- A specialized area of nursing practice employing theories of human behavior as its
science and purposely use of self as its art.
- Includes the continuous and comprehensive services necessary for the promotion of
optimal mental health, prevention of mental illness, health maintenance, management
and referral of mental and physical health problems, the diagnosis and treatment of
mental disorders and their sequela, and rehabilitation
BASIC PRINCIPLES OF PSYCHIATRIC NURSING
Accept and respect the client regardless of his behavior.
Limit or reject the inappropriate behavior but not the individual
Encourage and support expression of feelings in a safe and non-judgmental
environment. Increase verbalization, decreases anxiety.
Behaviors are learned.
All behavior has meaning.
INTERDISCIPLINARY TEAM PRIMARY ROLES
The psychiatrist is a physician certified in psychiatry by the American Board of
Psychiatry and Neurology, which requires 3-year residency, 2-years of clinical practice, and
completion of an examination. The primary function of the psychiatrist is diagnosis of, mental
disorders and prescription of medical treatments.
The clinical psychologist has a doctorate (Ph.D.) in clinical psychology and is
prepared to practice therapy, conduct research, and interpret psychological tests.
Psychologists may also participate in the design of therapy programs for groups of individuals.
The registered nurse gains experience in working with clients with psychiatric disorders after
graduation from an accredited program of nursing and completion of the licensure examination. The nurse
has a solid foundation in health promotion, illness prevention, and rehabilitation in all areas, allowing him
or her to view the client holistically. The nurse is also an essential team member in evaluating the
effectiveness of medical treatment, particularly medications. Registered nurses who obtain a master’s
degree in mental health may be certified as clinical specialist or licensed as advanced practitioners,
depending on individual state nurse practice acts. Advanced practice nurses are certified to prescribe
drugs in many states.
Psychiatric social worker:
Most psychiatric social workers are prepared at the master’s level, and they are licensed in
some states. Social workers may practice therapy and often have the primary responsibility for working
with families, community support, and referral.
Occupational therapist may have an associate degree (certified occupational therapy
assistant) or a baccalaureate degree (certified occupational therapist). Occupational therapy focuses on
the functional abilities of the client and ways to improve client functioning such as working with arts and
crafts and focusing on psychomotor skills.
Many recreation therapists complete a baccalaureate degree, but in some instances persons
with experience fulfill these roles. The recreation therapist helps the client to achieve a balance of work
and play in his or her life and provides activities that promote constructive use of leisure or unstructured
Vocational rehabilitation specialist:
Vocational rehabilitation includes determining clients’ interests and abilities and matching
them with vocational choices. Clients are also assisted in job-seeking and job-retention skills, as well as
pursuit of further education if that is needed and desired. Vocational rehabilitation specialists can be
prepared at the baccalaureate or master’s level and may have different levels of autonomy and program
supervision based on their education.
3 LEVELS OF PSYCHIATRIC NURSING (Levels of Health)
Objective: PROMOTION & PREVENTION
A. Client and Family Teaching (Health Teaching)
1.Teaching adolescent in preventing contracting STDs
CHLAMYDIA: #1 STD in the U.S.
#1 Sign: Greenish & purulent urethral discharge
PID (Pelvic Inflammatory disease) #1 cause of sterility in
#1 Drug of choice Erythromycin
2nd drug of choice Cephalosporin
2. Teaching pregnant women relaxation techniques
Objective: to prevent complication in labor, fetal distress, perineal laceration
(also can be prevented by Kegel’s exercise)
Stage I of labor (LAT-CAP)
L atent C chest breathing
A ctive A bdominal breathing
T ransitional P ant blow breathing
3. Teaching couples on contraceptives BON (Barrier, Oral Contraceptive,
Barrier - CONDOM
Oral - Artificial
Natural - not for M A M (Malnourished,
Anemics & Menses irregular)
4. Conducting rape prevention classes is an example of primary level of prevention.
B. Herbal Medicines
C. Psychosocial Support – family/friends/peers
Needs most support (ASA): Addicts, Suicidal, Alcoholics,
Suicide = Major depression, despair, hopeless, powerless
Prone: Male Age bracket prone for suicide
#1. Adolescent (identity crisis)
2. Elderly (ego-despair)
3. Middle age men (40 y.o. above) 4. Post partum depression
D. Giving Vaccines
II. Secondary : Screening, Diagnosis & Immediate Treatment
> Denver Development Screening Test (DDST) #1 test for PDD
Pervasive Development Disorder (PPD)
1. Autism: Age of onset (3 y.o.)
2. ADHD: Age of onset (6 y.o.)
Diet: Finger Food (high caloric, high CHO)
Rx: Ritalin (Methylphenidate); dextroamphetamine (Dexedrine)
3. Conduct disorder: Age of onset (6 y.o.)
B. Suicide Prevention / Intervention
Impending signs of Suicide
1. Sudden elevation of mood/sudden mood swings
2. Giving away of prized possessions
3. Delusion of Omnipotence (divine powers)
Used by SS (Suicidal, Schizophrenia)
4. When the patient verbalizes that the 2nd Gen TCA is working.
less than 2-4 wks (telling a lie)
1. One-on-one supervision and monitoring
2. No suicide contract – 24 hrs monitoring
- Patient is required to verbalize suicidal ideas
3. Non metallic/plastic/sharp objects: ex. belts, curtains
4. Avoid dark places
C. Case Finding (Epidemics)/Contact Tracing (STDs)
D. Crisis Intervention
Objective: To return the client to its normal functioning or pre crisis level.
Duration: (4-6 wks)
Disorganization is a phase in the crisis state which is characterized by the feelings of
great anxiety and inability to perform activities of daily living
A patient in crisis is passive and submissive, so the nurse needs to be active and should
direct the patient to activities that facilitate coping.
Types of Crisis:
1. Developmental Maturation Crisis
- Adolescence (identity crisis)
- Mid-life crisis;
2. Situational / Accidental crisis
- Most common: Death of a loved one
NSG DX: Ineffective Individual Coping/ Denial
- ex. murder, abortion , rape and fire
3. Adventitious – calamity, disaster
ex. World War I & II, epidemic, tsunami
In a DISASTER 1st assess/survey the scene
E. Emergency drugs and antidotes
Objective: Rehabilitation, which start upon admission
A. Occupational Therapy
- Usually use behavior modification for PDD (Pervasive Developmental
Disorders), anorexia & depression
- Also use fine motor rehabilitation for Post M.I. & Post CVA
B. Vocational Skills (Entrepreneur skills)
C. Aftercare Support – follow-up.
Needed by: addicts & residual schizophrenia due to remission & exacerbation
CRITERIA OF MENTAL HEALTH
(Jahoda, 1953; Staurt and Sundeen, 1995)
Ability to test assumptions about the world by empirical thought; includes social
Growth, development, & self-actualization
(by Maslow) which includes fully functioning person” (by Rogers)
Involves self- determination, self- responsible for decisions, balance between dependence
and independence, and acceptance of the consequences of one’s action
toward self; includes self-identity, self-acceptance, self-awareness, belongingness, security
COMPONENTS OF ASSESSMENT OF MENTAL STATUS
DSM V (Diagnostic and Statistical Manual for Mental Health)
Axis I Clinical Syndrome (S&Sx)
III Pathological Disorders
IV Environmental & Psychosocial stressors
VGlobal Functioning (assessment)]
CONCEPTUAL MODELS OF PSYCHIATRIC TREATMENT
PSYCHOANALYTICAL/PSYCHOSEXUAL MODEL. (Freud); Focus- Intrapsychic process
(conflicts, anxiety, defense mechanisms, impulses).
BEHAVIORAL FRAMEWORK: Focus- learned behavior; Pavlov’s Theory: Classical
Conditioning; Skinner’s Theory: Operant Conditioning.
INTERPERSOAL MODEL (Sullivan and Peplau); Focus- Interpersonal relationships
PSYCHOSOCIAL THEORY (Erik Erickson); Focus-Psychosocial tasks
EXISTENTIAL MODEL / HUMANISTIC MODEL (Rogers); Focus- Conscious human
BIOMEDICAL MODEL (Meyer, Kraeplin, Frances); Focus – Disease approach, syndromes,
PSYCHOSOCIAL THEORY OF ERIC ERIKSON
Most commonly used theory by health professionals.
Describes the human cycle as a series of eight EGO developmental stages from birth to death;
Focus: PSYCHOSOCIAL TASKS throughout the life cycle.
STAGES OF PSYCHOSOCIAL DEVELOPMENT:
PSYCHOSEXUAL (PSYCHOANALYTICAL) THEORY
OF SIGMUND FREUD
Infancy: Oral Phase; Stage of the Id
Toddler: Anal Phase; Stage of the Ego
Preschooler: Phallic Phase; Stage of the Superego (conscience)
Attachment of the child to the parent of the opposite sex and jealousy toward the
parent of the same sex
Oedipal Complex: Attachment of the son to his mother and jealousy toward the
Electra Complex: Attachment of the girl to her father and jealousy toward the
Schooler: Latency phase; Stage of the Strict Superego
Adolescent: Genital phase
FREUDIAN THEORY COMPONENTS:
1. LEVELS OF AWARENESS:
– Composed of past experiences, logical and governed by REALITY
PRINCIPLE; are remembered and easily recalled or available to the individual
– the Preconscious; composed of material that has been deliberately
pushed out of conscious level; helps repress unpleasant thoughts or feelings and can
examine or censor certain desires or thinking; can be recalled with some effort
– Composed of the LARGEST BODY OF MATERIAL- the thoughts, memories and
feelings that are repressed and not available to the conscious mind, not logical and
governed by PLEASURE PRINCIPLE – and since it is usually painful and unacceptable to the
individual, it cannot be deliberately brought unacceptable to the individual, it cannot be
deliberately brought back into awareness unless in disguised or distorted form (dreams)
Three Elements of Personality
IMBALANCE or ABNORMAL FUNCTIONING OF THE THREE ELEMENT OF PERSONALITY
↑Id + ↓SE = Conduct Disorder and Antisocial Personality Disorder
↓Id + ↑SE = Obsessive Compulsive Disorder
Psychoanalytic term for that part of the psyche that is UNCONSCIOUS, the reservoir of
INSTINCTS, primitive drives governed by the PLEASURE PRINCIPLE and is SELF- CENTERED. The
Ids says, “I want, what I want, when I want it”.
Psychoanalytic term for that part of the psyche that is CONSCIOUS, The “I” that is
shown to the environment and most in touch with REALITY and the MEDIATOR between the
primitive, pleasure- seeking, instinctive drives of the ID and the self- critical, prohibitive forces
of the SUPEREGO and is directed by REALITY PRINCIPLE. This is the thinking- feeling part of
personality. The Ego says, “I would want to have it if only I can afford it;” “Not now, I am not
yet ready; perhaps next week.”
Psychoanalytic term for that part of the psyche that RESTRAINS, controls, inhibits and
prohibits impulses and instincts, is self- critical, and is called the CONSCIENCE or EGO IDEAL.
The Superego says, “I should not want that; It is not good to even wish for it.”
ESSENTIAL ELEMENTS OF A NURSE- CLIENT CONTRACT
1. Names of RN and patient
2. Roles of RN and patient
3. Responsibilities of RN and patient
4. Goals / Expectations
5. Purpose of a relationship
6. Meeting location / time
7. Condition for termination
FOUR PHASES OF NURSE- CLIENT RELATIONSHIP (NCR)
A. Pre-interaction/Pre-orientation (For the Nurse)
- Stage of Self-Awareness à To prevent Counter Transference
#1 CORE VALUE OF Psychiatric Nursing
Assessment of problems, needs, expectations of clients
Identify anxiety level of self and client
Set goals of relationship.
Define responsibilities of nurse and client. Stage of testing.
Establish boundaries of relationship. Stress confidentiality.
Contract – 2 famous psychiatric contracts:
1. No suicide contract à Major depression = emergency
TWO definitions of no suicide contract:
A. 24 hrs monitoring
B. Verbalization to the nurse of all suicide ideas
2. Diet contract à Eating disorder
The start of termination phase: “Good morning, full name, RN, shift, session, date start & end.”
C. WORKING PHASE
Promote acceptance of each other
Accept client as having value and worth as a unique individual.
- Stage of resistance
- Counter transference phase
- Most difficult phase
-- NCP is on going
- Identification of the problem/exploration
- The #1 Psychiatric Core Value is Consistency à For manipulative patients
Be consistent to patient with: BAAAM COPS
B orderline C onduct d/o
A ntisocial O ral/eating disorder
A lzheimer’s P aranoid
A utistic S uicidal
Use therapeutic and problem- solving techniques
Maintain PROFESSIONAL, therapeutic relationship
Keep interaction reality- oriented- here and now
Provide ACTIVE LISTENING and REFLECTION of feelings
Use non- verbal communication to support client
Recognize blocks to communication and work to remove them
FOCUS on client’s:
Confronting and working through identified problems
Problems- solving skills
Help client develop alternative, adaptive coping mechanisms
Personal biases (manifestation by counter-transference & vice versa) are seen during working phase
Plan for termination of relationship early the relationship
- Stage of Separation Anxiety à
Signs & symptoms: Regression: Temper tantrums, thumb sucking, apathy, fetal position
- Phase of prognosis à Evaluation
Anticipate problems of termination:
ο Increased dependency on the nurse
ο Recall of previous negative experience- rejection, depression, abandonment, etc.
ο Regressive behaviors
Discuss client’s feelings and objectives achieved
Continuous, dynamic process of SENDING and RECEIVING MESSAGES by various
verbal or non- verbal means (words, signals, signs, symbols) utilized in a goal- directed
THERAPEUTIC COMMUNICATION TECHNIQUES
a. Offering of self – safety, service, comfort
“I am here. I will sit here beside you.
I will lead you to the group therapy session.”
*Ursula, age 25, is found on the floor of the bathroom in the day treatment cleaning with
moderate lacerations to both wrists. Surrounded by broken glass, she sits staring blanking at
her bleeding wrist while staff members call for an ambulance. The best way the nurse should
do is to approach Ursula slowly while speaking in the calm voice, calling her name and telling
her that the nurse is here to help her. This approach provides reassurance for a patient in
b. Reflection: (mirror of feelings) “It must be difficult for you.” “You seem angry. You seem
When patient with symptoms of severe depression says to the nurse “I can’t talk;
I have nothing to say.” And continues being silent. The most appropriate response of the
nurse is to say, “It may difficult for you to speak at this time; perhaps you can do so at
another time”. This response will convey that the nurse is willing to wait for the patient’s
readiness to engage in conversation.
Daughter of patient newly diagnosed w/ Alzheimer’s says, “I can’t be. Nobody in the
family is senile,” correct 5response of RN includes statement like, “It sounds as if you are
shocked over the diagnosis.”
