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MAKATI* CAVITE * PAMPANGA * CABANATUAN* BAGUIO * TUGUEGARA* VIGAN * LUCENA * MORAYTA* DAVAO *BACOLOD * KIDAPAWAN* ILIGAN * GENERAL SANTOS*BULACAN* ILOILO * CEBU* MANILA HEAD OFFICE CARE OF THE CLIENTS WITH PSYCHOSOCIAL ALTERATIONS MENTAL HEALTH NURSING PSYCHIATRIC NURSING An interpersonal process whereby the nurse assist an individual, family or community, to promote mental health, to prevent or cope with the experience of mental illness and suffering and if necessary, to find meaning in these experiences GENERAL CONCEPTS OF MENTAL HEALTH AND ILLNESS MENTAL HEALTH A state of emotional, psychological and social wellness - Satisfying interpersonal relationships - Effective behavior and coping - A positive self-concept - Emotional stability State of adjustment with maximum effectiveness and satisfaction. Fundamental for personal happiness Contentment, achievement, optimism and hope Absence of mental and behavioral disorder or disturbances MENTAL ILLNESS Ones view of an act The reaction of others Overall cultural context in which the acts occur Often a matter of adjustment not a matter of a act NEEDS Organismic condition which exists within the individual which demands certain activities A state of tension w hich disrupts ones equilibrium Produces a relative degree of discomfort From metabolic processes, relationship with the environment and symbolic behaviors.

SA Self-esteem
Love and Belongingness

Love and Belonging Safety and Security Needs Physiologic (survival)

REMEMBER

*In Psychiatric Nursing: Safety is always a PRIORITY!

PERSONALITY DEVELOPMENT PERSONALITY Individuals internal and external adjustment to life. Integration of behaviors that is lifelong Integration of traits which can be investigated or described in order to render and account of the unique quality of an individual All that an individual is, feels and does consciously and unconsciously

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SIGMUND FREUDS PSYCHOSEXUAL THEORY Psychoanatomically, personality has three basic parts whose internal conflict and balance produce behavior (Structures of Personality): PRINCIPLE Id Pleasure Ego Reality Superego Moral Postulated that the mind consist roughly of three overlapping divisions/levels of awareness:
LEVEL Conscious Preconscious Unconscious DESCRIPTION Involves experiences which can be recalled at will without any effort Involves experiences which can be recalled at will but with some effort Involves experiences which cannot be recalled at will

ERIK ERIKSONS PSYCHOSOCIAL THEORY Psychosocial maturity Everyone goes thru a developmental stage featured by a developmental task that must be successfully completed if the succeeding tasks are being resolved in turn There is interplay between the positive and negative outcomes inherent in each task Womb to tomb The Psychosocial stages are: AGE-GROUP Infant Toddler Preschool School Age Adolescence Young Adult Middle Adult Maturity AGE 0-18 mos 18 mos- 3 yrs 3-5 yrs 6-12 yrs 12-18 yrs 18-25 (30) yrs 25 (30)-65 yrs 65 yrs death DEVELOPMENTAL TASK Trust vs Mistrust Autonomy vs Shame and Doubt Initiative vs Guilt Industry vs Inferiority Identity vs Role Diffusion/Confusion Intimacy vs Isolation Generativity vs Stagnation Ego-Integrity vs Despair VIRTUE Hope Will Purpose Competence Fidelity Love Care Wisdom

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Personality development is equated to psychosexual development (libido) Maturation of the sexual instinct is the last step in the maturation of emotional development Each stages interests become permanent parts of the personality The stages of Psychosexual Development: STAGE Oral Anal Phallic AGE Birth to 18 mos 18 to 36 mos 3 5 yrs Latency Genital 5-11 or 13 yrs (puberty) 11-13 yrs FOCUS mouth,lips,tongue Bladder Genitals School work, sports Capacity for the intimacy MAJOR CONFLICT Weaning Toilet training Penis envy Fear of castration Oedipal complex

HARRY STACK SULLIVANS INTERPERSONAL THEORY Personal interrelationships Self-image and self concept organizes behavior and is built as a result of his experience with significant other persons and their reflected appraisals Emphasizes social factors Maturation of inter-relational skills leads to personality maturation Stages of Interpersonal Model are:

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STAGE Infancy Childhood Juvenile AGE Birth - 1 yrs 1 - 6 yrs 6 9 yrs CHARACTERISTIC Crying to establish contact with others Language assists with learning to delay gratification of needs Competition Compromise Cooperation for developing relationships with peers Love assist in the development of chum relationship with a person of the same gender With sexual desire in establishing relationship with person of the opposite sex; Independence developed Interdependence is learned Learns lasting sexual relationships understood and able to apply rules Think and reason in abstract terms Further develops logical thinking and reasoning Now achieves cognitive maturity

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Formal Operational

12 -15 yrs

Preadolescence

9 -12 yrs

Early Adolescence

12 -14 yrs

Late Adolescence

14 21 yrs

JEAN PIAGETS COGNITIVE THEORY Motor activities involving concrete objects results in the development of mental functioning (learning) New operation building on already existing ones Increasing integration and coordination Maximal learning through the process of contemplative recognition Stages of cognitive development are: STAGE Sensorimotor AGE Birth 2 yrs CHARACTERISTIC Begins to form mental images Object permanence: tangible objects do not cease to exist just because they are out of sight. Develops sense of self as separate from the environment Expresses now self with language Understands symbolic gestures Begins to classify objects Thinking is still concrete Begins to apply logic to thinking Spatiality,Reversibility is being

LAWRENCE KOHLBERGS MORAL DEVELOPMENT Moral development depends primarily on cognitive development Moral development goes hand in hand with thinking and judgment The Stages of Moral Development are: STAGE AGE CHARACTERISTIC Stage 1: Punishment avoidance Pre conventional Toddler 7 yrs and obedient orientation (Egocentric focus) Stage 2: Instrumental Relativist Preschooler through Orientation School age Getting what you want by trade-off Stage 3: Interpersonal Conventional School age through Concordance Orientation (Societal focus) Adulthood Meeting expectations of others Adolescence and Stage 4: Law and Order Adulthood Orientation Fulfilling duties and upholding laws Stage 5: Social Contract Legalistic Post-conventional Middle-age or Older Orientation (Universal focus) Adult Sense of democracy and relativity of rules
Stage 6: Universal Ethical Principle Orientation Self-selection of universal principles SUMMARY OF PERSONALITY DEVELOPMENT 1. Development is a continuum 2. Behavior has meaning and is not determined by chance. 3. All behaviors should be goal-directed 4. The unconscious plays an active role in determining behavior. 5. The early years of life are extremely important for personality development

Middle-age or Older Adult

Preoperational

2 6 yrs 6 12 yrs

Concrete Operational

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THEORETICAL FRAMEWORK OF CARE B. Gestalt Model Emphasizes identifying the persons feelings and thoughts in the here and now 7.Medical-Biological Model Behavior disturbance is an illness or defect Illness is located in the body, either a neurostructurral defects, biochemical alteration or genetics Disease entities can be diagnosed, classified and labeled Somatic therapies are used which includes: o Electroconvulsive therapies o Psychosurgery o Bright Light Therapy o Transcranial Magnetic Stimulation (TMS) or Repetitive Transcranial Magnetic Stimulation (rTMS) TREATMENT MODALITIES 1.Individual Psychotherapy A method of bringing about change in a person by exploring his or her feelings, attitudes, thinking and behavior a confidential relationship between client and therapist that may occur in the therapists office, outpatient clinic, or mental hospital 2. Couple therapy An intervention involving two individuals sharing a common relationship (a married or no married, homosexual or heterosexual pair) is a way of resolving tension or conflict in a relationship 3. Family therapy a method of treatment in which members gain insight into problems, improve communication, and improve functioning of individual members as well as the family as a whole 4. Group therapy a method of therapeutic intervention based on the exploration and analysis of both internal and external conflict and the group process Members share a common purpose and are expected to contribute to the group to benefit others and receive benefit from others in return Major focus is the here-and-now experience

