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For Depressed client

· Assess suicide potential


· Let client talk about personal problems
· Do not leave alone

For Suicidal clients


Crisis intervention to assess suicide protential.
· Communicate intent “ are you tired of living?”
· Previous attempts
· Specific plan
· Social support system
· DO NOT make “ suicide contract”!

For Anxious clients


· Convey interest and care
· Don’t “force” client
· Help client identify source of anxiety
· Suggest relaxation techniques

For Violent clients


· Remain calm and in control of the situation
· Give client space, avoid sudden movements
· Encourage verbal expression of anger
· Restrain or seclude if necessary

For Compulsive clients


· Allow client to engage in rituals (these are used to cover up anxiety)
· Gradually limit length of time for rituals.

For Manipulative clients


· Set clear limits
· Hold client responsible for behavior

For Dependent clients


· Don’t reward dependent behavior
· Client should share responsibility for treatment

For Paranoid clients


· Don’t argue with client (simply state that you don’t share his beliefs)
· Be reliable and consistent

For Delusional clients


· Stay with client
· Don’t argue about the reality of delusions
· Orient frequently to reality (place, situation)
· Assess potential for self harm

For Somatization clients


· Respect client and his problems (client is not faking)
· Rule out physical basis for symptoms
· Help client express anxiety

DEFENSE MECHANISMS:
1. Conversion: A college student develops diarrhea on day of exam
2. Regression: Returning to immature ways of dealing with stress: crying, tantrums…
3. Repression: Blocking of unacceptable urges and feelings from awareness.
4. Denial: Blocking of unacceptable information or perceptions from awarness.
5. Dissociation of affect: A girl laughs when telling about her failed exam
6. Rationalization: Substituting an acceptable motive for attitudes or behavior for an
unacceptable motive
7. Reaction formation: you want to “kick your bosses ass” but end up kissing it.
8. Identification: A teenager dresses like Madonna and mimics her behavior.
9. Projection: “ you are acting like a teenager, not I”
10. Introjection: A boy yells at his dog like his father does him
11. Displacement: Client is upset about disease and yells at nurse. Nurse gets upset and
yells at nursing assistant
12. Undoing: “ magic,”

SIGNS AND SYMPTOMS

Aphasia
Receptive (Wernicke =difficulty to comprehend language) or expressive (Broca =
difficulty to find “the right word” language disorder

Apraxia
Failure to do, despite intact motor function

Agnosia
Failure to recognize

Dementia
Gradual impairment of cognitive functions, memory
· Alzheimer dementia: early memory loss
· Multi infarct dementia: step like decline

Delirium
Acute, organic, short lasting
Clouded consciousness
Confusion, disorientation, anxiety
Sometimes hallucinations
Delusions
Persistent false belief despite invalidating evidence
Grandeur
Paranoia
Somatic delusions

illusions
Misperception of external stimuli

Hallucinations
Perception without external stimuli

TERMS:
1. Neologisms: invents new words: Schizophrenia
2. Echolalia: echoes words or sentences: Schizophrenia
3. Word Salad: jumble of words without meaning: Schizophrenia
4. Flight of ideas: rapid switching from topic to topic: Mania
5. Confabulation: invents stories to fill memory gaps: Korsakoff encephalopathy.

DELIRIUM
Ø Acute onset
Ø Fluctuating consciousness
Ø Disorientation
Ø Optical hallucinations

DEMENTIA
Ø Gradual onset
Ø No impairment of consciousness
Ø Loss of intellectual functions: memory, orientation, language.

ALZHEIMER’S

ASSESSMENT:
§ Progressive memory loss
§ Declining mental, social, and self care abilities

ANALYSIS:
§ Risk of injury due to cognitive deficits
§ Family/caregiver burnout

IMPLEMENTATION:
§ Support family caregivers
§ Provide safe and familiar environment
§ Support client’s attempts at independence
§ Continually orient client to time, date and person
§ Advance directive should be drafted as early as possible

GRIEF DEPRESSION
Initial: shock/ denial Feeling of hopelessness

Illusions/hallucinations may occur Feeling of worthlessness

Low risk of suicide High risk of suicide

PERSONALITY DISORDERS:

 Behavior is inflexible across a broad range of situations

 Behavior is markedly deviant from cultural norms

 Significant distress and impairment of functioning

DEPENDENT Afraid of being helpless

Need to be cared for


COMPULSIVE Fear of loss of control

Tries to control physician


PASSIVE-AGGRESSIVE Appears willing but is not compliant
HISTRIONIC Dramatic, emotional

May display inappropriate sexual behavior


NARCISSISTIC Feels better than others

Perfect self image is threatened by disease


PARANOID May blame nurse or others for disease
SCHIZOID Anxious, withdrawn

(doesn’t want close relationships)


BORDERLINE Severe disorder!