“Tell me more about your feelings”
“Everyone is on my back. My husband says, ‘I don’t do anything right,’ & my boss
wants me to do things differently.” RN’s response to elaborate feelings includes statement
“Have you discussed this with your husband about how to cope with these
problems? Tell me.”
Appropriate response for an 80 y/o who says, “I told my children that I’m ready to
die.” Includes statement like “Tell me about your feelings & I will stay w/ you.”
d. Clarification – used in neologism and word saladà SAM (seen in Schizophrenia, Alzheimer’s,
“What do you mean by…?”(Used in Neologism and word salad)
“I could not follow you.” –(Used in flight of ideas and looseness of association)
“The ground is watching us.”, appropriate intervention includes clarify the
meaning of the word.
Brilliant & charming patient says, “I’ll be better off dead.” Best response of the RN
includes asking questions like, “Do you have plans of suicide”?
Pt says, “I’d like to take you out & give you a good show.” best response by the RN is
asking pt, “What do you mean by a good show?”
e. Reality Orientation/Reality Testing
- Nsg Dx: Altered Sensory Perception
- Delusion; Hallucination, Illusion & delusion
Client: “Help! Help! There are spiders on my back!”
Nurse: “I don’t see spiders but for you that is real.”
Alcoholic pt with delirium tremens states, “There are spiders crawling on my
back”. The appropriate response of the nurse would be, “there are no spiders, its only part
f. Giving Leads
“Aha..then…mmmh… go on… yes…”
g. Therapeutic Silence
h. Paraphrasing/restating – repeating
Repeats the MAIN IDEA; restate what the client says. (Patient: “I can’t believe I cannot go
home today.” Nurse: “You can’t believe that you can’t go home today?”)’
i. Summarizing – recap
Nurse: “Today you have described your understanding of how you feel when you are upset
with your son.”
j. Validation – interpret
Client: “I see a shadow.”
Nurse: “You’re frightened.”
A patient admitted to be listening to voices should be assessed by asking, “What
does the voice tells you?
“I know that Prof. Draper tried to rape me, rape my mind...& he’s still trying to
rape me”, correct of RN includes questions like “Are you frightened being unable to control
your thoughts?” Post-menopausal woman says, “I’m pregnant by God in heaven.” Appropriate
response by the nurse includes statement like, “You believe something special happened to
“It must be frightening to feel that way.” is an appropriate response for a suspicious
pt saying, “I think that my food is being poisoned”
RN’s correct response of pt w/. OCD who checks door 10-15 times includes statement
like, “It sounds as if you have much anxiety.”
k. Open-ended question / broad openings
Questions NOT answerable by ‘YES’ or ‘NO’; encourages further or broadened
“How are you?” “How’s your day?” “What are your favorite things?”
BLOCKS TO THERAPEUTIC COMMUNICATION
a. Never use why – it demands an explanation and also anxiety provoking
b. Closed Ended Question – questions answered by “yes” or “no”
Note: The only therapeutic closed-ended question à Suicidal pt.
“Are you planning to commit suicide?”-Confrontation
c. False Assurance
“Do not worry” ß To patient who are dying & w/ incurable illness
“You have the best doctor; everything will be all right.”
“Relax that is nothing to worry about.”
e. Belittling the patient – CHANGING THE SUBJECT
f. Non therapeutic silence/touch
g. Advising – never advise because they are sometimes persona; opinions
“I believe it would be better if you…”
STIMULUS: Any event affecting an individual
PROBLEM BEHAVIOR: Deficient, excessive, condemned, unwanted behavior
OPERANT BEHAVIOR: Activities that are strongly influenced by events that follow them.
TARGET BEHAVIOR: Activities that the nurse wants to develop or accelerate in the client.
REINFORCER: A reward positively or negatively influences and strengthens desirable
POSITIVE REINFORCER: A desirable reward produced by specific behavior (TV time after
NEGATIVE REINFORCER: A negative consequence of a behavior (Spanking child for
wetting the floor)
A. Classical Conditioning
(pairing of two stimuli in order to gain a new learning behavior – by Ivan Pavlov)
1. Acquisition (newly acquired behavior or the by product of classical conditioning)
B. Operant conditioning
- used in Behavior Modification
1. Positive reinforcement (Reward Orientation)
à Token Economy – use tokens as a source of reward.
Used in eating disorders and depression
> Token economy is also effective for toddlers
2. Negative Reinforcement (Punishment Orientation)
à Aversion Therapy/Aversion Technique
1. Desensitization – gradual exposure to the feared object
-- #1 treatment for phobia
2. Flooding/.Implosive Therapy – sudden exposure
3. Relaxation Technique – light stroking = labor
- Purse Lip Breathing Exercise = COPD/CAL (Chronic Airflow Limitation)
4. Biofeedback – mind over matter. Ex. HPN à ↓BP, palpitations, headache
5. Guided Imagery (Child) & Visualization (Adult)
DEFINITION:Psychotherapeutic processes that occur in formally organized groups designed to
change maladaptive or undesirable behavior.
Knowledge of therapeutic modalities enhances the performance of nursing
interventions during therapy. 8-10 patients are the optimal number of patients in a group.
TYPES OF GROUPS
Goals: Pre- determined
Format: Clear and specific
Factual material: Presented
Leader: Retains control
Goals: Not pre- determined. Responsibility for goal is shared by
group and leader
Format: Discussion flows according to group members’ concern
Materials and topics are not pre- elected.
Emphasis: More on FEELINGS rather than facts
ADVANTAGE OF GROUP THERAPHY
1. Economical: Less staff used.
2. Increased feelings of closeness→ Reduction on feelings of being alone.
3.With feedback group→
Corrects distortions of problems
Builds self- image and self- confidence
Increases reality- testing opportunities
Gives info on how one’s personality and behavior appear to others
4. With opportunities for practicing alternative behaviors and methods of coping with feelings
5. Provides attention to reality and provides development of insight into one’s problems by
expressing own experiences and listening to others in groups
PRINCIPLES OF GROUP THERAPY
1. Verbalization: Members express feelings and group reinforces appropriate communication.
Desired outcome of group therapy includes verbalization of feelings rather than
acting them out
2. Activity: Provides stimuli to verbalization and expression of feelings.
3. Support: Members gain support from one another through interaction, sharing and
4. Change: Members have opportunity to try out new and desirable behaviors in group,
supportive setting to effect change.
PHASES OF GROUP THERAPY
1. Initial Phase
Formation of group
Setting and clarification of goals and expectations
Initial meeting, acquaintance and interaction
2. Working Phase
Confrontation between members→ Cohesiveness
Identification of problems→ Problem- solving processes
In a group therapy when one client says to another, “Maybe you’re taking on someone
else’s problems.” this shows that they are in the working phase
3. Termination Phase
Evaluation of goals attainment
Support for leave- taking
In group therapy if a client says, “Leave me alone & get away from me.”, best
action of the RN is to maintain distance from the pt.
Behavior indicating that goal is met after socialization in a group therapy includes
participation of each group member telling the leader about specific problems
DEFINITION: Effective subjective response to an imagined or real internal or external threat.
□ Perceived SUBJECTIVELY by the conscious mind is as a painful, diffuse apprehension or
vague uneasiness, but the causative conflict or threats is not in the conscious mind or
□ Low / mild level of anxiety is healthy and helps in individual growth and
MAJOR ASSESSMENT CRITERION FOR MEASURING DEGREE OF ANXIETY:
Mild: The perceptual field is wide allowing the client to focus realistically on what
is happening to him. Alert senses, increased attentiveness, and increased motivation.
Moderate: Another word is selective inattention. The perceptual field narrows and
the client is able to partially focus on what is happening if directed to do so and can
verbalize feelings of anxiety.
The perceptual field is significantly reduced and the client may not be able to
focus on what is happening to him and may not be able to recognize or verbalize anxiety. All
senses affected; decreased perceptual field; drained energy; Learning and problem-solving not
possible. Start of sympathetic symptoms: tachycardia, palpitations, hyperventilation (brown
paper bag to prevent Respiratory Alkalosis) and cold clammy skin.
The perceptual field is severely reduced and the client experiences feelings of
panic and dread. Client overwhelmed and helpless; personality may disintegrate →
hallucinations and delusions. Pathological conditions requiring immediate intervention. Client
may harm self or others.
A patient stating, “Sometimes I feel like I’m going crazy & losing control over myself,” is
showing symptoms of panic attack
POTENTIAL NURSING DIAGNOSES
□ Ineffective Individual Coping
NURSING INTERVENTION IMPLEMENTATON:
□ Identify anxious behavior and anxiety levels and institute measures to decrease anxiety
at a level where learning can occur.
□ Provide appropriate environment where environmental stress & stimulation are low
(First nursing action):
Structured, NON-STIMULATING, uncluttered
SAFE from physical exhaustion and harm.
□ STAY. Do not leave client alone. Recognize if additional help is needed. Provide physical
care if necessary.
□ Establish PERSON-TO-PERSON relationship and maintain an accepting attitude:
ACCEPT client. Show willingness to LISTEN.
Encourage, allow EXPRESION OF FEELINGS at clients OWN PACE avoid forcing
□ Administer medication as directed and needed. The pharmacology therapy of choice is
the ANXIOLYTICS-reduces anxiety so client can participate in psychotherapy.
□ Assist to cope with anxiety more effectively. Assist to recognize individual strengths
Encourage measures to reduce anxiety: activities: relaxation techniques,
exercises (DANCING, WALKING, JOGGING), hobbies, talking with support groups,
desensitization treatment program
Provide individual or group therapy to identify anxiety and new ways of dealing
with it and develop more effective coping interpersonal skills.
If patient can be redirected back to the topic after he gets anxious while the RN gives
discharge teaching, it is an indication that discharge teaching can be resumed.
TYPES OF ANXIETY DISORDER
2. Obsessive Compulsive
3. Post Traumatic Stress Disorder (PTSD)
4. Generalized Anxiety Disorder (GAD)
5. Panic Disorder
PHOBIA AND PANIC DISORDER
A. Extreme anxiety and apprehension experienced by an individual when confronted with
feared object/ situation; commonly begins in early twenty’s (young adult) as a result of
childhood environmental factors characterized by ORDER & RIGIDITY; use compensatory
mechanism of the psychoneurotic pattern of behavior and development of symptoms
permits some measure of social adjustment.
B. PRECIPITATING FACTOR: Pressures of decision-making regarding life-style in early adult
TYPES OF PHOBIA
Agoraphobia: Fear of being alone, fear of open spaces or PUBLIC places where
help would not be immediately available (trains, tunnels, crowds, buses)
A client with agoraphobia who is already able to go outside the house indicates a positive
response to therapy.
Expected outcome for agoraphobia includes going out to see the mailbox
Social phobia: Fear of public speaking or situations in which public scrutiny may
Simple phobia: Fear of specific objects, animals or situations
Recognize the client’s feelings about phobic object/ situation
Specific precipitants are present with phobia
Avoid confrontation and humiliation; Provide constant support (Stay with client during
an attack) if exposure to phobic object or situation cannot be avoided
Do not focus on getting patient to stop being afraid
Provide relaxation techniques
Implement behavioral therapy: SYSTEMIC DESENSITIZATION (the #1 treatment for
PHOBIA). Administer antidepressants as ordered
A. A psychiatric disorder characterized by persistent, recurring anxiety-provoking thoughts
and repetitive acts; Unconscious control of anxiety by the use of rituals and thoughts
1.OBSESSION: Persistent, repetitive, uncontrollable thoughts
2. COMPULSION: Repetitive, uncontrollable acts of irrational behavior that serve NO
rational purpose → rigidity, rituals, inflexibility; the development of rituals permits some
measure of social adjustment
B. ASSESSMENT FINDINGS: Ritualistic, rigid, inflexible; with difficulty making decisions and
demonstrates striving at perfection; use verbal and intellectual defenses
Provide for physical safety (1st); meet physical needs
Accept, allow ritualistic activity; DO NOT INTERFERE with it; (The best time to interfere
with ritual is after client has completed it.) Accept behavior but set limits on length and
frequency of the ritual. Offer alternative activities; support attempts to reduce
dependency on the ritual; guide decisions
Provide structured environment, minimize choices
Provide socialization, group therapy
Administer CLOMIPRAMINE (ANAFRANIL) as ordered
A Tricyclic antidepressant used in phobias, anxiety and
obsessive-compulsive disorder; SIDE-EFFECTS/ ADVERSE REACTIONS:
Tachycardia, cardiac arrest, dizziness, tremors, seizures,
CONTRAINDICATIONS: Pregnancy, hypersensitivity;
Interactions/Incompatibilities: Hypertensive crisis, convulsions, with
POST-TRAUMATIC STRESS SYNDROME
A. A disorder following exposure to extreme traumatic event (wars, rape, natural
catastrophes) causing intense fear, recurring distressing recollections and nightmares
B. ASSESSMENT: 2 Cardinal Sign: FLASHBACK & NIGHTMARES. Images, thoughts, feelings →
intense fear and horror, sleep disturbances.
Depression, or irritability or outburst of anger
Exaggerated startle response; Poor impulsive control
Avoidance; Inability to maintain intimacy; Hypervigilance
C. PRIORITY NURSING DIGNOSIS:
Altered Sleeping Patterns
Altered Skin Integrity
Ineffective Individual Coping
D. NURSING INTERVENTATION
o Encourage VERBALIZATION about painful experience. Show empathy; be non-
judgmental; Help feel safe.
o Rational emotive-therapy; Allow to grieve
o Help client identify, label and express feelings safely
o Enhance support systems: Self-help groups, family psychoeducation, and socialization.
In a rape victim, a statement like, “If I should not have worn that red panty, it wont happen to
me”, shows denial
Statement of a rape patient who is beginning to resolve trauma includes, “I’m able to tell my
friends about being raped.”
An RN needs further teaching about caring for a post-traumatic client when she keeps on
asking the client to describe the trauma that caused patient’s distress after recovering from a
GENERALIZED ANXIETY DISORDER
1. Generalized anxiety disorder is an unrealistic anxiety in which the cause can be
The two major types of precipitating factors for anxiety are: treats to one biologic
integrity and treats to one’s self-esteem.
Anxiety is one of the defining characteristics of ineffective individual coping.
A patient with anxiety disorder may exhibit difficulty in coping.
