Psychiatric Nursing

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PSYCHIATRIC NURSING

Mental Health
y

A state of emotional, psychological and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self-concept and emotional stability.

COMPONENTS OF MENTAL HEALTH
y y y

Autonomy and Independence-can work
interdependently without losing autonomy

Maximization of One·s Potential-oriented
towards growth and self-actualization

Tolerance of Life·s Uncertainties-can face the

challenges of day-to-day living with hope & positive look y Self-esteem-has realistic awareness of her abilities and limitations y Mastery of the Environment-can deal with and influence the environment y Reality Orientation-can distinguish the real world from a dream, fact from fantasy

MENTAL ILLNESS
-State of imbalance characterized by a

disturbance in a person·s thoughts, feelings and behavior

Criteria to Diagnose Mental Disorders
Dissatisfactions with one·s characteristics, accomplishments, abilities y Ineffective or dissatisfying relationships y Dissatisfaction with one·s place in the world y Ineffective coping with life·s events y Lack of personal growth
y

PSYCHIATRIC NURSING
y

Interpersonal process whereby the nurse through the therapeutic use of self assist an individual family, group or community to promote mental health, to prevent mental illness and suffering, to participate in the treatment and rehabilitation of the mentally ill and if necessary to find meaning in these experiences

CORE OF PSYCHIATRIC NURSING
Interpersonal relationship y FOCUS: Patient
y

Foundation
y

Central Nervous System Cerebrum
Frontal lobe ² control organization of thought, body movement, memories, emotions and moral behavior. x Associated with schizophrenia, attention deficit / hyperactive disorder and dementia Parietal lobe ² interpret sensations of taste and touch and assist is spatial orientation.

Foundation
Central Nervous System
Temporal lobes ² are centers for the sense of smell, hearing, memory, and expression of emotions. Occipital lobes ² assist in coordinating language generation and visual interpretation, such as depth perception.

Neurotransmitters
` ` ` ` ` `

Dopamine-controls complex movements, motivation,
cognition, regulates emotional responses Serotonin-regulation of emotions, controls food intake, sleep and wakefulness, pain control, sexual behaviors Acetylcholine- controls sleep and wakefulness cycle (decreased in Alzheimer·s) Histamine-controls alertness,peripheral allergic reactions, cardiac stimulations GABA-modulates other neurotransmitters Norepinephrine / Epinephrine-causes changes in attention, learning and memory, mood

Foundation
Neurotransmitters Sympathetic Parasympathetic Increase v/s Decrease GI motility motility Decrease GU function function Moist mouth

Decrease v/s Increase GI Increase GU Dry mouth

Genetics and Hereditary
Alzheimer·s disease ² linked with defects in chromosomes 14 and 21 Schizophrenia Mood disorders (depression) Autism and AD/HD

Sigmund Freud
y

Father of Psychoanalysis - ´Your behavior today is directly or indirectly affected by your childhood days or experiences. - STRUCTURE ² Personality Structure

Personality Structure
y

ID (4-5MONTHS)
Impulsive / Instinctual drive I want to« PLEASURE PRINCIPLE I want to« PHYSIOLOGIC NEEDS I want to« PRIMARY PROCESS

Personality Structure
y

SUPEREGO
Should not Small voice of GOD Set norms, standards and values MORAL PRINCIPLE Conscience

Personality Structure
y

EGO
Executive REALITY PRINCIPLE Conscious Competencies Decision Maker; Problem-Solving; Critical and Creative thinking

Imbalances between Personality Elements

ID

M ± anic A ± nti-social SE N ± arcissistic

Imbalances between Personality Elements

SE ID

O ± bsessive Compulsive A ± norexia nervosa

Imbalances between Personality Elements

EGO

Schizophrenia

Libido
y Sexual

energy responsible for survival of human beings y Psychosexual Theory of Freud

ORAL STAGE
y 18

months y Cry, suck, mouth y EGO @ 6 months
Child cries ² fed ² successful Child cries ² ignored ² unimportant - narcissistic

FIXATION
y

occurs when a person is stuck in a certain developmental stage

REGRESSION
y Returning

to an earlier developmental stage y Infantile behavior

ANAL STAGE
y y y

18 months ² 3 years old SUPEREGO develops Toilet training
Good Mother ² Normal Bad Mother
x Clean, organized, obedient ² OC (anal retentive) x Dirty, disorganized ² Anti-social (anal expulsive)

PHALLIC STAGE
y y

Preschooler (3 ² 6 years old) Parent
Oedipus Complex
x Castration Fear

Electra Complex
x Penis Envy

REPRESSION
y UNCONSCIOUS

forgetting of an anxiety provoking concept

SUPRESSION
y CONSCIOUS

forgetting of an anxiety provoking situation

IDENTIFICATION
y

attempts to resemble or pattern the personality of a person being admired of

INTROJECTION
y

acceptance of another values and opinion as one·s own

LATENCY STAGE

6 to 12 years old y School y Reading, writing, arithmetic y Ability to care about and relate to others outside home
y

SUBLIMATION
y

placing sexual energies toward more productive activities

SUBSTITUTION
y

replace a goal that can·t be achieved for another that is more realistic.

GENITAL STAGE

12 years old and above y Developing satisfying sexual and emotional relationships with members of the opposite sex y Planning life·s goals
y

EGO DEFENSE MECHANISMS
Function-To ward off anxiety *without defense mechanisms, anxiety might overwhelm and paralyze us and interfere with daily living 2 Features: 1. 1. they operate on an unconscious level (Except suppression) 2. 2. they deny, falsify or distort reality to make it less threatening

EGO DEFENSE MECHANISMS
Repression vs. Suppression
y

REPRESSION
Unconscious forgetting of an anxiety provoking concept

y

SUPRESSION
Conscious forgetting of an anxiety provoking situation

EGO DEFENSE MECHANISMS

Regression vs. Fixation
Regression y Returning to an earlier developmental stage Fixation y occurs when a person is stuck in a certain developmental stage

EGO DEFENSE MECHANISMS
Rationalization vs. Intellectualization
y

RATIONALIZATION
Self-saving with incorrect illogical explanation

y

INTELLECTUALIZATION
Excessive use of abstract thinking; technical explanation

EGO DEFENSE MECHANISMS
Displacement vs. Projection vs. Introjection
y

DISPLACEMENT
Feelings are transferred or redirect to other person or object that is less threatening

y

PROJECTION
Blaming; Falsely attributing to another his/her own unacceptable feelings.

y

INTROJECTION
Acceptance of another·s values and opinions as one·s own

EGO DEFENSE MECHANISMS
Sublimation vs. Substitution
y

SUBLIMATION
Transfer of sexual energy to a more productive activity.

y

SUBSTITUTION
Replaces a goal that can·t be achieved for another that is more realistic.

EGO DEFENSE MECHANISMS
Dissociation vs. Isolation
DISSOCIATION
Separating and detaching idea, situation from its emotional significance.

ISOLATION
Individual strips emotion when talking or responding about it.

EGO DEFENSE MECHANISMS
y y

Conversion
Anxiety converted to physical symptoms

Compensation
Overachievement in one area to overpower weaknesses or defective area.

y

Undoing
Doing the opposite of what have done

EGO DEFENSE MECHANISMS
y

Denial
Failure to acknowledge an unacceptable trait or situation

y

Fantasy
Magical thinking

y

Reaction Formation
Opposite of intention

EGO DEFENSE MECHANISMS
y

Acting out
Deals with emotional conflict or stressors by ACTION rather than reflection or feelings.

y

Symbolization
Creates a representation to an anxiety provoking thing or concept

y

Splitting
Labile emotions; all bad ² all good

DEFENSE MECHANISMS COMMONLY USED IN EACH RESPECTIVE DISORDERS
Paranoid ² Projection Phobia ² Displacement Amnesia ² Dissociation Anorexia ² Supression Bipolar Disorder ² Reaction Formation Borderline ² Splitting Schizophrenia ² Regression Substance Abuse ² Denial Depression ² Introjection OC ² Undoing Catatonic - Repression

y

Woman who is angry with her boss writes a short story about a heroic woman.

y y y y y y

Woman who is angry with her boss writes a short story about a heroic woman. Four-year old with new baby brother starts sucking his thumb and wanting a bottle. Patient criticizes the nurse after her family failed to visit. Man who is unconsciously attracted to other women teases his wife about flirting. Short man becomes assertively verbal and excels in business. Recovering alcoholic constantly preaches about the evils of drink.

