Myk's Psychiatric Nursing Notes 4

EATING DISORDERS
ANOREXIA NERVOSA ---------------BULIMIA NERVOSA
- Eat, eat, eat --------------------------- Eat, eat, vomit
- Less 85% expected body weight ------- Normal weight
- 3 months amenorrhea --------------- Irregular menstruation

BULIMIA NERVOSA
• Metabolic alkalosis (vomiting results to decrease hydrochloric acid)
• Metabolic acidosis (diarrhea results to decrease bicarbonate)
• Dental caries
• Wound in knuckles

MANAGEMENT
• Fluid and electrolyte imbalance
• Meal contract
• Weight gain for client
• After eating stay with client for 1 hour and accompany when going to the
comfort room

PHARMA NOTES:
ANTI – PSYCHOTIC DRUG
• Stelazine
• Serentil
• Thorazine
• Trilafon
• Clozaril
• Mellaril
• Haldol
• Prolixin

SCHIZOPHRENIA
• Ego disintegration
• Impaired reality perception
• Genetic vulnerability
• Stress – Diathesis Model
• Biological theory – increase dopamine level
• Exact cause unknown

ASSESSMENT
• Affect: Appropriate, Inappropriate, Flat, Blunt (incomplete)
• Ambivalence: pulled into 2 opposing forces
Autism
• Looseness, no idea, not related to one another

ASSESSMENT
NEGATIVE ------------------------POSITIVE
Hypoactive ------------------------ Hyperactive
Withdrawn ------------------------- Sociable
Thought Blocking ------------------Flight of ideas
Apathy
I. ASSESS
• Content of thought

NURSING DIAGNOSIS
• Disturbed thought process
PLANNING/IMPLEMENTATION
• Present reality
• Provide safety
EVALUATION
• Improved thought process

II. ASSESS
• Hallucinations/Illusions

NURSING DIAGNOSIS
• Disturbed sensory perception
PLANNING/IMPLEMENTATION
• Present reality
• Safety
EVALUATION
• Improved sensory perception

III. ASSESS
• Suspicious

NURSING DIAGNOSIS
• Risk for other directed violence
PLANNING/IMPLEMENTATION
• Present reality
• Safety
EVALUATION
• Eliminate/minimize risk for other directed violence

IV. ASSESS
• Suicidal

NURSING DIAGNOSIS
• Risk for self directed violence
PLANNING/IMPLEMENTATION
• Present reality
• Safety
EVALUATION
• Eliminate/minimize risk for self directed violence

LOOSENESS OF ASSOCIATION
• Thinking that is overgeneralized, diffuse, and vague with only a tenuous
connection between one thought and the next

FLIGHT OF IDEAS
• Jumping from on topic to another

AMBIVALENCE
• Pulled between 2 strong opposing forces

MAGICAL THINKING
• acting like magician
ECHOLALIA
• Client repeats what you say

ECHOPRAXIA
• Client repeats what you do

WORD SALAD
• Just words no rhyme

CLANG ASSOCIATION
• Words that rhyme

NEOLOGISM
• Formation of new words (needs clarification)

DELUSION: PERSECUTORY
• “The NBI is out to get me”

DELUSION: RELIGIOUS
• “I am Jesus Christ the savior”

DELUSION: GRANDEUR
• “ I am the queen of the world”

DELUSION: IDEAS OF REFERENCE

• “The nurses are talking about me”

CONCRETE ASSOCIATION
• Also known as “pilosopo”

THOUGHT BLOCKING
• Unable to think

-----------------------HALLUCINATIONS------ ILLUSIONS
STIMULUS ------------ ABSENT------------ PRESENT
VISUAL ----------------ABSENT------------ PRESENT
AUDITORY ----------- ABSENT------------ PRESENT
TACTILE ABSENT --- ABSENT------------ PRESENT

• Present reality to clients experiencing hallucinations

• Technique in handling clients with hallucinations
• Hallucinations
• Acknowledgement “I know the voices are real to you”
• Reality orientation “I know the voices are real but I don’t hear them”
• Diversion “Lets go to the garden”
• 10% of schizophrenic clients hear voices

PARKINSON’S DISEASE
• If acethylcholine (on switch) is increased there is excessive movement resulting
to decrease in dopamine (off switch)

ANTI-PSYCHOTIC
Decrease dopamine level
Parkinson like effect
Extra pyramidal side effect
With akathesia
Restless, inability to rest
AKINESIA
• Muscle rigidity

DYSTONIA
• Torticollis (wryneck)

OCULOGYRIC CRISIS
• Fixed stare

OPISTHOTONUS
• Arched back
• Lips – smacking
• Tongue – protruding
• Cheeks – puffing
• The 3 are irreversible and called tardive dyskinesia
• Neuroleptic malignant syndrome – hyperthermia

