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MOSC MEDICAL COLLEGE HOSPITAL, KOLENCHERY

ORIENTATION MANUAL CUM NURSING


CARE GUIDELINES
FOR
STAFF NURSES
&
NURSING STUDENTS

PSYCHIATRIC UNIT

INDEX
SLNO

CONTENT

PAGE NO

SLNO

Signs and symptoms of psychiatric


disorders
Commonly used psychiatric abbreviations

1-9

17

b. Alcohol withdrawal managment

32-33

10

18

c.

34-35

11-18

19

ICD10 classification codes of mental and


behavioral disorders
Daily ward routines

Caring Depression and suicidal


patients
d. Caring manic and violent patients

19

20

37-39

Professional behavior

19

21

Therapeutic communication techniques

20

22

Patient safety issues

21

23

e. Caring
patients with psychotic
disorders: delusions and hallucination
managment
f. Caring
patients
with
obsessive
compulsive disorder
g. Caring patients with dissociative
disorders
h. Caring children with mental disorders

Safety issues for nurses

21

24

i.

Caring elderly patients

41-42

Preparation of patient unit

22

25

j.

42

10

Patient admission protocol

22

26

k.

11

Patient discharge protocol

24

27

l.

Caring patient with food refusal/feeding


problems
Managing commonly experienced
psychotropic medication sideeffects
Managing extra pyramidal sideeffects

12

doctors rounds and nurses responsibilities

27-28

28

m. Managing patients with lithium toxicity

46-47

13

Medication administration guidelines

28

29

n. Special diet requisites, diet planning

48

14

Psychiatric
nursing
documentation
guidelines
Specific nursing care guidelines

29-30

30

o. Motivation counseling for substance


use disorder
Drugs used in psychiatry

49

a. Organic Brain disorderdelirium, dementia

31-32

2
3

15
16

31

CONTENT

PAGE NO

35-36

40
40
41

43-45
45-46

50-58

2. Selective inattention: blocking out only those things that


generate anxiety.
3. Hyper vigilance: excessive attention and focus on all internal
and external stimuli, usually secondary to delusional or
paranoid states;
Emotion: complex feeling state with psychic, somatic, and behavioral
components that is related to affect and mood.

SIGNS AND SYMPTOMS


OF PSYCHIATRIC
DISORDERS

Disturbances in Affect: observed expression of emotion, possibly


inconsistent with patient's description of emotion.
1. Appropriate affect: condition in which the emotional tone is in
harmony with the accompanying idea, thought, or speech;
also further described as broad or full affect in which a full
range of emotions is appropriately expressed.
2. Inappropriate affect: disharmony between the emotional
feeling tone and the idea, thought, or speech
accompanying it.
3. Blunted affect: disturbance in affect manifested by a severe
reduction in the intensity of externalized feeling tone.
4. Restricted or constricted affect: reduction in intensity of
feeling tone less severe than blunted affect but clearly
reduced.
5. Flat affect: absence or near absence of any signs of
affective expression; voice monotonous, face immobile.
6. Labile affect: rapid and abrupt changes in emotional
feeling tone, unrelated to external stimuli.
Disturbances in mood: mood is a pervasive and sustained
emotion subjectively experienced and reported by a patient and
observed by others; examples include depression, elation, and
anger.
Dysphoric mood: an unpleasant mood.
Euthymic mood: normal range of mood, implying absence of
depressed or elevated mood.
Expansive mood: a person's expression of feelings without
restraint, frequently with an overestimation of their
significance or importance.
Irritable mood: a state in which a person is easily annoyed

Disturbances of consciousness:

Disorientation: disturbance of orientation in time, place, or


person.
Clouding of consciousness: incomplete clear mindedness
with disturbances in perception and attitudes.
Stupor: lack of reaction to and unawareness of
surroundings.
Delirium: bewildered, restless, confused, disoriented reaction
associated with fear and hallucinations.
Coma: profound degree of unconsciousness.
Somnolence: abnormal drowsiness.
Confusion: disturbance of consciousness in which reactions
to environmental stimuli are inappropriate: manifested by a
disordered orientation in relation to time place, or person.
Drowsiness: a state of impaired awareness associated with
a desire or inclination to sleep.
Sun downing: syndrome in older people that usually occurs
at night and is characterized by drowsiness, confusion,
ataxia and falling as the result of being overly sedated with
medications; also called sundowner's syndrome.

Disturbances of attention: attention is the amount of effort exerted


in focusing on certain portions of an experience; ability to sustain a
focus on one activity; ability to concentrate.
1. Distractibility: inability to concentrate attention; state in which
attention is drawn to unimportant or Irrelevant external
stimuli.

and provoked to anger.


Mood swings (labile mood): oscillations between euphoria
and depression or anxiety.
Elevated mood: air of confidence and enjoyment: a mood
more cheerful than usual.
Euphoria: intense elation with feelings of grandeur.
Ecstasy: feeling of intense rapture.
Depression: psychopathological feeling of sadness.
Anhedonia: loss of interest in and withdrawal from all
regular and pleasurable activities, often associated with
depression.
Alexithymia: a person's inability to describe or difficulty in
describing or being aware of emotions or mood.
Suicidal ideation: thoughts or act of taking one's own life.
Elation: feelings of joy, euphoria, triumph, intense self
satisfaction, or optimism.
Hypomania: mood abnormality with the qualitative
characteristics of mania, but somewhat less intense.
Mania: mood state characterized by elation, agitation,
hyperactivity, hyper sexuality, and accelerated thinking and
speaking.
Melancholia: severe depressive state; used in the term
involutional melancholia both descriptively and also in
reference to a distinct diagnostic entity.
La belle indifference: inappropriate attitude of calm or lack of
concern about one's disability.
Anxiety: feeling of apprehension caused by anticipation of
danger, which may be internal or external.
Free-floating anxiety: pervasive, unfocused fear not attached
to any idea.
Fear: anxiety caused by consciously recognized and realistic
danger.
Agitation: severe anxiety associated with motor
restlessness; similar to irritability characterized by excessive
excitability with easily triggered anger or annoyance.
Tension: increased and unpleasant motor and psychological
activity.
Panic: acute, episodic, intense attack of anxiety
associated with overwhelming feelings of dread and

autonomic discharge.
Apathy: dulled emotional tone associated with detachment or
indifference.
Ambivalence: coexistence of two opposing impulses
toward the same thing in the same person at the same
time
Guilt: emotion secondary to doing what is perceived as
wrong.
Impulse control: ability to resist an impulse, drive. or
temptation to perform an action.
Physiological disturbances associated with mood:
Anorexia: loss of or decrease in appetite.
Hyperphagia: increase in intake of food.
Insomnia: lack of or diminished ability to sleep.
o Initial: difficulty in falling asleep.
o Middle: difficulty in sleeping through the night
without waking up and difficulty in going back to
sleep.
o Terminal; early morning awakening.
Hypersomnia: excessive sleeping.
Diurnal variation: mood is regularly worst in the morning,
immediately after awakening, and improves as the day
progresses.
Diminished libido: decreased sexual interest, drive, and
performance (increased libido is often associated with
manic states).
Constipation: inability to defecate or difficulty in defeacating.
Fatigue: a feeling of weariness, sleepiness, or irritability
following a period of mental or bodily activity.
Pica: craving and eating of nonfood substances, such as
paint and clay.
Bulimia: insatiable hunger and voracious eating: seen in
bulimia nervosa and atypical depression.
Disturbances in motor behavior: aspect of the psyche that
includes impulses, motivations, wishes, drives, instincts, and
cravings, as expressed by a person's behavior or motor activity.
Echopraxia: pathological imitation of movements of one
person by another.

Tic: involuntary, spasmodic motor movement.


Sleepwalking (somnambulism): motor activity during sleep.
Akathisia: subjective feeling of muscular tension secondary
to antipsychotic or other medication, which can cause
restlessness, pacing, repeated sitting and standing; can be
mistaken for psychotic agitation.
Convulsion: An involuntary, violent muscular contraction or spasm.
Clonic convulsion: convulsion in which the muscles
alternately contract and relax.
Tonic convulsion: convulsion in which the muscle contraction
is sustained.
Seizure: an attack or sudden onset of certain symptoms,
such as convulsions, loss of consciousness, and psychic or
sensory disturbances; seen in epilepsy and can be
substance- induced.
Generalized tonic- clonic seizure: generalized onset of tonic
clonic movements of the limbs, tongue biting, and
incontinence followed by slow, gradual recovery of
consciousness and cognition; also called grandmal seizure
and psychomotor seizure.
Simple partial seizure: localized ictal onset of seizure without
alterations in consciousness.
Complex partial seizure: localized ictal onset of seizure with
alterations in consciousness.
Disturbances in thinking: Specific disturbances in form and
flow of thought.
Neologism: new word created by a patient, often by
combining syllables of other words, for idiosyncratic psychological reasons.
Word salad: incoherent mixture of words and phrases.
Circumstantiality: indirect speech that is delayed in reaching
the point but eventually gets from original point to desired
goal'; characterized by an overinciusion of details and
parenthetical remarks.
Tangentiality: inability to have goal-directed associations of
thought; speaker never gets from desired point to desired
goal.
Incoherence: thought that generally is not understandable;
running together of thoughts or words with no logical or

Catatonia and postural abnormalities: seen in catatonic


schizophrenia and some cases of brain diseases, such as
encephalitis.
Catatonic excitement: agitated, purposeless motor activity,
uninfluenced by external stimuli.
Catatonic stupor: markedly slowed motor activity, often to a
point of immobility and seeming unawareness of
surroundings.
Catatonic rigidity: voluntary assumption of a rigid posture,
held against all efforts to be moved.
Catatonic posturing: voluntary assumption of an
inappropriate or bizarre posture, generally maintained for
long periods.
Waxy flexibility: condition of a person who can be molded
into a position that is then maintained; when an examiner
moves the person's limb, the limb feels as if it were made of
wax.
Akinesia: lack of physical movement, as in the extreme
immobility of catatonic schizophrenia; may also occur as an
extra pyramidal side effect of antipsychotic medication.
Negativism: motiveless resistance to all attempts to be
moved or to all instructions.
Cataplexy: temporary loss of muscle tone and weakness
precipitated by a variety of emotional states.
Stereotypy: repetitive fixed pattern of physical action or
speech.
Mannerisrn: ingrained, habitual involuntary movement.
Automatism: automatic performance of an act without
thinking about its consequences; representative of
unconscious symbolic activity.
Command automatism: automatic following of suggestions
(also automatic obedience).
Mutism: voicelessness without structural abnormalities.
Psychomotor agitation: excessive motor and cognitive over activity,
usually nonproductive and in response to inner tension.
Hyperactivity
(hyperkinesias):
restless,
aggressive,
destructive activity often associated with some underlying
brain pathology.

grammatical connection, resulting in disorganization.


Perseveration: persisting response to a previous stimulus
after a new stimulus has been presented; often associated
with cognitive disorders.
Verbigeration: meaningless repetition of specific words or
phrases.
Echolalia: psychopathological repeating of words or phrases
of one person by another; tends to be repetitive and
persistent; may be spoken with mocking or staccato
intonation.
Condensation: fusion of various concepts into one.
Irrelevant answer: answer that is not in harmony with the
question asked (person appears to ignore or not attend to
the question).

Loosening of associations: flow of thought in which ideas


shift from one subject to another in a completely unrelated
way; when severe, speech may be incoherent.
Derailment: gradual or sudden deviation in train of thought
without blocking; sometimes used synonymously with
loosening of associations.
Flight of ideas: rapid, continuous verbalizations or plays on
words produce constant shifting from one idea to another;
ideas tend to be connected, and in the less severe form a
listener may be able to follow them.
Clang association: association of words similar in sound but
not in meaning; words have no logical connection; may
include rhyming and punning.
Blocking: abrupt interruption in train of thinking before a
thought or idea is finished; after a brief pause, person
indicates no recall of what was being said or s going to be
said.

Specific disturbances in content of thought.

Poverty of content: thought that gives little information


because of vagueness, empty repetitions, or obscure
phrases.
Overvalued idea: unreasonable, sustained false belief
maintained less firmly than a delusion.
Delusion: false belief based on incorrect inference about
external reality, not consistent with patient's intelligence and
cultural background; cannot be corrected by reasoning.
Bizarre delusion: an absurd, totally implausible, strange false
belief (for example, invaders from space have implanted
electrodes in a person's brain).
Mood-congruent delusion: delusion with mood- appropriate
content (for example, a depressed patient believes that he or
she is responsible for the destruction of the world).
Mood-incongruent delusion: delusion with content that has
no association to mood or Is moodneutral(for example, a
depressed patient has delusions of thought control or
thought broadcasting).
Nihilistic delusion: false feeling that self, others, or the world
is nonexistent or coming to an end.
Delusion of poverty: a person's false belief that he or she is
bereft or will be deprived of all material possesParanoid delusions: includes persecutory delusions and
delusions of reference, control, and grandeur (distinguished
from paranoid ideation, which is suspiciousness of less than
delusional proportions).
Delusion of persecution: a person's false belief that he or
she is being harassed, cheated, or persecuted; often found
in litigious patients who have a pathological tendency to take
legal action because of imagined mistreatment.
Delusion of grandeur: a person's exaggerated conception of
his or her importance, power, or identity.
Delusion of reference: a person's false belief that the
behavior of others refers to himself or herself; that events,
objects, or other people have a particular and unusual
significance. usually of a negative nature; derived from idea
of reference. in which a person falsely feels that others are
talking about him or her (for example, belief that people on
television or radio are talking to or about the person).

Delusion of self-accusation: false feeling of remorse and


guilt.
Delusion of control: false feeling that a person's will.
Thoughts. or feelings are being controlled by external
forces.
Thought withdrawal: delusion that thoughts are being
removed from a person's mind by other people or forces.
Thought insertion: delusion that thoughts are being
implanted in a person's mind by other people or forces.
Thought broadcasting: delusion that a person's thoughts can
be heard by others, as though they were being broadcast
over the air.
Thought control: delusion that a person's thoughts are being
controlled by other people or forces.
Delusion of infidelity (delusional jealousy): false belief
derived from pathological jealousy about a per- son's lover
being unfaithful.
Erotomania: delusional belief. more common in women than
in men. that someone is deeply in love with them
Hypochondria: exaggerated concern about health that is
based not on real organic pathology but, rather, on
unrealistic interpretations of physical signs or sensations as
abnormal.
Obsession: pathological persistence of an irresistible
thought or feeling that cannot be eliminated from
consciousness by logical effort; associated with anxiety.
Compulsion: pathological need to act on an impulse that, if
resisted, produces anxiety; repetitive behavior in response
to an obsession.
Phobia: persistent. Irrational. Exaggerated. and invariably
pathological dread of a specific stimulus or situation;
results in a compelling desire to avoid the feared stimulus.
Specific phobia: circumscribed dread of a discrete object or
situation (for example. dread of spiders or snakes).
Social phobia: dread of public humiliation. as in fear of
public speaking. Performing. or eating in public.
Acrophobia: dread of high places.
Agoraphobia: dread of open places.

Algophobia: dread of pain.


Ailurophobia: dread of cats.
Erythrophobia: dread of red (refers to a fear of blushing)
Pan phobia: dread of everything.
Claustrophobia: dread of closed places.
Xenophobia: dread of strangers.
Zoophobia: dread of animals.
Needle phobia: the persistent. intense. Pathological fear of
receiving an injection; also called blood injection phobia.
Disturbances in speech.
Pressure of speech: rapid speech that is increased in
amount and difficult to interrupt.
Poverty of speech: restriction in the amount of speech
used; replies may be monosyllabic.
Non spontaneous speech: verbal responses given only
when asked or spoken to directly; no self initiation of
speech.
Poverty of content of speech: speech that is adequate in
amount but conveys little information because of
vagueness, emptiness. or stereotyped phrases.
Dysarthria: difficulty in articulation, not in word finding or in
grammar.
Excessively loud or soft speech: loss of modulation of
normal speech volume; may reflect a variety of pathological
conditions ranging from psychosis to depression to
deafness.
Stuttering: frequent repetition or prolongation of a sound or
syllable. leading to markedly impaired speech fluency.
Aphasic disturbances: disturbances in language output.
Motor aphasia: disturbance of speech caused by a cognitive
disorder in which understanding remains but the ability to
speak is grossly impaired; halting, laborious, and inaccurate
speech (also known as Bocas, nonfluent, and expressive
aphasia).
Sensory aphasia: organic loss of the ability to comprehend
the meaning of words; fluid and spontaneous but incoherent
and nonsensical speech (also known as Wernicke's, fluent,
and receptive aphasia).
Nominal aphasia: difficulty in finding correct name for an

object (also termed anomia and amnestic aphasia).


Syntactical aphasia: inability to arrange words in proper
sequence.
Jargon aphasia: words produced are totally neologistic;
nonsense words repeated with various intonations and
inflections.
Global aphasia: combination of a grossly nonfluent aphasia
and a severe fluent aphasia.
Alogia: inability to speak because of a mental deficiency or
an episode of dementia.

