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PSYCHIATRIC NURSING  The psychiatric-mental health nurse uses counseling

Benchmark Period in Psychiatric History June Mellow interventions to assist clients in improving or regaining their
Historical Perspective of the Treatment of Mental Illness – focuses on clients’ psychosocial needs and strengths previous coping abilities, fostering mental health, and
- argued that the nurse as the therapist is particularly suited to working preventing mental illness and disability
with those with severe mental illness in the context of daily activities,
focusing on the here and now to meet each person’s psychosocial needs Standard Vb. Milieu Therapy
 The psychiatric-mental health nurse provides, structures, and
Psychiatric Nursing in the Philippines maintains a therapeutic environment in collaboration with the
• The National Center for Mental Health (NCMH) was client and other health care providers
established thru Public Works Act 3258.
• It was first known as INSULAR PSYCHOPATHIC Standard Vc. Self-Care Activities
HOSPITAL, situated on a hilly piece of land in Barrio  The psychiatric-mental health nurse structures interventions
Mauway, Mandaluyong, Rizal and was formally opened on around the client’s activities of daily living to foster self-care
December 17, 1928. and mental and physical well-being
• This hospital was later known as the NATIONAL MENTAL Standard Vd. Psychobiologic Interventions
HOSPITAL, given on November 12, 1986, it was given its
present name thru Memorandum Circular No. 48 of the  The psychiatric-mental health nurse uses knowledge of
Office of the President. psychobiologic interventions and applies clinical skills to
restore the client‘s health and prevent further disability
• On January 30, 1987, NCMH was categorized as a Special
Research Training Center and hospital under Department of Standard Ve. Health Teaching
Health.  The psychiatric-mental health nurse, through health teachings
• Today, NCMH has an authorized bed capacity of 4,200 and a assists clients in achieving satisfying, productive, and healthy
daily average of 3,400 in-patients. It sprawls on a 46.7 patterns of living
Benchmark V: Decade of the Brain hectare compound with a total of 35 Pavilions/Cottages and
52 Wards. Standard Vf. Case Management
 The 1990s – declared the Decade of the Brain
• The NCMH is a special training and research hospital  The psychiatric-mental health nurse provides case
 During this decade, a steep increase in brain research
mandated to render a comprehensive (preventive, promotive, management to coordinate comprehensive health services and
occurred that coincided with an increased interest in biologic
curative and rehabilitative) range of quality mental health ensure continuity of care
explanations for mental disorders
 The Decade crystallized the fact that some behaviors are services nationwide.
Standard Vg. Health Promotion and Maintenance
caused by biologic irregularities and not willful contraries, or
Standards of Mental Health Clinical Nursing Practice  The psychiatric-mental health nurse employs strategies and
worse
Standards of Care interventions to promote and maintain mental health and
 The Decade brought back nursing into the mainstream of prevent mental illness
psychiatric care
Standard I. Assessment
 The psychiatric-mental health nurse collects health data Standard VI. Evaluation
Psychiatric Nursing Practice
 The psychiatric-mental health nurse evaluates the client’s
Linda Richards
Standard II. Diagnosis progress in attaining expected outcomes
 Graduated in 1873 from New England Hospital for Women
and Children in Boston  The psychiatric-mental health nurse analyzes the data in
determining diagnoses MENTAL HEALTH
 Improved nursing care in psychiatric hospitals and organized • State in the relationship of the individual and his environment
educational programs in state mental hospitals in Illinois in which the personality structure is relatively stable, and
 First psychiatric nurse Standard III. Outcome Identification
environmental stresses are within its absorptive capacity.
 Believed the mentally sick should be at least as well cared for  The psychiatric-mental health nurse identifies expected
(WHO)
as the physically sick outcomes individualized to the client
• A positive state in which one is responsible, displays self-
awareness, is self-directive, is worry-free and can cope with
Harriet Bailey Standard IV. Planning
usual daily tension
- published the first psychiatric nursing textbook, Nursing Mental  The psychiatric-mental health nurse develops a plan of care
• A state of complete physical, mental and social well-being
Diseases in 1920 that prescribes interventions to attain expected outcomes
and not merely the absence of disease
• Relative and dynamic concept. Not the same to all people
Hildegard Peplau Standard V. Implementation
• Changes at different point in time. It is not static
– described the therapeutic nurse-client relationship with its phases and  The psychiatric-mental health nurse implements the
tasks and wrote extensively about anxiety interventions identified in the plan of care FACTORS THAT AFFECT MENTAL HEALTH
• Inherited characteristics – genetic make-up
The interpersonal dimension forms the foundation of nursing practice Standard Va. Counseling • Nurturing during childhood
today • Life circumstances
 Believes that crises is temporary • Believed that vast majority of mental disorder were due to
FACTORS INFLUENCING A PERSON’S MENTAL HEALTH unresolved issues that originate in childhood
• Individual factors – vitality, finding meaning to life, CHARACTERISTICS OF A PERSON WITH GOOD MENTAL
biological make-up, emotional resilience, spirituality, sense of LEVELS OF AWARENESS
HEALTH
harmony in one’s life Conscious – aware at any time
• Have positive self-concept & relate well to people & their
Pre-conscious – can be retrieved rather easily through conscious part
• Interpersonal factors – Intimacy, helping others, effective environment
Unconscious – repressed memories, passion, unacceptable urges
communication, maintaining a balance of separateness and • Form close relationship with others
connection • Make decision pertaining to reality rather than fantasy
• Be optimistic & appreciate & enjoy life
• Social, Cultural factors – access to adequate resources, • be independent or autonomous in thought and action
sense of community, intolerance of violence PERSONLITY STUCTURE
• Be creative, using varying approaches as they perform task or
ID – source of all drives, instincts, reflexes, needs, genetic inheritance
solve problem
COMPONENTS OF MENTAL HEALTH and capability to respond to wishes that motive us
• Consistent as they appreciate and respect the rights of others
• Autonomy and Independence • Present at birth
 Individual follows guiding values and rules to live • Displays willingness to listen and learn from others • Unlearned selfish source of libidal energy
by • Operates on pleasure principle through the use of fantasy and
SELF - AWARENESS images
 Engage in independent action and thinking
• Process by which the individual gains recognition of his or • Compulsive with no sense of right or wrong
 Consider the opinions and wishes of others
her own feelings, beliefs and attitudes • Demands immediate satisfaction
 Can work interdependently or cooperatively with • The ability to recognize the nature of one’s own behavior,
others without losing his autonomy attitude and emotion
• SIGNIFICANCE – if id is not controlled effectively the
individual function in antisocial; lawless manner or ways
• Key to self-understanding
• Maximizing one’s potential because his primitive drives or impulses are freely express
• Help understand and accept the difference of others
 Keep aiming
 Keep going EGO – begins during the first 8 months of life and is fairly develop when
SELF – CONCEPT
 Use talents the child reaches 2 years
– part of self that lies within conscious awareness depends on how a
 Continually strive to grow • The self or the I
person thinks he or she is viewed by others
• Problem solver and reality tester
 Self-actualization
• Able to differentiate subjective experience, memory images
• Self – esteem Good self-concept leads to self-acceptance
and object reality
 Accept strength and limitations • Attempts to negotiate a solution with the outside world
 Awareness of abilities and limitations SELF-ACCEPTANCE – regards of oneself with realistic concept of
• Controls and guides the action of individual
strength and weakness, accept others easily
• Part of the personality that experiences anxiety and uses
• Tolerating life’s uncertainties defense mechanism for protection
 Positive outlook in life Behaviors of a self-accepting person:
• Influenced by heredity, environmental factors and maturation
 Face challenges life has to offer • Perserving
• SIGNIFICANCE – if the individual does not develop a strong
 Optimism • Trusting and accepting others
ego to arbitrate effectively between id and superego the
• Seeing reality
 Have the courage to rise after falling individual will surely develop intrapersonal and interpersonal
• Minimizing weakness
conflict
• Increase strengths
• Mastering the environment
• Learning from mistakes
 Learn to adopt or cope and relate SUPEREGO – moral component of personality
• Reaching out to others
 Can deal with the environment • Consists of “conscience” (“should-nots”) and ego ideal
• Continuing growth towards self-actualization
 Can influence the environment (“should”)
 Being competent and creative • Operates both in the conscious and unconscious but operates
PSYCHODYNAMICS OF PERSONLITY
mostly on the unconscious level
PERSONALITY – is the sum total of or whole being
• Reality Orientation • Develops around 3-4 years and fairly develop at age 10
– Aggregate of the physical and mental qualities of
 Distinguished real world from a dream • Formed and influence from the internalization of what parents
individual as it interacts in characteristic fashion
teach their children regarding right or wrong through rewards
 Distinguished facts from fantasy – Sum total of the person’s distinctive character,
and punishments
 Behave appropriately behavior, attitude
 Act accordingly – The way one carries himself • SIGNIFICANCE – if superego is so strong the life of the
– Express through behavior individual is dominated by its restriction on behavior, he or
• Stress management – Complex, dynamic and unique she is likely to be unhappy, inhibited and anxiety-guilt ridden.
 Tolerate life stresses Individuals become inferior if he/she cannot live up to
 Experience failure without devastation CONCEPT of PERSONALITY – all behavior have meaning and is not parental standards
 Cope and tolerate anxiety determined by chance
 Resolve conflicts, stress and anxiety
SIGMUND FREUD (1856 – 1939)
• Learns by thinking images
• Develop expressive language and
symbolic play
– Intuitive phase (4-7)
• Egocentrism (seeing things from own
point of view)

3. CONCRETE OPERATIONAL STAGE (8 – 12 yr)


– Able to think more logically as concept of moral
judgment, numbers, spatial relationship

FREUD’S PSYCHOSEXUAL STAGES OF DEVELOPMENT 4. FORMAL OPERATION STAGE (12 – adulthood)


– Develops adult logic
– Able to reason, form conclusion, plan for the
future, think abstractly and builds ideas

