Psychiatric Nursing Slides

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  • Phases Orientation  Purpose of the group is stated, Objectives and expectations are laid out Working  Leaders role is to keep the group focused, Support for each other to attain group goals Termination  Leader acknowledges each member’s contribution and experience as a whole  Members prepare for separation
  • Anxiety about being in places or situation from which escape might be difficult (or embarassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic or panic like symptoms. Agoraphobic fears typically involve characteristics cluster of situations that include being outside the home alone: being in a crowd or standing in a line; being on a bridge; and traveling on a bus, train or automobile.
  • First described by Emil Kraeplin and Eugen Bleuler. Previously known as dementia precox. Schizophrenia is a combination of two Greek words “schizien” and phren “mind” Age of onset: Late teens or early twenties Strong genetic compoenent
  • First described by Emil Kraeplin and Eugen Bleuler. Previously known as dementia precox. Schizophrenia is a combination of two Greek words “schizien” and phren “mind” Age of onset: Late teens or early twenties Strong genetic compoenent
  • Paranoid Characterized by prominent persecutory or grandiose delusions Most common form of the illness Undifferentiated Delusions and hallucinations of any type are prominent Accompanied by incoherence and grossly disorganized behavior Disorganized Characterized by the absence of systematized delusions and the presence of incoherence and inappropriate affect Residual Positive symptoms are minimal and negative symptoms predominate Catatonic * Motor disturbances predominate consisting of either agitated hyperactivity or a decrease in gross motor activity
  • Paranoid Characterized by prominent persecutory or grandiose delusions Most common form of the illness Undifferentiated Delusions and hallucinations of any type are prominent Accompanied by incoherence and grossly disorganized behavior Disorganized Characterized by the absence of systematized delusions and the presence of incoherence and inappropriate affect Residual Positive symptoms are minimal and negative symptoms predominate Catatonic * Motor disturbances predominate consisting of either agitated hyperactivity or a decrease in gross motor activity
  • Paranoid Characterized by prominent persecutory or grandiose delusions Most common form of the illness Undifferentiated Delusions and hallucinations of any type are prominent Accompanied by incoherence and grossly disorganized behavior Disorganized Characterized by the absence of systematized delusions and the presence of incoherence and inappropriate affect Residual Positive symptoms are minimal and negative symptoms predominate Catatonic * Motor disturbances predominate consisting of either agitated hyperactivity or a decrease in gross motor activity
  • Limit Setting is an effective technique that involves three steps: stating the behavioral limit (describing the unacceptable behavior), identifying the consequences that will occur if the limit is exceeded, an identifying the behavior that is expected or desired. Consistent limit-setting in a matter of fact, nonjudgemental manner is crucial to the success of this technique. For example. The client may approach the nurse in a flirtatious manner and attempt to gain personal information. The nurse would use limit-setting by saying” It is not acceptable for you to ask personal questions. If you continue to do that, I will terminate our interaction”. Confrontation is another technique designed to manage manipulative or deceptive behavior. The nurse points out the client’s problematic behavior while remaining neutral and matter of fact; the nurse avoids responding to the client in an accusatory manner. Confrontation can also be sued to keep the client focused on the topic and in the present. The nurse can keep the focus on the client’s behavior rather than his or hear attempts to justify the behavior. Nurse: You've said you’re interested in learning to mange anger outbursts, but you have missed the last 3 group meetings Client: Well I can tell no one in the group likes me. Why should I bother? Nurse: The group meetings are designed to help you and the others, but you can’t work on issues if you are not here.
  • Mild delirium that becomes more pronounced in the evening is called sundowning.
  • Homosexuality-> sexual attraction to members of the same sex Heterosexuality-> sexual attraction to members of the opposite sex Bisexuality  sexual attraction to members of the opposite sex and the same sex Masochism  experiencing sexual attraction, urges or arousal when receiving pain Sadism  experiencing sexual attraction, urges or arousal when giving pain Frotteurism  pleasure from rubbing genitals against unconsenting victim Pedophilia  sexual pleasure with children below 13 Necrophilia  sexual pleasure with the dead Voyerism  experiencing intense pleasure from watching people undress Transvestism  cross dressing with the opposite sex Transexualism  going from one sex to another
  • Anorexia nervosa is a life threatening eating disorder characterized by the aforementioned symptoms.
  • Psychiatric Nursing Slides

    1. 1. PSYCHIATRIC NURSING
    2. 3. Mental Health <ul><li>A state of emotional, psychological and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self-concept and emotional stability. </li></ul>
    3. 4. COMPONENTS OF MENTAL HEALTH <ul><li>Autonomy and Independence - can work interdependently without losing autonomy </li></ul><ul><li>Maximization of One’s Potential- oriented towards growth and self-actualization </li></ul><ul><li>Tolerance of Life’s Uncertainties- can face the challenges of day-to-day living with hope & positive look </li></ul><ul><li>Self-esteem- has realistic awareness of her abilities and limitations </li></ul><ul><li>Mastery of the Environment- can deal with and influence the environment </li></ul><ul><li>Reality Orientation- can distinguish the real world from a dream, fact from fantasy </li></ul>
    4. 5. MENTAL ILLNESS <ul><li>- State of imbalance characterized by a disturbance in a person’s thoughts, feelings and behavior </li></ul>
    5. 6. Criteria to Diagnose Mental Disorders <ul><li>Dissatisfactions with one’s characteristics, accomplishments, abilities </li></ul><ul><li>Ineffective or dissatisfying relationships </li></ul><ul><li>Dissatisfaction with one’s place in the world </li></ul><ul><li>Ineffective coping with life’s events </li></ul><ul><li>Lack of personal growth </li></ul>
    6. 7. PSYCHIATRIC NURSING <ul><li>Interpersonal process whereby the nurse through the therapeutic use of self assist an individual family, group or community to promote mental health, to prevent mental illness and suffering, to participate in the treatment and rehabilitation of the mentally ill and if necessary to find meaning in these experiences </li></ul>
    7. 8. CORE OF PSYCHIATRIC NURSING <ul><li>Interpersonal relationship </li></ul><ul><li>FOCUS: Patient </li></ul>
    8. 9. Foundation <ul><li>Central Nervous System </li></ul><ul><li>Cerebrum </li></ul><ul><ul><li>Frontal lobe – control organization of thought, body movement, memories, emotions and moral behavior. </li></ul></ul><ul><ul><ul><li>Associated with schizophrenia, attention deficit / hyperactive disorder and dementia </li></ul></ul></ul><ul><ul><li>Parietal lobe – interpret sensations of taste and touch and assist is spatial orientation . </li></ul></ul>
    9. 10. Foundation <ul><li>Central Nervous System </li></ul><ul><ul><li>Temporal lobes – are centers for the sense of smell, hearing, memory, and expression of emotions. </li></ul></ul><ul><ul><li>Occipital lobes – assist in coordinating language generation and visual interpretation, such as depth perception. </li></ul></ul>
    10. 11. Neurotransmitters <ul><li>Dopamine- controls complex movements, motivation, cognition, regulates emotional responses </li></ul><ul><li>Serotonin- regulation of emotions, controls food intake, sleep and wakefulness, pain control, sexual behaviors </li></ul><ul><li>Acetylcholine- controls sleep and wakefulness cycle (decreased in Alzheimer’s) </li></ul><ul><li>Histamine- controls alertness,peripheral allergic reactions, cardiac stimulations </li></ul><ul><li>GABA- modulates other neurotransmitters </li></ul><ul><li>Norepinephrine / Epinephrine- causes changes in attention, learning and memory, mood </li></ul>
    11. 12. Foundation <ul><li>Neurotransmitters </li></ul><ul><li>Sympathetic Parasympathetic </li></ul><ul><li>Increase v/s Decrease v/s </li></ul><ul><li>Decrease GI motility Increase GI motility </li></ul><ul><li>Decrease GU function Increase GU function </li></ul><ul><li>Moist mouth Dry mouth </li></ul>
    12. 13. Genetics and Hereditary <ul><li>Alzheimer’s disease – linked with defects in chromosomes 14 and 21 </li></ul><ul><li>Schizophrenia </li></ul><ul><li>Mood disorders (depression) </li></ul><ul><li>Autism and AD/HD </li></ul>
    13. 14. Sigmund Freud <ul><li>Father of Psychoanalysis </li></ul><ul><li>- “Your behavior today is directly or indirectly affected by your childhood days or experiences. </li></ul><ul><li>- STRUCTURE – Personality Structure </li></ul>
    14. 15. Personality Structure <ul><li>ID ( 4-5MONTHS) </li></ul><ul><ul><li>Impulsive / Instinctual drive </li></ul></ul><ul><ul><li>I want to… PLEASURE PRINCIPLE </li></ul></ul><ul><ul><li>I want to… PHYSIOLOGIC NEEDS </li></ul></ul><ul><ul><li>I want to… PRIMARY PROCESS </li></ul></ul>
    15. 16. Personality Structure <ul><li>SUPEREGO </li></ul><ul><ul><li>Should not </li></ul></ul><ul><ul><li>Small voice of GOD </li></ul></ul><ul><ul><li>Set norms, standards and values </li></ul></ul><ul><ul><li>MORAL PRINCIPLE </li></ul></ul><ul><ul><li>Conscience </li></ul></ul>
    16. 17. Personality Structure <ul><li>EGO </li></ul><ul><ul><li>Executive </li></ul></ul><ul><ul><li>REALITY PRINCIPLE </li></ul></ul><ul><ul><li>Conscious </li></ul></ul><ul><ul><li>Competencies </li></ul></ul><ul><ul><li>Decision Maker; Problem-Solving; Critical and Creative thinking </li></ul></ul>
    17. 18. Imbalances between Personality Elements ID SE M – anic A – nti-social N – arcissistic
    18. 19. Imbalances between Personality Elements ID SE O – bsessive Compulsive A – norexia nervosa
    19. 20. Imbalances between Personality Elements EGO Schizophrenia
    20. 21. Libido <ul><li>Sexual energy responsible for survival of human beings </li></ul><ul><li>Psychosexual Theory of Freud </li></ul>
    21. 22. ORAL STAGE <ul><li>18 months </li></ul><ul><li>Cry, suck, mouth </li></ul><ul><li>EGO @ 6 months </li></ul><ul><ul><li>Child cries – fed – successful </li></ul></ul><ul><ul><li>Child cries – ignored – unimportant - narcissistic </li></ul></ul>
    22. 23. FIXATION <ul><li>occurs when a person is stuck in a certain developmental stage </li></ul>
    23. 24. REGRESSION <ul><li>Returning to an earlier developmental stage </li></ul><ul><li>Infantile behavior </li></ul>
    24. 25. ANAL STAGE <ul><li>18 months – 3 years old </li></ul><ul><li>SUPEREGO develops </li></ul><ul><li>Toilet training </li></ul><ul><ul><li>Good Mother – Normal </li></ul></ul><ul><ul><li>Bad Mother </li></ul></ul><ul><ul><ul><li>Clean, organized, obedient – OC (anal retentive) </li></ul></ul></ul><ul><ul><ul><li>Dirty, disorganized – Anti-social (anal expulsive) </li></ul></ul></ul>
    25. 26. PHALLIC STAGE <ul><li>Preschooler (3 – 6 years old) </li></ul><ul><li>Parent </li></ul><ul><ul><li>Oedipus Complex </li></ul></ul><ul><ul><ul><li>Castration Fear </li></ul></ul></ul><ul><ul><li>Electra Complex </li></ul></ul><ul><ul><ul><li>Penis Envy </li></ul></ul></ul>
    26. 27. REPRESSION <ul><li>UNCONSCIOUS forgetting of an anxiety provoking concept </li></ul>
    27. 28. SUPRESSION <ul><li>CONSCIOUS forgetting of an anxiety provoking situation </li></ul>
    28. 29. IDENTIFICATION <ul><li>attempts to resemble or pattern the personality of a person being admired of </li></ul>
    29. 30. INTROJECTION <ul><li>acceptance of another values and opinion as one’s own </li></ul>
    30. 31. LATENCY STAGE <ul><li>6 to 12 years old </li></ul><ul><li>School </li></ul><ul><li>Reading, writing, arithmetic </li></ul><ul><li>Ability to care about and relate to others outside home </li></ul>
    31. 32. SUBLIMATION <ul><li>placing sexual energies toward more productive activities </li></ul>
    32. 33. SUBSTITUTION <ul><li>replace a goal that can’t be achieved for another that is more realistic. </li></ul>
    33. 34. GENITAL STAGE <ul><li>12 years old and above </li></ul><ul><li>Developing satisfying sexual and emotional relationships with members of the opposite sex </li></ul><ul><li>Planning life’s goals </li></ul>