Lilliputian hallucination: false perception in which objects are


seen as reduced in size (also termed micropsia).
Mood-congruent hallucination: hallucination in which the
content is consistent with either a depressed or a manic
mood (for example, a depressed patient hears voices saying
that the patient is a bad person; a manic patient hears
voices saying that the patient is of inflated worth, power, and
knowledge).
Mood-incongruent hallucination: hallucination in which the
content is not consistent with either depressed or manic
mood (for example, in depression, hallucinations not
involving such themesas guilt, deserved punishment, or
inadequacy; in mania, hallucinations not involving such
themes as inflated worth or power).
Synesthesia: sensation or hallucination caused by another
sensation (for example, an auditory sensation accompanied
by or triggering a visual sensation; a sound experienced as
being seen or a visual event experienced as being heard).
Command hallucination: false perception of orders that a
person may feel obliged to obey or unable to resist.
Illusion: misperception or misinterpretation of real external
sensory stimuli.

Disturbances of perception
Hallucination: false sensory perception not associated with
real external stimuli; there may or may not be a delusional
interpretation of the hallucinatory experience.

Hypnagogic hallucination: false sensory perception


occurring while falling asleep; generally considered a non
pathological phenomenon.
Hypnopompic hallucination: false perception occurring while
awakening from sleep; generally considered non
pathological.
Auditory hallucination: false perception of sound, usually
voices but also other noises, such as music; most common
hallucination in psychiatric disorders.

Visual hallucination: false perception involving sight


consisting of both formed images (for example, people) and
unformed images (for example, flashes of light); most
common in medicallydeter- mined disorders.

Olfactory hallucination: false perception of smell; most


common in medical disorders.
Gustatory hallucination: false perception of taste, such as
unpleasant taste,
Tactile (haptic) hallucination: false perception of touch or
surface sensation, as from an amputated limb
(phantom limb); crawling sensation on or under the skin
(formication),
Somatic hallucination: false sensation of things occur- ring in
or to the body, most often visceral in origin (also known as
cenesthesic hallucination).

Disturbances of memory.
Amnesia: partial or total inability to recall past experiences;
may be organic or emotional in origin.
Anterograde: amnesia for events occurring after a point in
time.
Retrograde: amnesia for events occurring before a point in
time.
Paramnesia: falsification of memory by distortion of recall.
Retrospective falsification: memory becomes unintentionally
(unconsciously) distorted by being filtered through a person's
present emotional, cognitive, and experiential state .
..Confabulation: unconscious filling of gaps in memory by
imagined or untrue experiences that a person believes but
that have no basis in fact; most often associated with organic
pathology.
Deja vu: illusion of visual recognition in which a new situation

is incorrectly regarded as a repetition of a previous memory.


Deja entendu: illusion of auditory recognition.
Deja pense: illusion that a new thought is recognized as a
thought previously felt or expressed.
Jamais vu: false feeling of unfamiliarity with a real
situation that a person has experienced.
Levels of memory.
Immediate: reproduction or recall of perceived material
within seconds to minutes.
Recent: recall of events over past few days.
Recent past: recall of events over past few months.
Remote: recall of events in distant past.
Intelligence: ability to understand, recall. mobilize, and constructively
integrate previous learning in meeting new situations.
Mental retardation: lack of intelligence to a degree in which
there is interference with social and vocational performance:
mild (IQ of 50 or 55 to approximately 70), moderate (lQ of 35
or 40 to 50 or 55), severe (lQ of 20 or 25 to 35 or 40), or
profound (IQ below 20 or 25); obsolete terms are idiot
(mental age less than 3 years), imbecile (mental age of 3 to
7 years), and moron (mental age of approximately 8 years).
Dementia: organic and global deterioration of intellectual
functioning without clouding of consciousness
Dyscalculia (acalculia): loss of ability to do calculations; not
caused by anxiety or impairment in concentration.
Dysgraphia (agraphia): loss of ability to write in cursive
style; loss of word structure.
Alexia: loss of a previously possessed reading facility; not
explained by defective visual acuity.
Pseudodementia: clinical features resembling a dementia
not caused by an organic condition; most often caused by
depression (dementia syndrome of depression) .
Concrete thinking: literal thinking; limited use of metaphor
without understanding of nuances of meaning; one
dirnensional thought.
Abstract thinking: ability to appreciate nuances of meaning;
multidimensional thinking with ability to use metaphors
and hypotheses appropriately.
Insight: a person's ability to understand the true cause and meaning

of a situation (such as a set of symptoms).


Intellectual insight: understanding of the objective reality of a
set of circumstances without the ability to apply the
understanding in any useful way to master the situation.
True insight: understanding of the objective reality of a
situation, coupled with the motivation and the emotional
impetus
to master the situation.
Impaired insight diminished ability to understand the objective
reality of a situation.
Judgment: ability to assess a situation correctly and to act
appropriately in the situation.

Impaired judgment: diminished ability to understand a


situation correctly and to act appropriately Eidetic image:
visual memory of almost hallucinatory vividness.

ARREVIATIONS
PRACTICE

USED

IN

1. AD - Alzhiemers Dementa
2. VD - Vascular Dementia
3. ADS- Alcohol Dependence Syndrome

CLINICAL

4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.

ODS- Opiod Dependence Syndrome


CDS- Cannabis Dependence Syndrome
NDS- Nicotine Dependence Syndrome
IDS - Inhalant Dependence Syndrome
BZD DS- Benzodiazepine Dependence Syndrome
DT- Delirium Tremens
WS- Withdrawal State
PDD- Persistent Delusional Disorder
ATPD- Acute Transient Psychotic Disorder
SAD- Schizoaffectoive Disorder
BPAD- Bipolar Affective Disorder
RDD- Recurrent Depressive Disorder
DSH- Deliberate Self Harm
OCD- Obsessive Compulsive Disorder
PTSD- Post Traumatic Stress Disorder
AN- Anorexia Nervosa
BN Bulimia Nervosa
OMD Organic Mental Disorder
ADHD Attention Deficit Hyperactivity Disorder
MR Mental Retardation

24.
25.
26.
27.
28.
29.
30.
31.
32.
33.

AA Alcoholic Anonymous
ADD Attention Deficit Disorder
ADL Activities of Daily Living
ECT Electro Convulsive Therapy
OT Occupational Therapy
GAD Generalised Anxiety Disorder
SSRI Selective Serotonin Reuptake Inhibitors
TCA: Tricyclic Antidepressants
ASD Autism Spectrum Disorder
PDD pervasive development disorder

F01Vascular dementia
F01.0Vascular dementia of acute onset
F01.1Multi-infarct dementia
F01.2Subcortical vascular dementia
F01.3Mixed cortical and sub cortical vascular dementia
F01.8Other vascular dementia
F01.9Vascular dementia, unspecified
F02Dementia in other diseases classified elsewhere
F02.0Dementia in Pick's disease
F02.1Dementia in Creutzfeldt-Jakob disease
F02.2Dementia in Huntington's disease
F02.3Dementia in Parkinson's disease
F02.4Dementia in human immunodeficiency virus [HIV]
disease
F02.8Dementia in other specified diseases classified
elsewhere
F03Unspecified dementia
A fifth character may be added to specify dementia in F00F03, as follows:
.x0 Without additional symptoms

The ICD-10
Classification codes of
Mental
and Behavioral
Disordes
F00-F09
Organic, including symptomatic, mental disorders
F00 Dementia in Alzheimer's disease
F00.0Dementia in Alzheimer's disease with early onset
F00.1Dementia in Alzheimer's disease with late onset
F00.2Dementia in Alzheimer's disease, atypical or mixed
type
F00.9Dementia in Alzheimer's disease, unspecified

10

.x1 Other symptoms, predominantly delusional


.x2 Other symptoms, predominantly hallucinatory
.x3 Other symptoms, predominantly depressive
.x4 Other mixed symptoms
F04Organic amnesic syndrome, not induced by alcohol and
other substances
F05Delirium, not induced by alcohol and other psychoactive
substances
F05.0Delirium, not superimposed on dementia, so described
F05.1Delirium, superimposed on dementia
F05.8Other delirium
F05.9Delirium, unspecified
F06Other mental disorders due to brain damage and
dysfunction and to physical disease
F06.0Organic hallucinosis
F06.1Organic catatonic disorder
F06.2Organic delusional [schizophrenia-like] disorder
F06.3Organic mood [affective] disorders
.30 Organic manic disorder
.31 Organic bipolar affective disorder
.32 Organic depressive disorder
.33 Organic mixed affective disorder
F06.4Organic anxiety disorder
F06.5Organic dissociative disorder
F06.6Organic emotionally labile [asthenic] disorder
F06.7Mild cognitive disorder
F06.8Other specified mental disorders due to brain damage
and dysfunction and to
physical disease
F06.9Unspecified mental disorder due to brain damage and
dysfunction and to physical
disease
F07Personality and behavioral disorder due to brain disease,
damage and dysfunction
F07.0Organic personality disorder
F07.1Postencephalitic syndrome
F07.2Postconcussional syndrome
F07.8Other organic personality and behavioural disorder due
to brain disease, damage

and dysfunction
F09Unspecified organic or symptomatic mental disorder
F10--F19 Mental and behavioural disorders due to
psychoactive substance use
F10.-Mental and behavioural disorders due to use of alcohol
F11.-Mental and behavioural disorders due to use of opioids
F12.-Mental and behavioural disorders due to use of
cannabinoids
F13.-Mental and behavioural disorders due to use of
sedatives or hypnotics
F14.-Mental and behavioural disorders due to use of cocaine
F15.-Mental and behavioural disorders due to use of other
stimulants, including caffeine
F16.-Mental and behavioural disorders due to use of
hallucinogens
F17.-Mental and behavioural disorders due to use of tobacco
F18.-Mental and behavioural disorders due to use of volatile
solvents
F19.-Mental and behavioural disorders due to multiple drug
use and use of other psychoactive substances
Four- and five-character categories may be used to
specify the clinical conditions, as follows:
F1x.0 Acute intoxication
.00 Uncomplicated
.01 With trauma or other bodily injury
.02 With other medical complications
.03 With delirium
.04 With perceptual distortions
.05 With coma
.06 With convulsions
.07 Pathological intoxication
F1x.1 Harmful use
F1x.2 Dependence syndrome
.20 Currently abstinent
.21 Currently abstinent, but in a protected
environment
.22 Currently on a clinically supervised
maintenance
or
replacement
regime
[controlled dependence]

11

.23 Currently abstinent, but receiving


treatment
with aversive or blocking drugs
.24 Currently using the substance [active
dependence]
.25 Continuous use
.26 Episodic use [dipsomania]
F1x.3 Withdrawal state
.30 Uncomplicated
.31 With convulsions
F1x.4 Withdrawal state with delirium
.40 Without convulsions
.41 With convulsions
F1x.5 Psychotic disorder
.50 Schizophrenia-like
.51 Predominantly delusional
.52 Predominantly hallucinatory
.53 Predominantly polymorphic
.54 Predominantly depressive symptoms
.55 Predominantly manic symptoms
.56 Mixed
F1x.6 Amnesic syndromes
F1x.7 Residual and late-onset psychotic disorder
.70 Flashbacks
.71 Personality or behaviour disorder
.72 Residual affective disorder
.73 Dementia
.74 Other persisting cognitive impairment
.75 Late-onset psychotic disorder
F1x.8 Other mental and behavioural disorders
F1x.9 Unspecified mental and behavioural disorder

F20.5 Residual schizophrenia


F20.6 Simple schizophrenia
F20.8 Other schizophrenia
F20.9 Schizophrenia, unspecified
A fifth character may be used to classify course:
.x0 Continuous
.x1 Episodic with progressive deficit
.x2 Episodic with stable deficit
.x3 Episodic remittent
.x4 Incomplete remission
.x5 Complete remission
.x6 Other
.x9 Course uncertain, period of observation too short
F21 Schizotypal disorder
F22 Persistent delusional disorders
F22.0 Delusional disorder
F22.8 Other persistent delusional disorders
F22.9 Persistent delusional disorder, unspecified
F23 Acute and transient psychotic disorders
F23.0 Acute polymorphic psychotic disorder without
symptoms of schizophrenia
F23.1 Acute polymorphic psychotic disorder with symptoms
of schizophrenia
F23.2 Acute schizophrenia-like psychotic disorder
F23.3 Other acute predominantly delusional psychotic
disorders
F23.8 Other acute and transient psychotic disorders
F23.9 Acute and transient psychotic disorders unspecified
A fifth character may be used to identify the presence or
absence of associated acute stress:
.x0 Without associated acute stress
.x1 With associated acute stress
F24 Induced delusional disorder
F25 Schizoaffective disorders
F25.0 Schizoaffective disorder, manic type
F25.1 Schizoaffective disorder, depressive type
F25.2 Schizoaffective disorder, mixed type
F25.8 Other schizoaffective disorders
F25.9 Schizoaffective disorder, unspecified

F20-F29 Schizophrenia, schizotypal and delusional disorders


F20 Schizophrenia
F20.0 Paranoid schizophrenia
F20.1 Hebephrenic schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia
F20.4 Post-schizophrenic depression

12

F28 Other nonorganic psychotic disorders


F29 Unspecified nonorganic psychosis
F30-F39
Mood [affective] disorders
F30 Manic episode
F30.0 Hypomania
F30.1 Mania without psychotic symptoms
F30.2 Mania with psychotic symptoms
F30.8 Other manic episodes
F30.9 Manic episode, unspecified
F31 Bipolar affective disorder
F31.0 Bipolar affective disorder, current episode hypomanic
F31.1 Bipolar affective disorder, current episode manic
without psychotic symptoms
F31.2 Bipolar affective disorder, current episode manic with
psychotic symptoms
F31.3Bipolar affective disorder, current episode mild or
moderate depression
.30 Without somatic syndrome
.31 With somatic syndrome
F31.4 Bipolar affective disorder, current episode severe
depression without psychotic symptoms
F31.5 Bipolar affective disorder, current episode severe
depression with psychotic symptoms
F31.6 Bipolar affective disorder, current episode mixed
F31.7 Bipolar affective disorder, currently in remission
F31.8 Other bipolar affective disorders
F31.9 Bipolar affective disorder, unspecified
F32 Depressive episode
F32.0 Mild depressive episode
.00 Without somatic syndrome
.01 With somatic syndrome
F32.1 Moderate depressive episode
.10 Without somatic syndrome
.11 With somatic syndrome
F32.2 Severe depressive episode without psychotic
symptoms
F32.3 Severe depressive episode with psychotic symptoms
F32.8 Other depressive episodes

F32.9 Depressive episode, unspecified


F33 Recurrent depressive disorder
F33.0 Recurrent depressive disorder, current episode mild
.00 Without somatic syndrome
.01 With somatic syndrome
F33.1 Recurrent depressive disorder, current episode
moderate
.10 Without somatic syndrome
.11 With somatic syndrome
F33.2 Recurrent depressive disorder, current episode severe
without psychotic symptoms
F33.3 Recurrent depressive disorder, current episode severe
with psychotic symptoms
F33.4 Recurrent depressive disorder, currently in remission
F33.8 Other recurrent depressive disorders
F33.9 Recurrent depressive disorder, unspecified
F34 Persistent mood [affective] disorders
F34.0 Cyclothymia
F34.1 Dysthymia
F34.8 Other persistent mood [affective] disorders
F34.9 Persistent mood [affective] disorder, unspecified
F38 Other mood [affective] disorders
F38.0 Other single mood [affective] disorders
.00 Mixed affective episode
F38.1 Other recurrent mood [affective] disorders
.10 Recurrent brief depressive disorder
F38.8 Other specified mood [affective] disorders
F39 Unspecified mood [affective] disorder
F40-F48 Neurotic, stress-related and somatoform disorders
F40 Phobic anxiety disorders
F40.0 Agoraphobia
.00 Without panic disorder
.01 With panic disorder
F40.1 Social phobias
F40.2 Specific (isolated) phobias
F40.8 Other phobic anxiety disorders
F40.9 Phobic anxiety disorder, unspecified
F41 Other anxiety disorders
F41.0 Panic disorder [episodic paroxysmal anxiety]

13

F41.1 Generalized anxiety disorder


F41.2 Mixed anxiety and depressive disorder
F41.3 Other mixed anxiety disorders
F41.8 Other specified anxiety disorders
F41.9 Anxiety disorder, unspecified
F42 Obsessive - compulsive disorder
F42.0 Predominantly obsessional thoughts or ruminations
F42.1 Predominantly compulsive acts [obsessional rituals]
F42.2 Mixed obsessional thoughts and acts
F42.8 Other obsessive - compulsive disorders
F42.9 Obsessive - compulsive disorder, unspecified
F43 Reaction to severe stress, and adjustment disorders
F43.0 Acute stress reaction
F43.1 Post-traumatic stress disorder
F43.2 Adjustment disorders
.20 Brief depressive reaction
.21 Prolonged depressive reaction
.22 Mixed anxiety and depressive reaction
.23 With predominant disturbance of other emotions
.24 With predominant disturbance of conduct
.25 With mixed disturbance of emotions and conduct
.28 With other specified predominant symptoms
F43.8 Other reactions to severe stress
F43.9 Reaction to severe stress, unspecified
F44 Dissociative [conversion] disorders
F44.0 Dissociative amnesia
F44.1 Dissociative fugue
F44.2 Dissociative stupor
F44.3 Trance and possession disorders
F44.4 Dissociative motor disorder
F44.5 Dissociative convulsions
F44.6 Dissociative anaesthesia and sensory loss
F44.7 Mixed dissociative [conversion] disorders
F44.8 Other dissociative [conversion] disorders
.80 Ganser's syndrome
.81 Multiple personality disorder
.82 Transient dissociative [conversion] disorders occurring in
childhood and adolescence
.88 Other specified dissociative [conversion] disorders

