PSYCHIATRIC NURSING

BY : GOLIE MAE P. MENDOZA

Sleep
- is a state of rest during which muscle movements and awareness of the surroundings diminish.
- ↓ PR ↓ RR

CAUSES :
1. secondary to medical and psychiatric disorder
- parkinson’s disease,huntington’s disease, viral encephalitis,brain tissue,thyroid disease
2. substance abuse
- alcohol,caffeine ,antihistamine drug ,steroids and cns drugs
3. environmental factors

SLEEP STAGES :

1. Lightest stage
- muscles relax and brain waves are fast and irregular (theta waves)
- 3-7 times per second

2. Relatively light stage

- comprises 50% of sleep
- theta waves continue but become interspersed with sleep spindles

3. Deep sleep
- delta waves account for less than 50% of brain waves
- delta waves-large, slow waves of high amplitude and low frequency

4. NON-REM, deep sleep

- delta waves account for more than 50% of brain waves
- delta waves-large, slow waves of high amplitude and low frequency

5. REM,deep sleep
- 90% min.after sleep onset
- 20-25% of total sleep time
- During this stage,the sleeper shows darting eye movements,muscle twitching,and short,rapid brain waves
resembling those seen during the waking state

• stages 1-4 : non-rapid eye movement sleep

• stage 5 : rapid eye movement sleep

NON-REM(non-rapid eye movement)

- controls by basal ganglia infront of hypothalamus which is activated by heart

REM(rapid eye movement)

- controls by pons and adjacents portion of mid-brain
FACTORS AFFECTING SLEEP :
1. age
2. environment
3. lifestyle
4. medication

SLEEP DISORDERS

PRIMARY INSOMIA
- common sleep disorder
- e.g. difficulty falling asleep,sleeping too lightly,frequent awakenings during the night,inability to fall
back to sleep once awakened,waking up early in the morning and being unable to get back to sleep

S/S
- non refreshing sleep
- daytime fatigue and lack of energy
- Haggard appearance
- Irritability
- Poor attention span
- anxiety

TREATMENT:
* relaxation music
* improved sleep hygiene
* behavioral interventions
* cognitive therapy
* alternative and complimentary measures
* pharmacologic interventions e.g. sleeping aids

PRIMARY HYPERSOMIA
- is a condition of excessive sleepiness characterized by either prolonged sleep periods at night or daytime
sleep episodes occurring nearly everyday.

SYMPTOMATIC CATEGORIES:

1.monosymptomatic
- pt. has isolated excessive daytime sleepiness unrelated to abnormal nocturnal awakenings

2.polysymptomatic
- long nighttime sleeps and signs of sleep “drunkenness”
- combative awakenings in the morning

KLEINE-LEVIN SYNDROME
- refers to recurrent episodes of hypersomia or excessive sleep
- characterized by periods of hypersomia that lasts from days to weeks and recur several times a year

PT. EXPERIENCED:
- hypersexuality
- compulsive overeating
- irritability
- impulsive behavior
- depersonalization
 - hallucinations
- depression
- confusion

CAUSES
- GENETIC
- Autonomic dysfunction
- Viral infection
- Neurologic symptoms

S/S
- excessive sleepiness on the daily basis
- daytime napping without feeling refreshed
- long night time sleeping (8-12 hours)
- fainting episodes
- headache
- memory loss
- dizziness
- impaired performance
- mild depression
- orthostatic hypotension

TREATMENT :
- relief of symptoms
- behavioral approaches
- sleep hygiene techniques
- pharmacologic:
*anti-depressants
* stimulants e.g modafinil ,pemoline , methylphenidate, dextroamphetamines
* caffeine

NARCOLEPSY
- sudden, uncontrollable attacks of deep sleep lasting up to 20 min.
- accompanied by paralysis and hallucinations
- may experienced cataplexy- sudden loss of muscle tone and strength

S/S
- excessive daytime sleepiness,even during active states,such as eating and talking
- cataplexy
- brief episodes of sleep paralysis(inability to move or speak when falling sleep or waking up)
- dreamlike hallucinations at sleep onset or when awakening from sleep
- disturbed night time sleep(turning and jerking)

DIAGNOSTICS
- overnight polysomnography
- multiple sleep latency test(MSLT)

NURSING INTERVENTIONS
- review recommended lifestyle changes
- help the pt. plan and maintain a regular sleep schedule
- teach him about purpose,administration and adverse effects of prescribed drugs eg. MODAFINIL
 - monitor for adverse effects
CIRCADIAN RHYTHM SLEEP DISORDER
- the pt internal sleep awake pattern is out of synch with the demands of his work,schedule,travel
requirements or social activities.

Circadian
- refers to biological rhythms with a cycle of about 24 hours.
- Function as the bodies internal “clock”,regulating the 24 hour sleep-wake cycle and other body functions
such as body temp,hormones and heart rate
-
TYPES OF CIRCADIAN RHYTHM SLEEP DISORDERS :

1. Delayed-sleep phase sleep disorder

- PT. sleeps according to a delayed clock time,relative to the light-dark cycle and social,economic,and family
demands,more common among adolescent
- inability to fall asleep by 2a.m-5a.m.
2. Jetlag sleep disorder
- causes difficulty awakening in the morning
- results from rapid travel across more than one time zone
3. Shift work sleep disorder
- cause by frequent changing shift work
- excessive sleepiness during major awake period.