ANTI – PARKINSON
Anticholinergics Dopaminergics
(Decrease Ach) (Increase Dopa)
Artane, Akineton Parlodel
Benadryl Larodopa
Cogentin Eldepryl
Symmetrel

OTHER SIDE EFFECTS OF DECREASE DOPAMINE

• Photosensitivity
• Agranulocytosis – decrease WBC
• Clients prone to infection due to decrease WBC
• First sign for infection is sore throat

TYPES OF SCHIZOPHRENIA
DISORGANIZED SCHIZOPHRENIA
- Sad but smiles (inappropriate affect)
- No reaction (flat affect)
- Flight of ideas (disorganized speech)
- Giggling (hebephrenic giggle)
- Combination of positive and negative signs and symptoms

CATATONIC SCHIZOPHRENIA
- Ambivalence
- Waxy flexibility
- Favorite word is “No”
- Negativism (client do not follow what you tell them to do)
Nursing management: meet needs

PARANOID SCHIZOPHRENIA
- Suspicious
- Mistrust, scared, withdrawn
Nursing management:
- Gain trust by 1 to 1 short interaction but frequent
- Foods should be in a sealed container
- Medications should be in tamper resistant foil.
Violent:
- Keep door open
- Position near door
- Don’t touch client
- Call for reinforcement
- One arms length away from the client.

PARANOID SCHIZOPHRENIA
- No more positive symptoms just withdrawn

UNDIFFIRENTIATED SCHIZOPHRENIA
- Mixed classification, cant be classified

PHAMRA NOTES:

BI-POLAR, MANIC
• Lithium: undergo first kidney test and check for blood levels
• Level: .6 – 1.2 meq/L
• Increase urination
• Tremors, fine hand
• Hydration of 3L/day
• Increase
• Uu (diarrhea)
• Mouth dry

Signs of Lithium toxicity

• Nausea, vomiting, diarrhea
• Increase sodium
* Wait for 2 – 4 weeks before lithium therapy takes effects

BIPOLAR DISORDER/MANIC PROFILE

• 20 years old
• Female
• Stress
• Obese

ASSESSMENT
• Decrease appetite (give finger foods)
• Decrease sleep (place in a private room)
• Hyperactive
• Increase sexual activity – only means of addressing anxiety so decrease level of
anxiety
• Risk for injury/other directed violence
• Impaired social interaction (care giver role: strain and stay with client)
• Self esteem decrease (to cover up their sadness there is compensation to cover
defective doing)
• Because there is decrease self esteem there will be increase compensation
resulting to increase interference with ADL’s and harm to others
• Compensation is the culprit
• Management: increase self esteem to decrease compensation and
decrease interference with ADL’s and harm to others

HOW TO INCREASE SELF ESTEEM OF MANIC PATIENTS

T- no sports (basketball, volleyball), no fine motor skills only gross motor skills
A lot energies toward more productive endeavors (sublimation)
S - escorted walk outdoors
K – punching bag (displacement)

PHARMA NOTES:

ANTI – DEPRESSANTS
• Asendin
• Norpralamin
• Tofranil
• Sinequan
• Anafranil
• Aventyl
• Vivactil
• Elavil
• Prozac
• Paxil
• Zoloft

ALCOHOL LEADS TO:

• Blackout: awake but unaware
• Confabulation: inventing stories to increase self esteem
• Denial: “I am not an alcoholic”
• Dependence: cant leave with out leading to enabling where in the significant
other tolerates the abuser co dependence is another term
• Tolerance: gradual increase in amount of stimuli to experience the same
euphoria

MANAGEMENT
• Detoxification: withdrawal with medical doctor supervision
• Avoid alcohol therapy
• Aversion therapy a more technical term for avoid alcohol therapy
• Antabuse: Disulfiram makes the client never drink alcohol because it causes
vomiting
• Alcoholics anonymous
• Interval of 12 hours after last dose of alcohol or experience nausea and
vomiting and hypotension
• Alcoholism may result to Vitamin B1 (Thiamine) deficiency

WERNICKE’S ENCEPHALOPATHY
• Problem with motor

KORSAKOFF’S PSYCHOSIS
• Problem with memory
• 24 – 72 hours after last dose of alcohol expect:
• Delirium Tremens: sympathetic nervous system
• Prevent hallucinations/Illusions by placing client in a well lit room
• Formication: feeling of bugs crawling under the skin

ALZHEIMERS DISEASE
• Axon (away) and Dendrites (toward) nerve
• Neurofibrillary tangles
• Neurotic plaques