` ` ` ` ` `

Man reacts to news of the death of a loved one ´ No, I don·t believe you. The doctor said he was fine.µ Student is unable to take a final exam because of a terrible headache. After flirting with her male secretary, a woman brings her husband tickets to a show. ´I didn·t get the raise because my boss doesn·t like me.µ Five-year old girl dresses in her mother·s shoes and dress and meets daddy at the door. After his wife·s death, husband has transient complaints of chest pain and difficulty breathing- the symptoms his wife had before she died.

Man forgets wife·s birthday after a marital fight. ` Businessman who is preparing to make an important speech that day is told by his wife that morning that she wants a divorce. Although visibly upset, he puts this incident aside until after his speech, when he can give the matter his total concentration.
`
` ` `

A man cannot accept his physician's diagnosis of cancer is correct and seeking a second opinion. Slamming a door instead of hitting as person, yelling at your spouse after an argument with your boss. focusing on the details of a funeral as opposed to the sadness and grief

y

y

y

y y

stating that you were fired because you didn't kiss up the the boss, when the real reason was your poor performance having a bias against a particular race or culture and then embracing that race or culture to the extreme sitting in a corner and crying after hearing bad news; throwing a temper tantrum when you don't get your way forgetting sexual abuse from your childhood due to the trauma and anxiety lifting weights to release 'pent up' energy

Psychosocial Theory of Development

Erik Erickson

PSYCHOSOCIAL THEORY ² Erikson·s
0-18 mos.

Trust vs. Mistrust

-attachment to mother which lays foundations for later trust in others -conflict: general difficulties relating to others. suspicion, fear of the future

y y y

PSYCHOSOCIAL THEORY ² Erikson·s 18 m0s ² 3 yrs Autonomy vs.
Shame/Doubt Gaining some basic control of self and environment Conflict: independence-fear conflict, severe feelings of self-doubt

PSYCHOSOCIAL THEORY ² Erikson·s
3 yrs ² 6 yrs

Initiative vs. Guilt

-becoming purposeful and directive -conflict: aggression-fear conflict; sense of inadequacy and guilt

PSYCHOSOCIAL THEORY ² Erikson·s
6 yrs ² 12 yrs Industry vs. Inferiority y Developing social, physical and school skills, competence y Conflict: sense of inferiority; difficulty learning and working

PSYCHOSOCIAL THEORY ² Erikson·s
y y y

12 yrs ² 20 yrs Identity vs. Role Diffusion Making transition from childhood to adulthood; developing a sense of identity Conflict: confusion of who one is, identity submerged in relationships or group memberships

PSYCHOSOCIAL THEORY ² Erikson·s
21 yrs ² 35 yrs Intimacy vs. Isolation -establishing intimate bonds of love and friendship -conflict: emotional isolation

PSYCHOSOCIAL THEORY ² Erikson·s
35 yrs ² 55 yrs Generativity vs. Stagnation

-fulfilling life·s goals that involve family, career and society, developing concerns that embrace future generations -conflict: self-absorption. Inability to grow as a person

PSYCHOSOCIAL THEORY ² Erikson·s
y y y

55 yrs ² above Integrity vs. Despair Looking back into one·s life and accepting its meaning Conflict: dissatisfaction with life, denial of or despair over prospect of death

Cognitive Theory of Development

Jean Piaget

assimilation
y

people transform incoming information so that it fits within their existing schemes or thought patterns

accommodation
y

people adapt their schemes to include incoming information

PIAGET·S COGNITIVE THEORY
y

SENSORIMOTOR STAGE-development
proceeds from reflex activity to representation and sensorimotor solutions to problems

0 to 18 months
y

PRE-OPERATIONAL STAGE-

development proceeds from sensorimotor representation to prelogical thought and solutions to problems y can use these representational skills only to view the world from their own perspective. y Understand the meaning of symbolic gestures

2 to 7 years

`
` `

CONCRETE OPERATIONAL-development proceeds
from prelogical thought to logical solutions to concrete problems understand concrete problems cannot yet contemplate or solve abstract problems

` 7 to 12 years
`

FORMAL OPERATIONAL-development proceeds from
logical solutions to concrete problems to logical solutions to all classes of problems cannot yet contemplate or solve abstract problems can also reason theoretically

` `

` 12 and above

Harry Stack Sullivan

Interpersonal Theory

SULLIVAN·S INTERPERSONAL THEORY y Infancy-anxiety develops as a result of unmet needs
by the mother (bodily needs); needs met, the child has
sense of well-being

0 to 18 months

y

Childhood-anxiety as a result of lack of
praise/acceptance from parents -gratification leads to positive self-esteem - moderate anxiety leads to uncertainty and insecurity; - severe anxiety results in self-defeating patterns of behavior 18 months to 6 years

y

Juvenile-severe anxiety may result in a need to
control or restrictive, prejudicial attitudes -learns to negotiate own needs 6 to 9 years

`

Pre-adolescence-capacity to attachment, love and

collaboration emerges or fails to develop -move to genuine intimacy with friend of the same sex ` 9 to 12 years ` Adolescence-if self-system is intact, areas of concern expand to include values, career decisions and social concerns -lust is added to interpersonal equation -need for special sharing relationship shifts to opposite sex -new opportunities for social experimentation lead to consolidation or self-ridicule ` 12 to adulthood

Hildegard Peplau

NURSE PATIENT RELATIONSHIP

PEPLAU·S NPR
y y

PRE-INTERACTION
Major task of nurse- to develop self-awareness

ORIENTATION
Major task of the nurse: to develop a mutual acceptable contract

y

WORKING
Major task: identification and resolution of patient·s problem

y

TERMINATION
Major task: to assist the patient to review what he has learned and transfer his learning to his relationship with others

THERAPEUTIC COMMUNICATIONS
y

ORIENTATION
Broad Opening Recognition Giving information Silence Offering Self ² ´Do you want me to sit beside you?µ

THERAPEUTIC COMMUNICATIONS
`

WORKING
` ` ` ` ` ` ` ` ` ` Focusing ² ´Let us discuss this topic more.µ Exploring ² ´Tell me more about it.µ Encourage Evaluation ² ´IS this what you want?µ Reflecting ² same idea Restating ² same statement Verbalizing Implied ² ´Are you going to kill yourself?µ Seeking Clarification ² ´May you please repeat that statementµ General lead ² ´Please continue.µ; ´And then?µ Limit setting ² ´Stop.µ Interpreting ² ´Maybe that thing is very significant to you.µ

THERAPEUTIC COMMUNICATIONS
y

TERMINATION
Summarizing ² ´Let us now sum up.You have stated earlier«etc.µ ´Do you have any questions?µ ´Our next therapy«µ Look for changes in behavior Resistance is a common problem

Therapeutic Communication Techniques
y Accepting-indicating y Eg.µYesµ

reception

´I follow what you saidµ Nodding..

