Psychiatric Nursing Notes

Psych focuses in feelings or self awareness.

Beliefs determine feelings which affects behavior (manifestation of feelings)
Sigmund Freud is the father of PSYCHOANALYSIS.
What happens to childhood will affect adulthood.
STRUCTURE OF PERSONALITY
ID
impulsive, want to, wants pleasure.
PLEASURE PRINCIPLE.
Guiding principle is PAIN AVOIDANCE.
SUPEREGO
should not
small voice of God
to stop
EGO
executive decision maker.
In touch with reality principle.
ID DOMINANT PERSONALITIES
Manic
Anti Social experienced by serial killers
Narcissistic
SUPEREGO DOMINANT PERSONALITIES
Obsessive Compulsive
Anorexia Nervosa
EGO if destroyed result in impaired reality perception.
Schizophrenia
LIBIDO
Sexual energy responsible for survival.
Oral Stage
0 18 months evident.
ID is developed.
*FIXATION Person is stuck in certain developmental shape.
*REGRESSION Return to an earlier developmental stage.
EGO Developed on the 6th month.
Anal Stage
18 months 3 years old.

 Able to control bladder, bowel.

Best time for toilet training.
SUPEREGO is developed.
TOILET TRAINING
Good Mother------------------------ Bad Mother
Successful -----------------Dirty ---------------------- Clean
-------------------------disorganized --------------- organized
------------------------- disobedient ---------------- obedient
------------------------- Anti-social ------------------- O.C
----------------------- Anal expulsive ----------- Anal retentive
PHALLIC STAGE
3 6 years old.
Experience pleasure by manipulating genitals.
Love hate relationship.
Oedipus Complex boy loves parent of the opposite sex.
Imitates daddy called identification.
Castration fears.
Electra Complex girl loves parent of the opposite sex.
Imitates mommy called identification.
Penis envy.
*Conscious upper level of thinking.
*Preconscious tip of tongue.
*Unconscious protects us from traumatic experiences.
LATENCY STAGE
6 12 years old.
School age.
Separation anxiety.
Reading, Writing, Arithmetic.
Lasts for 6 years.
GENITAL STAGE
12 years old and above
Sexual reawakening.
Very important stage.

PHARMA NOTES:
ANTI - ANXIETY DRUGS
Valium
Librium
Ativan
Serax
Tanxene
Miltown
Equanil
Vistaril
Atarax
Ideral
Buspar
ERIC ERIKSON
There is more to life than just sex.
Psychosocial Theory of development.
You can develop a positive side or a negative side.
Developmental task begins at 0 18 months.
-------------------- POSITIVE ------NEGATIVE -------- FACTOR
0 18 mos. ----------Trust ------------ Mistrust ------------ Feeding
18 mos. 3 yrs. ----Autonomy -------Shame & Doubt ---- Toilet Training
3 yrs. 6 yrs. -------Initiative ---------- Guilt --------------Independence
6 yrs. 12 yrs. -----Industry ---------Inferiority ------------ School
12 yrs. 20 yrs. ----Identity ---------Role Confusion --------- Peers
20 yrs. 25 yrs. ----Intimacy -----------Isolation --------------Love
25 yrs. 45 yrs. ---Generativity --------Stagnation -----------Parenting
45 yrs. - above ----Ego Integrity --------- Despair ------------Reflection

LOBES OF BRAIN
1. FRONTAL LOBE
- Language
- Learning
- Personality
- Judgment
2. TEMPORAL LOBE
- Hearing
- Smell
3. PAREITAL LOBE
- Touch
- Taste
4. OCCIPITAL LOBE
- Visual

3 STEPS TO INTERACT WITH ENVIRONMENT

1. Sensory eyes, ears, tongue
2. Integration
3. Motor voluntary or involuntary
VOLUNTARY NERVOUS SYSTEM
also called as somatic
Brain
Spinal Cord
Motor Nerve
Synapse
Muscle Fiber
Motor nerve to muscle fiber you need Acethylcholine which is an On switch.
INVOLUNTARY NERVOUS SYSTEM
also called autonomic nervous system.
AUTONOMIC NERVOUS SYSTEM
-----------------------SYMPATHETIC ------------PARASYMPATHETIC
-------------------(Awake, ADRINERGIC) --------(Relax, CHOLINERGIC)
Heart Rate ------------ Increase -------------------- Decrease
Respiratory Rate ------ Increase -------------------- Decrease
GI ---------------------Decrease ------Increase (Moist mouth, Diarrhea)
GU -------------------- Decrease ---- Increase (Urinary Frequency)
Neurotransmitter---- Epinephrine, Norepinephrine ----Acethylcholine

