Care of Clients with Maladaptive Patterns of Behavior I.

Overview of Psychiatric Nursing Psychiatric Nursing 3rd Keltner/Schwecke/Bostromret [ P 2 - 6 ]/ Psychiatric Mental Health Nursing.3rd ed- videbeck [p- 9] A. Evolution of Mental Health- Psychiatric Nursing Practice The modern era pf psychiatric era can be traced from events in England and France near the end of 18th century known as Enlightenment Before this: - mentally ill were often regarded as no better than wild animals How the community response? ABC Assistance: - the lest restrictive approach, provided food, money and often enabled the family to maintain integrity as a unit Banishment

- occurred in some communities, were deranged were strangers - led to wandering bands of lunatics . . . living no one cared how, and dying no one care where - the legendary Ship of Fools boatloads of the mentally disordered cast out to sea to find their right minds Confinement - the most restrictive method of coping with mentally ill who were often chained - old and young, men and women, insane, criminals, and paupers were indiscriminately mixed - they were thought to be immune to normal biologic stressors such as cold, heat, hunger - placed on display for the amusement of their caretakers and paying public fees collected - attendants serves as ringmasters using whips to encourage their patients to perform
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- most common treatment such as bleeding, bathing, vomiting and purging and forced feeding Five Periods Serves as Benchmarks Benchmark I: Period of Enlightenment Philippe Pinel in France and William Tuke in England Philippe Pinel [1793] - became superintendent of the French institution for men and later also for women Dismayed by their conditions, wrote! - They were abandoned to the incompetence of the callous- heartless, coldhearted, unfeeling director and to the brutality of the servants. When he assumed office - Unchained the shackled- bind, cloth the naked, fed the hungry, abolished whips and other instruments of abuse Simultaneously in France and William Tuke in England
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- Was planning a private facility that would ensure moral treatment for the mentally ill - After seeing deplorable/awful, terrible and unacceptable conditions in public facilities , the York Retreat were opened, providing: a place in which the unhappy might obtain refuge a quiet haven in which the shattered bark might find a means of reparation or safety Asylum - Its concepts were developed by Pinel & Tuke - Define as: protection, social support or sanctuary from the stresses of life Dorothea Dix - Instrumental in developing concepts of asylum: to alleviate sufferings with adequate shelter, nutritious food and warm clothing Asylum as a place of rest and restorations exist which can be considered the 4s: Parents, Professionals, Patients and Public
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Nursing Practice: 1873 Linda Richards from New England Hospitals for Women and Children in Boston [consider the 1st American Psychiatric Nurse] - improve nursing care in psychiatric hospitals - organized educational programs in state mental hospitals in Illinois - believes that mentally sick should be at least as well cared for as the physically sick 1882 first training of nurses to work with persons with mental illness: - care was primary custodial focused on nutrition, hygiene and activity - nurses adapted the medical and surgical principles to their care with tolerance and kindness Nursing theories: Hildegard Peplau and June Mallow Peplau Interpersonal Relationships in Nursing and Interpersonal techniques the Crux-root, heart of psychiatric nursing
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- describes the therapeutic relationship with its phases and tasks - the interpersonal dimension that was crucial to her beliefs forms the foundations of practice today Mellow - described her approach of focusing on clients psychosocial needs and strengths Benchmark II Period of Scientific Study - shift is focus from sanctuary to treatment, personified by Sigmund Freud Freud describes human behavior in psychological terms, explained importance of dreams, and proposed to unlock the hidden parts of the mind - Introduced terms such as id, ego, superego and free association - He challenged society to look at human beings objectively and fostered a ,milieu of thinking about the mind and mental disorders - Emil Kraepelin and Eugene Bleuler
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Benchmark III Period of Psychotropic Drug - Chlorpromazine [thorazine] antipsychotic and lithium antimanic were introduced followed later Immipramine [tofranil] antidepressant - Viewed as miracle drug hospital employee describes confusion and hostility as deafening and crazy staff has to fight his way on the unit in the morning and at night Impact: - Powerful patients appeared beyond reach appears less agitated and decrease psychotic thinking - Depressed patient regained normal feelings, hospitals days shortened - Allowed patient to be treated in less restrictive environments: ethical, moral and legal questions have risen to this treatment modality Benchmark IV Period of Community Mental Health As various treatment approaches were being developed in the milieu derived by S. Freud
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theories, criticism grew and psychiatric system plunged into psychiatric Siberia Movie Snake Pit reveals a mindless, ineffective cruel system of care Hallmark: - publics declining confidence in the state hospital system - failure of various treatment approaches to eradicate mental illness - legislative climate emphasizing the civil rights of mentally ill - newfound faith in psychotropic drugs These hallmarks led to the creation of Community Mental Health Centers [CMHC] * Deliberate shift from institution to extra institutional care; goal is to: Deinstitutionalization of the state hospital system - geographical isolation were addressed thru community treatment centers and community living arrangements [halfway houses]
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- keeping closer to the family addressed the issues of isolations from family members Community Mental Health Program were developed with these programs - emergency care 24-hr inpatient care partial hospitalization care - outpatient care consultation and education for the population served by the centers - screening services Deinstitutionalization Refers to the depopulating of state mental hospitals Benchmark V - Decade of the Brain [1990s] Steep increase in brain research occurred that coincide with an increased interest in biologic explanation for mental disorders - significant changes in public awareness occurred which enable clinicians to discuss complex topics with patient and families Nursing responds to this challenge thru:
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- augmentation of psychobiologic content in their curriculum B. The Mental Health Nurse 1. Role Psychiatric mental health nursing is a specialized area of the nursing practice that utilizes a wide range of theories and research on human behavior as its science and the purposeful use of self as its art [American Nurses Association, 2006] 2. Essential Qualities C. Interdisciplinary Team - Regardless of the treatment setting, rehabilitation program or population: interdisciplinary team is most useful in dealing with mental illness - thru collaboration they can meet clients needs more effectively Team core skills areas of competencies - interpersonal skills: tolerance, patience and understanding
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- humanity: warm, acceptance, empathy, genuine, and nonjudgmental attitude - knowledge: based on mental disorders, symptoms and behavior - communication skills - personal qualities: consistency, assertiveness and problem - solving abilities - teamwork skills: collaborating, sharing and integrating - risk assessment/risk management skills

Team primary function * Psychiatrist - diagnosis of mental disorders and prescription of medical treatments * Psychologist - interprets psychological testing - participate in the design of therapy programs for group of individuals
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* Psychiatric nurse - must have solid foundation in health promotion, illness prevention, and rehabilitation * Psychiatric Social Worker - practice therapy and works with families, community support and referral * Occupational Therapist - focuses on the functional abilities of the client and ways to improve client function such working with arts and crafts, focusing on the psychomotor skills. * Recreational Therapist - helps client to achieve a balance of work and play , provides activities that promotes constructive use of leisure * Vocational Rehabilitation Specialist - determines clients interest and abilities and matching them with vocational choices
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- assist client in job-seeking and job-retention skills as well as in pursuit of further education D. The Mental Health Illness Continuum The Continuum of Care provides: - a wide range of treatment modalities to help individuals in achieving his/her optimal level of functioning - helps integrate all levels of service so that patient can move smoothly while receiving quality of care Role of the nurse: - assess individuals current level of functioning comprehensively and thus direct the person to appropriate resources to enhance quality of life and decrease fragmentation of care Decision Tree Used to match the needs of the patient with appropriate services based on: - safety needs and intensity of supervision needed - severity of symptoms and level of functioning
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- type of treatment needed, example: * Individual with auditory hallucinations telling her to kill her son needs inpatient hospitalization with 24-hour nursing care supervision in a safe environment * Thoughts of suicide but without plan might be managed effectively by attending a day treatment program for 5 days a week for 2 weeks * With history of medication non compliance who needs a place to love placed in a group homes with 24 supervision Decision Tree
Suspected Mental Health problem

Problem Confirmation

Leave the system

No
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Yes
Risk assessment - dangerous to self/others - gravely disabled - acutely psychotic - suicidal/homicidal

NO
Hospital based care

Yes

Community based care - severity of patients illness - amount of supervision required Discharge Planning

Residential service

Outpatient service

Self-help resources

Other

I. Hospital Based Care

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Goal: 1. assist individuals with attaining initial stabilization and a safe level of functioning 2. asses for appropriate referral for after care Highest priority for admission to hospital based: safety for self and others - necessitates a 24 hr. supervision, this includes - recognition of individuals who are actively suicidal, self mutilating or threatening to others Criteria for Admissions: - risks for accidental harm that is gravely disabled - acutely psychosis o those who are confused and disoriented might not be functioning well to meet their basic needs for: food, clothing, shelter, medical care, or physical safety - provides thorough psychiatric evaluation - to able to identify underlying cause

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- those experiencing toxic reactions to medications or other substances and those who need medical interventions when withdrawal from substances produces a life-threatening situation Types Inpatient units vary: * small hospital might have one closed inpatient unit that accepts all types of diagnosis * larger hospital might offer more options Important type: Psychiatric Intensive Care Unit [PICU] Purpose: initially control symptoms/behavior so that individuals can be transferred to a more treatment oriented units/programs - has 8 to 10 beds with more safety precautions and more staff - seclusions and restraints are being used - staff equipped to handle at-risk behaviors: suicide, assault, self-mutilation, sexually acting-out, arson and escape
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Discharge Planning: Uses multidisciplinary treatment conferences and discharge planning to ensure holistic are Team members collaborate /coordinate - determines aftercare services within the continuum of care
Psychiatrist , nurse, social worker, dietitian, pharmacist, activity therapy and chaplain Physical therapy, neurology, internal medicines and after care services

II. Community- Based Care: Nurses have a major role in community based services because of: - psychotherapeutic management skills, knowledge of psychopathology and pharmacology - ability to adapt the use of nursing process to any setting - holistic approach help reintegrate mentally illness into community living and assist individual in linking with community resources
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Nurses might need to advocate and negotiate for services Medical clinics dental services financial services

vocational services

Transportation Housing Medicare - Medicaid legal justice system telehealth Church-related services employees assistance program consumer groups 1. Traditional Outpatient Services Person providing counseling: psychiatrist, psychologist and social worker, clinical nurse specialist Process: For chronic cases once a month visit - Medication review or counseling During counseling visits: - assessment of needs for additional services is made to determine whether they need more intensive services or a different type of services
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Example: Dx w/ chronic undifferentiated schizo attends community support program Meets case supervisor every other weeks after receiving his Haloperidol Dec from the nurse who assess for effectiveness of the medication & side effects He also participates in his social club which offers lunch and social activities 2x/week Psychiatrist meets him every 3 months for medication evaluation 2. Partial Programs and Day Treatment Process: - Individuals who need supervision, structured activities, ongoing treatment and nursing care - Programs vary in length 4 to 8 hrs/day and 1 to 5 days a week and can occur during the day, evening and night Might provide treatment for specific population based on: - Child, adolescent, adult or older adult Type of problem
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- Drug addiction and mental problem Example: Dx with severe depression discharged from hospital but unable to return to work Attends partial program for 2 weeks that meets 10 am 3 pm from monday to Friday Attends groups that focus on exercises, spiritual, coping with loses and self esteem issues Lunch time provides an opportunity for socialization with program members 3. Residential Services - are available to help individuals who needs temporary or long-term housing LOS - LOS last for 3 to 6 mos. With 24 hr supervision A. Extended Care Facilities nursing homes - 24 hr supervision and medical nursing care
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- severe developmental disabilities, dementia, acute and chronic medical illnesses B. Group Homes - might provide temporary or permanent housing for individual with chronic mental disorders Depending on the needs of residents: - staff might be present for 24 hr or less or - group therapy and well structured activities or - provides only meals, a bed and laundry facilities C. Halfway Houses: residents are expected to: - seek employment, participate in cooking and cleaning chores - attends self-help group that meets on site D. Apartment Living: provides variety of degree of supervision and programming - staff may be available on site on a daily basis offering group sessions and activities or
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- only visits periodically to ensure medication compliance and attendance on various appointments E. Foster Boarding Homes: staff by nonprofessional but has professional supervision - shelters provide room and board to homeless and services for special population: abused women and their families/addiction F. Self - Help Groups - sources of support on the continuum of care - meetings are conducted by members, not professionals and takes place on a weekly basis E. Standards of Mental Health Nursing Standard I Theory : Applies appropriate theory that is scientifically sound as a basis decision regarding nursing practice
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Standard II Data Collection: Continually collects data that are comprehensive, accurate and systematic Standard III Diagnosis Utilizes nursing diagnosis and or under standard classification of mental disorders to express conclusions supported by recorded assessment data and current scientific premises. Standard IV Planning Develops nursing care plan with specific goals and interventions delineating nursing actions unique to each client care Standard V Intervention Intervene as guided by the nursing care plan to implement nursing actions that promote maintain or restore physical and mental health, prevent illness and effect rehabilitation
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Standard VA Psychotherapeutic Intervention Uses psychotherapeutic interventions to assist clients regaining or improving their previous coping abilities to prevent further disability Standard VB Health Teaching Assist clients, families and groups to achieve satisfying and productive patterns of living through health teaching Standard VC Activities of Daily Living Provides structures and maintains a therapeutic environment in collaboration with the client and other health care providers Standard VD Psychotherapy Utilizes advance clinical expertise in individual, group, family psychotherapy and other treatment modalities to functions as a psychotherapist and recognizes professional accountability to nursing practice Standard VI - Evaluation
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Evaluates clients response to nursing action in order to revise the database, nursing diagnosis and nursing care plan Standard VII Peer Review Participate in peer review and other means of evaluation to assure quality of nursing care provided for the client Standard VIII Continuing Education Assumes responsibility for continuing education and professional development and contributes to the professional growth of others Standard IX Interdisciplinary Collaboration Collaborates with other health care providers in assessing, planning, implementing and evaluating programs and other mental health activities Standard X Utilization of Community Health System Participates with other member of the community in assessing, planning, implementing, and evaluating mental health services and community system that include promotion of the broad
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continuum pf primary, secondary and tertiary prevention of mental illness. Standard XI Research Contributes to nursing and mental health field through innovations in theory and practices and participation research F. Legal Issues - Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret. [ P-155 -169] Law and mental health have been linked for many years: Even in ancient Rome : - should the individual have a guardian? Could the individual enter into a contract? - person with a mental disability could not form a marriage contract, if the law made him ward [dependent], the person did not have any legal rights Middle Age - mental illness posses by demons
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- kings will hold custody of property of the mentally ill profits were applied to the maintenance of the individuals and their household American colony [17th cent] - lack of facilities meant that families had to care for mentally ill people, if no family: wanderers - no distinction between a homeless person and mentally ill person Massachusetts: - passed a law to manage people who had mental illnesses and were dangerous: be detained but there were no procedures for commitment of a person with mental illness Commitment: a term referring to the various ways that an individual enters a mental health treatment Important Concept related to location and tenure of mental health Concept of Least Restrictive Alternatives:
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Providing mental health treatment in the least restrictive environment, using least restrictive treatment. Three most common types: Voluntary, emergency and longer term judicial or civil commitment I. Voluntary - Nurses are the most familiar with clients who access treatment voluntarily by consenting to be admitted and treated - Treats clients whose clinical conditions vary widely in their psychiatric severity on a voluntary basis However: if seeks discharge and is an immediate danger to themselves or others placed on an emergency commitment status pending further evaluation and treatment II. Emergency Commitment
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Severe mental illness affects clients cognitive functions refuses treatment for a variety of reasons: - psychosis, paranoia, delusions, hallucinations rejects treatment: fear of being harmed - mood disturbances who are depressed and suicidal refuses: hopelessness and wish to die - results to immediate risks of self-harm or harm-to-others - unable to provide food, clothing and shelters for himself EC for a shorter period and generally has more restrictive criteria for admissions - must be seen by physician, psychologist, social worker, Note: taking away an individuals freedom through a commitment procedure is a serious matter The US Supreme Court has established the standards of clear and convincing evidence as the standard of proof that must be met for commitment.
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III. Civil or Judicial Commitment: this is for longer time Legal basis for extended detention of an individual for treatment lies in the: parens patriae power Parens patriae power of the: 1. State to protect and care of the individuals with disabilities and the 2. Police power of the state to protect the community from persons who are threat For judicial: client be given time to prepare a defense state why hospitalization is not necessary * Client has the right for his attorney to cross-examine physician regarding the necessity of confinement * California [effective 1-1-2003]: passed a law for mandatory outpatient treatment Purpose: to break the cyclical pattern of clients, who upon discharged from an inpatient treatment
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unit, discontinued medication, detoriorate, exhibit dangerous behavior, and subsequently requires re-admission to the acute psychiatric setting Psychiatric Advance Directives [PADs] * legal documents utilized when a patient is unable to participate in the decisionmaking process * allows a competent person to describe warning signs of declining mental health and consent or refuse a treatment method * allows competent person to agree on commitment in a psychiatric care facility for a determined period of time and to appoint a surrogate [substitute] decision maker * PADs implementation: - reduces hospital length of stay - impacts on burden on mental health legal system - significantly decreases involuntary commitments
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Confidentiality: * Health Insurance Portability and Accountability Act [HIPAA] 1999: - regulates the protection and privacy of health information * HIPPAA Privacy Rule: for all health care provider who sends bills or are paid for health care Privacy Rules defines: - any individual identifiable health information than an organization keeps, files, uses - or shares in an oral, electronic or written form * Violation of privacy: civil and criminal penalties for fines or prison sentences - mental health records, to includes psychotherapy and drug and alcohol treatment Nursing Implications * Upon admission: ask to signs a release of information documents, the information usually are:
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- information that will be released - person or parties that information will be shared with such as health care providers and insurance providers - purpose of releasing the information - period or time the information will be released * the release of information even for the best intended purpose and even with subpoena from HIPPAA is risky,: must consult employers attorneys Privilege Communication Enacted by statute [decree/bill] to designate professionals such as physician, nurses, psychologist] * privilege belongs to the client and he only can assert [declare] or waive [ignore] this privilege * allows certain information given to the professionals to remain secret during any litigation [court
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case, legal actions] - exclude the mandatory reporting of child, elder, impaired adult - domestic violence - communicable diseases relating to public safety - information that will prevent felony /crime such as murder Duty to Warn and Protection: Tarasoff Case: Indian student misinterpret a New Years kiss as a serious romantic gestures [Tatiana Tarasoff] After several months: - Tarasoft dated other guy and told him she did not view their relationship as a serious one - He become subsequently depressed and sought mental health counseling and communicates with the therapist that he will harm her upon her arrival [South America] - Ran out of the therapist office and arrested by police and released Tarasoff returns
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- He went to her home and fatally wounded her with a knife Family of Tarassof - File a case against the school Supreme Court - Justices rule out protective privilege ends when the public perils begins Duty to warn: - Established the responsibility of a treating mental health professional to notify an intended, identifiable victim Rights of Client - individuals when enter a mental health facility, they usually retain the rights : unless clearly restricted by using due process to certify that an individual lacks the capacity or competence Retain their rights to: * vote manage financial matters enters into a contractual relationship and
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asserts constitutional rights to seek advice of an attorney Other basic rights: * send and received unopened mail wears own clothes

receive visitors

keep and use personal possessions access to telephone * to be informed regarding potential risks and benefits reasonable alternatives before giving consent for any specific: therapy surgery treatment including medications * nurses: need to disclose serious side effects that will uncomfortable and irreversible to the client * client are able to give informed consent unless there has been a judicial ruling to the contrary In documented emergency or endangered situation: Nurses are able to administer medications and treatment without the clients consent
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* many states requires all client receives a written summary of their rights in their own language on admissions * treatment facilities are expected to know the dominant language of the clients that they serve and make provisions to have clients rights available in those languages

Seclusions and Restraints Since the Middle Ages, mental health facilities have been using S/R to control behaviors New rules states: Health care professional were to use S/R only when less restrictive alternatives to ensure client safety had failed: such talking [ e.g. - Lloyd Latigay, Samuel Marquez, Mario Tinonga]
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* Coercion or force, discipline, punishment, or staff convenience were unacceptable reasons for placing a person in S/R However: A. 1 hour rule, it requires: - a face-to-face evaluation by a licensed independent practitioner within 1 hour of initiation or restraints used for behavioral management, additional is: B. Clients family and legal representatives be notified when restraints are used Right to Treatment Budget shortfall - layoff: few employees clients can not receive proper treatment U.S. Supreme Court: ruled that healthcare professionals cannot keep an individual in a mental hospital without treatment if he or she is non- dangerous and capable of defining and carrying out a plan of self-carte in the community Right to Refuse Treatment
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Giving of psychotrophic medications cause side effects such as akithesia and tardive diskenesia [wormlike movement of the tongue] NOTE: If there were no agreement about the appropriate medications to be given --Patient has the rights to refuse medications *During emergency situations, if there is potential danger, clients can be forcibly medicated Nursing Implications: - nurses must be aware of state laws, policies and procedures in administering medications whether involuntary or involuntary - frequent nursing assessment for side effects and careful documentation of clients complaints related to side effects are essential for readjustment or discontinuance Nurses should carefully analyze and questions the reasons for the refusal of medications
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- is it because of clients denial of the illness or symptomatology, side effects, displeasure with the treatment staff - client and family medication education by nurses, physician and pharmacist and a reassuring therapeutic relationship will greatly adhere in medications adherence Electroconvulsive Therapy Views as traumatic procedures However- can be effective treatment for a life- threatening depression Client needs to give informed consent for the procedures, which includes being knowledgeable about the risks and benefits. - potential side effects is memory loss that is temporary but is sometimes irreversible Q: who can give informed consent - if incompetent client can not give informed consent, then a relative of the client is sufficient
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* client has rights to refuse ECT unless there is clear and convincing evidence that it is necessary The state must have compelling evidence - that ECT is necessary and would be effective and - that the other forms of treatment have not been beneficial or not available The Americans with Disabilities Acts Disabilities Acts - mental barriers that limit the ability of the individual in one or more major activities Court Rule: if a persons mental condition is stabilized, there is no disability However: they are protected if the fact that they once had mental disability [depression] is used against them in the employment situation Excluded : uses controlled substances for unlawful purposes, takes prescribed drugs without the supervision of a health care professionals, possess direct threat to others
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However: it is important to recognize that this must be based on actual behavior of the individual and not on the mental disability itself Employer - cannot ask a person about prior history of mental health treatment as part of an application process for employment neither questions about the prior use health insurance coverage are not permitted - can evaluate the individual as to the ability to perform the job functions Competency to Stand Trial: criteria includes the following - does the individual charged with the crime understand the criminal charges - is there an understanding of the legal process and the consequences of the charges - can the individual advice an attorney and defend the charges Fundamentally: it is the persons awareness of the legal process that the mental health professional
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has to evaluate Court, judges, prosecutors could request a court ordered evaluation, asking for the persons competency to stand trial Criminal Responsibility [Insanity Defense] - insanity defense relates to the state of the mind at the time of offense [legal doctrine: mens rea] For a person to be found guilty, the individual must be able to form intent [intention/aim/purpose] IF: because of mental illness, intent cannot be formed and the person is possibly responding to hallucinatory voices, there is no quilt involved. M Naghten Rule: an accused will not be held responsible if at the time of the commission of the act, he was laboring under such a defect of reason, from the disease of the mind, as to not know the nature and quality
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of the act he was doing, or if he did know it, that he did know he was doing what was wrong Daniel M Naghten: shot and murdered the secretary to the prime minister instead of the intended victim because he has irrational belief that he was plotting against him. - found not guilty by reason of insanity After s person is found not guilty by reasons of insanity he or she is usually hospitalized Guilty But Mentally Ill [GBMI] Individual found guilty but because of the plea that mental illness caused the person to commit the crime, the person is sent to prison and treated for mental illness - many thought that fewer people would adopt an insanity defense with the GBMI plea
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Nursing Responsibilities in the Criminal Justice System Malpractice Situations that will potentially lead to a malpractice lawsuit - irreversible side effects of some medications and the trend of short-term hospitalization Negligence - Primary practice for malpractice lawsuits * the actions of the professional causes injury resulting in measurable damages Elements of a Malpractice Suit Based on Negligence I.
I. Nurse had a legal duty or relationship to provide a standard of care II. To establish in that relationship is a breach of duty Care is measured by the Reasonably Prudent Nurse Standard - What would another nurse working in a mental health facility have done in same situations? - Expert witness can testify regarding the adherence or departure from the standard of care

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explores whether the nurse was the causal link in the injury [damage] that occurred: II. Court 2 test to determine connections 1. but for test - the alleged damages would not have occurred but for the act of negligence 2. substantial factor test - the negligence was substantial factor in causing the damage Example: nurse gave wrong medications, or the nurse did not know about the drug interactions that led to injury

element to consider by the court is: III.Last Whether there is a proven injury because of the nurses behavior Most damaging and reckless behavior would involve a gross negligence: - acting with willful and conscious disregards of the rights of others

Documentation: - records are excellent source of communicating with other mental health professionals/ agencies - used to validate reimbursement for care
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- must carefully record a clear outline of all clients symptoms to documents *Adequate legible documentation is the best means of defense against a lawsuit and the best ways to validate that adhered to their scope of practice and a safe standard of care {NIC-NOC] Important: * be specific and to document symptoms by writing in quotes what the client expresses to you, such as: I am hearing voices that say I am a bad person * recording the actual words of the client is more definite than simply noting, the client is hallucinating * record the time it happens is more adequate Client record is a sequential document: thus it does not save space for late entries, only label entries and initial them Essentially important to document:
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when the person has achieved the goals outlined in the treatment plan If exacerbation of the illness: - treatment plans needs to reflect the change Informed consent regarding giving of psychiatric medications side effects *do not use improper abbreviations that the agency does not authorize * accurate recording of VS especially when taking psychotropic medications * careful documentations means words and grammar are corrects * if makes error in documentations place a single line through the words without making them illegible and then initial the error Sexual Misconduct Social workers, psychiatrist and psychologist: 14% had a sexual relationship with a client Cases for removal of nurses license had been reported All mental health professions consider such behavior unethical, and in many states this behavior is criminal,
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especially within a few months of the therapeutic relationships Suicide and Homicide More common: Malpractice suits Wrongful death actions for homicidal clients injury to a third party Death from suicide * some states have ruled that individuals working in government agencies have sovereign immunity and are protected from liability in malpractice situations When conducting a nursing assessment that includes a suicidal component: use extreme caution! - when individual threatens intent of suicide with a definite plan and - demonstrate lethality and access to the means to commit suicide Intent - aim, goal, and target Lethality - causing or sufficient to cause death Means - resources
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Nurse: must communicate this information, in a timely manner, to mental health provider. Then they must follow appropriate steps to provide safety, including involuntary commitment, or escape liability If there is Q, nurse should seek legal consultation HOWEVER: clinicians are not liable for errors of clinical judgment, they are liable only for departures from the relevant standard of care, given the clinical situation Tarassoft case: important to communicate with the mental health treatment team when a client threatens to harm someone! Ethical Issues: they connected to legal implications for nursing care Ethics: is the body of knowledge that explores the moral problems about specific issues In nursing practice:
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- look at the rules, principles and ethical guidelines developed to guide conduct Laws reflect the moral character of a society and are developed with an ethical basis, therefore: * we must consider ethical principles when evaluating a dilemma or problematic situation A. Autonomy: Refers to having respect for an individuals decision or self-determination about health care issues * problems with the rights to die and in mental health: rights to least restrictive alternatives Case of Involuntary Commitment: - difficult for mental health personnel to follow the law but rather than to do what the client currently desires.
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- caregivers must follow clients decision, but if the client is demonstrating intent by threatening suicide with an active plan., therefore: proceeding against the wishes of the client is necessary for safety and compliance with the law this decision is ethical tern as paternalistic decision or parentalism Q: autonomy and privacy in relation to video monitoring of psychiatric clients placed in seclusion NOTE: one loses autonomy when in seclusion or restrained and to add video is threatening to client To justify use of video: - keep a records that a monitor is being used and the therapeutic reasons for such use - clients is notified of the monitoring - only staff with clinically competent can access to the monitor
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- staff nurse should perform visualization assessment of the client Ethical treatment means balancing the good of a safe environment with the potential of harm from a loss of privacy B. Beneficence: refers to bringing about the good Nurses - have special duty and responsibility to act in a manner that is going to benefit and to harm clients Goals: in mental health treatment to assist individuals in return to a mentally healthy way of life Moral Rule: Primum no nocere [first do no harm] Example: giving of neuroleptic medications, considering of ECT treatment, C. Distributive Justice Comparative treatment of individuals in the allotment of benefits and burdens Principles of justice holds: a person should be treated according to what is fair, given what is due or
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owed Q - Who is going to get the treatment and the cost of treatment? II. Mental Health Psychiatric Nursing Practice A. Personality Theories and Determinants of Psychopathology 1. Psychoanalytical - originated with S. Freud [Psychiatric Nursing 3rd Keltner/Schwecke/Bostrom. [ P 26 - 27]
Emphasizes unconscious process or psychodynamics factors As the basis for motivation and behavior

Personality is formed in early childhood First 6 years of life: individuals drives instincts, psychic energy or libido, psychosexual attitude Personality Process
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Consist of 3 processes: Id, Ego, and Superego function as a whole to bring about behavior When these processes function in harmony individual experiences stability When these processes function not in harmony individual experiences conflicts ID - at birth wanted to experience only pleasure
Instinctual drive is known as pleasure principle To seek Pleasure it involves: Primary Process Thinking enable individual to strive for pleasure through the use of fantasies and images

Compulsive without Morals

EGO Focus on Reality Principle -

To seek Reality it involves: Secondary Process Thinking: enable individual to rationalize, logical thinking and intelligence

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Strives to meet the demands of the ID while maintaining the well-being of the individual by distinguishing fantasy from the environmental reality

- Ego is the part of personality that experiences anxiety and uses defense mechanism for protection - Heredity, environmental factors and maturation influence the formation of ego SUPEREGO - concerned with right or wrong conscience!
Formed from the internalization of what the parents teach their children about right and wrong through rewards and punishments Self concept is affected by the perception of ones actions as good or right

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Levels of Consciousness that central in understanding problems of the personality and behaviors
Consciousness or material within an individuals awareness [only a small part of the mind]

Unconscious consisting of memories, conflicts, experiences and material that have been repressed and cannot be recall at will [is a larger areas]

Preconscious materials refers to memories that cannot be recalled to consciousness with some effort

Drive force, compel, oblige Instinct - impulse, nature, character Compulsive: neurotic, habitual, irrational, uncontrolable
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S. Freud believes:
Uncovering unconscious material generates understanding of behavior

Enable individuals to make choices about behavior and thus improve mental health

Defense Mechanism: The ego usually copes with anxiety by rational means: - Anxiety too painful individual copes by using defense mechanism to protect ego and to diminish anxiety Defense mechanisms are primarily unconscious behavior: some are voluntarily 3 kinds of Anxiety thats the Basis of Mental Disorder
Painful feelings connected with childhood conflicts are repressed! Later in life as similar conflicts are once again experienced, repression fails These feelings emerge causing anxiety and discomfort

Insight into the meaning of symptoms and behaviors facilitates change

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Reality anxiety stems from external threat Neurotic anxiety deals with fear that instincts will cause one to do something to invite punishment such as being promiscuous[immoral] Moral anxiety deals with guilt that is experienced if one acts contrary to the conscience such as stealing money from a friend Goals for Psychoanalysis - to bring the unconscious into conscious so that individuals can work through the past and understand and present behavior. - by overcoming repression and resistance to exploring feelings and thoughts, childhood experiences can be analyzed
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- uncovering the causes of current behaviors leads to insight only then they will be able to decrease their self defeating behaviors and improve mental health Therapist Role: - uses free association [letting patient say everything that comes to mind] so that repressed material can be identified and interpret for the patients - dream analysis can also help uncover meaning of dreams increases awareness of present behavior Transference encourage working through feelings that would otherwise remain unconscious Relevance to Nursing Practice: - nurses must recognize and understand maladaptive defense mechanism used by the patient - carefully points out these mechanism and works with patients to decrease these behaviors and increase adaptive ones
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- can assist patient to think, feels, beliefs, and needs not according to someones else - can assit patient with accepting their desires and drives as normal human phenomenon for which they need not feel guilty or shame - assist in choosing acceptable ways of expressing their desires and drives 2. Interpersonal [Harry Stack Sullivan] Healthy Person a social being with the ability to live effectively in relationship with others Mental Illness any degree of lack of awareness of the processes in interpersonal relationship Relationship viewed as a source of anxiety, maladaptive behaviors and personality formation Conceptualized therapeutic community/ milieu develops satisfying interpersonal relationship
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Personality is labeled as a self-system - labeled personality as an energy which main goal is to reduce tension
Self-system - develops relatively enduring patterns for avoiding or minimizing anxiety during Tension of anxiety Interpersonal Encounters

Tension of needs stems from physiochemical requirements of life

Self-system develops in infancyTension for need of sleep Good me - needs satisfied Bad me - needs are unmet and anxiety persist Not me - when anxiety is severe and information is not completely integrated into personality on a conscious level [ but in the subconscious must express by therapist]
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Infant moves to early childhood and develops language: shapes child Good me fused into a sense of a whole individual + feed back from others = self-concept Bad me with different behaviors in different situations [reflected appraisals] positive & negative ways Personality Development - development focus on tools or behaviors needed to accomplish developmental tasks Infancy: birth - 1 year - crying as a tool to established contact with others - learns thru crying on counting on others Childhood - 1 6 years - language assist with learning to delay the gratification of needs
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Juvenile period 6 to 9 years - competition, compromise, and cooperation are tools for developing relationship with peers Preadolescence 9 to 12 years - collaboration and the capacity for love assist in the development of chum [friend, associate. acquaintance,] relationship with a person of same sex - same tools , with sexual desire facilitate learning to establish relationship with members of opposite sex in early adolescence 12 to 14 years of age = develops sense of independence Late adolescence - sense of independence moves towards sense of interdependence - learns to form lasting sexual relationships Anxiety activates behaviors that reduces it and helps individuals to differentiate among experiences
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[a process of learning] Severe anxiety/ panic does not convey information and produces confusion even leading to amnesia Less severe anxiety informs individual of the different situations that cause and relief tension Therapist role Focus of therapy patients current interpersonal relationship and experience - focus often on loneliness, fear of rejection, clarification of emotions and their causes - use of anxiety for learning about self and others - management of interpersonal frustration - development of self respect Goal of therapy develop mature and satisfactory relationship relatively free from anxiety therapist-patient relationship a vehicle for analyzing patients interpersonal process and testing out new skills
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Distortions created by Not me are often revealed Therapist helps correct these distortions by - clear communication - consensual [agreement in opinion] validation and presentation of reality Therapist challenge negative self- image thru - present appraisals of patients as a worthwhile, respectable individuals with rights, dignity and valuable abilities Relevance to nursing: - Hildegard Peplau apply Sullivans concept: nurses helps client reduce anxiety and helps converts into a constructive ways 3. Cognitive Behavioral [Aaron Becks cognitive & Albert Ellis rational-emotive therapy RET] Focus on thinking and behaving rather than on the expression of feelings
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Cognitive approach Individuals abilities to: Think, judge, decide, analyze and do

Individuals present: Perception, thoughts, assumptions, beliefs, values, attitudes and philosophies Needs modification or changes

S. Freud: symptoms of disturbances as having been produced by childhood experiences Irrational/ automatic thoughts; causes the problem due to: Concepts: Self- defeating behaviors are maintained Individual think both
Rationally Irrationally

&
Repetition of Irrational thoughts leads to emotional disturbances.