Broad Openings
Allowing the client to take the initiative in introducing the topic y Eg. ´is there something you·d like to talk about?µ ´Where would you like to begin?µ
y

Consensual Validation
Searching for mutual understanding, for accord in the meaning of the words y Eg. ´Tell me whether my understanding of it agrees with yoursµ ´Are you using this word to convey that. . .?µ
y

Encouraging Comparison
Asking that similarities and differences be noted y Eg. ´was it something like..?µ ´Have you had similar experiences?µ
y

Encouraging Description of Perceptions
Asking the client to verbalize what he or perceives y Eg.µTell me when you feel anxiousµ ´What is happening?µ ¶What does the voice seem to be saying?µ
y

Encouraging Expression
Asking client to appraise the quality of his or her experience y Eg. ´what are your feelings in regard to..?µ ´Does this contribute to your distress?µ
y

Exploring
Delving further into a subject or idea y Eg. ´Tell me more about that.µ ´Would you describe it more fully?µ ´What kind of work?µ
y

Focusing
Concentrating on a single point y Eg. ´This point seems worth looking at more closelyµ ´Of all the concerns you·ve mentioned, which is most troublesome?µ
y

Formulating a Plan of Action
-Asking the client to consider kinds of behavior likely to be appropriate in future situations y Eg. ´What could you do to let your anger out harmlessly?µ ´Next time this comes up, what might you do to handle it?µ

General Leads
Giving encouragement to continue y Eg. ´Go onµ ´And then?µ ´Tell me about itµ
y

Giving Information
Making available the facts that the client needs y Eg. ´My name is«µ ´Visiting hours are«µ ´My purpose in being here is« ´
y

Giving Recognition
Acknowledging, indicating awareness y Eg. ´Good morning, Mr. S«µ ´You·ve finished your list of things to do.µ ´I noticed that you·ve combed your hairµ
y

Making Observations
Verbalizing what the nurse perceives y Eg. ´You appear tense..µ ´I notice that your biting your lipsµ
y

Offering Self
Making oneself available y Eg. ´I·ll sit with you awhileµ ´I·ll stay here with youµ ´I·m interested in what you thinkµ
y

Placing Event in Time or Sequence
Clarifying the relationship of events in time Eg. ´what seemed to lead up to«? ´Was this before or after?µ

Presenting Reality
Offering for consideration that which is real y Eg. ´I see no one else in the room.µ ´Your mother is not here; I am a nurse.µ
y

Reflecting
Directing client actions, thoughts, and feelings back to client y Eg. Client: ´Do you think I should tell the doctor«? Nurse: ´Do you think you should?µ
y

Restating
Repeating the main idea expressed y Eg. Client: I can·t sleep. I stay awake all night.µ Nurse:You have difficulty sleeping.µ Client:µI·m really mad, and upsetµ Nurse:You·re really mad and upset.µ
y

Seeking Information
Seeking to make clear that which is not meaningful or that which is vague y ´I·m not sure that I follow.µ ´Have I heard you correctly?µ
y

Silence
Absence of verbal communication, which provides time for for the client to put thoughts or feelings into words, regain composure, or continue talking y Eg. Nurses says nothing but continues to maintain eye contact and conveys interest.
y

Suggesting Collaboration
Offering to share , to strive, to work with the client for his or her benefit y Eg. Perhaps you and I can discuss and discover the triggers for your anxiety
y

Summarizing
Organizing and summing up that which has gone before y Eg. ´Have I got this straight?µ
y

Translating into Feelings
seeking to verbalize client·s feelings that he or she expresses only indirectly y Eg. Client: ´I·m deadµ Nurse: ´Are you suggesting that you feel lifeless?µ
y

Verbalizing the Implied
Voicing what the client has hinted at or suggested y Eg. Client: I cant· talk to you or anyone. It·s a waste of time.µ Nurse: ´Do you feel that no one understandsµ
y

Voicing Doubt
Expressing uncertainty about the reality of the client·s perceptions y ´Isn·t that unusual?µ ´Really?µ ´That·s hard to believe.µ
y

Nontherapeutic Communication Techniques
Advising-telling the client what to do Agreeing- indicating accord with the client y Eg. ´I think you should«.µ
y
´That·s rightµ

Agreeing
Indicating accord with the client y ´that·s right.µ ´I agreeµ
y

Belittling Feelings expressed
Misjudging the degree of the client·s comfort y Client: ´I have nothing to live for..I wish I was deadµ
y

Nurse: ´Everybody gets down in the dumps.µ

Challenging
Demanding proof from the client y ´But how can you be President of the Philippines?µ
y

Defending
Attempting to protect someone or something from verbal attack y ´This hospital has a fine reputation.µ
y

Disagreeing
Opposing the client·s ideas y Eg. ´That·s wrongµ
y

Disapproving
Denouncing the client·s behavior or ideas y ´That·s badµ ´I·d rather you wouldn·tµ
y

Giving approval
Sanctioning the client·s behavior or ideas y ´ That·s good.µ ´I·m glad that..µ
y

Giving Literal Responses
Responding to a figurative comment as though it were a statement of fact y Client: ´They·re looking in my head with television camera.µ Nurse: ´Try not to watch television.µ
y

Indicating the existence of an external source
y

´What makes you say that?µ

Interpreting
Asking to make conscious that which is unconscious y ´What you really mean is..µ
y

Introducing an unrelated topic
Changing the subject y Client: ´I·d like to die.µ Nurse: ´did you have visitors last night?µ
y

Making stereotyped comments
Offering meaningless cliches or trite comments y ´Keep your chin up.µ y ´Just have a positive outlook.µ
y

Probing
Persistent questioning of the client y ´Now tell me about this problem. I need to know.µ
y

Reassuring
Indicating there is no reason for anxiety y ´Everything will be alright.µ
y

Rejecting
Refusing to consider or showing contempt for the client·s behavior, ideas y ´Let·s not discuss..µ
y

Requesting an explanation
Asking the client to provide reasons for thoughts, feelings, behaviors, events y ¶Why do you think that?µ
y

Testing
Appraising the client·s degree of insight y ´Do you know what kind of hospital this is?µ
y

Using Denial
Refusing to admit that a problem exists y Client: ´I am nothing.µ Nurse: ´Of course, you·re something.µ
y

NONNON-THERAPEUTIC COMMUNICATIONS y Overloading ² ´blah, blah, blahµ
y y y y y y y y

Underloading - ignoring Value Judgment ² use of adjectives False Reassurance ² ´Don·t worry, you will be fine later.µ Focusing on Self ² ´I gave you meds so you are now feeling goodµ Incongruence Internal Validation ² biased judgment Giving Advice ² ´If I were you, ill« Changing Subject -

LOSS AND GRIEVING

GRIEF- refers to the subjective emotions and affect that are a normal response to the experience of loss y ANTICIPATORY GRIEVING- when people facing an imminent loss begin to grapple with the very real possibility of the loss or death in the near future
y

DISENFRANCHISED GRIEF-grief over a loss that is not or cannot be acknowledged openly, mourned publicly or supported socially y COMPLICATED GRIEVING-when a person is void of emotion, grieves for prolonged periods, has expressions of grief that seem disproportionate to the event
y

LOSS
Physiologic Loss y Safe and Security Loss y Love and Belongingness Loss y Self-Esteem Loss y Self-actualization Loss
y

GRIEVING PROCESS
y y y y y

Denial Anger Bargaining Depression Acceptance Dysfunctional grieving ² grieving which extends from 4 to 6 weeks leading to CRISIS

y

Interventions
y y y y y y y

Explore client·s perception and meaning of the loss Allow adaptive denial Assist client to reach out for and accept support Encourage client to examine patterns of coping in past and present situation of loss Encourage client to care for himself Offer client food without pressure to eat Use effective communication

CRISIS AND ITS MANAGEMENT

CRISIS y situation that occurs when an individual·s habitual coping ability becomes ineffective to merit demands of a situation y TYPES OF CRISES: y MATURATIONAL / DEVELOPMENTAL
Normal expected crisis that runs through age

y y

SITUATIONAL
Unexpected and sudden event in life

ADVENTITIOUS
Calamities, war

Characteristics of a Crisis state
Highly individualized y Lasts for 4-6 weeks y Self-limiting y Person affected becomes passive and submissive y Affects a person·s support system
y

PHASES OF A CRISIS
y y

y

y y

Pre-crisis: State of equilibrium Initial Impact (may last a few hours to a few days): High level of stress, helplessness, inability to function socially Crisis (may last a brief or prolonged period of time): Inability to cope, projection, denial, rationalization Resolution: attempts to use problem-solving skills Post crisis: may have OLOF or may have symptoms of neurosis, psychosis

CRISIS MANAGEMENT
Role of the nurse is to return the client to its pre-crisis state by assisting and guiding them until they achieved their OLOF. y Goal: to enable patient to attain an OLOF y Nurse·s Primary Role: Active and Directive
y

Steps in Crisis Intervention
y y y y y y

Identify the degree of disruption the client is experiencing Assess the client·s perception of the event Formulate nursing diagnoses Involve the patient and family if applicable with planning Implement interventions- new and old coping mechanisms Evaluate-reassessment, reinforcement