F44.9 Dissociative [conversion] disorder, unspecified


F45 Somatoform disorders
F45.0 Somatization disorder
F45.1 Undifferentiated somatoform disorder
F45.2 Hypochondriacal disorder
F45.3 Somatoform autonomic dysfunction
.30 Heart and cardiovascular system
.31 Upper gastrointestinal tract
.32 Lower gastrointestinal tract
.33 Respiratory system
.34 Genitourinary system
.38 Other organ or system
F45.4 Persistent somatoform pain disorder
F45.8 Other somatoform disorders
F45.9 Somatoform disorder, unspecified
F48 Other neurotic disorders
F48.0 Neurasthenia
F48.1 Depersonalization - derealization syndrome
F48.8 Other specified neurotic disorders
F48.9 Neurotic disorder, unspecified
F50-F59Behavioural syndromes associated with physiological
disturbances and physical factors
F50 Eating disorders
F50.0 Anorexia nervosa
F50.1 Atypical anorexia nervosa
F50.2 Bulimia nervosa
F50.3 Atypical bulimia nervosa
F50.4 Overeating associated with other psychological
disturbances
F50.5 Vomiting associated with other psychological
disturbances
F50.8 Other eating disorders
F50.9 Eating disorder, unspecified
F51 Nonorganic sleep disorders
F51.0 Nonorganic insomnia
F51.1 Nonorganic hypersomnia
F51.2 Nonorganic disorder of the sleep-wake schedule
F51.3 Sleepwalking [somnambulism]
F51.4 Sleep terrors [night terrors]

14

F51.5 Nightmares
F51.8 Other nonorganic sleep disorders
F51.9 Nonorganic sleep disorder, unspecified
F52 Sexual dysfunction, not caused
by organic disorder or disease
F52.0 Lack or loss of sexual desire
F52.1 Sexual aversion and lack of sexual enjoyment
.10 Sexual aversion
.11 Lack of sexual enjoyment
F52.2 Failure of genital response
F52.3 Orgasmic dysfunction
F52.4 Premature ejaculation
F52.5 Nonorganic vaginismus
F52.6 Nonorganic dyspareunia
F52.7 Excessive sexual drive
F52.8 Other sexual dysfunction, not caused by organic
disorders or disease
F52.9 Unspecified sexual dysfunction, not caused by organic
disorder or disease
F53Mental and behavioural disorders
associated with the puerperium,
not elsewhere classified
F53.0 Mild mental and behavioural disorders associated with
the puerperium, not elsewhere classified
F53.1 Severe mental and behavioural disorders associated
with the puerperium, not elsewhere classified
F53.8 Other mental and behavioural disorders associated
with the puerperium, not elsewhere classified
F53.9 Puerperal mental disorder, unspecified
F54Psychological and behavioural factors associated with
disorders or diseases classified elsewhere
F55 Abuse of non-dependence-producing substances
F55.0 Antidepressants
F55.1 Laxatives
F55.2 Analgesics
F55.3 Antacids
F55.4 Vitamins
F55.5 Steroids or hormones
F55.6 Specific herbal or folk remedies

F55.8 Other substances that do not produce dependence


F55.9 Unspecified
F59Unspecified behavioural syndromes associated with
physiological disturbances and physical factors
F60-F69 Disorders of adult personality and behaviour
F60 Specific personality disorders
F60.0 Paranoid personality disorder
F60.1 Schizoid personality disorder
F60.2 Dissocial personality disorder
F60.3 Emotionally unstable personality disorder
.30 Impulsive type
.31 Borderline type
F60.4 Histrionic personality disorder
F60.5 Anankastic personality disorder
F60.6 Anxious [avoidant] personality disorder
F60.7 Dependent personality disorder
F60.8 Other specific personality disorders
F60.9 Personality disorder, unspecified
F61 Mixed and other personality disorders
F61.0 Mixed personality disorders
F61.1 Troublesome personality changes
F62 Enduring personality changes, not attributable to brain
damage and disease
F62.0 Enduring personality change after catastrophic
experience
F62.1 Enduring personality change after psychiatric illness
F62.8 Other enduring personality changes
F62.9 Enduring personality change, unspecified
F63 Habit and impulse disorders
F63.0 Pathological gambling
F63.1 Pathological fire-setting [pyromania]
F63.2 Pathological stealing [kleptomania]
F63.3 Trichotillomania
F63.8 Other habit and impulse disorders
F63.9 Habit and impulse disorder, unspecified
F64 Gender identity disorders
F64.0 Transsexualism
F64.1 Dual-role transvestism

15

F64.2 Gender identity disorder of childhood


F64.8 Other gender identity disorders
F64.9 Gender identity disorder, unspecified
F65 Disorders of sexual preference
F65.0 Fetishism
F65.1 Fetishistic transvestism
F65.2 Exhibitionism
F65.3 Voyeurism
F65.4 Paedophilia
.5 Sadomasochism
F65.6 Multiple disorders of sexual preference
F65.8 Other disorders of sexual preference
F65.9 Disorder of sexual preference, unspecified
F66 Psychological and behavioural disorders associated with
sexual development and orientation
F66.0 Sexual maturation disorder
F66.1 Egodystonic sexual orientation
F66.2 Sexual relationship disorder
F66.8 Other psychosexual development disorders
F66.9 Psychosexual development disorder, unspecified
A fifth character may be used to indicate association with:
.x0 Heterosexuality
.x1 Homosexuality
.x2 Bisexuality
.x8 Other, including prepubertal
F68 Other disorders of adult personality and behaviour
F68.0 Elaboration of physical symptoms for psychological
reasons
F68.1 Intentional production or feigning of symptoms or
disabilities, either physical or psychological [factitious
disorder]
F68.8 Other specified disorders of adult personality and
behaviour
F69 Unspecified disorder of adult personality and behaviour
F70-F79 Mental retardation
F70 Mild mental retardation
F71 Moderate mental retardation
F72 Severe mental retardation
F73 Profound mental retardation

F78 Other mental retardation


F79 Unspecified mental retardation
A fourth character may be used to specify the extent of
associated behavioural impairment:
F7x.0 No, or minimal, impairment of behaviour
F7x.1 Significant impairment of behaviour requiring attention
or treatment
F7x.8 Other impairments of behaviour
F7x.9 Without mention of impairment of behaviour
F80-F89 Disorders of psychological development
F80 Specific developmental disorders of speech and language
F80.0 Specific speech articulation disorder
F80.1 Expressive language disorder
F80.2 Receptive language disorder
F80.3 Acquired aphasia with epilepsy [Landau-Kleffner
syndrome]
F80.8 Other developmental disorders of speech and
language
F80.9 Developmental disorder of speech and language,
unspecified
F81 Specific developmental disorders of scholastic skills
F81.0 Specific reading disorder
F81.1 Specific spelling disorder
F81.2 Specific disorder of arithmetical skills
F81.3 Mixed disorder of scholastic skills
F81.8 Other developmental disorders of scholastic skills
F81.9 Developmental disorder of scholastic skills,
unspecified
F82 Specific developmental
disorder of motor function
F83 Mixed specific developmental disorders
F84 Pervasive developmental disorders
F84.0 Childhood autism
F84.1 Atypical autism
F84.2 Rett's syndrome
F84.3 Other childhood disintegrative disorder
F84.4Overactive disorder associated with mental retardation
and stereotyped movements
F84.5 Asperger's syndrome

16

F84.8 Other pervasive developmental disorders


F84.9 Pervasive developmental disorder, unspecified
F88 Other disorders of psychological development
F89 Unspecified disorder of psychological development
F90-F98 Behavioural and emotional disorders with onset
usually occurring in childhood and adolescence
F90 Hyperkinetic disorders
F90.0 Disturbance of activity and attention
F90.1 Hyperkinetic conduct disorder
F90.8 Other hyperkinetic disorders
F90.9 Hyperkinetic disorder, unspecified
F91 Conduct disorders
F91.0 Conduct disorder confined to the family context
F91.1 Unsocialized conduct disorder
F91.2 Socialized conduct disorder
F91.3 Oppositional defiant disorder
F91.8 Other conduct disorders
F91.9 Conduct disorder, unspecified
F92 Mixed disorders of conduct and emotions
F92.0 Depressive conduct disorder
F92.8 Other mixed disorders of conduct and emotions
F92.9 Mixed disorder of conduct and emotions, unspecified
F93 Emotional disorders with onset specific to childhood
F93.0 Separation anxiety disorder of childhood
F93.1 Phobic anxiety disorder of childhood
F93.2 Social anxiety disorder of childhood
F93.3 Sibling rivalry disorder
F93.8 Other childhood emotional disorders
F93.9 Childhood emotional disorder, unspecified
F94 Disorders of social functioning with onset specific to
childhood and adolescence
F94.0 Elective mutism
F94.1 Reactive attachment disorder of childhood
F94.2 Disinhibited attachment disorder of childhood
F94.8 Other childhood disorders of social functioning
F94.9 Childhood disorder of social functioning, unspecified
F95 Tic disorders
F95.0 Transient tic disorder
F95.1 Chronic motor or vocal tic disorder

F95.2 Combined vocal and multiple motor tic disorder [de la


Tourette's syndrome]
F95.8 Other tic disorders
F95.9 Tic disorder, unspecified
F98 Other behavioural and emotional disorders with onset
usually occurring in childhood and adolescence
F98.0 Nonorganic enuresis
F98.1 Nonorganic encopresis
F98.2 Feeding disorder of infancy and childhood
F98.3 Pica of infancy and childhood
F98.4 Stereotyped movement disorders
F98.5 Stuttering [stammering]
F98.6 Cluttering
F98.8Other specified behavioural and emotional disorders
with onset usually occurring in childhood and adolescence
F98.9Unspecified behavioural and emotional disorders with onset
usually occurring in childhood and adolescence
F99 Unspecified mental disorder
F99 Mental disorder, not otherwise specified

17

Assisting
10.00-11 am

11.00 am 12.30

Medication
change

administration

based

on

order

Documentation & chart checking


discharge procedure if any
sending all patients for OT

12.30- 1.00 pm

Lunch

2.00-3.30 pm

Medication and documentation

3.30- 4.30 pm

Report writing & handing over

Administ

Assisting
therapy
Presentin
Carrying

4.30- 5.00 pm
Patient visit documentation
5.00 pm
Medication and documentation
8.30-9.00 pm
Medication and documentation
9.30 pm
After 9.30

DAILY WARD ROUTINES

TIME
8.00-8.30 am

NURSES ACTIVITY
Handing over
Inventory checking
Prayer

8.30- 8.45 am

Patient unit visit and documentation

8.45 -9.00 am

Bed making
Maintenance of patient unit

9.00-9.15 am

Orderly maintenance
collection

9.15- 10.30 am

Rounds

Lights off

Any emergency comes intimate to duty


doctors
Checking the sleeping pattern of
patients

PROFESSIONAL BEHAVIOR TO BE MAINTAINED BY THE


NURSES WHILE HANDLING PATIENTS WITH PSYCHIATRIC
DISORDERS
of

drugs

&

report

18

Display professional behavior while interacting and caring for


the patients with psychiatric disorders.
o Never disclose your personal details to the patient
and relatives.
o Avoid wearing ID Tag by the staff and students.

3- 4pm r

o
o

o
o

o
o
o
o
o

o
o

Be in proper uniform, should be properly groomed


and dressed while on duty.
Maintain the boundaries of time, space while
interacting with the patients to avoid transference,
counter transference.
Address the patient by their name, which will convey
acceptance and respect to the patient.
Convey empathy and warmth to the patient; try to
understand patients behaviour from their context in
order to understand the meaning of patients
behavior.
Establish therapeutic nurse patient relationship
keeping in mind about the professional boundaries.
Maintain good rapport with the patient and their
family members.
Nurse should display emotional maturity in their
behaviour.
Treat all patients equally irrespective of their caste,
rich or poor.
Never allow physical punishment to the patient by
other patients, relatives, security or other staff
members.
Approach aggressive/ violent patient with extreme
calmness, firm approach.
Spend more time with patient with depression,
decreased talk, decreased self care, decreased food
intake.
Spent less time with manic patients; but ensure
patients nutritional needs are met, safety issues are
properly tackled.
Be firm and calm while interacting with
aggressive patients
Never argue/ provoke the patient who is
irritable/ aggressive.
If patient is irritable and argumentative;
leave the patient alone for a while and
approach the patient in a calm and quiet
manner.

Avoid using harsh punitive words while


caring aggressive patients.
Explain the procedure to the patient and bystanders
and keep hospital policies and procedures while
doing procedures (administering injection, dressing,
inserting IV Cannula, checking vitals etc).

THERAPEUTIC COMMUNICATION TECHNIQUES


1. Active listening: listen to patients feelings, problems ,
issues without making any comment.
2. Giving broad opening encouraging patient to talk openly
3. Restating: Repeating the main thought expressed by
the patient. nurse is listening and validates, reinforces
or calls attention to something important that has For
example, "You
say that your mother left you when you were
five years old."
4. Clarification: Attempting to put vague ideas or unclear
thoughts of the patient into words
to enhance the nurse's understanding or asking the
patient to explain what he means.
For example, I am not sure what you mean. Could you
tell me about that again?"
5. Reflection: Directing back the patient's ideas, feelings,
questions and content. For example
"You are feeling tense and anxious what happened?
6. Humor: The discharge of energy through comic
enjoyment
7. Informing: The skill of information giving.For example,
"I think you need to know more
about your medications."
8. Focusing: Questions or statements that help the
patient expand on a topic of importance.
For example, "I think that we should talk more about

19

14. If the patient is irritable and restless, restrain them and give
PRN medicine according to doctors order
15. If patient is drowsy after giving PRN medication, withhold
the next dose,
16. if the patient is not willing to take food or not able to take
food or medicine consult concern doctor and start IVF.
17. Written consent to be taken from the bystanders.

your relationship with your father."


9. Sharing perceptions: Asking the patient to verify the
nurse's understanding of what the
patient is thinking or feeling. For example, "You are
smiling, but I sense that you are really
very angry with me."
10. Theme identification: This involving identi- fication of
underlying issues or problems experienced by the
patient that emerge repeatedly during the course of the
nursepatient relationship. For example, "I noticed
that you said you have been hurt or rejected
by the man. Do you think this is an underlying
issue?"
11. Silence: Lack of verbal communication for a
therapeutic reason. For example, sitting with
a patient and non-verbally communicating interest and
involvement.

SAFETY ISSUES FOR NURSES

PATIENT SAFETY ISSUES

1. Do not allow the patient and bystanders to keep sharp object


and glass items
2. All medicine should be handed over to the nurse including
bystanders medicine
3. Door lock has not been kept in any of rooms and bath rooms
4. Switch board should be kept away from patient unit
5. Explain ward rules to the patient and bystanders at the
admission time
6. Allow to keep necessary items near to the patient
7. Only one bystander allowed for normal patient .if the patient
is in isolation two bystanders is allowed.
8. If the patient is having suicidal ideation explain the risk of
keeping long shall belt ect to the bystanders.
9. Observe isolation patient frequently
10. Monitor vital signs in each shift and record it
11. Sharp object and glass item should be kept away from
patient.
12. Two bystanders are allowed to isolation patient.
13. Bystanders should monitor the patient even they are going
to toilet

Only use minimum necessary article while doing procedure


to avoid injury
Do not use ID tag
Do not visit patient unit alone, especially violent patients in
the isolation. Ask the attender to accompany with you. let
him stand near to the patient.
If the patient get violent, restless or irritable shift them to
isolation and give restrain.
Do not provoke the patient argue with them.
Do not reveal nurses identity/ personal details to the patient
Bystanders are not suppose to leave the ward without
informing staff/ nurses
Written concern to be taken from bystanders

OCCUPATIONAL THERAPY: ROLE OF STAFF NURSE AND


STUDENT
I.
II.
III.

Encourage the patient to involve activities


Assess the patient activity level and prognosis
If the patient is violent and irritable not send to OT.

BIO MEDICAL WASTE MANAGEMENT


Dispose the waste safely as per hospital policy and protocols.
Yellow

20

Human tissues, lab cutlers, organs, body parts,


cotton dressing ,solid plaster casts, bedding
contaminated with blood

Red
Blue
Black

Tubings, catheters, gloves, intravenous sets.


Sharp needle syringes, blades, scalpels, glasses
Discarded medicines, paper waste ,cytotoxic drugs

3.
4.
5.
PREPARATION OF PATIENT UNIT

6.

1. Choose bed appropriate to patient condition (Whether


isolation bed or non isolation bed)
2. Prepare bed according to the patient condition
3. Patient unit consist of one bed, one locker, one stool, that
should be clean.
4. Avoid placing iv stand in the ward unnecessary
5. All switch board should be placed away from the patient.
6. Ensure that the linen is changed when it is dirty, provide
clean bed.
7. Keep the bed alignment in the unit properly.

7.

8.

9.

10.

PATIENT ADMISSION
PROTOCOL

11.

ADMISSION PROCEDURE
Admission to psychiatric inpatient can be either from Psychiatry OPD
or from Casualty

12.

