MENTAL HEALTH AND PSYCHIATRIC NURSING • “Loco Parentis”: MD gives consent for the best intention of the patient

HEALTH AND ILLNESS CONTINUUM

INTRODUCTION

• Joyce Travelbee: An Interpersonal Process whereby the professional nurse

practitioner assists the IFGC, to promote mental health, prevent or cope with the
experience of mental illness and suffering and of necessary, to find meaning in
these experience.
• Levels of Prevention:
- Primary: Promotive & Preventive aspects of care; healthy clients with
abscence of symptoms
- Secondary: Curative aspects of care
- Tertiary: Rehabilitiation

ROLES OF THE PSYCHIATRIC NURSE

• Teacher
• Socializing Agent
• Technician
• Parent Surrogate
• Patient Advocate
• Counselor
• Ward Manager
• Researcher
• *Creator of a Therapeutic Environment

QUALITY OF PSYCHIATRIC NURSING CARE

MENTAL HEALTH (WHO, 1998)
• Structure
- Qualification of the Nurse • A state of well-being in which every individual…
- Functions of the Nurse - (1) realizes his or her own potential - SELF IMAGE
- Organization and Administration of Nursing Care - (2) can cope with normal stresses of life - RESILIENCY
- Physical Facilities and Equipment - (3) can work productively and fruitfully - PRODUCTIVITY & CREATIVITY
• Process - (4) and is able to make a contribution to his community - SENSE OF
- Assessment PURPOSE
- Analysis of Data
- Planning MENTAL ILLNESS (WHO,1999)
- Implementation
- Evaluation • A Diagnosable illness that significantly interferes with an individual’s thinking,
• Outcome feeling, or social activities and even daily functioning
- Progress of Care • Factors that may bring about Mental Illness:
- Effect of Care - Family Dynamics: Patterns of relating or interaction between family members
- Behaviour:
LEGAL CONSIDERATIONS Response to Stimuli -> Reflexive
- -> Goal Directed
• Rights of clients and related issues - -> Frustration
- Patient’s Bill of Rights - Needs: An organismic condition that exists w/i an individual and which
• Involuntary Hospitalization demand certain activity
- Some px’s do not have knowledge about their condition Result of Metabolic process
- Involuntary hospitalization may be converted into voluntary admission Change in one’s relationship with external Environment
• Release from the hospital Symbolic Behaviour
• Conservatorship and guardianship • Conflict: The result of the prescence of two opposing or incompatible drives that
- Responsibility of Social Workers requires a person to make a choice between possible responses
• Least Restrictive environment • Stress: Occurs when a person has difficulty dealing with life situations, problems
- When choosing interventions for patient, start from least restrictive to most and goals
restrictive - Recurring
- Last resort is application of mechanical restraint - Normal
- Start with Verbalization > Meds > Behavioral/Limit Setting > etc,. - Cannot be avoided
• Confidentiality - Brought about by a stressor
• Duty to Warn 3rd Parties • Frustration: A state that results when stress becomes sufficiently great and
- When threats are verbalized by the patient reaches a point above the threshold of an individual
• Insanity Defense - Responses:
• Nursing Liability Fixation
Aggresion
ETHICAL ISSUES Regression
• Autonomy Resignation
• Beneficience
• Nonmaleficence
• Justice
• Veracity
• Fidelity
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 STRESS ADAPTATION MODEL (STUART, 2009)
• Primary Appraisal: Determines whether an activity or action constitutes stress or
not
• Secondary Appraisal: Looking at your available coping resources
• Introjection: Accepting another person’s attitudes, beliefs and values as one’s
own
• Displacement: Ventilation of intense feelings toward persons less threatening that
the one who aroused those feelings
• Projection: Unconscious blaming of unacceptable inclination or thoughts on an
external object
• Undoing: Exhibiting acceptable behaviour to make up for or negate unacceptable
behaviour
• Reaction Formation: Acting the opposite of what one thinks or feels
• Compensation: overachievement in one area to offset real or perceived
deficiences in another area
• Conversion: Expression of an emotional conflict through the development of a
physical symptoms usually sensorimotor in nature
• Substitution: replacing the desired gratification with one that is more readily
available
• Sublimation: substituting a socially acceptable activity for an impulse that is
unacceptable
• Denial: failure to acknowledge an unbearable condition; failure to admit the
reality of a situation or how one enable a problem to continue
• Rationalization: Excusing own behaviour to avoid guilty, responsibility, conflict,
anxiety or loss of self-respect

MODES OF COPING
• Adaptive
- Solves the problem that is causing the anxiety so the anxiety is decreased
- The px is ojective, rational and productive
• Palliative
- Temporarily decreases the anxiety but does not solve the problem, so the
anxiety eventually returns
- Temporary relief allows the patient to return to problem solving
• Maladaptive
- Unsuccessful attempts to decrease the anxiety without attempting to solve
the problem
- The Anxiety remains
• Dysfunctional
ANXIETY - Is not successful in reducing anxiety or solving the problem
- Even minimal functioning becomes difficult and new problems begin to
• A vague feeling of dread and apprehension in response to external or internal develop
stimuli that can have behavioural, emotional, cognitive and physical symptoms
• A normal occurence SECURITY OPERATIONS
• Levels of Anxiety:
Mild Moderate Nursing Interventions • Selective Inattention
- Tuning out details associated with anxiety-producing situations
• Somnolent Detachment
Alert - Sharpened Selectively Attentive Help the client Identify - Sleep used to avoid anxiety
senses the anxiety • Preoccupation
- Self-absorbed or engrossed in one’s own thoughts to a degree that hinders
Increase motivation Perceptual field limited to Encourage to talk about effective contact with or relationship to external reality
immediate task feelings and concerns
• Apathy
- Emotional Detachment or numbing even experiences are remembered
Slight muscle tension Moderate Muscle Help the client identify
Tension thoughts and feelings
that occured before the CRISIS AND CRISIS INTERVENTIONS
onset of the anxiety
• Crisis: State of disequilibrium resulting from a stressful event or perceived threat
Enlarged Perceptual Diaphoresis, Pounding Help px identify the where the individual’s usual coping mechanisms become ineffective in dealing
Field Pulse, Headache, Dry thoughts and feelings with it
Mouth, High Voice Pitch, that occured before the • Types:
GI Upset, Polyuria, Inc. onset of the anxiety - Developmental:
Automatism Maturational
Part of the process of life
Anticipatory Guidance: Impact is not much
EGO DEFENSE MECHANISMS - Situational
Suddenly occur and not anticipated to happen; beyond one’s coping
• Suppression: Conscious exclusion of unacceptable memory or experience - Adventitious
• Repression: di naalala, unconsious forgetting Extraordinary; Traumatic
• Dissociation: Temporary alteration in consciousness or identity Man-made or natural disasters
• Intellectualization: Acknowledging the facts but not the emotion • Balancing Factors
• Regression: Moving back to a previous developmental state - Individual’s perception of the event
• Fixation: Immobilization resulting from unsuccesful completion of tasks in a - Situational Support
developmental stage - Coping Mechanisms
• Identification: modeling actions and opinions of influential others while searching
for identity or aspiring to reach a personal, social or occupational goal

