Care of Clients with Maladaptive Patterns of Behavior, Acute and

Chronic
Psychiatric nursing countertransference and for care to be
more effective
Mental Health o You cannot control your emotions; you
 A state of emotional, psychological and social might get attached to the patient which
wellness evidenced by satisfying interpersonal would lead to ineffective care and
relationships, effective behavior and coping, positive countertransference
self-concept and emotional stability. o Orientation Phase: signing of contract occurs
here, setting of boundaries and roles are also
COMPONENTS OF MENTAL HEALTH done here
 Autonomy and Independence - can work o You also inform the patient of the exact
interdependently without losing autonomy time when the contract will end
 Maximization of One's Potential - oriented towards o Working Phase
growth and self-actualization o If during this phase you experience
 Tolerance of Life's Uncertainties - can face the countertransference, best action is to
challenges of day-to-day living with hope & positive inform your superior and you will be
look assessed
 Self-esteem - has realistic awareness of her abilities o You are allowed to terminate the
and limitations contract here, but if other measures are
 Mastery of the Environment - can deal with and suggested you may follow it
influence the environment o Terminal or termination phase
 Reality Orientation - can distinguish the real world o Evaluation phase
from a dream, fact from fantasy o If plan has of management has been met
 FOCUS: Patient
MENTAL ILLNESS o Do not ignore the feelings of the patient but
 State of imbalance characterized by a disturbance in a the nurse should divert it back to the
person’s thoughts, feelings and behavior problem of the patient
o It is a policy that a nurse cannot handle
Criteria to Diagnose Mental Disorders friends, family members, and people who
 Dissatisfactions with one's characteristics, have a relationship to the nurse. This may
accomplishments, abilities also lead to countertransference because the
 Ineffective or dissatisfying relationships nurse is already attached to the clients
 Dissatisfaction with one's place in the world o This will affect the care and judgment of the
 Ineffective coping with life's events client
 Lack of personal growth
Foundation
PSYCHIATRIC NURSING  Etiology of mental disorders remain unknown
 Interpersonal process whereby the nurse through the  But there are some theories like biochemical theories
therapeutic use of self-assist an individual family,
group or community to promote mental health, to Central Nervous System
prevent mental illness and suffering, to participate in Cerebrum
the treatment and rehabilitation of the mentally ill and  Frontal lobe - control organization of thought, body
if necessary, to find meaning in these experiences movement, memories, emotions and moral behavior.
o Associated with schizophrenia, attention deficit/
hyperactive disorder and dementia
CORE OF PSYCHIATRIC NURSING  Parietal lobe - interpret sensations of taste and touch
 Interpersonal relationship and assist is spatial orientation.
o Transference: unacceptable behavior, feeling,  Temporal lobes - are centers for the sense of smell,
cognition or thought of a patient towards the hearing, memory, and expression of emotions.
nurse  Occipital lobes - assist in coordinating language
o Countertransference: unacceptable behavior, generation and visual interpretation, such as depth
feeling, cognition or thought of the nurse towards perception.
the patient
o Pre-orientation Phase: self-awareness; know Neurotransmitters
patient’s information and history, know reason  Biochemical theories say that neurotransmitters have
for admission an effect to the mental processes, behavior, cognition,
o If you think that you cannot handle the and thoughts of a patient
client you can refuse, to not experience
  Dopamine - controls complex movements,  I want to... PHYSIOLOGIC NEEDS
motivation, cognition, regulates emotional responses  I want to... PRIMARY PROCESS
o If low, it will cause tremors  All about I, me, and myself
o If increased, there is a possibility to have SUPEREGO
increased cognition, to the point you are not  Should not
intact with reality. A patient may become  Small voice of GOD
delusional: fixed problems in thoughts and  Set norms, standards, and values
cognition (Schizophrenia)  MORAL PRINCIPLE
o Do not contradict the delusion of your  Conscience
patient because it is a fixed belief and it may  Contradicts ID
cause anxiety EGO
o Present reality by giving instructions to  Executive
activities that will revert them back to reality  REALITY PRINCIPLE
o Do not argue but do not tolerate it, just keep  Conscious
on mind to ignore the delusion and divert the  Competencies
delusion to reality
 Decision Maker; Problem-Solving; Critical and
 Serotonin - regulation of emotions, controls food Creative thinking
intake, sleep and wakefulness, pain control, sexual
 Balances ID and superego
behaviors
 Once this is fully developed, you are now intact to
o Problems in this neurotransmitter may be
reality
found in depression, anorexic, bulimic
patients Imbalances between Personality Elements
 Acetylcholine - controls sleep and wakefulness cycle
(decreased in Alzheimer's)
 Histamine - controls alertness, peripheral allergic
reactions, cardiac stimulations
 GABA - modulates other neurotransmitters
o Modulates norepinephrine and epinephrine
o When patient is having panic anxiety there is
a problem with epinephrine
 Norepinephrine / Epinephrine - causes changes in
attention, learning and memory, mood  Manic- usually seen in a bipolar patient. Patient
experiences hyperactivity
Sympathetic Parasympathetic o Extreme exaggerated behaviors
Increase v/s Decrease v/s  Antisocial personality disorder- personality problems
Decrease GI motility Increase GI motility in interpersonal relationships
Decrease GU function  Narcissistic- there is illusion of grandiosity
Increase GU function
- urinary retention
Moist mouth Dry mouth

Genetics and Hereditary

 Alzheimer's disease - linked with defects in
 chromosomes 14 and 21
 Schizophrenia
 Mood disorders (depression)
 Autism and AD/HD

SIGMUND FREUD  These are people who are strict law followers
 Father of Psychoanalysis  Obsessive compulsive disorder- recurring, unwanted
 “Your behavior today is directly or indirectly affected thoughts, ideas or sensations that make them feel
by your childhood days or experiences.” driven to do something repetitively
o Repression a defense mechanism wherein o Those with ritualistic behaviors
there is unconscious forgetting o Do not try to contradict because it will only
 STRUCTURE – Personality Structure increase their anxiety, because that is their
coping mechanism
Personality Structure o Do not abruptly stop it, but give schedules
for those ritualistic behavior
ID (4-5MONTHS)  Obsessive compulsive personality disorder- are those
 Impulsive/ Instinctual drive who are perfectionists
 I want to... PLEASURE PRINCIPLE
 o They are perfectionists because they know  There is a possibility that memories will go back
that being unorganized is not acceptable to once a person undergoes psychoanalysis or because
the society of triggers
 Hallucinations are sensations that seem to be real but
SUPRESSION
 CONSCIOUS forgetting of an anxiety provoking
situation
is only created in the mind
 Hallucination vs illusion IDENTIFICATION
o Both these involve the senses, it only differs  Attempts to resemble or pattern the personality of a
in cognition person being admired of
o Hallucination has no stimulus but can sense o Idolizing a person and copying them
something (behaviors, attitudes, physical appearance)
o Illusions have stimulus but is interpreted
wrongly INTROJECTION
 Acceptance of another values and opinion as one's
Libido own
 Sexual energy responsible for survival of human  Thoughts and opinions of other people are taken as
beings own
 Psychosexual Theory of Freud  Claiming of other people’s stories

ORAL STAGE LATENCY STAGGE

 18 months  6 to 12 years old
 Cry, suck, mouth  School
 EGO at 6 months  Reading, writing, arithmetic
 Child cries - fed - successful  Ability to care about and relate to others outside
 Child cries – ignored - unimportant - narcissistic home

FIXATION SUBLIMATION
 Occurs when a person is stuck in a certain  Placing sexual energies toward more productive
developmental stage activities
o Unacceptable to acceptable behaviors to the
REGRESSION society
 Returning to an earlier developmental stage o Diverting sexual urges to activities that are
 Infantile behavior acceptable to the society

ANAL STAGE SUBSTITUTION

 18 months 3 years old  Replace a goal that can't be achieved for another that
 SUPEREGO develops is more realistic.
 Toilet training o Unachievable to achievable
o Good Mother - Normal
o Bad Mother GENITAL STAGE
 Clean, organized, obedient - OC (anal  12 years old and above
retentive)  Developing satisfying sexual and emotional
 Dirty, disorganized - Anti-social (anal relationships with members of the opposite sex
expulsive)  Planning life's goals

PHALLIC STAGE EGO DEFENSE MECHANISMS

 Preschooler (3 6 years old)
 Parent Function - To ward off anxiety
o Oedipus Complex * without defense mechanisms, anxiety might overwhelm and
 Castration Fear paralyze us and interfere with daily living
o Electra Complex
 Penis Envy 2 Features:
 Daughter to father 1.1. they operate on an unconscious level (Except suppression)
2. 2. they deny, falsify or distort reality to make it less
REPRESSION threatening
 UNCONSCIOUS forgetting of an anxiety provoking
REPRESSION VS. SUPPRESSION
concept
 80% of rape victims go into repression
REPRESSION
  Unconscious forgetting of an anxiety provoking
concept SUBLIMATION VS. SUBSTITUTION

SUPRESSION SUBLIMATION
 Conscious forgetting of an anxiety provoking  Transfer of sexual energy to a more productive
situation activity.
o Unacceptable behavior to acceptable
REGRESSION VS. FIXATION behavior to the society

REGRESSION SUBSTITUTION
 Returning to an earlier developmental stage  Replaces a goal that can't be achieved for another that
o Inappropriate behavior during anxiety is more realistic.
o E.g. tantrums of an adult
 Infantile behavior DISSOCIATION VS. ISOLATION
FIXATION
 Occurs when a person is stuck in a certain DISSOCIATION
developmental stage  Separating and detaching idea, situation from its
o A stage is not satisfied emotional significance.
o Satisfaction of the stage is done by a person o Detaching from the self temporarily d/t
e.g. smoking anxiety
o This is different from regression and
mannerisms ISOLATION
 Individual strips emotion when talking or responding
RATIONALIZATION VS. INTELLECTUALIZATION about it.

RATIONALIZATION
 Self-saving with incorrect illogical explanation EGO DEFENSE MECHANISMS
o Reasoning out even with the wrong reasons
INTELLECTUALIZATION Conversion
 Excessive use of abstract thinking; technical  Anxiety converted to physical symptoms
explanation o E.g. stress is converted to headache
o Excessive rationalization
o Possibly correct but not necessary to the Compensation
current situation  Overachievement in one area to Overpower
o Focusing on situations that is not really the weaknesses or defective area.
o There should be presence of weakness,
problem
limitation, or insecurity that will be covered
DISPLACEMENT VS. PROJECTION VS. up by other achievements
INTROJECTION Undoing
 Doing the opposite of what have done
DISPLACEMENT o Trying to compensate for the wrong a person
 Feelings are transferred or redirect to another person has done
or object that is less threatening o E.g. a guy hurt a woman and then gave her
 Keyword: anger or feelings flowers after
 Anger redirection o Restitution- you do something wrong to a
person but compensate by doing good to
PROJECTION people who are involved to the person
 Blaming; Falsely attributing to another his/her own Denial
unacceptable feelings.  Failure to acknowledge an unacceptable trait or
o This can be seen in paranoid patients situation
o “Takot sa sarili nilang multo”  Alcoholic patients commonly use this defense
o A person unconsciously transfers his/her mechanism
own negative behavior to others
Fantasy
o The person is aware that he/she possesses
 Magical thinking
that behavior but subconsciously blames
others for it
Reaction Formation
INTROJECTION  Opposite of intention
 Acceptance of another's values and opinions as one’s
Acting out
own
  Deals with emotional conflict or stressors by  Man forgets wife's birthday after a marital fight.
ACTION rather than reflection or feelings
 Businessman who is preparing to make an important
Symbolization speech that day is told by his wife that morning that
 Creates a representation to an anxiety provoking she wants a divorce. Although visibly upset, he puts
thing or concept this incident aside until after his speech, when he can
give the matter his total concentration.
Splitting
 Labile emotions; all bad - all good  A man cannot accept his physician's diagnosis of
cancer is correct and seeking a second opinion
DEFENSE MECHANISMS COMMONLY USED IN
EACH RESPECTIVE DISORDERS  slamming a door instead of hitting as person, yelling
 Paranoid - Projection at your spouse after an argument with your boss
 Phobia - Displacement
 Amnesia - Dissociation  focusing on the details of a funeral as opposed to the
 Anorexia - Suppression sadness and grief
 Bipolar Disorder - Reaction Formation
 Borderline - Splitting  stating that you were fired because you didn't kiss up
 Schizophrenia - Regression the boss, when the real reason was your poor
 Substance Abuse-Denial performance
 Depression - Introjection
 OC - Undoing  having a bias against a particular race or culture and
 Catatonic - Repression then embracing that race or culture to the extreme

 Woman who is angry with her boss writes a short  sitting in a corner and crying after hearing bad news;
story about a heroic woman. throwing a temper tantrum when you don’t get your
way
 Four-year old with new baby brother starts sucking
his thumb and wanting a bottle.  forgetting sexual abuse from your childhood due to
the trauma and anxiety
 Patient criticizes the nurse after her family failed to
visit  lifting weights to release 'pent up' energy

