Psychiatric Nursing

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

Criteria for Mental Health: ⊗ Self-awareness ♦ Ability to:  recognize one’s thoughts feelings, asset potentials and weakness.  experience genuine feelings as anger, happiness, resentment ♦ Leads to self-acceptance, self-understanding in order to understand others ⊗ Autonomy: ability to function independently and function with wi th others ⊗ Perceptive ability  Awareness of stimuli, reality orientation.  Orientation to: Time, Place, Person ⊗ Integral capacity: Ability to harmonize psychic forces (id, ego, super ego). ⊗ Self-actuation lif e changes, happy to work with others  Ability to adopt to life  Satisfaction in every endeavor  Genuine cooperation ⊗ Mastery of one’s environment: Awareness of the changes around him

MENTAL HYGIENE ⊗ A science that deals with: Promotive, Preventive, Curative, Rehabilitative aspects of care. MENTAL DISORDER ⊗ A medically diagnosable illness which results in significant impairment of one's cognitive, affective or relational abilities and is equivalent to mental illness. MENTAL ILLNESS ⊗ A state in which an individual shows deficit in functioning and is unable to maintain personal relationship. ⊗ A state of imbalance characterized by a disturbance in a person’s thoughts, feelings and behavior ⊗ Factors that increase the risk: Crises, Abuses, Poverty Pove rty

Psychiatric Nursing: Lecture Aid

© Lester R. L. Lintao

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

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

Main tool of the nurse: Therapeutic use of self Characteristics of a Good Psychiatric Nurse: ⊗ Empathy ⊗ Genuineness ⊗ Congruence ⊗ Unconditional positive regard

THE PSYCHIATRIC SETTING Admitting a Client in the Psychiatric Setting Areas to be assessed: ⊗ Health perception ⊗ Orientation ⊗ Metabolic pattern ⊗ Elimination pattern

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



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COMMON BEHAVIORAL SIGNS AND SYMPTOMS Disturbance in Perception ⊗ Illusion - misperception of an actual external stimuli ⊗ Hallucination - false sensory perception in the absence of external stimuli Management: ⊗ Acknowledge the feelings ⊗ Reorient to reality ⊗ Provide distractions

⊗ ⊗ ⊗ ⊗ ⊗ ⊗ ⊗ ⊗ ⊗ ⊗ ⊗

Neologism - pathological coining of new words Circumstantiality - excessive inclusion of details Word salad - incoherent mixture of words and phrases Flight of ideas - shifting of one topic from one subject to another in a somewhat related way Looseness of Association - shifting of a topic from one subject to another in a completely unrelated way Verbigeration - meaningless repetition of word or phrases Perseveration - persistence of a response to a previous question Echolalia - pathological repetition of words of others Stilted language – use of flowery words Clang association - the sound of the word gives direction to the flow of thought Delusion – fixed, false belief which cannot be corrected by appeal or logical reasoning  Grandeur - an exaggerated belief of identity  Nihilistic - the client denies the existence of self or part of self that he or she is the object of environmental  Persecution - belief that attention and being singled out for harassment h arassment  Self-depreciation - worthlessness or hopelessness  Somatic - false belief to body function

Disturbances of Affect ⊗ Inappropriate affect - disharmony between the stimuli and the emotional reaction ⊗ Blunted affect - severe reduction in emotional reaction ⊗ Flat affect - absence or near absence of emotional reaction ⊗ Apathy - dulled emotional tone ⊗ Lability of affect – rapid “mood swings”



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Disturbances in Motor Activity ⊗ Echopraxia - the pathological imitation of posture/action of others ⊗ Waxy flexibility - maintaining the desired position for long periods of time without discomfort ⊗ Akinesia - loss of movement ⊗ Bradykinesia - slowness of all voluntary movement including speech ⊗ Ataxia - loss of coordinated movement ⊗ Automatism - repeated purposeless behavior Disturbances in Memory ⊗ Confabulation - filling in of memory gaps ⊗ Amnesia - inability to recall past events • Anterograde - immediate past • Retrograde - distant past ⊗ Déjà vu - a subjective feeling that an experience which is occurring for the first time has been experienced before b efore ⊗ Jamais vu – a feeling that the familiar does not seem familiar ⊗ Dementia • gradual deterioration of intellectual functioning • results in decreased capacity to perform ADL Other behavioral signs & symptoms ⊗ Agitation – a state of anxiety associated with motor restlessness ⊗ Agnosia - inability to recognize and interpret sensory stimuli s timuli ⊗ Akathisia - a feeling of muscular quivering, an urge to move about constantly and an inability to sit still ⊗ Ambivalence - presence of two opposing feelings at the same time ⊗ Delirium - refers to acute change or disturbance in a person's: LOC, cognition, emotion , perception ⊗ Derealization - feeling of strangeness towards the environment ⊗ Dysthymia - persistent state of sadness ⊗ Elation (euphoria)- feeling of expression of excitement ⊗ Mutism – refusal to speak ⊗ Narcolepsy - sleep disorder characterized by frequent irresistible urge to sleep with episodes of cataplexy (sudden loss of muscle power) ⊗ Insomnia – inability to attain enough sleep ⊗ Hypersomnia – excessive sleep ⊗ Parasomnia – abnormal sleep behavior



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USE OF APPROPRIATE COMMUNICATION TECHNIQUES Communication: reciprocal exchange of ideas between or among persons Modes: ⊗ Verbal - written/spoken ⊗ Non-verbal - posture, tone of voice, facial expression Types of Non-verbal communication: ⊗ Kinesis • body movement • eye contact • gestures ⊗ Paralanguage • voice quality • non-language vocalization (crying, sobbing, moaning) ⊗ Proxemics – law of space relationship ⊗ Touch – physical act ⊗ Cultural artifacts ⊗ Meta communication • based on role expectations • hidden meaning of words

Elements: FEEDBACK

ge Messa

(Channel)

(Context)

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



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Barriers to Therapeutic Communication ⊗ Belittling ⊗ Interrupting / ignoring ⊗ Giving advice ⊗ Social response ⊗ Changing the subject ⊗ Approving / disapproving ⊗ Moralizing NURSE – PATIENT RELATIONSHIP

Hildegard Peplau Anxiety Tasks Phase Pre-Interaction Phase Nurse ⊗ Major task: develop self-awareness ⊗ begins when the ⊗ includes all of what the nurse thinks and does nurse is before interacting with the patient assigned/chooses a ⊗ data gathering, planning for first interaction patient ⊗ patient is excluded as an active participant Patient ⊗ Major task: establish trust and rapport Orientation phase ⊗ when the nurse⊗ conduct initial interview patient interacts ⊗ establish contract with the patient for the first time ⊗ learn about the patient and his initial concerns and needs ⊗ encourage the patient to feel comfortable with the meeting ⊗ manage present emotions of the patient ⊗ provide support and empathy of the patient’s feelings ⊗ assure confidentiality