    34. 35. EGO DEFENSE MECHANISMS <ul><li>Function-To ward off anxiety </li></ul><ul><li>*without defense mechanisms, anxiety might overwhelm and paralyze us and interfere with daily living </li></ul><ul><li>2 Features: </li></ul><ul><li>1. 1.   they operate on an unconscious level (Except suppression) </li></ul><ul><li>2.  2.  they deny, falsify or distort reality to make it less threatening </li></ul>
    35. 36. EGO DEFENSE MECHANISMS <ul><li>Repression vs. Suppression </li></ul><ul><li>REPRESSION </li></ul><ul><ul><li>Unconscious forgetting of an anxiety provoking concept </li></ul></ul><ul><li>SUPRESSION </li></ul><ul><ul><li>Conscious forgetting of an anxiety provoking situation </li></ul></ul>
    36. 37. EGO DEFENSE MECHANISMS <ul><li>Regression vs. Fixation </li></ul><ul><li>Regression </li></ul><ul><li>Returning to an earlier developmental stage </li></ul><ul><li>Fixation </li></ul><ul><li>occurs when a person is stuck in a certain developmental stage </li></ul>
    37. 38. EGO DEFENSE MECHANISMS <ul><li>Rationalization vs. Intellectualization </li></ul><ul><li>RATIONALIZATION </li></ul><ul><ul><li>Self-saving with incorrect illogical explanation </li></ul></ul><ul><li>INTELLECTUALIZATION </li></ul><ul><ul><li>Excessive use of abstract thinking; technical explanation </li></ul></ul>
    38. 39. EGO DEFENSE MECHANISMS <ul><li>Displacement vs. Projection vs. Introjection </li></ul><ul><li>DISPLACEMENT </li></ul><ul><ul><li>Feelings are transferred or redirect to other person or object that is less threatening </li></ul></ul><ul><li>PROJECTION </li></ul><ul><ul><li>Blaming; Falsely attributing to another his/her own unacceptable feelings. </li></ul></ul><ul><li>INTROJECTION </li></ul><ul><ul><li>Acceptance of another’s values and opinions as one’s own </li></ul></ul>
    39. 40. EGO DEFENSE MECHANISMS <ul><li>Sublimation vs. Substitution </li></ul><ul><li>SUBLIMATION </li></ul><ul><ul><li>Transfer of sexual energy to a more productive activity. </li></ul></ul><ul><li>SUBSTITUTION </li></ul><ul><ul><li>Replaces a goal that can’t be achieved for another that is more realistic. </li></ul></ul>
    40. 41. EGO DEFENSE MECHANISMS <ul><li>Dissociation vs. Isolation </li></ul><ul><li>DISSOCIATION </li></ul><ul><ul><li>Separating and detaching idea, situation from its emotional significance. </li></ul></ul><ul><li>ISOLATION </li></ul><ul><ul><li>Individual strips emotion when talking or responding about it. </li></ul></ul>
    41. 42. EGO DEFENSE MECHANISMS <ul><li>Conversion </li></ul><ul><ul><li>Anxiety converted to physical symptoms </li></ul></ul><ul><li>Compensation </li></ul><ul><ul><li>Overachievement in one area to overpower weaknesses or defective area. </li></ul></ul><ul><li>Undoing </li></ul><ul><ul><li>Doing the opposite of what have done </li></ul></ul>
    42. 43. EGO DEFENSE MECHANISMS <ul><li>Denial </li></ul><ul><ul><li>Failure to acknowledge an unacceptable trait or situation </li></ul></ul><ul><li>Fantasy </li></ul><ul><ul><li>Magical thinking </li></ul></ul><ul><li>Reaction Formation </li></ul><ul><ul><li>Opposite of intention </li></ul></ul>
    43. 44. EGO DEFENSE MECHANISMS <ul><li>Acting out </li></ul><ul><ul><li>Deals with emotional conflict or stressors by ACTION rather than reflection or feelings. </li></ul></ul><ul><li>Symbolization </li></ul><ul><ul><li>Creates a representation to an anxiety provoking thing or concept </li></ul></ul><ul><li>Splitting </li></ul><ul><ul><li>Labile emotions; all bad – all good </li></ul></ul>
    44. 45. DEFENSE MECHANISMS COMMONLY USED IN EACH RESPECTIVE DISORDERS <ul><ul><li>Paranoid – Projection </li></ul></ul><ul><ul><li>Phobia – Displacement </li></ul></ul><ul><ul><li>Amnesia – Dissociation </li></ul></ul><ul><ul><li>Anorexia – Supression </li></ul></ul><ul><ul><li>Bipolar Disorder – Reaction Formation </li></ul></ul><ul><ul><li>Borderline – Splitting </li></ul></ul><ul><ul><li>Schizophrenia – Regression </li></ul></ul><ul><ul><li>Substance Abuse – Denial </li></ul></ul><ul><ul><li>Depression – Introjection </li></ul></ul><ul><ul><li>OC – Undoing </li></ul></ul><ul><ul><li>Catatonic - Repression </li></ul></ul>
    45. 46. <ul><li>Woman who is angry with her boss writes a short story about a heroic woman. </li></ul>
    46. 47. <ul><li>Woman who is angry with her boss writes a short story about a heroic woman. </li></ul>
    47. 48. <ul><li>Four-year old with new baby brother starts sucking his thumb and wanting a bottle. </li></ul>
    48. 49. <ul><li>Patient criticizes the nurse after her family failed to visit. </li></ul>
    49. 50. <ul><li>Man who is unconsciously attracted to other women teases his wife about flirting </li></ul>
    50. 51. <ul><li>Short man becomes assertively verbal and excels in business. </li></ul>
    51. 52. <ul><li>Recovering alcoholic constantly preaches about the evils of drink. </li></ul>
    52. 53. Man reacts to news of the death of a loved one “ No, I don’t believe you. The doctor said he was fine.”
    53. 54. <ul><li>Student is unable to take a final exam because of a terrible headache. </li></ul>
    54. 55. <ul><li>After flirting with her male secretary, a woman brings her husband tickets to a show. </li></ul>
    55. 56. <ul><li>“ I didn’t get the raise because my boss doesn’t like me.” </li></ul>
    56. 57. <ul><li>Five-year old girl dresses in her mother’s shoes and dress and meets daddy at the door. </li></ul>
    57. 58. <ul><li>After his wife’s death, husband has transient complaints of chest pain and difficulty breathing- the symptoms his wife had before she died </li></ul>
    58. 59. <ul><li>Man forgets wife’s birthday after a marital fight. </li></ul>
    59. 60. <ul><li>Businessman who is preparing to make an important speech that day is told by his wife that morning that she wants a divorce. Although visibly upset, he puts this incident aside until after his speech, when he can give the matter his total concentration. </li></ul>
    60. 61. <ul><li>A man cannot accept his physician's diagnosis of cancer is correct and seeking a second opinion </li></ul>
    61. 62. <ul><li>slamming a door instead of hitting as person, yelling at your spouse after an argument with your boss </li></ul>
    62. 63. <ul><li>focusing on the details of a funeral as opposed to the sadness and grief </li></ul>
    63. 64. <ul><li>stating that you were fired because you didn't kiss up the the boss, when the real reason was your poor performance </li></ul>
    64. 65. <ul><li>having a bias against a particular race or culture and then embracing that race or culture to the extreme </li></ul>
    65. 66. <ul><li>sitting in a corner and crying after hearing bad news; throwing a temper tantrum when you don't get your way </li></ul>
    66. 67. <ul><li>forgetting sexual abuse from your childhood due to the trauma and anxiety </li></ul>
    67. 68. <ul><li>lifting weights to release 'pent up' energy </li></ul>
    68. 69. Erik Erickson Psychosocial Theory of Development
    69. 70. PSYCHOSOCIAL THEORY – Erikson’s <ul><li>0-18 mos. T rust vs. M istrust </li></ul><ul><li>-attachment to mother which lays foundations for later trust in others </li></ul><ul><li>-conflict: general difficulties relating to others. suspicion, fear of the future </li></ul>
    70. 71. PSYCHOSOCIAL THEORY – Erikson’s <ul><li>18 m0s – 3 yrs A utonomy vs. S hame/Doubt </li></ul><ul><li>Gaining some basic control of self and environment </li></ul><ul><li>Conflict: independence-fear conflict, severe feelings of self-doubt </li></ul>
    71. 72. PSYCHOSOCIAL THEORY – Erikson’s <ul><li>3 yrs – 6 yrs I nitiative vs. G uilt </li></ul><ul><li>-becoming purposeful and directive </li></ul><ul><li>-conflict: aggression-fear conflict; sense of inadequacy and guilt </li></ul>
    72. 73. PSYCHOSOCIAL THEORY – Erikson’s <ul><li>6 yrs – 12 yrs Industry vs. Inferiority </li></ul><ul><li>Developing social, physical and school skills, competence </li></ul><ul><li>Conflict: sense of inferiority; difficulty learning and working </li></ul>
    73. 74. PSYCHOSOCIAL THEORY – Erikson’s <ul><li>12 yrs – 20 yrs Identity vs. Role Diffusion </li></ul><ul><li>Making transition from childhood to adulthood; developing a sense of identity </li></ul><ul><li>Conflict: confusion of who one is, identity submerged in relationships or group memberships </li></ul>
    74. 75. PSYCHOSOCIAL THEORY – Erikson’s <ul><li>21 yrs – 35 yrs Intimacy vs. Isolation </li></ul><ul><li>-establishing intimate bonds of love and friendship </li></ul><ul><li>-conflict: emotional isolation </li></ul>
    75. 76. PSYCHOSOCIAL THEORY – Erikson’s <ul><li>35 yrs – 55 yrs Generativity vs. Stagnation </li></ul><ul><li>-fulfilling life’s goals that involve family, career and society, developing concerns that embrace future generations </li></ul><ul><li>-conflict: self-absorption. Inability to grow as a person </li></ul>
    76. 77. PSYCHOSOCIAL THEORY – Erikson’s <ul><li>55 yrs – above Integrity vs. Despair </li></ul><ul><li>Looking back into one’s life and accepting its meaning </li></ul><ul><li>Conflict: dissatisfaction with life, denial of or despair over prospect of death </li></ul>
    77. 78. Jean Piaget Cognitive Theory of Development
    78. 79. assimilation <ul><li>people transform incoming information so that it fits within their existing schemes or thought patterns </li></ul>
    79. 80. accommodation <ul><li>people adapt their schemes to include incoming information </li></ul>
    80. 81. PIAGET’S COGNITIVE THEORY <ul><li>SENSORIMOTOR STAGE- development proceeds from reflex activity to representation and sensorimotor solutions to problems </li></ul><ul><ul><li>0 to 18 months </li></ul></ul><ul><li>PRE-OPERATIONAL STAGE- development proceeds from sensorimotor representation to prelogical thought and solutions to problems </li></ul><ul><li>can use these representational skills only to view the world from their own perspective. </li></ul><ul><li>Understand the meaning of symbolic gestures </li></ul><ul><ul><li>2 to 7 years </li></ul></ul>
    81. 82. <ul><li>CONCRETE OPERATIONAL- development proceeds from prelogical thought to logical solutions to concrete problems </li></ul><ul><li>understand concrete problems </li></ul><ul><li>cannot yet contemplate or solve abstract problems </li></ul><ul><ul><li>7 to 12 years </li></ul></ul><ul><li>FORMAL OPERATIONAL- development proceeds from logical solutions to concrete problems to logical solutions to all classes of problems </li></ul><ul><li>cannot yet contemplate or solve abstract problems </li></ul><ul><li>can also reason theoretically </li></ul><ul><ul><li>12 and above </li></ul></ul>
    82. 83. Harry Stack Sullivan Interpersonal Theory
    83. 84. SULLIVAN’S INTERPERSONAL THEORY <ul><li>Infancy- anxiety develops as a result of unmet needs by the mother (bodily needs ); needs met, the child has sense of well-being </li></ul><ul><ul><li>0 to 18 months </li></ul></ul><ul><li>Childhood- anxiety as a result of lack of praise/acceptance from parents </li></ul><ul><li>-gratification leads to positive self-esteem </li></ul><ul><li>- moderate anxiety leads to uncertainty and insecurity; - severe anxiety results in self-defeating patterns of behavior </li></ul><ul><ul><li>18 months to 6 years </li></ul></ul><ul><li>Juvenile- severe anxiety may result in a need to control or restrictive, prejudicial attitudes </li></ul><ul><li>-learns to negotiate own needs </li></ul><ul><ul><li>6 to 9 years </li></ul></ul>
    84. 85. <ul><li>Pre-adolescence - capacity to attachment, love and collaboration emerges or fails to develop </li></ul><ul><li>-move to genuine intimacy with friend of the same sex </li></ul><ul><ul><li>9 to 12 years </li></ul></ul><ul><li>Adolescence- if self-system is intact, areas of concern expand to include values, career decisions and social concerns </li></ul><ul><li>-lust is added to interpersonal equation </li></ul><ul><li>-need for special sharing relationship shifts to opposite sex </li></ul><ul><li>-new opportunities for social experimentation lead to consolidation or self-ridicule </li></ul><ul><ul><li>12 to adulthood </li></ul></ul>
    85. 86. Hildegard Peplau Nurse Patient Relationship
    86. 87. PEPLAU’S NPR <ul><li>PRE-INTERACTION </li></ul><ul><ul><li>Major task of nurse- to develop self-awareness </li></ul></ul><ul><li>ORIENTATION </li></ul><ul><ul><li>Major task of the nurse: to develop a mutual acceptable contract </li></ul></ul><ul><li>WORKING </li></ul><ul><ul><li>Major task: identification and resolution of patient’s problem </li></ul></ul><ul><li>TERMINATION </li></ul><ul><ul><li>Major task: to assist the patient to review what he has learned and transfer his learning to his relationship with others </li></ul></ul>