 Man who is unconsciously attracted to other women

teases his wife about flirting Therapeutic Communication

 Short man becomes assertively verbal and excels in  Non-verbal cues are more accurate than verbal cues
business. o Reaction formation may be seen in these
situations
 Recovering alcoholic constantly preaches about the  Therapeutic communication is important because it
evils of drink. can affect the progress of the patient
 Always assert and affirm authority
 Man reacts to news of the death of a loved one “No, I o The healthcare provider should be followed
don't believe you. The doctor said he was fine.” and not the patient
 For paranoid patients, always position in front of the
 Student is unable to take a final exam because of a
patient but should have a space in between
terrible headache.
o Because standing on the sides may pose as a
 After flirting with her male secretary, a woman
brings her husband tickets to a show. threat to the patient
o Being too close or too far may also present
 “I didn't get the raise because my boss doesn't like as a threat to the patient
me." o Paranoid patients are hypervigilant
 Reality orientation
 Five-year old girl dresses in her mother's shoes and o Alcoholic patients who are already in
dress and meets daddy at the door. withdrawal may experience formication
o Sensation that resembles that of small
 After his wife's death, husband has transient insects crawling on (or under) the skin
complaints of chest pain and difficulty breathing- the
when there is nothing there.
symptoms his wife had before she died
o Acknowledge what the patient feels
(because they are not inventing things) to
 reduce anxiety, explain that you understand  Client and Family Teaching (Health Teaching)
how the patients feel but don’t forget to  No existing illness yet
present the reality to the patient
o Divert the attention to a realistic Secondary
environment  Screening, Diagnosis, and Immediate Treatment
 General leads  Screening
o Broad opening statements, leave the o Denver Development Screening Test
direction of the conversation to the patient (DDST) #1 test for PDD
o Used when patients have difficulty in
expressing or verbalizing thoughts and Tertiary
feelings
o Schizophrenic patients are disorganized,  Rehabilitation
general leads may be helpful
o May also be used in geriatric patients
 Silence
o If you remain silent when a patient is
talking it indicates that you are listening
o A sign of respect to the person speaking Four phases of nurse- client relationship (NCR)
o Best therapeutic communication used for
Pre-interaction/Pre-orientation (For the Nurse)
paranoid patients, to be able to establish
trust  Stage of Self-Awareness  To prevent Counter
o May help develop rapport Transference
 #1 CORE VALUE OF Psychiatric Nursing
AIM: PLAN THE RELATIONSHIP
 Upon admission, discharge instruction plan should
already be formulated
Therapeutic communication o You already know the chief complaint
 Continuous, dynamic process of SENDING and (existing problems)
RECEIVING MESSAGES by various verbal or non- o To not neglect other problems that will come
verbal means (words, signals, signs, symbols) utilized out during the working phase
in a goal- directed professional framework.
 Offering self Orientation (initiation)
o Offering safety, service, comfort  Assessment of problems, needs, expectations of
o “I’ll sit beside you” clients
o “Do you need help?”  Identify anxiety level of self and client
o You want to tell the patient that you want to  Set goals of relationship.
provide care  Define responsibilities of nurse and client. Stage of
o Very helpful for depressed patients, this testing.
shows that people care for them  Establish boundaries of relationship. Stress
o E.g. Ursula, age 25, is found on the floor of confidentiality.
the bathroom in the day treatment cleaning  Contract – 2 famous psychiatric contracts:
with moderate lacerations to both wrists.
Surrounded by broken glass, she sits staring o 1. No suicide contract  Major depression
blank at her bleeding wrist while staff = emergency
members call for an ambulance. The best
way the nurse should do is to approach o TWO definitions of no suicide contract:
Ursula slowly while speaking in the calm o 24 hours monitoring
voice, calling her name and telling her that
the nurse is here to help her. This approach o Verbalization to the nurse of all suicide
provides reassurance for a patient in distress ideas
3 LEVELS OF PSYCHIATRIC NURSING (Levels of  Diet contract  Eating disorder
Health)
 The start of termination phase: “Good morning,
Primary full name, RN, shift, session, date start & end.”
 Objective: PROMOTION & PREVENTION
  Discuss client’s feelings and objectives achieved
Working phase Levels of awareness

 Promote acceptance of each other

o Accept client as having value and worth as a
unique individual.
o Stage of resistance
 Counter transference phase
 Most difficult phase
 NCP is on going
 Identification of the problem/exploration
 The #1 Psychiatric Core Value is Consistency  For
manipulative patients
 Be consistent to patient with: BAAAM COPS
B orderline C onduct d/o
A ntisocial O ral/eating disorder
A lzheimer’s P aranoid
A utistic S uicidal
 Conscious- you can immediately answer or remember
 Use therapeutic and problem- solving techniques because this is still in your memory
o Maintain professional, therapeutic relationship o Composed of past experiences, logical
o Keep interaction reality- oriented- here and now and governed by REALITY
o Provide active listening and reflection of feelings PRINCIPLE; are remembered and easily
o Use non- verbal communication to support client recalled or available to the individual
o Recognize blocks to communication and work to  Subconscious- information or memory where you
remove them need to exert effort in order to remember
o the Preconscious; composed of material that
 FOCUS on client’s:
o Confronting and working through identified has been deliberately pushed out of
conscious level; helps repress
problems
unpleasant thoughts or feelings and can
o Problems- solving skills
examine or censor certain desires or
o Increasing independence
thinking; can be recalled with some effort
o Help client develop alternative, adaptive coping
 Unconscious- memories or information that are
mechanisms already repressed
o Personal biases (manifestation by counter- o Composed of the LARGEST BODY OF
transference & vice versa) are seen during MATERIAL- the thoughts, memories and
working phase feelings that are repressed and not available
to the conscious mind, not logical and
governed by PLEASURE PRINCIPLE –
Termination and since it is usually painful and
unacceptable to the individual, it cannot
 Plan for termination of relationship early the be deliberately brought back into awareness
relationship unless in disguised or distorted form
 Stage of Separation Anxiety  Signs & symptoms: (dreams)
Regression: Temper tantrums, thumb sucking, o Information cannot be totally remembered
apathy, fetal position when crying o Largest storage among the three
 Phase of prognosis  Evaluation
 Maintain boundaries
 Anticipate problems of termination:
o Increased dependency on the nurse
o Recall of previous negative experience- Additional notes
rejection, depression, abandonment, etc.
o Regressive behaviors  Exploration is a sign of suicide
o Emphasize to the patient that a discharge o They are giving their belongings to other
instruction has been made which would help people
his/ her progression  If a patient has suicidal ideations, do you confront or
o Discharge plan is discussed in this phase
ask that patient?
 o Yes, because it is considered to be o They cannot explain d/t decreased levels of
therapeutic serotonin
o A no suicide attempt contract will be given, o Volume of the voice may also be an
because once a suicide happen the hospital indicator depending on the client
and staff will be held liable  Mood and affect
o When you ask the patient if he/she will o Affect can be seen in the client’s facial
perform suicide the patient will know that expression
o Affect is the experience of feeling
the nurse is knowledgeable leading to delay
an emotion while mood is a state
in the plan, do this until serotonin levels go
of emotion
back to normal and depression will be o Affect is usually short-lived
solved while mood can last for hours or days
o Confrontation is therapeutic to suicidal o Blunted vs. flat affect
patients. You can ask when, where, and how o A person with flat affect has no or nearly
can be asked but never why no emotional expression. He or she may not
 Asking questions starting with why is never react at all to circumstances that usually
therapeutic evoke strong emotions in others. A person
o Because why is an open-ended question, with blunted affect, on the other hand, has
leading the patient to rethink of the thoughts a significantly reduced intensity in
and feelings that drove them to do suicide emotional expression
o Inappropriate vs labile affect
Mental status examination o Inappropriate affect is an affect that is
 A systematic assessment that checks if a person is incongruent with the situation or with the
mentally sound or not content of a patient's
o Assessment in terms of their mental health ideas or speech. Labile affect that
o No tools are available for this exam characterized by rapid changes in emotion
o Not used to create a diagnosis but only to unrelated to external events or stimuli
assess  Inappropriate affect is somehow
o Only used to add confirmation to a specific similar to the reaction formation
mental disorder o Restricted affect is a term used to describe
 Clinical eye may be used in this assessment a mild constriction in a client's
 Histrionic personality disorder physical affect: range and/or intensity of
o Characterized by a pattern of excessive emotion or display of feelings
attention-seeking behaviors, usually  The person does not want to really
beginning in early childhood, including show his/her feelings
inappropriate seduction and an excessive  Speech
desire for approval. o There are certain forms or types of speech
 Hygiene should be assessed that manifests in mental disorders
 Eye contact o Bipolar patients manifest flight of ideas
o Does the person engage in eye contact? when speaking (flight of ideas where one
o But always take into consideration of the sentence has little connection to the second
norms and practices about eye contact of statement) d/t hyperactive thinking
the patient o Schizophrenia not intact with reality when
 Attitude speaking (delusional)
o Mannerisms (can usually be seen in  Loses association in spoken
statements
Tourette’s and autism)
 Word salad (speaking of words not
o It is important to detect mannerisms
related to one another)
because this may be a sign of neurologic
o Neologisms can also be observed in
dysfunction
schizophrenic patients
o Alcohol and drug use may induce
 Coining or use of new words
mannerisms because these damages the
 Invented words that is only known
CNS
by the patient
 Appearance  When talking to the patient, clarify
o Check the way a person dresses, is it what these words are to the client
appropriate for the time and occasion? o Echolalia, echopraxia, and palilalia
o Can be observed in narcissists and people  Echolalia is the repetition of
with illusion of grandeur words spoken by others,
 Speech whereas palilalia is the automatic
o Depressed patients can only answer close- repetition of one's own words
ended questions
  Echopraxia (also known as o Should be in supine during ECT, then after
echokinesis) is the involuntary place in a side-lying position to allow
repetition or imitation of another drainage of secretions
person's actions.  6-12 treatments, “every other day”
 Can be seen in autism patients  Before ECT
o Clanging- rhyming of words or phrases also o Should be on NPO
observed in schizophrenic patients] o Food is introduced when gag reflex is back
o Blocking  Before ECT a major depressed client undergoes the ff
 People with meds:
thought blocking often interrupt  Phenobarbitals are given as anticonvulsants and may
themselves abruptly mid-sentence. also decrease heart rate of patients
 Can be observed in schizophrenic-  SSRi (Selective Serotonin Reuptake
paranoid type Inhibitor inhibitor) –2 weeks
 This occurs d/t hallucinations of  Antidepressants  TCA 2nd Generation
the patient o 2-4 weeks
 Thought
 MAOIs – are taken for 2 weeks
o Thought insertion can be seen in
schizophrenia Side Effects
 Experiencing one's
 After ECT, reorient the patient because antegrade
own thoughts as someone else's
amnesia is expected after therapy
o Thought withdrawal
o Temporary RECENT Memory Loss
 Delusion that thoughts have been
ANTEROGRADE amnesia
taken out of the patient's mind
o Intervention: Re-orient client to 3 spheres
o Disturbed sensory perception and altered
o Reintroducing yourself, therapy, where
thought process may be a nursing diagnosis
patient is, time and date, secure the safety of
o Agnosia- loss of the ability to recognize
a patient as well
objects, faces, voices, or places
o confusion/disorientation (usually 24 hours)
o Apraxia- inability to perform learned
o Headache  ↑02 demand, ↑cerebral
(familiar) movements on command
hypoxia
 Inability to use objects properly
o Muscle spasm
o Aphasia- impairment of language, affecting
o Wt. gain (stimulate thalamic/limbic 
the production or comprehension of speech
and the ability to read or write appetite)