TYPES OF THERAPIES
Treatment Modalities

Individual Psychotherapy
One to one relationship between therapist and client y For dissociative, anorexia, paranoid, narcissistic y Change is achieved by the exploration of feelings, attitudes, thinking behavior and conflict
y

SEVEN SUBTYPES:
` ` ` `

` `

CLASSICAL PSYCHOANALYSIS Based on Freud·s theory To uncover unconscious feelings and thoughts that interfere with the client·s living a fuller life Free association-client is encouraged to say anything that comes to mind, without censoring thoughts or feelings Dream analysis Working through(transference)-process of repeated interpretation to the person of his or her unconscious processes has the effect of bringing about change

Al relationship PSYCHOTHERAPY y PSYCHOANALYTICAL
y y y

Uses dream analysis, transference and free association Therapist is much more involved and interacts with the client more freely Done through intimate professional relationship between the nurse/therapist and the client over a period of time (introductory, working and termination phase)

SHORT TERM DYNAMIC PSYCHOTHERAPY y Indication-persons with specific symptom or interpersonal problem that he/she wants to work on y Therapist directs the content y Use of transference and dream analysis y Weekly sessions (total number-12 to 30) y Successful for highly motivated individuals who have insight and with positive relationship with the therapist
y

y y y y y y

y y y y

TRANSACTIONAL ANALYSIS Eric Berne Each person has three ego states and change from one to another frequently Parent-concepts of standards of behavior and how things should be done e.g. Go and take out the garbage. Adult-rational thinking and data analyzing part of the personality e.g.Would you please take out the garbage Child- feelings associated with persons, things or incidents represent the need-gratifying aspects of the personality. E.g. Is that why you married me?To be your garbage man? For group, family and individual Client to identify ego states for each given situation Rewarding of positive or negative behaviors with strokes Client work through these behaviors

COGNITIVE PSYCHOTHERAPY y Restructuring or changing ways in which people think bout themselves y Thought stopping y Positive self-talk y Decatastrophizing y Therapists help patients identify these thoughts
y

BEHAVIORAL THERAPY y Changes in maladapted behavior can occur without insight into the underlying cause y Based on learning theory y Modeling y Operant conditioning y Self-control therapy-combination of cognitive & behavioral approaches ´talking to selfµ y Systematic desensitization y Aversion therapy
y

y y y y y

GESTALT THERAPY Emphasis on the ´here and nowµ Only present behavior can be changed, not history Uncover repressed feelings and needs Techniques: have a person behave the opposite of the way he/she feels, presuming that a person can then come in contact with a submerged part of the self; in dreams, person is ask to play the roles of persons in the dream to get in touch with different repressed feelings

Milieu Therapy

Milieu Therapy
Total environment has an effect on the individual·s behavior y Components
y

Physical Environment Interpersonal relationships Atmosphere of safety, caring, and mutual respect For alcoholics

PROGRAMS FOR MILIEU SHOULD HAVE:
` ` ` ` ` ` `

an emphasis on group and social interaction No rules and expectations mediated by peer pressure A view of patients· roles as responsible human beings An emphasis on patients· rights for involvement in setting goals Freedom of movement and informality of relationships with staff Emphasis on interdisciplinary participation Goal-oriented, clear communication

Group Therapy

Group Therapy
Number of people coming together, sharing a common goal, interest or concern, staying together and developing relationships y For PTSD and Alcoholics y Phases
y

Orientation Working Termination

Characteristics of Group Therapy
Universality ´You are not aloneµ y Instilling hope and inspiration y Developing social skills by interacting with one another y Feeling of acceptance and belonging y Altruism ´Giving of one·s selfµ
y

Psychoanalytically oriented group therapy y Psychodrama y Family therapy
y

Assumption of Family Therapy
For alcoholic and schizophrenic

Assumption of Family Therapy
Client: Whole family y Concepts:
y

The family is the most fundamental unit of the society. Adaptive or maladaptive patterns of behavior are learned from the family Dysfunction in the family = dysfunction in the individual
y

Purpose
Improve relationships among family members Promote family function Resolve family problems

OTHER TYPES OF THERAPIES
y

SUPPORT GROUPS
For those with AIDS, Mother-Against-Drug Dependence

y

SELF-HELP GROUPS
Alcoholic Anonymous

RULES FOR PSYCHOTHERAPEUTIC MANAGEMENT
y y y y y y

Provide support, treat patients with respect and dignity Do not place patients in situations wherein they will feel inadequate or embarrassed Treat patients as individuals Provide reality testing Handle hostility therapeutically Provide psychopharmacologic treatment

BEHAVIORAL THERAPIES
Treatment Modalities

BEHAVIORAL THERAPY
y

Pavlov·s Classical Conditioning
All behavior are learned

y

B.F. Skinner·s Operational Conditioning
Reinforcements

BEHAVIORAL THERAPY
Behavioral Modification ² Substance Abuse Token Economy ² Anorexia / Schizo Systematic Desensitization - Phobia

y

y

y

ATTITUDE THERAPY
Treatment Modalities

ATTITUDE THERAPY
1. 2. 3. 4. 5. 6.

Paranoid ² Passive Friendliness Withdrawn ² Active Friendliness Depressed / Anorexia ² Kind Firmness Manipulative ² Matter of Fact Assaultive ² No Demand Anti-social ² Firm, consistent

PSYCHOSOMATIC THERAPY
Treatment Modalities

Electroconvulsive Therapy

Electroconvulsive Therapy
Effective in most affective disorders y The induction of a grandmal seizure in the brain. y Abnormal firing of neurons in the brain causes an increase in neurotransmitters y Number of Treatments: 6-12 ,3 times a week, about .5-2seconds y Unilateral or bitemporal
y

Electroconvulsive Therapy
Indications: y Patients who require rapid response y Patients who cannot tolerate pharmacotherapy or cannot be exposed to pharmacotherapy y Patients who are depressed but have not responded to multiple and adequate trials of medication

Electroconvulsive Therapy
Preparations for ECT: ` Pretreatment evaluation and clearance ` Consent ` NPO from midnight until after the treatment ` Atropine Sulfate-to decrease secretions, succinylcholine (Anectine)- to promote muscle relaxation, Methohexital Sodium(Brevital)anesthethic ` Empty bladder ` Remove jewelry, hairpins, dentures and other accessories ` Check vital signs ` Attempt to decrease patient·s anxiety

Electroconvulsive Therapy
Care after ECT: y O2 therapy of 100% until patient can breathe unassisted y Monitor for respiratory problems, gag reflex y Reorient patient y Observe until stable y Careful documentation. y Male erectile dysfunction

OTHER THERAPIES

NEUROSURGERY

ANXIETY

Peplau·s Levels of Anxiety
y

Mild

Associated with the tension of day-today living Perceptual field increased More alert than usual Adaptive
y

Moderate

Narrowed perception Difficulty focusing Selective inattention Mild somatic complaints: stomachache and butterflies in the stomach

Interventions for Mild to Moderate Anxiety
y y y y y

y y y

Assist the client in identifying anxiety. Anticipate anxiety provoking situations. Use nonverbal language to demonstrate interest Encourage the client to talk about his or her feelings. Avoid closing off avenues of communication (refrain from offering advice or changing the topic). Encourage problem-solving Explore past and present coping behaviors Provide outlets for working off excess energy.

Levels of Anxiety
Severe Very narrowed perception Unable to focus on problem solving Increased physical discomfort All behavior is aimed at relieving anxiety Direction is needed to focus attention y Panic Awe, dread and terror Unable to see the whole situation or reality Distortion of perception Disorganization of the personality A frightening and paralyzing experience
y

Interventions Inter ventions for Severe and Panic Levels of Anxiety
y y y y y y y y y

Maintain a calm manner. Remain with the person. Minimize environmental stimuli. Reinforce reality. Listen for themes in communication. Attend to physical safety and medical needs first. Physical limits may need to be set. Provide opportunities for exercising. Assess the person·s need for medication or seclusion.

