Psychiatric Nursing Notes by Dr. Fausto

Psychiatric Nursing
Prof. Rolando Y. Fausto, RN, MAN

BASIC CONCEPTS IN PSYCHIATRIC NURSING
MENTAL HEALTH
state of emotional, psychological,
and social wellness evidenced by
effective behavior and coping, (+)
self concept and emotional
stability.
Characteristics :
• attitude of self-acceptance
• growth, development and self-
actualization (maximization of one’s
potential)
• tolerance of life’s uncertainties
• autonomous behavior
• reality orientation
• environmental mastery
• stress management
MENTAL ILLNESS
• A state of imbalance characterized by a
disturbance in a persons’ thoughts, feelings
and behavior.
CHARACTERISTICS
• Dissatisfaction with one’s characteristics,
abilities, and accomplishments.
• ineffective or nonsatisfying relationships.
• dissatisfaction with one’s place in the
world.
• ineffective coping with life events.
• lack of personal growth
Poverty and abuses
are major factors which increases the risk of
mental illness in the home.
PSYCHIATRIC NURSING
• Interpersonal process
whereby the professional nurse
practitioner through the use of
self, assist an individual 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.
Science in Psychiatric Nursing.
• the use of different theories in the
practice of nursing, serves as the
science of psychiatric nursing.
Art in Psychiatric Nursing.

• The therapeutic use of self is
considered as the art of psychiatric
nursing.
Mental Hygiene.
• It is the science that deals with
measures to promote mental health,
prevent mental illness and suffering and
facilitate rehabilitation.
CORE CONCEPT
- It is the positive use of one’s self
in the process of therapy.
- It requires self-awareness.
BASIS OF THERAPEUTIC USE OF
SELF
JOHARIS WINDOW
Known to Not known to
self self
Known to Public self Semi-public self
others I II
Not known Private self Area of the
to others III unknown
IV
METHODS USE TO INCREASE
SELF AWARENESS
• INTROSPECTION
• DISCUSSION
• ENLARGING ONE’S
EXPERIENCE
• ROLE PLAY
Psychosocial Theories and
Therapy
Psychoanalytic Theorists
Pioneered by Sigmund Freud
(1856-1939) in Vienna.
THREE DIVISIONS OF THE MIND
CONSCIOUS – Part of the mind that is
focused on awareness.
SUBCONSCIOUS – Part of the mind that
contains information that can be recalled
at will.
UNCONSCIOUS – largest part of the
mind; contains materials and information
that can never be recalled
STRUCTURES OF PERSONALITY
• ID – has no sense of right and wrong;
funtions based on the pleasure
principles.
• EGO – integrator of the personality;
functions based on reality.
• SUPEREGO – the conscience;
functions based on morality.
THEORIES OF PERSONALITY
DEVELOPMENT
FREUD’S PSYCHOSEXUAL THEORY
0 – 18 MONTHS : ORAL STAGE
AREA OF GRATIFICATION : MOUTH
18 MONTHS – 3 YEARS OLD : ANAL
STAGE
AREA OF GRATIFICATION : BOWELS
3 – 6 YEARS OLD : PHALLIC STAGE
AREA OF GRATIFICATION : GENITALS
GENITALS
6 – 12 YEARS OLD : LATENCY (QUIET
STAGE)
AREA OF GRARIFICATION : NONE;
SEXUAL ENERGY IS DIVERTED TO
PLAY ACTIVITIES.
12 -21 YEARS OLD : GENITAL STAGE
AREA OF GRATIFICATION :
SECONDARY SEX CHARACTERISTICS;
REAWAKENING OF SEXUAL DRIVES
Psychoanalytic Theorists
(cont’d)
Deterministic theory that all human
behavior is caused and can be explained
Personality components conceptualized
as id, ego, and superego
Behavior motivated by subconscious
thoughts and feelings; treatment
involving analysis of dreams and free
association
Psychoanalytic Theorists (cont’d)
Ego defense mechanisms
Psychosexual stages of
development
Transference and
countertransference
Psychoanalysis is lengthy,
expensive, and practiced on a
limited basis today; however,
Freud’s defense mechanisms
remain current.
EGO DEFENSE MECHANISM
Developmental Theorists
Erik Erikson (1902-1994) was a
psychoanalyst who described
eight stages of psychosocial
development that are still widely
used today by many disciplines
Jean Piaget (1896-1980)
described cognitive and
intellectual development in
children in 4 stages:
sensorimotor, preoperational,
concrete operations, formal
operations.
ERIKSON’S PSYCHOSOCIAL
THEORY
0 – 12 MONTHS : TRUST VS
MISTRUST
• IF THE NEEDS OF THE CHILD
CONSISTENTLY MET, TRUST
DEVELOPS
1 – 3 YEARS OLD – AUTONOMY VS

SHAME AND DOUBT
• IF TOILET TRAINING IS NOT
HURRIED, AUTONOMY DEVELOPS
3 – 6 YEARS OLD – INITIATIVE VS GUILT
IF THE CHILDS’ SEXUAL CURIOSITY IS
HANDLED WITHOUT ANXIETY , INITIATIVE
DEVELOPS.
6 – 12 YEARS OLD – INDUSTRY VS

INFERIORITY
IF THE CHILDS’ EFFORT AT LEARNING IS
SUPPORTED, INDUSTRY DEVELOPS
12 – 18 YEARS OLD – IDENTITY VS
ROLE CONFUSION
IF THE ADOLESCENTS’ VOCATIONAL
DECISIONS IS SUPPORTED, IDENTITY
DEVELOPS.
18 – 25 YEARS OLD – INTIMACY VS
ISOLATION
IF THE ADOLESCENTS’ DECISION
REGARDING LOVE RELATIONSHIP IS
SUPPORTED, INTIMACY DEVELOPS.
25 – 65 YEARS OLD – GENERATIVITY
VS STAGNATION
IF AN ADULT ENJOYS’ SUPPORT
FROM FAMILY, GENERATIVITY
DEVELOPS.
65 AND ABOVE – INTEGRITY VS

DESPAIR
IF THE ELDERLY HAS A SATISFYING
PAST RECOLLECTION, INTEGRITY
DEVELOPS.
PIAGET’S COGNITIVE THEORY
0 – 2 YEARS OLD : SENSORY MOTOR
• DEVELOPMENT PROCEEDS FROM
REFLEX ACTIVITY TO SENSORY
MOTOR LEARNING.
• CHILD LEARNS THAT HE IS
SEPARATE FROM THE ENVIRONMENT.
• CHILD LEARNS THE CONCEPT OF
OBJECT PERMANENCE. e.g. : peek-a-
boo.
2 – 7 YEARS OLD : PRE-OPERATIONAL
STAGE
2 – 4 YEARS OLD : PRE-CONCEPTUAL –
DEVELOPMENT PROCEEDS FROM
SENSORY MOTOR LEARNING TO
PRELOGICAL THOUGHT.
THE CHILD LEARNS LANGUAGE AND
SYMBOLS
4 – 7 YEARS OLD : INTUITIVE THOUGHT
– THE CHILD IS ABLE TO THINK IN
TERMS OF CLASS.
- THE CHILD IS ABLE TO DETERMINE
THAT INDIVIDUALS HAVE ROLES.
7 – 12 YEARS OLD : CONCRETE

OPERATIONAL STAGE
DEVELOPMENT PROCEEDS FROM
PRE-LOGICAL TO LOGICAL
CONCRETE STAGE.
12 – ADULTHOOD : FORMAL
OPERATIONAL STAGE
• THE CHILD IS ABLE TO THINK
ABSTRACTLY, ABLE TO APPLY THE
SCIENTIFIC METHOD.
Interpersonal Theorists
Harry Stack Sullivan (1892-1949)
Interpersonal Theorists
Hildegard Peplau (1909-

1999)
Hildegard Peplau (1909-1999)
Leading nursing theorist and
clinician: developed the nurse-
patient relationship with phases
and tasks
Identified roles of the nurse:
stranger, resource person,
teacher, leader, surrogate,
counselor
Described four levels of anxiety
(mild, moderate, severe, panic)
still widely used today.
Humanistic Theorists
Abraham Maslow (1921-1970)

Hierarchy of needs: basic
physiologic needs, safety and
security needs, love and
belonging needs, esteem
needs, self-actualization
Carl Rogers (1902-1987)
Client-centered therapy
Concepts of unconditional positive
regard, genuineness, and empathetic
understanding
Behavioral Theorists
Behaviorism focuses on
behaviors and behavior
changes, rather than explaining
how the mind works. B. F.
Skinner, the most noted theorist
in this area, developed theory
and principles of operant
conditioning:
 All behavior is learned.
 Behavior has consequences
(reward or punishment).
 Rewarded behavior tends to
recur.
Behavioral Theorists
 Positive reinforcement increases
the frequency of behavior.
 Removal of negative reinforcers
increases the frequency of
behavior.
 Continuous reinforcement is the
fastest way to increase behavior;
random intermittent reinforcement
increases behavior more slowly but
with longer-lasting effect.
• Positive punishment – aversive
consequences decrease a particular
behavior.
• Negative punishment – withdrawing
reward decreases a particular behavior.
• Treatment modalities based on
behaviorism include behavior
modification, token economy, and
systematic desensitization
Existential Theories
Cognitive therapy focuses on
immediate thought processing and is
used by most existential therapists.
Albert Ellis founded rational emotive
therapy, based on the idea that
people make themselves unhappy
through “irrational beliefs and
automatic thinking”—the basis for
the technique of changing or
stopping thoughts. Viktor Frankl
developed logotherapy in the belief
that life must have meaning and
therapy is the search for that
meaning.
Existential Theories (cont’d)
Gestalt therapy (Frederick “Fritz” Perls)
emphasizes self-awareness and identifying
thoughts and feelings in the here and now.
Reality therapy (William Glasser) focuses on
the person’s behavior and how that behavior
keeps the person from achieving life goals.
Existential theorists believe that deviations
occur when the person is out of touch with self
or environment; thus, the goal of therapy is to
return the person to an authentic sense of self.
Examples of Cognitive technique
1.Cognitive restructuring – teaching the