* individual who blames themselves & others & who Keeps dysfunctional operant * think & feel that something is behavior bad maintain emotional disturbances
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RET teaches individuals to stop blaming themselves and to accept themselves as they are with flaw[fault/error] and imperfection [defect/deficiency] inappropriate emotions & self defeating behavior RET attacks problems from a cognitive, emotion and behavior standpoint by using A-B-C theory of personality: A activating event Problems: A does not cause C, rather B causes C B is the belief about A Intervention: aimed at B and it is called D - challenging C is the emotion reaction or disputing irrational belief According to Ellis & Beck:
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Some irrational beliefs and inappropriate rules for living that most individuals subscribe to: - that one should feel loved and approved by everyone - that one must be totally competent in order to be considered worthwhile - that people have little ability to change or to control their feelings - that influences of the past should definitely determine feelings in the present - that rejection or unfair treatment has catastrophic consequences - that one should never make mistakes Distorted Perceptions: be examined for: - erroneous beliefs, self deceptions and blind spots that leads to: - excessive inappropriate emotional reactions to events or stimuli Reality testing and problem solving are aimed at correcting faulty cognitions and processes so that individual develops more realistic appraisals of himself and his world

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Therapist Role: patient-therapist relationship is viewed as a collaborative effort to achieve for:

Patient: Have many irrational should, oughts, must [SOM] Therapist effort: Improved self-esteem, coping, relationships and life styles

Process of therapy : focus on the present Therapist: - explains how to replace irrational thinking with rational thinking to reduce dysfunctional feelings & behaviors. - accepts patient as they are and does not allow them to rate or condemn themselves due to
SOM

- homework assignments given focusing on skills development & positive statement & behaviors - new positive self statements are encouraged to enable patient to begin to think, feels and behave differently. May use role playing Patients: - learns how to responsibility for their ideas & behavior - works to eliminate disturbing behaviors

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Relevance to Nursing
Nurses - change irrational beliefs and to reduce stress and anxiety through effective problem solving by: - identify many self-depreciating or negative feelings about themselves and correct by pointing out specific positive behaviors
Patient - awareness of their qualities or aspects can be facilitate beliefs that they are worthwhile and have valuable characteristics, thus; - self blame & quilt is reduced - feels better about themselves

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Patients who project blames can be shown that they alone are responsible for their behaviors Alcoholism blames others for their problems facts is that they alone are responsible for continuing drinking and for the problems that results from drinking * Patients who continually function according to SOM can be taught on to act according to their personal wants and beliefs and need not condemn themselves for being their own persons Self-awareness allows individuals to more 4. Humanistic fully make choices to enhance quality of life in
Human potential & inherent worth of human beings as: unique, self actualizing, selfdetermined with the capacity to develop selfawareness the full range of human experiences

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Abraham Maslow father of humanistic theory viewed human beings as motivated by basic needs
Coping behaviors available to an individual determines his ability to meet & satisfy basic needs Blocking or inability to meet basic needs leads to ineffective coping or in severe case - psychopathology

5. Psychobiologic Bases of Behavior - Psychiatric Nursing 3rd Keltner/Schwecke/Bostrom. [Page 64 - 82 ] * Many mental disorder that were formerly thought to be caused by psychosocial stressors/or traumatic early life experiences are the results of altered or disordered brain biology * 1990 were declared the decade of the brain
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- psychobiological concepts enables the nurse to better assess patients behaviors and plan appropriate nursing interventions and also to understand drug mechanism

Neuroanatomy and Neuropathology of the Brain The nervous system is divided into the CNS and peripheral nervous system [PNS] CNS divided into I. Cerebrum II. Brainstem and III. Cerebellum I. Cerebrum Divides into 2 cerebral hemispheres, constitutes: a. multiple nervous system pathways c. limbic structures b. cerebral cortex d basal ganglia A. Nervous System Pathways - some specialized neurons in the cerebral cortex transmit information by way of pathways:
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Pathway is a bundle of communicating neurons At CNS a neuronal pathway [bundle of neurons] can be called: tract, peduncle, fasciculus or lemniscus At PNS a neuronal pathway is called a nerve hence cranial nerve III A number of large CNS pathways are readily apparent structure within the white areas of the brain [white matter]. * Much public interest in the differences between the: Right hemisphere/ brain visual-spatial [space], experiential task Left hemisphere/ brain language, mathematics, reasoning Theres greater appreciation for the interrelatedness of the two hemispheres Corpus Callosum connects the two hemispheres serves as communication pathways Note: Corpus callosum is severed: a split brain syndrome develops
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B. Cerebral Cortex The outmost part of the brain and composed of gray matter Consist of: neuronal cell bodies, dendrites and synapse and is not myelinated [myelianted axons is of white matters] Cerebral cortex is divided into 4 lobes: frontal, temporal, parietal, & occipital 1. Frontal Lobes: divided into: 1.1. Motor cortex - controls voluntary motor activity [synapse in the spinal cord spinal nerves to peripheral for muscle movement] This voluntary movement is referred to as the pyramidal system or the corticospinal tract this pyramidal is used because many of the neurons in this tract pass through the pyramids of the lower brain stem
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The extra pyramidal system lies outside the pyramids 1. 2. Premotor Cortex Associated with movement patterns for voluntary activity and with inhibiting lower motor neurons from overreacting to stimuli * Premotor Cortex & Extrapyramidal system many movement disorders arises to include psychotrophic use! Motor + Premotor Cortex = somatrophic organization meaning area of motor strip controls a specific area: Area of motor strip where the head is located controls head movements Area where the feet are hanging controls feet movements. 1. 3. Prefrontal Area Responsible for thought, goal - oriented behavior, and inhibition
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Seat of personality, and injuries here results in personality changes * Hypofrontality: - people with schizophrenia has decrease in cerebral blood flow [CBF] particularly at prefrontal area of the cortex, resulting in decline frontal functioning: - decline in organization, planning, learning, problem solving and critical thinking 2. Temporal lobes: Divides into - a primary auditory receptive areas damaged leads to: aphasias, both visual and - secondary auditory areas and auditory - visual areas Patient with visual aphasia cannot recognize in print that once understood [words are as unrecognizable as printed Russians would be to most people]
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Patient with auditory aphasia hear sounds but cannot associate the sounds with meaning 3. Parietal lobes: primary sensory- association areas interprets sensation. 4. Occipital lobe divided into visual receptive & visual association areas for vision C. Limbic System refers to the limbic lobes and its structures: - frontal cortex, hypothalamus, amygdale, hippocampus numerous tracts - brain nuclei and the autonomic nervous system Limbic systems controls four Fs feeding, fighting, fleeing and fornicating, memory, emotions/motivation includes the feelings about people, institutions and life that affects behaviors example: feelings helps determine if an act is right or wrong, good or bad, and whether or not a particular act will be performed
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Feelings the visceral aspects of behavior Limbic Olfactory Function - must note how significant smell is to emotions [department stores sells perfumes] * Pleasure/feeding functions - hypothalamus involves in several aspects of feeding * Fight or flight limbic function Composed of 3 major areas: amygdala, hypothalamus and midbrain Electrical stimulation of these areas elicits rage behavior or flight Bilateral lesioning of the amygdale and hypothalamus calm effect * Memory limbic function Limbic system is crucial to memory Amygdale and hypothalamus key structures in the transfer of information from short termto long term memory Bilateral lesions of the hypothalamus[nuclei] r/t anoxia near drowning
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Lesions of the hypothalamus[mamillary] r/t thiamine deficiency [korsakoffs psychosis] causes memory problems D. Basal Ganglia Basal Ganglia & Extrapyramidal system - involved in motor movements Extrapyramidal system complements [balance/harmonize] the pyramidal system
Pyramidal system
Transmit commands for voluntary movements

Extrapyramidal system Modulates movements and maintains appropriate muscle tone and adjust postures - balances excitatory & inhibitory neurons that have different neurotransmitters dopamine primary inhibitory neurotransmitter acetylcholine primary excitatory neurotransmitter gamma-aminobutyric acid [GABA] - inhibitory

Basal Ganglia affects opposite side of the body Extrapyramidal System - affects contralateral side
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* because this system maintains muscle tone and posture movements are noticeable at REST Example: Parkinsons disease: - extrapyramidal disorder manifest with a resting tremor - these unwanted movement diminish during concentration and with intentional movement - absent during sleep Basal ganglia dysfunction: meaningless, unintentional movement that occurs unexpectedly 1. Parkinsons: rigidity, braykenesia, resting tremor, masklike face, shuffling gait 2. Chorea: sudden, jerky and purposeless movements [Huntingtons disease, Sydenhams chorea]
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3. Athetosis: slow, writhing, snakelike movements, especially of fingers and wrists 4. Hemiballismus: a sudden, wild flailing [wave/swing wildly] of one arm II. Brainstem: collective term for the midbrain, pons and medulla oblongata 1. Midbrain: represents the continuation of the CNS below the cerebrum 2. Pons: literally means bridge between midbrain and medulla oblongata 3. Medulla Oblongata responsible for many important functions: respirations, regulation of blood pressure, partial regulation of heart rate, vomiting and swallowing Reticular Formation [RT] multineural pathway which resides within the brainstem
RT regards as a primitive brain - input from most sensory pathways passes the RT where it is: Integrated and then projected to areas such as thalamus & hypothalamus Affects motor, sensory and visceral functions

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Reticular Activating System [RAS] Serves as a screening device that allows a person to tune out some stimuli and attend to other stimuli - tuning out is fortunate: study or sleep in some environments is possible Activated by : - sensory stimuli, pain, movement, feedbacks from the cortex, muscle tone and sympathomimetic drugs [stimulants] - - - Any of these helps a person to remain awake -

* Due to many synapses RAS can be easily depressed - if disruptions occurs and persons cannot sleep psychosis can occur * Once it is tune off- coma results

III. Cerebellum Writing with a pen, reading a book, shooting a basketball or climbing possible due to cerebellum Functions coordinating muscle synergy and activity but does not initiate movements
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 maintenance of equilibrium Cerebellar Dysfunction: can produce intention tremors that are on the same side of the body as the lesions intention tremors occurs when a person is asked to touch something have tremors when they try to concentrate on moving a limb Basal Ganglia tremors at rest Cerebellar Dysfunctions: awkwardness of intentional movement 1. ataxia: awkwardness of posture and gait; incoordination; overshooting the goal when reaching for an object; inability to perform rapid, alternating movements, such as finger tapings; awkward use of speech muscles, resulting in irregularly spaced sounds 2. decreased tendon reflexes on affected side 3. asthenia: muscles tire easily
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4. intention tremors: noticed when intending to do something, such as reaching for a pencil 5. nystagmus * small nucleus in the basal ganglia plays an important part of the addiction puzzle Neurons and Neurotransmitter Neurons basic subunit of the nervous system and there are almost 100 billion of them in the brain * composed of cell body with a large nucleus with main function to transmit information by: - sending action potentials [waves of electrical depolarization] down their processes to other neurons 2 processes: Dendrites receives impulses from other neurons and transmit those impulses to the cell body
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Axons carry impulses away from the cell body to other neurons, muscle, or gland 3 basic types of neurons: Sensory neurons [afferent] send messages to the CNS Motor neurons [efferent neurons] send messages from the CNS to the periphery Association neurons [interneurons] lies between sensory and motor vast majority Most impulses [action potentials] travel from one neuron to another thru: Neurotransmitters across a 20nm space [synapse] which separates the cells 4 major group/subsystem of neurotransmitter Neurotransmitter Chemical Mental Disorder Transmitter Cholinergic Ach acetylcholine Decrease in Alzheimers systems disease Monoamine Catecholamine
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systems

Neuropeptides

Amino acids

Dopamine Norepinephrine Epinephrine Serotonin Enkephalins Endorphins Substance P Somatostatin GABA Glycine Glutamate Aspartate

Increase in schizophrenia Decrease in depression Decrease in depression

Decrease in anxiety

Autonomic Nervous System: divided into: I. Parasympathetic [craniosacral] nervous system: * Cholinergic systems conserves energy and divided into:
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Cranial: has a neuronal component over - Oculumotor CN III Facial CN VII Glossopharyngeal CN IX Vagus CN X ii. Sacral: neuronal element at 2nd 4th sacral spinal cord areas * Loss of cholinergic pathway is found in Alzheimers disease contributes to memory loss leading to: - forgets facts, how to use words, and how to use common objects Essentials: Psychotrophic drugs have anticholinergic properties - anticholinergic blocks the functions of these nerves: CN III affects pupils dilatation and ciliary constrictions CN X affects vagus nerve heart & GI tract CN VII affects tearing and salivation Thus anticholinergic effects on these nerves cause: pupil dilation, decreased lacrimation, dry mouth, tachycardia and a slowed GI system
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II. Sympathetic [thoracoclumbar] nervous system - expends energy and forms a continuous column running from the first thoracic to the third lumbar spinal cord areas Hypothalamus has both sympathetic and parasympathetic functions and is considered the highest autonomic center in the CNC effects on illness conditions * hypothalamus dysfunction can lead to anorexia nervosa refusal to eat Ventricular System - the brain floats in approximately 140 cc of cerebrospinal fluids [CSF]; however, the CNS produces 800 cc/day CSF circulates around the brain in the subarachnoid space and inside ventricles in the brain Subarachnoid space: brain is covered by 3 connective tissues called meninges - a narrow space between the middle meningeal layer, arachnoid and inner most layer pia matter
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Ventricles - form 4 spaces within the brain: lies in each of the hemisphere - 4th ventricles communicate with the ventricles space and eventually, the CSF in the subarachnoid space enters the vascular system thru the arachnoid villi. - Arachnoid villi is compromised : such as trauma/meningitis CSF build up quickly
Blockage of CSF outflow within or from the brain - overproduction of CSF causing ventricular expansion Example: hydrocephalus

Enlargements of Ventricles

Brain atrophy Death of large # cortical neurons - [neurodegeneration] seen in chronic alcoholics and Alzheimers disease neurodevelopmental problems seen in schizophrenia

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Schizophrenia: Phenomenon of refereed to as increase in ventricular brain ratios [VBRs] - increase in ventricular size is apparent related to neurodevelopmental reasons - brain around the ventricles have failed to develop and the ventricles are enlarged to fill the empty space Alzheimers disease - leading cause of dementia cause by brain atrophy enlarged ventricles, narrowing of gray matter - loss of ch Trauma CNS trauma can experience brain insults similar in dementia or Parkinsonism Victims of vehicular accidents, gunshots, boxers exhibit symptoms based on nature of injury
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Prefrontal lobe injury may experience personality changes or psychosis Repeated blows to the head - dementia pugilistica [punch-drunk syndrome] Temporal lobe injury - memory loss pr aphasia Etiology of Aggression biological expressions of aggression: - focus on areas on limbic system, frontal lobe, and temporal lobe - NT: serotonin, GABA and dopamine influences expression/suppression of aggressive behaviors 6. Psychosocial Psychiatric Mental Health Nursing 4th edition: Fortinash/holoday Worret P 86-87 & Psychiatric Nursing 3rd Keltner/Schwecke/Bostrom p 34 35 Freud saw biological instincts 5 years of life
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Erickson saw social interaction as the driving source influencing human development across life span Combining his concepts and Freud: effects of the social environment on biologic maturation conceptualize psychosocial theory of human development, entitled the 8 stages of man each stage builds on the previous stage influenced by past experiences
Each stage represents a psychosicial crisis

Ego needs to resolve - either successfully/ unsuccessfully

Moves to the next level

Each stage represents specific traits: - one positive & one negative Source of crisis: - internal [biologic] and external [social]

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Stage

Virtue

I. trust vs mistrust 0-18 mos [0-1]

Hope

Behavior reflecting mastery Realistic trust of self and others Confidence in

Behavior reflecting developmental problem Suspiciousness/testing of others Fear of criticism &

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others Optimism and hope Shares openly with others

II. autonomy vs. shame and doubt 18 mos.- 3

affection Dissatisfaction and hostility Projection of blame and feelings Withdrawal from others Or overly trusting others Nave and gullible Shares too quickly and easily Self-control Self-doubt/selfand will power consciousness Realistic self- Dependence on other for concept and approval self esteem
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years

Willpower Pride and sense of goodwill Simple cooperativeness Generosity tempered by withholding

Feelings of being exposed/attacked Sense of being out of control of the self and ones life Obsessive-compulsive behavior Or Excessive independence or defiance, grandiosity Denial of problems Unwillingness to ask for help Impulsiveness/inability to wait
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III. Initiative Vs. guilt 3 -5 yrs Purpose

Reckless disregard for safety of self and others An adequate Excessive conscience quilt/embarrassment Initiative Passive and apathy balanced with Avoidance of restraints activities/pleasures Appropriate Rumination and self pity social behavior Assuming a role as victims/self-punishment Curiosity and Reluctance to show exploration emotions Underachievement of potentials Healthy Or competitiveness lack of follow-through
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Sense of direction Original and purposeful activities

IV. Industry vs. inferiority 6-12 yrs

Sense of competence Completion of project Pleasure in Competence efforts and effectiveness

on plans Little sense of quilt for actions Excessive expression of emotions Labile emotions Excessive competitiveness/ showing off Feelings unworthy and inadequate Poor work history: quitting, being fired, lack of promotions, absenteeism, lack of productivity
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Ability to cooperate and compromise

Identification with admired others

Inadequate problemsolving skills Manipulation of others/violation of others rights Lack of friends of the same sex Or Overly highachieving/perfectionistic Reluctance to try new things for fear of failing Feeling unable to gain love or affection unless totally successful Being workaholic
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V. Identity vs. role confusion 6-12yrs. Sense of self

Confident sense of self Emotional stability Commitment to career planning and realistic long-term goal

Lack of or giving up of goals, beliefs, values, productive roles Feelings of confusion, indecision, alienation Vacillation [hesitant],between dependence and independence Sense of having Superficial, short-term a place in relationship with the society opposite sex Establishing Or - dramatic overrelationship confidence with opposite acting-out behaviors: sex alcohol/drug abuse
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Fidelity to friends Development of personal values Testing out adult roles Ability to give and receive Sense of belonging Commitment and mutuality with others

Flamboyant [showy] display of sex role behaviors

VI. Intimacy vs. isolation 18-25/30

Persistent aloneness/isolation Emotional distance in all relationships Prejudice against others Lack of established vocation; many career changes
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Collaboration in work and affiliation Sacrificing for others Responsible sexual behaviors

VII.

Productive,

Seeking intimacy through casual sexual encounters Or possessiveness and jealousy Dependency of parents/partners Abusive towards love ones Inability to try new things socially or vocationally; staying in routine/mundane [ordinary/dull] job and activities Self-centeredness/self104

Generativity Focus constructive, vs. concerns for creative activity stagnation next 30-65 generation

indulgence Exaggerated concern for appearance and possession Lack interest in the welfare of others Personal and Lack of civic and professional professional growth responsibilities/activities Parental and Loss of interesting social marriage and/or responsibilities extramarital affairs Or too many professional or community activities to the detriment of the
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family or self VIII. Satisfaction Feelings of self Sense of helplessness, Integrity vs. and acceptance hopelessness, despair acceptance worthlessness, 65 death uselessness, meaningless Withdrawal and loneliness Sense of Regression dignity, worth Focusing on past and importance mistakes, failures, and dissatisfaction Adaptation of Feeling too old to start life according all over to limitations Suicidal ideas or apathy Valuing ones Inability to occupy self
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life Sharing of wisdom Exploration of philosophy of life and death

with satisfying activities: hobbies, volunteer work, social events. Or inability to reduce activities Overtaxing strength and abilities Feeling indispensable Denial of death as inevitable

7. Psychospiritual Spirituality - an integrative energy that produces inner harmony or wholeness - sense of coherence provides a sets of
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- driving force that permeates all aspects that gives meaning to life self-determined - sense of transcendence over reality drawing strength from the inner sources, values that are Living fully for the present, a sense of inner knowing basis for living Hope is a central concept of spirituality, and the faith factor helps provides coping skills Faith belief and trust in God assist an individual in the challenges and celebrations of life. 8. Eclectic B. General Assessment Considerations: [Straight As in Psychiatric & Mental Health Nursing: A review series : Lippincot p 15-22]
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I. Principles and Techniques of Psychiatric Nursing Interview: General Information: Psychiatric assessment: * scientific process of identifying a patients psychosocial problems, strengths, and concerns * informations gathered leads to analyze the patient mental, emotional, and behavioral status Psychiatric Nursing Interview: A systematic psychiatric interview helps the nurse to gather broad information: - assess psychological conditions - identifies the underlying or precipitating cause of his current problems - identifies patients coping methods and their effects on his psychological growth - formulates care plan - assesses patient progress and the effectiveness of treatment
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- patient might not understand its purpose: nurse must explain why information is necessary and help the patient recognize the benefits of dealing with problems openly General Guidelines for conducting a patient interview - Ensuring the patients privacy: ask who will accompany during the interview like adolescence if they wish they parents to be around, couples: if wife wants her husband to be with her. - Choosing a quite, calm private setting interruptions and distractions threatened confidentiality and may interfere with effective listening - Reassuring patient is that he is safe - Showing support and sensitivity - Listen carefully and objectively and objectively to make patient feel comfortable enough to discuss his problems and responding with sensitivity Interviews Dos A. Do set Clear Goals
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Assessment interview is not a random discussion - obtaining information, screening for abnormalities, or investigating for an identified psychiatric conditions [depression, paranoia, suicidal thoughts] B. Do Heed Unspoken Signals Listen carefully for indications of anxiety/distress - what topics does the patient ignore or pass over vaguely C. Do Check Yourself Monitor your own reactions - may provoke emotional response strong
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enough to interfere with your professional judgment Ex. Depressed patient makes you feels depressed, hostile own makes you feel who is lost with reality may induce fear Interviews Donts A. Dont Rush - building a trusting relationship takes time B. Dont Make Assumptions - dont make assumptions about past events affects the patient emotionality try to discover what each event meant to him! Ex. Stated his father died dont assumes it provoked sadness: Death by itself
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does not cause sadness, guilt, or anger! What matters is how the patient perceives the loss C. Dont Judge the Patient Dont let personal values cloud your professional judgment Ex- judge attire on its appropriateness and cleanliness, not on whether it suits your taste - Using reliable information sources: - If mentally ill cant provide answers and unreliable: ask permission to interview family members, verify information through family members and friends - Checking hospital records from previous admissions and compare his present behavior from the past
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- Consider patients culture: cultural beliefs affect response to illness, adaptation to care and behavior during interview culture- mental illness is a stigma- affects treatment decisions First time: follow certain steps: - Introducing yourself and explaining and explain purpose of interview - Asking the patient how he would like to be addressed - Sitting in a comfortable distance and give him undivided attention while maintaining a professional friendly attitude * potential for violence: sits close the door than in corner of the room - Speaking in a calm, non threatening tone-quality, to encourage patient to be candid open/honest - Gathering information about the patients educational level, housing conditions, income, current employment status, and family may provides clues to his problems
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- Assessing his economic & personal situation aid in determining their impact on his current psychological status economic/personal hardships causes distress during illness Note specific details to explore patients chief complaint When the symptoms began - abrupt or gradual onset how severe they are how long they last and how it affects his level of functioning For recurring problem: - What prompted him to seek help at this time - Patient description of the problem use direct quotes when documenting! * be aware: patients dont have overriding concerns and others may insist nothing is wrong - Overt- [obvious/unconcealed] signs of mental illness [patient enmeshedtrapped in a medical problem may fail to recognize their own depression may require careful observation! - Nonverbal clues indicating the problem
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- Information provided by the patients family or friends helpful when patient is unaware of the problem If patient is capable of holding in-depth conversation obtain a detailed personality profile! Ego functioning: coping mechanism especially his ability to handle the stress, use of violence, withdrawal or denial; impulses control and degree of insight and judgment Sense of identity look for indications for patients talents, accomplishment, adaptability and capacity to find emotional support Developmental level note stumbling blocks for maturational process Explore previous psychiatric/psychological disturbances: - episodes of delusions, violence, attempted suicide, drug or alcohol abuse, or depression and - previous psychiatric treatment
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Obtain a detailed psychosocial history - Relationships. Lifestyle, coping skills, sexual habits, diet, sleep pattern and use of alcohol, tobacco or drugs - Work, school, religious practice, community life, hobbies or interest - Social network and support system - Significant life changes: recent marriage, divorce, illness, jobs loss, or death of a loved ones to include how he felt when these changes occurred

Obtained a detailed family history - Family customs, child rearing- practices and emotional support received during childhood * observes how the patients react when disclosing family history - Emotional health of relatives: family history of substance abuse, alcoholism, suicide, psychological disorder, psychiatric hospitalization, child abuse or violence
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- Physical disorders affecting family members Review patients medical history - Kidney/liver failure, infections, thyroid/metabolic disorders, increase intracranial pressure Take detailed medication history: - All medications taken to include OTC, nutritional, herbal - Compliance with medications - Improvements in symptoms since starting the medications - Adverse reactions 2. Mental Status Assessment The Nursing Process Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret. P 42-61 * problem solving method that continues to provides nurses with a reliable, organized framework for delivery of nursing care
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* designed to meet the needs of the client, family, community and the environment 6 standard steps that helps gives nurses treat and evaluated clients response to health problem in a a systematic interactive ways: Standard I Assessment Standard II Nursing Diagnosis Standard III Outcome Identification Standard IV Planning Standard V Implementation Standard VI Evaluation Standard VII Documentation
I II VI III

IV

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VII

Standard I Assessment Mental Status Assessment and Psychological Assessment are essential parts as the physical exam to general medicines MSE: Helps the nurse collect objective data about the clients appearance, behavior/activity, attitude, speech, mood and affect, perception, thoughts, sensorium, cognition, insights and reliability Psychosocial criteria: assessed clients stressor, coping skills, relationships, cultural, spititual and work-related issues Important components to assess for behaviors or risk factor threatening the safety of client or others: * suicide, self-harm, assault/violence, withdrawal from alcohol or other substance, allergic
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reactions, command hallucination. Assess for physical pain or medical problem that may affect client functions or well-being Establish trust [ reliance/dependence] and rapport [ a relation with empathy] Display a calm, empathetic, non judgmental, manner Identify the current problem and relate that understanding to client/family Determines client current level of mental, emotional, psychological functioning * to include cognition [ level of perception] mood , affect, coping, relatedness, hygiene and posture Conduct a mental status assessment Ask the client and family what outcomes they expect to get from treatment Components of Assessment: Mental Status & Psychosocial Criteria Mental Status Assessment: Appearance: Dress grooming hygiene
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cosmetics age posture facial expression Behavior/Activity Hypoactive or hyperactive rigid, relaxed restless agitated motor movements, Gait [way of walking] and coordination facial grimacing gestures mannerisms Passive combative bizarre [odd repetitive gestures and movements] Attitude Interactions with the interviewer: cooperative resistive friendly hostile ingratiating [bring oneself into favor Apple polishing]
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Speech Quantity: poverty of speech [few words], poverty of contents [lack of content] voluminous [too many words] Quality: articulate [well spoken] congruent [makes sense] monotonous [repeated one tone] talkative repetitious spontaneous, circumlatory, confabulation [fabrication] tangential[superficial], pressured [ rapid, urgent]
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stereotyping [repetitive] disorganized [unstructured] fragmented Rate: slowed, rapid, normal Mood and Affect Mood intensity, depth, duration Sad fearful depressed, angry, anxious, ambivalent [opposing feelings] happy ecstatic [overjoyed], grandiose Affect intensity, depth, duration Appropriateness sad apathetic, [indifferent] constricted [narrowed] blunted [little expression] flat [no expression, labile
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[changing expression] euphoric [exaggerated happiness] bizarre [odd, abnormal] Perceptions Hallucinations illusions depersonalization [detachment] derealization [disconnected from reality] distortions [ views objects out of proportion] Thoughts Form and content: logical vs illogical loose association flight of ideas, autistic [ internal stimulated thoughts] thought blocking broadcasting neologism, word salad obsessions [persistent thought] rumination [ re thinking same
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thought], delusions, Sensorium/ Cognition Level of consciousness orientation [ aware of persons, place, time and situations] attention span, recent and remote memory [can recall current and past events] Concentration ability to comprehend and process information Intelligence fund of knowledge, has sufficient knowledge Judgment makes rational decisions, ability to assess and evaluate situations, understand consequences of behavior and takes responsibility of actions Insights aware of the situations [ such as own illness
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and reasons for hospitalizations ability to perceive and understand the cause and nature of owns situations aware of symptoms of mental disorder - ability to abstract and use proverbs [ understands common saying and expressions] Psychosocial Criteria Stressors internal: psychiatric or mental illness; including pain, perceived loss, such as loss of self concept/self esteem external: actual loss death of loved ones, divorce, lack of support system, job or financial loss, retirement, dysfunctional family system Coping Skills
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 adaptation to internal and external stressor use of functional adaptive coping mechanisms and techniques management of activities of daily living, ability to solve problems associated with daily living Relationships attainment and maintenance of satisfying, interpersonal relationships congruent with developmental stage, includes sexual relationship as appropriate for age and status Cultural ability to adapt and conform to prescribed norms, rules, ethics and ways of life of an identified group Spiritual [value-belief]
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 presence of a self-satisfying value-belief system that the individual regards as right, desirable, worthwhile and comforting Occupational engagement in useful, rewarding activity, congruent with developmental stage and society standards [work, school, recreation] Assessment setting other than mental health unit: ER, intensive care unit, medical surgical unit, home environment,, community center, private practice Assessment sources Ideally the patient is the primary source of information * if too ill family members or friends may be interviewed Example: extremely confused, delusional, hallucinating, unable to speak, unconscious nurse have to rely on others
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* information given others than the client must be evaluated in terms of the persons relationship to the client Medical records also serves as a source [client history], electronic charting provide easy access Laboratory studies also provides information regarding patients body chemistry, abnormal liver enzyme and alcohol/drug levels in the blood * abnormal BUN/electrolytes levels RT kidney disease, liver enzyme : - agitation , depression, lethargy * abnormal glucose and insulin levels mood changes and sensorium * positive toxicology possible violence
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Assessment Rating Scale Several standardized rating scale are used to assess and monitor a clients * psychiatric diagnosis * mental functioning or abnormal behavior - Hamilton Anxiety Scale - Anxiety Beck Inventory Depression - Mania Rating Scale - Mania Brief Psychiatric Rating Scale Schizophrenia - Abnormal Involuntary Movement Scale [AIMS] Extra Pyramidal Side Effects Standard II Nursing Diagnosis Statement that describes a persons health state and responses to actual or potential health problems * based on reliable clinical judgment by the nurse following an extensive nursing assessment
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North American Nursing Diagnosis Association International [NANDA-I] definitions:

A clinical judgment focusing
Individual Family Community RESPONSES TO ACTUAL / POTENTIAL Health Problem Lifes Process

Makes the Nurse ACCOUNTABLE

For achievement of OUTCOMES

Provides a framework for therapy

Actual currently experiencing or a potential problem called risk diagnosis * risk diagnosis: example is risk for suicide must have risk factors such as hx of suicide/verbal threat * risk factors replaces the etiology
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 Nursing Diagnosis Statements in relationship to life Processes Life Nursing diagnosis process Biolo Imbalance nutrition: less gic than body requirements Psych Chronic low self esteem/ ologic readiness to enhance self concept Socio- Impaired social cultur interaction/social isolation al In medical model of psychiatry health problems are the mental disorders in the Diagnostic and Statistical Manual of Mental Disorders Global Assessment of Functioning ( GAF) uses to assess client functioning Standard III Outcome Identification Predicts clients behavior (outcomes) resulting from nursing intervention
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* Outcomes statement: are specific , measurable indicators that the nurses uses to evaluate the results of their interventions * * times are the most accurate in actual client situations and not in hypothetical cases A. Example: correct outcomes [descriptive with measurable timelines] 1. Verbalize absence of suicidal thoughts and plans in 24 hrs. Incorrect: Not be overwhelmed by suicidal thought 2. bathe and dress self by 8:00 am each day in 72 hrs. B. Example: outcome statement from nursing diagnosis Nursing Diagnosis: Anxiety Correct Outcome Statement: Verbalizes feelings calm, relaxed, with absence of muscle tension and diaphoresis; practices deep breathing
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Incorrect Outcome Statement: stress reduction

exhibits decreased anxiety; engages in

Nursing Outcomes Classification [NOC]

Describes Outcomes as Concepts That reflects a patient, family, caregiver, family or community actual state Rather than expected goals

Example of NOC indicators for depression level Depression Se Sub Mo M N level ve stan der il o overall re tial ate d n
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rating Depressed Mood Loss of interest in activities Negative life events Weight loss Weight gain

1 2 1 2

3 3

e 4 5 4 5

1 2 1 2 1 2

3 3 3

4 5 4 5 4 5

Standard IV. Planning Nurse plans clients care with the client, physician and interdisciplinary team Identifying priorities of care
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 Coordinates and delegating responsibilities according to the treatments team expertise as it relates to clients needs Making clinical decisions about the use of psychotherapeutic, scientific principles using evidence based practiced Evidenced-Based Practice in Mental Health Nursing EBP care is more effective when it is based on evidence or when available evidence is not ignored Interdisciplinary Standard Care Plans Generally features the:
NANDA Diagnosis Client Outcomes, and Interventions that COMPLY With nursing practice standards

They reduce the need to create new care plan Nurses primarily identifies, evaluate and resolve the problems Standards guidelines for all disciplines encourages consistency of care There is very little writing, so the nurse has more tome to spend with clients
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 They satisfy managed care criteria for quality outcomes and length of stay They promote safe, effective, evidence based practice over time Clinical Pathways: :Also called the critical pathways or care map is: [47]
A standardized multidisciplinary planning tool Monitors client care Through : projected caregivers intervention expected client outcomes Based on: Clients DSMIV-TR mental disorder

Projects the clients entire length of treatment from the day of admission Also mapped out a continuum of chronologic targets usually the number of days of the clients estimated length of stay Concept Mapping [51]
A critical problem-solving plan that promotes the students understanding of the relations between IDEAS CONCEPTS - TOPICS

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Shows relevant elements of the clients HOLISTIC DATA BASE

developmental, medical, nursing, pharmacology, laboratory teaching and learning needs

Students present data on self-adhesive notes that shows the relationships between the elements A superior way to prepare students for clinical experience * allows students to combine complex, relevant data into manageable pieces * requires students to understand the situation as a whole rather than relying on memory * helps both the students and instructor to make connections between concepts Standard V. Implementation The nurse sets in motions the intervention prescribed in the planning phase General considerations directed towards clients and families during this phase
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* promotes health and safety * monitoring medications schedules & effects * providing adequate nutrition/hydration * create a nurturing, therapeutic environment * continuing to built trust, self esteem, dignity * participate in therapeutic group activities * developing client strength and coping methods * improving communication and social skills * connecting family and community support system * preventing relapse through effective discharge planning