1. Welcome the patient to the ward; nurse should receive the


patient to the ward. Check the admission sheet; confirm the
name of the patient, address, age and gender of the patient,
name of the treating doctor and date and time of admission.
2. If admission is coming from casualty enquire about the
patients status to the nurse in the casualty; if patient is

13.
14.

21

violent or need constant supervision or sick make provision


to provide isolation room.
a. If patient is coming from casualty and is a new
patient in this hospital make them to pay the
psychiatric consultation charge of Rs 75/Check the weight of the patient if patient is cooperative, if
uncooperative check weight later.
Assign the bed and orient the patient to their bed; give
admission counseling to the bystanders.
Take the consent of admission from the bystanders in the
backside of the inpatient case record.
Enter the newly admitted patient details in the admission and
discharge book and intimation book.
If patient is restless/ violent and if injections e.g
serenace/lopez is not given at casualty; chemically restrain
the patient if PRN order of inj Haloperidol+phenargan/ Inj
Lopez is written in the doctors order sheet.
Check vitals and document in the TPR chart and in the
inpatient case record (baseline vital parameters i.e.
Temperature, Pulse, RR, Weight at the time of Admission)
Enquire about whether the patient had food; if medication
order is written in the order sheet give oral medication after
ensuring the patient had taken food.
Enquire about any payment done before admission , if not
paid make them to do the advance payment of Rs 1500/- if
they do not have money with them they need to produce
letter from PRO claiming of payment afterwards and that
letter need to be attached with the inpatient chart.
Investigations investigations like blood routine/ urine
routine if not done during the past 6 months, carry out the
standing order of investigation( perform blood and urine
routine, if confused and elderly serum Na+ , K+). Send
the other blood investigations as per doctors order.
Admission inpatient case record has to be kept in the
concerned in the ward inpatient chart folder.
Keep the OP charts in the respective OP Folder of the
respective bed no and keep it in the cupboard.
Ask the bystanders to submit the patient medications as well
as bystander medication to the nurses station. Keep the
medication in the concerned box as per the bed no.

15. Bystanders medications have to be kept separately in cover


with the name of the bystanders and kept in the same box.
16. Complete the nurses chart; write the receiving notes in the
nurses chart.
17. Receiving notes should contain:
a. Date and time of admission , whether admission is
from OPD / Casualty, brought by whom( relative /
police/ neighbors), k/c/o specify the diagnosis,
presenting chief complaints, record the present
condition of the patient( conscious/ orientation, mood
affect, thought , perception), whether patient is
cooperative/ noncooperative. Whether admission
counseling is given, recorded the vitals.
18. Prepare the medicine cardex with the patient name IPNO,
medication details with signature of the staff in the respective
timings.
19. Write the Doctor name, PG Student in charge name in the
top of Doctor Order sheet.
20. Assign Bed no of the patient in the computer
21. Check the belongings of the patient with the help of attender
or security for sharp and hazardous items, if found it has to
be labeled (name of the patient, hospital no, Bed No,DOA)
and kept in the store room and one slip ( name , specify the
things ) need to be kept in the concerned medicine box.

F&G ward: Rs 120/day


12. Any one attender should be with the patient for 24hours,
( Two bystanders can stay if the patient is violent) .
13. Bystanders should not leave the ward without informing
sister on duty. Never leave the patient alone
14. Doctors rounds timings ; morning 9am-11am
15. Visiting time: visitors are not permitted during morning
rounds timings. During night i.e. from 9pm-6am, no visitors
are allowed and the ward remains closed.
16. Patient belongings
a. Keep only necessary dresses and other items near
to patient
b. Never keep valuables in the ward like money,
jewellary, ATM card, if it gets lost the hospital
authorities are not held responsible.
c. Baggages will be checked by the security / nurse at
the time of admission for sharp instruments, belt,
knife, scissor, pin, blade, belt , breakable things,
helmet, flask ,rope, beedi, alcohol, walking stick,
long umbrella, sari, rope, belt, shawl etc. If found it
has to be handed over to the nurse and will be kept
labeled in nurses custody and will be return back on
the time of discharge.
d. Hand over the medications of the patient as well as
the bystanders to the nurse, in order to maintain the
safety, left over medicines will be return back to
patient at the time of discharge.
17. Explain about the routine tests like blood test, x-ray, TFT,
ECG, lithium(If required)
18. Explain about the canteen facilities (K3 ward canteen
Advance Rs 300/day), chapel facility.
19. Specific instructions to the bystanders regarding rules and
regulations and ward behavior.
a. Never say opinion, critize or laugh at other patients.
b. Smoking, drinking, tobacco uses are strictly
prohibited in the ward.
c. Never quarrel with others patients
d. Obey the rules and regulations in the ward.
e. Keep the patient room clean, keep minimum things
f. Never allow the patient to sleep during day time

ADMISSION COUNSELING
8. Welcome the patient and relatives to the ward
9. Orient the patient and bystanders about their bed , the ward
and ward routines, include nurses station, occupational
therapy room, bath room, drinking water, food facilities,
entertainment activities, doctors visiting time.
10. Explain the minimum duration of stay expected is 1-2 weeks.
Never expect sudden changes because the effect of
medicine will take two weeks time for proper effect.
11. Explain about the details of room rent/ cost of hospital stay
K3 ward :
Single room Rs 720/day;
Double room Rs395/day
Advance for single room-RS 4000/- and
double room Rs 2500/-

22

20.

21.

22.

23.

g. Bystanders are not suppose to leave the ward with


out in forming staff nurses
h. No visitors are permitted during the time of doctors
visit.
i. Male bystanders are not permitted with female
patients during night time , they have to sleep
outside the female cubicle.
j. Mobile phones are to be switch off or make it silent
mode from 9pm to 6 am
k. Patients are not supposed to use mobiles.
l. Only one bystander is allowed to stay with the
patient during night admission.
m. Bystanders need to inform, if the patient is not
sleeping during night to the night duty nurse
In order to assure the safety of suicidal ideation patient, lock
has not been kept in any of the bath rooms, inside any
rooms.
Enquire about any medical illness, previous treatment
records and if any; ask them to handover the records to the
nurse next day.
Occupational therapy- Occupational therapist will be
conducting daily OT sessions at 11am to 12.30pm in F&G
ward; 3-4pm at K3 ward.
a. Its mandatory for all the patients to attend the OT as
it is a part of treatment (except the patient is violent
or unmanageable).
b. Relatives are not permitted inside the OT room
during the session
Bystanders need to ensure that their patient is drinking
plenty of fluids (2-3l/day) to avoid unwanted side effects of
medicines.

V.

PATIENT DISCHARGE PROTOCOL


DISCHARGE COUNSELING
IV.

About mental illness


a. Mental illness is similar to other chronic illness like
diabetes or hypertension. It is caused by the
disturbance in chemicals in the brain. Imbalance in

23

the neurochemicals leads to sleep disturbance and


onset of symptoms.
b. Psychiatric medications correct these imbalances in
the brain neurochemicals and cause reduction in
symptoms by crossing the blood brain barrier.
Medication has to be taken for longer duration to
achieve and sustain remission. If patient
continuously takes the medicines without missing
any doses; its helps in maintaining the chemicals in
the brain and control mental illness.
c. Abrupt stopping of medications or missing multiple
doses leads to lowering drug level in the brain and
which causes neurotransmitter imbalance which
ultimately leads to relapse.
d. Never expect sudden changes in the patients
behavior soon after initiating the drug treatment
because the effect of medicine will take two weeks
time for proper effect
Importance or medication compliance
a. Explain the medications, its dose and time to the
bystander in detail.
b. Medications have to be administered to the patient
by a responsible family member, never allows the
patient to take medicines unsupervised.
c. Ensure that the patient swallowed the medications.
Advice patient to take medication along with food,
i.e. first the medicine then food.
d. Is you doubt that the patient is spitting medication or
refusing medication, crush and mix the powdered
medications in the gravy of the curry or inform the
doctor.
e. Take medications at correct time at correct dose.
Never stop, increase or decrease the medicine
without doctors order.
f. Is you forget the morning dose, never double the
dose during night, if you remember within 11am take
the morning dose , and all other doses should be
taken in the prescribed time.
g. Patient is not allowed to stop medication even
though any physical disturbances appear.

VI.

VII.

VIII.

h. Never chose medicine by them self, never take any


over the counter drugs without prescription, as this
drugs may cause drug interaction and can be
harmful for the body.
i. Take necessary documents related to their illness
and medication if the patient is going and meeting
any other doctors.
j. Keep one or two tablets of all medications in patient
purse while travelling. Try not to skip medicine.
k. Refill the medication before 2days of finishing the
stock.
Diet and fluid intake
a. Drink plenty of water, while taking medicine drink at
least one glass of water in a day tell the patient to
drink 8-10 glass of water.
b. Try to avoid coffee, tea or excess water after 6pm;
as it can disturb night time sleep. After 6pm drink
one full glass of water for taking night time
medications. Ensure the patients voids before going
to bed at night.
c. Try to avoid fluids in evening as much as possible, it
may leads to insomnia
d. Include fiber diet like, vegetables, fruits in order to
prevent constipation.
Special advice regarding lithium and dietary sodium
intake:
a. Patient can take dietary salt in normal level. Never
use excess salt, nor avoid salt completely from food.
The level of lithium in the body has to keep in
equilibrium. Excess salt intake will decrease the
lithium level, and avoiding dietary salt leads to
lithium toxicity. Both are serious, if patient complains
about tremors, vomiting, slurred speech, ataxia,
confusion ; consult doctor immediately
i. Avoid salty foods like, canned foods, salted
mango, salted fish, papad, pickle
Life style modification
a. Never sleep during morning; if patient sleeps during
day time , their night time sleep will be disturbed

IX.

24

b. Encourage the patient to participate tin day today


activities
c. Sleep at least 8 hrs in night. Avoid night awakening
factors as much as possible like awakening for
urination, noise of television. If the patient doesnt
sleeps well at night for 2 days, report to the doctor
as sleep disturbance is the earliest sign of relapse.
d. Patient cannot tolerate stress as they are mentally ill;
so never disclose too much stressful issues of the
family to the patient. Never involve the patient in too
much stressful life situations.
e. Refrain the patient from those situations where their
night time sleep can get hindered E.g night vigil,
night prayers, marriage, death etc. make
arrangements for the patient to visit those places
before 8pm so that patient can sleep on time.
f. Exercise: encourage the patient to do exercise like
walking, doing house hold activities, in order to avoid
weight gain doe to the medications.
g. Avoid Alcohol and tobacco consumption; as it
will ruin the effect of the medicines or cause
excessive side effects.
Importance of regular follow-up visits
a. Do follow up visit as per doctors advice; Proper
follow up is necessary for sustaining recovery in
patients conditions.
b. Lithium blood test : during follow-up visits if serum
lithium test is been prescribed, instruct the bystander
and patient that morning medications should be
given only after giving the blood sample to check
lithium level.
c. Try to bring your patients while coming for follow-up,
avoid proxy follow up unless permitted by the doctor.
d. Do not wait for the follow-up day if the symptoms
worsen, immediately bring the patient to the
casualty.
e. Identify the signs and symptoms of relapse and seek
treatment before the condition worsens.

f.

Do report any medications side effects like, nausea


vomiting, stiffness, drooling, excessive tremors,
muscle rigidity etc at the earliest to the doctor.

click the respective medicine to be credited------enter the number of tablets to be credited ----enter
the IPNo---- save.
9. Hand over the medicines to be credited with the bystanders
in the cover with medicine bill /IP NO/name/ward
10. Writing medicine in the medicine cover

WARD DISCHARGE PROCEDURE


1. Confirm discharge from the treating doctor, see if the
discharge is against medical advice/ at request / normal
discharge
2. Check for the duration of first follow advice/ for no
medication from the treating doctor
3. If the patient is discharge against medical advice and
discharged with no medication/ if the patient is fit for
discharge make sure that the patient bystanders gives
consent for discharge in the discharge form or detailed
consent explaining the risk of discharge and acceptance of
the risk by the bystanders with bystanders name, relation
and sign.
4. Nurse should see the number of days after which the
patient is asked to do follow up in psychiatry the nurse
should provide one day medicine extra.
5. Check the medicines in the medicine box the number of
prescribed tables available in the medicine box, count the
number of days for which the medicine is advised and
calculate the number of tables to be purchased from the
pharmacy.
6. Indenting the medicine from the pharmacy by entering
in the computer.
7. Click on the patient bed number ---- click on the order---medication
----enter the medicine 1 st two letter
only ---enter ---- number of medicine needed --enter IP No
below-----Specify the pharmacy A &
D------save .
8. Crediting Medicine
a. Depending up on the medicine cost and the number
of medicine pending if the medicine is costly and if
more than 1 strip left ---- credit the medicine
b. Click on return to pharmacy ----- IP number ----Change the date of admission------from the
details of medicine intended from pharmacy ------

Medicine name and Dose


Tab. HALIDACE 5 mg BD
One tablet In the morning at 9
am
One tablet In the night at 9 am

11. Give specific instructions related medications as listed


below
12. AM OD
--before food
13. HR PRN
--if the patient is not sleeping after 11
administer PRN dose
14. Picolax
--advice not to take if patient is having
loose stool/watery stool
15. Mention
---if deeded to be taken in empty
stomach, specify the time
16. BD
---9 am to 9 pm
17. TID
----9-5-9
a. Tab Pacitane TID
---9-5-9
1. BD
---9-1-5
2. 1-1-0 ---9-5
b.
Antibiotics TID
---6-2-10
QID
----6-12-6-12
18. If diabetics , medicine has to be give with food or
immediately after food
19. Back side of cover if any medicine name is written cut the
name
20. When relative bring the purchased medicine, keep the
respective cover, recheck the medicine and tally the total
number is correct or not.
21. See the medicine box, if there is any slip of the belongings
in nurses custody; return the item to the bystanders and
cross the slip with signature.

25

22.
23.
24.
25.

26.
27.
28.
29.
30.
31.

32.

33.
34.
35.
36.
37.
38.
39.
40.
41.
42.

43.
44.

Billing procedure
Take the billing sheet
Write the discharge date. Tick the final bill
If
any
injection/accucheck/gloves/canula/dressing/GOTI/catheter/
nebulization
Isolation charge from ---- to ----Good will diet with date and number of days
Put signature of ward in charge
Send the billing sheet to billing section
Computer discharge procedure
Click patient ---Bed number----click ----- view --- from
admission date ---- any pending cancellation required-----medicine returns if any investigation pending

cancel all pending items.


If lab request is pending
----Inform over phone to lab the request no, hospital no and
request to cancel. If radiology/ medicine
request is
pending -----cancel the request
If nothing pending ----give discharge intimation in
computer click---- patient ------give discharge intimation
------ discharge status ------ alive/AMA/ death------Click on
alive /AMA-------- Save.
Attender will bring the discharge bill
Send the bill with bystander for payment in the cash
counter.
Due payment is done ----- see the bill payment provide
detailed discharge counseling to patient and bystanders
Give
book
medicine
/serum
lithium
slip/FBS/PBBS/TCDC/slip with explanation to own relatives
Now the patient can leave the ward, tell the security to open
the gate.
Enter the patient details in discharge book
Once the patient check the bed side
Enter the patient details in discharge book
Nurses note
time & date, discharge advice given, with whom patient left
the ward, any left the ward, any slip is give medicine
explained and given signature
OP chart and IP chart attach and keep in the attainders
table
Enter the discharge in the computer

45. Click request ------ discharge


------IP No/ward -----view patient details-----confirm--------- click
discharge
46. Group discharge
click request
discharge
-----ward view -----all patient details------ confirm all
patient---click discharge of patient------- discharge.

DOCTORS
ROUNDS
RESPONSIBILITIES

AND

NURSES

Before rounds:

Make sure that all staff members attend main rounds but
one staff nurse will stay in the nurses station to carry out
change in the medication order in the cardex before
giving morning medications and ensure that the new
order/ order change has been carried out .
Keep the newly admitted patients OP Chart ready before
rounds itself.
Check for any pending investigations results, if any--enter in the investigations sheet.
Any abnormal results found, a separate card has to be
mention and put above the order sheet in order to make
sure of doctors notification.
Students has to attend the rounds of their corresponding
patients and they must stand near to that patient with
patient chart
During the time of rounds:

26

Patient charts has to be produced during rounds


Ensure the rounds book has to be taking over during
rounds, any specific notifications, new order medication,
night PNR order has to be notified in the book.
Staff has to give explanation regarding the condition of
the patient, the level of sleep and any specific problems
made by the patients
The consultant doctor will see only his/her patient during
daily visit.

Main rounds will be carried out by corresponding allowed doctors


on each day

Check any side effect present like dry mouth, blurring of


vision, tremors, EPS etc.