2. Physical symptoms occur
1. Restlessness and inability to relax
2. Episodes of trembling and shakiness
3. Chronic muscular tension
5. Inability to concentrate
6. Chronic fatigue and sleep problems
7. Inability to recognize the connection between the anxiety and the physical
8. Focus on the physical discomfort
a. The cause usually can not be identified.
b. Panic disorder produces a sudden onset with feeling of intense apprehension and
c. Severe, recurrent, intermittent anxiety attacks lasting 5 to 30 minutes occur.
a. Choking sensation
b. Labored breathing
c. Pounding heart
d. Chest pain
g. Blurred vision
h. Numbness or tingling of the extremities
i. A sense of unreality and helplessness
j. A fear of being trapped
k. A fear of dying
L. Feelings of impending doom
a. Attend to physical symptoms
b. Assist the client to identify the thoughts that aroused the
anxiety and identify the basis for these thoughts.
c. Assist the client to change unrealistic thoughts to more
d. Use cognitive restructuring.
e. Administer anti-anxiety medications as prescribed
A client in panic disorder showing dilated eyes, trembling & says, “I can no longer
go further.” Should be accompanied in her room & RN should stay w/ her for a while
The goal of intervention in the care of the anxious patient is to enable him to develop
his capacity to tolerate mildanxiety. A combination of behavioral and somatic approaches is
effective in the management of anxiety.
Therapeutic communication appropriate to patient showing signs of panic disorder
includes providing a concrete direction
Another word: Sedatives/Hypnotics/Minor Tranquilizer
For: Delirium, anti-anxiety, insomnia
ACTION: Increases GABA (gamma amino butyric acid)
USES: Major use to reduce anxiety; also induce sedation, relax muscles, inhibit convulsion;
Used in neuroses, psychosomatic disorders, functional psychiatric disorders. DO NOT modify
Most commonly prescribed drugs in medicine
Greatest harm: When combined with ALCOHOL
I. Benzodiazepine Code: -ZEPAM/ZOLAM
Action: Anticonvulsant, muscle relaxant & anxiolytic
Diazepam (Valium)* best for: Status epilepticus , the best for delirium tremens (alcohol &
Oxazepam (Serax)* the best in sundown syndrome (seen in Alzheimers)
Advantage: Not hepatotoxic
Lorazepam (Ativan)* 2nd drug for sundown Syndrome
Triazolam (Halcion)* Anti-insomnia
Temazepam (Restoril)* Anti-insomnia
Flurazepam (Dalmane)* Anti-insomnia; do not stop abruptly à because of
rebound grand malseizure
Chlordiazepoxide (Librium)* 2nd drug of choice for delirium tremens
Side Effects: #1 Vital sign to be monitored: Respiratory Rate due to its Lethal Side Effect;
1. Early à decrease LOC à Lethargic
Late/Fatal à decrease RR à Respiratory Depression à RR below 12
Avoid strenuous activities
Antidote for Benzodiazepine intoxication: FLUMAZENIL (ROMAZICON); an anxiolytic antagonist
Action: Used as an anticonvulsant besides being a sedative
Code: TAL / AL
Phenobarbital (luminal)* commonly used anticonvulsant barbiturate
III Atypical Anxiolytics
Meprobamate (Equanil, Milltown)
Chloral Hydrate (Noctec)
Hydroxyzine (Atarax, Iterax, Vistaril)* anti emetic & antihistamine
Diphenhydramine (Benadryl)* Antiparkinsons, Antihistamine,
Zolpidem (Ambien, Stillnox) sleeping aid
DROWSINESS (Do not drive; assistance w/ walking; NO alcohol)
Mental confusion (Evaluate mood, sensorium, affect)
Habituation and increased tolerance
Withdrawal symptoms: high doses & prolonged use (>6mo)
PSYCHOTIC DISORDER: SCHIZOPHRENIA
Severe impairment of mental & social functioning with grossly impaired reality testing,
sensory perception and with deterioration & regression of psychosocial functioning.
ASSESSMENT FINDINGS (GENERAL SIGNS)
1. Increased dopamine –coming from the substancia nigra
2. Trauma à PTSD
3. Double-bind theory à 2 kinds of information/communication
4. Genetics 65% chances- if two parents are diagnose with schizophrenia
32.5% chances- if 1 parent is diagnosed with schizophrenia
5. Drug addicts and alcoholics: High probability for schizophrenia due to increase
Delusions & hallucination
DSM V Criteria for Schizophrenia:
Characterized by both (-) & (+) symptoms & social / occupational dysfunction for at
least SIX (6) months.
Patient with 5 admissions in 2 yrs is considered a chronic schizo.
(+) POSITIVE SIGNS OF SCHIZOPHRENIA: Due to EXCESS DOPAMINE
Do you know HILDDA PI?
Hallucination, Illusion, Looseness of Association, Delusion, Disorientation & Agitation
Paranoia & Insomnia
Schizophrenic patient says, “Pretty red dress, tomatoes are red…” is showing looseness of
(-) NEGATIVE SIGNS OF SCHIZOPHRENIA: Due to LACK OF DOPAMINE
Remember your POOR A’s?
Poor judgment, Poor insight, Poor self care
Alogia, Anergia, Anhedonia
NURSING DIAGNOSIS FOR NEGATIVE SYMPTOMS OF SCHIZOPHRENIA:
1. Alteration in Thought Process;
2. Alteration in Content of Thought
OTHER NEGATIVE SYMPTOMS:
All this signs & symptoms can also be seen in SAM (Schizophrenia, Alzheimer’s & Manic)
1. Neologism (creating NEW WORDS) vs. Word Salad (incoherent mixture of words)
2. Flight of Ideas (jumping from one RELATED topic to another): Commonly seen in
MANIC patients, also in Schizophrenia.
3. Verbigeration (meaningless repetition of action words (Verb)) vs. Perseveration
e.g. 1st stimulus à correct response
2nd & following stimulus à still responding to the 1st stimuli
4. Circumstantiality (beating around the bush; answers but delayed) vs. Tangentiality
(did not answer the stimulus/ question)
5. Clang association (use of rhymes in sentences) vs. Echolalia/Parroting & Echopraxia
(Commonly seen in AUTISM)
B. PRIORITIZED NURSING DIAGNOSES FOR ALL TYPES OF SCHIZOPHRENIA:
1. Risk for violence: Directed toward self or other (priority!!!)
2. Self-care deficit
3. Thought process, altered
4. Sensory/perceptual alterations ( related to illusion, delusion & hallucination)
5. Social isolation
C. 5 (FIVE) TYPES OF SCHIZOPHRENIA:
Presenting sign is SUSPICIOUSNESS, ideas of persecution and delusions; sees
environment as hostile and threatening. REMEMBER the 4 P’s:
Projection (#1 defense mechanism), Proxemics( 7 feet away from the patient),
Passive Friendliness (#1 attitude therapy: No touching, , no whispering & laughing) , delusion
of Persecution (#1 delusion of Paranoid Schizophrenia) ,
A patient who says,” The other staff members are laughing at my back.” shows a
paranoid delusion of schizophrenia.
Schizophrenic says, “Someone has placed a transistor in my brain,” correct
interpretation shows paranoid delusion
Statement like, “I don’t like to eat meat because animal produced foods are
Poisonous”, shows suspicious paranoid type schizophrenia.
Developmental Stage FIXATION: ORAL PHASE (TRUST vs. MISTRUST)
1. Consistency to build trust
2. Food: PACKED OR SEALED foods except canned goods: No metal
3. Social Isolation – no group session when schizophrenic
Paranoid who is suspicious saying, “This place is meant for bugs & prison,” In order to
encourage trust, the patient should be involved in the plan of care.
2. CATATONIC: With stereotyped position (catatonia) with waxy flexibility, mutism, bizarre
#1 Defense mechanism: Autism & mutism
#1 Cardinal Sign of Catatonia – waxy flexibility (cerea flexibilitas)
-Similar in children with autism
- Most dangerous/serious type of schizophrenia– may die from dehydration
Catatonic stupor – markedly slowed movement.
Catatonic posturing- bizarre or weird positions
Catatonic rigidity – cementation/stone-like position
Catatonic negativism – resistance towards flexion &
Catatonic hyperactivity or excitability
PRIORITIZED NURSING DIAGNOSIS:
1. Fluid & Electrolyte Imbalance
2. Altered Nutrition less than body requirement
3. Self Care Deficit
3. DISORGANIZED: Another word is Hebephrenic. Characterized with inappropriate behavior:
Silly crying, laughing, regression, transient hallucinations (Auditory).
All behaviors are similar with toddlers since they are anal fixated.
Developmental Stage FIXATION: Anal Fixation
#1 Defense Mechanism: Regression & Fixation
4. UNDIFFERENTIATED or MIXED : Symptoms of more than one type of schizophrenia
has delusions & disorganized behavior but DOES NOT meet the criteria for the above sub types
alone. The #1 drug of choice is Fluphenazine (Prolixin decanoate)
5. RESIDUAL: No longer exhibits overt symptoms, no more delusions but still has negative
Undifferentiated type chronic schizophrenia must be referred to a program
promoting social skills due to functional loss deficit.
PRINCIPLES OF CARE
1.Maintenance of safety: Protect from altered thought processes. Respond to feelings, and not
to delusions; Do not argue; Validate reality; remove from areas of tension
Suspiciousness & paranoid patient is threatening to the staff, the action of an RN that
shows a need for further teaching is when shegoes to the room of a pt. who yells,
“Everyone, out of here,”
Appropriate action of RN to a Schizophrenic who yells loudly, talks to wall and
saying “Don’t talk to me, bastard.” includes walking towards the pt & ask him who he is
2. Meeting of physical needs: May have to be fed / bathe initially
3. Establishment and maintenance of therapeutic relationship: Engage in individual
therapy; Promote trust; Encourage expression by verbalizing the observed; Offer presence-
Tolerate long silences
4. Implementation of appropriate family, group, social or diversional therapies
Patients with schizophrenia need activities that do not require interaction, so solitary
activities are preferred over team activities.
Admission assessment of a Schizophrenic client reveals auditory hallucination,
and drinking more than 6 L of water daily for past weeks, priority focus should be
Desired efficacy of treatment in schizophrenic patient who is mute & immobilized includes
standing up when RN enters the room.
Another word: Neuroleptic / Major Tranquilizers
USES: Schizophrenia, acute mania, depression and organic conditions; Non-psychiatric cases: Nausea and
vomiting, pre-anesthesia, intractable hiccups.
Antipsychotics can only decrease the positive symptoms of schizophrenia, but not the
negative symptom such as ambivalence.
Action: ↓ delusion, hallucinations, looseness of association to decrease levels of
dopamine in the substantia nigra
I. Phenothiazine Code: AZINE
Chlorpromazine (Thorazine)*#1 that causes photosensitivity/photophobia;
Side effects: Causes also red orange urine
In liquid form is usually put in a chaser à Chaser: 60- 100 ml juice (prone or tomato); to
prevent constipation & contact dermatitis; taken with straw (bite straw & sip)
Thioridazine (Mellaril)* ceiling dose/day: 800 mg à Adverse Effect: Retinitis pigmentosa
Prochlorperazine (Compazine)* #1 commonly used anti emetic
Compazine causes anticholinergic side effects
II. ButyrophenonesCode: PERIDOL
Haloperidol (Haldol, Serenase)* #1 drug used for extreme violent behavior
Instruct patient taking Haldol to wear sunscreen
III. Thioxanthenes Code: THIXENE
IV. Atypical Antipsychotics Code: DONE / ZAPINE or APINE
Clozapine (Clozaril) #1 that causes Agranulocytosis & Blood Dyscrasia
“I will need to monitor my blood level to continue my medication.” shows a correct
understanding of a patient while taking Clozaril.
Risperidone (Risperidone) #1 drug for Korsakoff’s psychosis
Aripiprazole (Abilify) newest antipsychotic drug
SIX COMMON ANTICHOLINERGIC SIDE EFFECTS OF ANTIPSYCHOTICS
(Anticholinergic effects are drug actions of antipsychotic drugs because they BLOCK
MUSCARINIC CHOLINERGIC RECEPTORS)
CODE: BUCO PanDan – anticholinergic S/Es
1. Blurring of Vision - ↑ sympathetic reaction (don’t operate machinery);
Mydriatic – pupil dilate à sympa à ↑ IOP à don’t use in glaucoma
2. Urinary Retention – (Post Partum, Autonomic Dysreflexia, paraplegia)
1. Provide Privacy – give bed pan
2. Sounds of dripping water – faucet
3. Intermittent cold & warm compress
1. Prevent constipation ↑ fiber (residue) AG or roughage,
prune/pineapple/papaya juice/ fruits
2. ↑ OFI
4. Orthostatic Hypotension/Postural Hypotension
- take BP in supine, Fowler’s & standing position. Difference of BP 15-20 mm Hg below
S/Sx: Pallor, dizziness
Nursing consideration: Slowly change position. Told patient to dangle feet first
5. Pan Photosensitivity (photophobia)
1. Use sun glasses, sun block, long sleeves or/and umbrella
Patients taking antipsychotic should be instructed to wear wide brimmed hat when going
6. Dan Dry mouth/ Xerostomia
Prioritized Nursing Intervention:
Give (1) ice chips, (2) chewing gum, (3) sips of water
ACUTE/COMMON SIDE-EFFECTS FOR PROLONGED USED OF ANTIPSYCOTICS
Extrapyramidal Symptoms (EPS) Common Signs & Symptoms:
Definition of EPS: Reversible side effect (except TARDIVE DYSKINESIA), which is a result of
neurological dysfunction of the Extrapyramidal System.
Patients taking with prolonged antipsychotic medications should always be assessed for
symptoms of extrapyramidal symptoms.
1. Akathisia –another word: Motor restlessness à 1-6 wks
Signs of motor restless: Foot tapping, finger fidgeting, can’t sit down for more than 15
minutes and pacing back & forth.
Patient is unable to remain still
Drug of Choice: CODE: CBA
#1 Cogentin (Benztropine Mesylate)
#2 Benadryl (Diphenhydramine Hcl)
#3 Akineton (Biperiden Hcl)
2.Dystonia – #1 cardinal Sign: Oculogyric crisis = involuntary rolling of eyeballs, neck
shoulder, jaw and throat spasm (dysphagia) à 2-5 days
Drug of Choice: CODE: CBA
#1 Cogentin (Benztropine Mesylate)
#2 Benadryl (Diphenhydramine Hcl)
#3 Akineton (Biperiden Hcl)
3.Pseudoparkinsonism - another word: Drug-induced Parkinsonism – #1 sign: Pill-rolling
tremors. Other signs: Mask-like face, flat affect, shuffling gait or festinating gait, cogwheel rigidity.
DRUG OF CHOICE:
#1 Artane (trihexyphenydyl)
#2 Amantadine ( Symmetrel) can also be used in Chicken pox, also an ANTI VIRAL
4.Tardive Dyskinesia – Starts with T: TONGUE (tongue rolling & tongue protrusion) lip smacking,
tongue rolling, protrusion of the tongue, vermicular or vermiform tongue rolling à irreversible. This is
Symptoms of tardive dyskinesia include fly catcher’s mouth, tongue thrusting, facial
grimacing, puckering of cheeks, and drooling of saliva.
