Pyschiatric Health Nursing Mental Health

WHO definition: state of complete physical, mental, and social wellness, not merely absence of disease or infirmity State of emotional, psychological, and social wellness evidenced by: satisfying interpersonal relationships effective behavior and coping a positive self-concept emotional stability Mental Illness Historically viewed as possession by demons, punishment for religious or social transgressions, weakness of will or spirit, and violation of social norms Today seen as a medical problem, although some stigma from previous beliefs remains Mental disorder is a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom (American Psychological Association [APA]) Components of Mental Health Autonomy and Independence-can work interdependently without losing autonomy Maximization of Ones Potential-oriented towards growth and self-actualization Tolerance of Lifes Uncertainties-can face the challenges of day-to-day living with hope & positive look Self-esteem-has realistic awareness of ones abilities and limitations Mastery of the Environment-can deal with and influence the environment Reality Orientation-can distinguish the real world from a dream, fact from fantasy

Mental Illness State of imbalance characterized by a disturbance in a persons thoughts, feelings and behavior (psychological, neurobiological and genetic factors.)

Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision
The DSM-IV-TR is a taxonomy published by APA and is used by all mental health professionals. It describes all mental disorders according to specific diagnostic criteria. The DSM-IV-TR is based on a multiaxial classification system Used to provide standard nomeclature of mental disorders ,define characterisitcs of mental disorders and assist in identifying underlying causes of mental disorders Axis I: all major psychiatric disorders except mental retardation and personality disorders Ex.Depression,Schizophrenia,anxiety and substance abuse disorder

Axis II: mental retardation, personality disorders, maladaptive personality features, and defense mechanisms Axis III: current medical conditions Axis IV reporting psychosocial and environmental problems that may affect the diagnosis, treatment and prognosis of mental disorder Axis V - presents global assessment of functioning (GAF) which rates the persons Overall psychological functioning on a scale of 0 100.

LEGAL CONCEPTS RELATED TO PSYCHIATRIC / MENTAL HEALTH NURSING

MENTAL HEALTH LAWS
A. A fundamental component of psychiatric nursing is understanding the legal framework, in any given state, that is used to regulate the care and treatment of clients with mental illness B. Laws are specific in addressing what is wrong in a particular society C. Adherence to the Patients Bill of Rights is essential Patients Bill of Rights Right for considerate and respectful care Right to obtain from physicians and other direct caregivers relevant, current, and understandable information concerning diagnosis, treatment and prognosis Right to make decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment Right to have an advance directive (such as living will and health care proxy) concerning treatment Right to every consideration of privacy Right to expect that all communications and records pertaining to his or her care will be treated as confidential by hospital, except in cases such as suspected abuse and public health hazard. Right to review the records pertaining to his or her medication Right to expect that within its capabilities an policies, a hospital will make a reasonable response to the request of a patient for appropriate and medically indicated care and services Right to ask the existence of business relationships among hospital and educational institution Right to consent or decline to participate in proposed research studies Right to expect reasonable continuity of care when appropriate and to be informed by physician Right to be informed of hospital policies and practices that relate to patient care, treatment and responsibilities

D. Types of Hospital admissions 1. Voluntary admission client of lawful age may apply in writing (standard admission form) for admission to a public or private psychiatric hospital

a. Voluntary admission is similar to a medical hospitalization b. All civil rights are retained 2. Involuntary admission (commitment)- client has no requested a. Most state laws permit commitment of the mentally ill based on the following: 1. Dangerous to self or others 2. Mentally ill and in need of treatment 3. Unable to provide for own basic needs 4. There is a time limit governing the length of commitment (48-72 hours) 5. The purpose is to detain only proper legal action is initiated, which provides for additional hospitalization 3. Emergency hospitalization is used to control an immediate threat by an acutely ill person to self or others 4. Observational Hospitalization- this type of commitment allows for short-term diagnosis and therapy. No emergency situation need occur a. Length of time varies according to states laws b. If the length of time runs out before the client is ready for discharge, a petition can be field for long-term commitment 5. Formal commitment- a long-term commitment allows for an indefinite time or until the client is ready for discharge A. Client retains right to a lawyer and right to request a court hearing B. Periodic reviews for long-term hospitalization may be made every 3, 6, or 12 months E. Nursing responsibilities 1. 2. 3. 4. Implement care that meets the Scope and Standard of Psychiatric-Mental Health Clinical Nursing Practice as described by the ANA Stay current with skills and knowledge base Keep accurate and concise nursing notes Maintain client/family confidentiality

5. 6.

Know the laws governing practice within the state, the rights and duties of the nurse, and the rights of the client Maintain current malpractice liability insurance coverage

DSM-IV-TR Categories Cluster A - people whose behavior is odd or eccentric (paranoid, schizoid, schizotypal) Cluster B - people who appear dramatic, emotional, or erratic (antisocial, borderline, histrionic, narcissistic) Cluster C - people who are anxious or fearful (avoidant, dependent, obsessive-compulsive) Disorders being considered for inclusion are depressive and passive-aggressive

Personality Disorders
Personality - an ingrained, enduring pattern of behaving and relating to self, others, and the environment; behaviors and characteristics are consistent across a broad range of situations and do not change easily Personality disorders - when personality traits become inflexible and maladaptive and significantly interfere with how a person functions in society or cause the person emotional distress; usually not diagnosed until adulthood; maladaptive behavior can be traced to early childhood or adolescence Cluster A Personality Disorders Clinical Picture Mistrust and suspiciousness, aloof and withdrawn, guarded or hypervigilant, restricted affect, use the defense mechanism of projection

Paranoid personality disorder

Nursing Interventions Approach in a formal, business-like manner, keep commitments, be straightforward, involve them in formulating their care plans, help them learn to validate ideas before taking action Improve functioning in the community, make referrals to social services, provide care that accommodates the desire for solitude

Schizoid personality disorder

Detached from social relationships, restricted affect, aloof and indifferent, no leisure or pleasurable activities, do not report feeling distressed about lack of emotion, intellectual and accomplished with solitary interests, indifferent to praise or criticism, dissociate from or no bodily or sensory pleasures Acute discomfort in relationships, cognitive or perceptual distortions, eccentric behavior, bizarre speech, affect flat and sometimes inappropriate

Schizotypal personality disorder

Promote self-care, social skills, and improved functioning in the community

Cluster B Personality Disorders Clinical Picture Antisocial Personality Disorder Pervasive pattern of disregard for and violation of rights of others, deceit and manipulation Histrionic Personality Disorder Excessive emotionality and attention seeking;colorful and theatrical speech;overly concerned with impressing others; emotionally expressive, gregarious, and effusive; emotions are insincere and shallow; self-absorbed; uncomfortable when they are not the center of attention and go to great lengths to gain that status

Nursing Interventions Forming therapeutic relationship o Limit setting o Confrontation Promoting responsible behavior Helping client solve problems and control emotions Enhancing roleperformance Long-term therapy to resolve family dysfunction and abuse Hospitalization when client is exhibiting self-harm behaviors or having intense symptoms Brief hospitalizations to stabilize condition

Borderline Personality Disorder

Pervasive pattern of unstable interpersonal relationships, selfimage, affect, and marked impulsivity

Give feedback about social interactions; teach social skills through role playing

Narcissistic Personality Disorder

Grandiose; lack of empathy; need for admiration; arrogant or haughty attitude; disparage, belittle, or discount the feelings of others; view their problems as the fault of others; hypersensitive to criticism and need constant attention and admiration

Use self-awareness skills to avoid anger and frustration; use matter-of-fact manner; set limits on rude or verbally abusive behavior

Cluster C Personality Disorders Clinical Picture Avoidant personality disorder Social inhibitions; feelings of inadequacy; hypersensitivity to negative evaluation; avoid situations or relationships that may result in rejection, criticism, shame, or disapproval; strongly desire closeness and intimacy but fear possible rejection and humiliation Submissive and clinging behavior; excessive need to be taken care of; pessimistic and self-critical; other people hurt their feelings easily; report feeling unhappy or depressed; difficulty making decisions; seek advice and repeated reassurances Preoccupation with orderliness, perfectionism, and control; formal and serious demeanor; constricted emotions; stubborn; preoccupied with details, rules, lists, and schedules; believe they are right; problems with judgment and decision making Nursing Interventions Explore positive self-aspects and reasons for self-criticism; practice self-affirmations and positive self-talk; cognitive restructuring techniques, such as reframing and decatastrophizing; teach social skills

Dependent Personality Disorder

Help identify strengths and needs; use cognitive restructuring; assist in daily functioning; teach problem solving and decision making; refrain from giving advice

ObsessiveCompulsive Personality Disorder

Help accept or tolerate less-than-perfect work; use cognitive restructuring techniques; encourage to take risks; practice negotiation Related Disorders: Depressive personality disorder Passive-aggressive personality disorder Assess risk for self-harm; encourage to become involved in activities; give factual feedback; use cognitive restructuring techniques; teach effective social skills

Depressive Personality Disorder

Sad, gloomy, or dejected affect; persistent unhappiness, cheerlessness, and hopelessness; inability to experience joy or pleasure in any activity; cannot relax; do not display a sense of humor; brood and worry over all aspects of daily life; thinking is negative and pessimistic Negative attitudes; resent, oppose, and resist demands expected by others; express resistance through procrastination, forgetfulness, stubbornness, and intentional inefficiency

PassiveAggressive Personality Disorder

Help examine the relationship between feelings and subsequent actions; teach appropriate ways to express feelings directly

PSYCHIATRIC NURSING
Interpersonal process whereby the nurse through the therapeutic use of self assist an individual family, group or community to promote mental health, to prevent mental illness and suffering, to participate in the treatment and rehabilitation of the mentally ill and if necessary to find meaning in these experiences It is a social process that promotes and maintains behavior that contributes to integrated functioning. It is a specialized area of nursing practice employing theories of human behavior as its science and purposeful use of self as its art.

PSYCHIATRIC MENTAL HEALTH NURSING It is organized around eight human response processes: activity, cognition, ecological, emotional, interpersonal, perception, physiologic and valuation Central Nervous System Cerebrum Frontal lobe control organization of thought, body movement, memories, emotions and moral behavior. Parietal lobe interpret sensations of taste and touch and assist is spatial orientation.