ANTI ² ANXIETY DRUGS
VALIUM LIBRIUM ATIVAN SERAX TRANXENE MILTOWN EQUANIL VISTARIL ATARAX INDERAL XANAX BUSPAR

ANTI ² ANXIETY DRUGS
y y y y y y y y y

Used only in a short time (1-2 weeks) Tolerance (after 7 days) and dependence (after 1 month) Liver function test Monitor for side effects. Avoid machines, activities needing concentration Z tract if given parenterally Avoid mixing with alcohol, antihistamines, antipsychotics Don·t stop abruptly but gradually for 2-6 weeks Avoid caffeine

Categories of ANXIETY DISORDERS
Anxiety Disorders

Basic Anxiety Disorder

Somatoform

Categories of ANXIETY DISORDERS
Basic Anxiety Disorders y Somatoform Disorders y Dissociative Disorders
y

BASIC ANXIETY DISORDER

Basic anxiety disorders
y Generalized Anxiety

Disorder y Panic y Phobia y PTSD y Obsessive Compulsive

Chronic Anxiety Disorder or Generalized Anxietyanxiety for days but Disorder ` Excessive worry and
` `

not more than 6 months Difficulty in controlling the worry Anxiety and worry are evident by 3 or more of the following :
` Restlessness, Keyed up ` Fatigue and irritability ` Decreased ability to concentrate ` Muscle tension ` Disturbed sleep

`

Anxiety or worry causes significant impairment in interpersonal relationship or activities of daily living

Post Traumatic Stress Disorders

Post Traumatic Stress Disorders
y

y

Disturbing pattern of behavior occurring after a traumatic event that is outside the range of usual experience. Characteristics Persistent re-experiencing of the trauma through recurrent intrusive recollections of the event, through dreams or flashbacks Persistent avoidance of the stimuli Feeling of detachment of estrangement from others Chemical abuse to relieve anxiety

Phobias
`

Definition
` Persistent, irrational fear of a specific object, activity or situation that leads to a desire for avoidance or actual avoidance of the object of fear

`

Specific Phobia
` Experience of high level of anxiety or fear provided by a specific object or situation

` `

Treatment: Systematic Desensitization Defense mechanisms
` Repression and displacement

Major Types of Phobias
y

Anxiety about being in places or situation from which escape might be difficult (or embarassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic or panic like symptoms. Agoraphobic fears typically involve characteristics cluster of situations that include being outside the home alone: being in a crowd or standing in a line; being on a bridge; and traveling on a bus, train or automobile.

Major Types of Phobias
y

y

y

Agoraphobia Comes from the Greek word ´Agoraµ Meaning ´market placeµ Fear of being alone in open or public spaces Social Phobia Fear of situations where one might be seen and embarrassed or criticized Specific Phobias Fear of a single object, situation or activity that cannot be avoided

Obsessive Compulsive Disorder
Obsessions  Preoccupation with persistent intrusive thoughts, impulses or images Compulsions > Repetitive behaviors or mental acts that the person feelds driven to perform in order t reduce distress or prevent a dreaded event or situation Cues: y Ritualistic behavior y Constant doubting if he/she has performed the activity

Examples
Washing or cleaning

Obsessions
³Wash away my sins´. Thought appeared after sexual encounter with a married man ³Everything must be in place´.

Compulsions
Young woman repeatedly washes hands

Need for order

Arranges and rearranges items

Germs or dirt

³Everything is contaminated´

Avoids touching all objects. Scrubs hands if she is forced to touch any object Secretary lines up objects in rows on her desk, then realigns them repeatedly during the day

Symmetry

³Secretaries who practice neatness never gets fired¶

Care Strategies
y y

y y y y y

Be nonjudgmental and honest; offer empathy and support Help patient to recognize the connections between the trauma experience and their current feelings, behaviors and problems. Encourage verbalizations of feelings, especially anger. Encourage adaptive coping strategies and techniques Encourage patients to establish or reestablish relationships Explore shattered assumptions. ´I·m a good person. This is a safe worldµ. Promote discussion of possible meaning of the events.

SOMATOFORM DISORDERS

Somatoform Disorders
y Body

Dysmorphic Disorder y Somatization y Conversion Disorders y Hypochondriasis y Psychogenic pain

Body Dysmorphic Disorder
y

Preoccupation with an imagined defect in his or her appearance

Somatization
y

A client expresses emotional turmoil or conflict through a physical system, usually with a loss or alteration of physical functioning

Conversion Disordersan y A psychological condition in which
anxiety-provoking impulse is converted unconsciously into functional symptoms

Hypochondriasis
y

Presentation of unrealistic or exaggerated physical complaints

DISSOCIATIVE DISORDERS

Dissociative Disorders
y Dissociative

amnesia y Dissociative fugue y Depersonalization y Dissociative Identity Disorder / Multiple Identity Disorder

Dissociative amnesia
y

Characterized by the inability to recall an extensive amount of important personaal information because of physical or psychological trauma

Dissociative fugue
y

The person suddenly and unexpectedly leaves home or work and is unable to recall the past

Depersonalization
y

Person experiences a strange alteration in the perception or experience of the self, often associated with a sense of unreality

Dissociative Identity Disorder / Multiple Identity Disorder
y

A person is dominated by at least one of two or more definitive personalities at one time

PSYCHOSOMATIC DISORDER

Psychosomatic Disorder
True / unconscious because of hormonal and bodily changes - Increase anxiety may result to asthma, stress ulcers or migraine
-

SCHIZOPHRENIA
y

y y y

A major form of psychotic disorder that affects a person·s thinking, language, emotions, social behavior and ability to perceive reality At least 2 of 5 types of positive and negative symptoms Characteristic Symptoms Social or occupational dysfunction
IPR Self care

y

Duration
Continuous for at least 6 months

Positive and Negative Symptoms
y

Positive Symptoms Hallucinations Delusions Illusions Abnormal thought patterns or perceptions Bizarre behavior

Negative Symptoms
y

Negative Symptoms Affective flattening Anhedonia Attention impairment Asocial behavior Anergia Autism Avolition

SCHIZOPHRENIA
First described by Emil Kraeplin and Eugen Bleuler. y Previously known as dementia precox. y Schizophrenia is a combination of two Greek words ´schizienµ and phren ´mindµ ‡ Age of onset: Late teens or early twenties ‡ Strong genetic compoenent
y

DELUSIONS
PERSECUTORY y RELIGIOUS y GRANDEUR y IDEAS OF REFERENCE
y

DISTURBED THOUGHT PROCESSES
` ` ` ` ` ` ` ` ` ` `

Looseness of Association Flight of Ideas Ambivalence Magical Thinking Echolalia / Echopraxia Word salad Clang association Neologism Thought blocking Concrete association Delusion, hallucination, illusion

Bleuler·s Four A·s of Schizophrenia
Affective Disturbances y Autism y Associative looseness y Ambivalence y Other A·s
y

Attention defects Disturbances of activities

SCHIZOPHRENIA
`

`

` `

`

Brief Psychotic Disorder-maybe seen when a person exhibits clinical symptoms of illogical thinking, incoherent speech, delusions, or disorganized behavior after psychological trauma Induced Psychotic Disorder-develops in a second person as a result of a close relationship with a person who has psychosis Delusional Psychotic Disorder Schizoaffective disorder-characterized by depression or elation as the psychosis symptoms of schizophrenia and MDD Schizophreniform-when a person exhibits features of schizophrenia for more than one week but less than 6 months

Subtypes:
`

Paranoid-most common form of the illness Suspicious ` Promote trust ` Short interaction but frequent ` Food in containers (sealed) ` Prepare food in front of them ` Let them seed preparation of drugs Violent ` Keep door open ` Position near door and with distance of 1 arm length (patient-nurse) ` Don·t touch ` Maintain eye contact ` Call reinforcements

Subtypes:
y

Disorganized-absence of systematized delusions; presence of incoherence & inappropriate affect
Inappropriate, flat affect Herbephrenic, flight of ideas

y

Catatonic
Risk for suicide Catatonic stupor, rigidity Waxy flexibility

Subtypes:
y

Undifferentiated
unclassified

y

Residual
No more positive symptoms but withdrawn

NURSING PROCESS
Disturbed Thought Process y Disturbed Sensory Process y Risk for self-directed violence y Risk for other directed violence
y

Present safety y Present reality
y

ANTIANTI- PSYCHOTIC
y

Tara, look natin sina Stella, Mel, at Thor na nag mo-moulin rouge«. Sssh , alam nyo ba na ang trio na yan na akala mo may halo ay mga closet queens pala«, namenµ ( Taractan, Loxitane, Stelazine, Mellaril, Thorazine, Molindone, Seroquel, Serlect, Trilafon, Haloperidol, Clozapine, Navane )