client maladaptive thoughts through
positive self-statements and refuting
irrational beliefs.
2.Thought s stopping – the client is taught
to consciously to say “stop” to maladaptive
thoughts.
PSYCHOBIOLOGY
- Is the scientific study
of the
relationships among the structure
and function of the brain,
biochemical and hormonal
processes, genetics, environmental
experiences, and human behavior
Neuroanatomy and Behavior
1.Frontal lobe – is responsible for higher
order thinking, abstract reasoning, decision –
making, speech, and voluntary muscle
movements. Dysfunction is associated with
illogical and psychotic thinking, uninhibite
behaviors and incoherent speech.
2.Occipital lobe – is responsible for visual
function. Dysfunction is associated with
illusions and visual hallucinations.
3. Temporal lobe – is responsible
for judgment, memory, smell,
sensory interpretation, and
understanding sound. Dysfunction is
associated with aggressive and
violent behaviors, olfatory and
auditory hallucinations and
language abnormalities.
Diencephalon – is embedded in the
cerebrum is superior to the brain stem. It is
composed of several structures:
1.Hypothalamus – is the main visceral
control center of the body and is vitally
important to homeostasis. It regulates the
autonomic nervous system, body
temperature, food intake, water balance,
biologic rhythms and drives, and hormonal
output of the anterior pituitary gland
2. Thalamus – receives and relays sensory
information and plays a role in memory
and in regulating mood.
3. Limbic system – comprises the limbic

lobe and the numerous structures
functioning with it, including the frontal
cortex, hypothalamus, amygdala,
hippocampus, brain stem, and
autonomic nervous system. Called the
emotional brain the limbic system
emotional responses
Neurotransmitters and receptor sites
1. Neurotransmitters are chemical
messengers that carry an inhibitory or
stimulating message from one neuron to
another across the space between these
(synapse). Many psychiatric disorders are
associated with abnormal interactions
between neurotransmitter system.
• Serotonin – is involved in depressive and
anxiety disorders, and possibly in eating
disorders. Many antidepressants increase
levels of serotonin at synaapses.
• Dopamine – is involved in schizophrenic
disorders. Many antipsychotic drugs block
dopamine at the post synapse to prevent it
from binding to its receptors.
• Norepinephrine – is a catecholamine
neurotransmitter of the symphatetic nervous
system, which mediates emergency response.
Changes in norepinephrine levels are
associated with depressive disorders,
including bipolar disorders.
• Gamma aminobutyric acid (GABA) – is
an inhibitory neurotransmitter. Antianxiety
drugs increase effects of GABA.
• Acetylcholine – is a major neurotransmitter
of the parasympathetic nervous system,
which controls muscles, memory, and
coordination. Changes in acetylcholine are
associated with Alzheimer disease
Hormonal Influence
• Hypothalamic-pituitary-adrenal axis (HPA)
has been found to be hyperactive in individuals
with depressive disorders.
• Underactive thyroiid gland – is linked to
depression
• Stress response – is a neuroendocrine
response, that causes significant release of
hormones, which affects multiple body
systems and can lead to psychological and
physiological symptoms.
Biology and Environment. Research is

ongoing about how an individual’s affects
brain development and functioning.
• Early life experiences (e.g. psychological
and physical abuse) can alter brain
structure and affect production of hormones
and neurotransmitters, which can be related
to symptoms of mental disorders in later life.
• Seevere abuse in early life (e.g., physical
or sexual abuse in infancy and early
childhood) can permanently increase gene
expression for corticotropin-releasing factor
(CRF) and increase risk for depression in
adulthood
Kindling model proposes that repeated
environmental lead to progressively greater
nueral responsiveness, which changes brain
excitability and therefore behavioral
responses o, ver time (Post, 1997). Example,
an early life experience can contribute to an
initial experience of mental illness, which is
hypothesized to increase sensitivity of the
brain and thus predispose to later episodes
of mental illness, given continued life
stressors.
Crisis Intervention
Caplan (1964) described 4 stages of crisis:
exposure to stressor; increased anxiety when
customary coping is ineffective; increased
efforts to cope; disequilibrium and significant
distress. Crises can be maturational,
situational, or adventitious; last 4-6 weeks;
outcome is either return to previous
functioning level, improved coping, or
decreased coping.Crisis intervention
techniques are authoritative. A balance of both
types is most effective.
CRISIS AND CRISIS
INTERVENTION
CRISIS – Situation that occurs when an

individual ‘s habitual coping ability
becomes ineffective to meet the
demands of a situation.
CHARACTERISTICS OF CRISIS
Highly individualized
Lasts for 4 -6 weeks
Person affected becomes passive and
submissive
Affects a persons’ support system
Ineffective coping mechanism
realistic perception is affected
TYPES OF CRISIS
MATURATIONAL/DEVELOPMENTAL
CRISIS – Expected, predictable and
internally motivated. E.g.; Growth,
parenthood
SITUATIONAL/ACCIDENTAL –
Unexpected, unpredictable and
externally motivated. E.g.; Car accident
SOCIAL CRISIS – Due to acts of nature.
E.g. earthquake, tidal waves.
MIXTURE OF
DEVELOPMENTAL/SITUATIONAL –
Rape victim who become pregnant.
CRISIS INTERVENTION
A way of entering into the life situation of
an individual, family, group, or community
to help them mobilize their resources to
decrease the effect of a crisis including
stress.
GOAL OF CRISIS INTERVENTION

To enable the patient to attain an
optimum level of functioning.
PHASES OF CRISIS
Denial – initial reaction
Increased Tension – the person
recognizes the presence of crisis and
continues to do ADL
Disorganization – the person is
preoccupied with the crisis and is unable
to do ADL
Attempts to reorganize – mobilizes
previous coping mechanisms.
MENTAL STATUS EXAMINATION
A – appearance
B – behavior
C – communication
J – judgment
O – orientation
I – insight
M – memory
A – affect
T – thought process/thought content
COMMON BEHAVIORAL SIGNS
AND SYMPTOMS
1. Disturbances in perception:
Illusion – misperception of an actual
external stimuli.
Hallucination – false sensory
perception in the absence of external
stimuli.
2. Disturbances in thinking:
Neologism – pathological coining of
new words.
Circumstantiality – over inclusion
of details.
Word salad – incoherent mixture
of words and phrases.
Verbigeration – meaningless
reception of words or phrases.
Perseveration – persistence of a
response to a previous question.
Echolalia – pathological repetition
of words of others.
Flight of ideas – shifting of one
topic form one subject to
another in a somewhat related
way.
Looseness of association –
shifting of a topic from one
subject to another in a
completely unrelated way.
Clang association – the sound of
the words gives direction to the
flow of thought.
Delusion –false belief which is
inconsistent with one’s knowledge
and culture and cannot be
corrected by reasons.
Thought broadcasting – a
delusional belief that others can
hear or know what the client is
thinking.
Thought insertion – a
delusional belief that others are
putting ideas to client’s head
Thought withdrawal – a delusional belief
that others are taking the client’s
thoughts away and the client is
powerless to stop it.
3. Disturbances of affect.
Inappropriate affect – disharmony between
the stimuli and the emotional reaction.
Flat affect – absence or near absence of
emotional reaction.
Apathy – dulled emotional tone.
Blunted affect – severe reduction
in emotional reaction.
Ambivalence – presence of two
opposing feelings.
Depersonalization – feeling of
strangeness towards one’s self
Derealization – feeling of
strangeness towards the
environment
4. Disturbances in motor activity
Echopraxia – the pathological
imitation of posture/action of
others.
Waxy flexibility – maintaining the
desired position for long periods
of time without discomfort.
5. Disturbances in memory.
Confabulation – filling in memory
gap.
Amnesia – inability to recall past
events.
Anterograde amnesia – loss
memory of the immediate past.
Retrograde amnesia – loss of
memory of the distant past.
Déjà vu – feeling of having been
to place which one has not yet
visited.
Jamais vu – feeling of not
having been to a place which
one has visited.
THERAPEUTIC RELATIONSHIPS
-It is a nurse-client interaction that is
directed toward enhancing the client’s well
being. The client coul be an individual,
family or community.
Elements of the therapeutic relationships
1. Contract – time, place, settings and the
purpose of the meetings as well as the
conditions for termination are established
between the nurse and the client.
2. Boundaries – The therapeutic nature of
the relationships (as it differ from social
relationships) are established.
- Roles of participants are clearly defined.
- The nurse is considered as a professional
helper.
- The client’s needs and problems are the
main concern.
3. Confidentiality – This is the basic
condition that the nurse should maintain in
the therapeutic relationships
- The nurse shares client’s information to
those who have a direct participation in the
client’s care.
- The nurse shall ask a written permission
from the client to share information to others
that is outside the health care team.
4. Therapeutic nurse behaviors – Are
behaviors that a nurse must maintained
during the relationships and should be
consistent with the following:
- Self-awareness
- Unconditional positive regard (respect)
- Empathy
- Cultural sensitivity
- Collaborative goal setting
- responsible ethical practice
PHASES
A. PRE-INTERACTION PHASE
• Begins when the nurse is assigned to a
patient.
• Phase of NPR in which the patient is
excluded as an active participant
• Nurse feels certain degree of anxiety
• Includes all of what the nurse thinks and
does before interacting with the patient
• Major task of the nurse: develop self
awareness
• Data gathering, planning for first
interaction
B. ORIENTATION PHASE
• Begins when the nurse and the patients
interacts for the first time
• Parameters of the relationship are laid
• Nurse begins to know about the patient
• Major task of the nurse: develop a
mutually acceptable contract
• Determine why the patient sought help
• Establish rapport, develop trust,
assessment
C. WORKING PHASE
• It is highly individualized
• More structured than the orientation
phase
• The longest and most productive phase
of the NPR
• Limit setting is employed
• Major task: Identification and
resolution of the patient’s problems
• Planning and implementation
D. TERMINATION PHASE
• It is a gradual weaning process
• It is a mutual agreement
• It involves feelings of anxiety
• It should be recognized in the orientation
phase
• Major task: to assist the patient to review
what he has learned and transfer his
learning to his relationship with others
• Evaluation
When to Terminate?
• When goals have been accomplished
• When the patient is emotionally stable
• When the patient exhibits greater
independence
• When the patient able to cope with
anxiety separation, fear and loss
How to Terminate?
• Gradually decreased interaction time
• Focus on future oriented topics
• Encourage expression of feelings
• Make the necessary referral
BASIC ELEMENTS
Sender – originator of the message
Receiver – recipient of information.
Channel – mode of communication.
Feedback – return response.
Context – the setting of
communication.
Criteria of successful communication:
Feedback
Appropriateness
Flexibility
Efficiency
Nonverbal Aspects of therapeutic
Communication
• Kinetics are body movements, such as
postures, facial expressions, and
mannerisms
• Proxemics – are the physical spaces
between communicators
- intimate space – o to 18 inches
- 18 inches to 4 feet
- social space – more than 4 feet to 12
feet
- Public space – more than 12 feet
• Touch – can be use as therapeutic
communication provided that the nurse
should analyze the client’s condition and
the client’s likely response (should be use
with cautions). Specially to clients who are
paranoid and mistrustful.
Common problems in
communication
• Dysfunctional communication
• Double blind communication
• Differences between the denotative
and connotative meaning.
• Incongruent communication.
Common Techniques in
Communication
To initiate conversation:
- Giving broad opening: giving the
client to take the initiative in
introducing the topic.
Example: “Is there anything that you
want to talk about?”
“Where would you like to begin?”
-Giving recognition: acknowledging,
indicating awareness.
Example: “I noticed that you combed
your hair today.”
Good morning, Mr. S…”
To Establish Rapport and Build