DRUGS WITH ANTICHOLINERGIC EFFECTS

Anti Anxiety
Anti Psychotic
Anti Cholinergic
Anti Depressants
PHARMA NOTES:
MONOAMINE OXIDASE INHIBITORS (MAOI DRUGS)
Marplan
Nardil
Parnate
DEFENSE MECHANISMS
1. Displacement transfer of feelings to a less threatening object rather than the
one who provoked it.
2. Denial failure to acknowledge an unacceptable trait or situation.
3. DISOCIATION psychological flight from the self.
4. REGRESSION return to an earlier development state.
5. repression unconscious forgetting.

6. RATIONALIZATION illogical reasoning for an unacceptable trait and

situation.
7. REACTION FORMATION doing the opposite of what you have done.
8. UNDOING doing the opposite of what you have done.
9. IDENTIFICATION assuming trait for personal, social, occupational role.
10. PROJECTION attribute to others ones unacceptable trait.
11. INTROJECTION assume another persons trait as your own.
12. SUPPRESSION conscious forgetting.
13. SUBLIMATION putting destructive energies or hostile feelings towards a
more productive endeavors.
14. CONVERSION unexpressed or repressed feelings are converted to physical
symptoms.
15. COMPENSATION over achievement in one area to cover a defective part.
16. SUBSTITUTION replace difficult goal with more accessible one.
PHARMA NOTES:
ANTI PARKINSON DRUG - CAPABLES
Cogentin
Artane
Parlodel
Akineton
Benadryl
Larodopa
Eldepryl
Symmetrel
AUTONOMIC NERVOUS SYSTEM
----------------- SYMPATHETIC -------- PARASYMPATHETIC
Pupils ----------------Dilate ----------------Constrict
Blood Vessels --------Constrict ------------- Dilate
Blood Pressure --------Increase ------------ Decrease
THERAPEUTIC COMMUNICATION TECHNIQUES
THERAPEUTIC
1. Offer Self
2. Silence provide time to think
3. Making observation what you see you say
4. Active Listening nodding, eye contact
5. Broad Opening how are you today?
6. General Leads Go on, Im listening
7. Restating Im sad Youre sad? 1. Dont worry be happy
2. Changing the topic/subject
3. Ignore the client
4. Value based judgment never assume
5. Flattery
6. Advising
7. Giving Opinion

NONTHERAPEUTIC
1. Dont worry be happy
2. Changing the topic/subject
3. Ignore the client
4. Value based judgment never assume
5. Flattery
6. Advising
7. Giving Opinion
FEAR protects us from something bad.
ANXIETY
Vague sense of impending doom.
Triggers the sympathetic nervous system.
Assess level of anxiety of client.
TYPES OF ANXIETY
MILD ANXIETY
+ 1 level of anxiety.
Widened perceptual field.
Restless (say you seem restless).
Enhanced learning capacity.
MODERATE ANXIETY
+ 2 level of anxiety.
Client pace.
Give PRN meds.
SEVERE ANXIETY
+ 3 level of anxiety.
Dont know what to do/say.
Directive orders (please sit down).
PANIC
+ 4 level of anxiety.
May commit suicide.
Promote safety.
Never touch patient.
Hyperventilation (Respiratory Alkalosis)
Breathe into paper bag.
NURSING DIAGNOSIS:
ineffective individual coping.
Powerlessness.
Impaired skin integrity
PLANNING/IMPLEMENTATION:
decrease level of anxiety.

 Decrease environmental stimuli.