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• Phases of Crisis • Psychosocial Theory - Erik Erikson
Pre-Crisis Crisis Post-Crisis • Cognitive Theory - Jean Piaget
- Intellectual development is a result of constant interaction between
environmental influences and genetically determined attributes
• State of • Feeling of falling • Successful
Equilibrium apart resolution OR Sensorimotor (0-2 y/o) Preverbal; Learning occurs through
• Denial- relieve (Disorganization) unsuccessful use of senses and simple motor
tension • Attempt at re- resolution activities
(ineffective) organization
• Heightening of • Discover an Preoperational Can now use language and symbolic
tension Effective Coping Pre-Conceptual (2-4 y/o) representations in play
• Ineffective EGO CENTRIC
Coping
Preoperational Intuitive (4-6 y/o) Asks Questions, begins to understnad
relationships
• Characteristics of Crisis State INTUITIVE RELATIONSHIPS
- Highly Individualized
- Self Limiting 4-6 weeks Concrete Operations (7-11 y/o) Increased conceptual Dev’t: Problem
• Steps in Crisis intervention solving, Cause and Effect, Inductive
1. Assess the situation Reasoning, Logical Thought
2. Assist the client to develop cognitive awareness of the event
3. Assist the client in manageing feelings Formal Operation (>12 y/o) Can reason logically and abstractly;
4. Explore with the client the resources available can formulate and test hypothesis
5. Assist the client in action planning
• Techniques of Crisis Intervention • Eclectic Theory
- Abreaction: encourage Verbalization • Concepts from more than one school of though are used in developing a
- Clarification useable theory on personality development
- Suggestion
- Manipulation: Using the positive points of the clients for his/her advantage THE THERAPEUTIC RELATIONSHIP
- Reinforcement of behaviour: recognition
- Support of Defenses: Initial reaction is accepted but prolonged action must
• Component of a Therapeutic Relationship
be corrected - Trust
- Raising of Self Esteem - Congruence
- Exploration of solution - Genuine Interest
- Empathy
THEORIES OF PERSONALITY DEVELOPMENT - Acceptance
- Positive Regard
• Personality: It is the integration of interests, abilities and habits to create a unique • Self-Awareness
quality of response by an individual - The process of developing an understanding of one’s own values, beliefs,
• Model of Personality Structure - Sigmund Freud thoughts, feelings, attitudes, motivations, prejudices, strengths and
- Unconscious processes or psychodynamic factors as basis for motivation limitations and how these qualities affect us
and behaviour - Johari’s Window (Luft, 1970)
- SUPEREGO: Social Component • Therapeutic Use of Self
- EGO: Psychological Component; Reality Principle - Nurses use themselves as a therapeutic tool to establish the therapeutic
- ID: Biological Component: Pleasure Principle relationship with the client
- CONSCIOUS: Contact with outside world • Phases of the Nurse-Client Relationship
- PRECONSCIOUS: Material just beneath the surface of awareness - Pre-orientation
- UNCONSCIOUS: Difficult to retrieve material; well below the surface of Develop Self-Awareness
awareness Gather initial information about the patient (cart, other nurses, family
• Stages of Psychosexual Development - Sigmund Freud and relatives)
- Oral - Orientation
The mouth: sucking, swallowing, etc. Establish rapport, begin to build trust
EGO develops Set a contract with the client (Expectations, Confidentiality of
Forceful Feeding: Oral activities (Smoking, Cursing) Information, Parameters)
Deprivation: Dependency Give structure and boundaries of the relationship
Early Weaning: Aggression Prepare the client for termination
- Anal Do the initial assessment of the client
The Anus: Holding on and Letting go History Taking
Toilet Traning MSE
Too Harsh: OCD, Meaness - Working
Too Lax: Untidiness, Generosity Encourage verbalization of feelings
- Phallic Assist patient to learn more socially acceptable behavior
The Penis or Clitoris: Masturbation Assist patient to learn more effective coping patterns
SUPEREGO develops Assist the client to develop insight
Abnormal family setup leading to unsual relationship with mother/ On-going assessment of the clint
father - Termination
Vanity, self-obsession, sexual anxiety, inadequacy, inferiority, envy Encourage verbalization of the feelings that go with termination
Oedipal Complex: Boy to Mom Summarize what he learned in the relationship
Electra Complex: Girl to Dad Evaluate outcomes of the relationship
- Latent Solidify the closure of the relationship
Little or no sexual motivation present
- Genital
The penis or vagina: sexual intercourse

