Psychiatric Nursing

PSYCHIATRIC NURSING Presented by: Dave Jay Sibi. Manriquez, RN

Introduction
MENTAL HEALTH – balance in a persons internal life and adaptation to reality
Mental ILL Health – state of imbalance characterized by a disturbance in a persons thoughts, feelings and behavior

Psychiatric nursing
interpersonal process whereby the professional nurse practitioner ,through the therapeutic use of self (art) and nursing theories (science), assist clients to achieve psychosocial well being.
Core : interpersonal process

Related Terms
Mental hygiene
measures to promote mental health , prevent mental illness and suffering and facilitate rehabilitation
Main tool: therapeutic use of self
It requires self-awareness
Methods to increase self-awareness:
Introspection
Discussion
Experience
Role play

Assessment (psychosocial processes )
Appearance , behavior or mood
Speech , thought content and thought process
Sensorium
Insight and judgment
Family relationships and work habits
Level of growth and development

Common Behavioral Signs and Symptoms

Disturbances in perception
Illusion
misinterpretation of an actual external stimuli
Hallucinations
false sensory perception in the absence of external stimuli
PERCEPTION

PERCEPTION

Disturbances in thinking and speech
neologism – coining of words that people do not understand
Circumstantiality – over inclusion of inappropriate thoughts and details
Word salad – incoherent mixture of words and phrases with no logical sequence
THINKING & SPEECH

Verbigeration – meaningless repetition of words and phrases
Perseveration – persistence of a response to a previous question
Echolalia – pathological repetition of words of others
Aphasia – speech difficulty and disturbance
Expressive , receptive or global
THINKING & SPEECH

Flight of ideas- shifting of one topic from one subject to another in a somewhat related way
Looseness of association-incoherent illogical flow of thoughts (unrelated way)
Clang association – sound of word gives direction to the flow of thought
THINKING & SPEECH

Delusion – persistent false belief, rigidly held
Delusions of grandeur: special /important in a way
Persecutory: threatened
Ideas of reference: situation/events involve them
Somatic: body reacting in a particular way
THINKING & SPEECH

Jealous: thinking that their partner is unfaithful
Erotomanic: person, usually of high status, is in love with the client
Religious: illogical ideas about God and religion exhibited by extreme or extraneous behavior
Mixed: combination of above without a predominant theme
THINKING & SPEECH

Magical thinking – primitive thought process thoughts alone can change events
Autistic thinking – regressive thought process; subjective interpretations not validated with objective reality
Dereism – unorganized thinking
THINKING & SPEECH

Disturbances of affect
Inappropriate – disharmony between the stimuli and the emotional reaction
Blunted affect – severe reduction in emotional reaction
Flat affect – absence or near absence of emotional reaction
Apathy – dulled emotional tone
AFFECT

Depersonalization – feeling of strangeness from one’s self
Derealization – feeling of strangeness towards environment
Agnosia – lack of sensory stimuli integration
AFFECT

Disturbances in motor activity
Echopraxia – imitation of posture of others
Waxy flexibility – maintaining position for a long period of time
Ataxia – loss of balance
Akathesia – extreme restlessness
MOTOR ACTIVITY

Dystonia- uncoordinated spastic movements of the body
Tardive dyskinesia – involuntary twitching or muscle movements
Apraxia – involuntary unpurposeful movements
MOTOR ACTIVITY

Disturbances in memory
Confabulation – filling of memory gaps
Déjà vu – something unfamiliar seems familiar
Jamais vu- something familiar seems unfamiliar
Amnesia – memory loss (inability to recall past events)
Retrograde-distant past
Anterograde – immediate past
Anomia – lack of memory of items
MEMORY

Dynamics of Human Behavior
Behavior – the way an individual reacts to a certain stimulus
Conflict – situation arising from the presence of two opposing drives
Need - organismic condition that requires a certain activity

Dynamics of Human Behavior
Personality
totality of emotional and behavioral traits that characterize the person in day to day living under ordinary conditions; it is relatively stable and predictable.

FORMATION OF PERSONALITY
TEMPERAMENT
biological-genetic template that interacts with our environment.
a set of in-built dispositions we are born with
mostly unalterable
our nature.
CHARACTER
the outcome of the process of socialization, the acts and imprints of our environment and nurture on our psyche during the formative years (0-6 years and in adolescence).
the set of all acquired characteristics we posses, often judged in a cultural-social context.
Sometimes the interplay of all these factors results in an abnormal personality

THEORIES OF PERSONALITY DEVELOPMENT

Freud’s PSYCHOSEXUAL THEORY

Libido – inner drive
Parts of body –focus of gratification
Unsuccessful resolution - fixation
Structures of personality
Id: pleasure principle-instinct
Ego: controls action and perception –reality principle
Superego: moral behavior - conscience

0-18 m0s ;oral – mouth – trust and discriminating
18 mos. – 3 years ; anal – bowels – holding on or letting go
Negativism and toilet training age
3 -6 years phallic ; genitals –exploration and discovery ( inc. sexual tension)
Gender identification and genital awareness
Oedipus and Electra complex
Castration anxiety and penis envy

6-12 years – latency (quiet stage) sexual energy diverted to play. Institution of superego: control of instinctual impulses
12 – young adult – genital ; reawakening of sexual drives –relationships
Sexual maturation
Sexual identity ,ability to love and work

Eric Erickson’s PSYCHOSOCIAL THEORY

0-12mos
1-3y
3-6
6-12
12-18
18-25
25-60
60 and above
TRUST vs. MISTRUST
AUTONOMY vs. SHAME & DOUBT
INDUSTRY vs. INFERIORITY
INITIATIVE vs. GUILT
IDENTITY vs. IDENTITY CONFUSION
INTIMACY vs. ISOLATION
EGO INTEGRITY vs. STAGNATION
GENERATIVITY vs. DESPAIR

INFANCY
CONSISTENT MATERNAL –CHILD INTERACTION – TRUST
INNER FEELING OF SELF WORTH
HOPE

TODDLER
ALLOW EXPLORATION
PROVIDE FOR SAFETY
“ NO, NO” – NEGATIVISM
OFFER CHOICES / REVERSE PSYCHOLOGY
TOILET TRAINING – 18 MOS.-BOWEL
DAYTIME BLADDER: 2 yo
NIGHTIME BLADDER: 3 yo
REWARD W/ PRAISE AND AFFECTION
INDEPENDENCE

PRE-SCHOOL
PROVIDE PLAY MATERIALS
SATISFY CURIOSITY
TEACH AND REINFORCE(HYGIENE,SOCIAL BEHAVIOR)
SIBLING RIVALRY
WILLPOWER

SCHOOL AGE
HOW TO DO THINGS WELL-SUPPORT EFFORTS
CHUMS AND HOBBIES
NEEDS TO EXCEL/ACCOMPLISH
NEED FOR PRIVACY AND PEER INTERACTION
COMPETENCE

ADOLESCENCE
MAKE DECISION,EMANCIPATION FROM PARENTS
BODY IMAGE CHANGES
NEED TO CONFORM BUT KEEP INDIVIDUALITY
SELF - AWARENESS

YOUNG ADULT
COMMITMENT AND FIDELITY
RESPONSIBILITY
ACHIEVEMENT OF INDEPENDENCE

MIDDLE ADULTHOOD
SUPPORT-PERIOD OF ROLE TRANSITIONS
MIDLIFE CRISIS
ADJUSTMENT AND COMPROMISE
MOST PRODUCTIVE AND CREATIVE
ALTRUISM

LATE ADULTHOOD
SELF ACCEPTANCE
SELF WORTH
WISDOM

Jean Piaget’s COGNITIVE THEORY

0-2 SENSORIMOTOR
REFLEXES
IMITATIVE REPETITIVE BEHAVIOR
SENSE OF OBJECT PERMANENCE AND SELF SEPARATE FROM ENVT.
TRIAL AND ERROR RESULTS IN PROBLEM SOLVING