Temporal lobe are centers for the sense of smell, hearing, memory, and expression of emotions. Occipital lobe assist in coordinating language generation and visual interpretation, such as depth perception. Neurotransmitters Dopamine-controls complex movements, motivation, cognition, regulates emotional responses Serotonin-regulation of emotions, controls food intake, sleep and wakefulness, pain control, sexual behaviors Acetylcholine- controls sleep and wakefulness cycle (decreased in Alzheimers) Histamine-controls alertness,peripheral allergic reactions, cardiac stimulations GABA-modulates other neurotransmitters Norepinephrine / Epinephrine-causes changes in attention, learning and memory, mood Autonomic Nervous System Sympathetic (alert) Fight or flight Increases HR, RR and BP Decreases peristalsis Secretes epinephrine and norepinephrine Dilates pulmonary bronchioles Dilates pupils (mydriasis) Vasoconstriction Anticholinergic Parasympathetic (relax) Maintains normal body functioning Normalizes HR, RR and BP Increases peristalsis Secretes acetylcholine Constricts pulmonary bronchioles Constrict pupils (myotic) Vasodilation cholnergic

TYPES OF MEMORY Conscious highest level of awareness Pre-conscious thoughts not currently in persons awareness but she can recall recall them with some effort. Unconscious thoughts and feelings that motivate a person even though he is totally unaware of it. forgotten Repression Unconscious forgetting Suppression conscious forgetting Subconscious those in preconscious or unconscious level of awareness Sigmund Freud Father of Psychoanalysis Structure of personality ID (4-5MONTHS) SUPEREGO EGO Executive REALITY PRINCIPLE Should not Small voice of GOD Set norms, standards and values MORAL PRINCIPLE Conscience Direct opposition to the ID Impulsive / Instinctual drive I want to PLEASURE PRINCIPLE I want to PHYSIOLOGIC NEEDS I want to PRIMARY PROCESS

Conscious Competencies Decision Maker; Problem-Solving; Critical and Creative thinking Balancing force between ID and superego

Theories of Personality Development

ERIK ERIKSONS PYSCHOSICIAL THEORY OF DEVELOPMENT

AGE 0-18 months 18-3 3-6 6-12 12-20 20-40 40-60 60-above

+ Trust Autonomy Initiative Industry Identity Intimacy Generativity Ego Reality

Mistrust Shame and Doubt Guilt Inferiority Role confusion Isolation Stagnation Despair

FACTORS Feeding Toilet Training Independence School Peers Love Parenting Reflection

SIGMUND FREUD PSYCHOSEXUAL THEORY AGE 0-18 Oral STAGES PLEASURE SOURCE Mouth:Sucking,Biting, Swallowing Eliminating and retaining feces CONFLICT Fixation- strong attachment to a person or thing Regression- return to an earlier stage of development Anal retentive - obsession with cleanliness, perfection, and control Anal expulsive - messy and disorganized

18-3

Anal

3-6

Phallic

Genitals

Oedipus Complex - male children develop a sexual attraction to their mother Electra Complex - female children develop a sexual attraction to their father Sublimation- place sexual energies to productive endeavors

6-12 12-above

Latency Genital

Same sex friendships Sexual desires

Jean Piaget Cognitive Theory of Development AGE 0 to 18 months 2 to 7 years STAGE SENSORIMOTOR STAGE development proceeds from reflex activity to representation and sensorimotor solutions to problems 7 to 12 years CONCRETE OPERATIONAL development proceeds from sensorimotor representation to prelogical thought and solutions to problems can use these representational skills only to view the world from their own perspective. Understand the meaning of symbolic gestures development proceeds from prelogical thought to logical solutions to concrete problems understand concrete problems cannot yet contemplate or solve abstract problems

PRE-OPERATIONAL STAGE

12 and above

FORMAL OPERATIONAL

development proceeds from logical solutions to concrete problems to logical solutions to all classes of problems cannot yet contemplate or solve abstract problems can also reason theoretically

Harry Stack Sullivan Interpersonal Theory AGE 0 to 18 months STAGE Infancy anxiety develops as a result of unmet needs by the mother (bodily needs); needs met, the child has sense of well-being anxiety as a result of lack of praise/acceptance from parents gratification leads to positive self-esteem moderate anxiety leads to uncertainty and insecurity; - severe anxiety results in self-defeating patterns of behavior severe anxiety may result in a need to control or restrictive, prejudicial attitudes learns to negotiate own needs capacity to attachment, love and collaboration emerges or fails to develop move to genuine intimacy with friend of the same sex if self-system is intact, areas of concern expand to include values, career decisions and social concerns lust is added to interpersonal equation need for special sharing relationship shifts to opposite sex new opportunities for social experimentation lead to consolidation or self-ridicule

18 months to 6 years

Childhood

6 to 9 years

Juvenile

9 to 12 years

Preadolescence Adolescence

12 to adulthood

Hildegard Peplau Nurse Patient Relationship PHASES PREINTERACTION Begins when the nurse is assigned/chooses a patient Patient is excluded as an active participant Nurse feels certain degree of anxiety Includes all of what the nurse thinks and does before interacting with the patient Major task of the nurse is: Self-awareness When the nurse and patient interacts for the first time Nurse begins to know the patient Major task of the nurse: develop a mutually acceptable contract It is highly individualized More structured than the orientation phase The longest and most productive phase of the nurse-patient relationship Limit setting is employed Major task of the nurse: identification and resolution of the patients problem Gradual weaning process There is a mutual agreement It involves feeling of anxiety,fear of loss It should be recognized in the orientation phase Major task of the nurse: to assist the patient to review what he has learned and transfer his learning to his relationship with others.

ORIENTATION

WORKING

TERMINATION

STAGES

LEVEL I (Preconventional Level)

KOHLBERGS DEV OF MORAL REASONING LEVEL II (Conventional Level)

LEVEL III (Post Conventional Level)

Stage 1

Punishment and Obedience Orientation I must follow the rules otherwise I will be punished Instrumental Relativist Orientation I must follow the rules for the reward and favor it gives Good- Boy-Nice Girl Orientation I must follow the rules so I will be accepted Society- Maintaining Orientation I must follow rules so there is order in the society Social Contract Reorientation I must follow rules as there are reasonable laws for it. Universal Ethical Principle Orientation I must follow rules because my conscience tells me.

Stage 2

Stage 3

Stage 4

Stage 5

Stage 6

DEFENSE MECHANISMS COMMONLY USED IN EACH RESPECTIVE DISORDERS Paranoid Projection Phobia Displacement Amnesia Dissociation Anorexia Suppresion Bipolar Disorder Reaction Formation Borderline Splitting Schizophrenia Regression Substance Abuse Denial Depression Introjection OC Undoing Catatonic Repression

DEFENSE MECHANISM
Denial - refusal to acknowledge painful realities, thoughts, or feelings. Ex. I am not an alcoholic! Displacement - unconscious shift of emotions, affect, or desires from the original object to a more acceptable or immediate substitute. Projection - Blaming; Falsely attributing to another his/her own unacceptable feelings. Ex. A reviewee blames the review center for his failure in the board exams

Undoing - an attempt to erase an act, thought, feeling or desire Ex. After flirting with her male secretary, a woman brings her husband tickets to a show. Compensation - the counterbalancing of any defect. Ex. A student is poor in academics but is a talented artist Symbolization - one idea or object comes to represent another because of similarity or association between them. Substitution - an unattainable or unacceptable goal, emotion, or object is replaced by one that is attainable or acceptable. Ex. A little girl spanks her doll like her mother does to her Introjection - standards and values of other persons or groups are unconsciously and symbolically taken within oneself. Ex. Not just you.. Me, too Repression - painful or unacceptable ideas, memories, or feelings are removed from conscious awareness or recall.(unconscious forgetting) Ex. Man forgets wifes birthday after a marital fight. Supression - Conscious exclusion of unacceptable desires, thoughts, or memories from the mind. Ex. Businessman who is preparing to make an important speech that day is told by his wife that morning that she wants a divorce. Although visibly upset, he puts this incident aside until after his speech, when he can give the matter his total concentration. Reaction Formation - adopts conscious attitudes, interests, or feelings that are the opposites of their unconscious feelings, impulses, or wishes.(Plastic) Ex. having a bias against a particular race or culture and then embracing that race or culture to the extreme Regression - a return to earlier, usually childish or infantile, patterns of thought or behavior. Ex. sitting in a corner and crying after hearing bad news; throwing a temper tantrum when you don't get your way Dissociation - detachment of painful emotional conflicts from consciousness Ex. forgetting sexual abuse from your childhood due to the trauma and anxiety Conversion - emotional problems are converted into symptoms Ex. Student is unable to take a final exam because of a terrible headache. Fantasy- Magical thinking Identification - a person patterns his or her personality on that of another person, assuming the person's qualities, characteristics, and actions. Ex. Five-year old girl dresses in her mothers shoes and dress and meets daddy at the door. Intellectualization - reasoning is used as a means of blocking a confrontation with an unconscious conflict and the emotional stress associated with it. Rationalization - uses because justifying ideas, actions, or feelings with seemingly acceptable reasons or explanations. Ex. I did not get a high grade because I forgot to study. Sublimation - unacceptable instinctual drives and wishes are modified into more personally and socially acceptable channels. Ex. Woman who is angry with her boss writes a short story about a heroic woman.

THERAPEUTIC COMMUNICATION

ORIENTATION WORKING Focusing Let us discuss this topic more. Exploring Tell me more about it. Encourage Evaluation IS this what you want? Reflecting same idea Restating same statement Verbalizing Implied Are you going to kill yourself? Seeking Clarification May you please repeat that statement General lead Please continue.; And then? Limit setting Stop. Interpreting Maybe that thing is very significant to you. Broad Opening Recognition Giving information Silence Offering Self Do you want me to sit beside you?

TERMINATION Summarizing Let us now sum up. You have stated earlieretc. Do you have any questions? Our next therapy Look for changes in behavior Resistance is a common problem

Therapeutic Communication Techniques Therapeutic Communication Techniques Techniques Accepting Example Indicating reception Yes I follow what you said Nodding.. is there something youd like to talk about? Where would you like to begin? Tell me whether my understanding of it agrees with yours Are you using this word to convey that . .?