SCHIZOPHRENIA
STELAZINE MILLARIL SERENTIL HALDOL THORAZINE LOXITANE TRILAFON RISPERDOL CLOZARIL PROLIXIN

ANTI ² PSYCHOTIC DRUGS
y

Watch for side-effects
Increase v/s Constipation / dry mouth Postural hypotension Photophobia / photosensitivity Drowsiness Agranulocytosis Extrapyramidal symptoms
x x x x x x Parkinson·s syndrome Akathisia Akinesia Dystonia ² oculogyric crisis, torticollosis, opistothonus Tardive dyskinesia NMS

UNDESIRABLE EFFECTS
S-edation/sunlight sensitivity/sleepiness y T-ardive dyskinesia y A-nticholinergic/aganulocytosis/akathisia y N-euroleptic malignant syndrome y C-cardiac effects(Orthostatic hypotension) y E-xtrapyramidal(dystonia
y

Parkinsonism
Motor retardation or akinesia characterized by mask-like appearance, rigidity, tremors, ´pill-rollingµ, salivation y Generally occurs after 1st week of treatment or before second month y Administer anticholinergic agent, antiparkinson medication (Akineton)
y

Akathisia
Constant state of movement, characterized by restlessness, difficulty sitting still, or strong urges to move about y Generally occurs two weeks after treatment begins y Rule out anxiety or agitation before administration of an anticholinergic agent
y

Acute Dystonic reactions
y

y

y

Irregular, involuntary spastic muscle movement, wryneck or torticollis, facial grimacing, abnormal eye movements, backward rolling of eyes in the sockets May occur anytime from a few minutes to several hours after first dose of antipsychotic drug Administer anticholinergic agent, have respiratory support equipment available

Tardive Dyskinesia
y

y y

Most frequent serious side effect resulting from termination of the drug, during reduction in dosage, or after long term high dose therapy. Characterized by involuntary rhytmic, stereotyped movements, tongue protrusion, cheek puffing, involuntary movements of extremities and trunk Occurs in approximately 20-25% of patients taking antipsychotics for over two years No treatment except discontinuation of the antipsychotic agent

Neuroleptic Malignant Syndrome
y y y

y y

y

A potentially fatal syndrome May occur anytime during therapy Seen during the initiation of therapy, change of therapy, After a dosage increase or when a combination of meds is used. Early sign: rigidity or mental status changes catatonia, tachycardia, tachypnea, labile blood pressure, dysphagia, diaphoresis, incontinence, rigidity, myoclonus, tremors, low grade fevers Discontinue antipsychotic agent. Have cardiopulmonary support available; administer skeletal muscle relaxant(e.g. dantrolene) or central acting dopamine agonist (e.g. bromocriptine)

NOTES on SCHIZOPHRENIA
` ` ` ` ` ` ` ` ` ` ` `

Distorted EGO Disturbed thought process Disorganized personality Dopamine ² increase Autism Ambivalence Associative looseness Affect ² flat Stimulation Structure Socialization Support

Manifestations:
S-social isolation C-catatonic behavior H-hallucinations I-Incoherence Z-zero/lack of interest and initiative O-obvious failure in development P-peculiar behavior H-hygiene and grooming impaired R-recurrent illusions E-exacerbations and remissions N-no organic factor account S/S I-inability to return to functioning A-affect is inappropriate

ANTIANTI-PARKINSONIAN DRUGS
y

Dopaminergic Drugs

To live (Levodopa), you need a car (carbidopa) and a man (Amantidine) not your brother (bromocriptine) per (pergolide) se (selegiline)
y

ANTI-CHOLENERGIC
BACPAK ( BENADRYL, ARTANE, COGENTIN, PARSIDOL, AKINETON, KEMADRIN)

Other Treatments
y

y

Psychotherapy-individual, group, behavioral, supportive or family therapy maybe used depending on the clinical symptoms Milieu therapy- a structured environment to minimize environmental and physical stress and to meet the individual needs of the patients until they are able to assume responsibility for themselves

Concepts & Principles of Hallucination
` ` ` ` ` ` `

Possible to replace hallucination with satisfying interactions Can re-learn to focus attention on real things and people Hallucinations originate during extreme emotional stress when the patient is unable to cope Hallucinations are very real to the patient Patient will react as the situation is perceived Concrete experiences, not argument on confrontation will correct sensory distortion Hallucinations are a substitute for human relations

MOOD DISORDER/ AFFECTIVE DISORDER

BIPOLAR DISORDER

Bipolar Disorders
A distinct period of abnormally and persistently elevated, expansive or irritable mood lasting at least 1 week ` 3 or more of the following ` Psychomotor overexcitability or excitement ` Insomnia with fatigue ` Euphoria or elated mood ` Distractability ` Pressured speech ` Flight of ideas ` Manipulative or demanding behavior ` Destructive or combative behavior ` Delusions of grandeur ` Impaired judgment
`

Bipolar Disorders

y

Risk
Female 20 years old and above Stressful life Obese Care giver role restrain

Mania Vs Depression
Mania Depression Colorful, flamboyant Sad and gray Psychomotor retardation Monotonous speech

Appearance Behavior

Psychomotor agitation Communication Pressured speech Stuttering Cluttering

Mania Vs Depression
Depression Nx Risk for injury (self) suicidal precaution Nursing priority Safety and nutrition Safety and Nutrition Nutrition Finger foods and Increased in high in calories nutrients Mania Risk for Injury (others) Treatment Lithium; ECT TCA; SSRI; MAOI¶s ECT

Mania Vs Depression
Mania Milieu Non-stimulating environment Appropriate Quiet type; nonactivity competitive Attitude therapy Matter of fact Depression Stimulating Monotonous; Non-competitive Kind firmness; active friendliness

LITHIUM
y y y y y y y y

Level of lithium (0.5 to 1.5 meq/L) Increase urination (polyuria) Tremors ² fine hand Hydration Increase peristalsis U2 ² 4 weeks effective Increased bowel movements Mouth is dry
Assess function of kidney Toxicity: nausea and vomiting, diarrhea

PHARMACOLOGY MOMENTS
ANTIDEPRESSANTS

ANTIDEPRESSANTS
ASENDIN NORPRAMIN TOFRANIL SINEQUAN ANAFRANIL AVENTIL VIVACTIL ELAVIL PROZAC LUVOX PAXIL ZOLOFT

ANTIDEPRESSANTS
y

SSRI
Selective Serotonin Reuptake Inhibitor Safest Side effects are low 1 to 4 weeks Prozac, Paxil, Zoloft, Luvox

ANTIDEPRESSANTS
y

TCA
Tricyclic Antidepressants 2 to 4 weeks Anticholinergic amitriptyline, nortiptyline, doxepin trimipramine, amoxapine, anafranil, venlafaxine

ANTIDEPRESSANTS
y

MAOI·s
Increases all neurotransmitters 2 to 6 weeks Hypertensive crisis Don·t take: x Avocado x Aged cheese x Beer/ B6 (tyramine) x Chocolate x Fermented foods x Soy sauce x Pickles and preserved foods

ANTIANTI- DEPRESSANT
y

A.TCA
(Sinequam, Elavil,Vivactil, Ascendin, Norpramin, Aventyl,Tofranil)
´ knock! Knock! Who·s there? SEVANA to gagah!µ--------

y

B. SSRI
Ngongo: ´Paxil ka! Paxil ka! Prozoleta ka lang, kala ko luv mo ko!µ (PRAXIL, PROZAC, ZOLOFT,

LUVOX)
y

C. MAO
´Naman, parnate ko paµ (NARDIL, MANERIX, PARNATE)

SUICIDE
The intentional act of killing oneself Suicidal Ideation- means thinking about oneself A.Passive suicidal ideation-when a person thinks about wanting to die or wishes he/she were dead but has no plans to cause his/her death (e.g. reckless driving, heavy smoking, overeating, self-mutilation, drug abuse) B. Active suicidal ideation-when a person thinks about and seeks to commit suicide.
y