Relaxation techniques.
EVALUATION
effective individual coping.
GENERALIZED ANXIETY DISORDER
6 month excessive worrying.
Restless, difficulty concentration, sleep disorders, palpitations, edge of the seat,
easy fatigability.
PANIC ATTACKS/DISORDER
15 30 minutes sympathetic nervous system escalation.
Example is AGORAPHOBIA fear of open spaces.
POST TRAUMATIC STRESS DISORDER
victims becomes survivors and experience flashbacks or nightmares.
MALINGERING
pretending to be sick (conscious).
Primary Gain anxiety decreases, able to escape source of anxiety.
Secondary Gain able to get attention.
SOMATOFORM
no protection
unconscious
no organic basis of being sick
DIFFERENT TYPE OF SOMATOFORM
1. Conversion Disorder
cannot speak, see, hear.
Nervous system affected.
2. La Belle Indifference
do not care what happens to them.
HYPOCHONDRIASIS
has minor discomfort and interprets it as major illness.
Focus on clients feelings.
BODY DISMORPHIC DISORDER
Illusion of structural defect.
Favorite past time is doctor hopping.
Focus on clients feelings.
PSYCHOSOMATIC
Real pains/illness
Real symptoms because of anxiety
PSYCHOSOMATIC
Increase Anxiety

SNS
Increase BP & HR
Hypertension
Fat Deposits
Atherosclerosis
Calcium
Arteriosclerosis
Decrease Oxygen
Angina Pectoris
MI
Necrosis
CHF
Coma
PHOBIA
Irrational fear
Etiology: Knowledge of certain object
Bad experience
Immediate nursing objective: Removal of stimulus will remove anxiety
Systemic Desensitization gradually expose client to stimuli/feared object
Employ relaxation techniques
SNS
GABA (Gamma Amino Butyric Acid) stop
Epinephrine and Norepinephrine Go
ANTI-ANXIETY
Increase GABA and client becomes drowsy (no alcohol and coffee)
May develop orthostatic hypotension
Let patient sit then dangle feet and then stand
Develop anti cholinergic effects
If abruptly withdrawn to anti anxiety it may result to rebound phenomenon (1
week) may lead to seizures
Do it in gradual and in tapered dose
Anti anxiety leads to dependence
AUTISM
Unresponsive and does not want to be touched
Autistic Savant: high intelligence and has a ratio of 1:100
Assessment
Appearance flat affect and loves constancy and ritualistic
Behavior withdrawn
Communication echolalia
NURSING DIANOSIS
Impaired verbal communication
Impaired social interaction
Self mutilation
Risk for injury
PLANNING/IMPLEMENTATION

 Maslows hierarchy of needs

Expressive Therapy use of art as mode if communication
EVALUATION
Enhanced communication
Improved social interaction
Safety
ATTENTION DEFICIT HYPERACTIVITY DISORDER
7 years and below onset
Duration: 6 months and above
Settings: house and school
Assessment
Appearance: dirty, clumsy, hyperactive, impatient, easily distracted and has no
focus
Behavior
Communication: talkative
NURSING DIAGNOSIS
Risk for injury
Impaired social interaction
PLANNING/IMPLEMENTATION
Structure: place to play, sleep, eat and study
Schedule: there is always a time for everything that you do
Set limits
Safety
EVALUATION
Minimize risk for injury
Improved social interaction
FRONTAL LOBE OF ADHD
Decrease glucose
Decrease judgment
Increase impulsiveness
ADHD
Hyperactivity
Need a drug that brings glucose level up.
Give Ritalin a stimulant
May result in loss of appetite
Given after meals
Given 6 hours before bedtime
EATING DISORDERS
ANOREXIA NERVOSA ---------------BULIMIA NERVOSA
- Eat, eat, eat --------------------------- Eat, eat, vomit
- Less 85% expected body weight ------- Normal weight