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 IMPASSES TO AN EFFEECTIVE NURSE-PX RELATIONSHIP • Existential: Helps the person discovers an authentic sense of self, which
emphasized personal responsibility for one’s self, feelings, behaviours and choice
• Resistance: Patient refuses
• Transference: Px > S.O (Past) > Nurse (Present) SCHIZOPHRENIA SPECTRUM DISORDER AND OTHER PSYCHOTIC
• Counter-Transference: Nurse > S.O. > Patient DISORDER
• Inappropriate Boundaries: Violation of boundaries
• Feeling of sympathy and encouraging dependency: Empathy only > Reflecting • Psychotic Disorders: Inability to distinguish what is real from what is not
the feeling implied • Etiology
- Biochemical: Increased Dopamine
THE THERAPEUTIC COMMUNICATION TECHNIQUES - Psychologic: Mental defects
• Giving information/ Informing - Social: dysfunctional family realtionship and communication
• Giving recognition/ Acknowledging : Lack of nurturing
• Making observations : Inconsistencies
• Offering Self • Assessment - Blueler’s 4 A’s
• Placing event in time or sequence 1. Affect - Apathy (Flat Affect), Inappropriate (ineffective response to the
• Presenting reality or confronting situations)
• Reflecting 2. Ambivalence - prescence of two opposing feelings at the same time (co-
• Restating existing)
• Seeking clarification 3. Associative Looseness - Thought process > connection > impaired >
• Silence incoherent speech
• Suggesting collaboration 4. Autism - make-believe and fantasy world
• Summarizing • Positive Symptoms - Excessive Dopamine
• Translating into feelings - Delusions (Thought Content problems): Fixed false beliefs
• Verbalizing the Implied Grandeur: believe that one is an exalted person; reality > inadequate >
• Voicing doubt believe to be someone else; Enhance px’s self esteem
• Accepting Persecution/Paranoid: Falsely believe that one may harm him; prone
• Broad Openings to be violent to protect himself
• Consensual validation Reference: all communication is all about him
• Encouraging comparison Control: false belief that an external force control the client; thought
• Encouraging description of perceptions Insertion, thought withdrawal (removal), thought broadcast (somebody
• Encouraging expression knows what he is thinking)
• Exploring Religious
• Focusing on specifics Somatic: Body is changing in some way
• Formulating a plan of action Nihilistic: Body and its parts do not exist anymore
- Hallucinations:
ELEMENTS OF THE THERAPEUTIC MILIEU Auditory: most common
Visual
• Safety:
- Disorganized speech
- Physical Protection: Safety from physical harm through the management of Word Salad: jungle of words put together meaningless, not anxiety
risks in the environement provoking
- Psychological protection: involves the nurses’s active intervention to prohibit Clang Association: Rhyming words put together
verbal abuse, ridiucle and harrasmment of patients Neologism: New Words
• Structure: the physical environment, rules and daily schedules of treatment Perseveration: Same response to different stimuli
activities Verbigeration: No Stimuli > repeating words
• Norms: specific expectations of behavior that permeate the treatment Echolalia: With stimuli > repeating words
environment - Grossly disorganized or Catatonic behavior
• Limit Setting: reinforces the norm of making rules and expectations clear Regressive behavior
• Balance: process of gradually allowing independent behaviors in a dependent Catatonic behavior > motor manifestation
situation Psychomotor Aggitation
• Negative Symptoms - Decreased Dopamine
FRAMEWORK OF TREATMENT AND CARE MODALITIES - Alogia: Poverty of content
- Anhedonia: Inability to experience pleasure
- Avolition: Lack of motivation
• Biologic: Psychological conditions are caused by physiologic functions - Anergia: No energy
• Psycoanalytic: All human behaviour is caused and can be explained and - Asocial: No social ability
repressed sexual impulses and desires motivate much human behavior
- Inattention: Inability to focus
• Interpersonal: Inadequate or non-satsfying relationships produce anxiety, which is
the basis for emotional problems (Sullivan, 1953) • Types of Schizophrenia
- In DSM 5 there are no more different types of Schizophrenia and Psychosis
• Social: The environment can affect the individual
• Cognitive: People are capable of thinking rationally and irrationally which affects 1. Paranoid Type:
their thoughts and feelings; Cognitive Restructuring; Narrow to broad frame of Persecutory Delusions + Auditory Hallucinations
reference Most violent type
• Behavioral: Focuses on observable behaviors and what one can do externally to Very organized
bring about behavior changes; behavior can be learned or modified 2. Catatonic Type:
- Token Economy: Regularity of behaviour is rewarded Motor Manifesatations (Acute)
- Aversion Therapy: Behaviour is associated with unplesant consequences Stupor-Catatonic: Like unconscious
- Time out: Being quiet and regaining control Rigidity-Catatonic: assumes a stiff posture
- Systematic DesensitizationL Gradual exposure to identified source of fear Posturing: assumes bizarre posture
- Flooding: bombardement of fearful experience Waxy Flexibility: assumes a position and maintains as
- Behvaior Shaping: imatating behavior then giving reward imposed
• Humanistic: Focuses on the person’s positive qualities, his or her capacity to Negativistic: does the opposite of what he is expected to do
change, and the promotion of self-esteem Excitement: goes into hyperactivity without stimulus