SAD PERSON·S SCALE
y

y

y

S-Sex Men kill themselves 3x more than women though women make attempts 3x more often than men A-Age High risks groups:19 years or younger; 45 years or older, especially the elderly 65 and above D-Depression Studies report that 35-79% of those who attempt suicide manifested a depressive syndrome

` ` `

` ` `

`

P-Previous Attempts Of those who commit suicide, 65-70% have made previous attempts E-ETOH Alcohol is associated with up to 65% of successful suicides R-Rational Thinking Loss People with functional or organic psychoses are more apt to commit suicide than those in the general population S-Social Supports Lacking A suicidal person often lacks significant others, meaningful employment and religious supports O-Organized Plan The presence of a specific plan for suicide signifies a person at high risk N-No Spouse repeated studies indicate that persons who are widowed, separated, divorced or single at greater risk than those who are married S-Sickness Chronic, debilitating and severe illness is a risk factor

Scoring
0-2 Home with follow up care 3-4 Close follow up and possible hospitalization 5-6 Strongly consider hospitalization 7-10 Hospitalize

Situation:
Charles Brown, age 52 lost his wife in a car accident few months ago. Since that time, he has been severely depressed and has taken to drinking to numb the pain y How many points according to the SAD PERSONS SCALE?
y

Theories of SUICIDE
Psychodynamic theories y describe suicide as a wish to be at peace with the internalized significant person y Wish to be reunited with a deceased loved object y Suicide is an attempt to escape from an intolerable situation or intolerable state of mind
y

Theories of Suicide
` ` ` 1. 2.

3.

Sociological Theories Durkheim-pioneer of sociological research in the study of suicide 3 Principal types: Egotistic suicide-occurs when a person is insufficiently integrated into society Anomic suicide-occurs when a person is isolated from others through abrupt changes in social norms/status Altruistic suicide- occurs as a response to societal demands (deaths of Buddhist monks who set themselves on fire to protest the Vietnam war)

Theories of Suicide
Biochemical y Low serotonin levels
y

Precipitating factors
y

Social isolation-have difficulty forming and maintaining relationships Norman Cousins Story: a woman who committed suicide had written in her diary everyday during the week before her death ´Nobody called today. Nobody called today. Nobody called today. Nobody called today«µ

Precipitating factors
Severe life·s events-divorce, death, sickness, legal problems, interpersonal discord y Sensitivity to Loss-may react tragically to separation or loss of a loved one (had
y
insecure or unreliable childhood experiences)

ASSESSING VERBAL & NONVERBAL CLUES
y y

y

Verbal Clues: Overt Statements: ´I can·t take it anymore!µ; ´Life·s isn·t worth living anymore.µ; ´I wish I were dead.µ; ´Everyone will be better off if I am dead.µ Covert Statements: ´It·s ok now, soon everything will be fine,µ ´Things will never work out.µ ´I won·t be a problem much longer.µ ´Nothing feels good to me anymore.µ ´How can I give my body to medical science?µ

Nonverbal Clues
Behavioral Clues: sudden behavioral changes especially when depression is lifting and when the person has more energy available to carry out the plan y Signs: giving away prized possessions, writing farewell notes, making out a will and putting personal affairs in order
y

Nonverbal Clues
Somatic clues: physiological complaints can mask psychological pain and internalized stress y Headaches, muscle aches, trouble sleeping, irregular bowel habits, unusual appetite or weight loss
y

Nonverbal Clues
Emotional clues y Social withdrawal, feelings of hopelessness and helplessness, confusion, irritability and complaints of exhaustions
y

Suicide Precautions
y

y

y y y

Execute a ´no suicide contractµ. The client will inform the nurse when he/she has suicidal ideations Ask direct questions. Find out if the person has specific plan for suicide. Determine what method. Be alert for cries for suicide Provide a safe environment and protect client from self Encourage to ventilate feelings and thoughts

Suicide Precautions
` `

`

`

Give emotional support Make the patient realize that the tendency to commit suicide is due to the disturbance in the brain chemistry and is treatable-once they know that an episode of suicidal thinking will pass, they will likely not act on the impulse Provide structured schedule and involve in activities with others to increase self-worth and divert attention On discharge: help patient create ´plan for Lifeµ(list of warning signs of suicidal ideation and actions to take)

Suicide Precautions
y A.

B. C. D.

Always remember: That a suicidal person want to die only during the period of suicidal crisis-during this time the person is ambivalent about living and dying Suicidal people gives warning Persons recovering from depression are high risk for 9-15 months after recovery Suicidal people are extremely unhappy but not always mentally ill

Personality behaviors

SAD PERSON·S SCALE Personality problems y Schizoid y Dependent y Antisocial y Avoidant y Histrionic y Borderline

Paranoid Personality Disorder
y

A pervasive pattern of distrust and suspiciousness of others such that their motives are interpreted as malevolent Suspicious (e.g. others are exploiting or deceiving him) Doubt trustworthiness of others Fear of confiding in others Fear personal information will be used against him Interpret remarks as demeaning or threatening Hold grudges toward others Becomes angry and threatening when they perceive to be attacked by others

xIntervention: centered on building trust

Schizoid Personality Disorder
A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings Lacks desire for close relationships or friends including family Chooses to be alone Lack of sexual experiences Avoids activities Appears cold and detached
y

Interventions: building trust followed by identification and appropriate verbal expression

Schizotypal Personality Disorder Ideas of reference y A pervasive pattern of social
and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior
Magical thinking or odd beliefs Unusual perceptual experiences, including bodily illusions Peculiar thinking Vague, stereotypical, over elaborate speech Suspiciousness Blunted or inappropriate affect Eccentric appearance or behavior Few close relationships Uncomfortable in social situations

Interventions: Improving Interpersonal relationships, social skills., and appropriate behaviors

y

Characterized by deceit, manipulation, revenge and harm to others with an absence of guilt or anxiety
Violates rights of others Engages in illegal activities Aggressive behavior Lack of guilt or remorse Irresponsible in work and with finances Impulsiveness Recklessness Manipulative

Antisocial Personality Disorder
y

Interventions:

Consistency Kind firmness in confronting behaviors and enforcing rules and policies Limit setting Decrease impulsivity Enhance role performance Effective use of confrontation

Borderline Personality Disorder
y

Characterized by pervasive pattern of unstable interpersonal relationships; self-image and affect; and marked impulsivity
Frantic avoidance of abandonment; real or imagined Unstable and intense interpersonal relationships Identity disturbances Impulsivity Self-mutilating behavior Rapid mood shifts Chronic feelings of emptiness Problems with anger Transient dissociative and paranoid symptoms

Other important information
Priority nursing diagnosis: High risk for injury directed to self related to selfmutilation behaviors y Coping mechanisms used: Splitting
y

Classifying people as either ´goodµ or ´badµ

Interventions
y y y y

y y y

Use of empathy. Recognize the reality of the patient¶s pain. Offer support Empower and work with the patient to understand control and change dysfunctional behaviors. Provide safe environment Teach social skills Make a list of solitary activities to combat boredom

Narcissistic Personality Disorder
y y y y y y y y y

Ap

Grandiose self importance Fantasies of unlimited power, success or brilliance Believes he or she is special Needs to be admired Sense of entitlement Takes advantage of others for own benefit Lacks empathy Envious of others or others are envious of him Arrogant

need
y

Interventions Supportive confrontation on what the patient says and what exists. Limit setting and consistency to decrease manipulation and entitlement behaviors. Remain neutral, avoid power struggles, or becoming defensive.