Contraindications
Therapy for mental disorders  PPPP– Post MI, Post CVA, pacemaker, pregnant
women
Electroconvulsive therapy  People with cardiovascular problems
 ECT is passing of an electric current through  Neurologic problem  Alzheimer’s, degenerative
electrodes applied to one or both temples to disorder
artificially induce a grand mal seizure for the safe and
 Brain tumor, weakness of lumbosacral spine
effective treatment of depression.
 ECT’s mechanism of action is unclear at present Legal/Pre-Nursing Responsibilities
 For depressed patients Preparation: Similar to preparing a client for surgery
 Last resort for a depressed patient who can no longer  Informed Consent – if client is coherent, if not a
wait for the effect of an antidepressant medications or guardian may sign the consent forms.
is no longer responsive to medications  No metallic objects
o Metals can interfere with electrical
Advantages transmissions
 Quicker effects than antidepressants; Safer for  No nail polish to check peripheral circulation
elderly; 80 % improvement rate of major depressive  No contact lenses it may adhere to the cornea
episode with vegetative aspects  Let the patient void first
 Best therapy for major depression (last resort)  Wash & dry hair
 Invasive  6. Give following medications BEFORE ECT:
 Induction of 70-150 volts of electricity in).5-2secs.  Atropine sulfate – anticholinergic
Then, it is followed by a grand-mal  PRIMARY purpose – to dry secretions and
seizure lasting 30-60 secs. prevent aspiration
o Prone to aspiration that is why atropine  SECONDARY purpose – to prevent bradycardia
sulfate is given to decrease secretions and (vagolytic)
prevent aspiration  Phenobarbital (Luminal), Methohexital (barbiturate
Na)- minor tranquilizer also an anticonvulsant
  Succinylcholine (Anectine) – muscle relaxant o Behavior changes quicker if rewards are not
o Given because ECT can cause muscle spasm given frequently, because once reward is
 Priority vs. to focus ABC; check RR 12 less; LOC gone attitude may come back
 Before ECT  supine position; after ECT  side- o Should have a gap in between before you
lying give another reward
 Have patient VOID before giving ECT o This is to train them to maintain the good
behavior and not wait for the rewards
Nursing Diagnosis  If with bad behavior, punishment should be provided
 Risk for Airway Obstruction/aspiration right away
 Risk for Injury o Because there is a tendency that they will
 Impaired/Altered Cognition/LOC not believe that the punishment is not true
 Provides a stimulus to encourage good behavior
Nursing Intervention  Appropriate therapy for phobias is systematic
 5 S in Seizure desensitization
 Safety (#1 objective) o A gradual exposure of the person to feared
 Side-lying (#1 Position) objects
 Side rails up o E.g. fear of snakes, first show it from afar or
 Stimulus ↓ (no noise & bright lights) a stuffed toy, then progress until patient can
 Support the head with a pillow AFTER the seizure touch the snake
 FIRST & TOP priority: Ensure a patent airway. o Reinforce to the patient that not all snakes
Side-lying after removal of airway. Observe for are venomous
respiratory problems  If systematic desensitization is not effective, flooding
 Remain with client until alert. VS q 5 min until may be done
stable. o This is the abrupt exposure to feared objects
 REORIENT: Time, place (unit), person (nurse); until the patient becomes tolerant with it
Reassure regarding confusion and memory loss.
OPERANT CONDITIONING
Same RN before & after.
Burrhus Skinner
 used in Behavior Modification
Behavior therapy
1. Positive reinforcement (Reward Orientation)
TERMINOLOGIES o Token Economy – use tokens as a source of
 STIMULUS: Any event affecting an individual reward.
 PROBLEM BEHAVIOR: Deficient, excessive, o Used in eating disorders and depression
condemned, unwanted behavior o Token economy is also effective for toddlers
 OPERANT BEHAVIOR: Activities that are 2. Negative Reinforcement (Punishment Orientation)
strongly influenced by events that follow them. o Aversion Therapy/Aversion Technique
 TARGET BEHAVIOR: Activities that the nurse
wants to develop or accelerate in the client. BEHAVIORAL TREATMENTS
 REINFORCER: A reward positively or negatively 1. Desensitization – gradual exposure to the feared
influences and strengthens desirable behaviors. object
 POSITIVE REINFORCER: A desirable reward o #1 treatment for phobia
produced by specific behavior (TV time after doing 2. Flooding/Implosive Therapy – sudden exposure
homework) 3. Relaxation Technique – light stroking = labor
 NEGATIVE REINFORCER: A negative o Purse Lip Breathing Exercise = COPD/CAL
consequence of a behavior (Spanking child for (Chronic Airflow Limitation)
wetting the floor) 4. Biofeedback – mind over matter. Ex. HPN > ↓BP,
palpitations, headache
5. Guided Imagery (Child) & Visualization (Adult
Classical conditioning

 (pairing of two stimuli in order to gain a new learning Group therapy

behavior – by Ivan Pavlov)  Psychotherapeutic processes that occur in formally
 Acquisition (newly acquired behavior or the by- organized groups designed to change maladaptive or
product of classical conditioning) undesirable behavior.
 Extinction  Knowledge of therapeutic modalities enhances the
 Reward and punishment in order to change the performance of nursing interventions during therapy.
behavior of the patient 8-10 patients are the optimal number of patients in a
 How frequent do we need to do this? group.
 There should be 8-10 members only
 Maximum of 10, no longer therapeutic if too many
  All members should have or experience the same
problem 2. Working Phase
 Done during rehabilitation in order to gain other  Confrontation between members→ Cohesiveness
coping mechanisms of other patients who have  Identification of problems→ Problem- solving
overcome the problems processes
 In a group therapy when one client says to another,
“Maybe you’re taking on someone else’s problems.”
TYPES OF GROUPS this shows that they are in the working phase
1. Structured
o Goals: Pre-determined 3. Termination Phase
o Format: Clear and specific  Evaluation of goals attainment
o Factual material: Presented  Support for leave- taking
o Leader: Retains control  In group therapy if a client says, “Leave me alone &
2. Unstructured get away from me.”, best action of the RN is to
o Goals: Not pre-determined. maintain distance from the pt.
Responsibility for goal is shared by group and  Behavior indicating that goal is met after
leader socialization in a group therapy includes participation
o Format: Discussion flows according to group of each group member telling the leader about
members’ concern specific problems
o Materials and topics are not pre-elected.
o Leader: Nondirective
o Emphasis: More on FEELINGS rather than facts Milieu therapy

 Milieu therapy or environmental therapy

ADVANTAGE OF GROUP THERAPHY o If a patient is having a religious delusion
1. Economical: Less staff used.
remove images of saints, or smokes, because
2. Increased feelings of closeness > Reduction on
it only adds to the delusion of the patient
feelings of being alone.
o This does not bring the patient back to
3. With feedback group >
o Corrects distortions of problems reality
 Therapeutic milieu is an environment that is
o Builds self- image and self- confidence
structured and maintained as an ideal, dynamic
o Increases reality- testing opportunities
settings in which to work, with client
o Gives info on how one’s personality and
 For hyperactive patients do not place them in areas
behavior appear to others with a lot of activities
4. With opportunities for practicing alternative o Place them in safe environments
behaviors and methods of coping with feelings
 Any activity that is to be done should be supervised
5. Provides attention to reality and provides
by the nurse
development of insight into one’s problems by
expressing own experiences and listening to others in
groups
Crisis

 Expected especially when a person is growing up

(developmental crisis)
PRINCIPLES OF GROUP THERAPY o E.g. a girl undergoing puberty had her first
1. Verbalization: Members express feelings and group menstruation has increased anxiety because
reinforces appropriate communication. this is her first time
Desired outcome of group therapy includes o This cannot be avoided
verbalization of feelings rather than acting them out  Midlife crisis where a person experiences ttransition
2. Activity: Provides stimuli to verbalization and of identity and self-confidence that can occur in
expression of feelings. middle-aged individuals, typically 45 to 65 years old
3. Support: Members gain support from one another  When a person gets married, a person may also
through interaction, sharing and communication. undergo crisis because there will be a huge
4. Change: Members have opportunity to try out new adjustment
and desirable behaviors in group, supportive setting  Situational crisis involves an unexpected event that is
to effect change. usually beyond the individual's control. Examples
of situational crises include natural disasters, loss of
PHASES OF GROUP THERAPY a job, assault, and the sudden death of a loved one.
1. Initial Phase  Adventitious crisis where natural resources are
 Formation of group involved
 Setting and clarification of goals and expectations o Called events of disaster. They are rare,
 Initial meeting, acquaintance and interaction unexpected happenings that are not part of
 everyday life and may result from: Natural for a reformed lifestyle. People facing less serious
disasters, such as floods, fires, and trauma can bargain or seek compromise. Examples
earthquakes include the terminally ill person who "negotiates with
 You are considered healthy is you are able to cope up God" to attend a daughter's wedding, an attempt to
with the crisis in 4-6 weeks bargain for more time to live in exchange for a
o It should lessen in 4-6 weeks, but if it reformed lifestyle or a phrase such as "If I could trade
increases you need to seek professional help their life for mine".
o If it resolves then recurs, its fine so long as it  Depression – "I'm so sad, why bother with
resolves anything?"; "I'm going to die soon, so what's the
point?"; "I miss my loved one; why go on?"
During the fourth stage, the individual despairs at the
recognition of their mortality. In this state, the
individual may become silent, refuse visitors and
spend much of the time mournful and sullen.
 Acceptance – "It's going to be okay."; "I can't fight it;
I may as well prepare for it."
In this last stage, individuals embrace mortality or
inevitable future, or that of a loved one, or another
tragic event. People dying may precede the survivors
in this state, which typically comes with a calm,
retrospective view for the individual, and a stable
condition of emotions.
 It is important for nurses to guide patients not to stay
too long in denial stage
 Nurse should guide the patient through the stages
Stages of grief

