Basic Concepts in Psychiatric Nursing

BASIC CONCEPTS IN PSYCHIATRIC NURSING
MENTAL HEALTH
Is a state of emotional, psychological, and social wellness evidenced by satisfying personal relationships, effective behavior and coping, a positive self concept, and emotional stability.
COMPONENTS OF MENTAL HEALTH (Johnson, 1997)
Autonomy and Independence Maximizing Ones Potential Tolerating Lifes Uncertainties Self-esteem Mastering the Environment Reality Orientation Stress Management
COMPONENTS OF MENTAL HEALTH AUTONOMY AND INDEPENDENCE
The individual can look within for guiding values and rules to live by. The opinions and wishes of others are considered but do not dictate the persons decisions and behavior.
The person can work independently or cooperatively with others without losing his or her autonomy
COMPONENTS OF MENTAL HEALTH MAXIMIZING ONES POTENTIAL
The person has an orientation toward growth and self-actualization. He or she is not content with the status quo and continually and continually strives to grow as a person.
COMPONENTS OF MENTAL HEALTH TOLERATING LIFES UNCERTAINTIES
The person can face the challenges of lifes day-to-day living with hope and a positive outlook, despite not knowing what lies ahead.
COMPONENTS OF MENTAL HEALTH SELF-ESTEEM
The person has realistic awareness of his or her abilities and limitations.
COMPONENTS OF MENTAL HEALTH MASTERING THE ENVIRONMENT
The person can deal with and influence the environment in a capable, competent, and creative manner.
COMPONENTS OF MENTAL HEALTH REALITY ORIENTATION
The person can distinguish the real world from a dream, fact from fantasy, and act accordingly.
COMPONENTS OF MENTAL HEALTH STRESS MANAGEMENT
The person can tolerate life stresses, experience feelings of anxiety or grief appropriately, and experience failure without devastation.
He or she uses support from family and friends to cope with crises, knowing that the stress will not last forever.
MENTAL ILL HEALTH
A state of imbalance characterized by disturbance in a persons thoughts, feelings and behavior.
MENTAL DISORDER (AMERICAN PSYCHIATRIC ASSOCIATION, 1994)
Is a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (i.e., painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.
PSYCHIATRIC NURSING
Interpersonal process whereby the professional nurse practitioner through the therapeutic use of self assists a family, group, or community to promote mental health, to prevent mental illness and suffering, to participate in the treatment and rehabilitation of the mentally ill, and if necessary to find meaning in these experiences.
It is both a science and an art.
THE SCIENCE IN PSYCHIATRIC NURSING
The use of different theories in the practice of nursing serves as the science of Psychiatric Nursing
THE ART IN PSYCHIATRIC NURSING
The therapeutic use of self is considered as the art of Psychiatric Nursing.
THE CORE OF PSYCHIATRIC NURSING
The interpersonal process, that is, the human-to-human relationship, is the core of Psychiatric Nursing.
THE CLIENTS IN PSYCHIATRIC NURSING
The individual, the family, and the community, both mentally healthy and mentally ill, are considered as the clientele in Psychiatric Nursing.
MENTAL HYGIENE
It is the science that deals with measures to promote mental health, prevent mental illness and suffering and facilitate rehabilitation.
SAMPLE BOARD QUESTION NO.1
Which of the following is a generally accepted component of mental health? A) Autonomy B) Absence of anxiety C) Ability to control others D) Happiness
ANSWER
Letter A
Rationale: According to Johnson, 1997, autonomy and independence is one of the components of mental health.
A major predisposing factor of mental illness in the home is? A) Urbanization B) Poverty C) Political turmoil D) Genetics
ANSWER
Letter B
Rationale: Poverty and domestic abuses are some of the most common causes of mental illness at home
The science which deals with the measures to promote mental health and reduce incidence of mental illness is known as?
A) Psychiatric Nursing B) Psychology C) Psychiatry D) Mental Hygiene
ANSWER
Letter D
Rationale: Mental Hygiene is the science that deals with measures to promote mental health. Psychiatric Nursing is the interpersonal process whereby the nurse assists the patient to attain a state of mental health.
Nursing as an interpersonal process is?

A) The science of nursing B) The art of nursing C) The core of nursing D) The clientele of nursing
ANSWER
Letter C
Rationale: The core of Psychiatric Nursing is the human-to-human relationship or the interpersonal process.
Mental illness is?

A) Always hereditary in nature B) Is manageable but is never treatable C) A behavioral pattern associated with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. D) A state of emotional balance
ANSWER
Letter C
Rationale: Mental Illness is a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (i.e., painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.
THERAPEUTIC USE OF SELF
During therapeutic communication, nurses use themselves as a therapeutic tool to establish a therapeutic relationship with the client, to help the client grow, change, and heal.
It is the main tool used by the nurse in the practice of Psychiatric Nursing.
Using ones humanity personality, experiences, values, feelings, intelligence, needs, coping skills, and perceptions to help the client grow and change is called THERAPEUTIC USE OF ONES SELF (Northouse & Northouse, 1998).
It is the main tool used by the nurse in the practice of Psychiatric Nursing. It is the positive use of ones self in the process of therapy
Hildegaard Peplau (1952), who described this therapeutic use of self in the nurseclient relationship, believed that nurses must have a clear understanding of themselves to promote their clients growth and to avoid limiting clients choices to those valued by the nurse.
Therapeutic use of self requires SELFAWARENESS!!!
SELF-AWARENESS
Self-awareness means an understanding of ones personality, emotions, sensitivity, motivation, ethics, philosophy of life, physical and social image, and capacities (Campbell, 1980).
It is the process by which the nurse gains recognition of his or her own feelings, beliefs, and attitudes.
SELF-AWARENESS
The nurse needs to discover himself and what he believes before trying to help others with different views.
Most of the time, the nurses values and beliefs will conflict with those of the client, the nurse must learn to accept these differences among people and view each client as a worthwhile person regardless of the clients opinions and lifestyle.
SELF-AWARENESS
The greater the nurses understanding of his or her own feelings and responses, the better he or she can communicate with and understand others.
One tool that is useful in learning more about oneself is the JOHARI WINDOW (Luft, 1970), which creates a word portrait of a person in four areas and indicates how well a person knows himself or herself and communicates with others.
FOUR QUADRANTS OF THE JOHARI WINDOW
QUADRANT I Open Public Self Qualities one knows about oneself and others also know QUADRANT II Blind / Unaware Self Qualities known only to others QUADRANT III Hidden / Private Self Qualities known only to oneself
QUADRANT IV Unknown An empty quadrant to symbolize qualities as yet undiscovered by oneself or others
CREATING A JOHARI WINDOW First Step Appraise ones own qualities by creating a list of those qualities:
Ones values Attitudes Feelings Strengths Behaviors Accomplishments Needs Desires Sad thoughts
CREATING A JOHARI WINDOW
Second Step Find out how others perceive you by interviewing others and asking them to identify qualities they see in you, both positive and negative.
CREATING A JOHARI WINDOW
Third Step Compare lists and assign qualities to the appropriate quadrants.

If Quadrant I is the longest
list, this indicates the person is open to others; a small Quadrant I means the person shares little about himself or herself with others

If Quadrants I and III are
both small, the person demonstrates little insight.

The goal is to work toward
moving qualities from Quadrants II, III and IV into Quadrant I (qualities known to oneself and others), which indicates the person is gaining self-knowledge and self-awareness.
METHODS USED TO INCREASE SELF-AWARENESS
ROLE PLAY Putting yourself in the clients situation allows you to think about his or her thoughts, feelings and actions. INTROSPECTION Self-awareness can be accomplished through reflection, spending time consciously focusing on how one feels and what one values or believes. Keep a diary that focuses on experiences and related feelings. DISCUSSION Talk with others about your own experiences and feelings and how they feel about similar experiences. Try to seek alternative points of view.
ENLARGING ONES EXPERIENCE
CORE CONCEPTS ON THE CARE OF THE PSYCHOTIC PATIENT
COMMON BEHAVIORAL SIGNS AND SYMPTOMS
Disturbances Disturbances Disturbances Disturbances Disturbances
in in in in in
Perception Thinking Affect Motor Activity Memory
DISTURBANCES IN PERCEPTION
DISTURBANCES IN PERCEPTION: ILLUSION
Misperception of an actual external stimuli

Example An electrical cord on the floor may appear to be a snake!
DISTURBANCES IN PERCEPTION: HALLUCINATION
False sensory perception in the absence of an external stimuli Perceptual experiences that do not exist in reality
Example A person may see angels hovering above when nothing is there A person may hear voices in a room wherein he is alone
DISTURBANCES IN THINKING
DISTURBANCES IN THINKING: NEOLOGISM
Pathological coining of new words

These are words invented by the client Example:
I am afraid of grittiz. If there are any grittiz here, I will have to leave. Are you a grittiz?
DISTURBANCES IN THINKING: CIRCUMSTANTIALITY
Over inclusion of details.

Example: Nurse: How have you been sleeping lately? Client: Oh, I go to bed early, so I can get plenty of rest. I like to listen to music or read before bed. Right now I am reading a good mystery. Maybe I will write a mystery someday. But is it isnt
DISTURBANCES IN THINKING: WORD SALAD
Incoherent mixture of words and phrases.

This is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener.
Example: Corn, potatoes, jump up, play games, grass, cupboard.
DISTURBANCES IN THINKING: VERBIGERATION
Meaningless phrases.
repetition
of
words
and
Example: I want to go home, go home, go home, go home.
DISTURBANCES IN THINKING: PERSEVERATION
Persistence of a response to a previous question. Example: Nurse: How have you been sleeping lately? Client: I think people have been following me. Nurse: Where do you live? Client: At my place people have been
DISTURBANCES IN THINKING: ECHOLALIA
Pathological repetition of words of others.

Example: Nurse: Can you tell me how you are feeling? Client: Can you tell me how you are feeling? how you are feeling?
DISTURBANCES IN THINKING: FLIGHT OF IDEAS
Shifting of one topic from one subject to another in a somewhat related way. Excessive amount and rate of speech composed of fragmented or unrelated ideas.
DISTURBANCES IN THINKING: LOOSENESS OF ASSOCIATION
Shifting of a topic from one subject to another in a completely unrelated way. Example:
Nurse: Do you have enough money to buy that candy bar? Patient: I have a real yen for chocolate. The Japanese have all the yen and have taken all of our money and marked it. You know, you have to be careful of the Marxists because they are friends with the Swiss and they have all the cheese and all the watches and that means they have taken all the time. The worst thing about
DISTURBANCES IN THINKING: CLANG ASSOCIATION
The sound of the word gives direction to the flow of thought. Examples:
I will take a pill if I go up to the hill but not if my name is Jill, I dont want to kill. I want to sing ping pong that song wong kong long today, hey way.
DISTURBANCES IN THINKING: DELUSION
False belief which is inconsistent with ones knowledge and culture Examples: The client may claim to be engaged to a famous movie star or related to some public figure such as claiming to be the daughter of the President of the Philippines
DISTURBANCES IN AFFECT
DISTURBANCES IN AFFECT: INAPPROPRIATE AFFECT
Disharmony between the stimulus and the emotional reaction.
DISTURBANCES IN AFFECT: BLUNTED AFFECT
Severe
reduction emotional reaction.
in
Restricted
range of emotional feeling, tone, or mood
DISTURBANCES IN AFFECT: FLAT AFFECT
Absence or near absence of
emotional reaction
Absence
any facial expression that would indicate emotions or mood
of
DISTURBANCES IN AFFECT: APATHY
Dulled emotional tone

Feelings of indifference toward people, activities, and events
DISTURBANCES IN AFFECT: AMBIVALENCE
Presence of two opposing feelings.

Holding seemingly contradictory beliefs of feelings about the same person, event or situation
DISTURBANCES IN AFFECT: DEPERSONALIZATION
Feeling of strangeness towards oneself

Clients feel detached from their behavior Although client can state his name correctly, he feels as if his body belongs to someone else, or that his spirit is detached from his body. He may feel that his limbs are detached or that the size of his body parts is changed, or he is unable to tell where his body leaves off and the rest of the world begins Patient describes the feeling of having stepped outside their bodies and are observing
DISTURBANCES IN AFFECT: DEREALIZATION
Feeling of environment
strangeness
towards
the
Environmental objects become smaller or larger, or seem unfamiliar. Individual feels that the outside world has changed: Buildings may appear to be leaning Everything may seem gray and dull
DISTURBANCES IN MOTOR ACTIVITY
DISTURBANCES IN MOTOR ACTIVITY: ECHOPRAXIA

The pathological imitation of
posture or action of others.

Imitation of the movements
and gestures of another person whom the client is observing.
DISTURBANCES IN MOTOR ACTIVITY: WAXY FLEXIBILITY

Maintaining
the desired position for long periods of time without discomfort even when it is awkward or uncomfortable.
DISTURBANCES IN MEMORY
DISTURBANCES IN MEMORY: CONFABULATION
Filling in of memory gaps to save face in an embarasing situation. It is a confused persons tendency to make up a response to a question when he cannot remember the answer Example:
Nurse: Do you know Gemma? (referring to one of the residents at the patients home) Patient: Yes, I know her. I used to play cards with her husband.
DISTURBANCES IN MEMORY: AMNESIA
Inability to recall past events.
DISTURBANCES IN MEMORY: ANTEROGRADE AMNESIA
Loss of memory of the immediate past.
DISTURBANCES IN MEMORY: RETROGRADE AMNESIA
Loss of memory of the distant past.
DISTURBANCES IN MEMORY: DEJA VU
Feeling of having been to a place which one has not yet visited.
DISTURBANCES IN MEMORY: JAMAIS VU
Feeling of NOT having been to a place which one HAS VISITED.
SAMPLE BOARD QUESTION
A patient changes topics quickly while relating his past psychiatric history. However, the nurse is able to follow his thoughts. The patients pattern of thinking is called?
A) Looseness of association B) Flight of ideas C) Clang association D) Confabulation
ANSWER
Letter B
Rationale: Flight of ideas is the shifting of a topic from one subject to another in a somewhat related way. Looseness of association is the shifting of a topic from one subject to another in a completely unrelated way.
A patient states, The sun is shining. Where is my sun? I love Lucy. Let us play ball. The patient is displaying?
A) Clang association B) Flight of ideas C) Derealization D) Neologism
ANSWER
Letter B
Rationale: The patient is manifesting flight of ideas
The main function confabulation serves in patients with dementia, is to? A) Lessen isolation B) Protect their self-esteem C) Control others D) Enhance memory recall
ANSWER
Letter B
Rationale: Confabulation is the filling in of memory gaps and it serves to protect the patients self-esteem
A patient has mistakenly perceived a coiled piece of wire as a snake. This is an example of?
A) Illusion B) Hallucination C) Delusion D) Confabulation
ANSWER
Letter A
Rationale: The patient misperceived an actual external stimulus.
All of the following are disturbances in thinking, EXCEPT? A) Looseness of association B) Hallucination C) Delusion D) Clang association
ANSWER
Letter B
Rationale: Hallucination is a disturbance in perception.
CORE CONCEPTS ON THERAPEUTIC COMMUNICATION
COMMUNICATION
COMMUNICATION
It is the interchange of information between two or more people It is the exchange of ideas or thoughts.
ELEMENTS OF COMMUNICATION
Sender Originator of the information Message Information being transmitted Receiver Recipient of information Channel Mode of communication Feedback Return response Context The setting of the communication
VARIABLES THAT INFLUENCE COMMUNICATION
Perception Experience of sensing, interpreting, and comprehending the world in which the person lives
Values Principles, standards of quality considered worthwhile or desirable

Culture The totality of socially transacted behavior
LEVELS OF COMMUNICATION
Intrapersonal Occurs when a person communicates within himself Interpersonal Takes place within dyads (groups of two persons) and in small groups. The level of person-to-person communication is the heart of of psychiatric nursing Public Communication between a person and several
MODELS OF COMMUNICATION
Communication is an Act
Communication is an Interaction Communication is a Transaction
COMMUNICATION IS AN ACT
It is something that a person is doing to another person (example: person A talks to person B) There is an attempt to transfer the thoughts or ideas of one person into someone elses head. It suggests that the receiver plays a passive role and does not affect the communicator When misunderstandings occur, either the communicator is faulted for failing to send the correct message or the receiver is faulted for having allowed something to interfere
COMMUNICATION IS AN INTERACTION
It takes into account the process of mutual influence. When two people interact, they themselves into each others shoes. put
It is a circular process in which the participants take turns at being communicator and receiver
COMMUNICATION IS A TRANSACTION
It is viewed as a process of simultaneous mutual influence rather than as a turntaking event. No one is labeled either as a communicator or receiver. The symbolic interactionist model views human communication on the social, interpersonal level and accounts for the whole persons involved in the process. The participants are products of their social
MODES OF COMMUNICATION
Verbal Communication
Non-verbal Communication
VERBAL COMMUNICATION: THE SPOKEN WORD
Denotation
Connotation Private and Shared meanings
Denotation The meaning that is in general used by most persons who share a common language; the particular, explicit, literal meaning of the word.
Connotation Usually arises from a persons personal experience Suggests or implies something in addition to the literal meaning
Private and Shared Meanings For communication to take place, meanings must be shared. People labeled schizophrenic may use language in an idiosyncratic way or may use a private, unshared language called neologisms.
NON-VERBAL MESSAGES
They carry more meaning than verbal messages and involves the following: Body movement or kinetics
Voice quality (pitch and range) and nonlanguage sounds (sobbing or laughing)
NON-VERBAL MESSAGES
They carry more meaning than verbal messages and involves the following: Proxemics use of personal or social space
Intimate Distance actual contact to 1.5 feet Personal Distance 1.5 to 4 feet or 3 to 4 feet for interviews Social Distance 4 to 12 feet Public Distance 12 feet and beyond
Cultural Artifacts items in contact with interacting persons that may act as nonverbal stimuli (i.e., clothes, cosmetics,
CHARACTERISTICS OF SUCCESSFUL COMMUNICATION
1) Feedback (return response) If effective, may result in extension, clarification or alteration of the original communication
2) Appropriateness The reply is fitting and relevant to the communication; it is neither too much nor too little
CHARACTERISTICS OF SUCCESSFUL COMMUNICATION
3) Efficiency The language used is understood 4) Flexibility The absence of over-control or undercontrol
ESSENTIAL INGREDIENTS TO FACILITATE COMMUNICATION
Respond with empathy

Respond with respect Respond with genuineness
Respond with immediacy

Respond with warmth
THERAPEUTIC COMMUNICATION
An interpersonal interaction between the nurse and client during which the nurse focuses on the clients specific needs to promote an effective exchange of information
Skilled use of therapeutic communication techniques helps the nurse understand and empathize with the clients experience
GOALS OF THERAPEUTIC COMMUNICATION
Establish a relationship
therapeutic
nurse-client
Identify the most important client concern at the moment (the client-centered goal) Assess the clients perception of the problem as it unfolded.
This includes detailed actions (behaviors and messages) of the people involved and the
GOALS OF THERAPEUTIC COMMUNICATION
Teach the client and family necessary selfcare techniques Recognize the clients needs
Implement interventions address the clients needs designed to
Guide the client toward identifying a plan of action to a satisfying and socially acceptable
THERAPEUTIC COMMUNICATION TECHNIQUES

Accepting Focusing
Broad Openings
Consensual validation Encouraging Comparison Encouraging Description of
Formulating a Plan of Action

General Leads Giving Information Giving Recognition Making Observations Offering self
Perceptions Encouraging Expression Exploring

Placing Event in Time or Silence
Sequence Presenting Reality Reflecting Restating Seeking Information
Suggesting Collaboration
Summarizing Translating into Feelings Verbalizing the Implied Voicing Doubt
THERAPEUTIC COMMUNICATION TECHNIQUES: ACCEPTING
Definition Indicating reception Examples Yes I follow what you said Nodding Rationale An accepting response indicates the nurse has heard and followed the train of thought. It does not indicate agreement but is nonjudgmental.
THERAPEUTIC COMMUNICATION TECHNIQUES: BROAD OPENINGS
Definition Allowing the client to take the initiative in introducing the topic Examples Is there something youd like to talk about? Where would you like me to begin?
Rationale Broad openings make explicit that the client has the lead in the interaction. For the client who is hesitant about talking, broad
THERAPEUTIC COMMUNICATION TECHNIQUES: CONSENSUAL VALIDATION
Definition Searching for mutual understanding, for accord in the meaning of the words. Examples Tell me whether my understanding of it agrees with yours. Are you using this word to convey that . . Rationale For verbal communication to be meaningful, it is essential that the words being used should have the same meaning for all participants.
THERAPEUTIC COMMUNICATION TECHNIQUES: ENCOURAGING COMPARISON
Definition Helping the client to understand by looking at similarities and differences. Examples Was it something like. . . ? Have you had similar experiences?
Rationale Comparing ideas, experiences, or relationships brings out many recurring themes. The client benefits from making these
TECHNIQUES: ENCOURAGING DESCRIPTION OF PERCEPTIONS
Definition Asking client to verbalize what he or she perceives. Examples Tell me when you feel anxious What is happening? What does the voice seem to be saying?
Rationale To understand the client, the nurse must see
THERAPEUTIC COMMUNICATION TECHNIQUES: ENCOURAGING EXPRESSION
Definition Asking client to appraise the quality of his or her experience. Examples What are your feelings in regard to. . ? Does this contribute to your distress?
Rationale The nurse asks the client to consider people and events in light of his or her own values. Doing so encourages the client to make his or her
THERAPEUTIC COMMUNICATION TECHNIQUES: EXPLORING
Definition Delving further into a subject or idea. Examples Tell me more about that. Would you describe it more fully? What kind of work?
Rationale When clients deal with topics superficially, exploring can help them examine the issue more fully. Any problem or concern can be better understood
THERAPEUTIC COMMUNICATION TECHNIQUES: FOCUSING
Definition Concentrating on a single point.

Examples This point seems looking at more closely. Of all the concerns you have mentioned, which is most troublesome? Rationale The nurse encourages the client to concentrate his or her energies on a single point, which may prevent a multitude of factors or problems from
THERAPEUTIC COMMUNICATION TECHNIQUES: FORMULATING A PLAN OF ACTION
Definition Asking the client to consider kinds of behavior likely to be appropriate in future situations.
Examples What could you do to let your anger out harmlessly? Next time this comes up, what might you do to handle it? Rationale
THERAPEUTIC COMMUNICATION TECHNIQUES: GENERAL LEADS
Definition Giving encouragement to continue. Examples Go on. And then? Tell me about it.
Rationale General leads indicate that the nurse is listening and following what the client is saying without taking away the initiative for the interaction.
THERAPEUTIC COMMUNICATION TECHNIQUES: GIVING INFORMATION
Definition Making available the facts that the client needs.

Examples My name is. . . Visiting hours are. . . My purpose in being here is. . . Rationale Informing the client of facts increases his or her knowledge about a topic or lets the client know
THERAPEUTIC COMMUNICATION TECHNIQUES: GIVING RECOGNITION
Definition Acknowledging, indicating awareness. Examples Good Morning Ms. A. . . Youve finished your list of things to do. I notice that youve combed your hair. Rationale Greeting the client by name, indicating awareness of change, or noting efforts the client has made all show that the nurse recognizes the client as a
THERAPEUTIC COMMUNICATION TECHNIQUES: MAKING OBSERVATIONS
Definition Verbalizing what the nurse perceives.

Examples You appear tense. Are you uncomfortable when . . ? I notice that you are biting your lip. Rationale Sometimes clients cannot verbalize or make themselves understood.
THERAPEUTIC COMMUNICATION TECHNIQUES: OFFERING SELF
Definition Making oneself available. Examples I will sit with you awhile. I will stay here with you. I am interested in what you think.
Rationale The nurse can offer his or her presence, interest, and desire to understand. It is important that this offer is unconditional, that
THERAPEUTIC COMMUNICATION TECHNIQUES: PLACING EVENT IN TIIME SEQUENCE
Definition Clarifying the relationship of events in time. Examples What seemed to lead up to. . ? Was this before or after? When did this happen?
Rationale Putting events in proper sequence helps both the nurse and client to see them in perspective. The client may gain insight into cause-and-effect
THERAPEUTIC COMMUNICATION TECHNIQUES: PRESENTING REALITY

Definition Offering for consideration that which is real. Examples I see no one else in the room. That sound was a car backfiring. Your mother is not here. I am a nurse. Rationale When it is obvious that a client is misinterpreting reality, the nurse can indicate what is real. The nurse does this by calmly and quietly expressing the nurses perceptions of the facts not by way of arguing with the client or belittling his or her experience.
THERAPEUTIC COMMUNICATION TECHNIQUES: REFLECTING
Definition Directing client actions, thoughts, and feelings back to the client. Examples Client: Do you think I should tell the doctor? Nurse: Do you think you should? Client: My brother spends all my money and then has the nerve to ask for more. Nurse: This causes you to feel angry? Rationale Reflection encourages the client to recognize and accept his or her own feelings.
THERAPEUTIC COMMUNICATION TECHNIQUES: RESTATING

Definition Repeating the main idea expressed. Examples Client: I cant sleep. I stay awake all night. Nurse: You have difficulty sleeping. Client: I am really mad. I am really upset. Nurse: Youre really mad and upset. Rationale The nurse repeats what the client has said in approximately or nearly the same words the client has used. This restatement lets the client know that he or she communicated the idea effectively.
THERAPEUTIC COMMUNICATION TECHNIQUES: SEEKING INFORMATION
Definition Seeking to make clear that which is not meaningful or that which is vague. Examples I am not sure that I follow. Have I heard you correctly? Rationale The nurse should seek clarification throughout interactions with clients. Doing so can help the nurse to avoid making assumptions that understanding has occurred when it has not.
THERAPEUTIC COMMUNICATION TECHNIQUES: SILENCE
Definition Absence of verbal communication, which provides time for the client to put thoughts or feelings into words, regain composure, or continue talking. Examples Nurse says nothing but continues to maintain eye contact and conveys interest Rationale Silence often encourages the client to verbalize provided that it is interested and expectant. Silence gives the client time to organize thoughts, direct the topic of interaction, or focus on issues that are most important.
THERAPEUTIC COMMUNICATION TECHNIQUES: SUGGESTING COLLABORATION
Definition Offering to share, to strive, to work with the client for his or her benefit. Examples Perhaps you and I can discuss and discover the triggers for your anxiety. Lets go to your room and I will help you find what you are looking for. Rationale The nurse seeks to offer a relationship in which the client can identify problems in living with others, grow emotionally, and improve the ability
THERAPEUTIC COMMUNICATION TECHNIQUES: SUMMARIZING
Definition Organizing and summing up that which has gone before. Examples Have I got this straight? Youve said that. . During the past hour, you and I have discussed.. Rationale Summarization seeks to bring out the important points of the discussion and to increase the awareness and understanding of both participants. It omits the irrelevant and organizes the pertinent aspects of the interaction.
THERAPEUTIC COMMUNICATION TECHNIQUES: TRANSLATING INTO FEELINGS
Definition Seeking to verbalize clients feelings that he or she expresses only indirectly. Examples Client: I am dead. Nurse: Are you suggesting that you feel lifeless? Client: I am way out in the ocean. Nurse: You seem to feel lonely or deserted. Rationale Often the client says, when taken literally, seems meaningless or far removed from reality. To understand, the nurse must concentrate on
THERAPEUTIC COMMUNICATION TECHNIQUES: VERBALIZING THE IMPLIED
Definition Voicing what the client has hinted at or suggested. Examples Client: I cant talk to you or anyone. It is a waste of time. Nurse: Do you feel that no one understands? Rationale Putting into words what the client has implied or said indirectly tends to make the discussion less obscure. The nurse should be as direct as possible without being unfeelingly blunt or obtuse.
THERAPEUTIC COMMUNICATION TECHNIQUES: VOICING DOUBT
Definition Expressing uncertainty about the reality of the clients perceptions. Examples Isnt that unusual? Really? That is hard to believe.
THERAPEUTIC COMMUNICATION TECHNIQUES: VOICING DOUBT
Rationale Another means of responding to distortions of reality is to express doubt. Such expression permits the client to become aware that others do not necessarily perceive events in the same way or draw the same conclusions. This does not mean the client will alter his or her point of view, but at least the nurse will encourage the client to reconsider or reevaluate what has happened. The nurse neither agreed nor disagreed;
NON-THERAPEUTIC COMMUNICATION TECHNIQUES
These responses cut off communication and make it more difficult for the interaction to continue
It takes practice for the nurse to avoid making these typical comments

Advising Giving Literal Responses
Agreeing
Belittling Feelings
Indicting the Existence of an
Expressed Challenging Defending Disagreeing Disapproving Giving Approval
External Source Interpreting Introducing an Unrelated Topic Making Stereotyped Comments

Probing Requesting an Explanation
Reassuring
Rejecting
Testing
Using Denial
NON-THERAPEUTIC COMMUNICATION TECHNIQUES: ADVISING
Definition Telling the client what to do.

Examples I think you should. Why dont you?
Rationale Giving advice implies that only the nurse knows what is best for the client.
NON-THERAPEUTIC COMMUNICATION TECHNIQUES: AGREEING
Definition Indicating accord with the client. Examples That is right. I agree. Rationale Approval indicates the client is right rather than wrong. This gives the client the impression that he or she is right because of agreement with the nurse.
NON-THERAPEUTIC COMMUNICATION TECHNIQUES: BELITTLING FEELINGS EXPRESSED
Definition Misjudging the degree of the clients discomfort. Examples Client: I have nothing to live for. . . I wish I was dead Nurse: Everybody gets down in the dumps. OR I have felt that way myself. Rationale When the nurse tries to equate the intense and overwhelming feelings the client has expressed to everybody or to the nurses own feelings, the nurse implies that the discomfort is temporary, mild, self-limiting, or not very important.
NON-THERAPEUTIC COMMUNICATION TECHNIQUES: CHALLENGING
Definition Demanding proof from the client. Examples But how can you be the President of the United States? If you are dead, why is your heart beating? Rationale Often the nurse believes that if he or she can challenge the client to prove unrealistic ideas, the client will realize there is no proof and then will
NON-THERAPEUTIC COMMUNICATION TECHNIQUES: DEFENDING
Definition Attempting to protect someone or something from verbal attack. Examples This hospital has a fine reputation. I am sure your doctor has your best interests in mind. Rationale Defending what the client has criticized implies that he or she has no right to express impressions, opinions, or feelings.
NON-THERAPEUTIC COMMUNICATION TECHNIQUES: DISAGREEING
Definition Opposing the clients ideas. Examples That is wrong. I definitely disagree with. . . I do not believe that. . .
Rationale Disagreeing implies the client is wrong Consequently the client feels defensive about his or her point of view or ideas.
NON-THERAPEUTIC COMMUNICATION TECHNIQUES: GIVING APPROVAL
Definition Sanctioning the clients behavior or ideas. Examples That is good. I am glad that. . Rationale Saying what the client thinks or feels if good implies that the opposite is bad. Approval then, tends to limit the clients freedom to think, speak, or act in a certain way.
NON-THERAPEUTIC COMMUNICATION TECHNIQUES: GIVING LITERAL RESPONSES
Definition Responding to a figurative comment as though it were a statement of fact.
Examples Client: They are looking in my head with a television camera. Nurse: Try not to watch television. OR What channel?
Rationale Often the client is at a loss to describe his or her
NON-THERAPEUTIC COMMUNICATION TECHNIQUES: INDICATING THE EXISTENCE OF AN EXTERNAL SOURCE
Definition Attributing the source of thoughts, feelings, and behavior to others or to outside influences. Examples What makes you say that? What made you do that? Who told you that you were a prophet?
TECHNIQUES: INDICATING THE EXISTENCE OF AN EXTERNAL SOURCE
Rationale The nurse can ask, What happened? or What events led you to draw such a conclusion? But to question What made you think that? implies that the client was made or compelled to think in a certain way. Usually the nurse does not intend to suggest that the source is external but that is often what the client thinks.
NON-THERAPEUTIC COMMUNICATION TECHNIQUES: INTERPRETING
Definition Asking to make conscious that which is unconscious; telling the client the meaning of his or her experience.
Examples What you really mean is. . . Unconsciously you are saying. . . Rationale The clients thoughts and feelings are his or her
COMMUNICATION TECHNIQUES: INTRODUCING AN UNRELATED TOPIC
Definition Changing the subject. Examples Client: I would like to die. Nurse Did you have visitors last night? Rationale The nurse takes the initiative for the interaction away from the client. This usually happens because the nurse is uncomfortable, does not know how to respond, or
NON-THERAPEUTIC COMMUNICATION TECHNIQUES: MAKING STEREOTYPED COMMENTS
Definition Offering meaningless cliches or trite comments. Examples It is for your own good. Just keep your chin up Just have a positive attitude and you will be better in no time. Rationale Social conversation contains many cliches and much meaningless chit-chat. Such comments are of no value in the nurse-client relationship.
NON-THERAPEUTIC COMMUNICATION TECHNIQUES: PROBING
Definition Persistent questioning of the client. Examples Now tell me about this problem. have to find out. Tell me your psychiatric history.
You know I
Rationale Probing tends to make the client feel used or invaded. Clients have the right not to talk about issues or
NON-THERAPEUTIC COMMUNICATION TECHNIQUES: REASSURING
Definition Indicating there is no reason for anxiety or other feelings of discomfort. Examples: I would not worry about that. Everything would be alright. You are coming along just fine. Rationale Attempts to dispel the clients anxiety by implying that there is not sufficient reason for concern completely devalues the clients feelings.
NON-THERAPEUTIC COMMUNICATION TECHNIQUES: REJECTING
Definition Refusing to consider or showing contempt for the clients ideas or behaviors.
Examples Let us not discuss. . . I do not want to hear about. . .

Rationale When the nurse rejects any topic, he or she closes it off from exploration. In turn, the client will feel personally rejected
NON-THERAPEUTIC COMMUNICATION TECHNIQUES: REQUESTING AN EXPLANATION
Definition Asking the client to provide reasons for thoughts, feelings, behaviors, events. Examples Why do you think that? Why do you feel that way?
Rationale There is a difference between asking the client to describe what is occurring or has taken place and asking him to explain why. Usually a why
NON-THERAPEUTIC COMMUNICATION TECHNIQUES: TESTING
Definition Appraising the clients degree of insight.

