PSYCHIATRIC NURSING
”
HISTORY
- The first psych patient in the Philippines ia a
Spanish navy
- The first institution for the mentally ill in the
Philippines is Hospicio de San Jose
- NCMH previously National Mental Hospital
previously National Psychopathic Hospital previously
Insular Psychopathic Hospital
MENTAL HEALTH / MENTAL ILLNESS
- Mental health depends on the ability of an individual
to function, cope and adapt
o If able  HEALTHY
o If unable  ILL
- Neurotic individuals act weird but are still in contact
with reality
- Psychotic individuals act weird and are not in
contact with reality (Hallucination, Delusion)
- Axis I includes all psych disorders except PD and
MR
- AXIS II includes PD, MR and ego defense
mechanism
- Medical conditions are under Axis III while
psychosocial/environmental factors are under Axis
IV
- Self-awareness is the most significant task under
Pre-interaction
- Orientation phase includes building TECS: Trust,
Empathy, Contract, Set Limit
- Nurses collaborate with the patient in identifying the
problem and solution, not dictate, during the working
phase
SIGMUND FREUD
- Freud’s Psychoanalysis: Every behavior is caused
and can be explained
- Id: Innate, PLEASURE PRINCIPLE, no morals (not
concerned with right or wrong), aggressive 
CRIMINAL
- Ego: Balances id and superego, REALITY
PRINCIPLE, rational  IDEAL PERSON
- Superego: CONSCIENCE  TOO GOOD TO LIVE
- 3 Levels of Awareness
o Grand duty – CONSCIOUS (readily available)
o Recalling it’s not allowed – PRECONSCIOUS
(not available but recallable)
o Repressed thoughts (Motivator) –
UNCONSCIOUS (can never be recalled)
- Transference: Patient to Nurse (NORMAL)
- Oral: an infant becomes happy while sucking or
biting (id)
- Anal: anus, toilet training (learning from pleasure)
- Phallic: high libido, penis for both gender (boys –
masturbate / girls - penis envy), mama’s boy
(Oedipus), papa’s girl (Electra)  I wish my father
dead so that I could have my mother (vice versa)
- Latency: decreased libido, conscience
- Genital: independence, intimacy, orgasm
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- Compensation – “MVP ka nga, bagsak ka naman.
(Bagsaking Varsitarian)
- Conversion – psycho to physical
- Denial – “No!”
- Displacement – Kawawang aso
- Identification – a student says, I want to be a doctor
like you. / (Parang si Superman)
- Introjection – A student says, “Good morning, I am
your doctor.” / (Siya daw si Superman)
- Intellectualization – Newscaster (All brain, No heart)
- Projection – “Hindi ako, si B.” (The truth is, she is
and not B)
- Rationalization – Alibi / Maraming dahilan
- Reaction Formation – PLASTIK
- Regression – 18 year old boy bed-wets
- Repression – involuntary forget
- Suppression – voluntary forgets
- Resistance – Deadma
- Sublimation – unacceptable to acceptable (candy
instead of smoke)
- Substitution – impossible to possible (single lady,
day care instead of pregnant without husband)
- Undoing – Jollibee
ERIK ERIKSON
- Trust – be CPR (consistent, predictable, reliable)
o Mistrust if: cries if held by others / bites nipple
- Autonomy: support negativism / offer choices
- Initiative: planning, carry out plan
- Industry: schooling (social and cognitive skills)
- Identity: “Who am I?”
- Intimacy: mutual relationship
- Generativity: productive, look beyond self (children)
- Integrity: “Where am I?” ----- “I am ready / not ready
to die.”
Jean Piaget
- Sensorimotor: use of senses to separate self from
env’t
- Preoperational: symbols / illogical (1 kilo cotton is
heavier than 1 kilo nails)
- Concrete operational: concrete thinking
o NURSE: “Pag may tiyaga, may nilaga”
o PATIENT: “Baka o baboy?”
- Formal Operations
o NURSE: “Pag may tiyaga, may nilaga”
o PATIENT: “Pag may tiyaga, may reward.”
Thought Process
- Looseness of association – shifting from one topic to