Additional notes

 Voluntary admission- patient wants to seek mental

help so he/she surrendered self to the facility
o Contract may be ended by the patient
o He/ she may request to be discharged
o False imprisonment, assault, battery may be
charged if the nurse does not allow the client
to be discharged and was restrained
 Involuntary- those who were escorted to the facility
because they are still in denial of their condition
o Patients in this type of admission cannot
request to be discharged
o Contact the legal guardian who brought the
client there
 Safety and security must always be prioritized when a
patient is in jeopardy
o E.g. a patient is having seizures and the IV
lines are dislodged, ensure the safety of the
 Denial – The first reaction is denial. In this stage, client first side rails up!
individuals believe the diagnosis is somehow  How do you consider an alcoholic patient already
mistaken, and cling to a false, preferable reality. okay?
o Present the reality to the client  Delusion of grandeur- fixed false belief of being high
 Anger – When the individual recognizes that denial or important
cannot continue, they become frustrated, especially at  Flight of ideas are somewhat related to one another
proximate individuals. Certain psychological o Very common in bipolar disorders
responses of a person undergoing this phase would o Mentioning one word then connecting it to
be: "Why me? It's not fair!"; "How can this happen to another
me?"; "Who is to blame?"; "Why would this o Ex. Sir Gan—gun, I want to kill somebody
happen?".  Looseness of association- sentences are not
 Bargaining – The third stage involves the hope that connected with one another
the individual can avoid a cause of grief. Usually, the o Common in schizophrenic patients
negotiation for an extended life is made in exchange o Because they are not intact with reality
  Clanging- rhyming words o Patient is already disorganized
 Neologism- making of words  Panic: The perceptual field is severely reduced and
 Projection is used by paranoid patients the client experiences feelings of panic and dread.
 Conversion- anxiety converted to physical symptoms Client overwhelmed and helpless; personality may
 Compensation- weakness covered by greatness disintegrate → hallucinations and delusions.
 Orient the patient to location, time, place, and person Pathological conditions requiring immediate
 Narcissistic patient- always remind them of the roles intervention. Client may harm self or others.
and the patient should be the one following the nurse o A patient stating, “Sometimes I feel like I’m
o Reinforce to the patient that all the activities going crazy & losing control over myself,”
to be done is for her/his good is showing symptoms of panic attack
o Always set the boundaries  Perceptual field and anxiety are inversely
o Confrontation can be done since there is a proportional
contract o Sensorium or senses are involved
o As anxiety increases sensorium decreases
o When a patient is anxious, he/she can only
see what is in front and can only hear loud
MIDTERMS noises
 Talk to the patient in a short and direct manner, use
Anxiety close-ended questions
 DEFINITION: Effective subjective response to an  Always place yourself in front of the patient
imagined or real internal or external threat.  Identify the stimulus that causes anxiety and remove
it
 Perceived SUBJECTIVELY by the conscious mind is  Do not leave the patient alone during anxiety attack
as a painful, diffuse apprehension or vague o Safety is always priority
uneasiness, but the causative conflict or threats is not  Still give space and do not touch the patient unless
in the conscious mind or awareness. he/she permits you to do so
 Low / mild level of anxiety is healthy and helps in
individual growth and development. POTENTIAL NURSING DIAGNOSES
 So long as you are still oriented to time, space, and  Ineffective Individual Coping
situation the anxiety you are feeling is still normal  Anxiety
o Up to moderate level of anxiety may still be
considered normal NURSING INTERVENTION IMPLEMENTATON:
 There are internal and external threats  Identify anxious behavior and anxiety levels and
o Internal- formed in the mind institute measures to decrease anxiety at a level
o External- due to your situation or where learning can occur.
environment  Provide appropriate environment where
environmental stress & stimulation are low (First
MAJOR ASSESSMENT CRITERION FOR nursing action):
MEASURING DEGREE OF ANXIETY: o Structured, NON-STIMULATING,
uncluttered
 Mild: The perceptual field is wide allowing the client o SAFE from physical exhaustion and harm.
to focus realistically on what is happening to him.  STAY. Do not leave client alone. Recognize if
Alert senses, increased attentiveness, and increased additional help is needed. Provide physical care if
motivation. necessary.
o Expected incoming threats
 Establish PERSON-TO-PERSON relationship and
o Can still focus on other things maintain an accepting attitude:
 Moderate: Another word is selective inattention. The o ACCEPT client. Show willingness to
perceptual field narrows and the client is able to LISTEN.
partially focus on what is happening if directed to do o Encourage, allow EXPRESSION OF
so and can verbalize feelings of anxiety FEELINGS at client’s OWN PACE avoid
o Cannot focus anymore on other things forcing verbalization.
 Severe: The perceptual field is significantly reduced  Administer medication as directed and needed. The
and the client may not be able to focus on what is pharmacologic therapy of choice is ANXIOLYTIC-
happening to him and may not be able to recognize or reduces anxiety so client can participate in
verbalize anxiety. All senses affected; decreased psychotherapy.
perceptual field; drained energy; Learning and  Assist to cope with anxiety more effectively. Assist
problem-solving not possible. Start of sympathetic to recognize individual strengths realistically
symptoms: tachycardia, palpitations, hyperventilation  Encourage measures to reduce anxiety: activities:
(brown paper bag to prevent Respiratory Alkalosis) relaxation techniques, exercises (DANCING,
and cold clammy skin.
 WALKING, JOGGING), hobbies, talking with  Provide relaxation techniques
support groups, desensitization treatment program  Implement behavioral therapy: SYSTEMIC
 Provide individual or group therapy to identify DESENSITIZATION (the #1 treatment for
anxiety and new ways of dealing with it and develop PHOBIA). Administer antidepressants as ordered
more effective coping interpersonal skills.
 If patient can be redirected back to the topic after he
gets anxious while the RN gives discharge teaching, OBSESSIVE-COMPULSIVE DISORDER
it is an indication that discharge teaching can be
 A psychiatric disorder characterized by persistent,
resumed.
recurring anxiety-provoking thoughts and repetitive
acts; Unconscious control of anxiety by the use of
TYPES OF ANXIETY DISORDER rituals and thoughts
o OBSESSION: Persistent, repetitive,
 Phobia uncontrollable thoughts
o Fear of heights- acrophobia  These are thoughts that are
o Fear of fire- pyrophobia recurring in the mind
o Fear of doctor- iatrophobia  Thoughts that keeps a patient
o Fear of microorganisms- germaphobia preoccupied, thus, affects ADLs
o Fear of death- thanatophobia o COMPULSION: Repetitive, uncontrollable
o Fear of animals- zoophobia acts of irrational behavior that serve NO
 Obsessive Compulsive rational purpose → rigidity, rituals,
 Post-Traumatic Stress Disorder (PTSD) inflexibility; the development of rituals
permits some measure of social adjustment
 Generalized Anxiety Disorder (GAD)
 Things that the patient
 Panic Disorder
unconsciously does to decrease the
level of anxiety because of the
PHOBIA AND PANIC DISORDER
obsession
 Extreme anxiety and apprehension experienced by an  Helps in decreasing the anxiety felt
individual when confronted with feared object/ by the patient
situation; commonly begins in early twenty’s (young
 ASSESSMENT FINDINGS: Ritualistic, rigid,
adult) as a result of childhood environmental factors
inflexible; with difficulty making decisions and
characterized by ORDER & RIGIDITY; use
demonstrates striving at perfection; use verbal and
compensatory mechanism of the psychoneurotic
intellectual defenses
pattern of behavior and development of symptoms
 Acknowledge positive reinforcement
permits some measure of social adjustment.
 PRECIPITATING FACTOR: Pressures of decision- NURSING IMPLEMENTATION
making regarding life-style in early adult period
 Provide for physical safety (1st); meet physical needs
TYPES OF PHOBIA  Accept, allow ritualistic activity; DO NOT
INTERFERE with it; (The best time to interfere with
 Agoraphobia: Fear of being alone, fear of open ritual is after client has completed it.) Accept
spaces or PUBLIC places where help would not be behavior but set limits on length and frequency of the
immediately available (trains, tunnels, crowds, buses) ritual. Offer alternative activities; support attempts to
 A client with agoraphobia who is already able to go reduce dependency on the ritual; guide decisions
outside the house indicates a positive response to o Just set a time when to perform the
therapy. ritualistic behavior (time management)
 Expected outcome for agoraphobia includes going o Do not stop, because it will increase anxiety
out to see the mailbox  Provide structured environment, minimize choices
 Social phobia: Fear of public speaking or situations in  Provide socialization, group therapy
which public scrutiny may occur  Administer CLOMIPRAMINE (ANAFRANIL) as
 Simple phobia: Fear of specific objects, animals or ordered
situations o A Tricyclic antidepressant used in phobias,
NURSING IMPLEMENTATION anxiety and obsessive-compulsive disorder;
SIDE-EFFECTS/ ADVERSE REACTIONS:
 Recognize the client’s feelings about phobic object/ Tachycardia, cardiac arrest, dizziness, tremors,
situation seizures, CONTRAINDICATIONS: Pregnancy,
o Specific precipitants are present with phobia hypersensitivity; Interactions/Incompatibilities:
 Avoid confrontation and humiliation; Provide Hypertensive crisis, convulsions, with MAOIs
constant support (Stay with client during an attack) if
exposure to phobic object or situation cannot be
POST-TRAUMATIC STRESS SYNDROME
avoided
 Do not focus on getting patient to stop being afraid
  A disorder following exposure to extreme traumatic  A client expresses emotional turmoil or conflict
event (wars, rape, natural catastrophes) causing through a physical system, usually with a loss or
intense fear, recurring distressing recollections and alteration of physical functioning
nightmares  Involves a person having a significant focus on
o Retained in the patient’s mind physical symptoms, such as pain, weakness or
o They are detached because they do not know shortness of breath, that results in major distress
who to trust anymore. They think that and/or problems functioning. The individual has
people who surround them are going to do excessive thoughts, feelings and behaviors relating to
something bad the physical symptoms
 ASSESSMENT: 2 Cardinal Sign: FLASHBACK &  When validated by laboratories it is not confirmed to
NIGHTMARES. Images, thoughts, feelings → be true
intense fear and horror, sleep disturbances.
o Depression, or irritability or outburst of anger CONVERSION DISORDERS
o Exaggerated startle response; Poor impulsive  A psychological condition in which an anxiety-
control provoking impulse is converted unconsciously into
o Avoidance; Inability to maintain intimacy; functional symptoms
Hypervigilance  Anxiety is converted to physical symptoms
o The two cardinal signs should be present in order  Patients with this disorder do not fake the physical
to diagnose PTSD signs and symptoms
 PRIORITY NURSING DIGNOSIS  Physical symptoms can be confirmed through
o Altered Sleeping Patterns diagnostic tests
o Altered Skin Integrity  Does not do hospital-hopping because the doctor will
o Ineffective Individual Coping validate that the symptoms are real
NURSING INTERVENTATION
o Encourage VERBALIZATION about painful HYPOCHONDRIASIS
experience. Show empathy; be non-judgmental; Help  Presentation of unrealistic or exaggerated physical
feel safe. complaints
o To prevent level of anxiety  When a patient complains of backache and thoughts
o Rational emotive-therapy; Allow to grieve of it as bone cancer
o Help client identify, label and express feelings safely
o If they have difficulty in sharing the experience their DISSOCIATIVE DISORDERS
level of anxiety may increase  Dissociative amnesia
 Enhance support systems: Self-help groups, family  Dissociative fugue
psychoeducation, and socialization.  Depersonalization
o In a rape victim, a statement like, “If I should not  Dissociative Identity Disorder/Multiple Identity
have worn that red panty, it won’t happen to me”, Disorder
shows denial  These disorders are still because of anxiety
o Statement of a rape patient who is beginning to
resolve trauma includes, “I’m able to tell my friends DISSOCIATIVE AMNESIA
about being raped.”  Characterized by the inability to recall an extensive
o An RN needs further teaching about caring for a post- amount if important personal information because of
traumatic client when she keeps on asking the client physical or psychological trauma
to describe the trauma that caused patient’s distress  Once the patient has recovered from the crisis, the
after recovering from a PTSD memory of the patient will return
SOMATOFORM DISORDERS
 Body Dysmorphic Disorder DISSOCIATIVE FUGUE
 Somatization  The person suddenly and unexpectedly leaves home
or work and is unable to recall the past
 Conversion Disorders
 If the patient moves from one country to another the
 Hypochondriasis
patient will not be able to recall the previous life and
 Psychogenic Pain
the previous country he has been in
 This are all caused by anxiety
 Characterized by reversible amnesia for personal
identity, including the memories, personality, and
BODY DYSMORPHIC DISORDER
other identifying characteristics of individuality. The
 Preoccupation with an imagined defect in his or her
state can last days, months or longer.
appearance
 A perceived distortion to the physical body DEPERSONALIZATION
 This is not made up by the client but this is what  Person experiences a strange alteration in the
he/she sees perception or experience of the self, often associated
with a sense of unreality
SOMATIZATION
  Depersonalization/derealization disorder is a type of ***symptoms should be present for at least 6 months to
dissociative disorder that consists of persistent or confirm schizophrenia
recurrent feelings of being detached (dissociated) ***At least 2 positive symptoms and 1 negative symptoms\
from one’s body or mental processes, usually with a
feeling of being an outside observer of one’s life THEORIES
(depersonalization), or of being detached from one's 1) Increased dopamine –coming from the substancia nigra
surroundings (derealization).
2) Genetics
 This is not fixed, only temporary. The patient can still
go back to reality └ 65% chances- if two parents are diagnosed with
schizophrenia
MULTIPLE PERSONALITY DISORDER └ 32.5% chances- if 1 parent is diagnosed with
 A person is dominated by at least one of two or more schizophrenia
definitive personalities at one time 3) Drug addicts and alcoholics: High probability for
 Maintenance of at least two distinct and relatively schizophrenia due to increase Delusions & hallucination
enduring personality states. The disorder is
4) Pregnant woman who is a smoker may increase risk for
accompanied by memory gaps beyond what would be
explained by ordinary forgetfulness. development of schizophrenia of her baby
 The person won’t know about the different
personalities unless they are already being treated CLINICAL MANIFESTATIONS OF SCHIZOPHRENIA
 Once they verbalize and is conscious of the multiple  Characterized by both (-) & (+) symptoms & social /
personalities it is a sign of progress or recovery occupational dysfunction for at least SIX (6) months.
 Patient with 5 admissions in 2 yrs is considered a chronic
Psychotic Disorders schizophrenia
 (+) POSITIVE SIGNS OF SCHIZOPHRENIA: Due
SCHIZOPHRENIA to EXCESS DOPAMINE
 Severe impairment of mental & social functioning with HILDDA PI
grossly impaired reality testing, sensory perception and o Hallucination
with deterioration & regression of psychosocial o Illusion
functioning. o Looseness of Association
 Schizo = Split o Delusion of Grandeur
 Phrenia = Mind o Disorientation
 Dopamine is increased o Agitation
└ Dopamine is responsible in cognitive function o Paranoia
└ Increased levels will lead to delusions and o Insomnia
hallucinations  (-) NEGATIVE SIGNS OF SCHIZOPHRENIA: Due
 #1 HALLUCINATION of Schizophrenia is Auditory. to LACK OF DOPAMINE
 Irreversible disease POOR A’s
└ It can be managed but not treated o Poor judgment
└ Intake of antipsychotics drugs is lifetime o Poor insight
└ If intake of medications are stopped, schizophrenia o Poor self care
manifestations will return again o Alogia [lack of speech caused by a disruption
 Ego is damaged because ego is what keeps the patient in the thought process]
intact in the reality o Anhedonia [absence of sexual urges]