S/S
- inability to fall asleep before 2 am to 6am
- difficulty awakening in the morning
- feeling of being sleep-deprived
- significant social or work impairement
- need for multiple means to awaken

TREATMENT
1. chronotherapy
– manipulating the pt’s sleep schedule by progressively delaying bedtime by 1 or more hours each night,until
the pt can go to sleep and wake up at appropriate times
2. luminotherapy
- use of bright light to manipulate the circadian system
3. chronopharmacotherapy
- use of drugs to induce sleep or promote wakefulness when desired
- short-acting sedative hypnotic drug ( used to promote sleep)
- caffeine ( to keep pt.awake)

NURSING INTERVENTIONS
- promote compliance with sleep interventions
- review the required procedures with the pt
- assess his understanding of the procedure
 BREATHING – RELATED SLEEP DISORDERS
- marked by abnormal breathing during sleep

BREATHING DISORDERS :
1. obstructive-sleep apnea syndrome (OSAS)
- most common
2. central sleep apnea syndrome
3. central alveolar hypoventilation syndrome

S/S
- chronic daytime sleepiness
- snoring
- irritability
- frequent headaches
- tiredness and fatigue
- frequent daytime naps
- learning of memory problems
- depression
- excessive urination at night
- impotence
- heartburn or acid ingestion

STAY ALERT FOR:

- obesity
- hypertension
- jaw malformation
- S/S of tumors or other tissue abnormalities
- Reduced chest excursion(from obesity)
- Indications of cardiovascular and cerebrovascular conditions

DIAGNOSIS
1. polysomnography
2. home-sleep studies
3. diagnostic and statistical manual of mental disorders,4rth edition text-revision or DSM-IV-TR

TREATMENT
- lifestyle changes
- continuous positive airway pressure (CPAP)
- dental device that modify tongue or jaw position
- surgery: upper airway and jaw surgical procedures

NURSING INTERVENTIONS
- assists the pt in wt loss
- urge him to stop smoking
- encourage him to avoid alcohol and illicit drug use
- help family members deal with issues related to the pt’s snoring
SEXUALITY
- expressed not just in a person’s appearance but also in his attitude,behaviors and relationships
- result of biologic ,psychological,social and experimental factors,sexual dev’t,self-concept,body image and
behavior

HUMAN SEXUAL RESPONSE CYCLE

-refers to the progressive mental,physical and emotional changes that occur during sexual stimulation

PHASES OF SEXUAL RESPONSE CYCLE

1. DESIRE
- marked by strong urge for sexual stimulation and satisfaction
- ability,interest and willingness to receive sexual stimulation
2.EXCITEMENT / AROUSAL
- prepares both partners for intercourse
- muscle tension ↑
- PR ↑
- skin becomes flushed or blotchy(sexual flush)
- erection of nipples or grow hard
- wetting and erection,swelling of vagina
- result of psychological stimulation
- fantasizing and foreplay which involves petting and fondling of erogenous zones
3. PLATEAU
- continued stimulation an rubbing of erogenous zones
- may achieve,lose and regain a plateau several times without orgasm occurring
- PR RR BP ↑
- sexual flush deepens
- ↑ muscle tension
- flat
4. ORGASM
- “CLIMAX”
- peak of sexual response and shortest phase(longer in women than men)
- involuntary muscle contractions, ↑PR BP RR ,sphincter muscle contraction,sudden forceful release of
sexual tension
- occurs when stimulation process through the plateau stage
5. RESOLUTION PHASE
- body returns to it’s normal,unexcited state
- PR RR BP ↓
- muscle to slackens

SEXUAL DISORDER

SEXUAL DYSFUNCTION
- characterized by pain uring sex or by a disturbance in one of the phases of the sexual response cycle
- cause by distress,interpersonal problems,psychological factors,medical conditions( HPN,DM),substance
abuse or combination of this factors.

1.AROUSAL DISORDER
- individual cannot maintain the physiologic requirements for sexual intercourse
- women cannot maintain the lubrication-swelling response and men cannot maintain erection
2.DESIRE DISORDER
- individual have little or no desire to have an eversion to sexual contact
- Pt. dislikes and avoids genital sexual contact to his partner
3. ORGASMIC DISORDERS
- individual cannot complete sexual response cycle because of the inability to achieve an orgasm or delayed
4. SEXUAL DYSFUNCTION
- it is due to general medical condition (HPN,DM)
- caused by substance abuse,alcohol,prescription drugs and street drugs
5. SEXUAL PAIN DISORDER
- individual suffer from genital pain before,during and after sexual contact:
DYSPAREUNIA -genital pain associated with sexual contact
VAGINISMUS - recurrent or persistent involuntary contraction of the perineal muscles surrounding the
outer 3th of the vagina when vaginalpenetration is attempted.

PARAPHILIAS
- termed which generally refers to abnormal sexual behavior
- lasts for 6 months leading to distress or impairements to functioning
- umbrella termed for variation in sexual behavior
- marked by urges,fantasies or behavior that center on inanimate objects(clothing),suffering or
humiliation,children or nonconsenting persons.

IT IS ABNORMAL WHEN IT IS :
- uncontrollable
- inefficient that causes the problem
- viewed by the person’s culture as “bizarre”
- does harm to person and others

SPECIFIC PARAPHILIAS :
1.PHEDOPHILIA
- used of pre-pubertal children ages 13 or youger
2.FETISHISM
- sexual fantasies,urges or involveds fetish:uses non human objects to produce sexual arousal
3.EXHIBITIONISM
- exposing one’s genitals to unsuspecting strangers stimulated by the effect of shocking the victim
4.TRANSVESTISM
- sexual excitement through wearing of clothing from a woman

OTHER PARAPHILIAS :
1.SADISM
- inflicting pain
2.VOYEURISM
- sexual pleasure from looking at the sexual objects
3.MASOCHISM
- gets sexual gratification from being physically or mentally abused
4.FROTTEURISM
- sexually aroused upon rubbing or touching against a non-consenting person
RARE PARAPHILIAS :
1.ANILINGUS
- tongue brushing the anus
2.CONNILINGUS
- tongue brushing the vulva
3.PARTIALISM
- achieve arousal by inserting the penis into the other the other parts of the body
4.TELEPHONE SCATOLOGIA
- sex on phone, telephoning someone to achieve arousal
5.UROPHILIA
- urinating the partner
6.FELLATIO
- BJ, inserting penis into the mouth
7.COPROPHILIA
- smearing feces on the partner
8.EMETOPHILIA
- sexual attraction to vomit
9.HYBRISTOPHILIA
- sexual arousal by people who have commited crimes,particularly cruel or outrageous crimes
10.KLISMAPHILIA
- sexual pleasures from enemas
11.NECROPHILIA
- sexual attraction to corpses
12.PLUSHOPHILIA
- sexual attraction to stuffed toys
13.UROLAGNIA
- sexual attraction to urine
14.ZOOPHILIA / BESTIALITY
- sexual attraction to animals
15.INFANTALISM
- sexual attraction by wearing diaper
16.SEXUAL HYPOXYPHILIA
- sexual attraction to oxygen related

