ST.

LOUIS REVIEW CENTER Nursing Review and Tutorials

PSYCHIATRIC NURSING REVIEW NOTES Compiled by Gianina Marie Borja, RN CMT ST. LOUIS REVIEW CENTER PSYCHIATRIC NURSING & MENTAL HEALTH PSYCHIATRIC NURSING - a specialized area of nursing; SCIENCE: theories of human behavior ART: therapeutic or purposeful use of self - includes: promotion and maintenance of mental health prevention of mental illness management of mental and physical problems diagnosis and treatment of mental disorders referral and rehabilitation Basic Principles of PsychNsg: 1. Accept and respect the client regardless of his behavior 2. Limit the behavior, not the client 3. Always maintain a safe and non-judgmental environment 4. Encourage expression of thoughts and feelings 5. Remember that all behavior is learned 6. All behavior has meaning 3 Levels of PsychNsg: I. Primary ------------------- Objective: Promotion & Prevention II. Secondary --------------------------Obj: Screening, Diagnosis, & Immediate Treatment III. Tertiary ----------------------------Obj: Rehabilitation [which starts upon admission] MENTAL HEALTH focus: prevention - it is relative and dynamic - Definition: state of emotional, psychological, and social wellness as evidenced by satisfying interpersonal relationships, effective behavior and coping, a positive self-concept, and emotional stability. - Mental health is influenced by Individual factors [biologic make-up, emotional resilience, self concept], Interpersonal Factors [communication, intimacy, relationships], and Social/Cultural Factors [sense of community/family, access to resources, violence, diversity]. MENTAL ILLNESS - mental disorder is a clinically significant, psychological syndrome or pattern that occurs in an individual and is associated by a present distress, disability, or an increase in the risk of death, pain, disability, or a loss of freedom. ASSESSMENT OF MENTAL HEALTH Components of the Assessment of Mental Status: 1. SENSORIUM: Consciousness, Orientation, Attention, Concentration, Comprehension 2. APPEARANCE: Appropriateness, Grooming, Rigidity, Mannerisms 3. AFFECT/ MOOD: Appropriateness of affect, Mood swing, Duration, Intensity
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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

4. THOUGHT CONTENT: Self-concept, Areas of concern, Themes of thought, Delusions, Illusions, Hallucinations, Obsessions 1. THOUGHT PROCESS: ability to understand symbols; abstract reasoning

2. SPEECH: Coherency, Relevance, Meaning, Quality, Quantity MENTAL STATUS ASSESSMENT: a. General Assessment: facial expression, grooming and dress, body language, b. MOOD, FEELINGS, and AFFECT: mood, affective expression, and appropriateness of affect to thought content c. Perception and Thinking: i. Perceptual Disturbances Hallucinations, illusions, depersonalization ii. Thought Process Productivity of ideas, Continuity of thought, language impairments iii. Content of Thought Preoccupations, thought disturbances iv. Intellectual Functioning memory, abstract ability d. Use of Ego Defense Mechanisms e. Level of Self-esteem BACK TO BASICS THERAPEUTIC RELATIONSHIP - therapeutic, not social in nature; it is not a friendship; always patient-centered and goal directed; it is limited in nature STAGES/PHASES of a Nurse-Patient Relationship: 1. Pre-orientation Phase: objective is to prevent counter-transference 2. Orientation/ Initiation Phase: obj: establish trust & rapport; set goals - the phase where the termination phase is begun - assessment of problems, needs, & expectations of patient - define the responsibilities of nurse, schedules, contracts,, limitations, goals 3. Working Phase: - Obj: identification of problems, employment of problem-solving techniques, help client develop/restore coping mechanisms 4. Termination / Evaluation Phase: Obj: Evaluate if goals set were met - stage of separation anxiety and other problems of termination THERAPEUTIC COMMUNICATION [theracom] - an interpersonal interaction between a nurse and client; it is patient-centered and goal-directed. Components of TheraCom: 1. Confidentiality 2. Self-Disclosure 3. Privacy and Respecting Boundaries 4. Touch 5. Active Listening and Active Observation
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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

THERACOM TECHNIQUES: Offering of Self I am here. Accepting Yes, I follow what you said Broad Openings What are you thinking about?; open-ended questions; not answerable by yes or no Clarification What do you mean by? Encourage description of perceptions Tell me what you feel when you feel anxious. Exploration/Elaboration Tell me more Focusing What is one thing that is bad/good about; concentrating on a single point General Leads Hmmand then?; encourages continuation of expression Giving Recognition Hello., I noticed you combed your hair today. Making Observations I noticed that you are biting your nails. ; verbalizing what the nurse has observed. Paraphrasing/ Restating/ Repeating You dont think that this is right?; repeating the issue expressed. Reality Orientation/Testing I dont see lizards on your back. Reflection You seem upset. It must be difficult for you., Would you like that?; mirroring feelings; directing clients actions, thoughts, and feelings back to him. Silence absence of verbal communication Summarizing During the last half-hour, we have discussed; recap Validating [client: Im dead] nurse: You feel lifeless?; translating into feelings words the client expressed. Voicing Doubt Thats unusual; gently questioning the reality of the perception NON- THERACOM: Asking WHY Advising Agreeing and Disagreeing Approval and Disapproval Belittling the feelings expressed Challenging Defending False Assurances Introducing an Unrelated topic changing the subject Judging Non-therapeutic Touch Non-therapeutic Silence
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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