Days
Monday and Friday
Wednesday
Tuesday and Saturday
Thursday

Doctors name
SPECIAL INSTRUCTION RELATED TO PROCEDURES IN
Dr. TR John
Dr.Subalakshmi
PSYCHIATRIC UNIT
Dr.Nisha
Never carry thermometer tray for checking temperature,
Dr. Joseph Varghese
carry thermometer in hand with needed cotton to swipe.
Never do any procedures like dressing, nebulization in
After rounds
the bedside; bring the patient to the treatment room, do
Change the order sheet:
the procedures.
Ensure that the order sheet has been draped fully if the
space is inadequate for the next day or any drastic
changes in medicine order
In the order sheet the corresponding psychiatrist and PG
student name has to mention on the top.
Carry out if any consultation / review is advised
immediately after the rounds.
After rounds, rounds book has to be cross checked with
rounds order book,
Any changes in medicine order that has to be started
from 10 clock medicine its self, and carried out medicine
has to be labeled as a small tick mark in red pen for
easy understanding

PSYCHIATRIC NURSING
DOCUMENTATION GUIDELINES

A. Guidelines for documenting patient condition in the


nurses daily chart.
1. Consciousness and orientation: record whether the
patient is conscious and oriented
a. If any Deviation such as : disorientation specify
disoriented to person, place, time, date/
Confusion/ stupor etc
2. Record any serious physical problems such as fever,
breathlessness , pain etc
3. Vital parameters: are within normal limit/ specify if
abnormal
4. Abnormal physical s/s
a. Withdrawal s/s:nausea
/vomiting/sweating/tremors/s/s of delirium
tremens

MEDICINE ADMINISTRATION
GUIDELINES

For isolation patients / medicine refusal patients, make sure


that security or attainders accompany the staff nurse.
Assess the mood and status of the patient; if the patient is
slightly irritable tactfully handle the patient verbally.
Identify name, IP number and other details while giving
medicines.
Give minimum a glass of water to the patient for taking
medicine and make sure that patient swallow the medicine.
Do not allow the patient to go for bathroom or any where
immediately after medicine intake

27

5.
6.

7.

8.

9.

10.

11.

b. Medication side effects :


tremors/dystonia/akathesia/drooling/
hypotension etc
Overall
behavior:
cooperative/
uncooperative/
violent/suicidal/aggressive
Speech: relevant , coherent and goal directed/irrelevant/
incoherent/over talkative/mute/decreased talk/singing
songs
Psychomotor
activity(PMA):
normal/increased/decreased/
restless/hyperactive/hypoactive
Mood ( subjective emotional expression assessed by
asking (how is your mind now?) note whether the patient
mood
is
Euthymic(normal)/
dysthymic(
mild
sadness/depressed(
severe
sadness)/dysphoric(
unpleasant/
irritable)/euphoric(
cheerfulness
than
usual)/elated(
overchearfulness
with
hyperactivity)/exalted (intense elation with grandiosity)/
labile(frequently changing)
Affect(objective
emotional
state)
sad/happy/fearful/suspicious/blunted/constricted
/flat/apathetic (record whether mood is appropriate to
affect)
Thought
a. Any delusions present; if yes specify the type of
delusions
such
as
persecution/grandiose/infidelity/nihilistic/
somatic/hypochondriacal etc
b. Thought
insertion/control/withdrawal/broadcasting
c. Loosening
of
association/flight
of
ideas/circumstantiality
d. Depressive
cognitions:
hopelessness/helplessness/worthlessness/
suicidal thoughts
e. Obsession/compulsion/phobia
Perception

12.

13.

14.
15.
16.

a. Note for hallucination :if yes specify the modality


such
as
auditory/visual/tactile/
olfactory/gustatory
b. If auditory note whether is commanding
/persecutory in content
Cognitive status: normal cognition/ record if any specific
impairment
in
memory/judgment/concentration/attention/insight
Nutrition and elimination status
a. Parentral nutrition: getting IV fuids,mention
cannula site/ patency
b. Taking adequate food and fluids orally/
inadequate/ eats on compulsion/ryles tube
feeding/jejunostomy feeding/colostomy feeding
etc.
c. Bladder elimination: Voiding self/external
drainage/Foleys
catheter/incontinence/bed
wetting
d. Bowel movement: passed soft stool/ hard stool/
constipation for( mention the days)
Social interaction: poor/ excessive/normal
Attitude to staff/ visitors/other patients/ self/ illness.
Activities of daily living :performs ADL by self/ with
assistance/ with compulsion
Grooming and Personal hygiene: adequately maintained
by self/ inadequately maintained by self/ poor and not
maintained/ maintained with assistance

Documentation sample
8am. Mrs. Rosy is conscious, oriented to time and place. Vital
parameters within normal limit. Patient is uncooperative. She is over
talkative but relevant speech. Agitation and Increased psychomotor
activity present. Mood is elated and affect is cheerful. Flight of ideas,
delusions of persecution and grandiosity present .She is having
overeligiousity and excessive praying, singing songs. No
hallucination reported. Poor attention and concentration. Eats
excessive amount of food, normal bowel and bladder movement.
Excessive social interaction with other patients and staff. Personal
hygiene maintained by self; over grooming present. Performs

28

activities
of
daily
living
by
herself.
Sign(signature should be clear
and legible; if student mention the course e.gII PBBSC/IIIBSC)
General documentation guidelines

Detailed assessment of patient condition should be done


in the morning.
Document any sudden change in the patients condition/
deterioration with specific details and time
Document medication after giving medication/after
ensuring patient took medication
Do not document medication in advance.
Name/signature of the staff/ student should be legibly
written.
Ensure the date is written / time is written in the
medication sheet.
Record the dose of antibiotics/any medicine to be
administered for specific days; dose should be written
and circled with red pen above the nurses signature in
the respective column in the medication sheet.
For diabetic patients; in psychiatry administer oral
Hypoglycemic agents immediately after food
Consultation/review and their follow up and doctors
advices should be written in the nurses chart with time.
Document any specific procedures like restraining/ PRN
injection/
dressing/I&
D/
bandaging/
sitz
bath/nebulization with the indication and the response of
the patient with time and signature.

SPECIFIC NURSING CARE


GUIDELINES FOR
PATIENTS WITH VARIOUS
PSYCHAITRIC
DISORDERS
I.

NURSING CARE GUIDELINES FOR CARING


PATIENTS EXPERIENCING ORGANIC BRAIN
DISORDER
Two main brain disorder are acute brain disorder (delirium)
and chronic brain disorder like (dementia)

Delirium is an acute, reversible organic condition of multiple etiologies. It is very comm

29

andwho
minor
tranquillizers, are given with hypnotics as needed
hospitalized patients, or those in intensive care units, or postoperative patients, or those
have
to ensure
proper
various systemic medical conditions. Elderly people are more prone to develop delirium.
It has an
acutesleep.
onset and rapid progress

For patients who are at a risk of developing seizures,


anticonvulsants are necessary.
Risk factors Head injury, post-operative states , septicemia, intracranial infections such
meningitis
Theaspatient
should be nursed in an environment with
and encephalitis ,Uremia, hepatic failure, congestive cardiac failure, water and electrolyte
imbalances,
optimum sensory stimuli. Too much or too little sensory
hypoxia, hypercapnia Hypoglycemia, diabetic encephalopathy, circulatory disturbances
Primary and
stimulation
may be harmful.
secondary neoplasms of the brain Alcohol, barbiturates, digitalis, anticholinergics anticonvulsants,
Except for those with sensory deprivation the room should
opiates, cannabis, steroids Epilepsy, vitamin deficiency (B" B'2)' sensory deprivation, alcohol
be quietwithdrawal
and adequately lighted.
state
Frequent change of nursing personnel is to be avoided SO
that the patient is familiar with the attending staff.
Clinical features: clouding of consciousness which ranges from a mild dulling to deep coma. When mild
Relatives should be encouraged to visit the patient
the patient's awareness of himself and his surroundings is blurred with waxing and waning of the intensity
frequently for the same reason. Soft physical restraints may
of symptoms. Such fluctuations and presence of clear, lucid intervals are characteristic features of
be needed in case of severe restlessness and excitement.
delirium. The patient is restless, noisy and oversensitive to stimuli. Psychomotor activity is greatly
Take measures to prevent fall.
increased / decreased. Psychomotor activity is increased and purposeless activity is present. Mood is
Frequent
reorientation to time, place and person is needed,
labile or rapidly changing from fear, anxiety, and depression. Speech is irrelevant and
incoherent.
always
address
the patient by their name.
Attention and concentration are impaired. Disorientation of time, place and person is invariably present.
Delirium
Perceptual disturbances, in the form of illusions and hallucinations, both visual and auditory,
arepatient are having perceptual disturbances , not
touch
with
reality, disoriented and restless
prominent Markings on the bedsheet or on the wall are mistaken for crawling insects, which the subject

Nurse
should
ensure the safety of the patient by providing
tries to pick up and throwaway. Because of auditory hallucinations to which the patient may be
less stimulating, hazardless environment
responding, he does not reply or gives erratic replies to the examiner's questions.
Nursing care should be done in well ventilated room
Provide soft physical restrain if the patient is very much
NURSING CARE GUIDELINES FOR CARING PATIENTS
exited and pulls out iv line or tube feeding
EXPERIENCING DELIRIUM AND DEMENTIA.
Provide proper attention to his personal needs like bathing
Inform the doctor about the sudden worsening in the
,feeding dressing
patients condition

Allaying the patient fear and anxiety and providing rest


Send lab investigations at the earliest to identify the cause
Providing orientation to the person about the present
as ordered by the doctor. If lab values are abnormal, inform
situation frequently and remind about the situation.
the doctor at the earliest and start the corrective measures at

Attend to the basic need of the patient because the patient is


the earliest. Metabolic abnormalities are corrected
un able to look after him
Ensure adequate hydration status, IV Fluids as per order
Check vitals every 4th hourly and maintain strict intake output
and maintain the drop rate as ordered, avoid fluid overload.
chart.
If patient is able to take orally assist in feeding and ensure
Follow regularly daily schedule to prevent catastrophic
that the nutritional needs are met.
reaction
If needed catheterize the patient and maintain strict intake
In other organic disorder nurse can help the patient by
output.
participating in memory oriented task

To control agitation and restlessness, sedatives, both major

30

II.

Nurses can help the patient in supervising the patient daily


activities
Nurse should help the family by providing education and
support.

NURSING CARE GUIDELINES FOR THE MANAGEMENT


OF PATIENT WITH COMPLICATED/UNCOMPLICATED
ALCOHOL WITHDRAWAL

On admission collect the following information


o Duration of alcohol use, quantity of alcohol
consumption.
o Time of last drink and amount (Its necessary to
calculate the hours of alcohol withdrawal in
order to expect for the onset of the withdrawal
symptoms).
o History of complicated withdrawal e.g. delirium
tremens or withdrawal fits/ convulsion( if yes
monitor the patient carefully as he is at risk of
developing delirium tremens and withdrawal
seizures in this admission also).
o Previous treatment and relapses
Closely observe the patient; if the severe withdrawal
symptoms are expected /h/o of withdrawal convulsions
or delirium tremens or experiencing severe withdrawal
symptoms admit the patient in isolation room for
minimizing the environmental stimuli and close
observation and care.
Provide admission counseling to the bystanders; Explain
about the patient conditions and expected change in the
patient behavior; reassure and support the family
members. Educate them about the expected withdrawal
symptoms in the patient
Send blood investigation as ordered; especially Na+, K+,
LFT, BR
Check the vitals Q6H ( nurse need to expect
tachycardia, elevated BP, increases RR during acute
withdrawal- autonomic hyperactivity)

31

Assess the mental state of the patient ( check


consciousness,
orientation,
memory,
perception,
thought)
Assess the severity of withdrawal symptoms ( insomnia,
tremors, restlessness, irritability, sweating, tachycardia,
tachypnea, hypertension, nausea, vomiting, headache)
If uncomplicated withdrawal
o Encourage the patient to drink plenty of fluids,
eat adequate amount of food.
o Provide comfortable environment
o Administer IV Fluids if ordered ( if patient is
weak and unable to take adequate food and
fluids)
**Administer inj polybion along with first
DNS/ 5D infusion ( if we administer plain
DNS, 5D it will precipitate Wernicks
encephalopathy as the IV dextrose
glycolysis will utilize the existing
thiamine reserve and will leads to
thiamine deficiency)
o Administer medication and inj Thiamine as per
order.
Complicated withdrawal/ delirium tremens
o Close observation is needed
o Alert the doctors if the patient is experiencing
delirium tremens (Irrelevant talk, disorientation,
visual/ tactile hallucination, restlessness,
agitation confusion etc.) watch closely for any
episode of convulsion.
o Administer IV Fluids with Polybion, inj thiamine,
and other medication as per order.
o If confused and disoriented
Reorient the patient frequently and
reassure them that they are safe at
hospital
Chemical restrain: If restless and
agitated check for any order of
sedatives as PRN (E.g. Inj Lopez) and
administer the medication.

If inj serenace has been ordered


administer as IM with Inj Phenargan or
Inj Lopez IM/IV as ordered.
Try to avoid physical restrain as it can
increase the confusion and worsen the
condition.
o If withdrawal seizure develops
Inform the doctor immediately
Stabilize the patient, clear the airway,
and turn the patient to side lying position
to drain the saliva and froth to avoid
aspiration.
Watch for the type (focal / generalized)
and duration of seizure.
Administer anticonvulsants as per
order(inj phenytoin/ inj Levirecetam)
Be with the patient until patient condition
stabilizes.
o If
experiencing
visual
and
tactile
hallucination
Reassure the patient that he is safe in
the hospital and nothing will happen to
him.
Reorient him to reality.
Do not argue with the patient that what
is experiencing is not true or is false
Accept that hallucinations are genuine
for the patient but you are not able to
experience it.
Divert the patients attention into reality
oriented activity i.e eating, walking,
reality based conversation etc.
After settling withdrawal symptoms
o Motive the patient to seek de-addiction
treatment in S3 ward
Explain the treatment facilities and
benefits of treatment
Intimate S3 ward counselors if
family/patient is willing for S3 admission

III.

Transfer the patient to S3 ward for de- addiction

NURSING CARE GUIDELINES FOR THE MANAGEMENT


OF PATIENT WITH SEVERE DEPRESSION ADMITTED
WITH SUICIDAL ATTEMPT / HAVING ACTIVE SUICIDAL
THOUGHT

Clinical manifestation of Depression (ICD10) F32.1,.2,.3


(Depression-mild, moderate, severe), F33.1,.2,.3(RDD)
Cardinal symptoms: depressed mood, anhedonia, easy
fatigability.
Associated symptoms: insomnia, poor concentration and
attention, lack of appetite, decreased talk, decreased
psychomotor
activity,
forgetfulness,
hopelessness,
helplessness and worthlessness and suicidal thoughts
Psychotic symptoms: delusions (persecutory, nihilistic,
hypochondriacal, somatic, sin, guilt etc), hallucination (auditory
i.e. may be commanding type, visual hallucinations)
Somatic symptoms: frequent aches and pains, somatic
preoccupation
For details refer ICD10 refer page 119-128
At the time of admission
Explain the risk for future suicidal attempt to the
bystanders clearly at the time of admission; extreme
care should be taken for the safety of the patient.
For the immediate period two bystanders can be
permitted to stay with the patient for the purpose
of constant observation.
Send investigations if ordered. Especially Thyroid
function test; as hypothyroidism leads to depression
Thoroughly check the belongings for any hazardous
items; especially sharp items, shawl, sari, rope etc. If
found keep it labeled in the nurses station.
Admit the patient near to the nurses station in room
where other beds are occupied (** Patient with
active suicidal thoughts should not be admitted
in the isolation room).The patient can be
monitored easily by others.

32

Instruct firmly to the bystanders that patient should


not be left unattended at any point of time in a day.
One attender should always stay with the patient.
Watch closely the patient during night; ensure that
patient is sleeping at night (** during night when
others are sleeping there is high chance that the
patient with active suicidal ideas/ plan will execute
their action to commit suicide.
When patient is having uncontrollable suicidal
thoughts, and is not sleeping during night time, if
needed physically restrain the patient.
Routine care
Daily assess for any suicidal ideas, thought, plan
while assessing their mental state. Always watch for
any suicidal cues ( verbal/ nonverbal)
i. Verbal cues: I will to die; nobody likes/loves
me/ its better for me to leave the world so
that others can leave peacefully without me.
ii. Non verbal cues: writing letters, posting
SMS/ face book message, sudden shift in
patients mood.
Be with the patient and try to spend time with the
patient. Patient with depression requires constant
motivation and reassurance to ventilate their feelings
and thoughts to the nurse
Be non judgmental, provide reassurance in an
acceptable manner.
Encourage patient to eat food; for the initial days
patient need frequent assistance and support in
eating food and doing hygienic self care activities.
Ensure that the patient takes adequate amount of
food, performs activities of daily living
Encourage to attend Occupational therapy (create
awareness in the patient that it is a part of the
treatment
programme
and
attendance
is
compulsory).
Encourage the patient to communicate to others.
Never allow the patient to sleep during the day time
as it can disturb the night time sleep of the patient.

IV.

Bystander should accompany the patient to


bathroom and wait outside till the patient returns
from the bathroom/ toilet.
Ensure the patient swallows the medications after
giving medicine.
During night frequently visit patient and ensure
patient is sleeping. If restless and agitated
administer PRN orders if any and sedate the patient
(Early morning 3-6am nurse must watch the patient
vigilantly as it is the commonest time of attempting
suicide).
Positively appreciate the patient when the patient
performs ADL and other activities self/ on visible
improvement in patient condition.
At the time of discharge
i. Specially instruct the bystanders to watch
the patients behavior.( Research findings
shows that patient is more prone for
committing suicide while recovering from
depression)
ii. Never keep the medications near to the
patient; it has to be kept under lock and key.
iii. All discharge advises has to be provided as
mentioned in the discharge counseling.