GENDER IDENTITY DISORDER

- Is marked by discomfort with one’s apparent or assigned gender and a strong,persistent identification
with the opposite sex.
- Strong and persistent cross gender identification
- Adolescent-stated desire to be the other sex
- Feelings of discomfort with own sex or inppropriateness in gender own sex

S/S
- anxiety
- cross dressing
- depression
- self hatred
- disturbance in body image
- ineffective coping strategies
- self- medication such as hormonal therapy
- suicide attempts or ideation
- finding one’s genitals as “disgusting|”
NURSE-PATIENT RELATIONSHIP :
- accepting ,emphatic and non-judgemental attitude
- set limits on disclosure
- mandatory reporting of child abuse “DISGUSTING”

NURSING MANAGEMENT
- psychopharmacology : use of hormonal therapy
SSRI’s
- mileu management
- group therapy
- anger management
- sex education
- stress management
- self-help groups
- family therapy

EATING DISORDERS

ANOREXIA NERVOSA
- is a self-deprivation syndrome in which the person relentlessly pursues thinness
- weight drops to less than 85% of ideal body wt.
- onset is between 14-18 yrs old
- becoming thin is the key goal
- overestimation of actual proportions

S/S
- lanugo
- amenorrhea
- dental carries
- electrolyte imbalances
- scarring of knuckles
- hypotension
- loss of fatty tissue

TWO MAIN FORMS OF ANOREXIA

1. restricting type
- as the name implies
- limiting food intake
2. binge-eating or purging type
- self-induced vomiting
- used of laxatives
- used of diuretics or enemas

MANAGEMENT
- let the pt. stay in public places for 2º aftermeal
- address acid-base balance
- electrolyte balance
- modify the behavior
- gain wt 1-2 lbs. per week
 MEDICAL PROBLEMS
- low birth wt
- ↓ BP
- Reduce bone and mineral density
- Electrolyte imbalance

BULIMIA NERVOSA
- is marked by episodes of binge-eating followed by feelings of guilt,huliliation,depression and self
condemnation
- self-induced vomiting
- used of laxatives
- used of diuretics or enemas
- eating of 1500-3500 kcal
- onset is 15-21 yrs old and usually normal wt.

S/S
- depression
- dental carries
- sorethroat
- gingivitis
- gum swelling
- scarring of knuckles fatigue
- ulcer
- dry skin
- electrolyte imbalance

TREATMENT
- psychotherapy

NURSING INTERVENTIONS
- promote an accepting,non-judgemental atmosphere
- supervise the pt during mealtimes
- set time limit for each meal
- provide a pleasant ,relaxed eating environment
 SUBSTANCE RELATED DISORDER

SUBSTANCE ABUSE
- Is the repeated use of alcohol or other psychoactive drugs that leads to problems.
- Maladaptive pattern used of substance leading to clinically significant impairement or distress
- As manifested by :
• failure to fulfill major obligations at work
• recurrent substance used in hazardous situations
• recurrent used of substance related to legal problems
• continued used of substance despite problems

SUBSTANCE DEPENDENCE
- maladaptive pattern used of substance despite of problems caused by such use
- as manifested by 3 or more of the following :
• TOLERANCE
- continuity ; dependence to substance
- ↓ response to a drug that comes with repeated use
- Drug must take increasingly to a higher dose to achieve it’s effects
• Withdrawal
• A need for more of the substance at to what is intended
• A great deal of time spent upon acquiring the substance or in recovering from it’s effects
• Cutting up social or occupational or recreation activities
• Continued substance use despite of knowledge that the substance is causing physical or psychological
problem

SUBSTANCE INTOXICATION
- a reversible substance- specific syndrome caused by ingestion of or exposure to that substance

SUBSTANCE WITHDRAWAL
- an uncomfortable syndrome that occurs when tissue and blood levels of the abused substance↓ in a person
who has used that substance heavily over a prolonged period.
- May cause the person to resume taking the substance to relieve the symptoms,thereby contributing to
repeated drug use.
- Development of a substance-specific syndrome due to the cessation or reduction in the intake of a
substance

COMMONLY ABUSED SUBSTANCES :

- alcohol
- amphetamines and like drugs
- barbiturates
- cocaine
- narcotics
- depressants
- tranquilizers
- inhalants
- hallucinogens
- marijuana
 - opiods : heroin , morphine ,meperidine ( Demerol)

THREE C’S :

- CONTINUED USED DESPITES NEGATIVE CONSEQUENCES

- COMPULSIVENESS

- LOSS OF CONTROL

STIMULANTS DEPRESSANTS HALLUCINOGENS

COCAINE MARIJUANA MARIJUANA
METAMPHETAMINE BARBITURATES LSD
NICOTINE TRANQUILIZERS PSILOCYBIN
CAFFEINE PEYOTE / MESCALINE
MARIJUANA PCP / KETAMINE
MORPHINE ECSTASY
DEMEROL INHALANTS
ANABOLIC STEROIDS

AMPHETAMINES
- can be taken orally,injection,snorting,smoking
- ↑ arousal , reduce fatigue,feel stronger,alert and more decisive
- Used to treat obesity and narcolepsy

AMPHETAMINE SULFATE
- bennies,grannies or cartwheels

METAMPHETAMINE
- speed, meth, crank ,crystal

DEXTROAMPHETAMINE
- dixies , hearts , oranges

CAUSES
- depression
- family problems

S/S
- euphoria
- alert and hyperactive
- diaphoresis
- dilated pupils
- dry mouth
- seizures
- anorexia
- tachycardia a
 - nausea vomiting

DIAGNOSIS
- ECG
- DSM 1V CRITERIA
- Urine test

TREATMENT
- sedatives
- vit.c
- mannitol
- anti-cholinergics
- rehabilitation
CAFFEINE
- mild CNS stimulant,restore mental alertness
S/S
• tachycardia
• palpitations
• facial flushing
• hyperactivity
• sleep disturbance

DIAGNOSTIC
- caffeine blood levels
- urine drug screening test
- dsm criteria
- ECG

TREATMENT
- Avoidance of caffeine

NURSING INTERVENTIONS
- Advise pt.about the expected symptoms
- Reassure him thar the symptoms will subside and benign
- Assess pt.for other disorders with similar symptoms