    87. 88. THERAPEUTIC COMMUNICATIONS <ul><li>ORIENTATION </li></ul><ul><ul><li>Broad Opening </li></ul></ul><ul><ul><li>Recognition </li></ul></ul><ul><ul><li>Giving information </li></ul></ul><ul><ul><li>Silence </li></ul></ul><ul><ul><li>Offering Self – “Do you want me to sit beside you?” </li></ul></ul>
    88. 89. THERAPEUTIC COMMUNICATIONS <ul><li>WORKING </li></ul><ul><ul><li>Focusing – “Let us discuss this topic more.” </li></ul></ul><ul><ul><li>Exploring – “Tell me more about it.” </li></ul></ul><ul><ul><li>Encourage Evaluation – “IS this what you want?” </li></ul></ul><ul><ul><li>Reflecting – same idea </li></ul></ul><ul><ul><li>Restating – same statement </li></ul></ul><ul><ul><li>Verbalizing Implied – “Are you going to kill yourself?” </li></ul></ul><ul><ul><li>Seeking Clarification – “May you please repeat that statement” </li></ul></ul><ul><ul><li>General lead – “Please continue.”; “And then?” </li></ul></ul><ul><ul><li>Limit setting – “Stop.” </li></ul></ul><ul><ul><li>Interpreting – “Maybe that thing is very significant to you.” </li></ul></ul>
    89. 90. THERAPEUTIC COMMUNICATIONS <ul><li>TERMINATION </li></ul><ul><ul><li>Summarizing – “Let us now sum up. You have stated earlier…etc.” </li></ul></ul><ul><ul><li>“ Do you have any questions?” </li></ul></ul><ul><ul><li>“ Our next therapy…” </li></ul></ul><ul><ul><li>Look for changes in behavior </li></ul></ul><ul><ul><li>Resistance is a common problem </li></ul></ul>
    90. 91. Therapeutic Communication Techniques <ul><li>Accepting-indicating reception </li></ul><ul><li>Eg.”Yes” </li></ul><ul><li>“ I follow what you said” </li></ul><ul><li>Nodding.. </li></ul>
    91. 92. Broad Openings <ul><li>Allowing the client to take the initiative in introducing the topic </li></ul><ul><li>Eg. “is there something you’d like to talk about?” </li></ul><ul><li>“ Where would you like to begin?” </li></ul>
    92. 93. Consensual Validation <ul><li>Searching for mutual understanding, for accord in the meaning of the words </li></ul><ul><li>Eg. “Tell me whether my understanding of it agrees with yours” </li></ul><ul><li>“ Are you using this word to convey that. . .?” </li></ul>
    93. 94. Encouraging Comparison <ul><li>Asking that similarities and differences be noted </li></ul><ul><li>Eg. “was it something like..?” </li></ul><ul><li>“ Have you had similar experiences?” </li></ul>
    94. 95. Encouraging Description of Perceptions <ul><li>Asking the client to verbalize what he or perceives </li></ul><ul><li>Eg.”Tell me when you feel anxious” </li></ul><ul><li>“ What is happening?” </li></ul><ul><li>‘ What does the voice seem to be saying?” </li></ul>
    95. 96. Encouraging Expression <ul><li>Asking client to appraise the quality of his or her experience </li></ul><ul><li>Eg. “what are your feelings in regard to..?” </li></ul><ul><li>“ Does this contribute to your distress?” </li></ul>
    96. 97. Exploring <ul><li>Delving further into a subject or idea </li></ul><ul><li>Eg. “Tell me more about that.” </li></ul><ul><li>“ Would you describe it more fully?” </li></ul><ul><li>“ What kind of work?” </li></ul>
    97. 98. Focusing <ul><li>Concentrating on a single point </li></ul><ul><li>Eg. “This point seems worth looking at more closely” </li></ul><ul><li>“ Of all the concerns you’ve mentioned, which is most troublesome?” </li></ul>
    98. 99. Formulating a Plan of Action <ul><li>-Asking the client to consider kinds of behavior likely to be appropriate in future situations </li></ul><ul><li>Eg. “What could you do to let your anger out harmlessly?” </li></ul><ul><li>“ Next time this comes up, what might you do to handle it?” </li></ul>
    99. 100. General Leads <ul><li>Giving encouragement to continue </li></ul><ul><li>Eg. “Go on” </li></ul><ul><li>“ And then?” </li></ul><ul><li>“ Tell me about it” </li></ul>
    100. 101. Giving Information <ul><li>Making available the facts that the client needs </li></ul><ul><li>Eg. “My name is…” </li></ul><ul><li>“ Visiting hours are…” </li></ul><ul><li>“ My purpose in being here is… “ </li></ul>
    101. 102. Giving Recognition <ul><li>Acknowledging, indicating awareness </li></ul><ul><li>Eg. “Good morning, Mr. S…” </li></ul><ul><li>“ You’ve finished your list of things to do.” </li></ul><ul><li>“ I noticed that you’ve combed your hair” </li></ul>
    102. 103. Making Observations <ul><li>Verbalizing what the nurse perceives </li></ul><ul><li>Eg. “You appear tense..” </li></ul><ul><li>“ I notice that your biting your lips” </li></ul>
    103. 104. Offering Self <ul><li>Making oneself available </li></ul><ul><li>Eg. “I’ll sit with you awhile” </li></ul><ul><li>“ I’ll stay here with you” </li></ul><ul><li>“ I’m interested in what you think” </li></ul>
    104. 105. Placing Event in Time or Sequence <ul><li>Clarifying the relationship of events in time </li></ul><ul><li>Eg. “what seemed to lead up to…? </li></ul><ul><li>“ Was this before or after?” </li></ul>
    105. 106. Presenting Reality <ul><li>Offering for consideration that which is real </li></ul><ul><li>Eg. “I see no one else in the room.” </li></ul><ul><li>“ Your mother is not here; I am a nurse.” </li></ul>
    106. 107. Reflecting <ul><li>Directing client actions, thoughts, and feelings back to client </li></ul><ul><li>Eg. Client: “Do you think I should tell the doctor…? Nurse: “Do you think you should?” </li></ul>
    107. 108. Restating <ul><li>Repeating the main idea expressed </li></ul><ul><li>Eg. Client: I can’t sleep. I stay awake all night.” </li></ul><ul><li>Nurse:You have difficulty sleeping.” </li></ul><ul><li>Client:”I’m really mad, and upset” </li></ul><ul><li>Nurse: You’re really mad and upset.” </li></ul>
    108. 109. Seeking Information <ul><li>Seeking to make clear that which is not meaningful or that which is vague </li></ul><ul><li>“ I’m not sure that I follow.” </li></ul><ul><li>“ Have I heard you correctly?” </li></ul>
    109. 110. Silence <ul><li>Absence of verbal communication, which provides time for for the client to put thoughts or feelings into words, regain composure, or continue talking </li></ul><ul><li>Eg. Nurses says nothing but continues to maintain eye contact and conveys interest. </li></ul>
    110. 111. Suggesting Collaboration <ul><li>Offering to share , to strive, to work with the client for his or her benefit </li></ul><ul><li>Eg. Perhaps you and I can discuss and discover the triggers for your anxiety </li></ul>
    111. 112. Summarizing <ul><li>Organizing and summing up that which has gone before </li></ul><ul><li>Eg. “Have I got this straight?” </li></ul>
    112. 113. Translating into Feelings <ul><li>seeking to verbalize client’s feelings that he or she expresses only indirectly </li></ul><ul><li>Eg. Client: “I’m dead” </li></ul><ul><li>Nurse: “Are you suggesting that you feel lifeless?” </li></ul>
    113. 114. Verbalizing the Implied <ul><li>Voicing what the client has hinted at or suggested </li></ul><ul><li>Eg. Client: I cant’ talk to you or anyone. It’s a waste of time.” Nurse: “Do you feel that no one understands” </li></ul>
    114. 115. Voicing Doubt <ul><li>Expressing uncertainty about the reality of the client’s perceptions </li></ul><ul><li>“ Isn’t that unusual?” </li></ul><ul><li>“ Really?” </li></ul><ul><li>“ That’s hard to believe.” </li></ul>
    115. 116. Nontherapeutic Communication Techniques <ul><li>Advising-telling the client what to do </li></ul><ul><li>Agreeing- indicating accord with the client </li></ul><ul><li>Eg. “I think you should….” </li></ul><ul><ul><ul><li>“ That’s right” </li></ul></ul></ul>
    116. 117. Agreeing <ul><li>Indicating accord with the client </li></ul><ul><li>“ that’s right.” “I agree” </li></ul>
    117. 118. Belittling Feelings expressed <ul><li>Misjudging the degree of the client’s comfort </li></ul><ul><li>Client: “I have nothing to live for..I wish I was dead” </li></ul><ul><ul><li>Nurse: “Everybody gets down in the dumps.” </li></ul></ul>
    118. 119. Challenging <ul><li>Demanding proof from the client </li></ul><ul><li>“ But how can you be President of the Philippines?” </li></ul>
    119. 120. Defending <ul><li>Attempting to protect someone or something from verbal attack </li></ul><ul><li>“ This hospital has a fine reputation.” </li></ul>
    120. 121. Disagreeing <ul><li>Opposing the client’s ideas </li></ul><ul><li>Eg. “That’s wrong” </li></ul>
    121. 122. Disapproving <ul><li>Denouncing the client’s behavior or ideas </li></ul><ul><li>“ That’s bad” </li></ul><ul><li>“ I’d rather you wouldn’t” </li></ul>
    122. 123. Giving approval <ul><li>Sanctioning the client’s behavior or ideas </li></ul><ul><li>“ That’s good.” “I’m glad that..” </li></ul>
    123. 124. Giving Literal Responses <ul><li>Responding to a figurative comment as though it were a statement of fact </li></ul><ul><li>Client: “They’re looking in my head with television camera.” </li></ul><ul><li>Nurse: “Try not to watch television.” </li></ul>
    124. 125. Indicating the existence of an external source <ul><li>“ What makes you say that?” </li></ul>
    125. 126. Interpreting <ul><li>Asking to make conscious that which is unconscious </li></ul><ul><li>“ What you really mean is..” </li></ul>
    126. 127. Introducing an unrelated topic <ul><li>Changing the subject </li></ul><ul><li>Client: “I’d like to die.” </li></ul><ul><li>Nurse: “did you have visitors last night?” </li></ul>
    127. 128. Making stereotyped comments <ul><li>Offering meaningless cliches or trite comments </li></ul><ul><li>“ Keep your chin up.” </li></ul><ul><li>“ Just have a positive outlook.” </li></ul>
    128. 129. Probing <ul><li>Persistent questioning of the client </li></ul><ul><li>“ Now tell me about this problem. I need to know.” </li></ul>
    129. 130. Reassuring <ul><li>Indicating there is no reason for anxiety </li></ul><ul><li>“ Everything will be alright.” </li></ul>
    130. 131. Rejecting <ul><li>Refusing to consider or showing contempt for the client’s behavior, ideas </li></ul><ul><li>“ Let’s not discuss..” </li></ul>
    131. 132. Requesting an explanation <ul><li>Asking the client to provide reasons for thoughts, feelings, behaviors, events </li></ul><ul><li>‘ Why do you think that?” </li></ul>
    132. 133. Testing <ul><li>Appraising the client’s degree of insight </li></ul><ul><li>“ Do you know what kind of hospital this is?” </li></ul>
    133. 134. Using Denial <ul><li>Refusing to admit that a problem exists </li></ul><ul><li>Client: “I am nothing.” </li></ul><ul><li>Nurse: “Of course, you’re something.” </li></ul>
    134. 135. NON-THERAPEUTIC COMMUNICATIONS <ul><li>Overloading – “blah, blah, blah” </li></ul><ul><li>Underloading - ignoring </li></ul><ul><li>Value Judgment – use of adjectives </li></ul><ul><li>False Reassurance – “Don’t worry, you will be fine later.” </li></ul><ul><li>Focusing on Self – “I gave you meds so you are now feeling good” </li></ul><ul><li>Incongruence - </li></ul><ul><li>Internal Validation – biased judgment </li></ul><ul><li>Giving Advice – “If I were you, ill… </li></ul><ul><li>Changing Subject - </li></ul>
    135. 136. LOSS AND GRIEVING
    136. 137. <ul><li>GRIEF- refers to the subjective emotions and affect that are a normal response to the experience of loss </li></ul><ul><li>ANTICIPATORY GRIEVING- when people facing an imminent loss begin to grapple with the very real possibility of the loss or death in the near future </li></ul>
    137. 138. <ul><li>DISENFRANCHISED GRIEF-grief over a loss that is not or cannot be acknowledged openly, mourned publicly or supported socially </li></ul><ul><li>COMPLICATED GRIEVING-when a person is void of emotion, grieves for prolonged periods, has expressions of grief that seem disproportionate to the event </li></ul>
    138. 139. <ul><li>Physiologic Loss </li></ul><ul><li>Safe and Security Loss </li></ul><ul><li>Love and Belongingness Loss </li></ul><ul><li>Self-Esteem Loss </li></ul><ul><li>Self-actualization Loss </li></ul>LOSS
    139. 140. <ul><li>Denial </li></ul><ul><li>Anger </li></ul><ul><li>Bargaining </li></ul><ul><li>Depression </li></ul><ul><li>Acceptance </li></ul><ul><li>Dysfunctional grieving – grieving which extends from 4 to 6 weeks leading to CRISIS </li></ul>GRIEVING PROCESS
    140. 141. Interventions <ul><li>Explore client’s perception and meaning of the loss </li></ul><ul><li>Allow adaptive denial </li></ul><ul><li>Assist client to reach out for and accept support </li></ul><ul><li>Encourage client to examine patterns of coping in past and present situation of loss </li></ul><ul><li>Encourage client to care for himself </li></ul><ul><li>Offer client food without pressure to eat </li></ul><ul><li>Use effective communication </li></ul>