--administer Artane, Benadryl, Cogentin, Antiparkinsonian drug
5. Akinesia – absence of kinetic movements
ANTI- EPS MEDICATION
- Usually they are anticholinergic & antiparkinsonian drugs
Procyclidine (kemadryl, kemadrin)
Artane ( trihexyphenydyl)
Cogentin (Benztropine mesylate)
Akineton (biperiden Hcl)
ADVERSE EFFECT OF ANTIPSYCHOTIC DRUGS:
Neuroleptic Malignant Syndrome RARE, LIFE-THREATENING : (EXTREME EMERGENCY):
#1 Cardinal Sign is High fever, tremors, tachycardia, tachypnea, sweating,
hyperkalemia, stupor, incontinence, renal failure, muscle rigidity (Discontinue all drugs STAT;
ventilation; hydration; nutrition; renal dialysis; hydrotherapeutic measures).
Elevated blood pressure and diaphoresis are indicative of Neuroleptic malignant syndrome,
which is a medical emergency.
ANTIDOTE: Dantrolene (Dantrium) or Bromocriptine (Parlodel)
Bromocriptine is both an Antiparkinsons & Anti prolactin
AFFECTIVE / MOOD DISORDERS
MODELS OF CAUSATION: Genetic; Aggression turned inward; Objects loss; Personality
disorganization; Cognitive: Hopelessness; Learned helplessness- hopelessness;
Behavioral: Loss of positive reinforcement;
Biological: Decreased serotonin and norepinephrine *; Life stressors; and Integrative:
chemical, experiential, behavioral variables
An abnormal extension or over elaboration of sadness and grief; oldest and most frequently
described psychiatric illness; a pathologic grief reaction experienced by an individual who
does not mourn
The term depression is used in varied ways: a sign, symptom, syndrome,
emotional state, reaction, disease or clinical entity.
May be mild, moderate, severe, with (uncommon) or without psychotic features
1. Depressive Disorders
2. Manic-Depressive (Bipolar) Disorders
3. Suicidal Behavior
Depressive episode with no manic episodes
1. Major depression, single episode
2. Major depression, recurrent: Repeated episodes of major sadness or depression separated
by long intervals, occurring in clusters or increasing with age*
3. Dysthymia: Chronic depressive mood problems occurring in the absence of a major
depressive or organic or psychotic diagnosis.
Moderate Depression – crying at night
- Dysthymia – painful depression for 2
*Severe Depression – Crying at early morning, depression less than 2weeks
*Major Depression – Severe depression for more than 2 weeks
* - both of them have the same characteristics
BEHAVIORS COMMONLY ASSOCIATED WITH DEPRESSION
a. Affective: Anger, anxiety, apathy, bitterness, hopelessness, helplessness, sense of
worthlessness, low self-esteem, denial of feelings
b. Physiological: Fatigue, backache, anorexia, vomiting, headache, dizziness, insomnia,
chest pain, constipation, weight change, abdominal pains*
c. Cognitive: Confusion, indecisiveness, ambivalence, inability to concentrate, pessimism,
loss of interest, self-blame
d. Behavioral: Altered activity level, over-dependency, psychomotor retardation, withdrawal,
poor hygiene, agitation, irritability, tearfulness
In a depressed patient, hostility is turned towards the self, while in manic patient,
hostility is turned towards the environment.
Depression in children results to anhedonia (energy loss & fatigue, decreased
interest in previously enjoyed activities) like playing alone during recess.
o DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSION: At least five of the following, most of
the day, nearly daily, for 2 weeks:
1. Early morning depression
2. Loss of interest or pleasure (ANHEDONIA)*
4. Psychomotor retardation (slow mov’t)
5. Fatigue or loss of energy (anemia)
6. Feelings of worthlessness & ambivalence (fear of death vs. fear living) *
7. Self care deficit*
8. History of suicide*
9. Weight loss or gain
10. Flat affect*
1. Single, Annulled & Divorced
2. Loss of loved one (situational crisis)
3. SAD – Seasonal Affective Disorder – common on winter season (Nov.-Feb.) or intimate
Seasonal depression occurs during winter and fall this is due to abnormal melatonin
Intervention for pt with seasonal affective disorder (SAD) during a depressed
mood includes the use of broad spectrum light in high activity area. This produces high
intensity color like broad day light.
Also instruct the pt that the light source must be 3 ft away from the eye
5. Alcoholics/Drug addicts*
A 66 y/o American men, no hobby, no friend, retired 6 yrs ago, no money & has
history of alcohol abuse is at risk for suicide
7. Incurable Illness*
8. Post partum depression
Age bracket prone for suicide
#1. Adolescent (identity crisis)
2. Elderly (ego-despair)
3. Middle age men (45 y.o. above) 4. Post partum depression (7 days/2-4
Suicide and Self-destructive Behavior
Suicide is never a random act. Whether committed impulsively or after
painstaking consideration the act has both a message and a purpose. In general the purpose
or reason for suicide is to escape; to get away or end an intolerable situation, crisis, difficulty,
or relationship, e.g., escaping a terminal illness, avoiding being a burden to others, resolving
an untenable family situation, or to avoid punishment or exposure of socially or personally
Self-destructive behavior is action by which people emotionally, socially and
physically damage or end their lives. Typical behavior are biting one’s nails, pulling one’s hair
scratching or cutting one’s wrist. A complete suicide is the most violent self-destructive
Levels of self-destructive behavior:
1.Chronic self-destructive behavior – e.g. smoking, gambling, self-mutilation
2.Suicidal threat – a threat more serious than a casual statement of suicidal intent and
accompanied by behavioral changes, e.g., mood swings, temper outbursts, decline in school or
3. Suicidal gesture – more serious warning signal than a threat that maybe followed a suicidal
act that is carefully planned to attract attention without seriously injuring the subject
4. Suicidal attempt – a strong and desperate call for help involving a definite risk.
Cognitive styles of suicidal patients:
1. Ambivalence. They have 2 conflicting desires at the same time: To live and to die.
Ambivalence accounts for the fact that a suicidal person often takes lethal or near-lethal
action but leaves open the possibility for rescue.
2. Communication. Some, people cannot express their needs or feelings to others, or when
they do, they do not obtain the results they hope for. For them, suicide becomes a clear and
direct, if violent, form of communication.
Demographic Variables – suicide rates are higher among the following:
1. Single people
2. Divorced, separated or widowed
3. People who are confused about their sexual orientation
4. People who have experienced a recent loss: divorce, loss of job, loss of prestige, loss
of social status or who are facing the threat of criminal exposure
5. Caucasians, Eskimos and Native Americans
6. Protestants or those who profess no religious affiliation
1. People who have attempted suicide before
2. People who have experienced the loss of an important person at some time in the
past or the loss of both parents early in life, or the loss of or threat of their spouse, job,
money or social position
3. People who are depressed or recovering from depression or a psychotic episode
4. Those with physical illness, particularly when the illness involves an alteration of
body images or lifestyle
5. Those who abuse alcohol or drugs
6. Those who are recovering from a thought disorder combined with depressed
mood and / or suicidal ideation ( hallucinations that tell them to kill or harm themselves)
Management – people bent on suicide almost always give either verbal or nonverbal clues of
their intent. They actually make a powerful attempt to communicate to others their hurt ad
desperation. They are crying out for help.
1. A lethality assessment scale (Table 2) is an attempt to predict the likelihood of suicide.
General guidelines – the general task of the nurse is to work with the client to stop the
constricted processing of suicidal thinking long enough to allow the client and the family to
consider alternatives to suicide.
a. Take only threat seriously
b. Talk about suicide openly and directly
c. Implement basic suicide precautions:
d. Check on the client at least every 15 minutes or require the client to remain in
e. Stay with the client while all medications are taken
f. Search the client’s belongings for potentially harmful objects. Make the search in
the client’s presence and ask for the client’s assistance while doing so
4. Check articles brought in by visitors
5. Allow the client to have regular food tray but check whether the glass or any utensils are
missing when collecting the tray
6. Allow visitors and telephone calls unless the client wishes otherwise
7. Check that visitors do not potentially dangerous objects in the room
d. In addition to the above, maximum suicide precautions mean:
Provide one-to-one nursing supervision. The nurse must be in the room with the
client at all times
Maintain the client’s safety in the least restrictive manner possible
Do not allow the client to leave the unit for test or procedures
Serve the client’s meals in an isolation tray that contains no glass or metal
e. Expect that the client will be experiencing shame, and work to assists the client toward
f. Relieve the client’s obvious immediate distress
g. Find out what, in the client’s view, the most pressing need is
h. Assume a nonjudgmental, caring attitude that does not engender self-pity in the client
i. Ask why the client chose to attempt suicide at this particular moment. The answer will
shed light on the meaning suicide has for this patient and may provide information that
can lead to other helpful interventions
j. Decide if a no-harm, no suicide contract will be used
k. Be careful not to encourage staff behaviors that give clients or staff members a false sense
L. Do not make unrealistic promises
M. Encouraged the client to continue daily activities and self-care as much as possible
N. Decide with the client which family members and friends are to be contact and by whom
O. Be prepared to deal with family members who may be confused, angry or uninterested
P. Evaluate the client’s need for medication
Q. Evaluate the plan developed in collaboration with the client and arrange for appropriate
R. Monitor your personal feelings about the client and decide how they may be influencing
your clinical work
S. Work with other team members to evaluate the issues fully
T. Do a body examination
U. Recognize that people can and have hanged or strangled themselves with shoelaces,
brassiere straps, pantyhose, robe belts, etc.
2 LETHAL METHODS OF SUICIDE:
1. Low-risk = slashing of the radial pulse (more o females)
2. High-risk = drowning, gun shot, hanging, jumping from a
very high place/building, overdose of tranquilizer
(Midazolam & Dormicum)
a) SUICIDAL GESTURE: Directed toward the goal of receiving attention rather than actual
b) SUICIDAL THREAT: Occurs before the overt suicidal activity takes place: “Will you
remember me when I am gone,” “Take care of my children”;
c) SUICIDAL ATTEMPTS: Any self-directed actions taken by the individual that will lead to
death if not interrupted. A most suicidal person has made a specific plan, and has the
means readily available.
Best question to be asked after a patient who recovers from an overdose of pills
asking “Do you still want to end your life?”
IMPENDING SIGNS OF SUICIDE:
1. Sudden elevation of mood/sudden mood swings*
When a depressed patient suddenly becomes cheerful, it means that the patient is
recovering from depression and is in danger of committing suicide.
2. Giving away of prized possessions*
3. Delusion of Omnipotence (divine powers)
Used by SS (Suicidal, Schizophrenia)
4. When the patient verbalizes that the 2nd Gen TCA is working. ( telling a lie)
Suicidal attempts are common when client is strong enough to carry out a suicidal
plan, usually 10-14 days after start of medication, and after ECT
USUAL TIME FOR SUICIDE:
1. Early in the morning RATIONALE: The depression at this time is HIGH
2. In between nursing shifts RATIONALE: Nurses at this time are very busy
NURSING DIAGNOSIS: (common) Risk/Potential for Injury Directed to Self
STEP BY STEP PRIORITIZE NURSING INTERVENTIONS:
1. One-on-one nursing monitoring/intervention (never leave the client)*
2. Do not leave the patient for the 1st 24 hrs. (No suicide contract)*
3. Offering of self (best therapeutic communication)*
4. No metallic objects
5. No sharp objects
6. Needs stimulus – bright room Rationale: to see suicidal acts
7. Avoid religious music (increases guilt) and love songs = non-suggestive song is needed
8. Check for impending signs of suicide
= sudden elevation of mood;
#1 – sudden mood swings
A female patient who becomes euphoric for no apparent reason shows a behavior that
indicates recovery from depression, which increases the risk for suicide.
9. Activities focus on self-care
10. Join group therapy
Depressed patients usually turn their hostile feelings towards themselves.
Providing an activity that serves as an outlet for these aggressive feelings will make the
patient feel less guilty.
During family therapy, a mother asks, “How long will my daughters have suicidal
thoughts?” appropriate response of the RN- ‘’ Your daughter will go on to view suicide as a
way of coping.”
11. Monitor in giving medication – do not leave patient after giving medication for 30
minutes. Check under the tongue & pillow
12. Monitor patient in CR, between shift & during endorsement
13. #1 Attitude Therapy: Kind Firmness
14. Step by step Tx: ANTIDEPRESSANT another word is THYMOLEPTICS
1st SSRI (Selective Serotonin Reuptake Inhibitor) A
2nd Second Gen. TCA
4th ECT (last resort)
15. Meet physical needs:
Promote eating, rest, elimination
Promote self-care whenever appropriate possible
16. Support self-esteem:
Warm and consistent care
Being patient with client’s slowness
Simple tasks that increase success and self- esteem and imply confidence in
Example: Self care activities that will not easily tire the patient. Rationale:
Depressed patients have fatigue.
17. Decrease social withdrawal: Sit with client during quiet times; introduce to others when
The priority focus for a suicidal patient in the ER with a slash in her wrist is her
Assess attempt for suicide in a 16 y/o girl who is eating & sleeping poorly since break-
and saying,” My life is ruined now.”
ANTIDEPRESSANTS or THYMOLEPTICS
I. SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
Usually the FIRST LINE of drug. RATIONALE: FEWER SIDE EFFECTS
Action: Balance Serotonin – gradual effect (usually 2 weeks)
Effect: 2 wks.
Fluoxetine HCl (Prozac) – dry mouth (xerostomia)
Paroxetine HCl (Paxil)
Trazodone (Desyrel)) – adverse effect: Priapism (prolonged use)
Sertraline (Zoloft) – causes GI upset (diarrhea, insomnia): always with meals
Common Side Effects:
1. Weight Loss
2. Insomnia (single am dose)
1. For insomnia:
a. Induce sleep thru:
1. Warm bath (systemic effect)
2. Warm milk/banana (active substance:
b. Give meds in single AM dose
Antidepressants are best taken after meals
II. SECOND GENERATION TRICYCLIC ANTI DEPRESSANT
Action: Increases norepinephrine and/or serotonin levels in CNS by blocking their uptake by
presynaptic neurons or it balances Serotonin & Epinephrine levels.
Effect: 2-4 wks.
Clomipramine HCl (Anaframil) #1 for OCD*
Imipramine (Tofranil)* the best drug for enuresis
Norpramine (Desipramine) #1 antidepressant for elderly depression.