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 3. Disorganized Type - Tardive Dyskinesia (form of EPS) > Irreversible > Long term use of anti-
Disorganized speech and behaviours psychotic
Most regressed Lip smacking, cheek puffing, vernicular movement of the tongue,
4. Undifferentiated Type masticating
All positive symptoms • Rehabilitation
5. Residual Type - Compliance to treatment
Negative Symptoms only - Independence in activities of daily living
• Common Nursing Diagnosis - Social Skills
- Risk for violence - Develop more effective coping patterns
- Impaired verbal communication related to mutism or incoherence Role playing: test new behavior and deal with future hallucinations >
- Social Isolation Ignore and keep them busy
- Self Care Deficit: Nutrition and Grooming - Family Interaction
- Ineffective coping
• Psychotherapeutic Management MOOD DISORDERS
1. Promote safety of client and others
- establish a trusting relationship to encourage them to verbalize the • Categories of Mood Disorders
content of their hallucinations and delusions - Unipolar Disorder: Depressive Disorder or MDD
- Observe the px further - Bipolar Disorder: Depression with Hypomanic behaviours
2. Establish a Therapeutic Relationship
- The withdrawn px: Active Friendliness! Keep it short and frequent, One- MAJOR DEPRESSIVE DISORDER
on- one, Maintain distance when touching
- The suspicious px: Passive Friendliness! Make self available while
• Etiology
maintaning distance until px is ready to interact. Consistency and - Cognitive: They are pessimistic > Cognitive Therapy
honesty. - Biologic: Decrease in Norepinephrine, serotonin and increase in MAO
3. Use therapeutic communication (Endogenous - from within, depressed in the morning)
- For concrete thinking - Psychodynamic: Unresolved conflict, debilitating life experience (Early
Check abstrract thinking - proverbs stages of development), Reaction to life events (exogenous)
Schizophrenia - concrete thinker (literal)
• Dynamics
Be concrete in communicating - Loss > Heplessness / Abandonment > Hostility > STRON SUPEREGO >
- For incoherence
- For Mutism Guilty and Worthlessness > Internalized Hostility > Depression > Introjection
of Hostility (Suicide)
Give time to talk > open ended with spaces in between
• Manifestations
Neutral topics at first - Atleast 5 of the criteria for a minimum of 2 weeks, with no. 1 or 2 being
4. Do not reinforce delusions and hallucinations present always
- Do not argue about delusions
- Do not reinforce hallucinations 1. Sadness
- If a px is acting odd and the nurse suspects he is hallucinating, the px 2. Loss of Interest > Anhedonia
3. Worthlessness/Excessive or Inappropriate guilt
should be asked about it - Validating 4. Psychomotor disturbance (Slow in movement, Agitated)
- Help px to identify the stressors that might precipitate hallucination or
5. Diminised ability to concentrate or indeciciveness
delusions - feeling: anxiety 6. Somatic Manifesatations - Apetite Disturbance, Sleep Disturbance
- Focus on real peiple and real events
(Insomnia), Fatigue or loss of energy
5. Physiologic and Self-Care considerations 7. Recurrent thoughts of death
- Catatonic: Circulation, nutrition, hygiene
- Disorganized: instruction, be with patient • Nursing Diagnoses:
- Altered nutrition more than or less than body requirements
- Paranoid: sealed foods and open it in front of the px prepare the food - Anxiety
with the client, serve, family style, do not taste the food (Challenges the - Ineffective individual coping
client) - Hoplessness
6. Deal with socially inappropriate behaviour - Powerless
• Pharmacologic Treatment - Self-Esteem Disturbance: Low
- Antipsychotics - Sleep Patter Disturbance: Insomnia or Hypersomnia (Initial, Medial >
Typical Antipsychotics: Modify (+) symptoms Fragmented and light, Terminal > Wakes up in the wee hours of the night)
• Phenothiazines - Thorazine - Constipation
Atypical Antipsychotics: Modify both (+) and (-) symptoms - Social Isolation
• Seroquel, Zeldox, Clozaril • Interventions:
• Side Effects: 1. Provide for the px’s safety > Control of the environment
- CNS depression - Assess for cues and clues of suicide
- AntiCholinergic - Direct or indirect verbalization
- Orthostatic HypoBP - Validate: ask a question
- GI Upset- with meals - Gives off valuable things
- Endocrine Changes - Potentially harmful things
Gynecomastia - starving oneself
Ammenorrhea - puts into order his affairs
- Photosensitivity: Skin discoloration to direct sunlight - Makes his farewell note
• EPS - Extra Pyramiday Symptoms (caused by decrease in dopamine) - Change in behaviour and mood - uplifting of the depression (PRIORITY!!
- Akathisia: fidgety, restlessness
- Akinesia: muscle fatigue Might cause materialization of plans of suicide)
- Check lethality of suicide > How determined is the px to perform suicide
- Dystonia: Tongue protruding, opisthotonus, oculogyric crisis
- Pseudoparkinsonism: forward posture, shuffling gait, mask-like facies Planning of Suicide - More detailed, more likely
- Given anti-EPS: Akineton, Artane, Benadryl, Artane, Cogentin, Symmetrel Means (Low: Cutting the wrist; High: Strangulation, OD, Poisons,
Muriatic Acid)
• Adverse Effects Recent Loss
- Decreased seizure threshold
- Blood Dyscracias Age - Elderly
Sex: Females > attempt; Males > succesful
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 Civil Status: single and widowed • Assessment:
Previous history of suicide - Elevated, Expansive/Irritable mood (Labile affect - happy then angry) of
2. Promote a therapeutic Relationship atleast 1 week at least 3 of the following:
- Accept Patient 1. Pleasurable activities
- Spend Time with px 2. Increased in goal-directed activities or psychomotor agitation
- Respond to anger therapeutically 3. Inflated self-esteem or grandiosity - feeling of inadequacy
- Shout : Set Limits only 4. Pressure of speech (Fast) / Locaquious Speech (Productive)
- Self- Destructive: Limits 5. Flight of Ideas or feeling that thoughts are racing
3. Focus on the Client’s Strength 6. Distractibility
Be with Px 7. Somatic Manifestations > Nutrition and Sleep Deprivation
Music and Art Therapy 8. Sarcastic, Manipulative, Demanding
No activity that entails detailed works and decision making skills • Nursing Diagnosis
Assist the pc in decision making skills - Risk for other directed violence
• Pharmcotherapy - Risk for injury
- TCA Tricyclic Antidepressant: Blocks the reuptake of Norepinephrine and - Altered nutrition - less than body requirements
Serotonin - Ineffective individual coping
Delayed onset of effect > 3-4 weeks - Self-care deficit
Tofranil - Self-esteem disturbance
- MAOI Monoamine Oxidase Inhibitors - Sleep pattern disturbance
Nardil, Marplan - Impaire social interaction
Hypertensive Crisis due to thyramine rich foods (Processed food, - Altered role performance
Fresh foods) • Assault Cycle
- SSRI Selecetive Serotonin Reuptake Inhibitors - Trigger: had just started to become angry
Prozac, Zoloft Good time to express his feelings > Safe distance
- Atypical Antidepressants Calm approach
Effexer, Lexapro, Remeron non-confrontational approach
• ECT Electroconvulsive Therapy hands on sides, palms up
- Literally Depressesd Establish sporadic eye contact but no staring
- Acutely Suicidal - Escalating: More angry > More muscle tension
- Does not respond to other mes and to neurochemical therapy Time out
- Contraindications Go back to room (not isolation room)
Heart Conditions Check on px > regain control
Organic Mental Disorders Meds: Haldolor Thorazine and Benadryl
Active bleeding tendencies - Crisis: Aggression at peak
Pregnant Verbal limits: Tell px what expected to do
HTN, High temp if the px proceeds > restraint application
Fractures Ask help if the px will be on restraint
Pacemakers Crisis Team: help in gaining control because the px cannot control
- Nursing Considerations: himself > safe appliation of restraint
Informed Consent (responsible fam member) Tie on the frame of the bed
NPO (6-8 hrs) Monitor the client: Q15, Nailbeds, Cold clammy skin, Comfotable pos’n
Wear loose clothing Untie for 15 mins Q2 with relative or one to accompany him
Not required to shampoo, hair is dry Documentation
Remove dentures • Nursing Interventions
Encourage to void - Provide for px’s physical safety and safety of those around him or her
Monitor VS > Baseline: Before and After Hyperactivity > exhaustion > heart problem
Mouth Gag - Prevent aspiration Limit external stimuli > quiet, non-stimulating environment
Modified EECT: Pre Meds (IV Penothal), Short Acting Sedative, Place farthest to the nurse’s station
Atroping Sulfate, Anectine, Muscle Relaxant - Ensure theat nutritional and fluid balance needs are met
Not Modified: w/o sedatives Finger foods: High Caloric, High CHON (sandwhich, french fries,
- Outcomes of ECT chicken)
Like Grand Mal Seizures (desired) Fluids : Lithuim carbonate > Polyuria
Memory Impairement - Usre simple sentences and short to communicate
Results: willing to socialize - Set limits but respond to legitimate complaints
Provide privacy
BIPOLAR DISORDERS if with extreme talkativeness > keep statements concise
sexual > matter of fact
• Kinds
- Channel excessive energy into socially acceptable motor activities (Gross
- Bipolar I: Depression & Mania motor)
- Bipolar II: Depression & Hypomania Writing with supervision
• Etiology Brisk walking
- Biologic Cleaning activities
Genetic - Reinforce reality
Increased Norepinephrine & Serotonin - Enhance self-esteem
Increased in intracellular sodium - Major Extracellular Cation • Pharmacologic Treatment
- Psychodynamics: Extremes (Polar Experiences) - Anti-Anxiety: reduce hyperactivity
• Mania as defense against depression With lithium carbonate
- Hide Depression - Lithium carbonate
- Loss > Abandonment & Helplessness > Hostility > INCREASE ID > Denial of Most commonly used
Depression > Reaction Formation > Anger > Externalized > Mania Prevents reuptake of N&S
Check BUN
Therapeutic level: 0.6 ml - 1.2/1.5 (non-toxic)

