Psychiatric Nursing

I. Basic Concepts in Psychiatric Nursing

Mental Health
Mental Ill Health
Psychiatric Nursing
Interpersonal process whereby the professional nurse practitioner through the therapeutic use
of self, assist an individual family, group or community to promote mental health, to prevent mental
illness and suffering, to participate in the treatment and rehabilitation of the mentally ill and if
necessary to find meaning in these experiences.
Both a Science and Art
Core of Psychiatric Nursing:
-Interpersonal process
Clientele:
-Individual, family and the community
- Both mentally healthy and mentally ill
Main Tool of the Nurse
-Therapeutic use of Self
CONCEPTS
Use of Self
Therapeutic use of self

- positive use of ones self in the process of therapy

- it requires self-awareness

Basic Principles
Basis: Joharis Window
Known to self

Not Known to
self

Known to others

Public Self
I

Semi-public Self
II

Not known to
others

Private self III

Areas of the
Unknown
IV

Goal: To increase quadrant I, decrease quadrant II and III

Methods Used to Increase Self- Awareness
1. Introspection:
-Viewing ones self as honestly as possible
2. Discussion:
- Learning about oneself through association with others
3. Enlarging Ones Experience:
- Engage in a particular activity and noting ones reaction to it.
4. Role playing:
- A situation in which participants enact a role

Core Concepts on the Care of the Psychotic Patient

On Admission of the Client
1.
2.
3.
4.

Priority
Determine the reason why the client sought help
Clients rights
Initial assessment
J
O
I
M
A
T

Common Behavioral Signs and Symptoms

1.

Disturbance in perception:
Illusion -misperception of an actual external stimuli
Hallucination
-false sensory perception in the absence of external stimuli
Visual -seeing
Tactile -feeling that there are some insects crawling on the skin

2.

Disturbances in thinking
Neologism
- pathologic coining of words
Circumstantiality - over inclusion of details
Word Salad
- incoherent mixture of words and phrases
Verbigeration
- incoherent mixture of word or phrases
Perseveration
- persistence of a response to a previous question
Echolalia
- pathological repetition of words
Flight of ideas
- shifting from 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
Clang association
- the sound of the word gives direction to the flow of thought
Delusion
- false belief which is inconsistent with ones knowledge and
culture

3.

Disturbances of affect
Inappropriate affect
Blunted effect
Flat affect
Apathy
Ambivalence
Depersonalization
Derealization

4.

- disharmony between the stimuli and the emotional reaction

- severe reduction in emotional reaction
- absence or near absence of emotional reaction
- dulled emotional tone
- presence of two opposing feelings
- feeling of strangeness towards ones self
- feeling of strangeness towards the environment

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

5.

Disturbances in memory
Confabulation - filling in of memory gaps
Amnesia- inability to recall past events
Anterograde amnesia
- loss of memory of the immediate past
Retrograde amnesia
- loss of memory of the distant past
Dj vu - feeling of having been to a place which one has not yet visited
Jamais vu
- feeling of having been to a place which one has visited before

Use of Appropriate Communication Techniques

Communication:
Reciprocal exchange of ideas between or among persons.
Modes of communication:
1. Verbal- written/spoken
2. Non-verbal
- posture, tone of voice, facial expression
3. Meta communication - based on role expectations/hidden meaning of words
Elements of Communication
Sender - originator of information
Message - information being transmitted
Receiver- recipient of information
Channel - Mode of communication
Feedback
- return response
Context - the setting of communication
Criteria of successful communication
Feedback
Appropriateness
Flexibility
Efficiency
Common Problems in Communication
1.
2.
3.
4.

Dysfunctional communication
Double bind communication
Denotative vs. connotative meaning
Incongruent communication

Techniques of Communication
If your goal is:
To initiate conversation:
Giving broad opening
Giving recognition
To establish rapport and build trust:
Giving information
Use of silence
To gather information:
Focusing
Validating
Reflecting
Interpreting
Restating
To close a conversation:
Summarizing
How to Choose a Therapeutic Response in The Board Exam
Establish Nurse Patient Relationship
Nurse-Patient Relationship
Series of interaction between the nurse and the patient in which the nurse assists the patient to
attain positive behavioural change.

1.
2.