MARIJUANA
- Came from cannabis sativa, a hemp plant
- May be smoked,tea,mixed into foods,hand-rolled cigarettes
- A.k.a pot,grass,weed,mary jane,mj,roach,reefer,joints,herb,boo
- Duration of action is 6-12 hours

MEDICAL USE
- Anti-emetic

S/S
- Relaxation
- Euphoria
- Spontaneous laughter
- Red blood shot eye
 - Dry mouth
- ↑ appetite
- Poor coordination
- ↑ muscle strength

DIAGNOSTIC
- URINE TEST ( presence up to 21 days)
- DSM 4 criteria

TREATMENT
- Benzodiazepines
- Exercise
- Sedatives
- Tranquilizers
- Relaxation techniques
- Nutritional support

COCAINE
- Powerful addictive and stimulant
- Came from the coca leaves
- Cake,snow,c,snowball,blowflake,nose candy,hits,tornado

S/S
- Dilated pupil
- Perforated nasal septum
- Euphoria
- Sociability
- Vertigo
- Headache
- Talkativeness
- Increase energy
- Decrease appetite

DIAGNOSTIC
- Dsm 4
- Urine test

TREATMENT
- PROPANOLOL- tachycardia
- Anti-convulsant –seizure

HALLUCINOGEN
- “psychedelic drugs” produced hallucinations or profound distortions in the perception of reality
- Taken as injection and orally

EXAMPLE:
1. LYSERGIC ACID DIETHYLAMIDE (LSD)
- Acid,green,red dragon,microdot,sugar and big D
- Crystalline from applied to paper ( blotter acid)
- 200 x potent than psilocybin and 4000x potent than mescaline
- S/S : moves body slowly,dramatic effects on the senses,high intensified perception of colors,smells n
sounds,hallucinate causing to hear or feel something
 2. ECSTASY
- Stimulant and hallucinogenic
- Capsule,tablet,taken orally
- Called XTC,clarify,essence or adam
- Contain MDMA
- Experience sometimes called rolling

3. KETAMINE
- Distorts perception of sight and sound
- Can be snorted,smoked and injected
- Aka K,ket,vit,k,kit kat keller,cat valium

4. DEXTROMETORPHAN
- “robo” “DXM”
- Cough suppresing ingredient
- Mild stimulant effect

5. MESCALINE
- “peyote”,san pedro
- Cactus species and can be taken by capsule,injection and smoking
- Causes visual hallucination and alters spatial perception
- S/S : dizziness,vomiting,tachycardia,increase BP,RR.PR,headache

6. PSYLOCYBIN
- “psiloybe Mexicana mushrooms”
- Can be eaten and traditionally used by a Mexican healer
- Induces relaxation and sensation of being detached from the body

TREATMENT
- BENZODIAZEPINES
- Nifedipine for HPN pt.
- Diazepam for seizure

INHALANT
- Need of chemical vapors to attain altered mental or physical state
EXAMPLE:
1. Aerosols
- Paint,deodorant,silver and gold spray
2. Gases
- Butane,chloroform,nitrous oxide
3. Nitrites
- Room deodorizers
4. Volatile solvents
- Paint thinner,gasoline,marker,nail polish

S/S
- Slurred speech
- Appetite loss
- Runny nose
- Watery eyes
- Seizure
 - Hallucination and delusion

DIAGNOSTICS
- Serum drug levels
- CBC
- Serum electrolytes

TREATMENT
- Fluid replacement therapy
- Sedatives
- Anti-cholinergics and anti-diarrheal to relieve GI distress
- Anti-anxiety drugs
- Psychotherapy
- Relaxation
- Nutritional support

NICOTINE
- Main psychoactive component,tobacco
PHENCYCLIDINE
SEDATIVE ,HYPNOTIC OR ANXIOLYTIC DRUG

ALCOHOLISM
-a.k.a as ethanol
- a CNS depressant that reduces the activity of neurons in the brain
- a chronic disorder characterized by excessive alcohol intake and interfere in the individual’s
health,interpersonal relationship and economic functioning.

SIGNS OF INTOXICATION
1. 0.1-0.2 % - low coordination
2. 0.2-0.3 % - ataxia , tremors , irritability , stupor
3. 0.3-0.4 % - unconsciousness
4. 0.4-0.5 % - lethal dose , can kill

ALCOHOLIC PROGRESSION
1.pre – alcoholic phase
- starts of social drinking and tolerance begins to develop
2.prodromal phase
- alcohol becomes a need ,black out’s occur , denial begins to develop
3.crucial phase
- cardinal symptoms of alcoholism develops( loss of control)
4.chronic phase
- person becomes intoxicated all day

ALCOHOL OUTCOME
B – rain damage
A – lcoholic hallucinosis B.A.D
D – eath

BEHAVIORAL PROBLEMS OF ALCOHOLISM ( 5 d’S)

• denial
 • dependency
• demanding
• destructive
• domineering

ALCOHOL WITHDRAWAL
- a heavy drinker who stops drinking or abruptly reduces his alcohol intake is likely to go through
withdrawal.

S/S
• autonomic hyperactivity
• grand mal seizures
• psychomotor agitation and anxiety
• ↑ hand tremors
• Sleep disturbances( insomia and nightmares)
• Illusion and hallucinations
• Hyperthermia
• Tachycardia

ALCOHOL WITHDRAWAL DELIRIUM OR

DELIRIUM TREMENS
- a life threatening complication
- this syndrome manifest as delirium and experienced within 24-72 hours after the last intake

S/S
• tremor
• severe agitation
• autonomic overactivity
• ↑ PR ,RR ,BP

MEDICATIONS
• FUROSEMIDE, to ease dehydration
• MGSO4 , to reduce CNS irritability
• CHLORDIAZEPOXIDE,DIAZEPAM,ANTI-CONVULSANTS,ANTI-EMETICS OR ANTI-
DIARRHEAL,as needed to ease withdrawal symptoms
• ANTI-PSYCHOTICS, to control hyperactivity and psychosis
• PHENOBARBITAL, for sedation

KORSAKOFF’s PSYCHOSIS
- form of amnesia

S/S
• short-term memory loss
• disorientation
• inability
• to learn new skills
• confabulation – filling in of memory gaps
MANAGEMENT
• supplements of Vitamin B complex especially B2 and B12

