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Psychiatric Nursing
 

Psychiatric Nursing

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disorder of the brain, cerebrovascular accidents

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Psychiatric Nursing Psychiatric Nursing Presentation Transcript

  • 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
  • PERCEPTION
  • 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
  • Nursing considerations
    • 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
  • Nursing considerations
    • 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
  • Nursing considerations
    • 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
  • Nursing considerations
    • 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)
    • Nursing considerations
      • 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 (&quot;Sexual Disorder NOS&quot;)
      • 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
            • next
  • 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