Characteristics
NPR

Social Relationship

Phases

A. Pre-Interaction Phase
- begins when the nurse IS assigned/chooses a patient
- phase of NPR in which patient is excluded as an active participant
- nurse feels certain degree of anxiety
- includes all of what the nurse thinks and does before interacting with the patient
Major task of the nurse:
to develop self-awareness
Other tasks:
data gathering, planning for first interaction
B. Orientation Phase
- when the nurse-patient interacts for the first time
- parameters of the relationship are laid
- nurse begins to know about the patient
Major task:
to develop a mutually acceptable contract
Other tasks:
determine why the patient sought help
establish rapport, develop trust, assessment
C. Working Phase
- it is highly individualized
- more structured than the orientation phase
- the longest and most productive phase of the nurse-patient relationship
- limit setting is employed
Major task:
identification and resolution of the patients problems
Other tasks:
Planning and implementation
D. Termination Phase
- it is a gradual weaning process
- it is a mutual agreement
- it involves feeling of anxiety, fear and loss
- it should be recognized in the orientation phase
- it should be recognized in the orientation phase
Major task:
to assist the patient to review what he has learned and transfer his learning to his
relationship with others.
Other task:
Evaluation
When to terminate?

How to terminate?

Common Problems Affecting NPR

1. Transference

- the development of an emotional attitude of the patient either

positive or negative towards the nurse.
2. Resistance
- development of ambivalent feelings towards self-exploration.
3. Counter Transference - as experienced by the nurse

Initial Interventions
Principles of Care in Psychiatric Settings
1.
2.
3.
4.
5.
6.
7.

The nurse views the patient as a Holistic human being with interdependent and
interrelated needs.
The nurse accepts the patient as a unique being with inherent value and worth exactly as
he is.
The nurse should focus on the patients strengths and assets and not on his weakness and
liabilities.
The nurse views the patients behaviour non-judgmentally, while assisting the patient to
learn more adaptive ways of coping.
The nurse should explore the patients behaviour for the need it is designed to meet and
message it is communicating.
The nurse has the potential for establishing a nurse-patient relationship with most if not
all patients.
The quality of the nurse-patient relationship determine the degree of positive change that
can occur in the patients behaviour.

Level of Interventions in Psychiatric Nursing

Primary Interventions aimed at the promotion of mental health and lowering the rate of
cases by altering the stressors.
Secondary interventions that limits the severity of a disorder.
2 Components
1.
2.

Case Finding
Prompt treatment

Tertiary interventions aimed at reducing the disability after a disorder.

2 Components
1.
2.

Prevention of complication
Active program of rehabilitation

Characteristics of a Psychiatric Nurse

1.
2.
3.

Empathy the ability to see beyond outward behaviour and sense accurately another
persons inner experience.
Genuineness/Congruence ability to use therapeutic tools appropriately.
Unconditional Positive Regard respect

Roles of the Nurse in Psychiatric Settings

1. Ward Manager
Responsibility:
2. Socializing Agent
Responsibility:
3. Counselor
Responsibility:
4. Parent Surrogate
Responsibility:
5. Patient Advocate
Responsibility:
6. Teacher
Responsibility:
7. Technician
Responsibility:
8. Therapist
Responsibility:
9. Reality Base
Responsibility:
10. Healthy Role Model
Responsibility:

Types of Interventions
7.1 Biologic
7. 1. 1 Pharmacologic

II. Basic Concepts on Psychoparmacology

Neurons:
Neurotransmitters:
Classification of Psychopharmacologic Agents
A. Major Tranquilizers/Antipsychotics:
Indication:
MOA:
Examples:
Haloperidol (Haldol)
Fluphenazine ( Prolixin
Prochlorperazine (Compazine)
Chlorpromazine (Thorazine)
Side effects:
Blurred vision, dry mouth, tachycardia, palpitation, constipation, urinary retention
Skin: Photosensitivity
BP: Orthostatic hypotension
EPS: Extra Pyramidal Symptoms
- Pseudoparkinsonism
-pill-rolling tremor, mask-like face, cog-wheel rigidity, propulsive gait
- Akathisia
-restless leg syndrome
- Dystonia
- defect in muscle tone
Adverse effect:
1. Tardive dyskinesia-lip smacking
2. Agranulocytosis
3. Hepatoxicity
Principles of Nursing Care
C
H
E
C
K
B. Anti-Parkinsonian Agents:
Indication:
2 Types:
1.

2.

