PSYCHIATRIC NURSING

Mental Health

A state of emotional, psychological and

social wellness evidenced by satisfying
interpersonal relationships, effective
behavior and coping, positive self-concept
and emotional stability.

COMPONENTS OF MENTAL HEALTH

Autonomy and Independence-can work interdependently

without losing autonomy

Maximization of Ones Potential-oriented towards growth

and self-actualization

Tolerance of Lifes Uncertainties-can face the challenges of

day-to-day living with hope & positive look

Self-esteem-has realistic awareness of her abilities and limitations

Mastery of the Environment-can deal with and influence the

environment

Reality Orientation-can distinguish the real world from a

dream, fact from fantasy

MENTAL ILLNESS
-State of imbalance characterized by a

disturbance in a persons thoughts,

feelings and behavior

Criteria to Diagnose Mental Disorders

Dissatisfactions with ones characteristics,

accomplishments, abilities
Ineffective or dissatisfying relationships
Dissatisfaction with ones place in the
world
Ineffective coping with lifes events
Lack of personal growth

PSYCHIATRIC NURSING

Interpersonal process whereby the nurse

through the therapeutic use of self assist an
individual family, group or community to
promote mental health, to prevent mental
illness and suffering, to participate in the
treatment and rehabilitation of the mentally
ill and if necessary to find meaning in these
experiences

CORE OF PSYCHIATRIC NURSING

Interpersonal relationship
FOCUS: Patient

Foundation

Central Nervous System

Cerebrum

Frontal lobe control organization of thought,

body movement, memories, emotions and moral
behavior.

Associated with schizophrenia, attention deficit /

hyperactive disorder and dementia

Parietal lobe interpret sensations of taste and

touch and assist is spatial orientation.

Foundation
Central Nervous System

Temporal lobes are centers for the sense

of smell, hearing, memory, and expression
of emotions.

Occipital lobes assist in coordinating

language generation and visual
interpretation, such as depth perception.

Neurotransmitters

Dopamine-controls complex movements, motivation,

cognition, regulates emotional responses

Serotonin-regulation of emotions, controls food intake, sleep
and wakefulness, pain control, sexual behaviors
Acetylcholine- controls sleep and wakefulness cycle
(decreased in Alzheimers)
Histamine-controls alertness,peripheral allergic reactions,
cardiac stimulations
GABA-modulates other neurotransmitters

Norepinephrine / Epinephrine-causes changes in

attention, learning and memory, mood

Foundation
Neurotransmitters
Sympathetic
Parasympathetic
Increase v/s
Decrease v/s
Decrease GI motility Increase GI motility
Decrease GU function Increase GU function
Moist mouth
Dry mouth

Genetics and Hereditary

Alzheimers disease linked with defects in
chromosomes 14 and 21
Schizophrenia
Mood disorders (depression)
Autism and AD/HD

Sigmund Freud

Father of Psychoanalysis
- Your behavior today is directly or
indirectly affected by your childhood
days or experiences.
- STRUCTURE Personality
Structure

Personality Structure

ID (4-5MONTHS)

Impulsive / Instinctual drive

I want to PLEASURE PRINCIPLE
I want to PHYSIOLOGIC NEEDS
I want to PRIMARY PROCESS

Personality Structure

SUPEREGO

Should not
Small voice of GOD
Set norms, standards and values
MORAL PRINCIPLE
Conscience

Personality Structure

EGO

Executive
REALITY PRINCIPLE
Conscious
Competencies
Decision Maker; Problem-Solving; Critical and
Creative thinking

Imbalances between Personality

Elements

ID
SE

M anic
A nti-social
N arcissistic

Imbalances between Personality

Elements

SE
ID

O bsessive
Compulsive
A norexia
nervosa

Imbalances between Personality

Elements

EGO

Schizophrenia

Libido

Sexual energy responsible for survival

of human beings
Psychosexual Theory of Freud

ORAL STAGE
18 months
Cry, suck, mouth
EGO @ 6 months

Child cries fed successful

Child cries ignored
unimportant - narcissistic

FIXATION

occurs when a person is stuck

in a certain developmental
stage

REGRESSION
Returning to an earlier
developmental stage
Infantile behavior

ANAL STAGE

18 months 3 years old

SUPEREGO develops
Toilet training

Good Mother Normal

Bad Mother
Clean, organized, obedient OC (anal retentive)
Dirty, disorganized Anti-social (anal expulsive)

PHALLIC STAGE

Preschooler (3 6 years old)

Parent

Oedipus Complex
Castration

Fear

Electra Complex
Penis

Envy

REPRESSION

UNCONSCIOUS forgetting of
an anxiety provoking concept

SUPRESSION

CONSCIOUS forgetting of an
anxiety provoking situation

IDENTIFICATION

attempts to resemble or pattern

the personality of a person
being admired of

INTROJECTION

acceptance of another values

and opinion as ones own

LATENCY STAGE
6 to 12 years old
School
Reading, writing, arithmetic
Ability to care about and relate
to others outside home

SUBLIMATION

placing sexual energies toward

more productive activities

SUBSTITUTION

replace a goal that cant be

achieved for another that is
more realistic.

GENITAL STAGE
12 years old and above
Developing satisfying sexual
and emotional relationships
with members of the opposite
sex
Planning lifes goals

EGO DEFENSE
MECHANISMS

Function-To ward off anxiety

*without defense mechanisms, anxiety might
overwhelm and paralyze us and interfere with
daily living
2 Features:
1. 1. they operate on an unconscious level
(Except suppression)
2. 2. they deny, falsify or distort reality to make it
less threatening

EGO DEFENSE
MECHANISMS

Repression vs. Suppression

REPRESSION

Unconscious forgetting of an anxiety provoking

concept

SUPRESSION

Conscious forgetting of an anxiety provoking situation

EGO DEFENSE
MECHANISMS
Regression vs. Fixation
Regression
Returning to an earlier developmental stage
Fixation
occurs when a person is stuck in a certain
developmental stage

EGO DEFENSE
MECHANISMS

Rationalization vs.
Intellectualization

RATIONALIZATION

Self-saving with incorrect illogical explanation

INTELLECTUALIZATION

Excessive use of abstract thinking; technical

explanation

EGO DEFENSE
MECHANISMS

Displacement vs. Projection vs. Introjection

DISPLACEMENT

PROJECTION

Feelings are transferred or redirect to other person or object that is less

threatening

Blaming; Falsely attributing to another his/her own unacceptable

feelings.

INTROJECTION

Acceptance of anothers values and opinions as ones own

EGO DEFENSE
MECHANISMS

Sublimation vs. Substitution

SUBLIMATION

Transfer of sexual energy to a more productive

activity.

SUBSTITUTION

Replaces a goal that cant be achieved for another

that is more realistic.

EGO DEFENSE
MECHANISMS

Dissociation vs. Isolation

DISSOCIATION

Separating and detaching idea, situation from its

emotional significance.

ISOLATION

Individual strips emotion when talking or responding

about it.

EGO DEFENSE
MECHANISMS

Conversion

Anxiety converted to physical symptoms

Compensation
Overachievement in one area to overpower weaknesses
or defective area.

Undoing

Doing the opposite of what have done

EGO DEFENSE
MECHANISMS

Denial

Fantasy

Failure to acknowledge an unacceptable trait or

situation

Magical thinking

Reaction Formation

Opposite of intention

EGO DEFENSE
MECHANISMS

Acting out

Symbolization

Deals with emotional conflict or stressors by ACTION

rather than reflection or feelings.

Creates a representation to an anxiety provoking thing or

concept

Splitting

Labile emotions; all bad all good

DEFENSE MECHANISMS COMMONLY

USED IN EACH RESPECTIVE DISORDERS

Paranoid Projection
Phobia Displacement
Amnesia Dissociation
Anorexia Supression
Bipolar Disorder Reaction Formation
Borderline Splitting
Schizophrenia Regression
Substance Abuse Denial
Depression Introjection
OC Undoing
Catatonic - Repression

Woman who is angry with her boss writes a

short story about a heroic woman.