Examples Do you know what kind of hospital this is? Do you still have the idea that. . ?
Rationale These types of questions force the client to try to recognize his or her problems. The clients acknowledgement that he or she does
NON-THERAPEUTIC COMMUNICATION TECHNIQUES: USING DENIAL
Definition Refusing to admit that a problem exists. Examples Client: I am nothing. Nurse: Of course you are something. Everybody is something. Client: I am dead. Nurse: Do not be silly. Rationale The nurse denies the clients feelings or the
NON-VERBAL COMMUNICATION
This is transmitted with or without verbal communication. It is essential that the nurse become aware of her own non-verbal communication in addition to becoming skillful in identifying the clients non-verbal communication. Non-verbal communication provides clues about the validity of the spoken words and congruency with the clients behavior. The phrase Actions speak louder than
A list of ways in which communication is conveyed follows: Tone of voice Voice inflection Facial Expression Silence Gestures Mannerism Posture
non-verbal to others
List of ways in which non-verbal communication is conveyed to others: Eye contact Rate of speech A hurry up attitude An I couldnt care less attitude Physical appearance Touch Space
GUIDELINES FOR IDENTIFYING THERAPEUTIC RESPONSES IN THE BOARD EXAM
GUIDELINES FOR IDENTIFYING THERAPEUTIC RESPONSES IN THE BOARD EXAM
Identify therapeutic and non-therapeutic phrases

Open-ended or Closed-ended question? Avoid why questions and instead use what questions
Avoid false reassurances

Avoid focus on the nurse (use of the word I); or focus on the doctor. Focus on the patient instead.
GUIDELINES FOR IDENTIFYING THERAPEUTIC RESPONSES IN THE BOARD EXAM: LOOK FOR THERAPEUTIC PHRASES
The following are therapeutic phrases utilized by the nurse: It seems It sounds I will sit with you I will stay with you I will check Tell me
THERAPEUTIC RESPONSES IN THE BOARD EXAM: LOOK FOR NON-THERAPEUTIC PHRASES
The use of labels is non-therapeutic Thats good! Thats bad! Youre the best! Youre the worst!
The use of absolutes is non-therapeutic Always Never None All.
The use of commands is non-therapeutic You need to You must You should
GUIDELINES FOR IDENTIFYING THERAPEUTIC RESPONSES IN THE BOARD EXAM: USE OF OPEN-ENDED QUESTIONS
Tell me, how do you feel, then follow it up with I understand how you feel. I will stay with you for awhile.
THERAPEUTIC RESPONSES IN THE BOARD EXAM: USE OF CLOSED-ENDED QUESTIONS
Use of Closed-ended questions is therapeutic when dealing with: Manic patients
This would discourage them from over-control of the conversation
Rape or Crisis Victims
With their unstable condition, they may misconstrue use of open-ended questions as prying.
GUIDELINES FOR IDENTIFYING THERAPEUTIC RESPONSES IN THE BOARD EXAM: USE OF WHY QUESTIONS
The use of the question why is non-therapeutic Example:

Client: I was speeding along the street and did not stop at the sign Nurse: Why were you speeding?
Rationale Responses to why questions are considered prying, violate the clients privacy and places the client in a defensive position
GUIDELINES FOR IDENTIFYING THERAPEUTIC RESPONSES IN THE BOARD EXAM: USE OF WHAT QUESTIONS
The use of the question what is therapeutic

What is happening? What does the voice seem to be saying? What transpired after that?
GUIDELINES FOR IDENTIFYING THERAPEUTIC RESPONSES IN THE BOARD EXAM: AVOID FALSE REASSURANCES
Examples: I would not worry about that. Everything would be alright. You are coming along just fine.
Rationale This response blocks the fears, feelings and other thoughts of the client. Furthermore, vague reassurances without accompanying facts are meaningless to the client
GUIDELINES FOR IDENTIFYING THERAPEUTIC RESPONSES IN THE BOARD EXAM: USE OF THE WORD I
Example: Client: Should I move from my home to a nursing home? Nurse: If I were you, Id go to a nursing home, where youll get your meals cooked for you
Rationale: Therapeutic Communication is always client-centered, it is never nurse-centered.
GUIDELINES FOR IDENTIFYING THERAPEUTIC RESPONSES IN THE BOARD EXAM: USE OF THE WORD YOU
Examples Client: I am dead. Nurse: Are you suggesting that you feel lifeless? Client: I am way out in the ocean. Nurse: You seem to feel lonely or deserted.
Rationale: Therapeutic Communication is always
THERAPEUTIC RESPONSES IN THE BOARD EXAM: USE OF DIRECT QUESTIONS FOR SUICIDAL PATIENTS
Nurse: Do you have any plans of killing yourself?
GUIDELINES FOR IDENTIFYING THERAPEUTIC RESPONSES IN THE BOARD EXAM: AVOID THE AUTHORITARIAN ANSWER
Authoritarian Answer Avoid statements like I think you should. . I should know, I am the nurse Rationale Giving authoritarian answers implies that only the nurse knows what is best for the client
WHAT TO REMEMBER IN THERAPEUTIC COMMUNICATION
Be empathetic and not just sympathetic!
EMPATHY
Is the ability of the nurse to perceive the meanings and feelings of the client and to communicate that understanding to the client. It is considered one of the essential skills a nurse must develop Being able to put himself on the clients shoes does not mean that the nurse has had the same exact experiences as the client
EMPATHY
Both the client and the nurse give a gift of self when empathy occurs the client by feeling safe enough to share feelings, and the nurse by listening closely enough to understand.
Empathy has been shown to positively influence client outcomes Clients tend to feel better about themselves
EXAMPLE OF EMPATHY
Client: I am so confused! My son just visited and wants to know where the safety deposit box key is. Nurse: Youre confused because your son asked for he safety deposit key. (Using reflection) Nurse: Are you confused about the purpose of your sons visit? (Using clarification)
Note that from these empathetic moments,
SYMPATHY
Feelings of concern or compassion one shows for another. By expressing sympathy, the nurse may project his or her personal concerns onto the client, thus inhibiting the clients expression of feelings
EXAMPLE OF SYMPATHY
Client: I am so confused! My son just visited and wants to know where the safety deposit box key is. Nurse: I know how confusing sons can be. My son confuses me, too, and I know how bad that makes you feel. Note that the nurses feelings of sadness or even pity could influence the relationship and hinder the nurses abilities to focus on the clients needs.
These are communication techniques that contribute to therapeutic relationship, EXCEPT?

A) Active listening to what the patient says B) Labeling the patient C) Encouraging expression of feelings D) Clarifying
ANSWER
Letter B
Rationale: Labeling the patient is nontherapeutic.
Which one of the following techniques used is an example of giving a broad opening? A) When did this happen to you? B) Would you describe it in more detail? C) Where would you like to begin? D) I would like to spend time to talk with you.
ANSWER
Letter C
Rationale: Giving a broad opening provides an opportunity to the patient to choose the topic of the conversation.
A technique that enhances communication is illustrated by one of the following statements:

A) Why do you feel this way? B) It is for your own good. C) I am sure he only meant to help you. D) I would like to spend time with you.
ANSWER
Letter D
Rationale: Offering ones self facilitates the development of rapport between the nurse and the patient.
Which of the following elements refers to the setting of the communication? A) Sender B) Context C) Receiver D) Message
ANSWER
Letter B
Rationale: Context refers to the setting of the conversation.
Which of the following techniques of communication is appropriate when initiating a conversation?

A) Focusing B) Use of silence C) Giving broad opening D) Reflecting
ANSWER
Letter C
Rationale: Giving broad opening provides an opportunity for the patient to choose the topic of the conversation. Hence, it is appropriate to use when initiating a conversation.
NURSE PATIENT RELATIONSHIP
NURSE-PATIENT RELATIONSHIP
Series of interactions between the nurse and the patient in which the nurse assists the patient to attain positive behavioral change
CHARACTERISTICS OF THE NURSE-PATIENT RELATIONSHIP
Goal-directed
Focused on the needs of the patient Planned
Time-limited
Professional
BASIC ELEMENTS OF THE NURSE-PATIENT RELATIONSHIP
Trust
Rapport Unconditional positive regard
Setting limits
Therapeutic communication
PHASES OF THE NURSE-PATIENT RELATIONSHIP
Pre-orientation phase
Orientation phase Working phase
Termination phase
PRE-ORIENTATION PHASE
Begins when the nurse is assigned to a patient Phase of Nurse-Patient Relationship in which the patient is excluded as an actual participant
Nurse feels certain degree of anxiety
PRE-ORIENTATION PHASE
Includes all of what the nurse thinks and does before interacting with the patient Tasks include data gathering, planning for the first interaction Major task is to develop self-awareness
ORIENTATION PHASE
Begins when the nurse and the patient interacts for the first time Parameters of the relationship are to be laid
Nurse begins to know about the patient Tasks include establishing rapport, developing trust, assessment (and formulation of a nursing diagnosis).
WORKING PHASE
It is highly individualized
More structured than the orientation phase

The longest and most productive phase of the nurse-patient relationship Limit-setting is employed Tasks include planning and implementation
TERMINATION PHASE
It is a gradual weaning process
It is a mutual agreement
It involves feelings of anxiety, fear and loss It should be recognized in the orientation phase Tasks include evaluation Major task is to assist patient to review what has
TERMINATION PHASE
How to terminate?
Gradually decrease interaction time Focus on future oriented topics
Encourage expression of feelings

Make the necessary referral
PROBLEMS AFFECTING THE NURSE-PATIENT RELATIONSHIP TRANSFERENCE
Occurs when the client displaces onto the nurse attitudes and feelings that the client originally experience in other relationships
These patterns are automatic and unconscious
PROBLEMS AFFECTING THE NURSE-PATIENT RELATIONSHIP TRANSFERENCE
Example:
An adolescent female client working with a nurse who is about the same age as the teens parents might react to the nurse like she reacts to her parents. She might experience intense feelings of rebellion or make sarcastic remarks.
PROBLEMS AFFECTING THE NURSE-PATIENT RELATIONSHIP COUNTERTRANFERENCE
Occurs when the nurse displaces onto the client attitudes or feelings from his or her past.
Example: A female nurse who has teenage children and who is experiencing extreme frustration with an adolescent client may respond by adopting a parental or chastising tone.
PROBLEMS AFFECTING THE NURSE-PATIENT RELATIONSHIP RESISTANCE
Development of ambivalent feelings toward self-exploration
The basis for a therapeutic nurse-patient relationship begins with the nurses? A) Sincere desire to help others B) Sincere desire to help others C) Self-awareness and understanding D) Sound knowledge of Psychiatric Nursing
ANSWER
Letter C
Rationale: Prior to the nurse helping others, he should first have a thorough awareness of himself.
The nurse should introduce information about the end of the nurse-patient relationship?
A) During the Orientation phase B) As the goals of the relationship are reached C) About one or two sessions before the last meeting D) When the patient is able to handle it
ANSWER
Letter A
Rationale: In the establishment of a contract during the orientation phase, information about the end of the nursepatient relationship must also be included.
The goal of the orientation phase of the nurse-patient relationship is? A) assist the patient to review what he has learned B) plan interventions to meet patients goals C) formulating nursing diagnosis D) facilitate expression of thoughts and feelings
ANSWER
Letter C
Rationale: This provides the nurse with a sense of direction.
Which of the following is the most appropriate topic during the orientation phase of nurse and patient relationship?
A) patients perception of the reason of her being hospitalized B) identification of more effective methods of dealing with stress C) exploration of the patients inadequate coping skills
ANSWER
Letter D
Rationale: Establishment of a contract is the major task of the nurse in the Orientation phase.
The nurse knows that a therapeutic relationship is possible only when? A) Emotional difficulties are identified B) Mutual trust is achieved C) Patients self-esteem is enlarged D) Patient is motivated to change
ANSWER
Letter B
Rationale: Trust is the foundation of a therapeutic nurse-patient relationship.
PRINCIPLES OF CARE IN PSYCHIATRIC SETTINGS
The nurse views the patient as a holistic human being with interdependent and interrelated needs.
The nurse accepts the patient as a unique human being with inherent value and worth exactly as he is.
The nurse should focus on the patients strengths and assets and not on his weakness and liabilities
The nurse views the patients behavior nonjudgmentally, while assisting the patient to learn more adaptive ways of coping
The nurse should explore the patient behavior for the need it is designed to meet and the message it is communicating.
The nurse has the potential for establishing a nurse-patient relationship with most if not all patients.
The quality of the nurse-patient relationship determines the degree of change that can occur in the patients behavior.
LEVELS OF INTERVENTIONS IN PSYCHIATRIC NURSING
PRIMARY LEVEL OF PREVENTION
Interventions aimed at the promotion of mental health and lowering the rate of cases by altering the stressors.
Examples: Health education Information dissemination Counseling
SECONDARY LEVEL OF PREVENTION
Interventions that limit the severity of a disorder. Has two components: Case finding Prompt treatment
Examples: Crisis intervention
TERTIARY LEVEL OF PREVENTION
Interventions aimed at disability after a disorder.
reducing
the
Has two components: Prevention of complication Active program of rehabilitation

Examples: Alcoholics Anonymous
Promotion of mental illness is best achieved by? A) helping individuals use established successful coping mechanisms B) assisting individuals deal with physical problems C) helping individuals deal with physical problems D) assisting individuals deal with family
ANSWER
Letter A
Rationale: Strengthening an individuals coping mechanism is one of the best ways to prevent mental illness.
A psychiatric nurse would be more likely to work with people with mental disorders in which of the following settings?
A) Shelters B) Neighborhood centers C) Prisons D) All of these
ANSWER
Letter D
Rationale: Psychiatric nursing practice is applicable in all healthcare settings.
Which is an example of secondary prevention strategy in a psychiatric ward.? A) Monitoring of medication administration B) Monitoring of blood pressure C) Assessing of skin problems D) All of these
ANSWER
Letter D
Rationale: All the choices fall under the category of prompt treatment
Helping a patient find an alternative to her home, which had been destroyed by a fire, is an example of what level of prevention strategy?
A) Primary B) Secondary C) Tertiary D) Any of these
ANSWER
Letter C
Rationale: Providing assistance during recovery period falls under rehabilitation, which is tertiary level of prevention strategy
Health education, communication and information dissemination are examples of activities under?
A) Health promotion B) Rehabilitation C) Case finding D) Prompt treatment
ANSWER
Letter A
Rationale: Health education, communication and information dissemination are activities, which promotes health.
CHARACTERISTICS OF A PSYCHIATRIC NURSE
CHARACTERISTICS OF A PSYCHIATRIC NURSE
Empathy The ability to see beyond outward behavior and sense accurately another persons inner experiencing.
Genuineness / Congruence Ability to use therapeutic appropriately
tools
Unconditional Positive Regard
ROLES OF THE NURSE IN PSYCHIATRIC SETTINGS
Ward Manager Creates a therapeutic environment. Socializing Agent Assists the patient to feel comfortable with others
Counselor Listens to the patients verbalizations
Parent Surrogate Assists the patient in the performance of activities of daily living.
Patient Advocate Enables the patient and his relatives to know their rights and responsibilities Teacher Assists the patient to learn more adaptive ways of coping
Technician Facilitates the performance of nursing procedures

Therapist Explores the patients needs, problems and concerns through varied therapeutic means Reality Base
Healthy Role Model Acts as a symbol of health by serving as an example of healthful living.
THE NERVOUS SYSTEM AND HOW IT WORKS
BRAIN
The brain is divided into:
Cerebrum
Cerebellum Brain Stem Limbic System
CEREBRUM
The LEFT HEMISPHERE is the center for logical reasoning and analytic functions such as reading, writing and mathematical tasks. The RIGHT HEMISPHERE is the center for creative thinking, intuition, and artistic abilities
CEREBRUM
CEREBRUM
Each cerebral hemisphere is
divided into four lobes: Frontal Parietal Temporal Occipital
FRONTAL LOBES OF CEREBRUM

These control the:
Organization of thought
Body movement Memories Emotions Moral behavior

The frontal lobes:
Helps regulate arousal

Focus attention Allow
problem solving and decision making to occur

Abnormalities in the frontal
lobes are associated with: Schizophrenia Attention Deficit Hyperactivity Disorder Dementia
PARIETAL LOBES OF CEREBRUM

The
parietal lobes are involved with: Interpreting sensations of taste and touch Assisting in spatial orientation
TEMPORAL LOBES OF CEREBRUM

These function as centers
for: Hearing Memory Expressions of emotions
OCCIPITAL LOBES OF CEREBRUM

They assist in:
Coordinating
language
generation Visual interpretation Depth perception
CEREBELLUM
It
is the center for coordination of movements and postural adjustments
CEREBELLUM
Inhibited transmission of a
neurotransmitter, DOPAMINE, in this area is associated with a lack of smooth, coordinated movements in diseases such as PARKINSONS DISEASE and DEMENTIA
BRAIN STEM
This includes the following:
Midbrain
Pons Medulla Oblongata
MEDULLA OBLONGATA OF THE BRAIN STEM

This
contains the vital centers for respiration and cardiovascular function
PONS OF THE BRAIN STEM

This bridges the gap both
structurally and functionally, serving as a primary motor pathway
MIDBRAIN OF THE BRAIN STEM

This
includes most of the RETICULAR ACTIVATING SYSTEM (RAS) and the EXTRAPYRAMIDAL SYSTEM (EPS). The RAS influences motor activity, sleep, consciousness and awareness. The EPS relays information about movement and coordination from the brain to the spinal nerves
LIMBIC SYSTEM
Thalamus
Hypothalamus Hippocampus Amygdala
THALAMUS OF THE LIMBIC SYSTEM

This regulates:
Activity
Sensation Emotion
HYPOTHALAMUS OF THE LIMBIC SYSTEM

This is involved with:
Temperature regulation
Appetite control Endocrine function Sexual drive Impulse
behavior associated with feelings of anger, rage and excitement
HIPPOCAMPUS AND AMYGDALA OF THE LIMBIC SYSTEM

These structures are involved
in emotional arousal and memory.
LIMBIC SYSTEM
Disturbances in the limbic
system have been implicated in a variety of mental illnesses, such as: The memory loss seen in DEMENTIA The poorly controlled emotions and impulses seen in PSYCHOTIC or MANIC BEHAVIOR
NEUROTRANSMISSION
Neurons
or nerve cells communicate information with each other by sending electrochemical messages from neuron to neuron, in a process called NEUROTRANSMISSION.
NEUROTRANSMISSION
Electrochemical messages pass from:

The dendrites Through the cell body Down the axon Across the gaps between cells (SYNAPSE) To the dendrite of the next neuron
NEUROTRANSMISSION
NEUROTRANSMITTERS
These
are chemical substances manufactured in the neuron that aid in the transmission of information throughout the body
NEUROTRANSMITTERS
They
either excite or stimulate an action in the cells (EXCITATORY) or inhibit or stop an action (INHIBITORY).
NEUROTRANSMITTERS
Neurotransmitters fit into a
specific receptor cells embedded in the membrane of the dendrite, just like a certain key shape fits into a lock
NEUROTRANSMITTERS
After neurotransmitters are
released into the synapse and relay the message to the receptor cells, they are either: Transported back from the synapse to the axon to be store for later use (REUPTAKE); Or are metabolized and inactivated by enzymes, primarily MONOAMINE OXIDASE or MAO
MAJOR TYPES OF NEUROTRANSMITTERS

TYPE OF NEUROTRANSMITTER DOPAMINE MECHANISM OF ACTION Excitatory PHYSIOLOGIC EFFECTS Controls complex movements, motivation, cognition; regulates emotional response. Changes in attention, learning and memory, sleep and wakefulness, mood Fight-or-flight response Control of food intake, sleep and wakefulness, temperature regulation, pain control, sexual behaviors, regulation of emotion. Alertness, control of gastric secretions, cardiac stimulation, peripheral allergic responses
NOREPINEPHRINE (NORADRENALINE) EPINEPHRINE (ADRENALINE) SEROTONIN
Excitatory
Excitatory Inhibitory
HISTAMINE
Neuromodulat or
MAJOR TYPES OF NEUROTRANSMITTERS

TYPE OF NEUROTRANSMITTER
ACETYLCHOLINE NEUROPEPTIDES
MECHANISM OF ACTION
Excitatory or Inhibitory
PHYSIOLOGIC EFFECTS
Sleep and wakefulness cycle; signals muscles to become alert
Neuromodulator Enhance, prolong, inhibit, or limit the s effects of principal neurotransmitters
GLUTAMATE
GAMMAAMINOBUTYRIC ACID (GABA)
Excitatory
Inhibitory
Neurotoxicity results if levels are too high

Modulates other neurotransmitters
DOPAMINE
It is synthesized from the amino acid tyrosine It is implicated in Schizophrenia and other psychoses, as well as movement disorders in Parkinsons Disease
Antipsychotic medications work by blocking dopamine receptors and reducing dopamine activity
NOREPINEPHRINE
Excess norepinephrine has been implicated in a variety of anxiety disorders. Deficits in norepinephrine may affect memory loss, social withdrawal and depression.
Some antidepressants block the reuptake of norepinephrine, and others inhibit MAO from metabolizing it.
SEROTONIN
It is derived from a dietary amino acid named tryptophan. It has been found to play a role in the delusions, hallucinations, and withdrawn behavior in schizophrenia.
Some antidepressants block serotonin reuptake, thus leaving it available in the synapse for a longer time, which results in
HISTAMINE
The role of histamine in mental illness is under investigation Some psychotropic drugs block histamine, resulting in weight gain, sedation and hypotension.
ACETYLCHOLINE
It is synthesized from dietary choline found in red meat and vegetables. Persons with Alzheimers Disease have a decreased number of acetylcholine-secreting neurons
GAMMA-AMINOBUTYRIC ACID (GABA)
Drugs that increase GABA function, such as benzodiazepines, are used to treat anxiety and induce sleep
GLUTAMATE
This is an excitatory amino acid that at high levels can have major neurotoxic effects. This has been implicated in the brain damage caused by stroke, hypoglycemia, sustained hypoxia or ischemia, and some degenerative diseases like Alzheimers Disease.
PSYCHOPHARMACOLOGY
PSYCHOPHARMACOLOGY
Terms used in describing drugs and drug therapy important for the nurse to know: Efficacy
Potency Half-life
EFFICACY
This refers to the maximal therapeutic effect that can be achieved by a drug.
POTENCY
This describes the amount of drug needed to achieve that maximum effect Drugs that have a low potency require higher dosages to achieve efficacy High-potency drugs achieve efficacy at lower doses.
HALF-LIFE
This is the amount of time it takes for half of the drug to be removed from the bloodstream.
Drugs with a shorter half-life may need to be given 3 or 4 times in a day, but drugs with a longer half-life may be given once a day. The amount of time needed for a drug to
PRINCIPLES THAT GUIDE PSYCHOPHARMACOLOGIC TREATMENT
A medication is selected based on its effect on the clients target symptom, such as delusional thinking, panic attacks, or hallucinations.
The effectiveness of the medication is evaluated in large part by its ability to diminish or eliminate the target symptom.
Many psychotropic drugs must be given in adequate dosages for a period of time before their full effect is realized.
Tricyclic antidepressants can require 4 to 6 weeks to provide optimal therapeutic benefit.
The dosage of a medication is often adjusted to the lowest dosage effective for the client
Some higher dosages may be needed to stabilize the clients target symptoms, and lower dosages can be used to sustain those effects over time.
As a rule, elderly persons require lower dosages of a medication to produce therapeutic effects, and it may take longer for a drug to achieve its full therapeutic effect.
Psychotropic medications are often decreased gradually (tapering)rather than abruptly discontinued.
This is due to potential problems with rebound (temporary return of symptoms), recurrence of the original symptoms, or withdrawal (new symptoms resulting from discontinuation of the drug)
Follow-up care is essential to ensure compliance with the medication regimen, to make needed adjustments in dosage, and to manage side effects.
WHAT THE NURSE NEEDS TO KNOW ABOUT PSYCHOTROPIC DRUGS
How the drug works

Its side effects Contraindications
Interactions
Nursing interventions required for helping
PSYCHOTROPIC DRUG CATEGORIES
Antipsychotics
Antidepressants Mood Stabilizers
Anti-anxiety Drugs
Stimulants
1) ANTIPSYCHOTIC DRUGS
ANTIPSYCHOTIC DRUGS
These are also known as NEUROLEPTICS

These are used to treat symptoms of psychosis, such as delusions and hallucinations.
They work by blocking the receptors of the neurotransmitter Dopamine.
ANTIPSYCHOTIC DRUGS
Antipsychotic drugs are the primary medical treatment for Schizophrenia and are also used in psychotic episodes of acute mania, psychotic depression, and drug-induced psychosis.
Persons with dementia who have psychotic symptoms sometimes respond to low doses of antipsychotics.
TYPICAL ANTIPSYCHOTIC DRUGS

GENERIC (TRADE) NAME Chlorproma zine (Thorazine) Perphenazin e (Trilafon) Fluphenazin e (Prolixin) Thioridazine (Mellaril) FORMS DAILY DOSAGE (mg) 200 1600 EXTREME DOSAGE RANGE (mg/day) 25 2000
T, L, INJ
T, L, INJ T, L, INJ T, L
16 32 2.5 20 200 600
4 64 1 60 40 800
TYPICAL ANTIPSYCHOTIC DRUGS

GENERIC (TRADE) NAME Trifluoperazi ne (Stelazine) Thiothixene (Navane) Haloperidol (Haldol) Loxapine FORMS DAILY DOSAGE (mg) 6 50 EXTREME DOSAGE RANGE (mg/day) 2 80
T, L, INJ
C, L, INJ T, L, INJ C, L, INJ
6 30 2 20 60 100
6 - 60 1 - 100 30 - 250
ATYPICAL ANTIPSYCHOTIC DRUGS

GENERIC (TRADE) NAME Clozapine (Clozaril) Risperdone (Risperdol) Olanzapine (Zyprexa) Quetiapine FORMS DAILY DOSAGE (mg) 150 500
28 5 15
T
T T
EXTREME DOSAGE RANGE (mg/day) 75 - 700

1 16 5 - 20
300 600
200 - 750
MECHANISM OF ACTION OF ANTIPSYCHOTIC DRUGS
The major action of all antipsychotics in the nervous system is to block receptors for the neurotransmitter dopamine.
The typical antipsychotic drugs are potent antagonists (blockers) of dopamine receptors D2, D3, and D4. This makes them effective in treating target symptoms but also produces many extrapyramidal side effects.
MECHANISM OF ACTION OF ANTIPSYCHOTIC DRUGS
Newer, atypical antipsychotic drugs, such as clozapine (Clozaril), are relatively weak blockers of D2, which may account for the lower incidence of extrapyramidal side effects.
Atypical antipsychotics also inhibit the reuptake of serotonin, which makes them more effective in treating the depressive aspects of Schizophrenia
SIDE EFFECTS OF ANTIPSYCHOTIC DRUGS
Extrapyramidal Symptoms (EPS) are serious neurologic symptoms that are the major side effects of antipsychotic drugs, which include:
Acute Dystonia Pseudoparkinsonism Akathisia Tardive Dyskinesia
SIDE EFFECTS OF ANTIPSYCHOTIC DRUGS EXTRAPYRAMIDAL SYMPTOMS (EPS)
Blockade of D2 receptors in the midbrain region of the brain stem is responsible for the development of EPS Therapies for the neurologic side effects of acute dystonia, pseudoparkinsonism, and akathisia are similar and include:
1) Lowering the dosage of the
DRUGS USED TO TREAT EXTRAPYRAMIDAL SIDE EFFECTS

GENERIC (TRADE) NAME Amantadine (Symmetrel) Benztropine (Cogentin) Beperiden (Akineton) Diazepam (Valium) ORAL IM / IV DRUG DOSAGES DOSES (mg) CLASS (mg) 100 bid or Dopaminergi tid c Agonist 1- 3 bid 12 Anticholinergi c 2 tid qid 2 Anticholinergi c
5 tid
5 10
Benzodiazepi ne
DRUGS USED TO TREAT EXTRAPYRAMIDAL SIDE EFFECTS

GENERIC (TRADE) NAME Lorazepam (Ativan) Procyclidine (Kemadrin) Propranolol (Inderal) Trihexaphenid yl ORAL IM / IV DRUG DOSAGES DOSES (mg) CLASS (mg) 1 2 tid Benzodiazepi ne 2.5 5 tid Anticholinergi c
10 20 tid; up to 40 qid 2 5 tid
Beta-blocker
Anticholinergi c
SIDE EFFECTS OF ANTIPSYCHOTIC DRUGS (EPS) ACUTE DYSTONIA
This includes any of the following:

Acute muscular rigidity and cramping A stiff or thick tongue with difficulty of swallowing In severe cases, laryngospasm respiratory difficulties. and
Spasms
or stiffness in muscle groups can produce torticollis (twisted head and neck)

Spasms
or stiffness in muscle groups can produce opisthotonus (tightness in the entire body with the head back and an arched neck)
Spasms
or stiffness in muscle groups can produce an oculogyric crisis (eyes rolled back in a locked position)
TREATMENT FOR (EPS) ACUTE DYSTONIA
Rapid relief is brought about by immediate treatment with anticholinergic drugs such as:
Intramuscular benztropine mesylate (Cogentin) Intramuscular or intravenous diphenhydramine (Benadryl)
TREATMENT FOR (EPS) ACUTE DYSTONIA
Recurrent dystonic reactions would necessitate a lower dosage or a change in the antipsychotic drug.
SIDE EFFECTS OF ANTIPSYCHOTIC DRUGS (EPS) PSEUDOPARKINSONISM
Drug-induced Parkinsonism or pseudoparkinsonism have the following symptoms: A stiff, stooped posture Masklike facies Decreased arm swing A shuffling, festinating gait (with small steps) Cogwheel rigidity (ratchet-like movements of joints) Drooling Tremor Bradycardia
TREATMENT FOR (EPS) PSEUDOPARKINSONISM
Pseudoparkinsonism is treated by changing to an antipsychotic medication that has a lower incidence of EPS or by adding an oral anticholinergic agent or amantadine .
SIDE EFFECTS OF ANTIPSYCHOTIC DRUGS (EPS) AKATHISIA
Akathisia is reported by the client as an intense need to move about The client appears restless or anxious and agitated, often with a rigid posture or gait and a lack of spontaneous gestures.
This feeling of internal restlessness and the inability to sit still or rest often leads clients to discontinue their antipsychotic
TREATMENT FOR (EPS) AKATHISIA
Akathisia can be treated by a change in antipsychotic medication or the addition of an oral agent such as a beta-blocker, anticholinergic, or benzodiazepine.
SIDE EFFECTS OF ANTIPSYCHOTIC DRUGS (EPS) TARDIVE DYSKINESIA (TD)
TD is a syndrome of permanent, involuntary movements, is most commonly caused by the long-term use of typical antipsychotics.
Once it has developed, TD is irreversible. Symptoms of TD include: Involuntary movements of the tongue, facial and neck muscles, upper and lower extremities, and truncal musculature Tongue-thrusting and protrusion, lip-
TREATMENT FOR (EPS) TARDIVE DYSKINESIA
Although TD is irreversible, its progression can be arrested by decreasing or discontinuing the antipsychotic medication. Preventing the occurrence of TD is done by keeping maintenance dosages as low as possible, changing medications, and monitoring the client periodically for the initial signs of TD. Persons who have already developed signs of TD but who still need to take antipshychotic medication are often given
OTHER SIDE EFFECTS OF ANTIPSYCHOTIC DRUGS
Neuroleptic Malignant Syndrome Anticholinergic Side Effects
SIDE EFFECTS OF ANTIPSYCHOTIC DRUGS NEUROLEPTIC MALIGNANT SYNDROME (NMS)
NMS is a potentially fatal, idiosyncratic reaction to an antipsychotic drug with the following symptoms: Rigidity High fever Autonomic instability such as unstable blood pressure, diaphoresis, pallor, delirium and elevated levels of enzymes (particularly CPK). Confusion Being mute
SIDE EFFECTS OF ANTIPSYCHOTIC DRUGS NEUROLEPTIC MALIGNANT SYNDROME (NMS)
Dehydration, poor nutrition, and concurrent medical illness all increase the risk for NMS.
TREATMENT FOR NEUROLEPTIC MALIGNANT SYNDROME (NMS)

Immediate discontinuance of all antipsychotic medications Institution of supportive medical care such as rehydration and hypothermia, until the clients physical condition is stabilized.
SIDE EFFECTS OF ANTIPSYCHOTIC DRUGS ANTICHOLINERGIC SIDE EFFECTS
Symptoms usually decrease after 3 4 weeks but do not entirely remit and include the following: Orthostatic hypotension Dry mouth Constipation Urinary hesitance or retention Blurred near vision Dry eyes Photophobia
TREATMENT FOR ANTICHOLINERGIC SIDE EFFECTS
The client who is taking anticholinergic agents for EPS may have increased problems with anticholinergic side effects, but some nutritional or over-the-counter remedies can ease these symptoms
CLIENT TEACHING AND MEDICATION MANAGEMENT: ANTIPSYCHOTIC DRUGS
Drink sugar-free fluids and eat sugar-free hard candy to ease the anticholinergic effects of dry mouth.
Avoid calorie-laden beverages and candy because they promote dental caries, contribute to weight gain, and do little to relieve dry mouth Constipation can be prevented or relieved
Stool softeners are permissible, laxatives should be avoided.
but
Use sunscreen to prevent burning and avoid long periods of time in the sun. Wear protective clothing as photosensitivity can cause a patient to burn easily.
Rising slowly from a sitting or lying position will prevent falls from orthostatic
Monitor the amount of sleepiness or drowsiness you experience. Avoid driving a car or performing other potentially dangerous activities until your response time and reflexes seem normal.
If you forget a dose of antipsychotic medication, take it if the dose is only 3 to 4 hours late. If the missed dose is more than 4 hours late or the next dose is due, omit the forgotten dose.
If you have difficulty remembering your medication, use a chart to record doses when taken, or use a pill box labeled with dosage times and/or days of the week to help you remember when to take medication.
SIDE EFFECTS OF ATYPICAL ANTIPSYCHOTIC DRUGS CLOZAPINE (Clozaril)
This drug produces fewer traditional side effects than most typical antipsychotic drugs, but it has the potentially fatal side effect of agranulocytosis. This develops suddenly and is characterized by fever, malaise, ulcerative sore throat, and leukopenia.
This side effect can occur up to 24 weeks after
TREATMENT OF AGRANULOCYTOSIS DUE TO CLOZAPINE (Clozaril)
Blood samples should be taken weekly to monitor the WBC count of patients with agranulocytosis.
The drug must be discontinued immediately if the white blood cell count drops by 50% or to less than 3,000.
2) ANTIDEPRESSANT DRUGS
ANTIDEPRESSANT DRUGS
Antidepressant drugs are primarily used in the treatment of: Major depressive illness Panic disorder Other anxiety disorders Bipolar depression Psychotic depression
Although the mechanism of action is not completely understood, antidepressants somehow interact with two neurotransmitters, norepinephrine and serotonin, that regulate mood, arousal, attention, memory processing and appetite
These are divided into four groups