2-7Y PRE-OPERATIONAL
SELF-CENTERED,EGOCENTRIC
CANNOT CONCEPTUALIZE OTHER’S VIEW
ANIMISTIC THINKING
IMAGINARY PLAYMATE – SYMBOLIC MENTAL REPRESENTATION – CREATIVITY
2-4 PRE-CONCEPTUAL (PRE-LOGICAL)
4-7 INTUITIVE (UNDERSTANDING OF ROLES)

7-12Y CONCRETE OPERATIONAL
LOGICAL CONCRETE THOUGHT
INDUCTIVE REASONING (SPECIFIC TO GENERAL)
CAN RELATE, PROBLEM SOLVING ABILITY
REASONING AND SELF-REGULATION

12-ABOVE: FORMAL OPERATIONAL THOUGHT
Abstract thinking
Separation of fantasy and fact
Reality oriented
Deductive reasoning
Apply scientific method

Havighurst’s DEVELOPMENTAL TASKS

Baby to early childhood
Right from wrong and Conscience
Late childhood
Physical skills, wholesome attitude, social roles
Conscience morality and values
Fundamental skills in academics
Personal independence

Adolescence
Sexual social roles
Relationships
Independence and ideology
Early adulthood
Career
Selecting a mate
Finding Civic or social responsibility

Middle age
Achieving Civic or social responsibility
Adjusting to changes
Satisfactory career performance
Adjusting to aging parents
Adjusting to parental roles
Old age
Adjusting to changes
Establishing satisfactory living arrangements and affiliations

Kohlberg’s MORAL DEVELOPMENT/ THINKING/ JUDGEMENT

PRE-CONVENTIONAL (0-6)
PUNISHMENT AND OBEDIENCE
OBEDIENCE TO RULES TO AVOID PUNISHMENT
CONVENTIONAL ( 6-12 )
MUTUAL INTERPERSONAL EXPECTATIONS,RELATIONSHIPS AND CONFORMITY
SOCIAL SYSTEM AND CONSCIENCE MAINTENANCE
BEING GOOD IS IMPORTANT SELF RESPECT OR CONSCIENCE

POST –CONVENTIONAL (12 – 18 Y)
PRIOR RIGHT OR SOCIAL CONTRACT
UNIVERSAL ETHICAL PRINCIPLE
ABIDE FOR COMMON GOOD
RATIONAL PERSON-VALIDITY OF PRINCIPLES-AND BECOME COMMITTED TO THEM
INNER CONTROL OF BEHAVIOR UNDERSTANDING THE EQUALITY OF HUMAN RIGHTS AND DIGNITY OF HUMAN BEINGS AS INDIVIDUALS

Harry Stack Sullivan’s INTERPERSONAL THEORY

INFANCY
NEED FOR SECURITY-INFANT LEARNS TO RELY ON OTHERS TO GRATIFY NEEDS AND SATISFY WISHES, DEVELOPS A SENSE OF BASIC TRUST, SECURITY AND SELF WORTH WHEN THIS OCCURS

TODDLERHOOD / EARLY CHILDHOOD
CHILD LEARNS TO COMMUNICATE NEEDS THROUGH USE OF WORDS AND ACCEPTANCE OF DELAYED GRATIFICATION AND INTERFERENCE OF WISH FULFILLMENT

PRE-SCHOOL
DEVELOPMENT OF BODY IMAGE AND SELF-PERCEPTION
ORGANIZES AND USES EXPERIENCES IN TERMS OF APPROVAL AND DISAPPROVAL RECEIVED
BEGINS USING SELCTIVE INATTENTION AND DISASSOCIATES THOSE EXPERIENCES THAT CAUSE PHYSICAL OR EMOTIONAL DISCOMFORT AND PAIN

SCHOOL AGE
THE PERIOD OF LEARNING TO FORM SATISFYING RELATIONSHIPS WITH PEERS-USES COMPETITION,COMPROMISE AND COOPERATION
THE PRE-ADOLESCENT LEARNS TO RELATE TO PEERS OF THE SAME SEX

ADOLESCENCE
LEARNS INDEPENDENCE AND HOW TO ESTABLISH SATISFACTORY RELATIONSHIPS WITH MEMBERS OF THE OPPOSITE SEX

YOUNG ADULTHOOD
BECOMES ECONOMICALLY, INTELLECTUALLY AND EMOTIONALLY SELF SUFICIENT

LATER ADULTHOOD
LEARNS TO BE INTERDEPENDENT AND ASSUMES RESPONSIBILITY FOR OTHERS

SENESCENCE
DEVELOPS AN ACCEPTANCE OF RESPONSIBILITY FOR WHAT LIFE IS AND WAS AND OF ITS PLACE IN THE FLOW OF HISTORY

TREATMENT MODALITIES

REMOTIVATION THERAPY
TREATMENT MODALITY THAT PROMOTES EXPRESSION OF FEELINGS THROUGH INTERACTION FACILITATED BY DISCUSSION OF NEUTRAL TOPICS
STEPS :
climate of acceptance
creating bridge to reality
sharing the world we live in
appreciation of works of the world
climate of appreciation

MUSIC THERAPY
Involves use of music to facilitate expression of feelings, relaxation and outlet of tension

PLAY THERAPY
enables patient to experience intense emotion in a safe environment with the use of play
children express themselves more easily in play. revealing as reflection of child’s situation in the family
provide toys and materials – facilitate interaction – observe and help child resolve problems through play

Group therapy
Treatment modality involving three or more patients with a therapist to relieve emotional difficulties, increase self – esteem, develop insight , LEARN NEW ADAPTIVE WAYS TO COPE WITH STRESS and improve behavior with others
IDEAL 8 – 10 MEMBERS

MILIEU THERAPY
Consists of treatment by means of controlled modification of the patient’s environment to facilitate positive behavioral change
Increase patient’s
Awareness of feelings
Sense of responsibility and
Help return to community
clients plan social and group interaction
token programs , open wards and self medication are done

FAMILY THERAPY
A METHOD OF PSYCHOTHERAPY WHICH FOCUSES ON THE TOTAL FAMILY AS AN INTERACTIONAL SYSTEM
PROBLEM IS A FAMILY PROBLEM
focus on sick members behavior as source of trouble / symptom serve a function for the family
members develop sense of identity
points out function of the sick member for the rest of the family

PSYCHOANALYTIC
focuses on the exploration of the unconscious, to facilitate identification of the patients defenses
ANXIETY RESULTS BETWEEN CONFLICTS OF ID AND EGO
Becomes aware of unconscious thoughts and feelings to understand anxiety and defenses

HYPNOTHERAPY
Various methods and techniques to induce a trance state where patient becomes submissive to instructions

BEHAVIOR MODIFICATION
Application of learning principles in order to change maladaptive behavior
Believes that psychological problems are a result of learning
Everything learned can be unlearned

BEHAVIOR MODIFICATION
OPERANT CONDITIONING
Use of rewards to reinforce positive behavior
Perceived and self-reinforcement becomes more important than external reinforcement
DESENSITIZATION
Slow adjustment or exposure to feared objects (phobias)
Periodic exposure until undesirable behavior disappears or lessens

AVERSION THERAPY
An example of behavior modification
Painful stimulus is introduced to bring about an avoidance of another stimulus
End view: behavioral change

HUMOR THERAPY
To facilitate expression and enhance interaction
ACTIVITY THERAPY
Group interaction while working on a task together
OTHER THERAPIES

BIOLOGICAL/ MEDICAL THEORY
EMOTIONAL PROBLEM IS AN ILLNESS
cause may be inherited or chemical in origin
FOCUS OF TREATMENT IS MEDICATIONS AND ECT

BIOLOGICAL THERAPY
ELECTROCONVULSIVE THERAPY
Artificial induction of a grand mal seizure by passing a controlled electrical current through electrodes applied to one or both temples
mechanism of action – unclear
voltage: 70 – 150 volts
Duration: 0.5 – 2.0 seconds
6 to 12 treatments
intervals of 48 hours
indicators of effectiveness – occurrence of generalized tonic – clonic seizures

indications – depression , mania and catatonic schizophrenia
s/e: confusion, disorientation, short -term memory loss, seizure (30-60 sec)
NPO prior
Contraindications
Fever, pregnancy
Inc ICP, fracture
retinal detachment
TB with hemoptysis
cardiac d/o
consent needed
Reorient after, supportive care

medications given :
Atropine sulfate: decrease secretions
Succinylcholine (Anectine): promote muscle relaxation
Methohexital Sodium ( Brevital ): serves as an anesthetic agent
common complications:
loss of memory
headache
apnea
fracture
respiratory depression