Nursing Intervention
Also known as nursing orders or nursing prescriptions

Critical components of the Implementations phase

Most Powerful Piece of the Nursing Process

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They make up the Management and Treatment approach to: * an identified problem * and are selected to achieve client outcomes * and prevent or reduce problems

It describes a course of actions or therapeutic activity - that helps the client to move towards a more functional state

NI are not nondescriptive, weak and do not simply responds to physician orders Examples of descriptive action-oriented interventions * engage the client gradually in interactions with other clients, beginning with individual contacts,
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progressing to informal gatherings, and eventually moving on to structured group activities * teach the client/family that therapeutic effect of antidepressants drugs sometimes take up 2 weeks and that side effects often begin immediately Examples of nondescriptive, weak or vague interactions * assist the client in talking to others * teach client and family about the medications Examples of repeated physician orders and lacks definition * monitor the clients progress * check lithium levels services Nursing Intervention Classification [NIC]
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* notify social

 NIC is define as: any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes First comprehensive, standardized classifications of interventions States: that no one should not change intervention labels and definitions so that there will be no confusion across the settings Example to illustrate the effect of intervention Nursing diagnosis: powerlessness related to loss of control over mental illness As evidence by: verbal statement that noting will change the mental condition Interventions: teach the client that mental illness is treatable with medication and therapies Standard VI. Evaluation Nursing activities involved are critical because nurses are accountable for the standards of care in each discipline Two steps:
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1. Compares the clients current mental status state/condition with the outcome statement Example: is the clients anxiety reduced to a tolerable level? Can he sit calm for 10 minutes, attend activity for 15 minutes, or socialize with the staff for 5 minutes without distractions 2. Considers all of the possible reasons why the client did not achieve outcomes Sometimes it is too soon to evaluate the outcomes, and plan of actions need to continue for a loner period of time Example: client need another 2 days of one-to-one interactions before attending a group activities Standard VII. Documentation Mandatory for the nurse: - to record an evaluation of the clients changing condition
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- informed consent [for medication and treatment} - responses to medications - ability to engage in treatment programs - signs and symptoms [suicidal/homicidal tendencies being the most critical] - clients concerns [in clients words as appropriate] Nurse documents according to facility standards [SOAPIE, ABCIE, and FDAR] - narrative, a checklist, or electronic form Although the entire mental health team is responsible for client relating progress, the nurse is generally accountable Importance of documentation: - for legal issues such as confidentiality and privacy acts insurance reimbursement - accreditation quality assurance case management - peer review research 3. Diagnostic Examinations specific to psychiatric patients C. Building Nurse- Client Relationship
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Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret. P12-13 1. Nurse-client interaction vs, nurse client relationship Role of the Nurse: Therapeutic Alliance The primary aspect of working with client in any psychiatric setting is developing a therapeutic alliance * Alliance: is professional bond that exists between a nurse and a client and often plays a significant role in the client well-being Begins in the nurse-patient relationship and is the corner stone of nursing intervention in psychiatry The relationship is guided by standards and objectives and is primarily intended for the client It serves as a vehicle for the client to freely discuss their needs and problems in the absence of
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* judgment and criticism * gain insight * learn and practice new skills * effects life changes, * heal mental and emotional wounds * promote growth Must provide a safe environment for this relationship to occur Principles of the Nurse - Client Relationship I. The focus remains on the clients needs and problems rather than on the nurse or other issues. Frequently during session client redirect the focus away from self by changing subject matter like talking about weather, nurse appearance, environment problems : must recognize as divergent tactics that usually a form of resistance : * How to confront = confronts diversion in a mater -of- fact way and assist in refocusing the topic. * Reasons for divergent fear of being judged, resistance to discussing anxiety-producing material, boredom,
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repetition of material previously discussed, inability to stay focused due mental disorder II. The relationship is purposeful and goal directed The primary purpose of a therapeutic relationship is helping clients to meets adaptive goals Together client and nurse determine problematic issues and collaboratively decide what the client needs and is able to achieve * once goal are established client and nurse must agree to work towards the goals and put intentions into actions, modifying strategies when necessary III. The relationship is objective rather than subjective in quality Nurses are therapeutic only when they are objective Objective Refers to remaining free from bias, prejudice, and personal identification in interaction and process
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information based on facts. Example: - nurse ability to remain empathic instead of sympathetic when interacting with a client: a nurse lost a child during car accident, encounters depressed client who is grieving in the recent death of his son - nurse demonstrates objectivity by: * allowing and facilitating the clients full expression of thoughts and feelings - nurse response * warm, empathic way that remains client centered This approach helps the client : * relieve pentup feelings in a normal grieving process * allows client to feel understood
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* helps client to process and organize thoughts directed toward solving his/her own problems Subjective refers to emphasis on ones feelings, attitudes and opinions when interacting with the client Example of a nontherapeutic subjectivity Same situation, the nurse upon hearing the clients expression of feelings * nurse responded with: excessivedisclosure about his own similar feelings This approach represents a LOST in THERAPEUTIC BOUNDARIES thru: * identifying with the clients problem and becoming enmeshed [trapped]in the situation by
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personalizing it. Client response: * likely will stop sharing information because he or she feels unimportant and negated [null&void] * feels worries because the nurse is fragile or inept/.incompetent because he cannot event manage his own problems Client compromised by their own conditions and situations can not be BURDENED by the nurses problem IV. The relationship is time limit rather than open ended

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 STRUCTURED - Before establishing the relationship set necessary parameters by agreeing on specific days and time when they will meet and the number of times the meeting will take place * structures helps them realize that this relationship has LIMITS and is not OPEN client can meet when ever she wants and for as long as he wants

Principles of time-limited interactions: At times they have nor learned during formative meeting When participants define the amount of time they are WILLING and ABLE to give it . . . * eliminates anxiety-provoking guesswork All relationship have inevitable ending , Grief or sorrows, anguish, miseries can be avoided if both the client and the nurse are certain of their boundaries and enforce them together V. The relationship is therapeutic rather than social
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 TR is formed to help client: * solve problems and makes solutions * achieve growth * learn coping strategies * reinforce self worth, * let go of unwanted behaviors * examine relationships Some social conversation is usually in the beginning of the meting to help to establish and maintain rapport Therapeutic Social; Offer clients therapeutic Give and receive assistance friendship equally Focus on clients needs Meet both personal needs Discuss clients Share mutual ideas perceptions, thought, and experiences feelings and behaviors Actively listen and uses Gives opinions and
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therapeutic communication skills and techniques Encourage client to choose subject for discussion Encourage client to problem-solve towards independence Keeps no secrets that may harm client Set goals with the client

advice

Remain objective

Randomly discuss topics at will or whim/impulses Insist on helping as a friend; tolerate dependence Promise to keep secrets at any cost Recognizes that goals of relationship are not important Becomes
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subjectively involved Maintain healthy Accepts blurred boundaries boundaries Evaluate interactions with Avoid relationship client evaluation Stages of the Nurse Client Relationship I. Preorientation Stage: Several tasks to accomplish before meeting
First is to gather data about the client, his conditions, and his present situation Information is taken from: chart, staff report, physicians report, input from family, other sources police and tanods. Results to Autodiagnosis regarding clients: - perception, thoughts, feelings, and attitudes

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Avoid: * judgmentalism, biases, or stereotype/pigeon hole/label [Steorotype to form standardized opinion without adequate information] * a nurse learns information about a client reminds of him of a personal loved ones , feared person, the response of the nurse is subjective, non therapeutic and ineffective II. Orientation Phase Relationship starts to grow, wherein participants starts to: * becomes acquainted, built trust and rapport * demonstrate acceptance of the process that develops when working on important life issues The Contract
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 It can either be formal, informal, verbal or written Example : Nurse at inpatient unit I will be your contact persons while you are in [name of facility]. I work Monday through Friday from 8am to 5pm. Because of your busy schedule, it seems the best time for us to meet is at 9am, is that a good time for you? if the client agrees contract is established. At community level: may give also, time schedule and contact numbers Some contracts has specifically identified behaviors [expected outcomes] for the client to practice between meeting Regardless of the type of contract, the nurse should explain: * purpose of the meeting, what is expected during the meeting, and the roles for both the nurse and the client
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 Dependability is important and the nurse must keep all appointments with the client likewise with the client *** Important Client and the nurse together identify clients strength, limitations, and problem areas Outcome criteria are established and plan of care is formulated

III. Working Stage Begins when the client takes responsibility and actively engages in his or her own behavior changes *** Implications: committing to work on problems and concerns that caused disruptions in clients life rather than merely discussing them Prioritizing needs helps determines problems that requires immediate attention and promoting an organized ways to manage the problems
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General Principles Safety and health problems are a main priority above all Example : * determines first if the clients are free from danger to themselves or others, then: * address pertinent physical needs before traditional therapy begins Within the established relationship, the nurse helps the client to: * modify behaviors that are socially unacceptable [hostile remarks, swearing, isolation, poor hygiene] * helps client to explore thoughts and feelings and change problematic behaviors in a safe environment where the client can practice new skills * reinforce positive outcomes the client achieves IV. Termination Stage Actually begins in the orientations stage when the nurse sets meeting time and avoids confusion for client who is unwilling and unable to recognize the boundaries of their relationship
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 Generally occurs when the client has improved and has been discharged Ending treatment is sometimes traumatic who has valued a relationship Method can be use when preparing for termination Reduce the amount of time spent with the client in each session and increase the amount of time between sessions as the clients condition improves Prepare clients post discharge situations [plan for the future] rather than focus on new or past problems Have the client identify changes he has made towards growth, share perception of the clients growth Help the client express feelings about ending the relationship Tell client the relationship has been a pleasant one 2. Therapeutic use of self 3. Therapeutic communication Therapeutic Communication
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Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret. P-57- 61 Communication: Most powerful tool in psychiatric nursing the method used to activate e nursing process - foundation for the nurse-patient relationship- the domain[ sphere of influence] of psychiatric nursing Hildergard Peplau Concept: Believed that the therapeutic relationship between the nurse and client occurs in the environment of the nurse-patient relationship and passes through distinct but overlapping phases from: Orientation [admission] to Resolution [discharge]

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Communication is a dynamic, process in which two or more people share all types of information. Communication Process: consist of several structural components * Stimulus - a reason for the communication to occur * Sender - individuals who initiates the transmission of communication, both verbal and nonverbal * Message - information being sent and received, feelings or ideas * Medium - method which message is sent: - seen [visual- letter], heard [verbal-shout], felt [tactile- hug] or smelled [scent-perfumed] * Receiver - receives and interprets message Receiver must interpret the message exactly as the sender intends, producing effective communication * Feedback - receivers gives backs the message is how you measure effectiveness of message
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- a continual process because it is a response to the message and provides a new stimulus to the sender Factors that Influence Communication I. Environmental factors that controls effectiveness of communications A. Time: - timing of interaction is important, the phrase counting 10 describes a waiting or cooling off period necessary for some individuals to ensure that they are able to rationally discuss a topic or understand a critical concept Example: a nurse chooses to wait for a better time to begin teaching a client about medications because the client has just experienced an emotional outburst and unable to focus.
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* Careful chosen time will mean the difference between successful and unsuccessful client learning

B. Location: - instrumental in conveying the sincerity or importance of communication Example: if the location is noisy and other people are present, messages in the conversation may not be heard [noise] : a man wishes to propose marriage chooses a romantic environment [privacy] * The type, quality and perceived importance of the specific messages conveyed depends in part on the general comfort of the environment
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II. The relationship: a casual friend can give the same message to an individual as an intimate friend, but receiver may react quite defiantly to each person according to the nature of each relationship. III. Context: as well as the content must be appropriate to the type of interaction. Need to feel safe in their environment in order to disclose highly personal information IV. Attitude Determines how a person responds to another person and includes the persons biases, past experiences and level of openness and acceptance - people from one socioeconomic class, ethnic background or family background have difficulty in communicating with individuals from a different background or class due to language barriers, values or knowledge barriers [Iraq]
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- bipolar patient [kanindot] V. Knowledge - differences in knowledge often results to a problem

Sender Has greater knowledge of subject matter - has responsibility to make sure the receiver understands the message Receiver Has lesser knowledge of subject matter

Some people have an ability to relate [tell, narrate] a variety of people and are able to explain in simple, understandable ways VI. Perception is an individuals subjective experience that influences interpretation of the message
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senders must be certain that the receiver has a great understanding of the message Nonverbal Communication communication theories believes that non verbal communication is the most important parts of any message composing about 93% of any communication involves elements that do not involved actual words. Involves all 5 senses as a general rule, it is more revealing and truthful than verbal communications To be effective communicator: Nonverbal cues must be congruent or consistent with the verbal message I. Body Language or cues includes: - facial expression, reflexes, body posture, hand gestures, eye movements, mannerism, touch and
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other body motions - use of space, aslo known as proxemics - body posture & facial expressions to include eye movements are the two important cues to determine how a person is responding to the message Examples: 1. a client who is frowning, with clenched teeth and fists, narrowed eyes and red face remarks: I am always glad to see my mother contradiction b/w verbal and nonverbal 2. a slumped or stooped posture - depressed , feels sad, rejected 3. erect posture with shoulders back feels more confidentortrying to appear confident 4. closed posture with arms fold withdrawal or feels angry 5 gait, or the way individual walks indicates client self concept Client who bounces along with shoulders back and head uphigh usually beat up individual who
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walks at a slow-moving pace with slumped posture 6. hand gestures anger, restlessness, frustrations, hopelessness , relaxation, apathy Old sayings when in doubt, observe what people do, not only what they say II. Touch one must careful when deciding whether to touch a client with psychiatric disorder , some feels threatened and may respond with aggression, intimate move, inappropriate sexual response III. Appearance communicates a particular image, as well a clue to mental illness ways individuals uses clothing, makeup, hairstyle, jewelry ,hats, eyeglasses, grooming and hygiene

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Therapeutic Communication Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret. P-69 - foundation of psychiatric nursing and the pyschiatric nurse singlemst important tool 3 essential purpose: 1. to allow client to express thoughts, feelings, behaviours,and life expeiences in a meaningful way in order to proote healthy growth 2. understand the significance of the cient's problems and the role of the client and SO in his life 3. assist in the identification and resolution processes of the client's healthrelated behavior Principles of Therapeutic Communication The therapeutic use of self begins with knowing oneself, you will not be able to help others unless you are first able to help yourself 1
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Johary's

known to self and others Open

2 known only to others unknown to self Blind

Window

To increase - strive decrease the As the nurse - open As the nurse - pane 1 In the others

3 known only 4 to self unknown to unknown to others self or others Hidden Unknown

level of self-awareness, one must: to increase the open area in pane 1 and blind, hidden and unknown becomes better communicator: area in pane 1 increases shares things about herself grows larger and pane 3 decreases process of asking feedback from the
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- pane 2 grows smaller As a results the nurse becomes more self aware through interpersonal learning - pane 1 representing thoughts, feelings and behaviors that are known to self and others, becomes larger as the other 3 panes deceases in size Traits of Therapeutic Communication - these charatceristics allows the nurse to influence growth and change in others - it incorporates verbal and non verbal behaviors, attitudes, beliefs and feelings I. Genuiness - it is demonstrated by being consistent with both verbal and non verbal behavior consistency equates to openness, honest and sincere resulting to trust to nurses II. Positive Regards - refers to respect and acceptance, shows that the clients as worthy by:
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* addressing the client by name they prefer * accepts them for who and where they are - positive regards or respects is communicated thru: * sitting and listening to a client, expressing concerns about events affecting a client * validating clients feelings and concerns * effectively responding to the clients negative behavior III. Empathy - Foundation of all therapeutic nurse-client relationships - it is the nurse ability to see things from the clients point of view and communicate this understanding to the client Skills to help develop emphatic responses * attending physically: sitting infront of the client, at a slight angle, leaning slightly forward with hands and arms in an open space
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* attending emotionally: clearing your mind of other personal or work-related business and focusing your full attention to the client * actively listening: providing a response to each of the clients verbal and non verbal communications * focusing on clients strength * expressing caring, warmth, interest, and concern through nonverbal behaviors [kanindot mother carton- mosquito] * choosing the most important point of what the client is trying to say * demonstrate consistency between your non-verbal and verbal communications

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Responding Techniques that Enhances Therapeutic Communication* Assignment- role play for stud. Therapeutic Responding Technique Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret. P-69-72 - methods used that encourage clients to interacts in ways that promote their growth and move them towards their treatment goal : Silence Restating Reflecting Clarifying Confrontations Interpretation Summarizing, Role Playing Active listening Acknowledging Feelings Support and Reassurance Sharing Observations Voicing Doubts Broad, Open-Ended Statements Information Giving *Responding Techniques that Hinders Therapeutic Communications [page76-77]
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Offering false assurance Not Listening Literal Responses

Offering Approval

Giving

D. Documentation in psychiatric nursing practice Problem-oriented recording narrative recording Soapie/abcie process recording E. Therapeutic Modalities, Psychosocial Skills and Nursing Strategies 1. Biophysical/Somatic Interventions Psychiatric Nursing 5th ed. Keltner/schwecke/bostrom p 571-578 - Somatic therapies are treatment procedures that use physiologic or physical intervention to effect behavioral changes Early somatic therapies: * Insulin 1933 - coma therapy: giving too much insulin produces a reduction in patients symptoms
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* First convulsive therapies 1934: camphor oil-induced & Metrazol-induced convulsions therapy a. Electroconvulsive Therapy During ECT electric current passed through the brain for 0.2 8.0 seconds causing seizure induction of seizures is necessary for a therapeutic outcome Seizures are time and are subdivided into: - motor convulsions - 20 seconds required - increased heart rate - 30 to 50 seconds - brain seizures - 30 to 150 seconds : monitored by EEG How does it work? ECT: alters endocrine system in ways causing antidepressant effects: - levels of corticotrophin-releasing hormone, adrenocorticotropic hormone, thyroid-releasing hormone, prolactin, vasopressin alters neurotransmitters
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- acetylcholine, dopamine, gamma-aminobutyric acid, norepinephrine, serotonin alters/raises the seizures threshold causing antidepressant effects Number of treatment ECT two or three times a week up to 6 to 12 treatments or until patient improves or not going to improve - often experience relief after 2 or 3 treatment but occasionally up to 20 is needed - many patients need a maintenance to function at their best Indications: Major depression; appropriate treatment when associated with: 1. non responsive to an adequate trial of antidepressants 4.depressive stupor 2. high suicidal potential 5. catatonia 3. dehydrations 6. delusions - prophylaxis of recurrent major depressions - severe mania not controlled by medications
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- postpartum psychosis after nonresponse to antidepressant - schizophrenia [catatonic type] when nonresposive to medications - movements disorders refractory [disobedient]to treatment: parkinsons disease, NMS, tardive dyskenesia Contraindications: Very high risks: recent MI/CVA, IntracranialMass/pressure High risks : angina pectoris, CHF, extremely loose teeth, severe pneumonia, major bone fracture Retinal detachment, severe osteoporosis, high-pregnancy Conditions nonresponsive to ECT: Anxiety disorder behavioral disorders mild depression Personality disorder phobic disorder somatoform disorder Advantages: A safe procedure has same risk as general anesthesia: 1 death/ 50,000 Safer compared with tricyclic antidepressant [fewer cardiotoxic effects, cannot be used in attempted suicide]
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Not only safe, but effective than antidepressants Disadvantages Provides only temporary relief does not provide permanent cure Memory Loss Memory impairment: retrograde [memory before treatment] anterograde [memory and ability to learn new things after treatment No loss of mental function Electrodes: Unilateral placement on non-dominant side of the head [right-handed placed on right side] minimizes treatment impact on memory and learning Bifrontal placement: causes fewer problems Adverse Physiologic Effects Cardiac: hypertension, arrhythmias, cardiac output, changes in cerebrovascular dynamics
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Hemodynamics: combination with increase muscle tone, results in an generalized increase in oxygen consumption Increased in oxygen consumptions might result to ischemia Hyponatremia and migraine headache Preparations: - pretreatment evaluation: physical exam and laboratory workout and baseline memory abilities - consent must be signed, cases of profoundly depression, consent is contradictory in terms, family members and facility legal staff should be involved - if possible routine use of benzodiazepines or barbiturates for nighttime sedation be eliminated: raise the seizures threshold Responsibilities before - NPO approximately 6 to 8hrs.: except for antihypertensive and few other medications
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- Atropine or glycopyrrolate [robinul] given 1 hr before treatment or IV preceding treatment - Atropine: reduces secretions and subsequent risk of aspirations and counteracts the ECT-induced vagal stimulation - Urinate before treatment seizure induced incontinence is common - Hairpins, contact lenses and dentures be removed, VS be taken - Nurse be positive about treatment and helps reduces anxiety Procedures - IV lines inserted and electrodes attached to head and held in place with rubber strap - Bite block is inserted - Methohexital [brevital] sort-acting barbiturate given IV causes immediate anesthesia and anticipating the anxiety associated with jolt to hit and the anxiety by succinylcholine
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- Succinylcholine [anectine] nueroblocking agent given IV prevents the external manifestations of grand mal seizures, thus minimizing fractures and dislocation but not the brain seizures. Patient is conscious but unable to breath - Anesthesiologist mechanically ventilate patient with 100% oxygen - Electrical impulses given for 0.2 to 8.0 seconds - Seizures last less than this amount of time physician must decide whether to stimulate another seizures - Seizures duration longer than 180 seconds is associated with less favorable outcome can be terminate with diazepam or other benzodiazepines - Monitor devices: heart rate and rhythm, blood pressure and EEG - Ventilations and monitoring continue until recovers After ECT - Still mechanically ventilates until patient can breathe unassisted - Nurse monitor respiratory problems
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- ECT causes confusion/disorientation: help by reorientation time, place and person - Approximately 5 to 10% awakes in an agitated state benzodiazepine as needed - Observation is necessary until patient is oriented and steady particularly when attempting to stand - All aspects of treatment should be carefully documented for the patients record. Other Somatic Therapies A. Psychosurgery [lobotomy] - obviously, clinicians should eliminate all other options before using this drastic approach - new theories regarding frontal lobe brain function reasons to adopt - suffers public rejection
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- ethical issues: destroying brain tissues constitute an extreme and irreversible tactic B. Brain Light Therapy - formerly called phototherapy: exposes patients to intense light [5000 luxhours] each day rationale: environmental factor play a role in mood disorder SAD [seasonal affective disorder] results from decrease exposure to sunlight [during winter season] Indicated: bulimia, sleep maintenance insomnia and seasonal depression Contraindicated: glaucoma, cataracts, and use of photosensitizing medications C. Repetitive Transcranial Magnetic Stimulation - produces magnetic field over the brain influencing brain activity: increasing the release of a. neurotransmitter b. downregulates beta-adrenergic receptors thus ameliorating depressive symptoms
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Adverse effects: headache and transient hearing loss, seizures in previous seizure-free individuals cautions: with metal implant in their bodies, pacemakers, heart disease b. psychopharmacology Biological Theories of Depression Attributed to alteration in: 1. neurochemical 2. endocrine 3. circadian rhythm I. Neurochemical: Monoamine System The Monoamine Neurotransmitter system in the brain releases norepinephrine and serotonin throughout the brain and helps regulate [ MASVAA] M mood A arousal S sensory processing V vigilance A attention A - appetite Theories:
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I. neurochemical depressions results when levels of certain neurotransmitters are altered Biogenic amines norepinephrine and serotonin are affected 2. dysregulation of acetylcholine and gamma aminobutyric acid [GABA} Neurotransmitter Classifications Class I acetylcholine: much excitatory less inhibitory Class II the amines: dopamine, serotonin [inhibitory], norepinephrine - excitatory Class III Amino acids Aminobutyric acid [GABA] - inhibitory II. Endocrine: Normally = hypothalamus pituitary adrenal [HPA] mediates stress response Depressed = HPA malfunctions creates cortisol, thyroid and hormonal abnormalities Causes secetory rates of III. Circadian rhythm corticotrophin releasing
Medications, nutritional deficiencies, physical & psychological illness, hormonal fluctuations associated with womans reproductive system & aging. 24 cyclic alterations in the signals from hypothalamus hormone adrenocorticotropic hormone and cortisol secretions

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Circadian rhythm responsible for daily 1. regulation of wake - sleep cycle 2. arousal activities pattern 3. hormonal secretions0 Antidepressant Goals: a) alleviate depressive symptoms c) prevent recurrence of depression b) restore normal mood d) prevent a swing into mania for bipolar patient Antidepressant works at 3 different ways: 1. Change the rate at which NT Created and Broken down by the body
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To be high in the morning and low in the afternoon

2. Blocks the process in which a spent NT is recycled by a presynaptic neuron and used again reuptake 3. Interfere with the bonding of NT to a neighboring cell Treatment Strategies: First - line Agent - SSRIs, Novel Antidepressants Second - line Agent - TCAs Third - line Agent - MAOIs, ECT I.SSRI [Selective Serotonin Reuptake Inhibitors] - Effective antidepressant that has fewer side effects than TCAs and are far less dangerous than MAOIs - has fewer anticholinergic cardiovascular and sedating side effect blocks or inhibits reuptake of NT into the presynaptic neuron, thus prolonging its activitiy UE: CNS CNS stimulation: headache, insomnia, nervousness, agitation
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N: nausea, anorexia, diarrhea, vomiting S skin rashes, sexual dysfunction ED: takes in the morning to avoid insomnia, inform of therapeutic effect: requires 3-4 weeks of therapy- elderly at 10-12 weeks - for long therapy, liver/renal function test, warfarin therapy, monitor BP. HR, weight and stool consistency, rashes with a temperature should be reported, monitor for fluid and sodium imbalances among elderly EVAL: has improvement in clinical state [appearance, behavior, interest, mood, speech patterns] Citalofram Celexa Escitalofram Lexapro Fluoxetin Proxac Fluvoxamine Luvox Paroxetine Paxil Sertraline Zoloft Example:
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CNS effects includes: headache dizziness tremors anxiety insomnia, decreased libido impotence ejaculatory delay decreased orgasm Note: anxiety, insomnia and sexual dysfunction: related to serotonin 5HT2 receptor activation II. Tricyclic Antidepressant Pharmacologic Effects Theoretically: serum level of monoamines in depressed patient is low that achieving a normal mood is impossible A. blocks reuptake of NT into the presynaptic neuron keeping the NT in synapse longer B. makes more NT available to the postsynaptic cell Therapeutic Effects
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Sedation Anxiety reduction Activating antidepressants alleviate lethargy Urinary hesitancy [childhood enureis] Improved appetite Side Effects A. Peripheral Nervous System Anticholinergic :blocking of acetylcholine receptor resulting to inhibitions of nerve impulse transmission in the parasympathetic nervous system Anticholinergic effects Dry mouth and anhidrosis [decreased sweating which impairs cooling] Visual disturbances [ mydriasis dilatation of pupil of the eye, blurred vision, might precipitate acute attack of glaucoma] Constipation and bladder dysfunction [urinary retention and hesitancy] Note: older adult are most susceptible to these sides effects/ bladder problems
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Cardiac effects Anticholinergic effect blocks the parasympathetic brake system on the heart muscle causing it to speed up: tachycardia and arrhythmias leads to MI Amitriptyline [elavil] considered the most cardiotoxic antidepressant High levels of sedation, anticholinergic activity and orthosatic hypotention [less desirable drug for elder patient] Adrenergic: indicating a relationship to eiher epinephrine or norepinephrine: action upon release is associated with sympathetic nervous system [also called sympathomimetic] Antiadrenergic effect inhibit the bodys natural leading to inadequate cerebral
Blocks adrenergic receptors on peripheral blood vessels vasoconstricting reaction when persons stands perfusion - heart responds with tachycardia to compensate

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Dimming of vision, dizziness and fainting causing a sense of loss of control and can lead to falls and serious injuries

EVAL - has improvement in clinical state [appearance, behavior, interest, mood, speech patterns] Example: Amitriptyline Elavil Amoxapine Asendin Desipramine Norpramin Doxemin Sinequan Imipramine Tofranil Maprotiline Ludiomil Nortriptyline Aventyl Protriptiline Vivactil Trimipramine Surmontil III. Monoamine Oxidase Inhibitors [MAOI] -Third type of antidepressant being administered to hospitalized patient
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The Monoamine Neurotransmitter system in the brain releases norepinephrine and serotonin throughout the brain and helps regulate [ MASVAA] M mood A arousal S sensory processing V vigilance A attention A - appetite
MAOI blocks monoamine oxidase [major enzyme in the decomposition and inactivation of norepinephrine and serotonin] The enzyme inhibition: Increases levels of these neurotransmitter in the PNS and the CNS

- approximately 2 to 4 weeks is required for MAOI antidepressant to work

Side effects:
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 central nervous system: increases MAOI in the brain CNS hyper stimulation may occur - agitation, acute anxiety attack, restlessness and insomnia cardiovascular slow down release of norepinephrine - hypotension anticholinergic - dry mouth, blurring of vision, urinary hesitancy and constipation - hepatic and hematologic dysfunction very rare but potentially serious blood counts and liver function test are highly recommended prior to medication MAOI have a number of serious interactions: potential lethal interactants include drug and foods
Direct acting add new norepinephrine to the Drugs to drug body interactions Amphetamines, cocaine Dopamine, epidrine OTC weight loss and stimulants products containing: Phenyleprine , phenylpropanolamine, pseudoephidrine

Indirect acting releases existing norepnephrine from the neurons

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Sympathomimetic drug
Mixed acting having both direct and indirect properties

Because MAOI increases the amount of stored norepinephrine in the Peripheral Nervous System - potential exist for direct acting and mixed acting sympathomimetic

Induce release a large amount of

norepinephrine

Food drug interactions centered on amine Tyramine: product of tyrosine [ Precursor or forerunner to dopamine, norepinephrine, and epinephrine]. - aged cheese, bananas, avocados, salami, coffee, alcohol/beer All protein foods that have undergone protein breakdown by aging, fermentation, pickling or smoking should be avoided

Hypertensive Crisis: initial symptoms: - palpitation, tightness in the chest, stiff neck, throbbing radiating headache

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Cardiovascular consequences: MI, cerebral hemorrhage, myocardial ischemia, and arrythmias

ED: With hypertensive crisis- within several hours of ingestion of a tyraminecontaining product, stops immediately DC 10 days prior to surgery Given AM to avoid insomia, notify provider for signs of crisis Recommend wearing of identification band inicating on MAOI therapy Nardil Phenelzin Parnate , Transcypromamine Marplan Isocarboxazid
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most likely cause hypertension crisis EVAL: has improvement in clinical state [appearance, behavior, interest, mood, speech patterns] Antianxiety Drugs Gamma-Aminobutyric Acid System [GABA]
Inhibitory Amino Acid Neurotransmitter that slows down nerve transmission

Inhibition plays a role in anxiety because they synapse with adrenergic neurons in the brain

Inhibition role is lifted there is greater inhibition of the adrenergic system 199

1. GABAergic drug benzodiazepine decreases anxiety 2 GABA receptors blockers flumanzenil causes anxiety

Overall effect is slowing down or halting down neuronal firing

BENZODIAZEPINE:
Enhances the effects of inhibitory neurotransmitter GABA Neuronal inhibition important to brain function; Car without brake leads to accident Brain without inhibition of GABA produces: Thought accelerations, autonomic dysfunction, excessive anxiety, panic, severe seizures activities = equates to run away brain

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Helps GABA tone down or inhibit the anxiety response to stressor

Pharmacologic Effect: Generally depressing effect on CNS limbic system, thalamus and Hypothalamus 5 major effects of Benzodiazepine 1. reduces anxiety 3. relax muscle 5. produces amnesia 2. promote sleep 4. prevent seizures I. Reticular Activating System system of nerve pathways in the brain concerned with level of consciousness, from sleep and relaxation to full attention and concentration
Depresses RAS Incoming stimuli are mute and evoke less reaction

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Anxious patient

Uses these defenses - Hyper alertness and environmental scanning to guard against an environment perceived to be threatening.- reacts worried/troubled

Antianxiety drugs

Decreases environmental input, bodys react to is toned down and the environmental stressor are tuned out general relaxing posture takes place

II. CNS depression from sedation to anesthesia Causes state of disinhibition or

Sedating the patient and depressing the inhibitory neurons that affects the arousal loosening of inner impediment/barrier to conduct

Euphoria and excitement leading to poor judgment

Potential attraction of Benzodiazepine

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Tension Continuum

Anxiety

Carefree sense of being

Benzodiazepine - have the potential to move anxious person from the agony of the anxiety end to the relaxed feeling of carefree end Therapeutic Dose of Benzodiazepine degree of shift from anxiety to disinhibition is NOT gained or sought but the possibility of reaching the carefree zone Becomes DRUG of ABUSE CNS Side Effects: - drowsiness, fatigue and decreased coordination
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less frequent: slowing of reflexes, headaches, Peripheral Nervous System - occasional constipation, hypotension, incontinence, urinary retention Examples of Benzodiazepine Traizola Halcyo Alprazola m m n Oxazepa Serax Temazepa m m Diazepa Valium Flurazepa m m

Halazepa m Restoril Clonazepa m Dalman Prazepam e Xanax

Paxipa m Klonopi n Centrax

Lorazepa m Clorazepa te Quazepam

Ativan Tranxen e Doral

Antipsychotic Drug

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Cell body Axon synapse Cell body Neurons basic unit of CNS send information receives/give information from nerve cell to information dendrites Presynaptic ending reuptake mechanism MAOI system blocks dopamine receptors

Dendrites Protrusion from neuron receive /transmit

Postsynaptic antipsychotic drug

Neurotransmitter chemicals found in CNS that facilitates the transformation of nerve impulses across synapse between neurons

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Pharmacologic Effect

Emotional quieting I. CNS Increase Dopamine Schizophrenia Decrease in Norepinephrine Depression Decrease Serotonin Depression Sedation referred as major Alzheimers disease tranquilizers Decrease in Acetylcholine Decease in GABA Anxiety Decreases insomnia: frequent complaint among psychotic patient

Enables patient to take advantage other form of therapeutic interventions: 1. nurse-patient relationship 2. well managed mileu therapy

Psychiatric symptoms
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Modified by antipsychotic drugs: 1. Tranquilizing effect: one hour or so after injection, its effects are observed within 6 to 8 weeks. 2. Most effective in the treatment of positive symptoms of schizophrenia and not negative symptoms Positive symptoms caused by excessive dopamine level in mesolymbic tract [hyperactive] Abnormal thoughts, agitation, associational disturbances, bizarre behavior, conceptual diroganization Delusions, excitement , feelings of persecution, grandiosity, hallucinations, illusion, hostility, insomnia Suspiciousness Negative symptoms caused by too little dopamine in the mesocortical tract
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[hypoactive] Alogia, anergia, avolition, asocial behavior, attention deficit, blunted affect, communication difficulties Difficulty with abstraction, passive social withdrawal, poor grooming and hygiene, poor rapport Poverty of speech Measurement of progress equates to improvement in objective/subjective or positive or negative symptoms I. Alteration of Thoughts:
Clouded reasoning, ambivalence, delusional thoughts: Frustrating & Frightening Free patient to think more clearly and communicate better

Antipsychotic Drug

II. Alteration of Activity

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Internal turmoil and nuerochemical changes