HARRY STACK SULLIVAN’S INTERPERSONAL THEORY

PERSONALITY – behavior that can be observed within interpersonal


relationship

Personality development
Infancy – crying is used to establish contact with others
Childhood – language is used to assist with learning to delay the
gratification of needs
Juvenile period – competition, compromise and cooperation are tools
for developing relationship with others
Preadolescence – collaboration and the capacity for love assist in the
development of relationship with same gender
Early adolescence – with sexual desire, facilitate learning to establish
relationship with members of the opposite sex
Later adolescence – interdependence develop, learns to form lasting
sexual relationship
ERIK ERICKSON’S DEVELOPMENTAL THEORY ANXIETY
• Each stage of development is an emotional crisis involving – any painful feeling or emotion arising from social insecurity or blocks
positive and negative experiences to getting biological needs satisfied
• Growth/mastery of critical task results from having more
positive experience than negative experience SECURITY OPERATIONS
• Allows for corrective emotional experience beyond 5 yrs of – a person uses to defend oneself against anxiety and ensure self-esteem
life JEAN PIAGET’S COGNITIVE THEORY
• Views intellectual development as result of constant Somnolent detachment – use of sleep to avoid anxiety
interaction between environmental influences and genetically Apathy – emotional detachment or numbing
determined attributes Selective inattention – tuning out details associated with anxiety-
producing situation
4 STAGES OF COGNITIVE DEVELOPMENT Dissociation – prevents situation from integrating into conscious
1. SENSORIMOTOR STAGE (0 – 2 yr) awareness
– Learns by exploring objects and events and by Converting anxiety to anger – powerlessness is exchanged for a
imitating temporary feeling of power associated with anger directed outward
– Infants develop SCHEMATA (assimilation and
accommodations incoming information) 3 TYPES OF TENSION
Tension of needs – stemming from physiochemical requirement of life
2. PREOPERATION STAGE (2 – 7 yr) Tension of anxiety – from interpersonal situation
– Preconceptual phase (2-4 yr) Tension of need for help
• modeling refers to new behaviors that are learned by
SELF-SYSTEM – develops relatively enduring patterns for avoiding or imitating the behavior of another person
minimizing anxiety during interpersonal encounters and the meeting of
biologic needs • operant conditioning involves the use of tokens for desirable
– “good me” – needs are satisfied behavior
– “bad me” – needs are unmet and anxiety persists • systemic desensitization involves gradually confronting a
– “not me” – anxiety is severe and information is not stimulus that evokes intense anxiety, it is useful in treating
completely integrated into the personality on a phobias
conscious level – the therapist initially teaches the client how to
relax and begins a stimulus that causes mild
Behavioral Theories anxiety
Key Concepts – the client learns to invoke the relaxation response
• A behavioral framework is used to described a persons when confronted with a stimulus
functioning in terms of identified behaviors – the process continues until an intensely anxiety
– people learn to be who they are because of provoking stimulus no longer causes the client to • patterns of thinking leads to and perpetuates maladaptive
environmental shaping feel anxious behaviors
– behavior can be observed, described or recorded • aversive therapy operates on the principle that unpleasant • the amount of perceived control over a situation affects how
– behavior is subject to reward or punishment consequences result from undesirable behavior, it may be an individual responds to stressors and problems
– changing one’s environment can modify behavior used in treatment of paraphilias
• maladaptive behaviors are learned through classical and Treatments
• biofeedback involves training techniques used to control
operant conditioning; they may continue because they are
physiologic responses such as stress response and its • Cognitive therapy, a form of therapy developed by Aaron
rewarding to the individual Beck, encompasses various treatment methods in which the
physiologic manifestations
• maladaptive behaviors can be change without developing therapist and client work closely to identify maladaptive
insight into the underlying concepts by altering the • relaxation techniques are training techniques used to thought patterns and develop alternate ways of thinking and
environment counteract anxiety symptoms behaving.
• behavioral models posit that personality consist of learned • assertiveness training incorporates techniques to overcome – This is often used in depression that stems from
behaviors and personality becomes synonymous with passivity or aggression in interpersonal situation the individual’s negative self concept, or
behavior – if behavior changes, so does the personality exaggerated prolonged guilt, that result in
Application to nursing automatic thoughts of self deprecation.
Classical conditioning (Pavlov’s theory) • In the behavioral framework, the nurse assesses both adaptive – The goal of the therapy is to diminish depressive
• classical conditioning was developed by Ivan Pavlov and maladaptive behaviors. symptoms by helping the client challenge and
• he established that learning or conditioning can occur when a • The nurse and the client collaborate to identify behaviors that invalidate distorted thoughts through series of
stimulus is paired with an unconditioned response require change. mental exercises and replace them with
– a conditioned response is pairing of a stimulus • As a member of the treatment team, the nurse uses various appropriate, realistic thoughts.
with a response
– acquisition refers to the gaining of a learned
behavioral modification techniques to help the client. • In Rational-Emotive therapy developed by Albert Ellis,
response (once a response is learned, it continues) helps the client examine own irrational thoughts and behavior
Cognitive Framework through verbal discussion followed by activities that allows
– Extinction is the loss of learned response Key concepts the individuals to challenge the faulty beliefs by directly
Operant conditioning (Skinner’s theory)
• the cognitive framework focuses on distorted or negative confronting the feared situation. This is useful in mild to
• developed by B. F. Skinner, operant conditioning involves the thought patterns that lead to maladaptive or symptomatic moderate anxiety states
use of reinforce consequences to change the behavior feelings and behaviors • In Gestalt therapy, based on the collective efforts of Fritz
• positive reinforcement is a reward given to help continue the – distorted thinking leads to and perpetuates Perls and Paul Goodman, the therapist promotes the client’s
behavior maladaptive behaviors self awareness and increased self responsibility for meeting
• negative reinforcement removes undesirable consequences to – certain thought patterns can be identified as needs.
misperceptions
help continue the behavior • In Beck’s Cognitive therapy, developed by Aaron Beck, the
• positive punishment involves the use of aversive therapist teaches the client to identify and correct
consequences to decrease a particular behavior dysfunctional thoughts about the self, world and the future
• negative punishment involves withdrawing the reward to
decrease a particular behavior Cognitive techniques may be used:
– Cognitive restructuring – change of maladaptive
Behavioral treatments beliefs through positive self statements and
• behavioral modification involves the use of various learned refusing irrational beliefs
techniques to change maladaptive behavior, it is commonly – Thought stopping – constantly say “STOP” to
used with clients who have anxiety disorders, substance abuse maladaptive thoughts
problems or other specific behavioral problems
• Focused on human needs fulfilment, which is categorized into 1. Behavior refers to the way in which an organism responds to
6 incremental stages. a stimulus
– All behaviors are meaningful and purposeful

Varieties of behavior
A. Reflex action – automatic response to a stimulus (blinking reflex,
gag reflex)
B. Goal oriented behavior – presence of two factors:
• Presence of need within the individual
• Presence of goal outside the individual which is capable of
producing a change in his internal condition and thus satisfying the
need (e.g.. Hunger, anxiety)

– Need – an organismic condition which exist


within an individual and which demands certain
Humanistic Framework activity. It is a requirement for survival.
• Key Concepts
– Humanistic framework focuses on the “here and Sources of Need
now” – current behaviors, issues and problems – Biomedical Framework • Those which arise as a direct result of metabolic process
as well as spiritual values and meanings. Key Concepts (hunger and thirst)
– human nature is viewed as positive and growth • Physiologic, social and environmental factors can predispose • Those that results from a change in the person’s relationship
oriented, and existence involves search for to mental illness. with his external environment (drop in room temperature)
meaning and authenticity • Mental illness can be classified as in the multi axial DSM IV-
– Abraham Maslow’s theory of human motivation TR
• Symbolic behavior – talking, reading and thinking
theory describes human needs that are organized
CONFLICT
according to levels in which individuals move on Treatments
• The result o f the presence of two opposing or incompatible
to higher needs as lower, more basic needs are met • Diagnostic work ups include detailed history and lab test as
drives wherein the person is required to make a choice
– failure to develop one’s potential leads to poor well as careful observation of current behavior
between the possible responses
coping • Pharmacotherapy is a common treatment including g nurse
– lack of self awareness and unmet needs interfere patient interaction and milieu management.
DYNAMICS OF CONFLICT
with feelings of security as well as with
relationships Eclectic Theory
Conflict → ↑ anxiety → feeling of hopelessness, helplessness
– fundamental human anxiety is fear of death which Eclectic
and isolation → ↑ perceived conflict increases → ↑ anxiety
leads to existential anxiety • varied; made up of parts from various sources
• choosing what is best or preferred from a variety of sources or
Treatments styles
• Client centered therapy, developed by Carl Rogers is based STRESS and ANXIETY
on the belief that mental illness results from an individuals Schizophrenia
failure to develop fully as human being. Possible causes: STRESS – a stimulus or situation that produces distress and create
– Psychotherapy fosters the process of learning to be 1. Genetic physical and psychological demands on a person that requires coping and
fully one’s own self 2. Organic adapting
– The therapist is genuine and without façade when 3. Biomedical theories
relating to the client 4. Psychological theories – increased incidence among the lower CHARACTERISTICS OF STRESS
– The client’s behavior changes toward positive socio-economic groups • It is recurring
functioning when the therapist conveys 5. Unknown • It is normal
acceptance, respect and genuine empathy for the • It cannot be avoided
client Mood Disorders • It is brought about by stressors
• Existential therapy – a form of talk therapy that focuses on Predisposing factors:
life issues of freedom, helplessness, loss, isolation, aloneness, 1. Medical – Biological Theories STRESSOR – any condition, agent, situation, feeling, thought or
anxiety and death; through psychotherapy, the client a. Genetic – higher incidence among individuals with relatives behavior which demands an increase in any activity within the ANS &
discovers his own meaning of existence. with the disorder CNS
b. Biochemical – electrolyte imbalances, error in metabolism
MASLOW’S HIERARCHY OF NEEDS results in transposition of Sodium and Potassium within a ANXIETY – a response to internal conflict
• Human motivation as a hierarchy of dynamic process or neuron, low levels of NE, dopamine and serotonin - feeling of uncertainty; uneasiness, apprehension or tension
needs that are critical for the development of all humans that a person experiences in response to an unknown object or
Dynamics of Behaviour situation
• Provide outlets from working off excess energy
Anxiety is describe as: • Use non-verbal language to demonstrate interests
• Subjective experience
• Emotional pain INTERVENTIONS FOR SEVERE TO PANIC LEVELS OF
• Apprehension, fearfulness or a sense of powerlessness ANXIETY
• Warning signs of perceived danger or threat • Maintain a calm manner
• Emotional response that triggers behavior • Always remain with the client
• Alerting and individual to prepare for self-defense • Minimize environmental stimuli
• Occurring in degrees • Use clear and simple statements and repetition
• Contagious • Use a low pitched voice; speak slowly
• Part of a process, not an isolated phenomenon • Reinforce reality
• Listen for themes in communication
CATEGORIES OF STRESS • Attend physical and safety needs when necessary
• Normal anxiety • Set physical limit. Speak in a firm, authoritative voice.
– healthy life force • Provide opportunities for exercises
– Motivates people to make & survive change • Physical needs must be met to prevent exhaustion
– Proportionate to actual events • Assess need for medication or seclusion
• Acute anxiety
– Precipitated by an imminent loss or change that DEFENSE MECHANISM
threatens an individual’s sense of security • Protects people from painful awareness of feelings and
• Chronic anxiety memories that can provoke anxiety
– the person has lived with the stress for a long time
5 IMPORTANT PROPERTIES OF DEFENSE MECHANISM
PRECIPITATING FACTORS OF ANXIETY 1. Defenses are major means of managing conflict and affect
2. Defenses are relatively unconsciousness
• Threats to biological integrity – refers to the distortion in 3. Defenses are discrete from one another
homeostasis ----temperature control 4. Although defenses are often the hallmark of major psychiatric
• Threat to self-esteem – threat towards maintaining syndrome, they are reversible
established views of self, values and patterns of behavior he 5. Defenses are adaptive as well as pathological
uses to resists changes in self review
– Sense of isolation (alienation) MOST HEALTH DEFENSES
– Sense of insecurity (threat to identity) Altruism – emotional conflicts and stressors are dealt with by meeting
– Sense of helplessness the needs of others