WERNICKE’S ENCEPHALOPATHY
- inflammatory, hemorrhagic an degenerative condition of the brain
- severe state of korsakoff
- cause by a deficiency of B1

S/S
• double vision
• involuntary rapid eye movement
• lack of muscular coordination
• decrease of mental function

NURSING DIAGNOSIS
- Ineffective individual coping

PRINCIPLES OF NURSING CARE :

• well light room
• diet as tolerated
• monitor v/s
• administration of glucose
• vitamins

ALCOHOL DETOXIFICATION
- AS THE NAME IMPLIES ; cleansing

THREE S’s OF DETOX

• SAFETY
• SEDATION
• SUPPLEMENTS :multivitamins,vit.B complex and vit.C

MANAGEMENT
*disulfiram – it makes the body toxify if they drink alcohol
- drug of choice
- delays metabolism of alcohol

CHILDHOOD DISORDERS

ETIOLOGY
• genetic factors
• biochemical factors
• trauma
• resiliency theory
• family systems
 • behavioral theory
• cognitive theory

ASSESSMENT
• history of present illness
• development history
• neurological assessment
• medical history
• family history
• mental status assessment

DISORDERS DIAGNOSED
1. DEVELOPMENT DISORDERS
• mental retardation
• autism
2. DISRUPTIVE BEHAVIORAL DISORDER
3. INTERNALIZING DISORDER
4. TIC DISORDER
5. PSYCHOTIC DISORDER
6. ELIMINATION DISORDER
• ENURESIS – 5 years old,repeated urination on bed and clothing
• ENCOPRESIS – 4 years old , soiling clothing with feces or depositing feces inappropriate places

MENTAL RETARDATION
- refers to below average general intellectual functioning,with associated deficits in communication,social
skills,self-care and adaptive behavior.

S/S
• psychomotor skills deficit
• negativity and low self-esteem
• irritability when frustrated
• difficulty performing self-care activities
• neurologic impairments
• depression or labile moods

CLASSIFYING MENTAL RETARDATION

1. mild
2.
– IQ 55 – 59
- can reach until grade 6
- can be taught to live independently
3. moderate
- IQ 40 -54
- Can reach until grade 2
- Requires structure in living arangements
4. severe
- IQ 25 – 39
- requires great deal of assistance,no abstract ability,uncoordinated movement
5. profound
 - IQ below 25
- requires lifetime care

INTERVENTIONS
• behavior modification
• voice tone of staff should be matter of fact
• for descriptive behavior :
- seclusion
- therapeutic holding
• modeling
• consistency
• family therapy

NURSING CARE
• protect the child from self-directed violence
• trust and interpersonal relationship
• social functioning
• verbal communication
• control impulses / frustration tolerance
• cognitive skills
• personal identity and self-esteem
• accepting responsibility for behavior

AUTISM
- a pervasive developmental disorder and characterized by inappropriate responces to the environment and
pronounced impairments in language,communication and social interaction.
- Begins before age 3

S/S
• language delay
• deviant or totally absent
• aloof and indifferent to others
• stereotypical behavior
• rigid adherence to routine and sameness
• pre-occupation with repetitive activities
• hand flapping
• little or no eye contact
• no fear or danger

TREATMENT
• special education
• family support
• SSRI’s
• Lithium
• Risperidone(risperdal)
• Buspirone(buspar) – ease explosive outburst

NURSING INTERVENTIONS
 • choose your words carefully when speaking
• offer emotional support
• have close face-to-face contact with the child

ATTENTION DEFICIT-HYPERACTIVE DISORDER

PLANNING /IMPLEMENTATION
NURSING INTERVENTION
• protection from injury due to excessive hyperactivity
• improvement in social interaction
• self-esteem
• compliance with fact expectation
• provide a safe environment
• set limits on inappropriate behavior

PSYCHOPHARMACOLOGY
• Ritalin ( methylphenidate)
• Dexedrin ( dextroamphetamine)
• Cylert ( pemoline)
• Addena11 ( dextroamphetamine + amphetamine)
• Provigil ( modafinil)
• Concerta ( methylphenidate)

OPPOSITIONAL DEFIANT DISORDER

- Child with OOD talk back,argue,disobey and defy their parents or teachers
- Consistently negative and hostile

RISK FACTORS
- parental rejection
- family conflict

S/S
- hostile
- disobedient
- refusing to cooperate
- easily annoyed
- excessive arguing
- violating others right
- temper tantrums

MANAGEMENT
- PSYCHOTHERAPY
- ANGER MANAGEMENT

CONDUCT BEHAVIOR
- Aggressive behavior
- Child fights,bullies,intimidates and assaults others physically and sexually
- Violates other rights and society’s rule

RISK FACTORS
- Lack of attachment of parents
 - Lack of regard for societal rules
- Separation from parents
- Family neglect and abuse

S/S
- Fighting of family members
- Being cruel
- Cheating
- Using drugs
- Stealing and shoplifting
- Vandalizing and skipping in school

TREATMENT
- Psychotherapy
- Educational strategies
MANAGEMENT
- Establish a trusting relationship
- Provide clear behavioral guidelines
- Talk about acceptable choices

TIC DISORDER
- Neurobehavioral disorder characticerized by sudden,involuntary muscle movements(motor tics) and
vocalizations(vocal tics)
Motor tics
- Tend to affect the head,trunk or limbs
Vocal tics
- Include wide variety of sounds

CAUSES
- Decreased metabolic activity in the brain
- Neurotransmitter abnormalities

S/S
- Facial tics such as blinking
- Facial grimacing,neck or head jerking
- ,neck stretching
- Foot stamping
- Body twisting and bending

TREATMENT
- psychotherapy

CANCER
- malignant growth accompanied by abnormal cell division,invasion of surrounding tissues and metastasis
to distant sites