RATIONALE: Fewer anticholinergic S/E
Nortryptilline (Pamelor, Aventyl)
Trimipramine ( Surmontil)
Buproprion (Wellbutrin) 400 mg/day*(ceiling dose) EXCESS INTAKE: Grand mal seizure
Common Side Effects: 1. Sedation (at night)
2. Weight gain
Nursing Consideration: 1. Give meds at night
# 1 adverse effect – cardiac dysrhythmias
#1 screening test before taking TCA – ECG
When a depressed client taking TCA shows no improvement in the symptoms, the nurse must
anticipate the physician to discontinue TCA after two weeks and start on Parnate.
Nursing intervention before giving the drug includes checking the BP.
III. MAOI – MONO AMINE OXIDESE INHIBITOR
ACTION: Psychomotor stimulator or psychic energizers; block oxidative deamination of
naturally occurring monoamines (epinephrine, NOREPINEPHRINE, serotonin) → CNS
Effect: 2 weeks
Mannerix (Moclobemide) *the newest MAOI
Nardil (Phenelzine SO4)
CONTAINDICATIONS: TYRAMINE + MAOI = HYPERTENSIVE CRISIS
1. Tyramine rich-food, high in Na & cholesterol à Hypertensive Crisis
1. Aged cheese (except cottage cheese, cream cheese),
Cheddar cheese and Swiss cheese are high in tyramine and should be
2. Canned foods such as sardines, soy sauce & catsup
3. Organ meats (chicken gizzard & liver) & process foods (salami/bacon)à
3. Red wine (alcohol)
4. Soy sauce
5. Cheese burger
6. Banana, papaya, avocado, raisins (all over ripe fruits except apricot)
7. Yogurt, sour cream, margarine;
9. OTC decongestants
10. Pickled foods, Pickled herring
Foods contraindicated in MAOI therapy includes figs, bologna, chicken liver,
meat tenderizer, , sausage, chocolate, licorice, yeast, sauerkrauts, Food safe to give includes
fresh fish, Cream, Yogurt, Coffee, Chocolate , Italian green beans, sausage, yeast,
CALCIUM CHANNELBLOCKERS (-DIPINE)
1. Verapamil (Calan)
2. Phentolamine (Regitine) à also the #1drug for Pheochromocytoma (tumor in
IV. ELECTROCONVULSIVE THERAPY (ECT)
ECT is passing of an electric current through electrodes applied to one or both temples to
artificially induce a grand mal seizure for the safe and effective treatment of depression.
ECT’s mechanism of action is unclear at present
Quicker effects than antidepressants; Safer for elderly; 80 % improvement rate of
major depressive episode with vegetative aspects
- Best therapy for major depression (last resort)
- Induction of 70-150 volts of electricity in).5-2secs. Then, it is followed by a
grand-mal seizure lasting 30-60 secs.
- 6-12 treatments, “every other day”
- Before ECT a major depressed client undergo the ff meds:
1. SSRi (Selective Serotonin Reuptake Inhibitor inhibitor) –2 wks
2. Antidepressants à TCA 2nd Generation – 2-4 wks
3. MAOi – 2 wks
4. ECT (last resort)
1. Temporary RECENT Memory Loss –
Intervention: Re-orient client to 3 spheres
2. confusion/disorientation – (usually 24 hours)
3. Headache à ↑ 02 demand, ↑ cerebral hypoxia
4. Muscle spasm
5. Wt. gain (stimulate thalamic/limbic à appetite)
1. PPPP – Post MI, Post CVA, pacemaker, pregnant women
2. Neurologic problem à Alzheimer’s, degenerative disorder
3. Brain tumor, weakness of lumbosacral spine
Legal/Pre-Nursing Responsibilities: Preparation: Similar to preparing a client for surgery:
1. Informed Consent – if client is coherent, if not a guardian may sign the
2. No metallic objects
3. No nail polish to check peripheral circulation
4. No contact lenses it may adhere to the cornea
5. Wash & dry hair
6. Give following medications BEFORE ECT:
a. Atropine sulfate – anticholinergic
PRIMARY purpose – to dry secretions and prevent aspiration
SECONDARY purpose – to prevent bradycardia (vagolytic)
b. Phenobarbital (Luminal), Methohexital (barbiturate Na)- minor
tranquilizer also an anticonvulsant
c. Succinylcholine (Anectine) – muscle relaxant
7. Priority vs. to focus ABC; check RR 12 less; LOC
8. Before ECT à supine position; after ECT à side-lying
9. Have patient VOID before giving ECT
1. Risk for Airway Obstruction/aspiration
2. Risk for Injury
3. Impaired/Altered Cognition/LOC
5 S in Seizure
1. Safety (#1 objective)
2. Side-lying (#1 Position)
3. Side rails up
4. Stimulus ↓ (no noise & bright lights)
5. Support the head with a pillow AFTER the seizure
FIRST & TOP priority: Ensure a patent airway. Side-lying after removal of airway.
Observe for respiratory problems
Remain with client until alert. VS q 5 min until stable.
REORIENT: Time, place (unit), person (nurse); Reassure regarding confusion and
memory loss. Same RN before & after.
B. BIPOLAR DISORDERS: With one or more manic episodes, with or without a major depressive
1. Bipolar, depressive: Most recent or current behavior displaying major depression
2. Bipolar, manic: Most recent or current behavior displaying overactive, agitated
3. Bipolar, mixed: Rapid intermingling of depressed and manic behavior
4. Cyclothymania: Numerous occurrences of abnormally depressed moods over a period
of at least 2 years
Mood that is elevated, expansive, or irritable
Manic behavior is a defense against depression since the individual attempts to
deny feelings of unworthiness and helplessness.
• 1. Norepinephrine*
• 2. Serotonin
BEHAVIORS COMMONLY ASSOCIATED WITH MANIA
A. Affective: Elation/ euphoria, lack of shame, lack of guilt, humorous, intolerance of
criticism, expansiveness, inflated self-esteem*
B. Physiological: Dehydration, inadequate nutrition, needs little sleep, weight loss*
C. Cognitive: Ambitiousness, denial of realistic danger, distractibility, grandiosity, flight of
ideas, lack of judgment. *
D. Behavioral: Aggressiveness, provocativeness, excessive spending, hyperactivity, poor
grooming, irritability, argumentative*
DIAGNOSTIC CRITERIA FOR A MANIC EPISODE:
At least 3 of the following for at least 1 week:
1. Delusion of Grandeur – over self-worth, inflated self-esteem
RATIONALE: A defense to mask feelings of depression & inadequacies
3. Flight of ideas
4. Excessive involvement in pleasurable activities without regard for negative
5. Flight of ideas – talkative/pressured speech/pressure to keep talking
Tell manic pt to speak more slowly to make a sense if he keeps on moving one subject
6. Hyperactive & Distractibility
7. Easily Agitated
9. Increased Metabolism
10. Poor impulse control – impulsive
12. Pressured speech
1. Risk/ Potential for Injury directed to others /or to self
2. Fluid & Electrolytes Imbalances
3. Fluid Volume Deficit
1. Accept client; reject behavior
2. Provide consistent care
3. Set limits of behavior/external controls
*One staff to provide controls
*Do not leave alone in room when hyperactivity is escalating
*Explain restrictions on behavior
*Do not encourage performance/jokes
*Approach in a calm, collected, non-argumentative manner
4. Distract and redirect energy: Choose physical activities using large movements until acute
mania subsides (dancing, walking with staff)
Meet nutritional needs: High-calorie FINGER FOODS and fluids to be carried while
moving. Prone to become fatigue, so, give finger foods: potato chips, bread, raisin, and
sandwich. SHORTCUT: ALL HIGH CALORIC & HIGH CARBOHYDRATE DIET or ALL BAKERY
Tuna sandwich & apple are appropriate food for bipolar manic
A Husband of 36 y/o bipolar manic type says, “My wife hasn’t eaten or slept for days.”
The RN should place a priority focus on physical condition.
Encourage rest: Sedation PRN, short PM naps
7. Avoid ACTIVITIES that increases attention span such as chess, bingo, scrabble...
8. Avoid CONTACT SPORTS: Basketball, gym, strenuous activities & Increase perspiration!!
ACCEPTABLE ACTIVITIES: Brisk walking, punching bag, raking leaves, tearing newspaper
9. Productive activities: Gardening, finger painting, household chores,
Activity for Manic Bipolar includes raking leaves (quiet physical, constructive,
productive) to increase self-esteem; competitive is not safe.
10. Less environmental stimulus: No bright lights, do not touch
11. Encourage OFI: Because of Lithium and increased metabolism
12. Check Lithium intoxication
SELECTED SITUATIONS AND INTERVENTIONS:
A. Disturbing the Group Session
1. Separate the patient from the group, REMEMBER don’t touch the patient.
Touching the patient may increase AGITATION.
2. Setting of limits – “matter of fact” (#1 Attitude therapy for manipulative patients)
Patient in acute manic phase begins to disrobe, appropriate nursing action
includes removing patient from group meeting & accompany him to his room
B. Aggressive Reaction
1. Decrease environmental stimulation
A pt who is pt watching TV suddenly throws the pillows & chair, immediate action is
to place pt in seclusion.
“Staff 1st used a lesser means of control for less success.” Shows a documentation
that indicates a pt’s right is being safeguarded during aggressive reactions.
C. Violent Patients
1. Move to the door fast and call the crisis management team
1. Setting of Limits
2. Give avenues for verbalization/expression vs. Physical violence
MOOD STABILIZERS (ANTIMANIC DRUGS): LITHIUM
For: (Mood disorder specifically Mania (Bipolar Disorder)
USES: Elevate mood when client is depressed; dampen mood when client is in manic; used
in acute manic, bipolar prophylaxis; ACTS by reducing adrenergic neurotransmitter
levels in cerebral tissue through alteration of sodium transport → affects a shift in
intraneural metabolism of NOREPINEPHRINE
Action: ↓ hyperactivity and balance or stabilize the mood
Effect: 1 wk.
Lithium CO3 – Eskalith, Lithane, Lithobid
Lithium Citrate – Cibalith - S
Therapeutic Serum Level:
= 0.5-1.5 mEq (local/CGFNS)
= 0.6 – 1.2 mEq (NCLEX)
A. Early in therapy: Serum levels measured q 2-3 times per week; 12 hours after the last dose.
Long-term: q 2-3 months. Before lithium is begun baseline RENAL, CARDIAC, and THYROID
1. DIAMOX (ACETAZOLAMIDE) carbonic anhydrase inhibitor (for open angle glaucoma)
2. MANNITOL (Osmitrol) osmotic diuretics à Action to ↑ urine output, ↓ cerebral edema
3. MNGT. OF OVERDOSE: Induce emesis / lavage; airway; dialysis for severe intoxication
4. If patient forgets a dose, he may take it if he missed dosing time by 2 hours; if longer than
2 hours, skip the dose and take the next dose. NEVER DOUBLE A DOSE!!!
1. Before extracting Lithium serum level à Lithium fasting 12 hrs à check vital signs
2. Avoid diuretics to prevent hyponatremia
3. Avoid strenuous exercise/activities à gym works
4. Avoid sauna baths
5. Avoid caffeine à because it is a diuretic
6. For hypernatremia à AVOID Na CO3
7. Avoid taking soda and/or soda drinks
8. ↑ OFI – 3 L /day; ↑ Na – 3mg/day
A patient who is talking lithium must be placed in a normal sodium (3 gms.) , high
fluid diet (3 L of water). This is done to facilitate excretion of lithium from the body.
A. Increase Na = ↓ Lithium effect
For hypernatremia à AVOID Na CO3
Avoid taking soda and/or soda drinks
When the lithium level falls below 0.5, the patient will manifest signs and symptoms of
B. Decrease Na = ↑ Lithium intoxication à MORE dangerous!!!!
AVOID the 2 dangerous “D”: diuretics & dehydration
Avoid diuretics to prevent hyponatremia
Avoid strenuous exercise/activities à gym works
Avoid sauna baths (EXCESSIVE PERSPIRATION)
Avoid caffeine à because it is a diuretic
Stages in Lithium Intoxication
I. Early/Initial/Mild: 1.5 mEq
- Nausea, vomiting & anorexia
- Gross hand tremors
- Abdominal cramps à hypocalcemia à metabolic alkalosis
(Prolong vomiting à metabolic acidosis)
II. Moderate: 1.6 – 2.4 mEq
Symptoms are 2x the initial signs
III. Severe: ↑ 2.5 mEq
1. Nystagmus, tactile, olfactory & visual hallucination
2. POA (Polyuria, Oliguria, Anuria) à ARF (Kidney problem)
Lithium is nephrotoxic & teratogenic
3. Grand Mal Seizure à Cerebral hypoxia à ↓LOC à COMA à death
PSYCHOSOMATIC / SOMATOFORM DISORDERS
A. PSYCHOSOMATIC DISORDERS: Without any organic or REAL physiological “OBJECTIVE”
Emotional stress may exacerbate or precipitate an illness.
The way an individual reacts to stress depends on his physiological and psychological
Structural changes may take place and pose threat to life.
Defense mechanisms include REPRESSION, PROJECTION, CONVERSION and
Synergistic relationship exists between repressed feelings and overexcited organs.
Somatoform disorders result in impaired social, occupational and other areas of
PSYCHOPHYSIOLOGIC DISORDER: with real symptoms!
Physical symptoms whose etiologies are in part precipitated by psychological factors and may
involve any organ system.
Cardiovascular: Hypertension, Tachycardia
Gastrointestinal: Peptic Ulcer, ulcerative colitis, Colic
Respiratory: Asthma, Hyperventilation, Common colds, Hay fever
Skin: Blushing, Flushing, Perspiring, Dermatitis
Nervous: Chronic fatigue, Migraine headaches, Exhaustion
Endocrine: Dysmenorrhea, Hyperthyroidism
Others: Obesity, hyperemesis gravidarum
NURSING CARE: Holistic or TOTAL – physical and emotional
Understand that PHYSICAL SYMPTOMS ARE REAL and that the client is not faking and the
TREATMENT OF PHYSICAL PROBLEMS DOES NOT RELIEVE EMOTIONAL PROBLEMS Develop
Respect the client and his problems.
Help to express feelings, Allow client to feel in control
Let client meet dependency needs.
Help to work through problems and learn new coping mechanism.
TYPES OF SOMATOFORM DISORDERS / PSYCHOSOMATIC DISORDERS
1. CONVERSION DISORDER: Presence of physical symptoms with NO identified
CHARACERISTICS: #1 Sign “ Labelle Indifference”
A. Can take the form of blindness, deafness, paralysis or any other physical conditions but
with no organic basis.
B. Client derives primary and secondary gains from the physical symptoms.
ASSESS FOR: TWO GAINS IN CONVERSION DISORDER
REPRESSION: Keeps internal need or conflict out of awareness.