--------------------------ALCOHOL --- ALZHEIMERS

ONSET -------------------- Abrupt -------- Gradual
LEVEL OF CONSCIOUSNESS -- Fluctuating ----Unaffected
DURATION ----------- Hours to days --- Progressive
MEMORY -------------- Short term ---Short and long term

5 A’s OF ALZHEIMERS
1. Amnesia – memory loss
2. Anomia – don’t know the name
3. Agnosia – sensory problems smell, taste, sight
4. Aphasia
- expressive: cant say/express
- frontal lobe is affected particularly broca’s area
- receptive: cant hear
- temporal lobe is affected particularly wernicke’s area
5. Apraxia – cant do simple things
* Reminiscing Therapy – talk about past
• Patients with alzheimer’s may experience hallucinations, illusions thus becomes
restless and may wander
• As sun goes down client becomes restless, agitated, disoriented called
sundowning
• Drug of choice is Cognex and Aricept a cholinesterase inhibitor that increases
Ach causing delay in disease progression

SEROTONIN
• Responsible for happiness
• Decrease serotonin clients becomes sad give anti-depressants

SELECTIVE SEROTONIN REUPTAKE INHIBITOR

Safest drug
Side effects low
R
I to 4 weeks
- Increases serotonin and affects only serotonin
- Prozac, Paxil, Zoloft

TRICYCLIC ANTI DEPRESSANT

Two – four weeks
C
A
- Has higher incidence of side effects
- Also increases norepinephrine
- Asendin, Norpralamin, Tofranil, Sinequan, Anafranil, Aventyl, Vivactil,
Elavil

MONO AMINE OXIDASE INHIBITORS

• MAO kills serotonin
• Increased MAO results to decreased serotonin the more depressed the client
becomes
• MAOI kills MAO and increases all neurotransmitters (serotonin, epinephrine,
norepinephrine, dopamine but client becomes prone to hypertensive crisis
• Avoid tyramine rich foods
• Avocado, Alcohol
• Beer
• Chocolates, Cheese (aged)
• Fermented foods
• Pickles
• Preserved foods
• Soy sauce
• There is increase incidence of side effects after 2 – 6 weeks
• Marplan, Nardil, Parnate

PERSONALITY DISORDERS
1. Schizophrenia
- They avoid people because there is no enjoyment
2. Avoidant
- They avoid people because they are afraid of criticisms
- They have talent but has no confidence
3. Anti-Social
- Constantly breaks law
- Project charm
- They are witty and articulate
- Manipulative
4. Borderline
- They perceive life as an empty glass
- They like splitting friends
- Sudden change in mood “labile affect”
- Prone to suicide
5. Dependent
- “Cant live if living is without you”
6. Histrioinic
- Constantly wants to be the center of attention
- Excited, dramatic, manipulative
7. Narcissistic
- “I love myself”
- They get jealous even with achievement of family members
8. Obsessive – Compulsive
- “I am so organized”
9. Paranoid
- Suspicious
- May lead to domestic violence

ANTI – DEPRESSANT SIDE EFFECTS:

Male – erectile dysfunction, prone to impotence

GRIEF PROCESS
1. Denial – shock/disbelief
2. Anger – question “why me?”
3. Bargaining – if, then
4. Depression – 2 weeks or more sign and symptoms becomes major clinical
depression
5. Acceptance – client acts according to situation

ASSESSMENT
• Decrease self actualization
• Decrease self esteem
• Withdrawn: stay with client
• Suicidal: risk for self directed violence
• Increase/decrease eat, increase/decrease sleep, hypoactive, decrease sexual
urge
• Be sensitive to clients needs
FOR SUICIDAL OBSERVE FOR
Verbal
• “I wont be a problem”
• “This is my last day on earth”
• “I’ll soon be gone”
Non verbal
• Giving away of valuables
• Sudden change in mood

WHEN THE CLIENT IS SUICIDAL WHAT WILL THE NURSE DO

Direct: “Do you plan to commit suicide?”
Irregular/interval visits
Endorsement period, early morning clients are most likely to commit suicide

DOWNERS
Alcohol
Barbiturate
Opiates
Narcotics
Marijuana
Morphine
Codeine
Heroine

Resulting to:
• Bradycardia
• Bradypnea
• Moist mouth
• Pupils constrict
• Constipation
• Urinary retention
• Hypotension
• Coma
• Weight gain
• Narcotics overdose: give narcotic antagonist (Narcan, Naloxone hydrochloride)

UPPERS
Cocaine
Hallucinogens
Amphetamines
Resulting to:
• Tachycardia
• Awake
• Tachypnea
• Dry mouth
• Pupils dilate
• Hypertension
• Seizures
• Weight loss