Broad Openings

Allowing the client to take the initiative in introducing the topic Searching for mutual understanding, for accord in the meaning of the words

Consensual Validation

Encouraging Comparison

Asking that similarities and differences be noted

was it something like..? Have you had similar experiences?

Encouraging Description of Perceptions

Asking the client to verbalize what he or perceives

Tell me when you feel anxious What is happening? What does the voice seem to be saying? what are your feelings in regard to..? Does this contribute to your distress? Tell me more about that. Would you describe it more fully? What kind of work?

Encouraging Expression

Asking client to appraise the quality of his or her experience Delving further into a subject or idea

Exploring

Focusing

Concentrating on a single point

This point seems worth looking at more closely Of all the concerns youve mentioned, which is most troublesome?

Formulating a Plan of Action

Asking the client to consider kinds of behavior likely to be appropriate in future situations Giving encouragement to continue

What could you do to let your anger out harmlessly? Next time this comes up, what might you do to handle it? Go on And then? Tell me about it

General Leads

Giving Information

Making available the facts that the client needs

My name is Visiting hours are My purpose in being here is Good morning, Mr. S Youve finished your list of things to I noticed that youve combed your You appear tense.. I notice that your biting your lips Ill sit with you awhile Ill stay here with you Im interested in what you think what seemed to lead up to? Was this before or after? I see no one else in the room. Your mother is not here; I am a nurse. Client: Do you think I should tell the doctor? Nurse: Do you think you should?

Giving Recognition

Acknowledging, indicating awareness

do. hair

Making Observations

Verbalizing what the nurse perceives

Offering Self

Making oneself available

Placing Event in Time or Sequence Presenting Reality Reflecting

Clarifying the relationship of events in time Offering for consideration that which is real Directing client actions, thoughts, and feelings back to client

Restating

Repeating the main idea expressed

Client: I cant sleep. I stay awake all night. Nurse:You have difficulty sleeping. Client:Im really mad, and upset Nurse: Youre really mad and upset. Im not sure that I follow. Have I heard you correctly? Nurses says nothing but continues to maintain eye contact and conveys interest.

Seeking Information

Seeking to make clear that which is not meaningful or that which is vague Absence of verbal communication, which provides time for for the client to put thoughts or feelings into words, regain

Silence

composure, or continue talking Suggesting Collaboration Offering to share , to strive, to work with the client for his or her benefit Organizing and summing up that which has gone before seeking to verbalize clients feelings that he or she expresses only indirectly Voicing what the client has hinted at or suggested Expressing uncertainty about the reality of the clients perceptions Perhaps you and I can discuss and discover the triggers for your anxiety Have I got this straight?

Summarizing

Translating into Feelings

Client: Im dead Nurse: Are you suggesting that you feel lifeless? Client: I cant talk to you or anyone. Its a waste of time. Nurse: Do you feel that no one understands Isnt that unusual? Really? Thats hard to believe.

Verbalizing the Implied

Voicing Doubt

TECHNIQUES Advising Agreeing Belittling Feelings expressed

NONTHERAPEUTIC COMUNICATION TECHNIQUES DEFINITION EXAMPLES telling the client what to do I think you should. Indicating accord with the client Misjudging the degree of the clients comfort thats right. I agree Client: I have nothing to live for..I wish I was dead Nurse: Everybody gets down in the dumps. But how can you be President of the Company? This hospital has a fine reputation.

Challenging

Demanding proof from the client

Defending

Attempting to protect someone or something from verbal attack Opposing the clients ideas Denouncing the clients behavior or ideas

Disagreeing Disapproving

Thats wrong Thats bad Id rather you wouldnt Thats good. Im glad that.. Client: Theyre looking in my head with television camera. Nurse: Try not to watch television. What makes you say that? What you really mean is.. Client: Id like to die. Nurse: did you have visitors last night? Keep your chin up. Just have a positive outlook. Now tell me about this problem. I need to know. Everything will be alright. Lets not discuss.. Why do you think that?

Giving approval Giving Literal Responses

Sanctioning the clients behavior or ideas Responding to a figurative comment as though it were a statement of fact

Indicating the existence of an external source Interpreting Introducing an unrelated topic

Asking to make conscious that which is unconscious Changing the subject

Making stereotyped comments

Offering meaningless cliches or trite comments

Probing

Persistent questioning of the client

Reassuring Rejecting Requesting an explanation

Indicating there is no reason for anxiety Refusing to consider or showing contempt for the clients behavior, ideas Asking the client to provide reasons for thoughts, feelings, behaviors, events

Testing Using Denial

Appraising the clients degree of insight Refusing to admit that a problem exists

Do you know what kind of hospital this is? Client: I am nothing. Nurse: Of course, youre something.

ROLES OF THE PSYCHIATRIC NURSE

COUNSELOR-listens to the patients verbalizations PARENT SURROGATE- assists the patients in the performance of activities of daily living PATIENT ADVOCATE- enables the patient and his relatives to know their rights and responsibilities TEACHER- assists the patient to learn more adaptive ways of coping TECHNICIAN-facilitates the performance of nursing procedures THERAPIST-explores the patients needs, problems and concerns through varied therapeutic means SOCIALIZING AGENT- assists the patient to feel comfortable with others WARD MANAGER- creates a therapeutic environment

BEHAVIORAL SIGNS AND SYMPTOMS

Assessment ALWAYS SEND MAIL THRU POST OFFICE A-Affect/Appearance S-Speech M-Motor Behavior/Mood/Memory T-Thought Process P-Perception O-Orientation

Distubances in Perception Illusion misinterpretation of an actual external stimuli Hallucinations false sensory perception in the absence of external stimuli Auditory-Ex. I keep hearing my mothers voice telling me I am bad. She died a year ago. Tactile-Ex. A paranoid man feels electrical impulses from outer space entering his body and controlling his mind. Visual Ex. During alcohol withdrawal he kept shouting, I see snakes on the walls!

Distubances in Thinking Flight of Ideas shifting of one topic from one subject to another in a somewhat related way Ex. Say babe, hows it goinggoing to my sisters to get some moneymoney, honey, you got any breadbread and butter, staff of life, aint life grand? Looseness of Association incoherent, illogical flow of thought Ex. Cant go to the zoo, no money, OhI have a hat, these members make no sense, manWhats the problem?

Delusion belief held with strong conviction despite superior evidence to the contrary Delusions of Grandeur - a delusion that you are much greater and more powerful and influential than you really are Ex. A newly admitted patient told the nurse that she was muse of the United Nations and that she is the most beautiful among women. Persecutory A fixed, false, and inflexible belief that others are engaging in a plot or plan to harm an individual Ex. An intern believes that the chief of staff is plotting to kill him to prevent the intern from becoming powerful Ideas of Reference - involve the belief that casual events, people's remarks, etc. are referring to oneself when, in fact, they are not. Ex.The nurses are talking about me Somatic body reacting in a particular way Magical Thinking primitive thought process thoughts alone can change events Autistic Thinking regressive thought process subjective interpretations not validated with objective reality Nihillistism false sense of being worthless Abolition lack of ability to exercise willpower, indecision in performing voluntary acts Disturbances in Speech Clang Association sound of word gives direction to the flow of thought Ex. Good luck, buck, chuck, duck Neologism- invented words that people do not understand Ex. I am afraid to go to the hospital because the norks are looking for me there. Word Salad- incoherent mixture of words and phrases with no logical sequence Ex.I am fineapple pieno salefurniture storetake it slowcellar door Circumstantiality- over inclusion of inaapropriate thoughts and details Ex. N: Where are you going for the weekend Harry? P: Well, I first thought of going to my mothers but that was before I remembered that she was going to my sisters. My sister is having a picnic. She always has picnics at the beach. But I dont like the beach that she goes to so I decided to some place elseI finally decided to stay home. Verbigeration- meaningless repitition of words and phrases Perseveration- persistence of a response to a previous question Ex. N: How are you doing Harry? P: Fine nurse, just fine. N: Did you go for a walk? P: Fine nurse, just fine. Echolalia- repitition of words of others Ex. The nurse said to the client, Tell me your name. The client responded, Tell me your name, Tell me your name.

Aphasia- speech difficulty and disturbance Alogia-lack of speech

Disturbances of Affect Inappropriate- disharmony between the stimuli and the emotional reaction Blunted Affect- marked reduction in the range and intensity of emotional expression Flat Affect- absence or near absence of emotional reaction Apathy-dulled emotional tone Depersonalization-feeling of strangeness from ones self Derealization-feeling of strangeness towards environment Agnosia- inability to recognize the import of sensory impressions

Disturbances in Motor Activity Echopraxia- imitation of posture of others Ex. Everytime the nurse would move or gesture with her hands, the client would copy her gestures Waxy Flexibility-maintaining position for a long period of time Ex. The nurse lifted the clients arm to check the pulse, and the client left his arm extended in the same position Ataxia-loss of balance Akathesia-extreme restlessness Ex. The clients leg kept jiggling up and down when he talked to the nurse. When his feet were still, his arm would jiggle constantly during the interview Dystonia-uncoordinated spastic movements of the body Tardive Dyskenisia-involuntary twitching or muscle movements Apraxia- involuntary unpurposeful movements Disturbances in Memory Confabulation- filling of memory gaps, inventing stories to increase self esteem Ex.The nurse asked Harry who spent the weekend at home, what he did that weekend. Well, I just came back from California after signing a contract with MGM for a film on the life of Roosevelt. We have the most marvelous tour at the studiowent to lunch with the director. Deja vu- experience of feeling sure that one has witnessed or experienced a new situation previously, 2nd time-like feeling Jamais vu- not having been to the place on has been before Amnesia-memory loss, inability to recall past events Retrograde-distant past Anterograde-immediate past

Anomia- inability to name objects or persons Agraphia- partial or total loss of the ability to express ones thoughts coherently in writing Agnosia-loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective

LOSS AND GRIEVING

GRIEF- refers to the subjective emotions and affect that are a normal response to the experience of loss ANTICIPATORY GRIEVING- when people facing an imminent loss begin to grapple with the very real possibility of the loss or death in the near future DISENFRANCHISED GRIEF-grief over a loss that is not or cannot be acknowledged openly, mourned publicly or supported socially COMPLICATED GRIEVING-when a person is void of emotion, grieves for prolonged periods, has expressions of grief that seem disproportionate to the event LOSS Physiologic Loss Safe and Security Loss Love and Belongingness Loss Self-Esteem Loss Self-actualization Loss

