ± The nurse will convey concern, worth of the client, and a sense of understanding. ± To plan nursing care.
371

4. Evaluate client¶s access to a means of suicide to block the access. 5. Develop a formal ³no suicide´ contract with the client. 6. Advise the client to discontinue drugs and/or alcohol intake.

372

DEVELOPMENTAL DISORDERS
A. MENTAL RETARDATION
‡ ‡ Or Cognitive Developmental Delay; Is defined by IQ BELOW 70 before 18 y/o that is accompanied by impairments in performing age-expected activities in daily living; 3% of the US population are considered MR; Most mentally retarded are in the MILD range;
373

‡ ‡

‡

The causes of MR: 1. Specific ‡ Down¶s syndrome ± most common. ‡ Fragile X syndrome ‡ Phenylketonuria 2. Multifactorial causes ‡ Congenital anomalies ‡ Perinatal trauma ‡ Postnatal trauma ‡ Postnatal infections
374

DSM-IV Classification of Mental Retardation
Severity
Mild / Moron Moderate/ Imbecile Severe/ Idiot Profound
Normal IQ Borderline

IQ Range
55 - 69 40 - 54 25 - 39 Below 25 90 ± 110 70 ± 89
375

‡

MILD MR ± capable of EDUCATION; - Mental age of 8 ± 12 years old; - Can learn to read, write, achieve vocational skills, and function in the society; MODERATE MR ± the client is TRAINABLE; - Mental age of 3 ± 7 years old; - Can learn the activities of daily living; - Can be trained to work;

‡

376

‡

SEVERE MR ± the client is barely trainable; - Mental age 0 -2 years old; - Totally dependent and in need of custodial care; - May say few words; - With uncoordinated motor movements; PROFOUND MR ± mental age of young infant; - Requires full-time care; - No academic skills; - No fine or gross motor skills;
377

‡

B. DOWN SYNDROME (TRISOMY 21)
 Is the most common identifiable cause

of MR;
 Down syndrome is one of the most

widely known syndromes associated with MR;

378



Clinical Manifestations: 1. Characteristic facial anomalies and others. a. Brachycephaly b. Epicanthal folds c. Flat nasal bridge d. Low-set ears e. Oblique palpebral fissures f. Protruding tongue g. Simean crease of palms
2. Congenital heart defects ± VSD, TOF, PDA 3. Mental retardation 4. Hypotonia 5. Growth retardation
379

C. Fragile X Syndrome
   

2nd most common identifiable cause of MR; Most common inherited cause; Dx made during mid-childhood; Clinical Manifestations: 1. Mild to moderate MR 2. Elongated face, prominent ears, macrocephaly, high-arched palate; 3. Macroorchidism at puberty 4. Autism 5. Attention deficit, hyperactive 6. Self-mutilating or self-injurious behaviors;

380

D. Turner¶s Syndrome
 

rare genetic disorder found among females; There is an absence of a normal 2nd sex chromosomes; Genetic analysis reveals a 45,X chromosome constitution; Clinical Manifestations: 1. The most prevalent: a. Short stature, webbed neck, low posterior hairline, edema of the hand and feet; b. Broad chest with inverted or underdeveloped nipples; c. Immature reproductive organs, primary amenorrhea





381

AUTISTIC DISORDER
‡ Char by detachment from reality when selfpreoccupation and self-involvement are predominant; Strong genetic contributions but the exact cause remains UNKNOWN; Others suggest: o increase level of serotonin o abnormal serotonin receptors; Most are mentally retardate; Onset is usually at 30 months of age;
382

‡

‡

‡ ‡

‡

Clinical Manifestations: 1. Profoundly disturbed social relatedness; 2. Constant delay in the developmental profile; 3. Aloof and indifferent to others; 4. Prefers inanimate objects than human contacts; 5. Temper tantrums 6. Language is delayed and deviant: ‡ Abnormal intonation ‡ Pronoun reversals ‡ Echolalia
383