2A) Tricyclic and the related cyclic antidepressants 2B) Selective inhibitors (SSRIs) 2C) Monoamine (MAOIs) serotonin reuptake
Oxidase
inhibitors
MECHANISM OF ACTION OF ANTIDEPRESSANT DRUGS
The major interaction is with the monoamine neurotransmitter systems in the brain, particularly norepinephrine and serotonin.
Both of these neurotransmitters are released throughout the brain and help to regulate arousal, vigilance, attention, mood, sensory processing,
Norepinephrine, serotonin, and dopamine are removed from the synapses after release by reuptake into presynaptic neurons.
After reuptake, these three neurotransmitters are reloaded for subsequent release or metabolized by the enzyme Monoamine Oxidase
The cyclic antidepressants and venlafaxine block the reuptake of norepinephrine primarily and serotonin to some degree.
The Monoamine Oxidase Inhibitors (MAOIs) interfere with enzyme metabolism. The Selective Serotonin Reuptake Inhibitors (SSRIs) block the reuptake of serotonin
2A) CYCLIC ANTIDEPRESSANT DRUGS
CYCLIC ANTIDEPRESSANT DRUGS DRUG
The cyclic antidepressants became available in the 1950s and for years were the first choice of drugs to treat depression.
CYCLIC ANTIDEPRESSANTS DRUG ALERT!!!
These are potentially lethal if taken in an overdose. Depressed or impulsive clients who are taking these drugs need to have prescriptions and refills in limited amounts to decrease the risk.
CYCLIC ANTIDEPRESSANT DRUGS

GENERIC (TRADE) NAME Imipramine (Tofranil) Despiramine (Nopramin) Amitryptiline (Elavil) Nortryptiline (Pamelor) FORMS USUAL DAILY DOSAGE (mg) 150 - 200 150 - 200 150 - 200 75 - 100 EXTREME DOSAGE RANGE (mg/day) 50 - 300 50 - 300 50 - 300 25 - 150
T, C, INJ T, C T, INJ C, L
CYCLIC ANTIDEPRESSANT DRUGS

GENERIC (TRADE) NAME Trimipramin e (Surmontil) Protriptyline (Vivactil) Maprotiline (Ludiomil) Amoxapine FORMS USUAL DAILY DOSAGE (mg) 150 - 200 EXTREME DOSAGE RANGE (mg/day) 50 - 300
T T T
15 - 40 100 - 150 150 - 200
10 - 60 50 - 200 50 - 250
SIDE EFFECTS OF CYCLIC ANTIDEPRESSANT DRUGS
The cyclic antidepressant drugs block cholinergic receptors, resulting in anticholinergic effects such as:
Dry mouth Constipation Urinary hesitancy or retention Dry nasal passages Blurred near vision Agitation, delirium and ileus are more severe anticholinergic side effects that
SIDE EFFECTS OF CYCLIC ANTIDEPRESSANT DRUGS
Other common side effects include: Orthostatic hypotension Sedation Weight gain Tachycardia
Sexual dysfunction is frequently reported by clients taking TCAs
2B) MONOAMINE OXIDASE INHIBITOR (MAOI) ANTIDEPRESSANT DRUGS
MONOAMINE OXIDASE INHIBITORS (MAOIs)
The MAOIs were also discovered in the 1950s and were found to have a positive effect on depressed persons.
The MAOIs have a low incidence of sedation and anticholinergic effects
MONOAMINE OXIDASE INHIBITORS DRUG ALERT!!!
These are potentially lethal if taken in an overdose. Depressed or impulsive clients who are taking these drugs need to have prescriptions and refills in limited amounts to decrease the risk.
MONOAMINE OXIDASE INHIBITORS (MAOIs)

GENERIC (TRADE) NAME
Phenelzine (Nardil) Tranylcypromi ne (Parnate) Isocarboxazid (Marplan)
FORMS
T T
USUAL DAILY DOSAGE (mg) 45 60

30 - 50
EXTREME DOSAGE RANGE (mg/day) 15 - 90

10 - 90
20 - 40
10 - 60
SIDE EFFECTS OF MONOAMINE OXIDASE INHIBITORS (MAOIs)
The most common side effects of MAOIs include: Day-time sedation Insomnia Weight gain Dry mouth Orthostatic hypotension Sexual dysfunction
Sedation and insomnia are difficult to treat
SIDE EFFECTS OF MONOAMINE OXIDASE INHIBITORS (MAOIs)
Of particular concern with MAOIs is the potential for a life-threatening hypertensive crisis if the client ingests food containing tyramine.
The symptoms of this crisis are: Severe hypertension Hyperpyrexia Tachycardia Diaphoresis Tremulousness
FOODS (CONTAINING TYRAMINE) TO AVOID WHEN TAKING MONOAMINE OXIDASE INHIBITORS (MAOIs)
No mature or aged cheeses or dishes made with cheese, such as lasagna, pizza. All cheese is considered aged except cottage cheese, cream cheese, ricotta cheese, and processed cheese slices
No aged meats such as pepperoni, salami, mortadella, summer sausage, beef logs, and similar products. Make sure meat and chicken are fresh and have been properly refrigerated.
FOODS (CONTAINING TYRAMINE) TO AVOID WHEN TAKING MONOAMINE OXIDASE INHIBITORS (MAOIs)
No Italian broad beans (fava) pods or banana peel. Banana pulp and all other fruits and vegetables are permitted
Avoid all tap beers and microbrewery beer. Drink no more than two cans or bottles of beer (including non-alcoholic beer) or 4 ounces of wine per day No sauerkraut, soy sauce or soybean
MONOAMINE OXIDASE INHIBITORS DRUG INTERACTION DRUG ALERT!!!
The following drugs can cause a potentially fatal drug interaction when taken with MAOI antidepressants:
Other MAOI antidepressants SSRI antidepressants Certain cyclic compounds Meperidine (Demerol) Buspirone (BuSpar) Dextromethorphan
2C) SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRI) ANTIDEPRESSANT DRUGS
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
The SSRIs were first available in 1987 with the release of fluoxetine (Prozac). They have replaced the cyclic drugs as the first choice in treating depression, because they equal in efficacy and produce fewer troublesome side effects.
The SSRIs and clomipramine (cyclic antidepressant) are effective in the

GENERIC (TRADE) NAME Fluoxetine (Prozac) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) FORMS USUAL DAILY DOSAGE (mg) 20 150 - 200 EXTREME DOSAGE RANGE (mg/day) 50 - 80 50 - 300
C, L T
T
T
20
100 - 150
10 - 50
50 - 200
SIDE EFFECTS OF SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
Enhanced serotonin transmission can lead to several common side effects such as: Anxiety Agitation Akathisia or motor restlessness (treated with a beta-blocker such as propranolol or a benzodiazepine) Nausea (take medications with food) Insomnia which may continue to be a problem even if the medication is taken in the morning (a sedative hypnotic or lowdosage trazodone may be needed) Sexual dysfunction or a diminished sexual
SIDE EFFECTS OF SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
Less common side effects include: Sedation particularly with paroxetine or Paxil (indicates need for a change to another antidepressant) Sweating (indicates need for change to another antidepressant) Diarrhea (manage with symptomatic treatment) Hand tremor Headaches (manage with symptomatic treatment)
DRUG INTERACTIONS FOR SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
An uncommon but potentially serious drug interaction called serotonin or serotonergic syndrome can result from taking a MAOI and an SSRI at the same time
It can also occur if one of these drugs is taken too close to the end of therapy with the other Therefore, one drug must clear the persons
DRUG INTERACTIONS FOR SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
Symptoms of the serotonergic syndrome include: Agitation Sweating Fever Tachycardia Hypotention Rigidity Hyperreflexia
2D) OTHER ANTIDEPRESSANT COMPOUNDS
OTHER ANTIDEPRESSANT DRUGS

GENERIC (TRADE) NAME Buproprion (Wellbutrin) Venlafaxine (Effexor) Trazodone (Desyrel) Nefazodone (Serzone) FORMS USUAL DAILY DOSAGE (mg) 200 300 75 225 200 300 300 600 EXTREME DOSAGE RANGE (mg/day) 100 450 75 375 100 600 100 - 600
T T, C T T
SIDE EFFECTS OF OTHER ANTIDEPRESSANT DRUGS
Sedation is caused by nefazodone, trazodone, and mirtazapine Headaches are brought about by nefazodone and trazodone Dry mouth and nausea are also brought about by nefazodone Loss of appetite, nausea, agitation and insomnia are caused by Bupropion and venlafaxine Dizziness, sweating and sedation may be
SIDE EFFECTS OF OTHER ANTIDEPRESSANT DRUGS
Sexual dysfunction is much less common with the novel antidepressants, with one notable exception : trazodone can cause priapism (a sustained and painful erection that necessitates immediate treatment and discontinuation of the drug)
Priapism could result to impotence.
CLIENT TEACHING AND MEDICATION MANAGEMENT: ANTIDEPRESSANT DRUGS
Minimize nausea by taking medication with food. To reduce insomnia, take daily doses in the morning. If this is not effective, ask the physician if a medication for sleep is indicated. Do not use alcohol to induce sleep, because this will worsen insomnia.
For diarrhea and headaches caused by the
Initial sedation effects generally lessen with time. If they persist, talk to the physician about modifying the dose or changing medications
For motor restlessness or hand tremor, ask the physician for a medication such as propranolol (Inderal) or a benzodiazepine Use calorie-free beverages or sugar-free
Try to get a balanced diet to avoid excess weight gain. Exercise is also beneficial. Increase your intake of water and bulkforming foods to prevent or relieve constipation. Stool softeners are permitted. But laxatives should be avoided.
Do not drink antidepressants alcohol while taking
If problems with sexual drive or having an erection or orgasm occur, discuss them with the physician rather than altering or stopping medication. Other antidepressants may be appropriate.
If you miss a dose of the drug, follow the directions given by your physician.
3) MOOD STABILIZING DRUGS
MOOD STABILIZING DRUGS
These are used for the following:

To treat bipolar affective disorder by stabilizing the clients mood To avoid or minimize the highs and lows that characterize bipolar illness To treat the acute phases of mania
Lithium is the most established mood stabilizer Some anticonvulsant drugs are effective mood stabilizers such as: Carbamazepine (Tegretol) Valproic Acid (Depakene, Depakote)
Other anticonvulsants, such as gabapentin (Neurontin) and lamotrigine (Lamictal), are being used on a trial basis for mood stabilization
Occasionally, clonazepam (Klonopin), an anti-anxiety agent, is also used to treat acute mania.
MECHANISM OF ACTION OF MOOD STABILIZING DRUGS
Lithium normalizes the reuptake of certain neurotransmitters, such as: Serotonin Norepinephrine Acetylcholine Dopamine
Lithium also reduces the release of norepinephrine through competition with calcium
Valproic Acid is known to increase levels of the inhibitory neurotransmitter GABA. Both anticonvulsants, Valproic Acid and Carbamazepine, are thought to stabilize mood by inhibiting the kindling process the snowball-like effect seen when minor seizure activity seems to build up into more frequent and severe seizures.
In seizure management, anticonvulsants raise the level of the threshold to prevent these minor seizures.
It is suspected that this same kindling process may also occur in the development of full-blown mania, with stimulation by more frequent minor episodes. This explain why anticonvulsants are
DOSAGE OF MOOD STABILIZING DRUGS LITHIUM
Lithium is available in tablets, capsules, liquid and a sustained release form but NO PARENTERAL FORMS ARE AVAILABLE.
Daily dosages generally range from 900 mg to 3,600 mg. More importantly, the serum Lithium level should be about 1.0 mEq/L
DOSAGE OF MOOD STABILIZING DRUGS LITHIUM
Serum Lithium levels of less than 0.5 mEq/L are rarely therapeutic, and levels of more than 1.5 mEq/L are usually considered toxic.
The Lithium level should be monitored every 2 to 3 days while the therapeutic dosage is being determined, then weekly. When the clients condition is stable, the level may need to be checked once a month
DOSAGE OF MOOD STABILIZING DRUGS ANTICONVULSANTS
Carbamazepine is available in liquid, tablet, and chewable forms. Dosages usually range from 800 to 1,200 mg / day and the extreme dosage is 200 to 2,000 mg / day. Valproic acid is available in liquid, tablet, and capsule forms and as sprinkles, with dosages raging from 1,000 to 1,500 mg / day and the extreme dosage is 750 to 3,000 mg / day Serum drug levels, obtained 12 hours after the last dose of the medication, are
SIDE EFFECTS OF MOOD STABILIZING DRUGS - LITHIUM
Common side effects of Lithium therapy include: Mild nausea (take medication with food) or diarrhea Anorexia Fine hand tremors (use propranolol a beta blocker) Polydipsia Polyuria Metallic taste in the mouth
SIDE EFFECTS OF MOOD STABILIZING DRUGS - LITHIUM
Weight gain and acne are side effects that occur later in lithium therapy and both are distressing for clients. These are difficult to manage or minimize and frequently lead to noncompliance
TOXIC EFFECTS OF MOOD STABILIZING DRUGS - LITHIUM
These include: Severe diarrhea Vomiting Drowsiness Muscle weakness Lack of coordination
Untreated, these symptoms worsen and can lead to renal failure, coma and death.
DRUG ALERT!!! - LITHIUM
When toxic signs occur, the drug should be discontinued immediately. If Lithium levels exceed 3.0 mEq/day, dialysis may be indicated.
SIDE EFFECTS OF MOOD STABILIZING DRUGS - ANTICONVULSANTS
Side effects of carbamazepine and valproic acid include: Drowsiness Sedation Dry mouth Blurred vision
Carbamazepine may also cause rashes and othostatic hypotension. Valproic Acid may cause weight gain, alopecia
CLIENT TEACHING REGARDING MEDICATION MANAGEMENT: MOOD STABILIZING DRUGS
Have serum levels monitored periodically to ensure therapeutic levels of the medication. Take the medication with food to minimize nausea.
For the fine hand tremors, ask the physician to prescribe a beta-blocker such as propranolol (Inderal).
To help minimize weight gain, get a balanced diet and get regular exercise. Expect some weight gain.
Minimize side effects of sedation and drowsiness from anticonvulsant medications by taking larger doses at bedtime and smaller doses during the day.
Use calorie-free beverages and sugar-free candy to relieve dry mouth. Avoid calorieladen beverages, because they do not relieve dry mouth and stimulate more weight gain.
If you are taking lithium, keep water intake in a normal range and avoid heavy sweating, because this decreases serum lithium levels rapidly.
4) ANTIANXIETY DRUGS (ANXIOLYTICS)
ANTIANXIETY DRUGS (ANXIOLYTICS)
These drugs are used to treat: Anxiety and anxiety disorders Insomnia Obsessive-Compulsive disorder Depression Post-traumatic Stress disorder Alcohol withdrawal
Benzodiazepines have proved to be the most effective in treating anxiety.
MECHANISM OF ACTION ANTIANXIETY DRUGS (ANXIOLYTICS)
Benzodiazepines mediate the actions of the amino acid GABA, the major inhibitory neurotransmitter in the brain.
Benzodiazepines produce their effects by binding to a specific site on the GABA receptor. Buspirone is believed to exert its anxiolytic effect by acting as a partial agonist at
ANTIANXIETY DRUGS BENZODIAZEPINES

GENERIC DAILY (TRADE) NAME DOSAGE RANGE (mg) Alprazolam 0.75 1.5 (Xanax) Chlordiazepoxi 15 100 de (Librium) Clonazepam 1.5 20 (Klonopin) Chlorazepate 15 60 HALF LIFE (hours) SPEED OF ONSET
12 15 50 100
Intermediate Intermediate
18 50 30 200
Intermediate Fast
ANTIANXIETY DRUGS BENZODIAZEPINES

GENERIC DAILY (TRADE) NAME DOSAGE RANGE (mg) Flurazepam 15 30 (Dalmane) Lorazepam 28 (Ativan) Oxazepam 30 120 (Serax) Temazepam 15 30 (Restoril) HALF LIFE (hours) SPEED OF ONSET
47 100 10 20 3 21 9.5 20
Fast Moderately slow Moderately slow Moderately fast
DRUG ALERT!!! - BENZODIAZEPINES
Benzodiazepines effects of alcohol
strongly
enhance
the
Clients should not drink alcohol when taking benzodiazepines, or indeed any psychotropic drug.
ANTIANXIETY DRUGS NON-BENZODIAZEPINES

GENERIC DAILY (TRADE) NAME DOSAGE RANGE (mg) Buspirone 15 30 (BuSpar) HALF LIFE (hours) SPEED OF ONSET
3 31
Very slow
PROBLEMS ENCOUNTERED WITH USE OF BENZODIAZEPINES
Benzodiazepines have a tendency to cause physical dependence. Significant discontinuation symptoms occur when the drug is stopped that often resemble the original symptoms for which the client sought treatment.
This is especially a problem for clients with long-term benzodiazepine use, such as
PROBLEMS ENCOUNTERED WITH USE OF BENZODIAZEPINES
Benzodiazepines commonly psychological dependence.
cause
Clients fear the return of anxiety symptoms or believe themselves incapable of handling anxiety without the drugs.
This can lead to overuse or abuse of these drugs.
SIDE EFFECTS OF ANTIANXIETY DRUGS BENZODIAZEPINES
These are associated with CNS depression such as: Drowsiness Sedation Poor coordination Impairment of memory or clouded sensorium
When used for sleep, clients may complain of next-day sedation or a hangover effect
SIDE EFFECTS OF ANTIANXIETY DRUGS NON-BENZODIAZEPINES
Common side include: Dizziness Sedation Nausea Headache
effects
from
Buspirone
CLIENT TEACHING REGARDING MEDICATION MANAGEMENT: ANTIANXIETY (ANXIOLYTIC) DRUGS
It is important for clients to know that antianxiety agents are aimed at relieving symptoms, such as anxiety or insomnia, but do not treat the underlying problems that cause the anxiety.
Benzodiazepines strongly potentiate the effects of alcohol One drink may have the effect of three drinks
Clients should be aware of decreased response time, slower reflexes, and possible sedative effects of benzodiazepines when attempting activities such as driving or going to work. Drowsiness and sedation usually decrease with time. Benzodiazepine withdrawal can be fatal: once a course of therapy has been started, benzodiazepines should never be discontinued abruptly without the supervision
Take anxiolytic drugs only as prescribed. Do not increase the dosage or take extra doses even if your anxiety is increased without consulting the physician
5) STIMULANTS
STIMULANT DRUGS
Stimulant drugs, specifically amphetamines, were first used in the treatment of psychiatric disorders in the 1930s for their pronounced effects of CNS stimulation.
Today, the primary use is for attention deficit / hyperactivity disorder (ADHD) in children and adolescents, residual attention deficit disorder in adults, and narcolepsy (attacks of unwanted but irresistible daytime sleepiness that disrupt a persons life).
STIMULANT DRUGS
The primary drugs used to treat ADHD are the CNS stimulants: methylphenidate (Ritalin)
pemoline (Cylert) dextroamphetamine (Dexedrine)
MECHANISM OF ACTION OF STIMULANT DRUGS
Amphetamines and methylphenidate are often termed indirectly acting amines because they act by causing release of the neurotransmitters (norepinephrine, dopamine, and serotonin) from presynaptic nerve terminals, as opposed to having direct agonist effects on the postsynaptic receptors.
They also block the reuptake of these neurotransmitters.
DOSAGES OF STIMULANT DRUGS
For the treatment of narcolepsy in adults, both dextroamphetamine (Dexedrine) and methylphenydate (Ritalin) are given in divided doses totaling 20 200 mg/day.
The higher doses may be needed because adults with narcolepsy develop tolerance to the stimulants, requiring more medication to sustain improvement.
The dosages used to treat ADHD in children vary widely depending on: the physician
the age, weight and behavior of the child the tolerance of the family for the childs behavior

GENERIC (TRADE) NAME
Methylphenidate (Ritalin) Dextroamphetamine (Dexedrine) Pemoline (Cylert)
DOSAGE
Adults: 20-200 mg/day, orally, in divided doses Children: 10-60 mg/day orally, in 2-4 divided doses Adults: 20-200 mg/day, orally, in divided doses Children: 5-40 mg/day orally, in 2-3 divided doses Children: 37.5-112.5 mg/day orally, given once a day in the morning
SIDE EFFECTS OF STIMULANT DRUGS
The most common side effects of stimulants are: Anorexia Weight loss Nausea Irritability
Caffeine, sugar, and chocolate should be avoided because they may worsen these symptoms.
Less common side effects include: Dizziness Dry mouth Blurred vision Palpitations
The most common long-term problem with stimulants is the growth and weight suppression that occurs in some children.
This can usually be prevented by taking drug holidays on weekends, holidays, or during summer vacation, which helps to restore normal eating and growth patterns
CLIENT AND FAMILY TEACHING FOR MEDICATION MANAGEMENT: STIMULANT DRUGS
Never leave the supply of medication in a place the child can reach to avoid overdose or taking additional medication
Take the medication at meal time to minimize nausea and anorexia.
Monitor the childs weight and height because growth suppression can be a long-term consequence of stimulant therapy. Not giving the drugs during weekends during the summer can help resume normal growth patterns.
Try a dosage schedule that provides a dose of medication before beginning routine tasks of concentration such as nightly homework.
Avoid beverages containing caffeine. Limit intake of chocolate, sugar, or any other substance that increases the childs activity level. Alleviate dry mouth with beverages or sugar-free candy. calorie-free
Consult often with the school nurse or other person responsible for giving medications at school.
6) SENSITIZING DRUGS
DISULFIRAM (ANTABUSE)
Disulfiram is a sensitizing agent that causes an adverse reaction when mixed with alcohol in the body.
This agents only use is as a deterrent to drinking alcohol in persons receiving treatment for alcoholism.
ADVERSE REACTION WHEN DISULFIRAM (ANTABUSE) MIXES WITH ALCOHOL
Five to ten minutes after someone who is taking disulfiram ingests alcohol, symptoms begin to appear: Facial and body flushing from vasodilation A throbbing headache Sweating Dry mouth Nausea and vomiting Dizziness and weakness In severe cases, severe hypotension, confusion and even death.
MECHANISM OF ACTION OF DISULFIRAM (ANTABUSE)
Disulfiram inhibits the enzyme aldehyde dehydrogenase, which is involved in the metabolism of ethanol. Acetaldehyde levels are then increased from 5 to 10 times higher than normal, resulting in the disulfiram-alcohol reaction
SIDE EFFECTS OF DISULFIRAM (ANTABUSE)
Side effects of taking Disulfiram include: Fatigue Drowsiness Halitosis Tremor Impotence It can interfere with the metabolism of other drugs the client is taking such as: phenytoin (Dilantin), isoniazid (INH), warfarin (Coumadin), barbiturates, and long-acting
CLIENT EDUCATION FOR PATIENTS TAKING DISULFIRAM (ANTABUSE)
Many common products contain alcohol, such as: Shaving cream Aftershave lotion Cologne Deodorant Over-the-counter medications such as cough preparations When used by the client taking disulfiram, these products can produce the same reaction as drinking alcohol
ELECTROCONVULSIVE THERAPY (ECT)
Involves application of electrodes to the head of the client to deliver an electrical impulse to the brain; this causes a seizure
It is believed that the shock stimulates brain chemistry to correct the chemical imbalance of depression However, the mechanism of action of ECT is unclear at present
FACTS ABOUT ELECTROCONVULSIVE THERAPY (ECT)
Voltage of electrical current that is administered to the client 70 150 volts Length of electrical shock applied to the patient About 0.5 to 2.0 seconds Usual number of treatments needed to produce a therapeutic effect 6 12 treatments Frequency of treatments
Indicators of effectiveness of ECT The occurrence of generalized tonic-clonic seizure Indications for ECT Depression, Mania, Catatonic Schizophrenia
Contraindications to ECT Fever Increased intracranial tumor TB with history of hemorrhage Cardiac condition Recent fracture Retinal detachment Pregnancy
Need for consent prior to ECT Yes, consent is needed
Medications given to clients prior to ECT Atropine sulfate
To decrease secretions
Anectine (Succinylcholine)
To promote muscle relaxation
Methohexital Sodium (Brevital)
Serves as an anesthetic agent
Common complications of ECT Loss of memory Headache Apnea Fracture Respiratory depression
Mr. Bartes depression does not improve with antidepressant medication, and the physician orders electroconvulsive therapy (ECT). ECTs mechanism of action is?
A) Similar to that of antidepressant drugs B) Related to an increased production of chemicals in the brain C) Unclear at present D) Related to the patients perception of
ANSWER
Letter C
Rationale: The mechanism of action of ECT is unclear at present
Which of the following medications is given to a patient before ECT, to prevent aspiration?
A) Anectine B) Brevital C) Ritalin D) Atropine sulfate
ANSWER
Letter D
Rationale: Atropine sulfate is given to the patient, to decrease secretions to prevent aspiration.
Which of the following statements, indicate a common side effect of ECT, when a patient says:
A) I cannot sleep B) I have a headache C) I know you D) I feel that my muscles are stiff
ANSWER
Letter B
Rationale: Headache complication of ECT is a common
An appropriate intervention for a patient after ECT is to? A) Check the consent B) Re-orient the patient C) Serve meals right away D) Assist the patient to ambulate
ANSWER
Letter B
Rationale: Memory loss usually occurs after ECT, so the nurse needs to re-orient the patient
Which of the following complaints should the nurse address initially with ECT? A) I have a headache B) I cannot breathe C) I cannot remember anything D) I am hungry
ANSWER
Letter B
Rationale: Respiratory depression can occur after ECT due to the muscular relaxation effect of Anectine, so assess for respiration.
COMMON PSYCHOTHERAPEUTIC INTERVENTIONS
COMMON PSYCHOTHERAPEUTIC INTERVENTIONS

Remotivation Therapy Hypnotherapy
Music Therapy
Play Therapy Group Therapy Milieu Therapy Family Therapy Psyhcoanalysis
Humor Therapy
Behavior Modification Aversion Therapy Token Economy Desensitization Cognitive Therapy
REMOTIVATION THERAPY
Treatment modality that promotes expression of feelings through interactions facilitated by discussion of neutral topics
Reality orientation for rehabilitative patients only and not for actively psychotic patients
REMOTIVATION THERAPY
Five different steps: Climate of acceptance
Welcome clients, introduce self to each other Orientation to topic
Creating a bridge to reality
Sharing the world we live in
Discussion of the topic

Ask patient to reflect
Appreciation of the works of the world
Climate of appreciation
MUSIC THERAPY
Involves the use of music to facilitate relaxation, expression of feelings and outlet of tension
PLAY THERAPY
Treatment modality which enables the patient to experience intense emotion in a safe environment with the use of play
Example: For victims of child abuse, give dolls.
GROUP THERAPY
Treatment modality involving therapeutic interactions of three or more patients with a therapist to relieve emotional difficulties, increase self-esteem, develop insight and improve behavior in relation with others
The minimum number of members in a group is 3, while the ideal number is 8 - 10
GROUP THERAPY
Types of Groups:
Therapeutic Group
To gain insight into their problems (i.e. Alcoholics Anonymous)
Socialization group
To enhance interaction among patients
Life Review / Reminiscing Group
To lessen isolation
MILIEU THERAPY
Consists of treatment by means of controlled modification of the patients environment to facilitate positive behavioral change
Nurse identifies what each patient needs from the therapeutic milieu, while keeping in mind the needs of the larger patient group
FAMILY THERAPY
A method of psychotherapy which focuses on the total family as an interactional system Best suited for families where there is domestic violence
Goals include: Enhancement of communication among family members Mobilizing the familys inherent strengths
PSYCHOANALYSIS
A method of psychotherapy which focuses on the exploration of the unconscious, to facilitate identification of the patients defenses Behavioral disorders are related to unresolved anxiety-provoking childhood experiences that are repressed into the unconscious Goal is to bring repressed experiences into conscious awareness and to learn healthier means of coping with anxiety.
HYPNOTHERAPY
A therapeutic modality which involves various methods and techniques to induce a trans state where the patient becomes submissive to instructions
HUMOR THERAPY
Involves the use of humor to facilitate expression of feelings and to enhance interaction
Therapeutic laughing lessens the high levels of tension that often accompany discussions of serious matters.
BEHAVIOR MODIFICATION
A therapeutic intervention involving the application of learning principles in order to change maladaptive behavior It attempts to strengthen a desired behavior or response by reinforcement, either positive or negative.
Positive reinforcement
Example:
If the desired behavior is assertiveness, whenever the client uses assertiveness skills in a communication group, the group leader provides positive reinforcement by giving the client attention and positive feedback.
Negative reinforcement involves removing a stimulus immediately after a behavior occurs so that the behavior is more likely to occur again. For example, if a client becomes anxious when waiting to talk in a group, he may volunteer to speak first to avoid the anxiety.
AVERSION THERAPY
An example of behavior modification in which a painful stimulus is introduced to bring about an avoidance of another stimulus with the end view of facilitating behavioral change
Examples: A patient snaps a rubber band on the wrist when bothered by an intrusive thought
TOKEN ECONOMY
An example of behavior modification technique which utilizes the principle of rewarding desired behavior to facilitate change
DESENSITIZATION
Periodic exposure of the individual to a feared object, until the undesirable behavior disappears or is lessened
COGNITIVE THERAPY
Short term structured therapy between the patient and the therapist oriented towards present problems and solutions.
The main focus of cognitive therapy is in depression disorders to: Increase activity Reduce unwanted behavior Increase pleasure Enhancing social skills
COGNITIVE THERAPY
Anxiety Reduction Relaxation Training Systematic Desensitization

Cognitive Restructuring Thought Stopping Learning New Behavior Token Economy
A nurse consults the hospitals clinical nurse specialist in psychiatric nursing about group size. The nurse specialist will most likely say that the optimal number of patients in each group is?
A) 5 B) 10 C) 20 D) Unlimited
ANSWER
Letter B
Rationale: 8 10 patients is the optimal number of patients in a group
Milieu therapy involves?

A) Gathering together a member of a disturbed patients community B) Only immediate family members are involved in affecting behavior changes in the patient C) Emphasis on considering patient as a biophysical and sociocultural being D) Scientific manipulation of the
ANSWER
Letter D
Rationale: Milieu therapy involves scientific manipulation of the environment that can influence improvement of the patients behavior
What is the main goal of milieu therapy?