GRIEVING PROCESS KUBLER-ROSSs Denial Anger Bargaining Depression Acceptance Dysfunctional grieving grieving which extends from 4 to 6 weeks leading to CRISIS

CRISIS AND ITS MANAGEMENT

CRISIS- situation that occurs when an individuals habitual coping ability becomes ineffective to merit demands of a situation TYPES OF CRISES: MATURATIONAL / DEVELOPMENTAL Normal expected crisis that runs through age SITUATIONAL Unexpected and sudden event in life ADVENTITIOUS Calamities, war PHASES OF A CRISIS Pre-crisis: State of equilibrium Initial Impact (may last a few hours to a few days): High level of stress, helplessness, inability to function socially Crisis (may last a brief or prolonged period of time): Inability to cope, projection, denial, rationalization Resolution: attempts to use problem-solving skills Post crisis: may have OLOF or may have symptoms of neurosis, psychosis

CRISIS MANAGEMENT Role of the nurse is to return the client to its pre-crisis state by assisting and guiding them until they achieved their OLOF. Goal: to enable patient to attain an OLOF Nurses Primary Role: Active and Directive

Steps in Crisis Intervention Identify the degree of disruption the client is experiencing Assess the clients perception of the event Formulate nursing diagnoses Involve the patient and family if applicable with planning Implement interventions- new and old coping mechanisms Evaluate-reassessment, reinforcement TYPES OF THERAPIES Remotivation Therapy- treatment modality that promotes expression of feelings through interaction facilitated by discussion of neutral topics Music Therapy- involves use of music to facilitate expression of feelings, facilitate relaxation and outlet of tension Play Therapy- enables patient-to-experience intense emotion to a safe environment with the use of play Children express themselves more easily in play, revealing as reflection of childs situation in the family Group Therapy- Number of people coming together, sharing a common goal, interest or concern, staying together and developing relationships Milleu Therapy Total environment has an effect on the individuals behavior Increase patients awareness of feelings, increase sense:responsibility and help return to community

Family Therapy- Client: Whole family Concepts The family is the most fundamental unit of the society. Adaptive or maladaptive patterns of behavior are learned from the family Dysfunction in the family = dysfunction in the individual

Purpose Improve relationships among family members Promote family function Resolve family problems OTHER TYPES OF THERAPIES SUPPORT GROUPS SELF-HELP GROUPS

For those with AIDS, Mother-Against-Drug Dependence Alcoholic Anonymous

BEHAVIORAL THERAPIES Pavlovs Classical Conditioning - All behavior are learned B.F. Skinners Operational Conditioning -Reinforcements Behavioral Modification Substance Abuse Token Economy Anorexia / Schizo Systematic Desensitization Phobia ATTITUDE THERAPY Paranoid Passive Friendliness Withdrawn Active Friendliness Depressed / Anorexia Kind Firmness Manipulative Matter of Fact Assaultive No Demand Anti-social Firm, consistent

PSYCHOSOMATIC THERAPY Electroconvulsive Therapy Effective in most affective disorders The induction of a grandmal seizure in the brain. Abnormal firing of neurons in the brain causes an increase in neurotransmitters Number of Treatments: 6-12 ,3 times a week, about .5-2seconds Unilateral or bitemporal

ANXIETY
Peplaus Levels of Anxiety Mild Associated with the tension of day-today living Perceptual field increased More alert than usual Adaptive Moderate Narrowed perception Difficulty focusing Selective inattention Mild somatic complaints: stomachache and butterflies in the stomach Severe Very narrowed perception Unable to focus on problem solving Increased physical discomfort All behavior is aimed at relieving anxiety Direction is needed to focus attention Panic Awe, dread and terror Unable to see the whole situation or reality Distortion of perception Disorganization of the personality A frightening and paralyzing experience

Antipsychotic Drugs Sub Classification: Phenothiazines Chlorpromazine(Thorazine) Fluphenazine(Prolixin) Perphenazine(Trilafon) Prochlorperazine(Compazine) Thioridazine(Mellaril) Triflouperazine(Stelazine) Non-Phenothiazines Clozapine Haloperidol Olanzapine Risperidone Thioxanthenes Thiothixene(Navane)

Mechanism of Action: Antagonizes dopamine in the CNS and also blocks Cholinergic, Histaminic, Serotogenic, Adrenergic neurotransmitters(anticholinergic, antihistaminic, anti-emetic) blocks activity of the CNS receptors and sympathetic nervous system

Side Effects: Increase v/s Constipation / dry mouth Postural hypotension Photophobia / photosensitivity Drowsiness Agranulocytosis Extrapyramidal symptoms Parkinsons syndrome Akathisia Akinesia Dystonia oculogyric crisis, torticollosis, opistothonus Tardive dyskinesia Neuroleptic Malignant Syndrome Nursing Care Guidelines: Avoid sunlight Report sorethroat,fever,muscular rigidity Rduced psychomotor agitation and insomnia-1week Reduction of hallucinations,delusions, and thought disorder takes 6-8 weeks

for full therapeutic effect Monitor Potassium level, BP, Temperature

Antidepressant Drugs SSRI Antidepressant Drugs Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro) Action: Inhibits reuptake and destruction of serotonin to prolong its action Side Effects: Anxiety Agitation Akathisia Nausea Insomnia Sexual dysfunction (anorgasmia/impotence) Nursing Care Guidelines: 2-3 weeks initial effect 3-4 weeks full therapeutic effect Side Effects: Anticholinergic (blurred vision, urinary retention, dry mouth, constipation) Orthostatic hypotension Sedation Weight gain Tachycardia Sexual dysfunction Patient Teaching Taking in the evening Using caution when driving Nursing Care Guidelines: 2-3 weeks initial effect 3-6 weeks full therapeutic effect Emphasize compliance avoid citrus fruits as it decrease the absorption Monitor BP, HR and ECG Side Effects: Sedation Insomnia Weight gain Dry mouth Orthostatic hypotension Sexual dysfunction Hypertensive crisis with excessive tyramine or sympathomimetic drugs Nursing Care Guidelines: 2-3 weeks initial effect 3-4 weeks full therapeutic effect Avoid foods rich in tyramine(processed,preserved,fermented) because it will lead to hypertensive crisis Monitor BP and food items Side Effects: Anorexia Weight loss Nausea Irritability Patient Teaching Avoiding caffeine, sugar, and chocolate Taking after meals Long-term use can cause dependency

TCA Antidepressant Drugs Imipramine (Tofranil), Desipramine (Norpramin), Amitriptyline (Elavil), Doxepin (Sinequan), Clomipramine (Anafranil)

Action: Prolongs the action of norepinephrine Dopamine Serotonin by blocking the reuptake of this neurotransmitters

MAOI Antidepressant Drugs Phenelzine (Nardil) Tranylcypromine (Parnate) Isocarboxazid (Marplan)

Action: blocks the metabolic destruction of neurotransmitters by the enzyme monoamine oxidase

CNS Stimulant Drugs Methylphenidate (Ritalin) Pemoline (Cylert), Dextroamphetamine

Action: Increases levels of neurotransmitters in the brain thereby increasing and decreasing hyperactivity

Nursing Care Guidelines: Give in AM, not beyond 2PM 6 hours before bedtime

Anti-Manic Drugs(Mood Stabilizing Drugs) lithium; anticonvulsant medications LithiumCarbonate(Eskalith,Lithane,Quilinium) Carbamazepine (Tegretol) Valproic acid (Depakote) Lamotrigine (Lamictal) Gabapentin (Neurontin)

Uses: Bipolar disorder Action: Exact mechanism is unknown, alters the level of norepinephrine and other neurotransmitters

Side Effects (Lithium) Nausea Diarrhea Anorexia Fine hand tremor Polydipsia Polyuria Fatigue Weight gain Acne Nursing Care Guidelines: Initial Effect: 10-14 days Full Therapeutic Effect: 3-4 weeks Take after meals with food or milk Discontinue drug, if toxicity occurs diarrhea, vomiting, ataxia, tremor, drowsiness, lack of coordination or muscular weakness.Antidote for toxicity Mannitol or Acetazolamide Avoid caffeine,diuretics,and activities that increase perspiration Monitor serum level at least once a month o Maintenance dose:0.6-1.2 meq/L o Acute Level: 1.5meq/L o Level for the elderly: .4-1.0meq/L

ANTIANXIETY DRUGS Classification: BenzodiazipinesAlprazolam(Xanqax) Chlordiazepoxide(Librium) Chlorazepate(Tranxene) Diazepam(Valium) Lorazepam(Ativan) Azaspirones-Buspirone(Buspar) NonbenzodiazepinesHydroxyzine(Vistaril) Meprobamate(Equanil) Uses: Anxiety disorders, insomnia, OCD, depression, PTSD, alcohol withdrawal Action: Moderate the actions of GABA

Side Effects Tolerance and dependence Drowsiness Sedation Poor concentration Impaired memory Clouded sensorium Patient Teaching Using caution during driving due to slower reflexes and response time Never discontinuing abruptly as withdrawal can be fatal Avoiding alcohol Nursing Care Guidelines Use only in a short time (1-2 weeks) Tolerance (after 7 days) and dependence (after 1 month) Liver function test Monitor for side effects. Avoid machines, activities needing concentration

Z tract if given parenterally Avoid mixing with alcohol, antacids Dont stop abruptly but gradually for 26 weeks Avoid caffeine

CATEGORIES OF ANXIETY DISORDERS

Basic Anxiety Disorders Somatoform Disorders Dissociative Disorders

Basic Anxiety Disorders

Generalized Anxiety Disorder Post Traumatic Stress Disorders Phobia Obsessive Compulsive

Generalized Anxiety Disorder Excessive worry and anxiety for days but not more than 6 months Difficulty in controlling the worry Anxiety and worry are evident by 3 or more of the following : Restlessness Fatigue and irritability Decreased ability to concentrate Muscle tension Disturbed sleep Anxiety or worry causes significant impairment in interpersonal relationship or activities of daily living Post Traumatic Stress Disorders Disturbing pattern of behavior occurring after a traumatic event that is outside the range of usual experience. Characteristics Persistent re-experiencing of the trauma through recurrent intrusive recollections of the event, through dreams or flashbacks Persistent avoidance of the stimuli Feeling of detachment of estrangement from others Chemical abuse to relieve anxiety Phobias

Persistent, irrational fear of a specific object, activity or situation that leads to a desire for avoidance or actual avoidance of the object of fear Specific Phobia Experience of high level of anxiety or fear provided by a specific object or situation Treatment: Systematic Desensitization Defense mechanisms Repression and displacement

Major Types of Phobias Agoraphobia Fear of being alone in open or public spaces Social Phobia Fear of situations where one might be seen and embarrassed or criticized Specific Phobias Fear of a single object, situation or activity that cannot be avoided Clausrophobia close place Agoraphobia- open place Acrophobia high place Aelophobia cats Cynophobia dog

Obsessive Compulsive Disorder Obsessions Preoccupation with persistent intrusive thoughts, impulses or images Compulsions Repetitive behaviors or mental acts that the person feelds driven to perform in order t reduce distress or prevent a dreaded event or situation Cues: Ritualistic behavior Constant doubting if he/she has performed the activity Care Strategies Be nonjudgmental and honest; offer empathy and support Help patient to recognize the connections between the trauma experience and their current feelings, behaviors and problems. Encourage verbalizations of feelings, especially anger. Encourage adaptive coping strategies and techniques Encourage patients to establish or reestablish relationships Explore shattered assumptions. Im a good person. This is a safe world. Promote discussion of possible meaning of the events.