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THEORIES 1.Psychoanalytical Model Behavioral disturbances stems from emotionally painful experiences Repressed feelings lead to unresolved and unconscious conflicts in the mind Defense mechanism develop which produces the disturbed symptoms Psychotherapy uncovers the roots of conflict through interviews in long-term therapy Ex. S. Frued 2. Developmental Model Extended the work of Frued on personality development cross the lifespan while focusing on social and psychological development in the life stages Ex. E. Erikson and Jean Piaget 3. Interpersonal Model Extended the theory of personality development to include the significance of interpersonal relationship Ex. H.S. Sullivan and H. Peplau 4. Behavioral Model Behavior can be changed through a system of rewards and punishment Response to behavior by therapists should be consistent Ex. Pavlov and Skinner 5. Humanistic Model Focuses on a persons positive qualities, his or her capacity to change, and promotion of self-esteem Ex. Maslows Hierarchy of Needs 6. Existential A. Cognitive Model Focuses on immediate thought processing-how a person perceives or interprets his or her experience and determines how he or she feels and behaves

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NOTE

Yaloms Therapeutic/Curative Factors

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1. INSTILLATION OF HOPE is the first and often most important factor. Patients receive hope from observing others who have benefited from the group experience 2. UNIVERSALITY. Patients experience relief in knowing that they are not alone and unique, but that others experience similar problems, feelings, and concerns.we are all in the same boat 3. IMPARTING OF INFORMATION. Patients learn or are provided information about areas related to their needs. 4. ALTRUISM. Patients experience themselves as helpful or useful to others. 5. CORRECTIVE RECAPITULATION OF PRIMARY FAMILY GROUP. Patients renew previous dysfunctional family patterns and learn that these patterns can be changed to meet their present needs effectively. 6. DEVELOPMENT OF SOCIALIZING TECHNIQUES. Patients are taught appropriate social skills. 7. IMITATIVE BEHAVIOUR. Patients selectively model healthy behaviors of the leader and other group members. 8. CATHARSIS. Patients are not only allowed to express them appropriately. 9. EXISTENTIAL FACTORS. Patients share feelings about ultimate concerns of existence, such as death or isolation, and learn to accept that there is a limit to their control of these issues. 10. COHESIVENESS. Patients experience feelings of being accepted, valued, and part of a group experience 11. INTERPERSONAL LEARNING. Patients learn how their behaviours affect others and more appropriate ways of relating in the supportive atmosphere of the group. PSYCHOPHARMACOLOGY BASIC PRINCIPLES A medication is selected based on the clients target symptoms Many psychotropic drugs must be given in adequate for a period of time before their full effect is realized The dosage of medication is often adjusted to the lowest dose effective for clients

Elderly persons require lower dosages of medication to produce therapeutic effects and it may take longer for a drug to achieve its full therapeutic effect Psychotropic drugs are often decreased gradually rather than abruptly discontinued Follow-up care is essential to ensure compliance with the medication regimen, to make needed adjustments in dose and manage side effects
REMEMBER (Ang tunog ng BUS) Anti-anxiety Drugs Most common drugs are benzodiazepines - Diazepam(Valium), Lorazepam (Ativan), Chlordiazepoxide (Librium), Clorazepate (Tranxene) Buspirone (Buspar) is the first pure anxiolytic drug and acts as a partial agonist at serotonin receptor sites. Barbiturates may also be used for anxiety such as Phenobarbital Propranolol (Inderal) is a beta-blocker effectively interrupts the physiological responses of anxiety Antihistamines Hydroxyzine (Iterax, Atarax) has a central cholinergic effect and is good anti-anxiety agent

NURSING INTERVENTION Caution client to avoid potentially hazardous activities because of drowsiness Warn the client of the danger of concurrent use of alcohol and other CNS depressants Avoid abrupt withdrawal Do not give antacids concurrently Do not take medications with meals Watch for adverse reactions
REMEMBER ( Ang kuwento ni THOR) Antipsychotic Drugs Classified either by chemical class, potency but more importantly by typicality Low-potency drugs causes more anticholinergic side effects whereas highpotency drugs causes more EPS

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1.TYPICAL ANTIPSYCHOTIC DRUGS Traditional drugs effective for EFFECTIVE FOR WHAT TYPE OF SYMPTOM/S?_______ Examples are: o chlorpromazine (Thorazine), thioridazine (Mellaril), haloperidol (Haldol), fluphenazine (Prolixin) 2.ATYPICAL ANTIPSYCHOTIC DRUGS EFFECTIVE FOR WHAT TYPE OF SYMPTOM/S?_______ No endocrine side effects Prolactin increase) Potent antagonists of serotonin Examples are: o Clozapine (Clozaril, risperidone (Risperdal, olanzapine (Zyprexa), quetiapine (Seroquel) 3.DOPAMINE SYSTEM STABILIZER (DSS) EFFECTIVE FOR WHAT TYPE OF SYMPTOM/S?_______ DSS are thought to balance the dopamine systems by increasing dopamine in brain areas in which dopamine is deficient and decreasing dopamine in brain areas in which dopamine is overactive Only example is: o Aripiprazole (Abilify) (pag wala sa tamang KATINUAN)

- Manifested as tongue-thrusting and protrusion, lip-smacking, blinking, grimacing

WOF
2. NEUROLEPTIC MALIGNANT SYNDROME (NMS) Potentially fatal reaction to an antipsychotic drug; idiosyncratic Characterized by rigidity, high fever, autonomic instability and maybe confusion and muteness 3. ANTICHOLINERGIC EFFECTS Orthostatic hypotension, dry mouth, constipation, urinary retention, photophobia and sensitivity 4. ENDOCRINE CHANGES Lactation in females; gynecomastia and impotence in males 5. AGRANULOCYTOSIS WOF Esp. for those taking clozapine Decrease in white blood cell hence prone to infections

SIDE EFFECTS

REMEMBER

1. EXTRAPYRAMIDAL SIDE EFFECTS (EPSE) a. Acute Dystonia - Acute muscular rigidity and cramping, stiff thick tongue with difficulty swallowing; torticollis, opisthotonus or oculogyric crisis b. Pseudoparkinsonism - Stooped, stiff posture with mask-like faces, a festinating gait, cogwheel rigidity, drooling, bradykinesia, pill rolling tremors. c. Akathisia - Feeling of internal restlessness and inability to sit down d. Tardive Dyskinesia - Syndrome of permanent involuntary movements of the tongue, facial and neck muscles, upper and lower extremities even truncal musculature

NURSING INTERVENTION Check BP prior to administration Periodic liver function test and blood counts Observe for warning signs of adverse effects Note complaints of sore throat, nosebleed, rash, fever or other signs of infection Warn client that drowsiness may occur until tolerance is developed Teach the client to: - Avoid alcohol - Consult before taking other medications - Precautions to avoid skin damage from photosensitivity - High fiber diets, fluids, exercise and good oral hygiene NURSING INTERVENTION Anticholinergic and Dopaminergic drugs Given to control EPSEs in clients taking antipsychotic drugs A balance between acetylcholine and dopamine is required for normal movement

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NURSING INTERVENTION
Balance is accomplished in three ways 1. Drugs used to increase dopamine (Dopaminergic) 2. Drugs used to decrease the level of Ach (Anticholinergic) 3. A combination of the above drugs Dopaminergic drugs include: - Carbidopa-levodopa (Sinemet), amantadine (Symmetrel), bromocriptine (Parlodel), pergolide (Permax), selegilline (Eldepryl) - Common psychiatric side effects of dopaminergics: Confusion, hallucinations, delusions, depression, anxiety, agitation Anticholinergics used are: - Benztropine (Cogentine), biperiden (Akineton), trihexyphenidyl (Artane), dephenhydramine (Benadryl) - Common side effects of anticholinergics: Mydriasis and blurred vision, decreased secretions, , constipation, urinary retention and increased heart rate Antidepressant Drugs
REMEMBER