another (unrelated)
- Flight of ideas – shifting from one topic to another
(somewhat related) ----- may also be unrelated as
affected by env’l stimuli
- Circumstantiality – going around the bush before
giving the answer
- Tangential – going around the bush without giving
the answer.
- Though blocking – sudden stop in the middle of the
sentence
- Latency of response – delayed response
- Mutism – never talks
- World salad – nonsense mixture of words
- Perseveration – perseveres on giving the same topic
despite of varying questions
- Verbigeration – nonsense repetition of answer
(words / phrases)
- Neologism – invention of meaningless words
- Clang association – rhyming
- Alogia (Poverty of Content) – lack of meaning with
what the client says
SCHIZOPHRENIA
- Etiology: Dopamine hypothesis – Elevated Dopa
- Positive / Type I / Sobra-sobra  hallucination
- Negative / Type II / Kulang-kulang  Anergia
- PAranoiD schizophrenia
o P – Preoccupie with
o A – Allucination and
o D - Delusion
- Disorganized schizophrenia
o Disorganized speech, behavior and affect
- Catatonic schizophrenia
o High or low mov’t
o Echolalia / Echopraxia
o Negativism
o Mutism / Mannerism
- Undifferentiated all of the above (MIX)
- Residual schizophrenia  usually negative signs
- ECT Facts
o 3 diagnoses allowed for ECT: Schizophrenia,
Depression, Mania
o 3 situations that requires ECT: pregnant,
suicidal, agitated
o 70-150 volts
o 0.5-2 seconds
o 48 hrs interval, 2-3x/wk, 6-12-20 treatment
o Memory loss/confusion and headache are usual
side effects
- Antipsychotic Facts
st
o 1 gen., Traditional, Typical: Dopamine
antagonist  decreases dopa  treats (+) S/Sx,
worsens (-) S/Sx
nd
o 2 gen., Atypical: Dopamine Serotonin
Antagonist  decreases dopa in temporal
(decreases + S/Sx) and increases Serotonin in
frontal (Low Serotonin  increased Dopa 
decreased (-) S/Sx
rd
o 3 gen: Dopamine system stabilizer (decreases
dopa if increased and increases dopa id
decreased)
o EPSE
 Dystonia; Torticollis, writer’s cramp,
oculogyric crisis, laryngospasm  IM
Diphenhydramine / Anticholinergic
 Psudoprakinsonism: PD-like manifestations
 Antiparkinsonian Drugs (CABA SLP)
 Akathisia: “kiti-kiti”  change the drug
 Akinesia / Bradykinesia  anticholinergic
o Tardive Dyskinesia:
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 Worm-like tongue mov’t, lip smacking, teeth
grinding
 Not an EPSE, therefore, no anticholinergic
(may aggravate if given)
 AIMS to assess severity
o Neuroleptic Malignant Syndrome
 Muscle spasm (like EPS) + Fever and
altered LOC
 DOC: Dantrolene (muscle relaxant) and
Parlodel (dopa agonist)
 Priority intervention: Fluids
o Agranulocytosis
 Commonly associated with Clozapine and is
usually manifested by sore throat
 NR: CBC monitoring (hold and refer if WBC
is low)
o Other Side Effects:
 SZ / sedation  less stimulating
environment, padded side rails up
 Anticholinergic  prevent injury,
sunglasses, sugar-free candy or beverages,
frequent mouth care, rest, rise slowly from a
supine position, increase OFI, hear running
water, alternating warm and cold compress,
fiber
 Photosensitivity  sunscreen, sunblock,
long sleeves, wide brimmed hat, umbrella
 Hyperprolactinemia  patient may approach
you and complain of milk from breast  tell
patient it’s a side effect and just temporary
 Pisa syndrome  leaning  anticholinergic
 Metabolic syndrome = DM Type 2
- Priority Nursing Intervntions
o SAFETY (suicide)
o Trust
o Present reality
o Do not confront or argue
o Set limit
o Relaxed env’t, calm patient
o No touch
o Confidentiality
ANXIETY DISORDERS
- Abnormal if with disability
- Due to low GABA
- TYPES
o GAD – excessive anxiety and worry
o Panic Disorder – recurrent panic attack
(psychological and physical distress)
o OCD – rituals (NR: do not stop, give appropriate
time instead
o ASD and PTSD
 Both with history of experience