THE FOUR A’s of SCHIZOPHRENIA NURSING DIAGNOSIS FOR NEGATIVE SYMPTOMS OF

ACCORDING TO BLEULER SCHIZOPHRENIA:
ASSOCIATIONS, LOOSE: Jumping to different 1. Alteration in Thought Process
topics WITHOUT association or relevance
2. Alteration in Content of Thought
AMBIVALENCE (Two opposing
thoughts/feelings toward others at the same time)
A  OTHER POSITIVE SYMPTOMS:
AUTISM (withdrawal from environment and
others) → magical thinking, neologism, aloofness, All this signs & symptoms can also be seen in SAM
echolalia) (Schizophrenia, Alzheimer’s & Manic)
AFFECT, FLAT (Inappropriate or no display of 1. Neologism (creating NEW WORDS) vs. Word
feelings) Salad (incoherent mixture of words)
***should be assessed to diagnose schizophrenia 2. Verbigeration (meaningless repetition of action
words and phrases
 Perseveration  #1 Cardinal Sign of Catatonia – waxy flexibility
e.g. 1st stimulus → correct response  Most dangerous/serious type of schizophrenia–
2nd & following stimulus → still responding to may die from dehydration
the 1st stimuli  Catatonic stupor – markedly slowed movement.
3. Circumstantiality (beating around the bush;
o Waxy Flexibility
answers but delayed) vs. Tangentiality (did not
└ decreased response to stimuli and a
answer the stimulus/ question)
tendency to remain in an immobile
 Usually found in disorganized type of
posture
schizophrenia
└ lack of movement for a prolonged period
4. Clang association (use of rhymes in
of time
sentences/words connected) vs. Echolalia/Parroting
└ occurs because the patient is regressive
& Echopraxia-involuntary imitation of movements
o mutism
made by another.
 Catatonic hyperactivity or excitability
5 TYPES OF SCHIZOPHRENIA  Nursing Responsibility: prevent injury
1. PARANOID
 Presenting sign is SUSPICIOUSNESS, ideas of 3. DISORGANIZED/ HEBEPHRENIC
persecution and delusions  Characterized with inappropriate behavior:
└ sees environment as hostile and threatening o Silly crying
 most difficult to handle because they are usually o Laughing
uncooperative o Regression
 REMEMBER the 4 P’s: o Confusion
o Projection (#1 defense mechanism) attributing o disorganized thoughts
one’s own unacceptable feelings & thoughts to o transient hallucinations (Auditory)
others  Common in women
o Proxemics (4 feet away from the patient)  All behaviors are similar with toddlers since they are
o P Friendliness (#1 attitude therapy: No anal fixated.
touching, no whispering & laughing)  Developmental Stage FIXATION: Anal Fixation
o Delusion of Persecution (#1 delusion of  #1 Defense Mechanism: Regression & Fixation
Paranoid Schizophrenia) – thinking of being
attacked by someone else 4. UNDIFFERENTIATED/ MIXED
 Developmental Stage FIXATION: ORAL PHASE  Symptoms of more than one type of schizophrenia
(TRUST vs. MISTRUST) has delusions & disorganized behavior
 Defense Mechanism: Projection  The #1 drug of choice is Fluphenazine (Prolixin
 Nursing Care: decanoate)
1. Consistency to build trust
2. Food: PACKED OR SEALED foods except 5. RESIDUAL
canned goods: No metal  No longer exhibits overt symptoms, no more
3. Social Isolation – no group session when delusions but the signs and symptoms may comeback
schizophrenic due to non-compliance with drug intake
4. At least 4 feet away and in front of the patient  No more PO drugs, IV drugs are now given
when communicating  Nursing care: consistency
5. Never touch the patient  Give antipsychotic –hallucination / delusion
 Eg. Paranoid who is suspicious saying, “This place is  Undifferentiated type chronic schizophrenia must be
meant for bugs & prison,” In order to encourage trust, referred to a program promoting social skills due to
the patient should be involved in the plan of care. functional loss deficit
 Eg. How will you feed a malnourished paranoid
schizophrenic patient? Involve patient in all PRINCIPLES OF CARE FOR SCHIPHRENIA
interventions so that they will see that everything is 1. Maintenance of safety:
prepared safely with no harm  Protect from altered thought processes.
 Respond to feelings, and not to delusions
2. CATATONIC  Do not argue
 With stereotyped position (catatonia) with waxy  Validate reality
flexibility, mutism,
  Remove from areas of tension
 Eg. Appropriate action of RN to a Schizophrenic who 35 yrs-55 yrs GENERATIVITY VS. STAGNATION
yells loudly, talks to wall and saying “Don’t talk to  fulfilling life's goals that involve family, career and
society, developing concerns that embrace future
me, bastard.” includes walking towards the pt & ask
generations
him who he is talking to.  conflict: self-absorption. Inability to grow as a person
2. Meeting of physical needs
 May have to be fed / bathe initially 55 yrs-above INTEGRITY VS. DESPAIR
3. Establishment and maintenance of therapeutic  looking back into one’s life and accepting its
relationship meaning
 Engage in individual therapy  conflict: dissatisfaction with life, denial of or despair
over prospect of death
 Promote trust
 Encourage expression by verbalizing the observed JEAN PIAGET
 Offer presence-Tolerate long silences COGNITIVE THEORY OF DEVELOPMENT
4. Implementation of appropriate family, group, social or
diversional therapies ASSIMILATION
 people transform incoming information so that it fits
 Patients with schizophrenia need activities that do not
within their existing schemes or thought patterns
require interaction, so solitary activities are preferred
over team activities. ACCOMMODATION
 people adapt their schemes to include incoming
information
*Hindi to kasama sa lecture pa po hehe
ERIK ERICKSON PIAGET’S COGNITIVE THEORY
PSYCHOSOCIAL THEORY OF DEVELOPMENT
SENSORIMOTOR STAGE
0-18 mos. TRUST VS. MISTRUST  development proceeds from reflex activity to
 attachment to mother which lays foundations for later representation and sensorimotor solutions to
trust in others problems
 conflict: general difficulties relating to others.  0 to 18 months
suspicion, fear of the future
PRE-OPERATIONAL STAGE
 development proceeds from sensorimotor
18 mos-3 yrs AUTONOMY VS. SHAME/DOUBT representation to prelogical thought and. solutions to
 Gaining some basic control of self and environment problems can use these representational skills only to
 Conflict: independence-fear conflict, severe feelings view the world from their own perspective.
of self-doubt  Understand the meaning of symbolic gestures
 2 to 7 years
3 yrs-6 yrs INITIATIVE VS. GUILT
 becoming purposeful and directive CONCRETE OPERATIONAL
 conflict: aggression-fear conflict, sense of inadequacy  development proceeds from prelogical thought to
and guilt logical solutions to concrete problems
 understand concrete problems
 cannot yet contemplate or solve abstract problems
6 yrs-12 yrs INDUSTRY VS. INFERIORITY  7 to 12 years
 Developing social, physical and school skills,
competence FORMAL OPERATIONAL
 Conflict: sense of inferiority, difficulty learning and  development proceeds from logical solutions to
working concrete problems to logical solutions to all
 classes of problems
12 yrs-20 yrs IDENTITY VS. ROLE DIFFUSION  cannot yet contemplate or solve abstract problems
 Making transition from childhood to adulthood,  can also reason theoretically
developing a sense of identity  12 and above
 Conflict: confusion of who one is, identity submerged
in relationships or group memberships HARRY STACK SULLIVAN
INTERPERSONAL THEORY
21 yrs -35 yrs INTIMACY VS. ISOLATION
 establishing intimate bonds of love and friendship SULLIVAN'S INTERPERSONAL THEORY
 conflict: emotional isolation
INFANCY
  anxiety develops as a result of unmet needs by the
mother (bodily needs); needs met, the child has sense ORIENTATION
of well-being  Broad Opening
 0 to 18 months  Recognition
 Giving information
CHILDHOOD  Silence
 anxiety as a result of lack of praise/acceptance from  Offering Self - "Do you want me to sit beside you?”
parents
 gratification leads to positive self-esteem WORKING
 moderate anxiety leads to uncertainty and insecurity  Focusing - "Let us discuss this topic more”
 severe anxiety results in self-defeating patterns of  Exploring - "Tell me more about it.”
behavior  Encourage Evaluation - "IS this what you want?”
 18 months to 6 years  Reflecting - same idea
 Restating - same statement
JUVENILE  Verbalizing Implied - "Are you going to kill
 severe anxiety may result in a need to control or yourself?"
restrictive, prejudicial attitudes learns to negotiate  Seeking Clarification – “May you please repeat that
own needs statement”
 6 to 9 years  General lead - "Please continue.”; “And then?”
 Limit setting - "Stop"
PRE-ADOLESCENCE  Interpreting - "Maybe that thing is very significant to
 capacity to attachment, love and collaboration you.”
emerges or fails to develop
 move to genuine intimacy with friend of the same sex TERMINATION
 9 to 12 years  Summarizing – “Let us now sum up. You have stated
earlier... etc.”
ADOLESCENCE  “Do you have any questions?”
 if self-system is intact, areas of concern expand to  “Our next therapy...”
include values, career decisions and social concerns  Look for changes in behavior
 lust is added to interpersonal equation  Resistance is a common problem
 need for special sharing relationship shifts to opposite
sex THERAPEUTIC COMMUNICATION TECHNIQUES
 new opportunities for social experimentation lead to
consolidation or self-ridicule  Accepting-indicating reception
 12 to adulthood  E.g., “Yes"
“I follow what you said”
Nodding

BROAD OPENINGS
HILDEGARD PEPLAU  Allowing the client to take the initiative in
NURSE PATIENT RELATIONSHIP introducing the topic
 e.g., "is there something you'd like to talk about?”
PEPLAU'S NPR “Where would you like to begin?”
PRE-INTERACTION CONSENSUAL VALIDATION
 Major task of nurse- to develop self-awareness  Searching for mutual understanding, for accord in the
meaning of the words
ORIENTATION
 e.g., "Tell me whether my understanding of it agrees
 Major task of the nurse: to develop a mutual with yours”
acceptable contract “Are you using this word to convey that…?”
WORKING ENCOURAGING COMPARISON
 Major task: identification and resolution of patient's  Asking that similarities and differences be noted
problem
 e.g., "was it something like...?
“Have you had similar experiences?”
TERMINATION
 Major task: to assist the patient to review what he has ENCOURAGING DESCRIPTION OF PERCEPTIONS
learned and transfer his learning to his relationship
 Asking the client to verbalize what he or perceives
with others
 E.g., “Tell me when you feel anxious”
“What is happening?”
THERAPEUTIC COMMUNICATIONS
 “What does the voice seem to be saying?” “Was this before or after?”

ENCOURAGING EXPRESSION PRESENTING REALITY

 Asking client to appraise the quality of his or her  Offering for consideration that which is real
experience  E.g., “I see no one else in the room”
 e.g., “what are your feelings in regard to...?” “Your mother is not here; I am a nurse”
“Does this contribute to your distress?”

EXPLORING REFLECTING
 Delving further into a subject or idea  Directing client actions, thought, and feeling back to
 e.g., "Tell me more about that.” the client
“Would you describe it more fully?”  E.g., Client: “Do you think I should tell the doctor…?
“What kind of work?” Nurse: “Do you think you should?”

FOCUSING RESTATING
 Concentrating on a single point  Repeating the main idea expressed
 e.g., "This point seems worth looking at more  E.g., Client: “I can’t sleep. I stay awake all night”
closely" Nurse: “You have difficulty sleeping”
“Of all the concerns you've mentioned, Client: “I’m really mad, and upset”
which is most troublesome?” Nurse: “You’re really mad and upset”

FORMULATING A PLAN OF ACTION SEEKING INFORMATION

 Asking the client to consider kinds of behavior likely  Seeking to make clear that which is not meaningful
to be appropriate in future situations or that which is vague
 e.g., "What could you do to let your anger out  “I’m not sure that I follow”
harmlessly?" “Have I heard you correctly?”
“Next time this comes up, what might you
do to handle it?" SILENCE
 Absence of verbal communication, which provides
GENERAL LEADS time for the client to put thought or feelings into
 Giving encouragement to continue words, regain composure, or continue talking
 e.g., "Go on”  E.g., nurses say nothing but continues to maintain
“And then?" eye contact and conveys interest
"Tell me about it”
SUGGESTING COLLABORATION
GIVING INFORMATION  Offering to share, to strive, to work with the client for
 Making available the facts that the client needs his or her benefit
 E.g., “My name is…”  E.g., “perhaps you and I can discuss and discover the
“Visiting hours are…” triggers for your anxiety”
“My purpose in being here is…”
SUMMARIZING
GIVING RECOGNITION  Organizing and summing up that which has gone
 Acknowledging, indicating awareness before
 E.g., “Good morning, Mrs. S…”  E.g., “Have I got this straight?”
“You’ve finished your list of things to do.”
“I noticed that you’ve combed your hair” TRANSLATING INTO FEELINGS
 Seeking to verbalize client’s feelings that he or she
MAKING OBSERVATIONS expresses only indirectly
 Verbalizing what the nurse perceives  E.g., Client: “I’m dead”
 E.g., “You appear tense…” Nurse: “Are you suggesting that you feel
“I notice that you’re biting your lips” lifeless?”

OFFERING SELF VERBALIZING THE IMPLIED

 Making oneself available  Voicing what the client has hinted at or suggested
 E.g., “I’ll sit with you awhile.”  E.g., Client: “I can’t talk to you or anyone. It’s a
“I’ll stay here with you” waste of time.”
“I’m interested in what you think Nurse: “Do you feel that no one
understands”
PLACING EVENT IN TIME OR SEQUENCE
 Clarifying the relationship of events in time VOICING DOUBT
 E.g., “What seemed to lead up to…?”
  Expressing uncertainty about the reality of the
client’s perceptions INTRODUCING AN UNRELATED TOPIC
 “isn’t that unusual?”  Changing the subject
“really?”  Client: “I’d like to die.”
“that’s hard to believe” Nurse: “did you have visitors last night?”