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Anxiety Tasks Phase None ⊗ Major task: identification and resolution of the Working / Therapeutic Phase patient's problems ⊗ it is highly ⊗ planning and implementation individualized Teach ⊗ more structured Learn than the Change orientation phase ⊗ the longest and most productive Problems: phase ⊗ Transference ⊗ limit setting must  the development of an emotional be employed attitude towards the nurse  positive or negative ⊗ Counter transference – experienced by the nurse / therapist Patient ⊗ Reinforce and reward change and strength of Termination Phase patient ⊗ Encourage expression of feelings about termination of the relationship ⊗ Summarize the progress ⊗ Terminate the relationship without giving promises

THEORIES OF HUMAN DYNAMICS Psychosexual Development: Sigmund Freud Levels of Consciousness and the Psychic Forces



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Ego (Reality)

Superego (Moral)

Id (Pleasure)

Neurosis

Psychosis

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

Stages: Oral Stage (0-2 years) ⊗ The area of gratification is the mouth ⊗ Pleasures: sucking activities like fingers, toes or nipples ⊗ Dissatisfaction: resurface at a later age  overeating, smoking, nail-biting Nursing Implication: ⊗ Provide oral stimulation by giving pacifiers  Breastfeeding may provide more stimulation ⊗ Do not discourage thumb sucking

Anal Stage (2-4 years) ⊗ Children's attention is focused on the anal region. ⊗ Pleasure: elimination ⊗ Covers the ideal age for "toilet training" (2 1/2 years) ⊗ 2 concepts:  Holding on  Letting go



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Possible problems: ⊗ Compulsive need to be clean and orderly ⊗ Frugality and stinginess ⊗ Greed ⊗ Insistence on doing things at one's own rate at the expense of others ⊗ Rigid training ⊗ Excessive messiness and disorderly habits Nursing Implication: Help children achieve bowel and bladder control without undue emphasis on its importance.

Phallic Stage (4-6 years) ⊗ Pleasure: genital region  activities associated with stroking and manipulating their sex organs ⊗ Oedipus complex ⊗ Electra complex ⊗ Concept:  Onset of “normal homosexuality” Nursing implications: ⊗ Accept child's sexual interest ⊗ Help the parents answer child's questions about birth or sexual differences

Latency Stage (6 to 12 years) ⊗ Period of calmness / stable period. ⊗ Many of the disturbing behaviors are buried in the subconscious mind ⊗ Their energies are absorbed by the concerns in school, peers, sports and other recreational activities Nursing Implication: Help the child have positive experiences

Genital Stage (12 years & up) ⊗ Oedipal feelings are reactivated toward opposite sex ⊗ The person is on his/her way in establishing a satisfying life of his/her own Nursing Implication: ⊗ Provide appropriate opportunities for the child to relate with opposite sex ⊗ Allow child to verbalize feelings about new relationships



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Psychosocial Development Theory: Erik Erikson Childhood is very important in personality development. ⊗ Rejected Freud's attempt to describe personality solely on the basis of sexuality  believed that social factors greatly affect  felt that personality continued to develop beyond five years of age. ⊗

Period of Life Infant 0-18 months (Hope) Trust vs. Mistrust Toddler 18 mos. to 3 years (Willpower)

Primary Person Maternal person

Positive Resolution o

o

Paternal person

o o

o

Autonomy vs. Shame/Doubt Preschool 3 to 6 years (Purpose)

Family

Initiative vs. Guilt Schooler Neighbors/ 6 to 12 yrs. School (Competence) Industry vs. Inferiority Adolescent 12 to 18 yrs, (Fidelity)

o

o

o

o

Peer group

o

Negative Resolution

Reliance on the caregiver Development of trust in the environment

Sense of self-worth Assertion of choice and will Environment encourages independence, leading to sense of pride The ability to learn to initiate activities, to enjoy achievement and competence

Learning the value of work Acquiring skills and tools of technology Competence helps to order life and make things work Experiments with various roles in developing mature individuality

o

o

o o

o

o

o

o

Fear, anxiety and suspicion Lack of care, both physical & psychological by caretaker leads to mistrust of environment Loss of self-esteem Sense of external control may produce self-doubt in others

The inability to control newly developed power Realization of potential failure leads to fear of punishment and guilt Repeated frustrations and failures lead to feelings of inadequacy and inferiority that may affect their view of life

Pressures and demands may lead to confusion about self

Identity vs. Role confusion Psychiatric Nursing: Lecture Aid


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Period of Primary Life Person Young Adult Partners 18 to 24 yrs. in (Love) friendship Intimacy vs. Isolation Middle Adult 24 to 54 yrs. (Care) Generativity vs. Selfabsorption Late Adult, 54 yrs. to death, (Wisdom)

Partner

Positive Resolution o

o

o

o

Mankind

o

o

o

Integrity vs. Despair

A commitment to others Close heterosexual relationship and procreation The care and concern for the next generation Widening interest in work and ideas

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

Negative Resolution o

o

o

Withdrawal from such intimacy, isolation, selfabsorption and alienation from others

Self-indulgence and resulting psychological impoverishment

Disappointment of one’s life and desperate fear of death

Cognitive Development Theory: Jean Piaget Stages: Sensorimotor (0-2 years) ⊗ Reflex to complex ⊗ Begins to organize visual images and control motor responses ⊗ Coordinates sensory impressions ⊗ Pre-verbal stage Preoperational Stage (2-7 years) ⊗ Transitional period ⊗ Egocentric and irreversible thinking ⊗ Words become symbols for objects – symbolic thinking ⊗ Formation of ideas of categorization ⊗ Lack of ability to go back and rethink a process or concept. ⊗ Mental image – the symbolic process which are evident in plays ⊗ Construction of verbal schemas – preconcepts Psychiatric Nursing: Lecture Aid


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Concrete Operations (7 – 11 years) ⊗ Thinking appears to be stabilized o ability to think of the possible consequences of actions ⊗ Logical implications Formal Operations (11 years to adulthood) ⊗ Full patterns of thinking ⊗ Ability to use logic and symbolic processes o mathematical and scientific reasoning ⊗ Combinatorial thinking - multidimensional approach o hypothetic or hypothetico-deductive reasoning

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

Stage 1 • Behavior is based on the desire to avoid severe physical punishment by a superior power. • Right or wrong is based on consequences to him. • Punishment = wrong act

Stage 2 • Actions are based largely on satisfying one’s own personal needs. Stage 3 • Good behavior is that which pleases others and judgments are based on intentions. Children conform to rules to win the approval of others and to maintain good relationships. Stage 4 • What is right is what is accepted. •



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

Stage 5 • Behavior recognizes the laws as arbitrary and changeable. • For aspects of life not governed by laws, right and wrong are personal decisions based on agreement and contracts. Stage 6 • Morality is based on respect for others rather than on personal desires. • The individual conforms to both social standards and to internalized ideals to avoid selfcondemnation rather than to avoid social censure.