Dopaminergic Drugs
MOA:
Examples: Amantadine (Symmetrel)
Anticholinergic Drugs
MOA:
Trihexyphenidyl (Artane)
Biperiden Hydrochloride (Akineton)
Benztropine Mesylate (Cogentin)
Diphenhydramine Hydrochloride (Benadryl)

Side effects:
Anticholinergic: blurred vision, constipation, orthostatic hypotension
Adverse effects:
Dry mouth, urinary retention, sore throat
Principles of Nursing Care
C
H
E
C
K
C. Minor Tranquilizers/Anxiolytics
Indications:
MOA:
Examples:
Diazepam (Valium)
Chlordiazepoxide (Librium)
Aprazolam (Xanax)
Oxazepam (Serax)
Chlorazepate Dipotassium (Tranxene)
Side effects:
Adverse effects:
Principles of Nursing Care:
C
H
E
C
K
D. Antidepressants
Common Types:
1.
2.
3.

Tricyclics
MAO inhibitor
Stimulants

MOA:
Examples:
Imipramine (Tofranil)
Amitriptyline (Elavil)
Tranylcypromine (Parnate)
Isocarboxazid (Marplan)
Phenelzne (Nardil)
Ritalin (Methylphenidate)
Amphetamine (Benzedrine)
Adverse effect:
Cardiac arrhythmia, hypertensive crisis, growth suppression
Side effect:
Principles of Nursing Care:
C
H
E
C
K

Drug update: SSRI Selective Serotonin Reuptake Inhibitor

- inhibits serotonin uptake
Example: Fluoxetine (Prozac)
Side effects
: GI Discomforts
Adverse effects: Tremors, decrease in libido
E. Anti-manic agents
1. Lithium Carbonate
MOA:
C
H
E
C
K
2. Carbamazepine
7. 1. 2. Somatic Therapy
Electro-convulsive Therapy
MOA:
Voltage:
Duration:
Number of treatment
Frequency:
Indicators of effectiveness:
Indications:
1.
2.
3.

Depression
Mania
Catatonic schizo

Contraindications: (relative) there is no absolute contraindication to ECT

1. Fever
2. ICP brain tumor
3. Cardiac
4. TB with history of hemorrhage
5. Recent fracture
6. Retinal detachment
7. Pregnancy
Patient Preparation:
Before the procedure:
Consent:
Physical exam:
X-ray
ECG
EEG
NPO
Restrainments:
Administration of Atropine SO4
Anectine (Succinylcholine)
Methohexital Na (Brevital)
During the procedure:
Observe the patient tonic-clonic contraction
After the procedure:
Position
Vital signs
Reorient the patient
Common complications: Memory loss, headache, fracture, apnea

7.2 Psychosocial Interventions

III. Common Psychotherapeutic Interventions

1.

Remotivation therapy
5 Different Steps
1.
2.
3.
4.
5.

Climate of acceptance
Creating of bridge to reality
Sharing the world we live in
Appreciation of the works of the world
Climate of appreciation

2.

Music Therapy

3.

Play Therapy

4.

Group Therapy

5.

Psychodrama

6.

Milieu Therapy

7.

Family Therapy

8.

Psychoanalysis

9.

Hypnotherapy

10. Humor Therapy

11. Transactional Analysis
12. Behavior Modification
13. Aversion Therapy
14. Token Economy
15. Gestalt Therapy

IV. Dynamics of Human Behavior

Need is an organismic condition which requires a certain activity
Stress pressure of varying degrees: Distress unhealthy stress
Eustress healthy stress
Behavior way in which an organism responds to a stimulus
Conflict situation that arise from the presence of two opposing drives
Types:
Approach-Approach
-both of each chosen have positive attributes
Avoidance-Avoidance
-negative attribute
Approach-Attribute
- choice have positive and negative attributes
Double approach - avoidance

V. Basic Concepts on the Client

Personality
- The integration of those systems and habits that represents an individuals characteristic adjustment to
his environment
- Expressed through behaviour.
2 Characteristics of Personality
1. Distinctiveness- each individual is unique
2. Stability and consistency
personality is predictable

Determinants:
1. Psychological - type of climate at home
2. Cultural
- customs and traditions
3. Biological
- personality is not inherited
4. Familial
- parenting style
3 divisions of the mind:
1. Conscious
- part of the mind that is focused on awareness
2. Subconscious - part of the mind that contains information that can be recalled at will.
3. Unconscious - largest part of the mind; contains materials and information that can never be recalled.
Structures of Personality
ID

EGO

SUPEREGO

Theories of Personality Development

A. Freuds Psychosexual theory
First to identify/classify the stages of development
0-18 mos: Oral Stage
Area of Gratification:
Indicators of Fixation:
18 mos 3 years: Anal Stage
Area of Gratification:
Indicators of Fixation:
3-6 years: Phallic Stage
Area of Gratification:
Indicators of Fixation:
6-12 years Latency: (Quiet Stage)
Area of Gratification:
Indicators of Fixation:
12 -21 years Genital Stage
Area of Gratification:
Indicators of Fixation:
B. Eriksons Psychosocial Theory
First to include adulthood as a stage of development
0.12

mos: Trust vs. Mistrust

If the needs of the child is consistently met, trust develops.