Sublimation – unconscious process of substituting constructive and


socially acceptable activity for strong impulses that are not acceptable in
the original form.

BEHAVIOR RESPONSE TO ANXIETY Humor – deals with emotional conflict or stress by emphasizing the
• Anger amusing or ironic aspects of the conflict or stressor.
• Crying
• Withdrawal Suppression – conscious denial of a disturbing situation or feeling
• Forgetfulness
• Quarrelling INTERMEDIATE DEFENSES
• Complaining Repression – exclusion of unpleasant or unwanted experiences,
• Defensive behavior emotions, or ideas from conscious awareness
Displacement – transfer of emotion associated with a particular person,
LEVELS OF ANXIETY INTERVENTIONS FOR MILD TO MODERATE LEVELS OF object, or situation to another person, object, or situation that is non-
ANXIETY threatening
• Help client to focus and sole problems with the use of
communication techniques Reaction formation – unacceptable feelings or behaviors are kept out of
• Help client identify anxiety awareness by developing the opposite behavior or emotion
• Provide a calm presence
• Recognize the anxious person’s distress Somatization – transforming anxiety on an unconscious level into a
• Be willing to listen physical symptoms that has no organic cause
• Evaluate effective past useful coping mechanism
• Assist in developing alternative solution to a problem
Undoing – consciously doing something to counteract or make up for a Limbic system – crucial role in emotional status and psychological
transgression or wrongdoing function (norepinephrine, serotonin, dopamine  After interacting with the postsynaptic receptor, the
transmitter is released and taken back into the presynaptic
Rationalization – justifying illogical or unreasonable ideas, actions, or CEREBELLUM
cell, the cell from which it was released. This process,
feelings by developing acceptable explanation that satisfy the teller as  Coordinated muscle energy & activity referred to as the reuptake of neurotransmitter. Once inside
well as the listener  Maintenance of equilibrium the presynaptic cell, the transmitter is either recycled or
Intellectualization – consciously or unconsciously using only logical  Coordinates contraction inactivated by an enzyme within the cell. The monoamine
transmitters norepinephrine, dopamine, and serotonin are all
explanation without one’s feelings or an affective component
CEREBRUM – responsible for mental activities and a conscious inactivated in this manner by the enzyme monoamine
sense of being. Also responsible for language and the ability to oxidase.
Compensation – consciously covering up for a weakness by
overemphasizing or making up a desirable trait communicate
A second method of neurotransmitter inactivation is a little
Cerebral cortex – responsible for conscious sensation and the more complex.
IMMATURE DEFENSES
initiation of movement is a common target for drug action.
Passive aggression – deals with emotional conflict or stressors by
indirectly and unassertively expressing aggression towards another ◦ Parietal cortex – touch
NEUROTRANSMITTERS AND RECEPTORS
Acting-out behavior – deals with emotional conflict or stressors by
◦ Temporal – sound
actions rather than reflections or feelings ◦ Occipital – vision
◦ Frontal – initiation of skeletal muscle contraction
Dissociation – unconscious separation of painful feelings and emotion
from an unacceptable idea, situation or object  Prefrontal cortex - responsible for
thoughts, goal-oriented oriented
Identification – conscious or unconscious attempt to model oneself after behavior & inhibition
a respected person - Seat of Personality
◦ Basal ganglia – regulation of movements
Introjection – unconsciously incorporating values & attitudes of others ◦ Limbic system
as if they were your own
 Amygdala and hippocampus –
Devaluation – emotional conflict or stressors are dealt with by emotions, learning, memory and basic
attributing negative qualities to self or others drives

Idealization – attributing exaggerated positive qualities others NEUROTRANSMITTERS AND RECEPTORS


 Conduction along a neuron involves the inward movement of
Splitting – the inability to integrate the positive and negative qualities of sodium ions (Na) followed by the outward movement of
oneself or others into a cohesive image. potassium ions (K). When the current reaches the end of the
cell, a neurotransmitter is released. The transmitter crosses
Projection – person unconsciously rejects emotionally unacceptable the synapse and attaches to a receptor on the postsynaptic
personal features and attributes to other people, objects or situation. cell. The attachment of transmitter to receptor either
stimulates or inhibits the postsynaptic cell
Denial – escaping unpleasant realities by ignoring their existence
 the destruction of the action of the enzyme
Regression – unconscious return to an earlier and more comfortable acetylcholinesterase on the neurotransmitter acetylcholine.
developmental level Acetylcholinesterase is present at the postsynaptic membrane
and destroys acetylcholine shortly after it attaches to nicotinic
or muscarinic receptors on the postsynaptic cell.

ORGANIZATION OF THE NERVOUS SYSTEM A full explanation of the various ways in which psychotropic
BRAINSTEM – regulates the internal organs and responsible for vital drugs alter neuronal activity requires a brief review of the
functions such as regulation of blood gases and the maintenance of BP manner in which neurotransmitters are destroyed after
attaching to the receptors.
Hypothalamus – hunger, thirst and sex. To avoid continuous and prolonged action on the post-
- thought & emotions synaptic cell, the neurotransmitter is released shortly after
attaching to the postsynaptic receptor. Once released, the
RAS – allows human to sleep and carry out conscious mental activity transmitter is destroyed in one of two ways.
One way is the immediate inactivation of the transmitter
at the postsynaptic membrane.
 Listening to and understanding the 3. The nurse communicates that the client is not alone,
person in the context of the social rather, the nurse is working along with the client
setting of his/her life  Clarifying techniques
 Listening for ‘false notes” 1. Helps both participants identify major differences in
 Providing the client with feedback their frame of references, giving them the opportunity to
information about himself/herself of correct misconception before these cause any serious
which the client might not be aware misunderstanding.
◦ Clarifying techniques
 Paraphrasing  Degree of openness
 Restating 1. Open-ended questions
 Reflecting 2. Close-ended question
3. Indirect or implied question
 Exploring
Interference with therapeutic communication
THERAPEUTIC RELATIONSHIP 1. Nurse’s fear and feelings
 Therapeutic relationship is consistently focused on the  Avoid personalizing what the patients say or
client’s problem & needs do
Therapeutic Communication  Ask question in a kind and matter-of-fact
 Clinical Interview - “The client leads” Factors that enhances growth in others manner, by conveying empathy, and by
reiterating a desire to help
How to begin 1. Genuineness – self-awareness of one’s feelings 2. Nurse’s lack of knowledge and insecurity
◦ Setting – private, safe
◦ Seating – assume the same height, avoid face to 2. Empathy – one understands the ideas expressed  Patients are usually more accepting when the
face, avoid sitting without ready access to a door, nurse is honest about not knowing an answer
avoid a desk barrier 5 concepts of empathy and expresses a willingness to find answers
◦ Introduction – name, school, purpose, time limit ◦ Human trait 3. Ineffective responses
◦ How to start – use open-ended question ◦ Professional state  Nurses must avoid premature conclusions
◦ Guidelines: ◦ communication process  Do not be preoccupied with what to say next,
 Speak briefly ◦ caring process rather, listen to patient or they might be
 When you do not know what to say, ◦ special relationship listening to
“SAY NOTHING”
 When in doubt, focus on feelings 3. Positive regard – ability to view another person as being THERAPEUTIC RELATIONSHIP
worthy of caring about & as someone who has strength & • Suspending value judgment
 Avoid advice
achievement potential • Recognize their presence
 Avoid relying on questions
• Identify how or where you learned these response to client’s
 Pay attention to non-verbal cues ◦ Attitudes - the nurse takes the client & the
behavior
 Keep focus on the client relationship seriously
• Construct alternative ways to view the client’s thinking and
◦ Actions – behavior
 Dynamics of therapeutic communication
◦ Interpretation of communication Attending - foundation of interviewing • Helping client develop resources – consistently encourage client to
◦ Themes in patients communication - an intensity of presence or being with the client use their resources helps minimize the client’s feeling of
 Content themes helplessness & dependency & also validates their potential for
 Mood themes Non-verbal behaviors the reflect degree of attending change
 Interaction themes 1. Nurse’s posture
2. Nurse’s degree of eye contact Establishing boundaries
◦ Environmental consideration
3. Nurse’s body language  Transference – the process whereby a person unconsciously
◦ Physical consideration
◦ Kinesis consideration & inappropriately displaces onto individuals in his/her current
Therapeutic techniques life those patterns of behavior & emotional reaction that
Therapeutic communication skills originated in relationship to significant figures in childhood
 Effective tools in communicating
 Use of silence
◦ The use of silence - a specific channel for  Active listening
transmitting and receiving messages 1. nurse carefully note what the client is saying verbally &  Countertransference - the tendency of the nurse to displace
◦ Active listening nonverbally, as well as monitoring their own nonverbal onto the client feelings related to people in the nurse’s past
 Observing the client’s non-verbal response
behaviors 2. Helps strengthens the client’s ability to solve personal  Common countertransference reaction
problems 1. Boredom (indifference)
2. Rescue
3. Overinvolvement ◦ Suggest time out with patient
4. Overidentification misuse of honesty ◦ Avoid being alone with patient  Hyperactivity
5. Anger ◦ Leave temporarily if patient is agitated ◦ Patient should be in a quiet area, with minimal
6. Helplessness or hopelessness ◦ Call for staff assistance auditory & visual stimulation
◦ Remain calm, speak slowly and softly & respect
STAGES OF NURSE – PATIENT RELATIONSHIP  Hallucinations patient’s personal space
1. PREORIENTATION PHASE ◦ Comment on behavior ◦ Give direction in a kind, simple but firm manner
◦ Goal: to establish a client database & assess own ◦ Provide reality but acknowledge behavior
◦ Assess the hallucination based on content of the  Transference & countertransference
feelings regarding the client
messages ◦ Nurses must be open and clear
2. ORIENTATION PHASE ◦ Do not focus on hallucination once content is ◦ State action that they cannot meet patient’s need