Trust
- Giving information: making available
the facts that the client needs.
Example: “Visiting hours are…”
-Use of silence: refraining from speech
to give the patient a time to sort out
thoughts and feelings.
-Example: Nurse says nothing but
continues to maintain eye contact
and conveys interest.
To Gather Information
- Focusing: concentrating on a single
topic.
Example: Client: “ This point seems
worth looking at more closely.”
Nurse: “Of all the concerns you
mentioned, which is most
troublesome.”
- Validating: confirming one’s
observation.
Example: “Are you saying that…”
- Reflecting: directing client actions,
thoughts and feelings back to the client
Example: Client: “My sister spends all
my money and then has the nerve to
ask for more.”
Nurse: “This causes you to feel angry?”
Restating: repeating the main idea
expressed. Nurse repeats what the
client has said approximately or nearly
the same words the client has used.
Example: Client: “I can’t sleep. I stay
awake all night.”
Nurse: “You have difficulty sleeping.”
Client: “I’m really mad, I’m really
upset.”
Nurse: “You’re really mad and upset.”
•Summarizing: developing a
concise resume of what has
transpired
* The primary purpose of
communication is to: Give
information
COMMON PROBLEMS AFFECTING
COMMUNICATION
Transference – the development of an
emotional attitude of the patient either
positive or negative towards the nurse
Resistance – development of
ambivalent feeling towards self-
exploration
Counter transference – as
experienced by the nurse
LEVELS OF INTERVENTIONS IN
PSYCHIATRIC NURSING
• Primary – 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 – Intervention that limit the
severity of a disorder
Two components
1. Case finding
2. Prompt treatment
Examples: Crisis intervention
Administration of medications
Tertiary – interventions aimed at
reducing severity of mental disorder
and its associated disability through
rehabilitative activities.
Two components
1. Prevention of complication
2. Active program of rehabilitation
Examples: Alcoholic anonymous

Occupational therapy
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 tools appropriately
Unconditional positive regard –
RESPECT
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 patient’s
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
BASIC CONCEPTS ON
PSYCHOPHARMACOLOGY
• M-edicaion classification.
• E-ffectiveness of the drug.
Setting of parameters.
• D-ue time. Exact time the drug
should be given. Before
meals, after meals, empty
stomach or without regards to
meal
• S-afely give the drug. Identify
intervention for side/adverse
effect.
• Teachings – What to expect?
Should be able to give instructions
to the client about the therapeutic
effect and side effect of the drug.
Psychopharmacolgic agents
Tranquilizers/antipsychotic/neuroleptics
Common indication : Schizophrenia
Examples:
Old generation/Typical
Haloperidol (Haldol)
Prochlorperazine (Compazine)
Fluphenazine (Prolixin)
Chlorpromazine (Thorazine)
New Generation/Atypical
Clozapine (Clozaril)
Olanzapine (Zyprexa)
• Antipsychotic
• Decreased delusions,
hallucinations, and looseness of
association
• Best taken after meals
• Report sore throat and avoid
exposure to sunlight. Report
elevated temp. and muscle
rigidity,unstable BP, diaphoresis,
pallor. it indicate Neuroleptic
Malignant Syndrome.
Check the BP, the drug causes hypotension.
Observe for EPS,
check the CBC, drug causes leukopenia
Target: Dopamine
B. Anti-Parkinsonian drugs
Indication: EPS (Extrapyramidal
Syndrome)
Two Types:
1. DOPAMINERGIC DRUGS
Ex: Amantadine (Symmetrel)
Levodopa
Levodopa-Carbidopa (Sinemet)
2. ANTICHOLINERGIC DRUGS
Ex: Trihexylphenidyl HCL (Artane)
Biperiden Hydrochloride (Akineton)
Benztropine Mesylate (Cogentin)
Diphenhydramine Hydrochloride
(Benadryl)
• Antiparkinsonian drug
Muscles become less stiff; decreased
pill-rolling tremors
• Avoid driving, the drug causes blurred
vision
• Check the BP, the drug may cause
hypotension
C. Minor Tranquilizers/Anxiolytics
Common indication: Anxiety D/O
Ex: Diazepam (Valium)
Oxazepam (Serax)
Chlodiazepoxide (Librium)
Chlorazepate Dipotassium
(Tranxene)
Alprazolam (Xanax)
• Antianxiety; given as muscle relaxant to
patient’s in traction
• Decreased anxiety, adequate sleep
• Best taken before meals, food in the
stomach delays absorption
• Avoid driving, intake of alcohol and
caffeine containing foods, since it alters the
effect of drug
• Administer it separately, it is incompatible
with any drug
D. Tricyclic Antidepressants
Examples: Imipramine Hydrochloride
(Tofranil)
Amitriptyline (Elavil)
• Tricyclic anti-depressant; prevents the
reuptake of norepinephrine
• Increased appetite; adequate sleep
• Best given after meals
• Therapeutic effects may become evident only
after 2 – 3 weeks of intake
• Check BP, it causes hypotension, Check the
heart rate, it causes cardiac arrythmias, it also
causes constipation.
•Target: Norepinephrine
Serotonin
E. Antidepressant MAO inhibitors
Ex: Tranylcypromine (Parnate)
Phenelzine (Nadril)
Isocarboxazid (Marplan)
• Antidepressant MAO
inhibitors
• Increased appetite; adequate
sleep
• Report headache; it indicates
hypertensive crisis, avoid tyramine
containing foods like:
Avocado
Banana
Cheddar and aged cheese
Soy sauce and preserved foods
• It takes 2 – 3 weeks before initial
therapeutic effects become noticeable
• Monitor BP, There should be at
least a two week interval when
shifting from one antidepressant to
another
Note: If not, it will cause Serotonin
Syndrome.
F. Anti – Manic Agent
Lithium Carbonate
• Anti- Manic
• Decreased hyperactivity
• Increase fluid intake (3L / day) and
sodium intake (3 gm / day). Avoid
activities that increase perspiration
• It takes 10 – 14 days before therapeutic effect
becomes evident. Antipsychotic is administered
during the first two weeks to manage the acute
symptoms of mania until lithium takes effect.
Monitor serum level, normal is 0.5 – 1.5 meq/L,
Therpeutic level is 0.8 – 1.2 meq/L NAUSEA,
AOREXIA,VOMITING, WEAKNESS,
DIARRHEA, AND ABDOMINAL CRAMPS
indicates Lithium Toxicity, Mannitol is
administered if toxicity occurs.
ELECTRO-CONVULSIVE THERAPY
• Mechanism of action: Unclear at present.
• Voltage applied to the patient: 70 – 150
volts
• Duration of application: 0.5 – 2 seconds
• Usual number of treatments to produce
therapeutic effect: 6 – 12 treatments
• Frequency of treatments: An interval of
48 hours for each treatment.
• Indications of effectiveness: Generalized
tonic-clonic seizure
• Indication for ECT: Depression, Mania,
Catatonic Schizophrenia
• Contraindication to ECT: Fever, Increased
ICP, Cardiac problems,
TB with history of hemorrhage, Recent
fracture, Retinal detachment, Pregnancy.
• Consent needed prior to ECT: YES
Medication prior to ECT (Modified type)
Atropine Sulfate – to decrease secretions
Anectine (Succinylcholine) – to promote
muscle relaxation
Methohexital Sodium (Brevital) – serve as an
anesthetic agent
COMMON COMPLICATIONS: Loss of
memory, Headache, Apnea, Fracture (Long
Bones), Respiratory depression.
COMMON PSYCHOTHERAPEUTIC
INTERVENTIONS
• REMOTIVATION THERAPY –
treatment modalitythat promotes
expression of feeling through
interaction facilitated by discussion
of neutral topics.
5 Different Steps
1. Climate of acceptance
2. Creating of bridge of reality
3. Sharing the world we live in
4. Appreciation of the works of the
world
5. 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.
FAMILY THERAPY – a method of
psychotherapy which focuses on the total
family as an interactional system.
•MILIEU THERAPY – consists of
treatment by means of controlled
modification of the patients environment
to facilitate positive behavioral change.
•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 therapy
is 3, while the ideal number is 8 – 10.
•PSYCHOANALYSIS – a method of
psychotherapy which focuses on the
exploration of the unconscious, to facilitate
identification of the patient’s defenses.
• HYPNOTHERAPY – a therapeutic
modality which involves various methods
and techniques to includes a trance state
where the patient becomes submissive to
instructions.
HUMOR THERAPY – involves the use
of humor to facilitate expression of
feelings and to enhance interaction.
• BEHAVIOR MODIFICATION – a
therapeutic intervention involving the
application of learning principles in
order to change maladaptive behavior.
• TOKEN-ECONOMY – an example of
behavior modification technique which
utilizes the principle of rewarding
desired behavior to facilitate change.
• 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 change in behavior.
• DESENSITIZATION – periodic
exposure of the individual to a
feared object, until the undesirable
behavior disappears or is lessened.
ANXIETY AND ANXIETY RELATED
DISORDERS
Anxiety - is a vague feeling of
dread that is unwarranted by the
situation, with no identifiable
stimulus, accompanied by feelings
of uneasiness and apprehension.
COMPONENTS OF PERSONALITY
• ID – pleasure principles, gratification
of needs, urges and wants.
• EGO – reality principles, represents
“self”, “I”, referee, arbiter, balancer
between the ID and SUPEREGO
conflicts.
• SUPEREGO – moral principles,
values, what is right and what is
wrong, mostly parent’s introjected
values.
ANXIETY–it is the product of conflicts
between the ID and SUPEREGO
EGO defense mechanisms