NURSING CARE GUIDELINES FOR THE MANAGEMENT


OF PATIENT WITH BPAD MANIA WITH AGGRESSIVE
BEHAVIOUR

Clinical manifestation of mania (ICD10) F30.0,.1,.2 (hypomania, mania wi


symptoms,mania with psychotic symptoms ,)
Cardinal symptoms: over activity ,mood changes ,self important ideas.

33

Instruct firmly to the bystanders that patient should


Associated
symptoms:
hypersensitivity, hyper
vigilance
not be left
religiosity, hyperactivity, impulsiveness, compulsion to over explain (keep talking with rapid speech),
andunattended at any point of time in a day.
One attender should always stay with the patient.
difficulty falling asleep, distractibility, poor judgment,
Restrains;
Psychotic symptoms: delusions (grandiosity ,persecutory, nihilistic, etc), hallucination
(auditory
a) If the patient is seriously aggressive,
i.e. may be commanding type, visual hallucinations)
use the emergency bell to call security
For details refer ICD10 refer page
for restraining the patient
Cycle of aggression
b) while during restraining staff nurse
should accompany with the patient
Crisis phase
c) Before restraining explain the necessity
of restraining to the patient and
relatives.
d)
If the patient is restless, chemical
Post crisis
Escalation
restrains are provided
phase
phase
e) Closely monitor the patient hourly
f) Feeding and elimination need of the
patient has to be managed. if the patient
Triggering
Resolution phase
is not taking the food through mouth
phase
provide parental nutrition.
g) Routines medicines also has to be given
At the time of admission
to the patient on restrains
h) Reassess the restrain every 4 hourly,
Assess the level of aggression and causative
allow the activity of extremities.
factors, extreme care should be taken for the safety
of the patient. For the immediate period two
bystanders can be permitted to stay with the patient
for constant observation.
Routine care
Thoroughly check the belongings for any hazardous
Daily assess for any manipulative behavior. if any
items; especially sharp items, shawl, sari, rope etc. If
set limit for the manipulative behavior
found keep it labeled in the nurses station.
i. Do not argue, bargain or try to reason with
Talk with the patient in calm, firm slow and in clear
the patient
manner
ii. Provide appreciation to non manipulative
Follow routine admission procedures
behavior , explain about he consequences
Impulse provoking factors and persons has to be
of manipulative behavior
detached from the patient
If the patient have hyper sexuality, set limits on
If aggressive

Admit the patient to the isolation room which helps


the patient can be monitored easily by others.

34

patient behavior, be firm and assertive.


Be non judgmental, provide reassurance in an
acceptable manner.

V.

Encourage patient to eat food; for the initial days


patient need frequent assistance and support in
eating food and doing hygienic self care activities.
Encourage to attend Occupational therapy (create
awareness in the patient that it is a part of the
treatment
programme
and
attendance
is
compulsory). Provide restrictive and concentrative
activities and games like chess and charmers
Never allow the patient to sleep during the day time
as it can disturb the night time sleep of the patient.
Bystander should accompany the patient to
bathroom and wait outside till the patient returns
from the bathroom/ toilet.
Ensure the patient swallows the medications after
giving medicine.
During night frequently visit patient and ensure
patient is sleeping. If restless and agitated
administer PRN orders if any and sedate the patient
At the time of discharge
i. Specially instruct the bystanders to watch
the patients behavior. And consequences of
high risk behavior
ii. All discharge advises has to be provided as
mentioned in the discharge counseling.

2.
3.

4.

5.
6.
7.

NURSING CARE GUIDELINES FOR HANDLING


PATIENTS WITH PSYCHOTIC DISORDERS

duration)
a. Paranoid
b. Hebephrenic
c. Catatonic
d. Simple
e. Residual
f. Undifferentiated
g. Post schizophrenic depression
Acute psychosis( acute onset of psychotic symptoms with
less than one month duration)
Delusional disorder( 1 or more culturally appropriate
delusions without absence of other psychotic symptoms for
more than 3 consecutive months)
Schizoaffective disorders( presence of schizophrenic
symptoms and affective symptoms occur in the same
episodes
a. Manic type
b. Depressive type
Post partum psychotic disorder( acute onset of psychotic
symptoms within first 6weeks of delivery of a child)
Psychosis unspecified
Schizotypal disorders

Va. NURSING CARE GUIDELINES


EXPERIENCING DELUSIONS

Psychotic disorders are disorders in which the reality orientation is


impaired and show psychotic symptoms charecteresied by such as
hallucinations, delusions, fearfulness, aggressive behavior, violent
behavior etc. patient will not have insight about mental illness.

FOR

PATIENT

DELUSIONS : Fixed unshakable false belief based on the external reality that cann
reasoning .it occurs due to the dopamine - serotonin deregulation in the brain.
Types of delusions
Paranoid delusions( delusions seen in manic patients/ psychotic patien
reference( others are talking about them) delusions of persecution(others are trying

COMMON PSYCHOTIC DISORDERS


1. Schizophrenia ( psychotic symptoms with more than 1month

35

until
the delusions
intensity is reduced rather that
others), delusions of grandeur( he is having extraordinary power/ability), delusions of infidelity(
spouse
is
saying that your husband is loving and caring. Here
unfaithful or having extramarital affair)
triggering
Delusion congruent with depressive mood: nihilistic delusion( patient is dead or worldthe
is going
to factor is the presence of the husband.
o
If
the
patient
is experiencing severe persecutory
end), somatic delusions ( body/ bodily functioning is abnormal), delusions of sin and guilt( they are sinner
delusions and extremely fearful; nurse can reassure
and to be punished) hypochondriacal delusion( he is having serious illness like cancer/AIDS etc)
the patient by saying we are there with you
Other delusion : delusional perception( real perception triggers delusional belief), bizarre delusion
nothing will happen to you are safe in this hospital
no one can enter into the ward without our
Managing patients with delusions
permission.( address and handle their emotional
First and the most important step in managing these patients
component involved in delusion rather than
is establishing good rapport with the patient.
trying to convince that the delusions are unreal)
Nurse need to understand the fact the delusional experience
o Never argue with the patient about the delusion; it
is real for the patient and is caused by the neurochemical
will worsen the patients condition; sometimes the
changes in the brain; even though it may appear to be
patient can become violent.
Carefully monitor the patient if the delusions lead patients to
difficult to belief the existence of delusion however bizarre it
may be.
harm themselves or others.(delusions of infidelity,
Talk to the patient in a calm and non threatening manner as
persecutory, nihilistic, grandiose etc)
Discourage long discussions about irrational thinking,
the patient who is experiencing persecutory delusion may
appear extremely fearful.
instead talk about real events and real people.
Assess the type, and content of the delusion without
Encourage the patients to ventilate their feelings and listen
appearing to probe. Assess how frequently and how intense
to them and make them feel that your are genuinely
is the delusions for the patient.
concerned about the issues and problems of the patients.
Initially you can ask for clarification to confirm the intensity of
Patient reality based conversations are positively reinforced
delusion: e.g. If a patient is saying (looking fearful): they will
and encouraged.
Psycho education to the bystanders: if it is the first
kill me and my family. In response the nurse can seek
clarification in a non threatening manner why do you think
episode of illness, family members are not aware about what
they are trying to kill you?
is happening in the patient and they are not able to
Approach the patient with calmness, empathy and gentle
comprehend the irrational beliefs and statements made by
eye contact.
the patient.
o They may be helpless and may not know how to
The nurse should communicate clearly, directly in simple
sentences.
tackle the patient nor the situation
o Nurse should educate the bystanders that are a
Assess the situation and environmental triggers for
symptom of the illness that they are suffering with
delusional experience. If we identify the triggers nurse can
and the illness occurs due to the neurotransmitter
control or eliminate the triggers to handle the patient.
imbalance.
E.g. If wife is having delusion of infidelity; whenever the wife
o
Reassure the family members that the delusional
sees the husband, she gets aggressive saying that he is a
thinking will reduce as they starts to respond to the
cheat he is having extramarital affair.
o In this situation its better to convince the husband
medication and that will take at least a week to show
reduction in the intensity and severity of symptoms
and tactfully ask him to stay out of the patient vicinity

36

patient by name and purposefully involve him in reality


based activities like walking, talking eating etc.
Covey acceptance to the patient , accept that for the patient
the hallucinatory experience if true but convey him that you
are not able to experience the same.
Provide busy schedule of activities for him so that he will be
occupied in the reality oriented activities and thereby
preventing being all alone.
If the hallucinatory voice or images is scary in nature and if
the patient is extremely fearful; try to reassure the patient.
nothing will happen to you, you are safe here, we are there
to protect you
V.b. NURSING CARE GUIDELINES FOR PSYCHOTIC PATIENTS
Avoid touching the patient without informing the patient.
EXPERIENCING HALLUCINATIONS
If the voices are persecutory in nature e.g voices saying you
are useless, it go and die/ kill him he is trying to harm your
Hallucination : false perception without an real external stimuli; occurs due
to the
family.
Theneurochemical
patient is at risk of committing suicide or
disturbance in the specific sensory perceptual areas in the brain.
homicide. It is always better to calm down/ tranquilize the
Types
patient by restraining him physically of chemically.
Auditory : - patient hear sound of an object/ person/persons that other cannot hear.
Visual : patient see images/ light/ person/persons that other cannot see
VI.
NURSING CARE GUIDELINES FOR MANAGING
Tactile : patients feels sensation in the skin without any real stimuli
PATIENTS IN STUPOR
Olfactory : patient perceives smell that others cannot perceive
Stupors patients will be aware about the situation but they
Gustatory : Feeling abnormal taste that others cannot perceive
are not able to react to the environment.
Somatic : Feeling bodily changes that other cannot see or perceive.
Different types of stupor: manic stupor, depressive stupor,
dissociative stupor, catatonic stupor, organic stupor.
Stuporous patients will not interact with others, doesnt
Managing patient experiencing hallucination
perform their ADL, so treat the patient as a bedridden patient
and provide all necessary care required by the bedridden
Assess the type of hallucinations and content of
patients.
hallucinations, whether voices are commanding in nature or
Be with the patient and talk to the patient even though they
threatening in nature.
cannot communicate back, convey acceptance and respect
Assess the nonverbal hallucinatory behavior such as staring
to the patients.
aimlessly, self muttering, self smiling etc.
Reassure the bystanders and explain about the condition
Identify if there is any triggering factors, if yes try to
and expected time of recovery.
avoid/minimize the triggering factor in order to reduce the
Assist in feeding, bathing, positioning the patient. 2hourly
hallucination experience.
back care and position change is provided to prevent
If the nurse find a patient is talking to self, reorient the
bedsore.
patient to reality by distracting the patient by calling the
o

Educate them that Never argue with the patient


about the delusion; it will worsen the patients
condition; sometimes the patient can become
violent.

37

VII.

Provide necessary assistant for daily activities like washing


changing and eating,
Provide tube feeding is necessary if they are not ready in
taking food.
Closely monitor the patient for any fall or injury.
Prevent bed sores and infection by frequent change their
position in bed or ask them to sit up or walk as their
conditions improve.
Encourage the patient to participate in occupational therapy
as the condition improves.

NURSING CARE GUIDELINES FOR MANAGING PATIENT


WITH OCD

VIII.

The nurse should not criticize the behavior of the patient it


may produce guilt and embarrassment.
Setting limit to the ritualistic behavior and provide anxiety
alleviating medicines
Provide simple and precise therapeutic plan
Provide occupational therapy and routine activities with
Patient Corporation and participation.
Understand the fact that patient cannot reduce the duration
of compulsive act to normal time frame by self, never force
the patient to reduce the time duration as it can increase the
anxiety level in the patients.

NURSING CARE GUIDELINES


DISSOCIATIVE DISORDERS

FOR

PATIENTS

WITH

OBSESSIVE COMPULSIVE DISORDER


DISSOCIATIVE OR CONVERSION DISORDERS
a) Dissociative amnesia
b) Dissociative Convulsion
c) Dissociative trance and possession
d) Dissociative fugue
e) Dissociative stupor
f) Dissociative motor and sensory disorders
g) Multiple personality disorder

Obsessive thoughts and compulsive acts are the characteristic


feature of this disorder
I.
OCD predominantly obsessive type( thoughts, images,
doubts, impulses)
II.
OCD predominantly compulsive type( repeated washing,
bathing, checking, counting, spitting etc )
III.
OCD with obsession and compulsion

Understand the patients conditions and accept that these


thoughts, behavior or ritual are unavoidable and compulsive
in nature and patient cannot resist successfully
Establish good rapport, spent time with the patients to
express their feelings and concerns.
Be non judgmental and punitive; Avoid arguments, and
shouting at the patient for this behavior.
Patient will exit ritualistic behavior with varying degrees of
anxiety so the aim of the treatment is to reduce the
frequently and duration of behavior

38

In this disorder the bodily disturbance occurs without any


organic pathology but due to stress / traumatic life events.
The occurrence of the symptoms alleviate the anxiety in the
patient (primary gain)
The maintenance of the symptoms provides secondary gains
for the patients so they continue to show symptoms which
may include (enjoying sick role, more love and affection,
excuse form work or responsibilities etc.)
Labelle indifference is common in this disorder: lack of
concern about ones own disability( symptoms)
Patients often mimic symptoms by identifying the symptoms
of somebody else in the family or neighborhood or with some
emotional significance

VIII.

Nurse should establish rapport with the patient and their


family members, take detailed history and try to elicit
stressors in the patients life
Convey warmth and acceptance to the patient
Reassure the family member that the patient does not have
any organic pathology and the symptoms occur due to stress
and tension in the patients life.
Advice the family member to show love and affection at the
same time cut of the secondary gains in the patient.
Ignore the dissociative behavior but not the patient, care and
love the patient as usual.
Encourage the patient to involve in other activities,
discourage talks about the dissociative behaviors.
Encourage to participate actively in occupational therapy.

IX.

NURSING
CARE
GUIDELINES
WHILE
CARING
CHILDREN WITH MENTAL DISORDERS.
Mood disorders, psychotic disorders, mental retardation,
conduct disorder, autism , ADHD, brain damage , epilepsy
,unfavorable family situation, problems in schools are the
main reasons of admission in psychiatric unit.
The symptoms will be depending on the development of the
child
Establish good rapport with the child.
Never give an impression to the child that hospital is a form
of punishment, the ward should be maintain with friendly
atmosphere and daily routines should be adjusted according
to the childs need
Follow the routines maximum as like homes and staff should
mingle with the child during play time
Physically remove the child from the scene of quarrel /
arguments
Spent more time with the patients, reassure the patients and
explain about the conditions and the behavior the parents
need to display towards their child.
Sent blood Investigation as per order

39

Explain the rules and regulations to the child as well as to


their parents.
If child is restless and hyperactive, ensure safety by
removing hazardous objects from the patients / room at the
time of admission itself.
Set limits in interacting with other patients especially manic
patients, patients with substance use disorder.

NURSING CARE GUIDELINES WHILE CARING ELDERLY


PATIENTS
At the time of admission enquire about the problems related
to self care, feeding elimination, if the general condition is
weak, and cannot walk / need assistance admit the patient
in the bed near to toilet to meet the elimination needs
Nurse needs to observe the patient condition frequently and
especially during night as they can be more confused and
disoriented at night, they are more prone to experience side
effects of medication, confusion, memory impairment during
the period of hospital stay.
Sent investigation routine investigation, FBS, PPBS,
Creatinine, if confused or disoriented sent sodium,
potassium as per doctors order.
If the patient is restless, confused and agitated; Avoid PRN
injections, as much as possible as their condition may
worsen. So chemical restraining is avoided; and should be
given only after discussing with the treating doctor.
Intake and output charting, vitals 4th hourly need to be
maintained if the patients condition is weak.
Provide necessary assistance in feeding, bathing, and doing
activities of daily living.
Supervise feeding, ensure that the patient takes adequate
amount of food and fluids, and assist if needed.
If the patient is bedridden and sick, provide 2hrly back care,
changing position, sponge bath, mouth care, perineal care
as per the need.
During Night frequent observation is needed if confused and
restless provide dim light to avoid fall.

X.

Physical support should be provided where ever needed


while walking washing and dressing, because of the chances
of accidents.
Activity should be limited with proper rest periods
While watching TV sound should be adjusted according to
their level of hearing
In occupational therapy ,provide simple exercises and
instructions
Elderly patient many have problem in seeking nurses help,
nurse must anticipate the need of the patient
NURSING CARE GUIDELINES FOR MANAGING
PATIENTS WITH FOOD REFUSAL/ FEEDING PROBLEMS

Nurse should provide special attention to the patients


with food refusal/ poor feeding
Assess the nutritional status; assess for malnutrition and
dehydration .Assess the condition of the patient (patient
have swallowing difficulty neglecting food,)

Paranoid patient may refuse to eat due to


their paranoid delusion
o Depressive patient may refuse to eat due to
anhedonia/ anorexia.
o Manic patient may dehydrated or eating less
due to their hyperactivity and restlessness.
Depressed patients or patients with schizophrenia
who has ahnedonia/ avolition; tactfully assist or compel
the patient to eat food, do not leave the room until
patient ate meal completely. The patient may vomit the
food if they have delusion related to food.
Hyperactive, manic patients should be provided finger
foods, like chapatti, poori, bread, bun which they can
carry if they cannot sit still for a meal.
For paranoid patients who believes that their food is
being poisoned; convince the patient that the food is
safe, allow one bystander to taste the food in front of him
to convince him
o creative approaches may be adopted who is
refusing to eat the food brought by the relative
o

XI.