Slows down psychomotor activity

Antipsychotic Drug III. Alteration in Consciousness

Decreases confusion and clouding
Mental clouding and confusion

most disabling disorder

Antipsychotic Drug

IV. Alteration in Personal Relationship

Have history: - social withdrawal/ no close personal relationship If relationship with family exist - often strained /damage/injured Social damaging and Self absorptive thinking are results of > the considerable energy they expend to maintain some degree of equilibrium in the face of psychological turmoil

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Patient: - little effort in appearance and not particularly careful about their behavior - introspection [examines owns thought] - rumination [ reflect/meditate] - self-focused speech producing: - ineffective communication pattern that reinforced: - isolation and alienation

Antipsychotic drugs reduces inner turmoil, freeing psychic energy for normal interpersonal relationship and therapeutic nurse-patient relationship

V. Alteration in Affect
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Flattening, blunting, inappropriateness and lability are affective symptoms

Flat affect negative Cardinal symptoms: Only responsive to atypical type of antispychotic

Side Effects:: produces Central Nervous System and Peripheral Nervous System side effects I. PNS Anticholinergic effects result from blocking of cranial nerves with parasympathetic components 1. CN III Occulumotor mydriasis and impaired accommodation: blurred vision 2. CN VII Facial - dry mouth, decreased tearing and dry nasal passage 3. CN IX Glossopharyngeal dry mouth and dry nasal passage 4. CN X Vagus nerve tachycardia, constipation and urinary retention
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Antiadrenergic effects 1. hypotension - postural hypotension : blocking receptors on peripheral blood vessels from responding [constricting] automatically to a change in position 2. cardiac effects arrhythmias, ECG is advisable prior giving of antipsychotic II. Extrapyramidal Side Effects Abnormal involuntary movement disorder develop as a result because of drug-induced imbalance between dopamine and acetylcholine in the specific parts of the brain 1. akathisia subjective feelings of restlessness - demonstrated by: restless legs, jittery [nervous or jumpy] feelings - most common EPSE and respond poorly to treatment major reason to poor compliance to medication 2. akinesia and bradikenesia
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- akinesia refers to an absence of movements - - - bradikenesia refers to slow movements - weakness, fatigue, painful muscle, and anergia - akinesia responds to anticholinergic 3. dystonia abnormal posture caused by involuntary muscle spasms - demonstrates: sustained, twisted and contracted positioning of the limb, trunk, neck, mouth - appears in early treatment and has the following types: - torticollis - contracted positioning of the neck - occulogyric crisis - contracting positioning of the eyes upward - writers cramp - fatigue spasms affecting the hands - laryngeal pharyngeal constriction - potentially life threatening - responsive to anticholinergic drug parenterally III. Drug- Induced Parkinsonism
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Cardinal symptoms: bradykenesia, tremors and rigidity Symptoms: bardykenesia- abnormally slow movements, muscle rigidity, shuffling gait [dragging], stooped posture, flat facial affect, tremors, drooling IV Tardive dyskenisia tardive means late appearing develops approximately after 6 months or more of treatment - It is a repetitive, involuntary, purposeless movements Signs and Symptoms: - grimacing, rapid eye blinking, tongue protrusion and smacking, lip puckering [ wrinkle], and rapid movements of arms, legs and trunk V. Pisa syndrome older individual are susceptible of this effect of leaning to one side VI. Nueroleptic Malignant Syndrome
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- potential lethal side effect of antipsychotic 2. Supportive psychotherapy A. Nurse-Patient relationship therapy - see previous discussion B. Group Therapy Psychiatric Mental Health Nursing 4th ed./fortinash/holoday worret p 277 Goals in group therapy: 1. helping the client with problem-solving skills, 3.setting goals 2. social interactions 4.medication education and management * there is weak evidence to support this therapy Generally the group consist of 6 8 members and are for client with enough reality testing to participate in a meaningful manner
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Note: the type of group therapy suitable for clients with schizophrenia varies according to their level of functioning Theory used: Rogerian Model [carl roger] known as client-centered therapy Considered as humanistic theory helps client to : 1. express and clarify feelings 3. helps client to try out behaviors in a safe setting 2. promotes acceptance by the therapist and Client Education: - no studies to show providing education provides improvement of clients knowledge and a change behavior - only findings shows indications that this approach improves patients social functioning Self-Help Group - increasingly active in their own care with intent of decreasing dependence on professionals, decreasing stigma associated with mental illness
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C. Family Therapy - Psychiatric Mental Health Nursing 4th ed./fortinash/holoday worret p 529Developmental stages of each family member Influence the function or tasks of family members Key: emotional process necessary at each stage for successful transition to the next stage of family process

Family phases in the family life cycle

As family moves on: There is an ongoing redefinition : 1. roles, 2. entry and exit of members 3. changes in emotional & attachment needs 4. realignment of boundaries

Hallmark of healthy family: 1. open communication patterns in negotiating individual needs/tasks 2. secure attachment/emotional bonds Between family members 3. flexibility & adaptability to change
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4. ability to express/distinguish emotions and thoughts 5. ability to effectively manage social and economic stressors [groupings/financial] Family System Theory: views family as the primary emotional system that shapes and determines the outcome and course of ones life
Family interaction and relationship helps: - individual meet developmental task while allowing the family as a whole to move through the stages of the family life cycle Healthy emotional and psychologic environment

EGUAL

Relationships are interdependent and a change in one part of the system is followed by compensatory changes in other parts of the system

Family system: Strives to maintain a psychologic homeostasis or balance through emotional interactions or relationships among family members

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Subsystem: couples [marital dyad], siblings and parent-child: are the common subsystems or relationship within the family Extended family members also interact to form other subsystem affecting the overall family functioning Attachment: refers to the emotional bond between couples, parents, and children
Seeking & maintaining an emotional bond with significant others is an: 1. Innate [inborn] 2. primary [main] 3. motivating need in human being across the life span

Positive attachment built on trust: Someone is available provides a sense of safety and security

Serves as a buffer against the effects of stress leading to psychologic development to succeed

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Example: Positive attachment: a secure, positive emotional attachment for a child provides a safe psychologic environment for the child through the stages of individual development and maturity leading to psychologic autonomy within the network of emotional bonds Negative: avoidant and insecure results from trauma such as: - physical or sexual abuse emotional abuse loss of parent mental illness in a parent [depression leading to emotional abandonment] severe illness trauma by war famine catastrophe Child:
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Caregiver responds to a childs needs and development and how childs need met leads to: 3 attachment pattern 1. secure: care giver being responsive, attentive and approving leading to a securely attached child that exhibit less inhibited and more explorative behavior 2. avoidant: inconsistent in responding, in giving attentions leads to an anxious feelings - leads to ambivalently child: - try to reestablish contact, clings to the caregiver and constantly checks to see that the caregiver is nearby 3. anxious-ambivalent attachment constantly ignoring or deflecting the needs and attention child attempts to maintain proximity but avoids close contact with the caregiver
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Adult: Secure attachment style: [family left for usa-despida at regordon palmeras] - reports of positive early family relationship and trusting attitudes towards each others - have higher self-esteem Avoidant attachment - view relationship as less satisfying - less trusting of others and tends to avoid getting close to others Anxiously- ambivalent attachment - view others in a relationship as unreliable - view their own relationships as having less interdependence, trust and satisfaction Emotional Triangle - situation occurring in a family that tends to redirect anxiety and avoid actual or potential conflict between two people by introducing a third person or third issue into the mix
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- triangles may decrease anxiety but keeps the two individuals from addressing the source of conflict that has produced the anxiety - Temporarily diffuse a But if it becomes fixed and original conflict is not resolved symptoms may begin to appear in one of the
problem relationship members of the triangle

Boundaries - rules in the family that regulates interpersonal, emotional contact between individual family members and subsystem within the family Rigid: Limitless contact and support:
- do not allow contact with outside subsystem results in isolation and limit emotional support disengagement - Intruding on the development of independent emotional competence enmeshment

Symptoms Development:
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- depends on the amount of anxiety and stress being generated in the family and how much it disrupts the family system - degree of symptoms and level of anxiety present reflects level of psychological skills and coping skills available in managing internal and external stressors
Generally based on the emergence of various types of stressors as the family moves through time and available psychologic and social support resources

Symptoms development: Example:

Few symptoms appears in families - with strong emotional bonds - healthy coping under high levels of stress Exhibit symptoms indicative of high levels of anxiety due to: ineffective coping skills caused by : - Poor communication pattern - High level of interpersonal conflicts

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Role of the Family Therapist Therapist goal: use system approach to effect change by helping family members work out their differences and concerns by: - conduct extensive assessment of all family members as a whole by using genogram to identify relationship pattern genogram a 2-3 generation diagram designed to tract family process: these process includes: - conflict, types of boundaries, enmeshment, disengagement and family triangles - communicating and relating directly with each other - coaching, observing and providing feedback regarding family pattern of interaction - looks at symptoms related to the overall family system that is exhibiting difficulty in one or more
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subsystem: - couples or parent dyad, mother-son dyad, father-daughter dyad [individual therapy-focus on one] Role of the Nurse Vital role: 1. assessing symptoms of distress in family members 2. helping the family identify and mobilize available resources that facilitate emotional and support in the family as a whole Employ 15 minutes assessment using genogram by asking these 3 important assessment questions: - which family members are most involved with the problem - how does the illness affects the family - amount of distress/anxiety being experienced and acknowledge their concerns and fears by: a. answering questions and
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b. promoting communication and support from other family members - how does the family affect the illness - nurse uses therapeutic conversations to help reveal methods of managing the demands of care giving and most importantly: gives the nurse opportunity to: 1. provide feedbacks for effective coping 2. and to suggest additional resources for the family to use while negotiating the crisis 3. Counseling 4 Mental Health Teaching/Client Educations Psychiatric nurses provide treatment through the continuum of care: includesprimary, secondary and tertiary Primary Prevention:
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- biological, social, psychological intervention that promotes health and well being or reduces the incidence of illness in a community by altering the causative factors before they can do harm I. Assessment: identification of the following: - stressors that precipitate s maladaptive behavior - a target/vulnerable population that is high risk to stressor - children, adolescent and new families - families experiencing divorce or illness - women and elderly II. Planning and Implementation: specific intervention: a. health education b. environmental change c. support system A. Health Education: strengthening individual and groups through building competence [Competence - capability, ability, skills, aptitude, proficiency]
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Assumptions: maladaptive response result from a lack of competence - lack of perceived control of ones life - lack of effective coping strategies - results to lowered self-esteem Four levels of interventions: - increasing individuals/group awareness of issues/events related to health and illness such as developmental tasks - increasing ones understanding of dimensions of potential stressors, its possible outcomes [adaptive and maladaptive] and coping strategies - increasing ones knowledge of where and how to acquire needed resources - increasing individuals and group problem-solving skills, interpersonal skills, tolerance of stress and frustrations, motivation, hope and self esteem
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B. Environmental Change: modify individual or group environment or the larger social system; especially: a. when environmental placed new demands and does responds to developmental needs b. and environment does not provide little positive reinforcement Example: economic, work, housing, family, political C. Support of Social System: strengthening social support is a way of cushioning the effects of a potential stressful event Four types: - assess communities and neighborhood to identify problem areas and highrisk groups - improve linkages between community support system and formal mental health services - strengthening existing care giving network such as churches
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- helping individual or group develop, maintain, expand and use the existing social network Secondary Prevention - Involves reducing the prevalence [occurrence] of a disorder - Activities includes: early case findings screening and prompt early treatment - Crisis intervention- an important secondary treatment modality I. Assessment: obtain data regarding nature of crisis and its effect * identify the precipitating event: - including needs that are threatened by the event and the point at which symptoms appeared * identify the persons perception of the event - including the underlying themes and memories associated with the event * identify nature and strength of the persons support system and coping resources - including family, friends, SO who might of help * identify the persons previous strength and coping mechanism
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- including successful and unsuccessful coping strategies Crisis Intervention: to be discussed later last concept! Tertiary Prevention - activities that attempts to reduce the severity of the disorder and its associated disability * Rehabilitation process of enabling individuals to return to highest possible level of functioning: - developed from a need to create opportunities for people to live, learn and work in community environment of their choice 5. self enhancement, growth/therapeutic groups 6. assertiveness training incorporated in 7. stress management 8. behavioral modification

to be later discussion
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9. cognitive restructuring 10. mileu therapy Therapeutic Milieu An environment specially created and maintained to restore and promote optimal psychologic health and wellness Goals: * provide a physical and psychologically safe environment * maximize the highest level of psychological functioning * identifying acute or chronic physical illness that are affecting [psychiatric symptoms * promote healthy coping behavioral strategies and symptoms management * helps to promote independent activities of daily living * educating clients and their families about medications and other therapeutic modalities
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* establish a collaborative discharge planning between client/family and multidisciplinary team Elements of the Effective Milieu Safety, Structure, Norms. Limit Setting, Balance, and Environmental Modification I. Safety :- - - Safety, or being safe, implies freedom from danger or harm. * It is an important concern in any therapeutic environment and encompasses freedom from both psychological and physical harm. Protection from psychological harm is provided by norms that do not permit: * undue confrontation of one patient by another and of excessive confrontation of patient by others. * may be protected also by restricting visitors, including family members, who are known to
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disparage [ be little/laugh] at patients. Patient who experience severe anxiety may suffer unnecessarily if staff members do not intervene. * Interventions to decrease anxiety and promote a feeling of psychological safety may include : - giving psychotropic medications - assuring patients that a staff member will stay with them - providing such patients with a non stimulating environment. Freedom from physical harm also is important. Safety is ensured by developing unit norms that do not permit physical violence by any community member. - policies and procedures for control of aggression, who are acting in a threatening way, are Necessary:
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- some institutions use time out rooms [patients room or a designated but isolated spot on the unit] - may be physically restrained or secluded in a seclusion room until they are in control - Whenever restrained or secluded: must emphasize they neither are nor being punished, but rather that eternal control are being used until they are able to regain control II. Structure The physical environment, the regulations and the daily schedule of classes and groups - community meetings, activity groups, living skills groups, physical exercise program etc. . . Structure denotes the designs of the unit: - space, areas for socializing, and for privacy are required
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- telephones must be available and visiting rooms are appropriate In seclusions: - designs and locations and furnishing must maintain both safety and dignity III. Norms Norms are expectations of behavior that permeate the setting - intended to promote community living through behaviors that are socially acceptable Example of common norms that a violent behavior is not permitted Norms that can help attempts to build a climate of universality or shared experience - Talk about what he is feelings rather than to act on his feelings - Taking of medications may be negotiable - Focus on openness, giving and receiving feedbacks - Respect for the patient, privacy, acceptance, independence add individual responsibility IV. Limit Settings: Limit should be set on acting out behavior such as:
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- self destructive acts, physical aggressiveness, lack of compliance - use of drugs and illicit drugs V. Balance: represents the art of nursing - The process of gradually allowing independent behavior in a dependent situation - Independence is gained in increment because too much independence may overwhelmed the patient Example A self-destructive patient: Nurse: Attempts to balance the patients [and the nurse] need for safety [dependencycreating approach] with the patients need for self-control and independence A patient who is very religious
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Nurse: Balance patients rights to religious expressions with the need of treatment [ most common they will refuse medication on religious grounds] is this refusal true representations of religious beliefs or a psychotic manifestations Balance is important: Skillful use comes with the understanding of the ethical concerns, legal issues and psycho[pathology VI. Environmental Manipulations Nurse can facilitate a therapeutic environment and communicate patients worth Physical arrangement, safety issues and orientation features when addressed can lead to: - create an atmosphere in which patients are enabled to maximize their strength - flexibility in maintaining a therapeutic environment is important
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Ongoing review of environmental norms, rules and regulations is important aspects of milieu modifications Structure in Psychiatric Milieu : goals mentioned are structured: boundaries: Safety, Structure, Norms. Limit Setting, Balance, and Environmental Modification Client Nurse Attending scheduled activities Completing hygiene and grooming Participate in treatment planning & goal setting Participating in meal time Meeting regularly with members of the Participate in unit interdisciplinary team assignments Perform self care activities, can have free time to Ex. Watering plants, keeping room socialize organize, planned Adhere to medication treatment activities Boundaries: nurse maintains boundaries by:
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* clearly outlining the roles of the staff and the client * meeting responsibilities for achieving treatment goals * maintaining integrity of therapeutic milieu Safety: roles and responsibilities of the nurse to enforce the following basic rules for the client * will not have access to harmful items such as sharps, belts and shoelace * will not have the means to harm themselves or others on the unit * methods for maintaining clients art high risk for aggressive behavior are available to the staff * strong communication skills, staff training and collaborative relationships among staff are essential for ensuring clients that the environment is safe 11. play therapy 12. psychosocial support interventions 13. psychospiritual interventions
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14. Alternative Medicines: Complementary and Alternative Medicines [CAM] Psychiatric Mental Health Nursing 4th ed./fortinash/holoday worret p 577 * The greatest benefits: lies in promoting healthy lifestyles and managing chronic illness and disease 1. Mind-Body Interventions A. Meditation: - relaxation response to meditation consist of a wide range of beneficial and psychological effects - lowered heart rate /blood pressure rate decrease serum of adrenal corticosteroid - increased immunity to disease sense of calmness, peace and mental alertness Meditation therapies: biofeedback, visual imagery, stress reduction measures like yoga, progressive
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relaxation techniques Originally meditation is a religious practice: prayers, scripture reading, rosary Techniques: use of audiotapes that facilitate mastery of concentration Guidelines: - routine of selecting a special time and place - assuming a comfortable position, using deep breathing and progressive relaxation exercise - focusing attention on a chosen mental image B. Prayer - it is a silent or spoken, conversational or formal or recitation of a favorite psalm - there are many types of prayers as there are many types of religions or cultures - illness conditions sometimes interferes with individuals ability to pray because feelings of
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isolation, quilt, grief, or anxiety Types of prayer Prayer for healing purpose individual or group or an intercessory prayer [distant] Intercessory prayer laying on of hands and anointing the ill person with oil * Numerous studies: demonstrated significant positive associations between religion [faith] and health do not ignore the role that beliefs play in a persons coping C. Mindfulness-Based Stress Therapy MBSR Based on Zen consciousness paying attention to ones own inner experience through personal experiences. Asking questions such as who am I? - learns how to balance physical, mental, spiritual health by using all the senses
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- learn how to develop a deeper knowing of self from silent and stillness and to perceive thoughts more clearly because of embodied waked fullness Goal of meditation: to pay attention only to the present moment and being nonjudgmental about the thoughts that pass through the mind Kabat-Zinh: Human are miraculous beings, and we have infinitely more capacity and dimensions associated with our brains and our nervous system and with our deep intelligences, and I emphasize the plural, that we usually simply ignore MBSR: useful for anxiety, eating disorders and addiction, preventing recurrent depressions prostrate cancer, receiving bone marrow transplant, prison inmates and staff, D. Yoga originally practice in India
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Principle: living a balanced life: Concentration on 1. purity of body and mind 3. self restraint and contentment with life 2. studying relevant literature being - individual achieves the use of specific body postures [asana], gentle movements & stretches - breath control and minimizing stimulation of the senses, leading a simple life Benefits: purify your physical body leads to purification of the mind and renewal of vital energy 4. daily dedications to a higher

E. Use of Arts
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- music, dance, drama, literature, humor and art: part of environmental therapy Music with quiet background : often used in ICU, birthing rooms, dental procedures - provides a soothing atmosphere and is a distracting medium during times of stress and pain - allows to express emotions and feelings thru: dancing, singing and creative thinking - useful in reducing agitation I people with dementia [Alzheimers] Dance: expression of joy and celebration and as means to 1. increase self-esteem and body image 3. lessen depression, 2 fear and isolation and 4. express emotions Arts: help children and adult to express feelings about stressful situation and unconscious concerns F. Humor: humor and laughter are helpful for:
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1. expressing emotions 3. relieving tensions and anxiety 2. coping with painful or unpleasant situations - Laughter has positive effects on 1. cognitive ability, 3. respiratory and heart rates 2. blood pressures and 4. muscle tensions - Humor rooms supplied with videos and tapes, books, cartons and art work are available for clients. families, and agency staff: All are encourage to use humorous artwork on bulletin boards in inpatient rooms and staff work areas G. Exercise Benefits: brings a general sense of health and vitality, increases respiratory and cardiovascular efficiency and promotes a longer life H. Animal Assisted Therapy [AAT]
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a mind-body interventions to induce the relaxation response and enhance emotional and physiologic well-being AAT goal-directed intervention at various setting are designed to improve: 1. human physical 2. social 3. emotional 4. cognitive functioning - frequently used in conjunction with occupational and physical therapies for: 1. refining motor skills 3. assisting with maintaining balance and walking tolerance 2. increasing attention and self-esteem Benefits: - blind, deaf, or paralyzed uses animal companions to assist them in accomplishing ADL - reduction in hypertensions, heart rate and social isolation - increases morale of staff and caregivers
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Hospital protocol: acute and long tem health care units, pediatric wards, hospices, rehabilitations units and geriatric advocates such AAT I. Psychotherapy & Hypnosis Hypnosis involves use of mental images, concentration, the use of repetitive words or sounds, and total relaxation produces n altered state of consciousness that permits persons to concentrate with minimal distraction Useful: as deep relaxation tool in the treatment of substance addiction, smoking cessation, pain control, fears, phobias, reducing hypertension, pain muscle spasm in cerebral palsy and before giving of anesthesia induction 2. Energy Therapies
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A. Biofeedback - a technique that initially uses electrical equipment to assist person in gaining conscious control over body process that are normally beyond voluntary command - electrodes are attached to the affected area, send information into a monitoring device emits a signal to alert the person to changes in a particular body function [ increase or decrease in muscle tension] Example: Transcutaneous Electrical Nerve Stimulation [TENS] used for clients with chronic pain and muscle spasm - watching their responses on the device, client learn to use mental processes to gain self- control that

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particular body function * useful in: multiple physical, cognitive, and behavioral symptoms: hypertension, temperature control, GIT activity, migraine, and other vascular disorder B. Bioelectromagnetic - relates to the electrical current that exist within and external to the body the influences of the external currents on the body result of physical and behavioral changes! Examples: - electromagnetic energy produces by: x-rays, television, microwaves and light rays - low - energy frequencies are beneficial in diagnostic and treatment tools - using of nonthermal electromagnetic fields which do not cause heating of tissues Examples: unipolar magnets for arthritis pain relief: magnets are taped to various parts of the
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body, inserted in shoes and in mattresses [wristbond]

3. Alternative System of Medical Practice A. Traditional Chinese Medicines [TCM} uses a variety of therapies: - acupuncture/acupressure. massage herbal medicines, gigong and tai chi 1. Tai Chi - Chinese exercise program with roots from ancient martial art: consist of slow, gentle rhythmic movements, controlled breathing and creating an inner stillness - to prevent and for remedy of muscular and joint problems and reduces stress * Excellent exercise program for osteoarthritis, relief pain, joint stiffness and balance maintenance 2. Acupuncture
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- insertions of small needles at selected energy points of the body that corresponds to energy pathways * positive effects on: gynecologic, mental, neurologic problems and substance dependence Effective in pain control and anesthesia attributed to the release of endogeneous hormone [endorphin] produced within the CNS. B . Ayuverda/Ayurverdic Medicine - uses combination of therapies: meditation, yoga, massage, herbal, aromatherapy and biofeedback * - the body is a pharmacy hat can make is own natural drugs to heal itself - the body is also a microorganism of the universe with doshas principles - interacting to maintain balance:
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*Each doshas has a principal location in the body with emphasis on the interdependence of health and the quality of the persons sociocultural life - when imbalance occur: individual achieves restoration of balance of the internal environment through proper diet and life style C. Homeopathic Medicine - based on the belief that substances that produce certain disease symptoms in a healthy person provide a cure for a sick person experiencing the same symptoms - diluted substances are used to elicit cure: a very diluted solution containing poison ivy compound is used for a skin rash D. Naturopathy : Basic principles: Use of therapies that do no harm Physician primary role as a teacher Treatment of whole person Therapeutic use of nutrition
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Prevention of disease thru healthy life style Establishing and maintaining an optimal health and balance Uses: treatment spas sunlight, fresh air and water therapies, fasting, natural food diets, colonic enemas, acupuncture, massage, Chinese medicine E. Environmental Medicine - elimination of health hazards from the environment: - sensitivity and allergy symptoms has improved after eliminating certain foods or chemicals, molds, dust, pollens and other substance F. Cultural Based Community Medicines - also known as folklore medicines: follows naturalistic methods and a spiritual healer or shaman [medium, spiritualist] provides a religious rituals as a major components
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- symbols such as prayer wheels, sand paintings, meditation, amulets, group singing, chanting 4. Manual Healing Methods A. Osteopathy and Chiropractic Medicines - involves manipulation of soft tissues and joints Chiropractic study relationship between pressure, strain, or tension on the spinal cord and the ability of the neuromuscular system to act efficiently Manual adjustment of the spinal to correct alignments are the mainstay of treatment B. Massage - primary purpose: to produce muscle and total-body relaxation and to increase circulation - touch: basic medium of massage therapy is a form of communication and caring
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- forms may vary from gentle stroking to deep kneading, rubbing and percussion - done with the hands, forearms, elbow and feet C. Acupressure - therapist uses finger tips to apply pressure to more than 600 designated pressure-points in soft tissues - is both a diagnostic tool and a treatment D. Hand and Foot Reflexology originated in Egypt - also referred to as zone therapy , the main goal is to provide relaxation by removing tension in a zone area Technique: - based on the premises that the feet and hands are mirror of the body
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- with reflex points that corresponds to glands, organs and other structure in the body Feet are more responsive to massage than the hands: Massage of a reflex point without the use of oil, cream or lotion stimulates the corresponding organ in that zone E. Therapeutic Touch Benefits of contact touch such as massage: provides a sense of spiritual balance relieving mental and emotional tension and anxiety, improving blood flow, easing pain and stimulating the immune system * frotteurism becomes sexually aroused from touching or rubbing against non consenting person 5. Pharmacologic and Biologic Treatments
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A. Pharmacologic and biologic alternative therapies consist of variety of drugs and vaccines - some stimulates immune system and consist of herbal medications, all are non toxic! - shark and other anima cartilage use to treat AIDS, cancer, arthritis Cartilage inhibit tumor growth by cutting off the blood supply to the tumor suppressing the autoimmune reactions and promoting wound healing B. Herbal Medicines Hypericum ,the principal ingredients of St. Johns wort has been named as the natural Prozac C. Diet and Nutrition Todays affluent diet: which is high in animal fats, refined carbohydrates, and partially hydrogenated vegetables oil contribute to current health problem:
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*Several diets have been developed as specific treatments for diseases: - Macrobiotic cancer diets oriental beliefs of creating balance of yin and yan - Food-elimination diet reduces sensitivity to certain substance and to treat children with attention deficit/hyperactivity disorder F. Concepts of Anxiety 1. Defining Characteristics STRESS Hans Selye [Canadian endocrinologist and recognized stress researcher] Its the bodys non specific response to any demand made upon it

BODY =

Stress is a holistic event. Whole being is involved

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NON SPECIFIC = Adaptation Autonomic Nervous RESPONSE = stressful to you,

It is a general event! Selye described it as General Syndrome! All systems involved, primarily the

System and Endocrine [ductless] system It is a perceptual thing! It is highly personal. What may be isnt stressful to some else!

TO ANY DEMAND = Call it stressor the source of stress. Eutress is positive stress, distress is a negative stress MADE UPON IT = come from Mostly caused by external environment, but may also
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internal milieu like phlegm or abdominal gas

Some Physiologist: Uses the term stress and stressor Stimulus that cause the neurons in the hypothalamus of the brain to release CRH or corticotrophin releasing hormone which stimulates changes in the body It is state of the body [condition or status of the body]:thus it can only be observed by CHANGES it produces in our body The state of stress is intensified when a person is required to change activity or to increase the pace of activity in order to ADAPT. = necessary for both life and growth = essential for human to constantly adapt to its environment in order to SURVIVE The process of ADAPTING is referred to as COPING
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Each person has a limited amount of energy to use in adapting with stress = how quickly used is how quickly one adapts to stress and depends on: heredity, mental attitude and life style Types of Stressors 1. within the body tumor of the stomach 2. outside of the body angry remark from a friend 3. physiologic knife wound, overdose of medication and influenza virus 4. physiologic alcoholic spouse , fear of surgery, grief of some loved ones

Factors Influencing the Effect of Stressors: 1. Nature of Stressor: two components a. what the stressor means to a person: injection produces a high state of stress to some
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b. magnitude of stressor: pain from a cut elicit less stress than acute AP 2. Number of Stressor at once: number of stressor a person is coping with at one time greatly affects the response grounds for the nurse to consider a small stressor can elicit a disappropriate response Example: A patient who is coping with the separation of his wife, unknown cause of his illness and financial problem react angrily to a nurse who gave wrong medication [This example also shows how high stress can become a stressor itself] 3. Duration of Stressor At Once duration can reduce a persons ability to cope resistance to stressor is low during the stage of alarm becomes higher during resistance and drops normal at stage of exhaustion
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Note: if a persons stage of resistance is extended by the duration of the stressor beyond the persons coping power can be exhausted and can eventually dies Example: Surviving from gallbladder surgery, necessitates another surgery, at this point energy reserves used up and although operation was a success develops an infection that delay his going home. 4. Experience with Comparable Stressor for some people, contact with hospitals has been related solely to dying friends and relatives Stress as a Stimulus When define as stimulus it is conceptualized as a Disruptive Response. Assumptions: 1. Life change events are normative or tolerable and result in a similar impact across time and people 2. Persons perception of the event as a positive or negative tone is irrelevant
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3. There is a common threshold [shared entry] beyond which disruption occurs = viewed as a stable, additive phenomenon that is measurable by selected life events = correlation between life events and those onset of disease have been a models basic foundation = prevention of illness is associated with the monitoring and limiting changes that one is exposed to in a period of time Stress as a Response: When define as response the disruption is caused by a noxious or harmful stimulus or stressor Characteristic of Stress Response the stress is natural, protective and adaptive
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 physical and emotional stressors triggers specific and nonspecific response there are limits in the persons ability to adapt magnitude and duration of stressor may be so great that homeostatic mechanism for adaptation fails, leading to total dysfunctional or death repeated exposure to stimuli may result in permanent adaptive changes there are individual differences in response to the same stressor The concept of Response was developed by Selye when defines stress as the nonspecific response of the body to any kind of demand made upon it To differentiate cause of stress and response to stress: Selye created the term stressor: to denote the factor that produces stress and disturb bodys equilibrium. As state of the body : stress can be observed only by the changes it produces in the body: Types of response
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I. Globally : this response to stress is termed as General Adaptation Syndrome {GAS} or Stress Syndrome = can occur with the release of certain adaptive hormones and subsequent changes in the structure and chemical composition of the body = organs affected by the stress are: GIT, adrenal gland and lymphatic structures such as thymus, spleen and lymph nodes II. Locally: one organ or part of the body reacts alone and this is termed as Local Adaptation Syndrome {LAS} = example is inflammation

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Principal Neuroendocrine Pathways Mediate the Response to Stress Autonomic Nervous System The autonomic system controls the action of the glands; the functions of the respiratory, circulatory, digestive, and urogenital systems; and the involuntary muscles in these systems and in the skin. Controlled by nerve centres in the lower part of the brain, the system also has a reciprocal effect on the internal secretions, being controlled to some degree by the hormones and exercising some control, in turn, on hormone production. Two antagonistic divisions of the autonomic nervous system
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Sympathetic [or thoracolumbar division ] Prepares the organism for actions Fight of Flight Increase heart rate and blood pressure stimulates the heart and contracts arteries Increase respiratory rate Decrease peristalsis inhibits digestions Secretes epinephrine and norepinephrine Dilates pulmonary bronchi
Stress

Parasympathetic [or craniosacral] Prepares organism for feeding, digestion and rest Maintain normal body functioning Normalizes hear rate and blood pressure Normalizes respiratory rate Increase peristalsis Secretes cathecolamine Constrict pulmonary bronchioles

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Sympathetic Nervous System

Hypothalamus

Pituitary

Adrenal Cortex

Adrenal Medulla

MINERALOCORTICOIDS

NOREPINEPHRINE
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(pro inflammatory) Na retention blood to kidneys Protein anabolism GLUCOCORTICOIDS (Anti inflammatory) myocardial contractility Protein catabolism Gluconeogenesis clotting

peripheral vasoconstriction decrease increase renin EPINEPHRINE increase increase bronchial dilation increase blood increase metabolism increase fat mobilization General Adaptation Syndrome (GAS) Stage I Alarm Reaction
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Stage II Resistance Stage III Exhaustion Stages of GAS and LAS I. Alarm Reaction initial reaction = alerts the bodys defense against the stressor such as heat, bacteria, verbal or physical attack from someone ( enlargement of adrenal cortex and lymphatic system, increase hormonal level ) = resistance is low Phases: A. Shock phase: May perceived consciously or unconsciously Autonomic nervous system react = large amount of adrenaline and cortisone are released into the body
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= individual is ready for fight or flight Lasting from 1 minute to 24 hours B. Counter shock phase Body changes produce during the shock phase are reversed During this stage the person is best mobilized to react II. Stage of Resistance The bodys adaptation takes place body attempts t cope with the stressor and to limit the stressor to the smallest area of the body that can deal with it = shrinkage of adrenal cortex, lymph nodes closer to normal size = sustain normal level of hormones Resistance is high III. Stage of Exhaustion Adaptation that the body made at a second stage cannot be maintained Ways used to cope with the stressor have been exhausted adaptation has not
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overcome the stressor End of this stage body may either rest and return to normal or death and largely depends on: adaptive energy resources/severity of stressor. Stress as a Transaction: A concept that involves cognitive, affective and adaptation or coping variables that arises out of person Environment are seen as constantly intertwined each affecting and being affected by others Core Assumptions: 1. stress is not measurable as a singular concepts 2. persons cognitive appraisal of the situation mediate/facilitate stress experience Quoting Lazarus:
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 important role of personality factors in producing stress reactions he define stress in terms of transaction between individual and situation, rather than one situation this model is consistent with the nursing view of human experiences focusing on the individual differences in stress experiences Lazarus affirms that COPING involves both cognitive and behavioral strategies and represents an adjustment to the stressful situation coping is successful when: 1. the source of the problem has been dealt with direct action [problem solving, assertive communication] 2. the experiences of stress has been directly reduced [ imaginary and exercises]
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Lazarus has two important concepts 1. primary appraisal = includes personal judgment about the encounter and whether the situation is likely to cause harm or loss, is threatening or is challenging 2. secondary appraisal = involves individual assessment of coping abilities and resources to deal adequately with the situation Example: Primary: receiving all new job responsibilities and determines he may risk losing his job if he does not handle things well Secondary: reminding himself that he has solid knowledge and skills in the new areas of responsibilities and that he has supportive wife to support him.
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Stressors Related to Stages of Development each state of life has a particular vulnerabilities relatives to stress represents stages of childhood particular stressors that necessitates adaptation this developmental stressors are normally met as a challenges for growth

I. Child 1. Resolving conflict between independence and dependence 2. Beginning school 3. Establishing per relationship and adjustment 4. Coping with peer competitions

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II. Adolescence 1. Accepting changing body physique independence 2. Developing heterosexual or other relationship