• these are utilize when anxiety occurs
• it is use to safeguard the self-
esteem of an individual.
• it is mentally healthy because it
reduces anxiety.
• it is a way of coping with
psychological stress.
CAUTIONS:
• Over utilization of ego defense
mechanisms preclude learning more
adaptive coping.
• It overshadows reality when
overused.
• It will lead to maladaptive coping
when utilized excessively.
• Over utilization eventually will lead
to mental disorders.
• Mental disorders replaces adaptive
coping in dealing with anxiety.
Working with Anxious Clients
• Mild anxiety is an asset; can learn and
solve problems effectively; receptive to
teaching and suggestions. Perceptual fields
are widely open.
• Moderate anxiety can cause client’s
attention to wander; nurse must redirect
client back to topic and validate client has
heard and understood. Perceptual fields
become narrowed.
• Severe anxiety causes impairment of
many abilities; cannot learn or problem-
solve; nurse must calm client and focus on
lowering anxiety level. Perceptual fields are
closed.
INCIDENCE
• Anxiety disorders are the most common

psychiatric disorders.
• More prevalent in women
• More common in annulled and separated
persons
• More common in persons of lower
socioeconomic status
• Onset and clinical course are
variable.
• Anxiety can be communicated
nonverbally from one person to
another.
• Defense mechanisms are used to
reduce anxiety; when overused they
preclude learning more adaptive
coping skills.
• Physiologic responses can include
sympathetic stimulation (fight-or-
flight), discomfort, difficulty thinking
clearly, agitated motor activity,
tension headaches.
ETIOLOGY
• Biologic theories: Anxiety may have

an inherited component.
Neurotransmitters may be
dysfunctional in persons with anxiety
disorders.
• Psychodynamic theories: overuse of
defense mechanisms; results from
problems in interpersonal
relationships; as “learned” behavioral
response
TREATMENT
• Usually involves a combination of
medication (anxiolytics and
antidepressants) and therapy.
• Cognitive-behavioral therapy
includes positive reframing (turning
negative messages into positive ones)
and decatastrophizing (making a more
realistic appraisal of the situation).
• Assertiveness training helps the
client learn to negotiate interpersonal
situations more successfully.
PANIC DISORDER
Involves 15- to 30-minute episodes of
intense, escalating anxiety with
emotional fear and physiologic
discomfort.
Characteristics
• Client feels unreal and detached
from self during attack.
•Fears losing control or going insane
• Has temporarily disorganized
thought process, feels he or she is
dying
• Judgment is poor during an attack.
• Anticipation of attacks causes the
person to limit social activities and
may interfere with work, relationships,
family life.
Data Analysis
Nursing diagnoses include:
Risk for Injury
Anxiety
Fear
Social Isolation
Data Analysis (cont’d)
Situational Low Self-Esteem

Ineffective Coping
Powerlessness
Ineffective Role Performance
Disturbed Sleep Pattern
Intervention
• Promoting safety and comfort
• Using therapeutic communication
• Managing anxiety
• Client and family teaching
PHOBIAS
A phobia is an illogical, intense,

persistent fear of a specific object or
social situation that causes extreme
distress and interferes with normal life
functioning.
• Specific phobia is irrational fear of
an object or situation, such as storms,
heights), seeing blood or receiving an
injection, or others.
• Social phobia involves severe
anxiety, even panic, when confronted
with situations involving people,
eating in public, using public
bathrooms, or being the center of
attention.
Etiology
• Biologic (phobias run in families,
hormonal functions, or
neurotransmitter activity)
• Psychodynamic (faulty thinking,
belief one doesn’t control the
environment, or learned by modeling
from parents)
Treatment and Prognosis

Psychopharmacology: anxiolytics;
SSRI antidepressants; beta blockers
to slow heart rate and lower blood
pressure
• Behavioral therapies include
systematic desensitization and
flooding.
OBSSESSIVE-COMPULSIVE
DISORDER
•Obsessions are recurrent, persistent,
intrusive, and unwanted thoughts,
images, or impulses that cause
marked anxiety and interfere with
interpersonal, social, or occupational
functioning.
• Compulsions are ritualistic or
repetitive behaviors or mental acts
that a person carries out continuously
in an attempt to neutralize anxiety,
such as repeated checking or counting
rituals, excessive hand washing,
repeating words, touching rituals,
symmetry rituals, cleanliness, and so
forth. The person knows the rituals
are unreasonable but feels forced to
continue them in an attempt to relieve
anxiety caused by obsessions.
Treatment is most successful
with behavior therapy and medication
(SSRI antidepressants, fluvoxamine,
clomipramine, buspirone,
clonazepam). Behavior therapy
techniques used are exposure
(confronting anxiety-provoking
stimuli) and response prevention
(delaying or avoiding ritual
performance).
APPLICATION OF NURSING
PROCESS FOR OCD
Assessment
Client assessment focuses on
what behaviors or rituals are
performed when and how often,
client’s response, and so forth to
discover the pattern of behavior.
Data Analysis
• Anxiety
•Ineffective Coping
• Fatigue
• Situational Low Self-Esteem
• Impaired Skin Integrity (if scrubbing
or washing rituals
Intervention
• Using therapeutic
communication
• Teaching relaxation and
behavioral techniques
• Completing a daily routine
• Providing client and family
education
• GENRALIZED ANXIETY
DISORDER
•Excessive worry and anxiety that is

unwarranted more days than not.
• Seen most often by family
physicians
• Treated with SSRI antidepressants
and buspirone.
CLINICAL PICTURE OF ABUSE AND
VIOLENCE
Abuse is the wrongful use and
maltreatment of another person; can
be child, spouse, partner, or elder
parent.
Victims of abuse and trauma can have
both physical and psychological
injuries that might include:
• Agitation anxiety, silence
• Suppressed anger or resentment
• Shame and guilt
• Feelings of being degraded or
dehumanized; low self-esteem
• Relationship problems; mistrust of
authority figures
CHARACTERISTICS OF VIOLENT
FAMILIES
• Social isolation
• Power and control by abusive person
• Alcohol and other drug use
• Intergenerational transmission
process
CULTURAL CONSIDERATION
• Domestic violence occurs in families

of all ages and from all ethnic, racial,
religious, socioeconomic, and sexual
orientation backgrounds.
SPOUSE OR PARTNER ABUSE
• Involves the mistreatment of one

person by another in the context of
an intimate relationship
• 90% to 95% of domestic violence
victims are women.
• Pregnancy escalates domestic
violence.
• Abuse can occur in same-sex
relationships.
Treatment and Intervention
• Domestic violence laws varies and
are not always followed.
• Women may stay in abusive
relationships for fear of violence to
children, fear of increased violence or
death, financial dependence.
• Identifying women in violent
situations is a priority. More health
care agencies are beginning to ask
routine screening questions of all
women.
Treatment and Intervention (cont’d)
• Providing women with information

about shelters, services, and so forth
is essential.
• The nurse must never indicate that
he or she thinks the woman should
leave the relationship; need to keep
the door open for further
communication.
CHILD ABUSE
Child abuse is intentional injury of a
child. It may include physical abuse or
injuries, sexual assault or intrusion,
neglect or failure to prevent harm
(failure to provide adequate physical
or emotional care or supervision,
abandonment), or psychological
abuse. We have mandatory child
abuse reporting laws that include
nurses.
Parents who abuse children:
• Have minimal parenting knowledge
& skills
• Are emotionally immature and needy
• Are incapable of meeting their own
needs, much less those of a child
• Often raise their children the way
they were raised, including corporal
punishment and abuse
• Expect the child to meet all their
needs for love and affection
Assessment
Suspect child abuse when there are:
• Unusual injuries such as scalding
and cigarette burns
• Delays in seeking treatment;
inconsistent history, or illogical
explanation for the injuries
• Urinary tract infections, red, swollen,
or bruised genitalia, tears of vagina or
rectum
• Old injuries that were not treated
• Multiple, unexplained bruises
Treatment and Intervention
• Getting the child to a safe place

once abuse is identified
• Family therapy
• Individual therapy for the child
• Intensive involvement of social
service agencies
• Treatment for parents for any
substance abuse or psychiatric issues
ELDER ABUSE
Elder abuse is maltreatment of older
adults by family members or
caretakers and can include physical,
sexual, or psychological abuse,
neglect, self-neglect, financial
exploitation, or denial of adequate
medical treatment.
• 60% perpetrators are spouses, 20%
adult children, 20% others.
• People who abuse elders are almost
always in a caretaker role.
Charateristics
• Malnourished, dehydrated
• Rashes, sores, lice
• Elders are reluctant to report abuse
because they fear the alternative (nursing
home).
•Reluctance to talk openly
• Helplessness
• Withdrawal or depression
• Anger or agitation
• Smell of urine, feces, dirt
• Failure to keep needed medical
appointments
• Untreated medical condition
• Inability to manage own finances
• Inability to perform activities of daily
living
•Inadequate clothing
• Inability to manage money
• Unusual activity in bank accounts
• Different signatures on checks
• Recent changes in will that client could not
make
Possible indicators of abuse by
caregiver:
• Caregiver speaks for the elderly
person.
• Caregiver shows indifference or
anger.
• Caregiver blames elderly person for
physical problems.
• Caregiver shows defensiveness.
• Caregiver and client give conflicting
accounts
RAPE
Rape is a crime of violence and
aggression expressed through sexual
means. The act is against the victim’s
will or against someone who cannot
give consent. The victim can be any
age. Half of rapes are committed by
someone known to the victim. Rape is
underreported to the police. Same-sex
rape can occur between partners but
is most common in institutions.
Male rapists have been
categorized as:
• Sexual sadists aroused by pain
of victim
• Exploitative predators
• Inadequate men
• Those who rape as a displaced
expression of anger and rage
Physical and psychological trauma
to rape victims is severe:
• Medical problems: victims are
significantly less healthy;
pregnancy, STDs, HIV are
concerns.
• Victim may feel frightened,
helpless, guilty, humiliated, and
embarrassed; may avoid
previously pleasurable activities.
•Relationship problems may occur.
Treatment and intervention
include:
• Immediate support to ventilate

fear and rage
• Care by persons who believe
that the rape happened
• Coordination of all needed
services in one location
Treatment and intervention
include:
•Giving the victim control over

