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ANTHONY E.

ESTOLAS, RN
– A state of emotional, psychological and social
wellness evidenced by satisfying interpersonal
relationships, effective behavior and coping,
positive self-concept and emotional
stability.(Videbeck)
– Lifelong process of successful adaptation to a
changing internal and external environments.
– A clinically significant behavioral or psychological
syndrome or pattern that occurs in an individual
and that is associated with present distress,
increased risk of suffering, death, disability and
loss of freedom. (Videbeck)
– Loss of ability to respond to environment in ways
that are in accord with oneself and society.
• Accepts himself
• Perceives reality
• Mastery of self and environment
• Autonomy
• Unifying, integrated outlook in life
Theoretical Foundations
• Mental health-Psychiatric treatment
integrates concepts and strategies from
theories.
• Theoretical Models are used as guides for
treatments
• These theories attempt to explain human
behavior, health and mental illness
Theoretical Foundations
• Theoretical frameworks
– allow the systematic organization of knowledge
– guide data collection
– provide explanations for assessed behaviors
– guide care plan development
– provides rationales for interventions and
– determine evaluation criteria
– Guide research by providing assumptions to be
tested.
Theoretical Foundations
Psychosexual- Sigmund FREUD
Psychoanalytical Theory
Psychosocial Theory Erik ERIKSON

Cognitive Theory Jean PIAGET

Interpersonal Theory Harry Stack Sullivan

Moral Theory KOHLBERG

Spiritual Theory FOWLER


Theoretical Foundations
Behavioral Theories Pavlov and Skinner

Humanistic Theories Maslow and Carl Rogers

Psychobiology theory Neuroanatomy and


physiology
Theories of Personality development
• Freud’s Psychoanalytic theory
• Erikson’s Psychosocial theory
• Sullivan’s interpersonal theory
• Piaget’s Cognitive theory
• Fowler’s Spiritual theory
• Kohlberg’s Moral theory
Psychosexual/Psychoanalytical
• This theory supports the notion that EVERY
human behavior is caused and can be
explained

• Freud believes that “repressed” sexual urges,


desires, impulses or drives motivated much
human behavior
Psychosexual/Psychoanalytical
Components of Personality
1. ID- part of a person that reflects BASIC or
innate DESIRES, INSTINCT and SURVIVAL
impulses
2. EGO- represents the REALITY aspect
3. SUPER-EGO- part that reflects MORALITY
and ethical concepts, and values
Psychosexual/Psychoanalytical
Personality Stages and Functional Awareness
1. Conscious – perceptions, thoughts and
emotion that exist in the person’s
awareness
2. Pre-conscious/Subconscious- Thoughts and
emotions not currently in awareness but
can be recalled with effort
3. Unconscious- thoughts, drives and
emotions totally a person is Unaware
Psychosexual/Psychoanalytical

According to this theory, much of our


behavior is motivated by our
SUBCONSCIOUS thoughts or
feelings
Psychosexual/Psychoanalytical
Five Stages of psychosexual development
1. Oral
2. Anal
3. Phallic or Oedipal
4. Latency
5. Genital
Psychosexual/Psychoanalytical
Phase Age Focus

Oral 0-18 months Site of gratification: Mouth

Anal 1 ½ - 3 years Site of gratification: Anus

Phallic 3- 5 years Site of gratification: Genitals

Latency 6- 12 years Site of gratification: (School Activities)