Other Theories Behavioral Model (Ivan Pavlov, John Watson, B. F. Skinner) ⊗ Behavior is: • a response to a stimulus from the environment • learned and retained by positive reinforcement Interpersonal Model (Harry Stack Sullivan) ⊗ Focused on the role of the environment and interpersonal relations as the most significant influences on a individual’s development ⊗ Anxiety is communicated interpersonally Human Motivational Need Model. (Abraham Maslow) ⊗ Hierarchy of needs in order of importance ⊗ Primary needs (physiologic) need to be met prior to dealing with higher level needs Psychobiologic Model ⊗ Focus is in mental illness as a biophysical impairment. ⊗ Human behavior is influenced by genetics, biochemical alterations and function of brain and CNS. ⊗ The stress response is a neuroendocrine response

PSYCHOTHERAPY ⊗

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



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INDIVIDUAL THERAPY: Is a confidential relationship between client and therapist. ⊗ Hypnotherapy: Involves various methods and techniques to induce a trance state where the patient becomes submissive to instructions ⊗ Humor therapy: Use of humor to facilitate expression of feelings and to enhance interaction ⊗ Psychoanalysis: Focuses on the exploration of the unconscious, to facilitate identification of the patient's defenses

GROUP THERAPY • minimum number : 3 • Ideal number :8-10 Advantages: • decreases o isolation o dependence • develops o coping skills o interpersonal learning o opportunities for helping others o ability to listen to other members ⊗

Remotivation Therapy: Promotes expression of feeling through interaction facilitated by discussion of neutral topics

⊗

Family therapy: A method in which family members gain: o insight into the problems o improve communication o improve functioning of individual members as well as the family as a whole. o It focuses on the total family as an interactional system

⊗

Milieu Therapy • A therapeutic environment is organized to: o encourage and assist the client to control problematic behavior o function within the range of social norms

⊗

Play therapy • Effective for children suffering from maladjustment or behavior disorder. • The child is usually placed in a play room • Purpose - to discover the causes of the child's conflict through observation of his play and to interpret it to the child. Psychiatric Nursing: Lecture Aid


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⊗

Recreational therapy • Uses activities which vitalize the patient's interest and help him / her to relax and feel refreshed. • Example: Playing baseball may be prescribed for as a means of expressing hostility in a group.

⊗

Occupational therapy: Uses any mental or physical activity prescribed or guided to aid an individual's recovery from a disease or injury.

⊗

Musical therapy • Involves music which allows the child or adolescent to express herself or himself. • Also effective with those who have difficulty communicating.

⊗

Art therapy: Clients are encouraged to express their feelings or emotions by painting, drawing or sculpture.

⊗

Psychodrama therapy: Patients dramatizes their emotional problems in a group setting.

BEHAVIOR MODIFICATION THERAPY • A mode of treatment that focuses on modifying observable (overt) and quantifiable behavior • Systematic manipulation of the environment and variables thought to be functionally related to the behaviors. Limit Setting o Therapist gives an advanced warning of the limit and the consequences will follow if the client does not adhere to the limit. o The consequences should occur immediately after the client has exceeded the limit o Consistency must occur with all personnel. o Purposes: o Minimizes manipulation and splitting of the staff. o Provides a framework for the client to function in and enable a client to learn to make requests. • Systematic Desensitization o Clients are exposed slowly to a feared object or a thing that inhibits anxious responses and taught ways to relax. o Effective in treating phobias. •



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•

•

•

•

• •

Implosive therapy o The clients are exposed abruptly to intense forms of anxiety producers, either in imagination or in real life Cognitive Behavior therapy o Uses confrontation as a means of helping the clients restructure or rearrange irrational beliefs, maladaptive thinking, perception-, and behaviors. o Used for depression and adjustment difficulties. Biofeedback o Teaches the clients to control or change aspects of their internal environment. Aversion therapy o Uses unpleasant or noxious stimuli to change inappropriate behavior. o Examples o Antabuse to treat alcoholics Assertiveness Training o Clients are encouraged and taught how to appropriately relate to others Token-economy: Utilizes the principle of rewarding desired behavior to facilitate change.

ELECTROCONVULSIVE THERAPY (ECT) • Exact mechanism is unknown • Requires a consent Voltage : Length : Frequency : Interval : Indicator :

70-150 volts .5-2 seconds 6-12 treatments 48 hours tonic-clonic seizure

Indications of use: • Depression • Mania Contraindications: • Fever • Increased ICP • Cardiac conditions • TB with history of hemorrhage


•

Catatonic schizophrenia

Unhealed fracture • Retinal detachment • Pregnancy • Osteoporosis •


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Before the procedure: • Take vital signs • Diagnostic procedures o X-ray o ECG o EEG • Drugs given o Atropine sulfate (decrease secretions) o Anectine (Succinylcholine) (relax muscles) o Methohexital Na (Brevital) (anesthetic) During the procedure: • Observe for tonic-clonic seizure • Priority: Airway After the procedure: • Position • Check vital signs • Reorient the client • Watch out for complications: o Memory loss o Headache o Apnea o Respiratory depression o Fracture

BASIC CONCEPTS ON PSYCHOPHARMACOLOGY MAJOR TRANQUILIZERS/ ANTIPSYCHOTICS ⊗ Indication: Schizophrenia and Other Psychosis ⊗ Desired effect: control of symptoms ⊗ Best taken after meals ⊗ MOA: Block selected dopamine receptors  decrease dopamine  reduce symptoms Types Examples

• • •

Disadvantages

• •

Typical Haloperidol Mellaril Thorazine EPS Treats (+) symptoms only


Atypical • • •

• • •

Risperdal Seroquel Clozaril Expensive Less available More agranulocytosis


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Advantages

Cheaper Less or no EPS More available For both (-) & (+) symptoms Before 1990’s After 1990’s •

•

•

•

Side effects Blurred vision Dry mouth Tachycardia, palpitation, constipation, urinary retention Side effects Photosensitivity Orthostatic hypotension Extra Pyramidal Symptoms o Pseudoparkinsonism o pill-rolling tremors mask-like face o cog-wheel rigidity o propulsive gait o Akathisia - restless leg syndrome o Dystonia - defect in muscle tone

Nursing Action Avoid driving Give sugarless gum Monitor & report Nursing Action Don’t expose skin to sunlight Monitor BP Advise gradual change in position Discontinue the next dose Report at once Give antidote: Anticholinergics Akineton Artane Benadryl Cogentin Dopaminergics: L- Dopa Espequel Sporadel Nursing Action Withhold the next dose Notify the physician Cooling measures • • • •

• •

Side effects Neuroleptic Malignant Syndrome (NMS) Muscle rigidity + high grade fever •

Adverse effect: report promptly • Tardive dyskinesia - lip smacking • Agranulocytosis o Assess for:  Fever  Sore throat  Lab data: WBC count • Hepatotoxicity o Assess for ALT & AST