    141. 142. CRISIS AND ITS MANAGEMENT
    142. 143. <ul><li>situation that occurs when an individual’s habitual coping ability becomes ineffective to merit demands of a situation </li></ul><ul><li>TYPES OF CRISES: </li></ul><ul><li>MATURATIONAL / DEVELOPMENTAL </li></ul><ul><ul><li>Normal expected crisis that runs through age </li></ul></ul><ul><li>SITUATIONAL </li></ul><ul><ul><li>Unexpected and sudden event in life </li></ul></ul><ul><li>ADVENTITIOUS </li></ul><ul><ul><li>Calamities, war </li></ul></ul>CRISIS
    143. 144. Characteristics of a Crisis state <ul><li>Highly individualized </li></ul><ul><li>Lasts for 4-6 weeks </li></ul><ul><li>Self-limiting </li></ul><ul><li>Person affected becomes passive and submissive </li></ul><ul><li>Affects a person’s support system </li></ul>
    144. 145. PHASES OF A CRISIS <ul><li>Pre-crisis: State of equilibrium </li></ul><ul><li>Initial Impact (may last a few hours to a few days): High level of stress, helplessness, inability to function socially </li></ul><ul><li>Crisis (may last a brief or prolonged period of time): Inability to cope, projection, denial, rationalization </li></ul><ul><li>Resolution: attempts to use problem-solving skills </li></ul><ul><li>Post crisis: may have OLOF or may have symptoms of neurosis, psychosis </li></ul>
    145. 146. <ul><li>Role of the nurse is to return the client to its pre-crisis state by assisting and guiding them until they achieved their OLOF. </li></ul><ul><li>Goal: to enable patient to attain an OLOF </li></ul><ul><li>Nurse’s Primary Role: Active and Directive </li></ul>CRISIS MANAGEMENT
    146. 147. Steps in Crisis Intervention <ul><li>Identify the degree of disruption the client is experiencing </li></ul><ul><li>Assess the client’s perception of the event </li></ul><ul><li>Formulate nursing diagnoses </li></ul><ul><li>Involve the patient and family if applicable with planning </li></ul><ul><li>Implement interventions- new and old coping mechanisms </li></ul><ul><li>Evaluate-reassessment, reinforcement </li></ul>
    147. 148. TYPES OF THERAPIES Treatment Modalities
    148. 149. Individual Psychotherapy
    149. 150. Individual Psychotherapy <ul><li>One to one relationship between therapist and client </li></ul><ul><li>For dissociative, anorexia, paranoid, narcissistic </li></ul><ul><li>Change is achieved by the exploration of feelings, attitudes, thinking behavior and conflict </li></ul>
    150. 151. SEVEN SUBTYPES: <ul><li>CLASSICAL PSYCHOANALYSIS </li></ul><ul><li>Based on Freud’s theory </li></ul><ul><li>To uncover unconscious feelings and thoughts that interfere with the client’s living a fuller life </li></ul><ul><li>Free association-client is encouraged to say anything that comes to mind, without censoring thoughts or feelings </li></ul><ul><li>Dream analysis </li></ul><ul><li>Working through(transference)-process of repeated interpretation to the person of his or her unconscious processes has the effect of bringing about change </li></ul>
    151. 152. Al relationship <ul><li>PSYCHOANALYTICAL PSYCHOTHERAPY </li></ul><ul><li>Uses dream analysis, transference and free association </li></ul><ul><li>Therapist is much more involved and interacts with the client more freely </li></ul><ul><li>Done through intimate professional relationship between the nurse/therapist and the client over a period of time (introductory, working and termination phase) </li></ul>
    152. 153. <ul><li>SHORT TERM DYNAMIC PSYCHOTHERAPY </li></ul><ul><li>Indication-persons with specific symptom or interpersonal problem that he/she wants to work on </li></ul><ul><li>Therapist directs the content </li></ul><ul><li>Use of transference and dream analysis </li></ul><ul><li>Weekly sessions (total number-12 to 30) </li></ul><ul><li>Successful for highly motivated individuals who have insight and with positive relationship with the therapist </li></ul>
    153. 154. <ul><li>TRANSACTIONAL ANALYSIS </li></ul><ul><li>Eric Berne </li></ul><ul><li>Each person has three ego states and change from one to another frequently </li></ul><ul><li>Parent-concepts of standards of behavior and how things should be done e.g. Go and take out the garbage. </li></ul><ul><li>Adult-rational thinking and data analyzing part of the personality e.g.Would you please take out the garbage </li></ul><ul><li>Child- feelings associated with persons, things or incidents represent the need-gratifying aspects of the personality. E.g. Is that why you married me?To be your garbage man? </li></ul><ul><li>For group, family and individual </li></ul><ul><li>Client to identify ego states for each given situation </li></ul><ul><li>Rewarding of positive or negative behaviors with strokes </li></ul><ul><li>Client work through these behaviors </li></ul>
    154. 155. <ul><li>COGNITIVE PSYCHOTHERAPY </li></ul><ul><li>Restructuring or changing ways in which people think bout themselves </li></ul><ul><li>Thought stopping </li></ul><ul><li>Positive self-talk </li></ul><ul><li>Decatastrophizing </li></ul><ul><li>Therapists help patients identify these thoughts </li></ul>
    155. 156. <ul><li>BEHAVIORAL THERAPY </li></ul><ul><li>Changes in maladapted behavior can occur without insight into the underlying cause </li></ul><ul><li>Based on learning theory </li></ul><ul><li>Modeling </li></ul><ul><li>Operant conditioning </li></ul><ul><li>Self-control therapy-combination of cognitive & behavioral approaches “talking to self” </li></ul><ul><li>Systematic desensitization </li></ul><ul><li>Aversion therapy </li></ul>
    156. 157. <ul><li>GESTALT THERAPY </li></ul><ul><li>Emphasis on the “here and now” </li></ul><ul><li>Only present behavior can be changed, not history </li></ul><ul><li>Uncover repressed feelings and needs </li></ul><ul><li>Techniques: have a person behave the opposite of the way he/she feels, presuming that a person can then come in contact with a submerged part of the self; in dreams, person is ask to play the roles of persons in the dream to get in touch with different repressed feelings </li></ul>
    157. 158. Milieu Therapy
    158. 159. Milieu Therapy <ul><li>Total environment has an effect on the individual’s behavior </li></ul><ul><li>Components </li></ul><ul><ul><li>Physical Environment </li></ul></ul><ul><ul><li>Interpersonal relationships </li></ul></ul><ul><ul><li>Atmosphere of safety, caring, and mutual respect </li></ul></ul><ul><ul><li>For alcoholics </li></ul></ul>
    159. 160. PROGRAMS FOR MILIEU SHOULD HAVE: <ul><li>an emphasis on group and social interaction </li></ul><ul><li>No rules and expectations mediated by peer pressure </li></ul><ul><li>A view of patients’ roles as responsible human beings </li></ul><ul><li>An emphasis on patients’ rights for involvement in setting goals </li></ul><ul><li>Freedom of movement and informality of relationships with staff </li></ul><ul><li>Emphasis on interdisciplinary participation </li></ul><ul><li>Goal-oriented, clear communication </li></ul>
    160. 161. Group Therapy
    161. 162. Group Therapy <ul><li>Number of people coming together, sharing a common goal, interest or concern, staying together and developing relationships </li></ul><ul><li>For PTSD and Alcoholics </li></ul><ul><li>Phases </li></ul><ul><ul><li>Orientation </li></ul></ul><ul><ul><li>Working </li></ul></ul><ul><ul><li>Termination </li></ul></ul>
    162. 163. Characteristics of Group Therapy <ul><li>Universality  “You are not alone” </li></ul><ul><li>Instilling hope and inspiration </li></ul><ul><li>Developing social skills by interacting with one another </li></ul><ul><li>Feeling of acceptance and belonging </li></ul><ul><li>Altruism  “Giving of one’s self” </li></ul>
    163. 164. <ul><li>Psychoanalytically oriented group therapy </li></ul><ul><li>Psychodrama </li></ul><ul><li>Family therapy </li></ul>
    164. 165. Assumption of Family Therapy <ul><ul><li>For alcoholic and schizophrenic </li></ul></ul>
    165. 166. Assumption of Family Therapy <ul><li>Client: Whole family </li></ul><ul><li>Concepts: </li></ul><ul><ul><li>The family is the most fundamental unit of the society. </li></ul></ul><ul><ul><li>Adaptive or maladaptive patterns of behavior are learned from the family </li></ul></ul><ul><ul><li>Dysfunction in the family = dysfunction in the individual </li></ul></ul><ul><li>Purpose </li></ul><ul><ul><li>Improve relationships among family members </li></ul></ul><ul><ul><li>Promote family function </li></ul></ul><ul><ul><li>Resolve family problems </li></ul></ul>
    166. 167. OTHER TYPES OF THERAPIES <ul><li>SUPPORT GROUPS </li></ul><ul><ul><li>For those with AIDS, Mother-Against-Drug Dependence </li></ul></ul><ul><li>SELF-HELP GROUPS </li></ul><ul><ul><li>Alcoholic Anonymous </li></ul></ul>
    167. 168. RULES FOR PSYCHOTHERAPEUTIC MANAGEMENT <ul><li>Provide support, treat patients with respect and dignity </li></ul><ul><li>Do not place patients in situations wherein they will feel inadequate or embarrassed </li></ul><ul><li>Treat patients as individuals </li></ul><ul><li>Provide reality testing </li></ul><ul><li>Handle hostility therapeutically </li></ul><ul><li>Provide psychopharmacologic treatment </li></ul>
    168. 169. BEHAVIORAL THERAPIES Treatment Modalities
    169. 170. BEHAVIORAL THERAPY <ul><li>Pavlov’s Classical Conditioning </li></ul><ul><ul><li>All behavior are learned </li></ul></ul><ul><li>B.F. Skinner’s Operational Conditioning </li></ul><ul><ul><li>Reinforcements </li></ul></ul>
    170. 171. BEHAVIORAL THERAPY <ul><li>Behavioral Modification – Substance Abuse </li></ul><ul><li>Token Economy – Anorexia / Schizo </li></ul><ul><li>Systematic Desensitization - Phobia </li></ul>
    171. 172. ATTITUDE THERAPY Treatment Modalities
    172. 173. ATTITUDE THERAPY <ul><li>Paranoid – Passive Friendliness </li></ul><ul><li>Withdrawn – Active Friendliness </li></ul><ul><li>Depressed / Anorexia – Kind Firmness </li></ul><ul><li>Manipulative – Matter of Fact </li></ul><ul><li>Assaultive – No Demand </li></ul><ul><li>Anti-social – Firm, consistent </li></ul>
    173. 174. PSYCHOSOMATIC THERAPY Treatment Modalities
    174. 175. Electroconvulsive Therapy
    175. 176. Electroconvulsive Therapy <ul><li>Effective in most affective disorders </li></ul><ul><li>The induction of a grandmal seizure in the brain. </li></ul><ul><li>Abnormal firing of neurons in the brain causes an increase in neurotransmitters </li></ul><ul><li>Number of Treatments: 6-12 ,3 times a week, about .5-2seconds </li></ul><ul><li>Unilateral or bitemporal </li></ul>
    176. 177. Electroconvulsive Therapy <ul><li>Indications: </li></ul><ul><li>Patients who require rapid response </li></ul><ul><li>Patients who cannot tolerate pharmacotherapy or cannot be exposed to pharmacotherapy </li></ul><ul><li>Patients who are depressed but have not responded to multiple and adequate trials of medication </li></ul>
    177. 178. Electroconvulsive Therapy <ul><li>Preparations for ECT: </li></ul><ul><li>Pretreatment evaluation and clearance </li></ul><ul><li>Consent </li></ul><ul><li>NPO from midnight until after the treatment </li></ul><ul><li>Atropine Sulfate-to decrease secretions, succinylcholine (Anectine)- to promote muscle relaxation, Methohexital Sodium(Brevital)- anesthethic </li></ul><ul><li>Empty bladder </li></ul><ul><li>Remove jewelry, hairpins, dentures and other accessories </li></ul><ul><li>Check vital signs </li></ul><ul><li>Attempt to decrease patient’s anxiety </li></ul>
    178. 179. Electroconvulsive Therapy <ul><li>Care after ECT: </li></ul><ul><li>O2 therapy of 100% until patient can breathe unassisted </li></ul><ul><li>Monitor for respiratory problems, gag reflex </li></ul><ul><li>Reorient patient </li></ul><ul><li>Observe until stable </li></ul><ul><li>Careful documentation. </li></ul><ul><li>Male erectile dysfunction </li></ul>
    179. 180. OTHER THERAPIES <ul><li>NEUROSURGERY </li></ul>
    180. 181. ANXIETY
    181. 182. Peplau’s Levels of Anxiety
    182. 183. Peplau’s Levels of Anxiety <ul><li>Mild </li></ul><ul><ul><li>Associated with the tension of day-today living </li></ul></ul><ul><ul><li>Perceptual field increased </li></ul></ul><ul><ul><li>More alert than usual </li></ul></ul><ul><ul><li>Adaptive </li></ul></ul><ul><li>Moderate </li></ul><ul><ul><li>Narrowed perception </li></ul></ul><ul><ul><li>Difficulty focusing </li></ul></ul><ul><ul><li>Selective inattention </li></ul></ul><ul><ul><li>Mild somatic complaints: stomachache and butterflies in the stomach </li></ul></ul>
    183. 184. Interventions for Mild to Moderate Anxiety <ul><li>Assist the client in identifying anxiety. </li></ul><ul><li>Anticipate anxiety provoking situations. </li></ul><ul><li>Use nonverbal language to demonstrate interest </li></ul><ul><li>Encourage the client to talk about his or her feelings. </li></ul><ul><li>Avoid closing off avenues of communication (refrain from offering advice or changing the topic). </li></ul><ul><li>Encourage problem-solving </li></ul><ul><li>Explore past and present coping behaviors </li></ul><ul><li>Provide outlets for working off excess energy. </li></ul>