Genital 12 & above Site of gratification: Genitals


Psychosexual/Psychoanalytical
Phase Age Focus

Oral 0-18 months Major task: Weaning

Anal 1 ½ - 3 years Major task: Toilet training

Phallic 3- 5 years Major task: Oedipal & Electra complex

Latency 6- 12 years Major task : School activities

Genital 12 & above Major task: Sexual intimacy


Psychosexual model (Freud)
1. Oral
a. 0-18 months
b. Pleasure and gratification through mouth
c. Behaviors: dependency, eating, crying, biting
d. Distinguishes between self and mother
e. Develops body image, aggressive drives
Psychosexual model (Freud)
2. Anal
a. 18 months - 3 years
b. Pleasure through elimination or retention of
feces
c. Behaviors: control of holding on or letting go
d. Develops concept of power, punishment,
ambivalence, concern with cleanliness or
being dirty.
Psychosexual model (Freud)
3. Phallic/Oedipal
a. 3 - 6 years
b. Pleasure through genitals
c. Behaviors: touching of genitals, erotic
attachment to parent of opposite sex
d. Develops fear of punishment by parent of same
sex, guilt, sexual identity
Psychosexual model (Freud)
4. Latency
a. 6 - 12 years
b. Energy used to gain new skills in social
relationships and knowledge
c. Behaviors: sense of industry and mastery
d. Learns control over aggressive, destructive
impulses
e Acquires friends
Psychosexual model (Freud)
5. Genital
a. 12 - 20 years
b. Sexual pleasure through genitals
c. Behaviors: becomes independent of parents,
responsible for self
d. Develops sexual identity, ability to love and
work
Psychosexual/Psychoanalytical
Transference and Counter-transference
• TRANSFERENCE is the clients feeling toward
nurse arising from unconscious experiences
with early significant others
• COUNTER TRANSFERENCE is the nurse’s
feelings toward the patient arising also form
previous experiences
Psychosexual/Psychoanalytical
The Freudian View of Mental Illness
• All behavior has meaning
• Mental illness and manifestations are caused
by unconscious INTERNAL conflict arising
from unresolved issues in early childhood
• Ego defenses are utilized to relieve inner
tension
Psychosocial Theory
• Theory that focuses on developmental task,
focuses on EGO as this develops from social
interaction
• The developmental tasks are sequential and
depend on prior successful mastery
• An individual who fails to “master” the task
at appropriate age may return to work on
mastery
Psychosocial Theory
Use of the theory in Nursing
• Assessment can be done focusing on the
psychosocial development at specific age
• Appropriate interventions can be selected
based on task
• Nurses can promote healthy behaviors and
encourages hope that re-learning is possible
Erikson’s Psychosocial theory
• Trust versus mistrust
• Autonomy versus shame and doubt
• Initiative versus guilt
• Industry versus inferiority
• Identity versus role confusion
• Intimacy versus isolation
• Generativity versus stagnation
• Ego integrity versus despair
Psychosocial Model (Erikson)
1. Trust vs mistrust
a. 0 - 18 months
b. Learn to trust others and self vs withdrawal,
estrangement
2. Autonomy vs shame and doubt
a. 18 months - 3 years
b. Learn self-control and the degree to which
one has control over the environment vs
compulsive compliance or defiance
Psychosocial Model (Erikson)
3. Initiative vs guilt
a. 3 - 5 years
b. Learn to influence environment, evaluate own
behavior vs fear of doing wrong, lack of self-
confidence, over restricting actions
4. Industry vs inferiority
a. 6 - 12 years
b. Creative; develop sense of competency vs
sense of inadequacy
Psychosocial Model (Erikson)
5. Identity vs role confusion
a. 12 - 20 years
b. Develop sense of self; preparation, planning
for adult roles vs doubts relating to sexual
identity, occupational career
6. Intimacy vs isolation
a. 18 - 25 years
b. Develop intimate relationship with another;
commitment to career vs avoidance of
choices in relationships, work, or life-style
Psychosocial Model (Erikson)
7. Generativity vs stagnation
a. 21 - 45 years
b. Productive; use of energies to guide next
generation vs lack of interests, concern with
own needs
8. Integrity vs despair
a. 45 years to end of life
b. Relationships extended, belief that own life
has been worthwhile vs lack of meaning of
one’s life, fear of death
Interpersonal theory
• This concept focuses on interaction between
an individual and his environment
• Personality is shaped through “interaction”
with significant others
• We internalize approval or disapproval form
our parents
Interpersonal theory
Personality has three SELF-SYSTEM
1. “Good Me” develops in response to
behaviors receiving approval by parents/SO
2. “Bad Me” develops in response to behaviors
receiving disapproval by parents/SO
3. “Not Me” develops in response to behaviors
generating extreme anxiety in parents/SO
and this is denied as part of oneself
Interpersonal theory
Mental Health is Viewed as:
1. Related to conflict or problematic
interpersonal relationships
2. Past relationships, inappropriate
communication and current relationship
crisis are etiologic factors of mental illness
Interpersonal theory
Treatment of Mental illness:
• Focuses on anxiety and its causes
• Therapeutic relationship with client that is
active and participative
• Feelings and emotions are verbalized by the
clients to modify problematic relationships
Interpersonal theory
Usefulness in Nursing
• Nurse and client can participate in and
contribute to the relationship that is
therapeutic
• This relationship can be used as a corrective
interpersonal experience
• Anxiety management
Interpersonal Model (Sullivan)
1. Infancy
a. 0 - 18 months
b. Others will satisfy needs
2. Childhood
a. 18 months - 6 years
b. Learn to delay need gratification
3. Juvenile
a. 6 - 9 years
b. Learn to relate to peers
Interpersonal Model (Sullivan)
4. Preadolescence
a. 9—12 years
b. Learn to relate to friends of same sex
5. Early adolescence
a. 12—14 years
b. Learn independence and how to relate to
opposite sex
6. Late adolescence
a. 14—21 years
b. Develop intimate relationship with person of
opposite sex
Cognitive Theory
• This theory focuses on the inborn
development of thinking ability from infancy
to adulthood
• A person is born with a tendency to organize
and to adapt to their environment
• Mental illness is not directly discussed
Cognitive Theory
Usefulness of Cognitive theory in Nursing
1. This provides an understanding how an
individual think and communicate. Nurse
can provide intervention accordingly
2. Nursing interventions should be congruent
to the age-specific cognitive level
3. Teaching strategies are modified according
to cognitive process
Piaget
• Sensori-motor (birth to 2 )
• Pre-operational (2-7)
– Preoperational preconceptual (2-4)
– Preoperational intuitive (4-7)
• Concrete operational (7-12)
• Formal operational (12 to adulthood)
Cognitive Theory (Piaget)
A. 0 - 2 years: sensorimotor
-reflexes, repetition of acts
B. 2 - 4 years: preoperational/preconceptual
-no cause and effect reasoning;
egocentrism; use of symbols; magical
thinking
C. 4 - 7 years: intuitive/preoperational
-beginning of causation
Cognitive Theory (Piaget)
D. 7 - 11 years: concrete operations
- uses memory to learn
- aware of reversibility
E. 11 - 15 years: formal operations
-reality, abstract thought
-can deal with the past, present and future
Behavioral Theory
• This concept describes a person’s function in
terms of identified BEHAVIORS
• People learn to be who they are
• Behavior can be observed, described and
recorded
• Behavior is subject to reward or punishment
• Behavior can be modified by changing
environment
Behavioral Theory
• The Classical Conditioning by Pavlov
– Learning can occur when a stimulus is paired
with an unconditioned response
– Conditioned responses happens when stimulus is
present
– Acquisition – gain of learned response
– Extinction – loss of learned response
Behavioral Theory
• The Operant Conditioning by Skinner
– Rewards and punishments are utilized
– Positive reinforcement- rewards
– Negative reinforcement-
– Positive punishment
– Negative punishment- withdrawing reward
Behavioral Theory
Mental Illness is viewed as:
• Mal-adaptive BEHAVIORS are learned
through classical and operant conditioning
• Mal-adaptive behaviors can be changed by
altering environment
Behavioral Theory
Application to Nursing
1. The nurse assess both adaptive and ,al-
adaptive behaviors
2. The nurse and client collaborate in
identifying behaviors that need to change
3. Behavioral modification techniques are
utilized by the nurse in the treatment of
mental illness
Humanistic theory
• Human nature is positive and growth
centered and existence involves search for
meaning and truth
• Maslow’s theory of Needs are organized in a
hierarchy
Humanistic theory
Mental illness in this framework
1. The failure to develop one’s FULL potential
leads to poor coping
2. Lack of self awareness and unmet needs
interfere with feelings of security
3. Fundamental human anxiety is fear of
death which leads to existential anxiety
Humanistic theory
Application of the theory to Nursing
1. NCR is based on positive regard, respect
and empathy
2. Nurses assess the spiritual aspects of the
client including religion, love and
relationships
3. Through reflective listening and emphatic
responses, the nurse helps the client gain
self-understanding
KOHLBERG’S STAGES OF
MORAL DEVELOPMENT
PRECONVENTIONAL LEVEL
• Stage 1 Age 2-3
• Description:
– Punishment or obedience (heteronomous
morality)
– A child does the right things because a
parent tells him or her to avoid
punishment
PRECONVENTIONAL LEVEL
• Stage 2 Age : 4-7
• Description:
– Individualism
– Child carries out actions to satisfy own
needs rather than society’s. The child does
something for another if that person does
something for him in return
CONVENTIONAL LEVEL level 2
• Stage 3 Age : 7-10
• Description:
– Orientation to interpersonal relations of
mutuality
– A child follows rules because of a need to
be a good person in own eyes and in the
eyes of others
CONVENTIONAL LEVEL level 2
• Stage 4 Age : 10-12
• Description:
– Maintenance of social order, fixed rules
and authority
– Child follows rules of authority figures as
well as parents to keep the system working
POSTCONVENTIONAL LEVEL level 3

• Stage 5 Age :older than 12


• Description:
– social contract, utilitarian law making
perspective
– child follows standards of society for the
good of all people
POSTCONVENTIONAL LEVEL level 3

• Stage 6 Age :older than 12


• Descriptions:
– universal ethical principle orientation
– child follows internalized standards of
conduct
• Establish rapport
• Obtain understanding of problem
• Assess for risk factors & psychological functioning
• Identify nursing diagnosis & goals
• Perform mental status examination
• Identify behaviors/beliefs/areas to be modified to effect
positive change
• Formulate a plan of care
PSYCHOSOCIAL ASSESSMENT