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MINOR TRANQUILIZERS/ ANXIOLYTICS ⊗ Common indication: Anxiety disorders ⊗ Desired Effect: Decreased anxiety, adequate sleep ⊗ Have sedative effects Examples: (XL VASET) Xanax (Alprazolam) Librium (Chlordiazepoxide ) Valium (Diazepam) Ativan (Lorazepam) Serax (Oxazepam) Esquanile Tranxene (Chlorazepate Dipotassium) Nursing Implications: • Best taken before meals • Advise to avoid driving • Administer it separately with any drug Anxiolytics + Alcohol = severe hypotension / hypersedation Another anxiolytic = respiratory depression  death Other drugs = CNS depression Stimulants = less effective • • • •

ANTIDEPRESSANTS Desired effects: increased appetite, adequate sleep Tricyclic Antidepressants Examples: • Imipramine (Tofranil)

•

Amitriptyline (Elavil)

Nursing Implications: ⊗ Best given after meals ⊗ Effectivity: after 2-3 weeks ⊗ Check the BP, it causes hypotension ⊗ Check the heart rate, it causes cardiac arrythmias ⊗ Monitor I & O ⊗ Monitor for signs of increased IOP



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MAO INHIBITORS Indication: refractory depression Examples: • Tranylcypromine (Parnate) • Phenelzine (Nardil) • Isocarboxazid (Marplan)

PaNaMa

Nursing Implications: ⊗ Best taken after meals ⊗ Report headache; it indicates hypertensive crisis ⊗ Avoid tyramine containing foods like: • Avocado • Banana • Cheddar and aged cheese • Soysauce • Preserved foods ⊗ Effectivity: 2-3 weeks ⊗ Monitor the BP ⊗ There should be at least a two-week interval when shifting from one antidepressant to another

Selective Serotonin Reuptake Inhibitors • Fluoxetine (Prozac) • Paroxetine (Paxil) • Celatopram (Celexa) • Fluvoxamine (Luvox) • Sertraline (Zoloft) Nursing Implications: ⊗ Avoid the use of: • Diazepam • Tryptophan • Alcohol ⊗ Monitor PTT, PT ⊗ Never give to pregnant / lactating mothers.

ANTI-MANIC AGENT Examples: • Lithium Citrate (Cibalith – S)

•

Lithium Carbonate (Eskalith, Lithane, Lithobid)



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Nursing implications: ⊗ Never give to pregnant mothers ⊗ Best taken after meals ⊗ Increase intake of: • fluids (3 L /day) • sodium (3 gm/day) ⊗ Avoid activities that increase perspiration ⊗ Effectivity: 10-14 days ⊗ Antipsychotic is administered during the first 2 weeks Level (mEq/L) Status .5 – 1.5 Therapeutic

1.6

S/Sx

Abnormal

Vomiting Anorexia Nausea Diarrhea Abdominal cramps 2.0 and above Fatally toxic Lethargy (Altered LOC) 1.7 – 1.9

Toxic

Nursing Interventions Monitor Increase sodium & fluid intake D/C next dose Report *IV NSS D/C next dose Report *MANNITOL (antidote)

D/C next dose Report *Dialysis

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

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



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Types of Adaptation: General Adaptation Syndrome (GAS) • Involves the whole body in response to stress. • Compared to life process as it focuses on the “wear and tear of the body tissues.” Phases: • Alarm o Acute phase of the syndrome o Characterized as the “flight and fight” reaction o Defensive by nature but self-limiting o If stress is intense, it may lead to death • Resistance o Characterized as the state of adaptation o Person moves back to homeostasis • Exhaustion o Result of a prolonged exposure to stress and adaptive mechanisms can no longer persist. Local Adaptation Syndrome • Refers to inflammatory response and repair processes that occur at the local site of tissue injury. Eustress - positive stress Distress - negative stress and damaging stress CRISIS AND CRISIS INTERVENTION • A situation that occurs when an individual's habitual coping ability becomes ineffective to meet the demands of a situation. • A serious interruption and disturbance of one's equilibrium or homeostasis • Leads to potentially dangerous, self-destructive or socially unacceptable behavior. Characteristics • Highly-individualized • Self-limiting: 4-6 weeks • Person affected becomes passive and submissive • Affects a person’s support system



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Type Maturational / Developmental

Situational / Accidental

Description expected, predictable and internally motivated Unexpected, unpredictable and externally motivated

Social / Adventitious Due to acts of nature

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

Natural calamities

Phases DENIAL

INCREASED TENSION

DISORGANIZATION

REORGANIZATION

FULL REORGANIZATION

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

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



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Kinds of Rape • Power – to prove masculinity • Anger – means of retaliation • Sadistic – to express erotic feelings Silent Rape Syndrome • A maladaptive reaction to rape • The victim: o fails to disclose information about the rape o is unable to resolve feelings about the sexual assault o Results to increase anxiety and may develop a sudden phobic reaction. Rape Trauma Syndrome (RTS) • Refers to a group of signs and symptoms experienced by a victim in reaction to rape Phases: • Acute / Impact – shock, numbness, disbelief • Repression / Denial – refusal to discuss the event • Heightened Anxiety – fear, tension, nightmares • Stage of Resolution

BATTERED WIFE SYNDROME (BWS) • A form of cyclic domestic violence • Men: low self-esteem • Women: Dependent personality disorder

(taken from the book of Shiela Videbeck)

Characteristics of Abusive Husbands: • They usually come from violent families • They are immature, dependent and non-assertive • They have strong feelings of inadequacy



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CHILD ABUSE • An act of omission of responsibility or commission in which intentional harm is inflicted on a child. Components of Omission: • Child abandonment – leaving the child physically • Child neglect - lack of provision of those things which are necessary for the child's growth and development Types of Commission:

Physical Abuse - is an intentional physical harm inflicted on a child by a parent or other person. Emotional abuse - insult and undermining one's confidence Sexual abuse - in the form of sexual contact

Characteristics of Abusive Parents: • They come from violent families • They were also abused by their parents • They have inadequate parenting skills • They are socially isolated because they don't trust anyone • They are emotionally immature • They have negative attitude towards the management of the abused Warning signs of Child Abuse / Neglect: • Child’s excessive knowledge on sex and abusive words • Hair growth in various lengths • Inconsistent stories from the child and parent/s • Low self-esteem • Depression • • • • •

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

Assessment, Planning and Nursing Actions for Crisis • Primary concerns: o Physical injuries o Alleviation of psychological trauma Psychiatric Nursing: Lecture Aid


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Nurse should display: o Sensitivity o Attitude (Nonjudgmental) o Confidentiality o Respect o Empathy o Dignity • Evidences are important: o stained clothing o fingernail scrapings o mouth or anal smears containing semen • Intervention focuses on family as a unit • If the victim is a child: Play and art therapy •

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

Common Defense Mechanisms Used: •

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

•

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

•

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



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•

Displacement o The redirection of feelings to a less threatening object o After an argument with his father, a boy goes to the room and kicked his door.