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 10 days to 2/3 weeks to reach this level - Undoing > RITUALS (to negate the anxiety)
Monitor level through Serum Lithium determination - Reaction formation
Has not taken lithium for atleast 12 hours - Isolation Repression
Side Effects: Fine tremors, Nausea, Diarrhea, GI Upset - With meals, - Real compulsion cannot be stopped by the person
Polyuria (Oliguria, Anuria), Polydipsia, Headache, Metallic Taste • Dynamics
Adverse Effects: Gross tremors, Vomiting, Tinnitus, Confusion, Ataxia - Unacceptable desire, feeling, wish or unresolved conflict > threatens the ego
• Interventions > repression (unconssious forgetting) > does not bother him but affects how
- No Diuretics we do things >
- Toxicity > Hemodialysis • Other Related Condiotion
- Oral form only - Dermatillomania: skin picking
- Cannot tolerate lithium (rivotril) clonazepam - Trichotillomania: hair picking
- Regular Na Diet (liberal but not excessive) - Onychophagia: nail biting
Lithum and Na has affinity (Looks for Na intracellulary and kicks off - Oniomania: compulsive buying
Na) - Body Dysmorphic Disorder: preoccupation with imagined defect
Dangerous: Hyponatremia & High Na (Excretion of Li) - Hoarding disorders
- Anti-Convulsants: Tegretol, Valproic Acid (Depatoke & Epival) - Body identity integrity disorder/Body Amputation Lovers
• Nursing Considerations (Short Term)
ANXIETY AND ANXIETY-RELATED DISORDERS - Do not stop the compulsion but lessen the number of compulsion: Limit
Setting > time limit for the compulsions
• Etiology
- Modification in the schedule
- Biologic - Use diversional activities > relaxing activities (e.g. Counting - requires
Affects the ANS precision such as baking)
Dec in GABA; Serotonin affectation - Recognize positive behavior
- Behavioral - Do not confront (the px knows that he has rituals)
- Psychodynamic - Thought stopping
ID and SUPEREGO - Avoidance of stressfuls ituations and recognition of the ritualistic behaviour
Repression: Main Defense mechanism as maladaptive
- Interpersonal • Nursing Considerations (Long Term)
- Demonstrate more effective coping
PHOBIC DISORDER
POST TRAUMATIC STRESS DISORDER
• Phobia is an irrational fear
• Defense Mechanisms: • Stress after a trauma experienced (adventitious crisis)
- Repression • Critical Incident Stress Debriefing: Made to talk about the event that has
- Displacement happened > Let go and Move on > Survivors not victims
- Symbolization • Duration: at least 1 month and longer
• Specific phobia • Manifestations
• Agoraphobia: fear of open spaces, being alone, escape is difficult
- Flashback: relieving the experience, very vivid, as if the tramatic event is just
• Social Phobia: Fear of any situation that a person can be embarrased and happening now (imagining)
humiliated > public - Emotional numbness/avoidance
• Dynamics
- Impaired functioning: cannot do daily activities of living
• Displacement of feeling to another object (symbol) > avoidance > impaired • Possible Nursing Diagnoses
ADLs > abnormal phobic disorder - Powerlessness - loss of control of the event
• Nursing Considerations:
- Altered role performance
- Do not let avoidance to take place for too long - Risk for injury
- Systematic Desensitization: gradual exposure to the object feared - Anxiety
- Aware of the fear: cannot control his reactions > acceptance that the client’s - Ineffective individual coping
fear are real - Sleep pattern distubance
- Safety - Self-esteem disturbance
• Management
GENERALIZED ANXIETY DISORDER - Assist in minimizing the px anxiety
- Provide for safety of the ox
- Assist in developing a more effective coping
• Persistent worrying; anxiety reaction > at least 6 mos - Psychotherapy: use of verbal channels (Change in the behaviours or
• Manifestations:
- Vigilant symptoms)
- Diffuse and free-floating anxiety: do not know what triggeres his own anxiety
- Maybe moderate but continous TREATMENT MODALITIES FOR ANXIETY
• Nursing Considerations
- All interventions for moderate and severe anxiety • Pharmacotherapy
- Anti- Anxiety Meds: Elevate the GABA
PANIC DISORDER Manifestations of dec. anxiety
Relaxed, Normal and stable VS
• Acute anxiety attack > highest level of anxiety (max 10 hours) Sedative Hypnotics (Barbituarates & H2 Blockers)
• Nursing Consideration: Ensure safety, remain with px Benzodiapines (Ends in -pam)
Side Effects:
OBBSESSIVE-COMPULSIVE DISORDER CNS depressants > safety
No stimulants: counter effect the drug
No depressants: alcohol
• Obsession: repetitive thoughts that cannot be controlled Postural HypoBP: less than 20mmHG > HOLD
• Compulsion: repetitive actions for coping with the anxiety that cannot be Adverse Effects:
controlled > affects ADLs (eating, going to work)
Physical and psychological dependence: take meds not more than
• Defense Mechanisms: 3 wks, Gradual withdrawal
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 Paradoxic Excitement: refer to MD - Chronic pain
Anti-Cholinergic Effects: - Ineffeective coping
Dry mouth - Disturbed Body Image
Constipation • Goals of Intervention:
Urinary retention - To make the px as functional as his condition to allow to improve the quality
Blurring of vision of life
Nausea - To relieve symptoms > medication
• Psychotherapy - Do not push awareness of or insight into conflicts/problems
- Psychoanalysis Initially do not insist to change his coping mechanism
• Milieu Therapy As time goes by, nurse can assist the cline to see the relationship of
the symptoms to the event
DISSOCIATIVE DISORDERS - Encourage expression of emotional feeling
- Assist in learning more effective coping strategies
• Dynamics:
- Psychotherapy
- Stressors > Unconscious way of dealing with it > walls of and detach from - Medications
the stressor - Stress Management Techniques
• Dissociative Amnesia
- Global Amnesia PERSONALITY DISORDERS
- Local Amnesia
- Continous Amnesia • Rigidity & Inflexibility > No Insight > Life-Long (No seeking of treatment)
• Dissociative Fugue • CLUSTER A - ODD AND ECCENTRIC
- Loss of memory and assumes identity and migrate 1. Paranoid
- Fugue state - Suspicious, does not trust easily
• Dissociative Identity Disorder/Multiple Personality Disorder - Questions loyalty of friends, aloof
- Various personalities - Does not give personal information
- EGO is impaired 2. Schizoid
- Person that is stressful to the patient; trance-like - Shy and Timid
• Derealization Disorder - Prefers to be alon, few friends
- Trans-like State - Engages in fantasy
- Dream like - Pre-morbid personality of schizophrenia
- All happening like a dream (comorbidity) 3. Schizotypal
• Goals of Care: Integrate the personalities or memories - Shy
- Establish trust and support > verbalization - With minimal delusions
- Ensure px safety - Magical Thinking
- Reduce self harm and violence • CLUSTER B - DRAMATIC, EMOTIONAL AND ERRATIC
• Treatment 1. Antisocial
- Milieu Therapy - Manipulative and Exploitative
- Psychotherapy - ID
- Psychoanalysis - Criminal acts, irresponsible, no good record, Friends for benefits
- Conduct disorder (below 18 y/o)
SOMATIC SYMPTOM ILLNESS 2. Histrionic
- Hysterical and dramatic
• Dynamics
- ID
- Stressor > anxiety > physical symptoms w/o organic basis > dec anxiety - Happening is important
(primary gain) and other advantages from the environment (secondary gain) - Gets attention of others by dressing up and being seductive
- Nurses should not gratify the secondary gain > rewarding of the sick role 3. Narcissistic
• Manifestations:
- Self-love
• Physical symptoms vary depending uponthe type of somatoform disorder
- Loces to be admired and praised
(anxiety attatched to the body functions) 4. Borderline
• Somatic Symptom disorder
- Not able to overcome dependence need, mother-dependent
- varied physical complaint - Independent > bad
- symbolic meaning - How she sees other people > Splitting (good or bad) even for 1 person
• Pain Disorder
- Fear of abandonment, manipulative, empty > blood trickling in her, self-
- Pain is the only manifestation > Excessive and Prolonged mutilation
- Pain is not proportionate to the cause • CLUSTER C - ANXIOUS AND FEARFUL
• Illness Anxiety Disorder/ Hypochondriasis 1. Avoidant
- Morbid preoccupation - Avoids relationships
- Misinterpretation of symptoms having grave illness - Fears rejection
• Conversion Disorder
- Considers self as stupid
- Conflicts that are not resolved 2. Dependent
- Alteration and loss in motor and sensory function - Relies on others
- La Belle Indifference/ “A Beautiful Indifference”: Patient is not worried with 3. Obsessive-Compulsive
the symptoms, not affected - Preoccupid with orders, rules, and norms
• Characteristics of the Physical Symptoms
- No time for pleasure
- Real (not fake) Symptoms • Nursing Diagnoses
Matter of fact - real symptoms > attend to the needs of the px; do not - Impaired social interaction
ignore - Altered family process
- No underlying or organic basis - Potential for violence
- With primary and secondary gains - Ineffective individual coping
- Somatoform Disorder vs. Malingering (Conscious simulation of an illness to - Low esteem
have the secondary gain) - Altered role performance
• Nursing Diagnosis • Intervention: Psychotherapy