• Previous Hospitalizations
• Educational Background
• Occupational Background
• Social Patterns
• Sexual Patterns
• Interest and Abilities
• Substance Use and abuse
• Coping Abilities
• Spiritual Assessment
MENTAL STATUS EXAMINATION
• Personal Information
• Appearance
• Behavior
• Speech
• Affect and Mood
• Thought Process
• Perceptual Disturbances
• Cognition
• Test to Assess Cognitive Function
• Interpretation
Any score over 24 (out of 30) is effectively normal. The normal
value is also corrected for degree of schooling and age.
Low to very low scores correlate closely with the presence of
dementia, although other mental disorders can also result in
abnormal findings of the MMSE testing.
The presence of physical problems can also interfere with the
interpretation.
For example a patient that is physically unable to hear or read
the instructions properly, or has a motor deficit that affects his
writing and drawing skills.
Nature of Psychiatric Nursing
The DSM(DIAGNOSTIC STATISTICAL MANUAL)-TR
(TEXT REVISION) IV- APA (AMERICAN
PSYCHIATRIC ASSOCIATION)
– A taxonomy that describes all mental disorders,
outlining specific diagnostic criteria for each based
on clinical experience and research.
– Clinicians utilize this to diagnose psychiatric
disorders.
– Purpose of DSM-TR:
1. Standard nomenclature/ classification
2. Defining characteristics
3. Underlying cause of disorders
Nature of Psychiatric Nursing
The DSM-TR IV : Multi Axis Classification
AXIS I- Major Psychiatric Disorders
AXIS II- Mental Retardation and Personality
Disorders
AXIS III- Current Medical Condition
AXIS IV- Psychosocial and Environmental
Problems
AXIS V- Global Assessment of Function
Nature of Psychiatric Nursing
Historical People Worth Mentioning
1. Aristotle- the Humors
2. Freud- -Psychosexual theory
3. Kraeplin- symptomatic classification of
mental disorders.
4. Bleuler- coined “schizophrenia”
Nature of Psychiatric Nursing
Psychiatric Nursing in the Philippines
• GO and NGOs
• Mental health programs
Nature of Psychiatric Nursing
Psychiatric Nursing in the Philippines
Mental Health
State of well being, where a person can realize his
potential.
Mental Ill Health
Disturbance of thought, feelings and behavior.
Mental Disorder
Medically diagnosable illness.
Mental Hygiene
Science which deals with measures employed to
promote mental health.
Nature of Psychiatric Nursing
Scope of Nursing Practice

• Individual, family and community


• Healthy and ill person
Nature of Psychiatric Nursing
Self Awareness
• The process by which the nurse gains
recognition of his/her own feelings, beliefs
and attitudes. (Videbeck)
• Initial nursing activity to do before practicing
psychiatric nursing.
Nature of Psychiatric Nursing
Self Awareness
• This is accomplish through reflection,
spending time deliberately focusing on how
one feels and what one values or believes.
Mental Health Concepts
• Assessment (psychosocial processes )
– Appearance , behavior or mood
– Speech , thought content and thought process
– Sensorium
– Insight and judgment
– Family relationships and work habits
– Level of growth and development
Common Behavioral Signs and Symptoms

1) Disturbances in perception
 Illusion
• Misinterpretation of an actual external stimuli.
 Hallucinations
• False sensory perception in the absence of external
stimuli.
2) Disturbances in thinking and speech
 Neologism
• Coining of words that people do not understand.
 Circumstantiality
• Over inclusion of inappropriate thoughts and details.
 Word salad
• Incoherent mixture of words and phrases with no logical
sequence.
 Verbigeration
• Meaningless repetition of words and phrases.
 Perseveration
• Persistence of a response to a previous question.
 Echolalia
• Pathological repetition of words of others.
 Aphasia
• Speech difficulty and disturbance
• Expressive , receptive or global
Magical thinking
• Primitive thought process thoughts alone can
change events.
Autistic thinking
• Regressive thought process
Subjective interpretations not validated with objective
reality.
 Flight of ideas
• Shifting of one topic from one subject to another in a
somewhat related way.
 Looseness of association
• Incoherent ,illogical flow of thoughts(unrelated way).
 Clang association
• Sound of word gives direction to the flow of thought.
 Delusion
• Persistent false belief,rigidly held.
• Delusions of grandeur- special /important in a way
• Persecutory-threatened
• Ideas of reference-situation/events involve them
• Somatic- body reacting in a particular way
3) Disturbances of affect
 Inappropriate
• 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.
 Depersonalization
• Feeling of strangeness from one’s self.
 Derealization
• Feeling of strangeness towards environment.
 Agnosia
• Lack of sensory stimuli integration.
4) Disturbances in motor activity
 Echopraxia
• Imitation of posture of others.
 Waxy flexibility
• Maintaining position for a long period of time.
 Ataxia
• Loss of balance.
 Akathesia
• Extreme restlessness.
 Dystonia
• Uncoordinated spastic movements of the body.
 Tardive dyskenisia
• Involuntary twitching or muscle movements.
 Apraxia
• Involuntary unpurposeful movements.
5) Disturbances in memory
 Confabulation
• Filling of memory gaps
 Déjà vu
• 2nd time-like feeling
 Jamais vu
• Not having been to the place one has been
before.
 Amnesia
• Memory loss (inability to recall past events)
 Retrograde-distant past
 Anterograde – immediate past
 Anomia – lack of memory of items
Therapeutic Relationships
• This is a nurse-client interaction that is
directed toward enhancing the client’s well-
being (Isaacs)
• A relationship established between a health
care professional and a client for the purpose
of assisting the client to solve his problems
Therapeutic Relationships
• The nurse- patient relationship is
characterized by a helping process
– The nurse and client work together for his
benefit
– The nurse uses herself therapeutically and this is
achieved by self-awareness
Therapeutic Relationships
• The nurse- patient relationship
– Respect the client and vale as individual
– Holistic care
– Maintain appropriate limits
– Covey empathy not sympathy
– Maintain honest and therapeutic communication
– Encourage expression of feelings
Therapeutic Relationships
ELEMENTS OF THE THERAPEUTIC RELATIONSHIP
• Contract
• Boundaries
• Confidentiality
• Therapeutic Behaviors
Therapeutic Relationships
ELEMENTS OF THE THERAPEUTIC RELATIONSHIP
Therapeutic Behaviors
1. Genuineness = sincerity and honesty
2. Concreteness= ability to identify client’s
feelings
3. Respect= shown through consideration of
patient as unique being
4. Self- exploration and self disclosure
Therapeutic Relationships
PHASES OF THE THERAPEUTIC RELATIONSHIP
1. Pre-Interaction- Pre-orientation
2. Orientation- Interaction
3. Working
4. Termination
Therapeutic Relationships
Phase Nursing Activities
Pre-interaction Nurse obtains data from
secondary sources
Interaction- Orientation Nurse establishes trust, assess
client, establishes mutual
agreement
Working Nurse assists the client to
meet goals and resolve
problems
Termination Nurse and client express
feelings about termination,
observes regressive behaviors
and evaluates NCR
Orientation
• Establishment of goals, rules, boundaries
etc..
• Rapport is built
• Identify expectations
• Trust is gained
• Assessment is done
• Goals are defined
• Contract is made
Working/Exploration/Identification
• Problems are identified
• Solutions are explored, applied and
evaluated
• Nurse assists the client to develop coping
skills, positive self concept and independence
• Promote insight and the use of adaptive
coping mechanisms
Termination/Resolution
• Nurse terminates the relationship based on
mutually agreed goals when these are
already achieved
• Focus of this stage is growth that has
occurred
• Client may become anxious and reacts
• Nurses must help patient resolve the anxiety
and ends the relationship professionally
Therapeutic Communication
• Therapeutic communication
– Dynamic process of exchanging information
– Composed of verbal and non-verbal techniques
that the nurse uses to focus on the client’s needs
Therapeutic Relationships
Therapeutic communication : ELEMENTS
1. Sender- the source of message
2. Message- the information transmitted
3. Receiver- recipient of message
4. Feedback- receiver’s response to the
message
Therapeutic Relationships
NON VERBAL COMMUNICATION
1. Proxemics- the physical space between the
sender and receiver
2. Kinetics- the body movements such as
gestures, facial expressions and
mannerisms
3. Touch- intimate physical contact
Therapeutic Relationships
NON VERBAL COMMUNICATION
4. Silence
5. Paralanguage- voice quality (tone, inflection)
or how a message is delivered
Therapeutic Relationships
VERBAL COMMUNICATION
• Use of therapeutic communication
techniques
• Effective communication should be
therapeutic, appropriate, simple, adaptive,
concise and credible
Therapeutic Communication
Open ended questions
Focus on FEEELINGS
State behaviors observed
Reflect, restate, rephrase
Neutral responses
Therapeutic Communication
Offering self I am here to help you