choices whenever possible
• Prophylactic treatment for STDs
• Referral to therapy services;
counseling, and groups for longer-
term help
PSYCHIATRIC DISORDERS
RELATED TO ABUSE AND
VIOLENCE
•Two psychiatric disorders are
associated with histories of
violence and abuse:
posttraumatic stress disorder
(PTSD) and dissociative
disorders.
PTSD
Is disturbing behavior resulting
after a traumatic event at least 3
months after the trauma occurred. Up
to 60% of persons at risk (combat
veterans, victims of violence, and
natural disasters) develop PTSD. It
includes persistent nightmares,
memories, flashbacks, emotional
numbness, insomnia, irritability,
hypervigilance, and angry outbursts.
Dissociative Disorders
Dissociation is a subconscious
defense mechanism that helps a
person protect the emotional self
from recognizing the full impact of
some horrific or traumatic event by
allowing the mind to forget or
remove itself from the painful
situation or memory. Dissociation
can occur both during and after the
event and becomes easier with
repeated use.
• Amnesia
• Fugue
• Dissociative identity disorder
(formerly multiple personality
disorder)
• Depersonalization disorder
Treatment and Interventions
• Involvement in group and/or
individual therapy in the
community
• Clients with dissociative
disorder or PTSD are seen in the
acute setting for brief periods
when symptoms are severe or
there is concern for their safety.
APPLICATION OF NURSING PROCESS
Assessment (PTSD)
• Often includes history of trauma or
abuse
• Client often appears hyperalert.
• Mood and affect: client is fearful and
anxious; needs large personal space;
has a wide range of emotions.
• Thought processes and content:
nightmares, flashbacks, destructive
thoughts or impulses
Assessment (cont’d)
• Sensorium and intellectual
processes: disorientation (during
flashbacks), memory gaps
• Judgment and insight: Impaired
decision-making and problem-solving
abilities
• Self-concept: client has low self-
esteem.
ASSESSMENT (cont’d)
• Roles and relationships:

problems with relationships,
work, authority figures.
• Physiologic considerations:
difficulty sleeping, under- or
overeating, use of alcohol or
drugs for self-medication
Data Analysis
• Risk for Self-Mutilation

• Ineffective Coping
• Post-Trauma Syndrome
• Chronic Low Self-Esteem
• Powerlessness
Intervention
• Promoting the client’s safety

• Helping the client cope with
stress and emotions using
grounding techniques
• Helping to promote the client’s
self-esteem
• Establishing social support
SEXUAL DISORDERS
FOUR ASPECTS OF SEXUALITY
• Genetic identity – person’s
chromosomal gender
• Gender identity – person’s
perception of his or her own maleness
or femaleness.
• Gender role – cultural role attributes
of one’s gender, such as expectations
regarding behavior, cognitions,
occupations, values, and emotional
responses.
Sexuality orientations
Heterosexuality- sexual attraction to
opposite sex.
Homosexuality – sexual attraction to
members of the same sex.
Bisexuality – attraction to both men
and women.
Transvestism – cross-dressing, or
dressing in the clothes of the opposite
sex.
Transexual – going from one sex to
another
• Sexual orientation – gender to which
one is romantically attracted.
Sexual Response Cycle
Stage 1: Desire
Sexual fantasies and the desire for
sexual activity.
Stage 2: Excitement
Subjective sense of sexual pleasure
along with physiological changes,
including penile erection in the male
and vaginal lubrication in the female
Stage 3: Orgasm
Peaking of sexual pleasure and the
release of sexual tension accompanied
by rhythmic contractions of the
perineal muscles and pelvic
reproductive organs.
Stage 4: Resolution
Sense of general relaxation, muscular
relaxation, and well-being. Females
may be able to respond to additional
stimulation almost immediately during
this stage.
Common Problems:
Females
• Lack of orgasm
• Vaginismus
Males
• Erectile dysfunction
• Ejaculatory disorders
- premature
- inhibited
- retrograde
Sexual Dysfunctions
• Hypoactive sexual desire disorder
• Female sexual arousal disorder
• Male erectile disorder
• Female orgasmic disorder
• Male orgasmic disorder
• Premature ejaculation
• Dyspareunia
• Vaginismus
Paraphilias
• Exhibitionism
• Fetishism
• Frotteurism
• Pedophilia
• Sexual masochism
• Sexual sadism
• Transvestic fetishism
• Voyeurism
Gender Identity Disorders
Childhood, adolescence, or adulthood
• persistent and intense distress about
being a male or a female, with an
intense desire to be the opposite sex,
a preoccupation with the activities of
the opposite sex, and a repudiation of
one’s own anatomical structures.
SUBSTANCE ABUSE
Substance abuse (using a drug
in a way that is inconsistent
with medical or social norms
and despite negative
consequences) is a major
concern nationwide.
14% of adults have an alcohol-
related disorder.
6.2% have a substance-related
disorder (excluding nicotine).
Adolescent substance abuse is
rising.
Increasing numbers of
babies are being born to
substance-addicted
mothers.
Half of all persons seeking
alcohol-related treatment
have at least one alcoholic
parent.
Etiology
Biologic factors include genetic
vulnerability and failure of
neurotransmitters to signal “enough.”
Psychological factors include familial
tendency (having an alcoholic parent or
relatives) and social influences; for
instance, there are higher rates of
cocaine and opioid use in urban areas
that have high crime rates, high
unemployment, substandard schools.
There are fewer social taboos against
alcohol use.
Types of Substance Abuse
Substance abuse includes alcohol,
prescription and OTC medications,
and illicit drugs. Polysubstance abuse
is abuse of more than one substance
and is common. .
Alcohol has been a major focus of
research, so more is known about it:
First intoxication episode occurs at
age 15 to 17 years (first drink may
be much earlier).
Severe difficulties begin to appear in
mid-20s to mid-30s.
Blackouts occur (person continues
to function but has no memory or
awareness of what he or she has
done).
There may be cycles of controlled
drinking, abstinence, drinking
problems, and so forth.
Programs attempting to teach
“social drinking” have been failures.
There are some reports of
spontaneous remission (quit
drinking without treatment).
Formost, alcoholism is a
chronic illness. Relapse and
repeated treatment are
common.
Alcohol Treatment and
Prognosis
Treatment is based on the
concept that alcoholism and
drug addictions are a medical
illness: chronic, progressive,
characterized by remissions
and relapses
Focus is on group experiences
involving education, problem-
solving techniques, cognitive
techniques to identify and modify
faulty thinking, coping with life,
stress, and other people without
the use of substances
Treatment may be as an
outpatient or inpatient depending
on client’s circumstances and
ability to abstain from alcohol or
drugs.
Safe withdrawal from alcohol
includes use of vitamin B1
(thiamine) supplements to
prevent or treat Wernicke-
Korsakoff’s syndrome, folic acid,
multivitamins, cyanocobalamin
(vitamin B12) for nutritional
deficiencies.
Alcohol withdrawal managed with
benzodiazepines (Diazepam-
Valium, Chlordiaxepozide-
Librium)
Disulfiram (Antabuse) to help client
abstain from alcohol; methadone as
a substitute for heroin; Naltrexone
(ReVia) to block effects of opioids
and reduce cravings for alcohol;
Clonidine (Catapres) to suppress
opiate withdrawal; Bromocriptine
(Parlodel) to decrease cocaine
cravings
Substance Abuse
Denial is a major component
of substance abuse, so
identifying clients can be
difficult. Several screening
devices are available.
Detoxification is a priority.
Key points to REMEMBER
Substance abuse – includes characteristics

of withdrawal and tolerance
Substance dependence – includes
characteristics of adverse consequences
and repeated use.
Co-dependent – includes all the
characteristics of a drug abuser that a
partner usually inherited but not technically
abuse drugs.
Danger in taking Inhalants – sudden death
from cardiac and respiratory depression.
CHILD AND ADOLESCENT DISORDERS
Degrees of Retardation
• Mild (IQ 50 to 70)
• Moderate (IQ 35 to 50)
• Severe (IQ 20 to 35)
• Profound (IQ below 20)
Causes
• Heredity, altered embryonic

development, perinatal problems
(fetal malnutrition, hypoxia,
infections, trauma)
• Medical conditions of infancy
• Deprivation of nurturing or
stimulation
PERVASIVE DEVELOPMENTAL
DISORDERS
Characterized by pervasive and
usually severe impairment of
reciprocal social interaction skills,
communication deviance, restricted
stereotypical behavioral patterns.
75% are also mentally retarded.
• Autistic Disorder
• Best known of these disorders
• More prevalent in boys
• Present by age 3
CONT’D
• Child has little eye contact, few

facial expressions, does not
communicate verbally or with
gestures, doesn’t relate to peers or
parents, lacks spontaneous
enjoyment; apparent absence of
mood and affect; cannot engage in
play or make-believe with toys
• Hand-flapping, body-twisting,
head-banging
• Autism may improve,
sometimes substantially, as
language and communication
skills are learned.
•Traits persist into adulthood.
Few attain complete
independence, marry, or have
children.
CONT’D
• Most autistic children are

mainstreamed in school.
• Medications may be used to
target specific behaviors but do
not treat the autism.
• Goals are to reduce behavioral
symptoms and promote learning,
development, and language skills.
ATTENTION DEFICIT
HYPERACTIVITY DISORDERS
• Inattentiveness, overactivity,
and impulsiveness
• Affects 3% to 5% of school-aged
children; affects boys more
frequently
• Can persist into adulthood
• Often diagnosed when child
starts school
CONT’D
• Child may be ostracized by

peers due to behavior
• No known cause; seems to be

familial tendency
Onset and Clinical Course
Most often diagnosed when

child starts school or preschool
ETIOLOGY
Essentially unknown, but likely to
be a combination of factors such
as environmental toxins, prenatal
influences, heredity, damage to
brain structure and function
TREATMENT
• Combination of behavioral strategies
and psychostimulants (Ritalin)
• Side effects: insomnia, loss of
appetite, weight loss or failure to gain
weight
• Behavioral strategies are necessary
at home and school to help the child
succeed: consistent rewards and
consequences for behavior, using
time-out, points systems, structured
routine and schedule for activities
APPLICATION OF NURSING
PROCESS
Assessment
• Information is gathered from all
available sources, including the child.
• A checklist often helps parents
focus on specific behaviors and keep
track of them at home.
• History: Parents report all efforts to
change child’s behavior are
unsuccessful.
• General appearance and motor
behavior: cannot sit still, squirms
and wiggles, darts around the
room, cannot carry on
conversation due to interrupting,
blurting out answers, not paying
attention to what is said, jumps
from one topic to another
• Mood and affect: Mood may be
labile with verbal outbursts or
temper tantrums, anxiety,
frustration, agitation; appears
driven to keep talking or moving
generally no problems in thought
process or content but may be
difficult to assess
processes: child alert and
oriented, no sensory or
perceptual alterations; ability to
concentrate and pay attention is
markedly impaired; very
distractible, says “I don’t know”
rather than taking time to
answer; unable to complete tasks
Judgment and insight: poor judgment,
takes risks, doesn’t perceive potential
harm
Self-concept: may be unaware that
behavior is different from others,
saying “no one likes me”; generally
low self-esteem due to lack of success
and difficulty with peer relationships;
may see self as stupid
CONT’D
unsuccessful; child is intrusive and
disruptive, incites negative responses
from others; parents and teachers
chronically frustrated and exhausted
• Physiologic considerations: child
may be thin if no time taken to eat
properly, trouble settling down for
bed, sleeps poorly, may have history
of injury if engaged in risky behaviors
Data Analysis
• Risk for Injury