1-3 years: Autonomy vs. Shame and Doubt

If toilet training is not hurried, autonomy develops.
3-6 years: Initiative vs. Guilt
If the childs sexual curiosity is handled without anxiety, initiative develops.
6-12 years: Industry vs. Inferiority
If the childs efforts at learning is supported, industry develops.
12-18 years: Identity vs. Role Diffusion
If the adolescents vocational decision is supported, identity develops.
18-25 years: Intimacy vs. Isolation
If the adolescents decisions regarding love relationship is supported, intimacy develops.
25-65 years: Generativity vs. Stagnation
If an individual enjoys support from the family, generativity develops.
65 onward: Integrity vs. Despair
If the person has a satisfying past recollection, integrity develops.

C. Piagets Cognitive Theory of Development.

First to Focus on Cognitive Development
0-2 years: Sensory Motor Stage
Development proceeds from reflex activity to sensory motor learning
Child learns that he is separate from the environment
Child learns the concept of object permanence
2-7 years: Pre-operational Stage
2-4 yrs: pre-conceptual development proceeds from sensory motor learning to pre-logical
thought.
The child learns language and symbols.
4-7 yrs: intuitive thought: The child is able to think in terms of class.
The child is able to determine that individuals have roles.
7-12 years: Concrete Operational Stage
Development proceeds from pre-logical concrete thought.
12 years to adulthood: Formal Operational Stage
The child is able to think abstractly, able to apply the scientific method.

VI Crisis and Crisis Intervention

Crisis situation that occurs when an individuals habitual coping ability becomes ineffective
to meet the demands of a situation.
Characteristics:
Types of Crisis:
1. Maturational/developmental crisis
- expected, predictable and internally motivated.
Example: growth
2. Situational/accidental - unexpected, unpredictable and externally motivated.
Example: car accident
3. Social crisis
- due to acts of nature
Example: earthquake
Crisis intervention
A way of entering into the life situation of an individual, family, group, or community to help
them mobilize their resources and to decrease the effect of a crisis inducing stress.
Phases of Crisis
Denial
Increased tension

initial reaction
the person recognizes the presences of a crisis and continues to
do activities of daily living.
Disorganization
the person is preoccupied with the crisis and is unable to ADL.
Attempts to reorganize individual mobilizes previous coping mechanism.

Some Conditions Requiring Crisis Intervention

1.

Rape

Some Facts of Rape:

Ruthless
Abusive
Personal
Experience
Essential Elements Necessary to Define an Act of Rape
1.
2.
3.

Use of threat/force
Lack of consent of the victim
Actual penetration of the penis into the vagina

Different Kinds of Rape

Power
Anger
Sadistic
Principles of Nursing Care:

Rape Trauma Syndrome (RTS)

1. acute phase
2. denial
3. heightened anxiety
4. stage of reorganization
Battered Wife Syndrome (BWS)
Characteristics of Abusive Husband:
1. They usually come from violent families
2. They are immature, dependent and non-assertive
3. They have strong feelings of inadequacy
Phases
1.
2.
3.

Tension building phase

Acute battering incident
Aftermath/honeymoon stage

Principles of Nursing Care:

Child Abuse
Abuse

- is what happens when an adult takes advantage of his authority over a

child.
Violence- refers to the use of force.
Neglect
- lack of provision of those things which are necessary for the childs growth
and development.
Physical abuse
- abuse in the form of inflicting pain
Emotional abuse - insult and undermining ones confidence
Sexual abuse
- abuse in the form of unwanted sexual contact
Characteristic 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 dont trust anyone
- they are emotionally immature
- they have negative attitude towards the management of the
abused
Indicators of Child Abuse
Principles of Nursing Care:

Where to report:
Whom to report:
Priority:

Anxiety:
Causes of Anxiety
2 classification factors
1.
2.