Active listening Eye to eye contact

Exploring Tell me more about…,.

Broad Openings What do you want to talk


about
Making observation You seemed depressed
Therapeutic Communication
Summarizing A few minutes ago, we were
talking about.. Then…
Voicing doubt I find it hard to believe

Encouraging description of What are these voices telling


perception you
Presenting reality The sound is produced by the
car
No one is in the room
Seeking clarification I am not sure of what you
mean
Therapeutic Communication
Verbalizing the implied Are you saying you want to
kill yourself ?
Reflecting Do you think you should?

Restating P: I cant sleep at night


N: You cant sleep at night ?
General leads GO on… then…. Hmm….you
were saying….
Focusing Lets talk more about what you
think of your problems
Non-therapeutic communication
• These are blocks to communication
• Usually, these are the common pitfalls of
communicating non-therapeutically:
– Giving advise
– Talking about self
– Telling client is wrong
– False reassurance
– Cliché’
– Asking ‘Why’
Non-therapeutic communication
Making judgment You are wrong

False reassurance It’s going to be alright

Invalidation I cannot talk now, I’m busy

Focusing on self I am the best nurse to care for


you
Changing the subject P: I’m afraid of the surgery
N: Ho many children do you
have
Giving advice If I were you, I will
Non-therapeutic communication
Agreeing Yes I think you are right

Disapproving I don’t want you to do that

Defending This hospital is the best

Requesting explanation “why”

Cliché There is the sun after the rain

Belittling feelings P: I’m so depressed today


N: everyone feels sad at times
Proxemics
Distances
INTIMATE= Touching to 1 ½ ft

PERSONAL= 1 ½ to 4 ft

SOCIAL= 4 to 12 ft

PUBLIC= 12 to 15 ft
Psychiatric Nursing Process
• Applies to all clients
• Utilizes unique process for psychological
assessment
• Similar to other types of nursing process
approaches
Psychiatric Nursing Process
• Nursing ASSESSMENT
Nursing History
Physical Examination including the Neurological
examination
Laboratory Examination
Psychiatric Nursing Process
• Nursing ASSESSMENT
– Refers to the scientific process of identifying a
patient’s psychosocial problems, strengths an
concerns
– Interview is done to acquires broad information
about a client
Psychiatric Nursing Process
• MENTAL STATUS ASSESSMENT
– Level of consciousness
– General appearance
– Behavior
– Speech
– Mood and affect
– Judgment
– Memory
– insight
Psychiatric Nursing Process
• MENTAL STATUS ASSESSMENT
– Observation of mood and affect
– Assessment of thought, sensorium and
intelligence
– Speech and content
– Assess developmental status and family-cultural-
spiritual background
Psychiatric Nursing Process
• MENTAL STATUS ASSESSMENT
– Emotional status
– Cognitive assessment
– Socio-cultural assessment
Psychiatric Nursing Process
• Physical Examination
– Observation for key signs

• Diagnostic Tests
– CT, MRI, PET, EEG
– Laboratory tests= CBC, Electrolytes, Drug levels
Psychiatric Nursing Process
– Other diagnostic tests
• Beck depression inventory
• Minnesota multiphasic personality inventory
• Draw-a person test
• Sentence completion test
• Thematic aperception test
Psychiatric Nursing Process
• Nursing Diagnoses
– Anxiety
– Ineffective coping- individual, family
– Fatigue
– Fear
– Sleep pattern disturbance
– Altered thought process
– Etcetera
Psychiatric Nursing Process
• Nursing Objectives
• Short term goals are set for immediate
problems, feasible and within client's
capabilities
• Long term goals are related to discharge
planning and prevention of recurrence of
symptoms
Psychiatric Nursing Process
• Nursing Objectives: The client will:
– Participate in treatment program
– Becomes oriented to three spheres and exhibit
reality-based behaviors
– Recognize reasons for behavior
– Maintain self-care activities
Psychiatric Nursing Process
• Nursing Interventions
– Use of therapeutic communication
– Therapeutic Groups
– Psychotherapy: Family, Milieu, Behavioral
modification, Crisis intervention,
Psychopharmacology
– Electroconvulsive therapy
Psychiatric Nursing Process
• Nursing Evaluation
– Determine if goals are met by collecting data and
comparing them to baseline
– Clients’ behavior should demonstrate optimal
orientation to reality and interaction with others
appropriately
Treatment Modalities
1. Therapeutic Environment- Milieu
2. Therapeutic Groups
3. Crisis intervention
4. Family therapy
5. Behavioral modification
6. Cognitive therapy
7. Psychotherapy
Therapeutic environment
• Research has documented that the
environment in which the mentally ill person
is treated is a major factor in enhancing or
impeding the therapeutic effects of other
treatment modalities
Therapeutic environment
Characteristics of a Therapeutic environment
1. The clients’ physical needs are met
2. The client is respected
3. Decision making authority is clearly defined
4. Client is protected from injury (self and
others)
Therapeutic environment
Characteristics of a Therapeutic environment
5. Clients are allowed freedom of choice
commensurate to his ability to decide
6. Nursing Personnel remain constant and
assignments are stable
7. Emphasis is placed on social interaction
between clients and staff
Therapeutic Modalities
Milieu therapy
– Total environment has an effect on the person’s
behavior- physical, emotional, relationships
Purposes of therapy
1. Improve client’s behavior
2. Involve client in decision making
3. Increase autonomy and communication
4. Set structure of unit and behavioral limits
Therapeutic Modalities
Milieu therapy
• The surrounding is made positive to effect
behavioral changes in the prescribed
directions
• Goals of milieu therapy: to help patient
develop sense of self-esteem, personal
growth, improve ability to relate to others
and return to the community better
prepared
Therapeutic modalities
Milieu therapy
– The nurse involves the client in decision making
– The nurse promotes the involvement of staff in
care
– Social skills are developed and sense of
community is fostered
Therapeutic Groups
– A treatment approach in which the entire milieu
is used as treatment
– This includes the physical environment and the
others clients
Therapeutic Groups
Group Therapy
– Involves meaningful interaction between
members of a group as they relate their personal
experiences to each other
– The main objective is for each group member to
examine his own behavior and relationship. The
group can influence to change his behavior and
relationships
Therapeutic Groups
• Groups of clients meet with one or more
therapists to work together to solve client
problems
Therapeutic Groups