• Ineffective Role Performance
• Impaired Social Interaction
• Compromised Family Coping
Intervention
Can be used in variety of
settings and taught to parents,
teachers, and caregivers:
• Ensuring safety
• Improved role performance
• Simplifying instructions
• Providing a structured daily
routine
• Providing client and family
education and support
CONDUCT DISORDER
• Persistent antisocial behavior of

children and adolescents that
significantly impairs ability to function
in social, academic, or occupational
areas
• Symptoms cluster around
aggression to people and animals:
destruction of property, deceitfulness
and theft, serious violation of rules..
CONT’D
• Associated with early sexual activity,
drinking, smoking, use of illegal
substances, and other reckless or
risky behaviors
• Three times more common in boys
30% to 50% are diagnosed as
antisocial personality disorder as
adults.
Symptoms can start before age 10
(and are more severe) or after age 10
(better outcomes as adults).
CONT’D
• Classified as mild, moderate, or
severe
• Etiology: genetic vulnerability,
environmental adversity, poor
coping
• Risk factors: poor parenting, low
academic achievement, poor peer
relationships, low self-esteem
CONT’D
• Conduct disorder associated with

family problems: child abuse,
exposure to violence,
socioeconomic disadvantages
ETIOLOGY
Combination of genetic
vulnerability, environmental
adversity, and poor coping. Risk
factors include poor parenting, low
academic achievement, poor peer
relationships, low self-esteem.
Assessment
• History: disturbed peer

relationships, aggression toward
people or animals, destruction of
property, deceitfulness, theft,
truancy, running away, staying
out all night; may be mild to
severe
behavior: typical for age group;
may be extreme in terms of
piercing, tattoos, use of profanity;
disparaging remarks about parents
and other authority figures
•Thought processes and content:
has capacity for rational thought
but believes “everyone is out to
get me”
•Judgment and insight: limited
insight (blames others), poor
judgment (taking risks)
• Self-concept: may appear

“tough” but has low self-
esteem and doesn’t value self
CONT’D
relationships disrupted, even
violent; verbal and physical
aggression common, unsuccessful
in school, unlikely to work
• Physiologic and self-care
considerations: risk for unplanned
pregnancy and STDs; use of
alcohol and drugs common; may
have injuries from fighting
Data Analysis
• Risk for Other-Directed

Violence
• Noncompliance
• Chronic Low Self-Esteem
Intervention
• Decreasing violence
• Increasing compliance with
treatment
• Improving coping skills and self-
esteem
• Promoting social interaction
•Providing client and family
education
EVALUATION
Treatment is effective if client
follows reasonable rules and
expectations and stops
behaving in aggressive or
illegal ways.
OPPOSITIONAL DEFIANT
DISORDER
• Enduring pattern of uncooperative,

defiant, and hostile behavior toward
authority figures that does not involve
major antisocial violations
• Behaviors cause dysfunction in
social, academic, and work situations.
• 25% go on to develop conduct
disorder.
CONT’D
• 10% are diagnosed with
antisocial personality disorder as
adults.
• Treatment is similar to conduct
disorder, depending on severity of
behaviors.
TIC DISORDERS
• Rapid, sudden, recurrent,

nonrhythmic stereotyped motor
movement or vocalization
• Runs in families
• Treated with atypical
antipsychotics such as olanzapine
or risperidone
CONT’D
Tourette’s Disorder
• Multiple motor tics and one or
more vocal tics; vocal tics can be
name-calling or profanity; can
persist into adulthood
• Person is embarrassed and self-
conscious and has significant
impairment in academic, social,
occupational areas.
CHRONIC MOTOR OR TIC DISORDER
Has only vocal tic or only motor tics,
not both like Tourette’s
SEPARATION ANXIETY DISORDER
• Excessive anxiety about separation

from home or loved ones, exceeding
what would be expected
• Results from combination of
temperament traits (passivity,
avoidance, fearfulness or shyness of
novel situations)
• Parenting behaviors that encourage
avoidance as a way to deal with
unknown situations
SELECTIVE MUTISM
• Persistent failure to speak
in social situations where
speaking is expected
• Excessively shy, socially
withdrawn, isolated, clinging
• Temper tantrums
Eating Disorders
Eating disorders can be viewed on a
continuum: the anorexic eats too little
or is starving, the bulimic eats in a
chaotic way, and the obese person
eats too much. There is much overlap
among the eating disorders: 50% of
clients with anorexia exhibit bulimic
behavior and 35% of normal-weight
clients with bulimia have a history of
anorexia. More than 90% of cases of
anorexia nervosa and bulimia occur in
females.
ANOREXIA NERVOSA
• Life-threatening eating disorder
characterized by:
• Client’s 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 refusal by client to
acknowledge the problem is severe or
that there is even a problem at all
• 85% of expected body weight
or less
• Amenorrhea
• Total absorption in quest for
thinness and weight loss
• Anorexia typically begins between
14 and 18 years of age.
• Ability to control weight give
pleasure to the client.
• Client may feel empty emotionally
and be unable to identify or express
emotional feelings.
• As illness progresses, depression
and labile moods are common.
• Client is socially isolated, mistrustful
of others; may believe that others are
trying to make her fat and ugly
BULIMIA NERVOSA
• Characterized by recurrent episodes

of binge eating, inappropriate
compensatory behaviors to avoid
weight gain (purging: self-induced
vomiting, use of laxatives, diuretics,
enemas, emetics, fasting, excessive
exercise).
• Binge eating is done in secret and
the client recognizes the eating
behavior as pathologic, causing
feelings of guilt, shame, remorse, or
contempt. Clients with bulimia are
usually in normal weight range but
may be underweight or overweight.
• Dentists may be the first to discover
bulimia due to loss of tooth enamel,
caries, chipped or ragged teeth.
• Begins about age 18 or 19
• Binge eating begins after an episode
of dieting.
• Between binges, eating may be
restrictive.
• Food is hidden in the car, desk at
work, and secret locations around the
house.
• Behavior may continue for years
before it is discovered.
ETIOLOGY
Specific etiology for eating
disorders is unknown, but
initially dieting may be the
stimulus that leads to the
eating disorder.
Assessment (EATING DISORDERS)
• History: Client with anorexia is
described by parents as a model child,
no trouble, dependable, before onset
of anorexia. Clients with bulimia are
eager to please and conform, avoid
conflict, but may have history of
impulsive behavior.
behavior: Clients with anorexia are
slow, lethargic, even emaciated; slow
to respond to questions, difficulty
deciding what to say, reluctant to
answer questions fully; often wear
baggy clothes or layers to hide weight
or keep warm; limited eye contact;
unwilling to discuss problems or enter
treatment.
• Clients with bulimia generally have a
normal appearance, are open and
talkative.
• Mood and affect: Moods are labile,
corresponding to eating or dieting
behavior. Clients with anorexia may
look sad and anxious and seldom
smile or laugh. Clients with bulimia
are initially cheerful but express
intense emotions of guilt, shame, and
embarrassment when discussing
bingeing and purging behaviors.
• Ask clients with eating disorders
about suicidal ideas and self-harm
urges; both are common.
Clients spend most of their time
thinking about food, dieting, food-
related issues. Body image
disturbance can be almost delusional.
Clients with anorexia may have
paranoid ideas about their family and
health care professionals being the
“enemy,” trying to make them fat.
Data Analysis
Nursing diagnoses may include:
•Imbalanced Nutrition: Less
Than/More Than Body Requirements
• Disturbed Body Image
• Other diagnoses such as Deficient
Fluid Volume, Constipation, Fatigue,
and Activity Intolerance may be
indicated.
Intervention
• Establishing nutritional eating
patterns
• Helping client identify emotions
and develop coping strategies
• Dealing with body image issues
• Client and family education
Evaluation
• Body weight within 5% to 10%
of normal
• No medical complications from
starvation or purging
Somatoform Disorders
• Somatoform disorders are
characterized by the presence of
physical symptoms that suggest a
medical condition without a
demonstrable organic basis to account
fully for the symptoms. Three central
features of somatoform disorders:
• Physical complaints that suggest
medical illness but have no
demonstrable organic basis
• Psychological factors and
conflicts that seem important in
initiating, exacerbating, and
maintaining the symptoms
• Symptoms or magnified health
concerns that are not under the
client’s conscious control
Five specific somatoform
disorders:
• Somatization disorder: multiple
physical symptoms; combination of
pain, GI, sexual, and
pseudoneurologic symptoms
• Conversion disorder: unexplained
deficits in sensory or motor function
such as blindness or paralysis
associated with psychological factors;
attitude of “la belle indifference” (lack
of concern or distress)
• Pain disorder: pain unrelieved by
analgesics; psychological factors
influence onset, severity,
exacerbation, and maintenance
Hypochondriasis: preoccupation
with fear that one has or will get a
serious disease
• Body dysmorphic disorder:
preoccupation with imagined or
exaggerated defect in physical
appearance
Data Analysis
• Nursing diagnoses include:
• Ineffective Denial
• Anxiety
• Disturbed Sleep Pattern
• Fatigue
• Pain
Intervention
• Providing health teaching
• Assisting client to express
emotions
• Teaching coping strategies
Evaluation
• Changes are likely to occur
slowly.
• Using fewer medications, making
fewer visits to physicians,
improved coping skills, increased
functional abilities would be
indicators of treatment success.
Personality Disorders
Personality disorders are
diagnosed when personality traits
become inflexible or maladaptive
and interfere with how one
functions in society or cause
emotional distress. They are
diagnosed in adulthood, but
maladaptive patterns can be
traced to childhood or
adolescence.
DSM-IV-TR CATEGORIES
• Cluster A: people whose

behavior is odd or eccentric
(paranoid, schizoid, schizotypal)
• Cluster B: people who appear
dramatic, emotional, or erratic
(antisocial, borderline, histrionic,
narcissistic)
• Cluster C: people who are
anxious or fearful (avoidant,
dependent, obsessive-
compulsive)
• Disorders being considered
for inclusion are depressive and
passive-aggressive.
Treatment
• Individual and group therapy may
be helpful to those desiring change,
but any changes are slow.
• Improvement in relationships,
improved basic living skills, relief of
anxiety may be goals of therapy.
• Cognitive-behavioral techniques
such as thought-stopping, positive
self-talk, and decatastrophizing can be
effective.
Pharmacologic treatment is based on
the type and severity of symptoms
rather than the particular personality
disorder itself. The four system
categories are:
• Aggression/impulsivity
• Mood dysregulation
• Anxiety
• Psychotic symptoms
CLUSTER A PERSONALITY D/O
• Paranoid personality disorder-
mistrust and suspicion of others;
guarded, restricted affect
• Schizoid personality disorder –
detached from social relationships;
restricted affect; involved more with
things than people
• Schizotypical personality disorder –
acute discomfort in relationships;
cognitive or perceptual distortions;
eccentric behavior
CLUSTER B PERSONALITY D/O
Antisocial Personality Disorder