Rejecting Stereotyping - generalization Using Denial You dont mean to say those things BEHAVIOR the way an organism responds to a stimulus; it is a response to a changed condition - all behavior has meaning and purpose - the perception is more important than what is actually happening NEED a requirement for survival CONFLICT the result of the presence of 2 or more opposing or incompatible drives wherein the person is required to make a choice. STRESS the wear and tear on the body - pressure brought on by a stressor; it is recurring, normal, and cannot be avoided. Stress Adaptation Syndrome Stage I: Alarm Reaction - fight or flight mechanism; increased Alertness and anxiety; task-oriented; defense-oriented Stage II: Resistance optimal adaptation to stress; increased use of coping mechanisms; defense-oriented behavior Stage III: Exhaustion loss of ability to resist stress; reality contact reduced FRUSTRATION a state where the stress surpasses the persons threshold. Major Behavioral responses to frustration: a. Fixation a strong and persistent response b. Aggression a response in some form of attack and is generally destructive > 2 Types of Aggression: i. Passive aggression ii. Active aggression c. Regression a response wherein the person reverts back to a previous period in life where he felt safe and able to cope d. Resignation act of giving up or withdrawing from reality ANXIETY a vague feeling of dread or uneasiness; has no identifiable stimulus for anxiety; subjective; painful apprehension; fear of the unknown FEAR fear is a response to a specific, identifiable threatening object. LEVELS OF ANXIETY MILD +1 : person is fully alert, senses are heightened, and perceptual field is widened, increased attentiveness MODERATE +2: selective inattention; perceptual field is narrowed; his focus needs to be directed to a point; can verbalize feelings of anxiety; increased vital signs SEVERE +3: perceptual field is greatly reduced; there is attention to detail but not necessarily on what is important; inability to solve problems; this is the start
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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

of the sympathetic symptoms; pacing, wringing of hands PANIC +4: focus is survival; perceptual field is severely reduced; tunnel vision; no problem solving, no focused attention; GENERAL INTERVENTIONS FOR ANXIETY: Identify anxious behavior and determine level of anxiety. Control environment Stay with client Establish a supportive and trusting relationship Show acceptance and be non-judgmental Do not confront patient; Encourage expression and verbalization Provide physical care and relaxation techniques As directed, administer medication Encourage individual or group therapy to identify new ways of coping

NO-NOs in ANXIETY: - pressuring patient to change even if he is not ready - Confrontation - Disapproving verbally - Withdrawing from the patient - Critically focusing on the anxious feelings of the client - Being non-therapeutic CRISIS an upset in a steady state; when faced with a situation that cannot be readily solved by the usual coping techniques; it is self-limiting [4-6 weeks] Types of Crisis: 1. Developmental/Maturational Crisis developmental stages of life 2. Situational/Accidental Crisis - accidents, miscarriages, rape, sudden death 3. Adventitious - calamities, disasters, war CRISIS INTERVENTION objective: to return to normal level of functioning - alleviate the impact of the crisis and help mobilize resources. General Principles in Crisis Intervention: - ensure safety of all those involved - help the client to verbalize - explain to client the facts; fantasies are more dangerous and frightening - never give false assurances - help him to seek help - assist him with everyday tasks GRIEF & LOSS GRIEF the normal emotional response to the experience of loss GRIEVING is the process of grief MOURNING/BEREAVEMENT the outward expression of grief KUBLER-ROSS STAGES OF GRIEVING: [DABDA] Denial
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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

Anger Bargaining Depression Acceptance INTERVENTIONS - assess how the client is coping with the loss - encourage client to reach out - encourage client to review personal strength - encourage client to care for herself - use therapeutic communication - maintain interpersonal skills EGO DEFENSE MECHANISMS - defense mechanisms serve a useful protective function ACTING OUT: an unconscious desire turned into reality COMPENSATION: making up for a perceived insufficiency through a specific behavior CONVERSION: translation of emotions to physical symptoms; psychosomatic; DENIAL: fighting with reality by stating that it doesnt exist Ex. This is not happening to me. DISPLACEMENT: transfer feelings of frustration & anger to a less threatening object/person DISSOCIATION: detachment or separation from ones consciousness during an emotionally extreme situation FIXATION: persistence of a thought or behavior pattern beyond its appropriate stage IDENTIFICATION: the unconscious behavior of associating with another person or the environment to preserve the ego; usually found in preschoolers INTELLECTUALIZATION: avoiding emotional involvement by focusing on the intellectual aspects; smothering emotions with facts. INTROJECTION: incorporating in one self the values and traits of another PROJECTION: placing unacceptable impulses of yourself onto someone else; blaming; scapegoat RATIONALIZATION: sour-graping; giving another logical reason as opposed to the real reason REACTION FORMATION: taking the opposite belief/behavior because the true belief/behavior is unacceptable; plastic REGRESSION: temporary retreat to a safer stage of development or to a behavior during stress REPRESSION: mainly unconscious; unintentional forgetfulness SPLITTING / STEREOTYPING / GENERALIZING: all good, all bad SUBLIMATION: socially unacceptable behavior into personally or socially acceptable behavior SUPPRESSION: unconscious voluntary or intentional pushing of conscious thoughts or feelings into the
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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

SYMBOLIZATION: unconscious; an object or act unconsciously holds a hidden meaning and carries an emotional feeling UNDOING / RESTITUTION: a way of compensating or apologizing for wrong doing SUICIDE - The intentional act of killing oneself Types of Suicide: a. Direct Suicide conscious & voluntary b. Indirect Suicide unconscious & hidden desires to die Population at Risk for Suicide - males; divorced spouses, Caucasians, adolescents, adults 30-40 yrs old, elders above 65 yrs old; with painful or debilitating diseases, psychosis, those with no social support group; lack spirituality or religion, those with a history of suicidal attempts INTERVENTIONS: - never ignore any suicidal ideation! - Promote clients safety by controlling his environment; suicide precaution, may need restraints - Crisis intervention, problem-solving - No-suicide contract - Help client identify support systems - One-to-one supervision at all times PERSONALAN PERSONALITY the cumulative of all the aspects of an individual; it is expressed through behavior Factors that influence Personality: a. Heredity b. Environment c. Training Theories on Personality: 1. Erik Eriksons Psychosocial Theory 2. Sigmund Freuds Psychosexual/ Psychoanalytical Theory ERIKSONS PSYCHOSOCIAL THEORY 8 stages of man TRUST vs. MISTRUST [0-18 months] the regular and constant interaction between mother and infant lay the foundations of trust for the infant if positive = realistic trust and confidence in others, optimism & hope mistrust = withdrawal; suspiciousness, projection; overly trusting in others AUTONOMY vs. SHAME & DOUBT [18 months 3 years] attempts to gain control over himself and his environment [autonomy] shame & doubt = affect his ability to achieve = compulsiveness, fear of criticism holding on or letting go stage social skill: parallel play INITIATIVE vs. GUILT [3-5 yrs]
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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