Psychopharmacologic Therapy

Benzodiazepines
Indications
Anxiety
Sedation/sleep
Muscle spasm
Seizure disorder
Alcohol withdrawal syndromes
Benzodiazepines

Anti-anxiety drugs
Generic Trade name
Alprazolam Xanax
Chlordiazepoxide Librium
Clorazepate Tranxene
Diazepam Valium
Lorazepam Ativan
Oxazepam Serax
Busipirone BuSpar
Benzodiazepines

Side effects
Drowsiness/ sedation
Ataxia
Feelings of detachment
Increase irritability and hostility
Anterograde amnesia
Increased appetite & weight gain
Nausea
Headache, confusion
Benzodiazepines

Anti-depressants
Indications
Depression
Bipolar depression
Panic disorder
Bulimia
Obsessive-compulsive d/o
Possibly
Attention deficit/Hyperactivity d/o
Post Traumatic Stress D/o
Conduct d/o
Anti-depressants

Tricyclic (TCA)
Generic Trade name
Amitriptyline Elavil
Imipramine Tofranil
Trimipramine Surmontil
Nortriptyline Pamelor
Trazodone Desyrel
Bupropion Wellbutrin
Anti-depressants

Side effects
Orthostatic hypertension
Anticholinergic effect
Dry mouth, blurred vision, constipation, excessive sweating, urinary hesitancy/ retention, tachycardia, agitation, delirium, exacerbation of glaucoma
Neurologic effects
sedation, psychomotor slowing, poor concentration, fatigue, ataxia, tremors
Decrease libido and sexual performance
Anti-depressants

Monoamine Oxidase inhibitors
Generic Trade name
Isocarboxazid Marplan
Phenelzine Nardil
Tranylcypromine Parnate
Anti-depressants

Side effects
Postural lightheadedness
Constipation
Delay ejaculation or orgasm
Muscle twitching
Drowsiness
Dry mouth
Anti-depressants

Dietary restrictions
Cheese, esp. aged and matured
Fermented or aged protein
Pickled or smoked fish
Beer, red wine, sherry; liquor & cognac
Yeast
Fava or broad beans
Beef or chicken liver
Spoiled/ overripe fruits; banana peel
yogurt
Tyramine Hypertensive Crisis Anti-depressants

Hypertensive Crisis
Signs
Sudden elevation of BP
Explosive headache, occipital may radiate frontally
Head & face flushed
Palpitations, chest pain
Sweating, fever
Nausea, vomiting
Dilated pupils, photophobia
Intracranial bleeding
Anti-depressants

Treatment
Hold next MAO dose
Don’t let pt. lie down
IM chlorpromazine 100 mg
Fever: manage by external cooling techniques
Anti-depressants

Serotonin Reuptake Inhibitors
Generic Trade name
Fluoxetine Prozac
Sertraline Zoloft
Paroxetine Paxil
Venlafaxine Effexor
Anti-depressants

Side effects
Nausea
Diarrhea
Insomnia
Dry mouth
Nervousness
Headache
Male sexual dysfunction
Drowsiness
Dizziness
Sweating
Anti-depressants

Mood stabilizing drugs
Indications
Acute mania
Bipolar prophylaxis
Possibly
Bulimia
Alcohol abuse
Aggressive behavior
schizoaffective
Mood stabilizing

Mode of action
Normalizes the reuptake of certain neurotransmitters such as serotonin, norepinephrine, acetylcholine and dopamine
Reduces the release of norepinephrine thru competition with calcium
Effects intracellularly
Lag period: 7-10 to 14 days
Mood stabilizing

Lithium carbonate
Trade names
Eskalith
Lithotabs
Lithane
Lithonate
MOA: unclear; interfere with metabolism of neurotransmitters; alter Na transport in nerves and muscle cells
Prelithium workup
Urinalysis (BUN and creatinine)
ECG, FBC, CBC
Mood stabilizing Preparation: tab, cap, liq & SR form Dose: 900 to 3600 mg/day

Side effects
Early
Nausea and diarrhea
Anorexia
Fine hand tremor (propranolol)
Thirst, Polydipsia (dec. crea, inc. albumin)
Metallic taste
Fatigue
Lethargy
Late
Weight gain
acne
Mood stabilizing

Contraindications
Brain damage/ CV disease
Epilepsy
Elderly/ debilitated
Thyroid and renal disease
Severe dehydration
Pregnancy (1 st trimester)
Can augment the effects of anti-depressants
Mood stabilizing

Nursing considerations
Therapeutic serum level: 0.5 – 1.2 meq/L
Maintenance level: 0.6 -1.2 meq/L
Toxic
Mild to moderate: 1.5 to 2 meq/L
Moderate to severe: 2 – 2.5 meq/L
Needs dialysis: 3 meq and above
Early signs of toxicity
Lethargy, mild nausea, vomiting, fine hand tremors, anorexia, polyuria, polydipsia, metallic taste, fatigue
Late signs of toxicity
Ataxia, giddiness, tinnitus, blurred vision, polyuria
Mood stabilizing

Lithium levels should be checked q 2-3 mos
Serum drawn in the AM, 12H after last dose
Common causes of inc. levels
Dec. Na intake
Diuretic therapy
Dec. renal functioning
F&E loss
Medical illness
Overdose
NSAIDS
Mood stabilizing

Diet: adequate Na+ and fluid
3g NaCl/ day
6-8 glasses of H2O
No caffeine
No driving: wait for clinical effect
Mood stabilizing

Management
Moderately severe toxicity
Osmotic diuresis: urea/ mannitol
Aminophylline & PLR IV
Adequate NaCl
Peritoneal/ hemodialysis
Severe toxicity
Assess hx quickly
Hold next lithium dose
Check BP, rectal T°, RR, LOC, support O2
Obtain labs
ECG
Emetic, NGT lavage
Hydrate: 5-6L/day c PLR; FBC-CDU
Mood stabilizing

Other drugs
Carbamazepine (Tegretol)
Side effects
Dizziness
Ataxia
Clumsiness
Sedation
Dysarthria
Diplopia
Nausea & GI upset
Preparation: liq, tab, chewable tab
Mood stabilizing 800 to 1200 mg/day

Assess drug levels q 3-4 days
Monitor salt and fluid intake
Avoid alcohol and non-prescription drugs
Refer dec. in UO
Don’t stop abruptly
C/I: pregnancy
Take with meals
Mood stabilizing

Other drugs
Valproic acid (Depakote, Depakene)
Side effects
Nausea
Hepatoxicity
Neurotoxicity
Hematological toxicity
Pancreatitis
Prep: tab, cap, sprinkles
MOA: inc. levels of GABA; inhibits the kindling process or “snoball”-like effect seen in mania & seizures
Mood stabilizing

Therapeutic level: 50 – 100 ug/mL
Dose: 1, 000 – 1,500 mg/day
Monitor serum levels 12H after last dose
Toxic effects
Severe diarrhea, vomiting, drowsiness, mm. weakness, lack of coordination
Renal failure, coma, death
Mood stabilizing

Anti-psychotic drugs
Indications
Psychotic symptoms of schizophrenia, acute mania and depression
Gilles de Tourette disorder
Treatment-resistant bipolar disorder
Huntington’s disease and other movement disorder
Possibly
Paranoid
Childhood psychoses
Anti-psychotic

MOA: block receptors of dopamine (D2, D3, D4)
If unresponsive after 6 weeks of therapy, another class is tried
General considerations
Calms without producing impairment of sleep
High therapeutic index
Non addicting, no tolerance
Avoided in pregnancy
Anti-psychotic

TYPICAL: High Potency
Fluphenazine (Prolixin)
Haloperidol (Haldol)
Thiothexene (Navane)
Trifluoperazine (Stelazine)
Anti-psychotic