Intense unstable relationships

Paranoia and suicidal behavior

Features of psychoses
ANXIETY DISORDERS:

 Clients are distressed and know that their symptoms are irrational.

PHOBIA Persistent excessive of specific objects or


situations.

Patient knows that his fear is unrealistic


PANIC ATTACK Abrupt onset, peak within 10 min.

Palpitations, tachycardia

Sweating, trembling, shaking

Fear of dying

Derealization: feeling of unreality of the


external world.

Depersonalization: feeling of being detached


from oneself
AGORAPHOBIA Hx of panic attacks

Patient avoids places where panic attack


might occur (especially public places)
OBSESSSIVE COMPULSIVE Obsessions: recurrent thoughts

Compulsions: repetitive behavior


POSTRAUMATIC STRESS DISORDER Traumatic event in client’s history

May occur any time after event

Persists for > 1 month

HYPOCHONDRIASIS & MALINGERING:

HYPOCHONDRIASIS Unrealistic interpretation of body signs

Client believes to have serious disease that is


unrecognized by family and physicians
FACTITIOUS DISORDER Intentional feigning of symptoms

Motivation: to assume the sick role: external


incentives such as economic gain or avoiding
legal responsibilities are absent
MALINGERING Intentional feigning of symptoms

Motivation: economic gain

Avoiding leagal responsibilities

MAJOR DEPRESSION
ASSESSMENT:

 Feeling of worthlessness
 Thoughts of death or suicide
 Lethargy
 Slow, muted speech
 Anorexia, weight loss

Early morning awakening


ANALYSIS:

 Risk of suicide
IMPLEMENTATION:

 Assess suicidal risk ( ask client directly)


 Remove potentially harmful objects
 Encourage verbal expression of feelings
 Encourage participation in group activities

MEDICATIONS:

 Antidepressants (require several weeks for full effect)


 Watch for anticholinergic side effects:

 Blurred vision

 Dry mouth

 Constipation

 Urinary retention

BIPOLAR DISORDER:
Manic episodes alternate with episodes of major depression.
Some clients have only manic episodes, no depressive episodes.

ASSESSMENT:
 Euphoria
 Grandiose ideas
 Uninhibited sexuality
 Buying sprees

 Psychomotor agitation
IMPLEMENTATION:

 Low stimulus environment


 Provide frequent small meals, snacks
 Encourage physical activity as a means to “act out”

MEDICATION:

 Lithium
 Watch for signs of toxicity

 Abdominal pain, nausea

 Hand tremor

 Ataxia, nystagmus

 Slurred speech

 Monitor serum levels closely

 Not to exceed 1 mEq/L

SCHIZOPHRENIA:

ASSESSMENT:

 Defect in reality testing


 Affect incongruent ( does not match thoughts)
 Thought form: tangential, circumstantial, loose associations

“POSITIVE SYMPTOMS”

 Delusions
 Hallucinations

“NEGATIVE SYMPTOMS”

 Flat affect

 Loss of interest

 Ambivalence

 Autism

CATATONIA:

 Waxy rigidity of muscles

 Client maintains bizarre positions


IMPLEMENTAION:

 Establish trusting, honest relationship

 Maintain calm, consistent manner

 Don’t challenge client’s thought content

 Decrease environmental stimuli

MEDICATION:

 Neuroleptics: monitor for signs of tardive dyskinesia

 Choreoathetosis

 Lateral movements of jaw

 Tongue protrusion
CLIENT EDUCATION:

 Stress importance to comply with follow up visits

 Encourage family support

DRUG ABUSE:
Abuse: recurrent use of drugs resulting in social failures at home, school or work, legal
problems or hazardous situations.
Dependence: Tolerance (needs larger doses to achieve effect). Withdrawal symptoms.

INTOXICAITON WITHDRAWAL
ALCOHOL Euphoria Nausea

Disorientaion Delusions, hallucinations

Unsteady gait Delirium

Tremor, seizures
BARBITURATES Sedation Delirium

Epilepsy

Coma, death
BENZODIAZEPINES Antianxiety Anxiety

Sedation Irritability

insomnia
AMPHETAMINES, Arousal Fatigue
COCAINE
Euphoria Dysphoria
OPIOIDS Euphoria Nausea, vomiting

Apathy Sweating, fever

Muscle aches
LSD Hallucinations NONE

Anxiety

Paranoid ideas