• Purposes
– To increase self-awareness
– To improve interpersonal relationships
– To make changes in behavior
– To enhancing group teaching and learning
Therapeutic Groups
• Structure of the Therapeutic Group
– One leader chosen by the group
– Members
– Size is usually 10
– Physical arrangement
– Time and place of meeting
Therapeutic Groups
Phases of group development
1. Beginning phase
– Info given, anxiety heightened
2. Middle phase
– Confrontation, cohesiveness, trust and self-
reliance
3. Termination phase
– Goals of the group are achieved
– Individuals leave the group when work is done
Therapeutic modalities
CRISIS
• A disturbance caused by a precipitating event
such as perceived loss, a threat of loss or a
challenge that is perceived as a threat to self.
Therapeutic modalities
CRISIS
Can be classified as to maturational crisis,
situational crisis or adventitious crisis
– Maturational= role changes
– Situational= loss of job, death
– Adventitious= fires, earthquakes and floods
– In a crisis, the person’s usual methods of coping
are INEFFECTIVE, resulting in increasingly greater
levels of anxiety.
Therapeutic Modalities
• Characteristics of Crisis:
– It is sudden
– It is short term may last for 4-6 weeks
– Individualized
– The person becomes dependent and
overwhelmed
Therapeutic Modalities
Factors that can produce crisis
• 1. Hazardous EVENTS
• 2. Threat to the individual’s equilibrium
• 3. Inadequate coping skills
Therapeutic Modalities

• There are four PHASES of Crisis (DIDA)


– Denial
– Increased Tension- when the person knows the
existence of crisis and still continues ADL
– Disorganization= pre-occupied and unable to
perform function
– Attempts to Reorganize= by mobilizing previous
coping mechanisms
Therapeutic Modalities
CRISIS INTERVENTION
– A technique of helping the person go through the
crisis
– To mobilize his resources
– To help him deal with the here and now
– A five step problem solving technique designed
to promote a more adaptive outcome including
improved abilities to cope with future crises
Therapeutic modalities
Goal of Crisis intervention: help the patient go back to his state
of optimum level of functioning
– IDENTIFY the problem- A solution is not possible unless
the problem be identified.
– LIST alternatives- all possible solutions to the problem
need to be listed.
– CHOOSE from among the alternatives- each options is
carefully considered, and the alternative chosen is usually
highly individualized, based on priorities and values of
the person
– IMPLEMENT the plan- the alternative is put into action.
The nurse may need to support and encourage patient to
take action
– EVALUATE the outcome- the effectiveness of the plan is
evaluated.
Therapeutic modalities
Family therapy
• An approach in which the therapist focuses
on the behavior of the entire family as a
system instead of focusing on the pathology
of one member
Therapeutic modalities
Family therapy
– Focuses on the client as a ‘family”
– Involvement of family members
Purposes of family therapy
1. Improve relationships among family members
2. Promote family functions
3. Resolve family problems
4. Help family find ways to cope with problems
Therapeutic modalities
Family therapy
• Problems are identified by each family
members and each discusses his/her
involvement in the problem
• Members discuss how problems affect
them and they explore how to solve them
Therapeutic Modalities
Family therapy
• The nurse functions to assess the family
interactions, makes observations and
encourages expression of feelings
• Helping the family resolve the problem is
the goal
Therapeutic Modalities
Behavioral Modification
– Therapy to change the unacceptable behavior
to acceptable
– The nurse determines the unacceptable
behaviors and she identifies adaptive behaviors
– Punishment is given to unacceptable behavior
– Reward is given to acceptable behavior
Therapeutic Modalities
Behavioral Modification
• Other Behavioral therapies
1. Self-control therapy
2. Aversion therapy
3. Desensitization
4. Modeling
5. Operant conditioning
Therapeutic Modalities
Cognitive therapy
• An active, directive, time-limited approach
• Therapeutic techniques are used to identify
reality testing
• The nurse helps the patient think and act
more realistically and adaptively about his
problems
Therapeutic Modalities
Play therapy
– Therapy with children in which they are helped
to express themselves or their behavior
through play
Therapeutic Modality: Psychotherapy
• A method of treating mental illness in which
verbal and expressive techniques are used to
help the person resolve inner conflict and
modify behaviors
Therapeutic Modality: Psychotherapy
1. Psychoanalysis
2. Client centered therapy
3. Rational emotive therapy
4. Gestalt therapy
5. Reality therapy
6. Transactional analysis
Therapeutic Modality: Psychotherapy
1. Psychoanalysis
– THE therapist obtains information about the
past and present experiences that have
repressed in the person’s subconscious mind
– By learning the source of the problem, the
problems can be brought to the conscious
where the therapist helps the individual dealt
with them
Therapeutic Modality: Psychotherapy
2. Client Centered therapy
– The therapist work with one client
– Accepting, non-judgmental environment aimed
at reducing the anxiety and reducing negative
defenses
– The patient is encouraged to express his
feelings and increase self-awareness
– When the person is aware of what he feels, he
can work on improving behavior
Therapeutic Modality: Psychotherapy
3. Rational-Emotive therapy
– This is based in the assumption that a person’s
behavior is due to his own thinking
– Problems arise as the person believes about eh
events
– The therapy aims to change the person’s belief
system
Therapeutic Modality: Psychotherapy
4. Gestalt Therapy
– The mind receives experiences as a whole
– When the experience is complete, the problem
will arise
– The goal of the therapy is to help patients
complete the experience through awareness
Therapeutic Modality: Psychotherapy
5. Transactional Analysis
– A group therapy method
– Helps people “analyze” their transaction or
interaction with others and guides them to the
conclusion: I’m OK you are OK
Responses to Illness
• Stress
• Anxiety
• Crisis
• Anger and hostility
Psychosexual/Psychoanalytical
Ego Defense Mechanisms
Unconscious Ego Defense Mechanism
• These are PSYCHOLOGIC adaptive mechanisms
• Mental mechanisms that develop as the
personality attempts to DEFEND itself,
establishes compromises among conflicting
impulses and allays inner tensions.
Unconscious Ego defense mechanism
• The unconscious mind working to protect the
person from anxiety.
• Releases tension .
Ego Defense Mechanisms
• Compensation • Covering up
weaknesses by
emphasizing a more
desirable trait.
• Attempt to ignore
• Denial unacceptable realities
by refusing to
acknowledge them.
Ego Defense Mechanisms
• Displacement • Discharging emotional
reactions from one
object to a LESS
threatening
object/person.

• Identification • Imitation of someone


feared or respected.
Ego Defense Mechanisms
• Intellectualization • Use of rational
explanations that
remove from the event
any personal
significance and
feelings.