- 3 months amenorrhea --------------- Irregular menstruation

BULIMIA NERVOSA
Metabolic alkalosis (vomiting results to decrease hydrochloric acid)
Metabolic acidosis (diarrhea results to decrease bicarbonate)
Dental caries
Wound in knuckles
MANAGEMENT
Fluid and electrolyte imbalance
Meal contract
Weight gain for client
After eating stay with client for 1 hour and accompany when going to the
comfort room
PHARMA NOTES:
ANTI PSYCHOTIC DRUG
Stelazine
Serentil
Thorazine
Trilafon
Clozaril
Mellaril
Haldol
Prolixin
SCHIZOPHRENIA
Ego disintegration
Impaired reality perception
Genetic vulnerability
Stress Diathesis Model
Biological theory increase dopamine level
Exact cause unknown
ASSESSMENT
Affect: Appropriate, Inappropriate, Flat, Blunt (incomplete)
Ambivalence: pulled into 2 opposing forces
Autism
Looseness, no idea, not related to one another
ASSESSMENT
NEGATIVE ------------------------POSITIVE
Hypoactive ------------------------ Hyperactive
Withdrawn ------------------------- Sociable
Thought Blocking ------------------Flight of ideas
Apathy
I. ASSESS
Content of thought

10

NURSING DIAGNOSIS
Disturbed thought process
PLANNING/IMPLEMENTATION
Present reality
Provide safety
EVALUATION
Improved thought process
II. ASSESS
Hallucinations/Illusions
NURSING DIAGNOSIS
Disturbed sensory perception
PLANNING/IMPLEMENTATION
Present reality
Safety
EVALUATION
Improved sensory perception
III. ASSESS
Suspicious
NURSING DIAGNOSIS
Risk for other directed violence
PLANNING/IMPLEMENTATION
Present reality
Safety
EVALUATION
Eliminate/minimize risk for other directed violence
IV. ASSESS
Suicidal
NURSING DIAGNOSIS
Risk for self directed violence
PLANNING/IMPLEMENTATION
Present reality
Safety
EVALUATION
Eliminate/minimize risk for self directed violence
LOOSENESS OF ASSOCIATION
There is connection with statements
FLIGHT OF IDEAS
Jumping from on topic to another
AMBIVALENCE
Pulled between 2 strong opposing forces

11

MAGICAL THINKING
acting like magician
ECHOLALIA
Client repeats what you say
ECHOPRAXIA
Client repeats what you do
WORD SALAD
Just words no rhyme
CLANG ASSOCIATION
Words that rhyme
NEOLOGISM
Formation of new words (needs clarification)
DELUSION: PERSECUTORY
The NBI is out to get me
DELUSION: RELIGIOUS
I am Jesus Christ the savior
DELUSION: GRANDEUR
I am the queen of the world
DELUSION: IDEAS OF REFERENCE
The nurses are talking about me
CONCRETE ASSOCIATION
Also known as pilosopo
THOUGHT BLOCKING
Unable to think
-----------------------HALLUCINATIONS------ ILLUSIONS
STIMULUS ------------ ABSENT------------ PRESENT
VISUAL ----------------ABSENT------------ PRESENT
AUDITORY ----------- ABSENT------------ PRESENT
TACTILE ABSENT --- ABSENT------------ PRESENT
Present reality to clients experiencing hallucinations
Technique in handling clients with hallucinations
Hallucinations
Acknowledgement I know the voices are real to you
Reality orientation I know the voices are real but I dont hear them
Diversion Lets go to the garden
10% of schizophrenic clients hear voices

12

PARKINSONS DISEASE
If acethylcholine (on switch) is increased there is excessive movement resulting
to decrease in dopamine (off switch)
ANTI-PSYCHOTIC
Decrease dopamine level
Parkinson like effect
Extra pyramidal side effect
With akathesia
Restless, inability to rest
AKINESIA
Muscle rigidity
DYSTONIA
Torticollis (wryneck)
OCULOGYRIC CRISIS
Fixed stare
OPISTHOTONUS
Arched back
Lips smacking
Tongue protruding
Cheeks puffing
The 3 are irreversible and called tardive dyskinesia
Neuroleptic malignant syndrome hyperthermia
ANTI PARKINSON
Anticholinergics Dopaminergics
(Decrease Ach) (Increase Dopa)
Artane, Akineton Parlodel
Benadryl Larodopa
Cogentin Eldepryl
Symmetrel
OTHER SIDE EFFECTS OF DECREASE DOPAMINE
Photosensitivity
Agranulocytosis decrease WBC
Clients prone to infection due to decrease WBC
First sign for infection is sore throat
TYPES OF SCHIZOPHRENIA
DISORGANIZED SCHIZOPHRENIA
- Sad but smiles (inappropriate affect)
- No reaction (flat affect)
- Flight of ideas (disorganized speech)
- Giggling (hebephrenic giggle)