•

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

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Fixation o An unhealthy mechanism which is an arrest of maturation at certain stages of development

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

•

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

•

Intellectualization o An overuse of intellectual concepts by an individual to avoid expression of feelings o A man who was asked to share a memorable experience about his grandmother who died discussed the stages of death and dying by Elizabeth Kubler Ross.

•

Projection o Attributing to others one's unconscious wishes/fears o Literally, this means to "throw off” or to blame others o A student who failed a subject blames his failure on poor teaching.

•

Reaction – Formation (AKA overcompensation) o Expression of feeling that is the direct opposite of one's real feeling. o A student who dislikes one of her classmates may act or show concern toward her. Psychiatric Nursing: Lecture Aid


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•

Rationalization o An individual finds a justifiable cause and acceptable reasons just to be saved from an embarrassing and anxiety producing thoughts or situations.

•

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

•

Repression o The involuntary or unconscious forgetting of unpleasant ideas or impulses.

•

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

•

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

•

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

•

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

•

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



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ANXIETY ⊗ Subjective response to stress ⊗ Vague sense of impending doom ⊗ An unpleasant emotional state consisting of psychophysiological responses to anticipation of unreal or imagined danger, resulting from unrecognized intrapsychic conflict. Signs and symptoms: Physical Mild ⊗ Increase in VS ⊗ Pupillary dilatation ⊗ Diaphoresis Physical Moderate ⊗ Anorexia ⊗ Nausea ⊗ Vomiting ⊗ Agitation ⊗ Diarrhea / constipation Severe ⊗ Headache ⊗ Inability to communicate ⊗ Physical symptoms becomes the focus of attention Panic ⊗ Fatigue ⊗ Muscular weakness

Cognitive Emotional ⊗ Increased ⊗ Minimal use of defense attentiveness and mechanism alertness Cognitive ⊗ Decreased perceptive ability

Emotional ⊗ Use of defense mechanism

Perceptive ability is greatly decreased ⊗ Inability to focus on major events

⊗

Defense mechanisms operate

Personality disorganization

⊗

Defense mechanism fail

⊗

⊗

Nursing Diagnoses: ⊗ Ineffective individual coping ⊗ Anxiety Nursing Management: ⊗ Prioritize safety ⊗ Encourage the client to verbalize feelings ⊗ Administer medications, as ordered ⊗ Carefully listen to the client ⊗ Environmental stimuli must be controlled Psychiatric Nursing: Lecture Aid


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ANXIETY DISORDERS Panic Disorder ⊗ A sudden surge of overwhelming anxiety and fear ⊗ May include terror, sense of unreality or fear of loosing control ⊗ Attack: 1 minute to 1 hour Phobic Disorder ⊗ Phobia is an irrational, unrealistic or exaggerated fear of a specific object, activity, or situation that in reality presents little or no danger. Examples: ⊗ Acrophobia – heights ⊗ Agoraphobia - open places and of being alone in public places ⊗ Algophobia – pain ⊗ Arachnophobia - spiders (arachnoids) ⊗ Claustrophobia - enclosed place ⊗ Monophobia - being alone ⊗ Pathophobia – disease ⊗ Social phobia - criticism, humiliation or embarrassment. ⊗ Thanatophobia - crowds

Generalized Anxiety Disorder (GAD) ⊗ Involves anxiety and worry that is excessive and unrelenting. ⊗ May alter ADL ⊗ Clients may experience: fatigue, irritability, restlessness, muscle tension, sleep disturbance Obsessive Compulsive Disorder ⊗ An anxiety disorder characterized by uncontrollable, unwanted thoughts and repetitive, ritualized behaviors. Post-Traumatic Stress Disorder (PTSD) ⊗ A delayed reaction of the person who has been involved or exposed to traumatic events. ⊗ Symptoms:  intense psychological distress  feeling of detachment or estrangement from others  insomnia  decreased concentration  avoidance of thoughts and feelings  recurrent distressing dreams  inability to recall an important aspect of the trauma Psychiatric Nursing: Lecture Aid


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Nursing Interventions ⊗ Modify environment – safe ⊗ Approach: kind-firmness ⊗ Nonjudgmental and calm attitude ⊗ Allow agreeable time for rituals ⊗ Give medications as ordered ⊗ Execute therapeutic modalities - biofeedback, change of the scenery, therapeutic touch, hypnosis, massage or relaxation exercises ⊗ Desensitization ANXIETY RELATED DISORDERS Somatoform Disorders (Briquet’s Syndrome) ⊗ Characterized by physical symptoms that mimic disease or injury for which there is no identifiable physical cause ⊗ Clients:  express emotional turmoil or conflict through physical symptoms  usually seek repeated medical attention ⊗ Associated with anxiety and depression Somatization Disorder (Briquet’s Disease) ⊗ A disorder applied to patients who chronically and persistently complain of varied physical symptoms that have no identifiable physical origin Conversion Disorder ⊗ A condition in which an anxiety-provoking impulse is converted unconsciously into functional symptoms. ⊗ Classic feature: Labelle indifference (lack of concern or distress) ⊗ Examples: Paralysis, blindness, loss of touch or pain sensation, dyspnea, seizures or convulsions Hypochondriasis ⊗ An individual presents an unrealistic or exaggerated physical complaints. ⊗ The person becomes, preoccupied with the fear of developing or having already a disease or illness in spite of medical reassurance. Body Dysmorphic Disorder ⊗ Preoccupation with an imagined defect in his or her appearance. ⊗ Slight physical abnormality = excessive concern / anxiety



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Dissociative Disorders ⊗ Conditions that involve disruptions or breakdowns of memory, awareness, identity and/or perception Dissociative Amnesia ⊗ Inability to recall extensive amount of important information ⊗ Caused by trauma ⊗ Characterized by:  Disorientation  Purposeless wandering  Impairment in ability to perform ADL ⊗ Rapid recovery generally occur Depersonalization Disorder ⊗ Periods of detachment from self or surrounding which may be experienced as "unreal" while retaining awareness that this is only a feeling and not a reality Dissociative Identity Disorder ⊗ Occurrence of two or more personalities within the same individual, each of which during sometime in the person's life is able to take control. Nursing Interventions: ⊗ Professional attention ⊗ Education of family ⊗ Resolution of primary cause ⊗ Supportive therapies ⊗ Offer support and empathy ⊗ Nonjudgmental attitude ⊗ Administer medications, as ordered ⊗ Listen attentively

PERSONALITY DISORDERS ⊗ Pervasive and inflexible patterns of functioning that is stable overtime, and leads to distress or impairment. ⊗ 10% to 13% of the general population Types of Personality Disorders:

Eccentric Personality Disorder (Type A) ⊗ Paranoid (Suspicious and distrustful)  Persons who display pervasive and long stand suspiciousness  More common in men Psychiatric Nursing: Lecture Aid


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Schizoid (Socially distant and detached)  Pattern of detachment from social relationship  Chooses solitary activities  Topics are inanimate objects and ideas ⊗ Schizotypal (Odd and eccentric)  “mild schizophrenia”  Acute discomfort in close relationships  Cognitive or perceptual distortion ⊗