Moderate Potency
Loxapine (Loxitane)
Molindone (Moban)
Perphenazine (Trilafon)
Anti-psychotic

Low Potency
Chlopromazine (Thorazine)
Chlorprothixene (Taractan)
Mesoridazine (Serentil)
Thioridazine (Mellaril)
Anti-psychotic

ATYPICAL
Clozapine (Clozaril)
Resperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Sertindole (Serlec’t)
Ziprasidone (Zeldox)
Anti-psychotic

Contraindications
CNS depression: brain damage, excess alcohol/ narcotics
Parkinson’s disease
Allergy
Blood dyscrasias
Acute narrow angle glaucoma
BPH
Anti-psychotic

Hypotension
Sedation
Dermal and ocular syndrome
Neuroleptic malignant syndrome
Anticholinergic syndrome
Movement syndrome (Extrapyramidal Syndrome)
Atropine psychosis
Agranulocytosis
Seizures
Side effects New! Anti-psychotic

Neuroleptic Malignant Syndrome
A potentially fatal, idiosyncratic reaction to an antipsychotic drug
10-20% mortality rate
Sx:
rigidity,
high fever,
autonomic instability (BP, diaphoresis, pallor, delirium, elev. CPK), confused or mute, fluctuate from agitation to stupor
Occurs in the first 2 weeks of therapy
Risk: high dose of high-potency drugs; dehydration, poor nx, concurrent med illness
Anti-psychotic TTT: dantrolene (Dantrium), Bromocriptine (Parlodel)

Movement Syndromes
Akathisia
Dystonia
Tardive dyskinesia
Bradykinesia
Parkinsonism
Anti-psychotic

Other s/e
Atropine psychosis (geriatrics)
Hyperactivity, agitation, confusion, flushed skin, sluggish reactive pupils
TTT: IM physostigmine
Agranulocytosis (Clozapine)
Occurs 3-8 wks after
Medical emergency
s/s: fever, malaise, sore throat, leukopenia
TTT: d/c, reverse iso, antibiotics
Seizures (Clozapine)
Occurs in 5% of patients; TTT: D/c drug
Anti-psychotic New!

Anticholinergics
Benztropine (Cogentin)
Trihexyphenidyl (Artane)
Biperiden (Akineton)
Procyclidine (Kemadrin)
Not withdrawn abruptly
Provide cool environment
Anti-psychotic

ANTIPARKINSONIAN MEDICATIONS
Adjunct to anti-psychotic agents to balance dopamine/ acetylcholine in the brain
s/e: glaucoma, tachycardia, HPN, cardiac dx, asthma, duodenal ulcer
A/e: blurred vision, photosensitivity, drowsiness, orthostatic hypotension, CHF, hallucinations

COMMON DRUGS:
Trihexyphenidyl (Artane)
benztropine (Cogentin)
Biperiden (Cogentin)
Selegiline (Eldepryl)
Pergolide (Permax)
ANTIHISTAMINE
Diphenhydramine HCl (BENADRYL)
DOPAMINE RELEASING AGENT
Amantadine (SYMMETREL)

Best taken after meals
Avoid driving
Check BP
Alcohol increases sedative effects
Avoid sudden position change
Drug is not withdrawn abruptly

PSYCHIATRIC DISORDERS

ANXIETY DISORDERS
PANIC DISORDERS
SPECIFIC PHOBIA
SOCIAL PHOBIA
OCD
PTSD
ACUTE STRESS DISORDER
GENERALIZED ANXIETY DISORDER
ANXIETY DISORDERS

PANIC ATTACKS
Discrete period of intense fear or discomfort in which at least 4 if the ff sx develop abruptly and peak within 10 mins:
Palpitations, pounding heart, or accelerated HR
Sweating
Trembling or shaking
Sensations of SOB and smothering
Feeling of choking
ANXIETY DISORDERS

Chest pain or discomfort
Nausea or abd. Pain
Feeling dizzy, unsteady, lightheaded or faint
Derealization or depersonalization
Fear of losing control or going crazy
Fear of dying
Paresthesias
Chills or hot flashes
ANXIETY DISORDERS

SPECIFIC-> PHOBIA ← SOCIAL
Excessive and unreasonable cued by the presence or anticipation of a specific object or situation
Defense mech commonly used include repression and displacement
Fear of social performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others
ANXIETY DISORDERS

OBSESSION COMPULSION
Recurrent and persistent thoughts, impulses, or images are experienced during the disturbance as intrusive and inappropriate
Cause anxiety or distress
Px knows that these are just product of one’s own mind.
Px feels driven to perform repetitive behaviors or mental acts in response to obsession or according to the rules that one deems must be applied rigidly.
Aimed at reducing anxiety
ANXIETY DISORDERS

OBSESSION COMPULSION
Fear of dirt & germs
Fear of burglary or robbery
Worries about discarding something important
Concerns about contracting a serious illness
Worries that things must be symmetrical or matching
Excessive hand washing
Repeated checking of door and window locks
Counting and recounting of objects in everyday life
Hoarding of objects
Excessive straightening, ordering, or of arranging things
Repeating words or prayers silently
ANXIETY DISORDERS

POST TRAUMATIC STRESS SYNDROME
Person has experienced, witnessed or been confronted with an event that involved actual or threatened death or serious injury, or a threat to physical integrity
Person reexperiences these in the mind
Involves intense fear, helplessness, or horror and numbing of general responsiveness (PSYCHIC NUMBING)
ANXIETY DISORDERS

ACUTE GENERALIZED STRESS ANXIETY
Meets the criteria for exposure to a traumatic event and person experiences 3 of the ff sx:
sense of detachment,
reduced awareness of one’s surroundings,
derealization,
depersonalization,
dissociated amnesia
Excessive anxiety or worry, occurring in more days than not for at least 6 mos, about a number of events or activities
Finds it difficult to control the worry
ANXIETY DISORDERS

MOOD/ AFFECTIVE DISORDERS
BIPOLAR D/O
BIPOLAR I: current or past experience of manic episode, lasting at least a week, that is severe enough to cause extreme impairment in social or occupational functioning.
MANIA: hyperactivity
DEPRESSED: extreme sadness or withdrawal
MIXED
BIPOLAR II: hx of 1 or more mj depressive episodes & at least 1 hypomanic episode; no mania
MOOD DISORDERS

MAJOR DEPRESSIVE D/O
@ least 5 sx of same 2- wk period with one being either depressed mood or loss of interest or pleasure.
Single episode or recurrent
Other sx: wt loss, insomnia, fatigue, recurrent thoughts of death, diminished ability to think, psychomotor agitation or retardation, feelings of worthlessness.
MOOD DISORDERS

CYCLOTHYMIC D/O
Hx of 2 yrs of hypomania with numerous periods of abnormally elevated, expansive or irritable moods.
Does not meet the criteria of mania or depression.
DYSTHYMIC D/O
@ least 2 yrs of usually depressed mood and at least 1 of the sx of mj depression without meeting the criteria for it
SEASONAL AFFECTIVE D/O
Depression that comes with shortened daylight in fall and winter that disappears during spring and summer.
MOOD DISORDERS

Dealing with Inappropriate Behaviors
AGGRESSIVE BEHAVIOR
Assist the client in identifying feelings of frustration and aggression
Encourage the client to talk out instead of acting out feelings of frustration
Assist the client in identifying precipitating events or situations that lead to aggressive behavior
Describe the consequences of the behavior on self and others
Assist in identifying previous coping mechanisms
Assist the client in the problem-solving techniques to cope with frustration or aggression
MOOD DISORDERS

DEESCALATION TECHNIQUES
Maintain safety
Maintain large personal space and use nonaggressive posture
Use calm approach and communicate with a calm, clear tone of voice (be assertive not aggressive
Determine what the client considers to be his or her need
Avoid verbal struggles
Provide clear options that deal with behavior
Assist with problem-solving and decision making regarding the options
MOOD DISORDERS

