FEAR – protects us from something bad.

ANXIETY
 Vague sense of impending doom.
 Triggers the sympathetic nervous system.
 Assess level of anxiety of client.
TYPES OF ANXIETY
MILD ANXIETY
 + 1 level of anxiety.
 Widened perceptual field.
 Restless (say you seem restless).
 Enhanced learning capacity.
MODERATE ANXIETY
 + 2 level of anxiety.
 Client pace.
 Give PRN meds.
SEVERE ANXIETY
 + 3 level of anxiety.
 Don’t know what to do/say.
 Directive orders (please sit down).
PANIC
 + 4 level of anxiety.
 May commit suicide.
 Promote safety.
 Never touch patient.
 Hyperventilation (Respiratory Alkalosis)
 Breathe into paper bag.

NURSING DIAGNOSIS PLANNING/IMPLEMENTATION

 Ineffective individual coping.  Decrease level of anxiety.
 Powerlessness.  Decrease environmental stimuli.
 Impaired skin integrity  Relaxation techniques

EVALUATION
 Effective individual coping.

GENERALIZED ANXIETY DISORDER

 6 month excessive worrying.
 Restless, difficulty concentration, sleep disorders, palpitations, edge of the seat, easy fatigability.
PANIC ATTACKS/ DISORDER
 15 – 30 minutes sympathetic nervous system escalation.
 Example is AGORAPHOBIA fear of open spaces.

POST TRAUMATIC STRESS DISORDER

 Victims become survivors and experience flashbacks or nightmares.

MALINGERING
 Pretending to be sick (conscious).
 Primary Gain anxiety decreases, able to escape source of anxiety.
 Secondary Gain able to get attention.

SOMATOFORM DISORDER
 No protection
 Unconscious
 No organic basis of being sick

DIFFERENT TYPES OF SOMATOFORM

1. Conversion Disorder
 Cannot speak, see, hear.
 Nervous system affected.
2. La Belle Indifference
 Do not care what happens to them.

HYPOCHONDRIASIS
 has minor discomfort and interprets it as major illness.
 Focus on clients feelings.
BODY DYSMORPHIC DISORDER
 Illusion of structural defect.
 Favorite past time is doctor hopping.
 Focus on clients feelings.
PSYCHOSOMATIC
 Real pains/illness
 Real symptoms because of anxiety
PHOBIA
 Irrational fear
 Etiology: Knowledge of certain object
 Bad experience
 Immediate nursing objective: Removal of stimulus will remove anxiety
 Systemic Desensitization gradually expose client to stimuli/feared object
 Employ relaxation techniques

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

BULIMIA NERVOSA
 Metabolic alkalosis (vomiting results to decreased hydrochloric acid)
 Metabolic acidosis (diarrhea results to decreased bicarbonate)
 Dental caries
 Wound in knuckles
MANAGEMENT
 Fluid and electrolyte imbalance
 Meal contract
 Weight gain for client
 After eating stay with client for 1 hour and accompany when going to the comfort room

SCHIZOPHRENIA
 Ego disintegration
 Impaired reality perception
 Genetic vulnerability
 Stress – Diathesis Model
 Biological theory – increase dopamine level
 Exact cause unknown
ASSESSMENT
 Affect: Appropriate, Inappropriate, Flat, Blunt (incomplete)
 Ambivalence: pulled into 2 opposing forces
 AUTISM: Looseness, no idea, not related to one another

ASSESSMENT
 NEGATIVE POSITIVE
Hypoactive Hyperactive
Withdrawn Sociable
Thought Blocking Flight of ideas
Apathy
I. ASSESS
 Content of thought
NURSING DIAGNOSIS
 Disturbed thought process
PLANNING/IMPLEMENTATION
 Present reality
 Provide safety
EVALUATION
 Improved thought process

II. ASSESS
 Hallucinations/ Illusions
NURSING DIAGNOSIS
 Disturbed sensory perception
PLANNING/IMPLEMENTATION
 Present reality
 Safety
EVALUATION
 Improved sensory perception

III. ASSESS
 Suspicious
NURSING DIAGNOSIS
 Risk for other directed violence
PLANNING/IMPLEMENTATION
 Present reality
 Safety
EVALUATION
 Eliminate/minimize risk for other directed violence

IV. ASSESS
 Suicidal
NURSING DIAGNOSIS
  Risk for self directed violence
PLANNING/IMPLEMENTATION
 Present reality
 Safety
EVALUATION
 Eliminate/minimize risk for self directed violence
LOOSENESS OF ASSOCIATION
 There is connection with statements
FLIGHT OF IDEAS
 Jumping from on topic to another
AMBIVALENCE
 Pulled between 2 strong opposing forces
MAGICAL THINKING
 acting like magician
ECHOLALIA
 Client repeats what you say
ECHOPRAXIA
 Client repeats what you do
WORD SALAD
 Just words no rhyme
CLANG ASSOCIATION
 Words that rhyme
NEOLOGISM
 Formation of new words (needs clarification)
DELUSION: PERSECUTORY
 “The NBI is out to get me”
DELUSION: RELIGIOUS
 “I am Jesus Christ the savior”
DELUSION: GRANDEUR
 “ I am the queen of the world”
DELUSION: IDEAS OF REFERENCE
 “The nurses are talking about me”
CONCRETE ASSOCIATION
 Also known as “pilosopo”
THOUGHT BLOCKING
 Unable to think