Predisposing factor
Factors that make you at risk
Precipitating factor
Factors that cause direct effect

Psychoanalytic theory
Anxiety is caused by a conflict between the Id and the Superego
Interpersonal Theory
Cause of anxiety is fear of interpersonal rejection
Behavioral Theory
Anxiety is a product of frustration
Learning Theory
Exposure to early life fearful experiences causes anxiety
Conflict theory
Presence of opposing drives
Biologic Theory
Anxiety may accompany physical ailments/diseases
Family Studies
Anxiety can run in families
Precipitating factors
Threat to ones biological integrity
e. g. surgery
Threat to ones self system
e. g. insult
Signs and Symptoms of Anxiety
Signs and
Symptoms

Mild

Moderate

Severe

Panic

Physical

PR, RR,
Pupillary
dilatation,
sweating

S/Sx becomes
the focus of
attention

S/Sx of
exhaustion are
ignored

Cognitive

Attentive and
alert

nausea, anorexia,
vomiting,
diarrhea,
constipation,
restlessness
narrowed
perceptual field
and selective
inattention

personality
disorganized

Emotional

Minimal use of
defenses

perceptual field
is greatly
narrowed; focus
of attention is
trivial events
defense
mechanisms
operate to
prevent panic,
amnesia, and
dissociation

use of any
defense
mechanism
available

Nursing Diagnosis
Principles of Nursing Care:
BE
C-ALM
A-DMINISTER MEDICATIONS
L-ISTEN
M-INIMIZE ENVIRONMENTAL STIMULI
Defense Mechanisms:

defense
mechanisms fail

Unconscious, specific intrapsychic adaptive efforts which are employed by the individual to
resolve emotional conflict and to cope with anxiety
Characteristics:
It is automatic
It is not the defense mechanism that is pathological but it is the frequent use of it
Used by both mentally healthy and mentally ill individuals
Types:
Compensation - an attempt to overcome a real or imagined shortcoming
Conversion
- emotional problems are converted to physical symptoms
Denial
- failure to acknowledge an intolerable thought, feeling, experience or reality
Displacement
- the redirection of feelings to a less threatening object
Dissociation
- detachment of certain activities from normal consciousness which then function
alone
Fantasy - conscious distortion of unconscious feelings or wishes
Fixation - arrest of maturation at certain stages of development
Isolation - cutting of or blunting of an unacceptable aspect of a total experience
Introjection
- symbolic assimilation or taking into ones self a love/hatred object
Identification
- conscious patterning of ones self from another person
Intellectualization
- over use of intellectual concepts by an individual to avoid expression of
feelings
Projection
- attributing to others ones unconscious wishes/fears
Reaction formation
- expression of feelings that is the direct opposite of ones real feelings
Rationalization - justifying ones actions which are based on other motives
Regression
- returning to an earlier level of development in the face of stress
Repression
- unconscious forgetting
Suppression
- conscious forgetting
Substituting
- replacing the desired unattainable goal with one that is attainable
Sublimation
- the channelling of unacceptable instinctual drive with one that is acceptable
Symbolization - less threatening object is used to represent another
Undoing - an attempt to erase an act, thought, feeling or desire
Anxiety Disorders
Panic Attacks
Intervention:
Agoraphobia
Intervention:
Social Phobia
Intervention:
Simple Phobia
Intervention:
Obsessive-compulsive behaviour
Intervention:
General Anxiety Disorder
Intervention:
Post-traumatic Stress Disorder
Intervention:
Nursing Diagnosis
Drug of Choice:

VII. Personality Disorders

Etiological Factors
1. Genetic Factors
2. Temperamental Factors
3. Biological Factors
4. Psychoanalytic Factors
Types:
Hypochondriacal
Anti-social - habitually breaks the law; with low self-esteem; lacks sense of guilt.
Dependent - incessant demands for attention from others
Schizoid withdrawn, last to catch up in fashion, introvert, aloof
Shizotypal bizarre behaviour, silly laughter
Borderline - fears separation; impulsive; unstable but intense relationships
Histrionic overly concerned with physical appearance, attention seeking behaviour
Extrovert

Avoidant fears rejection

Paranoid extreme mistrust and suspiciousness
Passive-Aggressive loves to procrastinate, expresses anger through passivity
Emphatic Narcissistic (self-love), believe that they are special and they demand special attention
Obsessive-Compulsive repetitive thoughts and action, perfectionist, inflexible, rigid
Nursing diagnoses;
1. Ineffective individual coping
2. Self- esteem disturbance
Principles of Nursing Care
1. consistency
2. limit setting

VIII Autism
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
1. resist normal teaching method
2. silly laughing or giggling
3. echolalia
4. acts as if deaf
5. no fear of danger
6. insensitive to pain
7. crying tantrums
8. loves to spin objects
9. resists change in the routine
10. not cuddly
11. sustained odd play
12. difficulty interacting with others
13. no eye contact
14. wants blocks not ball
15. points to anything
16. attachment to inanimate objects
Management of priority problems
Tantrum - involves headbanging = place a helmet on the head
Communication all vowels = use build up and break down
Routines consistency
Nursing diagnosis:
Potential for injury