SYMBOLISM: Symptom has symbolic value to client.
Secondary gain. (Not connected to the primary gain)
Additional advantages: Sympathy, attention, avoidance.
Reinforces maladjusted behavior.
Do’s: Divert attention from symptom; Provide social and recreational activities;
Reduce pressure on client; Control environment
Don’ts: Confront client with his illness; Feed into secondary gains through anticipating
2. HYPOCHONDRIASIS Preoccupation with an imagined illness with no observable symptoms
and no organic changes.
#1 Sign is “DOCTOR SHOPPING”: Inability to accept reassurance even after exhaustive
testing activities as going from doctor to doctor to find cure.
Preoccupation with body functions or fear of serious disease misinterpretation
and exaggeration of physical symptoms
Adoption of sick role and invalid life-style; signs of severe regression
Lack of interest in environment history of repeated absences from work
If the client is MALINGERING: Deliberately making up illness to prolong
hospitalization; ‘faking illness’
Show acceptance of the client.
Prepare for, assist in complete medical workup to reassure client and rule and medical
Psychotherapy, family therapy and group therapy:
A combination of somatic and behavioral treatment modalities facilities treatment of the
Meet physical needs giving accurate information and correcting misconception.
Demonstrate friendly, supportive approach but NOT focusing on the illness.
Provide diversionary activities that build self-esteem.
Help client refocus on topics other than the illness.
Assist client understand how he uses illness to avoid dealing with his problems.
DEFENSE MECHANISMS IN SOMOTOFORM DISORDERS: Denial, Projection, Conversion, and
A. DEFINITION: Psychiatric disorder involving disruption in the usually integrated functions of
consciousness, identity, memory, or perception of the environment; Client attempts to deal with
anxiety by BLOCKING certain areas out of the mind or deeply REPRESSING traumatic events, or by
PSYCHOLOGICAL RETREAT from reality; A condition NOT of organic origin and usually occurs as a
result of some very painful experience
AMNESIA: Selective or generalized and continuous loss of memory
FUGUE: State of dissociation involving amnesia and actual PHYSICAL FLIGHT – transient
disorientation where client is unaware that he has traveled to another location (Client
does not remember period of fugue.)
DEPERSONALIZATION: Alteration in perception or experience of self, sense of
detachment from self, as if self is NOT REAL
DISSOCIATIVE IDENTITY DISORDER ( MULTIPLE PERSONALITY): Donated by two or more
personalities, each of which controls the behavior while in the consciousness
Assess what form the dissociative disorder is manifesting and degree of interference in
ADL, lifestyle, and interpersonal relations
Reduce anxiety-producing stimuli
Redirect client’s attention away from self; increase socialization / diversional activities
Support modalities of treatment:
Abreaction: Assisting in the recall of past, painful experiences
Hypnosis; cognitive restructuring
Psychopharmacology: Anti-anxiety, antidepressant
Most appropriate intervention for Dissociative Personality Behavior includes
encouraging to chart alternative personality.
A. DEFINITION: Borderline state of personality characterized by defects in its development
or by pathologic trends in its structure; premorbid personality of individuals resembling
the compensatory mechanisms associated with the pathologic counterpart.
PREDISPOSING FACTORS & CAUSATION
1. Biological predisposition à malnutrition, neurologic defects & congenital
2. Development of maladaptive behavior
3. Freudian fixation
2. Maladaptive behavior à inflexible
3. Minor stressà poor tolerance à mood disturbance
4. in reality
5. Not caused by physiological pattern
- Attitude à can be changed
- do not adjust to environment
3 CLUSTERS OF PERSONALITY DISORDERS
1. Cluster A Disorders: Odd / Eccentric
a. Paranoid b. Schizoid c. Schizotypal
2. Cluster B Disorders: Dramatic / Erratic
a. Histrionic b. Narcissistic
c. Antisocial d. Borderline
3. Cluster C Disorders: Anxious/ Fearful
a. Dependent b. Avoidant
c. Passive Aggressive d. Obsessive Compulsive
CLUSTER A: ODD / ECCENTRIC
A. Paranoid Personality Disorder
CHARACTERISTICS: Code (MOST OF THEM STARTS WITH LETTER “P”)
- suspicious, distrustful à oral fixation
- Loneliness à suspicious/mistrust à pathologic jealousy, hypersensitive
#1 DEFENSE MECHANISM: Projection
#1 NURSING DIAGNOSIS: Social Isolation
#1NURSING CONSIDERATION/ INTERVENTIONS:
1. Passive Friendliness à no eye contact, mo touch, no laughing/giggling, non
3. Proxemics: 7 feet away from the patient
B. Schizoid Personality Disorder
- Socially distant, detached, low IQ
- introvert, loner, aloof, humorless
- avoids close relationships with family, friends, peers
- Flat affect à indifferent to praise
- Functional when works alone; more interested on objects
Shy, introverted since childhood but with fair contact with reality
Autistic thinking, dreaming, emotional detachment, avoidance of meaningful
interpersonal relationships, cold and detached
#1 NURSING DIAGNOSIS: Social Isolation
C. Schizotypal Personality Disorder
- Similar with schizophrenia
- Odd, eccentric, lowest IQ
- Magical thinking, e.g., superstitiousness, telepathy
- Ideas of reference or delusion of reference
- Cold/aloof à limit social contact=social anxiety
- Peculiarity in speech but no looseness of association
- may develop into schizophrenia or other psychotic disorders
- Withdrawn, unattached, odd and eccentric,
- Diminished affective (blunted/inappropriate affect) and intellectual skills, vague, over
- Frequent part of vagabond or transient groups of society
#1 NURSING DIAGNOSIS: Social Isolation
CLUSTER B: DRAMATIC/ ERRATIC
A. Antisocial Personality Disorder
- 15-40 y.o, mostly in males
- History of conduct disorder (6-11 yo)
Low socioeconomic status à maladaptive
- Impulsive, aggressive, manipulative
- Low self-esteem
- lack remorse
- hates rule/regulations, authority figures
- coprolalia (bad words)
- Kills, cheats, steals, rapes, destroys
- #1 Defense Mechanism: Rationalization
- Underdeveloped superego; lack of guilt, conscience and remorse; unable to learn from
experience or punishment
- Life-long disturbances that conflict with laws and customs
- Unable to postpone gratification, immature, irresponsible
- Randomly acting out aggressive egocentric impulses on society; reckless, unlawful,
disregard for right of others.
- Steals, cheats, lies
- Appears charming, intellectual, smooth talker
- Antisocial patients have low tolerance to frustration.
1. SETTING OF LIMITS – “matter of fact,” voice not high nor low, does not say please.
Setting of limits prevent the patient from manipulating the nurse.
2. Consistency is a must regarding rules & regulation.
Efficacy of treatment is achieved for an antisocial if the patient is able to respect nurse’s &
other patients boundaries.
Positive outcome for antisocial personality disorder includes adherence to rule of hospital
Interventions that can be appreciated by antisocial include exchanging tokens for any
B. Borderline Personality Disorder
- Mostly in females
THEORIES: Faulty parent-child relationship; dysfunctional
Trauma; physical/sexual abuse (18 months) à low ego
Unfulfilled need of intimacy
- Impulsive, self-destructive, unstable
- Self-mutilation & suicidal
Therapeutic measure to prevent self-mutilation in borderline includes behavioral
The purpose of behavioral contract in borderline is to limit use of unhealthy defense
- Unpredictable behavior (gambling, shopping, sex, substance abuse)
- Disturbance in self-concept: Identity
- #1 DEFENSE MECHANISM: Splitting
“You’re the only nurse who understands me.” This statement is shown in a patient
- Identity disturbance with chronic feelings of emptiness (Anhedonia)
- Marked mood swings and impulsive unpredictable behavior with potential for self-
- Intense, brief, unstable interpersonal relationships with impulsiveness,
manipulation, physical fights and temper tantrums
A borderline patient indicates an improvement when she state, “I ran around the
rather than cutting myself”.
Borderline personality with a history of cutting her wrist shows an intense & a
affect during the middle phase of nurse-pt relationship. The patient says, "You’re a smart
nurse. I want to be just like you.” This statement shows Transference
A patient borderline state, “You’re a phony. You don’t know what happened to
me.”Best response of the nurse will be, “I’ll ensure what is necessary will be done to you
Intervention for borderline d/o includes setting of limits through saying, “The policy
of the unit is that, ‘You can’t leave in the unit in 1st 24 hrs.’”
C. Histrionic Personality Disorder
- More common in women, 2-3 % of the population
THEORY: Llacks Electra complex (no father figure)
- Emotional, dramatic, theatrical
- wants to be the center of attention
- Manipulative, Sexually seductive or provocative
- Exaggeration of emotion, Style of speech is excessively impressionistic
- Labile emotion, Positive: Creative, imaginative
- Extroverted, manipulative, vain with behavior directed toward gaining attention to self; -
Emotionally unstable; uses somatic complaints to avoid responsibility
D. Narcissistic Personality Disorder
- Usually Men
- Another: Metrosexual
- Vanity in personal appearance
- Exaggerated or grandiose sense of self-importance
- Boastful, egotistical, superiority complex
- preoccupied with fantasies: Power, success, beauty
- Excessive admirations; envies other, arrogant, lack of empathy
-Overblown sense of importance, grandiosity; with strong need for attention and admiration
CLUSTER C: ANXIOUS / FEARFUL
A. Obsessive –Compulsive Personality Disorder
- More in women
- Obsession – irresistible thought,
Compulsion – irresistible action
THEORIES: Genetic: Serotonin imbalance
Anal fixation à strict toilet training
- Cardinal Signs: RITUALISTIC
#1 DEFENSE MECHANISM: Undoing, Repression, Symbolization
# 1 Ritual: handwashing
Other Ritualistic behaviors: 4 C’s:
Controlling à perfectionism
Collects or hoarding
Rigid, over-conscientious, perfectionist, inflexible, cold affect
Driven by obsessive concerns
Sets high standards for self and others
Preoccupied with details, rules and organization
STEP TO STEP PRIORITY NURSING DIAGNOSIS:
Altered Sleeping Patterns
Altered Skin Integrity
Ineffective Individual Coping
PRIORITY NURSING INTERVENTIONS:
1. Give appropriate time to do rituals to decrease anxiety
In OCD, intervention includes giving an extra ½ hr to the pt to do the ritual before
Question most likely to elicit response for treatment of compulsive hand washing
includes asking “how much has the symptom interfered with your daily activities?”
2. Do not abruptly stop rituals
3. Setting of limits à avoid manipulative and controlling behaviors
4. TX: Tricyclics – antidepressants à balance serotonin and norepinephrine
Effects: 2-4 wks.
Clomipramine (Anaframil) #1 drug of choice for OC
Imipramine (Toframil) 2nd drug of choice
An oriented group therapy is indicated for OCD
B. Dependent Personality Disorder
- Most common personality disorder for Acute wife battering syndrome
- Co-dependency à enabling
Statement of pt that indicates ability to care for self after being victim of domestic
violence includes a statement like, “I have a car key & money hidden outside the house.”
Battered wife should be referred to shelter
Batterers are violent, loving & remorseful (dual personality)
Wife batterer has low-self esteem
Honeymoon episodes in acute wife battering syndrome showing statement of
reconciliation includes, “Mama, pls. get these red flowers. I love you & I’ll never do it again.”
- Submissive, clinging
- lacks self-confidence, low self-esteem, helpless, good follower
- Lacks self-confidence, helpless when alone, preoccupied with fear of being alone
- Fails to make decisions and accept responsibility→ induces others to take
A pt with Dependent personality who shows ineffective decision making should have
setting of limits & make behavioral contract on its daily activities.
C. Avoidant Personality Disorder
- Shy, timid, inferiority complex
- avoid open forum
- Over sensitive to rejection/criticism
- Social withdrawal = inept
- Depression, anxiety, anger are common
- Withdrawn, loner, lacks self-confidence; with feelings of discomfort/timidity
when with others
-Unwilling to get involved with others and in situations where negative evaluation,
rejection and failure are a possibility
C. Passive Aggressive Personality Disorder
- insecure à backbiter à plastic
- loves to procrastinate, cant finish a task
- Patients with passive-aggressive personality expresses anger through passivity.
#1 Defense Mechanism: Reaction formation.
Goal of nurse in Passive Aggressive Personality includes verbalization of anger when
Goal of Care for Passive Aggressive includes verbalization of feelings of anger when
the need arises.
COGNITIVE / ORGANIC MENTAL DISORDERS
With organic etiology
With deficits in COGNITION and MEMORY
Effects: Changes in levels of functioning and disturbed behavior
MOST COMMON AREAS OF DIFFICULTY (JOCAM)
J – Judgment (impaired)
O – Orientation (confused/disoriented;
C – Confabulation (filling in memory gaps)
A – Affect (mood changes, depression, tearful, withdrawn)
M- Memory (Impaired especially for names and recent events – compensated
by confabulation and circumstantiality)
DELIRIUM VERSUS DEMENTIA
SYMPTOMS OF DELIRIUM
* Difficulty with attention
* Easily distractible
* May have sensory disturbances such as illusions,
Misinterpretations or hallucinations
* Can have sleep – wake cycle disturbances
* Changes in psychomotor activity
* May experience anxiety, fear, irritability, euphoria,
TYPES OF DEMENTIA
Pick’s Disease: Similar picture to DAT, but with frontal lobe symptoms (personality changes)
and reactive gliosis.
Vascular/Multi-infarct Dementia: Patchy cognitive deterioration (dependent on infarct site)
appearing within 1 years of vascular injury; common in men and earlier in onset.
Huntington’s Disease: Autosomal dominant (chromosome 4) disorder with both motor (chorea,
gait disturbance, slurred speech) & cognitive changes (dementia)
Creutzfeldt-Jacob Disease: Dementia due to prions (infectious particle without DNA or RNA);
rapidly progressive from vague somatic complaints to ataxia, dementia then death.
Dopamine in the basal ganglia & extra-pyramidal system causes tremors (pill-rolling &
resting), bradykinesia, cogwheel rigidity, shuffling gait, mask-like fascies.
Progresses to depression & dementia, treated with L-dopa
Nursing care for the patient with dementia is geared towards maintaining
existing functions by minimizing regression.
Place an alarm signal to know that the pt is attempting to exit in a dementia
client who used to wander away from acute facility.
Degenerative disease of the central nervous system characterized by premature senile retardation.
Degenerative disorder of the cerebral cortex.
The etiology of Alzheimer’s disease is unknown
The most common non- traumatic cause of dementia is Alzheimer’s disease at 65, 10%
of the population has Alzheimer’s; by 85, the percentage increases to half. Multi-infarct
dementia is the second most common cause of non – traumatic dementia.