13

- Combination of positive and negative signs and symptoms

CATATONIC SCHIZOPHRENIA
- Ambivalence
- Waxy flexibility
- Favorite word is No
- Negativism (client do not follow what you tell them to do)
Nursing management: meet needs
PARANOID SCHIZOPHRENIA
- Suspicious
- Mistrust, scared, withdrawn
Nursing management:
- Gain trust by 1 to 1 short interaction but frequent
- Foods should be in a sealed container
- Medications should be in tamper resistant foil.
Violent:
- Keep door open
- Position near door
- Dont touch client
- Call for reinforcement
- One arms length away from the client.
PARANOID SCHIZOPHRENIA
- No more positive symptoms just withdrawn
UNDIFFIRENTIATED SCHIZOPHRENIA
- Mixed classification, cant be classified
PHAMRA NOTES:
BI-POLAR, MANIC
Lithium: undergo first kidney test and check for blood levels
Level: .6 1.2 meq/L
Increase urination
Tremors, fine hand
Hydration of 3L/day
Increase
Uu (diarrhea)
Mouth dry
Signs of Lithium toxicity
Nausea, vomiting, diarrhea
Increase sodium
* Wait for 2 4 weeks before lithium therapy takes effects
BIPOLAR DISORDER/MANIC PROFILE
20 years old
Female

14

 Stress
Obese
ASSESSMENT
Decrease appetite (give finger foods)
Decrease sleep (place in a private room)
Hyperactive
Increase sexual activity only means of addressing anxiety so decrease level of
anxiety
Risk for injury/other directed violence
Impaired social interaction (care giver role: strain and stay with client)
Self esteem decrease (to cover up their sadness there is compensation to cover
defective doing)
Because there is decrease self esteem there will be increase compensation
resulting to increase interference with ADLs and harm to others
Compensation is the culprit
Management: increase self esteem to decrease compensation and decrease
interference with ADLs and harm to others
HOW TO INCREASE SELF ESTEEM OF MANIC PATIENTS
T- no sports (basketball, volleyball), no fine motor skills only gross motor skills
A lot energies toward more productive endeavors (sublimation)
S - escorted walk outdoors
K punching bag (displacement)
PHARMA NOTES:
ANTI DEPRESSANTS
Asendin
Norpralamin
Tofranil
Sinequan
Anafranil
Aventyl
Vivactil
Elavil
Prozac
Paxil
Zoloft
ALCOHOL LEADS TO:
Blackout: awake but unaware
Confabulation: inventing stories to increase self esteem
Denial: I am not an alcoholic
Dependence: cant leave with out leading to enabling where in the significant
other tolerates the abuser co dependence is another term
Tolerance: gradual increase in amount of stimuli to experience the same
euphoria

15

MANAGEMENT
Detoxification: withdrawal with medical doctor supervision
Avoid alcohol therapy
Aversion therapy a more technical term for avoid alcohol therapy
Antabuse: Disulfiram makes the client never drink alcohol because it causes
vomiting
Alcoholics anonymous
Interval of 12 hours after last dose of alcohol or experience nausea and
vomiting and hypotension
Alcoholism may result to Vitamin B1 (Thiamine) deficiency
WERNICKES ENCEPHALOPATHY
Problem with motor
KORSAKOFFS PSYCHOSIS
Problem with memory
24 72 hours after last dose of alcohol expect:
Delirium Tremens: sympathetic nervous system
Prevent hallucinations/Illusions by placing client in a well lit room
Formication: feeling of bugs crawling under the skin
ALZHEIMERS DISEASE
Axon (away) and Dendrites (toward) nerve
Neurofibrillary tangles
Neurotic plaques
--------------------------ALCOHOL --- ALZHEIMERS
ONSET -------------------- Abrupt -------- Gradual
LEVEL OF CONSCIOUSNESS -- Fluctuating ----Unaffected
DURATION ----------- Hours to days --- Progressive
MEMORY -------------- Short term ---Short and long term
5 As OF ALZHEIMERS
1. Amnesia memory loss
2. Anomia dont know the name
3. Agnosia sensory problems smell, taste, sight
4. Aphasia
- expressive: cant say/express
- frontal lobe is affected particularly brocas area
- receptive: cant hear
- temporal lobe is affected particularly wernickes area
5. Apraxia cant do simple things
* Reminiscing Therapy talk about past
Patients with alzheimers may experience hallucinations, illusions thus becomes
restless and may wander
As sun goes down client becomes restless, agitated, disoriented called
sundowning
Drug of choice is Cognex and Aricept a cholinesterase inhibitor that increases
Ach causing delay in disease progression