3. Achieving 4. Choosing career

III. Young Adult 1. Getting married occupation 2 Leaving home education 3. Managing a home 4. Getting started in an 5. Continuing ones 6. Rearing children

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IV. Middle Adulthood 1. Accepting physical changes of aging 3. Helping teenage children be independent 2. Maintaining social status and standard of living 4. Adjusting to aging parents

V. Older Adult 1. Accepting decreasing physical abilities and health changes in residence 2. Adjusting to retirement and reduced income of spouse/friends

3. Accepting 4. Adjusting to death

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A. Physiologic Manifestation of Stress

1. pupils dilate to increase visual perception when serious threats to the body arise 2. increase heart rate, which leads to an increased pulse rate to transport nutrients and by products of metabolism more efficiently 3. blood pressure increases because of = constriction of vessels in blood reservoirs, such as skin, kidneys and large interior organs = increased secretion of rennin, an effect of norepinephrine = increased sodium and water retention due to release of mineralocorticoids which results in increased blood volume 4. skin is pallid or pale due to constriction of peripheral blood vessels and
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effects of norepinephrine 5. sweat production [diaphoresis] increase to control elevated body heat die to increase metabolism 6. urinary output decreases, mouth is dry 7. rate and depth of respiration increase due to dilation of bronchioles promoting hyperventilation 8. peristalsis of intestines decreases, resulting in possible constipation and flatus 9. for serious threats, mental alertness improves 10. muscle tension increases to prepare for rapid motor activity or defense blood sugar increases because of release of glucocortocoids and glucogenesis 11. lethargy, mental lassitude, inactivity [parasympathetic dominance] may ensue or follow 12. there may be decreased physiologic functioning and loss of skeletal muscle tone
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B. Psychologic Manifestation of Stress 1. anxiety 3. anger 2. fear 4. depression I. Anxiety: common reaction to stress is a state of mental uneasiness, apprehension, dread or foreboding or a feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationship Anxiety Source is not identifiable Related to the future, or anticipated even Vague Result of psychologic or emotional Fear Source is identifiable Related to the present Definite Result of a discreet physical or
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conflict

psychologic entity

Mild to moderate anxiety is needed to: anxiety is an effective coping strategy = accomplish developmental task = mild anxiety motivate to study = motivate goal and direct behavior = excessive can be hazardous

Four levels of Anxiety I. Mild Anxiety = produces slight arousal state that enhances perception, learning and productive
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abilities = healthy person experiences restlessness that prompts him to seek information and ask question II. Moderate Anxiety = increases clients arousal state to a state where the person expresses feeling of tension, nervousness or concern = perceptual abilities are narrowed III. Severe Anxiety = consumes most of the persons energies and requires intervention = perception is further decreased, unable to focus on what is really happening = focuses on only one specific detail of the situation generating the anxiety IV. Panic = overpowering, frightening level of anxiety causing the person to lose control = less frequent experienced, perception can be altered to a point where person distorts events
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II. Fear Mild or severe feeling of apprehension about some perceived threat = Response to something that has already occurred in response to an immediate or current threat or anticipation of something the person believes will happen = Object of fear may or may be not based on reality Example: beginning nursing student may be fearful in anticipation of the first experience in a client setting. She may have fear the client will not want her and she might harm the patient. III. Anger An emotional state consisting of subjective feeling of animosity or strong displeasure
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animosity- hostility, hatred, loathing, ill feeling, enmity, bitterness, acrimony, rancor or resentment, no love, dislikes, antagonism and bad blood = can be expressed in a non alienating verbal manner: [example in robinhood] = it is then considered a positive emotion and a sign of emotional maturity coz growth and beneficial interaction can result from it = commonly manifested in altered voice as a communication to desist or abstain from some action = other verbal expressions of anger can therefore be considered a signal to others of ones internal psychologic discomfort and call for assistance to deal with perceived threat

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Hostility usually marked by over antagonism or hatred and harmful or destructive behavior Aggression unprovoked attack or hostile, injurious or destructive actions or outlook Violence exertion of physical force to injure or abuse = verbally express anger differs from hostility, aggression, and violence, but it can lead to destructive and violence if the anger persist or unchanged

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Mediating Anger: Nurses often find difficulty to mediate anger and caring for angry patient is difficult for two reasons: 1. Clients rarely say: I feel angry or frustrated and rarely indicate the reasons for their anger = instead they refuse treatment and become verbally abusive or demanding may threatened violence or becomes overly critical 2. Anger from client can elicit fear and anger from nurses who may respond in a manner that intensifies the clients anger and even to the point of violence = majority of nurses responds in a way that reduces their own stress rather than the clients stress A response whose main purpose is reducing a nurse stress include: defending, providing reassurance, offering advice or persuading and retaliating aggressively
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Example of defensive response: I cant take care of everyone at once! We have been very buss this morning. = this response does not respond to clients problem but rather increase his tension and anger Example of reassuring response: Youll feel better a soon as you can walk or be discharge = it is a way of recognizing the problem and calming the patient and it doesnt encourage to talk about the problem Example of offering advice Yes, but . . . = giving advices should not be based on nurses values and ideas increases their
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powerlessness of the client Example of aggressive response You are spoiled. You could do that, what do you want now or some people here are lot sicker than you are? = indicates disapproval of clients behavior A response that reduces clients anger and stress includes: help, apologizing, asking relevant question and conveying understanding Example: I guess its pretty frustrating being alone and waiting for others to visit you Gluck (1981) Suggest Steps to Help Provide Understanding Responses to Clients
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1. 2. 3. 4. 5.

Focus on the feeling words of the client Note the general content of the message Restate the feelings and contents of what the client has communicated Observe the clients body language Ask if I were in the clients shoes, what would I be feeling?

IV. Depression An emotional state characterized by sadness, discouragement, guilts, decreased self-esteem, helplessness and hopelessness Emotional Feelings of tiredness, sadness, emptiness or numbness Irritability , inability to concentrate, difficulty in making decision, Behavioral loss of sexual desires, crying, sleep disturbances, social withdrawal Physical Loss of appetite, weight loss, constipation, headache and dizziness
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C. Cognitive Manifestation: thinking response that includes the following! 1. Problem Solving = involves thinking through the threatening situation, using specific steps similar to nursing process to arrive at solution: a. assess the situation, analyze, defines, b. choose alternatives, carriers out the selected c. alternatives and evaluates whether solution was effective d. weights alternatives/pros/cons e. list advantages and disadvantages 2. Structuring = arrangement or manipulation of a situation so that the threatening events do not occur
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= using direct and close ended question during an interview may be useful in avoiding threat 3. Self-Control = assuming a manner and facial expression that conveys a sense of being in control or in charge, no matter what the situation is. = discipline Note: 1. Helpful response that conveys strength = when self-control prevent panic and harmful or nonproductive actions in a threatening situation 2. Unhealthful may perceive as cool or unconcerned = self-control carried to an extreme can delay problem solving and prevent a person from
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receiving the support of others

4. Suppression = consciously and willfully putting a thought or feeling out of mind I wont deal with it today, Ill do it tomorrow =relieves stress but does not solve problem

5. Fantasy or Daydreaming = likened to make believe, unfulfilled wishes and desires are imagined as fulfilled = threatening experiences is reworked or replayed so that it ends different from reality
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= can be destructive and non productive if uses them to excess and retreat from reality 6. Prayer = often involves identifying and describing the problem, suggesting solutions and reaching out for support Example: Describing a problem: please help me, doctor says I have hypertension because Im overweight Suggesting a solution: what I need is to discipline and go on diet If these two leads to action prayer can be a constructive response asides from the support and meaning the person derives from it D. Verbal and Motor Manifestations [may be the first response evidence]
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1. Crying = in situation which cannot be managed cognitively and are perceived as painful, joyful, or sad, tension is being release in the form of crying = as a response crying tends to be socially acceptable in women and certain cultures among men = crying is beneficial as a release of tension and if it is followed by problem solving 2. Verbal Abuse = another release mechanism most often expressed towards stress provoking objects and events such as nonfunctional equipment, misplaced or lost item and rainy weather 3. Laughing
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= an anxiety reducing response that can lead to small incidents and at the way they handled the situation Example: preoccupied, stressed man whose wife had an accident may laugh at having black and brown shoes before rushing to the emergency room 4. Screaming = a response to fear or intense frustration and anger = can be harmful if unable to control it and becomes hysterical [Panic stricken & out of control] 5. Hitting and Kicking = can be spontaneous response to physical threat and does not have feeling of frustration Adult: socialized such response towards people and may direct them towards objects table
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Preschooler: have not matured: may hit or kick the nurse giving the injection. 6. Holding and Touching = are often responses to joyful, painful or sad events = this are gestures of support and comfort and varies among cultures E. Unconscious Ego Defense Mechanism = psychologic defensive or mental mechanism which develops as the personality attempts to defend itself Intervention for Stress Stress accompanies every disease and illness; therefore it is imperative that we will be able not only to recognize it but also assist people to cope with stress 1. Be sensitive to specific situation and experience that increases stress for patients
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= careful remarks by the nurse to an adult patient receiving IM who appears highly stressed 2. Orient patient to the hospital or agency = there is a role change independent wage earner to a dependent patient = nurse must be helpful to patient and SO in their adjustment = family can be of help in assisting in their adjustment by knowing visiting hours and what they can do to help 3. Support the patient and family in times of illness = nurse must be caring and understanding to help reduce anxiety and stress = allows families to ventilate their worries and anxieties 4. Give patient time to ventilate feelings and thoughts = as part of your plan, allows patient to describe their feelings = be sensitive to patients need = never investigate questions nor be busy to listen 5. Give the patient in hospital some way of maintaining identity
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= patients names and cloth are important part of his uniqueness = call patient by correct names and help hen dress in their own cloth in hospital if possible 6. Encourage patient to participate in the plan of care = reduces stress by allowing them feel that they some inputs in their own care and what is going to happen = not only effective to relieve stress but compliance has greater impact and feelings of worth thus improving their self-concept 7. Repeat information when the patient has difficult in remembering = highly stressful have difficulty remembering information especially among elderly = nurse must help by repeating information when requested and assist in applying
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8. Defer as many questions to newly admitted patient as possible until later in the day = admission itself is a stressor, question at this time is difficult to answer and more difficult to recall 9. Encouraged physical activity to reduce stress = if able encourage activities such as folding linen 10. Encourage that expectations are within the patients capabilities = any activity, recreation, or exercise, nurse must be sure that the patient can accomplish it = activities not within his capabilities may result to frustrations and depression 11. Bring patient and their families into contact with people in the community agencies who can help them make valid plans
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= social workers are familiar in assisting in their planning and arrangement that they need 12. Reinforce positive environmental factors and recognize negative ones to help reduce stress = help reinforce factors that maintain homeostasis and recognizing those factors that are discouraging 13. Provide information when the patient has insufficient information = fear of the unknown and incorrect information can cause stress [not on NPO, but was advised] 14. Assist a patient to make correct appraisal of a situation = lack of knowledge or misinterpretation of a sequence of events can draw incorrect conclusions Example: length of time it takes might misinterpret as something serious
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15. Provide an environment in which person can function independently to some degrees without assistance = independent people to assume dependent role is stressful 16. Arrange for other patient with similar experience to visit = meeting with people with colostomy and seeing their success to live a normal life pattern can lower stress 17. Communicate competence, understanding and empathy rather than stress and anxiety = patient and family or SO looks upon the nurse as a source of knowledge and skills 18. Encourage humor as a means of coping with stressor According to Simon (1988) humor has both psychologic and physical benefits Psychologically:
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= relieves tension and anxiety, aggression and distract sadness or quilt thus promoting a feeling or relaxation and well being During Laughter: = stimulation causes increases in respiratory and heart rate, muscles relaxation and oxygen exchange and a state of relaxation follows during laughter = humor stimulates production of cathecolamine [sympathetic dopamine] and hormones and increases pain tolerance by releasing endorphins Additional Guidelines for Minimizing Stress 1. Massage = a variety of massage strokes or movements may be used singly or in combination = duration ranges from 5 to 20 minutes in accordance with patients tolerance.
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a. effleurage [stroking], friction and pressure b. petrissage [kneading or massage muscles or to rub or press part of the body with hands], muscle vibration and percussion 2. Guided Imagery = the formation of mental representation of an object that is usually only perceived thru senses = images often evoke more than one sense Example: image of waves breaking upon a shore may combine the visual picture with the sound of waves and smell of salty air this images focus the mind away from the body Types Visual Auditory Example A valley scene with its many shades of greenery Ocean waves breaking rhythmically upon a beach
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Olfactory Fresh baked bread Gustatory A juicy hamburger Tactile - protioceptive Stroking a soft furry cat 4. Ego Defense Mechanism Sigmund Freud 3 Level of Awareness wherein Human Personality Functions 1. Conscious refers to the perception, thoughts, and emotions that exist in the persons awareness Example: being aware of happy feelings or thinking about loved ones 2. Pre conscious thoughts and emotions not currently in persons awareness, but he can recall with some effort Example: adult remembering what he or she did, thought or felt as a child
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3. Unconscious the realm[territory/area] of thoughts and feelings that motivate a person, even though he or she is totally unaware of them the realm includes most of the defense mechanism, some instinctual drives or motivations persons represses into the unconscious the memory of traumatic events that are too painful to remember The Principal Defense Mechanisms are: Repression, Projection, Reaction Formation, Fixation and Regression All defense mechanism has 2 characteristics in common: 1. They deny, falsify, or distort reality 2. They operate unconsciously so that the person is not aware of what is taking place
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DM 1. Repression

Definition Unconsciously and involuntarily forgetting of painful ideas, events, conflicts, impulses

2. Attributes, feelings, attitudes, impulses , wishes, or thoughts are transfer to other person or object especially when painful to be

Projection

Common A car accident unable to remember details of impact, but was aware of the time Coming home late and states that her friend did not bring home on

Patient A rape victim does not knot why she always hated her uncle

Psychotic Schizophren ia Obsessive compulsive, phobias, conversion reaction and dissociative Webster Seen in states that hallucinatio he used n and marijuana delusions in because her alcoholism friend made Bipolar him smoke disorder,
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acknowledge

time

3. Reaction formation A conscious behavior that is the exact opposite of an unconscious feelings

4. Fixation Aspects of personality is arrested/stuck at an

paranoid schizophreni a Tiona who Dondon Seen in dislikes who bipolar Neneng unconscious disorder and send her a ly hates obsessive flower for Sali, compulsive every continuousl disorder Sunday y tells the morning staff how wonderful Sali is Never learned to delay gratification leads to temper tantrum when
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it

5.

Regression

incomplete stage of psychosexual development Return to an earlier and more comfortable developmental level. Going back to earliest level of gratification.

needs not met at once

A 6 years old wets the bed at night since the birth of his sister

6. Suppression Voluntary exclusion from awareness; anxiety producing idea

Darwisa has Seen in isolated obsessiveherself in compulsive her room disorder, and has lain schizophreni in a fetal a, organic position brain since disorder admission I cannot Mobin tells her nurse that think of my he is not yet ready to talk exam result, about his alcoholic I have to do dependency
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or behavior 7. Attempts to make or prove that ones Rationalization feelings /behaviors are justifiable

my laundry I got 3.25 in my exam because the teacher ask difficult NCLEX questions

Tiona states that she cannot work because she is afraid of her co-worker instead of admitting she has history of mental illness

Denial

Unconsciously refusal to admit unacceptable ideas or behavior

Refuses to admit failure in subject despite getting 5 in

Mobin ,an alcoholic dependent, states that he still can control his

Seen in paranoid disorders, dissociative, obsessive compulsive

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final drinking examination s

9.

Sonia states Using logic that her explanations without boyfriend Intellectualizati feelings or an affective bicycle is on component much safer than her friends new faster 125 cc Honda motorcycle

disorder, conversion disorder, schizophreni a Gabby talks Seen in about his bipolar sons death patient and he fight cancer as mercifully short without showing signs of sadness
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10.

Consciously/unconscio usly attempt to model Identification oneself after a respected , admired idealized person

11.

Introjections

Neneng states to the nurse When I get out of this hospital I want to be a nurse Unconsciously While her Richard incorporating wishes, mother is talks and values, and attitudes of gone, he acts like his others as if they were disciplines therapist they were your own his younger analyzing brother just other like his patients mother

Little girl dress like her mother, tries to talks and act like her mother

Seen in severe or major depression Bipolar disorder

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12. Covering up the Compensation weakness by overemphasizing or making up a desirable trait 13 Sublimation Channeling instinctual drives into acceptable activities

would. Academical ly poor becomes an active member of dance troupe Arrested for stealing opens a security agency

14.

Redirection of an Husband emotional feeling from comes

Schizophren ic patient unable to talk express thought thru writing poetry Perpetrator of incest fears relapse organized a Parents club Webster Seen in yells at major
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Displacement one ideas, person or object to another

15.

Conversion

Snooky depression after being told he is not allowed to get out from his room Unconscious expression Migraine in Dondon develops of intrapsychic conflict the morning impotence after his wife symbolically though of exam & Tiona finds his affair with physical symptoms feels ill to his secretary Neneng take it. One hour. of cramming left her unprepared
317

home yells at wife after a bay day at work

16.

Undoing

Doing something to counteract or make up for a transgression or wrongdoing

After spanking her son, mother bake him a cookies

17.

Dissociation

The unconscious separation of painful feelings & emotions from an unacceptable idea, situation or object

Wife talks about husband expensive gambling debt as if they were

Dondon after getting food of Webster, apologizes, cleans the tables and swept the ground Darwisa recalls when she was sexually molested as a child felt as if she was

Seen in obsessive compulsive disorder

Usually happens as a result of painful experiences Split of affect from

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nothing to be concerned about.

outside of her body watching without feeling anything

18. Blocking

Persons thought and speech suddenly interrupted ( several seconds to a min)

idea in anxiety disorder, schizophreni a, dissociative disorder, conversion disorder Schizophren ia

19

Symptoms occurring in
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Filling in gaps of Confabulation memory by inventing what appears to be suitable memory replacement

organic psychosis, most common in Korsakkofs syndrome, dementia, amnestic disorder

20. Fantasy 21.

Daydream about living Consciousness on a tropical island Paseo development of suitable del Mar. feelings Aspect of personality is Never learn to delay arrested/stuck at an gratification, develops incomplete stage of temper tantrum when
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Fixation 22. Idealization

23.

Client thinks that TV new Ideas of announcer is references reporting story about himself 24. Thoughts not connected Breaking up with BF was Seen in with appropriate because they bipolar feelings/interactions are both had different interest patient Intellectualizati kept at cognitive level
321

psychosexual development Overestimation of some admired aspects/attribute of another person Fixed false ideas & interpretations of external events as though they had direct references to self

needs not met at once He was a perfect human being

on 25. Restitution 26.

to ignore/avoid emotional content Going back and trying to repair unconscious guilt feelings Inability to accept contradictory feelings, tolerate ambivalent feelings, there is tendency to categorize people and situation into the right-or-wrong and good-or-bad categories Short tempered toward student, but later accept her late requirements Sees her mother as good and her mother told her not to do something, now sees her mother as bad and opponent or adversarial

Splitting

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27.

Replacing of an Substitution unacceptable need or feelings with one that is more acceptable 28. Uses external object to Student brings to his represent repressed teacher a bouquet of Symbolization thoughts, feelings or flower impulses

Man rushes to marriage after his breakup with his former GF

Seen in schizophreni a, conversion disorder

29. Isolation

Talking emotionlessly Temporary or long-term about a traumatic splitting off a certain incidence feelings/ideas from

Seen in obsessive compulsive disorder,

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30. Resistance

others emotional from conversion intellectual disorder Obvious or hidden Nurse too busy with task opposition towards to spend time talking to a remembering or dying patient processing anxietyproducing information

Four Levels of Defense psychiatric nursing 3rd ed: keltner/schwecke/bostrom, p 152 ADAPTIVE Solves the problem that is causing the Description anxiety, so that anxiety is decreased, patient is objective, rational and productive
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Common Use

Anxiety about coming exams is reduced by studying PALLIATIVE effectively and passing the examTemporarily with a gradedecreases of A the anxiety Description but does not solve the problem, so anxiety eventually returns. Temporarily relief allows the patient to return to problem solving Common Anxiety about exam is temporarily Use reduced by jogging for half an hour. Effective study is then possible and a grade of A is achievable MALADAPTIVE Description Unsuccessful attempts to decrease the anxiety without attempting to solve the problem. Anxiety remains
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Common Use

Anxiety about exam is first ignored by going to a movie and handed by frantically cramming for a few hours. A passing grade of C is obtained

DYSFUNCTIONAL Description Not successful in reducing anxiety or solving the problem even minimal functioning becomes difficult and new problems begin to develop. Common Anxiety about the exam is first Use ignored by going out drinking with friends and escaped by passing out the night. A grade of F results and the course has to be repeated
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G. Crisis Health Nursing 4th ed./fortinash/holoday worret p 451 CRISIS: When a person faces an obstacle to life goals that is, for a time, insurmountable through
[impossible]

Psychiatric Mental

the utilization of customary problem solving skills

During a crisis: psychologic homeostasis is disrupted because the individuals coping abilities fails Coping: adjustive reaction or habitual patterns of behavior that persons uses in responses to situation Coping abilities: emphasizes various conscious and unconscious strategies used to deal with stress and tension
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Human coping abilities includes: flight or fight, compromise reactions such as anxiety, hypervigilance, sleep disturbances, emotional withdrawal, impaired concentration, and ADLs * Coping does not imply mastery over the crisis; rather it is the process to solve the situation 1. Types of Crisis A. External [situational] Crises - external stressors is a specific event that is apparent to another observer, centers on real events that: 1. threatens physical health 3. ability to obtain food 2. ability to obtain clothing or shelter 4. loss of loved ones/objects

B. Internal [subjective] Crises

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- internal stressors a threat to well-being that may not be obvious to the outside world such as: 1. aging, loss of independence 2. broken promise that represents profound abandonment or breach of loyalty that results to profound fear and quilt 3. threat to deeply held belief or a loss of faith C. Phases of Life [maturational] Crises - human experience normal and predictable changes on lifes continuum adolescence, career choice, marriage, parenthood, midlife, retirement and old age Each phase brings with it expectations from self and others and challenges that carry a potential crisis Example: Aging: brings loss of strength, mobility, elasticity, balanced, reduced memory, slower thinking
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Self-worth can be redefined thru: and other declining abilities Redefining ones criteria so he can be closer Person must redefined self-worth as they pass successfully through these phases between actual self and the expected reality: * Thus reducing Stress

D. Disaster [adventitious] Crises Natural disaster an ecologic phenomenon that disables entire communities; the devastation exceeds the capacity of the areas resources physically and emotionally and thus requires external assistance Man-made disaster - or acts of terrorism: murder, kidnapping, hijacking, arson,
Goal: [direct targets/victims of act may not be the actual target:] Through the use of coercion/force or threat of violence to create: 1. condition of fear and uncertainty-[ insecurity/doubt] 2. demoralization and helplessness Produces psychological casualties which will always outnumbered the physical casualties

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2. Phases of Crisis Development: Psychiatric Nursing 5th Ed. Keltner/Schwecke/Bostrom p 125 127 Anxiety generally rises to a severe or panic level during crisis [refer to previous topic on anxiety level: mild -panic]
When in crisis, individuals feels: 1. overwhelming helplessness and hopelessness when nothing appears to be working 2. immobilized and either give up or keep trying the same, ineffective coping methods 3. receptive [open] to help

I. Period of Disorganization Natural tendency: - being dependent on others for guidance and assistance
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Trust is less of an issue at this time The right type of help at the right time generally enables individuals to: a. overcome the problem c. return to normal b. regain equilibrium Common tendency for individual: to learn new coping skills and/or develop new improved relationships with others so they become functional better than they did before the crisis This tendency is why a crisis is said to have growth-promoting potential This period can not be tolerated emotionally or physically for more than 4 to 6 weeks - if the right of type of help is unavailable and the crisis is not successfully resolved: - individual in crisis becomes exhausted and physically ill
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- adopts dysfunctional coping patterns that mange the intense feelings without solving the problem - becomes emotionally ill, becomes violent, or attempt suicide to escape the pain Crisis Intervention Strategies: 1. Focus on 3 Ss: Survival, Safety and Security a. assess for and prevent suicide, violence, decompensation, and reactivation of serious medical or psychiatric problems b. arrange for urgent medical care if needed c. allow for expression of feelings, especially fear and anger, without allowing a loss of control d. assess for the effects of the crisis on thinking and functioning: decision making, sleeping, eating e. validate reactions and feelings as normal as typical [usual]reactions to an atypical [unusual]situation
333

f. decrease the sense of loss of control and overwhelming helplessness, hopelessness, and powerlessness by providing specific information about assistance available g. identify immediately available family and/or friends who can provide support and assistance, especially for food, shelter and clothing h. if hospitalized, offer PRN medications if appropriate

2. Reestablish equilibrium and stabilization: a. use quick anxiety reduction strategies b. offer support, realistic reassurance, information and education c. facilitate a sense of control over self and the situation d. intervene with dysfunctional coping mechanisms e. counteract irrational thinking and negativity 3. Focus on strengths and adaptive coping
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a. encourage use of adaptive coping and personal, spiritual, family and community resources b. involve available support systems as soon as possible and assist them with education and in accessing resources c. use techniques for reframing cognitive restructuring, and reality testing 4. Offer suggestions for concrete, specific problem solving a. focus on here and now reality, rather than underlying or long - term issues b. assist in decisions and setting priorities for immediate actions needed c. encourage activities of daily living, especially foods and fluids d. encourage use of prescribed medications as directed, if there are medical or psychiatric illnesses e. arrange for assessment of the need for hospitalization if indicated 5. Make provisions for follow-up care a. arrange for monitoring for 2 to 3 months because of risk for suicide can be present
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b. assess for underlying needs and problems requiring short term counseling and make referrals as needed c. teach and encourage use of adaptive coping strategies d. encourage use of personal and community resources for prevention of future crisis e. make a long-term counseling referrals if the crisis is not resolving or for chronic issues or illnesses f. refer to support or self-help group as appropriate UNIT III. Care of Client with Maldapative Patterns of Behavior Across the Lifespan 2. Anxiety Related Disorder A. Anxiety and Anxiety Disorder Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret. [ P 175- 178] Integral part of the universal human experience
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Function to warn the individual of impending threat, conflict, or danger When signals receive: Motivates person to act: - flees the threatening environment or control dangerous impulses - freeze or do not act

State of tension, dread, or impending doom coming from external influences that threatens to overwhelm an individual;

ToI. conceptualize physiologic and behavioral changes during stress: General Alarm Stage [fight flight] Adaptation Syndrome
Recovery

1. Hypothalamus 2. Posterior pituitary ADH 3. Anterior pituitary ACTH cortisol

water reabsorption Urine output adrenal cortex gluconeogenesis

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II. Resistance

III. Exhaustion

1 physiological response as noted in alarm reaction 2. energy level activity 4. adaptation to 3. physiologic stress adaptation 4. death

1. stabilization 2. hormonal levels return to normal 3. parasympathetic nervous system

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Responses to anxiety [page 177] Anxiety level physiologic cognitive/perceptual

emotional/behavioral

Historic and Theoretic Perspective I. Interpersonal Relationship in Nursing Hildergard Peplau * describes anxiety continuum/degree as: mild moderate severe panic! Mild range: - Optimum level of functioning facilitates: learning, creativity and personal growth Example: students often experience mild anxiety as they strive to achieve to excel in their work * Occasional moves to moderate stage as an adaptive mechanism to cope with pleasure or unpleasant situations
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Example: Student who is giving an important oral presentation or anticipating a difficult test experiences moderate anxiety, when he manage the stressor, he will move back along the continuum to mild anxiety Moderate and Severe anxiety: can either be acute or chronic Consequently: Severe anxiety: Impairs individual level of
- persons focuses energy primarily on reducing the pain and discomfort of anxiety, rather than: on coping with the environment functioning and eventually requires help to reverse the situation

] Panic Anxiety: Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret. [ P 173 175] - person is disorganized, with increased motor activity
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- distorted visual-perceptual field - loss of rational thought and decrease ability to relate to others In addition to anxiety description by degree, there are several types: I. Signal Anxiety: Type of anxiety a person experienced when identifies a precipitant
Successfully repressed Important to note: Signal Anxiety is learned It results from a situation that have been: Or coped with, by using another defense mechanism

Consequently the precipitant is successfully excluded from ones consciousness Signal anxiety is the predominant etiologic factor in phobic disorder A cue in the environment causes anxiety, which becomes severe in nature, resulting to panic attack
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Individual is unaware of the cue initially; the original experience in involving the cue is repressed Example: shopping at grocery store, becomes very anxious when passing an individual who smells of alcohol [uncle who drank alcohol heavily was abusive when intoxicated] Developed anxiety II. Trait Anxiety function of personality structure diathesis or
As part of developmental process/events: - have traumatic experience - have less success in coping with these events Unresolved conflict or confusion predisposition to anxiety when stressed

They have a higher probability of worrying than someone who does not have trait anxiety as part of their personality structure
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* High level of trait anxiety: - situations that re-create or represent the original conflict/experiences evoke more severe anxiety responses Example: woman worries excessively about her children being injured or catching colds because her mother is chronically ill for much of her childhood as a result, she limits their activity and is anxious and overprotective These anxious behaviors can be passed on to her children and continue to affect future generations III. State Anxiety:
situations identified as a conflictual or stressful and in which individual experiences limited control Often perceived as anxiety that occurs before butterflies in the stomach experiences before important examinations

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Example: Person bitten by a dog in the past, experiences an increased in heart rate when seeing a large dog walking down the street Free-floating anxiety is a pervasive sense of dread or doom unattached to any ideas or event Anxiety in the Context pf Psychiatric Mental Health Nursing Inherent in all nurse-client relationship is the nurses goal: - in making the relationship meaningful and moving forward - facilitate choices through the relationship Psychiatric Mental Health nurses primary goal of the nurse-client relationship is to become available to the individual Hildergard Peplau
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- described the nurse as a person who relates to the client rather than with the client - describes that nurses recognize the choices or potentials that exist in the emerging relationship between the nurse and the client Interpersonal Relationship addressed the unexplained discomfort: - needs, frustrations and conflicts that occur within the relationship - experiences that influence behavior by providing energy to that relationship - nurses should examine anxiety as it occurs in that relatinship Humanistic Theory (Patterson & Zderad -1976) Cornerstone of this theory: Interactive process between two persons: one needing help and one willing to give help - nurse is a participant in the process, he tries to be fully present in the process and it is in relationship with the client
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- nurse availability to the clients is critical Defense Mechanism - primary methods the ego [self] uses to control or manage anxiety - protects us from the threats to the physical, mental and social aspects of ourselves in various stages like: * Person with history of being abused as a child uses the repression defense mechanism to control the anxiety related to the trauma
Repressing the painful events Enables individual to engage in normal activities such as in schools, sports, making friends and even marriage and parenthood

Difficult to repress Painful trauma

Person uses dysfunctional methods to manage anxiety disrupts persons life!