• Introjection • Acceptance of other’s


norms as oneself.
Ego Defense Mechanisms
• Minimization • Not acknowledging the
significance of one’s
behavior

• Projection
• Blame is attached to
others or to
environment for
unacceptable thoughts,
mistakes, etc
Ego Defense Mechanisms
• Rationalization • JUSTIFICATION of
certain BEHAVIORS by
faulty logic/reasons

• Reaction Formation
• Acting OPPOSITELY to
the way they feel
Ego Defense Mechanisms
• Regression • Resorting to an earlier,
more comfortable level
of functioning that is
less demanding

• Repression
• Unconscious
mechanism of keeping
threatening desires or
thoughts from
becoming CONSCIOUS
Ego Defense Mechanisms
• Sublimation • Re-channeling of
aggressive energies
into socially acceptable
activities

• Substitution
• Replacement of a
highly valued object by
a LESS valuable or
acceptable and
available object
Ego Defense Mechanisms
• Undoing • Actions or words
designed to cancel
some disapproved
thoughts, impulses , or
acts in which the
person relieves GUILT
by making reparation
Disturbances in 2 or more of the following:
• Cognition (thinking about self, people, &
events).
• Affectivity (range, intensity, lability, &
appropriateness of emotional response)
• Interpersonal functioning
• Impulse control
192
Type Characteristics

Paranoid Suspicious & mistrust

Schizoid Hermitlike lifestyle, aloneness

Schizotypal Similar to but less severe than


those of schizophrenia

193
• Suspicious of others
• Doubt trustworthiness or loyalty of friends &
others.
• Fear of confiding in others.
• Suspicious, without justification, of spouse’s
or sexual partner’s fidelity.
• Interpret remarks as demeaning or
threatening.
• Hold grudges toward others.
• Become angry & threatening when they
perceive they are attacked by others.
194
• Lacks desire for close relationships or friends
• Chooses solitary activities; a lifelong loner
• Little interest in sexual experiences
• Avoids activities
• Appears cold & detached
• Lacks close friends
• Appears indifference to praise or criticism

196
• Ideas of reference
• Magical thinking or odd beliefs
• Unusual perceptual experience, including bodily
illusion
• Odd thinking & vague, stereotypical, over
elaborate speech
• Suspicious
• Blunted or inappropriate affect
• Odd or eccentric appearance or behavior
• Few close relationships
• Excessive social anxiety
197
Type Characteristics
Antisocial Disregard of others’ rights without
guilt
Borderline Problems with self-identity, IPRs,
mood shifts, & self-destructiveness.
Narcissistic Over-evaluation of self, arrogance, &
indifference to the criticism of others
Histrionic Dramatic behaviors, attention seeking,
& superficiality
198
• Deceitfulness as seen in lying or conning others
• Engages in illegal activities
• Aggressive behavior; violence
• Lack of guilt or remorse
• Irresponsible in work & with finances
• Impulsiveness
• Reckless disregard of safety for self or others
• Insensitivity

201
• Before age 15, these behaviors are diagnosed as
conduct disorder.
• DUI, substance abuse, domestic violence ie; child
abuse, wife abuse. -> meet clients at court/prison
• History is more important than mental status
assessment.
• Seems no conscience, irresponsible, immature &
dependent.
• Nursing care- set firm limits & be consistent in
confronting behaviors & enforcing unit rules.
• Frantic avoidance of abandonment; real or
imagined
• Unstable & intense IPR; Identity disturbances
• Impulsivity; Affective instability
• Recurrent suicidal behavior or self-mutilating
behavior – to express feelings of
anger/frustration
• Rapid mood shifts
• Chronic feelings of emptiness
• Transient dissociative & paranoid symptoms

203
• Uncertain about his self-image, career goals,
personal values, & sexual orientation
• Unhealthy R & in short-term intimate R
• For client’s impulsivity – Nurse’s self awareness
and set limit are important.
• Pt alternates between overidealization &
devaluation of individuals ie falls in love with the
perfect person and shortly can find no redeeming
quality in the formerly idealized person.
• Manipulation & dependency commonly occur. Pt
has great difficulty in being alone & therefore
seeks intense but brief relationships
• tend to view themselves as victims and assume
little responsibility for their problems
• Grandiose self-importance
• Fantasies of unlimited power, success, or brilliance
• Believes he/she is special or unique; Needs to be
admired
• Sense of entitlement (i.e., deserves to be favored or
given special treatment)
• Takes advantage of others for own benefit
• Lacks empathy
• Envious of others or others are envious of him/her
• Arrogant or naughty

205
• Family may complained “The pt never really
seemed to see me as a person with my own
thoughts and problems.”
• Needs to be center of attention
• Displays sexually seductive or provocative behaviors
• Shallow, rapidly shifting emotions
• Uses physical appearance to draw attention
• Uses speech to impress others but is lacking in depth
• Dramatic expression of emotion
• Easily influenced by others
• Exaggerates degree of intimacy with others

207
Type Characteristics
Dependent Submissiveness, helplessness, fear of
responsibility, & reliance on others for
decision making.
Avoidant Timidity, social withdrawal behavior,
& hypersensitivity to criticism.
Obsessive- Indecisiveness, perfectionism,
compulsive inflexibility, & difficulty expressing
feelings.
208
• Unable to make daily decisions without much advice
& reassurance.
• Needs others to be responsible for important areas of
life.
• Seldom disagrees with others because of fear of loss
of support or approval.
• Problem with initiating projects or doing things on
own because of little self-confidence.
• Performs unpleasant tasks to obtain support from
others.
• Anxious or helpless when alone because of fear of
being unable to care for self.
• Urgently seeks another relationship for support &
care after a close R ends.
• Preoccupied with fear of being alone to care for self.

209
• Avoids occupations involving interpersonal contact
because of fears of disapproval or rejection.
• Uninvolved with others unless certain of being liked.
• Fears intimate Rs due to fear of shame or ridicule.
• Preoccupied with being criticized or rejected in social
situations.
• Inhibited & feels inadequate in new interpersonal
situations.
• Believes self to be socially inept, unappealing, or
inferior to others.
• Very reluctant to take risks or engage in new
activities due to possibility of being embarrassed.

211
AVOIDANT
• A pervasive pattern of social interaction,
feeling of inadequacy, and hypersensitivity to
negative evaluation, beginning by early
adulthood and present in variety of context.
• Preoccupied with details, rules, lists, organization.
• Perfectionism that interferes with task
completion.
• Too busy working to have friends or leisure
activities.
• Over conscientious & inflexible.
• Unable to discard worthless or worn-out objects.
• Others must do things his/her way in work or task
related activity.
• Reluctant to spend and hoards money.
• Rigid and stubborn.