 Both would re-experience (flashback /
nightmare)
 ASD appears earlier and shorter
 PTSD is suicidal  SAFETY
 Phobic
Social phobia – fear of being humiliated
/ embarrassed
 Agoraphobia – fear of being in places  Second line: cardiotoxic, hepatotoxic,
where escape is difficult (“Something nephrotoxic, deadly (limit prescription to only
might happen to me and I might not get 1 week)
out of it.")  Take at bedtime
- Management (Anxiolytics – Addictive – short term)  Overdose: sz, coma, resp. depression 
o Benzodiazepines Physostigmine (Antilirium)
 Zolam, zepam, Tranxene, Librium o MAOI (PaMaNa)
rd
 Side effects  3 line (more food and drug interaction) –
S – slurred speech limit to 1 week prescription
E – edache  Prevent Hypertenive Crisis (Tx:
D – dizzy / double or blurred vision Phentolamine Mesylate)
A – ataxia / amnesia Avoid Tyramine (aged, fermented,
T – tremor smoked, preserved, avocado, banana,
E – excited CNS / encontinent urinary organ meat)
D – decreased bowel elimination and BP Avoid Sympathimimetic drugs
 Toxic signs: severe CNS depression  - General Nursing Responsiblities
Flumezanil (Romazicon) o Safety
 Nursing Responsibilities o Suicide precaution
V – vawal magtake ng ibang gamut without  View at irregular interval
order  Contract
A – avoid alcohol / ambulation assistance / o Engage in activities (lock patient’s room to force
avoid alert activities / avoid abrupt DC him to join activities)
L – lower dosage prn
I – initiate safety BIPOLAR
U – usual drowsiness disappears with - Bipolar I = Mania (7 days) + MDD
continued therapy - Bipolar II = Hypomania (4 days) + MDD
M –monitor liver / renal function - Manic Etiology: high serotonin and NE
o Sedative Hypnotics (Buspar / Atarax) - Management
- Other Management o 1st Priority: Lthium Carbonate
o Antidepressants (long term)  Level:
- Systematic desensitization – gradual exposure 0.6-1.2 mEq/L or 0.4 – 0.8 mEq/L
(phobia) (elderly)
- Flooding – sudden exposure (phobia)  Side Effects
- Anxiety Disorder (Nursing Responsibilties) F – Fine Tremor
A – Attend to physical symptoms / assure basic F – Folyuria
needs are met F – Folydipsie
N – no to interruption with compulsive behavior (give  Mild to moderate toxicity (1.5-2)
time) D – Diarrhea
X – Xafety D –Dizzy
I – Istay / Identify precipitating situations D – Dry mouth
E – Encourage verbalization / Environment quiet D – Decreased muscle strength
T – Trust / teach relaxation / D – Domiting
Y – Yes to calm D – Doarse hand tremor
 Moderate to severe toxicity (2-3)
MOOD DISORDER D – elirium
- Major Depressive Disorder (MDD)  anergia ----- A – Ataxia
Mania  hyper L – Large
A – Altered senses (tinnitus, blurred vision)s
MDD  >3 (Multi-organ failure / coma / death
- MDD– S/Sx at least 2 weeks  Lithium NR
- Nurture Cause: Anger turned inward L – Lithium level motior
- Nature Cause: Low Norepinephrine and Serotonin I – Intervene with toxicity (NaCl,/
- Management: Acetazolamide (Diamox) / Hemodialysis)
o All antidepressants has 2-3 weeks lag period T – Take with meals
o All has the following Side effect: Anticholinergic / H – Have a normal fluid balance
Sedation / Orthostatic BP I – Intake of Na should be consistent
o SSRI (“Sarsi”) – FPSCE U – Usually dangerous to fetus
 Safest – first line M – Must be taken at the same time each
 Take with food and at PM day
o TCA (TCASNAP)
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 nd
o 2 Priority: Anticonvulsants (Carbamazepine /
Valproic Acid)
o Atypical antipsychotic if with psychosis
- Bipolar (Mania) Nursing Responsibilities
T – Try short and simple sentences
H – Have the meaning of the client’s statement
E – Encourage the client to respect distances
M – Matter of fact
A – Avoid argument
N – No to excessive env’l stimulation
I – Insist rest and sleep
C – channel need to move into sociall acceptable
activity