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Assess for the side effects and treat symptomatically Do not give TCAs and SSRIs with or immediately with MAOIs Monitor blood pressure Avoid TYRAMINE-containing foods (aged cheese, wine, pickled and preserved foods and alcohol) may lead to HPN crisis (for MAOI) Teach clients to: - Take medications with food - Notify/consult before taking any other drugs - Not to drive or operate machineries - Advise that these drugs may not take effect until after 2 weeks
REMEMBER Antimanic Drugs (Ang kawad ng PLDT) Normalizes reuptake of certain neurotransmitters but exact mechanism is still unknown but there are theories which considers its action on the second messenger system of the body Standard drug of choice is Lithium Carbonate o Effective serum level is 0.6-1.2 meq/L o Effect of lithium takes 7-10 days o SIDE EFFECT: REMEMBER o Type of RELATIONSHIP of Na and Lithium: In the absence of lithium alternative drugs are: Valporic acid (Depakote) or carbamazepine (Tegretol)

(Kuwento nina ANA at ELA)

1.SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI) Block reuptake of serotonin at specific serotonin receptor sites Serotonin syndrome may appear in some clients Indicated for depression, OCD, panic disorders Examples are: Includes Paroxetine (Seroxat, Paxil), Sertraline (Zoloft), Fluvoxamine (Luvox), Fluoxetine (Proxac) __________ WOF 2.TRICYCLIC ANTI-DEPRESSANTS (TCA) Blocks reuptake of serotonin and norepinephrine Examples are: imipramine (Tofranil), Amitriptyline (Elavil), Clomipramine (Anafranil), Amoxapine (Asendin), Doxepin (Sinequan) __________ WOF 3.MONOAMINE OXIDASE INHIBITOR (MAOI) Prevents the breakdown of dopamine, serotonin and norepinephrine Examples are : Isocarboxacid (marplan), Phenelzine (Nardil), Tranylcypromine (Parnate) __________ WOF

NURSING INTERVENTION Remind the client to take the medications regularly Monitor salt and fluid intake Report decreased in urine output WOF Monitor for signs and symptoms of toxicity o Muscle weakness or twitiching, diarrhea, vomiting, hand tremors, drowsiness (DVDMC) Teach the client to: - Avoid caffeine - Take medications with meals For Anticonvulsants - Teach client not to drive until response had been determined - Avoid alcohol and non-prescription drugs - Do not stop the drug abruptly

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Psychostimulants Often termed indirectly acting amines because they act by causing release of the neurotransmitters (NE, dopamine and serotonin) from presynaptic terminals as opposed to having a direct agonist effects on the postsynaptic receptors. They also block the reuptake of these neurotransmitters Most common example is Methylphenidate (Ritalin) Most common side effects are anorexia, weight loss, nausea and irritability, growth and weight suppression Maybe formalized with counseling or individual psychotherapy It is a professional relationship - concepts of transference and counter-transference COMPONENTS 1. TRUST -Trust builds when the client is confident in the nurse and when the nurses presence conveys integrity and reliability. Trust develops when the client believes that the nurse will be consistent in his or her words and actions NOTE and can be relied on to do what he or she says. 2. GENUINE INTEREST -When the nurse is comfortable with himself or herself, aware of his or her strengths and limitations, and clearly focused, the client perceives a genuine person showing genuine interest. 3. EMPATHY -Is the ability of the nurse to perceive the meanings and feelings of the client and to communicate that understanding to the client.It is considered one of the essential skills a nurse must develop. 4. ACCEPTANCE -The nurse who does not become upset or respond negatively to a clients outbursts, anger, or acting out conveys acceptance to the client. 5. POSITIVE REGARD -The nurse who appreciates the client as a unique worthwhile human being can respect the client regardless of his or her behavior, background, or lifestyle. This unconditional nonjudgmental attitude is known as positive regard and implies respect. ROLES OF PSYCHIATRIC-MENTAL HEALTH NURSE 1. Nurse-Teacher 2. Mother Surrogate 3. Technical Nurse 4. Nurse-Manager 5. Socializing Agent 6. Counselor/ Nurse-Therapist

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NURSING INTERVENTION Caffeine-free beverages are suggested Taken after meals Keep out of reach of children, 10-day supply can be fatal
Anticholinesterase They target Ach deficiency. By attaching to and thus blocking ChE, these four drugs substantially increase the amount of intrasynaptic Ach available to cholinergic receptor..in short it INCREASES what neurotransmitter? Tacrine (Cognex), Denazepil (Aricept) THERAPEUTIC NURSE-CLIENT RELATIONSHIP Therapeutic Use of Self Nurses use themselves as a therapeutic tool to establish a therapeutic relationships with clients and to help clients grow, change and heal Self awareness o A process by which the nurse gains recognition of his or her own NOTE feelings, beliefs and attitudes o JOHARI window Nurse Client Relationship It is the purposeful use of the nurses interpersonal ski lls directed towards growth producing outcomes for clients. CHARACTERISTICS Frequently informal and spontaneous and occurs in various health care and community settings.

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PHASES
REMEMBER (What are the major tasks in each phase?)

2.

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1. 2. 3. 4.

Preorientation/Preinteraction Orientation Working Termination

REMEMBER

Components of NONVERBAL COMMUNICATION a. Kinesics b. Proxemics c. Paralanguage d. Touch e. Silence

(The longest and the most productive phase) Therapeutic Communication COMMUNICATION The reciprocal exchange of information Components - Sender, message, receiver, feedback and the context Models/ Types o Verbal Structural Model: Sender, Message, Receiver, Feedback, Context o Non-verbal 1. THERAPEUTIC COMMUNICATION (VERBAL) o The process in which the nurse consciously utilizes the principles of communication in a goal-directed professional framework. o Best responses should focus on the general guidelines GENERAL GUIDELINES NOTE * Open-ended questioning is best used * Here and now rather than the past * What rather than why * Orientation and presentation of reality * Actual client behaviors and nursing observations rather than giving inferences * Maintenance of biologic integrity * Nursing interventions rather than roles designated to other health team members * Sharing information and exploring alternatives rather than giving actual solutions REMEMBER (Ang ating CARE)
REMEMBER (What is the most important principle?) Therapeutic Milieu It is the purposeful use of all interactions to assist clients in developing interpersonal and social skills in a conductive physical and emotional environment Manipulates environmental stimuli to provide limits, protect clients and other members of the therapeutic community and promote optimal functioning (Role of the nurse?) REMEMBER

EVALUATING MENTAL FUNCTIONING NOTE Mental Status Examination Standardized nursing assessment procedure aimed at making a diagnosis and determine intervention Designed to determine present mental status Assessed according to the ff. mental functions: 1.General Description A.GENEREAL APPEARANCE: Type, condition, and appropriateness of clothing (for age, season, setting), grooming, cleanliness, physical condition, and posture B. BEHAVIORS during the interview Degree of cooperation. Resistance, or evasiveness C. SOCIAL SKILLS Friendliness, shyness or withdrawal D. Amount and type of MOTOR ACTIVITY Psychomotor agitation or retardation, restlessness, tics, tremors, hypervigilance, or lack of activity

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2. Emotional State A. AFFECT Labile, blunted, flat, incongruent, or inappropriate affect B. MOOD Specific moods expressed or observed- euphoria, depression, anxiety, anger, guilt, or fear 3. Thinking A.THOUGHT CONTENT Helplessness, hopelessness, worthlessness, suicidal thoughts or plans, suspiciousness, obsessions, poverty of content, denial, or delusions B. THOUGHT PROCESS reflected in speech Ambivalence, circumstantiality, tangentiality, thought blocking, loose associations, flight of ideas, perseveration, neologism or word salad 4.Experience PERCEPTION: Hallucination 5.Sensorium and Cognition A.SPEECH PATTERNS Amount, rate, volume, tone pressure, mutism, slurring or stuttering B. DEGREE OF CONCENTRATION AND ATTENTION SPAN G. JUDGMENT Soundness of problem solving and decisions Diagnostic Statistical Manual 4TH edition Text Revision (DSM-IV-TR) Specific diagnostic criteria developed by the American Psychiatric Association Includes diagnostic criteria and description of each category Important for nurses to be familiar with this system in order to communicate effectively and efficiently with other members of the mental health team o Axis I - Psychiatric clinical diagnosis o Axis II - Presence of mental retardation or personality disorders o Axis III General medical conditions o Axis IV Psychosocial stressor o Axis V - Global assessment of functioning (GAF) ANXIETY: A Central Concept Stress A generalized non-specific response of the body to any demands whether positive or negative. Damaging or unpleasant forms of stress is distress. When stress is sufficiently great and reaches a point above the threshold of an individual, frustration results Response to Stress: Fight or flight mechanism Hans Selyes General Adaptation Syndrome Stage I - Stage or alarm reaction Stage II - Stage of resistance Stage III - Stage of exhaustion Anxiety A feeling of severe discomfit or dread that arises from within the individual in response to a threat, which is less visible and definable than fear, which has a visible object or trigger. Subjective experience detected by the objective behaviors that result from it. Emotional pain.