IX. Mental Retardation

IQ less than 70
Not a mental illness
Main problem: Inadequate mental functioning
Age of Onset: 18 years old
Causes:
Maternal infection
Exact gestational age is not reached (premature)
Birth injuries
Nutritional deficiency
Toxoplasmosis
Anoxia
Lead poisoning
Recent infection measles
Environmental factors
Thyroid deficiency
Alcoholic Mother

RH Incompatibility
Damage to brain from various causes
AIDS
Toxemia
Inherited factor
Opiate intoxication
Neurological/neurodevelopment
impairment

Levels of Mental Retardation

1. Mild/Moron
2. Moderate/Imbecile
3. Severe/Idiot
4. Profound

IQ: 50/55-70
Educable
IQ: 35/40 -50/55 Trainable
IQ: 20/25 -35/40 Needs close supervision
Below 20-25
Needs custodial care

Nursing diagnosis:
Principles of Nursing Care:
1. Repetition
2. Role Modeling
3. Restructuring
Focus of Education:
Reading, writing, basic arithmetic

X. Attention Deficit Hyperactivity Disorder

Common in boys
Usually diagnosed before age 7
Main problem: Inattention, hyperactivity, and impulsivity
Causes:
Neurologic impairment
Pre-natal trauma
Early malnutrition
Frontal lobe-hypoperfusion
Use of drug by mother
Signs and symptoms:
Difficulty remaining seated
Easily distracted by extraneous stimuli
Fidgeting
Interrupts/intrudes on others
Child exhibits hyperactivity
Indulges in destructive behaviour
Talks excessively
Nursing diagnosis: Potential for injury
Principles of Nursing Care:
Nutrition:
Safety:
Drug of Choice: Methylphenidate (Ritalin)

XI. Eating Disorders

Common among females (adolescents)
Most common cause:
Psychological factors
Individual factors (conflict about growing up)
Parental factors (domineering parents)
Socio-cultural factors
Anorexia
Main sign: fear of gaining weight
Amenorrhea
No organic factor accounts for weight loss
Obviously thin but feels fat
Refusal to maintain normal body weight
Epigastric discomfort
X symptoms (peculiar symptoms)
Intense fear of gaining weight
Always thinking of food

Bulimia
Binge eating
Under strict dieting or vigorous exercise
Lacks control over eating binges
Induced vomiting
Minimum of 2 binge eating episode a week for
2 months
Increased/persistent concern of body
size/shape
Abuse of diuretics and laxatives

Nursing diagnosis:

Body image disturbance/self-esteem disturbance

Ineffective individual coping

Principles of Nursing Care:

1. Monitor patients weight
2. Oral hygiene
3. Stay with the patient during mealtime and within 2 hours after meals
4. encourage the patient to remain in a public place after meals
5. behaviour modification

XII. Sexual Disorders

Cause: Psychological factors, unresolved oedipal complex
Paraphilia a term which generally refers to abnormal sexual behaviour
Types:
Sexual Stimulus
Exhibitionism
- publicly showing the genitals
Fetishism
- from inanimate objects
Anilingus
- tongue brushing the anus
Cunnilingus
- tongue brushing the vulva
Fellatio
- inserting the penis into the mouth
Partialism
- inserting the penis into the other parts of the body
Pedophilia
- sexual intercourse with a child
Urophilia
- urinating on the partner
Coprophilia
- smearing feces on the partner
Masochism
- sexual gratification from experiencing pain
Sadism
- inflicting pain
Telephone scatologia
- sex on phone
Voyeurism
- sexual gratification by seeing others in the nude
Frotteurism
- rubbing the genitalia to the body parts
Transvestism
- using the apparel of the opposite sex
Nursing diagnosis: Altered sexual functioning
Principles of Nursing Care:
1. Limit setting
2. Behavior Modification

XIII. Schizophrenia
Split Mind
Not a single disease but a combination of disorders
Main Problem:
Signs and Symptoms:
1. Associative looseness
2. Autism
3. Apathy
4. Ambivalence
5. Auditory Hallucination
Most acceptable theory on the cause of Schizophrenia, Biologic Theory
Signs and Symptoms
Social isolation
Catatonic behaviour
Hallucination
Incoherent/marked looseness of association
Zero/lack of interest, energy, and initiative
Obvious failure to attain expected levels of development
Peculiar behaviour
Hygiene and grooming are impaired
Recurrent illusions and unusual perceptual experiences
Exacerbation and remissions are common
No organic factor accounts for signs or symptoms
Inability to return to baseline functioning after each relapse
Affect is inappropriate