    184. 185. Levels of Anxiety
    185. 186. Levels of Anxiety <ul><li>Severe </li></ul><ul><ul><li>Very narrowed perception </li></ul></ul><ul><ul><li>Unable to focus on problem solving </li></ul></ul><ul><ul><li>Increased physical discomfort </li></ul></ul><ul><ul><li>All behavior is aimed at relieving anxiety </li></ul></ul><ul><ul><li>Direction is needed to focus attention </li></ul></ul><ul><li>Panic </li></ul><ul><ul><li>Awe, dread and terror </li></ul></ul><ul><ul><li>Unable to see the whole situation or reality </li></ul></ul><ul><ul><li>Distortion of perception </li></ul></ul><ul><ul><li>Disorganization of the personality </li></ul></ul><ul><ul><li>A frightening and paralyzing experience </li></ul></ul>
    186. 187. Inter ventions for Severe and Panic Levels of Anxiety <ul><li>Maintain a calm manner. </li></ul><ul><li>Remain with the person. </li></ul><ul><li>Minimize environmental stimuli. </li></ul><ul><li>Reinforce reality. </li></ul><ul><li>Listen for themes in communication. </li></ul><ul><li>Attend to physical safety and medical needs first. </li></ul><ul><li>Physical limits may need to be set. </li></ul><ul><li>Provide opportunities for exercising. </li></ul><ul><li>Assess the person’s need for medication or seclusion . </li></ul>
    187. 188. ANTI – ANXIETY DRUGS <ul><li>VALIUM </li></ul><ul><li>LIBRIUM </li></ul><ul><li>ATIVAN </li></ul><ul><li>SERAX </li></ul><ul><li>TRANXENE </li></ul><ul><li>MILTOWN </li></ul><ul><li>EQUANIL </li></ul><ul><li>VISTARIL </li></ul><ul><li>ATARAX </li></ul><ul><li>INDERAL </li></ul><ul><li>XANAX </li></ul><ul><li>BUSPAR </li></ul>
    188. 189. ANTI – ANXIETY DRUGS <ul><li>Used only in a short time (1-2 weeks) </li></ul><ul><li>Tolerance (after 7 days) and dependence (after 1 month) </li></ul><ul><li>Liver function test </li></ul><ul><li>Monitor for side effects. </li></ul><ul><li>Avoid machines, activities needing concentration </li></ul><ul><li>Z tract if given parenterally </li></ul><ul><li>Avoid mixing with alcohol, antihistamines, antipsychotics </li></ul><ul><li>Don’t stop abruptly but gradually for 2-6 weeks </li></ul><ul><li>Avoid caffeine </li></ul>
    189. 190. Categories of ANXIETY DISORDERS Anxiety Disorders Basic Anxiety Disorder Somatoform
    190. 191. Categories of ANXIETY DISORDERS <ul><li>Basic Anxiety Disorders </li></ul><ul><li>Somatoform Disorders </li></ul><ul><li>Dissociative Disorders </li></ul>
    191. 192. BASIC ANXIETY DISORDER
    192. 193. Basic anxiety disorders <ul><li>Generalized Anxiety Disorder </li></ul><ul><li>Panic </li></ul><ul><li>Phobia </li></ul><ul><li>PTSD </li></ul><ul><li>Obsessive Compulsive </li></ul>
    193. 194. Chronic Anxiety Disorder or Generalized Anxiety Disorder <ul><li>Excessive worry and anxiety for days but not more than 6 months </li></ul><ul><li>Difficulty in controlling the worry </li></ul><ul><li>Anxiety and worry are evident by 3 or more of the following : </li></ul><ul><ul><li>Restlessness, Keyed up </li></ul></ul><ul><ul><li>Fatigue and irritability </li></ul></ul><ul><ul><li>Decreased ability to concentrate </li></ul></ul><ul><ul><li>Muscle tension </li></ul></ul><ul><ul><li>Disturbed sleep </li></ul></ul><ul><li>Anxiety or worry causes significant impairment in interpersonal relationship or activities of daily living </li></ul>
    194. 195. Post Traumatic Stress Disorders
    195. 196. Post Traumatic Stress Disorders <ul><li>Disturbing pattern of behavior occurring after a traumatic event that is outside the range of usual experience. </li></ul><ul><li>Characteristics </li></ul><ul><ul><li>Persistent re-experiencing of the trauma through recurrent intrusive recollections of the event, through dreams or flashbacks </li></ul></ul><ul><ul><li>Persistent avoidance of the stimuli </li></ul></ul><ul><ul><li>Feeling of detachment of estrangement from others </li></ul></ul><ul><ul><li>Chemical abuse to relieve anxiety </li></ul></ul>
    196. 197. Phobias <ul><li>Definition </li></ul><ul><ul><li>Persistent, irrational fear of a specific object, activity or situation that leads to a desire for avoidance or actual avoidance of the object of fear </li></ul></ul><ul><li>Specific Phobia </li></ul><ul><ul><li>Experience of high level of anxiety or fear provided by a specific object or situation </li></ul></ul><ul><li>Treatment: Systematic Desensitization </li></ul><ul><li>Defense mechanisms </li></ul><ul><ul><li>Repression and displacement </li></ul></ul>
    197. 198. Major Types of Phobias
    198. 199. Major Types of Phobias <ul><li>Agoraphobia </li></ul><ul><ul><li>Comes from the Greek word “Agora” </li></ul></ul><ul><ul><li>Meaning “market place” </li></ul></ul><ul><ul><li>Fear of being alone in open or public spaces </li></ul></ul><ul><li>Social Phobia </li></ul><ul><ul><li>Fear of situations where one might be seen and embarrassed or criticized </li></ul></ul><ul><li>Specific Phobias </li></ul><ul><ul><li>Fear of a single object, situation or activity that cannot be avoided </li></ul></ul>
    199. 200. Obsessive Compulsive Disorder <ul><li>Obsessions </li></ul><ul><li>Preoccupation with persistent intrusive thoughts, impulses or images </li></ul><ul><li>Compulsions </li></ul><ul><li>> Repetitive behaviors or mental acts that the person feelds driven to perform in order t reduce distress or prevent a dreaded event or situation </li></ul><ul><li>Cues: </li></ul><ul><li>Ritualistic behavior </li></ul><ul><li>Constant doubting if he/she has performed the activity </li></ul>
    200. 201. Examples Obsessions Compulsions Washing or cleaning “ Wash away my sins”. Thought appeared after sexual encounter with a married man Young woman repeatedly washes hands Need for order “ Everything must be in place”. Arranges and rearranges items Germs or dirt “ Everything is contaminated” Avoids touching all objects. Scrubs hands if she is forced to touch any object Symmetry “ Secretaries who practice neatness never gets fired’ Secretary lines up objects in rows on her desk, then realigns them repeatedly during the day
    201. 202. Care Strategies <ul><li>Be nonjudgmental and honest; offer empathy and support </li></ul><ul><li>Help patient to recognize the connections between the trauma experience and their current feelings, behaviors and problems. </li></ul><ul><li>Encourage verbalizations of feelings, especially anger. </li></ul><ul><li>Encourage adaptive coping strategies and techniques </li></ul><ul><li>Encourage patients to establish or reestablish relationships </li></ul><ul><li>Explore shattered assumptions. “I’m a good person. This is a safe world”. </li></ul><ul><li>Promote discussion of possible meaning of the events. </li></ul>
    202. 203. SOMATOFORM DISORDERS
    203. 204. Somatoform Disorders <ul><li>Body Dysmorphic Disorder </li></ul><ul><li>Somatization </li></ul><ul><li>Conversion Disorders </li></ul><ul><li>Hypochondriasis </li></ul><ul><li>Psychogenic pain </li></ul>
    204. 205. Body Dysmorphic Disorder <ul><li>Preoccupation with an imagined defect in his or her appearance </li></ul>
    205. 206. Somatization <ul><li>A client expresses emotional turmoil or conflict through a physical system, usually with a loss or alteration of physical functioning </li></ul>
    206. 207. Conversion Disorders <ul><li>A psychological condition in which an anxiety-provoking impulse is converted unconsciously into functional symptoms </li></ul>
    207. 208. Hypochondriasis <ul><li>Presentation of unrealistic or exaggerated physical complaints </li></ul>
    208. 209. DISSOCIATIVE DISORDERS
    209. 210. Dissociative Disorders <ul><li>Dissociative amnesia </li></ul><ul><li>Dissociative fugue </li></ul><ul><li>Depersonalization </li></ul><ul><li>Dissociative Identity Disorder / Multiple Identity Disorder </li></ul>
    210. 211. Dissociative amnesia <ul><li>Characterized by the inability to recall an extensive amount of important personaal information because of physical or psychological trauma </li></ul>
    211. 212. Dissociative fugue <ul><li>The person suddenly and unexpectedly leaves home or work and is unable to recall the past </li></ul>
    212. 213. Depersonalization <ul><li>Person experiences a strange alteration in the perception or experience of the self, often associated with a sense of unreality </li></ul>
    213. 214. Dissociative Identity Disorder / Multiple Identity Disorder <ul><li>A person is dominated by at least one of two or more definitive personalities at one time </li></ul>
    214. 215. PSYCHOSOMATIC DISORDER
    215. 216. Psychosomatic Disorder <ul><li>True / unconscious because of hormonal and bodily changes </li></ul><ul><li>Increase anxiety may result to asthma, stress ulcers or migraine </li></ul>
    216. 217. SCHIZOPHRENIA <ul><li>A major form of psychotic disorder that affects a person’s thinking, language, emotions, social behavior and ability to perceive reality </li></ul><ul><li>At least 2 of 5 types of positive and negative symptoms </li></ul><ul><li>Characteristic Symptoms </li></ul><ul><li>Social or occupational dysfunction </li></ul><ul><ul><li>IPR </li></ul></ul><ul><ul><li>Self care </li></ul></ul><ul><li>Duration </li></ul><ul><ul><li>Continuous for at least 6 months </li></ul></ul>
    217. 218. Positive and Negative Symptoms <ul><li>Positive Symptoms </li></ul><ul><ul><li>Hallucinations </li></ul></ul><ul><ul><li>Delusions </li></ul></ul><ul><ul><li>Illusions </li></ul></ul><ul><ul><li>Abnormal thought patterns or perceptions </li></ul></ul><ul><ul><li>Bizarre behavior </li></ul></ul>
    218. 219. Negative Symptoms <ul><li>Negative Symptoms </li></ul><ul><ul><li>Affective flattening </li></ul></ul><ul><ul><li>Anhedonia </li></ul></ul><ul><ul><li>Attention impairment </li></ul></ul><ul><ul><li>Asocial behavior </li></ul></ul><ul><ul><li>Anergia </li></ul></ul><ul><ul><li>Autism </li></ul></ul><ul><ul><li>Avolition </li></ul></ul>
    219. 220. SCHIZOPHRENIA
    220. 221. DELUSIONS <ul><li>PERSECUTORY </li></ul><ul><li>RELIGIOUS </li></ul><ul><li>GRANDEUR </li></ul><ul><li>IDEAS OF REFERENCE </li></ul>
    221. 222. DISTURBED THOUGHT PROCESSES <ul><li>Looseness of Association </li></ul><ul><li>Flight of Ideas </li></ul><ul><li>Ambivalence </li></ul><ul><li>Magical Thinking </li></ul><ul><li>Echolalia / Echopraxia </li></ul><ul><li>Word salad </li></ul><ul><li>Clang association </li></ul><ul><li>Neologism </li></ul><ul><li>Thought blocking </li></ul><ul><li>Concrete association </li></ul><ul><li>Delusion, hallucination, illusion </li></ul>
    222. 223. Bleuler’s Four A’s of Schizophrenia <ul><li>Affective Disturbances </li></ul><ul><li>Autism </li></ul><ul><li>Associative looseness </li></ul><ul><li>Ambivalence </li></ul><ul><li>Other A’s </li></ul><ul><ul><li>Attention defects </li></ul></ul><ul><ul><li>Disturbances of activities </li></ul></ul>
    223. 224. SCHIZOPHRENIA <ul><li>Brief Psychotic Disorder -maybe seen when a person exhibits clinical symptoms of illogical thinking, incoherent speech, delusions, or disorganized behavior after psychological trauma </li></ul><ul><li>Induced Psychotic Disorder -develops in a second person as a result of a close relationship with a person who has psychosis </li></ul><ul><li>Delusional Psychotic Disorder </li></ul><ul><li>Schizoaffective disorder -characterized by depression or elation as the psychosis symptoms of schizophrenia and MDD </li></ul><ul><li>Schizophreniform -when a person exhibits features of schizophrenia for more than one week but less than 6 months </li></ul>
    224. 225. Subtypes: <ul><li>Paranoid-most common form of the illness </li></ul><ul><ul><li>Suspicious </li></ul></ul><ul><ul><li>Promote trust </li></ul></ul><ul><ul><li>Short interaction but frequent </li></ul></ul><ul><ul><li>Food in containers (sealed) </li></ul></ul><ul><ul><li>Prepare food in front of them </li></ul></ul><ul><ul><li>Let them seed preparation of drugs </li></ul></ul><ul><li>Violent </li></ul><ul><ul><li>Keep door open </li></ul></ul><ul><ul><li>Position near door and with distance of 1 arm length (patient-nurse) </li></ul></ul><ul><ul><li>Don’t touch </li></ul></ul><ul><ul><li>Maintain eye contact </li></ul></ul><ul><ul><li>Call reinforcements </li></ul></ul>
    225. 226. Subtypes: <ul><li>Disorganized-absence of systematized delusions; presence of incoherence & inappropriate affect </li></ul><ul><ul><li>Inappropriate, flat affect </li></ul></ul><ul><ul><li>Herbephrenic, flight of ideas </li></ul></ul><ul><li>Catatonic </li></ul><ul><ul><li>Risk for suicide </li></ul></ul><ul><ul><li>Catatonic stupor, rigidity </li></ul></ul><ul><ul><li>Waxy flexibility </li></ul></ul>