A) Inclusion of the family in the therapy B) Change inappropriate behavior C) Patient-planned, patient-led activities D) Staff-led decision-making process
ANSWER
Letter C
Rationale: In milieu therapy, patients plan and lead activities rather than the staff.
In family should?
therapy
sessions,
the
nurse
A) Serve as a leader B) Focus on the sick member C) Neutralize blaming by setting contract D) Use paradoxical communication
ANSWER
Letter C
Rationale: A contract is essential at the beginning of therapy to make expectations clear.
Milieu activities which are initially appropriate for schizophrenic patients are the following, EXCEPT?
A) Basketball B) Painting C) Writing D) Listening to music
ANSWER
Letter A
Rationale: Patients with schizophrenia need activities that do not require interaction, so solitary activities are preferred over team activities.
DYNAMICS OF HUMAN BEHAVIOR
NEED
It is an organismic condition which requires a certain activity
STRESS
A broad class of experiences, in which a demanding situation taxes a persons coping abilities
A non-specific response of the body to any kind of demand made upon it (Hans Selye) This non-specific response is called the General Adaptation Syndrome (GAS) or the stress syndrome
BEHAVIOR
Way in which an organism responds to a stimulus
CONFLICT
Situation that arise from the presence of two opposing drives.
BASIC CONCEPTS ON THE PATIENT
PERSONALITY
The integration of those systems and habits that represents an individuals characteristic adjustment to his environment.
Personality is expressed through behavior
CHARACTERISTICS OF PERSONALITY
Distinctiveness Each individual is unique Stability and Consistency Personality is predictable
DETERMINANTS OF PERSONALITY
Psychological Type of climate at home Cultural Customs and traditions Biological Personality is not inherited
DIVISIONS OF THE MIND OR LEVELS OF AWARENESS
Freud believed that the human personality functions at three levels of awareness: Conscious
Preconscious Unconscious
DIVISIONS OF THE MIND / LEVELS OF AWARENESS CONSCIOUS
This refers to the perceptions, thoughts, and emotions that exist in the persons awareness such as being aware of happy feelings or thinking about a loved one
It is the part of the mind focused on awareness
DIVISIONS OF THE MIND / LEVELS OF AWARENESS SUBCONSCIOUS
Preconscious thoughts and emotions are not currently in the persons awareness, but he or she can recall them with some effort.
It is the part of the mind that contains information that can be recalled at will For example, an adult remembering what he or she did, thought, or felt as a child.
DIVISIONS OF THE MIND / LEVELS OF AWARENESS of thoughts and feelings This refers to the realm SUBCONSCIOUS
that motivate a person, even though he or she is totally unaware of them.
This realm includes most defense mechanisms and some instinctual drives or motivations. It is the largest part of the mind; contains materials and information that can never be recalled
PERSONALITY STRUCTURE
Sigmund Freud conceptualized personality structure as having three components: Id Superego Ego
ID
Is the part of ones nature that reflects basic or innate desires such as: Pleasure-seeking behavior Aggression Sexual impulses The id seeks instant gratification; causes impulsive, unthinking behavior; and has no regard for rules or social convention.
SUPEREGO
Is the part of a persons nature that reflects moral and ethical concepts, values, and parental and social expectations
Therefore, it is in direct opposition to the id.
EGO
Is the balancing or mediating force between the id and the superego. It represents mature and adaptive behavior that allows a person to function successfully in the world.
Freud believed that anxiety resulted from the egos attempts to balance the impulsive instincts of the id with the stringent rules of
STRUCTURES OF PERSONALITY
ID EGO AGE AT WHICH IT IS PRESENT DIVISION OF MIND DESCRIPTION 0 1 YEAR OLD 1 3 YEARS OLD CONSCIOUS AND UNCONSCIOUS INTEGRATOR OF PERSONALITY
SUPEREGO
3 6 YEARS OLD
UNCONSCIOUS
UNCONSCIOUS
NO SENSE OF RIGHT OR WRONG
EGO IDEAL GIVES REWARDS; CONSCIENCE GIVES PUNISHMENT MORALITY
BASIS
PLEASURE
REALITY
THEORIES OF PERSONALITY DEVELOPMENT
THEORIES OF PERSONALITY DEVELOPMENT
Freuds Psychosexual Theory

Eriksons Psychosocial Theory Piagets Cognitive Theory
FREUDS THEORY OF PSYCHOSEXUAL DEVELOPMENT
Freud based his theory of childhood development on the belief that sexual energy, termed libido, was the driving force of human behavior He proposed that children go through five stages of psychosexual development Oral Anal Phallic Latency
Psychopathology results when a person has difficulty making the transition from one stage to the next, or when a person remains stalled at a particular stage or regresses to an earlier stage.
ORAL STAGE
Age Birth to 18 months Focus Major site of tension and gratification is the mouth, lips and tongue, includes biting and sucking activities Id present at birth Ego develops gradually from rudimentary structure present at birth Indicators of Fixation: smoking, chewing
ANAL STAGE
Age 18 36 months Focus Anus and surrounding area are major source of interest Acquisition of voluntary sphincter control (toilet training) Indicators of Fixation: Parsimonious, punctual, precise, obsessive-compulsive
PHALLIC OR OEDIPAL STAGE
Age 3 5 years Focus Penis is organ of interest for both sexes. Masturbation is common Penis envy (wish to possess penis) seen in girls; oedipal complex (wish to marry opposite-sex parent and be rid of samesex parent) seen in boys and girls.
LATENCY STAGE
Age 5 11 or 13 years Focus Resolution of oedipal complex Homosexual stage formation of gangs (boy-boy or girl-girl) Sexual drive channeled into socially appropriate activities such as school work and sports Formation of the superego
GENITAL STAGE
Age 11 13 years Focus Final stage of psychosexual development Begins with puberty and the biologic capacity for orgasm; involves the capacity for true intimacy Area of gratification includes secondary sex characteristics, reawakening of sexual
ERIKSONS THEORY OF PSYCHOSOCIAL DEVELOPMENT
In each stage, the person must complete a life task that is essential to his or her wellbeing and mental health. These tasks allow the person to achieve lifes virtues
In his view, psychosocial growth occurs in sequential phases and each stage is dependent in completion of the previous stage and life task
For example, in the infant stage, trust versus mistrust, the baby must learn to develop basic trust (the positive outcome) such that he or she will be fed and taken cared of. The formation of trust is essential; mistrust, the negative outcome
1st Stage: TRUST VERSUS MISTRUST (Infant)
Age 0 12 months Virtue Hope Task Viewing the world as safe and reliable; relationships as nurturing, stable and dependable Concept If the needs of the child are consistently
2nd Stage: AUTONOMY VERUS SHAME AND DOUBT (Toddler)
Age 1 3 years Virtue Will Task Achieving a sense of control and free will Concept If toilet training is not hurried, autonomy develops
3rd Stage: INITIATIVE VERSUS GUILT (Pre-School)
Age 3 6 years Virtue Purpose Task Beginning development of a conscience; learning to manage conflict and anxiety Concept If the childs sexual curiosity is handled without anxiety, initiative develops
4th Stage: INDUSTRY VERSUS INFERIORITY (School Age)
Age 6 12 years Virtue Competence Task Emerging confidence in own abilities; taking pleasure in accomplishments Concept If the childs efforts at learning is supported, industry develops
5th Stage: IDENTITY VERSUS ROLE CONFUSION (Adolescence)
Age 12 18 years Virtue Fidelity Task Formulating a sense of self and belonging Concept If the adolescents vocational decision is supported, identity develops
6th Stage: INTIMACY VERSUS ISOLATION (Young Adult)
Age 18 25 Virtue Love Task Forming adult, loving relationships and meaningful attachments to others Concept If the young adults decisions regarding love relationships is supported, intimacy
7th Stage: GENERATIVITY VERSUS STAGNATION (Middle Adult)
Age 25 65 years Virtue Care Task Being creative and productive; establishing the next generation Concept If an adult enjoys support from the family, generativity develops
8th Stage: EGO INTEGRITY VERSUS DESPAIR (Maturity)
Age 65 years and above Virtue Wisdom Task Accepting responsibility for ones self and life Concept If the elderly has a satisfying past recollection, integrity develops
PIAGETS THEORY OF COGNITIVE DEVELOPMENT
Piaget believed that human intelligence progresses through a series of stages based on age with the child at each successive stage demonstrating a higher level of functioning than at previous stages. He also believed that biologic changes and maturation were responsible for cognitive development
Four stages of cognitive development: Sensorimotor Preoperational Concrete Operations Formal Operations
SENSORIMOTOR
Age 0 2 years Concepts The child develops a sense of self as separate from the environment and the concept of object permanence; that is, tangible objects dont cease to exist just because they are out of sight (example: peek-a-boo) He or she begins to form mental images
PREOPERATIONAL STAGE
Age 2 6 years Concepts The child develops the ability to express self with language, understands the meaning of symbolic gestures, and begins to classify objects
At 2 4 years, development proceeds from sensory motor learning to prelogical thought (pre-conceptual)
The child learns language and symbols
At 4 6 years, the child is able to think in
CONCRETE OPERATIONAL STAGE
Age 6 12 years Concepts Development from pre-logical to logical concrete thought The child begins to apply logic to thinking, understands spatiality and reversibility, and is increasingly social and able to apply rules Thinking is still concrete
FORMAL OPERATIONAL STAGE
Age 12 Adulthood Concepts The child is able to think abstractly and is able to apply the scientific method The child learns to think and reason in abstract terms, further develops logical thinking and reasoning, and achieves cognitive maturity.
Erikson described the psychosocial tasks of the developing person in his theoretical model. The primary developmental task of the young adult (age 18 25) is?
A) Intimacy versus isolation B) Industry versus inferiority C) Generativity versus stagnation D) Trust versus mistrust
ANSWER
Letter A
Rationale: The primary developmental task of the young adult is intimacy versus isolation
Jen, 5 years-old has been brought to the emergency room by their neighbor with second degree burns at her right hand. According to Freud, Jen is at what stage of psychosexual development?
A) Latency B) Oral C) Anal D) Phallic
ANSWER
Letter D
Rationale: The phallic stage of development is from ages 3 through 6.
Monica, a 19-year old college student belongs to what stage of psychosexual development?
A) Anal B) Latency C) Genital D) Phallic
ANSWER
Letter C
Rationale: Age 12 to adulthood is the genital stage of development according to Freud
Three-year old Messiah belongs to what stage of development? 1) 2) 3) 4) Anal Phallic Sensorimotor Pre-operational
B) 1,4 C) 2,3 D) 2,4
A) 1,3
ANSWER
Letter B
Rationale: In Freuds theory, age 1 3 belong to the anal stage while in Piagets theory, age 2 7 belong to the preoperational stage
A child who belongs to the phallic stage in Freuds theory must develop which of the following developmental tasks according to Erickson?
A) Trust B) Autonomy C) Initiative D) Industry
ANSWER
Letter C
Rationale: The phallic stage in Freuds theory (age 3 6) corresponds to the development of the developmental task of initiative versus guilt in Ericksons theory
CRISIS AND CRISIS INTERVENTION
CRISIS
A crisis is a turning point in an individuals life that produces an overwhelming emotional response
Individuals experience a crisis when they confront some life circumstance or stressor that they cannot effectively manage through use of their customary coping skills A situation that occurs when an individuals
CHARACTERISTICS OF A CRISIS STATE
Highly individualized
Lasts for 4 6 weeks Person affected becomes passive and submissive Affects a persons support system
TYPES OF CRISES
Maturational or Developmental Crisis

Situational or Accidental Crisis Social or Adventitious Crisis
MATURATIONAL OR DEVELOPMENTAL CRISIS
Expected, predictable and internally motivated events in the normal course of life such as: Leaving home for the first time Getting married Having a baby Beginning a career Growth Parenthood
SITUATIONAL OR ACCIDENTAL CRISIS
Unanticipated or sudden, unexpected, unpredictable and externally motivated events that threaten the individuals integrity such as: Death of a loved one Loss of a job Physical and emotional illness in the individual family or member Car accident
SOCIAL OR ADVENTITIOUS CRISIS
Includes natural disasters and acts of nature like: Floods Earthquakes Hurricanes War Terrorist attacks Riots Violent crimes such as rape or murder
PHASES OF A CRISIS
Denial Initial reaction Increased Tension The person recognizes the presence of a crisis and continues to do activities of daily living Disorganization The person is pre-occupied with the crisis and is unable to do activities of daily living
CRISIS INTERVENTION
A way of entering into the life situation of an individual, family, group, or community to help them mobilize their resources and to decrease the effect of a crisis inducing stress
GOAL OF CRISIS INTERVENTION
To enable the patient to attain an optimum level of functioning
TYPES OF CRISIS INTERVENTION
Authoritative Crisis Intervention

Facilitative Crisis Intervention
AUTHORITATIVE CRISIS INTERVENTION
Are designed to assess the persons health status and promote problem-solving such as:
Offering the person new information, knowledge or meaning Raising the persons self awareness by providing feedback about behavior
FACILITATIVE CRISIS INTERVENTION
Aim at dealing with the persons needs for empathetic understanding such as: Encouraging the person to identify and discuss feelings Serving as a sounding board for the person Affirming the persons self worth
PRIMARY ROLE OF THE NURSE IN CRISIS
Active and directive, the nurse has to assist the patient
Nurse Apple attends to patients who are in crisis. The goal of crisis intervention is to? A) Assist the patient explore available and appropriate resources in the community B) Assist the patient develop awareness of her feelings C) Assist the patient to achieve correct cognitive perception of the situation D) Assist the patient to seek new and useful
ANSWER
Letter D
Rationale: The goal of crisis intervention is to assist the patient to seek new and useful adaptive mechanisms within the context of her social support system.
This phase of crisis is characterized by feelings of great anxiety and inability to perform activities of daily living.
A) Disorganization B) Reorganization C) Attempt to escape the problem D) Increased tension
ANSWER
Letter A
Rationale: Disorganization is the phase of a crisis state which is characterized by feelings of great anxiety and inability to perform activities of daily living.
Which of the following would be most helpful during the early stages of crisis intervention
A) Help the patient to understand the crisis B) Encourage the patient to forget the experience C) Assess her thoughts thoroughly D) Protect the patient from potential harm
ANSWER
Letter A
Rationale: In crisis intervention, a thorough understanding of the crisis is necessary for appropriate planning
The nurses role in crisis therapy should be?

A) Non-directive and passive B) Firm and confrontational C) Active and directive D) Calm and non-expressive
ANSWER
Letter C
Rationale: A patient in crisis is passive and submissive so the nurse needs to be active and directive to facilitate coping.
Which of the following is expected of a person in crisis? A) Be able to adjust in a week B) Becomes submissive and passive C) Takes the lead in problem-solving D) Assists the nurse in decision-making
ANSWER
Letter B
Rationale: A patient in crisis is passive and submissive.
RAPE
RAPE
Is a crime of violence and humiliation of the victim expressed through sexual means Rape is the penetration of an act of sexual intercourse with a female against her will and without her consent, whether her will is overcome by force, fear of force, drugs, or intoxicants
It is also considered rape if the woman is
RAPE
According to Republic Act 8353, it refers to the insertion of the penis into the mouth, vagina, anus of a victim
Insertion of any object into the mouth or anus It is generally considered as an act of hostility, anger or violence
ESSENTIAL ELEMENTS NECESSARY TO DEFINE AN ACT OF RAPE
Use of threat / force

Lack of consent of the victim Actual penetration of the penis into the vagina
DIFFERENT KINDS OF RAPE
Anger Rape
Power Rape Sadistic Rape
ANGER RAPE
Distinguished by physical cruelty to the victim
violence
and
Rapist believes he is the victim of an unjust society and takes revenge on others by raping
He uses extreme force and viciousness to overcome the victim
POWER RAPE
The intent of the rapist is not to injure the victim but to command and master another person sexually
The rapist has an insecure self-image and feelings of incompetence and inadequacy The rape is the vehicle for expressing power, potency and might
SADISTIC RAPE
Involves brutality
The use of bandage and torture is not an expression of anger but necessary for the rapists sexual excitement
The assault is often eroticized and is sexually stimulating This is done to express erotic feelings
WARNING SIGNS OF RELATIONSHIP VIOLENCE
Emotionally abuses you (insults, makes belittling comments, acts sulky or angry when you initiate an idea or activity)
Tell you with whom you may be friends or how you should dress, or ties to control other elements of your life Talks negatively about women in general
Acts in an intimidating way by invading your personal space such as standing too close or touching you when you do not want him to
Cannot handle sexual or emotional frustration without becoming angry Does not view you as an equal; sees himself as smarter or socially superior
Guards his masculinity by acting tough

Is angry or threatening to the point that you have changed your life or yourself so you wont anger him
RAPE TRAUMA SYNDROME
It refers to a group of signs and symptoms experienced by a victim in reaction to a rape
PHASES OF THE RAPE TRAUMA SYNDROME Acute Phase

Characterized disbelief by shock, numbness and
Denial Phase Characterized by the victims refusal to talk about the event Heightened Anxiety Characterized by nightmares
fear,
tension,
and
NURSING CARE FOR RAPE VICTIMS
In the emergency setting, immediate emotional support
provide
The nurse should allow the woman to proceed at her own pace and not rush her through any interview or examination
Give as much control back to the victim as possible by allowing her to make decisions, when possible, about whom to call, what to
It is the victims decision about whether or not to file charges and testify against the perpetrator and the victim must sign consent forms before any photographs of hair and nail samples are taken for future evidence
The priority in the care of a rape victim is the preservation of evidence
Prophylactic treatment for STDs is offered

Prophylaxis can be offered to prevent pregnancy In some areas, HIV testing is strongly encouraged Referrals to encouraged rape crisis centers are
The initial treatment of a rape victim can significantly affect the psychological impact the assault will have on the victim. The first information elicited from a victim would be which of the following?
A) the marital state of the victim B) the victims perception of what occurred C) whether or not the rapist was known to her
ANSWER
Letter B
Rationale: Rape is a form of crisis. The severity of a crisis situation depends on the individuals perception of the event.
Rape is generally considered to be an act of ? A) Aggression B) Bestiality C) Exposure D) Sexual passion
ANSWER
Letter A
Rationale: Rape is generally considered to be an act of aggression, hostility and violence
Which of the following is most important for the emergency room nurse to take? A) Call the police B) Call a psychiatrist C) Provide emotional support D) Offer protection from pregnancy
ANSWER
Letter C
Rationale: Initially, the provision of a safe and supportive environment is necessary
The overall patient goal in rape counseling is to help the victim? A) Forget the incident and repress her feelings in order to be able to carry on with her life B) Identify the rapist in court C) Accept her part in the rape D) Acknowledge, face, and resolve the reaction she is experiencing
ANSWER
Letter D
Rationale: Rape is a form of crisis. In crisis intervention, the patient is considered as the primary rehabilitator.
Primary prevention of rape can be best accomplished by which of the following? A) Initiation of emergency measures after the rape B) Policewoman teaching a class on rape prevention C) Psychiatric hospitalization for the survivor of rape D) A lengthy jail sentence for the rapist
ANSWER
Letter B
Rationale: Conducting rape prevention classes is an example of primary level of prevention
SPOUSE OR PARTNER ABUSE
Is the mistreatment or misuse of one person by another in the context of an intimate relationship
The abuse can be emotional psychological, physical, sexual or combination (which is common) or a
Emotional or psychological abuse includes:

Name-calling Belittling Screaming Yelling Destroying property Making threats Refusing to speak to or ignoring the
Physical abuse includes the following:

Shoving Pushing
Severe battering and choking and may involve broken limbs and ribs, internal bleeding, brain damage, even homicide
Sexual abuse include the following assaults during sexual relations such as: Biting nipples
Pulling hair Slapping and biting
BATTERED WIFE SYNDROME
Cycle of domestic violence characterized by wife-beating by the husband, humiliation and other forms of aggression
The most common trait of abusive men is low self-esteem The most common trait of the abused woman is dependence
CHARACTERISTICS OF ABUSIVE HUSBANDS
They usually come from violent families

They are immature, dependent and nonassertive They have strong feelings of inadequacy
PHASES OF SPOUSE OR PARTNER ABUSE
Tension Building Phase Involves minor battering incidents Acute Battering Phase More serious form of battering occurs Aftermath / Honeymoon Phase The husband becomes loving and gives the wife hope
PRIORITY IN NURSING CARE FOR THE ABUSED SPOUSE OR PARTNER
Provision of shelter
DOs IN WORKING WITH VICTIMS OF PARTNER ABUSE
Do ensure and confidentiality
maintain
the
clients
Do listen, affirm, and say I am sorry you have been hurt. Do express: I am concerned for your safety. Do tell the victim: You have the right to be
DOs IN WORKING WITH VICTIMS OF PARTNER ABUSE
Do recommend a individual counseling
support
group
or
Do identify community resources and encourage the client to develop a safety plan
Offer to help the client contact a shelter, the police, or other resources
DONTs IN WORKING WITH VICTIMS OF PARTNER ABUSE
Dont disclose client communications without the clients consent Dont preach, moralize, or imply that you doubt the client Dont minimize the impact of the violence
Dont express outrage with the perpetrator
Seeing a patient for the first time, the nurse notices bruises on her upper arms and asks about them. After denying any problems, the patient starts to cry and says, He didnt really mean to hurt me, but I hate the kids to see. I am so worried about them. During the interview, it would be most important for the nurse to determine? A) The type and extent of abuse in the family B) The potential of immediate danger to the patient and her children C) The resources available to the patient
ANSWER
Letter B
Rationale: In domestic violence, the priority is the patients safety
When planning her care, which of the following is the most important to the patient?
A) The phone number of the local crisis hotline B) Referral to a psychotherapist C) Referral to assertiveness training classes for women D) No referral will be needed unless the
ANSWER
Letter A
Rationale: Provision of support is an essential component of the care of battered women.
In assessing a battered wifes method of coping, which method would the nurse least expect to find her using?
A) Assertiveness B) Alcohol abuse C) Self-blame D) Suicidal thoughts
ANSWER
Letter A
Rationale: Battered women are usually dependent and non-assertive
Wife beaters will usually manifest?

A) Maturity B) Low self-esteem C) Assertiveness D) Patience
ANSWER
Letter B
Rationale: Wife-beaters usually have low self-esteem
Abused women are more likely to become receptive to nursing intervention during the ?
A) Acute phase B) Honeymoon stage C) Tension building phase D) Time between the acute phase and the tension building phase
ANSWER
Letter D
Rationale: During this stage, the victim is in a state of crisis and is therefore more receptive to suggestions.
DONTs IN WORKING WITH VICTIMS OF PARTNER ABUSE
Dont imply that the client is responsible for the abuse Dont recommend couples counseling
Dont direct relationship the client to leave the
Dont take charge and do everything for the client
CHILD ABUSE
CHILD ABUSE
Child abuse or mistreatment is generally defined as the intentional injury of a child
CHILD ABUSE
It can include any of the following:

Physical abuse or injuries Neglect or failure to prevent harm Failure to provide adequate physical or emotional care or supervision Abandonment Sexual assault or intrusion Overt torture or maiming
TYPES OF CHILD ABUSE
Physical Abuse
Sexual Abuse Neglect
Psychological Abuse
TYPES OF CHILD ABUSE PHYSICAL ABUSE
Physical abuse of children often results from unreasonably severe corporal punishment or unjustifiable punishment such as hitting an infant for crying or soiling his diapers
Intentional deliberate assaults on children include: Burning Biting Cutting
TYPES OF CHILD ABUSE PHYSICAL ABUSE
The victim often has evidence of old injuries (e.g., scars, untreated fractures, multiple bruises of various ages) that the history given by parents does not explain adequately
TYPES OF CHILD ABUSE SEXUAL ABUSE
Sexual abuse involves sexual acts performed by an adult on a child younger than 18 years of age
Examples include: Incest Rape Sodomy performed directly by the person or with an object Oral-genital contact
TYPES OF CHILD ABUSE SEXUAL ABUSE
Sexual abuse includes:

Exploitation, such as:
Making, promoting, or selling pornography involving minors Coercion of minors to participate in obscene acts
TYPES OF CHILD ABUSE NEGLECT
Neglect is malicious or ignorant withholding of physical, emotional, or educational necessities for the childs well-being
TYPES OF CHILD ABUSE NEGLECT
Child abuse by neglect is the most prevalent type of maltreatment and includes: Refusal to seek health care or delay doing so; Abandonment Inadequate supervision Reckless disregard for the childs safety Punitive, exploitative, or abusive emotional treatment; Spousal abuse in the childs presence
TYPES OF CHILD ABUSE PSYCHOLOGICAL ABUSE
Psychological abuse includes Verbal assaults

Blaming Screaming Name-calling Using sarcasm
(emotional
abuse)
Constant family discord characterized by fighting, yelling, and chaos Emotional deprivation or withholding affection, nurturing Normal experiences that engender
CHARACTERISTICS OF ABUSIVE PARENTS
They come from violent families
They were also abused by their parents They have inadequate parenting skills They are socially isolated because they dont trust anyone The are emotionally immature
WARNING SIGNS OF ABUSED OR NEGLECTED CHILDREN
Serious injury such as fractures, burns, or lacerations with no reported history of trauma
Delay in seeking treatment for a significant injury Child or parent gives a history inconsistent with severity of injury, such as a baby with contre coup injuries to the brain (shaken
Inconsistencies or changes in the childs history during the evaluation by either the child or the adult
Unusual injuries for the childs age and level of development, such as fractured femur on a 2 month old or a dislocated shoulder in a 2 year old
High incidence of urinary tract infections; bruised, red, or swollen genitalia; tears or bruising of rectum or vagina
Evidence of old injuries not yet reported, such as scars, fractures not treated, multiple bruises that parent cannot explain adequately
COMMON INDICATORS OF CHILD ABUSE
Serious injuries in various stages of healing Healthy hair in various length Apathy, no reaction Depression Excessive knowledge of sex Self-esteem is low
Republic Act 7610, the anti-child abuse law requires reporting of suspected cases to authorities
PRIORITIES IN CHILD ABUSE
Remember that the nurse does not have to decide with certainty that abuse has occurred
Nurses are responsible for reporting suspected child abuse with accurate and thorough documentation of assessment
PRIORITIES IN CHILD ABUSE
The first part of treatment for child abuse or neglect is to ensure the childs safety and well-being
Assistance of social service agencies may be tapped
In assessing an abusive situation, the nurse would find what information most useful? A) The interaction between the child and his mother B) The time of abuse C) Presence of other children in the family D) Age of the mother
ANSWER
Letter A
Rationale: The interaction between a child and his mother provides a clue to the kind of relationship that the child has with his mother
Which of the following actions would be taken by hospital personnel when child abuse is suspected?
A) Confront the mother B) Notify the family C) Notify the child protective service D) Do nothing until the diagnosis is certain
ANSWER
Letter C
Rationale: Hospital personnel are required by law to report suspected cases of child abuse.
ANXIETY
ANXIETY
A stage of uneasiness or experienced to varying degrees
discomfort
Is frequently coupled with doubts, fears, obsessions. A feeling of terror or dread; the most uncomfortable feeling a person can experience
HILDEGARD PEPLAUS FOUR LEVELS OF ANXIETY
Mild Anxiety
Moderate Anxiety Severe Anxiety
Panic Anxiety
MILD ANXIETY
It is a positive state of heightened awareness and sharpened senses, allowing the person to learn new behaviors and solve problems.
The person can take in all available stimuli (enlarged perceptual field)
MODERATE ANXIETY
Involves a decreased perceptual field (focus on immediate task only) The person can learn new behavior or solve problems only with assistance Another person can redirect the person to the task.
SEVERE ANXIETY
This involves feelings of dread or terror

The person cannot be redirected into a task; he or she focuses only on scattered details and has physiologic symptoms of tachycardia, diaphoresis, and chest pain. People with severe anxiety often go to emergency departments, believing they are having a heart attack.
PANIC ANXIETY
It involves loss of rational thought, delusions, hallucinations, and complete physical immobility and muteness
The person may bolt and run aimlessly, often exposing himself or herself to injury.
SIGNS AND SYMPTOMS SEVERE OF ANXIETY SIGNS AND MILD MODERATE PANIC
SYMPTOMS ANXIETY Increased pulse rate, respiratory rate, blood pressure Pupillary dilation Sweating Attentive and alert patient COGNITIVE ANXIETY Nausea Anorexia Vomiting Diarrhea Constipation Restlessness Narrowed perceptual field and selective inattention Use of any defense mechanism ANXIETY Signs and symptoms become the focus of attention ANXIETY Signs and symptoms of exhaustion are ignored
PHYSICAL
Perceptual field is greatly narrowed. Focus of attention is trivial events Defense mechanisms (Amnesia,
Personality is disorganized
Minimal use of defense EMOTIONAL mechanisms
Defense mechanisms fail
PRIORITY NURSING DIAGNOSES FOR ANXIETY
Ineffective individual coping

Anxiety
PRINCIPLES OF NURSING CARE IN ANXIETY
Calm
Administer medications Listen to the patients concerns
Minimize environmental stimuli
The nurse is aware that the two major types of precipitating factors in anxiety are? A) Fear of disapproval and shame B) Conflicts involving avoidance and shame C) Threats to ones biologic integrity and threats to ones self-esteem D) A persons poor health and poor financial condition
ANSWER
Letter C
Rationale: The two major types of precipitating factors to anxiety are: threats to ones biologic integrity and threats to ones self-esteem
When working with a person who is anxious, what is the overall goal of nursing intervention?
A) Remove anxiety B) Develop the persons awareness of anxiety C) Protect the person from anxiety D) Develop the persons capacity to tolerate mild anxiety
ANSWER
Letter D
Rationale: The goal of intervention in the care of the anxious patient is to enable him to develop his capacity to tolerate mild anxiety
The nurse is caring for a patient with panic disorder and a patient with a phobia. What is one major difference between those two disorders?
A) Specific precipitants are present with panic disorder B) Specific precipitants are present with phobia C) The symptoms are different for each
ANSWER
Letter B
Rationale: Specific precipitants are present with phobia
A man in his mid-forties complaints of severe palpitations, sweating and intense fear when he had to speak in public. Because his job entails lecturing in auditoriums, what would the nurse suggest?
A) Behavior therapy with beta-adrenergic blockers B) Quitting his job altogether C) Telling jokes to reduce anxiety
ANSWER
Letter A
Rationale: A combination of behavioral and somatic approaches is effective in the management of anxiety
An appropriate nursing diagnosis for a patient with anxiety is which of the following?
A) Self-esteem disturbance B) Ineffective individual coping C) Unilateral neglect D) Altered thought process
ANSWER
Letter B
Rationale: Anxiety is one of the defining characteristics of ineffective individual coping.
EGO DEFENSE MECHANISMS
Freud believed that the self or ego used ego defense mechanisms to protect the self and cope with basic drives or emotionally painful thoughts, feelings, or events.
Most ego defense mechanisms operate at the unconscious level of awareness, so people are not aware of what they are doing and often need help to see the reality.

Compensation Rationalization
Conversion
Denial Displacement Dissociation Fixation Identification Intellectualization Introjection Projection
Reaction Formation
Regression Repression Resistance Sublimation Substitution Suppression Undoing
COMPENSATION
Overachievement in one area to offset real or perceived deficiencies in another area Examples: Napoleon complex: diminutive man becoming an emperor Nurse with low self-esteem works double shifts so her supervisor will like her
CONVERSION
Expression of an emotional conflict through the development of a physical symptom, usually sensorimotor in nature.
Example: A teenager forbidden to see x-rated movies is tempted to do so by friends and develops blindness, and the teenager is unconcerned about the loss of sight.
DENIAL
Failure to acknowledge an unbearable condition; failure to admit the reality of a situation, or how one enables the problem to continue
Examples: Diabetic eating chocolate candy Spending money freely when broke Waiting 3 days to seek help for severe abdominal pain
DISPLACEMENT
Ventilation of intense feelings toward persons less threatening than the one who aroused those feelings.
Examples: A person who is mad at the boss yells at his or her spouse A child who is harassed by a bully at school mistreats a younger sibling.
DISSOCIATION
Dealing with emotional conflict by a temporary alteration in consciousness or identity

Examples: Amnesia that prevents recall of yesterdays auto accident An adult remembers nothing of childhood sexual abuse
FIXATION
Immobilization of a portion of the personality resulting from unsuccessful completion of tasks in a developmental stage
Examples: Never learning to delay gratification Lack of a clear sense of identity as an adult
IDENTIFICATION
Modeling actions and opinions of influential others while searching for identity, or aspiring to reach a personal, social, or occupational goal.
Example: Nursing student becoming a critical care nurse because this is the specialty of an instructor she admires.
INTELLECTUALIZATION
Separation of the emotions of a painful event or situation from the facts involved; acknowledging the facts but not the emotions.
Example Person shows no emotional expression when discussing serious car accident.
INTROJECTION
Accepting another persons beliefs, and values as ones own.
attitudes,
Example: A person who dislikes guns becomes an avid hunter, just like a best friend.
PROJECTION
Unconscious blaming of unacceptable inclinations or thoughts on an external object.

Examples: Man who has thought about same-gender sexual relationship but never had one, beats a man who is gay. A person with many prejudices loudly identifies others as bigots.
RATIONALIZATION
Excusing own behavior to avoid guilt, responsibility, conflict, anxiety, or loss of self-respect
Examples: Student blames failure on teacher being mean Man says he beats his wife because she does not listen to him.
REACTION FORMATION
Acting the opposite of what one thinks or feels. Examples: Woman who never wanted to have children becomes a super-mom. Person who despises the boss tells everyone what a great boss she is.
REGRESSION
Moving back to a previous developmental stage in order to feel safe or have needs met
Examples: Five-year-old asks for a bottle when new baby brother is being fed. Man pouts like a four-year-old if he is not the center of his girlfriends attention.
REPRESSION
Excluding emotionally painful or anxietyprovoking thoughts and feelings from conscious awareness
Examples: Woman has no memory of the mugging she suffered yesterday Woman has no memory before age 7 when she was removed from abusive parents.
RESISTANCE
Overt or covert antagonism toward remembering or processing anxietyproducing information.

Examples: Nurse is too busy with tasks to spend time talking to a dying patient Person attends court-ordered treatment for alcoholism but refuses to participate.
SUBLIMATION
Substituting a socially acceptable activity for an impulse that is unacceptable Examples: Person who has quit smoking sucks on hard candy when the urge to smoke arises. Person goes for 15-minute walk when tempted to eat junk foods.
SUBSTITUTION
Replacing the desired gratification with one that is more readily available. Example: Woman who would like to have her own children opens a day care center.
SUPPRESSION
Conscious exclusion of unacceptable thoughts and feelings from conscious awareness.