◦ Goal: develop mutual trust, establish role of the


known ◦ Limit setting
◦ Ignore the hallucination
nurse as significant other to the client
Milieu Management
◦ Client recognizes needs & seek help  Delusions
◦ Trustworthiness is built when the nurse is honest  Consists of treatment by means of control modification of the
◦ Clarify the meaning of the delusions then ignore client’s environment to promote positive experiences
regarding intention, is consistent, and keeps
promises  Conflicting values  Purpose: helps patient recover from psychiatric & mental
◦ Assess the degree of patient’s awareness of ◦ Help client examine the effects or outcomes of health problem
problems & the ability & motivation to change their beliefs on their lives, relationship, and
◦ Talk about feelings directly then focus on coping happiness Characteristics of milieu therapy
more effectively with them • Friendly, warm, trusting, secure, supportive, comforting
◦ Provide structure by limit setting  Severe anxiety & incoherent speech atmosphere throughout the unit
◦ Spend frequent, brief time with patients, offer • An optimistic attitude about prognosis of illness
3. WORKING PHASE • Attention to comfort, food, and daily living needs; help with
support, and build trust
◦ Goal: identify & address client’s problem resolving difficulties related to tasks of daily living
◦ Reality testing helps patient see reality more  Manipulation • Opportunity for client to take responsibility for themselves
clearly & objectively compared with the past ◦ Provide limit setting and for the welfare of the unit in gradual steps
• Maximum individualization in dealing with clients
◦ Limit setting – intervention designed to prevent ◦ Help client express their needs directly to others
• Opportunity to live through & test out situations in a realistic
clients from harming themselves or others way
◦ Nurse’s awareness of personal feelings & reaction  Crying
◦ Unless a form of manipulation, allow client to cry • Opportunity to discuss interpersonal relationship in the unit
to the client is vital for effective interaction with among clients and between clients and staff
the client ◦ Provide privacy
◦ Be quiet and unobtrusive • Program carefully selected resocialization activities to
prevent regression
4. TERMINATION PHASE
◦ Goal: assist client to review what was learned and  Sexual innuendos or inappropriate touch
Elements of milieu therapy
to transfer learning interaction with others ◦ Remind client these actions are inappropriate
1. Safety
◦ Attempt to make termination official and state ◦ Physical protection – safety from physical harm
feelings about the relationship  Denial & lack of cooperation
◦ Psychological safety – nurse’s active intervention
◦ Reasons for terminating the nurse-client ◦ Reality testing & supportive confrontation with
to prohibit verbal abuse, ridicule or harassment of
relationship denial
patient
◦ Symptom relief
 Depressed affect, apathy, & psychomotor retardation
◦ Improved social functioning
◦ Patience, frequent contact, and empathy 2. Structure – the physical environment rules & daily schedules
◦ Greater sense of identity of treatment activities
◦ Encourage hygiene, proper nutrition and gradual
◦ Development of more adaptive behavior ◦ Patient education lead by the nurse
increase in activities
◦ Accomplishment of the client’s goals ◦ Opportunities for recreation
◦ Postponed major decisions until emotions have
◦ Impasses in therapy that the nurse is unable to subsided
resolve 3. Norms – specific expectations of behavior that permeates the
 Suspiciousness treatment environment
Interaction with client behaviors ◦ Communicate clearly, simply, and congruently. ◦ Promotes safety & trust
 Violent behavior ◦ Clarify misinterpretation ◦ To create an environment that is more predictable
◦ Stay out of striking distance ◦ Provide simple rationale or explanations for rules, & applicable to all who share the environment
◦ Avoid touching clients without approval activities, occurrences, noises and requests
◦ Change topic temporarily
4. Limit settings – should be set on acting-out behavior • Individuals have no control over anxiety & worrying becomes • Reduce immediate anxiety – stay physically close to patient,
habitual use simple sentences, firm voice, remove to smaller quiet
◦ Reinforces the norms of making rules & room to minimize stimuli
expectations clear & encourage the milieu therapy Characteristics: restlessness. Fatigue, poor concentration, irritability, • Patient education
concept---responsibility to self muscle tension, sleep disturbance, physical symptoms (dry mouth, upset • Cognitive restructuring
stomach)
5. Balance – the process of gradually allowing independent Psychopharmacology:
behavior in a dependent situation Psychotropic mgt: • SSRI
1. NPR – reduce level of anxiety • Benzodiazepine (clonazepam, lorazepam) – immediate effect
Activity therapy Goal: assist patient with developing adaptive, coping responses
 Consists of a variety of recreational and vocational activities  Promote trust Milieu mgt.: gross motor activities – diffuse energy
(recreational therapy, occupational therapy, music, art, and  Convey empathy
dance therapy) designed to test 7 examine social skills & C. OBSESSIVE – COMPULSIVE DISORDER
serve as adjunct therapies Psychopharmacology Obsession – persistent thoughts, impulses, images or desires that maybe
◦ Antidepressants: SSRI. SSNRI trivial or morbid
Concept and principles ◦ Benzodiazepine – short-acting - Recognize thoughts are irrational & senseless
1. Socialization counters the regressive aspect of
illness Compulsion – repetitive stereotyped behavior that are performed in a
2. Activities needs to be selected for specific Milieu mgt: particular manner in response to an obsession
psychosocial reason to achieve specific effects • Recreational activities - Performed to prevent discomfort & to bind or neutralized
3. Nonverbal means of expression as an additional • Relaxation exercises, meditation & biofeedback anxiety
behavioral outlet add a new dimension to • CBT - It interferes with normal routines, occupational & social
treatment functioning
4. Sublimation of sexual drives is possible through • Therapeutic touch & acupressure - Interferes with patient’s interpersonal relationship
activities
5. Indication for activity therapy: clients with low B. PANIC DISORDERS – recurrent panic attack & are worried about Etiology: genetic, increase brain activity in the frontal lobe & basal
self-esteem who are socially unresponsive having more attacks ganglia, serotonin dysregulation
• Panic attacks – sudden, intense fear or discomfort and peaks
Goals at 10 minutes Psychotherapeutic mgt.:
6. Encourage socialization in community & social 1. NPR:
activities • Feelings of impending doom
• Accept rituals permissively
7. Provide pleasurable activities • Avoid criticism or punishment, making demands, showing
8. Help client release tension and express feelings Types of panic disorder
impatient – positive feedback
9. Teach new skills, help client find new hobbies 1. Panic disorder with agoraphobia
• Allow extra time for slowness & client’s action
10. Offer graded series of experience, from passive • Feelings of terror that function is suspended, perceptual field
is severely limited & misinterpretation of reality • Help client verbalize feelings, solve problem & make
spectator role & vicarious experiences to more decisions
direct and active experience • Personality disorganization
• Protect from rejection by others & self-inflected harm
11. Free and/or strengthen physical & creative • Sign/symptoms: palpitations, chest pain, dyspnea, nausea,
abilities feelings of choking, chills & hot flashes
Psychopharmacology:
12. Increase self-esteem
2. Panic disorder without agoraphobia • Antidepressant:
o Clomipromine (anafranil)
ANXIETY DISORDERS • Agoraphobia - intense, excessive anxiety or fear about being • SSRI – fluoxetine (Prozac), setraline (Zoloft), fluovoxamine
 Group of conditions in which the affected person experiences in places or situations from which escape might be difficult or
persistent anxiety that the person cannot dismiss and that (Luvox) & paroxetine (Plaxil)
embarrassing or in which help might not be available if panic
interferes with daily activities attack occurs
 Etiology: Milieu mgt.:
1. Neurobiological – hereditary, brain chemistry, • Feared places are avoided e.g.. Outside, alone @ home, • Relaxation exercises & stress mgt.
developmental factors, disruption of the amygdala travelling in car, bus or plane, being on a bridge, riding in a • Recreational or social skills
2. Psychological - low self-esteem, shy or timid in elevator • CBT, problem-solving & communication or assertive training
childhood, critical parents, discomfort with groups
aggression, abuse, violence, poverty Etiology: hereditary, trauma, life stress or trauma, disruption in the
amygdala
D. PHOBIC DISORDERS
A. GENERAL ANXIETY DISORDER - Intense, irrational, persistent fear responses to an external object
• Characterized by excessive chronic anxiety or worry & might Psychotherapeutic mgt:
activity or situation
concern everyday events 1. NPR:
Phobia – response to experience anxiety & is characterized by a • Numbing of responses or reduced involvement with the F. SOMATOFORM DISORDERS
persistent fear of specific places or things external world - Characterized by the presence of physiologic complaints or symptoms,
• Persistent avoidance of situation, activities and people, which are not under voluntary control & no demonstrable organic
3 types of phobias thoughts and feelings finding and physiologic bases
1. Agoraphobia with history of panic disorders – • Denial, repression & suspension
fear of being in public or open spaces places or • Feel detached or estrange from family & friends → Types of somatoform disorders
situations in which escape might be difficult or withdrawal → depression 1. Somatization disorder
help might not be available • Lost interest in activities, hopelessness ◦ Conversion of mental states or experiences into
bodily symptoms associated with anxiety
2. Social phobia – fear of being humiliated, • Change in sleep pattern
◦ Recurrent, frequent & multiple somatic complaints
scrutinized, or embarrassed in public • Impulsive behavior, sudden life change
for several years without physiologic cause
3. Specific phobia – fear of a specific object or
2. Reexperiencing the trauma & intrusive memories – hallucinations ◦ Client’s constantly seek medical attention,
situation that is not either of the above (PTSD) undergo numerous tests; at risk for unnecessary
surgery or drug abuse
Etiology: environment, genetic predisposition 3. Arousal symptoms 2. Pain disorder
• ↑ arousal, anxiety, restlessness, irritability, disturbance in ◦ Associated with psychological factors like severe
Psychotherapeutic mgt.: pain in one or more of anatomical sites that causes
sleep, memory impairment or concentration
1. NPR: significant distress or impairment in functioning
• PTSD – outburst of anger, rage, survivor guilt
• Accept patient & their fears with a non-critical attitude ◦ Pain is exaggerated or out of proportion
• Provide & involve patient in activities that do not increase 4. Other symptoms ◦ Causes significant impairment in occupational or
anxiety but increase involvement, rather that promote social functioning or causes marked distress
• Anxiety or panic attack
avoidance ◦ Symptoms not intentionally produced or feigned
• Help client with physical safety and comfort • PTSD – grief, depression, suicidal ideation or attempts, 3. Hypochrondiasis
• Help patient recognize that their behavior is a method of impulsive self-destructive behavior, anxiety-relate disorders ◦ Worried & belief that they have serious disorders
avoiding anxiety & substance abuse base on the misinterpretation of bodily signs &
sensation for at least 6 months
Psychopharmacology: Psychotherapeutic mgt: prevent or minimize the symptoms ◦ Preoccupation persists despite appropriate medical
SSRI – to reduce anxiety & depression & block panic attacks, if present 1. NPR: develop trust tests & reassurances
• Nurse needs to be non-judgmental honest, emphatic, and ◦ Causes significant impairment in occupational or
Milieu mgt: supportive social functioning or causes marked distress
• Assertive training & goal-setting groups • Teach dynamics of ASD & PTSD 4. Conversion disorder
• Social skills group to help redevelop social skills and • Exposure therapy & systematic desensitization ◦ Alteration in voluntary or motor sensory
decrease avoidance • Expressive therapy (art, music, poetry) – facilitate functioning that suggest neurological or medical
• Behavior therapy – systemic desensitization, flooding, externalizing painful emotions that are difficult to verbalize condition
exposure, and self-exposure • Crisis counselling – ◦ Not due to malingering or factitious disorder and
not culturally sanctioned
E. ACUTE STRESS DISORDER & POST TRAUMATIC STRESS Psychopharmacology ◦ Cannot be explained by gen. medical condition or
DISORDERS • Benzodiazepine (clonazepam, lorazepam) – to reduce level effects of a substance
- Develop after exposure to a clearly identifiable traumatic event that of anxiety and fear. Help with sleep disturbance 5. Body dysmorphic disorder
threatens the self, others, resources, and/or sense of control or hope
• Clonidine & propanolol – diminish the peripheral autonomic ◦ Individual is preoccupied with an imagined defect
response associated with fear, anxiety & nightmare in appearance which are usually facial flaws.
ACUTE STRESS SYNDROME – symptoms occur within 1 month of
◦ Dermatologist & plastic surgeon is often consulted
extreme stressor; includes dissociative symptoms (depersonalization, • Lithium carbonate – prescribed to patients experiencing ◦ May also exhibit obsessive compulsive traits &
emotional detachment., dazed appearance, amnesia) explosive outburst depressive syndrome
POST STRESS DISORDER – severe traumatic event that is not an • SSRI (paroxetine, setraline, fluoxetine) – decrease ◦ Controls relationship through physical complaints
ordinary occurrence e.g.. Rape, fire, flood, earthquake, tornado, repetitive behaviors, disturbing images & somatic states
Causes:
bombing, plane crash, war, torture, kidnapping • TCA – depression, adehonia & sleep disturbances 1. Inability of the CNS to regulate & interpret sensory input or
Diagnostic criteria • Antipsychotic (respirodone) – psychotic thinking to decrease communication between right & left hemisphere
1. Dissociative symptoms & numbing 2. Hx of physical & sexual abuse witnessing violent acts in
Milieu mgt: childhood, poor nurturing from family, lack of job, and social
• Amnesia, depersonalization, derealization & awareness of
• Social activities skills
surrounding, numbing, detachment or lack of emotional 3. Need to be sick to relieve oneself of obligations & to gain
• Recreational & exercise program
response attention
• Group therapy 4. Dissociation
◦ Fugue states is characterized amnesia; b. Characterized by impairment in social interaction,
Psychotherapeutic mgt. consequently, patients do not remember what communication and restricted repertoire of activity
1. NPR: happened. & interest
• Use matter-of-fact caring approach c. Usually first observed before 3 years of age
• Encourage patient to verbalize & describe feeling 3. Depersonalization disorder – involves an altered sense of d. Sign & symptoms
• Use positive reinforcement & set limits self, so that the individual feel unreal or strange or believe  Impairment in communication &
• Be consistent that danger is not happening to then or to someone else imaginative activity
• Use diversion by including patient patients in milieu activities ◦ Reality testing remains intact  Impairment in social interaction
and recreational games  Markedly restricted, stereotypical
• Do not push awareness of or insight into conflicts or 4. Dissociative identity disorder – existence of 2 or more patterns of behavior, interest and
problems identities or personalities that take control of the person’s activities