Dramatic-Erratic Personality Disorder (Type B) ⊗ Antisocial (aggressive and manipulative)  Pattern of disregard for the violation of the rights of others  Low self-esteem ⊗ Borderline (destructive and unstable)  Characterized by patterns of instability in relationships, self image and mood  Self-mutilating behavior  More common in women ⊗ Histrionic (emotional and dramatic)  Excessive emotionally and attention-seeking behaviors that are dramatic and egocentric  Exaggerated expression of emotion  Overreaction to minor events ⊗ Narcissistic (boastful / superiority complex)  Grandiosity and need for constant admiration  Exploitation of others for fulfillment of own desire Anxious or Fearful Personality Disorder (Type C) ⊗ Avoidant (inferiority complex)  Social inhibition  Feelings of inadequacy and sensitivity  Low self-esteem  Social withdrawal in spite of a desire for affection and acceptance ⊗ Dependent (submissive)  Submissive clinging behavior related to excessive need to be cared for by others  Lack of self-confidence  Perceive self as helpless and stupid ⊗ Obsessive-Compulsive (perfectionist)  Preoccupied with orderliness, perfectionism, inflexibility, need to be in control  Formal and serious interpersonal relationship  Judgmental of self and others



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⊗

Passive-Aggressive  Intentional inefficiency  Passive resistance to demands for adequate performance in both occupational and social functioning

Nursing Diagnosis: • Ineffective individual coping • Self-esteem disturbance Nursing Care: Avoid client attempts to manipulate Set limits and boundaries Consistency is essential Clear communication Deal with frustration Specific treatment of symptoms •

– –

• • •

DISORDERS COMMONLY DIAGNOSED TO CHILDREN AUTISM ⊗ Characterized by:  impairment in communication skills  presence of stereotyped behavior, interests and activities. ⊗ Associated with impairment on social interactions ⊗ Treatable but not curable ⊗ More common among boys ⊗ Usually diagnosed at age 2 ⊗ Main problem: Interpersonal functioning ⊗ Most acceptable cause: Biological factors - brain anoxia, intake of drugs Signs and Symptoms ⊗ Odd play ⊗ Not cuddly ⊗ Echolalia ⊗ ⊗ ⊗ ⊗ ⊗

Crying tantrums Head towards anything Inanimate object attachment Loves to spin objects / self Difficulty interacting with others

⊗ ⊗ ⊗ ⊗ ⊗ ⊗ ⊗


Wants blocks Acts as deaf Resists normal teaching method / routine changes No fear of danger Insensitive to pain No eye contact Giggling or silly laughing


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Nursing Interventions ⊗ Environment:  safe  consistent ⊗ Encourage the client to participate for self-care ⊗ Promote communication  Speak calmly when giving instructions  Use simple words or phrases  Repeat instructions as necessary. ⊗ Haloperidol - symptomatic relief for hyperactivity, stereotypical and selfdestructive behavior

MENTAL RETARDATION ⊗ Not a mental illness. ⊗ Onset: 18 ⊗ IQ below 70 ⊗ Manifested by sub-average intellectual functioning in:  Communication  Social skills  Self-care  Health and safety  Home living Causes ⊗ HIV/ AIDS / rubella ⊗ Neurological / neurodevelopmental infection impairment ⊗ Alcoholic mother ⊗ Exact gestational age is not reached (premature) ⊗ Thyroid deficiency ⊗ Excessive lead poisoning ⊗ Opiate intoxication ⊗ Nutritional deficiency (lack in Folic Acid) ⊗ Damage to the brain ⊗ Anoxia ⊗ Toxemia (pregnancy-induced hypertension) ⊗ Environmental factors ⊗ Severe RH incompatibility Levels Mild/moron

IQ 51-70

o o

Moderate/Imbecile 36-50

o o

Severe/Idiot

20-35

o o o

Profound

Below 20

o o

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



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Principles of Nursing Care ⊗ Protective care ⊗ Education of the family  Their involvement is an important factor in the plan of care to promote progress and to minimize the stress. ⊗ Repetition ⊗ Role modeling ⊗ Restructuring ⊗ Focus of Education  Reading  Arithmetic  Writing ATTENTION DEFICIT HYPERACTIVITY DISORDER ⊗ Common in boys ⊗ Usually diagnosed before age 7 ⊗ Problems:  Inattention  Hyperactivity  Impulsivity Causes: ⊗ Abuse of the child ⊗ Drug exposure ⊗ Hypoperfusion (brain) ⊗ Developmental problems  Neurologic impairment  Pre-natal trauma  Early malnutrition Signs and Symptoms ⊗ Obstinacy ⊗ Negativism ⊗ Egocentrism

⊗ ⊗ ⊗ ⊗

Fighting syndrome ⊗ Aggressiveness ⊗ Tolerance is low ⊗

⊗ ⊗ ⊗

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

Nursing Diagnosis - Potential for injury



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Nursing interventions: ⊗ Provide nutrition and safety ⊗ Provide an environment that:  is calm  is structured  enables appropriate reaction to the environmental stimuli ⊗ Plan a firm and consistent care in which limits and standards are set. ⊗ Parent education ⊗ Pharmacology: Methylphenidate (Ritalin) Dexedrine Cyclert • • •

DISORDERS COMMONLY DIAGNOSED TO ADOLESCENTS AND ADULTS EATING DISORDERS ⊗ More common among females. Causes: ⊗ Psychological factors  Parental factors (domineering parents)  Individual factors (conflict about growing up)  Sociocultural factors Anorexia Nervosa ⊗ Main sign: Morbid fear of gaining weight ⊗ Other signs:  Sensitivity to cold temperatures  Denial of hunger  Amenorrhea  Obvious thinness but feels fat  Deliberate self-starvation with  Lanugo all over the body weight loss  Loss of scalp hair Bulimia Nervosa ⊗ Extreme measures to lose weight  uses diet pills, diuretics or laxatives  purges after eating  extreme exercise ⊗ Signs of purging  swelling of the cheeks or jaw area  cuts and calluses on the back of the hands and knuckles (Russel’s sign)  teeth that look clear



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⊗

Peculiar signs  depression  loss of interest in activities

Findings: (for both) ⊗ Weight loss of 15% or more of original body weight ⊗ Amenorrhea ⊗ Social withdrawal and poor family and individual coping ⊗ History of high activity and achievement in academics, athletics ⊗ Electrolyte imbalance ⊗ Depression / distorted body image Nursing Diagnosis: ⊗ Body image disturbance ⊗ Ineffective individual coping Nursing Interventions: ⊗ Reinforce treatment plans and dietary prescriptions ⊗ Establish a trusting relationship ⊗ Monitor weight and vital signs ⊗ Encourage client to express feelings ⊗ Decrease emphasis on foods, eating, weight ⊗ Involve in decision-making ⊗ Employ limit setting ⊗ Stay with the client after meal and for 1st four hours