Examples: A student decides not to think about a parents illness in order to study for a test A woman tells a friend she cannot think about her sons death right now
UNDOING
Exhibiting acceptable behavior to make up for or negate unacceptable behavior. Examples: A person who cheats on a spouse brings the spouse a bouquet of roses. A man who is ruthless in business donates large amounts of money to charity
When upset, the patient curls into a fetal position in bed. The nurse judges the patient to be exhibiting?
A) Fixation B) Regression C) Substitution D) Symbolization
ANSWER
Letter B
Rationale: Regression is turning to an earlier level of development in the face of stress
Family members often feel guilty that they are not doing enough to the patient, so their tendency is to blame the staff, nurses and doctors. This defensive response is ?
A) Displacement B) Rationalization C) Projection D) Sublimation
ANSWER
Letter C
Rationale: Projection is attributing to others ones unconscious wishes or fears. Usually it is seen in paranoid patients.
Alcoholics commonly mechanism known as? A) Denial B) Regression C) Displacement D) Sublimation
use
defense
ANSWER
Letter A
Rationale: Alcoholics usually use denial, rationalization, projection and isolation
Rationalization is exemplified in one of the following situations? A) An applicant for a job develops fever on the day of her personal interview B) A student says, I did not get good grades because the teacher does not like me. C) An unfaithful husband gives a gift to his wife after a heated argument
ANSWER
Letter B
Rationale: Rationalization is justifying ones action which are based on other motives. It is usually seen among alcoholics
An example of maladaptive use of defense mechanism is? A) An individual resorts to drinking when under stress to diffuse tension B) A former drug addict helps in the rehabilitation of drug users. C) A short man excels in public speaking D) A patient blames the nurse for his familys unacceptable ways.
ANSWER
Letter A
Rationale: Drinking alcohol when under stress makes a person at risk for various disorders.
ANXIETY DISORDERS
ANXIETY DISORDERS
These are emotional illnesses characterized by fear, autonomic nervous system symptoms and avoidance behavior They are diagnosed when anxiety no longer functions as a signal of danger or a motivation for needed change but becomes chronic and permeates major portions of the persons life, resulting in maladaptive behaviors and emotional instability Anxiety disorders have many manifestations but anxiety is the key feature of each
TYPES OF ANXIETY DISORDERS
Agoraphobia Panic Disorder Specific Phobia Social Phobia Obsessive-compulsive Disorder Generalized anxiety Disorder Acute Stress Disorder Post-traumatic Stress Disorder
AGORAPHOBIA
Is anxiety about or avoidance of places or situations from which escape might be difficult or help might be unavoidable
Fear of being alone in public places
SYMPTOMS OF AGORAPHOBIA
Avoids being outside alone or at home alone Avoids traveling in vehicles Impaired ability to work Difficulty meeting daily responsibilities (e.g., grocery shopping, going to appointments) Knows response is extreme
MANAGEMENT OF AGORAPHOBIA
Anti-anxiety medications
Social skills training Teach them how to:
Ask questions Give compliments Maintain eye contact Speak in a clear tone of voice Avoid criticism Avoid fidgeting
PANIC DISORDER
Is characterized by recurrent, unexpected panic attacks that cause constant concern Panic attack is the sudden onset of intense apprehension, fearfulness, or terror associated with feelings of impending doom
SYMPTOMS OF PANIC DISORDER
A discrete episode of panic lasting 15 to 30 minutes with four or more of the following: Palpitations Sweating Trembling or shaking Shortness of breath Choking or smothering sensation Chest pain or discomfort Nausea Derealization (sensing that things are not real) or depersonalization (feelings of being disconnected from oneself Fear of dying or going crazy
MANAGEMENT OF PANIC DISORDER
Relaxation exercises Deep breathing
Cognitive behavioral techniques
COGNITIVE BEHAVIORAL TECHNIQUES FOR PANIC DISORDERS
Positive Reframing
Decatastrophizing Assertiveness Training
POSITIVE REFRAMING
Turning negative messages into positive messages The therapist teaches the person to create positive messages for use during panic episodes Instead of thinking, My heart is pounding. I think I am going to die the client thinks, I can stand this. This is just anxiety. It will go away. The client can write down these messages
DECATASTROPHIZING
Involves the therapists use of questions to more realistically appraise the situation; the therapist may ask, What is the worst thing that could happen? Is that likely? Could you survive that? Is that as bad as you imagine? The client uses thought-stopping and distraction techniques to jolt himself from focusing on negative thoughts Splashing the face with water, snapping a rubber band worn on the wrist, or shouting
ASSERTIVENESS TRAINING
Helps the person take more control over life situations Techniques help the person negotiate interpersonal situations and foster selfassurance They involve using I statements to identify feelings and to communicate concerns or needs to others. Examples include I feel angry when you turn your back while Im talking, I want to
SPECIFIC PHOBIA
Is characterized by significant anxiety provoked by a specific feared object or situation which often leads to avoidance behavior
SYMPTOMS OF SPECIFIC PHOBIA
Marked anxiety response to the object or situation Avoidance or suffered endurance of object or situation Significant distress or impairment of daily routine, occupation, or social functioning Adolescents and adults recognize their fear as excessive or unreasonable.
MANAGEMENT OF SPECIFIC PHOBIA
Systematic Desensitization
SYSTEMATIC OR SERIAL DESENSITIZATION
The therapist progressively exposes the client to the threatening object in a safe setting until the clients anxiety decreases During each exposure, the complexity and intensity of exposure gradually increase but each time the clients anxiety decreases. The reduced anxiety serves as a positive reinforcement until the anxiety is ultimately eliminated
EXAMPLE OF SERIAL DESENSITIZATION
For a client who fears flying, the therapist would encourage the client to hold a small model airplane while talking about his or her experiences Later the client would talk about flying while holding a larger model of an airplane Later exposures might include walking past an airport, sitting in a parked airplane, and finally taking a ride in the plane Each sessions challenge is based on the
SOCIAL PHOBIA
Is characterized by anxiety provoked by certain types of social or performance situations, which often leads to avoidance behavior
SYMPTOMS OF SOCIAL PHOBIA
Fear of embarrassment or inability to perform Avoidance or dreaded endurance of behavior or situation Recognition that response is irrational or excessive Belief that others are judging him or her negatively Significant distress or impairment in relationships, work, or social life
MANAGEMENT OF SOCIAL PHOBIA
Social Skills training
OBSESSIVE-COMPULSIVE DISORDER
Involves obsession (thoughts, impulses or images) that cause marked anxiety and/or compulsions (repetitive behaviors or mental acts) that attempt to neutralize anxiety
SYMPTOMS OF OBSESSIVECOMPULSIVE DISORDER
Recurrent, persistent, unwanted, intrusive thoughts, impulses, or images beyond worrying about the realistic life problems Attempts to ignore, suppress, or neutralize obsessions with compulsions that are mostly ineffective Adults and adolescents recognize that obsessions and compulsions are excessive and unreasonable
OBSESSIVE-COMPULSIVE DISORDER
OBSESSIONS COMPULSIONS
FEAR OF DIRT AND GERMS
EXCESSIVE HAND WASHING
FEAR OF ROBBERY
BURGLARY
OR REPEATED CHECKING OF DOOR AND WINDOW LOCKS
WORRIES ABOUT DISCARDING COUNTING AND RECOUNTING SOMETHING IMPORTANT OF OBJECTS IN EVERYDAY LIFE WORRIES THAT THINGS MUST EXCESSIVE STRAIGHTENING, BE SYMMETRICAL OR ORDERING, OR ARRANGING OF MATCHING THINGS
MANAGEMENT OF OBSESSIVECOMPULSIVE DISORDER
Response prevention (delaying or avoiding performance of the rituals) Thought Stopping
GENERALIZED ANXIETY DISORDER
Is characterized by at least six months of persistent and excessive worry and anxiety that interferes with a persons life It is also characterized by motor tension, autonomic hyperactivity and cognitive vigilance
SYMPTOMS OF GENERALIZED ANXIETY DISORDER
Apprehensive expectations more days than not for 6 months or more about several events or activities Uncontrollable worrying Significant distress or impaired social or occupational functioning Three of the following symptoms: Restlessness Easily fatigued Difficulty concentrating or mood going blank
MANAGEMENT OF GENERALIZED ANXIETY DISORDER
Anti-depressants Psychotherapy
ACUTE STRESS DISORDER
Is the development of anxiety, dissociative, and other symptoms within 1 month of exposure to an extremely traumatic stressor
It lasts 2 days to 4 weeks
SYMPTOMS OF ACUTE STRESS DISORDER
Exposure to traumatic event causing intense fear, helplessness, or horror Marked anxiety symptoms or increased arousal Significant distress or impaired functioning Persistent re-experiencing of the event Three of the following symptoms: Sense of emotional numbing or detachment Dissociative amnesia (inability to recall important aspect of the event)
MANAGEMENT OF ACUTE STRESS DISORDER
Anti-depressant medications Group therapy
POST-TRAUMATIC STRESS DISORDER
Is characterized by the re-experiencing of an extremely traumatic event, avoidance of stimuli associated with the event, numbing of responsiveness, and persistent increased arousal
It begins within 3 months to years after the event and may last a few months or years
SYMPTOMS OF POST-TRAUMATIC STRESS DISORDER
Exposure to traumatic event involving intense fear, helplessness or horror Re-experiencing (intrusive recollections or dreams, flashbacks, physical and psychological distress over reminders of the event) Avoidance of memory-provoking stimuli and numbing of general responsiveness (avoidance of thoughts, feelings, conversations, people, places, amnesia, diminished interest or participation in life
SYMPTOMS OF POST-TRAUMATIC STRESS DISORDER
Increased arousal (sleep disturbance, irritability or angry outbursts, difficulty concentrating, hypervigilance, exaggerated startle reflex)
Significant distress or impairment
MANAGEMENT OF POSTTRAUMATIC STRESS DISORDER
Anti-depressant medications Group therapy
PRIORITY NURSING DIAGNOSIS FOR ANXIETY DISORDERS
PSYCHOPHARMACOLOGIC MANAGEMENT OF POSTTRAUMATIC STRESS DISORDER
Anti-anxiety or anxiolytic drugs or minor tranquilizers Diazepam (Valium) Oxazepam (Serax) Chlordiazepoxide (Librium) Chlorazepate Dipotassium (Tranxene) Alprazolam (Xanax)
EFFECTS OF ANXIOLYTIC DRUGS
Decreased anxiety
Adequate sleep
WHEN TO ADMINISTER ANXIOLYTIC DRUGS
Best taken before meals, food in the stomach delays absorption
SIDE EFFECTS OF ANXIOLYTIC DRUGS
Drowsiness
Sedation Poor coordination
Impaired memory and clouded sensorium
CLIENT TEACHING ON ANXIOLYTIC DRUGS
Avoid driving
Intake of alcohol and caffeine-containing foods alter the effect of the drug It potentiates the effect of alcohol
Administer separately, it is incompatible with any drug.
WORKING WITH CLIENTS WITH ANXIETY AND ANXIETY DISORDERS
Remember that everyone suffers from stress and anxiety occasionally that can interfere with daily life and work Avoid falling into the pitfall of trying to fix the clients problems Discuss any uncomfortable feelings with a more experienced nurse for suggestions on how to deal with your feelings toward these clients Remember to practice techniques to
SITUATION
Leonora Cielo is the nurse manager of the oncology unit on the 33rd floor of a large urban medical center. Recently, she has been increasingly afraid of riding in the elevator and of being in public places. This morning she experienced shortness of breath, palpitations, dizziness, and trembling while in the elevator. Leonora was examined by an emergency department physician.
Which of the following behaviors would the nurse expect to observe in the patient with agoraphobia?
A) The patient is afraid of talking to other people B) The patient is afraid to leave her home C) The patient is afraid of pain D) The patient is afraid of fire
ANSWER
Letter B
Rationale: Agoraphobia is fear of being alone in a particular place where escape is difficult
Leonora begins outpatient counseling sessions with a psychiatric clinical nurse specialist. Which nursing intervention would be most helpful in reducing Leonoras anxiety level?
A) Psychoanalytically psychotherapy B) Group psychotherapy C) Systematic desensitization oriented
ANSWER
Letter C
Rationale: Systematic desensitization is the treatment of choice for people with phobia
Because of the severity of Leonoras anxiety, the nurse referred her to a psychiatrist for medication evaluation. Which psychotropic drug regimen is most likely to be prescribed on a short-term basis?
A) Diazepam (valium) 5 mg orally three times a day B) Benztropine mesylate (Cogentin) 2 mg
ANSWER
Letter A
Rationale: An anxiolytic drug is the drug of choice
An appropriate nursing diagnosis for a patient with phobia is? A) Ineffective individual coping B) Altered thought process C) Sensory perceptual alteration D) Self-esteem disturbance
ANSWER
Letter A
Rationale: A patient with anxiety disorder may exhibit difficulty in coping
Which of the following outcomes indicate a positive response to therapy for a patient with agoraphobia?
A) Patient experiences palpitation when going out of the house B) The symptoms occur only when triggered C) The patient is able to visit the mailbox D) The patient is able to entertain visitors inside the house
ANSWER
Letter C
Rationale: The patients ability to go outside the house indicates a positive response to therapy.
PERSONALITY DISORDERS
PERSONALITY
It can be defined as an ingrained, enduring pattern of behaving and relating to self, others, and the environment; personality includes perceptions, attitudes, and emotions
These behaviors and characteristics are consistent across a broad range of situations and do not change easily
PERSONALITY DISORDERS
These are personality styles that are rigid and maladaptive, causing significant personal distress and impair social functioning.
These are diagnosed when personality traits become inflexible and maladaptive and significantly interfere with how a person functions in society or cause the person emotional distress.
ETIOLOGICAL FACTORS
Genetic Factors Due to inherited traits Temperamental Factors Due to emotional climate at home Biological Factors Due to imbalance in hormones and neurotransmitters
DSM-IV-TR PERSONALITY DISORDER CATEGORIES
The Diagnostic and Statistical Manual of Mental Disorders Text Revision of the American Psychiatric Association, in 2000, has made the following classification of personality disorders: Cluster A: Individuals whose behavior appears odd or eccentric (paranoid, schizoid, and schizotypal personality disorders) Cluster B: Individuals who appear dramatic, emotional, or erratic (antisocial, borderline, histrionic, narcissistic)
CLUSTER A
Paranoid
Schizoid Schizotypal
Symptoms / Characteristics Mistrust and suspicion of others Guarded or hypervigilant and generally appear alert to any impending danger Restricted affect Mood is labile, quickly changing from quietly suspicious to angry or hostile Responses become sarcastic for no apparent reason Uses the defense mechanism of projection, which is blaming other people, institutions
PARANOID PERSONALITY DISORDER
PARANOID PERSONALITY DISORDER
Nursing Interventions The nurse must approach these clients in a formal, business-like manner and refrain from chit-chat and jokes (serious and straightforward approach)
Involve the client in treatment planning Because these clients need to feel in control, it is important to involve them in formulating plans of care. The nurse asks what the client would like to accomplish in concrete terms. Clients are more likely to engage in the therapeutic process if they believe they have
Symptoms / Characteristics Detached from social relationships They display a constricted affect and little, if any emotion; aloof and indifferent, appearing emotionally cold, uncaring,or unfeeling Report no leisure or pleasurable activities because they rarely experience enjoyment Have a pervasive lack of desire for involvement with others in all aspects of life
SCHIZOID PERSONALITY DISORDER
SCHIZOID PERSONALITY DISORDER
Nursing Interventions Focus on improved functioning of the client in the community Assist the client to find a case manager one who can help the client obtain services and health care, manage finances, etc.
SCHIZOTYPAL PERSONALITY DISORDER
Symptoms / Characteristics Has social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships Has cognitive or perceptual distortions Possesses eccentric behavior
Symptoms / Characteristics Clothes are ill fitting, do not match, and may be stained or dirty Cognitive distortions include ideas of reference (events have special meaning for him), magical thinking that he has special powers, unfounded beliefs Interpersonal relationships are troublesome and may have only one significant relationship with a first degree
Nursing Interventions Development of self-care skills Nurse encourages client to establish a daily routine for hygiene and grooming Improve community functioning and provide social skills training
CLUSTER B
Antisocial
Borderline Histrionic
Narcissistic
ANTISOCIAL PERSONALITY DISORDER
Symptoms / Characteristics Violation of the rights of others Lack of remorse for behavior Shallow emotions Lying Rationalization of own behavior Poor judgment Impulsivity Irritability and aggressiveness
Symptoms / Characteristics Thrill-seeking behaviors Exploitation of people in relationships Poor work history Consistent irresponsibility
Nursing Interventions Promote responsible behavior
Limit setting State the limit in a matter-of-fact, nonjudgmental manner Identify consequences of exceeding the limit Identify expected or acceptable behavior
Consistent adherence treatment plan
to
rules
and
Consistent limit setting in a matter-of-fact, non-judgmental manner is crucial to success A client may approach the nurse flirtatiously and attempt to gain personal information.
The nurse would use limit-setting by saying, It is not acceptable for you to ask personal questions. If you continue, I will terminate our interaction. We need to use this time to work on solving your job-related problems.
The nurse should not become angry or respond to the client harshly or punitively
Nursing Interventions Confrontation

Point out problem behavior Keep client focused on self, behavior rather than justifying it.

Confrontation is a technique designed to manage manipulative or deceptive behavior. The nurse points out a clients problematic behavior while remaining neutral and matter-of-fact; he or she avoids accusing the client. The nurse can also use confrontation to keep clients focused on the topic and in
Example of use of confrontation: Nurse: Youve said youre interested in learning to manage angry outbursts, but youve missed the last three group meetings. Client: Well, I can tell no one in the group likes me. Why should I bother? Nurse: The group meetings are designed to help you and the others, but you cant work on issues if you are not there.
Nursing Interventions Helping clients solve problems and control emotions
Effective problem solving skills

Identifying the problem Exploring alternative solutions and consequences Choosing and implementing an alternative Evaluating the results related
Decrease impulsivity
Nursing Interventions: Take time-out from a stressful situation
Leaving the area and going to a neutral place to regain internal control helps clients to avid impulsive reactions and angry outbursts, regain control of emotions and engage in constructive problem-solving
Nursing Interventions: Enhancing role performance

Identify barriers to role fulfillment Decreasing and eliminating use of drugs and alcohol
BORDERLINE PERSONALITY DISORDER
Symptoms / Characteristics Fear of abandonment, real or perceived Unstable and intense relationships Unstable self-image Impulsivity or recklessness Recurrent self-mutilating behavior or suicidal threats or gestures Chronic feelings of emptiness and boredom Labile mood
Symptoms / Characteristics Irritability Polarized thinking about self and others (splitting) Impaired judgment Lack of insight Transient psychotic symptoms such as hallucinations demanding self-harm
Nursing Interventions: Promote clients safety

The nurse must always seriously consider suicidal ideation with the presence of a plan, access to means for enacting the plan, and self-harm behaviors and institute appropriate action The nurse can encourage clients to enter a no self-harm contract, in which a client promises to not engage in self-harm and to report to the nurse when he or she is losing control The nurse emphasizes that the no self-harm contract is not a promise to the the nurse but is the clients promise to himself to be
Nursing Interventions: Helping clients to emotions
cope
and
control
Clients often react to situations with extreme emotional responses without actually recognizing their feelings The nurse can help clients to identify their feelings and learn to tolerate them without exaggerated responses such as destruction of property or self-harm Keeping a journal often helps clients gain awareness of feelings. The nurse can review journal entries as a basis
Nursing Interventions: Helping clients to emotions
cope
and
control
Another aspect of emotional regulation is decreasing impulsivity and learning to delay gratification When clients have an immediate desire or request, they must learn that it is unreasonable to expect it to be granted without delay Clients can use distraction such as taking a walk or listening to music to deal with the delay or they can think about ways to meet needs themselves
Nursing Interventions: Cognitive Restructuring Techniques

These clients view everything, people and situations, in extremes totally good or totally bad. Cognitive restructuring is a technique useful in changing patterns of thinking by helping clients to recognize negative thoughts and feeling and to replace them with positive patterns of thinking
Thought-stopping is a technique to alter the process of negative or self-critical thought patterns such as I am dumb, I am stupid, I cant do anything right. When the thoughts begin, the client may actually say, Stop! in a loud voice to stop the negative thoughts Later, a more subtle means such as forming a visual image or a stop sign will be a cue to interrupt the negative

The client then learns to replace recurrent, negative thoughts of worthlessness with more positive thinking In positive self-talk, the client reframes negative thoughts into positive ones: I made a mistake, but it is not the end of the world. Next time, I will know what to do.

Decatastrophizing is a technique that involves learning to assess situations realistically rather than always assuming a catastrophe will happen The nurse asks, So what is the worst thing that could happen? or Can you think of any exceptions to that? In this way, the client must consider other points of view and actually think about the situation
Nursing Interventions: Structure time

Feelings of chronic boredom and emptiness, fear of abandonment, and intolerance of being alone are common problems that lead to self-harm Minimizing unstructured time by planning activities can help clients to manage time alone Clients can make a written schedule that includes appointments, shopping, reading the paper, or going for a walk
HISTRIONIC PERSONALITY DISORDER
Symptoms / Characteristics With a pervasive pattern of excessive emotionality and attention-seeking Clients are overly concerned with impressing others with their appearance Dress and flirtatious behavior are not limited to social situations or relationships but also occur in occupational and professional settings Clients are extroverts
Symptoms / Characteristics Clients are emotionally expressive, gregarious, and effusive. They often exaggerate emotions inappropriately: He is the most wonderful doctor! He is so fantastic! He has changed my life! to describe a physician she has seen once or twice. In such a case, the client cannot specify why she views the doctor so highly.
Symptoms / Characteristics Clients experience rapid shifts in mood and emotions and may be laughing uproaringly one moment and sobbing the next. Thus their display of emotion may seem phony or forced on observers Clients are uncomfortable when they are not the center of attention and go to great lengths to gain that status
Nursing Interventions: The nurse gives clients feedback about their social interactions with others including manner of dress and nonverbal behavior. Feedback should focus on appropriate alternatives not merely criticism The nurse might say, When you embrace and kiss other people on first meeting them, they may interpret your
Nursing Interventions: Teaching social skills and role-playing those skills in a safe, non-threatening environment can help clients to gain confidence in their ability to interact socially The nurse must be specific in describing and modeling social skills including establishing eye-contact, active listening, and respecting personal space
Nursing Interventions: Clients may be quite sensitive to discussing self-esteem and may respond with exaggerated emotions. It is important to explore personal strengths and assets and give specific feedback about positive characteristics Encouraging clients to use assertive communication, such as I statements, may promote self-esteem and help them
NARCISSISTIC PERSONALITY DISORDER
Symptoms / Characteristics Has a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy for others They believe that they are superior, special and they demand special attention They display an arrogant or haughty attitude They view their problems as the fault of others Underlying self-esteem is almost always
Nursing Interventions The nurse must use self-awareness skills to avoid the anger and frustration that their behavior and attitude can engender Clients may be rude and arrogant, unwilling to wait, and harsh and critical of the nurse. The nurse must not internalize such criticism or take it personally The goal is to gain cooperation of these clients with other treatment as indicate
Nursing Interventions She sets limits to rude or verbally abusive behavior and explains his or her expectations from the clients.
CLUSTER C
Avoidant
Dependent Obsessive-Compulsive
AVOIDANT PERSONALITY DISORDER
Symptoms / Characteristics Has a pervasive pattern of social discomfort and reticence, low self-esteem and hypersensitivity to negative evaluation They fear rejection, criticism, shame or disapproval They remain aloof in their relationships and feel inferior to others
Nursing Interventions: These clients require much support and reassurance from the nurse The nurse can help them to explore positive self-aspects, positive responses from others, and possible reasons for self-criticism Helping clients to practice selfaffirmations and positive self-talk may be useful in promoting self esteem
Nursing Interventions: Other cognitive restructuring techniques such as reframing and decatastrophizing can enhance self worth Positive reframing means turning negative messages into positive messages
Instead of thinking I will fail, the client thinks I may fail but I will keep trying until I succeed.
Decatastrophizing involves the nurses use of questions to realistically appraise the situation
DEPENDENT PERSONALITY DISORDER
Symptoms / Characteristics Has a pervasive and excessive need to be taken care of which leads to submissive and clinging behavior and fears of separation Has incessant demands for attention from others, lacks self-confidence, needs excessive reassurance and advice They are pre-occupied with excessive fears of being left alone to care for
DEPENDENT PERSONALITY DISORDER
Nursing Interventions: The nurse must help the clients to express feelings of grief and loss over the end of a relationship while fostering autonomy and self reliance Helping clients to identify their strengths and needs is more helpful than encouraging the overwhelming belief that the client cant do anything alone Clients may need assistance in daily functioning like planning menus, shopping, budgeting money, etc.
OBSESSIVE-COMPULSIVE PERSONALITY DISORDER
Symptoms / Characteristics Has a pervasive pattern of preoccupation with perfectionism, mental and interpersonal control and orderliness at the expense of flexibility, openness and efficiency They are formal, serious and answer questions with precision and much detail Clients check and recheck the details of any project or activity
Symptoms / Characteristics They have low self-esteem and are always harsh, critical, and judgmental of themselves; they believe they could have done better regardless of how well the job has been done They have difficulty in relationships, few friends, and little social life They cannot tolerate lack of control They have difficulty working
Nursing Interventions: Nurses may be able to help clients to view decision-making and completion of projects from a different perspective
Rather than striving for the goal of perfection, clients can set a goal of completing the project or making the decision by a specified deadline Helping clients to accept or to tolerate lessthan-perfect work or decisions made on time may alleviate some difficulties at work or at home
Nursing Interventions: Use of cognitive restructuring techniques like decatastrophizing may challenge some rigid and inflexible thinking Encouraging clients to take risks, such as letting someone else plan a family activity, may improve relationships Practicing negotiation with family or friends may help them to relinquish some of their need for control
OTHER RELATED DISORDERS
Depressive Personality Disorder

Passive Aggressive Personality Disorder
DEPRESSIVE PERSONALITY DISORDER
Symptoms / Characteristics Has a pervasive pattern of depressive cognitions and behaviors in various contexts but is much less severe than major depression They have a sad, gloomy, dejected affect They express unhappiness, cheerlessness, hopelessness regardless of the situation They repress or not express anger Thinking is negative, pessimism for them is being realistic
Symptoms / Characteristics Self-esteem is quite low with feelings of worthlessness and inadequacy even when clients have been successful. Self-criticism often leads to punitive behavior and feelings of guilt or remorse
Nursing Interventions Assess for the possibility of self-harm. If the client expresses suicidal ideation or has urges for self-injury, the nurse must provide safety precautions Cognitive restructuring techniques such as thought-stopping or positive self-talk can enhance self-esteem Giving compliments promotes receiving compliments, which further enhances positive feelings
Nursing Interventions Giving factual feedback, rather than general praise, reinforces attempts to interact with others and gives specific, positive information about improved behaviors. Oh, you are doing so well today is a general praise that does not identify specific positive behaviors You have talked to Mrs. Jones for 10 minutes even though it was difficult. I know that took a lot of effort. is specific
PASSIVE AGGRESSIVE PERSONALITY DISORDER
Symptoms / Characteristics Has a negative attitude and pervasive pattern of passive resistance to demands for adequate social and occupational performance Loves to procrastinate and expresses anger through passivity The negative attitude influences thought content: clients perceive and anticipate difficulties and disappointments where
Symptoms / Characteristics They habitually resent, oppose, and resist demands to function at a level expected by others. This opposition occurs most frequently in work situations but can also be evident in social functioning They express such resistance through procrastination, forgetfulness, stubbornness, and intentional inefficiency
Nursing Interventions: The nurse can help clients examine the relationship between feelings and subsequent actions For example, a client may intend to complete a project at work but then procrastinates, forgets or becomes ill and misses the deadline. Or the client may intend to participate in a family outing but becomes ill, forgets, or has an emergency when it is time By focusing on the behavior, the nurse can
Nursing Interventions: The nurse can also help the client to learn appropriate ways to express feelings directly especially negative feelings such as anger Methods such as having the client write about the feelings or role-play are effective.
POINTS TO CONSIDER WHEN WORKING WITH CLIENTS WITH PERSONALITY DISORDERS
Talking to colleagues about feelings of frustration will help you to deal with your emotional responses so you can be more effective with clients Clear, frequent communication with other health care providers can help to diminish the clients manipulation Do not take undue flattery or harsh criticism personally; it is a result of the clients personality disorder
The nurse is caring for a patient who is sarcastic and critical and often expresses feelings that are the opposite of what he is actually feeling. This patient is exhibiting which type of behavior?
A) Passive B) Aggressive C) Passive - Aggressive D) Assertive
ANSWER
Letter C
Rationale: Patients with passive-aggressive personality disorder loves to procrastinate, expresses anger through passivity
The nurse is caring for a patient diagnosed with paranoid personality disorder in an acute care facility. Which intervention would the nurse use to control the patients suspiciousness?
A) Keeping messages clear and consistent, while avoiding deception B) Providing pharmacologic therapy C) Providing social interactions with others
ANSWER
Letter A
Rationale: Consistency should be maintained when dealing with patients with personality disorder.
In caring for a patient who has antisocial personality disorder. Which of the following assessment findings should the nurse expect?
A) Manipulative behavior and inflated feelings of self-worth B) Manipulative behavior and inability to tolerate frustration C) Suicidal ideation and starvation
ANSWER
Letter B
Rationale: Antisocial patients are manipulative and have low tolerance to frustration.
In caring for a patient with borderline personality disorder, which interventions should the nurse perform?
A) Setting limits on manipulative behavior B) Allowing the patients to set time limits C) Using restraints judiciously D) Encouraging acting out behavior
ANSWER
Letter A
Rationale: Setting limits prevents the patient from manipulating the nurse.
The nurse is performing an admission interview with the patient who exhibits signs of narcissistic personality disorder. Which behavior patters is most characteristic of narcissistic personality disorder?
A) The patient has no close friends B) The patient is reticent in social situations C) The patient has grandiose sense of selfimportance
ANSWER
Letter C
Rationale: Patients who are narcissistic feel that they are special and they demand special attention from others.
In paranoid disorder, the part of the personality that is weak is called? A) Id B) Ego C) Superego D) Not me
ANSWER
Letter B
Rationale: The ego acts as the integrator of the personality
A patient says he must wash his hands from 9:00 AM to 9:45 AM each day and therefore cannot attend 9:00 AM group therapy sessions. Which concept does the nursing staff need to keep in mind in planning nursing interventions for this patient?
A) Fears and tensions are often expressed in disguised form through symbolic processes
ANSWER
Letter A
Rationale: The rituals performed by the obsessive-compulsive patient is their way of expressing fears and tensions.
In interacting with a patient with an antisocial personality disorder, what would be the most therapeutic approach?
A) Reinforce the patients self concept B) Gratify the patients inner needs C) Give the patient the opportunity to test reality D) Provide external controls
ANSWER
Letter D
Rationale: Providing external controls enables the nurse to set limits on the patients behavior
A SAMPLE BOARD QUESTION NO.9 help patient uses repetitive hand washing. To the patient use less maladaptive means of handling stress, the nurse could? A) Provide varied activities on the unit, as change in routine can break this ritualistic pattern B) Give the patient ward assignment that do not require perfection C) Tell the patient changes in routine at the last minute to avoid build up of anxiety D) Provide an activity in which positive
ANSWER
Letter D
Rationale: Providing positive reinforcement for the desired behavior can facilitate behavioral change.
Which is an example of limit setting as an effective nursing intervention in ritualistic hand washing behavior?
A) I dont want you to wash your hands so often anymore. B) If you continue to wash your hands so frequently, the skin on your hands will break down. C) You may wash your hands before the
ANSWER
Letter C
Rationale: Allowing the obsessivecompulsive patient to perform his rituals decreases the patients anxiety.
AUTISM
AUTISM
Is a disorder characterized by impairment in communication skills, or the presence of stereotyped behavior, interests and activities with associated impairment in social interactions
More common among boys Usually diagnosed at age 2
MAIN PROBLEM IN AUTISM
Impaired interpersonal functioning
MOST ACCEPTABLE CAUSE OF AUTISM
Biological Factors
Brain anoxia Intake of drugs
MOST COMMON SIGNS AND SYMPTOMS OF AUTISM
Resist normal teaching method Silly laughing or giggling Echolalia Acts as deaf No fear of danger Insensitive to pain Crying tantrums Loves to spin objects
MOST COMMON SIGNS AND SYMPTOMS OF AUTISM
Resists change in the routine Not cuddly Sustained odd play Difficulty interacting with others No eye contact Wants blocks and not balls Points to anything Attachment to inanimate objects
COMMON PROBLEMS AND APPROPRIATE MANAGEMENT
Tantrums Involves head-banging Place a helmet on the head

Communication All vowels Use of short sentences when talking to the child
PRIORITY NURSING DIAGNOSIS
Risk for injury
Autism can usually be diagnosed when the child is about? A) 2 years of age B) 6 years of age C) 6 months of age D) 1 to 3 months of age
ANSWER
Letter A
Rationale: Autism is usually during the toddler stage diagnosed
The treatment of choice for an autistic child probably will include? A) Psychoanalysis B) Behavior modification C) Group therapy D) Play therapy
ANSWER
Letter B
Rationale: Behavior modification enables the nurse to modify the childs maladaptive behavior
When interacting with patients who have autistic thinking and speaking patterns, what is likely to pose the greatest difficulty for the nurse?
A) Showing acceptance for their incomprehensible acts and verbalization B) Ignoring their bizarre behavior C) Speaking in a way that patients can understand
ANSWER
Letter D
Rationale: Interacting with patients with autistic thinking requires thorough analysis of their speech patterns, the meanings of their expressions and the relationship of these to their covert needs. This situation usually poses great difficulty on the part of the nurse.
In assessing the behavior of an autistic child, the nurse notes that a symptom that characteristically differentiates an autistic child from one with down syndrome and that is?
A) Retardation of activity B) Short attention span C) Difficulty in responding to a nurturing relationship
ANSWER
Letter C
Rationale: Autistic withdrawn children are usually
Primary treatment goals to facilitate recovery of an autistic child should include all of the following, EXCEPT?
A) Developing self-confidence B) Accepting healthy nurturance C) Maintaining contact with reality D) Encouraging the child to play with a ball
ANSWER
Letter D
Rationale: Autistic children want to play with blocks but not with balls.
MENTAL RETARDATION
MENTAL RETARDATION
The essential feature of mental retardation is below-average functioning (IQ less than 70) accompanied by significant limitations in areas of adaptive functioning such as communication skills, self care, home living, social or interpersonal skills, use of community resources, self-direction, academic skills, work, leisure, and health and safety manifested before the age of 18.
LEVELS OF MENTAL RETARDATION

LEVEL OF MENTAL RETARDATION
MILD / MORON MODERATE / IMBECILE SEVERE / IDIOT PROFOUND
INTELLIGENCE QUOTIENT (IQ)

50 / 55 TO 70 35 / 40 TO 50 / 55 20 / 25 TO 35 / 40 BELOW 20 / 25
WHAT CAN BE DONE

EDUCABLE TRAINABLE NEEDS CLOSE SUPERVISION NEEDS CUSTODIAL CARE
BASIS OF DIAGNOSIS OF MENTAL RETARDATION
The Intelligence Quotient should not be the only criterion used in making a diagnosis of Mental Retardation.
It should serve only to help in making a clinical judgment of the patients adaptive behavioral capacity This judgment should also be based on an evaluation of the patients developmental
CAUSES OF MENTAL RETARDATION
Congenital numerical deficiency or abnormal arrangement of brain cells Birth injuries due to pelvic disproportion, premature births or forceps delivery Rh blood-factor incompatibility between mother and child Infectious diseases, such as German measles of the mother during the first three months of pregnancy Infectious diseases during childhood, such
CAUSES OF MENTAL RETARDATION
Brain injuries occurring during childhood Endocrine deficiencies, such as thyroid deficiency, known to be the cause of cretinism Exposure to environmental deprivation, with poor housing and poor economic and social conditions. Familial or hereditary causes Inborn errors of metabolism, such as the inability to metabolize proteins,
PREVENTION OF MENTAL RETARDATION
Adequate medical care during the prenatal period and birth Early detection of various disorders Immunization against communicable diseases Educating parents to understand the important concepts of growth and development Educating family members and society to accept the mentally retarded
PREVENTION OF MENTAL RETARDATION
Intellectual stimulation through socialization, recreation, play and learning activities for affected individuals Genetic counseling
NURSING CARE FOR MENTALLY RETARDED PATIENTS
Help parents accept a diagnosis of mental retardation Consider the developmental or functional age and not the chronological age
Teach parents that they should:

Protect the child from danger Make the child as independent as his condition will permit Teach the child small social graces and manners which are a tremendous factor in helping to be accepted by others

Teach the child to refrain from holding their mouths open as this gives them a dull appearance
Select attractive, well-fitted clothing, hair style and good hygiene practices Eliminate the childs undesirable social

Teach the child only one thing at a time Demonstrate what they teach, whenever possible Use pictures, since these are valuable visual aids

Start teaching the child simple things, gradually progressing to more complex learning experiences
Remember that patience and repetition are necessary virtues Avoid prolonged teaching sessions since

Refrain from scolding because it blocks learning and instills fear Give compliments as a motivating force Not show fear themselves as this emotion will be transferred to the child

Recognize a temper tantrum as a childs attempt to meet some underlying emotional need such as attention, affection and security or as the expression of the childs dislike for activity Recognize that these children have a tendency to express jealousy
PRINCIPLES OF NURSING CARE FOR MENTALLY RETARDED PATIENTS
Repetition
Role Modeling Restructuring the Environment
FOCUS OF EDUCATION FOR MENTALLY RETARDED PATIENTS
Reading
Writing Basic Arithmetic
A child scores between 55 and 68 on a standardized intelligent quotient (IQ) assessment test. The nurse is aware that this degree of intellectual impairment would be considered?
A) Mild B) Severe C) Profound D) Moderate
ANSWER
Letter A
Rationale: Mild retardation means an I.Q. of 50 55 to approximately 70
When a child is diagnosed as being moderately retarded, it would be most helpful for the nurse to suggest that the parents?
A) Offer simple, repetitive tasks B) Concentrate on teaching, competitive situations C) Offer challenging, competitive situations D) Provide complete directions at the
ANSWER
Letter A
Rationale: Simple facilitate learning and repetitive tasks
Which of the following measures is of primary importance for the parents with a young mentally retarded child at home?
A) Limit the amount of environmental stimulation to which the child is exposed B) Have the same parent teach the child new skills C) Teach the child socially acceptable behaviors
ANSWER
Letter D
Rationale: Consistency facilitates adjustment of the child.
A six year-old girl is recently diagnosed as mildly retarded. An important aspect in nursing care of a mildly mentally retarded child is to?
A) Encourage her parents to concentrate on the child rather than on the condition at this time B) Delay extensive diagnostic studies until the child is older
ANSWER
Letter C
Rationale: Restructuring the childs environment prevents injury and promotes independence
Nursing intervention that focus on the cognitively impaired child most emphasize providing the child and family with support and education that are directed toward?
A) Finding a cure B) Optimal development C) Identifying the problem D) Curing major symptoms
ANSWER
Letter B
Rationale: The primary goal of care for the cognitively impaired child is to promote optimal development.
ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
A disorder characterized by:

Inattentiveness Over-activity Impulsiveness
A common disorder among boys

Occurs before the age of 7
MAIN PROBLEMS IN ADHD
Inattention
Hyperactivity Impulsivity
COMMON ETIOLOGICAL FACTORS
Neurologic impairment
Pre-natal trauma Early malnutrition
Frontal lobe hypoperfusion

Use of drugs by the mother during
SIGNS AND SYMPTOMS OF ADHD
Subdivided into:
Inattentive behaviors Hyperactive and Impulsive behaviors
SIGNS AND SYMPTOMS OF ADHD INATTENTIVE BEHAVIORS
Misses details Makes careless mistakes Has difficulty sustaining attention Does not seem to listen Does not follow-through on chores or homework Has difficulty with organization Avoids tasks requiring mental effort Often loses necessary things
SIGNS AND SYMPTOMS OF ADHD HYPERACTIVE / IMPULSIVE BEHAVIOURS
Fidgets Often leaves a seat, (e.g., during a meal) Runs or climbs excessively Can not play quietly Is always on the go; driven Talks excessively Blurts out answers Interrupts Cant wait for turn
PSYCHOPHARMACOLOGY FOR ADHD
Stimulant Drugs
Methylphenidate (Ritalin) drug of choice Dextroamphetamine (Dexedrine)
Amphetamine (Adderall)
STIMULANT DRUGS USED TO TREAT ADHD

GENERIC (TRADE) NAME Methylphenidate (Ritalin) DOSAGE (mg/day) NURSING CONSIDERATIONS 10 60 in 3 4 Monitor for appetite divided doses suppression and growth delays Give regular tablets after meals Alert client that full drug effect takes 2 days 5 40 in 2 3 Monitor for insomnia divided doses Give last dose in early afternoon Monitor for appetite suppression Alert client that full drug effect takes 2 days
Dextroamphetamine (Dexedrine)
NURSING CARE FOR ADHD
Ensuring the clients safety and that of others Stop unsafe behavior (priority nursing diagnosis is RISK FOR INJURY) Provide close supervision
Give clear directions about acceptable and unacceptable behavior
Improved role performance

Give positive expectations feedback for meeting
Manage the environment (e.g., provide a quiet place free of distractions for task completion)
Simplifying instructions and directions

Get the childs full attention Break complex tasks into small steps
Allow breaks
Structured daily routine

Establish a daily schedule Minimize changes
Client / Family education and support

Listen to parents feelings and frustrations
A 7 year-old child has attention deficit hyperactivity disorder. The child is most likely to exhibit which of the following?
A) Restlessness, decreased attention span and distractability B) Hyperactivity, somatic complaints, and distractability C) Impulsiveness, anhedonia and shyness D) Poor concentration, decreased attention
ANSWER
Letter A
Rationale: ADHD is characterized by Inattention, Hyperactivity and Impulsivity
An 8 year-old boy has recently been diagnosed with attention deficit hyperactivity disorder by his pediatrician. He and his parents come to the pediatric clinic together. Which of the following behaviors would the nurse be most likely to observe from the child?
A) Lethargy B) Preoccupation with body parts
ANSWER
Letter D
Rationale: ADHD is characterized by Inattention, Hyperactivity and Impulsivity
In providing care to a school-age child with attention-deficit hyperactivity disorder, the most effective intervention would be to?
A) Increase environmental stimulation and peer interaction B) Administer drug therapy (i.e., methyphenidate or Ritalin) and use behavior modification C) Provide parental education and diet
ANSWER
Letter B
Rationale: Ritalin is the drug of choice for ADHD because it increases attention span
Which nursing diagnosis is most applicable for a child with ADHD? A) Ineffective family coping related to ineffective parenting B) Potential for injury related to impulsivity C) Impaired verbal communication related to mutism D) Altered thought processes related to impaired reality
ANSWER
Letter B
Rationale: The priority needs of a child with ADHD are safety and provision of adequate nutrition
Which medication side effects is typically the greatest concern of parents with children with ADHD?
A) Dizziness B) Headache C) Increased appetite D) Delayed physical growth
ANSWER
Letter D
Rationale: Ritalin, the drug of choice for ADHD causes growth suppression, insomnia and suppression of appetite.
EATING DISORDERS
EATING DISORDERS
For many, eating symbolizes parental nurturing the love and care that are the prototype of and a basis for all future intimate relationships
For some, however, eating creates anxiety because of its association with unsatisfactory and unpleasant parent-child interactions.
ANOREXIA NERVOSA
ANOREXIA NERVOSA
This is a life-threatening eating disorder characterized by: the clients refusal or, inability to maintain a minimally normal body weight intense fear of gaining weight or becoming fat significantly disturbed perception of the shape or size of the body steadfast inability or refusal to acknowledge the seriousness of the
ANOREXIA NERVOSA
Clients with anorexia nervosa have: A body weight that is 85% less than expected for their age and height Experienced amenorrhea for at least three consecutive cycles A preoccupation with food and foodrelated activities
SIGNS AND SYMPTOMS OF ANOREXIA NERVOSA
Fear of gaining weight or becoming fat even when severely underweight (Main Sign) Body image disturbance
Amenorrhea Depressive symptoms such as depressed mood, social withdrawal, irritability, and insomnia
Preoccupation with thoughts of food

Feelings of ineffectiveness Inflexible thinking
Strong need to control the environment
Limited spontaneity and overly restrained emotional expression Complaints of constipation and abdominal pain Cold intolerance
Lethargy
Emaciation
Hypotension, hypothermia and bradycardia Hypertrophy of salivary glands
Elevated BUN
Electrolyte imbalances Leukopenia and mild anemia
Elevated liver function studies
BULIMIA NERVOSA
Is an eating disorder characterized by: Recurrent episodes (at least twice a week for 3 months) of binge eating (consuming a large amount of food, far greater than most people eat at a time, in a discrete period of usually 2 hours or less)
BULIMIA NERVOSA
Is an eating disorder characterized by: Binge eating followed by inappropriate compensatory behaviors to avoid weight gain such as:
Purging (compensatory behavior designed to eliminate food by means of self-induced vomiting, misuse of laxatives, enemas, and diuretics) Fasting Excessively exercising
SIGNS AND SYMPTOMS OF BULIMIA NERVOSA
Recurrent episodes of binge eating

Compensatory behavior such as self-induced vomiting, misuse of laxatives, diuretics, enema or other medications, or excessive exercise Self-evaluation overly influenced by body shape and weight
Restriction of total calorie consumption between binges, selecting low-calorie foods while avoiding foods perceived to be fattening are likely to trigger a binge
Depressive and anxiety symptoms Possible substance use involving alcohol or stimulants
Chipped, ragged, or moth eaten appearance of the teeth Increased dental caries
Menstrual irregularities Dependence on laxatives
Fluid and electrolyte abnormalities

Metabolic alkalosis (from vomiting) metabolic acidosis (from diarrhea) Mildly elevated serum amylase levels or
RISK FACTORS FOR EATING DISORDERS

DISORDE R BIOLOGIC RISK FACTORS DEVELOPMENTA FAMILY RISK L RISK FACTORS FACTORS SOCIOCULTURAL RISK FACTORS
Anorexia Nervosa
Obesity; dieting at an early age
Issues of developing autonomy and having control over self and environment; developing a unique identity; dissatisfaction with body image
Self-perceptions of being overweight, fat, unattractive, and undesirable; dissatisfaction with body image
Family lacks emotional support; parental maltreatment; cannot deal with conflict
Cultural ideal of being thin; media focus on beauty, thinness, fitness, preoccupation with achieving the ideal body
Same with above, weight-related teasing
Bulimia Nervosa
Obesity; early dieting; possible serotonin and norepinephrin e disturbances;
Chaotic family with loose boundaries; parental maltreatment including possible
COMMON NURSING DIAGNOSES RELATED TO EATING DISORDERS
Body image disturbance

Self-esteem disturbance Ineffective individual coping
NURSING INTERVENTIONS FOR ANOREXIA NERVOSA
Promote improved nutrition assume a calm, matter-of-fact attitude and positive expectation of the client, meeting minimal nutritional goals is non-negotiable. Tube or IV feedings Weigh daily, record intake and output, observe client during meals and bathroom activities Avoid discussing food, recipes, restaurants and eating
Promote improved nutrition Frequent, small meals are more acceptable Set time limit of about one-half hour to forestall mealtime marathon (protracted meals during which the client eats little) Collaborate with a dietitian Acknowledge and recognize efforts of clients who meet weight gain goals but avoid praise or flattery
Promote effective individual coping The best way is to involve the clients in their own treatment planning Give clients the opportunity to practice problem solving. Demonstrate positive belief in clients abilities to regain healthy functioning and a willingness to tolerate mistakes Set firm, clear limits to provide the secure environment needed to learn more effective coping behaviors
NURSING INTERVENTIONS FOR BULIMIA NERVOSA
Promoting effective coping with anxiety help them recognize events that create anxiety and to avoid binging and purging in response to anxiety Promoting improved fluid volume
Promoting effective individual coping
NURSING INTERVENTIONS FOR BULIMIA NERVOSA
Promoting effective individual coping

It is important for clients to identify situations or patterns of events that precede episodes of binging and purging.
They need to learn effective ways of expressing feelings and assertive techniques to diminish guilt interactions in the future
The nurse is monitoring a patient diagnosed with anorexia nervosa. In addition to monitoring the patients eating, the nurse should do which of the following after meals?
A) Encourage the patient to go for a walk to get some exercise B) Prevent the patient from using the bathroom for 2 hours after eating
ANSWER
Letter B
Rationale: Preventing the patient from using the bathroom for 2 hours after eating, prevents the patient from inducing vomiting
The nurse is caring for a patient who has bulimia. What treatment option is most effective?
A) Antidepressant B) Cognitive behavior therapy C) Anti-depressants and cognitive-behavior therapy D) Total parenteral nutrition and antidepressants
ANSWER
Letter C
Rationale: Combination of somatic and behavioral treatment modalities facilitates treatment of the disorder
The nurse is caring for a bulimic patient and an anorexic patient. What cognitive characteristics would be similar for both of these patients?
A) Perfectionism and pre-occupation with food B) Relaxed personality, but pre-occupied with food C) No similarities
ANSWER
Letter A
Rationale: Patients with eating disorders are usually high achievers, perfectionists and pre-occupied with food.
Psychologically, bulimic differs from an anorexic patient through awareness that her behavior is?
A) Acceptable B) Abnormal C) Easy to control D) Physically dangerous
ANSWER
Letter B
Rationale: Bulimic patients are aware of their abnormal behavior usually
The primary objective in the treatment of anorexia is to? A) Enable the patient to eat and gain weight B) Decrease anxiety to stimulate appetite C) Help patient to select food she likes D) Cure her anorexia condition and eat
ANSWER
Letter A
Rationale: Anorexic patients usually suppress their appetite, which makes it difficult for the nurse to convince them to eat.
SEXUAL DISORDERS
GENDER IDENTITY
This is an individuals personal or private sense of identity as female or male It develops from an interaction of biology, identity imposed by others and self-identity
GENDER ROLES
Refers to learning and performing socially accepted sex behaviors, i.e., taking on a feminine or masculine role
Proponents of andogeny (flexibility in gender roles), however, view most characteristics and behaviors as human qualities that should not be limited to a specific gender
TRANSSEXUALISM
Is a gender identity disorder in which a person has consistently strong feelings of being trapped in a body of a wrong sex.
PARAPHILIAS
A group of psychosexual disorders characterized by unconventional sexual behaviors

These are abnormal expressions of sexuality
They are not, by definition, pathologic

They only become so when severe, insistent, coercive and harmful to the self or
NON-COERCIVE PARAPHILIAS
Fetishism
Autoerotic Asphyxia Sexual Masochism
Transvestitism
NON-COERCIVE PARAPHILIAS FETISHISM
Sexual arousal elicited by inanimate objects (shoes, leather, rubber) or specific body parts (feet, hair)
NON-COERCIVE PARAPHILIAS AUTOEROTIC ASPHYXIA
Constriction of the neck to enhance a masturbation experience; often leads to accidental death
NON-COERCIVE PARAPHILIAS SEXUAL MASOCHISM
Erotic interest in receiving psychological or physical pain, real or fantasized
NON-COERCIVE PARAPHILIAS TRANSVESTITISM
Using the apparel of the opposite sex
COERCIVE PARAPHILIAS
Exhibitionism Voyeurism Frotteurism Obscene Phone Callers / Telephone Scatologia Pedophilia Urophilia Coprophilia Sadism
COERCIVE PARAPHILIAS EXHIBITIONISM
Intentional exposure of the genitals to a stranger or unsuspecting person May be accompanied by arousal and masturbation either during or after the exposure
COERCIVE PARAPHILIAS VOYEURISM
Secret observation of an unsuspecting person (usually a woman) engaged in a private act, e.g., undressing or having sex.
The voyeur often masturbates during or after the viewing
COERCIVE PARAPHILIAS FROTTEURISM
Intense sexual arousal elicited by rubbing the genitals against a non-consenting person
COERCIVE PARAPHILIAS OBSCENE PHONE CALLERS
Calling a non-consenting person and making sexual noises, using profanity, attempting to seduce, or describing sexual activity.
The caller often masturbates during or after the call
COERCIVE PARAPHILIAS PEDOPHILIA
Sexual interest in a child

Behavior ranges from exposure, voyeurism, and explicit talk to touching, oral sex and intercourse
COERCIVE PARAPHILIAS UROPHILIA
Urinating on the sexual partner
COERCIVE PARAPHILIAS COPROPHILIA
Smearing feces on the partner
COERCIVE PARAPHILIAS SADISM
Erotic interest in inflicting physical pain
OTHER FORMS OF PARAPHILIA
Anningulus
Cunnillingus Fellatio
Partialism
OTHER FORMS OF PARAPHILIA ANNILINGUS
Tongue brushing of the anus
OTHER FORMS OF PARAPHILIA CUNNILLINGUS
Tongue brushing of the vulva
OTHER FORMS OF PARAPHILIA FELLATIO
Inserting the penis into the mouth
OTHER FORMS OF PARAPHILIA PARTIALISM
Inserting the penis into the other parts of the body
TYPE OF THERAPY PERFORMED ON PATIENTS WITH PARAPHILIAS
Behavior Modification A therapeutic intervention involving the application of learning principles in order to change maladaptive behavior A method of attempting to strengthen a desired behavior or response by reinforcement , either positive or negative
Positive reinforcement is given to the client who exhibits the desired behavior Negative reinforcement involves removing a stimulus immediately after a (positive) behavior occurs so that the behavior is more likely to occur again
TYPE OF THERAPY PERFORMED ON PATIENTS WITH PARAPHILIAS
Aversion Therapy An example of behavior modification in which a painful stimulus is introduced to bring about avoidance of another stimulus with the end view of facilitating behavioral change Token Economy An example of behavior modification technique which utilizes the principle of rewarding desired behavior to facilitate
SEXUAL ADDICTION
The frequency of sexual activity can be viewed on a continuum, with most people falling in the middle range
Some have sex frequently in a way that enhances their lives; others have sex infrequently and report contentment and satisfaction A sexual pattern that falls at either extreme
SEXUAL ADDICTION
Is a disorder in which the central focus of life is sex People with these addictions spend 50% or more of all waking hours dealing with sex, from fantasy to acting out behavior. Acting out behavior is often victimless, e.g., overindulging in masturbation, fetishism, pornography use, or commercial telephone sex; or visiting prostitutes
SEXUAL ADDICTION
Sexual addiction is not simply the frequent enjoyment of sexual behaviors; rather, it is a progressive disease in which sex is used to numb pain.
The pay off is the same as in any other addiction, i.e., an intensely pleasurable, short-lived release from pain, and an escape from the problems of daily life.
The consequences are the same in the addicts life and eventually becomes
SEXUAL ADDICTION
Many sexual addicts grew up in homes where they were emotionally, physically, or sexually abused
Most of them suffer from low self-esteem and believe themselves unlovable. They have desperate need for love and they equate sex with proof of love.
SEXUAL ADDICTION
The components have the hallmarks of obsessive-compulsive behavior: Preoccupation
Spends hours thinking or obsessing about sex and is so time consuming that the person cannot fulfill work, school, or family responsibilities
SEXUAL ADDICTION
The components have the hallmarks of obsessive-compulsive behavior: Ritualization
The individual engages in specific behaviors done just the right way and in the same sequence at the right time. The ritual seems to control anxiety; once addicts begin a ritual, they cannot stop until the cycle is completed
SEXUAL ADDICTION
The components have the hallmarks of obsessive-compulsive behavior: Compulsivity
The individual cannot control sexual behavior and this behavior becomes the most important aspect of life
SEXUAL ADDICTION
The components have the hallmarks of obsessive-compulsive behavior: Shame and Despair
At the end of the cycle, the person experiences guilt and shame at the loss of control. The pain of despair creates the need to begin the cycle all over again. Like other addicts, these individuals want to stop their behavior, promise to stop, try to stop and are unable to stop without treatment.
PATIENTS WITH SEXUAL ADDICTION
Behavior Modification A therapeutic intervention involving the application of learning principles in order to change maladaptive behavior A method of attempting to strengthen a desired behavior or response by reinforcement , either positive or negative
Positive reinforcement is given to the client who exhibits the desired behavior Negative reinforcement involves removing a stimulus immediately after a (positive) behavior occurs so that the behavior is more likely to occur again
SEXUAL DYSFUNCTIONS
These are problems or difficulties with sexual expression classified according to the phase of the sexual response cycle that is affected This does not include dissatisfaction problems Contributory factors actually implicate past and current factors: Lack of sex education Internalization of the teaching that sex is dirty or sinful Parental punishment for normal exploration of ones genitals
SEXUAL DYSFUNCTIONS
Contributory factors actually implicate past and current factors: Negative feelings like guilt anxiety, anger which interfere with the ability to experience pleasure and joy
SEXUAL DYSFUNCTION
Fear of failure in sexual performance often becomes a vicious cycle, i.e., fear of failure creates actual failure, which in turn, produces more fear.
CLASSIFICATIONS OF SEXUAL DYSFUNCTION
Disorders of Sexual Desire

Arousal Disorders Orgasm Disorders
DISORDERS OF SEXUAL DESIRE
Inhibited Sexual Desire Persistently low interest or a total lack of interest in sexual activity Sexual Aversion Disorder Severe distaste for sexual activity or the thought of the sexual activity, which then leads to a phobic avoidance of sex The most common cause of sexual aversion disorder is childhood sexual abuse or adult rape
AROUSAL DISORDERS
Physiologic responses and subjective sense of excitement experienced during sexual activity Female Sexual Arousal Disorder
Lack of vaginal lubrication
Male Sexual Arousal Disorder
Occurs when the man has erection problems during 25% or more of sexual interactions; cannot attain a full erection or loses erection prior to orgasm (impotence / erectile inhibition)
ORGASM DISORDERS
Inhibited Female Orgasm / Frigid Woman is totally incapable of responding sexually Sexual response stops before orgasm occurs Pre-orgasmic Women who have never experienced an orgasm Secondarily Non-Orgasmic They have had orgasm in the past but
ORGASM DISORDERS
Inhibited Male Orgasm Male can maintain an erection for long periods (e.g., an hour or more) but has extreme difficulty ejaculating Could be organic, e.g., spinal cord injuries, multiple sclerosis, due to drugs or may be psychogenic (fear of pregnancy, performance pressure, fear of losing control, anxiety and guilt about engaging
ORGASM DISORDERS
Rapid Ejaculation One of the most common dysfunction among men Refers to the absence of voluntary control of ejaculation Probably due to:
Inability to perceive his arousal level accurately Lowered sensory threshold due to infrequent sexual activity Early conditioning as a result of hurried masturbation or hurried sexual intercourse Extreme anxiety during sexual interaction,
SEXUAL PAIN DISORDERS
Vaginismus
Involuntary spasms of the outer one third of the vaginal muscles making penetration of the vagina painful and sometimes impossible. Cause is mainly psychophysiologic: as protection against real or imagined pain; history of sexual trauma; emotional
SEXUAL PAIN DISORDERS
Dyspareunia
Pain during intercourse or immediately after
Could be due to skin irritations, vaginal infection, estrogen deficiency, or drugs; pelvic disorders, such as endometriosis, scar tissue, tumors
PROBLEMS WITH SEXUAL SATISFACTION
These are more related to the emotional tone of the relationship than the physiologic response
May be situational, due to lack of extragenital satisfaction, related to the relationship difficulties, due to lack of intimacy
NURSING CARE FOR SEXUAL DYSFUNCTIONS
Reduce anxiety and fear Accurate identification of feelings is the first step Help the client identify one anxietyproducing situation within their sexual interactions The nurse and client may analyze the situation to discover negative anticipatory thoughts that may be the source of the anxiety.
Decrease spiritual distress

Because the origin of spiritual distress is the lack of intimacy or connection within a sexual relationship, the goal of nursing care is to help clients achieve and maintain a level of intimacy each partner finds comfortable
Promote more effective family coping Apart from setting specific times to share feelings, and belief, some couples need training in more effective communication skills.
Teach couples to avoid the you language, which evokes a defensive response and results in arguments, and encourage use of the I language, which expresses personal thoughts, feelings and needs.
Example of You language
You only have sex on your mind. You are a
Promote comfort with personal identity

A multidisciplinary approach is most effective in helping transsexuals adjust to their situation
Family and friends need support and counseling to reintegrate this person into their lives as a person of the other sex
Promote effective role performance

Refer sexual addicts to self-help groups and specialized professional therapy Recovery is a long-term process facilitated by individual, group, couple, family, and family-of-origin therapy
Promote non-coercive sexuality patterns

If practiced with an adult consenting partner requires no nursing intervention except for client and partner education and possible couple negotiation about the behavior
Decrease violence against the self and others The most important nursing education regarding autoerotic asphyxia is community education Therapy for sex offenders is a specialized area that should not be taken lightly Behavior modification techniques, group therapy, hypnosis could be used
Decrease pain
Thorough physical examination is necessary to find and treat the organic cause of the pain
Vaginismus is treated with education, dilators and supportive psychotherapy
Increase knowledge
Teach clients sexual anatomy and the sexual response cycle Encourage couples to talk with one another about their individual responses
SEX THERAPY
Common components Information and education about sexual functions

Experiential and Sensory Awareness
Therapist helps clients to recognize feelings of anxiety, anger and pleasure by tuning into bodily cues
Insight
Therapist attempts to learn and understand what is causing and perpetuating the sexual
SEX THERAPY
Common components Cognitive Restructuring
Clients identify and re-evaluate their nonsexual fears about sexual interaction
Behavioral Interventions
Focus is on changing the non-sexual behavior that contributes to sexual problems Assertiveness training, communication training, stress-reduction exercises and problem-solving techniques
SCHIZOPHRENIA
SCHIZOPHRENIA
The term schizophrenia (split mind) was coined by Bleuler to describe a lack of integration of the patients functions There is disharmony between the patients thinking, feeling and acting. Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movements and behavior. It cannot be defined as a single illness; rather it is thought of as a syndrome or
SCHIZOPHRENIA
The main problem in schizophrenia is Altered Thought Process The most acceptable theory on the cause of schizophrenia is the Biologic Theory which says that schizophrenia is due to increased dopamine.
CHARACTERISTICS OF PATIENTS WITH SCHIZOPHRENIA
Patients are usually of the asthenic or slender, lightly muscled body type They tend to be introverted, deficient in their affective response ability, self conscious, retiring, moody and sensitive
Thought processes are disorganized and disturbed; emotion may be lacking or disassociated from the content of thought
There is failure in adapting to objective reality with its everyday problems, situations and demands and in forming satisfactory relationships with others
Instead of recognizing and adapting to the inevitable frustrations and problems of living, they utilize the mechanism of denial and withdraw from reality
Patient acts out in ways which would ordinarily be subject to social restraint Delusions and hallucinations are accessory symptoms which serve to fulfill denied wishes and to free the patient from intolerable feelings of guilt and anxiety.
TYPES OF SCHIZOPHRENIA
Paranoid Type
Catatonic Type Disorganized Type
Undifferentiated Type
Residual Type
SCHIZOPHRENIA PARANOID TYPE
Characterized by persecutory (feeling victimized or spied on) grandiose delusions, hallucinations, and occasionally, excessive religiosity (delusional religious focus) or hostile and aggressive behavior.
SCHIZOPHRENIA CATATONIC TYPE
Characterized by marked psychomotor disturbance, either motionless or excessive motor activity.

Motor immobility may be manifested by catalepsy (waxy flexibility) or stupor Excessive motor activity is apparently purposeless and is not influenced by external stimuli
Catatonic Stupor Marked decrease in reactivity to the environment and/or reduction in spontaneous movement and activity or mutism
Catatonic Negativism Apparently motive-less resistance to all instruction or attempts to be moved
Catatonic Excitement Excited motor activity, apparently purposeless and not influenced by external stimuli
Catatonic Posturing Voluntary assumption of inappropriate posture.
SCHIZOPHRENIA DISORGANIZED TYPE
Incoherence, associations, behavior
marked loosening of or grossly disorganized
Flat or grossly inappropriate affect
Does not meet the criteria for the catatonic type
SCHIZOPHRENIA UNDIFFERENTIATED TYPE
Characterized by mixed schizophrenic symptoms (of other types) along with disturbances of thought, affect and behavior
Prominent incoherence behavior delusions, hallucinations, or grossly disorganized
Patients whose manifestations cannot be fitted into one or the other types
SCHIZOPHRENIA RESIDUAL TYPE
Absence of prominent hallucinations, incoherence disorganized behavior
delusions, or grossly
SCHIZOPHRENIA RESIDUAL TYPE
Continuing evidence of the disturbance, as indicated by 2 or more of these residual symptoms: Marked social isolation or withdrawal Marked impairment in role functioning as wage-earner, student or homemaker Marked peculiar behaviors Marked impairment in personal hygiene and grooming Odd beliefs or magical thinking,
COMPARISON OF DIFFERENT TYPES OF SCHIZOPHRENIA

CATATONIC TYPE
Onset Distinguishing Feature Defense Mechanism Priority Nursing Diagnosis Priority Nursing Care Prognosis Acute Abnormal Motor Behavior Repression Impaired Motor Activity Circulation Nutrition Good
DISORGANIZED TYPE
Insidious Bizarre Behavior Regression Impaired Social Functioning Assistance with ADL Poor
PARANOID TYPE
Abrupt Suspiciousness Ideas of reference Projection Potential for injury directed at others Nutrition Safety Good
CRITERIA FOR PROGNOSIS OF SCHIZOPHRENIA
Favorable Prognosis Good socialization Late / acute onset Adequate support system Family history of mood disorder
CRITERIA FOR PROGNOSIS OF SCHIZOPHRENIA
Unfavorable Prognosis Poor / no socialization Early and insidious onset Few / no support system History of chronicity / many relapses
THEORIES OF CAUSATION OF SCHIZOPHRENIA
Biologic Genetic Theories

Schizophrenics inherit a genetic vulnerability for the disease Relatives of schizophrenics have a greater chance of developing the disease Concordance rates for schizophrenia are consistently higher for monozygotic than for dizygotic twins
Biologic Biological Theories
The dopamine hypothesis is the most widely held and extensively studied biochemical mechanism thought to underlie schizophrenia
Biologic Brain Structure
Ventricular size has been found to be significantly larger in chronic schizophrenics
Psychological Theories
Information Processing Deficit Attention and Arousal
Either hypo- or hyper-
Family Theories
Defect in family interaction / disordered family communication Familys Emotional Tone is highly critical, hostile or over involved
FUNDAMENTAL SIGNS AND SYMPTOMS OF SCHIZOPHRENIA AS IDENTIFIED BY BLEULER
Associative Looseness
Autism Apathy Ambivalence
SYMPTOMS OF SCHIZOPHRENIA
The symptoms of schizophrenia are divided into two major categories: Positive or hard symptoms / signs, which include delusions, hallucinations, and grossly disorganized thinking, speech and behavior
Negative or soft symptoms / signs such as flat affect, lack of volition, and social
SYMPTOMS OF SCHIZOPHRENIA
Medication can control the positive symptoms, but frequently the negative symptoms persist after positive symptoms have abated
POSITIVE OR HARD SYMPTOMS OF SCHIZOPHRENIA

Ambivalence Associative Looseness Delusions Echopraxia Flight of ideas Hallucinations Ideas of Reference Perseveration
POSITIVE OR HARD SYMPTOMS OF SCHIZOPHRENIA AMBIVALENCE
Holding seemingly contradictory beliefs or feelings about the same person, event or situation
POSITIVE OR HARD SYMPTOMS OF SCHIZOPHRENIA ASSOCIATIVE LOOSENESS
Fragmented or poorly related thoughts and ideas
POSITIVE OR HARD SYMPTOMS OF SCHIZOPHRENIA - DELUSIONS
Fixed false beliefs that have no basis in reality
POSITIVE OR HARD SYMPTOMS OF SCHIZOPHRENIA - ECHOPRAXIA
Imitation of the movements and gestures of another person whom the client is observing.
POSITIVE OR HARD SYMPTOMS OF SCHIZOPHRENIA - FLIGHT OF IDEAS
Continuous flow of verbalization in which the person jumps rapidly from one topic to another
POSITIVE OR HARD SYMPTOMS OF SCHIZOPHRENIA IDEAS OF REFERENCE
False impressions that external events have special meaning to the person
POSITIVE OR HARD SYMPTOMS OF SCHIZOPHRENIA - PERSEVERATION
Persistent adherence to a single idea or topic; verbal repetition of a sentence, word, or phrase; resisting attempts to change the topic Example: Nurse: How have you been sleeping lately? Client: I think people have been following me. Nurse: Where do you live?
NEGATIVE OR SOFT SYMPTOMS OF SCHIZOPHRENIA

Alogia Anhedonia Apathy Blunted Affect Catatonia Flat Affect Lack of Volition
NEGATIVE OR SOFT SYMPTOMS OF SCHIZOPHRENIA - ALOGIA
Tendency to speak very little or to convey little substance of meaning (poverty of content)
NEGATIVE OR SOFT SYMPTOMS OF SCHIZOPHRENIA - ANHEDONIA
Feeling no joy or pleasure from life or any activities or relationships
NEGATIVE OR SOFT SYMPTOMS OF SCHIZOPHRENIA - APATHY
Feelings of indifference toward people, activities, and events
NEGATIVE OR SOFT SYMPTOMS OF SCHIZOPHRENIA - BLUNTED AFFECT
Restricted range of emotional feeling, tone, or mood
NEGATIVE OR SOFT SYMPTOMS OF SCHIZOPHRENIA - CATATONIA
Psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless, as if in a trance
NEGATIVE OR SOFT SYMPTOMS OF SCHIZOPHRENIA - FLAT AFFECT
Absence of any facial expression that would indicate emotions or mood
NEGATIVE OR SOFT SYMPTOMS OF SCHIZOPHRENIA - LACK OF VOLITION
Absence of will, ambition, or drive to take action or accomplish tasks
GENERAL SIGNS AND SYMPTOMS OF SCHIZOPHRENIA

1) Perceptual changes Perceptions may either be heightened or blunted May occur in all the senses, or in just one or two 1a) Illusions
Clients misperceives or exaggerates stimuli in the external environment
1b) Hallucinations schizophrenia)
(hallmark
of

2) Disturbances in thought The thinking is nudged or unclear Thoughts are disconnected or disjointed Connections between one thought and another are vague Examples:
2a) Clang Associations 2b) Delusions
CLANG ASSOCIATIONS
Are ideas that are related to one another based on sound or rhyming rather than meaning.
Example: I will take a pill if I go up to the hill but not if my name is Jill, I dont want to kill.
DELUSIONS
Disturbances in the content rather than the form of thought Fixed false beliefs about ones environment or event occurring in it Types of delusions Persecutory or Paranoid Delusions Grandiose Delusions Religious Delusions Somatic Delusions Referential Delusions or Ideas of
PERSECUTORY / PARANOID DELUSIONS
Involves the clients belief that others are planning to harm the client or are spying, following, ridiculing, or belittling the client in some way. Sometimes the client cannot define who these others are. Examples:
The client may think that food has been poisoned or that rooms are bugged with listening devices Sometimes the persecutor is the government
GRANDIOSE DELUSIONS
Are characterized by the clients claim to association with famous people or celebrities, or the clients belief that he or she is famous or capable of great feats Examples: The client may claim to be engaged to a famous movie star or related to some public figure such as claiming to be the daughter of the President of the Philippines
RELIGIOUS DELUSIONS
Often center around the second coming of Christ or another significant religious figure or prophet These religious delusions appear suddenly as part of the clients psychosis and are not part of his or her religious faith or that of others Examples:
Client claims to be the Messiah or some prophet sent from God Believes that God communicated directly to him
SOMATIC DELUSIONS
Are generally vague and unrealistic beliefs about the clients health or bodily functions Factual information or diagnostic testing does not change these beliefs Examples A male client may say that he is pregnant A client may report decaying intestines or
REFERENTIAL DELUSIONS / IDEAS OF REFERENCE
Involve the clients belief that television broadcasts, music, or newspaper articles have special meaning for him or her
Examples: The client may report that the president was speaking directly to him on a news broadcast or that special messages are sent through newspaper articles
3) Changes in communication Clients have difficulty responding appropriately to events and people they encounter because of their distorted perceptions, impaired ability to sort and assimilate these perceptions, and difficulty communicating responses clearly Examples:
3a) Thought Disorganization 3b) Thought Blocking 3c) Tangential Communication 3d) Circumstantial Communication 3e) Alogia
THOUGHT DISORGANIZATION
Responses are inappropriate to the situation
THOUGHT BLOCKING
Difficulties articulating a response or stops mid-sentence as if they are stuck Clients may suddenly stop talking in the middle of a sentence and remain silent for several seconds to one minute
TANGENTIAL THINKING
Veering into unrelated topics and never answering the original question Example:
Nurse: How have you been sleeping lately? Client: Oh, I try to sleep at night. I like to listen to music to help me sleep. I really like country-western music best. What do you like? Can I have something to eat pretty soon? I am hungry! Nurse: Can you tell me how you have been sleeping?
CIRCUMSTANTIAL COMMUNICATION
Circumstantiality may be evidenced if the client gives unnecessary details or strays from the topic but eventually provides the requested information Example: Nurse: How have you been sleeping lately? Client: Oh, I go to bed early, so I can get plenty of rest. I like to listen to music or read before bed. Right now I am
ALOGIA
Poverty of content describes the lack of any real meaning or substance in what the client says
Example: Nurse: How have you been sleeping lately? Client: Well, I guess, I do not know, hard to tell.