Somatoform Disorders
Body Dysmorphic Disorder Somatization Conversion Disorders Hypochondriasis Psychogenic pain

Body Dysmorphic Disorder Preoccupation with an imagined defect in his or her appearance Ex. Michele, a young, attractive woman, is preoccupied that her nose is too long and ugly. She is preoccupied and quite distressed over her perception. Two plastic surgeons she consulted are hesitant to reshape her nose but have not altered her thinking that her nose makes her ugly. Somatization A client expresses emotional turmoil or conflict through a physical system, usually with a loss or alteration of physical functioning Hx of pain in at least 4 sites Hx of at least 2 GIT symptoms other than pain Hx of at least one sexual/reproductive symptom Hx of at least one neurologic disorder Ex. Deanna, 27, presents at the doctors office with excessive heavy menstruation. She tells the nurse that recently she experienced pain first in my back and then going to every part of my body.She states that she is often bothered with constipation and frequent vomiting when she eats the wrong food. She states she had been unwell and had suffered from seizures and still experiences it occasionally. The nurse becomes confused, not knowing what symptoms she wants the doctor to evaluate. Deanna tells the nurse she lives at home with her parents because her poor health makes it hard for her to hold a job

Conversion Disorders A psychological condition in which an anxiety-provoking impulse is converted unconsciously into functional symptoms Development of a symptom suggesting neurologic disorder(blindness, deafness etc.) or involuntary motor function(paralysis, seizures) Ex. Jan, a 28 year old former secretary, awakes one morning to find that she has a tingling in both hands and cannot move her fingers. Two days earlier, her husband had told her that he wanted a separation and that she would have to go back to work to support herself.

Hypochondriasis Presentation of unrealistic or exaggerated physical complaints Ex. Garry, 52, lost his wife to colon cancer 5 months ago, which he took very well. Recently he consulted the physician with the same complaint. He believes that he has liver cancer, despite repeated and extensive diagnostic tests, which are all negative. He has ceased seeing his friends, has dropped his hobbies and spends much of his time checking his sclera and resting his liver.

Nursing Diagnosis Ineffective Individual Coping Self-Care Deficit Diversional Activity Deficit

Nursing Interventions Offer explanations and support during diagnostic testing-reduces anxiety while ruling out organic illness After physical complaints have been investigated, avoid further reinforcement-directs focus away from physical symptoms Spend time with client at all times other than when client summons nurse to offer physical complaint-rewards non-illness related behaviors and encourages repetition of desired behavior Observe and record frequency and intensity of somatic symptoms-establishes a baseline and later evaluation of effectiveness of interventions Do not imply that symptoms are not real-psychogenic symptoms are real to the client even though causation is not organic Shift focus from somatic complaints to feelings or to neutral topics-conveys interest in client as a person rather than in clients symptoms Assess secondary gains that physical illness provides for client-nurse can work with the client to meet these needs in healthier ways and thus minimize secondary gains Use matter-of-fact approach to clients exhibiting resistance or covert anger-avoids power struggles, demonstrates acceptance of anger and permits discussion of angry feelings Set limits on manipulative behavior that violates rights of others-protects other clients and significant others Help client look at result of manipulative behavior on others-encourages insight and can help improve intrafamily relationships Show concern for client while avoiding fostering dependency needs-shows respect for clients feelings while minimizing secondary gains Reinforce clients strengths and problem-solving abilities-contributes to positive self-esteem

Dissiociative Disorders
Dissociative amnesia Dissociative fugue Depersonalization Dissociative Identity Disorder / Multiple Identity Disorder

Dissociative amnesia Characterized by the inability to recall an extensive amount of important personal information because of physical or psychological trauma Ex. A young woman was partly dressed and poorly nourished when found by a police road patrol. She had no knowledge of who she was. Her parents identified her when she appeared on a morning news television program. Hospital examination revealed the probability of recent rape. She was able to remember going to a party off-campus but had no recall of the party or the events after.

Dissociative fugue The person suddenly and unexpectedly leaves home or work and is unable to recall the past Depersonalization Person experiences a strange alteration in the perception or experience of the self, often associated with a sense of unreality Ex. Mrs. Chin Sue became highly distressed when she perceived changes in her appearance when she looked in a mirror. She thought her image looked wary and indistinct. Soon after, she described feeling as though she was floating in a fog with her feet not actually touching the ground. During therapy, it was learned that Mrs. Chin Sues son had revealed to her his HIV positive status

Dissociative Identity Disorder / Multiple Identity Disorder A person is dominated by at least one of two or more definitive personalities at one time Ex. Gertrude, a passive, conservative woman alternated personalities with Diana, who was sexy and flirtatious. During therapy, Gertrude and Diana revealed themselves as other distinct personalities.

PSYCHOSOMATIC DISORDER
hormonal and bodily changes Increase anxiety may result to asthma, stress ulcers or migraine

Schizophrenia
A major form of psychotic disorder that affects a persons thinking, language, emotions, social behavior and ability to perceive reality At least 2 of 5 types of positive and negative symptoms Characteristic Symptoms Social or occupational dysfunction Self care Duration Continuous for at least 6 months

Signs and Symptoms Positive Symptoms- symptoms that normal people dont exhibit Hallucinations false sensory perception/experiences that does not exist in reality Delusions persecutory or grandiose or ideas of preference.), Ambivalence-holding seemingly contradictory beliefs o feelings about the same person Associative looseness-fragmented or poorly related thoughts and ideas Perseveration-persistent adherence to a single idea or topic.(verbal repitition of a sentence, word or phrase;resisting attempts to change the topic Negative Symptoms- absence of those that normal people exhibit Affective flattening-absence of facial expression Anhedonia feeling no joy or pleasure from life or any activities or relationships Attention impairment Apathy-feeling of indifference towards people,activities and events Anergia Avolution-decreased motivation Types of Schizophrenia Types and Manifestations Distinguishing Features Defense Mechanism Nursing Diagnosis

CATATONIC Abnormal motor behavior-waxy flexibility,echopraxia Regression Impaired motor activity

DISORGANIZED Bizaare behavior Regression Impaired Social Functioning Assistance with ADL

Priority Nursing Care Circulation and nutrition Other types:undifferentiated-mixture of all types Residual- with minimal symptoms Manifestations: S-social isolation C-catatonic behavior H-hallucinations I-Incoherence Z-zero/lack of interest and initiative O-obvious failure in development P-peculiar behavior H-hygiene and grooming impaired R-recurrent illusions E-exacerbations and remissions N-no organic factor account S/S I-inability to return to functioning A-affect is inappropriate

PARANOID Suspiciousness and ideas of reference Projection Potential for injury directed at others Nutrition and Safety

Bipolar Disorder
Also called affective disorders, are pervasive alterations in emotions that are manifested by depression, mania or both Interferes with a persons life With accompanying self-doubt, guilt and anger which alter life activities

Mania-a distinct period during which mood is abnormally and persistently elevated, expansive or irritable lasting 1 week with at least 3 additional symptoms(can be inflated self-esteem, pressured speech, decreased need for sleep, flight of ideas, distractibility, psychomotor agitation); impairs the persons ability to function. Hypomania-a period of abnormally and persistently elevated, expansive or irritable mood lasting 4 days and including 3 or 4 additional symptoms (above); does not impair the persons ability to function and there are no psychotic features Euthymic mood-average affect and activity Anergia-lack of energy Anhedonia-lack of interest on previously enjoyed activities Primary Mood Disorders: Major depressive disorder Bipolar disorder Bipolar I disorder-one or more manic or mixed episodes usually accompanied by major depressive episodes Bipolar II disorder-one or more major depressive episode accompanied by at least one hypomanic episode

PREDISPOSING FACTORS I. Biologic theories -first degree relatives (3%-8%) -identical twins (2-4x higher risk than fraternal twins)

II. Neurochemical theories deficits of serotonin occur in people with depression norepinephrine maybe deficit in depression and increased in mania Kindling-process by which seizure activity in a specific area of the brain is initially stimulated by reaching a threshold of the cumulative effects of stress. Low amounts of electric impulses or chemicals such as cocaine that sensitize nerve cells or pathways. These highly sensitized nerve cells respond by no longer needing the stimulus to induce seizure activity, which now occurs spontaneously.

III. Psychodynamic theories 1. Freud-looked at the self-depreciation of people with depression and attributed that self approach to anger turned inward related to either a real or perceived loss. 2. Bibring-believed that ones ego(self) aspired to be ideal that is good and loving, superior or strong. Depression results when in reality these ideals all the time 3. Jacobson- compared the state of depression to a situation in which the ego is a powerless, helpless child victimized by the superego much like a powerful and sadistic mother who takes delight in torturing the child. 4.Meyer-viewed depression as a reaction to a distressing life experience such as an event with psychic casuality 5.Horney-believed that children raised by rejecting or unloving parents were prone to feelings of insecurity and loneliness, making them susceptible to depression and helplessness 6.Beck-saw depression as resulting from specific cognitive distortions in susceptible people. Early experiences shaped distorted ways of thinking.