Psychopharmacology: SSRI – to treat anxiety and depression


behavior with its own patterns of relating, perceiving, and  Childhood & Adolescent psychiatric disorders
thinking
◦ The person or host us unaware of the other
a. Asperger’s disorders – a severe developmental
Milieu mgt: disorder characterized by major difficulties in
personalities, but the other alters might be aware
• Relaxation exercises meditation and CBT of each other to varying degrees
social interaction & restricts & unusual interest &
• Family therapy behavior
◦ Defense mechanism: repression  Use monotone speech and rigid
G. DISSOCIATIVE DISORDER language
– disturbances in the normally well-integrated continuum of Psychotherapeutic mgt.  They cannot understand jokes and are
consciousness, memory, identity, and perception 1. NPR: taken advantage easily
• Establish trust & support, provide caring and empathy  Inability to show empathy to others but
• Assist in gathering data about feelings, conflicts, or situations want to meet people & make friends
 Dissociation – the removal from conscious awareness of
that patient experienced
painful feelings, memories, thoughts, or aspects of identity  Have an obsession with facts about
• Ensure client safety circumscribed and odd topics
◦ Unconscious defense mechanism that protects an
• Provide nondemanding, simple routine b. Attention deficit/hyperactivity disorder – characterized by
individual from the emotional pain of experiences
or conflicts that have been repressed • Confirm identity of client and orientation to time & place inattention, impulsiveness, and overactivity in school 9before
• Encourage client to do things for self and make decision 7 years old)
 Defense mechanism: repression about routine tasks ◦ Causes:
Causes:  Environmental exposure – perinatal
Milieu mgt:
• Inability to recall important personal information usually of a insults, head injury, psychosocial
• Individual therapy adversity, lead poisoning, and diet
traumatic or stressful nature • Task-oriented group
• The disorder is often associated with exposure to traumatic  Genetic and hereditary factors
• OT and art therapy  Dysfunction in the frontal lobe
event common during disaster and wartime • Cognitive therapy
• Sexual abuse during childhood ◦ Characteristics of ADHD
• Psychopathology: an escape mechanism from memory of • Self-help groups  Inattention
painful experiences or devoid of emotional satisfaction.  Difficulty paying attention
There is little or no participation of the conscious personality Childhood & Adolescent psychiatric disorders in tasks or play
so the person is unable to recall  Risk factors:  Does not seem to listen,
◦ Genetic factor follow through or finish
Types of dissociative disorders ◦ Social & environment – severe marital discord, tasks
1. Dissociative amnesia low socioeconomic status, large family &  Does not pay attention to
◦ Sudden inability recall important information of overcrowding, parental criminality maternal details & makes careless
one or more episodes not associated with organic psychiatric disorder, traumatic life event, mistakes
disorders usually of a traumatic or stressful nature sexual/physical abuse  Is easily distracted, lose
 Localized amnesia ◦ Psychosocial factor – things, & is forgetful in
 Selective amnesia ◦ Biochemical factors – alterations of daily activities
neurotransmitters (decrease in norephhinephrine & 
 General amnesia serotonin
Childhood & Adolescent psychiatric disorders
 Hyperactivity
◦ Temperament – a style of behavior a child
2. Dissocialise fugue – sudden, unexpected travel away from  Fidgets, is unable to sit still
habitually uses to cope with the demands &
or stay seated in school or at
home or some other location with the assumption of a new expectations of the environment
other times
identity or a confusion about one’s identity  Types of childhood mental disorders
 Runs & climbs excessively
1. Pervasive development disorders
in inappropriate situations
a. Autistic disorder
 Has difficulty playing and a refusal to accept blame for  assess the child’s previous & current
quietly in leisure activities misdeeds ability to separate from parents or
 Acts as if “driven by a  Behavior do not violate the rights of caregivers
motor”, constantly on the go others  Protect the child from panic levels of
 Talks excessively ◦ Conduct disorder – characterized by persistent anxiety by acting as parental surrogate
 Impulsivity pattern of behavior in which the rights of others &  Accept regression but giving emotional
 Blurts out answer before age-appropriate societal norms or rules are support to help child progress again
question has been violated.  Increase child’s self-esteem & feelings
completed  Predisposing factors: ADHD, of competence in the ability to
 Has difficulty waiting for oppositional child behaviors, parental perform , achieve, influence the future
own turn rejection, inconsistent parenting with  Help child accept and work through
 Interrupts, intrudes in harsh discipline, early institutional traumatic events or losses
others’ conversation & living, frequent shifting of parental 5. Psychopharmacology: antihistamines, anxiolytics
games figures, large family size, absence of and antidepressants
◦ Nursing Dx father or alcoholic father, antisocial & 6. Cognitive therapy, behavior modification
 Risk for injury drug-dependent family members, &
 Impaired social interaction association with a delinquent group  PERSONALITY DISORDERS
 Ineffective individual  Examples of behaviors: physically  Personality – sum total of the person’s distinctive character,
 Risk for violence for self-directed or aggressive, have poor peer behavior, attitudes, the way one carries himself , the way one
directed to others relationships & shows little concern for communicate
◦ Nursing intervention others & lack of guilt or remorse ◦ An enduring pattern of behavior that is considered
 Establish trust to be both conscious and unconscious and reflects
 Childhood & Adolescent psychiatric disorders a means of adapting to a particular environment &
 Talk to client about safe & unsafe c. Anxiety disorders
behavior – use clear, honest it cultural, ethnic and community standards
straightforward communication 1. Separation anxiety disorders – excessively (Carson)
 Assess the frequency & severity of anxious when separated from or anticipating a ◦ Healthy personality:
accidents separation from their home or parental figures ◦ Sees his or her own strengths weaknesses
 Provide supervision for potentially 2. Most children will express worry about harm or ◦ Identifies his or her own boundaries
dangerous permanent loss of the mother or major attachment ◦ Recognizes interaction & thoughts that lead to
figure strong emotions such as joy or anger
 Assist the client, parent or caregivers to
3. Characteristics: ◦ Interacts with others without expecting them to
make the distinction between
accidental & purposeful incident  Excessive distress when separated from meet all needs
or anticipating separation from home or ◦ Seeks a balance of work & play
◦ Childhood & Adolescent psychiatric disorders parental figure ◦ Accomplishes goals
 Give instruction slowly using simply  Excessive worries that one will be lost ◦ Defines & expresses spirituality
giving instruction or kidnapped or that parental figures
 Ask client to repeat exercise or will be harmed  Personality disorder – “enduring pattern of inner experience
instruction before beginning a task & behavior that deviates markedly from the expectation of the
 Fear of being home alone or in
 Administer stimulant in the morning to individual’s culture, is pervasive & inflexible, has an onset in
situation without other significant
maximize effectiveness for daytime adolescence or early adulthood, is stable over time, & lead to
adults
activity distress or impairment “ (APA, 2000)
 Refusal to sleep unless near a parental
 Help parents decrease their feelings of  Etiology of PD
figure & refusal to sleep away from
guilt & blame home ◦ Theorist – PD is related to unsuccessful mastery of
 Maintain a safe environment at home task in early stages of development that can lead to
 Refusal to attend school or other
& in school anxiety
activities without a parental figure
◦ Behaviorist – Developmentalist – believe that PD
◦ Oppositional defiant disorder – enduring pattern  Physical symptoms as a response to
originates in early childhood experiences (negative
of disobedience, argumentative, explosive angry anxiety
experiences)
outburst, low frustration tolerance, and a tendency 4. Nursing interventions:
◦ Genetic cmponents
to blame others for quarrels or accidents  Assess the quality of the relationship
◦ Stressful environment
 Recurrent pattern of negativistic, between child & parents or caregivers
disobedient, hostile , defiant behavior for evidence of anxiety, conflicts or  PERSONALITY DISORDERS
towards authority figures with serious difficulty of fit between child’s and  CRITERIA FOR A PERSONALITY DISORDER
violation of basic rights of others parent’s temperament 1. CLUSTER A DISORDERS (ODD, ECCENTRIC)
 Exhibit persistent testing of limits, an a. Paranoid personality disorder
unwillingness to give in or negotiate,
 These individuals interpret other 1. Avoid being too “nice” or  Has consistent disregard for others with
people's motives as threatening “friendly” exploitation & repeated unlawful
resulting in an increase in anxiety & 2. Do not try to increase actions.
the need for vigilance socialization  Unable to postpone gratification,
 Characterized by distrust & selfish and irresponsible
suspiciousness toward others, based on  PERSONALITY DISORDERS  Generally manipulative, does not feel