TERMINOLOGY

CELLULAR ABERRATION - an alteration in the cellular structure and function

NEOPLASM - new growth,abnormal cellular reproduction
TUMOR – growth of neoplastic cells clustered together
BENIGN – characterized by abnormal cell division but does not metastasize
ANAPLASIA - cells that lack normal cellular organization with respect to their cells of origin usually
anaplastic cells are malignant
DYSPLASIA – bizarre cell growth resulting in cells that differ in size,shape,arrangement from other cells of
the same type of tissue
HYPERPLASIA – increase in number cells of a tissue most often associated with periods of rapid body
growth
METAPLASIA – conversion of one type of mature cell into another type of cell
MALIGNANT – abnormal cell division with ability to invade surrounding cells,metastasize and recur
METASTASIZE – ability of the cancer cells to disseminate and establish growth in another are of the body
at a distance
STAGING –process of determining the size,spread and metastasis of a tumor
GRADING – identification of the type of tissue from which the tumor originated and the degree to which
the tumor cells retain the functional and structural characteristics of the tissue origin
SARCOMA – cancer related to connective tissue
CARCINOMA – cancer related to epithelial cells
LYMPHOMA – cancer related to the lymph nodes
LEUKEMIA – cancer related to blood

ETIOLOGY
- Viruses ( oncogenic viruses-prolonged infection cause ↓ immune system)
- Carcinogens
- Chemical carcinogens
e.g. air pollution,nicotine,hair colors,asbestos,dyes,fertilizers,bleach,drugs
- physical carcinogens
e.g. radiation,radioactive isotopes,ultraviolet rays,multiple deliveries,smoking,physical irritation
- Hormones :HRT (hormone replacement therapy)
- genetics
e.g familial pattern like retinoblastoma,lung cancer,breast cancer
- oncogene: repressed genetic code

PREDISPOSING FACTORS
Age – older and young children
Gender – both gender
Urban vs.rural dwellers – more exposure to carcinogens
Geographical distribution – influence of environment factors like diet
Occupation – chemical and industrial hazards
Heredity – familial history
Stress - ↓ immunocompetence
Pre-cancerous lesions – e.g. mole an warts
Lifestyle – smoking,diet

PATHOGENESIS
1. cellular transformation and derangement theory-cellular transformation as a result of exposure to agents.
2. failure of the immune response theory- inability of the immune system to destroy cancer cells.

MECHANISMS OF CARCINOGENESIS
By :BERENBLUM(1940) there are 2 types but becomes three:
1.INITIATION
- related to carcinogens that initiates the mutation process
 - alteration of the DNA structure
2.PROMOTION
- also called co-carcinogens that stimulates replication of mutant cells
3.PROGRESSION
- cells exhibit increase malignant behavior,show propensity to invade adjacent tissue and to metastasize

COMPARISON
BENIGN MALIGNANT
Similar to cell of origin Dissimilar
Uncapsulated Non-encapsulated
Compresses Invades
Slow growth rate Rapid growth rate
Seldom recur after excision Frequently recur after excision
Necrosis and ulceration is unusual

VIRUSES IMPLICATED IN MALIGNANT NEOPLASIA

- virus
- c- type RNA
- b-type RNA

PATHOPHYSIOLOGY
- DNA virus infects the cell,it becomes incorporated into the genes,DNA that is infected is transmitted to
subsequent generations.

A.cancer cell proliferation

- disrupts norml cell growth
RESULTING ALTERATIONS:
1.pressure
2.obstruction
3.pain
4.effusion
5.ulceration - erosion of blood

B. paraneoplastic syndrome
- production of enzymes,hormone and other substances
RESULTING ALTERATION:
1. ANEMIA - bleeding,↑ iron uptake of cancer cells
2. HYPERCALCEMIA - parathyroid are to ↑bone breakdown causes dehydration and immobilization

C. anorexia-cachexia syndrome
- deprivation of cellular nutrition
RESULTING ALTERATIONS:
1.tissue wasting – CHON depletion
2.edema – Tumors take up NA+
3. anorexia – cancer cells produces anorexic agents acts in satiety center

WARNING SIGNALS OF CANCER

 C – hange in bowel
A - sore that does not heal
U – nusual bleeding or discharge
T – hickening or lump in the breast or anywhere else
I – ndigestion or difficulty in swallowing
O – bvious change in wart or mole
N – aging cough or hoarseness of the voice

CAUTIONAL SIGNS

U – UNEXPLAIN ANEMIA
S – SUDDEN WT. LOSS

A - ANEMIA
L – LOSS OF WT.

DIAGNOSTIC TEST
- CYTOLOGIC EXAM
- BIOPSY – definitive test
- ULTRASOUND
- MRI
- RADIOLOGIC EXAMS
- RADIO DIAGNOSTICS TECHNIQUES
- CT SCAN
- LAB.TEST ( prostathic acid phosphatase,prostathic specific antigen,carcinoembryonic agent
- ENDOSCOPIC
- MONOCLONAL

PREVENTION
- avoid exposure to sunlight
- annual/oral exam.
- Breast : monthly breast self exam from age 20
- Lungs: avoid smoking,annual chest x-ray
- Colon : digital rectal exam -40yrs old ↑,rectal biopsy,proctoscopic exam,guaic stoolexam for 50 yrs old↑

DIETARY RECOMMENDATION
- ↑ total fat intake
- ↓ fiber foods
- fruits and cereals
- food rich in vit.A and vit.C daily
- cruciferous vegetable in the diet
- moderation on alcoholic beverages

THERAPEUTIC MODALITIES
- chemotherapy
- surgery
- radiation
- immunotherapy
- bone marrow transplant

MEDICATION
 - alkylating agents – busulfan,carboplatin,thiotepa,crisplatin
- nitrosureas – carmustine,lomustine,streptozocin
- topoisomerase 1 inhibitors – irinotecan,topotecan
- anti-metabolites – methotrezate,pentostatin,FUDR,5-FU
- anti-tumor antibiotics – bleomycin,plicamycin,dactinomycin
- mitotic spindle poisons – plant alkaloids,taxanes
- hormonal agents – androgens and anti-androgens,estrogen and anti-estrogen,steroids
- antibiotics - bactrim
- anti-emetics for nausea and vomiting

SIDE EFFECTS OF MEDICATION

- nausea and vomiting
- alopecia
- fatigue
- stomatitis
- diarrhea
- anorexia
- anaphylaxis
- immune suppression

SURGICAL INTERVENTION
CLASSIFICATIONS:
PREVENTIVE – excision of pre-cancerous lesions
DIAGNOSTICS – biopsy( fresh frozen section)
CURATIVE – removal of the entire tumor en bloc resection)
RECONSTRUCTIVE – improvement of structure and function
PALLIATIVE – relief of distressing symptoms,retardation of metastasize

CHEMOTHERAPY
- destroy all malignant tumor cells without excessive destruction of normal cells
- control tumor growth

ACTION
- damage genes inside the nucleus of cells
- damage cells at the point of splitting
- damage making copies of all their genes before split
- cells that are rest are prone to damage
- † drugs have more chance of killing more cells

RADIATION THERAPY
- Ionizing radiation is used to interrupt cellular growth

TWO TYPES:

EXTERNAL -
INTERNAL – OR IMPLANTATION,using high delivery dose of radiation to localized area.