Major Depressive Disorder

At least 5 of the following symptoms present during the 2 week period IN Interest is lacking in most everything. They may feel lethargic. Libido may be decreased and they are commonly apathetic. They may experience despair and become apathetic. S -Sleep is hard to come by. They often have several hours of sleep and then awaken with inability of going back to sleep. Real rest is often hopeless which may add to the depression. Some people may want to sleep all the time. They are so depressed, they do not want to go out of bed.

A - Appetite is very often depressed. Food doesnt look good or taste good. D Depressed people can be very tearful. They no longer smile and have a flat effect or no expression on their face. C Concentration is often lacking. They may not be able to do their jobs or maintain their relationships due to the depression. A Activity is decreased. They may become couch potatoes and refuse to participate in routine activities. Exercise may be an activity that they can no longer perform. G Guilt may bring a negative view of self, world or future. E energy level is decreased. They may have a poverty of ideas and turn their aggressive feelings inward. S suicide precautions are mandatory. Maintaining a safe environment and negotiating a contract with them may be life saving.

Mania Vs Depression Mania Colorful, flamboyant Psychomotor agitation Pressured speech Stuttering Cluttering Risk for Injury(others) Safety and Nutrition Finger foods and high in calorie Lithium;ECT Non-stimulating environment Quite type;non-competitive Matter of Fact Depression Sad and gray Psychomotor retardation Monotonous speech

Appearance Behavior Communication

Nursing Diagnosis Nursing Priority Nutrition Treatment Milleu Appropriate Activity Attitude Therapy

Risk for injury(self)suicidal precaution Safety and Nutrition Increased in nutrients TCA;SSRis;MAIOS;ECT Stimulating Monotonous;non-competitive Kind Firmness;Active Friendliness

Suicide
The intentional act of killing oneself Suicidal Ideation- means thinking about oneself A. Passive suicidal ideation-when a person thinks about wanting to die or wishes he/she were dead but has no plans to cause his/her death (e.g. reckless driving, heavy smoking, overeating, self-mutilation, drug abuse) Active suicidal ideation-when a person thinks about and seeks to commit suicide.

B.

SAD PERSONS SCALE S-Sex Men kill themselves 3x more than women though women make attempts 3x more often than men A-Age High risks groups:19 years or younger; 45 years or older, especially the elderly 65 and above D-Depression Studies report that 35-79% of those who attempt suicide manifested a depressive syndrome P-Previous Attempts Of those who commit suicide, 65-70% have made previous attempts E-ETOH Alcohol is associated with up to 65% of successful suicides R-Rational Thinking Loss People with functional or organic psychoses are more apt to commit suicide than those in the general population S-Social Supports Lacking A suicidal person often lacks significant others, meaningful employment and religious supports O-Organized Plan The presence of a specific plan for suicide signifies a person at high risk N-No Spouse repeated studies indicate that persons who are widowed, separated, divorced or single at greater risk than those who are married S-Sickness Chronic, debilitating and severe illness is a risk factor Theories of SUICIDE Psychodynamic theories describe suicide as a wish to be at peace with the internalized significant person Wish to be reunited with a deceased loved object Suicide is an attempt to escape from an intolerable situation or intolerable state of mind Sociological Theories Durkheim-pioneer of sociological research in the study of suicide

3 Principal types: 1. Egotistic suicide-occurs when a person is insufficiently integrated into society 2. Anomic suicide-occurs when a person is isolated from others through abrupt changes in social norms/status 3. Altruistic suicide- occurs as a response to societal demands (deaths of Buddhist monks who set themselves on fire to protest the Vietnam war) Precipitating factors Social isolation-have difficulty forming and maintaining relationships Severe lifes events-divorce, death, sickness, legal problems, interpersonal discord Sensitivity to Loss-may react tragically to separation or loss of a loved one (had insecure or unreliable childhood experiences)

Suicide Precautions Execute a no suicide contract. The client will inform the nurse when he/she has suicidal ideations Ask direct questions. Find out if the person has specific plan for suicide. Determine what method. Be alert for cries for suicide Provide a safe environment and protect client from self Encourage to ventilate feelings and thoughts Give emotional support Make the patient realize that the tendency to commit suicide is due to the disturbance in the brain chemistry and is treatable-once they know that an episode of suicidal thinking will pass, they will likely not act on the impulse Provide structured schedule and involve in activities with others to increase self-worth and divert attention On discharge: help patient create plan for Life(list of warning signs of suicidal ideation and actions to take) Always remember: A. That a suicidal person want to die only during the period of suicidal crisis-during this time the person is ambivalent about living and dying B. Suicidal people gives warning C. Persons recovering from depression are high risk for 9-15 months after recovery D. Suicidal people are extremely unhappy but not always mentally ill

Personality behaviors

PERSONALITY DISORDERS
Paranoid A pervasive pattern of distrust and suspiciousness of others such that their motives are interpreted as malevolent Suspicious (e.g. others are exploiting or deceiving him) Doubt trustworthiness of others Fear of confiding in others Fear personal information will be used against him Interpret remarks as demeaning or threatening Hold grudges toward others Becomes angry and threatening when they perceive to be attacked by others A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings Lacks desire for close relationships or friends including family Chooses to be alone Lack of sexual experiences Avoids activities Appears cold and detached A pervasive pattern of social and interpersonal deficits marked by acute Intervention: centered on building trust

Schizoid

Interventions: building trust followed by identification and appropriate verbal expression

Schizotypal

Interventions:

discomfort with and reduced capacity for close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior Ideas of reference Magical thinking or odd beliefs Unusual perceptual experiences, including bodily illusions Peculiar thinking Vague, stereotypical, over elaborate speech Suspiciousness Blunted or inappropriate affect Eccentric appearance or behavior Few close relationships Uncomfortable in social situations

Improving Interpersonal relationships, social skills, and appropriate behaviors

Anti-social

Characterized by deceit, manipulation, revenge and harm to others with an absence of guilt or anxiety Violates rights of others Engages in illegal activities Aggressive behavior Lack of guilt or remorse Irresponsible in work and with finances Impulsiveness Recklessness Manipulative Characterized by pervasive pattern of unstable interpersonal relationships; selfimage and affect; and marked impulsivity Frantic avoidance of abandonment; real or imagined Unstable and intense interpersonal relationships Identity disturbances Impulsivity Self-mutilating behavior Rapid mood shifts Chronic feelings of emptiness Problems with anger Transient dissociative and paranoid symptoms Grandiose self importance Fantasies of unlimited power, success or brilliance Believes he or she is special Needs to be admired Sense of entitlement Takes advantage of others for own benefit Lacks empathy Envious of others or others are envious of him Arrogant

Interventions: Consistency Kind firmness in confronting behaviors and enforcing rules and policies Limit setting Decrease impulsivity Enhance role performance Effective use of confrontation

Borderline

Interventions: Use of empathy. Recognize the reality of the patients pain. Offer support Empower and work with the patient to understand control and change dysfunctional behaviors. Provide safe environment Teach social skills Make a list of solitary activities to combat boredom Diary keeping Cognitive restructuring Suicide precaution Interventions Supportive confrontation on what the patient says and what exists. Limit setting and consistency to decrease manipulation and entitlement behaviors. Remain neutral, avoid power struggles, or becoming defensive.

Narcissistic

Histrionic

A pervasive pattern of excessive emotionality and attentive seeking Overly dramatic Draws attention to self

Interventions: Positive reinforcement in the form of attention, recognition or praise are given for

 Dependent

Extroverted and thrives on being the center of attraction Uses somatic complaints to avoid responsibility and support dependency Dissociation

unselfish or other-centered behaviors

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation Needs others to be responsible for important areas of life. Problems with initiating with projects or doing things on his own because of little self confidence Performs unpleasant tasks to obtain support from others Urgently seeks another relationship for support and care after a close relationship ends Preoccupied with fear of being alone to care for self A pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation Avoids occupations involving interpersonal contact due to fears of disapproval or rejection Preoccupied with being criticized or rejected in social situations Inhibited and feels inadequate in new interpersonal situations Very reluctant to take risks or engage in new activities due to the possibility of being embarrassed A pervasive pattern of preoccupation with orderliness, perfectionism and mental and interpersonal control at the expense of flexibility, openness and efficiency Preoccupied with details, lists, rules, organization Perfectionist Too busy working to have friends or leisure activities Unable to discard worthless or worn-out objects Reluctant to spend and hoards money Rigid and stubborn

Interventions: increase responsibility for self in day to day living; assertiveness training

Avoidant

Obsessive Compulsive

DELIRIUM & DEMENTIA Delirium

Characterized by disturbance of consciousness and a change in cognition such as impaired attention span and disturbances in consciousness that develop over a short period of time. Always secondary to another condition (medical condition or substance abuse) Frequent among the elderly and young febrile children Fluctuations of consciousness and inoculation throughout the day

Classified as mild to severe. Sundowning

Dementia
Characterized by multiple cognitive deficits that include impairment of memory which develops slowly 80-90% irreversible Reversible due to pathologic process Most common: Alzheimers Dementia

4 Symptoms of Dementia Loss of memory Deterioration of language function Loss of ability of think abstractly, plan, initiate, sequence, monitor or stop complex behavior Loss of ability to perform ADLs Stages of Dementia Stage 1 Stage 2 Stage 3 Stage 4 Mild (Forgetfulness) Losses in short term memory Memory aids compensate Aware of the problem, disturbed Not diagnosable at this time Moderate (Confusion) Progressive memory loss ST memory loss interferes with ADLs Withdrawn, Denial, Fear of Losing their minds Depression, Confabulation Problems increase when stressed Needs home care or in-home assitance Moderate to Severe (Ambulatory Dementia) Loss of reasoning ability, planning and verbal communication Frustrated, withdrawn, self-absorbed Depression decreases Reduced stress threshold Institutional care required Late (EndStage) Family recognition disappears Doesnt recognize self Nonambulatory Little purposeful activity Often mute, may scream spontaneously Forgets most ADLs Problems associated with immobility Institutional care required Return of primitive reflexes

LATER CHANGES IN DEMENTIA Aphasia speech Apraxia purposeful activity Agnosia sensory stimuli Anomia memory of items Amnesia loss of memory

CHEMICAL DEPENDENCE
Alcohol Abuse Substance Abuse

Substance Dependence maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by three or more of the following, occurring at any time in the same 12 month period Tolerance Withdrawal Substance is often taken in larger amounts or over a longer period than intended Persistent desire or unsuccessful effort to cut down Time is spent in activities necessary to obtain the substance, use the substance or recover from its effects Important social, occupational or recreational activities are given up or reduced because of substance use.