Woman who is angry with her boss writes a

short story about a heroic woman.

Four-year old with new baby brother starts

sucking his thumb and wanting a bottle.

Patient criticizes the nurse after her family

failed to visit.

Man who is unconsciously attracted to

other women teases his wife about flirting

Short man becomes assertively verbal and

excels in business.

Recovering alcoholic constantly preaches

about the evils of drink.

Man reacts to news of the death

of a loved one No, I dont
believe you. The doctor said he
was fine.

Student is unable to take a final exam

because of a terrible headache.

After flirting with her male secretary, a

woman brings her husband tickets to a
show.

I didnt get the raise because my boss

doesnt like me.

Five-year old girl dresses in her mothers

shoes and dress and meets daddy at the
door.

After his wifes death, husband has

transient complaints of chest pain and
difficulty breathing- the symptoms his wife
had before she died

Man forgets wifes birthday after a marital

fight.

Businessman who is preparing to make an

important speech that day is told by his
wife that morning that she wants a
divorce. Although visibly upset, he puts
this incident aside until after his speech,
when he can give the matter his total
concentration.

A man cannot accept his physician's

diagnosis of cancer is correct and
seeking a second opinion

slamming a door instead of hitting as

person, yelling at your spouse after an
argument with your boss

focusing on the details of a funeral as

opposed to the sadness and grief

stating that you were fired because you

didn't kiss up the the boss, when the
real reason was your poor performance

having a bias against a particular race

or culture and then embracing that race
or culture to the extreme

sitting in a corner and crying after

hearing bad news; throwing a temper
tantrum when you don't get your way

forgetting sexual abuse from your

childhood due to the trauma and
anxiety

lifting weights to release 'pent up'

energy

Erik Erickson

Psychosocial Theory of Development

PSYCHOSOCIAL THEORY
Eriksons
0-18 mos.

Trust vs. Mistrust

-attachment to mother which lays foundations

for later trust in others
-conflict: general difficulties relating to others.
suspicion, fear of the future

18 m0s 3 yrs Autonomy vs.

Shame/Doubt
THEORY

PSYCHOSOCIAL
Gaining some basic control
of self and
environment
Eriksons
Conflict: independence-fear conflict, severe
feelings of self-doubt

PSYCHOSOCIAL THEORY Eriksons

3 yrs 6 yrs

Initiative vs. Guilt

-becoming purposeful and directive

-conflict: aggression-fear conflict; sense of
inadequacy and guilt

PSYCHOSOCIAL THEORY Eriksons

6 yrs 12 yrs
Industry vs. Inferiority
Developing social, physical and school skills,
competence
Conflict: sense of inferiority; difficulty learning
and working

PSYCHOSOCIAL THEORY Eriksons

12 yrs 20 yrs Identity vs. Role Diffusion

Making transition from childhood to adulthood;
developing a sense of identity
Conflict: confusion of who one is, identity
submerged in relationships or group memberships

PSYCHOSOCIAL THEORY Eriksons

21 yrs 35 yrs
Intimacy vs. Isolation
-establishing intimate bonds of love and friendship
-conflict: emotional isolation

PSYCHOSOCIAL THEORY Eriksons

35 yrs 55 yrs

Generativity vs. Stagnation

-fulfilling lifes goals that involve family, career and

society, developing concerns that embrace future
generations
-conflict: self-absorption. Inability to grow as a
person

PSYCHOSOCIAL THEORY Eriksons

55 yrs above Integrity vs. Despair

Looking back into ones life and accepting its
meaning
Conflict: dissatisfaction with life, denial of or
despair over prospect of death

Jean Piaget

Cognitive Theory of Development

assimilation

people transform incoming information so

that it fits within their existing schemes or
thought patterns

accommodation

people adapt their schemes to include

incoming information

PIAGETS COGNITIVE THEORY

SENSORIMOTOR STAGE-

development proceeds from reflex activity to

representation and sensorimotor solutions to
problems

0 to 18 months

PRE-OPERATIONAL STAGE-

development proceeds from sensorimotor

representation to prelogical thought and
solutions to problems
can use these representational skills only to view
the world from their own perspective.
Understand the meaning of symbolic gestures

2 to 7 years

CONCRETE OPERATIONAL-development proceeds

from prelogical thought to logical solutions to concrete problems

understand concrete problems
cannot yet contemplate or solve abstract problems

7 to 12 years

FORMAL OPERATIONAL-development proceeds from

logical solutions to concrete problems to logical solutions to all
classes of problems

cannot yet contemplate or solve abstract problems

can also reason theoretically

12 and above

Harry Stack Sullivan

Interpersonal Theory

SULLIVANS
INTERPERSONAL THEORY

Infancy-anxiety develops as a result of unmet needs by

the mother (bodily needs); needs met, the child has sense of
well-being

0 to 18 months

Childhood-anxiety as a result of lack of

praise/acceptance from parents

-gratification leads to positive self-esteem
- moderate anxiety leads to uncertainty and insecurity;
- severe anxiety results in self-defeating patterns of
behavior

18 months to 6 years

Juvenile-severe anxiety may result in a need to control

or restrictive, prejudicial attitudes
-learns to negotiate own needs

6 to 9 years

Pre-adolescence-capacity to attachment, love and

collaboration emerges or fails to develop

-move to genuine intimacy with friend of the same sex
9 to 12 years

Adolescence-if self-system is intact, areas of

concern expand to include values, career decisions and

social concerns
-lust is added to interpersonal equation
-need for special sharing relationship shifts to opposite
sex
-new opportunities for social experimentation lead to
consolidation or self-ridicule
12 to adulthood

Hildegard Peplau

Nurse Patient Relationship

PEPLAUS NPR

PRE-INTERACTION

ORIENTATION

Major task of the nurse: to develop a mutual

acceptable contract

WORKING

Major task of nurse- to develop self-awareness

Major task: identification and resolution of

patients problem

TERMINATION

Major task: to assist the patient to review what

he has learned and transfer his learning to his
relationship with others

THERAPEUTIC
COMMUNICATIONS

ORIENTATION

Broad Opening
Recognition
Giving information
Silence
Offering Self Do you want me to sit
beside you?

THERAPEUTIC
COMMUNICATIONS

WORKING

Focusing Let us discuss this topic more.

Exploring Tell me more about it.
Encourage Evaluation IS this what you want?
Reflecting same idea
Restating same statement
Verbalizing Implied Are you going to kill yourself?
Seeking Clarification May you please repeat that statement
General lead Please continue.; And then?
Limit setting Stop.
Interpreting Maybe that thing is very significant to you.

THERAPEUTIC
COMMUNICATIONS

TERMINATION

Summarizing Let us now sum up.

You have stated earlieretc.
Do you have any questions?
Our next therapy
Look for changes in behavior
Resistance is a common problem

Therapeutic Communication
Techniques

Accepting-indicating reception
Eg.Yes
I follow what you said
Nodding..

Broad Openings

Allowing the client to take the initiative in

introducing the topic
Eg. is there something youd like to talk
about?
Where would you like to begin?

Consensual Validation

Searching for mutual understanding, for

accord in the meaning of the words
Eg. Tell me whether my understanding of
it agrees with yours
Are you using this word to convey
that. . .?

Encouraging Comparison

Asking that similarities and differences be

noted
Eg. was it something like..?
Have you had similar experiences?

Encouraging Description of
Perceptions

Asking the client to verbalize what he or

perceives
Eg.Tell me when you feel anxious
What is happening?
What does the voice seem to be saying?

Encouraging Expression

Asking client to appraise the quality of his

or her experience
Eg. what are your feelings in regard to..?
Does this contribute to your distress?

Exploring

Delving further into a subject or idea

Eg. Tell me more about that.
Would you describe it more fully?
What kind of work?

Focusing

Concentrating on a single point

Eg. This point seems worth looking at
more closely
Of all the concerns youve mentioned,
which is most troublesome?

Formulating a Plan of Action

-Asking the client to consider kinds of

behavior likely to be appropriate in future
situations
Eg. What could you do to let your anger
out harmlessly?
Next time this comes up, what might you
do to handle it?