MANIPULATIVE BEHAVIORS
Set clear, consistent, realistic, and enforceable limits and communicate expected behaviors
Be clear about consequences associated with exceeding set limits
Discuss behavior in nonjudgmental and nonthreatening manner
Avoid power struggles
Assist in developing means of setting limits on own behavior
MOOD DISORDERS

SCHIZOPHRENIA
characterized by impairments in the perception or expression of reality and by significant social or occupational dysfunction.
Once considered as a deadly disease
There is lack of insight in behavior
Dx: late adolescence and early adulthood
15-25 y.o. (men); 25-35 y.o. (women)
Obsolete term: dementia praecox = “cognitive deterioration early in life”
Eugene Bleuler: schiz “split”; phren “mind”
SCHIZOPHRENIA

Risk factors
Genetics: identical twins 50%, 15% for fraternal twins
Biochemical factors
Dopamine hypothesis: overactive
Serotonin imbalance
Decreased brain volume, enlarged ventricles, deeper fissures, and loss or underdeveloped brain tissue
Psychoanalytic
lack of trust during the early stages
Weak ego
Defenses: REPRESSION, REGRESSION, PROJECTION
Environment influences: poverty, lack of social support, hostile home environment, isolation, unsatisfactory housing, disruption in interpersonal relationships (divorce or death), job pressure or unemployment
SCHIZOPHRENIA

Subtypes
Catatonic type
prominent psychomotor disturbances are evident. Symptoms can include catatonic stupor and waxy flexibility
Disorganized type
where thought disorder and flat affect are present together
Paranoid type
where delusions and hallucinations are present but thought disorder, disorganized behavior, and affective flattening are absent
SCHIZOPHRENIA

Residual type
where positive symptoms are present at a low intensity only
Undifferentiated type
psychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types has not been met
SCHIZOPHRENIA

Symptoms
According to Bleuler: 4 A’s
Affect is inappropriate
Associative looseness
Autistic thinking
Ambivalence
SCHIZOPHRENIA

Positive symptoms
delusions, auditory hallucinations and thought disorder and are typically regarded as manifestations of psychosis.
Negative symptoms
considered to be the loss or absence of normal traits or abilities
E.G. flat, blunted or constricted affect and emotion, poverty of speech and lack of motivation.
Symptoms SCHIZOPHRENIA

Symptoms
S ocial isolation
C atatonic behavior
H allucinations
I ncoherence (marked looseness of association)
Z ero/ lack of interest, energy and initiative
O bvious failure to attain expected level of dev’t
P eculiar behavior
H ygiene and grooming impaired
R ecurrent illusions and unusual perception experiences
E xacerbations and remissions are common
N o organic factors accounts for the symptoms
I nability to return to baseline functioning after relapse
A ffect is inappropriate
SCHIZOPHRENIA

Nsg Dx: Abnormal thought process
BLOCKING: sudden cessation of a thought in the middle of a sentence, unable to continue the train of thought
CIRCUMSTANTIALITY: before getting to the point of answering a question, the individual gets caught up in countless details and explanations
CONFABULATION
LOOSENESS OF ASSOCIATION
NEOLOGISM
WORD SALAD
SCHIZOPHRENIA

Interventions
Assess physical needs
Set limits
Maintain safety
Initiate one-on-one interaction & progress to small groups
Spend time with clients
Monitor for altered thought process
Maintain ego boundaries, avoid touching
Limit time of interaction
Be neutral
Do not make promises that can’t be kept
SCHIZOPHRENIA

Establish daily routines
Do not “go along” with the client’s delusions or hallucinations
Provide simple complete activities
Reorient
Speak to the client in simple direct and concise manner
Set realistic goals
Explain everything that is being done
Decrease stimuli
Monitor for suicide risk
SCHIZOPHRENIA

Environment
Provide safe environment
Limit stimuli
Psychological Ttt
Behavior therapy
Social skills training
Self-monitoring
Social ttt
Milieu therapy
Family therapy
Group therapy (long-term ttt)
SCHIZOPHRENIA

Related psychotic disorders
SCHIZOAFFECTIVE DISORDER schiz + mood disorder (mania/ depression)
BRIEF PSYCHOTIC DISORDER sudden onset of psychotic symptoms, lasts less than 2 mos and client returns to premorbid level of functioning
SCHIZOPHRENIFORM DISORDER schiz sx lasting between 1 month and <6mos
DELUSIONAL DISORDER characterized by prominent, nonbizarre delusions
SCHIZOPHRENIA

PERSONALITY DISORDERS
CLUSTER A (odd & eccentric)
paranoid, schizoid, schizotypal
CLUSTER B (bad, dramatic & erratic)
antisocial, borderline, histrionic, narcissistic
CLUSTER C (anxious & fearful)
avoidant, dependent, OCD
PERSONALITY D/O

CLUSTER A: ODD & ECCENTRIC
PARANOID
chronic hostility projected to others; suspicious and mistrusts people
Seen mostly in men
SCHIZOID
social detachment = “loner” & “introvert”
Restriction of emotions
Attention fixed on objects rather than people
Functions well in vocations
SCHIZOTYPAL: interpersonal deficits
Magical thinking, telepathy
Apparent in childhood or adolescence
PERSONALITY D/O

Interventions for PARANOID D/O
Asses for suicide risk
Avoid direct eye contact
Establish trusting relationship
Promote increased self-esteem
Remain calm, nonthreatening and nonjudgmental
Provide continuity of care
Respond honestly to the client
PERSONALITY D/O

Follow thru on commitments
Provide a daily schedule of activities
Gradually introduce client to groups
Do not argue with delusions
Use concrete, specific words
PERSONALITY D/O

Do not be secretive with client
Do not whisper in presence of client
Assure that the client will be safe
Provide opportunity to complete small tasks
Monitor eating, drinking, sleeping and elimination patterns
Limit physical contact
Monitor for agitation and decrease stimuli as needed
PERSONALITY D/O

CLUSTER B: ERRATIC, DRAMATIC, OR EMOTIONAL
ANTISOCIAL
Syn: sociopath, psychopathic & semantic d/o
Etiology:
Genetics interfere in the dev’t of positive interpersonal relationships
Brain damage or trauma
Low socioeconomic status
Faulty family relationships: neglect
Secondary gains
15-40 y.o.
PERSONALITY D/O

Signs
Lack of remorse or indifference to persons hurt
Immediate gratification
Failure to accept social norms
Impulsivity
Consistent irresponsibility
Aggressive behavior
Reckless behavior that disregards the safety of others
80-90% of all crime is committed by antisocials (NIHM, 2000)
ANTISOCIAL PERSONALITY D/O

BORDERLINE
Latent, ambulatory and abortive schizophrenics
Between moderate neurosis and frank psychosis but quite stable
Theories
faulty separation from mother; parent and child are bound by guilt
Trauma at 18 mos (weakening of ego)
Unfulfilled need for intimacy
BORDERLINE PERSONALITY D/O

Signs
instability
Impulsivity: unpredictable gambling, shoplifting, sex & substance abuse
hypersensitivity, self-destructive, profound mood shifts
unstable & intense relations
Disturbance in self concept
Common in women
Defenses: denial, projection, splitting, projective identification
BORDERLINE PERSONALITY D/O

HISTRIONIC
Pattern of theatrical or overtly dramatic behavior
Signs
Discomfort when the client isn’t the center of attention
Self-dramatization and exaggerated emotions
uses physical appearance, sexually seductive and provocative behavior
Excessively impressionistic speech lacking in detail (labile emotions)
Problems in dependence & helplessness
More frequent in women
HISTRIONIC PERSONALITY D/O

NARCISSISTIC
Exaggerated or grandiose sense of self-importance
Develop early in childhood
Preoccupied with fantasies of unlimited success, power and beauty
Signs
arrogance, need for admiration,
lack of empathy,
seductive, socially exploitative, manipulative
Occurs more in men
NARCISSISTIC PERSONALITY D/O

CLUSTER C: ANXIOUS OR FEARFUL
AVOIDANT
Sensitive to rejection, criticism, humiliation, disapproval, or shame
Interferes with participation in occupational activities, dev’t of relationships, and take personal risks
social inhibition, longs for relationships
Anxiety, anger and depression are common
Social phobia may occur
Seen in 10% of clients in mental clinics
AVOIDANT PERSONALITY D/O