Substance Abuse A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following within a 12 month period. Recurrent substance use resulting in failure to fulfill major role obligations at work, school or home Used in dangerous situations Substance related-legal problems Continued substance use despite having persistent or recurring problems caused or exacerbated by the effects of the substance Alcohol Abuse Alcohol is a legal substance A central nervous system depressant A disease that can be arrested but not cured. Used with other substance

Alcohol equivalents One drink= 1 oz 86 proof hard liquor= 5 oz glass of table wine= 12oz can/bottle of beer

ALCOHOLISM
Intergenerational Transmission Awake but unaware Blackout Confabulation Denial, dependence Enabling, co-dependence Tolerance increases Detoxification - doctor Avoid alcohol during therapy Aversion therapy Antabuse disulfiram Belongings check for alcohol, mouthwash, elixir etc. B1 deficiency Complication Wernickes Encephalopathy (Motor) Korsakoffs Psychosis (Mind) Delirium Tremens Formication

Principles of Nursing Care Provide a well-lighted room DAT; Vitamin B1; Glucose Monitor v/s Long term therapy Support system Alcoholic Anonymous Alanon Alateen Family therapy Provide safety: alcohol free environment Increase self-esteem Resocialization

Stages of Alcohol Withdrawal I 8 hours after the last drink Mild tremors, tachycardia, increased BP, diaphoresis, nervousness 2 8-12 hours after the last drink Gross tremors, hyperactivity, profound confusion, loss of appetite, insomnia, weakness disorientation, illusions, hallucinations and delusions 3 12-48 hours after the last drink * severe hallucinations, grand mal seizures 4 3-4 days after the last drink Delirium tremens, confusion, agitation, hallucinations, insomnia and tachycardia

CODEPENDENCY An over responsible behavior-doing for others what they just as well do to themselves Women or wives of alcoholics Codependent individuals find themselves: 1. Attempting to control someone elses drinking 2. Spending inordinate time thinking about the alcoholic person 3. Covering up the persons drinking or lying 4. Feeling responsible for the persons alcohol use 5. Feeling guilty for the alcoholics behavior 6. Avoiding family and social events because of concerns or shame about the alcoholics behavior 7. Allowing moods to be influence by the alcoholic 8. Assuming the alcoholics duties and responsibilities 9. Often bailing the alcoholic out of financial or legal problems UPPERS AND DOWNERS UPPER Cocaine Hallucinogens Amphetamines

DOWNERS Marijuana Alcohol Barbiturates Narcotics Heroin Codeine Morphine Intervention: Behavioral Modification Detoxification Family Marital Therapy Self Help Groups Medication Cardinal signs Narcotics: pupillary constriction, decreased BP Stimulants: pupillary dilation, increased BP, paranoia Hallucinogen : Bloodshot eyes, dry mouth, cravings for junk foods Sedatives: tremors, sedation

SEXUAL AND GENDER IDENTITY DISORDERS Paraphilias

Data Base A.Etiologic factors 1. Sexual urges or fantasies that are directed toward nonhuman objects, infliction of pain to self, partner, children, or other nonconsenting individuals for at least 6 months duration 2.Diagnosis is made when the individual has acted on urges or is extremely distressed by the urges 3. Sexual arousal accompanies paraphiliac fantasies or stimuli 4. Person may or may not be able to function sexually without the paraphiliac fantasy or stimuli 5. May be symptomatic of other personality or psychiatric disorders 6. May occur as a behavior aberration or a disordered personality 7. Onset of fantasies and related behaviors may begin in childhood or early adolescence and becomes more defined in adulthood B. Types and Behavioral/Clinical Findings 1. 2. 3. 4. 5. 6. 7. 8. Fetishism: substitution of an inanimate object for the genitals Transvestic fetishisms: wearing clothes of the opposite sex to achieve sexual pleasure Exhibitionism: sexual pleasure obtained by exposing the genitals Pedophilia: attraction to children as sex objects Voyeurism: sexual gratification obtained by watching the sexual play of others Sadism: sexual gratification obtained from cruelty to others used as substitute for or an accompaniment to the sex act Masochism: sexual gratification obtained from self-suffering; used as a substitute for or an accompaniment to the sex act Frotteurism: sexual pleasure obtained by touching or rubbing against a nonconsenting person usually occurs in crowds or on public transportation 9. Necrophilia: sexual gratification obtained from sexual relations with a corpse 10. Telephone Scatologia: sexual gratification from or during lewdness on the telephone C. Therapeutic Interventions 1. 2. Rather unsuccessful with these individuals unless they really want to change If change is desired, psychotherapy may be effective treatment models a. Cognitive therapy b. Behavioral therapy

NURSING CARE OF CLIENTS WITH PARAPHILIAS A. Assessment 1. History of sexual behavior 2. Presence of other psychosocial difficulties 3. Level of Anxiety regarding sexual behavior 4. Pending criminal charges 5. Why client is seeking treatment at this time 6. Potential for violence toward others or self Analysis/Nursing Diagnoses 1. 2. 3. 4. 5. 6. 7. Anxiety related to threat to security, fear of discovery, and conflict between sexual desires and societal norms Disturbed body image related to feelings about size and functioning of genitalia and ineffective past sexual functioning Ineffective coping related to inability to meet basic sexual need and sexual role expectations and poor self-esteem Risk for infection related to frequent changes in sexual partners and sadistic or masochistic acts Risk for injury related to retaliation for sexual behavior or sadistic or masochistic acts Ineffective sexuality patterns related to an inability to achieve sexual satisfaction without the use of paraphiliac behaviors Risk for violence: directed toward others or self, related to choice of sex objects or obtaining sexual gratification by inflicting or receiving physical abuse

B.

C.

Planning/Implementation See Fundamental Principles When Caring for Clients with Sexual and Gender Identity Disorders

D.

Evaluation/Outcomes 1. 2. Ceases socially unacceptable behavior Seeks and continues long-term therapy

3. 4.

Limits paraphiliac behavior to consenting adults Utilizes safer sex techniques

Sexual Dysfunction
Data Base A.Etiologic factors 1. Inhibition or interference with the desire, excitement, orgasm or resolution phases of the sexual response cycle 2. Dysfunction is psychogenic, but it may begin with a physiologic basis 3. Dysfunction can be lifelong or acquired 4. Dysfunction can be generalized or situational B. Types and Behavioral/Clinical Findings 1. Sexual desire disorders: deficient, absent, or extreme aversion to and avoidance of sexual activity 2. Sexual arousal disorders: partial or complete failure to achieve a physiologic (subjective) response to sexual activity 3. Orgasm disorders: delay in or absence of orgasm or premature ejaculation 4. Sexual pain disorders: recurrent or persistent genital pain before, during, or after sexual activity C. Therapeutic interventions 1. Treatment of underlying physiologic cause if present 2. Sexual counseling for client and partner Nursing Care of Clients with a Sexual Dysfunction A. Assessment 1. Feelings about inability to function sexually 2. Expectations regarding sexual ability 3. Effect of sexual dysfunction on relationship with significant other B. Analysis/Nursing Diagnoses 1. Anxiety related to threat to security and fear of discovery 2. Disturbed body image related to feelings about size and functioning of genitalia and ineffective past sexual functioning 3. Ineffective coping related to inability to meet basic sexual needs and sexual role expectations and poor self-esteem 4. Sexual dysfunction related to lack of sex education, lack of communication with partner regarding individual responses, ineffective sexual techniques, physical (illness, injury, surgery, medication) or substance abuse (addiction) contributing to sexual dysfunction, feelings of vulnerability, value conflict, and actual or perceived sexual limitations C. Planning/Implementation 1. See Fundamental Principles When Caring for Clients with Sexual and Gender Identity Disorders 2. Recognize that the problem is real to the client regardless of age 3. Recognize that the desire to function sexually does not diminish with age D. Evaluation/Outcome 1. Reports an increased satisfaction in sexual functioning 2. Reports sexual ability approaches sexual expectations Intervention Psychotherapy Individual therapy Group Psychotherapy Social skills training Treatment of co-morbid physical and psychiatric features Hormonal treatments Medications Anti-androgen drugs (Medroxyprogesterone acetate and Cyproterone acetate)

AUTISM & ADHD

Autism
Living in their own world Appearance flat (consistent)

Behavior ritualistic, repetitive Communication echolalia, incomprehensible

Nursing Diagnosis: Impaired Verbal Communication Impaired Social Interaction Self Mutilation Risk for Injury

Attention Deficit/Hyperactive Disorder(ADHD)

7 years old and above Duration: 6 months and above Requires 2 settings: home and school Appearance: Dirty child Behavior: Clumsy, hyperactive, impatient Communication: talkative, bursts out Structure Setting limits Schedule Safety

Mental Retardation
Subnormal general intellectual functioning which originates during the developmental period and is associated with impairment of either learning and social adjustment or maturation or both.