    226. 227. Subtypes: <ul><li>Undifferentiated </li></ul><ul><ul><li>unclassified </li></ul></ul><ul><li>Residual </li></ul><ul><ul><li>No more positive symptoms but withdrawn </li></ul></ul>
    227. 228. NURSING PROCESS <ul><li>Disturbed Thought Process </li></ul><ul><li>Disturbed Sensory Process </li></ul><ul><li>Risk for self-directed violence </li></ul><ul><li>Risk for other directed violence </li></ul><ul><li>Present safety </li></ul><ul><li>Present reality </li></ul>
    228. 229. ANTI- PSYCHOTIC <ul><li>Tara, look natin sina Stella, Mel, at Thor na nag mo-moulin rouge…. Sssh , alam nyo ba na ang trio na yan na akala mo may halo ay mga closet queens pala…, namen” </li></ul><ul><li>( Taractan, Loxitane, Stelazine, Mellaril, Thorazine, Molindone, Seroquel, Serlect, Trilafon, Haloperidol, Clozapine, Navane ) </li></ul>
    229. 230. SCHIZOPHRENIA <ul><li>STELAZINE MILLARIL </li></ul><ul><li>SERENTIL HALDOL </li></ul><ul><li>THORAZINE LOXITANE </li></ul><ul><li>TRILAFON RISPERDOL </li></ul><ul><li>CLOZARIL PROLIXIN </li></ul>
    230. 231. ANTI – PSYCHOTIC DRUGS <ul><li>Watch for side-effects </li></ul><ul><ul><li>Increase v/s </li></ul></ul><ul><ul><li>Constipation / dry mouth </li></ul></ul><ul><ul><li>Postural hypotension </li></ul></ul><ul><ul><li>Photophobia / photosensitivity </li></ul></ul><ul><ul><li>Drowsiness </li></ul></ul><ul><ul><li>Agranulocytosis </li></ul></ul><ul><ul><li>Extrapyramidal symptoms </li></ul></ul><ul><ul><ul><li>Parkinson’s syndrome </li></ul></ul></ul><ul><ul><ul><li>Akathisia </li></ul></ul></ul><ul><ul><ul><li>Akinesia </li></ul></ul></ul><ul><ul><ul><li>Dystonia – oculogyric crisis, torticollosis, opistothonus </li></ul></ul></ul><ul><ul><ul><li>Tardive dyskinesia </li></ul></ul></ul><ul><ul><ul><li>NMS </li></ul></ul></ul>
    231. 232. UNDESIRABLE EFFECTS <ul><li>S-edation/sunlight sensitivity/sleepiness </li></ul><ul><li>T-ardive dyskinesia </li></ul><ul><li>A-nticholinergic/aganulocytosis/akathisia </li></ul><ul><li>N-euroleptic malignant syndrome </li></ul><ul><li>C-cardiac effects(Orthostatic hypotension) </li></ul><ul><li>E-xtrapyramidal(dystonia </li></ul>
    232. 233. Parkinsonism <ul><li>Motor retardation or akinesia characterized by mask-like appearance, rigidity, tremors, “pill-rolling”, salivation </li></ul><ul><li>Generally occurs after 1 st week of treatment or before second month </li></ul><ul><li>Administer anticholinergic agent, anti-parkinson medication (Akineton) </li></ul>
    233. 234. Akathisia <ul><li>Constant state of movement, characterized by restlessness, difficulty sitting still, or strong urges to move about </li></ul><ul><li>Generally occurs two weeks after treatment begins </li></ul><ul><li>Rule out anxiety or agitation before administration of an anticholinergic agent </li></ul>
    234. 235. Acute Dystonic reactions <ul><li>Irregular, involuntary spastic muscle movement, wryneck or torticollis, facial grimacing, abnormal eye movements, backward rolling of eyes in the sockets </li></ul><ul><li>May occur anytime from a few minutes to several hours after first dose of antipsychotic drug </li></ul><ul><li>Administer anticholinergic agent, have respiratory support equipment available </li></ul>
    235. 236. Tardive Dyskinesia <ul><li>Most frequent serious side effect resulting from termination of the drug, during reduction in dosage, or after long term high dose therapy. Characterized by involuntary rhytmic, stereotyped movements, tongue protrusion, cheek puffing, involuntary movements of extremities and trunk </li></ul><ul><li>Occurs in approximately 20-25% of patients taking antipsychotics for over two years </li></ul><ul><li>No treatment except discontinuation of the antipsychotic agent </li></ul>
    236. 237. Neuroleptic Malignant Syndrome <ul><li>A potentially fatal syndrome </li></ul><ul><li>May occur anytime during therapy </li></ul><ul><li>Seen during the initiation of therapy, change of therapy, After a dosage increase or when a combination of meds is used. </li></ul><ul><li>Early sign: rigidity or mental status changes </li></ul><ul><li>catatonia, tachycardia, tachypnea, labile blood pressure, dysphagia, diaphoresis, incontinence, rigidity, myoclonus, tremors, low grade fevers </li></ul><ul><li>Discontinue antipsychotic agent. Have cardiopulmonary support available; administer skeletal muscle relaxant(e.g. dantrolene) or central acting dopamine agonist (e.g. bromocriptine) </li></ul>
    237. 238. NOTES on SCHIZOPHRENIA <ul><li>Distorted EGO </li></ul><ul><li>Disturbed thought process </li></ul><ul><li>Disorganized personality </li></ul><ul><li>Dopamine – increase </li></ul><ul><li>Autism </li></ul><ul><li>Ambivalence </li></ul><ul><li>Associative looseness </li></ul><ul><li>Affect – flat </li></ul><ul><li>Stimulation </li></ul><ul><li>Structure </li></ul><ul><li>Socialization </li></ul><ul><li>Support </li></ul>
    238. 239. <ul><li>Manifestations: </li></ul><ul><li>S -social isolation </li></ul><ul><li>C -catatonic behavior </li></ul><ul><li>H -hallucinations </li></ul><ul><li>I -Incoherence </li></ul><ul><li>Z -zero/lack of interest and initiative </li></ul><ul><li>O -obvious failure in development </li></ul><ul><li>P -peculiar behavior </li></ul><ul><li>H -hygiene and grooming impaired </li></ul><ul><li>R -recurrent illusions </li></ul><ul><li>E- exacerbations and remissions </li></ul><ul><li>N -no organic factor account S/S </li></ul><ul><li>I -inability to return to functioning </li></ul><ul><li>A -affect is inappropriate </li></ul>
    239. 240. ANTI-PARKINSONIAN DRUGS <ul><li>Dopaminergic Drugs </li></ul><ul><li>To live (Levodopa), you need a car (carbidopa) and a man (Amantidine) not your brother (bromocriptine) per (pergolide) se (selegiline) </li></ul><ul><li>ANTI-CHOLENERGIC </li></ul><ul><li>BACPAK ( BENADRYL, ARTANE, COGENTIN, PARSIDOL, AKINETON, KEMADRIN) </li></ul>
    240. 241. Other Treatments <ul><li>Psychotherapy-individual, group, behavioral, supportive or family therapy maybe used depending on the clinical symptoms </li></ul><ul><li>Milieu therapy- a structured environment to minimize environmental and physical stress and to meet the individual needs of the patients until they are able to assume responsibility for themselves </li></ul>
    241. 242. Concepts & Principles of Hallucination <ul><li>Possible to replace hallucination with satisfying interactions </li></ul><ul><li>Can re-learn to focus attention on real things and people </li></ul><ul><li>Hallucinations originate during extreme emotional stress when the patient is unable to cope </li></ul><ul><li>Hallucinations are very real to the patient </li></ul><ul><li>Patient will react as the situation is perceived </li></ul><ul><li>Concrete experiences, not argument on confrontation will correct sensory distortion </li></ul><ul><li>Hallucinations are a substitute for human relations </li></ul>
    242. 243. BIPOLAR DISORDER MOOD DISORDER/ AFFECTIVE DISORDER
    243. 244. Bipolar Disorders
    244. 245. Bipolar Disorders <ul><li>A distinct period of abnormally and persistently elevated, expansive or irritable mood lasting at least 1 week </li></ul><ul><li>3 or more of the following </li></ul><ul><ul><li>Psychomotor overexcitability or excitement </li></ul></ul><ul><ul><li>Insomnia with fatigue </li></ul></ul><ul><ul><li>Euphoria or elated mood </li></ul></ul><ul><ul><li>Distractability </li></ul></ul><ul><ul><li>Pressured speech </li></ul></ul><ul><ul><li>Flight of ideas </li></ul></ul><ul><ul><li>Manipulative or demanding behavior </li></ul></ul><ul><ul><li>Destructive or combative behavior </li></ul></ul><ul><ul><li>Delusions of grandeur </li></ul></ul><ul><ul><li>Impaired judgment </li></ul></ul>
    245. 246. Bipolar Disorders <ul><li>Risk </li></ul><ul><ul><li>Female </li></ul></ul><ul><ul><li>20 years old and above </li></ul></ul><ul><ul><li>Stressful life </li></ul></ul><ul><ul><li>Obese </li></ul></ul><ul><ul><li>Care giver role restrain </li></ul></ul>
    246. 247. Mania Vs Depression Mania Depression Appearance Colorful, flamboyant Sad and gray Behavior Psychomotor agitation Psychomotor retardation Communication Pressured speech Stuttering Cluttering Monotonous speech
    247. 248. Mania Vs Depression Mania Depression Nx Risk for Injury (others) Risk for injury (self) suicidal precaution Nursing priority Safety and nutrition Safety and Nutrition Nutrition Finger foods and high in calories Increased in nutrients Treatment Lithium; ECT TCA; SSRI; MAOI’s ECT
    248. 249. Mania Vs Depression Mania Depression Milieu Non-stimulating environment Stimulating Appropriate activity Quiet type; non-competitive Monotonous; Non-competitive Attitude therapy Matter of fact Kind firmness; active friendliness
    249. 250. LITHIUM <ul><li>Level of lithium (0.5 to 1.5 meq/L) </li></ul><ul><li>Increase urination (polyuria) </li></ul><ul><li>Tremors – fine hand </li></ul><ul><li>Hydration </li></ul><ul><li>Increase peristalsis </li></ul><ul><li>U2 – 4 weeks effective </li></ul><ul><li>Increased bowel movements </li></ul><ul><li>Mouth is dry </li></ul><ul><ul><li>Assess function of kidney </li></ul></ul><ul><ul><li>Toxicity: nausea and vomiting, diarrhea </li></ul></ul>
    250. 251. PHARMACOLOGY MOMENTS ANTIDEPRESSANTS
    251. 252. ANTIDEPRESSANTS <ul><li>ASENDIN </li></ul><ul><li>NORPRAMIN </li></ul><ul><li>TOFRANIL </li></ul><ul><li>SINEQUAN </li></ul><ul><li>ANAFRANIL </li></ul><ul><li>AVENTIL </li></ul><ul><li>VIVACTIL </li></ul><ul><li>ELAVIL </li></ul><ul><li>PROZAC </li></ul><ul><li>LUVOX </li></ul><ul><li>PAXIL </li></ul><ul><li>ZOLOFT </li></ul>
    252. 253. ANTIDEPRESSANTS <ul><li>SSRI </li></ul><ul><ul><li>Selective Serotonin Reuptake Inhibitor </li></ul></ul><ul><ul><li>Safest </li></ul></ul><ul><ul><li>Side effects are low </li></ul></ul><ul><ul><li>1 to 4 weeks </li></ul></ul><ul><ul><li>Prozac, Paxil, Zoloft, Luvox </li></ul></ul>
    253. 254. ANTIDEPRESSANTS <ul><li>TCA </li></ul><ul><ul><li>Tricyclic Antidepressants </li></ul></ul><ul><ul><li>2 to 4 weeks </li></ul></ul><ul><ul><li>Anticholinergic </li></ul></ul><ul><ul><li>amitriptyline, nortiptyline, doxepin trimipramine, amoxapine, anafranil, venlafaxine </li></ul></ul>
    254. 255. ANTIDEPRESSANTS <ul><li>MAOI’s </li></ul><ul><ul><li>Increases all neurotransmitters </li></ul></ul><ul><ul><li>2 to 6 weeks </li></ul></ul><ul><ul><li>Hypertensive crisis </li></ul></ul><ul><ul><li>Don’t take: </li></ul></ul><ul><ul><ul><li>Avocado </li></ul></ul></ul><ul><ul><ul><li>Aged cheese </li></ul></ul></ul><ul><ul><ul><li>Beer/ B6 (tyramine) </li></ul></ul></ul><ul><ul><ul><li>Chocolate </li></ul></ul></ul><ul><ul><ul><li>Fermented foods </li></ul></ul></ul><ul><ul><ul><li>Soy sauce </li></ul></ul></ul><ul><ul><ul><li>Pickles and preserved foods </li></ul></ul></ul>
    255. 256. ANTI- DEPRESSANT <ul><li>A. TCA </li></ul><ul><li>“ knock! Knock! Who’s there? SEVANA to gagah!”-------- (Sinequam, Elavil, Vivactil, Ascendin, Norpramin, Aventyl, Tofranil) </li></ul><ul><li>B. SSRI </li></ul><ul><li>Ngongo: “Paxil ka! Paxil ka! Prozoleta ka lang, kala ko luv mo ko!” (PRAXIL, PROZAC, ZOLOFT, LUVOX) </li></ul><ul><li>C. MAO </li></ul><ul><li>“ Naman, parnate ko pa” (NARDIL, MANERIX, PARNATE) </li></ul>
    256. 257. SUICIDE <ul><li>The intentional act of killing oneself </li></ul><ul><li>Suicidal Ideation - means thinking about oneself </li></ul><ul><li>Passive suicidal ideation -when a person thinks about wanting to die or wishes he/she were dead but has no plans to cause his/her death (e.g. reckless driving, heavy smoking, overeating, self-mutilation, drug abuse) </li></ul><ul><li>Active suicidal ideation- when a person thinks about and seeks to commit suicide. </li></ul>
    257. 258. SAD PERSON’S SCALE <ul><li>S-Sex Men kill themselves 3x more than women though women make attempts 3x more often than men </li></ul><ul><li>A-Age High risks groups:19 years or younger; 45 years or older, especially the elderly 65 and above </li></ul><ul><li>D-Depression Studies report that 35-79% of those who attempt suicide manifested a depressive syndrome </li></ul>
    258. 259. <ul><li>P-Previous Attempts Of those who commit suicide, 65-70% have made previous attempts </li></ul><ul><li>E-ETOH Alcohol is associated with up to 65% of successful suicides </li></ul><ul><li>R-Rational Thinking Loss People with functional or organic psychoses are more apt to commit suicide than those in the general population </li></ul><ul><li>S-Social Supports Lacking A suicidal person often lacks significant others, meaningful employment and religious supports </li></ul><ul><li>O-Organized Plan The presence of a specific plan for suicide signifies a person at high risk </li></ul><ul><li>N-No Spouse repeated studies indicate that persons who are widowed, separated, divorced or single at greater risk than those who are married </li></ul><ul><li>S-Sickness Chronic, debilitating and severe illness is a risk factor </li></ul>