Different Types
Catatonic

Disorganized

Paranoid

Onset
Distinguishing feature

Acute
Abnormal motor
behavior

Insidious
Bizarre behavior

Abrupt
Suspiciousness and
ideas of reference

Defense mechanism

Repression

Regression

Projection

Nursing diagnosis

Impaired motor
activity

Impaired social
functioning

Potential for injury

directed at others

Priority nursing care

Circulation Nutrition

Assistance with ADL

Nutrition and Safety

Prognosis

Good

Poor

Good

Other types:

Undifferentiated
Residual with minimal symptoms

Criteria for Prognosis

Favorable Prognosis
1.
2.
3.
4.

Unfavorable Prognosis

Good socialization
Late/acute onset
Adequate support system
Family history of mood disorder

1.
2.
3.
4.

Poor/no socialization
Early and insidious prognosis
Few//no support system
History of chronicity/many
relapses

XIV. Mood Disorders

Predisposing Factors:
Genetic:

If one parent ahs bipolar disorder, 25 percent chance of transmission to the

child.

Aggression turned inward theory: overdeveloped superego

Object loss theory: loss of parent before age 11
Personality Organization Theory:

Cognitive Theory:

Obsessive-Compulsive theory, Oral dependent,

hysterical personalities have higher
predisposition to mood disorders.

Mood disorder results from (-) view of self, (-) view of future, (-)
interpretation of experience

Learned Helplessness Theory:

Mood disorder is caused by a belief that one has

no control over his environment

Psychoanalytic Theory:

Mania is a defense against an underlying

depression
Depression due to rigid SE

Biologic Factor:

Mania is cause by increased norepinephrine

while depression is cause by low norepinephrine

Precipitating Factors
1. Loss of a loved one
2. Major life events
3. Roles strain
4. Decreased coping resources
5. physiological changes
Types of Mood Disorders

1.

Depression
A. Major Depression-severe, lasts for at least 2 weeks
B. Dysthymic Depression-less severe (2 years)
C. DNOS lasts for 2 days 2 weeks

2.

Bipolar Disorders
A. Manic-severe, lasts for at least 1 week
B. Hypomanic-lasts for at least 4 days
C. Bipolar I with history of mania
Bipolar II with no history of mania
D. Cyclothymic numerous episodes of hypomania and depressed mood that lasts for at
least 2 years
Signs and symptoms:

Appearance

Mania
Colorful

Depression

Behavior

Highly driven, hyperactive

Sad
Passivity/Psychomotor
retardation

Communication Talkative (Flight of ideas) Monotonous

Nursing Diagnosis

Risk for injury

directed at others

Risk for injury to self

Nursing Care

Lithium

ECT

Milieu Therapy Non-stimulating

Activity

Stimulating

Quiet Type
Avoid competitive

Attitude therapy Matter of Fact

(attitude of casualness)

Monotonous activity
e. g. counting
Kind firmness

Suicide
Ultimate form of self-destruction
cry for help
Major intervention:

Prevention
Listen

Risk Factors
Sex (more female attempts at suicide but more males commit suicide)
Unsuccessful previous attempt
Identification with a family member who committed suicide
Chronic
Illness (e.g. Cancer)
Depression/Dependent personality
Age (18-25 and 40)/Alcoholism
Lethality of previous attempt/Losses
Nursing Diagnosis: Risk for self-directed injury
Nursing Care:
1.
2.
3.
4.

One-on-one monitoring
Frequent unscheduled rounds
Avoid use of metals and glass utensils
Monitor for the signs of impending suicide (e.g. giving away of prized possession)

XV. Conditions Common in the Elderly

Delirium
Disorientation
Acute
Involves young and old
Clouded sensorium
Reversible
Good prognosis

Dementia
Loss/impairment of memory
Chronic
Exclusive in the elderly
Clear sensorium
Irreversible
Poor prognosis

Alzheimers disease: Irreversible

Main pathology: presence of senile plaques-destroys neurons (decreased acethylcholline)
Signs and symptoms:
Aphasia-inability to talk
Agnosia- inability to recognize object
Apraxia-inability to perform ADL
Amnesia/Memory Loss/Mnemonic disturbance
3 phases
1.
2.
3.