General Leads

Giving encouragement to continue

Eg. Go on
And then?
Tell me about it

Giving Information

Making available the facts that the client

needs
Eg. My name is
Visiting hours are
My purpose in being here is

Giving Recognition

Acknowledging, indicating awareness

Eg. Good morning, Mr. S
Youve finished your list of things to
do.
I noticed that youve combed your
hair

Making Observations

Verbalizing what the nurse perceives

Eg. You appear tense..
I notice that your biting your lips

Offering Self

Making oneself available

Eg. Ill sit with you awhile
Ill stay here with you
Im interested in what you think

Placing Event in Time or

Sequence
Clarifying the relationship of events in time
Eg. what seemed to lead up to?
Was this before or after?

Presenting Reality

Offering for consideration that which is

real
Eg. I see no one else in the room.
Your mother is not here; I am a nurse.

Reflecting

Directing client actions, thoughts, and

feelings back to client
Eg. Client: Do you think I should tell the
doctor? Nurse: Do you think you
should?

Restating

Repeating the main idea expressed

Eg. Client: I cant sleep. I stay awake all
night.
Nurse:You have difficulty sleeping.
Client:Im really mad, and upset
Nurse: Youre really mad and upset.

Seeking Information

Seeking to make clear that which is not

meaningful or that which is vague
Im not sure that I follow.
Have I heard you correctly?

Silence

Absence of verbal communication, which

provides time for for the client to put
thoughts or feelings into words, regain
composure, or continue talking
Eg. Nurses says nothing but continues to
maintain eye contact and conveys interest.

Suggesting Collaboration

Offering to share , to strive, to work with

the client for his or her benefit
Eg. Perhaps you and I can discuss and
discover the triggers for your anxiety

Summarizing

Organizing and summing up that which has

gone before
Eg. Have I got this straight?

Translating into Feelings

seeking to verbalize clients feelings that he

or she expresses only indirectly
Eg. Client: Im dead
Nurse: Are you suggesting that you feel
lifeless?

Verbalizing the Implied

Voicing what the client has hinted at or

suggested
Eg. Client: I cant talk to you or anyone.
Its a waste of time. Nurse: Do you feel
that no one understands

Voicing Doubt

Expressing uncertainty about the reality of

the clients perceptions
Isnt that unusual?
Really?
Thats hard to believe.

Nontherapeutic Communication
Techniques

Advising-telling the client what to do

Agreeing- indicating accord with the client
Eg. I think you should.
Thats right

Agreeing

Indicating accord with the client

thats right. I agree

Belittling Feelings expressed

Misjudging the degree of the clients

comfort
Client: I have nothing to live for..I wish I
was dead
Nurse: Everybody gets down in the dumps.

Challenging

Demanding proof from the client

But how can you be President of the
Philippines?

Defending

Attempting to protect someone or

something from verbal attack
This hospital has a fine reputation.

Disagreeing

Opposing the clients ideas

Eg. Thats wrong

Disapproving

Denouncing the clients behavior or ideas

Thats bad
Id rather you wouldnt

Giving approval

Sanctioning the clients behavior or ideas

Thats good. Im glad that..

Giving Literal Responses

Responding to a figurative comment as

though it were a statement of fact
Client: Theyre looking in my head with
television camera.
Nurse: Try not to watch television.

Indicating the existence of an

external source

What makes you say that?

Interpreting

Asking to make conscious that which is

unconscious
What you really mean is..

Introducing an unrelated topic

Changing the subject

Client: Id like to die.
Nurse: did you have visitors last night?

Making stereotyped comments

Offering meaningless cliches or trite

comments
Keep your chin up.
Just have a positive outlook.

Probing

Persistent questioning of the client

Now tell me about this problem. I need to
know.

Reassuring

Indicating there is no reason for anxiety

Everything will be alright.

Rejecting

Refusing to consider or showing contempt

for the clients behavior, ideas
Lets not discuss..

Requesting an explanation

Asking the client to provide reasons for

thoughts, feelings, behaviors, events
Why do you think that?

Testing

Appraising the clients degree of insight

Do you know what kind of hospital this
is?

Using Denial

Refusing to admit that a problem exists

Client: I am nothing.
Nurse: Of course, youre something.

NON-THERAPEUTIC
COMMUNICATIONS

Overloading blah, blah, blah

Underloading - ignoring
Value Judgment use of adjectives
False Reassurance Dont worry, you will
be fine later.
Focusing on Self I gave you meds so you
are now feeling good
Incongruence Internal Validation biased judgment
Giving Advice If I were you, ill
Changing Subject -

LOSS AND GRIEVING

GRIEF- refers to the subjective emotions

and affect that are a normal response to the
experience of loss
ANTICIPATORY GRIEVING- when
people facing an imminent loss begin to
grapple with the very real possibility of the
loss or death in the near future

DISENFRANCHISED GRIEF-grief over a

loss that is not or cannot be acknowledged
openly, mourned publicly or supported
socially
COMPLICATED GRIEVING-when a
person is void of emotion, grieves for
prolonged periods, has expressions of grief
that seem disproportionate to the event

LOSS

Physiologic Loss
Safe and Security Loss
Love and Belongingness Loss
Self-Esteem Loss
Self-actualization Loss

GRIEVING PROCESS

Denial
Anger
Bargaining
Depression
Acceptance
Dysfunctional grieving grieving which extends
from 4 to 6 weeks leading to CRISIS

Interventions

Explore clients perception and meaning of the

loss
Allow adaptive denial
Assist client to reach out for and accept support
Encourage client to examine patterns of coping in
past and present situation of loss
Encourage client to care for himself
Offer client food without pressure to eat
Use effective communication

CRISIS AND ITS

MANAGEMENT

CRISIS
situation that occurs when an individuals

habitual coping ability becomes ineffective to

merit demands of a situation

TYPES OF CRISES:
MATURATIONAL / DEVELOPMENTAL

SITUATIONAL

Normal expected crisis that runs through age

Unexpected and sudden event in life

ADVENTITIOUS

Calamities, war

Characteristics of a Crisis state

Highly individualized
Lasts for 4-6 weeks
Self-limiting
Person affected becomes passive and
submissive
Affects a persons support system

PHASES OF A CRISIS

Pre-crisis: State of equilibrium

Initial Impact (may last a few hours to a few days):
High level of stress, helplessness, inability to
function socially
Crisis (may last a brief or prolonged period of time):
Inability to cope, projection, denial, rationalization
Resolution: attempts to use problem-solving skills
Post crisis: may have OLOF or may have symptoms
of neurosis, psychosis

CRISIS MANAGEMENT

Role of the nurse is to return the client to

its pre-crisis state by assisting and guiding
them until they achieved their OLOF.
Goal: to enable patient to attain an OLOF
Nurses Primary Role: Active and Directive

Steps in Crisis Intervention

Identify the degree of disruption the client is

experiencing
Assess the clients perception of the event
Formulate nursing diagnoses
Involve the patient and family if applicable with
planning
Implement interventions- new and old coping
mechanisms
Evaluate-reassessment, reinforcement

TYPES OF THERAPIES
Treatment Modalities

Individual Psychotherapy

Individual Psychotherapy

One to one relationship between therapist

and client
For dissociative, anorexia, paranoid,
narcissistic
Change is achieved by the exploration of
feelings, attitudes, thinking behavior and
conflict

SEVEN SUBTYPES:

CLASSICAL PSYCHOANALYSIS
Based on Freuds theory
To uncover unconscious feelings and thoughts that
interfere with the clients living a fuller life
Free association-client is encouraged to say anything
that comes to mind, without censoring thoughts or
feelings
Dream analysis
Working through(transference)-process of repeated
interpretation to the person of his or her unconscious
processes has the effect of bringing about change

PSYCHOANALYTICAL PSYCHOTHERAPY
Al
Uses
dream analysis, transference and free
relationship
association
Therapist is much more involved and interacts
with the client more freely
Done through intimate professional relationship
between the nurse/therapist and the client over a
period of time (introductory, working and
termination phase)