period of development of the conscience initiatives in taking on higher levels of motor and intellectual skills if positive = initiative is reinforced = adequate conscience if negative = excessive guilt = passivity, apathy; labile emotions, showing off social skill: cooperative play INDUSTRY vs. INFERIORITY [5-11 yrs.] efforts to interact within a broader social context; he creates his own toys, games encouragement & praise = industry and competence; completion of activities criticism & excessive discipline = sense of inferiority, inadequate problem solving skills; perfectionist, intense fear of failing IDENTITY vs. ROLE DIFFUSION & CONFUSION [11 18 yrs] constructs personality theories about himself and those around him if identity is formed = sense of self, confidence, emotional stability, role diffusion = his attempt of being too many people role confusion = not knowing where he belongs to = may seek a negative identity INTIMACY vs. ISOLATION [young adulthood] ability to be intimate with others on levels of friendship and sexuality if intimacy is not established = isolation, emotional distance, casual sex encounters; possessiveness and jealousy, dependence, abusiveness if positive = ability to give and receive love, responsible sexual behaviors GENERATIVITY vs. STAGNATION [middle adulthood] focuses on his contribution to the next generation (children, nieces, nephews, etc.) if positive = productive, constructive, creative; parental & societal responsibilities no sense of generativity = state of self-absorption; self-centeredness INTEGRITY vs. DESPAIR [late adulthood] he assesses himself based on the cumulative experiences of a lifetime; accepts responsibility for what his life has been and finds its worth satisfaction with his life = sense of integration, dignity, worth, and importance; many regrets = sense of despair, helplessness, worthlessness; withdrawal, loneliness

FREUDS PSYCHOANALYTICAL / PSYCHOSEXUAL THEORY -iceberg theory, components of personality, and role of early childhood experiences in shaping the personality LEVELS OF CONSCIOUSNESS: iceberg 1. Conscious functions when awake; the thinking being; EGO - past experience, recent events are recalled easily 2. Preconscious / Subconscious part where ideas and reactions are stored and partially forgotten; it prevents unacceptable memories from surfacing in the conscious - thoughts and experiences are recalled but with effort 3. Unconscious the largest part of the mind - storage of all memories, feelings, reactions, etc. - memories cant be recalled at will; but through dreams, Freudian slips, unexplained behavior, jokes, lapses of memories COMPONENTS OF PERSONALITY:
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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

1. ID the unconscious part of the person; contain the primitive drives and urges - pleasure principle - developed during infancy 2. EGO the self I; the integrator of the personality - developed during toddler stage - reality principle 3. SUPEREGO the conscience - developed during preschool age STAGES OF PSYCHOSEXUAL DEVELOPMENT: ORAL PHASE [0-18 months] Mouth is the pleasure area; satisfaction through feeding, sucking, and swallowing ANAL PHASE [18 months 3 years] - Anus is pleasure area; satisfaction through elimination and retention - Critical period of toilet training; first experiences with discipline and authority - Reality principle is introduced - EGO development and start of Superego development PHALLIC PHASE [3-5 years] - Genitals is pleasure area; satisfaction through masturbation, fantasy, and play - Girls: penis envy and Elektra complex - Boys: Oedipus complex - Resolution of these complexes occurs through identification with same sex parent - SUPEREGO is developed LATENCY [6-12 years] - this stage is marked by expanding social network, more peer relationships - increased intellectual activity GENITAL PHASE [12 onwards] - marked by sexual maturity that starts with puberty - Genitals are again the pleasure area; establishments of relationships with opposite sex PERSONALITY DISORDERS - are diagnosed when ones personality becomes inflexible and maladaptive and interferes with how he functions in society or causes emotional distress CATEGORIES / CLUSTERS OF PERSONALITY DISORDERS: Cluster A: Odd / Eccentric 1. Paranoid Personality Disorder - suspicious, distrustful - suspicions = pathological jealousy, hypersensitivity - delusions of persecution - Defmex: PROJECTION - Theracom: PASSIVE FRIENDLINESS
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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