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Commonly used defense mechanism To be able to identify with the peers she admires to diffuse/spread her identity to be accepted as one of the group Identification
Teenager dresses and groom like most popular girls

Being indifferent carries the threat of rejection creating overwhelming anxiety

NOTE: - all defense mechanism reduces anxiety and most people uses variety of them to get through their de4velopmental milestone Individuals who use defense mechanism rigidly or consistently will not grow and develop emotionally
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healthy, responsible beings Example: antisocial personality individual often relies on defense mechanism of projection Projection: control anxiety by projecting his own inadequacies onto another person/ situation In one sense: projection effectively reduces anxiety, yet constant usage, individuals fails to confront and deal with his vulnerabilities and ceases to grow Role of therapist - Helps these individuals confronts the traumatic event and level of functioning increases as they learn to manage anxiety in a healthier ways

Types of Defense Mechanism [table 9-1 page 176]

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High Adaptive Level Humor, sublimation, suppression Mental inhibitions: Compromise formation level Displacement, dissociation, repression Minor Image Distorting level Devaluation Disavowal Level Denial, projection Major Image Distorting Level Splitting of self image or image of others Etiology I. Biological Model Hans Selye II. Psychodynamics anxiety are identified as warning to the ego it is involved in the development of personality and personality functioning and the development and treatment of neuroses and psychoses
349

Psychoanalytic theory proposes 3 types of anxiety 1. Reality anxiety : painful emotional experience resulting from the perception of danger in the external world Example: fear of possible terrorist attack - fear is the response to the external danger [consequently fear parallel to anxiety] 2. Moral anxiety - egos experience of quilt or shame Example: experiencing guilt after expressing anger at family member 3. Neurotic anxiety: perceptions of a threat according to ones instincts Sigmund Freud theory of signal anxiety anxiety is a signal of impending emergence of threatening, unconscious mental content! Neurotic symptoms develop as an attempt to defend against anxiety:
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somatic symptoms, obsessions, compulsions and phobias III. Interpersonal Model Views anxiety as a response to the individuals external environment rather than the relatively simple psychoanalytical view of a response to instinctual drive:
Expectations, insecurities and frustrations Symptoms formations as a result of Conflicts between individual and primary groups [families, work colleagues and friends]

Interpersonal theory great deal of emphasis on early development and experiences in relation to future mental health
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Individuals first experience with anxiety is the infant perception of the anxiety of the mothering person SELF SYSTEM develops in the context of approval or disapproval
Disapproval results to threat to self system a fear of rejection or in other words anxiety

IV. Environmental Model [Social Psychiatry] Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret. [ P 178 - 180] The dynamic relationship between individuals and their environment = anxiety & its manifestations
Socioeconomic status Racial inequalities Fear of terrorist attack as a stressors Individual responds to the environment on a continuum, either: - adaptive - with symptoms formation: mental illness/physical illness

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V. Behavior Model Based on Learning theory - The etiology of anxiety is a generalization from an earlier traumatic experience to a benign setting or Associates Develops panic attack object embarrassment and during basketball shame with sports games child whose parents - Awkward ridiculed him while playing Early behavioral therapist working with PTSD reported success in using systematic desensitization Systematic desensitization is a method that comes from the learning theory - therapist exposes a deeply relaxed patient to a graded hierarchy of phobic stimuli In vivo desensitization - exposes the individuals progressively to a more anxietyprovoking situations
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Clinical Description I. Panic panic anxiety refers to anxiety symptoms that occur during panic attacks - sudden onset of distressing physical symptoms combined with thoughts of dread, impending doom, death and fear of being trapped Panic Attack [not classified as psychiatric illness, but symptoms of disorder] A distinct period of intense fear or discomfort in which four or more of the following symptoms develop abruptly and reach to peak within 10 minutes. 1. palpitations, 8. nausea or pounding heart, abdominal pain tachycardia 2. sweating 9. feeling dizzy, unsteady, lightheaded/faint 3. trembling or 10. derealization
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shaking 4. sensations of shortness of breath or suffocate 5. feeling of choking 6. chest pain or discomfort

[feeling of unreality] or depersonalization [being attached to oneself 11. fear of dying 12. paresthesias [numbness or tingling sensation] 7. chills or hot flushes 13. fear of losing control or going crazy Criteria for Panic Disorder diagnosed if met the following 2 criteria 1. recent and unexpected panic attacks are present 2. at least one of the attacks has been followed for 1 more months by: a. persistent concerns about having additional attacks
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b. worry about the implications of the attacks or its consequences [ losing control] c. significant change in behavior related to the attacks
Pervasive [invasive] symptoms of feelings of impending doom are frightening! - client responds by seeking help Not uncommon: Been ill for 8 to 10 years before presenting for treatment and experience one or two attacks/week

Panic attacks are not related to a. direct effects of a substance [illicit drugs, or alcohol] b. physiologic conditions [hyperthyroidism] Phobias
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* Client experiences panic attack in response to particular situations or learns to avoid the situations that causes the panic attack Agoraphobias - anxiety about being in places or situations from which escapes is difficult [or embarrassing] or - in which help is not readily available in the event of an unexpected or situational predisposed panic attack Criteria: I. must met criteria for Panic Disorder 1. persistent concern about having additional attack 2. worry about the implication or its consequences 3.. significant change in behavior related to the attack II. experiences agoraphobias
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Agoraphobic fears typically involve characteristics clusters of situations: - being outside the home alone - being alone in a crowd or standing in a bus, car, train, being on a bridge III. persons avoids agoraphobics situations or has stress or anxiety about having a panic attack or persons requires the presence of a companion IV stress attacks are not due to direct effects of a substance or general medical conditions V. phobias is not better explained by another mental disorder, as described in the panic disorder section Specific phobias - specific phobias as a marked and persistent fear that is excessive or unreasonable cued by the presence or anticipation of a specific object or situations such as : animals, insects, heights, flying or seeing blood
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Children with specific phobias express anxiety thru: crying throwing temper tantrum, freezing or clinging. Social phobia or social anxiety disorder - marked and persistent fear of one or more social performances situations in which the person is exposed to unfamiliar people or to possible criticism by others He fears that he will act in a way [or show anxiety] that he will be humiliating or acting embarrassing Posttraumatic Stress Disorder - PTSD: Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret. [ P 183 -189 ] Before: - pattern of response after traumatic events, most common among soldiers - this syndrome was called shell shock or combat fatigue
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Model Dx category: PTSD is describes as: - an individuals reaction to traumatic events in human experiences beyond combat, including the experiences of an adult and child survivors of: a. sexual abuse b. physical abuse c. disasters d. and grieving process To be diagnosed with PTSD: 1st group of defining criteria a. must experienced a traumatic event before the onset of symptoms b. must have experienced, witnessed, or been confronted with an event that involved actual or threatened death or serious injury c. threat to the physical integrity of self or others d. individuals response must have involved intense fear, helplessness or horror 2nd group of defining criteria
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a. includes various mechanisms or reexperiencing the traumatic event and includes one of the following: - recurrent and intrusive [invasive] disturbing recollections of the occurrence including: thoughts, images, or perceptions. b. sometimes experiences: - recurrent dreams of the incident - acting and feeling as thought the event was recurring - and feeling the experience of psychological distress when internal or external cues resemble the trauma 3rd group of defining criteria a. avoids stimuli associated with the trauma and experiences a numbing of general responsiveness if reminded via [by means] cues of the incident Numbness and avoidance are evident by at least three of the following:
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a. efforts to avoid thoughts, feelings or conversation about the trauma b. efforts to avoid persons/places that evoke memories of the trauma c. inability to remember an important aspect of trauma [repression] d. diminished interest or participation in significant activities e. a feeling of estrangement or detachment from others d. restricted range of affect f. a sense of impending doom [no expectations of a career or normal life span] 4th group of defining criteria - describes symptoms of increased arousal that were not present before the trauma. Two of the following must be present: a. irritability d. difficulty in concentrating b. sleep disturbances e. hypervigilance c. irritability or angry outburst f. exaggerated startle [surprise/frightened] response * Symptoms must persist for more than 1 month
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Acute symptoms occurred from 1 to 3 months duration Chronic persisted for at least 3 months Delayed onset more than 6 months Outcome Identification: client will; - demonstrate concerns for personal safety by beginning verbalize worries - participate actively in support group - identify and involve significant support system - assume decision-making role for own health care needs - acquire and practice strategies for coping with anxiety symptoms such as breathing technique; image, memory substitution and assertive behaviors - discuss the medication treatment regimen and take the mediation as prescribed - identify when to use PRN medication to decrease the heightened anxiety response to a cue in the environment

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Acute Stress Disorder: differs from PTSD in 3 ways: 1. experiences at least 3 symptoms of dissociation a. subjective sense of numbness or detachment b. reduced awareness of the surroundings [ being in daze stunt/schock] c. derealization [unreal feelings] d. depersonalization [ feeling of alienated] e. dissociative amnesia 2. time frame of development and durations is shorter a. symptoms last from 2 days to a month 3. dissociation symptoms prevents individual from coping Defining characteristics - the symptoms causes significant distress or impairment in social/occupational function
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- the onset of dissociative experience occurs during the traumatic or develops immediately afterwards Example: individual unable to perform necessary task, such as obtaining permit! Generalized Anxiety Disorder [GAD] Excessive anxiety and worry [apprehensive expectation] that occurs more days than not for at least 6 Months. Apprehensive: anxious, uneasy, worried, nervous, fearful, hesitant and frightened Three of the following symptoms must be present for 6months: - restlessness or feeling on edge - irritability - being easily fatigue - muscle tension - difficulty in concentration - sleep disturbances - Anxiety or worries interferes with the normal social/occupational functioning
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- and it is not due to the direct effects of a substance or a general medical conditions - it does not occur exclusively in the presence of another Axis I disorder [ mood, disorder, psychosis, or pervasive developmental disorder] Outcome Identification: client will; - demonstrate significant decrease in physiologic, cognitive, behavioral and emotional symptoms of anxiety - demonstrate effective coping skills - exhibit enhanced ability to make decisions and problem solve - demonstrate ability to function adaptively in mild anxiety states - discuss the medication regimen and take the medication as prescribed - identify when to call the therapist for more visits when a crisis occur - experiencing symptoms of heightened anxiety Obsessive Compulsive Disorder OCD is the presence of either obsessions or compulsions
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Obsessions: Recurrent and persistent thoughts, impulses, or images that a person experiences at some time as intrusive/disturbing and inappropriate and cause marked anxiety or distress

Individual tries to suppress or neutralize them with some thoughts or actions

Compulsions: Repetitive behaviors that the person feels driven to perform in response to an obsession

The behaviors/thoughts are an attempt to prevent or reduce the distress invoked by obsession or to prevent some dreaded threatening situation [such as fire in the example of checking appliances] Outcome Identification: client will; - participate actively in a learned strategies to manage anxiety and decrease OC behaviors, such a mindful behaviors - describe increasing sense of control over intrusive thoughts and ritualistic behaviors
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- demonstrate ability to cope effectively when thoughts or ritual are interrupted - spend less time involved in anxiety-binding activities and instead use time gained to complete ADL and participate in social/recreational activities - successfully manage times of increased stress by integrating knowledge that thoughts, impulses, and images are involuntary, thus reducing sense of responsibility and consequent anxiety - discuss medication regimen and takes it as prescribed - identify when to call the therapist for more visits when crisis occurs Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret. [ P 184 - 189 ] Interventions: following interventions are useful for clients with anxiety symptoms, regardless of diagnosis or treatment setting 1. Maintain safety for the client and the environment As clients anxiety escalate to a panic state, which can be frightened and harm the client and others. The nurse first priority is to protect the client and the environment
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2. Assess own level of anxiety and make a conscious effort to remain calm Anxiety readily transferable from one person to another 3. Recognize the clients use of relieve behaviors [pacing, wringing/soaked of hands] as indicators of anxiety Early interventions help to mange anxiety before symptoms escalate to more serious levels 4. Inform client of the importance of limiting caffeine, nicotine, and other CNS stimulants Limiting these substances prevents/minimizes physical symptoms of anxiety, such as rapid heart rate and jitteriness [agitation] 5. Teach the client to distinguish between anxiety that is connected to identifiable objects or sources illness, prognosis, hospitalization, and known stressors! And anxiety for which there is no
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immediate identifiable objects or sources Knowledge of anxiety and its related components increases the clients control over the disorder 6. Instruct the client in the following anxiety-reducing strategies. These lessens anxiety in a variety of ways and distract the client from focusing on the anxiety a. progressive relaxation technique b. mindful meditation, the individual: - learns meditation to reduce stress by concentrating on his body - pays attention to the act of breathing to enhance concentration - observes the act of breathing, attending to the intake and exhale of each breath - meditation discourages intrusive thoughts: the client aggress to deal with the subject of the intrusive thought at a later time
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- benefits by feelings in control of his own body. There is reduction of pain and anxiety, and individuals feels hopeful c. slow deep-breathing exercises d. focusing on a single object in the room e. listening to soothing music or relaxation tapes f. visual imagery or natures related DVD productions 7. Help the client build on coping methods that the clients used to manage anxiety in the past Coping methods that were previously successful will generally be effective in subsequent situations 8. Activate the client to identify support persons who will help the client perform personal tasks and activities that current circumstances make difficult like partial hospitalization program or a short stay hospitalization]
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A strong support system will help the client avoid anxiety-provoking situations/activities 9. Assist the client in gaining control of overwhelming feelings and impulses through brief, direct verbal interactions. Individual interactions executed at a appropriate intervals will reduce/manage clients anxious feelings/impulses 10. Help the client structure the environment so that it is less noisy. A less noisy environment creates a calming, stress-free atmosphere that reduces anxiety 11. Assess the presence and degree of depression and suicidal ideation in all clients with anxiety and related disorders A thorough result in early intervention that will possibly prevent self-harm 12. Administer anxiolytic medication as least restrictive measures.
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Medications is often the first appropriate method to reduce debilitating anxiety 13. Help the client to understand the importance of the medication regimen and to take it as prescribed. Medications is an effective addition to other psychosocial therapeutic interventions when necessary Additional Treatment Modalities I. Biologic Interventions Pharmacologic interventions with cognitive behavioral interventions = are among the most successful treatment of anxiety and related disorder SSRIs antidepressant now widely used to treat anxiety disorders and OCD and Panic disorder Fluoxetine and Fluvoxamine OCD Paroxetine GAD, OCD, Panic disorder and PTSD
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Benzodiazepine since 1960 most widely used in the treatment of anxiety disorder Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret. [ P 190 - ] Benzodiazepine alprazolam [xanax] clonazepam [klonopin] diazepam [valium] lorazepam [ativan] Non-Benzodiazepine buspirone [buspar] * may cause physical and psychological dependence alcohol and other NS depressant may potentiate action, especially among elders blood dyscrasias [fever, sore throat, bruising , rash, and jaundice] are rare herbal medications: kava kava and st. johns wart may potentiate action

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II. Electro Convulsive Therapy indicated for depression, however: when other treatment are too risky or have failed ECT can be used Example client with OCD have partial response to clomipramine and is suicidal, ECT is a reasonable treatment alternative relates to improve transmission of dopamine, serotonin, norepinephrine. III. Psychotherapy takes place in a group or individual setting Group therapy advantage: Opportunity for the client to learn from the successes and failures of others with similar symptoms Behavioral and Cognitive have been widely used Behavioral therapy:
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Behavioral treatment and desensitization effective for panic disorder with agoraphobia - first therapist and client define the phobic stimuli and Cognitive Therapy Psychologic First Aid - Recommended as initial response if a person or groups of individuals encounter a traumatic event or loss. This involves: - protecting an individuals who have experienced or witnessed the trauma from any further injury or harm by reducing their psychological arousal - support for individuals who are demonstrating distress is obtain: - keeping families together so that there is support among family members - information about stress reduction and common side effects of trauma must be given
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Research findings: * Brief cognitive behavioral therapy is the intervention of choice to prevent further trauma related to maladaptive responses B. Somatoform, Factitious and Dissociative Disorders Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret. [ P 190/196 - 197 ] & Psychiatric Nursing 3rd Ed: keltner et al; 44441]
Group of disorder that converts anxiety into physical symptoms for which there is no identifiable physical diagnosis A disorder that reflect complex interaction b/w the mind and the body with serious impairment in the persons social and occupational functioning

Psychoanalytical theory: Psychogenic complaints of: Pain, Disease or Loss of Function are generally related to

Repress aggressions or sexuality

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Biologic Theory: Prolonged stress or trauma

Altered perceptions and interpretation of bodily functions

Somatoform Dso.

Behavioral Theory: Individuals learn to use somatic symptoms

Communicate helplessness and manipulate others Attention from others exacerbate somatic symptoms

Cognitive Theory: Clients with somatic symptoms

Misinterpret meaning of body functions and sensations and becomes overly alarmed by them

- Genetic, developmental-learning, personality, and socio- cultural factors can: predispose, precipitate, and maintain somatoform disorder - stressful life events can also precipitate bodily concerns

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Coping Mechanisms
Repressions in reference to feelings, conflicts and unacceptable impulses

Denial of psychological problem even thought they were told that there are no physiological causes or basis for their symptoms

Displacement when anxiety is transformed into bodily symptoms

* Appears to be needy and dependent on others Clinical Descriptions: Somatization Disorder formerly called hysteria, characteristics pattern: * One who frequently seek and obtain medical treatment for multiple, clinically significantly
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somatic complaints DSM-IV TR: - symptoms must begin before the age of 30 years and - not adequately explain by any general medical disorder or the directs effects of a substance - sees many physician and even have exploratory and unnecessary surgical procedures Distribution of symptoms: - requires that symptoms have a distinct pattern that differs from general medical conditions Having these 3 criteria: - there is involvement of multiple organ system [GIT, sexual/reproductive/, and or nuerologic] - symptoms exhibit in early onset and chronic courses without development of physical signs and or structure abnormalities [ degenerative changes in bones/joints associated with complain of pain]
380

- clinical laboratory abnormalities commonly associated with general medical condition are absent Pain Disorder Predominantly focus pain in one or more anatomic sites that causes significant distress or impairment in function. - location of the pain does not change unlike in somatoform - psychological factors plays a role in the development and maintenance of pain disorder - there is no organic basis fort his disorder - often doctor shoppers and uses analgesic excessively without experiencing any relieve - anxious about their symptoms and depressed about even getting better 2 types Pain disorder related to psychological factor - there is underlying psychological factor in the pain disorder
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Example: feelings connected to the loss of job/status prior to the development of the disorder A womans chest pain prevent her from going to work Pain disorder associated with both psychological factors and a general medical condition Example : Experienced mild MI now convinced that he no longer can engage in recreational activities such as bicycling or swimming with the fear of suffering another MI Conversion Disorder Major Characteristics: I. Criteria
Deficit or alteration in voluntary or motor or sensory function that suggests a neurological or medical conditions Psychological factors, major conflicts, or stressors are associated or precede its development

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* most common conversion symptoms suggest neurological diseases such as: - paralysis, blindness ,or seizures Primary gain refers to the alleviation of the symptoms Secondary gain gratification received as a result of how people in this patients environment respond to the illness - expressed forbidden thought / wish by converting it into physical symptoms that are more appropriate and acceptable - which also provides sympathy, care and attention from others II. Criteria
Specific, identifiable conflicts/stressors precede the development

A soldier suddenly develops paralysis of his hands he can no longer engage in combat because he cannot pull the trigger on his gun
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- the symptoms is related to the conflicts - he can talk about the combat but can not connect his feelings about fighting to the development of his paralysis III. Criteria
Demonstrates lack of concerns about the seriousness of the symptoms which is inconsistent of the problem Rationale - his symptoms binds his anxiety so that it is not behaviorally expressed

This lack of concern is the la belle indifference or beautiful indifference [hallmark symptoms of conversion disorder Coping Mechanisms
Repressions in reference to feelings, conflicts and unacceptable impulses

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Conversion - when anxiety is transformed into bodily symptoms

Hypochondrias: Criteria on the fear of having or the idea of having a serious medical disorder based on the I Focuses individuals misinterpretation of bodily symptoms

II.This misinterpretation of symptoms persist despite appropriate medical evaluation and assurance

Individuals preoccupation with symptoms is not as intense or distorted as it would be in a III. a. delusional disorder nor b. restricted in dysmorphic disorder

IV.
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Preoccupation causes clinically significantly distress or impairment in social, occupational or other major areas of functioning

V.
Duration of disturbances must be at least 6 months

VI.
Not due to another anxiety disorder, somatoform or major depressive episodes

Body Dysmorphic Disorder [BDD]

Preoccupation with an imagined defect in appearance

Causes clinically distress and impairment in social/occupational functioning

- diagnosis may take years because client can hide their symptoms Examples of symptoms:
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- excessive grooming, checking in the mirror and skin picking Often resulting to: - reports poor grades as a results this preoccupation of body imperfection. - then have numerous absences and if symptoms is severe they quit school - when experiencing severe symptoms hesitant to leave home - frustrated about perceived deficit becomes angry and violent [ throws comb at bathrooms mirror] High risk for suicide: must assess! - ask if patient has any worries about his body appearance - like hair, facial feature, hips, fingers and any other body area that he identifies as concerning - ask directly about the concerns and how the person perceives the deficit - determine the amount of time the client spends thinking about the imagined defect
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- what actions has the person taken to hide or get rid of the deficit [ makeup, surgery, baggy cloths] - how has the concern about the deficit affects persons ability to function at school, work, and within the family Factitious Disorder
Intentionally produce physical or psychological signs and symptoms to presume sick role For economic gain, avoiding school or legal responsibilities or to improve physical well being

- some adults demonstrate factitious disorder in prison, military and groups that are controversial - some develops after an actual physical illness Adults clients are often knowledgeable in medical terminologies Works in health care system Dissociative Disorder [Dissociate - disconnect/separate in thought or fact] Dissociative Amnesia
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Defining symptoms:
One or more episodes of inability to recall important personal information, usually of a traumatic or stressful in nature That is too extensive for ordinary forgetting to explain [dissociation]

- does not occur exclusively during the course of dissociative identity disorder - does not result from the effects of a substance [blackouts during ethyl alcohol intoxication] - does not occur from the effects of a general medical conditions [ amnesia after head trauma] Precipitant: Something that causes severe psychological stress such as threat to physical injury or death Types: Recent amnesia can occur immediately after a traumatic event
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Remote amnesia can occur regarding past traumatic events such as childhood abuse Demonstrates confusion about Dissociative Fugue personality identity or assumes a new
Sudden, unexpected travel away from home or ones customary place of work, with an inability to recall ones past [or where one has been] identity which is sometimes partial filling in the blanks

- last from a few hours to several days and usually follows severe psychological stress, such as: - marital quarrels, personal rejection, military conflict, or natural disaster
The fugue state then allows escape or flight from an intolerable event or situation

Each with its own relatively enduring pattern of: Dissociative Identity Disorder Perceiving about the Relating to, & Thinking environment and self

390

2 Criterion must demonstrate two or 1. Individual more distinct identities or personalities

states

2. At least two of these personality states recurrently take control of the persons behavior - The person, or host is unaware of the other personalities, but the other personalities may be aware of each other in varying Allows degree person to survive the trauma but:
Highly painful emotional and sexual abuse Dissociation: Defense mechanism against extreme anxiety - splitting off of these painful stimuli Leaves an impaired personality with disconnected parts or alters which contains feelings and behaviors associated with the trauma

391

Each personality is quite different from others and from the original personality, they have their own: - names, behavior, traits, memories, emotional characteristics and social relationships Most common personality: - a fearful, terrified child and persecutory personality modeled on the abusers Example: a shy woman may have alternate personalities that are promiscuous/immoral, flamboyant/showy, childlike and aggressive General Outcome Expectation Client will: Contract the nursing staff if thoughts are suicidal or harmful towards others. Identify situation and events that trigger somatic concerns or dissociative and select ways to prevent or manage them. Describe somatic symptoms that occur with the increase in levels of anxiety.
392

 Discuss the connection between anxiety-provoking situations or events and somatic symptoms or dissociatives states. Explain relief behaviors and thoughts openly. Identify adaptive, positive techniques and strategies that relief anxiety and decrease somatic focus or the dissociative episodes. Demonstrate behaviors that represent reduced somatic symptoms or provide the client with a means of reassociation when experiencing a dissociative state. Use learned anxiety-reducing strategies such as mindful meditation (see Box 9-3). Demonstrate the ability to problem solve, concentrate, and make decisions. Verbalize the feeling of being relaxed and les concerned about somatic sensations or disorder. Sleep through the night for 6 to 8 hours. Use appropriate supports from the nursing and medical community, family, and friends.
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 Learned to manage anxiety to tolerable levels without dissociating of focusing on somatic sensations. Seek help form appropriate sources when there is an awareness of new somatic concerns. List the medication used to control the symptoms as well the appropriate dosage and scheduled times. Continue post discharge symptoms management including medication and others therapies. Somatization disorder Client will: Construct an exercise program that includes anxiety reducing techniques. Address two positive somatic responses (e.g... massages therapy, the satisfied feeling after a successful exercise session). Keep an intake log to document somatic preoccupation and stressors (including instructive thoughts or concerns).
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 Help the therapist to coordinate the information from the primary care provider and any other involved specialist. Take the medication as prescribed and be able to identify the rationale for the medication. Contract the therapist for more frequent visits if somatization increases. Dissociative identify disorder Client will: Alert the therapist or use a hotline such as 1-800 SUICIDE or 1-800-273TALK when feeding suicidal. Respond to his or her name when addressed by a member of the treatment team. Refer to self in the first-person pronoun form: I think. Identify periods of increasing anxiety. Inform others of dissatisfaction in a noun threatening manner. Use assertive-response behaviors to meet needs (see chapters 4-23)
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 Keep a written journal to identify stressors and when the dissociation occurs. Take medication as prescribed. Identify when to utilize a prn medication to decrease the heightened anxiety response to a cue in the environment. Contract the therapist if symptoms increase. Nursing interventions 1. Identify the degree of suicidal ideation and depression in clients with all types of anxiety and associated disorder. A through evaluation of clients with anxiety disorders and associated disorders will help to prevent suicide and other destructive behaviors early in the intervention process. 2. Monitor ones own level of anxiety and make a conscious effort to remain calm.
396

Anxiety is readily transferable from one person to another. Individual with somatic form illness have a risk of an increase of symptoms during times of increased anxiety. 3. Recognize that the clients use of relief behaviors focuses on somatic sensations as indicators of anxiety. Early interventions help to manage anxiety before symptoms escalate to more serious levels. 4. Educate the client about the importance of limiting caffeine, nicotine, and other central nervous system stimulants. Limiting these substance prevent of minimizes physical symptoms of anxiety, such as rapid heart rate and jitteriness, which may cue other somatic concerns. 5. Teach the client to distinguish between somatic sensations that are connected to identifiable objects
397

or sources (such as a cold, pain from a fall) and somatic concerns for which there is no immediate identifiable object or source but are a reaction to an increase in anxiety. Knowledge of anxiety an d its related components increases the client control over the disorder. 6. Instruct the client to perform the following strategies to reduce anxiety and distract the focus on somatic concerns a. Progressive relaxation technique b. Slow deep-breathing exercise c. Focusing on a single object in the room d. Soothing music or relaxation tapes e. Visual imagery (guided imagery) 7. Help the client build on coping methods that helped to manage anxiety in the past.
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Coping methods that were previously successful will generally be effective in subsequent situations. 8. Active the client to contract support persons who will increase socialization and provide emotional support as the client attends work or school, even when client is feeling poorly. A strong support system helps the client avoid anxiety provoking situations or activities. 9. Help the client gain control of overwhelming feelings and impulses through brief, direct verbal interactions. Individual interactions at appropriate intervals help reduce or manage a client anxious feeling or impulses. 10. Help the client to understand the importance of the medication regimen and the need to take medications as prescribe.
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Medications are an effective adjunct to other psychosocial therapeutic interventions when necessary. Additional Treatment Modalities Pharmacologic Interventions 1. SSRIs antidepressant drug most commonly used to treat somatoform for body dysmorphic disorder [ BDD] 2.symptomatic dissociative identity disorder [DID] Research studied the best medication regimen with somatoform: - Clomipramine [anafril] - Improves ability to function to includes those with delusions Psychotherapy: group or individuals Group advantage: learn from the successes and failures of others with similar symptoms
400

Cognitive therapy: - clients understanding that symptoms are a learned response to thoughts or feelings about behaviors that occurs in daily life 3. Psychophysiologic Response and Sleep Disorder Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret p 408 Sleep temporary state of unconsciousness that many think restores and repairs the body Neurotransmitter: Sleep promoting functions Arousal functions:
Adenosine, Acetylcholine & Melatonin Serotonin & Norepinephrine

Circadian Rhythm - influenced by the bodys internal biologic clock at hypothalamus adjust sleepwake intervals in a cyclical 24-hour pattern
401

Sunlight & other artificial light

Photoreceptors in the retina suppresses releases of melatonin

State of wakefulness occurs during daylight hours

State of darkness

Photoreceptors in the retina releases melatonin

State of sleepiness occurs during night hours

Restorative Sleep Pattern: Have 2 distinct patterns I. Non Rapid Eye Movement [NREM], has four stages: II. REM active sleep stage 1 Upon closing eyes Individual is NREM and drifting into a easily awakens slight light sleep state
402

2 NREM 3 NREM

Becomes less easily aroused VS recording reflect In deep state: a decline from sleep terror, baseline somnambulism 4 VS at the lowest Muscles are NREM level from baseline very relaxed After moving from wakefulness through stages1 through 4 NREM goes back to 4 then 2, then to REM Takes approximately Active cerebral 90 min. after state: individuals falls - increase asleep cerebral Also referred to as: metabolism paradoxical sleep - decrease
403

Active dreaming takes place

muscle movement

Etiology: Biologic Factors: - inherent biochemical alterations in neurotransmitter - use of substances that influences sleep [tricyclic antidepressant interferes with REM] Prescribed drugs and the OTC medications: - clients who stops taking these medication are at risk for a substance induced sleep disorder such as: Examples of substances that influence sleep are: 1. stimulants such as caffeine, amphetamines and cocaine 2. sedatives effects of opiates, hypnotics and antianxiety medications Genetic/Hereditary/Familial Factors
404

- there has been connection b/w a genetic predisposition or familial association and some types of sleep disturbances * Delayed Sleep Phase [additional type of circadian rhythm sleep disturbances] associated with genetic disposition Psychiatric/Cognitive/Behavioral Factors - sleep disturbances also occur with some mood and anxiety disorder General medical Conditions - sleep fragmentation often occurs in patient experiencing chronic pain * sleep abnormalities from medical illness does not reflect severity or intensity of the disease process - chronic lung disease or a cardiac conditions varies Sociocultural/Environmental Factors - demanding works add school schedules and social demands that poses a challenge among adolescents and
405

adults Clinical Descriptions:

Dyssomnias Characterized by abnormalities in amount, quality ,or timing of sleep: - primary/secondary insomnia - narcolepsy - breathing-related sleep disorder - circadian rhythm sleep disorder - jet lag, shift work type/ delayed sleep phase Parasomnias: Characterized by abnormal behavior or physiologic events occurring in association with sleep, specific sleep stages or sleep-wake transitions: - nightmare disorder - sleep terror disorder -sleep walking disorder

Dyssomnias 1. Known as Insomnia - characterized by predominant complaint of: 1. difficulty of initiating or maintaining sleep 2. experiencing non restorative sleep for at least 1 month
406

Insomnia at least 1 mo.

1. leads to excessive daytime sleepiness causing impairment in ADL 2. anxiety results either in response or in anticipation of an anxietyprovoking experience 3. often interferes with individuals social/occupational functioing

2. Narcolepsy - is the sudden onset of brief sleep attacks, lasting 10 to 20 minutes that typically takes place 2 to 6 x/day - suddenly falls asleep when engaging in a meaningful activities: driving a car, eating, interacting with people 70% of people with narcolepsy experience: Cataplexy sudden loss of muscle tone and voluntary muscle movements strong emotional experiences : laughing or crying can cause this reactions
407

Sleep paralysis where they are not able to speak or move just before the onset or upon awakening from a deep sleep attack Hypnopompic hallucination bright perceptual experiences upon awakening or when entering a deep sleep 3. Breathing Related Sleep Disorder - group of disorders resulting from a deep-elated breathing conditions such as: 1. Obstructive or central sleep apnea syndrome 2. central alveolar hypoventilation Persons with obstructive sleep apnea syndrome - have narrowing or complete obstructions of the upper airway resulting to load snoring episodes and regular apneic periods during sleep that last 10 to 30 seconds - individuals with large neck circumference, obese 4. Circadian Rhythm Disorder
408

Group of sleep pattern disturbances with persistent or recurrent pattern of sleep deprivation that results from: Difference in
Imposed sleep-wake cycle The individuals own circadian sleep wake pattern requirements

VS. A. Jet Lag Type: - period of sleepiness and alertness that occur at an inappropriate time of day relative to local time - occurs after repeated travel across more than one time zone B. Shift Work Type - usually the result of night shift work frequently rotating shift work - experience insomnia during the major sleep period and excessive sleepiness during major awake period. C. Delayed Sleep Phase
409

- occurs when individuals has persistent pattern of late sleep onset and late in awakening times and is unable to fall asleep and wake up at the desired earlier times. Parasomnias: Generally, parasomnias are abnormal behavior or physiologic events occurring in association with sleep, specific sleep stages or sleep-wake transitions: A. Nightmare Disorder - usually takes place during the REM late in the sleep cycle - experiences fragmented sleep as a result of waking up during the night with frightening dreams that threatens their survival, security or self-esteem [3Ss] - usually able to recall the nightmares in bright details B. Sleep Terror Disorder - experiences arousal during non-REM
410

- awakens early part of the night due to extreme anxiety or panic - it is not unusual for the person to scream or cry and appear disoriented during a sleep terror disorder C. Sleepwalking Disorder [somnambulism] - repeatedly engage in complex behaviors: walking, dressing, toileting and driving all while they are in deep non REM - while sleepwalking: they are in trance - spell, dream arousal is difficult - at times they are awaken while performing their task - most frequently: returns to sleep and later awakens without any recall D. Parasomnia Not Otherwise Specified - sleep disorder related to another mental disorder: - insomnia or hypersomnias RT mental disorder: mood/anxiety disorder - sleep disorder that results from a general medical condition - substance-induced sleep disorder
411

- involves prominent complaints of sleep disturbances that results from the use, or recent Discontinuation of use, substance/medications: alcohol , caffeine Pharmacological Modalities Benzodiazepine - greatest Triazolam potential for halcyon psychologic Temazepam & physiologic restoril dependency Flurazepam - not commonly dalmane the first-line treatment - interfere with REM

Abrupt or toorapid withdrawal: - restlessness, irritability, insomnia & seizures ,caffeine counteract sedation,
412

grapefruit alters absorptions Nonbenzodiazepines Zalepon sonata Zolpidem ambient Eszopoclone lunesta Antidepressant Trazodone desyrel Mirtazapine remeron Amitryptyline elavil - have less abuse potential and have less of a problem with rebound insomnia Low rate of side effects and adverse events Not anticholinergic recommended effects for elderly
413

Antihistamines Diphenhyramine benadryl Melatonin receptor antagonist Ramelteon Nursing Interventions: prioritized from most urgent to least urgent 1. monitor the clients sleep patterns and identify risks [breathing-related sleep disorder, sleep walking, narcolepsy, daytime fatigue] to prevent harm and injury to the client 2. activate the client to keep sleep diary so that they will identify patterns that promotes sleep patterns disturbances
414

3. develop a sleep hygiene plan and educate the client about sleep hygiene practice to promote rest and sleepdeprived client Sleep hygiene practice: - go to sleep and awaken at the same time each day in order to promote a consistent sleepwakefulness pattern. Try to avoid daytime napping - reduce or eliminate the use of stimulants [caffeine, nicotine and other substances [alcohol that interferes with sleep] - avoid physical exercise or mental stimulant just before bedtime - practice effective coping strategies to mange stress [ progressive relaxation, deep breathing] - create an environment that is conducive to restorative sleep [comfortable temperature, quiet environment, comfortable clothings, low-level lighting, pillows]
415

- develop a bedtime routine that will be conducive to promoting sleep [taking a warm bath, reading a book, practicing meditation] 4. teach the client about useful strategies for symptoms management to promote a sense of control over the problem 5. help the client to structure and maintain a quiet, comfortable environment that is conducive to sleep to promote sleep and rest during designated periods through out the day/night 6. help the client to identify specific stressors that affect his or her ability to obtain restorative sleep to help the client avoid or reduce stressors and avoid restorative sleep 7. promote the development of adaptive coping skills, such as relaxation technique, through client and family education to assist the client in managing the psychosocial stressors that negatively affects their ability to
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obtain restorative sleep 8. identify the clients social support system to foster use of this resource in the clients adaptation to perceive psychosocial stressors 9. promote compliance with prescribed medication plans in the treatment of a cooccurring psychiatric illness or in the short term treatment of a primary sleep disorder. The use of medication is an effective intervention in the treatment sleep pattern disturbances. 10. teach the client the importance of limiting the intake of substances that cause a substance-induced sleep disorder: alcohol, amphetamines, other stimulants, nicotine, caffeine. 11. educate the client regarding the effect that circadian rhythm disturbances have a restorative sleep patterns and explore ways to reestablish regular sleep pattern when routines are disrupted
417

12. refer the client to a sleep disorder specialist as needed 4. Personality Disorders Nursing 4th Ed K.Fortinash, P. Worret p 284 Personality Disorder: Psychiatric Mental Health

A. An enduring pattern of inner experience & behavior that deviates markedly from the expectations of individuals culture. This pattern is manifested in two or more of the following areas: 1. cognitive: ways of perceiving/interpreting self, other people/events 2. affectivity: range, intensity, lability, appropriateness of emotional control 3. interpersonal functioning 4. impulse control B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations
418

C. The enduring pattern leads to clinically insignificant distress/impairment in social, occupational or other important areas of functioning D. The pattern is stable and of long durations, and its onset can be traced back at least to adolescence or early childhood E. The enduring pattern is not better accounted for as a manifestation or consequences of another mental disorder F. The enduring pattern is not due to the direct physiologic effects of substance: drug abuse, medication or a general medical conditions: head injury Theoretic Perspective Sigmund Freud: note: sc: successful completion

uc: unsuccessful completion

419

Oral

SC: includes ability to relate to others without excessive dependency/jealousy trust begins to develop and with trust comes a sense of reliance and trust of self UC: self-centered , dependent and jealousy Anal Childs: develops enough sphincter control to be able to control excretion of feces [1-3 yrs.] SC: ability to manage ambivalence- uncertainty and makes decisions without shame Or self-doubt, shows autonomy and dependency UC: unable to make decisions, withholds friendships or cannot share with others, full of rage stubborn, may have sadomasochistic tendencies [ desires to hurt someone or to be hurt by others Phallic Child: becomes interested with genitals: Phallus [penis] is the principal
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organ concern for both boys and girls. 3 to 6 or 7 years SC: child masters his or her internal processes and impulses and gains a beginning sense of relating to other people in the environment: UC: adult unable to resolve the conflict- can experience multiple psychiatric disorder particularly those involve the superego function of guilt [ antisocial personality disorder does not have a well-developed superego Antisocial personality disorder, borderline, histrionic and narcissistic: Experienced problem identifying with their sexual identity during the critical phallic stage Example: histrionic sexually provocative, but denies that this behavior is sexually driven has experienced an internal conflict with his or her
421

sexual identity Latency Child: sexual drives[ libidal] is suppressed , attentions turns to learning and industry [6-7 yrs] - there is further development of the ego in an effort to gain control over instinctual impulses - explores environment and play: learns how to do things: he enjoys it. - to keep on enjoying life and have fun - he continually develop inner control over instinctive drives and emotions Important for adult life: able to delay gratification: which helps in areas of work, learning, and relationships. UC: have either too much or too little ability to develop their inner control:
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Those who lack inner control: have difficulty in relationship/problem solving abilities, Those who have excess inner control: isolates emotions and are more regulated, using repetition of thoughts/behaviors to relate or problem solve. Genital Importance of this stage: opportunity to rework earlier issues that the individual has not resolved: In the service of achieving a healthy identity, mature sense of sexual and adult identity With his ability to work and learn: individuals establish goals and values within the context of their own unique personal identities. A. childhood personality disorder 1. Conduct Disorder Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret p 377
423