    259. 260. Scoring <ul><li>0-2 Home with follow up care </li></ul><ul><li>3-4 Close follow up and possible hospitalization </li></ul><ul><li>5-6 Strongly consider hospitalization </li></ul><ul><li>7-10 Hospitalize </li></ul>
    260. 261. Situation: <ul><li>Charles Brown, age 52 lost his wife in a car accident few months ago. Since that time, he has been severely depressed and has taken to drinking to numb the pain </li></ul><ul><li>How many points according to the SAD PERSONS SCALE? </li></ul>
    261. 262. Theories of SUICIDE <ul><li>Psychodynamic theories </li></ul><ul><li>describe suicide as a wish to be at peace with the internalized significant person </li></ul><ul><li>Wish to be reunited with a deceased loved object </li></ul><ul><li>Suicide is an attempt to escape from an intolerable situation or intolerable state of mind </li></ul>
    262. 263. Theories of Suicide <ul><li>Sociological Theories </li></ul><ul><li>Durkheim-pioneer of sociological research in the study of suicide </li></ul><ul><li>3 Principal types: </li></ul><ul><li>Egotistic suicide -occurs when a person is insufficiently integrated into society </li></ul><ul><li>Anomic suicide -occurs when a person is isolated from others through abrupt changes in social norms/status </li></ul><ul><li>Altruistic suicide - occurs as a response to societal demands (deaths of Buddhist monks who set themselves on fire to protest the Vietnam war) </li></ul>
    263. 264. Theories of Suicide <ul><li>Biochemical </li></ul><ul><li>Low serotonin levels </li></ul>
    264. 265. Precipitating factors <ul><li>Social isolation-have difficulty forming and maintaining relationships </li></ul><ul><li>Norman Cousins Story: </li></ul><ul><li>a woman who committed suicide had written in her diary everyday during the week before her death “Nobody called today. Nobody called today. Nobody called today. Nobody called today…” </li></ul>
    265. 266. Precipitating factors <ul><li>Severe life’s events- divorce, death, sickness, legal problems, interpersonal discord </li></ul><ul><li>Sensitivity to Loss -may react tragically to separation or loss of a loved one ( had insecure or unreliable childhood experiences) </li></ul>
    266. 267. ASSESSING VERBAL & NONVERBAL CLUES <ul><li>Verbal Clues: </li></ul><ul><li>Overt Statements: “I can’t take it anymore!”; “Life’s isn’t worth living anymore.”; “I wish I were dead.”; “Everyone will be better off if I am dead.” </li></ul><ul><li>Covert Statements: “It’s ok now, soon everything will be fine,” “Things will never work out.” “I won’t be a problem much longer.” “Nothing feels good to me anymore.” “How can I give my body to medical science?” </li></ul>
    267. 268. Nonverbal Clues <ul><li>Behavioral Clues: sudden behavioral changes especially when depression is lifting and when the person has more energy available to carry out the plan </li></ul><ul><li>Signs: giving away prized possessions, writing farewell notes, making out a will and putting personal affairs in order </li></ul>
    268. 269. Nonverbal Clues <ul><li>Somatic clues: physiological complaints can mask psychological pain and internalized stress </li></ul><ul><li>Headaches, muscle aches, trouble sleeping, irregular bowel habits, unusual appetite or weight loss </li></ul>
    269. 270. Nonverbal Clues <ul><li>Emotional clues </li></ul><ul><li>Social withdrawal, feelings of hopelessness and helplessness, confusion, irritability and complaints of exhaustions </li></ul>
    270. 271. Suicide Precautions <ul><li>Execute a “no suicide contract”. The client will inform the nurse when he/she has suicidal ideations </li></ul><ul><li>Ask direct questions. Find out if the person has specific plan for suicide. Determine what method. </li></ul><ul><li>Be alert for cries for suicide </li></ul><ul><li>Provide a safe environment and protect client from self </li></ul><ul><li>Encourage to ventilate feelings and thoughts </li></ul>
    271. 272. Suicide Precautions <ul><li>Give emotional support </li></ul><ul><li>Make the patient realize that the tendency to commit suicide is due to the disturbance in the brain chemistry and is treatable-once they know that an episode of suicidal thinking will pass, they will likely not act on the impulse </li></ul><ul><li>Provide structured schedule and involve in activities with others to increase self-worth and divert attention </li></ul><ul><li>On discharge: help patient create “plan for Life”(list of warning signs of suicidal ideation and actions to take) </li></ul>
    272. 273. Suicide Precautions <ul><li>Always remember: </li></ul><ul><li>That a suicidal person want to die only during the period of suicidal crisis-during this time the person is ambivalent about living and dying </li></ul><ul><li>Suicidal people gives warning </li></ul><ul><li>Persons recovering from depression are high risk for 9-15 months after recovery </li></ul><ul><li>Suicidal people are extremely unhappy but not always mentally ill </li></ul>
    273. 274. Personality behaviors
    274. 275. SAD PERSON’S SCALE Personality problems <ul><li>Schizoid </li></ul><ul><li>Dependent </li></ul><ul><li>Antisocial </li></ul><ul><li>Avoidant </li></ul><ul><li>Histrionic </li></ul><ul><li>Borderline </li></ul>
    275. 276. Paranoid Personality Disorder <ul><li>A pervasive pattern of distrust and suspiciousness of others such that their motives are interpreted as malevolent </li></ul><ul><ul><li>Suspicious (e.g. others are exploiting or deceiving him) </li></ul></ul><ul><ul><li>Doubt trustworthiness of others </li></ul></ul><ul><ul><li>Fear of confiding in others </li></ul></ul><ul><ul><li>Fear personal information will be used against him </li></ul></ul><ul><ul><li>Interpret remarks as demeaning or threatening </li></ul></ul><ul><ul><li>Hold grudges toward others </li></ul></ul><ul><ul><li>Becomes angry and threatening when they perceive to be attacked by others </li></ul></ul><ul><ul><ul><ul><ul><li>Intervention: centered on building trust </li></ul></ul></ul></ul></ul>
    276. 277. Schizoid Personality Disorder <ul><ul><li>A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings </li></ul></ul><ul><ul><li>Lacks desire for close relationships or friends including family </li></ul></ul><ul><ul><li>Chooses to be alone </li></ul></ul><ul><ul><li>Lack of sexual experiences </li></ul></ul><ul><ul><li>Avoids activities </li></ul></ul><ul><ul><li>Appears cold and detached </li></ul></ul><ul><li>Interventions: building trust followed by identification and appropriate verbal expression </li></ul>
    277. 278. Schizotypal Personality Disorder <ul><li>A pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior </li></ul><ul><li>Interventions: Improving Interpersonal relationships, social skills., and appropriate behaviors </li></ul><ul><ul><li>Ideas of reference </li></ul></ul><ul><ul><li>Magical thinking or odd beliefs </li></ul></ul><ul><ul><li>Unusual perceptual experiences, including bodily illusions </li></ul></ul><ul><ul><li>Peculiar thinking </li></ul></ul><ul><ul><li>Vague, stereotypical, over elaborate speech </li></ul></ul><ul><ul><li>Suspiciousness </li></ul></ul><ul><ul><li>Blunted or inappropriate affect </li></ul></ul><ul><ul><li>Eccentric appearance or behavior </li></ul></ul><ul><ul><li>Few close relationships </li></ul></ul><ul><ul><li>Uncomfortable in social situations </li></ul></ul>
    278. 279. Anti-social Personality Disorder <ul><li>Characterized by deceit, manipulation, revenge and harm to others with an absence of guilt or anxiety </li></ul><ul><ul><li>Violates rights of others </li></ul></ul><ul><ul><li>Engages in illegal activities </li></ul></ul><ul><ul><li>Aggressive behavior </li></ul></ul><ul><ul><li>Lack of guilt or remorse </li></ul></ul><ul><ul><li>Irresponsible in work and with finances </li></ul></ul><ul><ul><li>Impulsiveness </li></ul></ul><ul><ul><li>Recklessness </li></ul></ul><ul><ul><li>Manipulative </li></ul></ul><ul><li>Interventions: </li></ul><ul><ul><li>Consistency </li></ul></ul><ul><ul><li>Kind firmness in confronting behaviors and enforcing rules and policies </li></ul></ul><ul><ul><li>Limit setting </li></ul></ul><ul><ul><li>Decrease impulsivity </li></ul></ul><ul><ul><li>Enhance role performance </li></ul></ul><ul><ul><li>Effective use of confrontation </li></ul></ul>
    279. 280. Borderline Personality Disorder <ul><li>Characterized by pervasive pattern of unstable interpersonal relationships; self-image and affect; and marked impulsivity </li></ul><ul><ul><li>Frantic avoidance of abandonment; real or imagined </li></ul></ul><ul><ul><li>Unstable and intense interpersonal relationships </li></ul></ul><ul><ul><li>Identity disturbances </li></ul></ul><ul><ul><li>Impulsivity </li></ul></ul><ul><ul><li>Self-mutilating behavior </li></ul></ul><ul><ul><li>Rapid mood shifts </li></ul></ul><ul><ul><li>Chronic feelings of emptiness </li></ul></ul><ul><ul><li>Problems with anger </li></ul></ul><ul><ul><li>Transient dissociative and paranoid symptoms </li></ul></ul>
    280. 281. Other important information <ul><li>Priority nursing diagnosis: High risk for injury directed to self related to self-mutilation behaviors </li></ul><ul><li>Coping mechanisms used: Splitting </li></ul><ul><ul><li>Classifying people as either “good” or “bad” </li></ul></ul>
    281. 282. Interventions <ul><li>Use of empathy. </li></ul><ul><li>Recognize the reality of the patient ’ s pain. </li></ul><ul><li>Offer support </li></ul><ul><li>Empower and work with the patient to understand control and change dysfunctional behaviors. </li></ul><ul><li>Provide safe environment </li></ul><ul><li>Teach social skills </li></ul><ul><li>Make a list of solitary activities to combat boredom </li></ul>
    282. 283. Narcissistic Personality Disorder <ul><li>Grandiose self importance </li></ul><ul><li>Fantasies of unlimited power, success or brilliance </li></ul><ul><li>Believes he or she is special </li></ul><ul><li>Needs to be admired </li></ul><ul><li>Sense of entitlement </li></ul><ul><li>Takes advantage of others for own benefit </li></ul><ul><li>Lacks empathy </li></ul><ul><li>Envious of others or others are envious of him </li></ul><ul><li>Arrogant </li></ul><ul><li>Interventions </li></ul><ul><ul><li>Supportive confrontation on what the patient says and what exists. </li></ul></ul><ul><ul><li>Limit setting and consistency to decrease manipulation and entitlement behaviors. </li></ul></ul><ul><ul><li>Remain neutral, avoid power struggles, or becoming defensive. </li></ul></ul>A pervasive pattern of grandiosity, need for admiration and lack of empathy
    283. 284. Histrionic personality Disorder <ul><li>A pervasive pattern of excessive emotionality and attentive seeking </li></ul><ul><ul><li>Overly dramatic </li></ul></ul><ul><ul><li>Draws attention to self </li></ul></ul><ul><ul><li>Extroverted and thrives on being the center of attraction </li></ul></ul><ul><ul><li>Uses somatic complaints to avoid responsibility and support dependency </li></ul></ul><ul><ul><li>Dissociation </li></ul></ul><ul><li>Interventions: Positive reinforcement in the form of attention, recognition or praise are given for unselfish or other-centered behaviors </li></ul>
    284. 285. Dependent Personality Disorder <ul><li>A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation </li></ul><ul><ul><li>Needs others to be responsible for important areas of life. </li></ul></ul><ul><ul><li>Problems with initiating with projects or doing things on his own because of little self confidence </li></ul></ul><ul><ul><li>Performs unpleasant tasks to obtain support from others </li></ul></ul><ul><ul><li>Urgently seeks another relationship for support and care after a close relationship ends </li></ul></ul><ul><ul><li>Preoccupied with fear of being alone to care for self </li></ul></ul><ul><ul><ul><li>Interventions: increase responsibility for self in day to day living; assertiveness training </li></ul></ul></ul>
    285. 286. Avoidant Personality Disorder <ul><li>A pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation </li></ul><ul><ul><li>Avoids occupations involving interpersonal contact due to fears of disapproval or rejection </li></ul></ul><ul><ul><li>Preoccupied with being criticized or rejected in social situations </li></ul></ul><ul><ul><li>Inhibited and feels inadequate in new interpersonal situations </li></ul></ul><ul><ul><li>Very reluctant to take risks or engage in new activities due to the possibility of being embarrassed </li></ul></ul>