IMMUNOLOGIC
ALTERATIONS IN IMMUNE RESPONCES:
DEFENSE MECHANISM:
*skin
* cilia
*Mucous membrane
*acidity in G.I.
* tears

WHITE BLOOD CELL

1.granulocytes
2.agranulocytes

IMMUNITY
NATURAL
• PHYSICAL BARRIERS
e.g skin,mucosa,cilia,coughing and sneezing
• CHEMICAL BARRIERS
e.g. acid in GI secretions
* WBC
* INFLAMMATORY RESPONSE
Causes vasodilation→ increase capillary release → histamine – bradykinin
ACQUIRED
• PASSIVE
e.g. immunizations , breastmilk

• ACTIVE
e.g. antibody

RESPONCES TO INVASION

1.PHAGOCYTIC
- granulocytes and macrophages
2. HUMORAL
* anti-body response – immunoglobulins
* recognition,production
* agglutination – two anti-bodies clamp together and neutralizes
* opsonization – B cells coats antigen nd become susceptible to anti-totoxic agent
3.CELLULAR RESPONSE
4.COMPLEMENT SYSTEM

HUMORAL RESPONSES
TYPES OF IMMUNOGLOBULINS
1. Ig –G
- 75% of total IG
- Appears in serum and tissues(interstitial fluid)
- Assumes amajor role in bloodbone and tissue infections
- Activates the complement system
- Enhances phagocytosis
 - Crosses rhe placenta

2. Ig-A
- 15% of total IG
- Appears in body fluids (blood,saliva,tears,breastmilk, and pulmonary,GI secretions,prostatic and vaginal
secretions)
- Prevents absorption of antigens from food
- Passes to neonate in breast milk for protection

3. Ig-M
- 10% of total IG
- Appears mostly in intravascular serum
- Appears as the first immunoglobulin produced in response to bacterial and viral infections
- Activates the complement system

4. Ig-D
- .2% of total Ig
- Appears in small amounts in serum
- Possibly influences b-lymphocyte differentiation,but role is unclear

5. Ig-E
- 0.004% of total IG
- Appears in serum
- Takes part in allergic and some hypersensitivity reactions
- Combats parasitic infections

CELLULAR RESPONSE
USES T- CELLS
A. Effector cells :cytotoxic (killer)
1. Carry CD8 antigen
2. Attack malignant cells
3. Responsible for transplanted organ rejection and grafted tissues

B. Regulator cells
1. Helper T-cells
a. Carry CD4 anitgen
b. Initiate immune response
2. Suppressor T-cells
a. Carry CD8 antigen
b. Stop immune response

STAGES IN IMMUNE RESPONSE

1.RECOGNITION
- recognition of foreign invaders
2.PROLIFERATION
- after exposure,sensitized lymphocytes stimulates some of the resident dormant T and B lymphocytes to
enlarge,divide and proliferate
3. RESPONSE
- attacks the foreign bodies
4.EFFECTOR
- couples with antigen and destroys it
COMPLEMENT SYSTEMS
- When an anti-body couple with an antigen = complement
- Proteins interact sequencially into domino effect
• Classic Pathway – from C4 to C1
• Alternate pathway – from C3 to C1

DIAGNOSTIC EVALUATION
- Leukocytes and lymphocytes
- Humoral immunity test
• B cell qualification with monoclonal antibody
• Specific antibody
- Cellular immunity

ALTERATIONS THAT OCCUR WITHIN IMMUNE SYTEMS AND RESULT IN ILLNESS :

1.incompetency
- immune deficiency or malignancy as with AIDS

2.overreaction
- hypersensitivity, as with allergic reactions
3. loss of ability to recognize self
- autoimmune disorders

PRIMARY IMMUNODEFICIENCY
- Phagocytic dysfunction
- B-cell deficiency
- T-cell deficiency
- Combined B-cell and T-cell deficiency
- Deficiency of the complement reaction

PHAGOCYTIC DYSFUNCTION
-pt. increase incidence of bacterial and fungal infections
- diagnosis is made on the:
* history,s/s
* lab.-analysis of cytocidal activity of phagocytic cells by nitroblue tetrazolium reductase test

MEDICAL MANAGEMENT
- Early diagnosis
- Prophylactic antibiotic
- Granulocyte transfusion
- Granulocyte macrophages colony stimulating factor (GM-CSF)
- Granulocyte colony – stimulating factor (C-CSF)

B-CELL DEFICIENCY
TWO TYPES:

1. AGAMMAGLOBUNEMIA (BRUTON’S DISEASE)

-Complete lack of differentiation of B-cell precurser

2. HYPOGAMMAGLOBUNEMIA –common variable immunodeficiency (CVID)
- Decrease level of immunoglobulin
- Most common in adults
- Recurrent pyogenic infection
 - Increase incidence of autoimmune disease
- Pt.becomes symptomatic after 5-6 months after birth
- May develop pernicious anemia
- Diagnosed by marked deficiency or absence of all serum immunoglobulin
- Treated with IV immunoglobulin,antimicrobial therapy
- Parenteral injections of vit.B

T-CELL DEFICIENCY
- Di-george syndrome or thymic hypoplasia
• Primary T-cell deficiency
• Hypoparathyroidism-hypocalcemia (resistant to standard therapy)
• Susceptible to yeast,fungal,protozoan and viral infection
• Most common presentationin chronic mucocutaneous candidiasis