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C. DEGREE OF CONSCIOUSNESS To time, place, person, and level of consciousness D. MEMORY Immediate recall, recent, remote, amnesia, and confabulation E. INTELLECTUAL FUNCTIONING Educational level, use of language and knowledge, abstract vs concrete thinking and calculation F. INSIGHT Degree of awareness of illness, behavior, problems, and their causes

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Triggers autonomic relief behaviors aimed at eliminating anxiety. Contagious; communicated from one person to another. LEVELS OF ANXIETY NOTE Mild (+1) - Greater alertness to the environment occurs - People may feel more energetic and motivated - Behavior may be more efficient Moderate (+2) - Perceptual field begins to narrow - Shuts out periphery; focused on central concerns - Selective Inattention Severe (+3) - Perceptual fields is greatly reduced - People generally focus on small details but maybe unable to focus on the whole - Inability to focus on events and environment Panic (+4) - Disruption of the perceptual field - Disorganization of the personality - Inability to control the self or environment - Behavior purposeless and communication unintelligible - Complete immobility maybe present DRUG THERAPY Antianxiety Coping Responses COPING MECHANISMS - Any effort directed at stress management. - It can be problem, cognitive or emotion focused DEFENSE MECHANISMS - Methods of attempting to protect the self and cope with basic drives or emotionally painful thoughts, feelings or events - Become counterproductive when used to the extreme DEFENSE MECHANISM Denial Repression Suppression Rationalization Intellectualization Dissociation Introjection identification
NOTE

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Compensation Sublimation Reaction formation Undoing Displacement Projection

Conversion Regression Fixation

DEFINITION Unconscious refusal to admit an unacceptable idea or behavior Unconscious and involuntary forgetting of painful ideas, events, and conflicts Conscious exclusion from awareness anxiety-producing feelings, ideas and situations Conscious or unconscious attempts to make or prove that ones feelings or behaviors are justifiable Consciously or unconsciously using only logical explanations without feelings or an affective component The unconscious separation of painful feelings and emotions from an unacceptable idea, situation, or object Unconsciously incorporating values and attitudes of others as if they were your own Process by which the person tries to become like someone he admires by talking on thoughts, mannerisms or tastes of that person Consciously covering up for a weakness by overemphasizing or making up a desirable trait Consciously or unconsciously channeling instinctual drives into acceptable activities A conscious behavior that is the exact opposite of an unconscious feeling Consciously doing something to counteract or make up for a transgression or wrongdoing Unconsciously discharging pent-up feeling to a less threatening object, person or animal Unconsciously (or consciously) blaming someone else for ones difficulties or placing ones unethical desires on someone else Unconscious expression of intrapsychic conflict symbolically through physical symptoms Unconscious return to an earlier and more comfortable developmental level Immobilization of a portion of the personality resulting from unsuccessful completion of tasks in a developmental stage

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CRISIS Results in a period of severe disorganization resulting from the failure of an individuals usual coping mechanisms, lack of usual resources, or both Individual is in a state of disequilibrium Self-limiting (4-6 weeks) and is precipitated by new or sudden situations Occurs in all ages Response is relative Ineffective resolution leads to future crisis FORMS/CATEGORIES - Maturational/Developmental crisis - Situational/Accidental crisis - Adventitious/Social crisis METHODS (STEPS) OF CRISIS INTERVENTION 1. An assessment of the individual and the problem 2. Planing of therapeutic intervention 3. Intervention 4. Resolution of the crisis 5. Anticipatory planning GRIEF Refers to the subjective emotions and affect that are normal response to the experience of the loss KUBLER-ROSS STAGES OF GRIEF Denial Anger Bargaining Depression Acceptance

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NURSING INTERVENTION
Short-term therapy focused on solving immediate problem Cope with an immediate problem - Does not go into cause or require insight The goal is to return the client into pre-crisis level of functioning Involves clarifying present situations and problems, mobilize internal and external resources and teach new coping skills.
NOTE CRISIS INTERVENTION STRATEGIES 1. Focus on survival, safety and security a. Assess for and prevent suicide, violence, decompensation, and reactivation of serious medical or psychiatric problems b. Validate reactions and feeling as normal 2. Reestablish equilibrium and stabilization 3. Focus on strengths and adaptive coping a. Encourage use if adaptive coping and personal, spiritual, family and community resources 4. Offer suggestions for concrete, specific problem solving a. Focus on the here and now 5. Make provision for follow-up care a. Arrange for monitoring for 2-3 months- the risk of suicide can persist

NURSING INTERVENTION Acceptance Provide opportunity for the persons to tell their story Recognize and accept the varied emotions people express in a loss Provide support for the expression of difficult feelings such as anger and sadness Encourage maintain established relationships Acknowledge the usefulness of counseling for especially difficult problems
REMEMBER (Ang taong PAGOD) ANXIETY DISORDERS Anxiety usually predominates and the person is usually in a state of conflict Persistent or recurrent Certain defense mechanism are used repeatedly in an attempt to control anxiety Anxiety maybe present despite the absence of triggers Creates a significant impairment in socio occupational functioning o Primary gain refers to the individuals desire to relieve anxiety in order to feel better and more secure o Secondary gain refers to the attention and support the individual derives from others because of illness

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1.Generalized Anxiety Disorder Excessive worry and anxiety Difficulty in controlling the worry Anxiety and worry is evident in - restlessness, fatigue and irritability, diminished concentration, muscle tension, disturbed sleep Chronic feelings of nervousness and apprehension for no apparent reason 2.Panic Disorders Recurrent, unexpected panic attacks followed by a month or more of worry about having additional attacks, worry about the results of the attacks, and behavioral changes related to the attacks 3.Obsessive-Compulsive Disorder Obsessions are intrusive, inappropriate, recurrent, and persistent thoughts, impulses, or images that are distressful or produce anxiety compulsions are repetitive behaviors, such as hand washing, or mental acts, such as counting, performed in response to an obsession
REMEMBER

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Dissociative symptoms immediately after Avoidance of stimuli related to trauma Increased arousal or anxiety - Sleep disturbance, hypervigilance, easy startle Re-experiencing or relieving the traumatic event - distressing thoughts dreams Impairment in socio-occupational functioning 6.Posttraumatic Stress Disorder Same as that of ASD Numbing of responsiveness - Inability to recall aspects of the event - Restricted affect - Sense of foreshortened future Survivor guilt Occurs usually within 6 months after the event or even more (delayed)

(What is the most common ritual?)

4.Phobic Disorder Phobia is a persistent and irrational fear of a specific object, activity or situation that results in a compelling desire to avoid the dreaded object or situation The fear is recognized as excessive and unreasonable in proportion to the actual danger Maybe primary or secondary Categorized into: - Agoraphobia o Fear of being in public places wherein escape may be difficult; fear of the fear - Social phobia - Specific phobia (e.g. Claustrophobia) 5.Acute Stress Disorders Exposure to a traumatic event involving threat of death/injury to self or others, or actual injury to self and others Responses of horror, helplessness and fear

NURSING INTERVENTION To reduce anxiety - Provide a calm and quit environment - Ask patients to identify what and how they feel - Encourage the patients to discuss feelings - Help patients identify possible causes of their feelings - Listen carefully for patients expressions of helplessness and hopelessness - Plan and involve patients in activities such as walking or playing recreational games
For panic - Remain with the client and provide safety - Reduce environmental stimuli and approach always in a calm manner - Focus clients attention on a simple, repetitive task For ritualistic behaviors - Avoid interfering with the ritual - Set rational limits on ritualistic behavior in terms of timing frequency and location

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Structure simple activities or task for patients Encourage to participate in activities where clients can attain control and success Recognize and reinforce non ritualistic behaviors