    286. 287. Obsessive Compulsive Personality Disorder <ul><li>A pervasive pattern of preoccupation with orderliness, perfectionism and mental and interpersonal control at the expense of flexibility, openness and efficiency </li></ul><ul><ul><li>Preoccupied with details, lists, rules, organization </li></ul></ul><ul><ul><li>Perfectionist </li></ul></ul><ul><ul><li>Too busy working to have friends or leisure activities </li></ul></ul><ul><ul><li>Unable to discard worthless or worn-out objects </li></ul></ul><ul><ul><li>Reluctant to spend and hoards money </li></ul></ul><ul><ul><li>Rigid and stubborn </li></ul></ul>
    287. 288. <ul><li>End of First Module </li></ul><ul><li>Thank you! </li></ul>
    288. 289. Delirium <ul><li>Characterized by disturbance of consciousness and a change in cognition such as impaired attention span and disturbances in consciousness that develop over a short period of time. </li></ul><ul><ul><li>Always secondary to another condition (medical condition or substance abuse) </li></ul></ul><ul><ul><li>Frequent among the elderly and young febrile children </li></ul></ul><ul><ul><li>Fluctuations of consciousness and inoculation through out the day </li></ul></ul><ul><li>Classified as mild to severe. </li></ul><ul><li>Sundowning </li></ul>
    289. 290. Dementia <ul><li>Characterized by multiple cognitive deficits that include impairment of memory which develops slowly </li></ul><ul><ul><li>80-90% irreversible </li></ul></ul><ul><ul><li>Reversible due to pathologic process </li></ul></ul><ul><ul><li>Most common: Alzheimer’s Dementia </li></ul></ul><ul><li>4 Symptoms of Dementia </li></ul><ul><ul><li>Loss of memory </li></ul></ul><ul><ul><li>Deterioration of language function </li></ul></ul><ul><ul><li>Loss of ability of think abstractly, plan, initiate, sequence, monitor or stop complex behavior </li></ul></ul><ul><ul><li>Loss of ability to perform ADLs </li></ul></ul>
    290. 291. Stages of Dementia <ul><li>Stage 2 Moderate (Confusion) </li></ul><ul><ul><li>Progressive memory loss </li></ul></ul><ul><ul><li>ST memory loss interferes with ADLs </li></ul></ul><ul><ul><li>Withdrawn, Denial, Fear of Losing their minds </li></ul></ul><ul><ul><li>Depression, Confabulation </li></ul></ul><ul><ul><li>Problems increase when stressed </li></ul></ul><ul><ul><li>Needs home care or in-home assitance </li></ul></ul><ul><li>Stage 1 Mild (Forgetfulness) </li></ul><ul><ul><li>Losses in short term memory </li></ul></ul><ul><ul><li>Memory aids compensate </li></ul></ul><ul><ul><li>Aware of the problem, disturbed </li></ul></ul><ul><ul><li>Not diagnosable at this time </li></ul></ul>
    291. 292. Stages of Dementia <ul><li>Stage 3 </li></ul><ul><li>Moderate to Severe </li></ul><ul><li>(Ambulatory Dementia) </li></ul><ul><ul><li>Loss of reasoning ability, planning and verbal communication </li></ul></ul><ul><ul><li>Frustrated, withdrawn, self-absorbed </li></ul></ul><ul><ul><li>Depression decreases </li></ul></ul><ul><ul><li>Reduced stress threshold </li></ul></ul><ul><ul><li>Institutional care required </li></ul></ul><ul><li>Stage 3 </li></ul><ul><li>Late </li></ul><ul><li>(EndStage) </li></ul><ul><ul><li>Family recognition disappears </li></ul></ul><ul><ul><li>Doesn’t recognize self </li></ul></ul><ul><ul><li>Nonambulatory </li></ul></ul><ul><ul><li>Little purposeful activity </li></ul></ul><ul><ul><li>Often mute, may scream spontaneously </li></ul></ul><ul><ul><li>Forgets most ADLs </li></ul></ul><ul><ul><li>Problems associated with immobility </li></ul></ul><ul><ul><li>Institutional care required </li></ul></ul><ul><ul><li>Return of primitive reflexes </li></ul></ul><ul><li> </li></ul>
    292. 293. Delirium Vs Dementia Delirium Dementia Onset Usually sudden Usually gradual Course Usually brief with return to usual level of functioning Usually long-term and progressive, occasionally maybe arrested or reversed Age group any elderly
    293. 294. Sexual Disorders <ul><li>Homosexuality </li></ul><ul><li>Heterosexuality </li></ul><ul><li>Bisexuality </li></ul><ul><li>Masochism </li></ul><ul><li>Sadism </li></ul><ul><li>Frotteurism </li></ul><ul><li>Pedophilia </li></ul><ul><li>Necrophilia </li></ul><ul><li>Voyeurism </li></ul><ul><li>Transvestism </li></ul><ul><li>Transexualism </li></ul>
    294. 295. ALCOHOL
    295. 296. ALCOHOLISM <ul><li>Intergenerational Transmission </li></ul><ul><li>Awake but unconscious </li></ul><ul><li>Blackout </li></ul><ul><li>Confabulation </li></ul><ul><li>Denial, dependence </li></ul><ul><li>Enabling, co-dependence </li></ul><ul><li>Tolerance increases </li></ul><ul><li>Detoxification - doctor </li></ul>
    296. 297. Stages of Alcohol Withdrawal <ul><li>I  8 hours after the last drink </li></ul><ul><ul><li>Mild tremors, tachycardia, increased BP, diaphoresis, nervousness </li></ul></ul><ul><li>2  8-12 hours after the last drink </li></ul><ul><ul><li>Gross tremors, hyperactivity, profound confusion, loss of appetite, insomnia, weakness disorientation, illusions, hallucinations and delusions </li></ul></ul><ul><li>3  12-48 hours after the last drink </li></ul><ul><ul><li>* severe hallucinations, grand mal seizures </li></ul></ul><ul><li>4  3-4 days after the last drink </li></ul><ul><ul><li>Delirium tremens, confusion, agitation, hallucinations, insomnia and tachycardia </li></ul></ul>
    297. 298. ALCOHOLISM <ul><li>Avoid alcohol during therapy </li></ul><ul><li>Aversion therapy </li></ul><ul><li>Antabuse – disulfiram </li></ul><ul><li>Belongings – check for alcohol, mouthwash, elixir etc. </li></ul><ul><li>B1 deficiency </li></ul><ul><li>Complication </li></ul><ul><ul><li>Wernicke’s Encephalopathy (Motor) </li></ul></ul><ul><ul><li>Korsakoff’s Pychosis (Mind) </li></ul></ul><ul><li>Deliruim Tremens </li></ul><ul><li>Fornication </li></ul>
    298. 299. AUTISM <ul><li>Living in their own world </li></ul><ul><li>Appearance – flat (consistent) </li></ul><ul><li>Behavior – ritualistic, repetitive </li></ul><ul><li>Communication – echolalia, incomprehensible </li></ul><ul><li>NX: Impaired Verbal Communication </li></ul><ul><li>Impaired Social Interaction </li></ul><ul><li>Self Mutilation </li></ul><ul><li>Risk for Injury </li></ul>
    299. 300. ADHD <ul><li>Attention-deficit / hyperactive disorder </li></ul><ul><li>7 years old and above </li></ul><ul><li>Duration: 6 months and above </li></ul><ul><li>Requires 2 settings: home and school </li></ul><ul><li>Appearance: Dirty child </li></ul><ul><li>Behavior: Clumsy, hyperactive, impatient </li></ul><ul><li>Communication: talkative, bursts out </li></ul><ul><li>Structure </li></ul><ul><li>Setting limits </li></ul><ul><li>Schedule </li></ul><ul><li>Safety </li></ul>
    300. 301. Eating Disorders Anorexia Nervosa Bulimia Nervosa Pica Compulsive Eating Behavior
    301. 302. EATING DISORDERS
    302. 303. Anorexia Nervosa <ul><li>Symptoms: </li></ul><ul><li>Refusal to maintain body weight over a minimum normal weight for age and height </li></ul><ul><li>Intense fear of gaining weight or becoming fat, even though underweight </li></ul><ul><li>Disturbance in the way in which one’s bodyweight, shape or size is experienced </li></ul><ul><li>In females, absence of menses of at least 3 consecutive cycles </li></ul><ul><li>Inability or refusal to acknowledge the seriousness of the problem </li></ul><ul><li>Onset: 12-15, 17-21 years of age </li></ul>
    303. 304. Etiology <ul><li>Cultural pressure </li></ul><ul><li>Serotonin imbalance  controls appetite and the satiety control center </li></ul><ul><li>Family Patterns </li></ul><ul><ul><li>Perfectionist </li></ul></ul><ul><ul><li>Does not permit verbalization of feelings </li></ul></ul><ul><ul><li>Marital problems </li></ul></ul>
    304. 305. Clinical Presentation <ul><li>Terrified of gaining weight </li></ul><ul><li>Pre-occupied with thoughts of food </li></ul><ul><li>See themselves as fat even when emaciated </li></ul><ul><li>Peculiar handling of food </li></ul><ul><ul><li>Cutting food into small bits </li></ul></ul><ul><ul><li>Pushing pieces of food around the table </li></ul></ul><ul><li>May develop rigorous exercise program </li></ul><ul><li>Self-induced vomiting, laxatives and diuretics </li></ul><ul><li>Cognition so disturbed that they judge their self-worth by their weight. </li></ul>
    305. 306. Clinical Presentation <ul><li>Low weight </li></ul><ul><li>Amennorrhea </li></ul><ul><li>Yellow skin </li></ul><ul><li>Cold extremities </li></ul><ul><li>Peripheral edema </li></ul><ul><li>Muscle weakening </li></ul><ul><li>Constipation </li></ul><ul><li>Low T3 and T4 </li></ul><ul><li>Hypotension </li></ul><ul><li>Bradycardia </li></ul><ul><li>Hypokalemia </li></ul><ul><li>Anemia </li></ul><ul><li>Pancytopenia </li></ul><ul><li>Decreased bone density </li></ul>
    306. 307. Signs related to Purging Behaviors <ul><li>Gastrointestinal </li></ul><ul><ul><li>Parotid gland tenderness, Pancreatitis, esophageal and gastric erosion or rupture </li></ul></ul><ul><li>Metabolic </li></ul><ul><ul><li>Electrolyte abnormalities  hypokalemia </li></ul></ul><ul><li>Dental </li></ul><ul><ul><li>Erosion of dental enamel of the front teeth </li></ul></ul>
    307. 308. Objectives of care: <ul><li>Increasing body weight to at least90% of average weight for age and height </li></ul><ul><li>Reestablishing good eating behavior </li></ul><ul><li>Increasing self esteem </li></ul>
    308. 309. Nursing Interventions: <ul><li>Monitor daily caloric intake, activity level, weight and electrolyte status. </li></ul><ul><li>Establish nutritional eating patterns </li></ul><ul><ul><li>Sit with client during meals </li></ul></ul><ul><ul><li>Offer liquid protein supplement if unable to complete a meal </li></ul></ul><ul><ul><li>Observe signs of purging 1-2 hours after meals </li></ul></ul><ul><li>Provide accurate information on nutrition and discuss realistic and healthy diet </li></ul><ul><li>Help the client identify emotions and develop non-food related strategies. </li></ul><ul><ul><li>Convey warmth and sincerity </li></ul></ul><ul><ul><li>Ask the client to identify feelings </li></ul></ul><ul><ul><li>Assist the client to change stereotypical beliefs </li></ul></ul>
    309. 310. Nursing Interventions <ul><li>Assist in identifying at least three positive characteristics </li></ul><ul><li>Teach patient about their illness </li></ul><ul><li>Behavior modification : reward increase in weight with meaningful privileges </li></ul><ul><li>Identify patient’s non weight related interests to reduce anxiety and refocus attention. </li></ul>
    310. 311. Bulimia Nervosa <ul><li>Symptoms: </li></ul><ul><li>Recurrent episodes of binge eating </li></ul><ul><li>Feeling of lack of control over eating behaviors during the eating binges </li></ul><ul><li>Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self induced vomiting </li></ul><ul><li>Binge eating and inappropriate eating behaviors </li></ul><ul><li>Persistent over concern with body shape and weight </li></ul>
    311. 312. Clinical Presentation <ul><li>Binge and Purging behaviors </li></ul><ul><li>Have depressive signs and symptoms </li></ul><ul><li>Disturbed home life </li></ul><ul><li>Major concerns </li></ul><ul><ul><li>Interpersonal relationships </li></ul></ul><ul><ul><li>Self-concept </li></ul></ul><ul><ul><li>Impulsive behaviors </li></ul></ul><ul><li>Chemical dependence is also common </li></ul>
    312. 313. Clinical Presentation <ul><li>Normal to slightly low weight </li></ul><ul><li>Dental carries </li></ul><ul><li>Parotid swelling </li></ul><ul><li>Gastric swelling and rupture </li></ul><ul><li>Callusses or scars on the hand </li></ul><ul><li>Peripheral edema </li></ul><ul><li>Hypokalemia, Hyponatremia </li></ul>
    313. 314. Management: <ul><li>Trust </li></ul><ul><li>Help patient identify feelings associated with binge-purge behaviors </li></ul><ul><li>Accept patient as worthwhile human beings because they are often ashamed of their behavior </li></ul><ul><li>Encourage patient to discuss positive qualities about themselves </li></ul><ul><li>Teach about bulimia nervosa </li></ul><ul><li>Encourage to explore interpersonal relationships </li></ul><ul><li>Encourage patients to adhere to meal and snack schedules </li></ul>
    314. 315. Management: <ul><li>Encourage the patient to approach the staff if she feels like binging or purging </li></ul><ul><li>Encourage to attend group sessions </li></ul><ul><li>Encourage family therapy </li></ul><ul><li>Encourage participation in art, recreation and occupational therapy </li></ul><ul><li>Encourage the patient to describe their body image at different ages of their lives. </li></ul>
    315. 316. <ul><li>Thank you! </li></ul>

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