4) Disruptions in emotional responses Restricted or inappropriate expression or emotion

5) Motor Behavior Changes Disorganized behavior and catatonia (manifested by unusual body movement or lack of movement) Examples:
5a) Catatonic Excitement The client moves excitedly but not in response to environmental influences 5b) Catatonic Posturing Clients hold bizarre postures for a period of time 5c) Stupor Client holds the body still and is

6) Self care deficits
They neglect to bathe, change clothes or attend to minor grooming tasks Some show little awareness of current fashion styles Wearing clothing that makes them look out of place is also seen

7) Activity Intolerance This is brought about by ambivalence about where to sit or what to eat

8) Altered Thought Processes
Examples:
8a) Magical Thinking 8b) Thought Insertion 8c) Thought Withdrawal 8d) Thought Broadcasting
MAGICAL THINKING
Belief that events can happen simply because one wishes them to happen.
THOUGHT INSERTION
They may state that others are placing thoughts in their mind or in their head against their will
THOUGHT WITHDRAWAL
They may state that others are taking their thoughts out of their head
THOUGHT BROADCASTING
They may state that they believe others can hear their thoughts They believe that thoughts are transmitted to others via radio, television or other means but not directly by the client

9) Unusual speech patterns Examples:
9a) Clang Associations 9b) Neologisms 9c) Verbigeration 9d) Echolalia 9e) Stilted Language 9f) Perseveration 9g) Word Salad
CLANG ASSOCIATIONS
Are ideas that are related to one another based on sound or rhyming rather than meaning.
Example: I will take a pill if I go up to the hill but not if my name is Jill, I dont want to kill.
NEOLOGISMS
These are words invented by the client Example:
I am afraid of grittiz. If there are any grittiz here, I will have to leave. Are you a grittiz?
VERBIGERATION
This is the stereotyped repetition of words or phrases that may or may not have meaning to the listener.
Example:
I want to go home, go home, go home, go home.
ECHOLALIA
This is the clients imitation or repetition of what the nurse says. Example:
Nurse: Can you tell me how you are feeling? Client: Can you tell me how you are feeling? how you are feeling?
STILTED LANGUAGE
This is the use of words or phrases that are flowery, excessive, and pompous Example:
Would you be so kind, as a representative of Florence Nightingale, as to do me the honor of providing just a wee bit of refreshment, perhaps in the form of some clear spring water?
PERSEVERATION
Persistent adherence to a single idea or topic; verbal repetition of a sentence, word, or phrase; resisting attempts to change the topic Example: Nurse: How have you been sleeping lately? Client: I think people have been following me. Nurse: Where do you live?
WORD SALAD
This is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener.
Example:
Corn, potatoes, jump up, play games, grass, cupboard.
OTHER DISORDERS RELATED TO SCHIZOPHRENIA

1) Delusional Similar to schizophrenia because they hold unusual bizarre beliefs and cannot be reasoned with regarding these beliefs. Unlike schizophrenic clients, delusional clients do not have persistent hallucinations
Delusions have a basis reality Hallucinations are not a dominant feature Behavior is within normal range except in relation to delusion

2) Psychotic disorders not elsewhere classified 2a) Schizophreniform Disorder
The duration of all symptoms (acute and residual) is less than six months and a return to normal functioning is possible. (Note that 6 months is the amount of time necessary to meet the diagnostic criteria for schizophrenia)
2b) Schizoactive Disorder

Dominant schizophrenic symptoms are accompanied at some, but not all times by a major depressive or manic syndrome There is a mood disorder in the form of either depression or mania

2) Psychotic disorders not elsewhere classified 2c) Brief Reactive Psychosis
Psychotic symptoms appear shortly after stressful event or a series of stressful events
2d) Induced Psychotic Disorder

A delusional system develops because of a close relationship with a person who already has a psychotic disorder with delusions Also known as folie a deux, two people share a similar delusion.
MEDICATIONS USED IN SCHIZOPHRENIA
Drug Classification
Antipsychotics or neuroleptics
Conventional antipsychotics These are dopamine antagonists Atypical antipsychotics Newer schizophrenic drugs which are both dopamine and serotonine antagonists
CONVENTIONAL ANTIPSYCHOTICS

Chlorpromazine (Thorazine) Trifluoperazine (Trilafon) Fluphenazin (Prolixin) Thioridazine (Mellaril) Mesoridazine (Serentil) Thiothixene (Navane) Haloperidol (Haldol) Loxapine (Loxitane) Molindone (Moban) Perphenazine (Etrafon)
ATYPICAL ANTIPSYCHOTICS
Clozapine (Clozaril) Risperidone (Risperdol) Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone (Geodon)
EFFECTS OF ANTIPSYCHOTICS
Prescribed primarily for efficacy in decreasing psychotic symptoms like delusions, hallucinations and looseness of association
They do not cure schizophrenia, they only manage the symptoms of the disease
WHEN TO ADMINISTER ANTIPSYCHOTIC MEDICATIONS
Best taken after meals
SIDE EFFECTS OF ANTIPSYCHOTIC MEDICATIONS

1) Extrapyramidal Side Effects or EPS Reversible movement disorders which include:
Dystonic Reactions Pseudoparkinsonism Akathisia Tardive Dyskinesia
DYSTONIC REACTIONS
They appear early in the course of treatment and are characterized by spasms in discrete muscle groups such as the neck muscles (torticollis) or eye muscles (oculogyric crisis)
These spasms may also be accompanied by protrusion of the tongue, dysphagia and laryngeal/pharyngeal spasm that can compromise the clients airway
DYSTONIC REACTIONS
Nursing considerations reactions include:
for
dystonic
Administering medications as ordered

Assessing for their effectiveness Reassuring client if frightened.
PSEUDOPARKINSONISM
Includes shuffling gait, masklike facies, muscle stiffness (continuous) or cogwheeling rigidity (rachet-like movements of joints), drooling, and akinesia (slowness and difficulty initiating movements.
These symptoms appear in the first few days after starting the medication Treatment of pseudoparkinsonism is
PSEUDOPARKINSONISM
Dopaminergic Drugs Amantadine (Symmetrel) Levodopa Levodopa-Carbidopa (Sinemet)
PSEUDOPARKINSONISM
Anticholinergic Drugs Trihexyphenidyl (Artane) Biperiden Hydrochloride (Akineton) Benzotropine Mesylate (Cogentin) Diphenhydramine Hydrochloride (Benadryl)
This is characterized by restless movement, AKATHISIA pacing, inability to remain still, and the clients report of inner restlessness. Described by patients as I feel as if I have ants in my pants. Akathisia usually develops when the antipsychotic is started or when the dose is increased
Beta-blockers such as propranolol have been
TARDIVE DYSKINESIA
A late appearing side-effect characterized by abnormal involuntary movements such as lip smacking, tongue protrusion, chewing, blinking, grimacing, and choreiform movements of the limbs and feet
This is irreversible once it has appeared
TARDIVE DYSKINESIA
Decreasing or discontinuing the medication can arrest the progression. Clozapine (Clozaril) has not been found to cause this side effect Nursing consideration includes proper assessment and subsequent reporting to the physician

2) Seizures These are infrequent side effects of antipshychotic medications The notable exception is Clozapine These may be associated with high doses of the medication Treatment is a lowered dosage or a different antipsychotic medication

3) Seizures
Nursing consideration includes:
Stopping the medication; Notifying the physician; Protecting client from injury; Providing reassurance and privacy for client after seizure

3) Neuroleptic Malignant Syndrome
This is a serious and frequently fatal condition seen in those being treated with antipsychotic medications
It is characterized by muscle rigidity, high fever, increased muscle enzymes (particularly CPK), and leukocytosis (increased leukocytes)

4) Neuroleptic Malignant Syndrome
Nursing considerations include:
Stopping the medication Notifying the physician immediately of its signs and symptoms

4) Agranulocytosis
Clozapine has the potentially fatal side effect of agranulocytosis (failure of the bone marrow to produce adequate white blood cells) This develops suddenly and is characterized by fever, malaise, ulcerative sore throat, and leukopenia

4) Agranulocytosis
May not be manifested immediately but can occur as long as 18 to 24 weeks after initiation of therapy.
Drug must be discontinued immediately

Weekly white blood cell counts (CBC) are necessary

4) Agranulocytosis
Nursing considerations include stopping the medication and notifying the physician immediately of its signs and symptoms
OTHER SIDE EFFECTS OF ANTIPSYCHOTIC MEDICATIONS AND THEIR NURSING CONSIDERATIONS

SIDE EFFECTS NURSING CONSIDERATIONS Sedation Caution about activities requiring client to be fully alert such as driving a car Photosensitivity Caution client to avoid sun exposure; advise client when in the sun, to wear protective clothing and sun-blocking lotion Weight Gain Encourage balanced diet with controlled portions and regular exercise; focus on minimizing gain Dry mouth Use ice chips or hard candy for relief
OTHER SIDE EFFECTS OF ANTIPSYCHOTIC MEDICATIONS AND THEIR NURSING CONSIDERATIONS

SIDE EFFECTS Constipation (anticholinergic symptom) Blurred vision (anticholinergic symptom) Urinary Retention (anticholinergic symptom) Orthostatic hypotension (anticholinergic symptom) NURSING CONSIDERATIONS Increase fluid and dietary fiber intake; client may need a stool softener if unrelieved Assess side effect, which should improve with time; report to physician if no improvement Instruct client to report any frequency or burning with urination; report to physician if no improvement over time Instruct client to rise slowly from sitting or lying position; wait to ambulate until no longer dizzy or light-headed
NURSING CARE FOR SCHIZOPHRENIA

1)
Promote adequate communication

Attend seriously to the client since he perceives nuisances of the nurses behavior
If a client complains of physical symptoms such as stomach distress, consider the symptoms as real until there is evidence otherwise.

2) Promote compliance with medical regimen Administer prescribed medications Observe client behavior for therapeutic effects Maintaining therapeutic blood levels is important

2) Promote compliance with medical regimen
Teach client about the therapeutic and possible untoward effects of drugs Help client to take action to prevent untoward effects

2) Promote compliance with medical regimen
Evaluate clients subjective response to the drug and attitude towards continued use. Compliance may be affected because:
They do not understand the administration instruction They are so disorganized to follow instruction The side effect of major tranquilizers are too uncomfortable

3) Assist with grooming and hygiene
Intervention begins by establishing clear expectations. Frequency and timing should be specified in writing
Avoid power struggles regarding completion of tasks. If initial prompts do not work, leave the client alone for a short period

4) Promote organized behavior
The first rule is to go slowly and keep calm Clients with disorganized behavior require direction and limits to make their actions more effective and goal directed.

5) Promote social interaction and activity
The clients effort to withdraw from social contact stem from past relationship failures and fear of rejection

6) Social skills training
Provide structure by clearly setting times for group meetings, beginning and ending each session with a statement of goals and recapping what the group has accomplished Address social skills that are essential to functioning in the milieu

6) Social skills training
Do not assume periods of quiet or inactivity are due to laziness or lack of interest
Help client find activities that are intrinsically rewarding or some social tangible reward yet are within their capacities

7) Promote reality-based perceptions as hallucinations and illusions often frighten clients Reassure client of their safety Protect them from physical harm as they respond to their altered perceptions Intervene quickly by giving additional doses of phychotropic medications or placing the client in a quiet room

7) Promote reality-based perceptions as hallucinations and illusions often frighten clients
Validate reality I know the voices are real to you but no one else can hear them. No one means to harm you. Help clients to distinguish reality from the hallucinatory experience

Make brief frequent contacts with the client to interrupt the hallucinatory cycle and to maintain trust Encourage the client to attend to stimuli in the environment such as conversation

7) Promote reality-based perceptions as hallucinations and illusions often frighten clients Help the client in activities that require cognitive or verbal involvement Support coping strategies that the client has identified as personally effective in reducing hallucinations

If needed, teach the client that the hallucination are part of the disease process Help the client monitor events or interactions that increase the hallucinations

8) Intervene with delusions
Do not argue with their general beliefs Focus on the reality-based aspects of their communications Protect them from acting on their delusion in a way that might harm themselves or others Observe for stressors that precipitate the delusion and help the client to avoid or

9) Promote congruent emotional responses
10) Promote involvement family understanding and
Which of the following is not characteristic of the patient with paranoid schizophrenia? A) Delusions B) Hallucinations C) Decreased sensitivity D) Ideas of reference
ANSWER
Letter C
Rationale: Paranoid schizophrenia patients are usually extremely sensitive.
Which defense mechanism is most characteristic of the patient with paranoid schizophrenia?
A) Undoing B) Projection C) Rationalization D) Suppression
ANSWER
Letter B
Rationale: Paranoid patients usually project their mistrust to others.
Thiodazine (Mellaril), an antipsychotic, is usually effective in treating all but one of the following symptoms of schizophrenia. Which symptom will not be affected by this drug?
A) Agitation B) Hallucinations C) Delusions D) Ambivalence
ANSWER
Letter A
Rationale: Antipsychotics can only decrease the positive symptoms of schizophrenia. Agitation is a negative symptom
The nurse BOARD QUESTION NO.4 with SAMPLE is caring for a patient disorganized schizophrenia. The patient is responding well to therapy but has had limited social contact with others. Which of the following interventions is most appropriate? A) Discourage the patient from interacting with others because if his efforts fail, it will be too traumatic for him B) Encourage the patient to attend a party thrown for the residents of the facility C) Encourage the patient to participate in one-
ANSWER
Letter C
Rationale: Participation in one-on-one interactions helps the patient in establishing beginning social contact with others.
A 27 year-old female has been admitted to the inpatient psychiatric unit with diagnosis of catatonic schizophrenia. She appears weak and pale. The nurse would expect to observe which behavior in the patient?
A) Scratching cat-like motions of the extremities B) Exaggerated suspiciousness, excessive food intake
ANSWER
Letter C
Rationale: Catatonic schizophrenia is usually manifested by stuporous withdrawal, hallucinations, delusions, waxy flexibility and catatonic rigidity.
MOOD DISORDERS
MOOD / AFFECTIVE DISORDERS
A group of psychiatric diagnoses characterized by disturbances in emotional and behavioral response patterns ranging from elation and agitation to extreme depression and a serious potential for suicide.
Group of disorders characterized by a decreased or entire loss of control over mood
COMMON ETIOLOGICAL THEORIES OF MOOD DISORDERS

1) Genetic Theory If one parent has a bipolar disorder, there is 25% chance of transmission to the child 2) Aggression Turned Inward Theory Overdeveloped superego leads depression
to

3) Object Loss theory Loss of parent before age 11 increases the risk for depression
4) Personality Organization Theory Obsessive-compulsive, oral-dependent, hysterical personalities have higher predisposition to mood disorders

5) Cognitive Theory Mood disorder results from negative views of the self, the future, and negative interpretation of experiences 6) Learned Helplessness Theory Mood disorder is caused by a belief that one has no control over his environment

7) Psychoanalytic Theory Mania is a defense against an underlying depression Depression is due to a rigid superego
8) Biologic Factor Mania is related to increased norepinephrine while depression is related to low norepinephrine
COMMON PRECIPITATING FACTORS OF MOOD DISORDERS
Loss of a loved one Major life events Roles strain Decreased coping resources Physiological changes
DIFFERENT TYPES OF MOOD DISORDERS
The two main types of mood disorders are:

Depression
Characterized by anergia (lack of energy), exhaustion, agitation, noise intolerance, and slowed thinking process
Bipolar Disorders
Diagnosed when a persons mood cycles between extremes of mania and depression
SUBTYPES OF DEPRESSIONS
Major Depression
Dysthymic Depression Depression Not Otherwise Specified
MAJOR DEPRESSION
Severe depression which lasts for at least 2 weeks during which the person experiences a depressed mood or loss of pleasure in nearly all activities
InMAJOR DEPRESSION addition, four of the following symptoms are present: Changes in appetite or weight Changes in sleep Changes in psychomotor activity Decreased energy Feelings of worthlessness or guilt Difficulty thinking, concentrating or making decisions Recurrent thoughts of death or suicidal ideation, plans, or attempts.
DYSTHYMIC DEPRESSION
It is less severe than major depression

It is characterized by at least 2 years of depressed mood for more days than not with some additional less severe symptoms that do not meet the criteria for a major depressive episode
DEPRESSION NOT OTHERWISE SPECIFIED (DNOS)
Depression that lasts for 2 days to 2 weeks
SUBTYPES OF BIPOLAR DISORDERS
Manic
Hypomanic Bipolar I
Bipolar II
Cyclothymia
MANIA
The diagnosis of manic episode or mania requires at least 1 week of unusual and incessantly heightened, grandiose or agitated mood in addition to three or more of the following symptoms: Exaggerated self-esteem Sleeplessness Pressured speech Flight of ideas Reduced ability to filter extraneous stimuli
MANIA
The diagnosis of manic episode or mania requires at least 1 week of unusual and incessantly heightened, grandiose or agitated mood in addition to three or more of the following symptoms:
Distractability Increased activities with increased energy Multiple, grandiose high-risk activities involving poor judgment and severe
HYPOMANIC
Less severe than mania

Lasts for at least 4 days
BIPOLAR I
With history of mania

The patient exhibits: Manic episodes Periods of normal behavior Periods of profound depression
BIPOLAR II
No history of mania
The patient exhibits: Depression Normal behavior At least one hypomanic episode, but NOT manic
CYCLOTHYMIA
Characterized by two years of numerous periods of both hypomanic symptoms that do not meet the criteria for bipolar disorder
Numerous episodes of hypomania and depressed mood that lasts for at least two years
DIFFERENCE BETWEEN MANIA AND DEPRESSION

MANIA DEPRESSION
Appearance Behavior
Colorful Highly driven, Hyperactive

Talkative (Flight of Ideas) Risk for injury directed at others
Sad Passivity Psychomotor retardation Monotonous speech Risk for injury: Self-directed
Communication Nursing Diagnosis
DIFFERENCE BETWEEN MANIA AND DEPRESSION

MANIA
Treatment of Choice Milieu Therapy Appropriate Activity Lithium Non-stimulating Quiet Type Avoid competitive
DEPRESSION
ECT Stimulating Monotonous activity Example: counting Kind Firmness
Attitude Therapy
Matter of fact (attitude of
MEDICATIONS USED IN MANIA
Drug Classification
Antimanic Medications
Lithium Carbonate
Anticonvulsant Medications
Used as mood stabilizers
LITHIUM CARBONATE
It is a salt contained in the human body

Its mechanism of action is not known but it is thought to work in the synapses to hasten destruction of catecholamines (dopamine and norepinephrine), inhibit neurotransmitter release, and decrease the sensitivity of post-synaptic receptors.
EFFECTS OF LITHIUM CARBONATE
It decreases hyperactivity
WHEN TO TAKE LITHIUM CARBONATE
IMPORTANT POINTS ON LITHIUM CARBONATE
Lithium is not metabolized; rather, it is reabsorbed by the proximal tubule and excreted in the urine
Periodic serum lithium levels are used to monitor the clients safety and to ensure that the dose given has increased the serum lithium level to treatment level or reduced it to maintenance level.
IMPORTANT POINTS ON LITHIUM CARBONATE
There is a narrow range of safety among maintenance levels (0.5 to 1.0 mEq/L), treatment levels (0.8 to 1.5 mEq/L) and toxicity levels (1.5 mEq/L and above)
It is important to asses for signs of toxicity and ensure that clients and their families have this information prior to discharge.
SYMPTOMS AND INTERVENTIONS OF LITHIUM TOXICITY

SERUM LITHIUM SYMPTOMS OF LEVEL LITHIUM TOXICITY 1.5 2.0 mEq/L Nausea and vomiting, diarrhea, reduced coordination, drowsiness, slurred speech, muscle weakness INTERVENTION S Withhold next dose; call physician. Serum lithium levels are ordered and doses of lithium are usually suspended for a few days or the dose is reduced

SERUM LITHIUM LEVEL 2.0 3.0 mEq/L SYMPTOMS OF LITHIUM TOXICITY Ataxia, agitation, blurred vision, tinnitus, giddiness, choreoathetoid movements, confusion, muscle fasciculation, hyperreflexia, hypertonic muscles, myoclonic twitches, pruritus, maculopapular rash, movement of limbs, slurred speech, large output of dilute urine, incontinence of bladder of bowel, vertigo INTERVENTIONS Withhold future doses, call physician, stat serum lithium level. Gastric lavage may be used to remove oral lithium; IV containing saline and electrolytes used to ensure fluid and electrolyte function and maintain renal function.

SERUM LITHIUM LEVEL 3.0 mEq/L and above SYMPTOMS OF LITHIUM TOXICITY Cardiac arrythmia, hypotension, peripheral vascular collapse, focal or generalized seizures, reduced levels of consciousness from stupor to coma, myoclonic jerks of muscle groups, and spasticity of muscles INTERVENTIONS All of preceding interventions plus lithium ion excretion is augmented with use of aminophylline, mannitol, or urea. Hemodialysis may also be used to remove lithium from the body. Respiratory, circulatory, thyroid and immune systems are monitored and assisted as needed.
CLIENT TEACHING FOR LITHIUM CARBONATE
Clients should drink adequate water (approximately 3 liters per day) and continue with the usual amount of dietary table salt (3 grams per day).
Having too much salt in the diet because of unusually high salty foods or the ingestion of salt-containing antacids can reduce receptor availability for lithium and increase lithium excretion, so the lithium level will be too low.
If there is too much water, lithium is diluted and the lithium level will be too low to be therapeutic.
Drinking too little water or losing fluid through excessive sweating, vomiting, or diarrhea will increase the lithium level, which may result in toxicity.
Monitoring daily weights and the balance between intake and output and checking for dependent edema can be helpful in monitoring fluid balance.
The physician should be contacted if the client has diarrhea, fever, flu, or any condition that leads to dehydration
It takes 10 14 days before therapeutic effect of lithium becomes evident Antipsychotics are administered during the first two weeks to manage the acute symptoms of mania until lithium takes effect
Anticonvulsants could also be used as mood stabilizers
ANTICONVULSANTS USED AS MOOD STABILIZERS

GENERIC (TRADE) NAME OF ANTICONVULSANT Carbamazepine (Tegretol) SIDE EFFECTS NURSING IMPLICATIONS Assist client to rise slowly from sitting position Monitor gait and assist as necessary Report rashes to physician
Dizziness, hypotension, ataxia, sedation, blurred vision, leukopenia, rashes
Divalproex (Depakote)
Ataxia, drowsiness, weakness, fatigue, menstrual changes, dyspepsia, nausea, vomiting, weight gain, hair loss
Monitor gait and assist as necessary Provide rest periods Give with food Establish balanced nutrition
client to rise
Gabapentin (Neurontin)
Dizziness, hypotension, Assist
ANTICONVULSANTS USED AS MOOD STABILIZERS

GENERIC (TRADE) NAME OF ANTICONVULSANT SIDE EFFECTS NURSING IMPLICATIONS
Lamotrigine (Lamictal)
Dizziness, hypotension, ataxia, coordination, sedation, headache, weakness, fatigue, menstrual changes, sore throat
Dizziness, hypotension, anxiety, ataxia, incoordination, confusion, sedation, slurred speech, tremor, weakness Dizziness, ataxia,
Assist client to rise slowly from sitting position Monitor gait and assist as necessary Provide rest periods
Assist client to rise slowly from sitting position Monitor gait and assist as necessary Orient client client to rise from sitting
Topiramate (Topamax)
Oxcarbazepine (Trileptal)
fatigue, Assist confusion, slowly
NURSING INTERVENTIONS FOR MANIA
Provide for clients physical safety and safety of those around the client The nurse assess clients directly for suicidal ideation and plans or thought of hurting others Clients in the manic phase have little insight into their anger and agitation and how their behaviors affect others. They often intrude into others space, take others belongings without permission, or appear aggressive in approaching others. This behavior can threaten or anger people
Set limits on clients behavior when needed and remind client to respect distances between self and others.
The nurse may say: John, you are too close to my face. Please stand back 2 feet. or It is unacceptable to hug other clients. You may talk to others, but do not touch them.
Use short simple sentences to communicate Clients with mania have short attention span, so he nurse uses clear , simple sentences when communicating
Keep channels of communication open with clients, regardless of speech patterns (pressured, rapid, circumstantial, rhyming, noisy or intrusive with flight of ideas)
The nurse can say, Please speak more slowly, I am having trouble following you. The nurse patiently and frequently
Clarify the communication
meaning
of
clients
When speech includes flight of ideas, nurse can ask clients to explain relationship between topics example, What happened then? Was that before or after you married?
the the for or got
Set limits regarding taking turns speaking and listening and giving attention to others when they need it
Frequently provide finger foods that are high in calories and protein (sandwiches, protein bars, fortified shakes)
Manic clients may be too busy to sit down and eat, or they may have such poor concentration that they fail to stay interested in food for very long
Promote rest and sleep by decreasing environmental stimulation The nurse provides a quiet environment without noise, television, or other distractions.
Establishing a bedtime routine, such as tepid bath may help clients to calm down enough to rest
Protect the clients dignity when inappropriate behavior occurs

Clients may lose sexual inhibitions resulting in provocative and risky behaviors. Clothing may be flashy or revealing, or clients may undress in public. They may engage in unprotected sex with virtual strangers. Clients may ask staff members or other clients for sex, graphically describe sexual acts, or display their genitals.
The nurse handles such behavior in a matterof-fact, non-judgmental manner

For example, Mary, lets go to your room and find a sweater.
REVIEW OF MAJOR SYMPTOMS OF DEPRESSIVE DISORDER
Depressed mood
Anhedonism (decreased attention to and enjoyment from previously pleasurable activities)
Unintentional weight change of 5% or more in a month Change in sleep pattern
Agitation or psychomotor retardation

Tiredness Worthlessness or guilt inappropriate to the situation (possibly delusional)
Difficulty thinking, focusing, or making decisions Hopelessness, helplessness and/or suicidal ideation
TREATMENT MODALITIES FOR DEPRESSIVE DISORDERS
Electroconvulsive Therapy
Psychopharmacology Cyclic antidepressants Monoamine oxidase inhibitors Selective serotonin reuptake inhibitors
Involves application of electrodes to the head of the client to deliver an electrical impulse to the brain; this causes a seizure
It is believed that the shock stimulates brain chemistry to correct the chemical imbalance of depression However, the mechanism of action of ECT is unclear at present
Voltage of electrical current that is administered to the client 70 150 volts Length of electrical shock applied to the patient About 0.5 to 2.0 seconds Usual number of treatments needed to produce a therapeutic effect 6 12 treatments Frequency of treatments
Indicators of effectiveness of ECT The occurrence of generalized tonic-clonic seizure
Indications for ECT Depression, Schizophrenia
Mania,
Catatonic
Contraindications to ECT Fever Increased intracranial tumor TB with history of hemorrhage Cardiac condition Recent fracture
Need for consent prior to ECT Yes, consent is needed
Medications given to clients prior to ECT

Atropine sulfate
To decrease secretions
Anectine (Succinylcholine)
To promote muscle relaxation
Methohexital Sodium (Brevital)
Serves as an anesthetic agent
Common complications of ECT Loss of memory Headache Apnea Fracture Respiratory depression
REVIEW OF BIOLOGIC FACTOR ON DEPRESSIVE DISORDERS
Depression is related to low levels of norepinephrine (particularly in brain synapses)
PSYCHOPHARMACOLOGY FOR DEPRESSIVE DISORDERS
Cyclic Antidepressants
Selective Serotonin Reuptake Inhibitors Monoamine Oxidase Inhibitors
MECHANISM OF ACTION
The precise mechanism of action by which antidepressants produce their therapeutic effects is not known, but much is known about their action on the CNS. The major interaction is with the monoamine neurotransmitter systems in the brain, particularly norepinephrine and serotonin. Both of these neurotransmitters are released throughout the brain, and help to regulate arousal, vigilance, attention, mood,
MECHANISM OF ACTION
Norepinephrine and serotonin are removed from the synapses after release by reuptake into presynaptic neurons. After reuptake, norepinephrine and serotonin are reloaded for subsequent release or metabolized by the enzyme Monoamine Oxidase (MAO).
MECHANISM OF ACTION
The Selective Serotonin Reuptake Inhibitors block the reuptake of serotonin

The Cyclic Antidepressants block the reuptake of norepinephrine and serotonin to some degree
The Monoamine Oxidase Inhibitors (MAOIs) interfere with enzyme metabolism of norepinephrine
TRICYCLIC ANTIDEPRESSANTS (TCAs)
Amitriptyline (Elavil) Amoxapine (Asendin) Doxepin (Sinequan) Imipramine (Tofranil) Despiramine (Norpramine) Nortriptyline (Pamelor)
EFFECTS OF TCAs
Prevents the reuptake of norepinephrine, increases appetite and produces adequate sleep
WHEN TO ADMINISTER TCAs
Best given after meals
SIDE EFFECTS OF TCAs
The cyclic antidepressants block cholinergic receptors, resulting in anticholinergic effects such as dry mouth, constipation, urinary hesitancy or retention, dry nasal passages, and blurred near vision
More severe anticholinergic effects, such as agitation, delirium, and ileus, may occur particularly in adults
IMPORTANT POINTS ON THE USE OF TCAs
Therapeutic effects may become evident only after 2 3 weeks of intake; they have a lag period before reaching a serum level that begins to alter symptoms
Check the blood pressure as they cause hypotension Check the heart rate as they cause cardiac arrythmias
TCAs are contraindicated in severe impairment of liver function and in myocardial infarction (acute recovery phase)
They cannot be given concurrently with MAOIs
Because of their anticholinergic side effects, TCAs must be used cautiously in patients with glaucoma, benign prostatic hypertrophy, urinary retention or obstruction, diabetes mellitus, hyperthyroidism, cardiovascular disease, renal impairment or respiratory disorders
Overdosage occurs over several days and results in confusion, agitation, hallucinations, hyperpyrexia and increased
MONOAMINE OXIDASE INHIBITORS
Isocarboxazid (Marplan) Phenelzine (Nardil) Tranylcypromine (Parnate)
EFFECTS OF MAOIs
Functions as antidepressants resulting into increased appetite and adequate sleep
WHEN TO ADMINISTER MAOIs
SIDE EFFECTS OF MAOIs
The most common side effects of MAOIs include daytime sedation, insomnia, weight gain, dry mouth, orthostatic hypotension and sexual dysfunction.
The sedation and insomnia are difficult to treat and may necessitate a change in medication
SIDE EFFECTS OF MAOIs
Of particular concern with MAOIs is the potential for a life-threatening hypertensive crises if the client ingests food that contains tyramine or takes sympathomimetic drugs
Because the enzyme monoamine oxidase is necessary to break down the tyramine in certain foods, its inhibition results to increased serum tyramine levels, which causes severe hypertension, hyperpyrexia, tachycardia, diaphoresis, tremulousness,
FOODS (CONTAINING TYRAMINE) TO AVOID WHEN TAKING MAOIs
Mature or aged cheeses or dishes made with cheese, such as lasagna or pizza. All cheese is considered aged except cottage cheese, cream cheese, ricotta cheese, and processed cheese slices
Aged meats such as pepperoni, salami, mortadella, summer sausage, beef logs, and similar products. Make sure meat and chicken are fresh and have been properly refrigerated
FOODS (CONTAINING TYRAMINE) TO AVOID WHEN TAKING MAOIs
Italian broad beans (fava) pods or banana peel. Banana pulp and all other fruits and vegetables are permitted
All tap beers and microbrewery beer. Drink no more than two cans or bottles of beer (including non-alcoholic beer) or 4 ounces of wine per day Sauerkraut, soy sauce or soybean
IMPORTANT POINTS ON THE USE OF MAOIs
It takes 2 3 weeks before initial therapeutic effect become noticeable as it also has a lag period before they reach therapeutic levels
Monitor the blood pressure There should be at least a two-week interval when shifting from one anti-depressant to another. Because of the lag period a
MAOI DRUG INTERACTIONS
The following drugs cause interactions with MAOIs Amphetamines Ephedrine Fenfluramine Isoproterenol Meperedine Phenylephrine Phenylpropanolamine Pseudoephedrine SSRIs
potentially
fatal
These are the newest category of antidepressants that are effective for most clients
Their action is specific to serotonin reuptake inhibition These drugs produce few sedating, anticholinergic and cardiovascular side effects, which makes them safer for use in
Because of their low side effects and relative safety, people using SSRIs are more apt to be compliant with the treatment regimen than clients using more troublesome medications.
Insomnia decreases in 3 to 4 days, appetite returns to a more normal state in 5 to 7 days, and energy returns in 4 to 7 days.
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) GENERIC (TRADE) NAME SIDE EFFECTS NURSING IMPLICATIONS
Fluoxetine (Prozac) Headache, nervousness, anxiety, sedation, tremor, sexual dysfunction, anorexia, constipatin, nausea, diarrhea, weight loss Administer in AM (if nervous) or PM (if drowsy) Monitor for hyponatremia Encourage adequate fluids Report sexual difficulties to physician Administer in PM if client is drowsy Encourage use of sugar free beverages or hard candy Drink adequate fluids Monitor hyponatremia; report sexual difficulties to physician Administer with food Administer in PM if client is drowsy Encourage use of sugar free hard candy or beverages Encourage adequate fluids
Sertraline (Zoloft)
Dizziness, sedation, headache, insomnia, tremor, sexual dysfunction,diarrhea, dry mouth and throat, nausea, vomiting, sweating
Paroxetine (Paxil)
Dizziness, sedation, headache, insomnia, weakness, fatigue, constipation, dry mouth and throat, nausea, vomiting, diarrhea, sweating
Citalopram (Calexa)
Drowsiness, sedation, Monitor for hyponatremia insomnia, nausea, vomiting, Administer with food weight gain, constipation, Administer dose at 6PM or
NURSING INTERVENTIONS FOR DEPRESSION
Provide for safety of the client and others The first priority is to determine if the client with depression is suicidal If a client has suicidal ideation or hears voices commanding him to commit suicide, measures to provide a safe environment are necessary The nurse asks additional questions to determine the lethality of the intent and plan
Begin a therapeutic relationship by spending nondemanding time with the client Clients may be unable to sustain a long interaction, so several shorter visits help the nurse to asses status and to establish a therapeutic relationship The nurses presence conveys genuine interest and caring. Silence can convey that clients are worthwhile even if they are not interacting. My name is Sheila, I am your nurse today. Im going to sit with you for a few minutes. If you need anything, or if you would like to talk,
Promote completion of activities of daily living by assisting the client only as necessary The nurse asks the client to perform a global task, Martin, it is time to get dressed. If a client cannot respond to the global request, the nurse breaks the task into smaller segments. Clients with depression can become overwhelmed easily with a task that has several steps.
Establish adequate nutrition and hydration The nurse can explain that beginning to eat will help stimulate appetite Food offered frequently and in small amounts can prevent overwhelming clients with a large meal that they feel unable to eat Sitting up with clients during meals can promote eating Monitoring food and fluid intake may be
Promote rest and sleep This may include the short-term use of sedatives or giving medication in the evening if drowsiness or sedation is a side-effect. It is also important to encourage clients to remain out of bed and active during the day to facilitate sleeping at night It is important to monitor the number of hours client sleep as well as if they feel
Encourage the client to verbalize and describe emotions Clients with depression are often overwhelmed by the intensity of their emotions Talking about these feelings can be beneficial. Initially, the nurse encourages the clients to describe in detail how they are feeling Sharing the burden with another person
Work with the client to manage medications and their side effects.
The nurse knows that sadness typically accompanies grief and depression. Which affect changes indicate major depressions?
A) Fear, timidity and lack of interest around B) Withdrawal, negative attitude, and little or no eye contact C) Lack of initiative, dominating personality, and defensiveness D) Irritability, apathy and self-doubt
ANSWER
Letter D
Rationale: Depression is usually manifested by irritability, apathy, self-doubt, sadness and psychomotor retardation.
Which nursing approach would be best for a patient with symptoms of severe depression?
A) Allow the patient time for quiet thought; remain silent B) Ask the patient to join the nurse and the other patients in the TV lounge C) State that the nurse would like to go with a patient for a short walk around the
ANSWER
Letter C
Rationale: Walking is a therapeutic activity for a patient with mood disorder. Providing assistance to the patient conveys a feeling of importance.
Which nursing approach is important in depression? A) Providing motor outlets for aggressive, hostile feelings. B) Protecting against harm to others C) Reducing interpersonal contacts D) De-emphasizing preoccupation with elimination, nourishment and sleep
ANSWER
Letter A
Rationale: Depressed patients usually turn their hostile feelings towards themselves. Providing an outlet for these aggressive feelings will make the patient feel less guilty.
When a patient with symptoms of severe depressions says to the nurse, I cant talk; I have nothing to say. And continues being silent, what should the nurse say?
A) Say, Alright, you do not have to talk. Let us play cards instead. B) Explain that talking is an important sign of getting well and that the patient is expected to do so
ANSWER
Letter D
Rationale: This response will convey that the nurse is willing to wait for the patients readiness to engage in a conversation.
When assessing patients who are in a depressed episode and those who are exhibiting a manic episode of bipolar mood disorders. Which characteristics common to both episodes of the disorder is the nurse likely to note?
A) Suicidal tendency B) Underlying hostility C) Delusions
ANSWER
Letter B
Rationale: In the depressed patient, hostility is turned towards the self. In the manic patient, hostility is turned towards the environment.
An extremely hyperactive patient exhibiting manic behavior is admitted to the hospital. In view of the patients elated state, the nurse should arrange for the patient to be in a room
A) With another patient who is very quiet B) That will provide a great deal of stimuli C) That has had most of the furniture removed
ANSWER
Letter C
Rationale: The priority for a hyperactive patient is safety
A hyperactive, manic patient might be redirected therapeutically by? A) Asking the patient to guide other patients in group games B) Encouraging the patient to tear pictures out of magazines for a scrapbook C) Suggesting the patient initiate social activities on a unit with other patients D) Encourage the patient to write a short
ANSWER
Letter B
Rationale: This provides the patient an opportunity to rechannel excess energy into a more productive activity.
A patient who has a history of bipolar disorder (manic) demonstrates grandiosity. The best interpretation of this behavior is that the patient is?
A) Afraid of talking to other people B) Manifesting conceit C) Compensating for low self-esteem D) Deliberately attempting to intimidate others
ANSWER
Letter C
Rationale: Delusions of grandeur is the patients way of compensating for poor selfesteem.
Which of the following food selections is appropriate for a manic patient? A) Cheeseburger B) Rice toppings C) Chicken soup D) Potato chips
ANSWER
Letter A
Rationale: High calorie finger foods which the patient can carry around as he moves is the most appropriate selection for a manic patient.
An individual who is on a psychiatric unit and has a diagnosis of depression makes all of the following remarks to the nurse during her hospitalization. Which one suggests an improvement in her condition?
A) I am making a plan to organize child care for parents while they attend services at my church. B) My room mate does not show any
ANSWER
Letter A
Rationale: At the height of depression, patients usually have difficulty conceptualizing activities. The patients plan to organize child care indicates that his ability to conceptualize is working. This indicates recovery from depression.
SUICIDE
SUICIDE
It is the intentional act of killing oneself