2. Schizoid Personality Disorder - aloof, socially distant, introvert, loner, humorless - flat affect; fair contact with reality - avoids meaningful interpersonal relationships - inability to experience pleasure - Theracom: respect their space and privacy of their thoughts - Therapy: Psychotherapy & Group therapy to develop interpersonal & social skills 3. Schizotypal Personality Disorder - Sx of Schizoid + magical thinking, ideas/delusions of reference, peculiarity of speech but no looseness of association; withdrawn, detached; inappropriate or blunt affect - teach self-care and assist in developing social skills Cluster B: Dramatic / Erratic 1. Antisocial Personality Disorder - usually males with history of conduct disorder during childhood - may have history of sexual or physical abuse or violence - may appeal as sweet talking, charming, intellectual - impulsive, aggressive, manipulative, low self-esteem, lack remorse, hates rules and authority figures - Defmex: RATIONALIZATION, DISPLACEMENT - Theracom: Limit Setting; matter-of-fact approach Consistency - help client learn how to solve problems and manage emotions of anger 2. Borderline Personality Disorder - mostly females - unfulfilled need for intimacy; chronic feeling of emptiness and anhedonia - disturbance in EGO and self-concept - impulsive, self-destructive, emotionally unstable - with marked mood swings and unpredictable behavior - Defmex: SPLITTING - promote safety, help client cope and control emotions - Theracom: Limit setting, Confrontation, No Self-Harm Contract 3. Histrionic Personality Disorder - common in women; wants to be the center of attention; usually provocative - emotional, dramatic, manipulative, seductive, impressionistic speech, extrovert, creative, emotionally unstable, vain - Theracom: provide factual feedback on behavior 4. Narcissistic Personality Disorder - mostly in males; metrosexual - boastful, egotistical, superiority complex, arrogant, lack of empathy - superficial relationships - Theracom: matter-of-fact Cluster C: Anxious / Fearful 1. Avoidant Personality Disorder - fear of rejection - inferiority complex, shy, timid; social withdrawal, loner
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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

- hypersensitive to negative evaluation/criticism - Theracom: promote self-esteem, support 2. Dependent Personality Disorder - submissive, clinging, emotionally needy, very low self-esteem, helpless - mostly women - lack self-confidence; unable to make decisions for herself; fear of being alone - Priority: Safety, refer to shelter - Theracom: foster self-reliance, autonomy, problem-solving skills, decisionmaking, and self-esteem 3. Passive Aggressive Personality Disorder [plastic] - pervasive pattern of passive resistance to the demands for social performance with a negative attitude; loves to procrastinate and forget; moods fluctuate rapidly - client may shift from blaming others to exaggerated remorse and guilt 4. Obsessive-Compulsive Personality Disorder - Obsession: persistent and repetitive thought or emotion - Compulsion: irresistible desire to perform an action, uncontrollable irrational acts - Anal Fixation strict toilet training Cardinal Sign: Ritualistic behavior [main = handwashing] - need to be perfect and precise; self and environmental control - Theracom: give appropriate time to do the rituals to relieve anxiety; do not interfere; Set limits on time length and frequency of ritual; offer alternative activities; control the environment and minimize choices avoid manipulative and controlling behaviors - Meds: TCAs = first choice is Clomipramine (Anaframil) second choice is Imipramine (Tofranil) NERBYOSO ANXIETY RELATED DISORDERS - all have insomnia due to decrease in gamma aminobutyric acid [GABA] - given anxiolytics to control symptoms Panic Disorder recurrent, unexpected panic attacks followed by 1 month of persistent concern or worry about having future attacks - Meds: SSRIs, TCAs, MAOIs, benzodiazepine anxiolytics [antianxiety] - decrease environmental stimuli, structured environment, slow & deep breathing, engage in relaxing physical activity, performing repetitive activities - help client produce a positive self-talk Phobia Disorder an illogical, intense, persistent fear of a specific object or a social situation that causes extreme distress and interferes with normal functioning - Types: agoraphobia, social phobia, algophobia, xenophobia, zoophobia - Psychotherapy, Behavioral Therapy, systematic desensitization - relaxation techniques, provide constant support, avoid confrontation & humiliation Obsessive-Compulsive Disorder also a personality disorder [discussed above]

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Post Traumatic Stress Syndrome [PTSD] a disorder following the exposure to an extremely traumatic event causing intense fear and recurring recollections and nightmares wherein the experience is relived - Cardinal signs: FLASHBACKS & NIGHTMARES - Symptoms: sleep disturbance, irritability, depression, anger outbursts, hypervigilance, inability to maintain intimacy, poor impulse control, exaggerated startle response - Theracom: encourage verbalization; show empathy; be non-judgmental; help client find ways of expressing feelings safely, encourage to reach out to support systems Generalized Anxiety Disorder [GAD] free-floating anxiety - Cardinal sign: chronic worrier Dissociative Disorder overuse of the DefMex Dissociation - disruption in the usually integrated functions of consciousness Types of Dissociative disorders: 1. Dissociative Amnesia client cant remember personal information 2. Dissociative Fugue client has episodes of suddenly leaving the house or work without any explaination; 3. Dissociative Identity Disorder [Multiple Personality Disorder] - client displays 2 or more identities or personalities that take over his behavior; 4. Depersonalization Disorder client has a persistent feeling of being detached ANXIOLYTICS / ANTI-ANXIETY MEDICATION - Sedative / Hypnotic / Minor Tranquilizer - Prescribed for anxiety, insomnia, & Delirium; OCD, PTSD, alcohol withdrawal Use: reduce anxiety; induces relaxation, sedation, inhibit convulsions Harm: never mix with alcohol BENZODIAZIPINES [-zepam / -zolam] - anticonvulsant, anxiolytic, muscle relaxant Diazepam (Valium) Chlordiazaproxide (Librium) Alprazolam (Xanax) Estazolam (Prosom) Oxazepam (Serax) Lorazepam (Ativan) Clonazepam (Klonopin) Halazepam (Paxipam) Midrazolam (Dormicum) Prazepam (Centrax) Triazolam (Halcion) Temazepam (Restroril) Flurazepam (Dalmane) Side Effects: tend to cause physical & psychological dependence; drowsiness, sedation, poor coordination Health Teaching: do not stop abruptly; dont take more than the prescribed dose; do not drink alcohol; do not drive a car or operate machinery; in elderly, fall precautions. Warning: monitor Respiratory Rate = sign of Respiratory Depression
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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