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

 Present reality to clients experiencing hallucinations

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

PARKINSON’S DISEASE
 If acethylcholine (on switch) is increased there is excessive movement resulting to decrease in
dopamine (off switch)
AKINESIA
 Muscle rigidity
DYSTONIA
 Torticollis (wry-neck)
OCULOGYRIC CRISIS
 Fixed stare
OPISTHOTONUS
 Arched back
 Lips – smacking
 Tongue – protruding
 Cheeks – puffing
 The 3 are irreversible and called TARDIVE DYSKINESIA
 NEUROLEPTIC MALIGNANT SYNDROME  Hyperthermia

OTHER SIDE EFFECTS OF DECREASE DOPAMINE

 Photosensitivity
 AGRANULOCYTOSIS – decrease WBC
 Clients prone to infection due to decrease WBC
 First sign for infection is sore throat
TYPES OF SCHIZOPHRENIA
DISORGANIZED CATATONIC PARANOID RESIDUAL UNDIFFIRENTIATED
UNCLASSIFIED
- Sad but smiles - Ambivalence - Suspicious - No more - Mixed classification,
(Inappropriate affect) - Waxy flexibility - Mistrust, positive cant be classified
- No reaction (flat - Favorite word is “No” scared, symptoms
affect) - Negativism (client do withdrawn just
- Flight of ideas not follow what you Nursing withdrawn
(disorganized speech) tell them to do) management:
- Giggling Nursing - Gain TRUST
(hebephrenic giggle) management: by 1 to 1 short
- Combination of Meet needs interaction but
positive and negative frequent
signs and symptoms - Foods should
be in a sealed
container
- Medications
should be in
tamper resistant
foil.
Violent:
- Keep door open
- Position near
door
- Don’t touch
client
- Call for
reinforcement
- One arms
length away from
the client.

BIPOLAR DISORDER/ MANIC PROFILE

 20 years old
 Female
 Stress
 Obese
ASSESSMENT
 Decrease appetite (give finger foods)
 Decrease sleep (place in a private room)
 Hyperactive
 Increase sexual activity – only means of addressing anxiety so decrease level of anxiety
 Risk for injury/other directed violence
 Impaired social interaction (care giver role: strain and stay with client)
 Self esteem decrease (to cover up their sadness there is compensation to cover defective doing)
 Because there is decrease self esteem there will be increase compensation resulting to
increase interference with ADL’s and harm to others
 Compensation is the culprit
 Management: increase self esteem to decrease compensation and decrease interference
with ADL’s and harm to others
HOW TO INCREASE SELF ESTEEM OF MANIC PATIENTS?
T - no sports (basketball, volleyball), no fine motor skills only gross motor skills
A -llot energies toward more productive endeavors (sublimation)
S - escorted walk outdoors
K - punching bag (displacement)

PHARMACOLOGY NOTES
ANTI – DEPRESSANTS
 Asendin  Vivactil
 Norpralamin  Elavil
 Tofranil  Prozac
 Sinequan  Paxil
 Anafranil  Zoloft
 Aventyl

ALCOHOL LEADS TO:

 Blackout: awake but unaware
 Confabulation: inventing stories to increase self esteem
 Denial: “I am not an alcoholic”
 Dependence: cant leave with out leading to enabling where in the significant other tolerates the
abuser co dependence is another term
 Tolerance: gradual increase in amount of stimuli to experience the same euphoria
MANAGEMENT
 Detoxification: withdrawal with medical doctor supervision
 Avoid alcohol therapy
 Aversion therapy a more technical term for avoid alcohol therapy
 Antabuse: Disulfiram makes the client never drink alcohol because it causes vomiting
 Alcoholics anonymous
 Interval of 12 hours after last dose of alcohol or experience nausea and vomiting and hypotension
 Alcoholism may result to Vitamin B1 (Thiamine) deficiency

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

ALZHEIMERS DISEASE
- Axon (away) and Dendrites (toward) nerve
- Neurofibrillary tangles
- Neurotic plaques
ALCOHOL/ DELIRIUM ALZHEIMERS
ONSET Abrupt Gradual
LEVEL OF CONSCIOUSNESS Fluctuating Unaffected
DURATION Hours to days Progressive
MEMORY Short term memory loss Short term and long term
(orient patient)

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

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

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

ANTI – DEPRESSANT SIDE EFFECTS

 MALE – Erectile dysfunction, prone to impotence

GRIEF PROCESS [D.A.B.D.A]

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

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

WHEN THE CLIENT IS SUICIDAL WHAT WILL THE NURSE DO

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