DEPENDENT
Lacks confidence and unable to function in an independent role
Allows other persons to be responsible of their lives
Most frequent personality disorder in the mental health clinic
submissive behavior, low self-esteem, inadequate, helpless
DEPENDENT PERSONALITY D/O

OBSESSIVE-COMPULSIVE
Preoccupied with rules & regulations, overly concerned about trivial detail, excessively devoted to their work
Depression is common
Men are more affected than women
O-C PERSONALITY D/O

UNDER STUDY PERSONALITY D/O
PASSIVE-AGGRESSIVE: sullen and argumentative, resents others, resists fulfilling responsibilities, complains of being unappreciated
DEPRESSIVE: gloomy, brooding pessimistic, guilt-prone, highly critical of self and others, cheerless.
PERSONALITY D/O

Interventions
Maintain safety against self-destructive behaviors
Allow the client to make choices and be as independent as possible
Encourage the client to discuss feelings rather than act them out
Provide consistency in response to the client’s acting out
Discuss expectations and responsibilities with the client
Inform the client that harm to self, others, and property is unacceptable
PERSONALITY D/O

Identify splitting behavior
Assist the client to deal directly with anger
Develop a written contract with the client
Encourage the client to participate in group activities, and praise nonmanipulative behavior
Set and maintain limits
Remove the client from group situations in which attention-seeking behaviors occur
Provide realistic praise for positive behaviors in social situations
PERSONALITY D/O

Hypoactive sexual disorder (asexuality)
Sexual aversion disorder (avoidance of or lack of desire for sexual intercourse)
Female sexual arousal d/o (failure of normal lubricating arousal response)
Male erectile d/o
Female orgasmic disorder
Male orgasmic disorder
Premature ejaculation
PSYCHOLOGICAL SEXUAL D/O SEXUAL DISORDERS

Vaginismus
Secondary sexual dysfxn
Paraphilias
Gender identity d/o
PTSD due to genital mutilation or childhood sexual abuse
Other sexual problems
Sexual dissatisfaction (non-specific)
Lack of sexual desire
anorgasmia
Impotence
STD
SEXUAL DISORDERS

Infidelity
Delay or absence of ejaculation, despite adequate stimulation
Inability to control timing of ejaculation
Inability to relax vaginal muscles enough to allow intercourse
Inadequate vaginal lubrication preceding and during intercourse
Burning pain on the vulva or in the vagina with contact to those areas
SEXUAL DISORDERS

Unhappiness or confusion related to sexual orientation
Persistent sexual arousal syndrome
Sexual addict
hypersexuality
Post Ejaculatory Guilt Syndrome, the feeling of guilt after the male orgasm
SEXUAL DISORDERS

SEXUAL EXPRESSION
HETEROSEXUALITY
HOMOSEXUALITY
BISEXUALITY
TRANSVESTISM
SEXUAL DISORDERS

PARAPHILIAS
EXHIBITIONISM: the recurrent urge or behavior to expose one's genitals to an unsuspecting person.
FETISHISM: the use of non-sexual or nonliving objects or part of a person's body to gain sexual excitement. Partialism refers to fetishes specifically involving nonsexual parts of the body.
FROTTEURISM: the recurrent urges or behavior of touching or rubbing against a nonconsenting person.
SEXUAL DISORDERS

SEXUAL MASOCHISM: the recurrent urge or behavior of wanting to be humiliated, beaten, bound, or otherwise made to suffer.
SEXUAL SADISM: the recurrent urge or behavior involving acts in which the pain or humiliation of the victim is sexually exciting.
TRANSVESTIC FETISHISM: a sexual attraction towards the clothing of the opposite gender.
SEXUAL DISORDERS

PEDOPHILIA: the sexual attraction to prepubescent or peripubescent children.
VOYEURISM: the recurrent urge or behavior to observe an unsuspecting person who is naked, disrobing or engaging in sexual activities, or may not be sexual in nature at all.
SEXUAL DISORDERS

Other paraphilias not otherwise specified ("Sexual Disorder NOS")
telephone scatalogia (obscene phone calls)
necrophilia (corpses)
partialism (exclusive focus on one part of the body)
zoophilia(animals)
coprophilia (feces)
klismaphilia (enemas)
urophilia (urine)
SEXUAL DISORDERS

SOMATOFORM D/O
SOMATIZATION D/O: hx of many physical complaints beginning before the age of 30 occurring over a pd of several yrs resulting in ttt being sought or significant occupational or social fxning.
CONVERSION D/O: 1 or more sx of deficits affecting voluntary motor or sensory function suggesting a neurological or general medical condition; preceded by conflicts or stressors; can’t be explained and sanctioned by cultural behavior.
Most common: blindness, deafness, paralysis, inability to talk
“ La belle indifference”

HYPOCHONDRIASIS: preoccupation with fears of having, or ideas that one has, a serious dse based on the person’s misinterpretation of bodily sx and persist despite appropriate medical eval and reassurance and has existed for @ least 6 mos. (e.g.:extensive use of home remedies)
PAIN D/O: pain in 1 or more anatomical sites severe enough to warrant clinical attention and causes clinically significant distress or impairment in fxning.

Interventions
Do not reinforce the sick role
Discourage verbalization about physical symptoms by not responding with positive reinforcement
Explore with the client the needs being met by the physical symptoms
Convey understanding that the physical symptoms are real to the client
Report and assess any new physical complaint
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EATING DISORDER BEHAVIORS
BINGE: rapid consumption of large quantities of food in a discrete period of time. (A: hundrends of Cal; B: thousands of Cal at a sitting)
PURGE: Maladaptive eating regulation response that includes excessive exercise, forced vomiting, OCD Rx diuretics, diet pills, laxatives and steroids.
FAST/ RESTRICT: Includes vegetarian diet eliminating all meat without substituting nonanimal sources of protein, OC about food choices, and eating habits.
EATING DISORDERS

ANOREXIA BULIMIA
Rare vomiting or diuretic/laxative abuse
More severe wt loss
Slightly younger
More introverted
Hunger denied
Eating behavior may be considered normal and a source of esteem
Sexually inactive
Obsessional and perfectionist features dominate
Frequent
Less wt loss
Slightly older
More extroverted
Hunger experienced
Eating behavior considered foreign and source of distress
More sexually active
Avoidant, dependent, or borderline features as well as obsessional features
EATING DISORDERS

ANOREXIA BULIMIA complications
Death from starvation (or suicide, in chronically ill)
Amenorrhea
Fewer behavioral problems (these increase with level of severity)
Death from hypokalemia or suicide
Menses irregular or absent
Drug and alcohol abuse, self-mutilation, and other behavioral problems
EATING DISORDERS

DELIRIUM
The medical dx term that describes an organic mental disorder characterized by a cluster of cognitive impairments with an acute onset with a specific precipitating factor.
Sx: diminished awareness of the environment, disturbances in psychomotor activity and sleep-wake cycle.
COGNITIVE: the mental process characterized by knowing, thinking, and judging.
COGNITIVE DISSONANCE: arises when 2 opposing beliefs exists at the same time.
COGNITIVE DISTORTIONS: (+) or (-) distortions of reality that might include errors of logic, mistakes in reasoning, or individualized view of the world that do not reflect reality.
Term: confusion = cognitive impairment
See dementia
COGNITIVE DISORDERS

DEMENTIA
The medical dx term that describes an organic mental d/o characterized by a cluster of cognitive impairments of generally gradual onset and irreversible without identifiable precipitating stressors.
Types:
VASCULAR or MULTI-INFARCT
VASCULAR WITH ALZHEIMER’S DSE
AD: most common
DEMENTIA WITH LEWY BODIES: 2 nd most common; neurofilament material
PARKINSONIAN DEMENTIA
AIDS DEMENTIA COMPLEX
COGNITIVE DISORDERS