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 COGNITIVE DISORDERS - Mild Stage
2-3 years
• Affects the area of cognition such as: Amnesia: Forgetfullness is the hallmark
- Conscioussness No recent memory
- Memory Routine: consistent arrangement
- Perception Other cognitive difficulties (Decision making, judegement, reasoning)
- Orientation Repetitive Questioning
- Attention - Moderate Stage
- Language Disturbance 3-4 years
• Delirium: Acute confusion state Confusion & Disorientation
- Causes Supply the information
CHF Orientation board: Font Size
Uremia They can easily see vivid hues - amenable
Pnuemonia Every start of contact - orientation
Meetabolic Disorders Apraxia
VCA Forgets ADLS
Dehydration Self care deficit
Infection Be with the px
Metabolic Disorders - Severe Stage
Prescription Drugs with anticholinergic properties 5-10 yrs
- Manifestations Personality and emotional changes
• Dementia: Progressice cognitive deterioration Deterioration in all areas of function
- Causes (Reversible) • Nursing Diagnoses
Encepalopathy - Risk for injury
Infections - Altered thought process
Toxic conditions - Impaire communication
- Causes (Irreversible) - Impaired socialization
AD - Low Esteem
PD - Care giver role strain
Pick’s DSE • Nursing Considerations:
Huntington’s Chorea - Promote px’s safety and protection from injury
- Manifestations - Structure environment and routine
Memory Impairement - Amnesia - Promote adequate sleep, proper nutrition. hygience and activity
1 or more of the ff cognitive disturbances - Going along
Aphasia - Initial work - simple work
Apraxia - Provide interaction and involvement
Agnosia - Provide emotional support
Disturbance in executive functions (planning, organizing, - Family/caregiver support
sequencing, abstracting)
Cognitive defects can cause significant impairement insocial and EATING DISORDERS
occupational function
• Alzheimer’s DSE • Anorexia Nervosa
- Etiology: - Characterized by Self imposed starvation
unknown - Etiology
Genetic Biologic: Genetic Predispositions, Dysfunctional hypothalamus,
Toxic Decreased serotonin
- Development Social: Thin is in, Rely on physique to get the approval of others
- Developmental Factor
Overprotective / Domineering Enmeshed Family > decreased control
and helplessness
Disturbed body image > sees onself as fat (uses diuretics and
laxatives, locks up in room and does extraneous exercise
Conflicts about growing up (does not like to be adolescent)
- Dynamics
Stressors > Anxiety > Starvation > Decreased Anxiety > Personality
Type (Achiever, Perfectionist)
- Assessment
Refusal to maintain body weight at normal or minimum
Intense fear of gaining wt
Dec VS
Amennorhea
Lanugo
Hypogly F&E imbalance
- Nursing Diagnoses
Alt. Nutrition: Less than body requirements
Ineffective coping
Body image disturbance
- Management
Feed the patient
Be firm and consistent
Be with them to assess what the client had eaten and set limits >
do not force the client > make agreement