7. Stereotypical behaviors ‡ Rocking ‡ Hand flapping ‡ Extraordinary insistence on sameness ‡ Preoccupation with peculiar interests (fans, aircons)

384

‡

Nursing Interventions: 1. Maintain a consistent and familiar environment. 2. Set consistent and firm limits for behaviors. 3. Encourage verbalization of feelings and concerns. 4. Prevents destructive behaviors. 5. Provide routine for ADL¶s.
385

‡

Pharmacologic Tx: 1. Haloperidol (Haldol) - to decrease or relieve: ‡ Temper tantrums ‡ Aggressiveness ‡ Self-injury ‡ Hyperactivity ‡ Stereotypical behaviors 2. Naltrexone 3. Clomipramine 4. Clonidine 5. Stimulants
386

DISRUPTIVE BEHAVIOR DISORDERS
ATTENTION-DEFICIT HYPERACTIVITY DISORDER ‡ Is char by inattention, impulsiveness, and overactivity; ‡ ‡ ‡ ‡ Is a relatively common among SCHOOLAGED CHILDREN (2-11%); The exact etiology is STILL UNKNOWN; Experts suggest that dysfunction of the frontal lobe; May occur together with learning disabilities;
387

‡

Possible Etiologies: 1. Environmental exposures a. Perinatal insults b. Head injury c. Psychosocial adversity d. Lead poisoning 2. Food additives and history of allergies. 3. Genetic predisposition especially among identical and fraternal twins.

388

MAIN PROBLEMS OF ADHD:*** I ± Inattention H ± Hyperactivity I ± Impulsivity NURSING DIAGNOSIS: Risk for injury.***

389

‡

Management: 1. Multidisciplinary approach (environmental and behavioral) is the treatment of choice. 2. Pharmacotherapy ‡ CNS STIMULANTS work for 70-75% of ADHD (only for children older than 7 years old)  Effective in decreasing motor activities and increasing attention span and concentration;  *** Methylphenidate (Ritalin) ± most common;  Dextroamphetamine (Dexadrin)  Pemoline (Cylert)  Clonidine (Catapres) ‡ TCA¶s (Imipramine, desipramine, nortriptyline) 390

TIC DISORDERS
‡ Term used to describe several disorders that are characterized by motor and/or vocal tics; TIC ± is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization;
 Tics can be suppressed for a period of time but not indefinitely;  Tics are exacerbated by stress and diminished during sleep and when the person is engaged in an absorbing activity;
391

‡

‡

Motor Tics ± typically rapid, jerky movements of the eyes, face, neck, and shoulders; Vocal Tics ± most common are throat clearing, grunting, or other repetitive noises;
 Echolalia  Palilalia  Coprolalia

‡

392

‡

TOURETTE¶S SYNDROME ± is a chronic
idiopathic movement disorder that is char by the presence of multiple motor and vocal tics for more than 1 year;  May experience all types of tics in his lifetime;  Will lead to significant impairment on social, academic, or occupational functioning;  May feel ashamed and self-conscious;  Rare and more common among BOYS than girls;  Onset usually by age 7 years;  Dx: Haloperidol (Haldol)
393

ABUSE
± Wrongful use and maltreatment of another person (spouse, partner, child, or elderly) ± May lead to: » Physical injuries » Psychological injuries

394

± Victims of abuse may also show:  Upset  Numb  Agitation  Withdrawn ± low self-esteem  Aloof ± Domestic violence goes undisclosed for months or years (due to FEAR OF THE ABUSER)

395

± Char of a Violent Family:
1. Social Isolation ‡ Do not invite others into their home or tells others what is going on; ‡ Threat from the abuser; 2. Abuse of Power and Control ‡ Abuser is almost always in a position of power and control over the victim; ‡ Physical, economic, or social power;

396

3. Alcohol and Drug Abuse ‡ Abuser commonly uses alcohol or drugs; ‡ Alcoholism is also present in 50% of abused women; ‡ Alcohol and drugs are also associated with date rape; 4. Intergenerational transmission process ‡ Family violence is a learned response; ‡ 1/3 of abusive men grew from a violent family or with history of abuse;
397