40

such as allowing him to open the seal of cover of


the food items, fruits, eggs etc..
Monitor fluid and food intake, ensure that the patient
drinks at least 8-12 glass of water till 6pm.
Ensure patient is taking adequate amount of food, if
needs assistance; encourage and assist the patient
to take food.
Enquire about the food preference
Do not provoke the patient ,make the patient
calm
Explain patient and bystanders about consequences
of avoiding food(may be chance of side effect of
drug ie drowsiness, EPS, constipation
Encourage to take small and frequent food, fluids
Watch for any signs of dehydration and vital
statusoccurs informed concern doctor and start
i/v fluids /RT feeds
Food should be served pleasurably; Provide
stimulating environment for eating like clean bed,
clean linen etc.
It is mandatory to maintain strict intake output for
patient who is sick, admitted in the isolation room.
Enquire daily about the bowel and bladder
movements. Report if there is any constipation,
urinary retention to the doctor
Advice the bystander to provide fiber rich food such
as vegetables, salads etc to increase the bulk of
stool and avoid constipation.
Avoid too much oily/salty foods.

NURSING
PATIENTS
HYGIENE.

CARE GUIDELINES FOR


WITH POOR SELF CARE/

MANAGING
PERSONAL

OCD patients spends excessive time for bathing,


personal hygiene
Depressed patients will not maintain personal
hygiene because of lack of interest/ lack of energy to
perform bathing and hygienic activities
Manic patients may take excessive interest in
bathing, grooming and maintain personal hygiene
Schizophrenia patients will not take bath because of
lack of drive to take bath / delusional belief that other
will watch while taking bath/ camera is installed in
bathroom
Dementia patients may be incontinent to stool or
urine, openly defecate in the wards.
Establishing rapport is the first action that help
the nurse to handle this problem
Nurse should assess the patients ability to perform
self care activities
Identify the reason for not maintaining the personal
hygiene through their verbal or nonverbal
interactions.
Nurse should firmly and assertively insist the patient
to maintain personal hygiene, e.g. taking the patient
to bathroom and assisting in bathing if needed.
Create a habit of bathing once/ twice daily/ washing
hands before and after bathing, toileting/ dressing/
changing clothes/ combing hair etc.
Never scold of criticize the patient
Encourage them or appreciate them while they take
positive effort to maintain self hygienic activities.
For OCD patients, mutually set time and duration for
these activities without threatening or provoking
anxiety in the patients, gradually reduce the time
spent on these activities.
Assess the patient condition ( hygiene status ,activity
level ,co-operation and self care)
If the patient is co-operative and able to do self care
advice to take daily bath before ward rounds
Comb the hair, Nail should be cut short
Change their own dresses daily

XII.

Encourage the patient to take oral hygiene explain


the bystanders about he importance of personal
care.

NUSRING GUIDELINES FOR MANAGING COMMONLY


EXPERIENCED SIDEEEFECTS DUE TO PSYCHOTROPIC
MEDICATION.

Dry mouth: Provide patient with, frequent slips of water. Ensure that
patient practices strict oral hygiene. Advice the patient to take sips of
water frequently. Apply glycerin to lips, if excessively dry or cracked.
Avoid dehydration particularly during work and exercise, exposure to
extreme heat and concurrent use of medication can cause dry mouth
Blurred vision: Explain that this symptom will most likely subside
after few weeks. Advice patient to avoid driving until vision clears.
Clear small items from the pathway to prevent falls
Constipation: Provide food high in fiber e.g vegetables, salads,
leafy vegetables etc. Drink 2-3litres of water until 6pm.Encourage
increase physical activity and fluid intake if not contraindicated.
Assess the patients pattern of daily bowel activity and stool
consistency. Take measures to reduce constipation
Urinary retention: Palpate the patients bladder for urinary retention
.Instruct the patient to report any difficulty in urination, monitor intake
and output. Try applying hot and cold compress over the bladder.
Bring the patient to the toilet and turn on the pipe/ pour some water
over the legs.
Nausea, GI upset: Tablets or capsules may be administered with
food to minimize GI upset. Concentrates may be diluted and
administered with fruit juice ,they should be mixed immediately
before administration
Skin rash: Report appearance of any rash on skin to physician.
Avoid spilling any of liquid concentrate on skin, contact dermatitis
can occur with same medication

41

Sedation: Discuss with physician that the possibility of administering


the drug at bed time. Discuss psychiatrist a possible decrease in
dosage or any order for less sedating medicines. Instruct patient not
to drive or operate dangerous equipment while experiencing
sedation. Inform the patient hat drowsiness generally subsides with
continued therapy

Agranulocytosis : Agranulocytosis usually occurs within the 1 st 3


months of treatment, observe for the symptoms of sore throat, fever
malaise. A complete blood count should be monitored if these
symptoms appeared agranulocytosis a potentially fatal blood
disorder in which the patient WBC count can drop in to extremely low
levels. For the I st 6 months of continues therapy with clozapine
obtain patient WBC count on a weekly bases , then bi weekly for the
patient with acceptable WBC count if the WBC is below 1500/mm
clozapine should be stopped .Great risk period is first 6 months ,
explain the risk of treatment .agranulocytosis side effect should be in
form to the family members

Orthostatic hypotension: Elderly people are more susceptible for


orthostatic hypertension, they required dose adjustment because of
age relate denial and hepatic function will be present .Instruct the
patient to rise slowly from lying or sitting position. Monitor blood
pressure (lying and standing), document and report significant
changes. After the administration of drug like haloperidol, keep the
patient, If needed in recumbent
(head low and leg raised )for
after 30 min after administration to minimize hypertensive effect.
Advice not to take shower or tube bath

Hyper salivation/ drooling: Use sugar free gums to increase


swallowing rate. Prescription of medications such as an anti
cholinergic according to doctors order
Insomnia: Administer or instruct patient to take drug early in the
day to reduce insomnia. Instruct to avoid caffeinated drinks or food.
Abrupt with drawl of drug may cause insomnia. Never allow the
patient to sleep during day time. Avoid excessive water intake after
6pm. Make the patient to urinate before going to bed. provide
comfortable environment to sleep, minimize noise.

Photosensitivity Ensure that the patient use sun screen lotion and
use umbrellas while exposing sun light. In form the patient that he
may develop sensitivity to sun light mainly for anti depressants
Sexual dysfunction: Men may report abnormal ejaculation or
impotence.Women may experience delay or loss of orgasms if side
effect become in tolerate, a selection to another antidepressant may
necessary. Amenorrhea offer reassurance of reversibility instruct
patient to continue use of contraception amenorrhea does not
indicate cessation of ovulation

Hyperglycemia: Monitor regularly for glucose level. Patient with risk


factors for diabetics should undergo fasting blood glucose testing.
Monitor for symptoms of hyperglycemia
Headache: Administer analgesics as per doters order. Check the
vitals .Request physician for order change to another drug. Teach
patient relaxation technique

Weight gain : Weight patient every day. Provide opportunity for


physical exercise. Provide diet and exercise instruction
ECG changes: Never prescribe this medication to the person who
have history of arrhythmias .Monitor vitals every shifts. Observe for
symptoms of dizziness, palpitation, syncope, weakness, dyspnea,
peripheral edema. Plan to perform a base line ECG if patient is at
risk of arrhythmias

XIII.

NURSING
CARE
GUIDELINES
FOR
PATIENTS
EXPERIENCING EXTRA PYRAMIDAL SYMPTOMS

EPS develops due to the impact of antipsychotics on the dopaminergic (D2) recept
pyramidal tract. Dopaminergic antagonism effect on D2 receptors leads to dopaminer
the extra pyramidal tract leading to acute or chronic movement disorders which are
pyramidal symptoms.

Seizure: closely observe the patient with history of seizures. Take


precautions for seizures

42

24. Neuroleptic malignant syndrome (LIFE THREATENING PSYCHIATRIC


characterized by muscle cramps and tremors, low to high grade fever,
pressure, alteration in the Level of Consciousness, raised WBC, CPK, hyp
metabolic acidosis, hyperthermia, profuse sweating, muscle rigidity, inte
spasm leads to dyspnoea leading to respiratory failure, dysphagia.
a. Investigations : serum Calcium( hypocalcaemia is common), ABG
acidosis, LFT, CPK, urine myoglobin, coagulation profile- PT, APTT, C
Neuroleptic induced Parkinsonism: lead pipe cogwheel rigidity, tremors, bradykinesia
Blood routine
(decreased movements), masklike face, stooped posture, drooling of saliva, slow gait,Scan,
slowed
b. Treatment
speech etc.
i.
Mechanical ventilator support- ICU admission is mandatory
o Common among elderly, females.
ii.
Stop all medications
o Treatment : inj phenergan 12.5/25mg / 50mgIM stat
iii.
IV Benzodiazepines
i. Withhold antipsychotics
iv.
IV Fluids
ii. Start tab Pacitane/ tab phenergan
v.
Antipyretics
iii. Soft diet
vi.
Dopaminerigics : Bromocriptine/ Amantadine
iv. Plenty of fluids
vii.
Muscle relaxants
Acute dystonia: painful spasm of neck, back, jaw, tongue, leadsviii.
to tongue
ECT protrusion,
torticollis, and opistonus, upward rolling of eyes
Nursing care Guidelines for EPS
o Common among young men
o Treatment : Inj Phenergan 12.5/25mg / 50mgIM stat
25. Assess the patient status.
26. Reassure the patient and bystanders about the condition.
v. Stop antipsychotics
27. Check the vital parameters - temperature, pulse, respiratory
vi. Start tab Pacitane/ tab phenergan
vii. Soft diet
rate, blood pressure.
viii. Plenty of fluids
28. Inform the doctor.
Akathesia: subjective feeling of motor tension and restlessness or inability
to stand/sit
still.the patient.
29. Closely
monitor
30.
Plenty
of
oral
fluids are encouraged.
(patient says i feel to walk while sitting and while walking i feel to lie down, when lying down
31.
Immediately
carry
out the treatment orders.
feels like walking etc)
32.
For
NMS
o s/s : inner sense of restlessness, fidgeting or swinging of legs, pacing, inability to
a. After shifting the patient from ICU to ward; admit the
stand still for few minutes (often misjudged as manic excitement)
patient
o # Risk factors :high dose, rapid increase in dose, high potency drugs, older
age,to the isolation room.
b. Close monitoring is needed
females, iron deficiency etc
c. Check the vitals 4th hourly
o Treatment : reduce antipsychotics
d. Administer IV fluid as per order
If still persists switch to another antipsychotics
e. If patient is on Ryles tube feeding: provide Ryles
Add benzodiazepines if not improving add Tab Propanalol 10/20mg tube feeding every 2hrly.
If still not improving tab cyproheptadine/ Pramipexole
f. After gag reflux has returned, start oral feed,
Tab livogen ( if iron deficiency is suspected)
semisolid, solid, liquid foods
Tardive dyskinesia: involuntary movement of tongue, lips, jaw, trunk or extremities
leads to elevate the head end while feeding the
g. Always
rapid jerky and non repetitive movements or repeated rhythmic oscillatory movements.patient to avoid aspiration.
o Note ( gradual onset over a period of months to years, most common among
elderly plenty of fluids if orally tolerated
h. Encourage
i. Positioning and back care is needed for sick/
females, typical antipsychotics)
o Treatment : lower the dose of antipsychotics/ change the antipsychotics
bedridden patient.
Neuroleptic induced parkinsonism
Acute Dystonia
Akathisia
Tardive dyskinesia
Neuroleptic malignant syndrome

43

j.

Slowly encourage the patient to walk. Ambulation is


encouraged once the patients condition improves.
Maintain strict intake output chart.

foods, salted fish etc; as excessive salt consumption


will eliminate more lithium through kidney ( renal
k.
tubules mistake lithium instead of sodium as they
have similar molecular property) thereby lowering
the serum lithium level.
XIV.
NURSING CARE GUIDELINES FOR PATIENTS ON
o Patient should not avoid dietary salt completely ; as
LITHIUM THERAPY AND MANAGEMENT OF LITHIUM
it can leads to lithium toxicity ( renal tubules will
TOXICITY
reabsorb all the lithium leading to toxicity)
Nurse should ensure that patient took adequate food before
LITHIUM(Licab, Lithosun, Elcab, Intalith CR, Lithosun SR) Available form: 300mg, 400mg, 450mg
giving lithium tablet as it can cause GI disturbances
Available forms: lithium carbonate , lithium bicarbonate
Nurse should ensure that patient drinks minimum 8 Dose : starting :300mg BD slowly titrated to 400mgBD, 450mg BD maximum dose up to 1800mg
12glasses of water per day ( as lithium causes polyuria it
per day
may lead to dehydration if fluid intake becomes minimal)
Action: it is a mood stabilizer, used for control irritability, impulsivity, manic hyperactivity,
Serum lithium monitoring
especially in bipolar mania, schizoaffective disorder, depressive disorder, alcohol dependence
o After lithium initiation serum lithium level is checked
syndrome
on 4th day of initiation
Therapeutic level: 0.6-1.2meq/l prophylactic level: 0.5-1meq/l child and elderly: 0.4-0.8meq/l
o Blood sample should be taken after 12hours of
Side effects :tremor, muscle weakness, delirium, seizures( as lithium lowers seizure
previous dose and before the next due dose
threshold).memory impairment, hypothyroidism, goiter, weight gain,
hyperparathyroidism,
o
polydypsia, polyuria, T-wave changes, Sinus nodal dysfunction,
hair
loss,
acne,
rash, the
psoriasis,
Nurse should watch
patient on lithium if he is receiving
anorexia, nausea, vomiting, diarrhea.
any diuretics as it can increase diuresis and can leads to
Lithium toxicity
dehydration further resulting in lithium toxicity.
Mild : 1.5-2meq/l ( s/s:nausea,vomiting, ataxia, dizziness, slurred
lethargy,be
weakness)
speech,
Nurse should
aware that lithium alters TFT, cause
Moderate : 2-2.5meq/l (s/s anorexia, persistent vomiting, anorexia,
blurred
vision,
muscle
arrhythmia, cause SIADH.
fasciculation, hyperactive deep tendon reflex, convulsion, delirium,
coma,and report immediately to the
Watchsyncope,
closely forstupor,
side effects
circulatory failure
treating doctor.
Severe :>2.5meq/l (s/s generalized convulsion, oliguria, renalfailure,
death)
Avoid
excessive intake of coffee, tea, beverages by the
patient.
If patients serum lithium does not reach in the therapeutic
level after one week and if the patients condition doesnt
improves as expected
Nursing care guidelines for patient receiving lithium therapy
o enquire about dietary salt consumption; if excessive
provide diet counseling
Preliminary blood investigations should be carried out as per
o
Doubt whether patient is not swallowing the drug /
doctors order e.g. TFT, ECG, BR etc
hiding the drug in the mouth and spitting the drug
Patient started on lithium therapy should be taught about the
Management
of lithium toxicity
dietary sodium intake and fluid intake

If
the
patient
is experiencing severe tremors, nausea ,
o Patient should consume dietary sodium the normal
vomiting, ataxia, confusion, slurring of speech **nurse
level, should not put additional salt in the rice, should
avoid too much salty foods e.g. pickle, papad, salted

44

XV.

should doubt lithium toxicity and inform the doctor at the


earliest.
Mild toxicity
o Reassure the patient and the bystanders
o Withhold tab lithium if ordered by the doctor
o Encourage the patient to drink plenty of fluids
especially salted limejuice, rice soup with salt as it
will help to wash out the excess lithium from the
body
o Observe the patient condition and report if the
condition worsen
Moderate toxicity
o Reassure the patient and the bystanders
o Stop the drug as per the doctors order
o Closely monitor the patient, vital signs to be
monitored especially pulse rate ( irregular, rapid
pulse rate need to be reported)
o If it an overdose: induction of emesis , gastric
lavage, activated charcoal has to be given as per
the doctors order
o If IV Fluid, inj Mannitol is advised ; Normal saline is
the fluid of choice ; administer IV NS , inj Mannitol in
order to flush out excess lithium from body
Severe lithium toxicity
o Reassure the patient and the bystanders
o Fluid resuscitation with Normal saline to be done
immediately
o If advised for hemodialysis, immediately informs
dialysis room and shift the patient to dialysis room
for hemodialysis as soon as possible.

GOO DWILL DIET (FREE DIET FOR TEN POOR PATIENTS


PER DAY)

Sister In charge/ head nurse will assess the patients


socioeconomic status and patient condition and advice for
goodwill diet to the occupational therapist.
Send the good will diet requisition in the special diet
requisition slip with good will diet seal to the dietician.
Give the Tiffin career to the patient and instruct them that
they will get morning breakfast, lunch, dinner( evening tea is
not included)
Ensure that at the time of discharge the bystander returns
the Tiffin Carrier

Hepatic diet (diet that give rest/ minimal work to the liver )patient teaching for ADS patients with deranged LFT.