Histrionic personalityofDisorderemotionality and y A pervasive pattern excessive
attentive seeking
Overly dramatic Draws attention to self Extroverted and thrives on being the center of attraction Uses somatic complaints to avoid responsibility and support dependency Dissociation y

Interventions: Positive reinforcement in the form of attention, recognition or praise are given for unselfish or other-centered behaviors

Dependent Personality Disorder
y

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation
Needs others to be responsible for important areas of life. Problems with initiating with projects or doing things on his own because of little self confidence Performs unpleasant tasks to obtain support from others Urgently seeks another relationship for support and care after a close relationship ends Preoccupied with fear of being alone to care for self
x Interventions: increase responsibility for self in day to day living; assertiveness training

Avoidant Personality Disorder
y

A pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation
Avoids occupations involving interpersonal contact due to fears of disapproval or rejection Preoccupied with being criticized or rejected in social situations Inhibited and feels inadequate in new interpersonal situations Very reluctant to take risks or engage in new activities due to the possibility of being embarrassed

Obsessive Compulsive Personality Disorder
A pervasive pattern of preoccupation with orderliness, perfectionism and mental and interpersonal control at the expense of flexibility, openness and efficiency
` ` ` ` ` ` Preoccupied with details, lists, rules, organization Perfectionist Too busy working to have friends or leisure activities Unable to discard worthless or worn-out objects Reluctant to spend and hoards money Rigid and stubborn

`

Delirium
y

Characterized by disturbance of consciousness and a change in cognition such as impaired attention span and disturbances in consciousness that develop over a short period of time.
Always secondary to another condition (medical condition or substance abuse) Frequent among the elderly and young febrile children Fluctuations of consciousness and inoculation through out the day

Classified as mild to severe. y Sundowning
y

Dementia
y

Characterized by multiple cognitive deficits thaty 4 Symptoms of Dementia include impairment of Loss of memory memory which develops Deterioration of language function slowly Loss of ability of think abstractly,
plan, initiate, sequence, monitor or 80-90% irreversible stop complex behavior Reversible due to pathologic Loss of ability to perform ADLs process Most common: Alzheimer·s Dementia

Stages of Dementia
y

Stage 2

Moderate (Confusion)

Progressive memory loss ST memory loss interferes with ADLs Withdrawn, Denial, Fear of Losing their minds Depression, Confabulation Problems increase when stressed Needs home care or in-home assitance

y

Stage 1

Mild (Forgetfulness)

Losses in short term memory Memory aids compensate Aware of the problem, disturbed Not diagnosable at this time

Stages of Dementia
`

Stage 3 Moderate to Severe (Ambulatory Dementia)
` Loss of reasoning ability, planning and verbal communication ` Frustrated, withdrawn, selfabsorbed ` Depression decreases ` Reduced stress threshold ` Institutional care required
`

Stage 3 Late (EndStage)
` ` ` ` ` ` ` ` ` Family recognition disappears Doesn·t recognize self Nonambulatory Little purposeful activity Often mute, may scream spontaneously Forgets most ADLs Problems associated with immobility Institutional care required Return of primitive reflexes

Delirium Vs Dementia
Onset Course Delirium Usually sudden Usually brief with return to usual level of functioning Dementia Usually gradual Usually long-term and progressive, occasionally maybe arrested or reversed elderly

Age group

any

Sexual Disorders
y y y y y y y y

Homosexuality Heterosexuality Bisexuality Masochism Sadism Frotteurism Pedophilia Necrophilia

y y y

Voyeurism Transvestism Transexualism

ALCOHOL

ALCOHOLISM
y y y y y y y y

Intergenerational Transmission Awake but unconscious Blackout Confabulation Denial, dependence Enabling, co-dependence Tolerance increases Detoxification - doctor

Stages of Alcohol Withdrawal
y y

I 8 hours after the last drink
Mild tremors, tachycardia, increased BP, diaphoresis, nervousness

2 8-12 hours after the last drink
Gross tremors, hyperactivity, profound confusion, loss of appetite, insomnia, weakness disorientation, illusions, hallucinations and delusions

y y

3 12-48 hours after the last drink
* severe hallucinations, grand mal seizures

4 3-4 days after the last drink
Delirium tremens, confusion, agitation, hallucinations, insomnia and tachycardia

ALCOHOLISM
y y y y y y

Avoid alcohol during therapy Aversion therapy Antabuse ² disulfiram Belongings ² check for alcohol, mouthwash, elixir etc. B1 deficiency Complication
Wernicke·s Encephalopathy (Motor) Korsakoff·s Pychosis (Mind)

y y

Deliruim Tremens Fornication

AUTISM
y y y y

Living in their own world Appearance ² flat (consistent) Behavior ² ritualistic, repetitive Communication ² echolalia, incomprehensible

NX: Impaired Verbal Communication Impaired Social Interaction Self Mutilation Risk for Injury

ADHD ` Attention-deficit / hyperactive disorder
` ` ` ` ` ` ` ` ` `

7 years old and above Duration: 6 months and above Requires 2 settings: home and school Appearance: Dirty child Behavior: Clumsy, hyperactive, impatient Communication: talkative, bursts out Structure Setting limits Schedule Safety

Eating Disorders
Anorexia Nervosa Bulimia Nervosa Pica Compulsive Eating Behavior

EATING DISORDERS

Anorexia Nervosa
Anorexia nervosa is a life threatening eating disorder characterized by the aforementioned symptoms. Symptoms: ` Refusal to maintain body weight over a minimum normal weight for age and height ` Intense fear of gaining weight or becoming fat, even though underweight ` Disturbance in the way in which one·s bodyweight, shape or size is experienced ` In females, absence of menses of at least 3 consecutive cycles ` Inability or refusal to acknowledge the seriousness of the problem ` Onset: 12-15, 17-21 years of age

Etiology
Cultural pressure y Serotonin imbalance controls appetite and the satiety control center y Family Patterns
y

Perfectionist Does not permit verbalization of feelings Marital problems

Clinical Presentation
Terrified of gaining weight y Pre-occupied with thoughts of food y See themselves as fat even when emaciated y Peculiar handling of food
y

Cutting food into small bits Pushing pieces of food around the table

May develop rigorous exercise program y Self-induced vomiting, laxatives and diuretics y Cognition so disturbed that they judge their selfworth by their weight.
y

Clinical Presentation
y y y y y y y

Low weight Amennorrhea Yellow skin Cold extremities Peripheral edema Muscle weakening Constipation

y y y y y y y

Low T3 and T4 Hypotension Bradycardia Hypokalemia Anemia Pancytopenia Decreased bone density

Signs related to Purging Behaviors
y

Gastrointestinal
Parotid gland tenderness, Pancreatitis, esophageal and gastric erosion or rupture

y y

Metabolic
Electrolyte abnormalities hypokalemia

Dental
Erosion of dental enamel of the front teeth

Objectives of care:
Increasing body weight to at least90% of average weight for age and height y Reestablishing good eating behavior y Increasing self esteem
y

Nursing Interventions:
Monitor daily caloric intake, activity level, weight and electrolyte status. ` Establish nutritional eating patterns
`

` Sit with client during meals ` Offer liquid protein supplement if unable to complete a meal ` Observe signs of purging 1-2 hours after meals

Provide accurate information on nutrition and discuss realistic and healthy diet ` Help the client identify emotions and develop non-food related strategies.
`

` Convey warmth and sincerity ` Ask the client to identify feelings ` Assist the client to change stereotypical beliefs

Nursing Interventions
y y y y

Assist in identifying at least three positive characteristics Teach patient about their illness Behavior modification : reward increase in weight with meaningful privileges Identify patient·s non weight related interests to reduce anxiety and refocus attention.

Bulimia Nervosa
Symptoms: y Recurrent episodes of binge eating y Feeling of lack of control over eating behaviors during the eating binges y Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self induced vomiting y Binge eating and inappropriate eating behaviors y Persistent over concern with body shape and weight

Clinical Presentation
y y y y

Binge and Purging behaviors Have depressive signs and symptoms Disturbed home life Major concerns
Interpersonal relationships Self-concept Impulsive behaviors

y

Chemical dependence is also common

Clinical Presentation
Normal to slightly low weight y Dental carries y Parotid swelling y Gastric swelling and rupture y Callusses or scars on the hand y Peripheral edema y Hypokalemia, Hyponatremia
y

Management:
y y y

y y y y

Trust Help patient identify feelings associated with binge-purge behaviors Accept patient as worthwhile human beings because they are often ashamed of their behavior Encourage patient to discuss positive qualities about themselves Teach about bulimia nervosa Encourage to explore interpersonal relationships Encourage patients to adhere to meal and snack schedules

Management:
Encourage the patient to approach the staff if she feels like binging or purging y Encourage to attend group sessions y Encourage family therapy y Encourage participation in art, recreation and occupational therapy y Encourage the patient to describe their body image at different ages of their lives.
y

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