NATURE: Gradual, progressive; Onset: Usually after 65 (2-4%); may begin at 40-65; may
die within 2 yrs or 8-10 yrs if with total care. The main pathology is the of presence of
senile plaques that destroys neurons leading to decreased acetylcholine.
The primary need of a patient with Alzheimer’s is Reorientation.
4 CARDINAL SIGNS OF ALZHEIMER’S
1. Agnosia – sensory–inability to recognize objects/subjects
Patient with agnosia is unable to recognize persons.
1st to forget: The name of an object
2nd to forget is the function of an object
2. Apraxia – sensory-inability for purposeful mov’t. ex. Tremors
3. Amnesia – 1st amnesia to appear: Anterograde amnesia –recent memory
2nd amnesia to appear: Retrograde – past
Tx: Reminiscing Group Therapy
4. Aphasia – sensory-inability for speech and communication
Predisposing/Contributing Factors: Psychiatric Mental Health Nursing 3rd edition by Mary C.
Exact cause unknown but several hypothesis were introduced; (pg 342-343)
1. Acetylcholine Alteration: Decrease in acetylcholine reduces the amount of
neurotransmitter which results in disruption of cognitive process.
2. Accumulation of Aluminum: Studies show that aluminum accumulates in damaged areas
of the brain.
3. Alterations in the Immune System: Antibodies are being produced in the brain which causes
a reaction against self it is called autoimmune
4. Head Trauma: Head injuries
5.Genetic Factor: Pattern of inheritance
THREE STAGES OF ALZHEIMERS
Early stage (Forgetfulness Stage: Mild)
The first symptom of Alzheimer’s disease is Progressive memory loss. This is followed by
disorientation, personality changes, language difficulty, and other symptoms & dementia.
The patient can compensate for the memory loss but the family may notice personality
changes and mood swing. Recent memory is affected including the ability to learn new
information. Managing daily living activities becomes progressively more difficult. The patient
may notice difficulty balancing his checkbook and may forget where he put things.
Forgetfulness: loose things; forget names, short-term memory loss, and the individual is
aware of the intellectual decline.
Early Confusion: Symptoms of confusion begins and concentration may be interrupted.
Individual may forget major event in personal history such as birthday of his/her child:
experience declining activity to perform task; individual may deny memory loss. Findings that
are observed in the early stages of Alzheimer’s disease are inappropriate affect,
disorientation to time, paranoia, memory loss, and an impaired judgment.
* Response of nursing assistant to an Alzheimer’s patient that Needs Further Teaching
includes a statement like, “How many glasses of water did you drink today?” -à Anterograde
Middle stage (Wandering Stage/Sundown syndrome)
The patient is increasingly disoriented and completely unable to learn and recall
new information. He may wander or become agitated or physically aggressive. He may have
bladder incontinence and may require assistance with activities of daily living. Individual may
be unable to recall major life events even the name of spouse. Disorientation in the
surroundings is common and the person may be unable to recall the day, season, and year.
Sleeping becomes a problem. Symptoms worsen in the evening known as “SUNDOWNING.”
Late stage (Kluver Bucy like Syndrome)
The patient may be unable to walk and is completely dependent on caregivers.
He’s totally incontinent of bowel and bladder. He may even be unable to swallow and is at risk
for aspiration. He’s unable to speak intelligibly. In the late stages of Alzheimer’s disease it is
better to go along with the patient’s reality rather than confront him with logical reasoning.
Asking close ended simple questions that relate to his reality is non-threatening and calming.
Note that the nurse’s response in a way that is congruent is the main concern. The individual
may not recognize family members. There may be problems of immobility.
Nursing Diagnosis: Risk for trauma
1. Milieu Therapy is needed: a CONSISTENT UNCHANGING & FAMILIAR ENVIRONMENT IS
NEEDED to decrease chances of disorientation & confusion.In milieu therapy, patients
plan and lead activities rather than the staff Millieu therapy involves scientific
manipulation of the environment that can influence improvement patient’s behavior
2. Store frequently used items within reach.
3. Keep bed in unelevated position with soft padding if client has history of seizure and
keep the rails up.
A confused Alzheimer’s patient who gets out of bed several times must be
provided with a safe environment like placing a hand rails for the patient to hold. Bed of
confused Alzheimer’s patient must always have its side rails up.
4. Assign room near nurses’ station.
5. Assist patient with ambulation.
6. Keep dim light on at night. Decrease environmental stimulus.
7. If patient is a smoker, stay with him/her at all times.
8. Frequently orient patient to time, place and situation.
9. If patient is prone to wander, provide an area in which the client is safe to wander.
10. Family counseling about Alzheimer’s disease includes checking that pt is wearing ID
bracelet when going out at all times
11. Soft restrain may be required if the client is disoriented hyperactive as ordered by the
12. Provision of simple, structured environment, ↓ choices
Consistency and ROUTINE in care to increase security; Brief, frequent
contacts; reinforce reality-oriented comments
Ample time and patience to allow client to talk / complete using
associative patterns to improve recall: simplicity, focusing, repeating, summarizing.
Allow REMINISCING of past life / exploits / achievements. Reminiscing
helps lessen the patient’s loneliness.
13. Wear the Medical Alert Bracelet – (name, Address, Tel #, Diagnosis, Medication)
14. Avoid afternoon naps, avoid caffeine, TV & radio remote
15. REMEMBER THE 3 C’s for Alzheimer’s to DECREASE DISORIENTATION: Color, Calendar,
Nursing Diagnosis: Altered thought process
1. Frequently orient the patient to reality.
Sensory stimulation for elders helps to increase pt’s arousal
2. Keep explanation simple and use face-to-face interaction. Speak slowly and do not
shout. In caring for elderly w/ Alzheimer’s use short & simple words & face him while
you are talking.
3. Discourage rumination of delusional thinking. Talk about real people and real events.
4. Monitor for medication side effects.
5. Use soft tone, simple sentences, and a slow, calm manner when speaking to a person with
Alzheimer’s disease. If he doesn’t understand you, repeat yourself using the same words. Your
nonverbal communication is more important than your actual spoken message. Don’t a hurried
tone, which will make the patient feel stressed. Move slowly and maintain eye contact.
Nursing Diagnosis: Self-care deficit
1. Identify self-care deficit and provide assistance.
Urinary incontinence in patient with Alzheimer’s can be controlled by
decreasing fluid intake at night time
2. Allow plenty of time for the patient to perform task.
3. Provide guidance and support for independent actions by talking the patient through
4. Provide structure schedule of activities that does not change from day to day.
5. ADLs should follow home routine as closely as possible.
6. Provide client’s nutritional needs, safety and security.
7. Give foods high in carbohydrates to an Alzheimer’s who refuses
to eat his meal
In an Alzheimer’s caregiver class, the nurse tells the student that the reason why pt’s do
not take a bath is that they cant remember anymore if they have taken the bath already.
Screening Test: MS Brunner and Suddarth (pg 160)
2. Computed tomography
3. Magnetic Resonance Imaging
Confirmative Test: MS Brunner and Suddarth (pg 160)
Cerebral biopsy after death.
Complication: MS Brunner and Suddarth (pg 158)
Anticholinesterase:Increases ACH (acetylcholine) levels
MS Brunner and Suddarth (pg 160)
Tacrine hydrochloride (Cognex)
No cure or definitive treatment exists for Alzheimer’s disease. However, three drugs,
tacrine (Cognex), rivastigmine (Exelon), and donepizel (Aricept), have been approved by the
Food and Drug Administration to improve cognitive function in patients with mild to moderate
Tacrine hydrochloride (Cognex)-monitor patient for liver toxicity
Tacrine hydrochloride (Cognex)-enhances acetylcholine uptake in the brain, thus
maintaining memory skills for a period of time.
SUMMARIZED DRUGS USED TO TREAT DEMENTIA
BEST HERBAL DRUG FOR ALZHEIMERS:
Enhancing memory with ginkgo biloba
Ginkgo biloba, a plant extract, contains several ingredients that many believe can slow
memory loss in people with Alzheimer’s disease, Research has shown that ginkgo produces arterial,
venous, and capillary dilation, leading to improved tissue perfusion and blood flow. Adverse
effects are uncommon but may include GI upset or using anticoagulants.
#1 CAUSE: Unknown
#1 Personality Disorder of Eating Disorders: Obsessive Compulsive Personality
THEORIES OF CAUSATION:
1. Behavioral: Attention-seeking by rejecting foods; manipulation to gratify needs
2. Family interaction: Ambivalent feelings towards mother; overprotection, rigidity, lack of personal
boundaries and independence; use of anorexia to avoid interpersonal conflicts. The issue of CONTROL is a
central one for the client with anorexia nervosa. It is believed that symptoms are caused by stressor that
the adolescent perceives as a loss of control in some aspect of her life. Controlling intake and weight gain
is a way the client establishes a sense of control over her life.
3. Psychoanalytic: Regression to oral and anal developmental stage to avoid adolescent sexuality and
. Medical: Genetic predisposition, increased catecholamines, hypothalamus dysfunction
4. Altered Body Image
Change of body image causes difficulty in self-esteem. Long term treatment for
anorexia/bulimia includes outpatient family therapy sense of control over herself is a positive
outcome in eating disorder.
NURSING INTERVENTION FOR EATING DISORDERS
1. DIETARY THERAPY → restoration and stabilization of nutritional and fluid balance
a. Feedings: Oral, IV or tubes; monitor hydration and electrolytes
An anorexic patient with high urine specific gravity must be encouraged to have
an increase fluid intake
b. Caring and nurturance when possible
c. Provide education 1) on growth & development and normal nutrition 2) Limit setting: Based
on weight gain or loss, grant or restrict privileges; use behavioral contract to enforce limits
2. ASSESS AND EVALUATE:
Weight and % of normal body weight loss; weighing 3x a week: Same time,
clothing and weighing scale. Limit activity based on weight gain: For wt. Loss –
complete bed rest; gain less than 100 g- with bathroom privileges; more than 200
g- may ambulate in the hospital
Eating patterns: Amount, type of foods, time and place of eating, whether food is
forced or followed by vomiting; Provide surveillance 30 min. to 1 hr after meals
Preventing the patient from using the bathroom for 2 hours after eating, prevents
the patient from inducing vomiting.
Presence of anemia, hypotension, bradycardia, amenorrhea
3. PROVIDE A STRUCTURED ENVIRONMENT that offers safety and comfort and helps DEVELOP
INTERNAL CONTROL→ reduces need to control by self-starvation.
4. Help client accept eating problem and set realistic, attainable short-term goals
5. Provide support is developing better outlets for emotional expression; Encourage outside
interests not related to food
6. Provide teaching on therapeutic diet: Balanced, calories restriction to effect WEIGHT GAIN
(1-2 pound per week)
7. Offer PRAISE for progress; accept lapses (behavior modification)
8. Instruct and support in behavioral modification program: 1) Control speed of eating –
chewing food well; 2) Self monitoring w/ food diary; & 3) Praise/reinforce compliance
Best discharge plan for anorexic teen includes attending a support group
DRUG ADDICTION/NONALCOHOLIC SUBSTANCE ABUSE
SUBSTANCE ABUSE TERMS AND DEFINITTIONS
a. ASSESSMENT FINDINGS
History. Academic or job failures, marital failures, stealing to support habit,
personality change, violent acting out
Physical Examination: Malnutrition; abdominal cramps; diaphoresis, yawning,
lacrimation, rhinorrhea 10 hours after the last opiate injection; needle marks on arms
along path of a vein (wearing of long- sleeves); nasal discharge with nasal septum
Social: Inability to maintain ADL and fulfill role responsibilities and obligations
B. NURSING DIAGNOSES, POTENTIAL:
Altered health maintenance/nutrition related to chemical dependence; lack of
interest in food
High Risk for Violence: Directed toward self or others related to feelings of
suspicion or distrust; intake of mind-altering substances; misinterpretation of stimuli
Defensive Coping related to denial of problem; projection of responsibility or
blame; rationalization of failures
NON-ALCOHOLIC ABUSED SUBSTANCES
Another word for alcohol is “Booze” “Brew”
GENERAL PRINCIPLES OF CARE: ALCOHOL DETOXIFICATION
3 A’s =
Alcohol Withdrawal à Aversion Therapy (Punishment)
Antabuse (Disulfiram) = no effect unless mixed with alcoholà
Action: Inhibit Antabuse effect Acetaldehyde dehydrogenase
> Dosage: Acute phase = 500 mg in 1st 2 wks.
Maintenance Phase = 250 mg & ↓
>Prohibited Household items with alcohol: mouthwash, cough syrup/elixir, vinegar, fruitcake,
shaving cream, astringent, and toner, acetone/nail polish
Cough medicines and other over-the-counter medicines are alcohol-based and
may cause antabuse reaction when it is combined with antabuse.
Antabuse may worsen renal damage thus it is contraindicated for patients with renal
Effect of Antabuse with Alcohol
1. Nausea & Vomiting
3. Intense headache
4. Abdominal cramps
> Short term objective for an alcoholic: To stop/cut denial
Long term objective: Abstinence (similar with STD/HIV/AIDS)
> # 1 group therapy for Alcoholics
(12 step recovery program – AA (Alcoholic Anonymous)
for victims of alcoholics: AL-ANON
for alcoholic teens: ALATEEN
Correct response of an RN to alcoholic patient who says, “I don’t want to attend group
meeting, I don’t need their alcoholic advice.” Is a statement like,“ The group activity may not
seem helpful to you but you can help them.”
> Screening Questions for alcohol abuse:
1. When was the last time you have taken alcohol?
2. How much alcohol have you taken for the last 24-48 hrs?
In a detoxification unit, the nurse asks the pt when was the last time he drink
alcohol to determine the onset of alcohol withdrawal syndrome.
Goal in alcohol detoxification includes maintaining maximum physical integrity
during withdrawal period.
Statement of a pt who is alcoholic and undergoing detoxification saying, “I can
quit whenever I want.” shows denial
CAGE SCREENING QUESTION FOR AN ALCOHOLIC
C cut down alcohol (Do you need to cut down alcohol?)
A annoyed (Are you annoyed when someone will ask you “Are you an alcoholic?)
G guilty (Are you guilty of taking too much alcohol?)
E eye opener (stimulant) Do you use an eye opener early in the morning to decrease the
after effects of alcohol?
3 Stages of Alcohol Intoxication
I. Alcohol Serum Level = 0.04 -0.05% > unsteady gait
> ↓ social & sexual inhibition
II. ASL = 0.08-0.1 or 100 mg/dl
> slurring of speech
> Fruity odor à similar to ketoacidosis
> Legal intoxication
III. ASL = 0.15-0.2 – severe alcohol intoxication
> 4 Common Complications with History of Alcoholism
1. Liver Cirrhosis
2. Gastritis à inflammation
4. Wernicke’s Korsakoff’s à peripheral neuritis ß lack of Vit. B1 (thiamine)
(Sx: Tingling sensation/numbness of extremities: Avoid electric blankets!)