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 Make part in decisions - Urophilia: Sexual satisfaction from urinating
Limit setting: stay with px 1 hr after meals, place in a public place - Coprophilia: Defacating
after meal - Necrophilia: Sexual satisfaction obtained from a corpse
Monitor px weight - Telephone Scatologia: Telephone sex
Nutritional assessment - Zoophilia: Bestiality
Same clother for weighing
Weight gain 1-2 lbs per week CHILDHOOD AND ADOLESCENT DISORDERS
500 cal per day
Constipation: inc fluid intake , do not give lasat but a stool • Separation Anxiety Disorders
softener - Normal among infants (8-9 mos)
Increase self -esteem - Manifestations:
Good point of clients Follows mother around
Assist in expression of feelings If separated - forever, something would happen to mother
Do not use startcvation to reduce anxety School phobia - separation to mother because of school
Journaling - Management
Exercise Accompany the child
Activities Desensitize the child - used to separate to mother (Gradual experience
Verbaliztions of separation)
- Bulimia Nervosa: Characterized by binge-eating over a short period of time Counterproductive - Home study > no independence
follwed by purging behaviour • Childhood Depression
Biology Etiology: dysfunctional Hypothalamus, Decreased Serotonin - Causes:
Psychodynamic: Ambivalent feelings towards self - knows that eating is Loss of parents - divorce, separation, death
maladaptive Death of a person close to child or pet
Low self-esttem Movement to another neighborhood
Depression Academic problems or failure
Physical illness or injury
SEXUAL DISORDERS • Conduct Disorder
• Gender Identity Disorders - Repetitive or persistent pattern of conduct in which either the basic rights of
- Gender Identity (Psychological state) VS Sexual Identity (Physical state: boy others are violated
or girl) - Manifestations
• Sexual Dysfunction Aggresion to people and animals
- Inhibition of sexual appetite or psycho-physiological change that compromise Destruction of property
the sexual response cycle Deceitfulness or theft
- Human Sexual Response Cycle: Serious violations of rules
Desire • Management
Excitement - Group and individual psychotherapy
Plateu - Cognitive treatment: problem-solving, skills training
Orgasm - Parent training
Resolution - Family Therapy
- Sexual Desire Disorder: Lack of interest to engage in sexual activity
- Sexual Aversion: Negative experience in the past that makes the person not • Autistic Disorder
like sex - Etiology
- Sexual Arousal Disorder: Failing to achieve the necessary physiologic Genetic
changes to happen to get into sexual activity (Penile Erection and Vaginal Biochemical
Lubrication) Defect in Metabolism
- Orgasmic Disorder: Prolonged plateau that does not reach orgasm - Social Impairement
- Dyspareunia: Painful sexual intercourse Does not want people; wants inanimate
- Vagisnismus: Problem of vaginal muscles, arrest of the penis at the vaginal Impaired verbal communication
canal Cannot establish eye contact
• Sexual Perversion: Sexual instincts that are expressed in ways that are socially Disturbance in personal identity (pronouns)
prohibted or unacceptable or biologicaly undesirable Repetitive act
- Pedophilia: Sexual pleasure by an adult to a child less than 13 y/o Peculiar reaction to change - resist change, peculiar actions
- Incest: Sexual contact with a person belonging to the same blood line Nutrition
- Exhibitionism: Sexual gratification from the exposure of one’s genitalia - Nursing Considerations
- Transvestism: Finds pleasure in wearing the garments of the opposite sex Optimum Function- develop capabilities that he does not have
- Fetishism: Experience of sexual arousal from an oject symbolic to the person Call the child by name
of the opposite sex Safe environment - consistency
- Frotteurism: Attains sexual orgasm through touching and rubbing of genitals Establish more relationship
to a non-consenting person Medication - Haloperidol
- Voyeurism: Arousa in watching others sexual activity • Asperger’s Disorder
- Masochism: Sexual satisfaction obtained from enduring pain inflicted by - Severely sustained impairement in social interaction
partner - Restricted, repetitive patterns of beahviour, interests and activities
- Sadism: Sexual satisfaction obtained from inflicting pain to partner - No significant delays in language, cognitive development or age-appropriate
- Sodomy: Anal intercorse as the preferred sexual act between adults self-help skills
- Pedarasty: Anal intercourse with a boy - Treatment:
- Nymphomaniac: Female excessive desire for sexual act - May benefit from Autistic’s Treatment
- Satyriasis: Male Excessive desire for sexual act • Mental Retardation
- Fellatio: Oral sex of the male genital - Subaverage intellectual capacity
- Cunnilingus: Oral sex of the female genital - Ave IQ 90-110
- Pertialism: Oral sex does not proceed to genital sex - Deficit in daptive ability
- Pyromania: Sexual arousal obtained from fire - Causes of MR
- Klismaphilia: Sexual gratification from enema FAS