Occurs more frequently when a biologic or adoptive parent has : 1. antisocial personality disorder 3. mood disorder 2. alcoholic dependence 4. schizophrenia or a history of ADHD Factors that put the child at risk 1. parental rejection/neglect 6.early institutional living 2. difficult infant temperament 7. frequent change of caregiver 3. inconsistent child-rearing practice with harsh punishment 8. large family size 4. physical or sexual abuse 9. lack of supervision 5. association with delinquent peer group 10. certain family psychopathology Clinical Description
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DSM IV-TR A.- repetitive and persistent pattern of behavior that violates both : a. the basic rights of others and b. major age- appropriate societal norms or rules are violated c. as manifested by the presence of 3 or more of the following in the: preceding 12 months/least preceding 6 months Aggression to people and animals: 1. often bully [terrorize, torment, persecute], threatens, or intimidates others 2. often initiates initial fights 3. has used a weapon that can cause serious physical harm to others [ bat, knife, broken bottle] 4. has been physically cruel to other people/animal 5. has stolen while confronting a victim [ mugging [ attack], purse [reward], snatching, extortion,
425

armed robbery] 6. has forced someone into sexual activity 7. the severity of this behavior: involves rape, assault or homicide [rarely] Destruction to property: 1. has deliberately set fires with the intention of causing serious damage 2. has deliberately destroyed others property [other than by setting fire] Deceitfulness of theft 1. has broken into someone else house, building , or car 2. dishonest/often lies to obtain goods or favors or to avoid obligations 3. has stolen items of nontrivial value without confronting a victim [ shoplifting, but without breaking and entering; forgery] Serious violations of rules 1. often stays out at night despite parental inhibitions, beginning before age 13
426

2. has run away from home overnight at least twice while living in parental or parental surrogates home 3. often truant [malingerer]from school, beginning before age 13 years of age 4. do not sympathize with other people and are unconcerned
Although they project an image of toughness Often experience low self-esteem with poor frustration tolerance, irritability, temper outburst and reckless behavior

Clinical significant impairment in : B. The disturbances in behavior causes Social, Academic, or Occupational Functioning 2. Oppositional Defiant Disorder - more often occurs in families where child care is disrupted by succession of different caregivers:

427

a. where harsh

c. inconsistent or neglectful child-rearing

practices b. present of serious marital problems Clinical Description

Essential feature: Negativism, defiance, disobedience, and hostility toward authority figures typically present with a. persistent stubbornness b. resistance to directions c. and unwillingness to compromise or negotiate with adults Other evidence of defiance: - deliberate and persistent test of limits - typically ignoring directions - arguing, refusing to accept responsibility for misbehavior

During early childhood - shows evidence of difficult temperament high reactivity, difficulty to sooth During school years : a. low self-esteem, b. mood lability c. low frustration tolerance
428

d. swearing use of alcohol ,tobacco, illicit drugs : they impact on adult relationship e. disrupt adult relationship Additional: Attention-Deficit/Hyperactive Disorder [ADHD] p 375 Cornerstone : Inattention , hyperactivity and impulsivity a. Inattention: a. often seems not to listen when spoken c. does not follow instructions, b. fails to give close attention d. to details, fails to finish work, loses things b. hyperactivity: a. fidget [jerk] with hands/ feet or squirms in seat c. runs about/climbs excessively b. difficult to engage in play/leisure d. often on the go or acts as if driven by a motor c. impulsivity a. often blurt/cry out answers before questions have been completed
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b. difficulty to wait for turn c. often interrupts/intrudes on others Tics Disorder Tourretes Disorder genetic neurologic disorder, 10-15% in children due to: head trauma, carbon monoxide poisoning and complications from pregnancy Clinical Descriptions: A TIC is a sudden, rapid, involuntary, repetitive movement or vocalization Stress typically exacerbates tics and distracting activities such as reading/chewing may reduce them Motor tics: a. eye blinking b. neck jerking c. shoulder shrugging d. facial grimace e. coughing Complex motor tics: a. facial gestures b. grooming behaviors c. jumping d. touching e. stamping
430

f. smelling an object g. echopraxia imitations of other movement Vocal tics: a. throat clearing b. grunting - mumble c. sniffing d. snorting e. barking Complex vocal tics: a. coprolalia repeating unacceptable words typically obscene b. palilalia repeating ones own sounds or words c. echolalia repeating the last-heard words, sounds or phrases from another person Nursing Interventions: As the nurse implements the individualized and prioritized care plan, the nurse role is to: support the child and family through the behavioral change process: 1. conduct a thorough assessment with the parents/guardians and the client to observe interactions and then assess them separately
431

2. assess client for suicidal ideation and for past aggressive behaviors including triggers to aggressive behavior to ensure the clients safety and to prevent harm to others 3. maintain a safe environment by continually assessing for contrabands [objects that are sharps, alcohol, or illicit drug] and being aware of nay behavioral changes or signals that may indicate increasing anger or aggression to prevent violence and maintain a safe environment 4. establish a therapeutic alliance and maintain appropriate boundaries to ensure consistency an d security 5. help the client to identify strength and positive qualities to foster self esteem, self-assurance and confidence
432

6. demonstrate, teach and reinforce cooperative, respectful and positive behaviors to assist the client in developing and redefining successful and positive relationships 7. set clear and consistent limits in a calm and nonjudgmental manner to promote a safe environment and to develop trust 8. redirect disruptive behavior with recreational activities to channel excess energy and prevent escalation 9. inform client of the consequences for not adhering to the limits to allow the client the opportunity to responds and to express feelings and cognitively process options
433

10. use timeouts or quiet time when the client does not responds to limits to give the clients time to deescalate in a quiet environment and process the event 11. role-play situation that triggers aggresivity or self-mutilation to reinforce alternative methods of coping 12. teach anger management techniques to lessen the feelings of powerlessness and prevent future escalation 13. for younger children: initiate therapeutic play to encourage the client to express thoughts and feelings in alternative ways in the absence of adequate language and to reestablish healthy boundaries

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14. establish a behavioral program for pre-school and school aged children that rewards the client for expressing self-safety to reinforce positive behaviors and enhance self-esteem and sense of self-accomplishment 15. engage client in a group therapy and recreational activities to assist the client in developing positive peer communication and improve social skills and motor skills 16. provide positive feedbacks and recognition when client adheres to the behavioral programs and treatment to promote self-esteem and to reinforce positive behavior 17. teach the parents/guardians about the disorder, the importance of consistency and structures and the
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significance of medications compliance to minimize quilt , increase knowledge about the disorder and realistic expectations and reinforce the consequences of medications non compliance Pharmacologic Interventions The predominant medications: stimulants, antidepressant, antianxiety agents, anticonvulsants and antipsychotic b. Odd/Eccentric Behaviors Keltner/Schwecke/Bostrom p 479 Misinterpretation leads in 1. Paranoid a. anxiety
Characteristics: Suspiciousness & Mistrust of people Interprets actions of others as personal threats b. need to scan the environment c. hypersensitive to other peoples motive d. feels vulnerable because they think other treat them unfairly e. unable to laugh at themselves and often humorless/serious f. speech is logical and goal directed - but bases of arguments are false due to suspiciousness Affect: - Blunted, appears to be cold but capable to close relationship with a select few but suspicious at times

Psychiatric nursing 3rd ed.

436

- But externalize their own feelings by projecting their own desires and traits to others - ideas of reference

Hospitalized: 1. when their behavior is out of control in response to a threat perceived as overwhelming or immediate 2. they are quick to responds with anger or rage if feels severely threatened loss of control and potential for violence 2. Schizoid
a. rarely have close friends and appears uncomfortable interacting with others b. thought of a hermit shyness and introversion c. responds with short answers to questions and do not initiate spontaneous conversation

437

Cold and neglectful early parenting seen in their histories - do not view relationship as beneficial - result to withdrawal

Do not want to be involved in interpersonal or social relationships -

Defense mechanism: intellectualization - describes emotional and interpersonal experiences as matter-of-fact and interpersonal manner Reality oriented - but fantasy and daydreaming may be more gratifying than real persons and situations

Hospitalized: 1. nurse should initially build trust 2. identification and verbalization of feelings 3. slowly involved in milieu and group activities and help increase social skills
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3. Schizotypal
Looks similar with schizophrenia but with major exception: Psychotic symptoms are infrequent and less severe - most common in the biological relatives of schizophrenic

- have problems in thinking, perceiving and communicating - unusual perception- body illusions - outward appearance: eccentric - behavior: odd - fantasy about imaginary relationship may be substituted for real relationship - blunted or inappropriate affect - peculiar thinking, suspicious - vague stereotype , over elaborate speech

Ideas of reference the belief that some events have special meaning [example: people laughing perceived as laughing at the patient]

439

Hospitalized: 1. interventions offering support, kindness, and gentle suggestions will help the patient become more involved in activities with others - essential to help improve social skills and appropriate behavior: 2. clear , simple explanations and request will reduce patients feelings of being threatened and controlled Low dose of phenothiazine to manage anxiety C. Dramatic, Emotional, and Erratic 1. Antisocial
Main feature: Disregards for the rights of others, demonstrated by: - repeated violations of laws - promiscuous [immoral] and have no quilt feelings/remorse - lying, cheating, reckless, - charming and intellectual - guilt, sorrow for offenses, loyalty is nonexistence no conscience - do not behave as responsible, mature and independent adult Experience distress & anxiety because of hostility towards them, but they see the problem as being with others and not themselves

440

Diagnosis of antisocial personality disorder is based on: History of disorder is based on history of distorted life functioning rather than on mental status Hospitalized: Long-term treatment in a therapeutic milieu is necessary for a change Short-term hospitalization:
441

1. nurse initiate therapeutic relationship: by setting limits - manipulative behavior , bend rules for their wants and needs 2. nurse must steadfast [unwavering, firm] and consistent in confronting with behaviors and enforcing rules, and policies 3. helping the patient to be aware of the consequences assist them in realizing what the results of his Behavior 4. avoids moralizing and assist the client verbalize feelings that may reflect anxiety and depression Groups of other individuals with same diagnosis can be effective in confronting inappropriate and manipulative behavior because these individuals are experts in spotting smooth talking, rationalizing and lying.
442

Keys to working with antisocial patient: consistency by the nursing staff and accountability by the patient
Has problems with self identity 2. Borderline Personality Disorder Relationship Thinking Mood Behaviors

Identity - uncertain about his image, career goals, personal values and sexual orientation Relationship - interpersonal relationship exist in choosing unhealthy relationship and in short-term relationship - alternates between overidealization and devaluation pf individuals: Example: fall in love with the perfect person and then finds no redeeming qualities in the formerly idealized
443

person - manipulation and dependency commonly occur - patient finds great difficulty in being alone seeks intense but brief relationship Mood: - depression, intense anger and labile mood - intense emotional pain contributes to mood shifts which range from euphoria to - crying to acting-out behaviors such as displays of temper and physical fights - impulsiveness is manifested repetitive self-destructiveness such as selfmutilation, suicidal behaviors, use of substance, and anorexia bulimia - impulsive activities: overspending, promiscuity, compulsive eating and unhealthy risk taking and decision making Research: 75& with BPD are women and victims of sexual abuse
444

The dissociation used by a child sex abuse victim may result to splitting Splitting inability to view both self and others as having both good and bad qualities Therefore: Self & others are viewed as either all good or all bad Splitting helps individual avoid the pain and feelings associated with past abuse or current situations involving threat of rejections and abandonment

Biological: - inadequate regulations of serotonin, dopamine - abnormalities of cholinergic and adrenergic system predispose to: - dysphoria unpleasant mood state - emotional lability and hyperactivity

Environmental factors: - traumatic home environment emotional conflict in the family - neglect of the childs feelings and needs - verbal, emotional, physical and sexual abuse

Stress related events may triggers the individuals vulnerable temperament and create misery and frustrations

445

Concept of Mhalers
Separation individualization phase: At age 2 child is able to see self and others as separate Normal child retain the image of nurturing figures when they are absent can integrate good and bad coexisting When parent cling to the child and prevent autonomy and individualization When parent withdraw attention and support, leaving the child to develop: -feelings of confusion, rage and abandonment [may continue throughout life]

Persons ambivalent needs for attachment and detachment [brings negative feedback from others]

Attachment is evident by: 1.clinging 2.dependency and 3.idealization behaviors

446

Create conflict between abandonment and dominion

Detachment is evident by: 1. anger 2. pouting [shows displeasure] 3. depression 4. devaluation

BPD in response to unmet needs for love: 1. dismisses safety and becomes self-destructive in search for attention and love

Becomes suicidal when blocked, frustrated or stressed Recurrent self-mutilation: 1. is a cry for help 3. helplessness or quilt 2. expression of intense anger 4.form of self punishment

447

Interventions 1. use of empathy is important in establishing a relationship 2. acknowledges the reality of patients pain, offers support and empowers and works with the patient to understand, control and changes dysfunctional behavior 3. patient is in crisis situation: because of suicidal ideation or behavior, self mutilation and inability to function: Nurse: provides safe environment to decrease self harm, but work with patient to find alternatives to express anger and rage: 1. ventilation and discussion of feelings, punching pillows and the use of foam bats 4. to diminish self-harm behavior - identify feelings to help express feelings and verbally express them
448

appropriately so that the patient can understand that his actions are habitual responses to handling emotions - may ask patient to write in a notebook on a daily basis - sharing the journal with the nurse, patient gains an understanding of self and a sense of autonomy and responsibility 5. manipulative: consistency, limit setting and supportive confrontation are helpful to provide clear expectations regarding patients behaviors 6. patients are adept [skillful] at sidestepping [avoid/escape]rules, avoid consequences, and at pitting staff members at each other all for the sake of getting what he wants: - enforcing unit rules , providing clear structure, and placing responsibility for appropriate behavior on the patient though vigorously resisted will benefit the patient Pharmacology - not generally used, nor it is therapeutic
449

- transient psychotic states due to overwhelming stress are treated with lowdose of nueroleptics for 3 to 12 weeks to decrease symptoms - lithium, valporic acid and carbamazepine are used for rapid mood swing - benzodidiazepines are used cautioslu for anxiety, sleep disorders and restlessness - SSRIs are useful in reduction of anger, impulsiveness and mood instability Milieu Management Firm limits, consistency and clear structure are basic to the milieu for BPD patient Consistency f communication among staff members is essential to minimize patients attempt to divide the staff Geoup discussions, stress management, anger management, assertiveness training 3. Narcissistic
Displays grandiosity about his importance and achievements Based on reality but is distorted, but: 1. Distorted unclear 3. Convoluted - complicated 2. Embellished - overstated Just to meet patients needs of self-importance

450

Narcissistic: - overvalues himself - arrogant - indifferent to the criticism of others, while hiding feelings of anger, rage or emptiness - those around this person viewed as superior or inferior - relationship with this patient: shallow but may be meaningful if selfesteem is enhanced - use others selfishly to meet their own needs but do not reciprocate - has sense of entitlement and expect special treatment - uses rationalization to blame others - makes excuses and provides alibi for self-centered behavior Etiology:
451

Self-centered person is arrested at an early developmental stage

Parents do not provide adequate empathetic experience or adequate exposure to dillusioning realities

Parents fails to mirror what is appropriate or inappropriate back to the child. Consequently the child develops without feedback about his behaviors Hospitalized: - must deal with decreasing the constant recitation of self-importance and grandiosity - limit settings and consistency approach are used to decrease manipulation and entitlement behavior - realistic short term goal focused on here and now are essential to decrease patients use of fantasy and rationalization and to increase responsibility for self Dramatizes all events and draws attention to self 4. Histrionic
452

- extroverted and thrives on being the center of attention Etiology: Mother-child relationship - mother negates he childs inner feelings - child then turn to his father for nurturance father responds to the childs dramatic emotional behavior Behavior- is silly [stupid, ridiculous], colorful, frivolous [playful], seductive - hurry and restless - temper tantrum and outburst of anger are seen - overreaction to minor events - uses somatic complaints to avoid responsibility and support dependency Speech: is vague, descriptive, superficial and overembellished but lacking in detail, insight and depth Defense mechanism: - dissociation to avoid feelings [they can not deal with their own feelings]
453

Interventions: - positive reinforcement in the form of attention, recognition, or praise is given for unselfish or other-centered behavior d. anxious, fearful 1. obsessive compulsive 2. Dependent Pervasive and excessive need to be taken care of that leads to
[invasive , persistent]

1. submissive

2. clinging behaviors

3. fears of separation

Dependent persons: - want others to make everyday decision for them - fells inferior and cling to others excessively because they are afraid they will be left alone - avoiding responsibility and expressing helplessness Cultures dictates: - females should maintain a dependent role
454

- parents or society believes that the child should not exhibit certain autonomous behaviors - child in turn may believe disapproval or loss of attachment are consequences of these behaviors Interventions: - assertiveness is an important area so that the patient can clearly state their own feelings, needs and desires - verbalization of feelings and how to cope 3. Avoidant
1.Timid [nervous, hesitant] 5. fearful& shy but desire 2. socially uncomfortable relationships & challenges 3. withdrawn and 6. afraid to ask questions 4. hypersensitive to criticism 7. lack self confidence when interacting To keep anxiety at minimum level they: - avoid situations where they might be disappointed or rejected

455

Interventions: Essential part of the relationship, the nurse should: - discuss patients feelings and fears before and after the patient does something he is afraid to do so - helps patient gradually confronts what he fears [most important part] - includes patient in interactions with others and then progress to small group as the patient is able to tolerate - relaxation technique to resolve anxiety to be successful in his interactions - gives positive feedback for any real success or attempt to engage in interaction to promote self esteem
1. overly strict 4. Obsessive-Compulsive Personality Disorder 2. set standards for themselves that are too high their works is never good enough 3. preoccupied with rules, trivial [small]details, and Procedures 4. serious about his activities no time for pleasure 5. afraid to make mistakes can be indecisive [unable to makeup his mind], he will put off decisions until all facts

456

Perfectionist and inflexible

1.Finds difficult to express warm/tender emotions 2. little give and take in relationship 3. rigid, controlling and cold

Early parent-child relationships around the issues of autonomy, control and authority may predispose a person to this disorder This malady [problem] may be inherited Interventions:
457

- must support patient in exploring feelings and in attempting new experiences and situations - helps understand/aware how he affects others - confront with patient procrastination and intellectualization

Nursing Interventions: Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret p 295 Focus towards modifying lifelong disruptive and dysfunctional behaviors and thoughts while promoting safety
458

1. assess the client for suicidal ideation and determines the level of lethality to prevent suicide, harm or injury 2. if warranted, place the client on suicidal precaution, depending on his or her level of lethality: Ex. Patient who verbalized plans to hang himself while on the unit needs close individual observation, even with no means or provisions to carry out the intent 3. Establish contract of safety with the client by asking the client to write statement indicating that he will harm himself. If suicidal impulses become so strong, encourage the client to seek out staff members to discuss the increase in intensity of suicidal ideation to protect the client from acting on suicidal impulses
459

4. encourage the client to attend all unit group sessions to receive support from the peers and to provide opportunities for problem solving 5. assess the client for an escalation of anger to rage and possible impulsive actions against others [obtain history of violence if possible]to prevent harm or injury to others 6. contact with the client that he will o longer threatened staff or peers during hospitalization to ensure safety of others 7. teach the client other options to manage angry, impulsive feelings and behaviors such as leaving the room where the conflicts is occurring or using a quiet area [ ex. Unlocked secluded room]until the impulses to
460

do harm passes. Removing client from a stimulating provocative environment will decrease angry impulses 8. discuss angry feelings in a group settings focused on exploring alternative problem-solving options. alternative actions will distract the client from angry feelings and help to focus energy on constructive activities 9. assess the client for evidence of self-mutilation- self destructive clients are likely to repeat such acts 10. obtain contract from the client that he will approach a staff member when the urge to self-mutilate is present to ensure the safety of the patient
461

11. place the client on an individual, close watch until the urge to do harm self passes or until client is able to identify another way to obtain emotional relief [ wrapping in a sheet or participating in a movement therapy] to protect client from harmful impulses and redirect the impulses toward alternative, constructive method 12. if self-mutilation occur, attends to wounds in a matter of facts manner to provide the client safe care in an nonjudgmental manner 13. encourage client to keep journal of thoughts and feelings the client had before experiencing the urge to self mutilate , to help the client acknowledge feelings and thoughts and help decrease impulsivity
462

14. medicate the client with an anxiolytic or antipsychotic medications, prn as ordered to help client control his intense anxiety or rage rather than self-mutilate 15. use of time-out period, seclusion, and physical restraints if all attempts of least restrictive measures have been unsuccessful to protect the client 16. assist the client in recognizing thought patterns that contribute to impulsive behaviors: abandonment, anger, rage or anxiety plays in precipitating impulsive behaviors 17. suggest alternatives behaviors to deal with intense feelings: such as:
463

- recognizing the intense emotional state and writing in a journal or thinking about an action that helps to relieve the intensity of the feelings without resorting to impulsive or self-destructive behavior - talking about the intense feelings while looking at the mirror, telling the mirror what the client would like to express to the object of anger - identify healthy options to deal with the anger, such as discussing the issue with the persons who is involve in the interactions - role-playing, to approach the problem that precipitated the intense feelings 18. help the client explore behaviors that relates to the community, such as driving and responsibilities for the environment
464

19. evaluate the clients family system by observing the family dynamics and determines the clients role within the family how the client interacts within the family system and the role the client takes [ such as: victim, placater - calm down ]

Mood Disorders & Adjustment Disorders Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret. [ P 208 ]

465

When sorrow comes, they come not in single spies, but in battalion W. Shakespears Success or exciting life events generates mood elevation, elation and euphoria A person who has suffered a loss will fill: - grief and sadness and will sometimes even experience physical symptoms and problems with thinking * Additional symptoms clusters that may occur: changes in sleep, appetite, thinking, activity, self worth and suicidal thinking - - - thus, these illness affects the total person, not just the mood Etiology: there is no single explanation for its cause! Hypothesis - - - mood disorders have neurobiologic, etholic, psychosocial, and cognitive that
466

contributes to the development of depression and mania I. Neurobiologic Factors - biologic theories related to altered neurotransmission and neuroendocrine dysregulation A. Neurotransmitter: - controls a wide range of behavior and function, including appetite, arousal, sleep, cognition and movement Monoamine neurotransmitter system : norepinephrine and serotonin - less in depression and more than normal level in mania B. Nueroendocrine Dysregulation - dysregulation of the limbic hypothalamus-pituitary-adrenal[HPA] Regulates endocrine Involves in behaviors as in: functions and autonomic Fight, flight, feeding, axis Hypothalamus: nervous system sleeping and sex And
467

Manufactures serotonin a major neurotransmitter for mood disorders

In response to stress:
Hypothalamus Releases: Corticotropic Releasing Hormone [CHR] HPA axis is often hyperactive in depression - cortisol is elevated in depression

Stimulates the anterior pituitary to secrete Adrenal Corticotropic Hormone [ACTH]

ACTH release Cortisol into the blood stream: * serum cortisol is elevated in stress

468

HPA function: - related to the 24 hours cycle of circadian rhythm that controls physiologic process - clients with mood disorders have disrupted or irregular cyclic patterns - cortisol is low in the morning and highest in the late afternoon - patient with mood disorders have disrupted sleep-wake cycles - person with mania have a decreased need for sleep - whereas, with depression experience hypersomial, Genetic Transmission Degree Related to illness Probability First degree Bipolar disorder and Have greater risk for developing mood relatives unipolar disorder Higher with bipolar than in unipolar Monozygotic Bipolar disorder High rate the other twin will havetwin usually bipolar Adoption Genetic and environment. With high
469

rate from genetic Ethologic Factors evolutionary concepts as explanation of mood disorders! Human behavior serves the survival of the species and helps individuals adapt to their environment Psychoanalytic Theory * Basic Premise unconscious process results in expression of symptoms to include depression & Creating quilt & loss of Mania self-esteem
S. Freud: Loss generates intense, hostile feelings towards the loss object Thus: depression is linked with loss and aggression Turns these feelings onto self [anger inward]

Psychodynamically: mania is a defense against depression

Reverse the effect: Triumph feelings of self confidence Client denies feelings of anger, low self-esteem and worthlessness Mania: represents a conquered superego with little inclination to control id This distorted view of reality is refraining from insisting on using it: - demonstrates outside hostility towards others

470

Clients with depression have experienced: - early childhood loss & deprivation Cognitive Theory: - depression points to errors of logical thinking as a causative factors for depression Assumptions: Underlying Cognitive structures or schema
are shaped by early life experiences - Predisposed to negative processing of information Diatheses Stress model: When a person predisposed to depression with negative schemata encounter stress: the negative processing is activated resulting in depressive thinking

471

It is the perception of the Beck differentiated 3 Levels of cognition influence depression: situation, rather that the objects of the facts that in emotional Automatic thoughts /Schemata results or assumptions/Cognitive distortions: behavioral response: Ex: develops shyness as I. Automatic Thoughts dislikes because she was Thoughts a person is aware, although appears briefly person does not recognize them Ex: new college graduate has a clerical, during lunch, she was not invited These forms the persons perception of the situation Ex: views as rejection and decided not to joint working at a job that was beneath her

II. Schemata or assumptions are internal representations of the self and the world
Mind uses this representation to understand, code, and recall information Facilitates information processing

472

Triad of thinking [schemata] that gives rise to the development of depression 1. negative, self-depreciating views of self 2. pessimistic views of the world, so that life experiences are interpreted in a negative ways 3. the belief that negativity will continue into the future, promoting a negative view of future events III. Cognitive distortions: links schemata and automatic thoughts: Cognitive distortions: leads to - - Faulty information processing can lead to feelings of helplessness , apathy, powerlessness, and depression
Cognitive distortions: - overgeneralization [drawing general conclusion based on isolated incidents] Ex: not selected as a finalist concluded that the judges hated everything about her
- dichotomous thinking [perceiving events & experiencing in only one of two opposite categories ] Ex: convinced other contestant were either beautiful and smart or unattractive or dull - magnification [ placing a distorted emphasis on a single event] Ex: convinced that the judges were trying to tell her not to compete

Hopelessness/Learned Helplessness Theory

473

Lack of motivation to act in response to the environment

Leads to uncontrollable stressful events that an individual experience

Facing current events and past experiences: - Persons have the expectation [cognition] that external events are uncontrollable

Results in helplessness, passivity and sadness

Other symptoms of depression: - low appetite and decrease self esteem

Hopelessness sufficient cause of depression

474

Key elements of depressions: Individuals inferred negative outcomes and negative about self:- helplessness is only a part of hopelessness

The occurrence of an unpleasant event; person at risk for depression and having negative expectations attributes: 1. instability perceives she will not recover from divorce 2. globalization feels her entire life is ruined 3. excessive importance to those events her former marriage is the only focus of her life Cognitive vulnerability: persons negative style & negative life events = leads to helplessness * may lead to hopelessness depression: Symptoms: apathy, lack of energy, slow initiation of voluntary behavior and psychomotor retardation
475

* Lack of social support during times of negative life events leads to increase hopelessness and helplessness Important factor: Life Events and Stress Theory Quantity and nature of life
All life events, event pleasant ones, are capable of causing various degree of stress Person perception or appraisal of events is as important as the change in daily life caused by events events and in the size and perceived support from the clients social network

Factors that contribute significantly to vulnerability for depression: 1. lack of intimate, confiding relationship with significant others 2. having three or more children at home 3. being unemployed 4. loss of ones mother before age of 11 years
476

Occurrence of stressful life events and depression with regard to gender differences: * women more on interpersonal stressor * men reported more legal and work related stressful life events Life stressors can lead to adjustment disorder differs from depression: - main distinction: specific psychosocial stressor can be identified in adjustment disorder Acute case: occurs within 3 months and chronic case last longer than 6 months: Symptoms usually decrease once the stressor is removed Symptoms disappear outside of the setting linked with the stressor, especially when the stressor is located specific : work setting Clinical Description 2. Bipolar Disorder - are the patterns of manic, hypomanic, and depressed episodes over time
477

- depressed and manic episode are not due to effects of a substance, antidepressant medications or ECT A. Manic Episode - abnormally persistently elevated, expansive, irritable mood for at least a1 week duration 3 of the following symptoms are present: a. inflated self-esteem e. racing thoughts b. decreased need for sleep f. distractibility c. more than usual talkativeness g. increase in goal-directed activity [mapping] d. excessive involvement in pleasurable activities Manic Episode:
1. exhibit abnormally and persistently elevated , expansive or irritable mood [for 1 week] 2. appears euphoric, with periods punctuated by irritability and anger 3. emotional lability- mood and affect fluctuates between euphoria and anger - common

478

Cognitive 1. Inflated self esteem and grandiosity are common symptoms As mania becomes more intense: Reports: describes himself as glowing terms and may believe they are capable of amazing feats and achievements During severe episode: Reports : delusion of grandeur believes that they possess extraordinary gifts and talents, are famous, or personally know someone famous 2. Experience a thought-flow disturbance with racing thought and flight of ideas Flight of ideas connected thought occur quickly resulting in little elaboration and rapid changing of subject 3. Deny the seriousness of their status and lack judgment regarding personal, social and occupational needs and activities

479

Behavioral symptoms As mania increases 1. more talkative and speech is pressure [delivered with urgency] Rate of speech often increases and becomes more rapid 2. there is decrease need for sleep and does not feel tired [e.g. s. marquez] 3. exhibit extremes in appearance, wearing bright colors, unusual dress and heavy make ups 4. begins and engage in more activities [ e.g. m.tinonga- sweeps surroundings] 5. taking additional tasks and initiating new projects Appears to be Productive, but as Mania Increases: Actual productive activities decreases as patient becomes more distractable, disorganized and agitated 1. begun to physically move faster pacing, fidgeting [ twitch. squirm], rarely letting their body stay still As insights and judgment becomes more impaired: 1. involved in activities that they perceive as pleasurable but carry a high risk for harm or negative consequences - involves in extramarital affairs, promiscuity, spending sprees [extravagant], gambling, wild driving and unwise business deal These behaviors often have serious health, financial, legal and interpersonal consequences

480

Social symptoms At first mania appears to promote sociability: - clients becomes more outgoing and active When Insight and judgmental fails: - becomes intrusive interrupting others conversations, changing from euphoria to anger and disrupting social interactions Difficult to set physical and emotional boundaries Interrupting personal space and personal issues of others The funny witty [amusing] client becomes angry and isolated as the mood escalates and intensifies

Perceptual symptoms: Distractibility attention is easily and frequently drawn to irrelevant external stimuli - client unable to screen out secondary stimuli [noises, other voices, visual attractions] that are not necessary or relevant to the task at hand Distractibility interferes with attention, concentration, and memory Perceptual disturbances also occur in the form of: a. hallucination usually auditory with themes that pattern with grandiosity, power, and occasionally paranoia

481

B. Hypomanic Episode Manic and hypomanic shares common criteria They differ primarily in severity and duration
Hypomanic episode: Are not enough to cause significant impairment in social and occupational functioning or to require hospitalization To be diagnose: represents definite a change in the persons usual functioning for a at least 4 days 1. appears extremely happy and agreeable, at ease with social conversations and humorous 2. moments of elevated mood seem desirable - they represent dysfunctional affective states during which the client is not fully control of moods and accompanying behaviors - they perceive that they are productive, creative, and function at a high level [ as judgment decline they fail to recognize consequences of their actions]

482

Type Bipolar I Disorder and Bipolar II Disorder Type Bipolar I Single manic episode Most recent episode Hypomanic Most recent episode Characteristics [p 221] Only one manic episode / no past major depressive episodes Current hypomania At least one previous depressive, manic, or mixed episode Current mania At least one previous depressive, manic, or mixed episode
483

Manic Most recent episode Mixed Most recent episode Depressed Bipolar II

Meets criteria for both manic and depressive current episode At least one past major depressive or mixed episode Current depressive mood At least one past manic or mixed episode No previous full manic episode At least one past major depressive episode and past or current hypomanic episode

Differences in the bipolar disorder on the mood continuum ____________________ manic episode ----------------hypomanic episode Ciclothymic disorder normal mood - - - - - - - - - - - - - - - - - - dysthymia
484

______________________ major depression ____________________ manic episode Hypomanic episode ----------------hypomanic episode normal mood - - - - - - - - - - - - - - - - - - dysthymia ______________________ major depression ____________________ manic episode ----------------hypomanic episode Manic episode normal mood - - - - - - - - - - - - - - - - - - dysthymia ______________________ major depression ____________________ ----------------manic episode hypomanic episode
485

normal mood Bipolar I Mixed - - - - - - - - - - - - - - - - - - dysthymia ______________________ major depression ____________________ manic episode ----------------hypomanic episode Bipolar II normal mood - - - - - - - - - - - - - - - - - - dysthymia ______________________ major depression 4. Cyclothymic Disorder Chronic mood disorder of at least 2 years duration [1 year for children and adolescent] With many period of hypomanic symptoms, depressed mood and anhedonia Have not been without the symptoms for more than 2 months over a period of 2 or more years
486

 these symptoms are less severe or intense than those in major depressive or manic episodes 5. Major Depressive Disorder [unipolar depression] experiences only episode of depression, no manic or hypomanic
Emotional: 2 primary symptoms: depress mood and anhedonia [loss of interest and pleasure in activities] One of these symptoms must present q/day for at least 2 weeks: 1. client describes his mood as depressed, sad, empty, or numb 2. reports of difficulty experiencing pleasure or satisfaction from their usual activities [ sex, eating, friendship] 3. anxiety, irritability, or anger 4. feelings of loneliness, helplessness or hopelessness Affects : flat and constricted, with minimal expression, appears rather normal as the persons attempts to disguise his inner struggles

487

Cognitive 1. diminished ability to think, concentrate on given task or conversation 2. unable to make decision about routines concerns what cloth to wear, or what to buy 2. recurrent thought of death thoughts of suicide, death from a natural causes, existential thought on dying [occupy at large portions of his waking hours] 3. excessive focus on self-worthlessness and quilt 4. have problems with their job: inability to organize, begin and complete their work 5. negative thinking- feelings of worthlessness and excessive quilt Delusional with fixed beliefs that cannot be changed by logic Delusions focus on persecution, punishment Nihilism - belief of nonexistence or nothingness] Somatic concerns

488

Behavioral 1. significant weight loss or gain in exchange in appetite - when it represents a 5% change in body weight in 1 month time - change in appetite 2. insomnia or hypersomnia - are common symptoms 3. psychomotor agitation or retardation and fatigue a. psychomotor agitation - appears restless, paces, fidgets [twitch] or irritable b. psychomotor retardation - appears slowed down in movement or speech - entire body is slowed: prone to constipation & slowed in food digestion 4. appears disheveled [messy, untidy] - not careful in attending their dress, appearance, hygiene 5. exhibit stooped posture and makes little eye contact 6. remarks of feelings fatigue and loss of energy- citing an inability to accomplish tasks and increase need for naps 7. often appears very tired Note: fatigue cause them to visit physician they believe it is an indicative of a physical problem thus depression is often initially diagnosed during a visit to a primary care giver.