SHORT TERM DYNAMIC

PSYCHOTHERAPY
Indication-persons with specific symptom
or interpersonal problem that he/she wants
to work on
Therapist directs the content
Use of transference and dream analysis
Weekly sessions (total number-12 to 30)
Successful for highly motivated
individuals who have insight and with
positive relationship with the therapist

TRANSACTIONAL ANALYSIS
Eric Berne
Each person has three ego states and change from one to
another frequently
Parent-concepts of standards of behavior and how things
should be done e.g. Go and take out the garbage.
Adult-rational thinking and data analyzing part of the
personality e.g.Would you please take out the garbage
Child- feelings associated with persons, things or incidents
represent the need-gratifying aspects of the personality.
E.g. Is that why you married me?To be your garbage man?
For group, family and individual
Client to identify ego states for each given situation
Rewarding of positive or negative behaviors with strokes
Client work through these behaviors

COGNITIVE PSYCHOTHERAPY
Restructuring or changing ways in which
people think bout themselves
Thought stopping
Positive self-talk
Decatastrophizing
Therapists help patients identify these
thoughts

BEHAVIORAL THERAPY
Changes in maladapted behavior can occur
without insight into the underlying cause
Based on learning theory
Modeling
Operant conditioning
Self-control therapy-combination of
cognitive & behavioral approaches talking
to self
Systematic desensitization
Aversion therapy

GESTALT THERAPY
Emphasis on the here and now
Only present behavior can be changed, not history
Uncover repressed feelings and needs
Techniques: have a person behave the opposite of
the way he/she feels, presuming that a person can
then come in contact with a submerged part of the
self; in dreams, person is ask to play the roles of
persons in the dream to get in touch with different
repressed feelings

Milieu Therapy

Milieu Therapy

Total environment has an effect on the

individuals behavior
Components

Physical Environment
Interpersonal relationships
Atmosphere of safety, caring, and mutual
respect
For alcoholics

PROGRAMS FOR MILIEU SHOULD

HAVE:

an emphasis on group and social interaction

No rules and expectations mediated by peer pressure
A view of patients roles as responsible human beings
An emphasis on patients rights for involvement in
setting goals
Freedom of movement and informality of
relationships with staff
Emphasis on interdisciplinary participation
Goal-oriented, clear communication

Group Therapy

Group Therapy

Number of people coming together, sharing

a common goal, interest or concern, staying
together and developing relationships
For PTSD and Alcoholics
Phases

Orientation
Working
Termination

Characteristics of Group Therapy

Universality You are not alone

Instilling hope and inspiration
Developing social skills by interacting with
one another
Feeling of acceptance and belonging
Altruism Giving of ones self

Psychoanalytically oriented group therapy

Psychodrama
Family therapy

Assumption of Family Therapy

For alcoholic and schizophrenic

Assumption of Family Therapy

Client: Whole family

Concepts:

The family is the most fundamental unit of the society.

Adaptive or maladaptive patterns of behavior are learned from
the family
Dysfunction in the family = dysfunction in the individual

Purpose

Improve relationships among family members

Promote family function
Resolve family problems

OTHER TYPES OF THERAPIES

SUPPORT GROUPS

For those with AIDS, Mother-Against-Drug

Dependence

SELF-HELP GROUPS

Alcoholic Anonymous

RULES FOR PSYCHOTHERAPEUTIC

MANAGEMENT

Provide support, treat patients with

respect and dignity
Do not place patients in situations
wherein they will feel inadequate or
embarrassed
Treat patients as individuals
Provide reality testing
Handle hostility therapeutically
Provide psychopharmacologic
treatment

BEHAVIORAL THERAPIES
Treatment Modalities

BEHAVIORAL THERAPY

Pavlovs Classical Conditioning

All behavior are learned

B.F. Skinners Operational Conditioning

Reinforcements

BEHAVIORAL THERAPY

Behavioral Modification Substance

Abuse

Token Economy Anorexia / Schizo

Systematic Desensitization - Phobia

ATTITUDE THERAPY
Treatment Modalities

ATTITUDE THERAPY

1.
2.
3.
4.
5.
6.

Paranoid Passive Friendliness

Withdrawn Active Friendliness
Depressed / Anorexia Kind Firmness
Manipulative Matter of Fact
Assaultive No Demand
Anti-social Firm, consistent

PSYCHOSOMATIC
THERAPY
Treatment Modalities

Electroconvulsive Therapy

Electroconvulsive Therapy

Effective in most affective disorders

The induction of a grandmal seizure in the
brain.
Abnormal firing of neurons in the brain
causes an increase in neurotransmitters
Number of Treatments: 6-12 ,3 times a
week, about .5-2seconds
Unilateral or bitemporal

Electroconvulsive Therapy
Indications:
Patients who require rapid response
Patients who cannot tolerate
pharmacotherapy or cannot be
exposed to pharmacotherapy
Patients who are depressed but have
not responded to multiple and
adequate trials of medication

Electroconvulsive Therapy
Preparations for ECT:
Pretreatment evaluation and clearance
Consent
NPO from midnight until after the treatment
Atropine Sulfate-to decrease secretions,
succinylcholine (Anectine)- to promote muscle
relaxation, Methohexital Sodium(Brevital)anesthethic
Empty bladder
Remove jewelry, hairpins, dentures and other
accessories
Check vital signs
Attempt to decrease patients anxiety

Electroconvulsive Therapy
Care after ECT:
O2 therapy of 100% until patient can
breathe unassisted
Monitor for respiratory problems, gag
reflex
Reorient patient
Observe until stable
Careful documentation.
Male erectile dysfunction

OTHER THERAPIES

NEUROSURGERY

ANXIETY

Peplaus Levels of Anxiety

Peplaus Levels of Anxiety

Mild

Associated with the tension of day-today living

Perceptual field increased
More alert than usual
Adaptive

Moderate

Narrowed perception
Difficulty focusing
Selective inattention
Mild somatic complaints: stomachache and
butterflies in the stomach

Interventions for Mild to Moderate

Anxiety

Assist the client in identifying anxiety.

Anticipate anxiety provoking situations.
Use nonverbal language to demonstrate interest
Encourage the client to talk about his or her
feelings.
Avoid closing off avenues of communication (refrain
from offering advice or changing the topic).
Encourage problem-solving
Explore past and present coping behaviors
Provide outlets for working off excess energy.

Levels of Anxiety

Levels of Anxiety

Severe
Very narrowed perception
Unable to focus on problem solving
Increased physical discomfort
All behavior is aimed at relieving anxiety
Direction is needed to focus attention
Panic
Awe, dread and terror
Unable to see the whole situation or reality
Distortion of perception
Disorganization of the personality
A frightening and paralyzing experience

Interventions for Severe and Panic

Levels of Anxiety

Maintain a calm manner.

Remain with the person.
Minimize environmental stimuli.
Reinforce reality.
Listen for themes in communication.
Attend to physical safety and medical needs first.
Physical limits may need to be set.
Provide opportunities for exercising.
Assess the persons need for medication or seclusion.