It is the ultimate form of self-destruction It is a cry for help
SUICIDE
Suicidal thoughts are common in people with mood disorders, especially depression In the United States, men commit approximately 72% of suicides, which is roughly 3 times the rate of women, although women are 4 times more likely than men to attempt suicide.
SUICIDE
The higher suicide rates for men are partly the result of the method chosen (e.g., shooting, hanging, jumping from a high place).
Women are more likely to overdose on medication
RISK FACTORS FOR SUICIDE
Clients with psychiatric disorders who are at increased risk for suicide include: Depression Bipolar disorder Schizophrenia Substance abuse Post-traumatic stress disorder Borderline personality disorder
Environmental factors that increase suicide risk include: Isolation Recent Loss Lack of social support Unemployment Critical life events Family history of depression or suicide
A history of suicide attempts increases risk for suicide. The first two years after an attempt represent the highest risk period, especially the first three months.
Those with a relative who committed suicide are at increased risk for suicide: the closer the relationship, the greater the risk
One possible explanation is that the relatives suicide offers a sense of permission or acceptance of suicide as a method of escaping a difficult situation
THEORETIC FOUNDATIONS OF SUICIDE
Psychodynamic theories
According to Freud is a conflict between the instinct for life and the instinct for death
Suicide occurs when the wish for death predominates. Others view suicide as an aggression
Sociologic Theories The social and cultural contexts in which the individual lives influence the expression of suicidality. There are four types:
Egoistic Suicide The individuals ties to the community are too loose or tenuous, and the individual is not interested in maintaining his or her relationship with the community
Sociologic Theories
Anomic Suicide An individual experiences the aloneness or estrangement that occurs when there is a precipitous deterioration in ones relationship with the society
Sociologic Theories
Fatalistic Suicide
An individual is excessively regulated, or there are no personal freedoms or no hope (e.g., suicide of slaves)
Sociologic Theories
Altruistic Suicide
Rules of customs demand suicide under certain conditions, or selfinflicted suicide is honorable
LEVELS OF SELF-DESTRUCTIVE BEHAVIOR
Chronic self-destructive behavior Smoking, gambling, self-mutilation Suicidal threat A threat more than a casual statement of suicidal intent and accompanied by behavioral changes, e.g., mood swings, temper outbursts, decline in school or work performance
LEVELS OF SELF-DESTRUCTIVE BEHAVIOR
Suicidal gesture More serious warning signal than a threat that may be followed by an act that is carefully planned to attract attention without seriously injuring the subject
Suicidal attempt A strong and desperate call for help involving a definite risk
FAMILY CHARACTERISTIC OF SUICIDAL PATIENTS
Poor family history or tendencies Early trauma Rigid, disorganized or dysfunctional family system Disturbed parent-child relationship Unresolved loss History of abuse
COGNITIVE STYLES OF SUICIDAL PATIENTS
Ambivalence
They have two conflicting desires at the same time: to live and to die Ambivalence accounts for the fact that a suicidal person often takes lethal or nearlethal action but leaves open the possibility for rescue.
COGNITIVE STYLES OF SUICIDAL PATIENTS
Communication
Some people cannot express their needs or feelings to others, or when they do, they do not obtain the results they hope for. For them, suicide becomes a clear and direct, if violent, form of communication
DEMOGRAPHIC VARIABLES
Suicide rates are higher among the following: Single people Divorced, separated or widowed People who are confused about their sexual orientation People who have experienced a recent loss: divorce, loss of job, loss of prestige, loss of social status or who are facing the threat of criminal exposure
SUICIDAL IDEATION
Means thinking about killing oneself

Active suicidal ideation is when a person thinks about and seeks ways to commit suicide
Passive suicidal ideation is when a person thinks about wanting to die or wishes he or she were dead but has no plans to cause his or her death
LETHALITY ASSESSMENT SCALE
A scale used in an attempt to predict the likelihood of suicide

KEY TO SCALE
1
DANGER TO TYPICAL SELF INDICATORS No predictable Has no notion of risk of immediate suicide or history suicide of attempts, has satisfactory social support network, and is in close contact with significant others

KEY TO SCALE
2
DANGER TO TYPICAL SELF INDICATORS Low risk of Person has immediate considered suicide suicide with low lethal method; no history of attempts or recent serious loss; has satisfactory support network;

KEY TO SCALE DANGER TO TYPICAL SELF INDICATORS Moderate risk of Has considered immediate suicide with high suicide lethal method but no specific plan or threats; or has plan with low lethal method, history of low lethal attempts, with tumultuous family history and reliance on

KEY TO SCALE
4
DANGER TO TYPICAL SELF INDICATORS High risk of Has current high immediate lethal plan, suicide obtainable means, history of previous attempt, has a close friend but is unable to communicate with him; has a

KEY TO SCALE DANGER TO TYPICAL SELF INDICATORS Very high risk of Has current high immediate lethal plan with suicide available means, history of high lethal suicide attempts; is cut off from resources; is depressed; uses alcohol to excess; and is threatened with a
GUIDE QUESTIONS IN LETHALITY ASSESSMENT
Does the client have a plan? If so, what is it? Is the plan specific? Are the means available to carry out this plan? (For example, if the person plans to shoot himself, does he have access to a gun and ammunition?)
If the client carries out the plan, is it likely to be lethal? (For example, a plan to take 10
GUIDE QUESTIONS IN LETHALITY ASSESSMENT
Has the client made preparations for death such as giving away prized possessions, writing a suicide note, or talking to friends one last time?
Where and when does the client intend to carry out the plan? Is the intended time a special date or anniversary that has meaning for the client?
WHAT IS THE PRIORITY NURSING DIAGNOSIS IN SUICIDE
Risk for injury Self directed
NURSING CARE FOR SUICIDAL PATIENTS
Provide one-on-one monitoring

Have frequent unscheduled rounds Avoid use of metals and glass utensils
Monitor for the signs of impending suicide
MAJOR INTERVENTIONS FOR SUICIDAL PATIENTS
Prevention
Listen
A 19 year-old patient is brought to the emergency room because she slashed her wrists. What is the nurses first concern?
A) Stabilization of physical condition B) Determination of antecedent, causal factors relevant to the wrist slashing C) Reduction of anxiety D) Obtaining a detailed nursing history
ANSWER
Letter A
Rationale: The priority for the patient is her physiologic homeostasis
Which characteristic should the nurse recognize as common in a person engaged in gradual self-destructive behavior such as in obesity, drug addition, and smoking?
A) Acceptance of death wish B) Denial of possibility of death C) Ability to control own behavior D) Ignorance of the consequences of own behavior
ANSWER
Letter B
Rationale: Self-destructive behavior usually is related to the patients denial of the possibility of death
A patient relates to the nurse, I was going to kill myself last night. What is the best initial response of the nurse?
A) Say nothing. Wait for the patients next comment B) What were you going to do this time? C) Have you felt this way before? D) You seem upset. I am going to be here with you. Perhaps you will want to talk
ANSWER
Letter D
Rationale: This response facilitates free expression of feelings.
Which feeling is the nurse likely to identify as the antecedent of self-destructive behavior?
A) Omnipotence B) Grandiosity C) Low self-esteem D) Self-satisfaction
ANSWER
Letter C
Rationale: Low self-esteem causes depression. When depression begins to lift, the patient may now have enough energy to carry out a suicidal plan.
In planning patient care, a nurse need to know that self-destructive behavior may be interpreted as the?
A) Directing hostile feelings toward self B) Directing hostile feelings toward others C) Directing hostile feelings toward an internalized love object D) Internalized on the fear of death
ANSWER
Letter C
Rationale: Suicide can be related to directing of hostile feelings toward an internalized love object.
It would be important to the nurse to implement definite suicide precautions for a depressed patients mood change suddenly to one of ?
A) Cheerfulness B) Psychomotor retardation C) Agitation D) Hostility
ANSWER
Letter A
Rationale: When a depressed person suddenly becomes cheerful, it means that the patient is recovering from depression and is in danger of committing suicide.
Ursula, 25, is found sitting on the floor of a bathroom with moderate lacerations to both wrists. With broken pieces of glass around her, she stares blankly at her bleeding wrists while friends call for an ambulance. How should a nurse approach Ursula initially? A) Enter the room quietly and move beside her to assess her injuries B) Call for back-up before entering the room and restraining her. C) Move as much glass away and then quietly sit next to her
ANSWER
Letter D
Rationale: This approach provides reassurance for a patient in distress
Ursula is taken to the hospital and admitted on emergency basis for 72 hours, as provided by state law. Ursula says to the admitting nurse, I am not staying here. I was a little upset and did a stupid thing. I want to live. Which response is most appropriate? A) Unfortunately, you have no right to leave at this time. You must be evaluated further. B) Cutting your wrist certainly was a stupid thing to do. What are you trying to accomplish anyway? C) You have been admitted on an emergency basis and can be held by 72 hours. You have
ANSWER
Letter C
Rationale: This response provides orientation to the patient about the present situation
Determining Ursulas suicide potential during the mental status examination involves assessing several factors, the most significant of which is her?
A) History of previous attempts B) Suicide plan C) Emotional state D) Self-esteem
ANSWER
Letter B
Rationale: The presence of a definite plan increases the risk for suicide.
A female patient who is on a psychiatric unit is being observed for signs of suicidal intent. Which of these behaviors by the patient is most likely a sign of suicidal risk?
A) She continuously falls asleep after midnight B) She has constant body aches without organic cause C) She becomes euphoric for no apparent
ANSWER
Letter C
Rationale: The patients behavior indicates recovery from depression, which increases the risk for suicide.
ALZHEIMERS DISEASE
ALZHEIMERS DISEASE
An organic mental disorder defined as a chronic, progressive condition that is the major cause of degenerative dementia seen in the elderly
The main pathology is the presence of senile plaques that destroys neurons leading to decreased acetylcholine
COMPARISON OF DELIRIUM AND DEMENTIA

INDICATOR Onset Duration Level of Consciousness Memory Rapid Brief (hours to days) Impaired, fluctuates Short-term impaired DELIRIUM DEMENTIA Gradual and insidious Progressive deterioration Not affected
memory Short-term then Long-term memory impaired, eventually destroyed
Speech
May be Normal in early stage, slurred,rambling, progressive aphasia in later pressured, irrelevant stage Temporarily disorganized Impaired thinking, eventual loss of thinking abilities
Thought Processes Perception
Visual or tactile Often absent, but can have hallucinations, delusions paranoia, hallucinations, illusions Anxious, fearful if Depressed and anxious in
Mood
4As OF ALZHEIMERS DISEASE
Aphasia
Loss of language ability Initially there is difficulty in finding words
There is deterioration of language function and exhibits palilalia (echoing sounds) and echoing words
Apraxia
Loss of purposeful movement without loss of muscle power or coordination in general Ability to conceptualize or perform motor tasks deteriorates There is difficulty in pursuing complex tasks or become so obsessed with an aspect of an act that they cannot complete it.
Agnosia
Loss of sensory ability to recognize objects Initially, has difficulty recognizing everyday objects like chairs and tables In the later stages, cannot recognize even loved ones or their own body parts.
Amnesia
Mnemonic disturbances or memory loss In the initial stages, there is recent memory loss such as forgetting food cooking on the stove In later stages, there is remote memory loss such as forgetting names of children,
STAGES OF ALZHEIMERS DISEASE
Early or Forgetfulness Stage

Second or Advanced Stage Final or Terminal Stage
EARLY OR FORGETFULNESS STAGE
Has difficulty remembering names and appointments and may forget where things are placed
Have problems with spatial orientation
Shows affect changes and emotionally unstable at times
seems
SECOND OR ADVANCED STAGE
Cognitive deficits are present May last from 2 12 years
Memory for past events may still exist, but the person has no recall of recent ones. Orientation and concentration are affected and has increasing difficulty comprehending everyday events There is restlessness at night and increased
FINAL OR TERMINAL STAGE
Lasts for several months to 5 years
There is symptoms
severe
disorientation,
psychotic
Kluver-Busy-like syndrome (hyperorality, blunting of emotions, bulimia, attempt to touch every object in sight) occurs
Eventually becomes bedridden, emaciated and helpless
PREDISPOSING FACTORS IN ALZHEIMERS DISEASE
Genetics In 10% to 20%, runs in the family Viral Aluminum Vitamin B12 deficiency Related with Downs syndrome Possible defect in the immune system Disrupted biochemical pathways and other metabolic (glucose) abnormalities
DRUGS THAT SLOW THE PROGRESS OF DEMENTIA

NAME OF CHOLINESTERASE INHIBITOR
Tacrine (Cognex)
DOSAGE RANGE AND ROUTE
NURSING CONSIDERATIONS
40 160 mg orally per Monitor liver enzymes day divided into 4 doses for hepatotoxic effects Monitor for flu-like symptoms 5 10 mg orally per day Monitor for nausea, diarrhea, and insomnia Test stools periodically for GI bleeding
Donepezil (Aricept)
Rivastigmine (Exelon)
3 12 mg orally per day Monitor for nausea, divided into 2 doses vomiting, abdominal pain, and loss of appetite
Galantamine (Reminyl)
16 32 mg orally per Monitor
for
nausea,
NURSING CARE FOR ALZHEIMERS PATIENTS
Promote normal motor behavior Living areas must be well lit and furniture left in the same place Safety bars installed near toilets, showers, and tubs Teach safe use of walkers and wheelchairs Evaluate clients using tranquilizers and antidepressants for postural hypotension Avoid crowds or large open spaces
Maintain self-care Allow the client to do as much as possible unassisted Remind client about daily grooming Remind client about grooming and personal hygiene Use mouth swabs with dilute hydrogen peroxide if client resists mouth care Total bed care
Promote adequate sleep

Allow sleepless clients to wander in a confined area until they are tired Make sure room is lighted and without shadows Leave a radio on to provide more stimulation
Support knowledge processes

Support optimal verbal expression Call the client by name, approach in a clear view and give simple directions
Support optimal role performance Client must be viewed as an active family member
Promote optimal patterns of elimination Toileting routine is essential Promote optimal nutritional status
Support optimal memory function

Gently orient client Do not argue about verbal discrepancies. Rather, direct client towards areas of interest that are familiar and pleasurable Music therapy
Promote optimal orientation

Structure environment to support cognition Hearing or visual aids are necessary to prevent sensory loss or distortion Easy to read clocks, orientation boards and consistent daily routine Do not quiz the client
Support appropriate conduct or impulse control Client functions best in an environment where stimulation is controlled and sensory overload is prevented Changes must be done slowly Call client by name, approach in full view and refrain from touching client Requests should be simple and non-
Maintain optimal attention span

Repeat requests as needed Speak in simple phrases, loud enough to be heard and reinforce meaning with non-verbal gesture Lower clients anxiety level by moving slowly, speaking clearly and providing
Maintain optimal perceptual functioning A quiet environment with soft music prevents sensory overload When speaking with the client, stand or sit so that you are in direct view First giving a verbal warning, touch the clients shoulder or hands, and slowly and clearly explain all procedures. Use touch with caution Sometimes a very soothing touch can
Maintain optimal perceptual functioning When responding to hallucination Simply state that you understand that these thoughts seem very real but that you do not experience the same thoughts Do not argue or ask client to elaborate Give assurance that these thoughts will go away
When a patient has dementia, it is most important that the nurse plan the daily activities to?
A) Be highly structured B) Be changed each day to meet the patients need for variety C) Be simplified as much as possible to avoid problems with decision-making D) Provide many opportunities for making
ANSWER
Letter A
Rationale: A highly structured environment decreases the burden of decision making for the patient.
What will the nurse most commonly note in the clinical picture of dementia? A) Memory loss for events of the distant past B) Quarrelsome behavior directly related to the extent of lack of blood supply to the brain C) Increased resistance to change D) Ability to perform ADL
ANSWER
Letter C
Rationale: Increased resistance to change is a common manifestation of dementia
An important part of the nursing care for a patient with dementia would be? A) Minimizing regression B) Correcting memory loss C) Rehabilitating toward independent functioning D) Preventing further deterioration
ANSWER
Letter A
Rationale: Nursing care for the patient with dementia is geared toward maintaining existing functions by minimizing regression.
The patient is in the early stage of Alzheimers disease and his adult son attended an appointment at the community health center. The nurse is reading the autopsy report of a patient who recently died. The report reveals senile plaques, neurofibrillary tangles, and atrophy. These changes are characteristic of which illness?
A) Meningitis
ANSWER
Letter D
Rationale: Alzheimers disease is characterized by presence of senile plaques, neurofibrillary tangles, and atrophy of the brain.
While conversing with the nurse the son states, I am tired of hearing about how things were 30 years ago. This statement indicates?
A) A lack of knowledge of the disease B) Unusual behavior in the father C) His fathers level of anxiety D) His fathers antagonism toward him
ANSWER
Letter A
Rationale: Patients with dementia usually talk about the past
The nurse discusses the possibility of the patient attending day treatment for patients with Alzheimers disease. The best rationale the nurse would give for day treatment is that
A) The patient would have more structure for his day B) The staff are excellent in the treatment they offer to the patients
ANSWER
Letter C
Rationale: Attending day increases social interaction demented patient. treatment for the
Three of the following statements are true about Alzheimers disease. Which one is inaccurate?
A) There is degeneration of the cortex and atrophy of the cerebrum B) Death usually occurs 1 to 10 years after onset C) There is progressive deterioration of intellectual function and change in
ANSWER
Letter D
Rationale: The etiology disease is unknown of Alzheimers
Mrs. Reyes, 72, with Alzheimers disease, has difficulty remembering where her room is on the unit. Which of the following would best help her alleviate this problem?
A) Paint the door to her room light pink B) Assign her a peer who will help her find her room C) Print her name in large letters on the door to her room
ANSWER
Letter C
Rationale: Printing the patients name in large letters on the door to her room provides reorientation for the patient.
Mang Nano, 75, was diagnosed as having primary degenerative dementia of the Alzheimers type. Alzheimers disease is a ?
A) Functional disorder B) An irreversible condition C) Generally reversible condition D) Delirious state
ANSWER
Letter B
Rationale: Alzheimers disease, a dementia, is irreversible
One of the important areas of concern for the staff and family in the care of Mang Nano is his safety. An appropriate nursing diagnosis would be?
A) Impaired physical mobility B) Altered thought process C) Impaired verbal communication D) Potential for injury
ANSWER
Letter D
Rationale: Due to cognitive and memory deficits, a patient with Alzheimers disease is at risk for injury.
The nurse should include in her health teaching that Mang Nanos progressive loss of memory leads to inability to recognize family members. This sign of Alzheimers disease is known as?
A) Apraxia B) Mnemonic disturbance C) Agnosia D) Aphasia
ANSWER
Letter C
Rationale: Agnosia is inability to recognize objects and persons.
ALCOHOLISM
ALCOHOLISM
A state of physical and psychological dependency on alcohol manifested by an individuals inability to refrain from drinking or to control his consumption of alcohol
World Health Organization definition A chronic disease or a disorder characterized by excessive alcohol intake and interference in the individuals health, interpersonal relationship and economic
DYNAMICS OF ALCOHOLISM
Social drinking may progress to abuse

The reliance on excessive drinking as a means of dealing with personal tension and discomfort clearly suggests the psychological factors play a key role in the development of alcohol abuse. Alcohol being a depressant aids in the relaxing of the individual and releases
PHASES OF PROGRESSION OF ALCOHOLISM

1) Pre-alcoholic Phase Starts with social drinking until tolerance begins to develop 2) Prodromal Phase Alcohol becomes a need; blackouts occur; denial begins to develop 3) Crucial Phase Cardinal symptoms of alcoholism develops (loss of control over drinking) 4) Chronic Phase
ETIOLOGICAL THEORIES OF ALCOHOLISM

1) Psychoanalytic Theories Due to fixation in the oral stage of development
2) Learning Theories Due to a learned behavior 3) Biological Theories Due to inherited traits
MANIFESTATIONS OF DIFFERENT BLOOD LEVELS OF ALCOHOL

BLOOD LEVEL 0.1% TO 0.2% 0.2% TO 0.3% MANIFESTATION Low coordination Presence of ataxia, tremors, irritability, stupor Unconsciousness
0.3% and above
EFFECTS OF ALCOHOL
A sedative anesthetic, alcohol is absorbed in the small intestine; approximately 95% is broken down by the liver, the rest is excreted through the lungs, the kidneys and skin.
Generally, a person can metabolize 10 ml of alcohol or 1 ounce of whiskey every 90 minutes
EFFECTS OF ALCOHOL
If taken in exceedingly high doses, it can depress respiration and cause death. Intoxication occurs when a persons blood alcohol level is 0.10% or more
EFFECTS OF ALCOHOL
Simple intoxication lasts less than 12 hours and is usually followed by a hangover with unpleasant symptoms (nausea, vomiting, gastritis, headache, fatigue, sweating, thirst, vasomotor instability) occurring approximately 4 6 hours after alcohol ingestion. The cause is uncertain but the symptoms are attributed to hypoglycemia and the accumulation of lactic acid and acetaldehyde in the blood.
POSSIBLE OUTCOMES OF ALCOHOLISM
Brain damage
Alcoholic hallucinosis Death
COMMON BEHAVIORAL PROBLEMS OF ALCOHOLIC PATIENTS
Denial
Dependency Demanding
Destructive
Domineering
COMMON DEFENSE MECHANISMS UTILIZED BY ALCOHOLICS
Denial
Rationalization Isolation
Projection
STAGES OF ALCOHOL WITHDRAWAL SYNDROME

1) Tremulousness Occurs during the drinking period up to 2 hours afterward. There is anxiety, agitation and irritability As it progresses, tremors, tachycardia and diaphoresis are exhibited

2) Hallucinations Begins 12 48 hours after the person stops drinking Gastrointestinal symptoms of nausea, vomiting, diarrhea and anorexia are present
Delirium tremens A condition of severe memory disturbance, agitation, anorexia and hallucinations Begins a few days after drinking stops and ends within 1 5 days There is elevated temperature, severe diaphoresis, hypertension and tachycardia Behavioral symptoms include confusion with disorientation, agitation, tremors,
COMMON WITHDRAWAL SIGNS AND SYMPTOMS
Hallucinations (visual and tactile)

Increased vital signs Tremors
Sweating and seizures
COMMON WITHDRAWAL SYNDROMES EXPERIENCED BY ALCOHOLICS

SYNDROME CAUSE ONSET ESSENTIAL FEATURE
Delirium
OTHER SIGNS AND SYMPTOMS

Increased vital signs Visual and tactile hallucinations Coarse tremors Retrograde amnesia Anterograde amnesia Confabulation Confusion Opthalmoplegia
DELIRIUM TREMENS
Faulty metabolis m of alcohol
Acute
KORSAKOFF S PSYCHOSIS
Thiamine Chronic and Niacin deficiency
Memory Disturbances
WERNICKES PSYCHOSIS
Thiamine deficiency
Chronic
PHARMACOLOGIC TREATMENT OF ALCOHOLIC PATIENTS
Vitamin B1 (Thiamine) is often prescribed to prevent or to treat Wernickes syndrome and Korsakoffs syndrome, which are neurologic conditions that can result from heavy alcohol use. Vitamin B12 (Cyanocobalamin) and folic acid are often prescribed for clients with nutritional deficiencies Alcohol withdrawal is managed with a benzodiazepine anxiolytic agent, which is used to suppress the symptoms of
PHARMACOLOGIC TREATMENT OF ALCOHOLIC PATIENTS
Disulfiram (Antabuse) may be prescribed to help deter clients from drinking. If a client taking disulfiram drinks alcohol, a severe adverse reaction occurs with flushing, a throbbing headache, sweating, nausea and vomiting. In severe cases, severe hypotension, confusion, coma, and even death may result The client must avoid a wide variety of products that contain alcohol such as cough syrup, lotions, mouthwash, perfume, aftershave, vinegar and vanilla and other
DRUGS USED USE ALCOHOLIC PATIENTS FOR DRUG DOSAGE NURSING

CONSIDERATIONS Lorazepam (Ativan) Alcohol withdrawal 2 4 mg every 2 4 hours prn Monitor vital signs and global assessments for effectiveness; may cause dizziness and drowsiness Monitor vital signs and global assessments for effectiveness; may cause dizziness and drowsiness
Chlordiazepoxid e (Librium)
Alcohol withdrawal
50-100 mg, repeat in 2-4 hours if necessary, not to exceed 300 mg/day
Disulfiram (Antabuse)
Maintain 500 mg/day for 1- Teach client to read abstinence 2 weeks, then 250 labels to avoid products from alcohol mg/day with alcohol
Thiamine (Vitamin B1)
Prevent or treat Wernicke, Korsakoff syndrome Treat
100 mg/day
Teach client proper nutrition
about
Folic Acid
1 2 mg/day
Teach
client
about
NURSING INTERVENTIONS FOR ALCOHOLIC PATIENTS

1) Using confrontation strategies Several family members, friends, etc., can speak calmly and slowly with minimal emotion. Present facts by saying, You have alcohol on your breath, or You have slurred speech The next step requires them to make clear and direct statements about consequences Either you get help now

2) Avoiding non-therapeutic communication The nurse should avoid the role of rescuer, patsy and prosecutor and function in the role of a non-judgmental problem solver who points out the consequences of the behavior.

3) Make use of educating video tapes and talks by recovered alcoholics 4) Referral and self-help groups

5) Encourage lifestyle changes. Nurses can help clients discuss ways to alter their destructive habits by suggesting different coping strategies and by encouraging clients to discover new interests and capabilities within themselves. Recognizing that relapses are always a threat, nurses may set up contracts with the client.
CONCEPT OF LOSS
STAGES OF GRIEF / GRIEVING
Shock, Numbness, Disbelief Searching behavior Yearning and Protest Anger towards God Anguish, Disorganization and Despair Reality of the loss is accepted
Identification stage A family member imitates characteristics of the dead person

Reorganization / Restitution Life normalizes
some
STAGES OF DEATH / DYING
Denial No, not me! Anger Why me? Bargaining If only.
Depression Stage of silence Acceptance Yes, it is me
PRIORITY NURSING DIAGNOSIS FOR THE GRIEVING / DYING
PRIORITY NURSING DIAGNOSIS FOR THE GRIEVING / DYING
Be physically present
Be non-judgmental Encourage verbalization of feelings
Allow the patient to cry

Recognize your own thoughts about death
THANK YOU !!!

Basic Concepts in Psychiatric Nursing

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Basic Concepts in Psychiatric Nursing

Uploaded by

Copyright:

Available Formats

BASIC CONCEPTS IN PSYCHIATRIC NURSING

COMPONENTS OF MENTAL HEALTH (Johnson, 1997)

COMPONENTS OF MENTAL HEALTH AUTONOMY AND INDEPENDENCE

COMPONENTS OF MENTAL HEALTH MAXIMIZING ONES POTENTIAL

COMPONENTS OF MENTAL HEALTH TOLERATING LIFES UNCERTAINTIES

COMPONENTS OF MENTAL HEALTH SELF-ESTEEM

COMPONENTS OF MENTAL HEALTH MASTERING THE ENVIRONMENT

COMPONENTS OF MENTAL HEALTH REALITY ORIENTATION

COMPONENTS OF MENTAL HEALTH STRESS MANAGEMENT

MENTAL ILL HEALTH

A state of imbalance characterized by disturbance in a persons thoughts, feelings and behavior.

MENTAL DISORDER (AMERICAN PSYCHIATRIC ASSOCIATION, 1994)

THE SCIENCE IN PSYCHIATRIC NURSING

THE ART IN PSYCHIATRIC NURSING

The therapeutic use of self is considered as the art of Psychiatric Nursing.

THE CORE OF PSYCHIATRIC NURSING

THE CLIENTS IN PSYCHIATRIC NURSING

SAMPLE BOARD QUESTION NO.1

SAMPLE BOARD QUESTION NO.2

SAMPLE BOARD QUESTION NO.3

SAMPLE BOARD QUESTION NO.4

Nursing as an interpersonal process is?

SAMPLE BOARD QUESTION NO.5

Mental illness is?

THERAPEUTIC USE OF SELF

THERAPEUTIC USE OF SELF

THERAPEUTIC USE OF SELF

THERAPEUTIC USE OF SELF

FOUR QUADRANTS OF THE JOHARI WINDOW

CREATING A JOHARI WINDOW

CREATING A JOHARI WINDOW

FOUR QUADRANTS OF THE JOHARI WINDOW

FOUR QUADRANTS OF THE JOHARI WINDOW

both small, the person demonstrates little insight.

FOUR QUADRANTS OF THE JOHARI WINDOW

METHODS USED TO INCREASE SELF-AWARENESS

ENLARGING ONES EXPERIENCE

CORE CONCEPTS ON THE CARE OF THE PSYCHOTIC PATIENT

COMMON BEHAVIORAL SIGNS AND SYMPTOMS

Disturbances Disturbances Disturbances Disturbances Disturbances

Perception Thinking Affect Motor Activity Memory

DISTURBANCES IN PERCEPTION: ILLUSION

Misperception of an actual external stimuli

DISTURBANCES IN PERCEPTION: HALLUCINATION

DISTURBANCES IN THINKING: NEOLOGISM

Pathological coining of new words

DISTURBANCES IN THINKING: CIRCUMSTANTIALITY

Over inclusion of details.

DISTURBANCES IN THINKING: WORD SALAD

Incoherent mixture of words and phrases.

Example: Corn, potatoes, jump up, play games, grass, cupboard.

DISTURBANCES IN THINKING: VERBIGERATION

Example: I want to go home, go home, go home, go home.

DISTURBANCES IN THINKING: PERSEVERATION

DISTURBANCES IN THINKING: ECHOLALIA

Pathological repetition of words of others.

DISTURBANCES IN THINKING: FLIGHT OF IDEAS

DISTURBANCES IN THINKING: LOOSENESS OF ASSOCIATION

DISTURBANCES IN THINKING: CLANG ASSOCIATION

DISTURBANCES IN THINKING: DELUSION

DISTURBANCES IN AFFECT: INAPPROPRIATE AFFECT

Disharmony between the stimulus and the emotional reaction.