214
• Anxiety
• High risk for self-mutilation
• Hopelessness
• Impaired communication
• Ineffective individual coping
• Self-esteem disturbance
• Social isolation

216
Nursing Care
• Nurse-Patient relationship – trust, empathy,
authenticity
• Focus on specific behaviors, distress to self
or others or both & awareness of
dysfunctional & self-defeating patterns
• Case management – stress reduction &
crisis intervention
• Assertive training; Social skill training
• Psychobiological therapy (with caution)
• Milieu therapy – setting limits

217
Conclusion
• Personality traits -> individualization
• Disorder = rigid, dysfunctional, distress
• Distress come from others’ reaction to or
behaviors toward that person -> evoke
interpersonal conflict
• Usually have more than one DSM diagnosis
• Long-term hospitalization is unnecessary
• Limit setting – multidisciplinary work
• Px - have a fairly good prognosis only with
therapy

218
Substance-Related Disorders

Personal and societal toll


Terminology & criteria for diagnoses
Care plan and interventions

225
Introduction
• Epidemiology - # 1 health problem in the US ->
effects on cost, quality of life, society
• Types - Alcohol, tobacco, other drugs ie opium,
heroin, codeine, synthetic narcotics.
• Cigarettes and alcohol – gateway drugs
• History – medical use, social use, illegal use
• Central nervous system (CNS) was affected
• Substance dependency – Client experiences
tolerance and withdrawal symptoms

226
Substance
• Prescribed medications
– Ritalin
– OxyContin
• Over-the-counter cough, cold, sleep, and diet
medication.
• Narcotics
– Heroin
– Morphine
– Demerol
– Methadone.
• Inhalants
• Hallucinogen
– Marijuana, LSD, PCP…
• Stimulants
– Cocaine
– Amphetamines
227
Other Substance & Trends
• Club drugs ie MDMA (ecstasy), GHB, Rohypnol,
ketamine, methamphetamine, LSD
• CNS depressants ie. Valium, phenobarbital
• Steroids
• 1960 – hallucinogens, amphetamines
• 1970 – heroin, marijuana, sedatives
• 1980 – cocaine – injection, smoking

228
Terminology
• Dependence
– physical & psychological
• Codependence
– an emotional, psychological and behavioral
pattern of coping that an individual develops as a
result of prolonged exposure to a dysfunctional
pattern of behavior within the family.
– The individual experiences difficulty with identity
development and set in functional boundaries
which lead to taking care of others rather than self.

229
• Tolerance
– May be influenced by the enzyme ie French

• Cross-tolerance
– A condition in which tolerance to one drug often results in a
tolerance to chemically similar drugs.

• Withdrawal
– Abstinence syndrome.
– Physical signs and symptoms that occur when the addictive
substance is reduced or withheld .

• Dual diagnosis

• CAGE – cutdown, annoy, guilty, eye opener


• Blackout
– The person appears to function normally while drinking but later
is unable to remember what occurred.
– It may last a few hours or several hours.
• Withdrawal from Cocaine -> anxiety and
depression
• hallucinogens do not produce physical
dependence, so there are no withdrawal
symptoms
A Continuum of Substance Use
Non- Social use Dependence Addiction
use
• Social •Physical • Loss of control of
• Re- •Tolerance ingestion
creational •Withdrawal • Using despite
• Medical •Psychological related problems
•Compulsive • Tendency to
use relapse
•Craving

232
Etiology
• Biological theories
– Genetic predisposition
• Psychological theories
– Psychoanalytic theories
– Interpersonal theories
• Family theories
– Family system theory
• Learning theories
– Positive effect of mood alternations
– Media reinforcement
– Peer pressures
• Psychosocial and behavioral factors increase the
client’s vulnerability to drug or alcohol abuse.
233
Age & Substance Use

Grade 8th Grade 12th Grade College


Substance 1993 1993 2001
Alcohol 70 % 80 %
->92%(2001) 90%
Cigarettes 44 % 63 %

Marijuana 10 % 37 %

Cocaine 2 % 8 %
234
Perinatal Concerns
• 25-30% of women expose their children to
nicotine in utero
• 3 out of every 5 women of childbearing age
drink alcohol
• 10% of women of childrearing age use an illicit
drug
• Substances = teratogens -> malformations in
the fetus, intrauterine growth retardation,
subtle mental and behavioral deficits.
235
Fetal Alcohol Syndrome (FAS)
• Low birth weight
• Certain facial characteristics ie. microcephaly,
microthalmia, short palpebral fissures, poorly
developed philtrum, thin upper lip, short nose,
small chin, flattening of the maxillary area
• Neurological abnormalities ie developmental
and/or intellectual delays; it is a preventable
cause of mental retardation
• Fetal Alcohol Effect (FAE)- Less severe cases
236
Other problems of FAS & FAE
• Other organs – heart, hearing, visual, dental,
genital anomalies
• Hyperactivity, poor coordination, short
attention spans, dependency, social
withdrawal, impulsivity…
• Co-morbidity
• Depression, anger, suicidal ideation, antisocial
behaviors
• Preventable health problem for children
237
Adolescent Substance Abuse
• Health & social problem
• School drop-out
• Victim of abuse – child/parental, sexual
• Experienced trouble with law
• Suicide attempts
• Feelings of inferiority, history of mental
problems

238
Signs of Adolescent Drug Use
• Sudden behavioral changes
• Sweating, especially at night
• Needle marks
• Inebriation (intoxicated, drunk)
• Change in nutritional intake
• Nasal congestion
• Rhinorrhea with cocaine use
• School problems

239
Warning Ss of Teen Sub. Abuse
Physical Fatigue, health complaints, red/glazed
eyes, lasting cough
Emotional Personality, mood change, irritability,
irresponsible behavior, depression…
Family Arguments, breaking rules,
withdrawing
School Decreased interest, neg. attitude, drop
in grades, absences, truancy
Social Problems with law, changes to less
problems conventional styles in dress and music
240
Prevention of
Adolescent substance Use
• Positive role modeling
• Reinforce positive behaviors
• Support – cope with social pressure
• Establish normative expectations
• Help to anticipate pressures
• Involve in life skills training programs
• Open communication

241
Alcohol Abuse
• Body damage - brain cell -> neurological S/S Liver,
G-I, muscle, heart, sexual function …
• Blackouts –
• Wernicke’s syndrome - intact intellectual function
but poor memory, ataxia, confusion, vit B deficiency
• Korsakoff’s syndrome – disorientation
• Alcohol withdrawal syndrome (AWS) -
• Alcohol withdrawal delirium - Delirium
tremens (DT) – confusion, disorientation,
hallucination, tachycardia, tremor, …

242
Wernicke’s Encephalopathy

• Clouding of consciousness with an abrupt


onset of confusion and mental status changes
along with drowsiness.
• Ocular motor abnormalities.
• Ataxia of gait from weakness in limbs or
coordination of muscles or poor balance

243
Korsakoff Syndrome
• Difficulty in acquiring new information or learning
new skills
• Lack of insight into their deficit
• Amnesia
• Impaired short term memory
• Tendency for confabulation
• Apathy
• Inattention
• Impaired fine motor skills
• Impaired sense of smell
• Talkative an repetitive behaviors

244
Treatment of WKS
• IV or IM thiamine
• Medications
– Cholinersterase inhibitors
– Atypical antipsychotics
– SSRI
• Alcohol cessation
• Dietary consumption

245
Clinical Description
• Denial
• Dependence – compulsive use
• Abuse – dysfunction in work, …
• Intoxication
• Withdrawal
• Delirium
• Psychotic disorders