NONTHERAPEUTIC COMMUNICATION MAKING STEREOTYPED COMMENTS

TECHNIQUES  Offering meaningless cliché or trite comments
 Advising – telling the client what to do  “keep your chin up”
Agreeing – indicating accord with the client “just have a positive outlook”
 E.g., “I think you should…”
“That’s right” PROBING
 Persistent questioning of the client
AGREEING  “now tell me about this problem. I need to know”
 Indicating accord with the client
 “that’s eight.” “I agree” REASSURING
 Indicating there is no reason for anxiety
BELITTLING FEELINGS EXPRESSED  “everything will be alright”
 Misjudging the degree of the client’s comfort
 Client: “I have nothing to live for… I wish I was REJECTING
dead”  Refusing to consider or showing contempt for the
Nurse: “Everybody gets down in the dumps” client’s behavior, ideas
 “let’s not discuss…”
CHALLENGING
 Demanding proof from the client REQUESTING AN EXPLANATION
 “But how can you be president of the Philippines?”  Asking the client to provide reasons for thoughts,
feelings, behaviors, events
DEFENDING  “why do you think that?”
 Attempting to protect someone or something from
verbal attack TESTING
 “this hospital has a fine reputation”  Appraising the client’s degree of insight
 “do you know what kind of hospital this is?”
DISAGREEING
 Opposing the client’s ideas USING DENIAL
 E.g., “that’s wrong”  Refusing to admit that a problem exists
 Client: “I am nothing”
DISAPPROVING Nurse: “Of course, you’re something”
 Denouncing the client’s behavior or ideas
 “that’s bad” NON-THERAPEUTIC COMMUNICATIONS
“I’d rather you wouldn’t”  Overloading – “blah, blah, blah”
 Underloading – ignoring
GIVING APPROVAL  Value Judgement – use of adjectives
 Sanctioning the client’s behavior or ideas  False Reassurance – “Don’t worry, you will be fine
 “that’s good.” “I’m glad that…” later”
 Focusing on Self – “I gave you meds so you are now
GIVING LITERAL RESPONSES feeling good”
 Responding to a figurative comment as though it  Incongruence
were a statement of fact  Internal Validation – biased judgement
 Client: “They’re looking in my head with television  Giving Advice – “If I were you, I’ll…”
camera”  Changing Subject
Nurse: “Try not to watch television”
LOSS AND GREIVING
INDICATING EXISTENXE OF AN EXTERNAL
SOURCE GRIEF – refers to the subjective emotions and affect that are
 “What makes you say that?” a normal response to the experience of loss

INTERPRETING ANTICIPATORY GRIEVING – when people facing an

 Asking to make the conscious that which is imminent loss begin to grapple with the very real possibility of
unconscious the loss or death in the near future
 “what you really mean is…”
DISENFRANCHISED GRIEVING - grief over a loss that  INITIAL IMPACT (may last a few hours to a few
is not or cannot be acknowledged openly, mourned publicly or days): high level of stress, helplessness, inability to
supported socially function socially
 CRISIS (may last a brief or prolonged period of
COMPLICATED GRIEVING – when a person is void of time): inability to cope, projection, denial,
emotion, grieves for prolonged periods, has expressions of rationalization
grief that seem disproportionate to the event  RESOLUTION: attempts to use problem-solving
skills
LOSS  POST CRISIS: may have OLOF or may have
 Physiologic loss symptoms of neurosis, psychosis
 Safe and security loss
 Love and belongingness loss CRISIS MANAGEMENT
 Self-esteem loss  Role of the nurse is to return the client to its pre-crisis
 Self-actualization loss state by assisting and guiding them until they
achieved their OLOF
GRIEVING PROCESS  Goal: to enable patient to attain an OLOF
 Denial  Nurse’s Primary Role: active and directive
 Anger
 Bargaining STEPS IN CRISIS INTERVENTION
 Depression  Identify the degree of disruption the client is
 Acceptance experiencing
 Assess the client’s perception of event
 Dysfunctional Grieving – grieving which extends  Formulate nursing diagnoses
from 4 to 6 weeks leading to CRISIS  Involve the patient and family if applicable with
planning
INTERVENTIONS  Implement interventions – new and old coping
 Explore client’s perceptions and meaning of the loss mechanisms
 Allow adaptive denial  Evaluate – reassessment, reinforcement
 Assist client to reach out for and accept support
 Encourage client to examine patterns of coping in TYPES OF THERAPIES
TREATMENT MODALITIES
past and present situation of loss
 Encourage client to care for themselves INDIVIDUAL PSYCHOTHERPAY
 Offer client food without pressure to eat  One to one relationship between therapist and client
 Use effective communication  For dissociative, anorexia, paranoid, narcissistic
 Change is achieved by the exploration of feelings,
CRISIS AND ITS MANAGEMENT
attitudes, thinking behavior and conflict
CRISIS
SEVEN SUBTYPES
 Situation that occurs when an individual’s habitual
coping ability becomes ineffective to merit demands
CLASSICAL PSYCHOANALYSIS
of a situation
 Based on Freud’s theory
TYPES OF CRISES  To uncover unconscious feelings and thoughts that
interfere with the client’s living a fuller life
 MATURATIONAL/DEVELOPMENTAL: normal
expected crisis that runs through age  Free association – client is encouraged to say
anything that comes to mind, without censoring
 SITUATIONAL: an expected and sudden event in
thoughts or feelings
life
 Dream analysis
 ADVENTITIOUS: calamities, war
 Working through (transference) – process of repeated
CHARACTERISTICS OF A CRISIS STATE interpretation to the person of his or her unconscious
processes has the effect of bringing about change
 Highly individualized
 Lasts for 4-6 weeks
PSYCHOANALYTICAL PSYCHOTHERAPY
 Self-limiting
 Uses dream analysis, transference and free
 Person affected becomes passive and submissive association
 Affects a person’s support system  Therapist is much more involved and interacts with
the client more freely
PHASES OF A CRISIS
 Done through intimate professional relationship
 PRE-CRISIS: state if equilibrium between the nurse/therapist and the client over a
 period of time (introductory, working and dreams, person is asked to play roles of persons in the
termination phase) dream to get in touch with different repressed
feelings
SHORT TERM DYNAMIC PSYCHOTHERAPY
 Indication – persons with specific symptom or MILIEU THERAPY
interpersonal problem that he/she wants to work on  Total environment has an effect on the individual’s
 Therapist directs the content behavior
 Use of transference and dream analysis  Components
 Weekly sessions (total number – 12 to 30) o Physical environment
 Successful for highly motivated individuals who have o Interpersonal relationships
insight and with positive relationship with the o Atmosphere of safety, caring, and mutual respect
therapist o For alcoholics

TRANSACTIONAL ANALYSIS PROGRAMS FOR MILIEU SHOULD HAVE:

 Eric Berne  An emphasis on group and social interaction
 Each person has three ego states and change from one  No rules and expectations mediated by peer pressure
to another frequently  A view of patients’ roles as responsible human beings
 Parent – concepts of standards of behavior and how  An emphasis on patients’ rights for involvement in
things should be done. setting goals
o E.g., go and take out the garbage  Freedom of movement and informality relationships
 Adult – rational thinking and data analyzing part of with staff
the personality.  Emphasis on interdisciplinary participation
o E.g., would you please take out the garbage  Goal-oriented, clear communication
 Child – feelings associated with persons, things or
incidents represent the need-gratifying aspects of the GROUP THERAPY
personality  Number of people coming together, sharing a
o E.g., is this why you married me? To be your common goal, interest or concern, staying together
garbage man? and developing relationships
 For group, family and individual  For PTSD and alcoholics
 Client to identify ego states for each given situation  Phases
 Rewarding of positive or negative behaviors with o Orientation
strokes o Working
 Client work through these behaviors o Termination

COGNITIVE PSYCHOTHERAPY CHARACTERISTICS OF GROUP THERAPY

 Restructuring or changing ways in which people  Universality → “you are not alone”
think about themselves  Instilling hope and inspiration
 Thought stopping  Developing social skills by interacting with one
 Positive self-talk another
 DE catastrophizing  Feeling of acceptance and belonging
 Therapists help patients identify these thoughts  Altruism → “giving of one’s self

BEHAVIORAL THERAPY FAMILY THERAPY

 Changes in maladapted behavior can occur without  Psychoanalytically oriented group therapy
insight into the underlying cause  Psychodrama
 Based on learning theory  Family therapy
 Modeling
 Operant conditioning ASSUMPTION OF FAMILY THERAPY
 Self-control therapy – combination of cognitive and  Client: whole family
behavioral approaches “talking to self”  Concepts:
 Systemic desensitization o The family is the most fundamental unit of the
 Aversion therapy society
o Adaptive or maladaptive patterns of behavior are
GESTALT THERAPY learned from the family
 Emphasis on the “here and now” o Dysfunction in the family = dysfunction in the
 Only present behavior can be changed, not history individual
 Uncover repressed feelings and needs  Purpose
 Techniques: have a person behave the opposite of the o Improve relationships among family members
way he/she feels, presuming that a person can then o Promote family function
come in contact with a submerged part of the self; in o Resolve family problems
 Preparations for ECT:
OTHER TYPES OF THERAPIES  Pretreatment evaluation and clearance
 Consent
SUPPORT GROUPS  NPO from midnight until after the treatment
 For those with AIDS, Mother-Against-Drug  Atropine Sulfate – to decrease secretions
Dependence Succinylcholine (Anectine) – to promote muscle
relaxation
SELF-HELP GROUPS Methohexital Sodium (Brevital)- anesthetic
 Alcoholic Anonymous  Empty bladder
 Remove jewelry, hairpins, dentures and other
RULES FOR PSYCHOTHERAPEUTIC accessories
MANAGEMENT  Check vital signs
 Provide support, treat patients with respect and
dignity Care after ECT:
 Do not place patients in situations wherein they will  O2 therapy of 100% until patient can breathe
feel inadequate or embarrassed unassisted
 Treat patients as individuals  Monitor for respiratory problems, gag reflex
 Provide reality testing  Reorient patient
 Handle hostility therapeutically  Observe until stable
 Provide psychopharmacologic treatment  Careful documentation
 Male erectile dysfunction
BEHAVIORAL THERAPIES
TREATMENT MODALITIES OTHER THERAPIES
 Neurosurgery
 Pavlov’s Classical Conditioning: All behaviors are
learned ANXIETY
 B.F. Skinner’s Operational Conditioning:
Reinforcements PEPLAU’S LEVEL OF ANXIETY
 Behavioral Conditioning: substance abuse
 Token Economy: anorexia/schizo MILD
 Systematic Desensitization: phobia  Associated with the tension of day to day living
 Perceptual field increased
ATTITUDE THERAPY  More alert than usual
TREATMENT MODALITIES  Adaptive

1. Paranoid – passive friendliness

2. Withdrawn – active friendliness
3. Depressed/Anorexia – kind firmness
4. Manipulative – matter of fact MODERATE
5. Assaultive – no demand  Narrowed perception
6. Anti-social – firm, consistent  Difficulty focusing
 Selective inattention
PSYCHOSOMATIC THERAPY  Mild somatic complaints: stomachache and
TREATMENT MODALITIES butterflies in the stomach
ELECTROCONVULSIVE THERAPY INTERVENTIONS FOR MILD TO MODERATE
 Effective in most affective disorders ANXIETY
 The induction of a grandmal seizure in the brain  Assist the client in identifying anxiety
 Abnormal firing of neurons in the brain causes an  Anticipate anxiety provoking situations
increase in neurotransmitters  Use nonverbal language to demonstrate interest
 Number of Treatments: 6-12, 3 times a week,  Encourage the client to talk about his or her feelings
about .5-2 seconds  Avoid closing off avenues of communication
 Unilateral or bitemporal (refraining from offering advice or changing the
topic)
Indications:  Encourage problem-solving
 Patients who require rapid response  Explore past and present coping behaviors
 Patients who cannot tolerate pharmacotherapy or  Provide outlets for working off excess energy
cannot be exposed to pharmacotherapy
 Patients who are depressed but have not responded to LEVELS OF ANXIETY
multiple and adequate trials of medication
SEVERE  Generalized Anxiety Disorder
 Very narrowed perception  Panic
 Unable to focus on problem solving  Phobia
 Increased physical discomfort  PTSD
 All behavior is aimed at relieving anxiety  Obsessive Compulsive
 Direction is needed to focus attention
GENERALIZED ANXIETY DISORDER
PANIC  Excessive worry and anxiety for days but not more
 Awe, dread and terror than 6 months
 Unable to see the whole situation or reality  Difficulty in controlling the worry
 Distortion of perception  Anxiety and worry are evident by 3 or more of the
 Disorganization of the personality following:
 A frightening and paralyzing experience o Restlessness, keyed up
o Fatigue and irritability
INTERVENTIONS FOR SEVERE AND PANIC LEVELS o Decreased ability to concentrate
OF ANXIETY o Muscle tension
 Maintain a calm manner o Disturbed sleep
 Remain with the person  Anxiety or worry causes significant impairment in
 Minimize environmental stimuli interpersonal relationship or activities of daily living
 Reinforce reality
 Listen for themes in communication POST TRAUMATIC STRESS DISORDER
 Attend to physical safety and medical needs first  Disturbing pattern of behavior occurring after a
 Physical limits may need to be set traumatic event that is outside the range of usual
 Provide opportunities for exercising experience
 Assess the person’s need for mediation or seclusion
Characteristics
ANTI-ANXIETY DRUGS  Persistent re-experiencing of the trauma through
 Valium recurrent intrusive recollections of the event, through
 Librium dreams or flashbacks
 Ativan  Persistent avoidance of the stimuli
 Serax  Feeling of detachment of estrangement from others
 Tranxene  Chemical abuse to relieve anxiety
 Miltown
 Equanil PHOBIAS
 Vistaril
Definition
 Atarax
 Persistent, irrational fear of a specific object, activity
 Inderal
or situation that leads to a desire for avoidance of the
 Xanax
object of fear
 Buspar
Specific Phobia
ANTI-ANXIETY DRUGS
 Experience of high level of anxiety or fear provided
 Used only in a short time (1-2 weeks) by a specific object or situation
 Tolerance (after 7 days) and dependence (after 1
month) Treatment
 Liver function test  Systematic Desensitization
 Monitor side effects
 Avoid machines, activities needing concentration Defense Mechanisms
 Z tract if given parenterally  Repression and displacement
 Avoid mixing with alcohol, antihistamines,
antipsychotics MAJOR TYPES OF PHOBIAS
 Don’t stop abruptly but gradually for 2-6 weeks
 Avoid caffeine AGORAPHOBIA
 Comes from the Greek word “agora”
CATEGORIES OF ANXIETY DISORDERS  Meaning “market place”
 Basic Anxiety Disorders  Fear of being alone in open or public spaces
 Somatoform Disorders
 Dissociative Disorders SOCIAL PHOBIA
 Fear of situations where one might be seen and
BASIC ANXIETY DISORDERS embarrassed or criticized
  True/unconscious because of hormonal and bodily
SPECIFIC PHOBIAS changes
 Fear of a single object, situation or activity that  Increase anxiety may result to asthma, stress ulcers or
cannot be avoided migraine