P S Y C H I A T R I C N U R S I N G

5.Body Dysmorphic Disorder Preoccupation with some imagined defect in physical appearance which is out of proportion to any actual abnormality

For ASD and PTSD - Assure them that their feelings and reaction are typical reactions to serious trauma - Encourage safe verbalizations of feelings especially anger - Encourage adaptive coping strategies, exercise, relaxation techniques and sleep-promoting strategies - Facilitate progressive review of the trauma and its consequences - Encourage the patients to establish or re-establish relationship SOMATOFORM DISORDERS Involves physical symptoms without any organic or physiologic cause Not under voluntary control Symbolizes repressed and unresolved conflicts 1.Somatization Disorder Chronic somatic complaints of long-duration Complaints changes from one anatomic site to another A complicated medical history is common 2.Pain Disorder Prolonged and severe pain that seem unrelated to physical causes Seems to correlate with psychological stress May present with abuse of analgesics 3.Conversion Disorder Loss of sensory or motor functioning that seems unrelated to physical cause The physical problem is symbolic of underlying anxiety Presence of la belle indifference 4.Hypochondriasis Preoccupation with the belief that a serious illness is present despite reassurance to the contrary and may interfere with daily life Physical signs and symptoms are consistently misinterpreted to mean that the clients is ill

NURSING INTERVENTION
Avoid reinforcing the symptoms - do not focus on them to reduced secondary gain - Do not attempt to persuade the client that the symptoms are not real or that the client should give it up Increase self esteem by involving clients in activities in which they can be successful Encourage to identify and explore feelings DISSOCIATIVE DISORDERS Sudden temporary change in consciousness, identity or motor behaviors The repression of ideas that leads to amnesia and other forms of dissociation is conceived as a way of protecting the individual from emotional pain 1.Dissociative Amnesia Inability to recall personal information Loss of memory of important personal events that were traumatic or stressful in nature 2.Dissociative Fugue Sudden unexpected travel away from home or work with loss of memory about the past Assumption of partial/completely new identity 3.Dissociative Identity Disorder Existence of 2 or more identities or personalities that take control of a persons behavior 4.Depersonalization Expresses feelings of detachment from or an outside observer of ones body or mental processes Unreality or self-estranged (derealization)

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and/or grandiose) All the following are prominent; disorganized speech, disorganized behavior, flat or inappropriate affect At least two of the following are present: A. Motoric immobility, waxy flexibility, or stupor B. Excessive motor activity (purposely) C. Extreme negativism or mutism D. Peculiar movements, stereotype of movements, prominent mannerisms, or prominent grimacing E. Echolalia or echopraxia Characteristic symptoms (see criteria A) are present, but criteria for paranoid, catatonic, or disorganized subtypes are not met A. Characteristic symptoms (see box: DSM-IV-TR criteria for Schizophrenia, criterion A) are no longer present; criteria are unmet for paranoid, catatonic, or disorganized subtypes B. There is continuing evidence of disturbance, such as the presence of negative symptoms or criteria A symptoms, in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

P S Y C H I A T R I C N U R S I N G

NURSING INTERVENTION
Reduce external stress and demands on the client Present reality Reassure the client that memory will return Encourage to explore and verbalize feelings Set rational limits on behavior Assist in the exploration or preceding event Reduce the clients anxiety

Disorganized Catatonic

SCHIZOPHRENIA Occurs in the late adolescence and early adulthood More common in lower socio-economic groups High prevalence among family members and in twins

Undifferentiated

Residual

DSM-IV-TR SCHIZOPHRENIA CRITERIA! A. Characteristic symptoms (at least two of the following): Delusion Hallucinations Disorganized speech Grossly disorganized or catatonic behavior Negative symptoms B. Social-occupations dysfunction: work, interpersonal, and self-care functioning below the level achieved before onset C. Duration: continuous signs of the disturbance for at least 6 months D. Schizoaffective and mood disorders not present and not responsible for the signs and symproms E. Not caused by substance abuse or general medical disorder FOUR AS OF SCHIZOPHRENIA 1. Affective disturbances REMEMBER ( THE 4SUM?) 2. Autism 3. Associative looseness 4. Ambivalence
DSM-IV-TR FOR SCHIZOPHRENIA SUBTYPES CRITERIA! Paranoid Preoccupation with one or more delusions or frequent auditory hallucinations (content frequently persecutory

DSM-IV-TR

ETIOLOGY Biological Theories - Genetic component is present - Dopamine hypothesis excessive dopaminergic activities in the cortical areas causes acute psychotic symptoms - Neurostructural changes Developmental Theories - Impaired interpersonal relationship with primary caregiver - Poor ego boundaries, fragile ego and ego disintegration Family Theories - Schizophrenic mother - Double-bind Vulnerability-Stress Model - Recognizes both biological and psychodynamic

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P S Y C H I A T R I C N U R S I N G

TYPES OF DELUSION 1. Persutory/paranoid delusion 2. Grandiose delusion 3. Religious delusion 4. Somatic delusion 5. Referential delusion 6. Nihilistic delusion TYPES OF HALLUCINATION 1. Auditory 2. Visual 3. Tactile 4. Gustatory 5. Olfactory 6. Kinesthetic 7. Cenesthetic

Avoid whispering or laughing when patients are unable to hear all of a conversation - Avoid competitive activities with some patients Encourage differentiation of self from others and the environment Allow and encourage verbalization of feelings Increased the clients self-esteem - Provide opportunities to be successful - Convey an attitude of respect - Do not embarrass patients - Reinforce positive behaviors - Encourage participation in self-care activities MOOD DISORDERS 1. Major Depression 2. Mania 3. Bipolar disorder OTHER 1. Dysthymia 2. Hypomania 3. Cyclothymia 4. Seasonal Affective Disorder MAJOR DEPRESSION Abnormal extension and over elaboration of sadness and grief ETIOLOGY Biological theories of depression - Genetics play a role in its occurrence - Levels of norepinephrine and serotonin altered, decreased availability in the CNS - Endocrine changes Psychological theories - Object loss theory - Debilitating early life experiences - Aggression towards the self - Intrapsychic conflict - Cognitive theory - Antipsychiatric model - Learned helplessness

NURSING INTERVENTION General Principles for a therapeutic relationship - Be calm when talking to patients - Accept patient as they are but do not accept all behavior - Keep all promises - Be consistent - Be honest Maintain a safe and therapeutic environment Meet the patients physiologic needs Help patient maintain contact with reality - Orient the patients to time and place if indicated Reduce hallucinations and delusions - Present reality without arguing - Engage in conversations that are simple, direct, specific and concrete - Do not dwell on the content of delusions Decrease withdrawal - Engage in one relationships as tolerated by clients - Engage in social activities - Allow interpersonal distance if necessary - Do not touch the patients without warning them

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ESCAPES FROM DEPRESSION Complete hopelessness and inactivity Soliciting or winning sympathy Use of alcohol/substances Frenzied activity Excessive motor activity Suicide Allow and encourage verbalization of feelings Bolster self-esteem - Accept patients where they are and focus on their strengths - Point out even small accomplishments - Reinforce decision making by patients - Redirect clients conversation away from self -reproach and derogation - Involve patients in activities in which they can experience success - Respond to anger therapeutically Recognize dependence - Make decisions for patients that they are not ready to make for themselves Spend time with withdrawn patients Encourage increasing participation in social, recreational and occupational activities Never reinforce delusions or hallucinations DRUG THERAPY Antidepressants Electroconvulsive Therapy (ECT) Induction of grand mal seizures through the application of electrical current to the brain to effect behavioral changes Indicated for clients with major depression, acute manic states, schizophrenics (catatonic), OCD and some personality disorders (antisocial) Exact mechanism of actions is still unknown There are no absolute contraindications however relative contraindications include: - Cardiac problems Increased intracranial pressure - Severe osteoporosis - Acute and chronic pulmonary disorders - Pregnancy (if with complication) The side effects are headache, confusion and temporary memory loss

P S Y C H I A T R I C N U R S I N G

KEY FEATURES OF MAJOR DEPRESSIVE DISORDERS At least a 2-week period of maladaptive functioning is present that is a clear change from previous levels of functioning. Al least five of the following symptoms must be present during that 2-week period, out of which must be (1) or (2): 1. Depressed mood 2. Inability to experience pleasure or markedly diminished interest in pleasurable activities (Anhedonia) 3. Appetite disturbance with weight change (loss or gain of more than 5% of body weight within 1 month) 4. Sleep disturbance 5. Psychomotor disturbance 6. Fatigue or loss of energy 7. Feelings of worthlessness or excessive or inappropriate guilt 8. Diminished ability to concentrate or indecisiveness 9. Recurrent thoughts of death or suicidal ideations The mood disturbance causes marked distress or significant impairment in social or occupational functioning, or both. No evidence of a physical or substance-induced cause exists for the patients symptoms or for the presence of another major mental disorder that accounts for the patients depressive symptoms.