the belief (unsupported by evidence) b. Schizotypal personality disorder guilty, sorrow & not loyal
that others want to exploit, harm, or  Individuals with this disorder may have  Charming, intellectual and smooth
deceive the person & often act in behavior similar to those of someone talkers
defense of a fragile self-concept with schizophrenia, however psychotic
 They repeatedly neglect
 They demonstrate jealousy, controlling episode are infrequent & less severe
responsibilities, tell lies and perform
behaviors, and unwillingness to forgive  Characteristics: destructive or illegal acts, without
 Common in men than women 1. Ideas of reference developing any insight into predictable
 Irritable and stubborn – prejudice 2. With magical thinking/odd consequences
beliefs leading to
 With ideas of reference  Hostile, unable to follow rules
interpersonal difficulties
 Blunted affect , humorless and serious  Diagnose before age 15 as conduct
3. Problems in thinking,
 Fear in confiding in others disorder
communicating and
 Hold grudges towards others perceiving  Criteria for Antisocial PD
 Easily get angry if they are threatened 4. Has eccentric appearance 1. Violate rights of others
 Emotionally cold in appearance but are and shows evidence of 2. Engage in illegal activities
acceptable of close relationship to few magical thinking or 3. Aggressive behavior
b. Nursing guidelines perceptual distortion that 4. Lack of guilt or remorse
c. – may carry or conceal weapons are not clear delusions or 5. Irresponsible in work &
hallucination with finances
 PERSONALITY DISORDERS 6. Impulsiveness
b. Schizoid personality disorder 5. Sensitive to behavior of
other people especially 7. Recklessness
 Individuals with this disorder lacks
personal & social relationship. They rejection & anger  Etiology: genetics, environment,
are detached from others & withdraws 6. Speech may be difficult to family environment (unstable parent –
from interaction – hypersensitive follow – the individual child realationship
develops a personalized
 Introverted since childhood, rarely
style with vague association
 PERSONALITY DISORDERS
have close friends  Nursing guidelines
7. Socially inept
 Use autistic thinking, daydreaming are 1. Prevent or reduce untoward
 Nursing guideline
more gratifying effects of manipulation
1. Offer support like kindness
 They respond with short answers to (flattery, seductiveness,
questions & do not initiate spontaneous 2. Be calm, non-threatening in instilling guilt) by setting
conversation all or approaches limits
 They are reality-oriented but maintain 3. Respect client’s need for 2. Encourage client to
fair contact with others social isolation – cannot verbalize feeling
 They function in a solitary occupation tolerate group therapy 3. Be firm, steadfast and
but shows indifference to praise or 4. Speak in a gentle manner to consistent in dealing with
criticism from others encourage to get involve in patient’s behavior and
group activities reinforcing rules & policies
 Can be a precursor to schizophrenia or
5. Be aware of client’s 4. Help client be aware of the
delusion disorder
suspiciousness & employ consequences of their
 Defense mechanism: appropriate intervention behavior
INTELLECTUALIZATION 6. Assist & teach the client 5. Explain & point out the
 DSM IV criteria about social skills & effects of their behavior
1. Lacks desire for close appropriate behavior to towards others
relationship or friends improve his interpersonal 6. Avoid moralizing
2. Choose to be alone relationship c. Borderline personality disorders
3. Lack sexual experience  PERSONALITY DISORDERS  Characterized by impulsiveness,
4. Avoid activities unpredictable, unstable moods
2. CLUSTER B CRITERIA (DRAMATIC, EMOTIONAL,
5. Appears cold and detached  Desperately seek relationship to avoid
ERRATIC)
 Nursing guideline: a. Antisocial personality disorder feeling abandoned
 Chronic sense of boredom
 Overspending, promiscuity, overeating  Convey unussuming self-confidence b. Avoidant personality disorder
 Problems with identity & self-image  Point out reality  These clients are timid, socially
 Tell client no one is perfect uncomfortable, with self care and
 history of substance abuse & multiple
withdrawn
or dramatic suicidal gesture, risk of c. Histrionic personality disorder
 Individual with this disorder are  Social inhibition and avoidance of all
suicide and mutilation
characterized by excessive emotional situation that require interpersonal
 Manipulative and dependent
attention seeking behavior and are contact
 Emotional lability
dramatic and ego-centric  Hyeprsensitive to criticism
 Defense mechanism: projection  Seductive, flamboyant and shallow –  Uncertain and lacks confidence and
 Etiology: use speech to impress others afraid to ask question or speak in
public
 Inadequate regulation of serotonin &  Needs to be the center of attention
dopamine & other transmitters  Impulsive and melodramatic  Nursing guidelines
 Parents may cling to the child and  Demands “the best of everything” and  Be friendly, gentle,
prevent autonomy, individual or parent can be very critical reassuring approach
 Help client to confront fears
withdraws support & attention making  Related factors: mother-child
gradually
the child confuse relationship
 Support & direct client in
 PERSONALITY DISORDERS  Nursing guidelines:
accomplishing short-term
 Pharmacologic mgt:  Understand seductive behavior as a goals
 Neuroleptic drugs (3-12 wks) response to distress
 Relaxation techniques
 Lithium  Keep communication & interaction
 Valporic acid professional, despite temptation to  PERSONALITY DISORDERS
collude with the client in a flirtatious & c. Obsessive-compulsive personality disorder
 Carbamazepine
misleading manner  Perfectionist and inflexible
 Benzodiazepine
 Encourage & model the use of concrete  Overly strict & often set standards for
 Nursing guidelines themselves that are too high
& descriptive rather that vague &
 Set realistic goals, use clear action impressionistic language  Preoccupied with details, rules, trivial
word and procedures
 Be aware of manipulative behaviors  Teach and role-model assertiveness
 Difficult to express emotions or
 Provide clear & consistent boundaries  PERSONALITY DISORDERS warmth
& limits 3. CLUSTER C DISORDERS (ANXIOUS, FEARFUL)  They try to control partner in a
 Use clear 7 straightforward a. Dependent personality disorder relationship
communication  “pervasive & excessive need to be  Serious, affect is constricted and would
 Avoid rejecting or rescuing taken care of that leads to submissive speak in monotone voice
 Assess for suicidal & self-mutilating and clinging behavior & fears of
behavior separation” (APA, 2000)  Defense mechanism:
c. Narcissistic personal disorder  Extreme dependency in a close intellectualization, rationalization,
 Individuals with this disorder display relationship, with an urgent search to reaction-formation
grandiosity about his performance and find a replacement when one  Etiology: early parent-child
achievement relationship ends - they are afraid to be relationship
 Arrogant, extrovert alone  Nursing guidelines:
 Believe to be special with need to be  They want others to make decision for  Help client make decision
admired them – they need direction and encourage follow-through
 Feel intense shame & fear that if they reassurance behaviors
are “bad”, they will be abandoned  They feel the need to be rewarded if  Encourage leisure activities
 Afraid of their own mistakes, as well as they do good deeds for others  Guard against engaging in
the mistakes of others.  To avoid conflict they become passive, power struggle with client
conceal sexual feelings and anger
 Defense mechanism: rationalization  Confront client’s
 Nursing guidelines: procastination and
 PERSONALITY DISORDERS  Increase responsibility for intellectualization
 Nursing guidelines: self in daily livings
 Supportive confrontation  Be assertive
 MOOD DISORDERS
 Mood – a person’s state of mind exhibited through feeding &
 Remain neutral; avoid engaging in  Encourage client to
emotions (APA, 2001)
power struggle or becoming defensive verbalize feeling
in response to the client’s disparaging  Be aware of  Mood disorders – extreme change in mood that presents
remarks countertranference problems in daily functioning
- alteration in effect or mood that occurs when an individual  Significant anorexia or wt  Patient is depressive mood for at least 2 years
experience exaggerated feeling for a prolong period of time that is loss  With poor appetite or over-eating
psychologically, physically & socially unacceptable  Excessive or inappropriate  Insomia or hypersomia
 Causes: guilt  Low energy or fatigue
◦ Genetics c. Catatonic features – psychomotor  Low self-esteem
◦ Biochemistry attraction including immobility,  Poor concentration or difficulty making decisions
◦ Personality excessive motor activities, mutism,  Feelings of hopelessness
◦ Environment echolalia or echopraxia, inappropriate  Difference between MDD & DD (duration &
 Types of depression: posturing severity)
1. MAJOR DEPRESSIVE DISORDER (MDD)  negativism  Patient may engage in activities to generate
◦ Characterized by 1 or more major depressive
episodes, which are defined as at least 2 weeks by
d. Postpartum depression – mood excitement
disturbance that occurs during the first  may turn to substance abuse or food
depressive mood or less of interest accompanied
30 days post partum  Patients do not readily recognize their symptoms
by at least 4 additional symptoms of depression
e. Psychotic depression – delusions & as abnormal
◦ Signs/behavior
hallucination  MANIC DISORDERS
a. Depressed mood most of the day
b. Anhedonia  Delusion of guilt, delusions  STAGES OF MANIA