Antidote: Flumazenil (Romazicon) anxiolytic antagonist BARBITURATES ANTICONVULSANTS [ -tal / -al ] - more used as an anticonvulsant than a sedative Secobarbital (Seconal) Phenobarbital (Luminal) commonly used Methohexital (Brevital) Amobarbital (Amital) Pupillary constriction = sign of overdose ATYPICAL ANXIOLYTICS Diphenhydramine (Benadryl) Hydroxyzine (Atarax, Iterax, Vistaril) Meprobamate (Milltown, Equanil) Chloral Hydrate (Noctec) Zolpidem (Ambien, Stillnox) Side Effects: drowsiness, mental confusion, habituation & increased tolerance, withdrawal symptoms Health Teaching: no driving or operate machinery; no alcohol; evaluate mood, affect, and sensorium for indications of mental confusion SIKAT! SOMATOFORM / PSYCHOSOMATIC DISORDERS - without any organic or real physiological or objectively observable symptoms - Somatization: transference of mental experiences into bodily symptoms - Defmez: Repression, Projection, Conversion, and Introjection - General Interventions: understand that the symptoms are real to the patient; be therapeutic; help client develop problem solving skills and coping mechanisms; provide diversionary activities to distract client from the symptom; Antidepressants as ordered. TYPES OF SOMATOFORM DISORDERS: 1. CONVERSION DISORDER the presence of physical symptoms with no identifiable physical etiology - Sx: La Belle Indifference seemingly lack of concern of manifestation - Defmex: Denial, Projection, Conversion, & Introversion Interventions: divert attention from symptom; provide social and recreational activities, control environment 2. HYPOCHONDRIASIS preoccupation with an imagined illness with no observable symptoms and no organic changes - Cardinal sign: Doctor Shopping; conditions are mostly terminal or debilitating - Diagnostic Test: using Placebo Scandal!! SEXUAL DYSFUNTION - deviations in sexual behavior
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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

Principles of Care: Limit behavior but accept that the patient is in emotional pain; Protect the client from others; Set limits on him acting out sexually; Develop and support self-esteem; provide diversional activities. PARAPHILIA sexual fantasies or urges that directed towards non-human objects, pain to self or partner, and to non-consenting adults (children). Exhibitionism Fetishism Frotteurism Masochism Pedophilia Sadism Transvestism Voyeurism Zoophilia

Hiyak! EATING DISORDERS General Interventions: Dietary Therapy oral or tube feedings, monitor hydration and electrolytes, provide health teachings, set limits based on weight loss or gain, restrict or grant privileges; use behavioral contracts; positive and negative reinforcement; weigh 3 times a week; assess eating patterns; never leave patient until 2 hours after meal (watch for purging). ANOREXIA NERVOSA ignoring their feelings of hunger & signs of physical weakness, - has an intense fear of gaining weight or becoming fat > Sx: intense fear of becoming fat or gaining weight Emaciation Amenorrhea for at least 3 consecutive cycles Depressive symptoms such as withdrawal, irritability, & insomnia Cold intolerance & lethargy Electrolyte imbalance, constipation, and abdominal pain Inflexible thinking Hypotension, hypothermia, bradycardia, reduced BMR > Criteria of treatment: Weight gain & adequate food intake (1-2 pounds/wk) >COD: cardiac dysrhythmias due to hypokalemia BULIMIA NERVOSA recurrent episodes of binge eating followed by inappropriate compensatory behaviors such as avoid weight gain, such as purging, fasting, or excessive exercise >Sx: may be of normal weight, overweight, or underweight Very critical of body image Depressive or anxiety symptoms Possible substance abuse involving alcohol or stimulants Loss of dental enamel, increase in dental carries, moth-eaten teeth Menstrual irregularities Esophageal tears and varices Callous finger Chipmunk face
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WALA SA MOOD MOOD / AFFECTIVE DISORDERS - pervasive alterations in a persons emotions, manifested by depression or mania; they interfere with the persons life/functioning - are neurobiologic dysfunctions that cause altered emotional responses. >CATEGORIES OF MOOD DISORDERS: UNIPOLAR DISORDER includes Major Depresson >Depression an abnormal extension or elaboration of sadness & grief - Sx: anger, anxiety, bitterness, hopelessness, low self-esteem, fatigue, backache, anorexia, vomiting, insomnia, chest pain, confusion, indecisiveness, pessimism, over-dependency, psychomotor retardation, poor hygiene, agitation, crying, irritability > MAJOR DEPRESSION: severe depression of more than 2 weeks - Diagnostic Criteria: - at least 5 occurring most of the day, daily for 2 weeks Early morning depression Anhedonia Insomnia Psychomotor retardation Fatigue, anergia Feelings of worthlessness & ambivalence Self care deficit History of suicidal attempts Weight loss or gain; constipation Flat affect BIPOLAR DISORDER / MANIC-DEPRESSIVE DISORDER > Depression > MANIA abnormally elevated mood in which the person is extraordinarily energetic; needs little rest, sleep or food; - Sx: elation/euphoria, lack of shame & guilt, intolerant to criticism, dehydration, inadequate nutrition, insomnia, weight loss, flight of ideas, lack of judgment, aggressiveness, provocativeness, hyperactivity, poor grooming - Diagnostic Criteria for Mania: Delusion of grandeur Insomnia Flight of ideas & pressured speech Hyperactive & distracted Easily agitated, restless Manipulative Increased metabolism Poor impulse control Violent, aggressive, hypersexual - Interventions: accept client but reject behavior, consistent care, set limits, never leave patient when hyperactive, dont encourage performances, distract and redirect energy , use physical activities until mania wears out, meet nutritional needs (high-calorie finger
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foods & fluids that can be carried around), encourage rest, lessen environmental stimuli, check for lithium intoxication. ANTIDEPRESSANTS SELECTIVE SEROTONIN REUPTAKE INHIBITORS [SSRI] first line in major depressive disorders, panic disorders, anxiety disorders, & bipolar disorders take in the morning Side Effects: agitation, restlessness, anxiety, akathisia (motor restlessness), nausea, insomnia, sexual dysfunction, weight loss [ -xentine / - zodone ] Paroxentine HCl ( Paxil) Fluoxentine HCl (Prozac) Fluvoxamine (Luvox) Venlafaxine (Effexor) Trazodone (Desyrel) Nefazodone (Serzone) Sertaline (Zoloft) Citalopram (Celexia) TRICYCLIC ANTIDEPRESSANTS [TCA] are potentially fatal if overdosed; anticholinergic effect take at night always take an ECG before giving TCAs; adverse effect of cardiac dysrhythmias [ -pramine / -tryptilline ] Clomipramine HCl (Anaframil) Norpramine (Desipramine) Imipramine (Tofranil) Trimipramine (Surmontil) Amitryptilline (Elavil) Protryptilline (Vivactil) Maprotilline (Ludiomil) Nortryptilline (Pamelor, Aventyl) Amoxapine (Asendin) Doxepine (Sinequan) Buproprion (Wellbutrin) MONO AMINE OXIDASE INHIBITOR [MAOI] low sedation and anticholinergic effects; use with extreme caution never give food with TYRAMINE = fatal side effect , hypertensive crisis (occipital headache) Tyramine food: Aged cheeses (including lasagna or pizza) Aged meats (salami, sausage, pepperoni) No tap beers; only 2 cans or bottles of beer No soy sauce, cheesehburgers, canned food (high salt) [ PAMMANA ] Parnate (trancyclopromine) Marplan (Isocarboxacid) Mannerix (Moclobemide Nardil (Phenelzine SO4)