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 Genetic • Substance Intoxication
Exposure to measles during pregnancy • CNS Depressants: Depressant effects
Perinatal Problems • CNS Stimulants: Stimulating effects
Postnatal problems • Substance Withdrawal (Opposite)
Environment • CNS Depressants: Stimulating Effects
- Classification • CNS Stimulants: Depressant Effects
Profound: 20-25 • CNS Stimulants
Severe: 25-40, Mental Age 0-3 y/o - Forms:
Moderate: 40-55, Mental Age 3-8 y/o, Trainable to unskilled - - Amphetamines (Shabu)
semiskilled work - 8-12 hrs
Mild: 55-70, Mental Age 8-12 y/o Educable, Vocational Skills - Cocaine
Slow Learners: 70-89 (not mental retardation) - More potent than Shabu; 1-2 hrs
- Nursing Interventions - Ecstasy
Optimize mental functioning - Heightened Sexuality, feeling of closeness to one another (club drug)
Planning with parents - Effects
Routine and repetition in teaching them - Intoxication:
Down Syndrome - Euphoria
Teach socially acceptable behavior - Loss of Apetite
Speech > Tantrums is communication - Increased VS > Cardio Respi Effects
Joints > Enhance - Delusions and Hallucinations > Drug-Induced Psychosis
• ADHD / Disruptive Disorder - Formication: Specific for cocaine “bulbs” uner skin
- Manifestations - Urine Test: done ASAP not more than 4 days
Inattention/Distractability
Impulsivity
Hyperactivity
- Nursing Interventions
Limit Setting: Quiet non-stimulating environment
Safety
School: Shorter activities
Stimulants - Ritalin (Side Effects: Anorexia & Organic Based Ticks)
No Junk Foods
• Learning Disorders
- Deficits in acquiring expected skills compared with other children of the same
age and intellectual capacity
- Categories
Reading Disorder
Mathematics Disorder / Discalculia
Language Disorder
Disorder of Written Expression
Learning disorder not otherwise specified
• Motor Skills Disorder
- Low performance in ADLs that require coordination below what is expected
for age and intellectual level
- Clumsy gross and fine motor skills, resulting in poor performance in sports
and even poor handwriting
• Tic Disorder: Rapid and repetitive muscle contractions resulting in movements or
vocalization that are experienced as involuntary
• Tourette Syndrome: Multiple motor tics and one or more vocal tics
• Elimination Disorder: When the child is chronologicaly and developmentally
beyond the point at which it is expected that these functions can be mastered
- Encopresis: Constipation and overflow incontinence; w or w/o constipation
and overflow incontinence
- Enuresis: Repeated voidin into a child’s clothes or bed; may be involuntary or
intentional

SUBSTANCE ABUSE

• Regular Use
• Impairement of functioning
• Hazardous
• Substance Dependence
- Substance Abuse
- Takes the substance longer than intended to
- Needs more time to take and get the substance
- Withdrawal Symptoms:
Substance Specific symptoms upon reduction or cessation of the
substance
Tolerance: Higher dose to bring about the same effect
Symptoms for 1 year
• Physical Dependence: Withdrawal Symptoms
• Psychological Dependence: Takes the substance to avoid the unpleasant effects
of withdrawal

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