c. Significant weight loss or gain (5% wt. of deserved punishment, 1. Mild elation or hypomaniac (4 days)
in month) somatic delusions, nihilistic ◦ Affect – feeling of happiness, confidence
delusion, & delusion of
d. Insomia or hypersomia (2 hrs in 1 ◦ Thought – flight of ideas, inflated self-esteem
month) poverty
◦ Behavior – always on the go, increase sexual drive
e. Increase or decrease motor activities f. Seasonal affective disorder (SAD) – 2. Acute manic episodes
f. anergia occur in conjunction with a seasonal ◦ Intensified symptoms
g. Feelings of worthlessness or change ◦ Mood disturbance & lability
inappropriate guilt (may be delusional)  MOOD DISORDERS ◦ Enthusiastic & intrusive
h. Recurrent thoughts of death or suicidal ◦ Hyperactivity
◦ Psychopharmacological mgt.
ideation ◦ Flight of ideas
a. SSRIs
i. Decrease concentration or b. Tricyclics ◦ Distractibility
indecisiveness c. Antidepressant ◦ Distortion of self-esteem
 MOOD DISORDERS d. MAOIs 3. Delirium – state of extreme excitement
◦ Characteristics ◦ Nursing guidelines: ◦ Disorientation, incoherence
a. Disregards grooming, cleanliness & a. Establish trust
◦ Visual or olfactory hallucination
personal appearance  Nonjudgmental & friendly
b. Stooped posture & dejected facial approach ◦ Exhaustion, dehydration, injury even death
expression  Use silence & stay with  MANIC DISORDERS
c. Dishevelled, downcast, lacking eye patient  Basic syndromes of bipolar disorders
contact & tearful  Avoid challenging or testing
d. Agitated the client
a. Manic episodes – elevated, expansive or irritable mood
◦ Specifiers:  Do not argue b. Hypomanic episodes – less, severe level of impairment
a. Atypical depression – occurs in  Divert patient’s attention c. Depressive episodes – hypersomia, hyperphagia, wt. gain,
younger population b. Bolster self-esteem leaden paralysis, little energy
 Increase appetite or wt. c. Be amphatic d. BIPOLAR DISORDER
gain, hypersomnia, leaden d. Point out or reward small visible ◦ Bipolar I disorder – experiences swings between
paralysis & extreme accomplishment manic episodes and major depression
sensitivity to interpersonal e. Do not embarrass patient ◦ Bipolar II disorder – characterized by 1 or more
rejection f. Never reinforce hallucination, depressive episodes accompanied by at least one
b. Melancholic depression – older adults delusions or irrational beliefs hypomanic episodes
g. Encourage verbal expressions of anger ◦ Cyclothymic disorders – a swing between a
 Anhedonia & inability to be h. Provide non-threatening one-to-one hypomanic and depressive symptoms
cheered up relationship
 Depression worse in AM ◦ Behavior of bipolar disorder
 Early AM awakening i. Guide patient to appropriate decisions  Objective behavior
 Psychomotor retardation or by using problem solving  Disturbance of speech,
agitation  MOOD DISORDERS social, interpersonal &
2. DYSTHMIC DISORDER
occupational relationship, ◦ Rigid excersie program  Use of ipecac syrup
activity & appearance  Menstrual irregularities
uncontrollably eat large amounts of
 Speech – rapid, pressured, food  Dental carries
loud, easily distracted ◦ Hyperactive  Russel’s sign
 Altered social, interpersonal substance abuse  Loss of control over eating
& occupational relationship family conflict  Anxious & feeling weakness
 Subjective behavior ◦ Amenorrhea  Angry & agitated or depressed
 Alteration of affect – ◦ Hypotension, bradycardia, hyponatremia  Mod disorders
euphoric, grandiosity, labile ◦ Dry skin with lanugo  Substance abuse
 Alteration of perception – ◦ Delayed gastric emptying  Self – induce vomiting
delusion & hallucination ◦ Slow peristalsis----constipation ◦ Etiology
 MANIC DISORDERS ◦ Dehaydration  Low serotonin activity
◦ Nursing responsibilities ◦ Refeeding syndrome  Inherited
 Use matter of fact tone ◦ Pitting edema  Cycles of low self-esteem, extreme
 Clear, concise direction & comments – ◦ Osteopenis or osteoporosis concerns about body shape & wt., strict
remarks should be simple & brief ◦ Cardiac arrythmias dieting, binge eating & compensatory
 Limit – setting ◦ Bizaare behavior regarding fool & eating behavior
 Reinforcement of reality ◦ Feel abandoned or inadequate  Ambivalence
 Respond to legitimate complaints ◦ Depression, irritability, social withdrawal,  Feel unworthy of nurturing
 Redirect patient into more healthy lessened sex drive & obsession symptoms
activities  EATING DISORDERS
 Provide for can be eaten easily  EATING DISORDERS ◦ Psychotherapeutic mgt
 Assess amount of sleep & rest ◦ Etiology  Medical stabilization
 Provide quiet place to sleep  Biologic factors – increase serotonin  Wt. restoration –
 Structure activities during the day  A culture of thinness, relational  Help patient reestablish appropriate
orientation of women eating behavior
 Do not drink caffeine at bedtime
 Genetic component  Elevate self-esteem
◦ Psychopharmacology
 Family environment  Medical treatment – IV lines & feeding
 Lithium –
 Odd eating habits & emphasis on tubes
 Anticonvulsant & atypical
antipsychotics
appearance ◦ Nursing guidelines
◦ Milieu mgt.  Rejection of food & wt. loss as a  Convey warmth & sincerity
positive reinforcement  Listen emphatically
 Safety
 Childhood sexual abuse  Be honest
 Consistency among staff
 Regression to a prepubertal state  Set appropriate behavioral limit
 Reduction of environmental stimuli
 Fear of being out of control  Assist patient in identifying their
 Dealing with patient who are escalating
 Defense mechanism: REACTION qualities
 Reinforcement of appropriate hygiene
FORMATION  Collaborate with patient
& dress
 BULIMIA NERVOSA  Teach patient about disorders
 Nutrition & sleep issues
◦ Intermittent binge period and periods of restrictive  Determine patient’s weight with their
 EATING DISORDERS eating back on the scale
 ANOREXIA NERVOSA ◦ Loss of control over eating  Initiate behavioral modification
◦ Limit their intake or refuse to eat but do not lose ◦ Anxious & feeling of weakness – before eating  Express emotions assertively
their appetite while binging  Help patient identify & express bodily
◦ Perfectionist & introvert with self-esteem & peer ◦ Angry & agitated or depressed sensation
relationship problems ◦ Mood disorders  identify non-weight related interest
◦ Substance sbuse ◦
◦ Clinical manifestation/behaviors Psychopharmacology
Restricters Vomiters-purgers ◦ Self-induce vomiting  Anxiolytics
◦  Atypical antipsychotics
Normal or slightly ↑ Induction of  EATING DISORDERS
vomiting 7 excessive use of laxative or diuretics ◦ Clinical manifestation/behavior  Antidepressants - SSRI
◦ Avoids people  Secretive about behavior
denies concern
 SCHIZOPHRENIA
 Binge eating
◦ Competitive, compulsive, obsessive  F/E abnormalities
dental problems
 Use of laxatives
 Schizophrenia – mental disorder characterized by 3. Illusions – misinterpretation of environmental stimuli 2. CATATONIC TYPE – psychomotor disturbances
4. Depersonalization – feeling of the individual that the self has
disturdance in thought & sensory perception & deterioration ◦ Motoric immobility, waxy flexibility or stupor
been changed or altered
in psychosocial functioning ◦ Excitement (excessive motor activity)
5. Affective flattening – absence of emotional response
 Psychotic – delusions, any prominent hallucinations, ◦ Extreme negativism or mutism ---- withdrawal
disorganized speech or disorganized catatonic behavior 6. ambivalences ◦ Peculiar movements
(APA, 2000)  SCHIZOPHRENIA ◦ Echolalia or echopraxia
 Comorbidity  Common delusions in schizophrenia 3. DISORGANIZED TYPE – most severe prognosis,
1. Substance abuse 1. Delusions of reference – everything that is occurring in the disintegration of personality & is withdrawn, disorganized
2. Depressive symptoms environment has significance to oneself speech, disorganized behavior, flat or inappropriate affect
3. Anxiety disorders 2. Delusion of persecution – false belief that one is being singles
 Theory out for harm by others – someone is platting against him/her
4. UNDIFFERENTIATED TYPE – characterized by atypical
1. Dopamine hypothesis symptoms that do not meet the criteria for other subtypes
3. Somatic delusion – appearance or functioning of one’s body
2. Alternative biochemical hypothesis – structural cerebral is altered ◦ Characteristics symptoms
abnormalities, reduced gray matter, increase ventricular brain 4. Grandiose delusion – false belief that one is a very powerful ◦ Prognosis is favorable
ratio & important person 5. RESIDUAL TYPE
3. Genetics
4. Autoimmune
5.
6.
Nihilistic delusion – “I am dead”
Delusions of influence – one is controlled by others or outside
◦ Continuing evidence of negative symptoms
5. Double bind communication – 2 messages that contradict without characteristic symptoms of schizophrenia
force
each other are sent causing the child to be confused on what Jealousy – false belief that one’s mate in unfaithful; may have so-called  SCHIZOPHRENIA
action to engage in which immobilize the child & results to proof  Assessment
anxiety  Symptoms of loose association ◦ Objective Sx
6. Birth & pregnancy complication, viral infxn, poor nutrition or 1. Neologism  Less concerned with their appearance
starvation, exposure to toxin 2. Echolalia  Introspection & apathy
7. Stress – development/family 3. Word salad
8. Weak ego  Anergia
9. Vitamin deficiency – vitamins B1, B6, B12, vit. C 4. Clang association  Inadequate interpersonal
communication
 SCHIZOPHRENIA  SCHIZOPHRENIA
 Hostility
 Precipitating factors  3 broad clinical symptoms
 Withdrawal
1. Positive symptoms
1. Emotional - marital problem
◦ Reflects the presence of overt psychotic or  Psychomotor agitation or inactive or
2. Somatic – pregnancy, physical illness distorted behavior catatonic
◦ Subjective Sx