OBSESSIVE COMPULSIVE DISORDERS SCHIZOPHRENIA

 A major form of psychotic disorder that affects a
OBSESSIONS person’s thinking, language, emotions, social
 Preoccupation with persistent intrusive thoughts, behavior and ability to perceive reality
impulses or images  At least 2 of 5 types of positive and negative
symptoms
COMPULSIONS  Characteristic Symptoms
 Repetitive behaviors or mental acts that the person  Social or occupational dysfunction
feels driven to perform in order to reduce distress or o IPR
prevent a dreaded event or situation o Self-care
 Duration
CUES: o Continuous for at least 6 months
 Ritualistic behavior
 Constant doubting if he/she has performed the POSITIVE AND NEGATIVE SYMPTOMS
activity
POSITIVE SYMPTOMS
EXAMPLE  Hallucinations
OBSESSIONS COMPULSIONS
S  Delusions
Washing or “Wash away my Young woman  Illusions
cleaning sins.” Thought repeatedly washes
 Abnormal thought patterns or perceptions
appeared after sexual hands
 Bizarre behavior
encounter with a
married man
NEGATIVE SYMPTOMS
Need for “Everything must be Arranges and
 Affective flattening
order in place” rearranges items
Germs or “Everything is Avoids touching all  Anhedonia
dirt contaminated” objects. Scrubs  Attention impairment
hands if she is  Asocial behavior
forced to touch any  Anergia
object  Autism
Symmetry “Secretaries who Secretary lines up  Avolition
practice neatness objects in rows on
never gets fired” her desk, then DELUSIONS
realigns them  Persecutory
repeatedly during  Religious
the day  Grandeur
 Ideas of Reference
CARE STRATEGIES
 Be nonjudgmental and honest; offer empathy and DISTURBED THOUGHT PROCESS
support  Looseness of association
 Help patient to recognize the connections between  Flight of ideas
the trauma experience and their current feelings,  Ambivalence
behaviors and problems  Magical thinking
 Encourage verbalizations of feelings, especially anger  Echolalia/Echopraxia
 Encourage adaptive coping strategies and techniques  Word salad
 Encourage patients to establish or reestablish  Neologism
relationships  Thought blocking
 Explore shattered assumptions. “I’m a good person.  Concrete association
This is a safe world”
 Promote discussion of possible meaning of events

BLEULER’S FOUR A’s OF SCHIZOPHRENIA

 Affective disturbances
 Autism
 Associative looseness
PSYCHOSOMATIC DISORDER
  Ambivalence
 Other A’s  Present safety
o Attention deficits  Present reality
o Disturbances of activities
ANTI-PSYCHOTIC
SCHIZOPHRENIA  Tara, look natin sina Stella, Mel, at Thor na nag mo-
 Brief Psychotic Disorder – may be seen when a moulin rogue… sssh, alam niyo ba na ang trio na yan
person exhibits clinical symptoms of illogical na akala mo may halo ay mga closet queens pala…,
thinking, incoherent speech, delusions, or namen”
disorganized behavior after psychological trauma  Taractan, Loxitane, Stelazine, Mellaril, Thorazine,
 Induced Psychotic Disorder – develops in a second Molindone, Seroquel, Serlect, Trilafon, Haloperidol,
person as a result of a close relationship with a person Clozapine, Navane
who has psychosis
 Delusional Psychotic Disorder  Stelazine
 Schizoaffective Disorder – characterized by  Serentil
depression or elation as the psychosis symptoms of  Thorazine
schizophrenia and MDD  Trilafon
 Schizophreniform – when a person exhibits features  Clorazil
of schizophrenia for more than one week but less  Millaril
than 6 months  Haldol
 Risperidol
SUBTYPES:  Prolixin

Paranoid – most common form if the illness ANTI-PSYCHOTIC DRUGS

Suspicious Watch for side-effects
 Promote trust  Increase v/s
 Short interaction but frequent  Constipation/dry mouth
 Food in containers (sealed)  Postural hypotension
 Prepare food in front of them  Photophobia/photosensitivity
 Let them see preparation of drugs  Drowsiness
 Agranulocytosis
Violent  Extrapyramidal symptoms
 Keep door open o Parkinson’s syndrome
 Position near door and with distance of 1 arm length o Akathisia
(patient-nurse) o Akinesia
 Don’t touch o Dystonia – oculogyric crisis, torticollis,
 Maintain eye contact opisthotonos
o Tardive dyskinesia
Disorganized – absence of systematized delusions; presence
o NMS
of incoherence and inappropriate affect
 Inappropriate, flat affect
UNDESIRABLE EFFECTS
 Hebephrenic, flight of ideas
 S-edation/sunlight sensitivity/sleepiness
 T-ardive dyskinesia
Catatonic
 A-nticholinergic/agranulocytosis/akathisia
 Risk for suicide
 N-euroleptic malignant syndrome
 Catatonic stupor, rigidity
 C-ardiac effects (orthostatic hypotension)
 Waxy flexibility
 E-xtrapyramidal (dystonia)

Undifferentiated PARKINSONISM
 Unclassified  Motor retardation or akinesia characterized by mask-
like appearance, rigidity, tremors, “pill-rolling”,
Residual salivation
 No more positive symptoms but withdrawn  Generally occurs after 1st week of treatment or before
second month
NURSING PROCESS  Administer anticholinergic agent, anti-Parkinson
 Disturbed thought process medication (Akineton)
 Disturbed sensory process
AKATHISIA
 Risk for self-directed violence
 Risk for other directed violence
  Constant state of movement, characterized by MANIFESTATIONS
restlessness, difficulty sitting still, or strong urges to S – social isolation
move about C – catatonic behavior
 Generally occurs two weeks after treatment begins H – hallucinations
 Rule out anxiety or agitation before administration of I – incoherence
an anticholinergic agent Z – zero/lack of interest and initiative
O – obvious failure in development
ACUTE DYSTONIC REACTIONS P – peculiar behavior
 Irregular, involuntary spastic muscle movement, H – hygiene and grooming impaired
wryneck or torticollis , facial grimacing, abnormal R – recurrent illusions
eye movements, backward rolling of eyes on the E – exacerbations and remissions
sockets N – no organic factor account S/S
 May occur anytime from a few minutes to several I – inability to return to functioning
hours after a first dose of antipsychotic drug A – affect is inappropriate
 Administer anticholinergic agent, have respiratory
support equipment available ANTI-PARKINSONIAN DRUGS

TARDIVE DYSKINESIA DOPAMINERGIC DRUGS

 Most frequent serious side effect resulting from  To live (Levodopa), you need a car (Carbidopa)
termination of the drug, during reduction in dosage, and a man (Amantadine) not your brother
or after long term high dose therapy a (Bromocriptine) per (Pergolide) se (Selegiline)
 Characterized by involuntary rhythmic, stereotyped
movements, tongue protrusion, cheek puffing, ANTI-CHOLINERGIC
involuntary movements of extremities and trunk  BACPAK (Benadryl, Artane, Cogentin, Parsidol,
 Occurs in approximately 2—25% of patients taking Akineton, Kemadrin)
antipsychotics for over two years OTHER TREATMENTS
 No treatment except discontinuation of the  Psychotherapy – individual, group, behavioral,
antipsychotic agent supportive or family therapy may be used depending
on the clinical symptoms
 Milieu therapy – a structured environment to
minimize environmental and physical stress and to
NEUROLEPTIC MALIGNANT SYNDROME meet the individual needs of the patients until they
 A potentially fatal syndrome are able to assume responsibility for themselves
 May occur anytime during therapy
CONCEPTS AND PRINCIPLES OF HALLUCINATION
 Seen during the initiation of therapy, change of
 Possible to replace hallucination with satisfying
therapy, after a dosage increase or when a
interactions
combination of meds is used
 Can re-learn to focus attention on real things and
 Early sign: rigidity or mental status changes
people
 Catatonia, tachycardia, tachypnea, labile blood
 Hallucinations originate during extreme emotional
pressure, dysphagia, diaphoresis, incontinence,
stress when the patient is unable to cope
rigidity, myoclonus, tremors, low grade fevers
 Hallucinations are very real to the patient
 Discontinue antipsychotic agent. Have
cardiopulmonary support available; administer  Patient will react as the situation is perceived
skeletal muscle relaxant (e.g., dantrolene) or central  Concrete experiences, not argument on confrontation
acting dopamine agonist (.e.g., bromocriptine) will correct sensory distortion
 Hallucinations are a substitute for human relations
NOTES ON SCHIZOPHRENIA
 Distorted EGO BIPOLAR DISORDER
 Disturbed thought process MOOD DISORDER/AFFECTIVE DISORDER
 Disorganized personality  A distinct period of abnormally and persistently
elevated expansive or irritable mood lasting at least 1
 Dopamine – increase
week
 Autism
 3 or more of the following
 Ambivalence
o Psychomotor overexcitability or excitement
 Associative looseness
o Insomnia with fatigued
 Affect – flat
o Euphoria or elated mood
 Stimulation
o Distractibility
 Structure
o Pressured speech
 Socialization
o Flight of ideas
 Support
o Manipulative or demanding behavior
 o Destructive or combative behavior
o Delusions of grandeur ANTIDEPRESSANTS
 Risk  Asendin
o Female  Norpramin
o 20 years old and above  Tofranil
o Stressful life  Sinequan
o Obese  Anafranil
 Aventil
o Care giver role strain  Vivactil
 Elavil
 Prozac
 Luvox
 Paxil
 Zoloft

MANIA VS DEPRESSION SSRI

MANIA DEPRESSION  Selective Serotonin Reuptake Inhibitor
Colorful, Sad and gray  Safest
APPEARANCE
flamboyant  Side effects are low
Psychomotor Psychomotor  1 to 4 weeks
BEHAVIOR
agitation retardation  Prozac, Paxil, Zoloft, Luvox
Pressured Monotonous
COMMUNICATIO speech speech TCA
N Stuttering  Tricyclic Antidepressants
Cluttering  2 to 4 weeks
Risk for Injury Risk for Injury
 Anticholinergic
(others) (self)
Nx  Amitriptyline, Nortiptyline, Doxepin Trimipramine,
Suicidal
Amoxapine, Anafranil, Venlafaxine
precaution
NURSING Safety and Safety and
MAOI’s
PRIORITY nutrition nutrition
 Increases all neurotransmitters
Finger foods Increased in
 2 to 6 weeks
NUTRITION and high in nutrients
calories  Hypertensive crisis
Lithium; ECT TCA; SSRI;  Don’t take:
TREATMENT o Avocado
MAOOI’s; ECT
Non- Stimulating o Aged cheese
MILIEU stimulating o Beer/B6 (tyramine)
environment o Chocolate
Quiet type; Monotonous; o Fermented foods
APPROPRIATE o Soy sauce
non- non-
ACTIVITY
competitive competitive o Pickles and preserved foods
Matter of fact Kind firmness;
ATTITUDE
active A. TCA
THERAPY
friendliness “knock! Knock! Who’s there? SEVANA to gagah!” --------
(Sinequam, Elavil, Vivactil, Ascendin, Norpramin,
LITHIUM Aventyl, Tofranil)
 Level of lithium (0.5 to 1.5 meq/L)
 Increase urination (polyuria) B. SSRI
 Tremors – fine hand Ngongo: “Paxil ka! Paxil ka! Prozoleta ka lang, kala ko luv
 Hydration mo ko! (Praxil, Prozac, Zoloft, Luvox)
 Increase peristalsis
 U2 – 4 weeks effective C. MAO
“naman, parnate ko pa” (Nardil, Manerix, Parnate)
 Increased bowel movements
 Mouth is dry
SUICIDE
o Assess function of kidney
 The intentional act of killing oneself
o Toxicity: nausea and vomiting, diarrhea
Suicidal Ideation – means thinking about oneself
 Passive suicidal ideation – when a person thinks
PHARMACOLOGY MOMENTS about wanting to die or wishes he/she were dead but
ANTIDEPRESSANTS has no plans to cause his/her death (e.g., reckless
 driving, heavy smoking, overeating, self-mutilation,  Durkheim – pioneer of sociological research in the
drug abuse) study of suicide
 Active suicidal ideation – when a person thinks  3 Principal Types:
about and seeks to commit suicide  Egoistic suicide – occurs when a person is
insufficiently integrated into society
SAD PERSON’S SCALE  Anomic suicide – occurs when a person is isolated
 S-Sex. Mean kill themselves 3x more than women from others through abrupt changes in social
though women make attempts 3x more often than norms/status
men  Altruistic suicide – occurs as a response to societal
 A-Age. High risk groups: 19 years or younger; 45 demands (deaths of Buddhist monks who set
years or older, especially the elderly 65 and above themselves on fire to protest the Vietnam war)
 D-Depression. Studies report that 35-79% of those
who attempt suicide manifested a depressive BIOCHEMICAL
syndrome  Low serotonin levels
 P-Previous Attempts. Of those who commit suicide,
65-70% have made previous attempts PRECIPITATING FACTORS
 E-ETOH. Alcohol is associated with up to 65% of  Social Isolation – have difficulty forming and
successful suicides maintaining relationships
 R-Rational Thinking Loss. People with functional
or organic psychoses are more apt to commit suicide Norman Cousins Story:
than those in the general population A woman who committed suicide had written in her
 S-Social Support Lacking. A suicidal person often diary every day during the week before her death
lacks significant others, meaningful employment and “Nobody called today. Nobody called today. Nobody
religious supports called today. Nobody called today. Nobody called
 O-Organized Plan. The presence of a specific plan today…”
for suicide signifies a person at high risk
 N-No Spouse. Repeated studies indicate that persons  Severe life’s events – divorce, death, sickness, legal
who are widowed, separated, divorced or single at problems, interpersonal discord
greater risk than those who are married  Sensitivity to Loss – may react tragically to
 S-Sickness. Chronic, debilitating and severe illness is separation or loss of a loved one (had insecure or
a risk factor unreliable childhood experiences)