DSM-IV-TR CRITERIA!

NURSING INTERVENTION Maintain clients safety Provide for adequate nutrition, hydration elimination, exercise and physical hygiene Help client have adequate rest and sleep Provide a simple and structured schedule and environment Develop trust Offer sincere concern and empathy

>>>Konti nalang. Ur almost done =) "Dattebayo!" (BELIEVE IT!)- Naruto I do not know anyone who has gotten to the top without hard work. That is the recipe. It will not always get you to the top, but it will get you pretty near. ~M. Thatcher

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NURSING INTERVENTION Pre-ECT Secure the informed consent Keep client on NPO at least 4 hrs prior Remove dentures, eyeglasses, contact lenses etc. Client must be asked to void prior Remain with the client; safety precautions Encourage client to verbalize feelings Pre-medications maybe given as ordered (Atropine sulfate, succinylcholine [Anectine] )
NOTE

P S Y C H I A T R I C N U R S I N G

Post-ECT Client is oxygenated Turn head to the sides Monitor vital signs Stay with the patient until he is fully awake Reorientation Provide a highly structured schedule of routine activities to minimize confusion

REMEMBER

(Ang AMA ng PUSA)

SAD PERSONS SCALE S ex A ge (<19 or >45) D epression P revious Suicide Attempt E thanol (Alcohol) Abuse R ational Thinking Impaired (judgment) S ocial Support Lacking ( including recent loss of loved one) O rganized Plan N o Spouse (single, divorced, widowed, separated) S ickness especially Chronic *This scale should be used as a guideline only: use your judgment and dont neglect unspecified factors ETIOLOGY Psychodynamic Theories - Instinct for life vs. instinct for death - Aggression towards the self - 3 Ps Pain, perturbation and pressure Sociological Theories - Social and cultural contexts influence ideations of suicide Biological Theories - There is decreased serotonin and its metabolites in patients who are suicidal Predisposing Factors Include: - Psychiatric disorders (mood, substance, psychotic disorders) - Personality traits (hostility, impulsivity, chronic depression) NURSING INTERVENTION Evaluate patients for suicidal risk (suicidal cues) Note behaviors like making a will, saying goodbyes and giving away prized possessions Suspect suicidal ideation in the depressed Inquire directly about frequency and content of suicidal ideation Ask patients about the advantages and disadvantages of suicide Evaluate the patients access to means of suicide Develop a formal no suicide contract with patients

SUICIDE Direct self-destructive behavior; self-inflicted death Influenced by a persons cultural beliefs, values and norms Never a random act, whether done impulsively or with painstaking consideration, the act has both a message and a purpose More common in white persons and least common in black persons Common among schizophrenics, depressed and alcoholic patients More common in spring More likely to occur in the early morning hours LEVELS OF SUICIDAL BEHAVIOR Suicidal gestures - non-lethal, self-injurious acts done to get attention Suicidal ideations - thoughts of suicide Suicidal threats - verbal statements Suicidal attempt - actual implementation Completed suicide - warning signs have been missed/ignored COMMON EXPRESSIONS OF SUICIDAL PATIENTS Cry for help - redemption Escape - relief of pain Heroism - retaliatory Loss of self-esteem - reunion Manipulation Martyrdom Rebirth

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Monitor closely and continuously Encourage verbalization of feelings Support patients reason to live BIPOLAR DISORDERS Individuals experience extremes in mood polarity DSM-IV-TR Manic-depressive CRITERIA! BIPOLAR DISORDERS I. Manic Episode: A. A distinct period of abnormal and persistent elevated, expansive, or irritable mood that lasts at least 1 week or less if hospitalization is required. B. At least three of the following symptoms must occur during the episode (or four if the patient is only irritable). 1. Inflates self-esteem or grandiosity 2. Decreased need for sleep 3. Very talkative 4. Flight of ideas or subjective feeling that thoughts are racing 5. Distractability 6. Increase in goad-directed activity (social, occupational, educational, or sexual) or psychomotor agitation 7. Excessive involvement in pleasurable activities that have a high potential for personal problems (e.g. sexual promiscuity, spending sprees, bad business investments) C. Mood disturbance severe enough to cause problems socially, interpersonally, or at work, or the person has to be hospitalized, to prevent harm to self or others. D. Not due to a substance II. Bipolar disorders: A. Bipolar episodes are divided into bipolar I and bipolar II. There are six categories of bipolar I. In bipolar I, the patient must have a history of a manic episode. B. Bipolar II: The patient has experienced major depression and a hypomanic episode (but not a manic episode) ETIOLOGY Psychodynamic theories - Mania as a defense or a mask of depression - Developmental: Mistrust and dependence Biological theories Genetics is influential in bipolar disorders Excessive levels of neurotransmitters

P S Y C H I A T R I C N U R S I N G

NURSING INTERVENTION Provide for patients physical safety and safety of those around him Remind the client to respect distances between self and others Use short simple sentences to communicate Ask the clients to clear their messages and to decode metaphors, themes and symbols used in speech Provide the clients with a list of daily activities Ensure that food and fluid needs are met For patients too busy to eat - Provide patients with foods that can be eaten on the run ( finger foods) because patients cannot sit ling enough to eat - Provide high-protein, high calorie snacks - Weight patients regularly Reduce stimulation from the environment and others - A quiet room maybe indicated to decreased environmental stimuli - Remain quietly with the client rather than encouraging activities and conversations Channel clients need for movement into socially acceptable motor activities - Goal-oriented activities are encourage - Competitive sports activities are not allowed initially - Mental activities will not be done by patients
NOTE

AGGRESSIVE BEHAVIORS PHASES OF THE AGGRESSIVE CYCLE PHASE DESCRIPTION Triggering phase Escalation phase Patients response are nonviolent and present no danger to others When verbalization and tension reduction strategies fail and patients become irrational (they begin to swear,scream,threaten), the nurse must take control of the situation. Reached when the patient is approaching an attack on the

Crisis phase

NURSING INTERVENTIONS Convey emphatic support Encourage ventilation Provide directions for the client in calm firm voice Tell the client to take timeout for cooling Show of force Use involuntary seclusion, restraints, or IM

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environment, self, other patients, or staff. Verbal limits are ineffective, and external control by the staff is essential. Accusation, recriminations, lowering of voice, decreased body tension, change in conversational content, more normal responses, relaxation. Crying, apologies, reconciliatory interactions, repression of assaultive feelings (which might later appear as hostility, passive aggression) medications (prn), if ordered

P S Y C H I A T R I C N U R S I N G
Recovery phase

3. PSYCHOLOGICAL -instilling or attempting to instill fear -Isolating or attempting to isolate victim from friends, family, school or work 4. SEXUAL -Coercing or attempting to coerce any sexual contact without consent -Attempting to undermine the victims sexuality 5. ECONOMIC -making or attempting to make the victim financially dependent RAPE AND TRAUMA SYNDROME Sleep disturbance, nightmares Loss of appetite Fear, anxieties, phobias and suspicions Decreased activities and motivation Disturbance in relationships Self-blame, guilt and shame Lowered self-esteem, worthlessness Somatic symptoms

Postcrisis depression

Assess patient and staff injuries Evaluate patients progress toward self-control Process incident with patient. Discuss alternative solutions to the situation and feelings. Facilitate reentry to unit