MOOD STABILIZERS / ANTIMANIC MEDICATION [ LITHIUM ] - used for mood disorders especially Mania in bipolar disorder
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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

Lithium Carbonate (Eskalith, Lithane, Lithboid) Lithium Citrate (Cibalith S) Carbamazepine (Tegretol) Therapeutic Serum Level 0.5 1.2 mEq (after 12 hour lithium fasting) Antidotes: Diamox (Acetazolamide) Mannitol (Osmitrol) - Hyponatremia = increased lithium level - Interventions: Monitor Lithium serum level, avoid diuretics & caffeine, avoid excessive sweating >Lithium Intoxication: Stages EARLY/MILD Nausea & vomiting, anorexia, diarrhea, gross hand tremors, abdominal cramps MODERATE symptoms are twice the initial signs SEVERE/LATE nystagmus; tactile, olfactory, & visual hallucinations, Polyuria, Oliguria, Anuria; Acute renal failure; Grand mal seizure BEAUTIFUL MIND PSYCHOTIC DISORDERS SCHIZOPHRENIC DISORDERS - A severe impairment of mental & social functioning with grossly impaired reality testing, sensory perception, & with deterioration & regression of psychosocial functioning. 4 As of Schizophrenia: Autism: withdrawal from the environment, magical thinking, neologisms, aloofness Ambivalence: two opposing feelings toward the same thing Associative Looseness: jumping from topic to another without any relevance Affect, Flat: inappropriate or no display of expression/feelings Categories of Schizo Symptoms: 1. POSITIVE - delusions, hallucinations, illusions, associative looseness, delusions, disorientation, agitation, paranoia, & insomnia 2. NEGATIVE - poor judgment, insight, & self-care; alogia, anergia, anhedonia, neologism, word salad, flight of ideas, verbigiration, circumstantiality, Tangentiality, Clang association, Echolalia & Echopraxia Principles of Care: Maintain safety; do not argue with the patient; validate & reinforce reality; prioritize physical needs; therapeutic relationship; individual therapy; proper diversional activities TYPES OF SCHIZOPHRENIA
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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

1. PARANOID SCHIZOPHRENIA Cardinal Sign: SUSPICIOUSNESS Sx: Delusions of persecution Defmex: Projection Interventions: Keep distance, Passive Friendliness, keep isolated 2. CATATONIC SCHIZOPHRENIA Cardinal Sign: Catatonia (waxy flexibility) Sx: mutism, bizarre mannerisms, similar with autism Defmex: Autism & Mutism Catatonic characteristics: Catatonic Stupor markedly slow movement Catatonic Posturing weird & awkward positions Catatonic Rigidity stone-like positions Catatonic Negativism resistance toward flexion/extension Catatonic Hyperactivity or exitability occasional periods of agitation & excitement 3. DISORGANIZED SCHIZOPHRENIA Hebephrenic Cardinal Sign: extremely disorganized behavior Sx: inappropriate behavior, silly crying & laughing, transient auditory hallucinations, flat or inappropriate affect, incoherence, loose associations 4. UNDIFFERENTIATED SCHIZOPHRENIA / MIXED Mixed schizophrenic symptoms with disturbances in affect, thought, or behavior Drug of Choice: Fluphenazine (Proxilin decanoate) 5. RESIDUAL SCHIZOPHRENIA Characterized by a history of a psychotic symptoms, withdrawal, flat affect, or looseness of association but there are no more delusions or overt symptoms ANTIPSYCHOTIC MEDICATIONS / NEUROLEPTICS / MAJOR TRANQUILIZERS - decreases hallucinations, delusions, & associative looseness - cause anticholinergic effects - cause EPS (extrapyramidal symptoms) with prolonged use PHENOTHIAZINES [ -azine ] Chlorpromazine (Thorazine) Thioridazine (Mellaril) AE: retinitis pigmentosa Fluphenazine (Prolixin) Acetophenazine (Tindal) Pherphenazine (Trilafon) Promazine (Sparine) Mesoridazine (Serentil) BUTYROPHENONES [ -peridol ] Haloperidol (Haldol, Serenase) Droperidol (Inapsine)

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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