FRONTAL LOBE DEMENTIA or PICK’S DSE: cytoplasmic collections; 3 rd most common; loss of expressive language & comprehension
CREUTZFELDT-JAKOB DSE: prion ( proteinaceous infectious particles) = spongy brain; related to TSE & BSE in mad cow dse
CORTICOBASAL DEGENERATION or HUNTINGTON’S DSE/CHOREA: jerky mov’ts
SUPRANUCLEAR PALSY: clumping of protein tau = slow mov’t, weak eye mov’t (esp. downward), impaired walking &balance
COGNITIVE DISORDERS

Reversible Causes:
Subdural hematoma
Tumor (meningioma)
Cerebral vasculitis
Hydrocephalus
Terms: disorientation, memory loss (sensory, primary, secondary, tertiary, working memory), confabulation, confusion
Disturbing behaviors
Aggressive psychomotor
Nonaggressive psychomotor
Verbally aggressive
Passive
Functionally impaired: loss of ability to do self-care
COGNITIVE DISORDERS

DELIRIUM vs. DEMENTIA
Rapid onset w/ wide fluctuations
Hyperalert to difficult to arouse LOC
Fluctuating affect
Disoriented, confused
Attention & sleep disturbed
Memory impaired
Disordered reasoning
Gradual, chronic with continuous decline
Normal LOC
Labile affect
Disoriented, confused Attention intact, sleep usually normal
Memory impaired
Disordered reasoning & calculation
COGNITIVE DISORDERS

DELIRIUM vs. DEMENTIA
Incoherent, confused, delusional, stereotyped
Illusions, hallucinations
Poor judgment
Insight may be present in lucid moment
Poor but variable in MSE
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Disorganized, rich in content, delusional, paranoid
No change in perception
Poor judgment
No insight
Consistently poor & progressively worsens in MSE
COGNITIVE DISORDERS

ALZHEIMER’S DEMENTIA
Most common type of dementia
Stages:
MILD: impaired memory, insidious loses in ADL, subtle personality changes, socially normal
MODERATE: obvious memory loss, overt ADL impairment, prominent behavioral difficulties, variable social skills, supervision needed
SEVERE: fragmented memory, no recognition of familiar people, assistance needed with basic ADL, fewer troublesome behaviors, reduced mobility (4 A’s)
COGNITIVE DISORDERS

Symptoms
AGNOSIA: Difficulty recognizing well-known objects
APHASIA: Difficulty in finding the right word
APRAXIA: Inability or difficulty in performing a purposeful organized task or similar skilled activities
AMNESIA: Significant memory impairment in the absence of clouded consciousness or other cognitive symptoms
COGNITIVE DISORDERS

PSYCHIATRIC D/O IN CHILDREN
MENTAL RETARDATION
PERVASIVE DEV’TAL D/O
AUTISM
RETT’S D/O
CHILDHOOD DISINTEGRATIVE D/O
ASPERGER’S D/O
PDD NOS
LEARNING D/O
READING
MATHEMATICS
WRITTEN EXPRESSION
ACADEMIC PROBLEM
LEARNING D/O NOS
CHILDHOOD DISORDERS

MOTOR SKILLS D/O
COMMUNICATION D/O
EXPRESSIVE LANGUAGE
MIXED RECEPTIVE/EXPRESSIVE
PHONOLOGICAL
STUTTERING
SELECTIVE MUTISM
COMMUNICATION D/O NOS
MOV’T & TIC D/O
DEV’TAL COORDINATION
TRANSIENT TIC
CHILDHOOD DISORDERS

CHRONIC MOTOR&VOCAL TIC
TOURETTE’S D/O
STEREOTYPIC MOV’T D/O
TIC D/O NOS
DISORDERS OF INTAKE & ELIMINATION
PICA
RUMINATION
FEEDING D/O
ENURESIS
ENCOPRESIS
OTHER: BULIMIA, ANOREXIA
CHILDHOOD DISORDERS

ADHD & DISRUPTIVE BEHAVIOR D/O
ADHD
ADHD NOS
CONDUCT D/O
OPPOSITIONAL DEFIANT
CHILD ANTISOCIAL
DISRUPTIVE BEHAVIOR NOS
MOOD D/O
MJ DEPRESSIVE D/O
BIPOLAR I OR II
DYSTHYMIC
MIXED EPISODE
HYPOMANIC EPISODE
MOOD D/O DUE TO MEDICAL CONDITION
SUBSTANCE-INDUCED MOOD D/O
CHILDHOOD DISORDERS

ANXIETY D/O
D/O OF RELATIONSHIP
SEPARATION ANXIETY
REACTIVE ATTACHMENT OF INFANCY OR EARLY CHILDHOOD
PARENT-CHILD RELATIONAL PROBLEM
SIBLING RELATIONAL PROBLEM
PROBLEMS RELATED TO ABUSE OR NEGLECT
CHILDHOOD DISORDERS

MENTAL RETARDATION
an IQ below 70, significant limitations in two or more areas of adaptive behavior (i.e., ability to function at age level in an ordinary environment), and evidence that the limitations became apparent in before 18 y.o.
The following ranges, based on the Wechsler Adult Intelligence Scale (WAIS), are in standard use today:
Class IQ Terms
Profound Below 20 Idiot
Severe 20–34 Imbecile
Moderate 35–49 Moron
Mild 50–69
Borderline 70–79
CHILDHOOD DISORDERS

RETT’S D/O
Development is normal until 6-18 months, when language and motor milestones regress,
purposeful hand use is lost
Acquired deceleration in the rate of head growth (resulting in microcephaly in some)
Hand stereotypes are typical and breathing irregularities such as hyperventilation, breath holding, or sighing are seen in many.
Early on, autistic-like behavior may be seen
Common in females
CHILDHOOD DISORDERS

CHILDHOOD DISINTEGRATIVE D/O or HELLER’S SYNDROME
CDD has some similarity to autism, but an apparent period of fairly normal development is often noted before a regression in skills or a series of regressions in skills.
characterized by late onset (>3 years of age) of dev’tal delays in language, social function and motor skills; skills apparently attained are lost
CHILDHOOD DISORDERS

ASPERGER’S D/O
characterized by difference in language and communication skills, as well as repetitive or restrictive patterns of thought and behavior.
Signs: unable to interpret or understand the desires or intentions of others and thereby are unable to predict what to expect of others or what others may expect of them
Narrow interests or preoccupation with a subject to the exclusion of other activities
Repetitive behaviors or rituals
Peculiarities in speech and language
Extensive logical/technical patterns of thought
Socially and emotionally inappropriate behavior and interpersonal interaction
Problems with nonverbal communication
Clumsy and uncoordinated motor mov’ts
CHILDHOOD DISORDERS

CHRONIC MOTOR/ VOCAL TIC
TIC is a sudden, repetitive, stereotyped, nonrhythmic, involuntary movement (motor tic) or sound (phonic tic) that involves discrete groups of muscles.
can be invisible to the observer (e.g. abdominal tensing or toe crunching)
CHILDHOOD DISORDERS

TOURETTE’S D/O
characterized by the presence of multiple physical (motor) tics and at least one vocal (phonic) tic; these tics characteristically wax and wane
TTT: Neuroleptic medications
haloperidol (Haldol)
pimozide (Orap)
CHILDHOOD DISORDERS

ADHD
Inattention:
Failure to pay close attention to details or making careless mistakes when doing schoolwork or other activities
Trouble keeping attention focused during play or tasks
Appearing not to listen when spoken to
Failure to follow instructions or finish tasks
Avoiding tasks that require a high amount of mental effort and organization, such as school projects
Frequently losing items required to facilitate tasks or activities, such as school supplies
Excessive distractibility
Forgetfulness
Procrastination, inability to begin an activity
Difficulties with household activities (cleaning, paying bills, etc.)
Difficulty falling asleep, may be due to too many thoughts at night
Frequent emotional outbursts
Easily frustrated
Easily distracted
Hyperactivity-impulsive behaviour
Fidgeting with hands or feet or squirming in seat
Leaving seat often, even when inappropriate
Running or climbing at inappropriate times
Difficulty in quiet play
Frequently feeling restless
Excessive speech
Answering a question before the speaker has finished
Failure to await one's turn
Interrupting the activities of others at inappropriate times
Impulsive spending, leading to financial difficulties
CHILDHOOD DISORDERS