489

Social Symptoms must cause personal distress and significant impairment in social and occupational functioning 1. withdraws from family and social interaction 2. marital distress is often a cited stressor episode of erratic [unpredictable] behavior, mood and cognition alienate a loved one

6. Dysthymic Disorder
Chronic, low level depression: Must have 3 of the following for most of the day, nearly every day for 2 years [1 year for children and adolescents] 1. poor appetite or overeating 5. poor concentration or difficulty in making decision 2. insomnia or hypersomnia 6. feelings of hopelesness 3. low energy 4. low self-esteem

490

Emotional Predominant symptoms: 1. depressed mood - reports feelings of chronically down & gloomy 2. generalized loss of interest of interest/pleasures in activities [in depression anhedonia is not a primary emotional symptoms] 3. irritability or angry mood find themselves impatient with family members

Cognitive 1. low self-esteem and inadequacy 2. quilt and brooding [dark, threatening] about the past 3. difficulty with concentration , decision making 4. negative thinking pessimism, despair , helplessness

5. lack of self-confidence

491

Behavioral 1. commonly complain of chronic fatigue feels exhausted from usual activities [ believes they have physical illness or chronic fatigue syndrome keeps on visiting health centers] 2. display decreased activity and productivity 3. everything becomes a chore [responsibility/task] often finds difficult to accomplish

Social 1. social withdrawal most common 2. tired, irritable, and depressed 3. no longer get satisfaction from outings/activities with family or friends 4. clients mood state and negativity prevent people from wanting to be with them

492

Nursing Interventions: 1. conduct suicide assessment as necessary to ensure the clients safety and prevent harm to self and others 2. maintain a safe, harm-free environment through close and frequent observations to minimize the risk of selfharm or violence 3. establish rapport and demonstrate respect for the client to facilitate the clients willingness to communicate thoughts and feelings

493

4. assist the client in verbalizing feelings to promote a healthy, expressive form of communication 5. identify the clients social support system and encourage the client to use it to minimize isolation and loneliness and provide assistance with monitoring the illness and treatment 6. praise the client for an attempts at alternate activities and interactions with others to encourage socialization 7. gently refuse to part of secrecy agreements with the client, instead encourage the client to share important and relevant information with staff to promote the clients participation in care and responsibility for own actins

494

8. monitor and implement strategies to ensure adequate fluid intake and output, food intake, and weight to ensure adequate nutrition and hydration and adequate weight for body size and metabolic needs 9. promote self-care activities, such as bathing, dressing, feeding and grooming, to establish the clients level of functioning and increase self-esteem 10. assist the client in establishing daily goals and expectations to promote structure and direction and minimize cognitive difficulties 11. plan self-care activities around those times when the clients has more energy to increase activity tolerance and minimize fatigue
495

12 reduce choices of clothing, activities, and tasks and increase choices as the client improves cognitively to make decision making easier and minimize stress 13. asses the clients cognitive/perceptual process to ascertain the existence of hallucination/delusions that are troubling or harmful for the client 14. assist the client in identifying negative, self-defeating thoughts and modifying them with realistic thoughts to promote more accurate, positive thoughts about self, others 15. encourage the client to attend therapeutic groups that provide feedbacks regarding thinking to reframe thinking with the support of others
496

16. provide simple, clear directive communications in a low-stimulus environment to assist with focus, attention, and concentration with minimal distractions 17. teach the client and SO about the disorder and the treatment when the client is able to learn to increase knowledge , promote adherence to treatment, and minimize quilt about the disorder 18. gradually increase level of activity and exercise to minimize fatigue and increase level of tolerance 19. identify resources of external stress and assist the client in coping with them in a more effective manner to minimize stressors and promote adaptive coping mechanism
497

20. establish limits with the clients with mania in a firm, consistent and caring way to provide acceptable boundaries for behavior 21. teach the client and family on how to self-mange their illness at home, including identifying prodromal symptoms, seeking help, and implement appropriate strategies to prevent or minimize recurrent episodes 7. Clients at Risk for Suicidal and Self-Destructive Disorder Type Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret. [ P 462 ] A. Sociologic Theory Erik Durheim First classified the social and cultural aspects of suicide into 4 subtypes
498

Anomic: Act of self destruction by individuals who have become alienated from important relationships in their groups, especially as this relates to their standard of living [ example: suicide after a stock market crash]

Egoistic: Self-inflicted deaths of individuals who turn against their own conscience [devout catholic forbidden after abortion]

Altruistic: Self-inflicted deaths based on obedience to a groups goal instead of the persons own best interest [terrorist incidents on 9-11]

Fatalistics: Self-inflicted deaths resulting from excessive regulations [suicide of a convicted prisoner to escape a prolonged period of incarceration]

499

B. Psychoanalytic theory
S. Freud: Describe suicide: Self destruction as an anger turn directed inward toward the internalized love object They ignored other critical feelings states such as: - shame, hopelessness, helplessness, worthlessness and fear

C. Interpersonal Theory
Individuals never isolates from the interactions of significant people in their lives * Sullivan viewed suicide as evidence of failure to resolve interpersonal conflict - Sullivan believes we need to view the suicidal act within the context of the perceptions of the suicidal persons by his significant others

500

Irregularities in serotonin system

D. Biologic Factor

Epidemiology A. Age tow most vulnerable age-groups: older adult and youths between 15 to 24 years old Older Adults: - highest among older population age 65 years and greater/ 85 and above most vulnerable Failure to: a. adapt to significant losses c.
501

b. inability to tolerate emotional pain and negative attitude towards aging process related to: - loneliness illness rejection by family and society - sudden termination from meaningful works - disruptions from long-standing relationships feelings of emptiness Youth: Causative factors - psychiatric disorders, drugs or alcohol, depression, conduct disorder - experiencing difficulty interacting with peers - pregnancy, breakup in a significant relationships - issues of sexual orientation and feelings of isolation - firearms most common method B. Sex: men by far have greater incidence of completed suicide. Women has higher rate in suicide attempts and gestures
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C. Socioeconomic Status crosses all socioeconomic levels - both economic well-being and poverty create a circumstances leading to the choice of suicide as solution to stressful events D. Familial Influences - suicidal behavior is a frequently a symptom of prolonged and progressive family disruptions and dysfunction Significant changes in the family: divorce, death of a loved ones, and social isolation Familial disposition often have histories of suicidal behavior among their immediate/extended families D. Co-Occurrence With Related Health Issues Psychiatric disorders: Mood disorder: depression
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- possibility of suicide increases with recurrent episodes of depression and experiences: a. feels hopeless d. social isolation b worthlessness e. inability to problem-solve, c. anger f. cognitive rigidity The suicidal risk increases if incorporated with alcohol or substance abuse

Schizophrenia: - have high levels of subjective stress and feelings of hopelessness - loneliness and dissatisfaction with social relationships due to chronic aspect of illness Panic Disorder - panic disorder with phobias and obsessive-compulsive is a risk factors Borderlines Personality Disorder
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- there is recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior - experience: loss or perceived loss Impulsivity traits: important risk factors Alcohol and Drugs Drugs contribute to: - poor, impulsive decisions that leads to high risk, self injurious behavior - co morbid [gloomy]with depression loss of relationship, job or functioning because or medical illness - social isolation, increased drinking, recent employment, Risks Factors: Age Sex Race/ethnicity Physical and emotional symptoms
505

- high risk indicator are serious depression, significant changes in weight, serious sleep disturbances extreme fatigue and loss of energy Suicide Plans - presence and nature of the suicide plan are the most critical factors in assessing suicidal risk History of previous attempts Social supports and resources - availability of support system determines outcome of an emotional crisis - this life line of caring, support, confrontation, and limit setting Recent loses - major emotional determinants of suicidal behavior is a real or perceived losses, separations, or abandonment Medical problem: - suffers painful, debilitating, acute or chronic conditions or who have terminal illness Alcohol and other drug
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- drugs slows down inhibitions, and heightens depression and quicken impulsivity Cognition and problem-solving ability - inability to adequate identify problems and corresponding solutions Lethality Assessment Factor Lethality potential for causing death related to the level of danger associated with the suicide plan - level of hopelessness determine its level Imminence the likelihood that an event will occur within a specific time period [within 24 hours] Intent the method used chosen and its accessibility Imminence versus Nonimminence - determination of imminence is critical - determination of imminence is subjective: at best is clinical judgment based on experiences
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- specifics of suicide plan often offer clues as to when the individual will ready to act. Imminent risk for the client: - specific plan as to access to lethal measures hopelessness - behavior that signals a decision to die Plus: no vision for the future - admission of wanting to die guilty thoughts If a person has high lethality [imminently dangerous to self] and refuses treatment: Legal consideration for safety called an involuntary hold-and treat status - patient receives care in 72 hours: to give time for clinician to evaluate risk and its treatment - clients rights are protected to prevent abuse If judged not to be imminently in danger in hurting or killing himself
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- choose lest restrictive treatment options such as: partial hospitalization program or outpatient For outpatient program: usually involves outpatient structured program and medication administration PLUS: An advance directive is generally written that gives the individuals choices in care: - where the individual wants to be hospitalized - any specified practitioner to provide the care during the crisis period - any reactions to medications that the patient experienced in the past 3 points to provide a level of safety for the individual at risks 1. request outlined 2. advance directives 3. legal statutes mandating care Ideation vs. Intent Suicidal Ideation direct or indirect thoughts or fantasies of suicide or self-injurious acts
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 expressed verbally or through writing or art work without definite intent or actions expressed expresses symbolically thinks about suicide without clear intent places a person at lower risk Intent 2 categories of suicidal intention: consciously & unconsciously 1. conscious suicidal intention - awareness of the outcomes or anticipated results of the suicidal behavior - awareness of the rescue possibilities: - part of the plan includes various avenues of rescue, designed to difficult to rescue or remote: - aware of the lethality index of the chosen method 2. unconscious suicidal intention: more difficult requires higher level o skills - there is cluster of symptoms characteristic of the dynamics of selfdestruction: 1.depression 4. anxiety 7. hopelessness 10. failure 2. quilt 5. hostility 8.dependency
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3. fantasies symbolic of death 6. hurting others 9. killing oneself Motivation to hurt or kill oneself is outside of awareness client expresses it by extreme risk-taking Behaviors: - bridge builders, -high-wire artist without net: as metaphor [symbol] for suicidal risk * important to listen to the communication of intent among suicidal persons. Chosen Method and Accessibility The 3rd determining factor of lethality most critical - method and its availability determine the outcomes of behavior Persons who complete suicide tend to engage in only one high-lethality act through violent methods: 1. using firearms 3. hanging 5. use of carbon monoxide 2. piercing vital organs 4. jumping from high places poisoning
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Non-fatal attempters tend to engage in multiple low-lethality: allows time for rescue RT slowness of physiologic actions. 1. self-poisoning [most common] 2. wrist cutting Hanging most common in hospitals Sharp objects are usually NOT available But: 1. sheets, towels, belts, cords, plastic garbage and articles of clothing are to create nooses 2. cheek psychotropic medications for overdose suicidal attempt 3. sneaking of sharp objects proper screening Men who has complete suicide select more violent means: guns /knives/hanging Women jump from high places or overdose Warning Signs of Suicide: IS PATH WARM? Ideation Purposelessness Withdrawal
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Substance abuse Anxiety Anger Trapped Recklessness Hopelessness Mood change Erroneous Belief Facts About Suicide 1.Most people communicate directly about their People who talk about suicidal intent verbally suicide do not commit in writing, art work and suicide 2. behaviorally through previous attempt high risk indicators 3. manipulation is not usually a factor Treat all intent seriously 1. mostly gives warning signs of their intent by: People who are serious - giving away possession, wrapping up business, about isolating committing suicide do not from friends
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give clues

Young children do not commit suicide An improved mood means the suicide crisis is over

- demonstrating an increased incidents of accidents - preoccupied about death in writing, music and art - makes self- depreciating comments related to worthlessness and hopelessness Consider all threats from young children seriously. Completed suicide shows improved mood and energy meaning the persons ambivalence has ended and that he has made the decision to commit the act

Only people with the diagnosis of depression

Although depression is the single best indicator; at risk: schizophrenia, substance related, panic disorder, posttraumatic stress disorder, obsessive-compulsive
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kills themselves Individuals who selfmutilate are really suicidal

disorder Self-mutilation occurs when individuals has difficulty adjusting his affects or is feeling numb after an emotional trauma feels overwhelmed with Unmodulate [adjust] feelings Suicide are thinking about death

Nursing Interventions to implement consistently with all suicidal clients: p.476 I. To Provide Safety and Prevent Violence: 1. All unit precautions for preventing suicide should be enforced and maintain a safe environment by doing the following: a. routine counting silverware and all sharp objects before and after clients use b. having awareness of the clients whereabouts at all times
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c. providing a one-to-one supervision of the client as necessary, based on assessment of the clients current lethality level d. planning: all units always has experienced staff, especially at staff mealtimes, breaks, vacations, staff meetings e. provides a roommates for the suicidal client f. requesting that visitor clear all gifts with the staff g. searching the suicidal individual for drugs, sharp objects, cords, shoelaces, and other potential weapons after a return from a pass h. thoroughly assessing a client before any passes to leave the unit are granted to determine current risk level i. encouraging the client to write a no-suicide contract as a means of communication between the staff
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and the client to promote self-exploration and to encourage new methods of asking for assistance when feeling hopeless - this will indicate nurse caring, concerns and consistent follow-up through - offering the client an opportunity to take charge of himself when feeling hopeless and powerless Note: No-suicide contracts do not preclude [prevent] the need for constant observation/supervision 2. Mindful: suicides occur within 90 days after hospitalization - nurse notify - families, guardians, social services or legal authorities the necessity to remove possible weapons from the clients home environment 3. working with suicidal clients is emotionally draining and anxiety ,nurses must help create supportive
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environment: clinical supervisions and informal discussions regarding feelings about suicide II. To assist in the development of improved coping skills 1. Use specific technique that include nonjudgmental , empathic listening, encouragement, tolerance of expression of pain, and flexible responses to client needs 2. Encourage to focus on strength rather than weakness so that the client becomes aware of positive qualities and capabilities that have helped with coping in the past 3. Helps reduces the overwhelming effects of problems by helping clients prioritize their concerns. Breaking the issues down into ore manageable parts achieves this goal Nurses can assist in this process by doing the following:
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a. encourage client to prioritize problems from the most to least significant b. supporting client in finding immediate solutions for the urgent problems c. postponing findings solutions to those problems that do not require an immediate solutions d. encouraging to delegate problem-solving to others when appropriate e. helping client to acknowledge problems that are beyond his control f. identifying, defining, and promoting healthy adaptive behaviors in clients g. encouraging continuance of healthy behaviors when improved coping strategies are demonstrated [positive enforcement] h. encourage individuals to discuss the feelings generated by ineffective coping [ frustrations, anger, inadequacy e.g george reales] i. affirming the clients rational decisions that have based on accurate judjment j. reinforcing clients attempt to make independent decision
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k. responding to delusional statements by stating the reality of the situation without arguing with the clients reality III. To enhance family and social support system a. enlist the family as partners in the clients treatment family attendance at psycho education groups and family therapy is crucial b. determines degree of family support that contribute to overall risk management inform family members about the critical signs that the client will exhibit encourage removal of lethal weapon 8. Schizophrenia and other Psychoses A. Schizophrenia Psychiatric Mental Health Nursing 4th Ed K.Fortinash, P. Worret. [ P 249 ] From historical perspective: it is described as a complex, multifaceted [many faces] disorder that goes beyond
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hallucination, delusions, or decreased motivation and drives that are most commonly associated with it.
1856 Morel coins the term dementia praecox 1868 Kahlbaum sues catatonic to describe immobilized by psychological factor 1870 Hecker uses hebephrenic to describe silly behavior, regressed bizarre behavior 1896 - Emil Kraepelin uses paranoia to describe highly suspicious and group all three catatonic, hebephrenic, paranoia and called it dementia praecox: - identified the cognitive impairment [memory impairment] labeled it the disorder as dementia praecox - referring to the psychosis that ended in severe intellectual deterioration [dementia] and that had a premature [praecox]onset Dementia praecox has 2 hallmark symptoms: 1. hallucinations sensory perceptual disorder involving all of the 5 senses 2. delusions a false fixed belief held by the individual that does not change with reason or logic Preceded by: Dereism is a loss of connection with reality and logic thoughts becomes private and idiosyncratic [ peculiar] experiences thought blocking abrupt blocking of flow of thought/ideas

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1857 -Eugene Bleuler - coined the word schizophrenia meaning split mindedness schizo [split] and phren [ mind]: the personality splits into different parts The split is inconsistent between emotions, thought and behavior - first to redefine schizophrenia as a thought disorder Identified the 4As of schizophrenia: Affect: observable outward bodily expressions of emotions such as joy, sorrow and anger a. blunted : restricted expressions of emotions c. flat : lack of expressions of emotions c. labile : rapid change in emotional expression d. inappropriate: does not match emotions felt Autistic thinking: disturbances in thought resulting from the intrusion of a private fantasy world Ambivalent: simultaneous holding 2 different attitudes, emotions, thoughts, feelings about a person object or situation Looseness of association: thought disturbances in which there is a rapid changes from one subject to another in a unrelated, fragmented manner

522

Schizophrenia and Genetic Risks Relationship to Genetic risks for Person with developing Schizophrenia schizophrenia 46 Identical twin Child [both parents have schizophrenia] 50%

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Child [one parent Etiology has schizophrenia] 1. Brothers, sister or parents Nephew, niece or grandchild First cousin

12% 12% 5% 2% Heredity/Genetic Factors

2. Dopamine hypothesis - persons with schizophrenia have increased level of dopamine 3. Environmental Factors - toxins, pollutions infections and viral exposures, malnutrition; being born in winter, being born in a city and childhood brain injury
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Viral exposures particularly influenza a risk factor for developing schizophrenia Cause high level of arousal, leading to a specific 4. Stress and Stress Models episodes recurrence of the illness:
Life events and subsequent stress: - increases dopaminergic transmission - results in intense hallucinatory experiences

Callista Roys Nursing Adaptation Model

continually adapts to internal & external stimuli [some of which are stress producing] - Persons - persons uses both physiologic [biologic] and psychosocial modes of adaptation 5. Disease and Trauma Developmentally related to disease and trauma occurring during the prenatal period or in early childhood Complications that possibly increase risk for schizophrenia: 1. viral infection during pregnancy 3. rhesus incompatibility 2. maternal preeclampsia 4. anemia and diabetes mellitus 6. Substance Abuse

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1. nicotine 75% 3.15 to 25% - cannabis 2. alcohol 30 to 50% 4. 5 to 10% - cocaine and amphetamines Research: Substance disorders in schizophrenia are especially common among men with history of childhood conduct disorder problems. Stressful life events such as like interpersonal loses 7. Psychologic Theories Socio-cultural stresses poverty or homelessness
Stressful emotional situation where one lives

Research: person with Schizophrenia have better outcomes when they come from families where there is: 1. little criticism and anger 2. where emotional bonds are relatively distant [not enmeshed not entangled] 3. where family members interact less 8. Cultural and Environmental Theories
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Although it exist in all socioeconomic groups, it is most commonly inhabit the lower socioeconomic classes
Downward drift hypothesis: Client with schizophrenia who possesses low social skills either 1. moves into a lower socioeconomic groups or 2. fails to rise t a higher groups

Course of Illness:
Premorbid [morbid- dark] describes features that contributes to later development of illness - mild deficit in social, motor and cognitive function occurring during childhood/adolescence - slight motor abnormalities, deficit in social functioning, organizational ability - deficit in intellectual functioning around the age of 17 to 17

Prodromal includes symptoms and behavior that signal the approaching onset of the illness [may last 2 to 5 years psychotic symptoms emerging late in this phase, marking the onset of psychosis] - mood swing: anxiety, irritability, dyphoria or anguish - cognitive: distractibility, difficulty in concentration, disorganized thinking - obsessive behaviors - social withdrawal and role functioning deterioration - sleep disturbances

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Psychotic Phase: A. Acute phase: experiences Florid [flowery/extravagant] positive symptoms: delusions, hallucinations Negative symptoms: apathy, withdrawal and avolition - unable to perform self-care activities hospitalization for safety and treatment B. Recovery or Maintenance: occurs 6 to 18 months after acute treatment Symptoms are present but less severe - 5 to 10 years after the onset: most clients have a leveling off of their illness and functioning - Generally able to care for themselves with some supervision C. Stable Phase: time in which symptoms are in remission [decrease] - some symptoms may persist in milder form [residual symptoms] - some are able to live independently in their community

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529

Clinical Symptoms:
Perceptual Hallucinations: Auditory: may be commanding content matches delusions Visual: may see images not actually present Tactile: feels like surrounded by spider webs Olfactory & Gustatory: refuses to eat because food seems to smell or taste bad Illusions: false perceptions caused by misinterpretations of real objects Altered Internal Sensation Formication: sensations of worms crawling around inside one Chill: feelings of chills in the marrow of bones Agnosia: perceptual failure to recognize familiar environmental stimuli such as sounds or objects seen and felt [refer to as: negative hallucinations] Distortion of Body Image: with respect to size, facial expression, activity, amount and nature of detail exaggeration or diminution of body parts Negative Self-Perception: With respect to ability and competence

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- Client and families must recognize that hallucinations are symptoms of the illness and are real to the client - Hallucinations responds a reduction of stress and an increase in antipsychotic medications - They often becomes less troubling when: - clients are distracted: keep client busy, use of competing stimuli to drown out the voices - whistling, clapping, shouting the word stop - teach client not to wait for the voices to occur - help occupy their minds with some activity
Thought Delusions: unusual ideas, not reality based Omnipotence: perception of unrealistic power Persecution: perception that someone out to harm or kill Controlling or being controlled: with respect to outside force or entity Derealization: loss of ego boundaries cannot tell where own body ends and environment begins Feels world around him is not real or is distorted Ideas of Reference: perceptions other people are talking to or about the individual Incoherent of language: Neologism invented words Incoherent nonsensical thoughts

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532

NORMAL self-fulfilling to occasional escape from reality and imagine ourselves as more powerful or successful than we really are these period of fantasy are generally short lived and well with our control Schizophrenia their convictions [assurance, certainty] is fixed - they reject any attempt to explain the reality during this time - arguing further leads to mistrust or anger Family members: - need to realize that delusions are a result of the illness and not stubbornness /stupidity of the client - avoid emotional reactions, sarcasm and threats - any empathic response is always possible no matter what the delusions or conviction is
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Ex. Patient believes he is at the center of someone who wants him death cannot sleep Empathic response It must be difficult not to be able to get some sleep and feel afraid. You are safe here in this hospital and the care you receive here will make you feel better This type of response: 1. builds trust 2. rapport 3. adherences to the treatment plan can help client improve

Results of thought disturbances: 1. speech is affected - circumstantiality: subtle [slight] form of speech disorder person digresses [deviate] to unnecessary details
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- tangeliality respond in a irrelevant manner to the topic at hand [ex. Mr.X student about to pass the door, Mr. X is blocking, student ask puede you pasa, Mr. X is staring blankly at the sky. Student ask, what are you looking: Mr X answer - planeta, planeta boom boom boom ] Thought process change with the individuals clinical status: As clinical status worsen: 1. evolve in a world of fantasy autistic thinking [internally stimulated thought not reality based 2. perseveration persistent repetition of same idea in response to different questions 3. poverty of thought lack ability to produce thought 4. loosesness of association fragmented, incoherent thought At this stage: difficult to communicate frustrating to the family - do not force yourself to listen frustrating
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Psychoeducation: 1. teaching at times when symptoms are relatively stable 2. simplifying instructions and reducing distractions [ or providing distraction to offset symptoms as necessary] 3. provide both visual and verbal information 4. using direct, clear terms versus abstraction or concepts 5. teaching in a small segments with frequent reinforcement 6. not offering choices that often confuse the individual, yet offering more choices as clients improves
Emotional Labile affect, range of motions Apathy indifferent or dulled response Flattened restricted facial expression Reduced responses exaggerated euphoria, Rage Inappropriate affect laughing at sad events, crying over joyous ones

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Emotional blunting and lack of displaying emotions are examples of Negative symptoms Some clients: 1.avoid eye contact 2. decrease expression with a monotone and lack gestures
Cognitive Errors in memory recall and retention, especially working memory Difficulty in comprehending, processing and categorizing information Difficulty in sustaining attention: Unable to complete task, errors of omission Lack of judgment: unable to assess or evaluate situations or make rational choices Lack of insight: unable to perceive and understand cause and nature of own and others situation [e.g. own illness] Difficulty in executive functioning [planning, decision-making, problem solving]

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Cognitive disturbances affects everyday performance: One area that is greatly affected is: Vigilance ability to maintain attention over time - unable to maintain attention has difficulty in following instructions critical to their care - have difficulty in verbal fluency negative impact on social and work related interactions Other cognitive deficiency: - difficulty in learning, reasoning and problem solving hinders ability to adapt to a rapidly changing world
Behavioral: Little impulse control: - sudden scream as a protest of frustration - injury to a body part believed to be offensive - self-mutilation to substitute physical or emotional pain - responds to command hallucination Inability to cope with depression: - depressed client has 50% suicidal - lack of social support - frequent exacerbation and remissions in one who has insight Inability to manage anger - anger & lack of impulse control leads to violence verbal aggression, destruction of property, injury to others and homicide Substance abuse as coping: - dull painful psychologic symptoms Non-compliance with medications may feel it is NOT needed or has too many side effects

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Violence behavioral disturbances of greatest concerns Challenge for nurses: 1. note changes in client behavior 3. interact according to the clients level of crisis 2. read the situation accurately 4. intervene at a level that meets clients need Important: ask for thought of violence and determine the intended victims How to manage persistent violence: setting limits and using behavioral approach
Social: Poor peer relationships: - few friends as a child or adolescence - preference to be in solitude Low interest in hobbies and activities - daydreamer - preoccupied and detached - not functioning well in social or occupational areas - behavioral autism: marked impairment in social and behavioral functioning

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540

Poor social competence hallmark of schizophrenia as seen in many negative symptoms Typically they have history of: 1. schizoid/schizotypal personality Subtypes: a.1 Catatonic
Predominant feature: intense psychomotor disturbance - from one form of stupor [ psychomotor retardation] or excitement [psychomotor excitement] Psychomotor disturbance manifestations: - posturing immobility catalepsy [waxy flexibility] mutism negativism - there is sometimes automatic obedience - - then excessive and purposeless movement Other symptoms: - echopraxia [imitating movement of others] echolalia [repeating what was said by others]

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Presents a nursing challenge: While in the state of psychomotor excitement: - client develops hyperpyrexia or collapse from extreme exhaustion - close watch to prevent harm to self and others While on stuporous state: the disease is life threatening: - person approaches a vegetative condition: will not eat and in danger of malnutrition/starvation - pressure ulcers from lack of mobility and strange position - constipation, status pneumonia among elderly Delusions often persist throughout the withdrawn state: Ex. Client believes that he has to hold his hand out flat in front of him because forces of good and evil are coming a.2 Paranoid: - results in less neurologic and cognitive impairment - in acute phase appears extremely ill and danger to self/others
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Delusions: tends to be persecutory or grandiose and have a consistent theme

Persecutory delusion generates: Anxiety Suspiciousness Anger Hostility and Violent Behavior

a. 3. Undifferentiated type: Does not meet criteria for paranoid, disorganized or catatonic, but has some aspects of each types:
Psychotic manifestations: - extreme fragmented delusions vague hallucinations - bizarre and disorganized behavior disorientation Mixture of positive and negative symptoms Developmental milestone often have been delayed Thought process fragmented Have high fantasy content [primary process thinking] Has few or new friends Dress and grooming are careless and seems to be bored in life Nightmares and early morning awakens disturbs sleep patterns incoherent

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a. 4 Disorganized type: [formerly known as hebephrenic]

Severe disintegration of the personality characterizes this form of schizophrenia Speech is disorganized: 1. word salad communications that includes both real and imaginary words in no logical order 2. incoherent speech 3. clanging Behavior is Odd [out of ordinary] 1. grimace grunting [mumble sounds], sniffing [inhale] posturing rocking stereotyped behavior uninhibited sexual behaviors masturbating in public Socially withdrawn and incompetent Primary thinking process is a common defect

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a.5 Residual - acute episode of schizophrenia and is now free of prominent positive symptoms but has negative Symptoms 1. absence of prominent delusions, hallucinations, disorganized speech and disorganized or catatonic behavior 2. continuing evidence of the presence of negative symptoms or reduced positive symptoms

b. Other Psychotic Disorder b.1 schizophrenic form - same with schizophrenia with two exceptions: 1. duration - at least 1 month but less than 6 months [ 6 months for schizophrenia ]
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2. impairment of function - social or occupational functioning does not occur b.2 Schizo Affective Disorder Represents more severe mood swings of either mania or depression and some other psychotic symptoms [ but there must be at least one 2 week period in which there are only psychotic episodes] [ most believe that he etiology is related to a combination of biologic, genetic and environmental factors] b.3 Delusional Disorder: manifest symptoms similar to those in schizophrenia Following differentiate delusional disorder from schizophrenia: - delusions has a basis in reality - have never met the criteria for schizophrenia - relatively normal except in relation to their delusions
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- if mood episodes have occurred concurrently with delusions total duration in only brief - symptoms are due directly to a substance or medical condition. b.4 Brief Reactive Psychotic Disorder - includes all psychotic disturbances that last less than 1 month and are not related to a mood disorder, general medical condition or substance-induced disorder At least on e of the following must be present: Delusions hallucinations disorganized speech grossly disorganized or catatonic behavior b.4. Psychosis induced Polydypsia Compulsive water drinking [between 4 and 10L/day] associated with hyponatremia [6 - 20% in schizophrenia]
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Desires to drink relates to thirst and osmotic dysregulation Reasons : patient claims: cleansing the body, washing away evil spirits, relief of dry mouth caused by drugs Major concerns: hyponatremia causes: 1, light-headedness weakness lethargy muscle cramps nausea and vomiting confusion convulsions and coma Treatment includes: Frequent weighing restricted fluid intake sodium replacement Positive reinforcement Nursing interventions: p 271-272 1. Observe and monitor risks factors, especially for suicide or violence towards others. a. promotes safety of the client and others and reduces the risk for violence 2. reduce/minimize environmental stimulation. a. promotes a quite, soothing milieu that will lessen the clients impulsivity and agitation and prevent
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accident or injury 3. provide frequent timeouts or brief, low-key interactions. a. calms the clients by providing opportunities for rest, relaxation and ventilation of impulsivity feelings, which reduces the risk of acting-out behaviors 4. support and monitor prescribed medical and psychosocial interventions. a. encourages the client and family to participate in the treatment plan b. prevents the clients behavior from escalating to violence 5. Use clear, concrete statements versus abstract, general statements. a. client is not always able to understand complex message and as such the client sometimes has misinterpretations or hallucinations b. schizophrenia generally respond better to concrete messages during acute phase 6. Attempt to determine factors that worsen clients hallucinatory experiences [ stressors that trigger sensory- perceptual disturbances]
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a. although hallucination have biochemical etiology - outside stressors sometimes intensify 7. Praise the client for : a. a reality-based perceptions c. reduction/cessation in aggressive/acting-out behaviors b. appropriate social interactions d. group participation. Warranted praise reinforces: a. repetition of functional behaviors when given at appropriate times during the treatment plan such as when medication has begun to take effect 8. Educate the client and family/SO : a. about client symptoms c. continued use of therapeutic support service after the discharge. b. importance of medications compliance This facilitates : a. learning and increases the client and family/SO knowledge base
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b. ensures clients continued therapeutic support c. possible prevents relapse after discharge from the hospital 9. Distract the client from delusions that tend to exacerbate aggressive or potentially violent episodes. a. engaging the client in more functional, less anxiety-provoking activities 1. increases the reality base 2. decreases the risk for violent episodes that trouble delusions cause 10. Focus on the meaning of the clients delusional system rather than focusing on the delusional content itself. a. helps to meet the clients needs b. reinforces reality c. discourages the false-belief without challenging or threatening the client 11. Accompany the client to group activities a. beginning with the more structured, less threatening ones first and gradually incorporating more informal, spontaneous activities.
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1. promotes the clients socialization skills 2. expands the reality base in a non threatening way 12. Assist in personal hygiene, appropriate dress, and grooming until the client is able to function independently. a. helps to prevent physical complications and preserve self-esteem. 13. Establish routine times and goals for self-care and add more complex tasks as the clients condition improves. a. routine and structure tend to organize and promote reality based experiences 14. Spend intervals of time with the client each day Engaging them in nonchallenging interactions. a. helps to ease the client into the community by first developing 1. trust 2. rapport 3. and respects 15. Assess the clients elf concept. A low self-esteem results to from social isolation
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16. Act as a role model for social behaviors in interactions by: a. maintaining good eye contact b. appropriate social distance c. calm demeanor. This helps the client to identify appropriate social behavior. 17. Keep all appointments for interactions with the client. a. this will promotes clients trust and self-esteem 18. Listen actively to the clients family/SO: a. allowing them to express fears and anxieties about mental illness b. giving them support and empathy and emphasizing clients strength . This will help the client to : a. express emotions and assist in calming the clients irrational fears b. while acknowledging realistic concern; it also promotes hope and bonding between the family/SO and the client 19. Hold onto hope for the clients until they are able to have hope for themselves.
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a. increase clients level of participation in his care as the clients conditions improves. 1. allows to client choices within the limits of the setting 2. identify clients strength/assets and incorporate this in your plan. 3. focus activities/tasks that the client can do versus focusing on the clients limitations.. These interventions promotes the clients : a. hope and strength b. and empower them the client as he strives to achieve mental and emotional health. 20. To help families and caregivers overcome negative symptoms [apathy, lack of motivation, lack of interest, lack of energy] Thornton identified 4 Four Ss of Schizophrenia Stimulation: introducing slowly and gradually a. new routines b. people c. events and

d. situations to the clients

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Structure: providing daily routine and expectations for every part of the day: a. waking b. dressing c. eating d. activity Socialization: getting people in their lives to help with : a. fiancs b. health c. food and d. socializing Support: a. offering encouragement to try new tasks b. accompanying clients to new places until the client makes his friends Treatment Modalities: Psychopharmacology Somatic Therapy - ECT combined with atypical antipsychotic medications is beneficial Milieu Therapy - 24 hours environmental therapy that shelters, protects, supports and enhances the client with mental illness within the psychiatric setting
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Behavioral Modification - precise approach to bringing about behavioral change

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