ANTI ANXIETY DRUGS

VALIUM
LIBRIUM
ATIVAN
SERAX
TRANXENE
MILTOWN
EQUANIL
VISTARIL
ATARAX
INDERAL
XANAX
BUSPAR

ANTI ANXIETY DRUGS

Used only in a short time (1-2 weeks)

Tolerance (after 7 days) and dependence (after 1
month)
Liver function test
Monitor for side effects.
Avoid machines, activities needing concentration
Z tract if given parenterally
Avoid mixing with alcohol, antihistamines,
antipsychotics
Dont stop abruptly but gradually for 2-6 weeks
Avoid caffeine

Categories of
ANXIETY DISORDERS
Anxiety
Disorders

Basic
Anxiety
Disorder

Somatoform

Categories of
ANXIETY DISORDERS

Basic Anxiety Disorders

Somatoform Disorders
Dissociative Disorders

BASIC ANXIETY DISORDER

Basic anxiety disorders

Generalized Anxiety Disorder

Panic
Phobia
PTSD
Obsessive Compulsive

 Excessive
Chronic
Anxiety
worry and Disorder
anxiety for daysor
but not
more than 6 months
Generalized
Anxiety
Difficulty in controlling
theDisorder
worry

Anxiety and worry are evident by 3 or more of the

following :

Restlessness, Keyed up
Fatigue and irritability
Decreased ability to concentrate
Muscle tension
Disturbed sleep

Anxiety or worry causes significant impairment

in interpersonal relationship or activities of daily
living

Post Traumatic Stress Disorders

Post Traumatic Stress Disorders

Disturbing pattern of behavior occurring after

a traumatic event that is outside the range of
usual experience.
Characteristics
Persistent re-experiencing of the trauma
through recurrent intrusive recollections of
the event, through dreams or flashbacks
Persistent avoidance of the stimuli
Feeling of detachment of estrangement
from others
Chemical abuse to relieve anxiety

Phobias

Definition

Specific Phobia

Persistent, irrational fear of a specific object, activity or

situation that leads to a desire for avoidance or actual
avoidance of the object of fear
Experience of high level of anxiety or fear provided by a
specific object or situation

Treatment: Systematic Desensitization

Defense mechanisms

Repression and displacement

Major Types of Phobias

Major Types of Phobias

Agoraphobia
Comes from the Greek word Agora
Meaning market place
Fear of being alone in open or public spaces
Social Phobia
Fear of situations where one might be seen and
embarrassed or criticized
Specific Phobias
Fear of a single object, situation or activity that
cannot be avoided

Obsessive Compulsive Disorder

Obsessions
Preoccupation with persistent intrusive
thoughts, impulses or images
Compulsions
> Repetitive behaviors or mental acts that the person
feelds driven to perform in order t reduce distress
or prevent a dreaded event or situation
Cues:
Ritualistic behavior
Constant doubting if he/she has performed the
activity

Examples

Obsessions

Compulsions

Washing or cleaning

Wash away my sins.

Thought appeared after
sexual encounter with a
married man

Young woman repeatedly

washes hands

Need for order

Everything must be in
place.

Arranges and rearranges

items

Germs or dirt

Everything is
contaminated

Avoids touching all

objects. Scrubs hands if
she is forced to touch any
object

Symmetry

Secretaries who practice

neatness never gets fired

Secretary lines up objects

in rows on her desk, then
realigns them repeatedly
during the day

Care Strategies

Be nonjudgmental and honest; offer empathy and support

Help patient to recognize the connections between the trauma
experience and their current feelings, behaviors and
problems.
Encourage verbalizations of feelings, especially anger.
Encourage adaptive coping strategies and techniques
Encourage patients to establish or reestablish relationships
Explore shattered assumptions. Im a good person. This is a
safe world.
Promote discussion of possible meaning of the events.

SOMATOFORM DISORDERS

Somatoform Disorders

Body Dysmorphic Disorder

Somatization
Conversion Disorders
Hypochondriasis
Psychogenic pain

Body Dysmorphic
Disorder
Preoccupation with an imagined defect in
his or her appearance

Somatization

A client expresses emotional turmoil or

conflict through a physical system, usually
with a loss or alteration of physical
functioning

A psychological condition in which an

anxiety-provoking impulse is converted
unconsciously into functional symptoms

Conversion Disorders

Hypochondriasis

Presentation of unrealistic or exaggerated

physical complaints

DISSOCIATIVE DISORDERS

Dissociative Disorders

Dissociative amnesia
Dissociative fugue
Depersonalization
Dissociative Identity Disorder /
Multiple Identity Disorder

Dissociative amnesia

Characterized by the inability to recall an

extensive amount of important personaal
information because of physical or
psychological trauma

Dissociative fugue

The person suddenly and unexpectedly

leaves home or work and is unable to recall
the past

Depersonalization

Person experiences a strange alteration in

the perception or experience of the self,
often associated with a sense of unreality

Dissociative Identity
Disorder / Multiple

A person is dominated
by at least one of
Identity
Disorder

two or more definitive personalities at one

time

PSYCHOSOMATIC
DISORDER

Psychosomatic Disorder
-

True / unconscious because of

hormonal and bodily changes
Increase anxiety may result to
asthma, stress ulcers or
migraine

SCHIZOPHRENIA

A major form of psychotic disorder that affects a

persons thinking, language, emotions, social behavior
and ability to perceive reality
At least 2 of 5 types of positive and negative symptoms
Characteristic Symptoms
Social or occupational dysfunction

IPR
Self care

Duration

Continuous for at least 6 months

Positive and Negative Symptoms

Positive Symptoms
Hallucinations
Delusions
Illusions
Abnormal thought patterns or perceptions
Bizarre behavior

Negative Symptoms

Negative Symptoms
Affective flattening
Anhedonia
Attention impairment
Asocial behavior
Anergia
Autism
Avolition

SCHIZOPHRENIA

DELUSIONS

PERSECUTORY
RELIGIOUS
GRANDEUR
IDEAS OF REFERENCE

DISTURBED THOUGHT PROCESSES

Looseness of Association
Flight of Ideas
Ambivalence
Magical Thinking
Echolalia / Echopraxia
Word salad
Clang association
Neologism
Thought blocking
Concrete association
Delusion, hallucination, illusion

Bleulers Four As of Schizophrenia

Affective Disturbances
Autism
Associative looseness
Ambivalence
Other As

Attention defects
Disturbances of activities

SCHIZOPHRENIA

Brief Psychotic Disorder-maybe seen when a person

exhibits clinical symptoms of illogical thinking, incoherent
speech, delusions, or disorganized behavior after
psychological trauma
Induced Psychotic Disorder-develops in a second person
as a result of a close relationship with a person who has
psychosis
Delusional Psychotic Disorder
Schizoaffective disorder-characterized by depression or
elation as the psychosis symptoms of schizophrenia and
MDD
Schizophreniform-when a person exhibits features of
schizophrenia for more than one week but less than 6
months

Subtypes:

Paranoid-most common form of the illness

Suspicious
Promote trust
Short interaction but frequent
Food in containers (sealed)
Prepare food in front of them
Let them seed preparation of drugs
Violent
Keep door open
Position near door and with distance of 1 arm
length (patient-nurse)
Dont touch
Maintain eye contact
Call reinforcements

Subtypes:

Disorganized-absence of systematized
delusions; presence of incoherence &
inappropriate affect

Inappropriate, flat affect

Herbephrenic, flight of ideas

Catatonic

Risk for suicide

Catatonic stupor, rigidity
Waxy flexibility

Subtypes:

Undifferentiated

unclassified

Residual

No more positive symptoms but

withdrawn

NURSING PROCESS

Disturbed Thought Process

Disturbed Sensory Process
Risk for self-directed violence
Risk for other directed violence
Present safety
Present reality

ANTI- PSYCHOTIC

Tara, look natin sina Stella, Mel, at Thor na nag

mo-moulin rouge. Sssh , alam nyo ba na ang
trio na yan na akala mo may halo ay mga closet
queens pala, namen
( Taractan, Loxitane, Stelazine, Mellaril,
Thorazine, Molindone, Seroquel, Serlect,
Trilafon, Haloperidol, Clozapine, Navane )

SCHIZOPHRENIA
STELAZINE
SERENTIL
THORAZINE
TRILAFON
CLOZARIL

MILLARIL
HALDOL
LOXITANE
RISPERDOL
PROLIXIN

ANTI PSYCHOTIC DRUGS

Watch for side-effects

Increase v/s
Constipation / dry mouth
Postural hypotension
Photophobia / photosensitivity
Drowsiness
Agranulocytosis
Extrapyramidal symptoms

Parkinsons syndrome
Akathisia
Akinesia
Dystonia oculogyric crisis, torticollosis, opistothonus
Tardive dyskinesia
NMS

UNDESIRABLE EFFECTS

S-edation/sunlight sensitivity/sleepiness
T-ardive dyskinesia
A-nticholinergic/aganulocytosis/akathisia
N-euroleptic malignant syndrome
C-cardiac effects(Orthostatic hypotension)
E-xtrapyramidal(dystonia