Causes: 1. congenital numerical deficiency or abnormal arrangement of brain cells 2. birth injuries due to pelvic disproportions, premature births or forceps delivery 3. infectious diseases e.g. german measles of the mother during the first 3 months of pregnancy 4. infectious diseases during childhood e.g. meningitis or encephalitis 5. endocrine deficiencies such as thyroid deficiency, known to be the cause of cretinism 6. exposure to environmental deprivation, with poor housing and economic and social conditions 7. familial or hereditary causes 8. inborn errors of metabolism e.g. inability to metabolize proteins, carbohydrates or fats 9. genetic defects e.g. abnormalities in the genes and chromosomes

Physical Appearance small head; almond-shaped, downward slanted eyes; thick lips.short fat hands with usually one palmar line (simian crease); yellow complexion tongue is flabby with deep groves and fissures friendly and love to imitate others acute leukemia is more prevalent in them usually mouth breathers and prone to respiratory infections many die at an early age Temper tantrums

Classification of Mental Retardation according to IQ CATEGORY Borderline Mild Moderate Severe Profound IQ 68-85 52-67 36-51 20-35 Under 20

Mild (Educable/Moron) Can develop social communication skills; minimal retardation in sensorimotor areas; often not distinguished from normal until late age (0-5 years) Can learn academic skills up to approximately 6th grade until late teens. Can be guided toward social conformity, educable (6-20 years) Can usually achieve social and vocational skills adequate to minimum self-support but may need guidance and assistance when under unusual social or economic stress(21-adult Moderate (Trainable/Imbecile) Can talk or learn to communicate; poor social awareness; fair motor development, profits from training in self-help; can be managed with moderate supervision (0-5) Can profit from training in social and occupational skills; unlikely to progress beyond second grade in academic subjects; may learn to travel alone in familiar places (6-20) May achieve self-maintenance in unskilled or semi-skilled work under sheltered conditions; needs supervision and guidance when under mild social or economic stress (21-adult) Severe(Imbecile) Poor motor development; speech is minimal; generally unable to profit from training in self-help; little or no communication skills (05) Can talk or learn to communicate; can be trained in elemental health habits, profits from systematic habit training (6-20) May contribute partially to self maintenance under complete supervision; can develop self-protection skills to a minimal useful level in a controlled environment (21-adult) Profound (Idiot) Gross retardation; minimal capacity for functioning in sensorimotor areas;needs nursing care (0-5) Some motor development present; may respond to minimal or limited training in self-help (6-20) Some motor and speech development; may achieve very limited self-care; needs nursing care (21-adult) Nursing Care Help parents accept diagnosis of mental retardation Consider the developmental/functional age, not the chronological age Teach parents/caregivers that they should: Protect the child from danger Make the child as independent as his condition will permit Teach the child to refrain from holding their mouths open as this gives them a dull appearance Select attractive, well-fitting clothing, hairstyle and good hygiene practices Teach parents/caregivers that they should: Eliminate the childs undesirable social traits, e.g. touching their noses and ears, scratching Teach the child only one thing at a time Demonstrate what they teach as much as possible Use pictures for these are valuable teaching aids Start teaching the child simple things, gradually progressing to complex learning experiences Remember that repetition and patience are necessary virtues Refrain from scolding because it blocks learning Recognize that temper tantrum as a childs attempt to meet some underlying emotional needs

Eating Disorders
Anorexia Nervosa Bulimia Nervosa

Anorexia Nervosa
Symptoms: Refusal to maintain body weight over a minimum normal weight for age and height Intense fear of gaining weight or becoming fat, even though underweight Disturbance in the way in which ones bodyweight, shape or size is experienced In females, absence of menses of at least 3 consecutive cycles Inability or refusal to acknowledge the seriousness of the problem Onset: 12-15, 17-21 years of age

Etiology

Cultural pressure Serotonin imbalance controls appetite and the satiety control center Family Patterns Perfectionist Does not permit verbalization of feelings Marital problems

Clinical Presentation Part 1 Terrified of gaining weight Pre-occupied with thoughts of food See themselves as fat even when emaciated Peculiar handling of food Cutting food into small bits Pushing pieces of food around the table May develop rigorous exercise program Self-induced vomiting, laxatives and diuretics Cognition so disturbed that they judge their self-worth by their weight.

Clinical Presentation Part 2 Low weight Amennorrhea Yellow skin Cold extremities Peripheral edema Muscle weakening Constipation Low T3 and T4 Hypotension Bradycardia Hypokalemia Anemia Pancytopenia Decreased bone density

Signs related to Purging Behaviors Gastrointestinal Parotid gland tenderness, Pancreatitis, esophageal and gastric erosion or rupture Metabolic Electrolyte abnormalities hypokalemia Dental Erosion of dental enamel of the front teeth

Objectives Increasing body weight to at least90% of average weight for age and height Reestablishing good eating behavior Increasing self esteem

Nursing Interventions: Monitor daily caloric intake, activity level, weight and electrolyte status. Establish nutritional eating patterns Sit with client during meals Offer liquid protein supplement if unable to complete a meal Observe signs of purging 1-2 hours after meals Provide accurate information on nutrition and discuss realistic and healthy diet Help the client identify emotions and develop non-food related strategies. Convey warmth and sincerity Ask the client to identify feelings Assist the client to change stereotypical beliefs Assist in identifying at least three positive characteristics Teach patient about their illness Behavior modification : reward increase in weight with meaningful privileges Identify patients non weight related interests to reduce anxiety and refocus attention.

Bulimia Nervosa
Symptoms: Recurrent episodes of binge eating Feeling of lack of control over eating behaviors during the eating binges Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self induced vomiting Binge eating and inappropriate eating behaviors Persistent over concern with body shape and weight

Clinical Presentation Binge and Purging behaviors Have depressive signs and symptoms Disturbed home life Major concerns Interpersonal relationships Self-concept Impulsive behaviors Chemical dependence is also common Normal to slightly low weight Dental carries Parotid swelling Gastric swelling and rupture Callusses or scars on the hand Peripheral edema Hypokalemia, Hyponatremia

Etiology Behavior

Communication Nursing Diagnosis Nursing Priority Treatment / Therapy Environment

ANOREXIA Psychological (Freudian); Socio-cultural; gender Diet, diet, dietdie Fear of weight gain; preoccupation with food (knowledgeable in nutrition) Denial Nutrition Body Image disturbance Nutrition, promote self-esteem CBT; weight gain; behavioral modification / Kind Firmness Stay with the client one hour after eating; Dont allow client to go to toilet at once

BULIMIA Familial, internal Diet, diet, dietvomit Binge eating; purging; still on diet Verbalization of body dysmorphic image Imbalance nutrition more than or less than Nutrition; promote self-esteem CBT; weight gain; behavioral modification / Kind Firmness Stay with the client one hour after eating; Dont allow client to go to toilet at once

Management: Trust Help patient identify feelings associated with binge-purge behaviors Accept patient as worthwhile human beings because they are often ashamed of their behavior Encourage patient to discuss positive qualities about themselves Teach about bulimia nervosa Encourage to explore interpersonal relationships Encourage patients to adhere to meal and snack schedules Encourage the patient to approach the staff if she feels like binging or purging Encourage to attend group sessions Encourage family therapy Encourage participation in art, recreation and occupational therapy Encourage the patient to describe their body image at different ages of their lives.

VIOLENCE & ABUSE Battered Wife Syndrome

Often done by the husband to his wife Abusive husband believes that he owns his wife (as one of his possessions) and starts to be violent and abusive when the wife shows signs of being independent (like having her own job)

Profile of the Abuser Inadequate With low self-esteem Poor problem-solving and social skills Immature Needy Unreasonably jealous Possessive He longs for power and a sense of control, which he is able to have when he bullies and punishes the family physically Profile of the Abused Dependent Low self-esteem Perceives herself as unable to function away from her husband Equates success with her blind loyalty to her husband Fear of being killed by the abuser if they try to escape Nursing Intervention Assessment for physical injuries immediately after the episode of violence Provision of temporary shelter Individual psychotherapy or counseling, group therapy, or support and self-help groups help the women to deal with the trauma and help them to build new relationships that are healthier

Rape
A crime of violence expressed through sexual means (Videbeck) The female victim is forced into a sexual intercourse, against her will, whether the force was done under the influence of drugs, threat to ones life, or use of intoxicants Age range: 15 months -82 years Peak age: 16-24 years old

Underreported because: Guilt and shame Fear of further injury A false belief that she has no recourse in the legal system Nursing Intervention Give immediate support to the victims and allow expression of fear and rage The client should be allowed to proceed at her own pace and not be rushed in the interview or examination Give as much control to the client as possible, ask permission before doing any procedures or taking any samples for evidence Give prophylactic treatment for STDs such as Chlamydia, gonorrhea, or both Pregnancy and HIV testing is also done Prophylactic treatment with ethinyl estradiol and norgestrel could be offered Therapy is supportive and focused on restoring the patients sense of control, relieving feelings of helplessness, dependency, trauma and obsession that follow rape up to the level of regaining trust, strengthening support system, restoring daily functions and dealing with guilt, shame, and anger

Types of Child Abuse Physical abuse Sexual Abuse Neglect Psychological Abuse

Physical Abuse Involves the performance of a severe corporal punishment of hitting or beating child victims These acts include biting, burning, cutting, poking, twisting limbs, or scalding with hot water Signs and symptoms: Untreated fractures bruises of various ages injuries not explained adequately by caregivers Nursing Intervention Report all cases of child abuse to the AUTHORITY. Assess the child both physically and psychologically Perform a thorough physical and psychiatric exam Interview the abused child with the following in mind: developmental level, psychological readiness (allow the child to disclose at his/her own pace and not coercing the client) Interview the parents and note the ff: discrepancy between their narration and the actual evidences gathered, inconsistency in their stories, delay in their consultation Treat the presenting injuries and do the necessary tests and screening for STD. Ensure the childs safety from any immediate threat, may arrange for the placement in a temporary shelter Long-term, the child may need to undergo play therapy The parent abusers may also need to undergo psychiatric treatment, parenting classes or treatment for substance abuse The whole family may need to undergo family therapy Referral to the Social Service to investigate the home and the set-up in the family and to determine and make the needed arrangements in case when the abused child needs to be put in a permanent foster care to ensure safety Sexual Abuse Neglect Intentional or ignorant withholding of physical, emotional, or educational needs for the improvement of the childs well-being May be in the form of: refusal or delay in seeking medical treatment abandonment inadequate supervision recklessness with the childs safety spouse abuse in the childs presence, failure to enroll the child in school Psychological Abuse Abuse which adversely affects the childs emotional make-up These may include: verbal abuse blaming screaming name-calling constant family arguments resulting to fighting and yelling withholding of affection and experiences that promote love, security, and self-worth Involves sexual acts committed by an adult towards an individual below 18 years of age This may involve incest, rape, sodomy, exposure, rubbing or fondling of the victims genitals This also includes sexual exploitation of involving minors in acts of pornography or in doing obscene acts