Frequently prescribed stimulants are methylphenidate (Ritalin and Concerta), amphetamines (Adderall) and dextroamphetamines (Dexedrine)
Feingold diet which involves removing salicylates, artificial colors and flavors, and certain synthetic preservatives from children's diets.
CHILDHOOD DISORDERS

CONDUCT D/O
repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated,
AGGRESSION TO PEOPLE & ANIMALS
DESTRUCTION OF PROPERTY
DECEITFULNESS OR THEFT
SERIOUS VIOLATIONS OF RULES
Beginning before age 13
CHILDHOOD DISORDERS

OPPOSITIONAL DEFIANT
characterized by an ongoing pattern of disobedient, hostile, and defiant behavior toward authority figures that goes beyond the bounds of normal childhood behavior
Signs
Losing temper
Arguing with adults
Refusing to follow the rules
Deliberately annoying people
Blaming others
Easily annoyed
Angry and resentful
Spiteful or even revengeful
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CHILDHOOD DISORDERS

SUBSTANCE ABUSE
Excessive or unhealthy use of substances, such as alcohol, tobacco or drugs, or use of products such as food
Terms:
TOLERANCE: the declining effect of the same drug dose when it is taken repeatedly over time
HABITUATION: a psychological dependence of the use of a drug
ADDICTION: the biological and/ or psychological behaviors related to substance dependence
WITHDRAWAL SYMPTOMS: result from a biological need that develops when the body becomes adapted to having an addictive drug in the system; occurs when serum levels decrease
SUBSTANCE ABUSE

ADDICTION
ALCOHOL: blood alcohol levels of 0.1% (100mg alcohol/dl of blood) or higher
WITHDRAWAL
Anorexia
Anxiety
Easily startled
Hyperalertness
HPN
Insomnia
Irritability
Jerky mov’t
Possibly: hallucinations, illusions or vivid nightmares
Seizures (7-48 hrs after cessation)
Tachycardia
tremors
SUBSTANCE ABUSE

WITHDRAWAL DELIRIUM
Agitation
Anorexia
Anxiety
Delirium
Diaphoresis
Disorientation with fluctuating levels of consciousness
Fever (100 to 103 F)
Hallucinations and delusions
Insomnia
Tachycardia and HPN
Disulfiram (Antabuse) therapy
SUBSTANCE ABUSE

Nursing care
Obtain info about drug type and amount consumed
Assess v/s
Remove unnecssary obj from environment
Provide one-on-one supervision if necessary
Provide a quiet, calm environment with minimal stimuli
Maintain orientation
Ensure safety
Use restraints
Provide physical needs
Provide food and fluids as tolerated
Administer medications
Collect blood and urine samples for drug screening
SUBSTANCE ABUSE

SPOUSE ABUSE
Battering precipitates 1:4 suicide attempts of all women
Wives explain the injuries as being self-inflicted or accidental
Phases
Tension-building: series of small incidents that leads to beating
Acute beating phase: wife becomes object of assault behavior
Loving phase: batterer is remorseful and assures spouse that he will not harm her again. This leads to reconciliation.
ABUSE

Myths
They believe that if they try not to antagonize with their husband, he will change.
Efforts to coerce the wife out of the victim role can be fruitful.
Facts
Women stay in relationships with men who batter because they feel guilty or responsible of the husband’s behavior
Wife develops little sense of self-worth, immobilized and unable to remove self from the relationship.
Assessment: injuries, other evidence
Interventions: with consent
ABUSE

CHILD ABUSE
PHYSICAL BATTERING
EMOTIONAL
SEXUAL
NEGLECT
ABUSE

ELDERLY ABUSE
A variety of behaviors that threaten the health, comfort, and possibly the lives of the elderly, including physical and emotional neglect, emotional abuse, violation of personal rights, financial abuse, and direct physical abuse.
Commonly committed by care givers.
ABUSE

SEXUAL ABUSE
Components
Sexual Misuse: inappropriate sexual activity
Rape: there is actual penetration
Incest: refers to the relationship between the victim and abuser blood relative or step parent role
Interventions
Children: thru play or role playing with puppets
Prevention of further sexual abuse
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ABUSE

COMPLETED SUICIDE
Self-inflicted death
LEVELS OF SUICIDE
Ideation: thought
Attempt: acted upon but failed
Completed
SUICIDE

CHEMICAL RESTRAINT
CHEMICAL RESTRAINTS: Medications used to restrict the patient’s freedom of movement or for emergency control of behavior but are not a standard treatment for the px’s medical or psychiatric condition.
PHYSICAL RESTRAINTS: Are any manual method or physical or mechanical device attached to or adjacent to the px’s body that he or she cannot easily remove and that restricts freedom of movement or normal access to one’s body, material or equipment.

SECLUTION AND RESTRAINTS
SECLUTION: the involuntary confinement of a person alone in a room from which the person is physically prevented from leaving.
No therapeutic evidence other than a last resort to ensure safety.
Evidence suggest that it adds to further trauma and physical harm

GUIDELINES
All hospital staff who have direct contact with the px should have ongoing education and training in the proper use of seclusion and restraints and other alternatives
Physician or licensed practitioner should evaluate need within 1 hour after the initiation of this intervention.
Max of 4 hours for adults, 2 hours for ages 9-17, and 1 hour for children under 9 yrs
Orders may be renewed for 24 hrs before another face to face evaluation
Continuous assessment, monitoring and evaluation; recorded
Good nursing care
For both restrained and secluded: constant monitoring face to face or by both audio and video equipment.
Px should be released ASAP

OTHER GUIDELINES
SECLUSION
Room should allow observation and communication with px
Remove all items that px might use to harm self
Document: rationale, response to intervention, physical condition, nsg care, & rationale for termination
RESTRAINTS
Give support & reassurance
Position in anatomical position
Privacy is important
v/s & Circulation check
Should be released q 2hrs
Avoid tying to the side rails of bed
Assist in periodic change in body positions

TERMINATING THE INTERVENTION
As soon as met the criteria for release
Review with px the behavior that precipitated the intervention & px’s capacity to exercise control over behavior
DEBRIEFING: reviewing the facts related to an event & processing the response to them; can be used after any stressful event
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THERAPEUTIC IMPASSES
Are blocks in the progress of the nurse-pt relationship
Provokes intense feelings in both the nurse and patient
RESISTANCE
TRANSFERENCE
COUNTERTRANSFERENCE
BOUNDARY VIOLATIONS

RESISTANCE
Reluctance or avoidance of verbalizing or experiencing troubling aspects of oneself
Eg: suppression or repression, intensification of sx, self-devaluation or hopelessness, intellectual inhibitions, acting out or irrational behavior, superficial talk, intellectual insight/ intellectualization, transference reactions.

TRANSFERENCE
Unconscious response in which the px experiences feelings and attitudes toward the nurse that were originally associatated with other significant figures in his or her life.
HOSTILE TRANSFERENCE: anger and hostility, resistance
DEPENDENT TRANSFERENCE: submissive, subordinate and regards the nurse as a god-like figure; views relationship as magical

What do you do?
LISTEN
CLARIFY
REFLECT
EXPLORE/ ANALYZE

COUNTERTRANSFERENCE
Created by the nurse’s specific emotional response to the qualities of the patient; inappropriate in the context, content and intensity of emotion; nurses identify the px with individuals from their past, and personal needs
Types: Reactions of INTENSE
love or caring
Disgust or hostility
Anxiety, often in response to resistance by the px

Eg.
Difficulty empathizing
Feelings of depression before or after the session
Carelessness about implementing the contract
Drowsiness during the sessions
Encouragement of the px’s dependency
Arguments with the px
Personal or social involvement with the px
Sexual or aggressive fantasies toward the px
Tendency to focus on only one aspect or way of looking at information presented by the px
Attempts to help the px with matters not related to the identified nursing problems
Feelings of anger or impatience because of the px’s unwillingness to change
Dreams about or preoccupation with the px

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Psychiatric Nursing

by Jay-D Man

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