NURSING CARE GUIDELINES FOR PATIENT WITH


SPECIAL DIET REQUISITES

SPECIAL DIET REQUISITION

If patient is willing to avail special diet; send diet requisition


slip to dietician.
If patient is having any complaints / dissatisfaction related to
food provided, request the dietician to come and resolve the
issue.
At the time of discharge enter the days of special diet
availing in the billing sheet

If the doctor advised special diet, inform the dietician about


the diet and request for providing diet Counseling.

45

Food to be included :cereal porridge, of chappathi, skimmed


milk, tapioca, potato, ham, fruit, fruit juices, sugar, jaggery,
honey, biscuit, soft custard,
Foods to be avoided :meat, chicken, egg, ghee, butter, oil,
bakery items, dried fruits, nuts, spices, papads, chutney,
alcohol, fried preparations, whole milk.
Breakfast :idly, dosa, idiyappam,puttu,appam,oats, raggi
+samba, peascurry,egg white curry, parippu curry (with
minimal oil and coconut )
Fruit juice , salad midmorning
Noon and dinner : rice,/chappathi, vegetable thoran, curry
with minimal oil, curd, butter milk
Evening: tea, Skimmed milk, biscuit, steamed foods etc

Diabetic diet : patient teaching

patient consults doctor and started taking treatment


5. Maintenance :Maintaining the behaviour change or remaining
abstinent form alcohol/ substances
patient stopped drinking and taking regular treatment
6. Relapse: Returning to older behaviors and abandoning the new
changes.
He restarted drinking in the same pattern as before. He
does not take his treatment and does not go to the doctor

Avoid skipping Meal or fasting


Carry one or two fruits like apple, banana, and biscuit while
traveling long distance.
Avoid beef, duck pork, mutton meat and include chicken,
turkey, kaada (quail) meat by removing fat.
Include butter milk as mid morning ,midevening time
Avoid sweets as it can leads to rapid fluctuation on the blood
sugar levels
Include cereal, dial item for protein reserve
Take insulin / OHAs along or just before food.
Include food rich in vita k as vitamin k os essential to release
insulin. Include vegetables, cereals, leafy vegetables etc.
Include tender vegetables in diet-tender ladies finger, beans,
brinjal, raw banana cabbage, spinach, etc.
Include high fiber diet. Eat plenty of leafy vegetables,
spinach, muringa leaves.
Drink milk, tea with skimmed milk.
Include salads, cucumber, onion, radish, tomato, carrot,
Soup without oil, tomato juice, vegetable salad, lemon juice,
plain tea, garlic

XVI.

NURSING CARE GUIDELINES FOR PROVIDING


MOTIVATION COUNSELING FOR PATIENTS
ADMISSTTED WITH SUBSTANCE USE DISORDER

Stages of motivation / CHANGE


1. Pre-contemplation: Not yet acknowledging that there is a
problem behaviour that needs to be changed.
Patient does not think that he has a problem with alcohol.
2. Contemplation :( Acknowledging that there is a problem but not
yet ready or sure of wanting to make a change).
Patient understands that his drinking is causing him various
problems but does not how to reduce / stop.
3. Preparation :Preparing for change
patient talked to OTHERS about where to find treatment to
stop drinking.
4. Action / Willpower :(Changing behaviour)

46

Establish good rapport with patient and family member


Assess about their drinking pattern, duration of use, reason
for using substance and their motivation level, and the
complications related to substance use
Provide them feedback about their consequence of drinking
on various spheres of life, health, Socio familial,
Occupational. Financial, Legal
Enable the patient to think what his life would be in terms of
consequences, if he continues to use alcohol or drugs
It would be of help for the patient to decide in favor of
change if he is enabled to visualize the benefits of changing
his behaviour
Personalized feedback of following negative Consequences
of substance use help an individual to decide in favor of
change:
Make the patient and family to identify the benefits and risk
of stopping alcohol, if benefit is more than risk motivate them
to stop alcohol by seeking deaddiction treatment at S3 ward
( explain about the 31day treatment programme and the
serviced offered at S3 ward)
Enable the patient to compare his quality of life with his non
user friends and relatives,
Instilling hope by telling the patient that the goal is
achievable and you can do it helps.

Make the patient believe that he can do it

Inform S3 ward counselors about the patients willingness for


deaddiction treatment and arrange an appointment with the

counselors in the ward itself.

DRUGS USED IN PSYCHIATRY

Anti psychotic
Blocks D2
receptors in the
mesolymbic and
mesofrontal
system.
( concerned
with emotional
reaction)
sedation is
caused by alpha
adrenergic
blockage antdopaminaergic
actions are
responsible for
EPS

Class

Example of Trade name


drug

Phenothiazines

1.Chlorpromazin
e

Chlorpromazine
Sunprasine (50 mg, 100 mg
Megatil
Tranchlor
Siquil

2.Triflupromazine
3.Thioridazine

4.Trifluoperazine

5.Flufanazine
deconate

Thioxanthenes
1.Fluanxol
Butyrophenones
1.Haloperidol

Thioril (50 mg,100,mg,25,mg)


Redazine
Sycoril (25,100 mg)
Espazin (5mg)
Serentin
Neocalm
Psycalm
Prolinate (Inj 25 mg/1ml)
Anatense deconate (Inj
mg/1 ml)

25

Halidace (0.25 mg,1.5 mg,5


mg,10 mg, 20 mg)
Haloperidole
Hexidole (5 ,10 mg)
Serenace(.25 mg,.5 mg,10
mg,20 mg)
Trancodol DT

47

Indication

Contraindication

Organic psychiatric disorder


Delirium
Dementia
Delirium tremors
Drug induced psychosis
Functional disorder
Schizophrenia
Schizoaffective disorder
Paranoid disorder
Mood disorder
Mania
Depression with psychotic
symptoms
Child hood disorder
ADHD
Autism
Enuresis
Conduct disorder

Contraindications of typical
ant psychotics
Or 1 st generation
conventional
Known
hyper
sensitivity
Comatose patients
Blood dyscariasis
Parkinsons disease
Narrow
angle
glaucoma
Liver
renal
or
cardiac insufficiency
Elderly
and
severely ill patients
Prostatic
hypertrophy
Intestinal
obstruction
lactation

Neurotic and other psychiatric


disorder
Anorexia nervosa
Intractable OCD
Severe anxiety
Others
Antiemetic
Intractable hiccoughs
Touretters disorder

(1.5 mg,5mg,10 mg,20,mg)

Diphenylbutyl
Piperidines
Indolic derivatives
Dibenzoxazepines

Atypical anti
psychotics

Orap
Flumap 20 mg
Palipxr 3 mg
Pimozide
Penfluridol
Molindone
Loxapine

Clozapine

Moban
Loxapac(10 mg, 25 mg. 50 mg)

Lozapin(25 mg,100 mg)


Slzopin(25 mg,50 mg,100 mg)
Syclop(25 mg ,100 mg)
Syzopin

Respiridon
Resdone ,resperidone (1 mg,
2mg,3 mg,4 mg)
Risnia MD 3mg
Risdone MT (0.5 mg)
Roze 1 mg
Zisper MD
Sizodon
Sycodone
Olazipine

Oleanz (5 mg,2.5 mg,7.5 mg)


Oliza (2.5 mg,5 mg,7.5 mg,10
mg,15 mg,20 mg)
Oleaiz rapi tab (7.5 mg,10 mg)

Quetiapine

Q- pin ( 25 mg,50 mg,100


mg,200 mg,300 mg)

Aripriprazole

Socalm
Quatan
Quticool
Arpizole 9 5 mg ,10 mg)

48

Contraindication of atypical
ant psychotic
Second
generation
antipsychotics

Hypersensitivity
Severe depression
Dementia
related
psychosis
Lactation
Cardiac
dysarrtymias
Recent MI
Heart failure
Controlled epilepsy
In cardiac hepatic or renal
insufficiency

Ziprasidone

Aria 9 10 mg ,15 mg, 20 mg, 30


mg)
Arena
Pipra A

Iloperidone

Zisper
Geodone
flusure ( 4 mg)
Anti
parkinsonian
agents
Mechanism
of
action;
It
acts
by
increase
the
release
of
dopamine from
pre
synaptic
vesicles,
blocking
the
reuptake
of
dopamine
into
presynaptic
nerve terminals
or by excreting
an agonist effect
on post synaptic
dopamine
receptor

Anti cholinergic

Trihexy phenidyl
hydrochloride
(1-15 mg/day)
Benstropine (1-8
mg/day)

Dopaminergic
agents

Biperiden(2-6
mg/dl)

Barohexy (200 mg)


Bexol(2 mg0
Pacitine 2 mg)
Triphen (2 mg)
parintane(2 mg)

Brom (2.5 mg)


Encript(2.5 mg)

Mono
amino
oxidate type B
inhibitor

Selegiline

Drug

induced
parkinsonism
Drug
induced
extra
pyramidal reactions

Bromocriptine

Carbidopa
levodopa

Syndopa(10 mg0
Syndopa plus (10 mg)
Park met(10 mg)
Neo care (10 mg,50 mg)

Selerin(5 mg)
Selgin (5 mg)

49

Hypersensitivity
Angle
closure
glaucoma
Pyloric
duodenal
/bladder
Pregnancy
and
lactation
Melanoma
C V collapse
Narrow
angle
glaucoma
Paralytic illus.
Chronic pulmonary
disease
Sick
sinus
syndrome
Thyrotoxicosis

Antianxiety
drugs
Depress
subcortical
levels
of
CNS,limbic
system
and
reticular
formation. They
made potentiate
the effect of the
powerful
inhibitory
neurotransmitter
GABA in the
brain, these by
producing
a
calmative effect.
All levels of CNS
depression can
be affected from
mild sedation to
hypnosis
to
coma

SSRI
sblock
reuptake
of
serotonin in to
the presynaptic
nerve
terminals,increa
sing
synaptic
concentration of
serotonin

benzodiazepine

Selective
serotonin
reuptake
inhibitors

Alprazolam (0.56)
Clonazepam(0.520)
Diazepam
Lorazepam (2-6)
Chlordiazepoxide

Escitalopram
Paroxetine
sertaline

Xanax
Klonopin
Valium
Ativan
Sanprazole
Lopez (1mg,2 mg)
Librium(10 mg)

Anxiety disorder
Anxiety symptoms
Acute alcohol with drawl
Skeletal muscle spasm
Convulsive disorder
Status epilepticus
Pre operative sedation
Their use and for periods
greater than 4 months
have not been evaluated

Short term management


of insomnia
Depression
Anxiety disorder
Panic disorder
Depression

Lexapro
Paxil
Zoloft

50

Hypersensitivity to
benzodiazepines
Pregnancy
Lactation
Narrow
angle
glaucoma
Elder adults
In
depressed
patients
CNS
depression
can
exacerbate
symptoms

Severe
hepatic
insufficiency
Obstructive sleep
apnoea
Amnesia
Abnormal vision
Hepatitis
Anaphylactic
reaction
Diarrhea

Buspridone
Buspridone
does
not
depress
CNS,although t
Its
action
is
unknown,
the
drug
produce
desired effects
through
interaction with
serotonin
in
dopamine and
other
neurotransmitter
receptors.

Buspiridone

Sedative
Sonata
Ambies
Benzodiazepine

Nausea
Drugged feelings

Short term management of


insomnia

Insomnia associated with


anxiety
Sedation in critical care
Status epileptics
Prophylactic of symptoms
in umneoplastic induced
emisis

Severe
hepatic
imparement
CNS depression
Drowsinesss
Blurred vision
Pregnancy
Lactation
Diplopia

Buspar

Hypnotics

This drugs are


needed
to
produce
sleep
and
relive
insomnia

Depression

Lorazepam
Diazepam
Clonazepam

lopez
Ativan
Restoril
halcion

51

ANTIDEPRESS
ENT
This
drugs
ultimately work
the increase the
concentration of
nonepineprine,s
eratonine, and
dopamine in the
body. this is
accomplished by
blocking
the
reuptake
of
these
neurotransmitter
by the nurone

Amitriptyline( 5075 mg daily)

Tri
cyclic
antidepressent

Imipramine
(75mg/Daily

Fluoxetine
-40 mg)

(20

Escitalopram
Citalopram(20
mg daily)

Monoamio oxidate
inhibitors(MAOIs)

Depression
Depressive episode
Dysthymia
Reactive depression
Secondary depression
Abnormal grief reaction
Childhood psychotic disorder
Enuresis
Separation anxiety disorder
Somnambulism
School phobia
Other psychiatric disorder

Antidep
depsonil
elamin
depsol

Clomipramine
(10 mg -30to 200
mg)

Selective
serotonin
reup
take
inhibitor(SSRIs)

Elavil
Tryptomer
Amitone

anafranil
clonil

Panic attack
Anxiety
Agoraphobia
Social phobia

Barozac
prodep
flutinol
fludac
prosac
Citalo
Topdep
Nexito (10mg,5mg)

Sertaline (25-200
mg)

Daxid (50mg,100mg)
Setalin(25,50,100 mg)
Zosert(25,50 100 mg)
Serenata (50 mg)

Isocarbacid

Marplan

Trazodone (150-

Trazalon (25,50 mg)

52

OCD with or without depression


Eating disorder
Borderline personality disorder
Post-traumatic stress disorder
Depersonalization syndrome
Medical disorder like chronic pain,
migraine, peptic ulcer.

Individual
with
hypersensitivity
Acute
recovery
phase followed by
myocardial
infraction
Individual
with
angle
closure
glaucoma
Elderly patients
Hepatic, renal or
cardiac insufficiency
Patient who have
benign
prostate
hypertrophy
Patient with history
of seizures

Atypical
depressants

anti

Antimanic
modulates
the
effects of various
nurotransmitters
such
as
nonepinephrene,serato
nine,dopamine,glut
aminate and gaba

Anti convulsants

100 mg)

Trazodac (25,50 mg)

Mitrazapine (1545 mg)


Bupropion
Trazodone

Mirnite 15,30,45)
Mirtaz(7.5 ,15,30 mg)

Lithium
carbonate
(300-400)

Carbolith
(300,400,450 mg)
Elcab 300mg
Intalith 150,330,450, mg
Litium 300,400 mg
Lithosum 250,300,400

Carbamizepine
(200-1600 mg)

Carbatol
(100,200,400 mg)
Tegretol (100,200,300,400mg)
Zen (100,200)
Zen retard(200,300,400)

Clonazepam 0.5
-20 mg

Clonotril(.25 ,.5,1,2,mg)
Lonazep (.25,.5,1,2,mg)
Zepam (0.5,1,2,mg)

Valproic acid
These drugs act
on gama amino
beutiric acid an

Sodium valporate
Encornate chrono(200,300,500)
Epilex (200,500 mg)
Epival (200 mg)

53

Acute mania
Prophylaxis for bipolar and unipolar
mood disorder
Schizoaffective disorder
Cyclothymia
Impulsivity and aggression
Other disorder
Premenestral dysphoric disorder
Bulimia nervosa
Borderline personaliy disorder
Episodes of binge drinking
Trichotillomania
Cluster headache

Epilepsy
Trigeminal neuralgia
Bipolar disorder
Resistant schizophrenia

Hypersensitivity
Cardiac, renal,thyroid or
neurological dysfunction
Severe dehydration
History of seizures
Pregnancy and lactation
Urinary retention
Diabetics

Hypersensitivity
Lactation
Caution with elderly

inhibitory amino
acid
neuro
transmitter,
GABA
receptorsactivati
on serves to
reduce neuronal
exitability

Lamotrigine
100-200 mg

Epsoval (200 mg)


Torvate (200,300,500,750,1000
mg)
Valporin (100,200,300,500 mg)

Lamictal
Epitic (25,50,100 mg)
Lamipil(25,50,100 mg)
Lamogen (25,50,100 mg)

Alcohol withdrawal
Restless leg syndrome post
therapeutic neuralgia

Petitmal,akinetic
and
myoclonis sezures
Panic disorder
Unlabelled use
Acute manic episode
Uncontrolled leg movement
during sleep
Neuralgia

Gabapentin
900-1800 mg

VITAMINS
Vitamin B1 or
thiamine
Essential
for
normal
functioning
of
nerous tissue .it
is co enzyme in
CHO
metabolism.

Tablet forms

Injections

Rengunate 300 mg
Renjuron 300 mg
Gaba 300 mg
Gabalept (100,300,400 mg)
Neupent AF 900 mg

Benalgis (100 mg)


Betaxin

B-one (100 mg/ml)


Becousules
Becadexamine
Becelac forte

54

Acute mania,
prophylactic treatment of
bipolar disorderI,
rapid
cycling
bipolar
disorder
Schizoaffective disorder
Seizures
Migraine prophylaxis

Other
Bulimia nervosa
OCD
Agitation
PTSD

Substance use disorder


Substance withdrawal state
Prophylactic
for
wernicks
encephalopathy and korsakoffs
psychosis

Liver,renal, cardiac disease


Pregnancy
Glaucoma
Children less than three yrs
Causion
with
hepatic
imparement

DRUG
FOR
DEADDICTION

Disulfuram
Used to ensure
abstinence in the
treatment
of
alchohol
depentance .it is a
aldehydehydogena
ce inhibiter that
interfere
with
mechanism
of
alcohol
and
produce a marked
increase in blood
acetaldehyde
levels.

T ESPERAL (250,500 mg)

55

As an aversive conditioning in
treatment of alcohol dependence

Pulmonary
and
cardiovascular
disese
Brain damage
Hepatic disease
Seizures
Poly
drug
dependence