3. May be none 2. Negative symptoms – reflect a dimunition or loss of normal  Hallucnation
 4 A’s (Eugene Bleuler) function
Affect – outward manifestation of a person’s feelings & emotion – flat,  Illusion
blunted, inappropriate bizarre affect 3. Disorganized symptoms – presence of confused thinking,  Paranoid thinking
Associative looseness – haphazard & confused thinking manifested in incoherent or disorganized speech & disorganized behavior  Thoiught disorder
jumbled & illogical speech & reasoning  2 diagnostic categories  Delusions
Autism – thinking that is not bound to reality but reflects the private Type I schizophrenia  Confusion, incoherent speech,
perceptual world of the individual – delusions, hallucination, neologism  Onset of positive symptoms is generally acute clouding, & a sense of going crazy
Ambivalence – simultaneously holding 2 opposing emotions, attitudes,  Sx: delusions, excitement, feelings of persecution,  Inappropriate, flattened, blunted, or
ideas, or wishes towards the same person situation or object grandiosity, hallucination, hostility, ideas of reference, labile affect
 Phases of schizophrenia illusions, insomia
Type II schizophrenia  SCHIZOPHRENIA
1. Acute phase – period of florid positive symptoms as well as  Psychopharmacology
 Slow onset of negative symptoms aused by viral infxn &
negative symptoms ◦ Stabilize acute symptoms
abnormalities in cholecystokinin
2. Maintenance phase – period when acute symptoms decrease ◦ Maintain therapeutic plasma levels
in severity  Sx: dimunition or loss og normal function, anergia, ◦ Typical antipsycotics
anhedonia, alogia, avolition, blunted affect or affective
3. Stabilization phase – patient is might still experience flattening, attention deficits, poor eye contact, asocial
 Haloperidol (Haldol)
hallucination & delusions but not as severe nor as disabling as  Chlorpromazine (Thorazine)
behavior, difficulty in abstract thinking
they were during the acute phase  Thiothixene (Navane)
Common symptoms of schizophrenia  SCHIZOPHRENIA ◦ Atypical antipsychotics
1. Delusions – false fixed beliefs that cannot be corrected by  SCHIZOPHRENIA SUBTYPES  Clozapine (Clozaril)
reasoning 1. PARANOID TYPE  Respirodone (Respiradol)
2. Hallucinations – sensory perception for which no external ◦ Experience persecutory or grandiose delusion &  Olanzopine (Zyprexa)
stimulus exist auditory hallucination  Milieu mgt.
◦ For disruptive patients:  Have staff members available in the a. Successful crisis resolution occurs when
 Set limits dayroom so that patient can talk to real functioning is restored or enhanced through new
 Frequently observe escalating patients people about real people or real events learning
to intervene ◦ For disorganized patients: b. Unsuccessful crisis resolution is when functioning
 Modify the environment to minimize  Remove disorganized patient to a less is not restored to pre-crisis level, and the
objects that can be used as weapons stimulating environment individual experiences decreased level of
 Be careful in stating what the staff will  Provide a calm environment functioning
do if a patient acts out  Provide safe & relatively simple 4. Individual’s perception of the problem determine the crisis.
activities for these patients Each individual has unique response to the problem
 When using restraints, provide for
5. Balancing factors are important in predicting outcomes for
safety by evaluating the patient’s status  Nursing guidelines
the individual responding to a crisis
of hydration, nutrition, elimination, & ◦ Build a therapeutic alliance with patient
a. Perception of precipitating event is realistic rather
circulation ◦ Be calm than destored
 SCHIZOPHRENIA ◦ Accept patient b. Situational supports (ex. Family, friends)
◦ Keep promises
◦ For withdrawn patients:
◦ Be honest
c. Coping mechanism that alleviate anxiety
 Arrange non-threatening activities that ◦ Do not reinforce hallucinations or delusions  CRISIS
involve these patient in doing ◦ Do not touch patient without warning Type of Crisis
something
◦ Reinforce positive behaviors  Developmental crisis - occurs from transition from one
 Arrange furniture in a semicircle or
◦ Avoid competitive activities stage of maturation to another in the life cycle
around a table
◦ Do not embarrass patient
 Help client to participate in decision  Situational crisis – occurs to a sudden, unexpected event in
◦ Allow & encourage verbalization of feelings
making an individual life. These events is all about experiences of
 Reinforce appropriate grooming &  SCHIZOPHRENIA – LIKE DISORDERS loss.
hygiene 1. Schizoaffective disorders
 Provide psychosocial rehabilitation ◦ Uninterruptive period of illness during which at  Adventitious crisis – occurs in response to severe trauma or
some point the patient experiences a MDD, manic natural disaster. These crisis can affect individuals,
◦ For suspicious patients: communities and even nation
 Be matter-of-fact or mixed episodes along with the negative
symptoms of schizophrenia Sequence of Crisis Development
 Staff members should not laugh or
whisper around patients unless patient ◦ In the absence of prominent mood symptoms, 1. Pre-Crisis period – individual has emotional equilibrium
can hear what is being said patient exhibits delusion or hallucination 2. Crisis period – individual has the subjective experience of
 Do not touch suspicious patients 2. Schizophreniform disorder being upset, failure of usual coping mechanism, symptoms
without warning ◦ Patient exhibits features of schizopohrenia for are expereinced
more than 1 month but fewer that 6 months
 Be consistent in activities
◦ No impaired social or occupational function
3. Post-Crisis period – resolution of crisis
 Maintain eye contact Symptoms common in individual experiencing crisis
3. Brief psychotic disorder
◦ For patient with impaired communication:
 Be patient & do not pressure patient to
◦ Onset of at least 1 or more positive symptoms of  Physical symptoms – somatic complaints
psychosis
make sense  Cognitive symptoms – confusion, difficulty concentrating,
◦ Occur at least 1 day to less that an month then full
 Do not place patient in group activities racing thoughts, inability to make decisions
recovery
that would frustrate them, damage self-  Behavioral symptoms – disorganization, impulsive, angry
4. Psychotic disorder due to a general medical condition
esteem, or over-tax their abilities outburst, withdrawal from social interaction
◦ Presence of prominent hallucination or delusion
 Provide opportunities for purposeful
determined as resulting from the direct  Emotional symptoms – anxiety, anger, guilt, sadness,
psychomotor activity
physiologic effect of a specific medical condition depression, paranoia, suspicion, helplessness, powerlessness
◦ SCHIZOPHRENIA
 CRISIS
◦ For patient with hallucinations:  CRISIS
 It is an overwhelming reaction to a threatening situation in Management of Crisis: Crisis Intervention
 Attempt to provide distracting which an individual’s usual problem-solving skills and coping
activities 1. Assistance
responses are inadequate for maintaining psychological ◦ Assistance for an individual affected by a crisis
 Discourage situation in which patient equilibrium
talk to others about their disordered ◦ Assistance for groups or communities affected by
 General Consideration crisis
perception 1. Crisis occurs in all individuals at one time or another
 Monitor television selection  Mobile crisis team – interdisciplinary
2. Crisis is not necessarily pathological, it can provide stimulus teams provide services to groups of
 Monitor for command hallucination for growth & learning
that might increase the potential for communities affected by crisis
3. Crisis is time limited and is usually resolve one way or
patient to become dangerous  Disaster response team – teams have an
another in a brief period (4-6 weeks)
organized plan to provide help to large
segments of the population affected by
natural disaster
 Critical incident stress debriefing –
assistance is directed at groups of
professional such as hospital personnel,
police and firemen, who have been
involved in a crisis situation.
2. Role of the Nurse
 Nurse provides direct services to people in crisis and serve as
members of crisis intervention teams
◦ In acute and chronic hospital setting assist
individuals and families responding to the crisis of
serious illness, hospitalization and death
◦ In community setting provide assistance to
individuals and families in developmental and
situational crisis
◦ Nurses working with a particular group of client
should anticipate situations in which crisis may
occurs. They also collaborate with other health
team members to help an individual resolve crisis
 CRISIS
Principles of crisis intervention
 the goal of crisis intervention is to return the individual to
pre-crisis level of functioning
 Emphasis is on strengthening and supporting healthy aspects
of individual’s functioning
 A problem-solving approach is use in a systematic manner
◦ Assessing the individual’s perception to problem
assessing strengths and weaknesses of the
individual and family support system
◦ Planning specific outcomes or goals based on
priorities
◦ Providing direct intervention
◦ Evaluation outcome and results of intervention
 Use the framework of Maslow’s hierarchy of needs to
determine the priorities for intervention
◦ Physical resources – necessary for survival
◦ Social resources – necessary for regaining sense of
belonging
◦ Psychological resources – necessary for regaining
self-esteem
Role of crisis intervention worker includes:
 Establishes rapport and communities hope and optimism
 Assumes an active, directive role if necessary
 Make suggestions and offer alternatives