16

SEROTONIN
Responsible for happiness
Decrease serotonin clients becomes sad give anti-depressants
SELECTIVE SEROTONIN REUPTAKE INHIBITOR
Safest drug
Side effects low
R
I to 4 weeks
- Increases serotonin and affects only serotonin
- Prozac, Paxil, Zoloft
TRICYCLIC ANTI DEPRESSANT
Two four weeks
C
A
- Has higher incidence of side effects
- Also increases norepinephrine
- Asendin, Norpralamin, Tofranil, Sinequan, Anafranil, Aventyl, Vivactil, Elavil
MONO AMINE OXIDASE INHIBITORS
MAO kills serotonin
Increased MAO results to decreased serotonin the more depressed the client
becomes
MAOI kills MAO and increases all neurotransmitters (serotonin, epinephrine,
norepinephrine, dopamine but client becomes prone to hypertensive crisis
Avoid tyramine rich foods
Avocado, Alcohol
Beer
Chocolates, Cheese (aged)
Fermented foods
Pickles
Preserved foods
Soy sauce
There is increase incidence of side effects after 2 6 weeks
Marplan, Nardil, Parnate
PERSONALITY DISORDERS
1. Schizophrenia
- They avoid people because there is no enjoyment
2. Avoidant
- They avoid people because they are afraid of criticisms
- They have talent but has no confidence
3. Anti-Social
- Constantly breaks law
- Project charm
- They are witty and articulate
- Manipulative

17

4. Borderline
- They perceive life as an empty glass
- They like splitting friends
- Sudden change in mood labile affect
- Prone to suicide
5. Dependent
- Cant live if living is without you
6. Histrioinic
- Constantly wants to be the center of attention
- Excited, dramatic, manipulative
7. Narcissistic
- I love myself
- They get jealous even with achievement of family members
8. Obsessive Compulsive
- I am so organized
9. Paranoid
- Suspicious
- May lead to domestic violence
ANTI DEPRESSANT SIDE EFFECTS:
Male erectile dysfunction, prone to impotence
GRIEF PROCESS
1. Denial shock/disbelief
2. Anger question why me?
3. Bargaining if, then
4. Depression 2 weeks or more sign and symptoms becomes major clinical
depression
5. Acceptance client acts according to situation
ASSESSMENT
Decrease self actualization
Decrease self esteem
Withdrawn: stay with client
Suicidal: risk for self directed violence
Increase/decrease eat, increase/decrease sleep, hypoactive, decrease sexual urge
Be sensitive to clients needs
FOR SUICIDAL OBSERVE FOR
Verbal
I wont be a problem
This is my last day on earth
Ill soon be gone
Non verbal
Giving away of valuables
Sudden change in mood
18

WHEN THE CLIENT IS SUICIDAL WHAT WILL THE NURSE DO

Direct: Do you plan to commit suicide?
Irregular/interval visits
Endorsement period, early morning clients are most likely to commit suicide
DOWNERS
Alcohol
Barbiturate
Opiates
Narcotics
Marijuana
Morphine
Codeine
Heroine
Resulting to:
Bradycardia
Bradypnea
Moist mouth
Pupils constrict
Constipation
Urinary retention
Hypotension
Coma
Weight gain
Narcotics overdose: give narcotic antagonist (Narcan, Naloxone hydrochloride)
UPPERS
Cocaine
Hallucinogens
Amphetamines
Resulting to:
Tachycardia
Awake
Tachypnea
Dry mouth
Pupils dilate
Hypertension
Seizures
Weight loss

19