Parkinsonism

Motor retardation or akinesia characterized

by mask-like appearance, rigidity, tremors,
pill-rolling, salivation
Generally occurs after 1st week of treatment
or before second month
Administer anticholinergic agent, antiparkinson medication (Akineton)

Akathisia

Constant state of movement, characterized

by restlessness, difficulty sitting still, or
strong urges to move about
Generally occurs two weeks after treatment
begins
Rule out anxiety or agitation before
administration of an anticholinergic agent

Acute Dystonic reactions

Irregular, involuntary spastic muscle movement,

wryneck or torticollis, facial grimacing, abnormal
eye movements, backward rolling of eyes in the
sockets
May occur anytime from a few minutes to several
hours after first dose of antipsychotic drug
Administer anticholinergic agent, have
respiratory support equipment available

Tardive Dyskinesia

Most frequent serious side effect resulting from

termination of the drug, during reduction in
dosage, or after long term high dose therapy.
Characterized by involuntary rhytmic, stereotyped
movements, tongue protrusion, cheek puffing,
involuntary movements of extremities and trunk
Occurs in approximately 20-25% of patients taking
antipsychotics for over two years
No treatment except discontinuation of the
antipsychotic agent

Neuroleptic Malignant Syndrome

A potentially fatal syndrome

May occur anytime during therapy
Seen during the initiation of therapy, change of therapy, After
a dosage increase or when a combination of meds is used.
Early sign: rigidity or mental status changes
catatonia, tachycardia, tachypnea, labile blood pressure,
dysphagia, diaphoresis, incontinence, rigidity, myoclonus,
tremors, low grade fevers
Discontinue antipsychotic agent. Have cardiopulmonary
support available; administer skeletal muscle relaxant(e.g.
dantrolene) or central acting dopamine agonist (e.g.
bromocriptine)

NOTES on SCHIZOPHRENIA

Distorted EGO
Disturbed thought process
Disorganized personality
Dopamine increase
Autism
Ambivalence
Associative looseness
Affect flat
Stimulation
Structure
Socialization
Support

Manifestations:
S-social isolation
C-catatonic behavior
H-hallucinations
I-Incoherence
Z-zero/lack of interest and initiative
O-obvious failure in development
P-peculiar behavior
H-hygiene and grooming impaired
R-recurrent illusions
E-exacerbations and remissions
N-no organic factor account S/S
I-inability to return to functioning
A-affect is inappropriate

ANTI-PARKINSONIAN DRUGS

Dopaminergic Drugs

To live (Levodopa), you need a car (carbidopa)

and a man (Amantidine) not your brother
(bromocriptine) per (pergolide) se (selegiline)

ANTI-CHOLENERGIC
BACPAK ( BENADRYL, ARTANE,
COGENTIN, PARSIDOL, AKINETON,
KEMADRIN)

Other Treatments

Psychotherapy-individual, group, behavioral,

supportive or family therapy maybe used
depending on the clinical symptoms
Milieu therapy- a structured environment to
minimize environmental and physical stress and
to meet the individual needs of the patients until
they are able to assume responsibility for
themselves

Concepts & Principles of Hallucination

Possible to replace hallucination with satisfying

interactions
Can re-learn to focus attention on real things and people
Hallucinations originate during extreme emotional
stress when the patient is unable to cope
Hallucinations are very real to the patient
Patient will react as the situation is perceived
Concrete experiences, not argument on confrontation
will correct sensory distortion
Hallucinations are a substitute for human relations

BIPOLAR DISORDER
MOOD DISORDER/
AFFECTIVE DISORDER

Bipolar Disorders

Bipolar Disorders

A distinct period of abnormally and persistently elevated,

expansive or irritable mood lasting at least 1 week
3 or more of the following
Psychomotor overexcitability or excitement
Insomnia with fatigue
Euphoria or elated mood
Distractability
Pressured speech
Flight of ideas
Manipulative or demanding behavior
Destructive or combative behavior
Delusions of grandeur
Impaired judgment

Bipolar Disorders

Risk

Female
20 years old and above
Stressful life
Obese

Care giver role restrain

Mania Vs Depression
Mania
Colorful, flamboyant

Depression
Sad and gray

Behavior

Psychomotor
agitation

Psychomotor
retardation

Communication

Pressured speech
Stuttering
Cluttering

Monotonous
speech

Appearance

Mania Vs Depression
Nx

Mania
Depression
Risk for Injury (others) Risk for injury (self)
suicidal precaution

Nursing priority

Safety and nutrition

Nutrition

Finger foods and high Increased in

in calories
nutrients

Treatment

Lithium; ECT

Safety and Nutrition

TCA; SSRI; MAOIs

ECT

Mania Vs Depression
Milieu

Mania
Non-stimulating
environment

Depression
Stimulating

Appropriate
activity

Quiet type; noncompetitive

Monotonous; Noncompetitive

Attitude therapy

Matter of fact

Kind firmness;
active friendliness

LITHIUM

Level of lithium (0.5 to 1.5 meq/L)

Increase urination (polyuria)
Tremors fine hand
Hydration
Increase peristalsis
U2 4 weeks effective
Increased bowel movements
Mouth is dry

Assess function of kidney

Toxicity: nausea and vomiting, diarrhea

PHARMACOLOGY MOMENTS

ANTIDEPRESSANTS

ANTIDEPRESSANTS
ASENDIN
NORPRAMIN
TOFRANIL
SINEQUAN
ANAFRANIL
AVENTIL
VIVACTIL
ELAVIL
PROZAC
LUVOX
PAXIL
ZOLOFT

ANTIDEPRESSANTS

SSRI

Selective Serotonin Reuptake Inhibitor

Safest
Side effects are low
1 to 4 weeks
Prozac, Paxil, Zoloft, Luvox

ANTIDEPRESSANTS

TCA

Tricyclic Antidepressants
2 to 4 weeks
Anticholinergic
amitriptyline, nortiptyline, doxepin
trimipramine, amoxapine, anafranil,
venlafaxine

ANTIDEPRESSANTS

MAOIs

Increases all neurotransmitters

2 to 6 weeks
Hypertensive crisis
Dont take:
Avocado
Aged cheese
Beer/ B6 (tyramine)
Chocolate
Fermented foods
Soy sauce
Pickles and preserved foods

ANTI- DEPRESSANT

A. TCA
knock! Knock! Whos there? SEVANA to gagah!--------

(Sinequam, Elavil, Vivactil, Ascendin, Norpramin,

Aventyl, Tofranil)

B. SSRI
Ngongo: Paxil ka! Paxil ka! Prozoleta ka lang, kala ko luv
mo ko! (PRAXIL, PROZAC, ZOLOFT, LUVOX)

C. MAO
Naman, parnate ko pa
MANERIX, PARNATE)

(NARDIL,

SUICIDE
The intentional act of killing oneself
Suicidal Ideation- means thinking about oneself
A. Passive suicidal ideation-when a person thinks
about wanting to die or wishes he/she were dead
but has no plans to cause his/her death (e.g.
reckless driving, heavy smoking, overeating, selfmutilation, drug abuse)
B. Active suicidal ideation-when a person thinks
about and seeks to commit suicide.

SAD PERSONS SCALE

S-Sex Men kill themselves 3x more than women

though women make attempts 3x more often than
men
A-Age High risks groups:19 years or younger; 45
years or older, especially the elderly 65 and above
D-Depression Studies report that 35-79% of
those who attempt suicide manifested a
depressive syndrome

P-Previous Attempts Of those who commit suicide, 65-70% have made

previous attempts
E-ETOH Alcohol is associated with up to 65% of successful suicides
R-Rational Thinking Loss People with functional or organic psychoses
are more apt to commit suicide than those in the general population
S-Social Supports Lacking A suicidal person often lacks significant
others, meaningful employment and religious supports
O-Organized Plan The presence of a specific plan for suicide signifies
a person at high risk
N-No Spouse repeated studies indicate that persons who are widowed,
separated, divorced or single at greater risk than those who are married
S-Sickness Chronic, debilitating and severe illness is a risk factor

Scoring
0-2 Home with follow up care
3-4 Close follow up and possible
hospitalization
5-6 Strongly consider hospitalization
7-10 Hospitalize

Situation:

Charles Brown, age 52 lost his wife in a

car accident few months ago. Since that
time, he has been severely depressed and
has taken to drinking to numb the pain
How many points according to the SAD
PERSONS SCALE?