246
• Denial – N’s role - to question why they feel
threatened to help them to gain insight.
• Dependence – use of the drug is no longer under
control, & continue to use despite adverse
effects.
• Abuse- recurrent use -> failure to manage work,
school, or home roles, hazardous situation
• Withdrawal – physiological, behavioral ,
cognitive, and affective symptoms that occur
after reduction or discontinuance of a drug that
has been used heavily over a long period of time.
• Alcohol Withdrawal – tremulousness,
nervousness, anxiety, anorexia, nausea, vomiting,
insomnia, sleep disturbances, rapid pulse, high
bp, profuse perspiration, diarrhea, fever,
unsteady gait, difficulty concentrating, craving
Alcohol-related Disorders
Alcohol Alcohol withdrawal Substance induced
intoxication delirium
• Slurred speech • Nausea/vomiting • Impaired
• Incoordination • Anxiety consciousness
• Unsteady gait • Hallucination • Cognitive change
• Nystagmus • Sweating (memory,
• Attention/ • Psychomotor disorientation,
memory agitation hallucination)
impairment • Grand mal seizure • Short period of
• Stupor or • Hand tremor time/fluctuates
coma • Evidence of sub.
abuse
248
Alcohol
• Detoxification – 3Ss-
–Secure environment
–Sedation
–Supplements

249
CNS Depressant - Narcotics
• Opioids – endorphin agonist, euphoria
• Increasing pain threshold, reducing anxiety and
fear
• Decreased pulmonary ventilation/esp. elders
• Respiratory depression in neonates/preg
• Withdrawal is rarely fatal, but painful
– ie yawning, tearing, rhinorrhea, sweating, flushing,
tachycardia, tremor, restlessness, irritability, muscle
spasm, fever, nausea, diarrhea, vomiting, repetitive
sneezing, abdominal cramps, backache

250
CNS depressant - Barbiturates
• Medical – relieve anxiety, produce sleep,
anesthesia, epilepsy, soften withdrawal from
heroin
• Narrow therapeutic index
• Classification- ultrashort (30’-3h), short (3-4h),
intermediate (6-8h), long (10-12h)
• Intoxication: unsteady gait, slurred speech,
sustained nystagmus, confusion, irritability,
insomnia
• Tolerance

251
• Narrow therapeutic index- lethal dose being
only slightly higher than the therapeutic dose
• Barbiturates with short to intermediate
duration have the highest abuse potential i.e.
amobarbital( Amytal), pentobarbital
(Nembutal), and seconbarbital (Seconal).
Stimulant - Cocaine
• Medical – relief for altitude sickness, anesthetics,
• Block norepinephrine & dopamine reuptake
• CNS & PNS effects – euphoria, alertness, anorexia,
sexual stimulation
• Derivatives: crack, rock
• Physical dependence is less severe
• Psychological dependence is intense
• Highs (+ reinforcement) & lows ( - reinforcement)
• Cocaine-induced depression, suicide
• Death – caused by meta. & resp. acidosis, and
hyperthermia, prolonged seizure, tachyarrhythmias

253
Stimulant - Amphetamine
• Speed, ice, crank, poor person’s cocaine
• Medical – ADD, narcolepsy, obesity
• CNS effects – wakefulness, alertness, heightened
concentration, energy, euphoria, insomnia, amnesia,
restlessness, agitation,
• PNS effects- palpitations, tachycardia, hypertension
• Amphetamine-induced psychosis
• Facilitate excretion by acidification of urine

254
Hallucinogen
• Natural & synthetic
• Heighten awareness of reality or cause a
terrifying psychosis-like reaction, distortions in
body image, sense of depersonalization, loss of
the sense of reality, panic, anxiety, confusion,
paranoid reaction
• Altered perception -> unable to perform simple
tasks or lead to violent behaviors

255
Dual Diagnosis
• Comorbidity – 2 or more disorders in the same
person
• Dual diagnosis- 2 initial unrelated disorders
that interact and cause increased
manifestations of the other disorder
• Personality disorders – higher incidence – 47%
of antisocial; 2/3 of borderline; 4.5-15%
above the norm in Schizophrenia

256
Etiology of Dual Diagnosis
• Substance use -> calmer, feel better, less
anxious, decrease the intensity of
hallucinations.
• Compare with using antipsychotics – less
uncomfortable side effects
• Increase social acceptance, feeling of
autonomy or power -> self-esteem

257
Tx for Dual Dx
• Multifaceted & multidisciplinary – case
management, ind/gr therapy, skill training,
vocational counseling, …
• N-Pt Relationship – knowledgeable, skilled,
nonjudgmental, empathic
• Monitoring – S/s of withdrawal
• Milieu therapy – set limits
• Psychopharmacology - compliance

258
Impaired Professionals
• Incidence: 5% - chemical abuser
• 8-10% (or higher) -chemically dependent
• Common profile
– Family hx of sub abuse, depression, sexual abuse
– Academically and professionally successful
– Divorced
– Received professional treatment for sub abuse
– Regularly attends recovery self-help groups
• Report to supervisor immediately

259
Common Nursing Diagnoses
• Anxiety
• Ineffective individual coping/ self-care
• Altered health maintenance/ nutrition/
sensory-perception/ family process,
• Risk for injury/infection
• Impaired communication/ social interaction
• Violence, potential for

260
Substance Abuse Problems Needing
Collaboration
• 53% of drug abusers have at least 1 serious
psychiatric problem

• 37% of alcohol abusers have at least 1 serious


psychiatric problem

261
Pharmacological Treatment
• Alcoholism
– Naltrexone (Trexan, ReVia) –
– Disulfiram (Antabuse) –
• Opiod addict
– Methadone (Dolophine)
– L-alpha Acetylmethadol (LAAM)
– Naltrexone (Trexan, ReVia)
– Clonidine

262
Pharmacological Treatment (II)
• Stimulant dependence –
– Dopaminergic drugs ie. Amantadine (Symmetrel),
bromocriptine (Parlodel)
– Anticonvulsants ie carbamazepine (Tegretol)
– TCA ie desipramine (Norpramine)

• Hallucinogen dependence –
– Diazepam (Valium)

263
Supplementary Treatment
• Sedatives
– Benzodiazepine ie Librium, Valium
– Phenobarbital
• Thiamine (Vit B1)
• Folic Acid
• Magnesium sulfate
• Anticonvulsant
• Multivitamins

264
N-Pt Relationship
• Trust - communication
• Support – minimizes anxiety
• Consistency – objective & nonjudgmental
• Continually assess
– Presence of predictable defense style
– Psychophysiological responses
• Referral – local resources/ community
agencies

265
Milieu Therapy
• Drug-free – safety, structure, norms, limit setting
• Motivation
– Dependency vs. face the consequences
• 3Cs – Family members
– did not cause the disease,
– cannot control it,
– cannot cure it
• Belongingness – significant relationship, social
skills,

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Interdisciplinary Interventions
• Breaking through defenses - denial
• Understanding and accepting the disorder
• Identification with peers
• Development of hope
• Re-socialization
• Developing self-esteem and self-worth

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DELIRIUM

• Delirium is a serious and often undetected


neuropsychiatric syndrome.
• Failure to identify delirium can lead to
longer hospital stays and increased
morbidity and mortality.
Other Terms Applied to Delirium

• Acute Brain Syndrome


• Acute Confusional State
• Metabolic Encephalopathy
• Toxic Psychosis
• Acute Brain Failure
• Altered Mental Status