VICTIMS OF ABUSE AND VIOLENCE CYCLE OF ABUSE AND VIOLENCE

Period of Violence Tension-building phase Honeymoon phase

Abuse is not constant nor it is random There is an imbalance of power in a relationship The honeymoon phase is what convinces the partner to stay in the relationship FORMS OF ABUSE WITHIN FAMILIES 1. PHYSICAL -Inflicting or attempting to inflict physical injury or illness -Withholding access to resources necessary to maintain health 2. NEGLECT -failing or refusing to provide food, shelter, healthcare or protection for a vulnerable elder

NURSING INTERVENTION Reaffirm that they are worthwhile persons with dignity and rights, who is not cause and deserve the rape Convey to them that their anger is natural Move at the victims pace and be supportive Always give rationales and descriptions for any procedures Protect the patients rights
TYPES OF ABUSE AMONG SPECIAL POPULATION 1. Domestic 2. Partner 3. Child 4. Elder

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SUBSTANCE RELATED DISORDERS ALCOHOLISM Alcohol Genetic predisposition Usually appears between the ages 20-40 however becoming common in adolescents BAL should be@ least _____ % considered intoxicated REMEMBER More common in men than in women Chronic use leads to Wernickes-Korsakoff syndrome CAGE QUESTIONNAIRE Have you ever felt you ought to Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you used alcohol as an Eye-opener? SIGNS OF DRUG ABUSE Sudden loss of interest or deterioration in school work fand other activities Dropping old friends and associating with a new peer group Secretive behaviors; spends a lot of time alone Sudden and unexplained changes in mood, emotion and behavior Physical signs such as pupil changes, slurred speech, needle marks, photophobia etc. - One must determine drugs use pattern of the client from information provided by the client, family and friends: 1. Drugs being used 2. Quantity 3. Frequency 4. Length of use Analysis of blood and urine for substances

P S Y C H I A T R I C N U R S I N G

Substance Abuse -Pattern of pathologic use o Inability to cut or stop use despite physical disorder known to be increased by its use and despite the presence of complications o Usually intoxicated throughout the day - Impairment in functioning o Legal difficulties and failure in obligations o Behavioral changes Substance dependence NOTE - TOLERANCE WITHDRAWAL SYNDROME ETIOLOGY Psychoanalytic/Psychodynamic - fixation or regression to the oral stage of development Sociological - Learned behavior encouraged by a subculture in which drugs are easily available and its use is encouraged Biochemical - Physiologic dependence; readdiction or craving TYPES EXAMPLES CNS Depressants Alcohol Baribiturates Anxiolytics (Valium)) Inhalants Opioids (Heroin, Morphine) CNS Stimulants Amphetamine Nicotine Caffeine Hallucinogens Psylocibin (in Psilocybe mushrooms) Lysergic acid (LSD) Phencyclidine (PCP) Marijuana (Cannabis sativa) Dual Diagnosis The co-occurrence of psychiatric and substance use disorders

NURSING INTERVENTION
DETOXICATION PHASE - Encourage participation in a treatment program and refer to appropriate treatment resources - Support the client through the detoxification or withdrawal - Detoxification may take 2-3 weeks and should take place in an inpatient setting - Attend to clients physical problems

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REHABILITATIVE PHASE - Assist clients to identify the stresses and conflicts and encourage exploration of alternative coping strategies - Assist the client to identify social support network - Provide support to significant others - Provide health teachings to clients SEXUAL DISORDERS 1.Sexual Dysfunctions Inhibition of the sexual appetite or psychophysiological changes that compromise the sexual response cycle The sexual response cycle: - Phase 1: Appetitive - Phase 2: Excitement - Phase 3: Plateau - Phase 4: Orgasm - Phase 5: Resolution TYPES OF SEXUAL DYSFUNCTION Sexual desire disorder - Hypoactive - Sexual aversion disorder Sexual arousal disorder Orgasmic disorder - Premature ejaculation - Anorgasmia Sexual pain disorders - Dyspareunia - Vaginismus Predisposing factors - Biological - Psychosocial - Relationship factors 2.Paraphilias (sexual perversions) Sexual instinct is expressed in ways that are socially unacceptable and is prohibited Peaks between the age of 15 and 25 and decrease in incidence by age Always enters the cycle of sexual perversion PARAPHILIA CRITERIA! The following paraphilic activities last over a period of 6 months and cause distress or impairment in social, occupational, or other important areas of function: EXHIBITIONISM Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving exposing ones genitals to unsuspecting strangers. FETISHISM Recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors using nonliving objects. FROTTEURISM Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving touching and rubbing against a nonconsenting person. PEDOPHILIA Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors that involves sexual activity with a child or children generally 13 years of age or younger. The person is a least 16 years of age and at least 5 years older than the child or children involved. SEXUAL MASOCHISM Recurrent, intense sexually arousing fantasies, sexual fantasies, urges, or behaviors involving the act of being humiliated, beaten, restrained, or otherwise made to suffer. SEXUAL SADISM Recurrent, intense sexually arousing fantasies, urges, or behaviors involving acts in which the psychological or physical suffering of the victim is sexually exciting to the person.

P S Y C H I A T R I C N U R S I N G

DSM-IV-TR

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VOYEURISM Act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity. 3.Gender Identity Disorder Homosexuality Bisexuality Transexualism (gender dysphoric disorder) EATING DISORDERS 1.Anorexia Nervosa Profound disturbance in body image and a relentless pursuit of thinness often to the point of starvation Weight phobia Common in females; early adolescence Refusal to maintain body weight at a normal BMI or it is less than 85% of the DBW Disturbance in the way in which ones body weight or shape is experienced - self evaluation is based on body weight but is always in denial - Amenorrhea (at least 3 consecutive cycles) NOTE Other clinical features - Most aberrant behaviors directed towards losing weight are in secret - Refusal to eat with families or in public places - Drastic reduction in total food intake with disproportionate decrease in high carbohydrate and fatty foods - There is actual preoccupation with food - There are peculiar behaviors regarding food - Associated with obsessive-compulsive behaviors, depression and anxiety - Markedly decreased interest in sex - Overall prognosis is not good though some will spontaneous recovery TYPES Restricting type Binge eating/purging type ETIOLOGY Biological - Decreased serotonin in CNS - Presence of endogenous opiates for denial of hunger Socio-cultural - Society is focused on thinness and exercise - More common in females - Most frequent in developed countries Common in professions such as modeling and ballet Psychological - Reaction to the demands for more independence in increased social and sexual functioning - There is lack of autonomy and selfhood - Acts of extraordinary self-discipline - Intrusive and unempathetic mother model PHYSIOLOGIC SYMPTOMS Hypothermia Edema Bradycardia Hypersensitivity Hypotension Lanugo TREATMENT Hospitalizations Individual (Weight-oriented) Family therapy

P S Y C H I A T R I C N U R S I N G

NURSING INTERVENTION Monitor caloric intake Watch out signs of purging Weigh client Monitor activities Plan for a realistic and healthy diet Monitor nutritional and electrolyte status For anorexia nervosa - Increasing self-esteem is a primary objective - Listen empathetically - Engage clients in the food planning process - Help identity and express bodily sensations

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Identify non-weight related interest Improve social skills Characterized by an acute onset and may last from hours to a number of days and with a tendency to fluctuate during the course of the day It is potentially reversible but can be life-threatening if not treated Secondary either to a general medical condition or to effects of substances

P S Y C H I A T R I C N U R S I N G

2.Bulimia Nervosa Consist of recurrent episodes of eating large amounts of food accompanied by a feeling of out of control There are feelings of guilt, depression and self-disgust after There are recurrent compensatory behaviors: purging, fasting or excessive exercise They maintain normal body weight Common in female; adolescence or early adulthood ETIOLOGY Biological - Endorphin levels are increased Psychological - Parents maybe rejecting and neglectful - Difficulties with adolescent demands - Anorexics lacks ego strength while bulimic lacks superego control TYPES Purging Non-purging TREATMENT Individual psychotherapy

NURSING INTERVENTION Promote clients safety and struct ured environment Manage the clients confusion(i.g., reorientation, approaching clients calmly and speaking in a client low voice) Promote sleep and proper nutrition Keep the room lit to allay fears and prevent visual hallucinations Monitor effects of medications
DEMENTIA Altered mental state secondary to a cerebral disease Usually irreversible, gradual in onset, progressive, degenerative Characterized by a decreased intellectual function, personality change, impaired judgment and often change in affect Impairment in functioning is present DEMENTIA A. The development of multiple cognitive deficits manifested by both 1. Memory impairment (impaired ability to learn new information or to recall previously learned Information). 2. One (or more) of the following cognitive disturbances (As of Dementia): a. Aphasia (language disturbance) b. Apraxia (impaired ability to carry out motor functions despite intact motor function) c. Agnosia (failure to recognize or identify objects despite intact sensory functioning d. Disturbance or executive functioning (e.g., planning, organizing, sequencing, abstracting) B. The cognitive deficits in criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning. C. The course is characterized by a gradual onset and continuing cognitive decline.