DIAGNOSTIC
- Lymphocyte counts

MEDICAL MANAGEMENT
- Management of hypocalcemia
- Treatment of cardiac problems
- P carinii prophylaxis
- Transplantation of fetal thymus
- BMT(bone marrow transplant)

COMBINED B AND T CELL DEFICIENCY

- Ataxia telangiectasis
- Severe combined immunodeficiency ( SCID)
• Wiskott aldrich syndrome (compounded by thrombocytopenia)
• Medical managemnet: prompt treatment- stem cell and BMT

DEFICIENCIES OF THE COMPLEMENT SYSTEM

- Diminished resistance of bacterial infections
- Angioneurotic edema caused by an inheretid deficiency of the inhibitor of CI esterase
• Episodes of urticaria and edema and extremities

SECONDARY IMMUNODEFICIENCY
-AIDS
- background
- cases recognized in male homosexual population in 1981
- human immunodeficiency virus (HIV) isolated in 1984
- retrovirus transmitted by:
*direct contact with infected blood and bloody fluids
* contaminated needles
* infants born to HIV (+) mothers (15-30%)

AIDS
RISK FACTOR:
• Unprotected anal sex
• Injection drug use (sharing needles)
• Heterosexual with infected persons
 • Blood transfusion
• Occupational risk to health workers,especially through needle pricks

PATHOPHYSIOLOGY
A.retrovirus
a.carries genetic code in RNA
b.infects cells with CD4 antigen
c.takes over cells DNA and then duplicates
d.may remain dormant or become active
e.active: forms virus with destroys mast cell
TYPICAL COURSE OF HIV INFECTION:
1.contraction oif virus
a.acute mononucleosis-type illness within days to weeks
b.symptoms
2.seroconversion
- 6 weeks- 6 months past initial infection,antibodies to HIV are produced and Will test (+)
3.cells infected by HIV
4.loss of helper T-cells

DEVELOPMENT OF AIDS
S/S
- General malaise,fever,fatigue,night sweats,involuntary wt. loss,often diarrhea,rash,oral lesions and
candidiasis
- Multiple oppurtunistic infection,cancers

POST-INFECTION RELATED ISSUES:

1.aids dementia complex
a.direct effect of virus on brain
b.↓ memory,confusion
c.CNS infection

OPPORTUNISTIC INFECTION
1.CD4 amounts below 200 (normal is ↑1000/mm3)
2.pneumonia
- cough ,shortness of breath,tachypnea,tachycardia
- pneumocystin carinii
3.TB
- MDR strains (+)
- rapid progressive,diffuse pulmonary
4.candidiasis
- oral thrush
- esophagitis and vaginitis
5.mycobacterium avium:complex (MAC)
-25% aids case
- called as “ wasting syndrome”
6.other infection
a.viral
- herpex simplex,zoster virus,CMV of retina,GI tract,lungs
- parasitic:toxoplasma gondii,Cryptococcus neuformans,cryptosporidium

SECONDARY CANCERS
1.kaposi’s sarcoma
-often presenting symptom
- when lesions with vascular macules,papules,violet lesions on skin and viscera,often on face,GI tract and lungs
- initially painless,but become painful
- indicator of late-stage disease

2.Lymphomas
-non-hodgekin’s lymphoma and primary lymphomas of brain
- aggressive and rapid spread
3.invasive cervical carcinoma

TREATMENT
-No cure for HIV
-Fatal nature of disease
-Prevention is vital strategy

GOALS OF CARE
- Early identification of infection
- Promote health-maintenance activities
- Prevent opportunistic infection
- Treatment of disease complication(cancer)
- Provide emotional and psychosocial support

DIAGNOSTIC
1.enzyme-linked immunosorbent assay(ELISA)
- used as screening test for HIV infection
2.western blot antibody testing : combined with ELISA greater specificity (›99.9%)
3.HIV viral load test : measure amount of activity replicating HIV virus
4. CBC –anemia,thrombocytopenia
5.CD4 cell count
6. test to detect secondary cancers and infection

MEDICATION
- NRTI’s ( neucleoside reverse transcriptase inhibitors)
- Antibiotics
- Isoniazid
- Bactrim

NURSING CARE
- Safe sexual practices
- No sharing of needles
- Screening of donated blood
- Use of standard precautions

CARE OF CLIENT WITH HIV

- Maintain health and prevent development of opportunistic infection,cancers,physical needs,change over
course of illness
- Still a stigma associated with illness,assist client,family to deal with it,psychosocial support.

HYPERSENSITIVITY

- Antigen-antibody interaction
 - Causes tissue damage
- Involves immediate reaction after prior sensitization

TYPE 1
- Form allergic reaction with immunoglobulin
- Mast cells and basophils factors released which causes serious reaction
- Mast serious reaction : anaphylaxis S/S : hives,swelling,dob
- Anaphylactic reaction- characterized by vasodilation,increased capillary permeability,smooth muscle
contraction and eosenophilia

TYPE 2
- IgG or IgM
- Antibodies formed
- A cytotoxic reaction - which involves the binding of either IgG or IgM antibody to a cell bound
antigen,may lead to eventual cell and tissue damage
- Eg.myasthenia gravis,thrombocytopenia,pernicious anemia,hemolytic disease to newborn

TYPE 3
- IgG or IgM
- An immune complex reaction – marked by acute inflammation resulting from formation and deposition of
immune complexes S/S urticaria,joint pain,fever,rash and adenopathy
- Antibody-antigen immune complexes in circulation and block tissues

TYPE 4
- Delayed 24-48 hours
- Delayed or cellular reaction occurs 1-3 days after exposure to an antigen.the reaction in which tissue
damage,involves activity by lymphikines,macropahages and lysozymes

CARE
- Minimize expose to allergens

DIAGNOSTIC
- WBC count
- Radioallergosorbent test
- Skin test
- Blood type test

MEDICATIONS
- Antihistamine- diphenhydramine
- Epinephrine –“ bee sting kit” treatment for anaphylaxis ;IV or subcu.
- Cromolyn
- Glucocorticoids
- Plasmapheresis – nonmedication treatment

AUTOIMMUNE DISORDER

- Inability to recognize self

DIAGNOSTIC
- SEROLOGIC
- LUPUS ERYTHEMATOUSOS
MEDICATION
- Anti- inflammatory