SUBSTANCE-RELATED DISORDERS Alcoholism ⊗ A chronic disease or a disorder characterized by excessive alcohol intake and interference in the individual’s health, interpersonal relationship and economic functioning. (WHO) ⊗ Considered to be present when there is .1% or 10 ml for every 1000 ml of blood Signs of use: ⊗ .1-.2% - low coordination ⊗ .2-.3% - presence of ataxia, tremors, irritability, stupor ⊗ .3 and above - unconsciousness



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Progression: ⊗ Pre-alcoholic  starts with social drinking  tolerance begins to develop ⊗ Prodromal  alcohol becomes a need  blackouts occur  denial starts ⊗ Crucial - cardinal symptoms of alcoholism develops ⊗ Chronic - the person becomes intoxicated all day Outcome: ⊗ Brain damage ⊗ Alcoholic hallucinosis ⊗ Death Behavioral problems: ⊗ Denial ⊗ Dependency ⊗ Demanding

Destructive ⊗ Domineering ⊗

Alcohol Withdrawal ⊗ Occurs when an individual abruptly stops drinking ⊗ Symptoms develop within few hours ⊗ Symptoms include:  Careless behavior  Autonomic hyperactivity  Unusual perceptions (illusions, hallucinations)  Tachycardia (impending delirium tremens)  Increased temperature  Obvious hand tremors  Nightmares and insomnia Alcohol Withdrawal Delirium ⊗ AKA delirium tremens ⊗ Experienced within 48 to 72 hours after the last intake: ⊗ Symptoms include  Diaphoresis  Elevated VS  Agitation  Tremors (seizures)  Hyperexcitability to depression Psychiatric Nursing: Lecture Aid


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Chronic Problems: Korsakoff's Psychosis ⊗ A form of amnesia ⊗ Characterized by  short-term memory loss  disorientation  inability to learn new skills  confabulation ⊗ Deficiency in B1 and B12. Wernicke's Encephalopathy ⊗ An inflammatory hemorrhagic degenerative condition of the brain ⊗ caused by B1 deficiency ⊗ Symptoms include:  double vision  involuntary and rapid eye movements  lack of muscular coordination  decreased mental function Nursing Diagnosis: Ineffective individual coping Principles of Nursing Care: ⊗ Monitor vital signs ⊗ Well-lighted room ⊗ Diet as tolerated  Administration of glucose  Vitamins Alcohol Detoxification: ⊗ Drug of Choice: Disulfiram (Antabuse) - delays the metabolism of alcohol ⊗ Avoid alcohol-containing products ⊗ 3 S’s of detoxification:  Safety  Sedation  Supplementation (Vitamin B complex, Vitamin C)



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DRUG-RELATED DISORDERS Cocaine-Related Disorders (Stimulants) ⊗ Cocaine is a white powdered stimulant substance ⊗ Usually sniffed, snorted, smoked in a pipe or injected into a vein or subcutaneous tissue. ⊗ Poor man’s cocaine:  Shabu (sha-boo) ⊗ Signs of use:  Cocaine psychosis  Obvious dilation of the pupils  Cardiac problems  Agitation  Insomnia  No appetite  Excessive sweating  Severe to panic anxiety ⊗ Classic sign: Perforated nasal septum ⊗ Can cause a sudden heart attack even in healthy young people.

Cannabis-Related Disorders (Cannabinoids) Marijuana ⊗ Can act as stimulant or depressant and is often considered to be a mild hallucinogen with some sedative properties ⊗ Is not physically addicting but may lead to psychological dependence ⊗ Plant : cannabis sativa ⊗ Active component is Tetrahydocannabinol ⊗ Routes of use:  Orally (capsules, tablets, on sugar cubes)  With food  Smoked in a pipe or rolled as cigarette. ⊗ Acts within 15 minutes ⊗ Effects lasts approximately 2 to 4 hours ⊗ Physiologic symptoms include  Increased appetite  Hypothermia  Nausea and vomiting  Excitement  Drowsiness Movement problems (reduced coordination)   Inability to think clearly  Problems on judgment  Ataxia  Non-steady gait



41

⊗

Classic sign: bloodshot eyes

⊗

In large doses, it may cause:  Hallucination  Suicidal ideations  Delusions of invulnerability

Long-term Goals: ⊗ Community resources ⊗ Other coping means aside from denial ⊗ Personal responsibility (behavioral contract) ⊗ Isolation ⊗ Nutrition ⊗ Group therapy

SEXUAL DISORDERS ⊗ Sexuality - is the result of biologic, psychological, social and experimental factors that mold an individual's sexual development, self-concept, body image and behavior. Phases of the Sexual Response Cycle ⊗ Desire - the ability, interest and willingness to receive sexual stimulation ⊗ Excitement / Arousal  Result of psychological stimulation  Example is fantasizing during the desire phase and foreplay which involves petting and fondling of erogenous zones or areas of the body that are particularly sensitive to erotic stimulation. ⊗ Plateau – “intense moments” ⊗ Orgasm  formerly termed as climax  the shortest stage in the sexual response cycle  occurs when stimulation proceeds through the plateau stage to a point where the body suddenly discharges accumulated sexual tension ⊗ Resolution  the final phase of sexual response  organs and body systems gradually return to the unaroused state Sexual Dysfunction Disorders ⊗ Sexual Desire Disorders: Individuals who have little or no sexual desire or have an aversion to sexual contact.



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Sexual Arousal Disorder: Individuals cannot complete the physiologic requirements for sexual intercourse Examples  Women cannot maintain lubrication  Men cannot maintain an erection ⊗ Orgasm Disorders: Inability to achieve orgasm phase Example: Premature ejaculation ⊗ Sexual Pain Disorders: Individuals suffer genital pain (dyspareunias) Example: Vaginismus ⊗

Paraphilia (Sexual Deviation) ⊗ A term which generally refers to abnormal sexual behavior ⊗ Lasts for 6 months leading to distress or impairment to functioning. Examples: Anilingus Bestiality or Zoophilia Coprophilia Cunnillingus Exhibitionism Fellatio Fetishism Frotteurism

Masochism Necrophilia Partialism Pedophilia Sadism Telephone Scatalogia (AKA sex on phone) Transvestism Urophilia Voyeurism

tongue brushing the anus contact with animals smearing feces on the partner tongue brushing the vulva Involves exposing one’s genitals to unsuspecting strangers (usually women or children) inserting the penis into the mouth inanimate / non-living objects or articles  Touching or rubbing against the unsuspecting people.  Usually occurs in crowded places where escape is into the crowd is possible. Sexual gratification from experiencing pain Involves the use of corpses Inserting the penis into the other parts of the body Use of prepubertal children (13 years of age or younger) in an actual sexual act or a fantasy Sexual gratification from inflicting pain Involves telephoning someone and making lewd, obscene remarks or conversation. Sexual excitement through wearing the clothing of a woman urinating on the partner Act of observing unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity Includes cyber-voyeurism