• Antisocial personality disorder is
characterized by a pervasive pattern
of disregard for and violation of rights
of others; involves deceit and
manipulation. 50% of prisoners have
this disorder.
Assessment (ANTISOCIAL)
• History of problems in childhood and
adolescence
behavior: appears “normal”; may be
charming and engaging, trying to
manipulate
• Mood and affect: “chooses”
emotions to be displayed that display
him in a favorable light, but no true
genuine feelings of empathy, remorse
views the world as cold and hostile,
thinks everyone else is as ruthless as
he or she is, so trusts no one
processes: intact
• Judgment and insight: lacks insight,
poor judgment due to inability to
delay gratification, impulsivity, or
ethical/legal considerations of actions
• Self-concept: superficially appears

self-assured and confident, even
arrogant, but this covers low self-
esteem; poor relationships due to
exploitation and using others
• Roles and relationships: has trouble
keeping jobs, being a parent, staying
married, and so forth
DATA ANALYSIS
• Nursing diagnoses include:

• Ineffective Individual Coping
• Ineffective Role Performance
Violence
Intervention
• Forming therapeutic relationship
• Promoting responsible behavior
• Helping client solve problems
and control emotions
• Enhancing role performance
BORDERLINE PERSONALITY
DISORDER
Borderline personality disorder is

characterized by a pervasive
pattern of unstable interpersonal
relationships, self-image, and
affect and marked impulsivity.
Assessment (BORDERLINE)
• History: family problems common,
especially alcoholism and sexual abuse
behavior: mildly dysfunctional clients
appear normal; severely affected
clients may be disheveled, unable to
sit still, crying, out of control
ASSESSMENT COTN’D
• Mood and affect: dysphoric

mood, unhappy, restless, malaise;
intense feeling of loneliness,
boredom, frustration,
abandonment by others; mood is
labile and feelings are intense
CONT’D
polarized thinking is common;
others are “adored” after a brief
acquaintance, then despised if
they don’t meet client’s
expectations; obsessive and
ruminative thoughts about
abandonment, suicide, and self-
harm; may have dissociative
episodes
CONT’D

processes: oriented, intellectual
functions intact; may experience
transient psychotic symptoms such as
hallucinations under severe stress;
may have flashbacks of abuse
(consistent with PTSD diagnosis)
CONT’D
• Judgment and insight: judgment

is poor; impulsive and reckless
behaviors such as lying,
shoplifting, gambling are common;
limited insight: believes problems
are due to others “failing” them
CONT’D
• Self-concept: unstable and
shifts rapidly: needy one minute,
hostile and rejecting the next;
frequent self-injury; lacks
consistent view of self
CONT’D
• Roles and relationships: difficulty
fulfilling roles, especially involving
mundane tasks (school, work);
relationships are stormy given
client’s behavior, but client blames
others; clings to people, then
rejects them angrily; desires
relationships/friendships, but
behavior drives others away
CONT’D
considerations: in addition to self-
mutilation, bingeing and purging
are common; abuse of alcohol or
drugs, unprotected sex, reckless
behavior; usually difficulty
sleeping
Data Analysis
• Risk for Suicide
• Risk for Self-Mutilation
• Risk for Other-Directed Violence
• Social Isolation
Interventions
• Promoting the client’s safety
• Promoting the therapeutic
relationship
• Establishing boundaries in
relationships
• Teaching effective communication
skills
• Helping the client to cope and
control emotions
• Reshaping thinking patterns
• Structuring daily activities
OTHER CLUSTER B P.D.
• Histrionic personality disorder –

excessive emotionality and
attention-seeking
• Narcissistic personality disorder
– grandiose; lack of empathy;
need for admiration
CLUSTER C PERSONALITY D/O
• Avoidant personality disorder –

social inhibitions; feelings of
inadequacy; hypersensitivity to
negative evaluation
• Dependent personality disorder –
submissive and clinging behavior;
excessive need to be taken care of
• Obsessive-compulsive personality
disorder – preoccupation with
orderliness, perfectionism, and control
Mood Disorders
Mood disorders are diagnosed
when these alterations in
emotions are pervasive and
interfere with the person’s
ability to live life.
CATEGORIES
• Major Depression Disorder: 2 or

more weeks of sad mood, lack of
interest in life activities, and other
symptoms
• Bipolar disorder (formerly called
manic-depressive illness): mood
cycles of mania and/or depression
and normalcy
RELATED DISORDERS
• Dysthymic disorder: sadness, low

energy, but not severe enough to be
diagnosed as major depression
disorder
• Cyclothymic disorder: mood swings
not severe enough to be diagnosed as
bipolar disorder
• Seasonal affective disorder (SAD)
• Depressive personality disorder
• Postpartum or ‘maternity’ blues
RELATED D/O CONT’D
Postpartum depression
Postpartum psychosis
ETIOLOGY
Biologic theories include

genetics. neurochemical
theories, and
neuroendocrine or hormonal
fluctuations.
MAJOR DEPRESSIVE DISORDER
• Twice as common in women and

more common in single or divorced
people
• Involves 2 or more weeks of sad
mood, lack of interest in life activities,
and at least four other symptoms,
such as anhedonia, changes in weight,
sleep, energy, concentration, decision-
making, self-esteem, goal-setting
CONT’D
• Untreated, can last 6 to 24

months; recurs in 60% of people
• Symptoms range from mild to
moderate to severe.
• Antidepressants
• SSRIs include Prozac, Zoloft,
Paxil, Celexa. Prescribed for mild
and moderate depression.
• Tricyclic antidepressants (TCAs)
include Elavil, Tofranil, Norpramin,
Pamelor, Sinequan; used for
moderate and severe depression.
• Atypical antidepressants include
Effexor, Wellbutrin, Serzone.
MAOIs include Marplan, Parnate,
Nardil; used infrequently because
interaction with tyramine causes
hypertensive crisis.
• Electroconvulsive therapy (ECT) is
used when medications are ineffective
or side effects are intolerable. After
anesthesia and muscle relaxants, a
shock is administered via electrodes to
produce seizure activity in the brain.
• Treatments are administered in
a series (for instance, three times
a week for 6 weeks).
• Psychotherapy in conjunction
with medication is considered
most effective treatment. Useful
therapies include behavioral,
cognitive, interpersonal, family
therapy.
MAJOR DEPRESSIVE
DISORDER
Assessment
• Must include determination of
suicidal ideas and lethality and
client’s perception of the
problem
ASSESSMENT CONT’D
• Psychomotor retardation or
agitation, feelings of helplessness,
anxiety, sadness, guilt, frustration,
negativism and pessimism, lack of
pleasure, social withdrawal, reduced
concentration & decision-making,
fatigue & exhaustion, low self-esteem
and rumination about past bad deeds
or failures, loss of ability to function in
life roles, sleep disturbances,
overeating or undereating, lack of
attention to hygiene and grooming
Data Analysis
Nursing diagnoses may
include:
• Imbalanced Nutrition
• Anxiety
• Hopelessness
Intervention
• Providing for the client’s safety and
the safety of others
• Promoting a therapeutic relationship
• Promoting activities of daily living
and physical care
• Using therapeutic communication
• Managing medications
• Providing client and family teaching
BIPOLAR DISORDER
• Involves mood swings of depression
(same symptoms of major depressive
disorder) and mania. Major symptoms
of mania include grandiose mood,
agitation, exaggerated self-esteem,
sleeplessness, pressured speech, flight
of ideas, easily distractible, intrusive
behavior, with lack of personal
boundaries, high-risk activities with
potentially severe consequences, poor
judgment.
• Treatment may involve medication

with lithium; regular monitoring of
serum lithium levels is needed.
• Anticonvulsant drugs are used for
their mood-stabilizing effects:
Tegretol, Depakote, Lamictal,
Topamax, Trileptal, Neurontin; and
Klonopin (a benzodiazepine)
Assessment (BIPOLAR DISORDER)
behavior: Assessing a client in the
manic phase may be difficult and
based more on observations of the
client rather than client’s responses to
structured questions. Client jumps
from one subject to another, cannot
sit still, may wear flamboyant clothing
or makeup.
CONT’D
• Mood and affect: psychomotor
agitation, racing thoughts,
pressured speech, ignores
directions or requests from others,
unusual speech patterns
starts many grandiose projects but
finishes none; careless spending
sprees
CONT’D
processes: loud voice; may be
hypersexual
• Judgment and insight: poor
• Self-concept: false, grandiose
sense of well-being that covers low
self-esteem
• Roles and relationships: may be
charming and playful, then
sarcastic and angry; cannot take
“no” for an answer
considerations: inattention to
hygiene and grooming, hunger or
fatigue
Data Analysis
Nursing diagnoses may
include:
Violence
• Risk for Injury
• Imbalanced Nutrition
• Noncompliance
Intervention
• Providing for safety of client
and others
• Meeting physiologic needs
• Providing therapeutic
communication
• Promoting appropriate
behaviors
• Managing medications
SUICIDE
• Families need support when a
member has committed suicide or is
making attempts to do so. They may
feel guilty, angry, and ashamed and
are at increased risk for suicide
themselves.
Assessment
• Populations at risk
• Warnings of suicidal intent
• Risky behaviors
•Lethality assessment
Outcomes
The client will:
• Be safe from harm self or others
• Engage in a therapeutic relationship
• Establish a no-suicide contract
• Create a list of positive attributes
• Generate, test, and evaluate realistic
plans to address underlying issues
Intervention
• Using an authoritative role
• Providing a safe environment
• Initiating a no-suicide contract
• Creating a support system list
• Supervision
Schizophrenia
Schizophrenia is a syndrome or
disease process of the brain
causing distorted and bizarre
thoughts, perceptions, emotions,
movements, and behavior. It is
usually diagnosed in late
adolescence and early adulthood
(15 to 25 years for men, 25 to 35
years for women). Prevalence is
1% of total population.
Hard or positive symptoms are
amenable to antipsychotic
medication and include:
• Delusions
• Hallucinations
• Grossly disorganized thinking,
speech, and behavior.
Soft or negative symptoms persist
over time and are somewhat
amenable to atypical
antipsychotics only. They include:
• Flat affect
• Lack of volition (AVOLITION)
• Social withdrawal or discomfort
• Apathy
• Alogia (poverty of content)
TYPES OF SCHIZOPHRENIA
• Paranoid type: persecutory or