Theories of SUICIDE

Psychodynamic theories
describe suicide as a wish to be at peace
with the internalized significant person
Wish to be reunited with a deceased loved
object
Suicide is an attempt to escape from an
intolerable situation or intolerable state of
mind

Theories of Suicide

1.
2.
3.

Sociological Theories
Durkheim-pioneer of sociological research in the study
of suicide
3 Principal types:
Egotistic suicide-occurs when a person is insufficiently
integrated into society
Anomic suicide-occurs when a person is isolated from
others through abrupt changes in social norms/status
Altruistic suicide- occurs as a response to societal
demands (deaths of Buddhist monks who set themselves
on fire to protest the Vietnam war)

Theories of Suicide

Biochemical
Low serotonin levels

Precipitating factors

Social isolation-have difficulty forming

and maintaining relationships
Norman Cousins Story:
a woman who committed suicide had
written in her diary everyday during the
week before her death Nobody called
today. Nobody called today. Nobody called
today. Nobody called today

Precipitating factors

Severe lifes events-divorce, death,

sickness, legal problems, interpersonal
discord
Sensitivity to Loss-may react tragically to
separation or loss of a loved one (had insecure
or unreliable childhood experiences)

ASSESSING VERBAL & NONVERBAL CLUES

Verbal Clues:
Overt Statements: I cant take it anymore!;
Lifes isnt worth living anymore.; I wish I
were dead.; Everyone will be better off if I am
dead.
Covert Statements: Its ok now, soon everything
will be fine, Things will never work out. I
wont be a problem much longer. Nothing feels
good to me anymore. How can I give my body
to medical science?

Nonverbal Clues

Behavioral Clues: sudden behavioral

changes especially when depression is
lifting and when the person has more
energy available to carry out the plan
Signs: giving away prized possessions,
writing farewell notes, making out a will
and putting personal affairs in order

Nonverbal Clues

Somatic clues: physiological complaints

can mask psychological pain and
internalized stress
Headaches, muscle aches, trouble sleeping,
irregular bowel habits, unusual appetite or
weight loss

Nonverbal Clues

Emotional clues
Social withdrawal, feelings of hopelessness
and helplessness, confusion, irritability and
complaints of exhaustions

Suicide Precautions

Execute a no suicide contract. The client will

inform the nurse when he/she has suicidal
ideations
Ask direct questions. Find out if the person has
specific plan for suicide. Determine what method.
Be alert for cries for suicide
Provide a safe environment and protect client
from self
Encourage to ventilate feelings and thoughts

Suicide Precautions

Give emotional support

Make the patient realize that the tendency to commit
suicide is due to the disturbance in the brain chemistry
and is treatable-once they know that an episode of
suicidal thinking will pass, they will likely not act on
the impulse
Provide structured schedule and involve in activities
with others to increase self-worth and divert attention
On discharge: help patient create plan for Life(list of
warning signs of suicidal ideation and actions to take)

Suicide Precautions

A.

B.
C.
D.

Always remember:
That a suicidal person want to die only during
the period of suicidal crisis-during this time the
person is ambivalent about living and dying
Suicidal people gives warning
Persons recovering from depression are high risk
for 9-15 months after recovery
Suicidal people are extremely unhappy but not
always mentally ill

Personality behaviors

SAD PERSONS SCALE

Personality problems

Schizoid
Dependent
Antisocial
Avoidant
Histrionic
Borderline

Paranoid Personality
A pervasive pattern of distrust and suspiciousness of others
Disorder
such that their motives are interpreted as malevolent
Suspicious (e.g. others are exploiting or deceiving him)
Doubt trustworthiness of others
Fear of confiding in others
Fear personal information will be used against him
Interpret remarks as demeaning or threatening
Hold grudges toward others
Becomes angry and threatening when they perceive to
be attacked by others

Intervention: centered on building trust

Schizoid
Personality
A pervasive pattern of detachment from social relationships
and a restricted range of expression of emotions in
Disorder

interpersonal settings
Lacks desire for close relationships or friends including
family
Chooses to be alone
Lack of sexual experiences
Avoids activities
Appears cold and detached

Interventions: building trust followed by

identification and appropriate verbal expression

Schizotypal Personality
Ideas of reference
A pervasive pattern of social
Disorder
Magical thinking or odd beliefs
and interpersonal deficits
marked by acute discomfort
with and reduced capacity
for close relationships as
well as by cognitive or
perceptual distortions and
eccentricities of behavior

Interventions: Improving
Interpersonal
relationships, social
skills., and appropriate
behaviors

Unusual perceptual experiences,

including bodily illusions
Peculiar thinking
Vague, stereotypical, over
elaborate speech
Suspiciousness
Blunted or inappropriate affect
Eccentric appearance or
behavior
Few close relationships
Uncomfortable in social
situations

Anti-social Personality Disorder

Characterized by deceit, Interventions:

manipulation, revenge and

Consistency
harm to others with an
Kind firmness in
absence of guilt or anxiety
confronting behaviors and

Violates rights of others

Engages in illegal
activities
Aggressive behavior
Lack of guilt or remorse
Irresponsible in work and
with finances
Impulsiveness
Recklessness
Manipulative

enforcing rules and

policies
Limit setting
Decrease impulsivity
Enhance role performance
Effective use of
confrontation

Borderline Personality Disorder

Characterized by pervasive pattern of unstable

interpersonal relationships; self-image and affect; and
marked impulsivity

Frantic avoidance of abandonment; real or imagined

Unstable and intense interpersonal relationships
Identity disturbances
Impulsivity
Self-mutilating behavior
Rapid mood shifts
Chronic feelings of emptiness
Problems with anger
Transient dissociative and paranoid symptoms

Other important information

Priority nursing diagnosis: High risk for

injury directed to self related to selfmutilation behaviors
Coping mechanisms used: Splitting

Classifying people as either good or bad

Interventions

Use of empathy.
Recognize the reality of the patients pain.
Offer support
Empower and work with the patient to understand
control and change dysfunctional behaviors.
Provide safe environment
Teach social skills
Make a list of solitary activities to combat
boredom

Narcissistic
Grandiose self importance
Personality
Fantasies of unlimitedDisorder

power, success or brilliance

Believes he or she is special
Needs to be admired
Sense of entitlement
Takes advantage of others
for own benefit
Lacks empathy
Envious of others or others
are envious of him
Arrogant

Interventions
Supportive confrontation
on what the patient says
and what exists.
Limit setting and
consistency to decrease
manipulation and
entitlement behaviors.
Remain neutral, avoid
power struggles, or
becoming defensive.

ne

A pervasive personality
pattern of excessive emotionality
Histrionic
Disord

and attentive seeking

Overly dramatic
Draws attention to self
Extroverted and thrives on being the center of attraction
Uses somatic complaints to avoid responsibility and
support dependency
Dissociation

Interventions: Positive reinforcement in the form

of attention, recognition or praise are given for
unselfish or other-centered behaviors

Dependent
Personality
A pervasive and excessive need to be taken care of
Disorder
that leads to submissive and clinging behavior and
fears of separation

Needs others to be responsible for important areas of

life.
Problems with initiating with projects or doing things
on his own because of little self confidence
Performs unpleasant tasks to obtain support from
others
Urgently seeks another relationship for support and
care after a close relationship ends
Preoccupied with fear of being alone to care for self

Interventions: increase responsibility for self in day to

day living; assertiveness training

Avoidant Personality
Disorder

A pervasive pattern of social inhibition, feelings of

inadequacy and hypersensitivity to negative
evaluation

Avoids occupations involving interpersonal contact due to

fears of disapproval or rejection
Preoccupied with being criticized or rejected in social
situations
Inhibited and feels inadequate in new interpersonal
situations
Very reluctant to take risks or engage in new activities due
to the possibility of being embarrassed

Obsessive Compulsive
Personality Disorder

A pervasive pattern of preoccupation with orderliness,

perfectionism and mental and interpersonal control at
the expense of flexibility, openness and efficiency

Preoccupied with details, lists, rules, organization

Perfectionist
Too busy working to have friends or leisure activities
Unable to discard worthless or worn-out objects
Reluctant to spend and hoards money
Rigid and stubborn

End of First Module

Thank you!