Wernicke’s’ psychosis is due to thiamine deficiency.
Confabulation or making up of stories is one of the initial manifestations of
Two categories of Wernicke’s Korsakoff’s:
A. Wernicke’s Aphasia / Receptive Aphasia: Problems in interpretation (temporal
B. Korsakoff’s Psychosis – irreversible (the best drug is Risperidone (Risperdal): It has
Decrease extrapyramidal symptoms (EPS)
4 Stages of Alcohol Withdrawal
I. Early/Initial – Fine tremors, restlessness, tachycardia, diaphoresis, hyperventilation &
Symptoms of alcohol withdrawal is observed when the cup rattles to the side
when the patient stirs his coffee
II. Hallucination – #1 hallucination of Alcohol withdrawal is TACTILE
Nursing diagnosis for patient with delirium tremens who says, “There are bugs in
my bed crawling over me” is Altered Thought Process
2. Visual hallucination
Intervention: > Use lampshade to ↓ shadow (illusions)
Leaving a light on the patient’s room will decrease visual hallucinations, which
frequently occur in alcohol withdrawal syndromes.
à Shadow stimulates hallucination
don’t leave the patient (Offering of self)
Assigning a staff to the patient promotes safety especially during withdrawal episodes.
III. Pre-seizure/RUM FITS
Impending signs of Seizure
1. Epigastric pain (early sign in eclampsia)
2. High pitch cry/projectile
3. Eye pain/periorbital pain (scotomas) usually in eclampsia
4. Headache & Aura- ↑ ICP
5. Restlessness à cerebral hypoxia = ↓ 02 & glucose
IV. Delirium Tremens
Active Seizure = Grand mal/Tonic-Clonic
Delirium tremens is initially manifested by anxiety, restlessness, illusions, hallucinations
and elevated vital signs.
Observation indicating a need to be included during endorsement to next shift in an
alcoholic patient in the ER include observations of becoming fearful (delirium tremens)
DRUGS CAUSING DELIRIUM
Cardiac glycosides ■Cimetidine(Tagamet)
Hypoglycemic agents ■Insulin
Narcotics ■Propranolol (Inderal)
Reserpine ■Thiazide diuretics
MOST COMMON CAUSES OF DELERIUM
COMMONLY USED ANTICONVULSANTS
1. Valium (Diazepam) à best drug for delirium tremens
2. Librium (Clordiazepoxide)
Positive) outcome of Librium in alcoholic depressed woman includes an observation
that client can pick an object on floor w/ smooth coordination
3. Klonopin (Clonazepam) à
4. Phenytoin (Dilantin) à best anticonvulsant for children
SE: Gingival hyperplasia & red orange urine
Intervention: Massage the gums & use soft bristle toothbrush
Adverse Effect: Blood dyscrasia
thrombocytopenia S/SX: Bleeding of the gums
Lab test: Platelet count = 150,000-400,000; if ↓100,000-
Special Considerations: The only COMPATIBLE I.V. Solution for Phenytoin (dilantin) is
NSS (Normal Saline Solution)
5. Carbamazepine (Tegretol): Anticonvulsant à trigeminal neuralgia (tic douloureux)
A/E: Agranulocytosis/neutropenia –
S/Sx: Sore throat - Neutrophils 54-56 %
6. Valproic Acid (Depakene/Depakote) therapeutic serum level: 40-100 mcg.
Adverse Reaction: Hepatotoxic (assess SGPT or ALT)
7. Ethosuccimide (zarontin)
Chlordiazepoxide (Librium), multivitamins, thiamine and folic acid
help decrease withdrawal symptoms.
GENERAL PRINCIPLES OF CARE: DETOXIFICATION/OVERDOSE
A. Maintain airway: Intubation (keep airway on hand), suction
B. Start IV line
C. Monitoring: BP, respiration, pulse, temperature, LOC
D. Prevent and control seizures; Keep in calm, quiet environment
E. Check for trauma, protect from injury
A pt taking phencyclidine (PCP), shouts & walks back & forth, appropriate nursing
intervention includes seclusion, staying w/ the pt, and decreasing stimuli.
F. Administer ordered drugs; Detoxify / treat overdose-
NALOXONE (NARCAN) – Pure antagonist to narcotics-induces withdrawal and
stimulates respiration; DRUG OF CHOICE when in doubt the substance used
because NALOPHINE (NALLIN), a partial antagonist to narcotics, will ↑ respiratory
depression if barbiturates have also been used
METHADONE – drug substitute used for acute withdrawal and long-term
maintenance; changes an illegal to a legal drug, which is administered under
Antidepressants block the ‘high’ from stimulant abuse
G. Nutrition: High-calorie, high-protein, high-vitamin
SEXUAL DISORDERS / DYSFUNCTION
A. SEXUAL DISORDER: Deviations in sexual behavior; sexual behaviors that are directed
toward anything other than consenting adults or are performed under unusual
circumstances and are considered abnormal
B. PARAPHILIA: Sexual fantasies or urges that are directed toward nonhuman objects, the
pain to self or partner, or children and other nonconsenting individuals.
1. EXHIBITIONISM: Sexual gratification from exposing genitalia
2. FETISHISM: Sexual gratification from an inanimate object (usually clothing material)
substituted for the genitals
3. FROTTEURISM: Sexual gratification from toughing or rubbing against a nonconsenting
person (usually in crowds, public transportation)
4. MASOCHISM: Sexual gratification from self-suffering used as an accompaniment of the
sexual act or substitute for it
5. PEDOPHILIA: Sexual gratification from children
6. SADISM: Sexual gratification from inflicting pain or cruelty to others used as an accompaniment of the
sexual act or a substitute for it
7. TRANSVESTISM: Sexual gratification from wearing clothes of the opposite sex
8. VOYEURISM: Sexual gratification from watching the sexual play / act of others
9. ZOOPHILIA: Sexual gratification from animals
C. SEXUAL DYSFUNCTION: Generalized or situational, acquired or lifelong inhibition or
interference with any of the phases of the sexual responses which may be due to psychogenic
factors alone or psychogenic and biologic combined.
D. NURSING DIAGNOSES
1. Anxiety related to threat to security and fear of discovery
2. Anxiety related to conflict between sexual desires social norms
3. Sexual dysfunction related to actual or perceived sexual limitations
4. Sexual dysfunction related to inability to achieve sexual satisfaction without the use of
5. Potential for infection related to frequent changes in sexual partners or sadistic or
6. Potential for injury / violence related to sexual behavior and retaliation for sexual behaviors
E. GENERAL PRINCIPLES OF CARE
1. Acceptance NOT of the behavior but of the client who is in emotional pain
2. Protection of the client from others
3. Setting limits on the sexual acting out
4. Supporting of self-esteem: Avoidance of punitive remarks or responses
5. Provision of diversional activities
PERVASIVE DEVELOPMENTAL DISORDERS
Autism, Conduct Disorder, Attention Deficit Hyperactive Disorder (ADHD),
A. A type of developmental disorder for an unknown; probable underlying problem: failure to
develop satisfactory relationships with significant adults
- mostly males
- talented in music or math
- # 1 screening test – DDST (Denver Developmental Screening Test)
- Autism is usually diagnosed during the toddler stage.
1. Blank stare
2. Repetitive movement: head banging à padded room/helmet
3. Likes to follow bright moving objects
5. Temper tantrums
6. Clings to inanimate objects
B. ASSESSMENT FINDINGS:
1. Disturbance in sense of self-identity, in ego system formation: Inability to distinguish
between self and reality / environment → speaks of self in the third person
2. Withdrawal from reality.
3. Lacks meaningful relationship with outside world; turns to inanimate objects and self-
centered activities for security
4. Personality alteration – adaptive, inhibitory, steering mechanisms due to profound
interference in intellect
5. SEVERE AUTISM – Severe apathy, Association looseness, Autistic thinking, Poor grasp of
reality, Ambivalence, Poor communication skills, Poor interpersonal relations, Poor
C. NURSING DIAGNOSIS: Potential for Injury
D. NURSING IMPLEMENTATION:
1. Provide consistent, routine ADL in familiar environment
2. Set consistent and firm limits for his behavior
3. Make physical contact on a regular basis. Accept the client’s need to push but still
maintain regular contact.
4. Prevent acts of self-destructive behavior
5. Provide appropriate therapy:
● Removal from home, if necessary; consistent loving home care is still favored over hospitalization;
consistent care giver; never leave alone; and always provide safety.
● Psychotherapy: Play, group, individual therapy
Primary treatment goal to facilitate the recovery of an autistic child should
include playing with blocks not with balls .
Occupational Therapy #1 à behavior modification #2
Behavior modification in an autistic child enables the nurse to modify the child’s
● Pharmacology: Tranquilizers and amphetamines to reduce symptoms
Caring autistic children requires specialized skills.
ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)
A. Disruptive behavioral disorder evident before 7 years old and lasting at least 6 months
and characterized by hyperactivity and inattentiveness
THEORIES: ↑ Norepinephrine,Serotonin
- #1 Screening Test à DDST
1. Hyperactive à could not sit and stay in 15 minutes
2. ↑metabolism à fatigue
3. handwriting not legible
4. Easily agitated by noise & color (orange/yellow)
1. Severe inattentiveness with or without hyperactivity
2. Short attention span
3. Excessive impulsiveness
4. Squirming and fidgeting
5. 5. Hyperactive à could not sit and stay in 15 minutes
↑metabolism à fatigue
handwriting not legible
Easily agitated by noise & color (orange/yellow)
1. Set realistic, attainable goals
2. Provide firm, consistent discipline with opportunities to experience satisfaction and
3. Provide a structured environment-
● With a balance of energy expenditure and quiet time
● With learning experience utilizing child’s ability
● With exercise in perceptual-motor coordination
● With LESS STIMULATION
The priority needs of the child with ADHD are safety and provision of
Catching attention of a child with ADD includes getting him to look at his mom & give
him simple directions.
4. Administer drugs as ordered: RITALIN (methylphenidate) or dextroamphetamine sulfate
5. #1 Therapy: Occupational Therapy using behavior modification
DIET: ↑caloric content – finger foods
Vitamin B Complex ↑ appetite
Do not mix Caffeinated food/drinks with ACA/alcohol
Tx: 1. RITALIN (Methylphenidate: BEST GIVEN before BREAKFAST)
Always with meals
Ritalin, the drug of choice for ADHD causes growth suppression, insomnia and suppression of
1. Psychostimulant – to increase attention span
2. Dextroamphetamine (Dexedrine)
3. Pemoline (Cylert) very hepatotoxic!!!
4. Stratera ( Atomoxetine) newest psychostimulant!!
Contraindication: Do not give below 6 yo à hepatotoxic à SGPT
Stratera, a drug for ADD/ADHD enhances catecholamine effect.
àStatement like, “My son is able to accomplish his task better,” indicates
efficacy of the drug.
A. DEFINITION: Physical abuse and emotional neglect; may include sexual abuse
B. CAUSE: Exact-unknown; Present in all socioeconomic levels
● Obvious physical injuries, disturbance on parent-child interaction (Absence of PROTEST
on admission of a toddler is a sign of abuse.)
● Inconsistency of declaration of the type, location, cause of injury, discovery of
undeclared / unreported fractures
● Malnutrition / failure to thrive / emotional neglect
● Sexual abuse signs: Genital bruises, lacerations; STDs
History: Parents who were abused as kids
Other characteristics of abusive parents:
1) Tend to be young, immature, dependent;
2) Low in self- esteem
3) Lacks identity
4) Expect child to provide them with love and care (PERSONAL ROLE THEORY of causation)
5) With incorrect concept of what the child is, and can do
6) With inadequate resources and support system
Abusive parents usually have low-self-esteem and has little social involvement.
Child abuse is common in the lower socio-economic class.
The interaction between the abuse child and a mother provides a clue to the kind of
relationship that this child has with his mother.
In working with the mother of abused child, therapeutic use of self requires self
awareness initially, therefore the nurse has to deal with her feelings first.
Attendance to a parenting class is a step towards learning parenting skills, which are
lacking in abusive parents.
D. POTENTIAL NURSING DIAGNOSES
1) Impaired Skin Integrity
2) Infective Family Coping
E. NURSING IMPLEMENTATION
o FIRST: Meet physical needs; treat injuries
o MANDATORY: REPORTING of suspected cases to appropriate agency (SAVE EVIDENCES;
Notify the legal authorities about reports of a battered 7 y/o girl is part of the
responsibilities of an RN
EMOTIONAL SUPPORT to child: PLAY THERAPY to express feelings; NONJUDGMENTAL
ATTITUDE toward parents
ROLE MODELING for parents who are encouraged to care for child
DOCUMENTATION of ACTUAL FINDIGNS not interpretation nor opinion
POSSIBLE INDICATORS OF ELDER ABUSE
Physical abuse indicators
Frequent, unexplained injuries accompanied by a habit of seeking medical assistance
from various locations
Reluctance to seek medical treatment for injuries, or denial of their existence
Disorientation or grogginess indicating misuse of medications
Fear or edginess in the presence of family member or caregiver
Psychological or Emotional abuse indicators
Hesitance to talk openly
Anger or agitation
Withdrawal or depression
Financial abuse indicators
Unusual or inappropriate activity in bank accounts
Signatures on checks that differ from the elder’s
Recent changes in will or power of attorney when elder is not capable of making those
Missing valuable belongings that are no just misplaced
Lack of television, clothes, or personal items that are easily affordable
Unusual concern by the caregiver over the expense of the elder’s treatment when it is
not the caregiver’s money being spent
Dirt, fecal or urine smell, or other health hazards in the elder’s living environment
Rashes, sores, or lice on the elder
Elder has an untreated medical condition is malnourished or dehydrated not related to a
Indicators of self-neglect
Inability to manage personal finances, such as hoarding, squandering, or giving away
money while not paying bills
Inability to manage activities of daily living such as personal care, shopping, housework
Wandering, refusing needed medical attention , isolation, substance use
Failure to keep needed medical appointments
Confusion, memory loss, unresponsive
Lack of toilet facilities, living quarters infested with animals or vermin
Warning indicators from caregiver
Elder is not given opportunity to speak for self, to have visitors, or to see anyone
without the presence of the caregiver
Attitudes of indifference or anger toward the elder
Blaming the elder for his or her illness or limitations
Conflicting accounts of elder’s abilities, problems, and so forth
Previous history of abuse or problems with alcohol or drugs.