grandiose delusions and
hallucinations; sometimes excessive
religiosity; hostile and aggressive
behavior
• Disorganized type: grossly
inappropriate or flat affect,
incoherence, loose associations,
extremely disorganized behavior
• Catatonic type: marked psychomotor
disturbance, motionless or excessive
motor activity, extreme negativism,
mutism, peculiarities of voluntary
movement (echolalia, echopraxia)
• Undifferentiated type: mixed
schizophrenic symptoms along with
disturbances of thought, affect,
behavior
• Residual: at least one previous
psychotic episode but not
currently; social withdrawal, flat
affect, loose associations
CLINICAL COURSE
Varies among clients

• Most clients experience a slow and
gradual onset of symptoms.
• Younger age of onset associated
with poorer outcomes
• In first years after diagnosis, client
may have relatively symptom-free
periods between psychotic episode or
fairly continuous psychosis with some
shift in severity of symptoms.
• Over the long term, psychotic
symptoms diminish for most
clients and are managed more
easily.
• Many years of dysfunction
are rarely overcome.
RELATED DISORDERS
Schizophreniform disorder: symptoms
of schizophrenia are experienced for
less than the 6 months required for a
diagnosis of schizophrenia
Schizoaffective disorder: symptoms of
psychosis and thought disorder along
with all the features of a mood
disorder
Delusional disorder: one or more non-
bizarre delusions with no impairment
in psychosocial functioning
• Brief psychotic disorder: one
psychotic symptoms lasting 1 day
to 1 month; may or may not have
an identifiable stressor, such as
childbirth
• Shared psychotic disorder (folie
à deux): similar delusion shared
by two people, one of whom has
psychotic delusions
ETIOLOGY
Current etiologic theories focus

on biologic theories:
• Genetic
• Neuroanatomic theories
• Neurochemical theories
• Immunovirologic factors
TREATMENT
• Primary treatment of
schizophrenia is neuroleptic or
antipsychotic medication.
• Adjunctive Treatment
• Individual, group, and family
therapy
• Structured milieu therapy
• Community support programs
• Client/family education and
support
Assessment
• Previous hospitalizations
• Presence of suicidal ideation
• Current support system
• Client’s perception, appearance,
odd or bizarre speech or motor
behavior
• History
ASSESSMENT CONT’D
behavior
• Mood and affect: flat or blunted
affect, anhedonia
delusions
processes: hallucinations, concrete
or literal thinking
• Judgment and insight: impaired
judgment, limited insight
CONT’D
• Self-concept: may be distorted,

with depersonalization, loss of ego
boundaries resulting in bizarre
behaviors
• Roles and relationships: often
socially isolated, have difficulty
fulfilling life roles
CONT’D

considerations, may have multiple
self-care deficits (inattention to
hygiene, nutrition, sleep needs;
polydipsia occasionally seen in
longer-term clients)
Data Analysis
Common nursing diagnoses for
positive symptoms include:

Violence
• Disturbed Thought Processes
• Disturbed Sensory Perception
Nursing diagnoses for negative
symptoms and functional abilities
include:
• Self-Care Deficits
• Social Isolation
• Deficient Diversional Activity
• Ineffective Health Maintenance
Intervention
• Promote safety of clients and others.

• Establish a therapeutic relationship.
• Interventions for delusional
thoughts.
• Interventions for hallucinations.
• Protecting the client who has socially
inappropriate behaviors.
• Client and family teaching
COGNITIVE DISORDERS
Cognition involves the brain’s ability to
process, retain, and use information.
Cognitive abilities include reasoning,
judgment, perception, attention,
comprehension, and memory.
Disruption of these functions impairs
the person’s ability to make decisions,
solve problems, interpret the
environment, and learn new
information.
• Delirium is a syndrome that
involves disturbance of
consciousness accompanied by a
change in cognition. It develops
over a short period of time and
fluctuates over time. It causes
difficulty in paying attention,
distractibility, and disorientation.
Sensory disturbances include
illusions, misinterpretations,
hallucinations, disturbances in
sleep/wake cycle, anxiety, fear,
irritability, euphoria, apathy.
TREATMENT
• Treatment of the underlying

medical condition will usually
resolve delirium.
• Clients with head injury or
encephalitis may have cognitive,
emotional, or behavioral
impairment due to brain damage
from the disease or injury.
TREATMENT CONT’D
• Delirious clients who are quiet
and resting need no other
medication for delirium. Those
who are restless or a safety risk
may require low-dose
antipsychotic medication.
Sedatives and benzodiazepines
may worsen the delirium.
TREATMENT CONT’D
• Alcohol withdrawal is managed

medically with benzodiazepines.
• IV fluids or total parenteral nutrition
may be needed.
• Occasionally restraints are necessary
so that tubes and catheters aren’t
pulled out. Use judiciously and for
short periods because restraints may
increase agitation.
Dementia involves multiple
cognitive deficits, primarily
memory impairment, and at least
one of the following: aphasia,
apraxia, agnosia, or disturbance in
executive functioning. Dementia is
progressive unless the underlying
cause is treatable, such as
vascular dementia, which is rare.
CLINICAL COURSE
• Mild (excessive forgetfulness, difficulty
finding words, loses object, anxiety about
loss of cognitive abilities)
• Moderate (confusion, progressive
memory loss, can’t do complex tasks,
oriented to person and place, recognizes
familiar people; by the end of this stage
requires assistance and supervision)
• Severe (personality and emotional
changes, delusional, wanders at night,
forgets names of spouse and children,
requires assistance with ADLs)
ETIOLOGY
Various causes, but clinical picture

similar for all:
• Alzheimer’s disease
• Vascular dementia (may have
sudden onset; progression may be
arrested with treatment)
• Pick’s disease
• Creutzfeldt-Jakob disease
ETIOLOGY CONT’D
• Dementia due to HIV

• Parkinson’s disease
• Huntington’s disease
• Dementia due to head
trauma
TREATMENT
• Underlying cause, as in vascular
dementia, is treated to prevent further
deterioration.
• Medications such as Cognex, Aricept,
Exelon, Reminyl (stops progression for
2 to 4 months only) can be used to
slow progression.
• Symptomatic treatment of behaviors
such as delusions, hallucinations,
outbursts, labile moods, which vary
among clients
Major signs and symptoms
• Agnosia – inability to recognize name

of objects.
• Aphasia – deterioration of language
function.
• Apraxia – impaired motor function
• Executive functioning – inability to
think abstractly.
DELIRIUM DEMENTIA
• Onset: Sudden Gradual
• Disorientation Loss/Impairment of
memory
• Acute Chronic
• Involves young Exclusive in the
and old elderly
• Clouded sensorium Clear sensorium
• Reversible Irreversible
• Good prognosis Poor prognosis
• EEG Abnormal EEG Normal
DELIRIUM DEMENTIA
• LOC impaired not affected
fluctuates
• Speech may be normal in early
slurred, rambling, stage, aphasia in
pressured, irrelevant later stage.
• Thought process
Temporarily impaired thinking,
disorganized eventual lost of
thinking abilities
• Duration
Brief (hours to days) Progressive det.

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Psychiatric Nursing Notes by Dr. Fausto

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Psychiatric Nursing

Prof. Rolando Y. Fausto, RN, MAN

Art in Psychiatric Nursing.

1 – 3 YEARS OLD – AUTONOMY VS

6 – 12 YEARS OLD – INDUSTRY VS

65 AND ABOVE – INTEGRITY VS

7 – 12 YEARS OLD : CONCRETE

Hildegard Peplau (1909-

Abraham Maslow (1921-1970)

1.Cognitive restructuring – teaching the

3. Limbic system – comprises the limbic

Biology and Environment. Research is

CRISIS – Situation that occurs when an

GOAL OF CRISIS INTERVENTION

To Establish Rapport and Build

Examples: Alcoholic anonymous

EGO defense mechanisms

• Anxiety disorders are the most common

• Biologic theories: Anxiety may have

Situational Low Self-Esteem

A phobia is an illogical, intense,

Treatment and Prognosis

•Excessive worry and anxiety that is

• Domestic violence occurs in families

• Involves the mistreatment of one

• Providing women with information

• Getting the child to a safe place

• Immediate support to ventilate

•Giving the victim control over

• Roles and relationships:

• Risk for Self-Mutilation

• Promoting the client’s safety

Substance abuse – includes characteristics

• Heredity, altered embryonic

• Child has little eye contact, few

• Most autistic children are

• Child may be ostracized by

• No known cause; seems to be

Most often diagnosed when

• Risk for Injury

• Persistent antisocial behavior of

• Conduct disorder associated with

• History: disturbed peer

• Self-concept: may appear

• Risk for Other-Directed

• Enduring pattern of uncooperative,

• Rapid, sudden, recurrent,

• Excessive anxiety about separation

• Characterized by recurrent episodes

• Cluster A: people whose

Antisocial Personality Disorder

• Self-concept: superficially appears

• Nursing diagnoses include:

Borderline personality disorder is

• Mood and affect: dysphoric

• Sensorium and intellectual

• Judgment and insight: judgment

• Histrionic personality disorder –

• Avoidant personality disorder –

• Major Depression Disorder: 2 or

• Dysthymic disorder: sadness, low

Biologic theories include

• Twice as common in women and

• Untreated, can last 6 to 24