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

SCHIZOPHRENIA AND OTHER PSYCHOSES SCHIZOPHRENIA ⊗ A serious psychiatric disorder ⊗ One of the most profound disabling illnesses ⊗ Not a single disease entity but a combination of disorders ⊗ "split mind" ⊗ Characterized by: • impaired communication • loss of contact into reality • deterioration from a previous level of functioning ⊗ Nursing Diagnosis: Altered thought process ⊗ Theories • Biological • Neuroanatomic and neurochemical • Immunovirological Manifestations: Eugen Bleuler ⊗ Associative looseness ⊗ Autism ⊗ Affective disturbance ⊗ Ambivalence



44

Positive symptoms: ⊗ Ambivalence ⊗ Associative Looseness ⊗ Delusions ⊗ Echopraxia Negative symptoms: ⊗ Alogia ⊗ Anhedonia ⊗ Apathy ⊗ Avolition

Types Disorganized Prognosis: Poor Defense Mechanism: Regression Paranoid Prognosis: Good Defense Mechanism: Projection

Flight of ideasHallucinations ⊗ Ideas of reference ⊗ Perseveration ⊗

Blunted affect ⊗ Catatonia ⊗ Flat affect ⊗

Distinguishing features Peculiar / bizarre behavior Incoherence Stereotyping

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

Hallucinations Ideas of reference Delusion of persecution Suspiciousness

⊗ ⊗ ⊗ ⊗ ⊗ ⊗

Catatonic Prognosis: Good Defense Mechanism: Repression

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

⊗ ⊗ ⊗

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

Undifferentiated • Patients whose manifestation cannot be easily fitted into one or the other type Residual • Patients with minimal symptoms



45

Nursing Intervention Principles: ⊗ Establish:  a trusting relationship and provide acceptance  a clear, consistent and open communication ⊗ Set limits ⊗ Decrease environmental stimuli ⊗ Observe for suicidal ideation ⊗ Administer medications, as ordered. PSYCHOSES RELATED TO SCHIZOPHRENIA Schizophreniform Disorder

⊗ ⊗

Schizoaffective Disorder Delusional Disorder

⊗ ⊗ ⊗

Brief Psychotic Disorder

⊗ ⊗

Shared Psychotic ⊗ Disorder ( folie a deux)

Client presents symptoms of schizophrenia for less than 6 moths ADL may not be altered Client presents symptoms of psychosis and all features of a mood disorder (depression / mania) Client has 1 or more bizarre delusions ADL not impaired Client experiences sudden onset of at least 1 psychotic symptom Lasts from 1 day to 1 month 2 people share a similar delusion

MOOD DISORDERS Theories: Biological Neurochemical

Mania ⊗ Hereditary ⊗ High norepinephrine and serotonin levels

Neuroendocrine Psyhoanalytic

⊗

Defense mechanism against depression


Depression ⊗ Hereditary ⊗ Low norepinephrine and serotonin levels ⊗ Elevated glucocorticoid ⊗ Elevated TSH ⊗ Rigid superego


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Common Types of Mood Disorders Major Depressive Disorder ⊗ Lasts at least 2 weeks which impairs ADL ⊗ Characterized by depressed mood / loss of pleasure in most activities Clinical Symptoms of Major Depressive Episode ⊗ Affect is flat ⊗ Loss of memory ⊗ Obvious sleep disturbances ⊗ Sad feelings / Social withdrawal ⊗ Emotional blunting ⊗ Reduced appetite

Mania – abnormally and persistently elevated mood lasting for 1 week Clinical Symptoms of Manic Episode ⊗ Agitation ⊗ Flight of ideas ⊗ Increased activity ⊗ Grandiosity ⊗ High emotions ⊗ Talkative or pressured to keep talking ⊗ Easy distractibility ⊗ Reduced need for help

Bipolar Disorder ⊗ A person’s mood cycles between mania and depression for 1 week ⊗ Bipolar I Disorder  one or more of symptoms of manic episode  accompanied by major depressive episode ⊗ Bipolar II Disorder  one or more symptoms of major depressive episode with hypomania Related disorders: ⊗ Dysthymic Disorder  Lesser severe than major depression  No symptoms such as impaired communication, delusions and hallucinations ⊗ Cyclothymic Disorder ⊗ DNOS (Depression Not Otherwise Specified) - lasts for 2 days-2 weeks



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Appearance DM Attitude therapies Activity

Priority NDx Nursing Management

Mania Elated Projection Matter of fact

Depression Sad Introjection Kind firmness

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

Monotonous

Risk for injury: self-directed Group therapy Antidepressants ECT

SUICIDE ⊗ thought or act of taking one’s own life ⊗ ultimate form of self-destruction ⊗ "cry for help“ ⊗ reunion wish or fantasy ⊗ progressive failure to adapt feelings of anger or hostility ⊗ a way to end feelings of hopelessness and helplessness ⊗ an attempt "to save face" or seek a release to a better life Risk Factors ⊗ Sex (more female attempts suicide but more male commits suicide) ⊗ Use of drugs / alcohol ⊗ Identification with a dead family member ⊗ Chronic Illness (e.g. Cancer) ⊗ Irrational thinking ⊗ Depression/Dependent personality ⊗ Age (18-25 and 40) ⊗ Lethality of previous attempt/Losses Nursing Diagnosis: Risk for injury-Self directed Nursing care: ⊗ Safe environment ⊗ Always take overt or covert threats or attempts seriously ⊗ Ventilation of feelings ⊗ Encourage activities ⊗ Monitor closely (one-on-one, 24/7) ⊗ Empathy (show acceptance & appreciation) Psychiatric Nursing: Lecture Aid


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CONDITION COMMONLY DIAGNOSED IN THE ELDERLY Alzheimer’s Disease ⊗ A chronic, progressive degenerative cognitive disorder. ⊗ Marked by Dementia ⊗ Main Pathology: presence of senile plaques - destroys neurons (decreased acethylcholline) Signs and Symptoms: ⊗ Dementia ⊗ Cognitive disturbances o Aphasia – deterioration of language function o Apraxia – impaired motor function o Agnosia – inability to recognize objects / people ⊗ Executive functioning - loss of abstract thinking 3 PHASES: ⊗ Forgetfulness - difficulty of remembering appointments ⊗ Advance - difficulty of remembering past events but not recent events ⊗ Terminal - death occurs in 1 year Nursing Diagnosis: Altered thought processes Nursing Care: ⊗ Priority: safety & security ⊗ Always reorient the client (clock & calendar) ⊗ Use color instead of numbers & letters ⊗ Consistency – 1 nurse to lessen confusion DEATH AND DYING DEATH/D YING: Elizabeth Kubler-Ross Stages: Denial - "NO NOT ME" Anger - "WHY ME" Bargaining - "IF ONLY" Depression - Stage of silence Acceptance - "YES, IT'S ME" Nursing Diagnosis: Ineffective individual coping



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Psychiatric Nursing

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