Forgetfulness Phase-difficulty of remembering appointments

Advance Phase-difficulty of remembering past events but not recent events
Terminal Phase-death occurs in 1 year

Nursing Diagnosis: Altered thought processes

Nursing Care:
-

Calendar
Clock (frequent orientation)
Color
Consistency (one nurse to lessen confusion)

XVI. Substance Abuse and Substance Dependence

Substance Abuse: use of a substance for other than its legitimate medical purpose
Substance Dependence: physiological and psychological dependence of the body on a
substance as evidenced by tolerance and withdrawal
Tolerance: need for an increasing amount of the substance to produce its desired effect or it
refers to the declining effect of the drug.
Withdrawal: syndrome or a group of symptoms experienced by the patient when the amount
of the substance is reduced or when the intake is stopped.
Alcoholism
Definition:
WHO- alcoholism is a chronic disease or a disorder characterized by excessive alcohol intake
and interference in the individuals health, interpersonal relationship and economic functioning.
Alcoholism considered to be present when there is 1% or 10 ml for every 1000 ml of blood.
What happens at level:
.1-.2% (low coordination)
.2-.3% (presence of ataxia, tremors, irritability, stupor)
.3 and above (unconsciousness)
Theories of Causation
1.
2.
3.
4.

Psychoanalytic Theories
Learning Theories
Biological Theories
Socio-Cultural Theories

Progression of Alcoholism

1.
2.
3.
4.

Pre-alcoholic Phase starts with social drinking tolerance begins to develop

Prodromal Phase Alcohol becomes a need, blackouts occur; denial begins to develop
Crucial Phase cardinal symptoms of alcoholism develops (loss of control over drinking)
Chronic Phase the person becomes intoxicated all day

Outcome:
Brain Damage
Alcoholic Hallucinosis
Death
Common Behavioral problems of the Alcoholic Patient
Denial
Dependency
Demanding
Destructive

Domineering

Common Withdrawal Signs and Symptoms

Hallucinations
Increased vital signs
Tremors
Sweating and Seizure
Criteria

D. Tremens

Korsakoff Psychosis

Wernickes P.

Cause

Faculty metabolism
of alcohol

Thiamine & Niacin

deficiency

Thiamine
deficiency

Onset

Acute

Chronic

Chronic

Essential
feature

Delirium

Memory disturbances

Other S/Sx

Vital Signs
Visual and tactile
Coarse tremors

Retrograde A
Anterograde A
Confabulation
Korsakoffs P.

Long terms of care

Community resources
Other coping means aside from denial
Personal responsibility for not drinking
Isolation
Nutrition Vitamin B & C, CHO diet
Group therapy
Nursing diagnosis: Ineffective individual coping
Principles of Nursing Care:
1. Well-lighted room
2. DAT
3. Monitor vital signs
4. Administration of glucose
5. Vitamins
Drug of choice: Disulfiram (Anti-abuse) delays the metabolism of alcohol
Avoid:
Mouth wash
Over the counter cold remedies
Food sauces made up of wine
Fruit flavoured extracts
Aftershave lotion
Vinegar
Skin products
Commonly Abused Substances

Confusion
Opthalmoplegia
Ataxia
Thiamine def.

Substance

Physical signs

Withdrawal Effect

Amphetamine (shabu)

Weight loss, hyperactivity

Euphoria

depression

Cocaine

perforated nasal septum

psychomotor agitation

pinpoint pupils, drowsiness

piloerection & runny nose

dilated pupils & hallucinations

none

a. Stimulants

b. Narcotics
Heroin
c. Hallucinogens
LSD

Nursing Diagnosis:
Ineffective individual coping
Nursing interventions for substance abusers:
Behavior Modification (Firmness-matter of fact)
Detoxification
Antihypertensive; anti-anxiety- administered to patients who are abusing stimulants
Anti-anxiety; anti-depressants- administered to patients who are abusing depressants
Anti-anxiety (Librium), disulfiram (anti-abuse);- administered to patients who are abusing alcohol

XVII. Concept of Loss

Grief/Grieving-George Engel
1.
2.
3.
4.
5.

Shock, Numbness, Disbelief- Searching behaviour

Yearning and Protest anger towards God
Anguish, Disorganization, and Despair reality of the loss is accepted
Identification stage- a family member imitates some characteristics of the dead person.
Reorganization/restitution- life normalizes

Death/Dying: Elizabeth Kubler-Ross

Stages:
Denial No, Not me!
Anger - Why me?
Bargaining- If only
Depression silence
Acceptance Yes, its me.
Nursing Diagnosis: Ineffective individual coping
Nursing Care:
1.
2.
3.
4.
5.

Be physically present
Be non-judgmental
Encourage verbalization of feelings
Allow the patient to cry
Recognize your own thoughts about death and dying