DSM-IV-TR CRITERIA!

NURSING INTERVENTION
For binge eating - Create an atmosphere of trust - Identify feeling associated with binging/purging behavior - Improve self-esteem - Teach about eating disorders - Explore interpersonal relationships DELIRUIM Disturbance in consciousness accompanied by a change in cognition( e.g., memory deficit, disorientation, language disturbance, perceptual disturbance)

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P S Y C H I A T R I C N U R S I N G

REMEMBER

(Ano ang alagang hayop ng taong may dementia?)

Alzheimer s Disease Major cause of dementia in the elderly Unknown etiology but some theories include - Alterations in acetylcholine Very strong genetic predisposition Organic changes occur - Brain atrophy, widening of sulcus and ventricles - Neurofibrillary tangles and amyloid bodies Stage 1 Agitated or apathetic mood Attempts to cover up symptoms Decline in personal appearance Decline in recent memory Decreased concentration Depression Disorientation regarding time Disturbed sleep Stage II May last from 2-12 years Confabulation (unconscious filling of memory gaps with fabricated facts and experiences) Continuous repetitive behaviors Diminishing ability to understand or use language Disorientation to person, place and time Inability to recognize family members Inability to retain new information Incontinence of bowel and bladder Socially unacceptable behavior Stage III Terminal stage (months to 5 years) Compulsive touching and examination of objects Deterioration in motor abilities Non responsiveness Severe decline in cognitive functions

DRUG THERAPY Anti cholinesterase agents Antipsychotic agents - in low doses like haloperidol or risperidone
REMEMBER

(Sino naman ang boyfriend ni LOLA?)

NURSING INTERVENTION Remove any hazardous items or potential obstacles from the patients environment to provide and maintain safety Monitor food and fluid intake Provide verbal and non-verbal communication that is consistent and structured State expectations simply and completely Increase social interaction to provide stimulus for the patients Encourage the use of community resources Promote physical activity and sensory stimulations Orient the patient to his surroundings Monitor the environment Encourage the patient to express feelings
Personality Disorder formerly known as Character Disorder an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it CLUSTER A : odd or eccentric 1. Paranoid 2. Schizoid 3. Schizotypal CLUSTER B: dramatic, emotional or erratic 1. Histrionic 2. Antisocial 3. Narcissistic 4. Borderline CLUSTER C: anxious or fearful disorders 1. Avoidant 2. OC

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3. Dependent ONS 1. Passive-aggressive MENTAL DISEASES IN CHILDREN Mental illness in the children and adolescents Children are less able to verbalize feelings Irritability maybe a predominant feature Risk factors for childhood psychiatric disorders are - Genetic and biological factors - Adverse environmental influences - Family and socio-cultural factors - Stress experience - Children can be motivated by their peers - Negative effects of risk factors depend upon the severity of the risk and the resiliency of the child - Resilience is the ability to withstand problems of an undesirable childhood Mental Retardation Below average intellectual functioning and impairment in adaptive skills that is present before 18 years old Arrested or incomplete development of the mind Classified according to severity: 1. Mild IQ level 50-55 to 69 2. Moderate IQ level 35-40 to 50-55 3. Severe IQ level 20-25 to 35-40 4. Profound IQ below 20 or 25
REMEMBER

P S Y C H I A T R I C N U R S I N G

Pervasive Developmental Disorders Autistic disorder Retts disorder Childhood disintegrative disorder Aspergers disorder AUTISTIC DISORDER Disturbance in social relatedness Common features - Stereotypical behaviors -Peculiar preoccupations - Delayed socialization and communication Substantial percentage are mentally related (Diagnosed before ___) REMEMBER Attention Deficit And Disruptive Behavior Disorder Attention deficit hyperactivity disorder Conduct disorder Oppositional defiant disorder ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD or ADD) Most common pediatric psychiatric disorder Cardinal feature: o Inattention o Hyperactivity-impulsivity o Impulsivity REMEMBER (Diagnosed before___) DRUG THERAPY - Psychostimulants - The Feingold diet elimination of artificial flavoring and colorings and natural salicylates in food

(Diagnosed before___) > Genetic factors >Perinatal factors

ETIOLOGY >Chromosomal abnormalities >Complications of pregnancy >Acquired childhood disorders

NURSING INTERVENTION IN CHILDHOOD MENTAL DISORDERS Help the parents accept a diagnosis and plan a realistic approach to the situation Help shape family members and other peoples attitudes towards them and accept them Help in activities of daily living Standards of acceptable behavior within the ability of the child should be provided

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He should b taught to seek help when in difficulty to resist frustration and achieve emotional control Create a therapeutic environment
NOTE

REFERENCE: Fortinash, K.M. & Holoday, P.A. (2008). Psychiatric Mental Health Nurisng th (4 ed.). St. Louis: Mosby/Elsevier. Keltner, N.L.,Schwecke, L.H., & Bostrom, C. E. (2007). Psychiatric Nursing, (5th ed.). St. Louis: Mosby/Elsevier. Kozier, B., Berman, A., Snyder, S., & Erb, G., (2007). Kozier & Erbs th Fundamentals of Nursing: Concepts, Process & Practice (8 ed., Vol. 1). Upper Saddle River: Prentice Hall. Shives, L.R. (2008). Basic Concepts of Psychiatric-Mental Health Nursing (7th Ed.). Philadelphia: /Walters Kluwer Health/Lippincott Williams & Wilkins. Stuart, G.W. & Laraia M.T. (2005). Principles and Practice of Psychiatric Nursing (8th ed.). St. Louis: Mosby/Elsevier. Videbeck, S.L. (2008). Psychitric-Mental Health Nursing (4th ed. ). Philadelphia: Lippincott Williams & Wilkins. ***Edited August 2011/MERGE_Psychiatric Nursing Team

P S Y C H I A T R I C N U R S I N G

STIGMA An attribute or trait deemed by the persons social environment as negative, different and diminishing
NOTE ETHICAL DILEMMA Exists when moral claims conflict with one another. It can be defined as: o A difficult problem that seems to have no satisfactory solution o A choice between equally unsatisfactory alternatives NOTE PSYCHIATRIC REHABABILITATION The process of helping the person return to the highest possible level of functioning The range of social, educational, occupational, behavioral, and cognitive interventions used to increase the role performance of persons with serious and persistent mental illness and to enhance their recovery

CARE OF THE CAREGIVER ROLE STRAIN When the demands of providing care threaten to overwhelm the caregiver Characterized by: - Constant fatigue unrelieved by rest - Use of alcohol/other substances - Social isolation - Inattention to personal needs - Inability/unwillingness to be helped by others It may become a factor in the neglect or abuse of patients

NURSING INTERVENTION Refer caregivers to knowledgeable health professional who can provide information, support and assistance Provide outlets for dealing with caregivers feelings Help them seek and accept assistance from other people or agency and not wait until they are exhausted Provide support for a personal life
>uve finished this extra CHAKRA GREAT JOB!

Welcome to the Psychiatric Hotline If you are obsessive-compulsive, please press 1 repeatedly If you are co-dependent, please ask someone to press 2 If you have multiple personalities, please press 3,4,5 and 6 If you are paranoid-delusional, we know who you are and what you want. Just stay on the line so we can trace the call. If you are schizophrenic, listen carefully and little voice will tell you which number to press If you are depressed, it doesnt matter which number you press. No one will answer If you are delusional and occasional and occasionally hallucinate, please be aware that the thing you are holding on the side of your head is alive and about to bite off your ear. NOTE: These are supplemental handouts only. MERGE Team still advice you to have additional readings as necessary.

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