THIOXANTHINES [ - thixene ] Chlorprothixene (Taractan) Thiothixene (Navane) ATYPICAL ANTIPSYCHOTICS Clozapine (Clozaril) Risperidone (Risperidal) Arpiprazole (Ablify) Olanzapine (Zyprexia) Loxazipine (Loxitane) [ -done, -zapine, -apine ]

EXTRAPYRAMIDAL SYMPTOMS reversible side effects of prolonged use of antipsychotic drugs as a result of neurologic dysfunction of the extrapyramidal system 1. Akathisia motor restlessness Sx: foot tapping, finger fidgeting, pacing, cant sit still DOC: Cogentin (Benztropine mesylate) Benadryl (Diphenhydramine) Akineton (Biperiden HCl) 2. Dystonia cardinal sign: Occulogyric Crisis (rolling of eyeballs) Sx: spasm of the neck, shoulder, jaw & throat DOC: same with akathisia 3. Pseudoparkinsonism aka drug-induced parkinsonism Cardinal Sign: Pin-rolling tremors Sx: mask-like expression, flat affect, shuffling gait, cogwheel rigidity DOC: Artane (trihexyphenydyl) Amantidine (Symmetrel) antiviral 4. Tardive Dyskinesia permanent, medical emergency Cardinal sign: tongue rolling & protrusion 5. Akinesia absence of kinetic movement ADIK SUBSTANCE & ALCOHOL ABUSE ALCOHOLISM / ALCOHOL ABUSE - intervened through Chemical Aversion (Antabuse) - CNS depressant that is rapidly absorbed into the bloodstream Alcohol Intoxication: Initial: relaxation, loss of inhibitions Intoxication: slurred speech, unsteady gait, lack of coordination; impaired attention, concentration; may show aggressiveness or inappropriate sexual behaviors; may black out Overdose in a short period of time = vomiting, unconsciousness, respiratory depression = aspiration pneumonia, pulmonary obstruction Treatment of Overdose: gastric lavage or dialysis, cardio & respiratory support (ICU) Stages of Alcohol Withdrawal:
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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

-- peaks on the 2nd day and is over in 5 days; some may take 1-2 weeks 1. Early / Initial (starts 4 12 hours after last intake) Sx: Fine Tremors, restlessness, tachycardia, diaphoresis, & hyperventilation, hypertension, insomnia, N&V 2. Hallucination stage Sx: TACTILE hallucination main hallucination in alcohol withdrawal Visual hallucinations TheraCom: stay with patient, offer self, reorientation, eliminate shadows from his environment 3. Pre-Seizure / Rum Fits 4. Delirium Tremens - active seizure, grand mal seizure DOC: Benzodiazepines (Valium, Librium) grand mal Phenytoin (Dilantin) Common Complications with History of Alcoholism: 1. Liver Cirrhosis 2. Gastritis 3. Pancreatitis 4. Wernickes Aphasia receptive aphasia; problems in interpretation 5. Korsakoffs Psychosis irreversible; Sx: Peripheral neuritis (due to lack of Thiamine or Vit B1) Black outs = confabulation Disulfiram (Antabuse) used in chemical aversion therapy (negative reinforcement) causes nausea, vomiting, intense headache, abdominal cramps it has no effect unless mixed with alcohol Teach client to avoid household items with alcohol like mouthwash, cough syrup, vinegar, wine, fruitcake, astringents, toners, acetone, nail polish, shaving cream

DRUG ABUSE / NON-ALCOHOL SUBSTANCE ABUSE NARCOTICS / OPIOIDS (Demerol, Morphine, Codeine, Nalbuphine, Heroin) Signs of Abuse: Euphoria, anxiety, insomnia; marked respiratory depression with heroin, hyperpyrexia; use of long-sleeved shirts; apathy, lethargy, agitation, dilated pupils Overdose: coma, respiratory depression, unconsciousness = death Signs of Withdrawal: chills, perspiration, tremors, back ache, opoid cravings, yawning, restlessness, insomnia, N&V, rhinorrhea Heroin: lacrimation, runny nose, yawning, muscle spasm, N&V, panic Treatment: Naloxone (Narcan) Heroin Methadone [as substitute then tapered] ANXIOLYTICS / MINOR TRANQUILIZERS CNS depressant barbiturates are fatal if overdosed = coma, respiratory arrest, cardiac failure = death signs of abuse: slurred speech, respiratory depression, ataxia, unsteady gait, impairment in memory & attention = stupor = coma signs of withdrawal: fatigue, anxiety, depression, tremors, hallucinations, delusions, insomnia
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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

Treatment: gastric lavage + Sodium Bicarbonate, activated charcoal + tapering of the drug dose (prevents coma) STIMULANTS [UPPERS] crystal meth, speed, cocaine, amphetamines signs of abuse: rapid effects of euphoria, agitation, hyperactivity, irritability, seizures, dilated pupils, perspiration, chills, chest pain, confusion, cardiac dysrhythmias = seizures, coma cocaine nasal septum perforation signs of withdrawal: crashing; depression/ marked dysphoria, fatigue, apathy, disorientation, tactile hallucination, delirium tremens, suicidal ideation treatment: activated charcoal, gastric lavage +Thorazine to control hallucination & nausea HALLUCINOGENS LSD, PCP (Phencyclidine), ecstasy, designer drugs Abuse: hallucinations (visual),depersonalization, paranoia, incoherence, confusion, delirium, mania, agitation, convulsion, hyperthermia; PCP = seizures, respiratory depression (may be fatal) No signs of withdrawal nor physiologic overdose Treatment: small doses of valium + cooling measures (hyperthermia) .CANNABIS DERIVATIVES [cannabis sativa] marijuana abuse: similar to alcoholism; RED EYES, fatigue, increased appetite, euphoria, psychosis, inappropriate laughter, short-term memory, distortions in perception; excess = delirium no overdoses occur withdrawal: no clinically significant withdrawal syndrome is identified