PERSONALITY DISORDERS

- Unusual thoughts, behavior and perceptual

experience (illusion)

- NR:
o Trust
o Improve interpersonal skills
o Low dose antipsychotics

- NR:
o Safety
o Build trust
o Involve client in planning care

- NR:
o Consistently set limit
o Enforce rules
o Verbalization of feelings
o Confrontation
o Teach problem solving / anger management

- NR:
o Trust
o Slowly involve patient in a group

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 - NR:
- Unstable self-image, mood and relationship o (+) reinforcement
- NR: o Problem solving
o Consistently set limit o Proper way to express feelings
o No self-harm contract
o Safety (suicidal)
o Problem solving skills

- “I’m afraid of being alone.”

- NR:
o Decision making
- NR: o Cope with fear
o Self awareness o Problem solving
o Set limit
o Matter of fact

- Alone due to fear of rejection / shame /

embarrassment

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- NR: - Disturbance in executive functioning
o Cope with fear - Confabulation: to protect self-esteem
o Social skills
o Relaxation technique

EATING DISORDERS
- Anorexia Nervosa
o Underweight
o Undernourished
o Amenorrhea
- NR: o View self as fat
o Decision making o Loves food topic but doesn’t eat
o Understand other’s point of view o May have underlying depression
o It’s alright to make mistake - Bulimia
o Binge eating (relaxing / 2 hours)  Guilty
SOMATOFORM DISORDERS feelings  Purge (vomit, enema, diuretics)
- Psychological distress  Physical symptoms without o Normal or near normal body weight
pathologic basis o Dental problems
- Types: o GI problems (GERD-like)
o Somatization Disorder – 4 pain, 2 GI, 1 sexual, 1 o Russell’s sign (callus in knuckles)
pseudoneuro o F&E imbalance
o Conversion Disorder – Neuro / sensory o Acid-base imbalance
manifestations (La belle indifference – no - Management (Anorexia /Bulimia)
concern over symptoms) o Cognitive and Behavioral Therapy
o Pain Disorder – Pain o Antidepressant
o Hypochondriasis – fear that one has or will have o Antipsychotic
a disease / misinterpretation of normal body
processes
o Body Dysmorphic Disorder – self-claimed ugly
body part
- Management:
o Antidepressants / anxiolytics / stress
management

DISSOCIATIVE DISORDERS
- Dissociative Amnesia – unable to remember info
- Dissociative Fugue – suddenly leaves home
without reason, go somewhere else, assumes new
CHILDHOOD DISORDERS
identity (no past memory)
- Autism
- Depersonalization – strangeness towards self (as if
o Identified before 30 months or not later than 3
in a dream)
years of age
- Dissociative Identity Disorder – (multiple
o Impaired communication (no eye contact, not
personality) 2 or more distinct personalities
responsive)
o Lack of social relationship (aloof, preoccupied
DEMENTIA
with inanimate objects)
- Amnesia (Gradual: Antero  Global)
o Stereotyped motor behavior (headbanging,
- Aphasia (Expressive / Receptive)
echolalia, tantrums)
- Apraxia (ADL)
o Management
- Agnosia (recognize  Mcdonalds’ Karen)
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  Antipsychotic – calming effect o Horsakoff’s Psychosis  dementia-like
 Safety – helmet (amnesia, confabulation)
 Picture board - Management
 SPED o Disulfiram
- MR  Makes drinking very painful
o IQ <70  Take 12 hours after last alcohol intake
 Mild (Moron): IQ 55-69  While taking, avoid containing substance
 Moderate (Imbecile): IQ 40-54 (mouthwash)  may resume use 14 days
 Severe )Idiot): IQ 25-39 after the drug was DC
 Profound: IQ below 25 o Less stimulating env’t
o Decreased performance in school, work, usual o Alcoholic Anonymous – for alcoholics
task at home, speech, or even motor function o ALANON – wife of alcoholics
o Management o ALATEEN – children of alcoholics
 Teach one at a time o ACOA (Adult children of alcoholics)
 Demonstrate prn
 Safety PARAPHILIAS
 Assist with disabilities - Exhibitionism – bold/masturbate in public
 SPED - Fetishism – inanimate object
 (+) reinforcement - Frotteurism – rubbing
- ADHD - Pedophilia – act with children less than 13 (usually
o Inattentive, overactive, impulsive man to boy)
o Management - Masochism – harms self / wants to be harmed
 Stimulants - Sadism – harms partner
DOC: Methylphenidate (Ritalin) - Voyeurism - namvovoso
Pemoline (Cylert) - hepatotoxic - Transvestic Fetishism – cross dress
 (+) and (-) reinforcement - Urophilia – urine
- Necrophilia – dead body
RAPE - Zoophilia – animals
- RA 8353 - Telophonic Scatologia – SOP
- Penetration on a nonconsenting person - Anilingus – tongue to anus
- Types - Cunnilingus – tongue to vagina
o Statutory rape – victim is below legal age - Fellatio – mouth to penis
o Date rape - Partialism – insert penis to other parts in the body
o Gang rape - Coprophilia – feces
o Marital rape - Transsexualism – willing to change sex organ
o Rape by a stranger
- Management
o Preserve evidences
o Call victim as survivor
o Allow victim to decide on what to do next
o Antidepressants
o Anxiolytics
o Atypical anti-psychotic
o Ethinyl Estradiol and Norgestrel (Ovral) – to
prevent pregnancy
o Cognitive-behavioral therapy

ALCOHOL
- CNS depressant (relaxation, loss of inhibition,
slurred speech, lack of coordination)
- Overdose: unconscious, resp depression,
hypotension, death  gastric lavage, dialysis
- Withdrawal signs:
o similar to stimulants (tremor, anxiety,
elevated PR, BP and sweating
o Delirium tremens
o Benzodiazepine (DOC)
- Vitamin B1 (thiamine) deficiency r/t alcoholism
o Wernicke’s encephalopathy  delirium-like
(stupor, somnolence, ataxia)
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