Delirium

Characterized by disturbance of consciousness and a

change in cognition such as impaired attention span and
disturbances in consciousness that develop over a short
period of time.

Always secondary to another condition (medical condition or

substance abuse)
Frequent among the elderly and young febrile children
Fluctuations of consciousness and inoculation through out the
day

Classified as mild to severe.

Sundowning

Dementia

Characterized by multiple
cognitive deficits that
4 Symptoms of Dementia
include impairment of Loss of memory
memory which develops Deterioration of language
slowly
function

80-90% irreversible
Reversible due to
pathologic process
Most common:
Alzheimers Dementia

Loss of ability of think

abstractly, plan, initiate,
sequence, monitor or stop
complex behavior
Loss of ability to perform ADLs

Stages of Dementia

Stage 2

Progressive memory loss

ST memory loss interferes with ADLs
Withdrawn, Denial, Fear of Losing their minds
Depression, Confabulation
Problems increase when stressed
Needs home care or in-home assitance

Stage 1

Moderate (Confusion)

Mild (Forgetfulness)

Losses in short term memory

Memory aids compensate
Aware of the problem, disturbed
Not diagnosable at this time

Stages of Dementia

Stage 3
Moderate to Severe
(Ambulatory Dementia)

Loss of reasoning ability,

Stage 3
planning and verbal
Late
communication
(EndStage)
Frustrated, withdrawn,

Family recognition disappears

self-absorbed

Doesnt recognize self

Depression decreases

Nonambulatory

Reduced stress threshold

Little purposeful activity
Institutional care required Often mute, may scream spontaneously

Forgets most ADLs

Problems associated with immobility
Institutional care required
Return of primitive reflexes

Delirium Vs
Dementia
Delirium

Dementia
Usually gradual

Onset

Usually sudden

Course

Usually brief with return

to usual level of
functioning

Usually long-term
and progressive,
occasionally maybe
arrested or
reversed

Age group

any

elderly

Sexual Disorders

Homosexuality
Heterosexuality
Bisexuality
Masochism
Sadism
Frotteurism
Pedophilia
Necrophilia

Voyeurism
Transvestism
Transexualism

ALCOHOL

ALCOHOLISM

Intergenerational Transmission
Awake but unconscious
Blackout
Confabulation
Denial, dependence
Enabling, co-dependence
Tolerance increases

Detoxification - doctor

Stages of Alcohol Withdrawal

I 8 hours after the last drink

2 8-12 hours after the last drink

Gross tremors, hyperactivity, profound confusion, loss of

appetite, insomnia, weakness disorientation, illusions,
hallucinations and delusions

3 12-48 hours after the last drink

Mild tremors, tachycardia, increased BP, diaphoresis,

nervousness

* severe hallucinations, grand mal seizures

4 3-4 days after the last drink

Delirium tremens, confusion, agitation, hallucinations, insomnia

and tachycardia

ALCOHOLISM

Avoid alcohol during therapy

Aversion therapy
Antabuse disulfiram
Belongings check for alcohol, mouthwash, elixir etc.
B1 deficiency
Complication

Wernickes Encephalopathy (Motor)

Korsakoffs Pychosis (Mind)

Deliruim Tremens
Fornication

AUTISM

Living in their own world

Appearance flat (consistent)
Behavior ritualistic, repetitive
Communication echolalia, incomprehensible

NX: Impaired Verbal Communication

Impaired Social Interaction
Self Mutilation
Risk for Injury

Attention-deficit / hyperactive disorder

7 years old and above
Duration: 6 months and above
Requires 2 settings: home and school

ADHD

Appearance: Dirty child

Behavior: Clumsy, hyperactive, impatient
Communication: talkative, bursts out
Structure
Setting limits
Schedule
Safety

Eating Disorders
Anorexia Nervosa
Bulimia Nervosa
Pica
Compulsive Eating Behavior

EATING DISORDERS

Anorexia Nervosa
Symptoms:
Refusal to maintain body weight over a
minimum normal weight for age and height
Intense fear of gaining weight or becoming fat,
even though underweight
Disturbance in the way in which ones
bodyweight, shape or size is experienced
In females, absence of menses of at least 3
consecutive cycles
Inability or refusal to acknowledge the
seriousness of the problem
Onset: 12-15, 17-21 years of age

Etiology

Cultural pressure
Serotonin imbalance controls appetite
and the satiety control center
Family Patterns

Perfectionist
Does not permit verbalization of feelings
Marital problems

Clinical Presentation

Terrified of gaining weight

Pre-occupied with thoughts of food
See themselves as fat even when emaciated
Peculiar handling of food

Cutting food into small bits

Pushing pieces of food around the table

May develop rigorous exercise program

Self-induced vomiting, laxatives and diuretics
Cognition so disturbed that they judge their selfworth by their weight.

Clinical Presentation

Low weight
Amennorrhea
Yellow skin
Cold extremities
Peripheral edema
Muscle weakening
Constipation

Low T3 and T4
Hypotension
Bradycardia
Hypokalemia
Anemia
Pancytopenia
Decreased bone
density

Signs
related to Purging Behaviors
Gastrointestinal

Metabolic

Parotid gland tenderness, Pancreatitis,

esophageal and gastric erosion or
rupture
Electrolyte abnormalities
hypokalemia

Dental

Erosion of dental enamel of the front

teeth

Objectives of care:

Increasing body weight to at

least90% of average weight for
age and height
Reestablishing good eating
behavior
Increasing self esteem

Nursing Interventions:

Monitor daily caloric intake, activity level, weight and electrolyte

status.
Establish nutritional eating patterns

Sit with client during meals

Offer liquid protein supplement if unable to complete a meal
Observe signs of purging 1-2 hours after meals

Provide accurate information on nutrition and discuss realistic and

healthy diet
Help the client identify emotions and develop non-food related
strategies.

Convey warmth and sincerity

Ask the client to identify feelings
Assist the client to change stereotypical beliefs

Assist in identifying at least three

Nursing
Interventions
positive
characteristics
Teach patient about their illness
Behavior modification : reward
increase in weight with
meaningful privileges
Identify patients non weight
related interests to reduce
anxiety and refocus attention.

Bulimia Nervosa
Symptoms:
Recurrent episodes of binge eating
Feeling of lack of control over eating
behaviors during the eating binges
Recurrent inappropriate compensatory
behavior in order to prevent weight gain,
such as self induced vomiting
Binge eating and inappropriate eating
behaviors
Persistent over concern with body shape
and weight

Clinical Presentation

Binge and Purging behaviors

Have depressive signs and symptoms
Disturbed home life
Major concerns

Interpersonal relationships
Self-concept
Impulsive behaviors

Chemical dependence is also common

Clinical Presentation

Normal to slightly low weight

Dental carries
Parotid swelling
Gastric swelling and rupture
Callusses or scars on the hand
Peripheral edema
Hypokalemia, Hyponatremia

Trust
Help patient identify feelings
associated with binge-purge
behaviors
Accept patient as worthwhile
human beings because they are
often ashamed of their behavior
Encourage patient to discuss
positive qualities about themselves
Teach about bulimia nervosa
Encourage to explore interpersonal
relationships
Encourage patients to adhere to
meal and snack schedules

Management:

Management:

Encourage the patient to approach the

staff if she feels like binging or purging
Encourage to attend group sessions
Encourage family therapy
Encourage participation in art,
recreation and occupational therapy
Encourage the patient to describe their
body image at different ages of their
lives.

Thank you!