SPOUSE OR PARTNER ABUSE
± Is the maltreatment or misuse of one person by another in the context of an intimate relationship; 90 ± 95% of domestic violence victims are WOMEN; Pregnancy increases violence in a relationship;

±

±

398

± This can be: 1. Psychological or emotional abuse ± Name-calling ± Belittling ± Shouting ± Destroying properties ± Threats ± Refusing to speak to the victim

399

2. Physical Abuse ‡ Shoving ‡ Pushing ‡ Battering ‡ Choking ‡ Fractures ‡ Homicide

3. Sexual Abuse ‡ During sex; ‡ Biting nipples ‡ Pulling hair ‡ Slapping ‡ Hitting ‡ Rape

400

± Char of an Abuser:
inAdequacy ³Isip Bata´ (immature)

pUr problem-solving skills low Self-esteem jEalous and possessive act is Rewarding
401

± Why women stay with their abusive husbands?

1. DEPENDENCY - is the most common reason. 2. Cycle of Violence

402

CYCLE OF VIOLENCE

Violent behavior

Tension Building

Period of Remorse
403

1. Violent Behavior
‡ Explodes in violent / abusive attack;

2. Period of Remorse
‡ ‡ ‡ ‡ ‡ ‡ Or ³Honeymoon Period´ Regret and apology ³I¶m sorry«. It will never happen again«. Promise«´ Buys gifts, flowers, jewelries, etc. Wife believes her husband. May start from weeks to months«. Then becomes frequent.
404

3. Tension Building Stage ± Arguments again ensue; ± Silence ± No complaints

± ³Assess for signs of abuse«´
405

CHILD ABUSE
± or child maltreatment; ± Intentional injury to a child; ± May include: ‡ Physical abuse and injuries ‡ Neglect or failure to prevent harm ‡ Failure to provide care ‡ Abandonment ‡ Sexual assault ‡ Torture
406

± Types of Child Abuse: ‡ Physical ‡ Emotional ‡ Neglect ‡ Sexual

407

± Physical Abuse
‡ ‡ ‡ ‡ ‡ ‡ ‡ Usually due to corporal punishment; Hitting and Burning Biting and Cutting Poking Twisting limbs Scalding with hot water ³Evidence of old injuries (healed fx) and multiple bruises of various stages.´ ³Stop crying««««´ ³Diumebs ka na naman..«««.´
408

‡ ‡

± Emotional Abuse
‡ Verbal assaults ‡ Constant family violence ‡ Withholding affection and love

409

± Neglect
‡ Is the most common type of maltreatment; ‡ Refused or delay to seek medical help. ‡ Abandonment ‡ Inadequate supervision ‡ Disregard for safety ‡ Spousal abuse in child¶s presence ‡ Failure to enroll to school
410

± Sexual Abuse
‡ 75% of cases involve father-daughter incest; ‡ ‡ ‡ ‡ Rape Sodomy Molestation Exploitation of minors

411

± Char of Parents (in Child Abuse) ‡ Lack of parenting skills ‡ Lack of understanding in children¶s needs ‡ Lack of money ‡ Lack of education ‡ With history of child abuse

412

± Warning Signs of Abused Children:

‡ A ± Absence of trauma but with
serious injuries (fracture, burns, lacerations)

‡ B ± Bruised, red, swollen, teared genitalia
(vagina and anal)

‡ U ± Unusual injuries for age and
development (Femoral fx in a 2 month old)

‡ S ± Switching and inconsistencies in
child¶s history.

‡ E ± Evidence of old injuries.*** ‡ D ± Delay in seeking treatment for severe
injury.
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± Nursing Interventions: 1. Ensure the child¶s safety and wellbeing. 2. Thorough psychiatric evaluation. 3. Establish trust to help child deal with trauma of abuse. 4. Use play therapy to express his feelings. 5. Refer to social works.

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