INHALANTS Intoxication: apathy, dizziness, nystagmus, lack of coordination, slurred speech, unsteady gait, tremors, muscle weakness, blurred vision, stupor, coma - Acute Toxicity: anoxia, respiratory depression, arrhythmias - Death: caused by bronchospasm, aspiration, cardiac arrest, suffocation - Treatment: no antidote; respiratory & cardiac support CRACKED EGGS PERVERSIVE DEVELOPMENTAL DISORDERS AUTISTIC DISORDER - characterized by the inability to form significant relationships with adults - Sx: doesnt recognize the self/ego; speaks in the third person; withdrawal from reality; values inanimate objects & self-centered activities; personality alteration SEVERE AUTISM apathy, associative looseness, autistic thinking, ambivalence ATTENTION-DEFICIT HYPERACTIVITY DISORDER - disruptive behavioral disorder evident before age 7; - characterized by hyperactivity and inattentiveness - TheraCom: provide firm & consistent discipline with opportunities for success & satisfaction; provide a structured environment with less stimulation - provide a balance of energy expenditure & quiet time - Meds: methylphenidate (Ritalin) or dextroamphetamine sulfate CONDUCT DISORDER - a persistent antisocial behavior of children and adolescents - have little empathy for others; low self-esteem; low frustration tolerance; temper outbursts
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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

MENTAL RETARDATION - characterized by below average intellectual functioning (IQ below 70) that is accompanied by significant limitations in adaptive functioning areas - degree of retardation has a great impact on the childs ability to function - Degree of Retardation (based on IQ level) a. Mild IQ = 50 70 b. Moderate IQ = 35 50 c. Severe IQ = 20 35 d. Profound IQ = below 20 WANGAK! COGNITIVE DISORDERS COGNITION the brains ability to process, retain, & use information - include reasoning, judgment, perception, attention, comprehension, & memory COGNITIVE DISORDERS a disruption in the higher-level functioning of the brain causing devastating effects on their ability to function in life DELIRIUM - a syndrome that involves a disturbance of consciousness with a change in cognition - usually develops in a short period of time - Sx: difficulty with attention & concentration; easily distracted; disoriented, sensory disturbances (hallucinations, illusions, misinterpretations); changes in psychomotor activity, may have anxiety, fear, irritability, euphoria, or apathy - Medication: antipsychotics (Haloperidol) Interventions: Promote clients safety (close supervision, ready assistance, control environment); use calm voice & simple sentences to communicate; give client time to make decisions, quiet & non-stimulating environment, monitor clients visitors; promote sleep & nutrition; monitor elimination patterns DEMENTIA - a mental disorder that involves multiple cognitive deficits; primarily memory impairment & at least one of the cognitive disturbances - is gradual - Prominent Early Sign: memory impairment (short then long term, eventually destroyed) - Sx: difficulty learning new material, deterioration of language function Cognitive Disturbances: 1. Aphasia deterioration of language function 2. Apraxia inability to execute motor functions 3. Agnosia inability to recognize or name objects 4. Disturbance in Executive functioning inability to think abstractly & to plan, initiate, sequence, monitor, & stop complex behavior Stages of Dementia: 1. Mild hallmark: FORGETFULNESS; difficulty finding words, frequently losses objects, may begin social withdrawal 2. Moderate Confusion is apparent, progressive memory loss, still oriented to person & place; inability to perform complex tasks; may lose the ability to live independently 3. Severe Personality & emotional changes; may be delusional; WANDERING; forgets names of spouse, children, own name; need assistance in ADLs

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ST. LOUIS REVIEW CENTER Nursing Review and Tutorials

Interventions: Promote safety & prevent injury; supervision of ADLs; promote adequate sleep, nutrition, hygiene, & activity; structure environment & routine ; provide emotional support; promote interaction & involvement ABUSAR! FAMILY VIOLENCE - includes physical, emotional, & sexual abuse of children, child neglect, spouse battering, marital rape, & elder abuse SPOUSE / PARTNER (boyfriend/same sex relationships) ABUSE - the mistreatment of one person by another in the context of an intimate relationship - may include one or a combination of physical, emotional, psychological, or sexual abuse CHILD ABUSE - intentional injury of a child - includes physical, sexual, psychological, emotional abuse & neglect Types of Child Abuse: a. Physical Abuse often the result of unreasonably severe corporal punishment b. Sexual Abuse sexual acts performed by an adult on a child below 18 yrs of age c. Neglect the malicious or ignorant withholding of the physical, emotional, or educational necessities of the child; the most prevalent type of maltreatment d. Psychological Abuse/Emotional Abuse verbal assaults (blaming, screaming, name-calling, sarcasm) ELDERLY ABUSE - maltreatment of older adults by family members or caretakers - may include physical, emotional, or sexual abuse; neglect, self-neglect, financial exploitation, denial of adequate medical treatment RAPE - a crime of violence & humiliation through sexual means - the penetration of an act of sexual intercourse against her will or consent - mostly unreported due to victims feelings of shame & guilt or fear of further injury - Rapists are usually 25-44 yrs of age, & have history of other crimes - Intervention: immediate support and verbalization of feelings, allowing her to make decisions (to help her regain control), prophylactic treatment for STDs and HIV testing - Therapy INTERVENTIONS FOR ABUSE: - Priority: promote clients safety (from harming others or self) - Help client develop an escape/emergency plan when threats arise - Reorient to reality (flashbacks, dissociation) - Dont grab, force, or touch client without permission - Teach deep breathing, relaxation techniques, & distraction techniques - Promote self-esteem (survivor rather than victim) - Establish a social support system - Refer when needed (Police, social welfare, psychologist, etc.)

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