SCORING ASSESSING VERBAL AND NONVERBAL CLUES

 0-2 home with follow up care
 3-4 close follow up and possible hospitalization VERBAL CLUES:
 5-6 strongly consider hospitalization  Overt Statements: “I can’t take it anymore!”; “Life
 7-10 hospitalize isn’t worth living anymore.”; “I wish I were dead.”;
“Everyone will be better off if I am dead.”
SITUATION:  Covert Statements: “It’s ok now, soon everything will
 Charles Brown, age 52 lost his wife in a car accident be fine”; “Things will never work out.”; “I won’t be a
few months ago. Since that time, he has been problem much longer.”; “How can I give my body to
severely depressed and has taken to drinking to numb medical science?”
the pain
 How many points according to the SAD PERSONS NONVERBAL CLUES
SCALE?  Behavioral Clues: sudden behavioral changes
especially when depression is lifting and when the
person has more energy available to carry out the
plan
 Signs: giving away prized possessions, writing
farewell notes, making out a will and putting personal
affairs in order
THEORIES OF SUICIDE  Somatic Clues: physiological complaints can mask
psychological pain and internalized stress
PSYCHODYNAMIC THEORIES  Headaches, muscle aches, trouble sleeping, irregular
 Describe suicide as a wish to be at peace with the bowel habits, unusual appetite or weight loss
internalized significant person  Emotional Clues: social withdrawal, feelings of
 Wish to be reunited with a deceased loved object hopelessness and helplessness, confusion, irritability,
 Suicide is an attempt to escape from an intolerable and complaints of exhaustions
situation or intolerable state of mind
SUICIDE PRECAUTIONS
SOCIOLOGICAL THEORIES
  Execute a “no suicide contract.” The client will o Chooses to be alone
inform the nurse when he/she has suicidal ideations o Lack of sexual experiences
 Ask direct questions. Find out if the person has o Avoids activities
specific plan for suicide. Determine what method o Appears cold and detached
 Be alert for cries for suicide  Interventions: building trust followed by
 Provide a safe environment and protect client from identification and appropriate verbal expression
self
 Encourage to ventilate feelings and thoughts SCHIZOTYPAL PERSONALITY DISORDER
 Give emotional support  A pervasive pattern of social and interpersonal
 Make the patient realize that the tendency to commit deficits marked by acute discomfort with and reduced
suicide is due to the disturbance in the brain capacity for close relationships as well as by
chemistry and is treatable – once they know that an cognitive or perceptual distortions and eccentricities
episode of suicidal thinking will pass, they will likely of behavior
not act on the impulse o Ideas of reference
 Provide structured schedule and involve in activities o Magical thinking or odd beliefs
with others to increase self-worth and divert attention o Unusual perceptual experiences, including bodily
 On discharge: help patient create “plan for Life” (list illusions
of warning signs of suicidal ideation and actions to o Peculiar thinking
take) o Vague, stereotypical, overelaborate speech
Always remember: o Eccentric appearance or behavior
 That a suicidal person wants to crisis – during this o Few close relationships
time the person is ambivalent about living and dying o Uncomfortable in social situations
 Suicidal person gives warning  Interventions: improving interpersonal relationships,
 Persons recovering from depression are high risk for social skills, and appropriate behaviors
9-15 months after recovery
 Suicidal people are extremely unhappy but not ANTI-SOCIAL PERSONALITY DISORDER
always mentally ill  Characterized by deceit, manipulation, revenge and
harm to others with an absence of guilt or anxiety
PERSONALITY BEHAVIORS o Violates rights of others
o Engages in illegal activities
PERSONALITY PROBLEMS o Aggressive behavior
 Schizoid o Lack of guilt or remorse
 Dependent
o Irresponsible in work and with finances
 Antisocial
o Impulsiveness
 Avoidant
o Recklessness
 Histrionic
o Manipulative
 Borderline
 Interventions:
o Consistency
PARANOID PERSONALITY DISORDER
o Kind firmness in confronting behaviors and
 A pervasive pattern of distrust and suspiciousness of
others such that their motives are interpreted as enforcing rules and policies
malevolent o Limit setting
o Suspicious (e.g., others are exploiting or o Decrease impulsivity
deceiving him) o Enhance role performance
o Doubt trustworthiness of others o Effective use of confrontation
o Fear of confiding in others
o Fear personal information will be used against BORDERLINE PERSONALITY DISORDER
him  Characterized by pervasive pattern of unstable
o Interpret remarks as demeaning or threatening interpersonal relationships; self-image and affect; and
o Hold grudges toward others marked impulsivity
o Frantic avoidance of abandonment; real or
o Becomes angry and threatening when they
imagines
perceive to be attacked by ithers
o Unstable and intense interpersonal relationships
 Intervention: centered on building trust
o Identity disturbances
SCHIZOID PERSONALITY DISORDER o Impulsivity
 A pervasive pattern of detachment from social o Self-mutilating behavior
relationships and a restricted range of expression of o Rapid mood shifts
emotions in interpersonal settings o Chronic feelings of emptiness
o Lacks desire for close relationships or friends o Problems with anger
including family o Transient dissociative and paranoid symptoms
 o Urgently seeks another relationship for support
OTHER IMPORTANT INFORMATION and care after a close relationship ends
 Priority nursing diagnosis: high risk for injury o Preoccupied with fear of being alone to care for
directed to self-related to self-mutilation behaviors self
 Coping mechanisms used: splitting  Interventions: increase responsibility for self in day
o Classifying people as either “good” or “bad” to day living; assertiveness training

INTERVENTIONS AVOIDANT PERSONALITY DISORDER

 Use of empathy  A pervasive pattern of social inhibition, feelings of
 Recognize the reality of the patient’s pain inadequacy and hypersensitivity to negative
 Offer support evaluation
 Empower and work with the patient to understand o Avoids occupations involving interpersonal
control and change dysfunctional behaviors contact due to fears of disapproval or rejection
 Provide safe environment o Preoccupied with being criticized or rejected in
 Teach social skills social situations
 Make a list of solitary activities to combat boredom o Very reluctant to take risks or engage in new
activities due to the possibility of being
NARCISSISTIC PERSONALITY DISORDER embarrassed
 Grandiose self-importance
 Fantasies of unlimited power, success or brilliance OBSESSIVE COMPULSIVE PERSONALITY
 Believes he or she is special DISORDER
 Needs to be admired  A pervasive pattern of preoccupation with
 Sense of entitlement orderliness, perfectionism and mental and
interpersonal control at the expense of flexibility,
 Takes advantage of others for own benefit
openness and efficiency
 Lacks empathy
o Preoccupied with details, lists, rules,
 Envious of others or others are envious of him
organization
 Arrogant
o Perfectionist
 Interventions:
o Too busy working to have friends or leisure
o Supportive confrontation on what the patient
activities
says and what exists
o Unable to discard worthless or worn-out objects
o Limit setting and consistency to decrease
o Reluctant to spend and hoards money
manipulation and entitlement behaviors
o Rigid and stubborn
o Remain neutral, avoid power struggles, or
becoming defensive
DELIRIUM
HISTRIONIC PERSONALITY DISORDER  Characterized by disturbance of consciousness and a
change in cognition such as impaired attention span
 A pervasive pattern of excessive emotionality and
and disturbances in consciousness that develop over a
attentive seeking
short period of time
o Overly dramatic
o Always secondary to another condition (medical
o Draws attention to self
condition or substance abuse)
o Extroverted and thrives on being the center of
o Frequent among the elderly and young febrile
attraction
children
o Uses somatic complaints to avid responsibility
o Fluctuations of consciousness and inoculation
and support dependency
throughout the day
o Dissociation
 Classified as mild to severe
 Interventions: provide reinforcement in the form of
 Sundowning
attention, recognition or praise given for unselfish or
other centered behaviors
DEMENTIA
 Characterized by multiple cognitive deficits that
DEPENDENT PERSONALITY DISORDER
include impairment of memory which develops
 A pervasive and excessive need to be taken care of
slowly
that leads to submissive and clinging behavior and
o 80-90% irreversible
fears of separation
o Reversible due to pathologic process
o Needs others to be responsible for important
o Most common: Alzheimer’s Dementia
areas of life
o Problems with initiating with projects or doing  4 Symptoms of Dementia
o Loss of memory
things on his own because of little self
confidence o Deterioration of language function
o Performs unpleasant tasks to obtain support from o Loss of ability to think abstractly, plan, initiate,
others sequence, monitor or stop complex behavior
 o Loss of ability to perform ADLs
ALCOHOL
STAGES OF DEMENTIA
ALCOHOLISM
STAGE 1 MILD (FORGETFULNESS)  Intergenerational Transmission
 Losses in short term memory  Awake but unconscious
 Memory aids compensate  Blackout
 Aware of the problem, disturbed  Confabulation
 Not diagnosable at this time  Denial, dependence
 Enabling, co-dependence
STAGE 2 MODERATE (CONFUSION)  Tolerance increases
 Progressive memory loss
 ST memory loss interferes with ADLs  Detoxification – doctor
 Withdrawn, denial, fear of losing their minds
 Depression, confabulation STAGES OF ALCOHOL WITHDRAWAL
 Problems increase when stressed
 Needs home care on in-home assistance 1 → 8 hours after the last drink
 Mild tremors, tachycardia, increased BP, diaphoresis,
STAGE 3 MODERATE TO SEVERE (AMBULATORY nervousness
DEMENTIA)
 Loss of reasoning ability, planning and verbal 2 → 8-12 hours after the last drink
communication  Gross tremors, hyperactivity, profound confusion,
 Frustrated, withdrawn, self-absorbed loss of appetite, insomnia, weakness, disorientation,
 Depression decreases illusions, hallucinations and delusions
 Reduced stress threshold
 Institutional care required 3 → 12-48 hours after the last drink
 Severe hallucinations, grand mal seizures
STAGE 4 LATE (END STAGE)
 Family recognition disappears 4 → 3-4 days after the last drink
 Doesn’t recognize self  Delirium tremens, confusion, agitation,
hallucinations, insomnia and tachycardia
 Nonambulatory
ALCOHOLISM
 Little purposeful activity
 Avoid alcohol during therapy
 Often mute, may scream spontaneously
 Aversion therapy
 Forgets most ADLs
 Antabuse – disulfiram
 Problems associated with immobility
 Belongings – check for alcohol, mouthwash, elixir,
 Institutional care required
etc.
 Return of primitive reflexes
 B1 deficiency
DELIRIUM VS DEMENTIA
 Complication
DELIRIUM DEMENTIA
o Wernicke’s Encephalopathy (Motor)
ONSET Usually sudden Usually gradual
o Korsakoff’s Psychosis (Mind)
Usually brief with Usually long-term and
COURS return to usual progressive,  Delirium Tremens
E level of occasionally maybe  Fornication
functioning arrested or reversed
AGE Any Elderly AUTISM
GROUP  Living in their own world
 Appearance – flat (consistent)
SEXUAL DISORDERS  Behavior – ritualistic, repetitive
 Homosexuality  Communication – echolalia, incomprehensible
 Heterosexuality
 Bisexuality NX: Impaired verbal communication
 Masochism Impaired social interaction
Self-mutilation
 Sadism
Risk for injury
 Frotteurism
 Pedophilia ADHD
 Necrophilia  Attention-deficit/hyperactive disorder
 Voyeurism  7 years old and above
 Transvestism  Duration: 6 months and above
 Transsexualism  Requires 2 settings: home and school
  Parotid gland tenderness, pancreatitis, esophageal and
 Appearance: dirty child gastric erosion or rupture
 Behavior: clumsy, hyperactive, impatient
 Communication: talkative, bursts out Metabolic
 Electrolyte abnormalities → hypokalemia
 Structure
 Setting limits Dental
 Schedule  Erosion of dental enamel of the front teeth
 Safety
OBJECTIVES OF CARE
EATING DISORDERS  Increasing body weight to at least 90% of average
 Anorexia Nervosa weight for age and height
 Bulimia Nervosa  Reestablishing good eating behavior
 Pica  Increasing self-esteem
 Compulsive Eating Behavior

ANOREXIA NERVOSA NURSING INTERVENTIONS

 Monitor daily caloric intake, activity level, weight
Symptoms: and electrolyte status
 Refusal to maintain body weight over a minimum  Establish nutritional eating patterns
normal weight for age and height o Sit with client during meals
 Intense fear of gaining weight or becoming fat, even o Offer liquid protein supplement if unable to
though underweight complete a meal
 Disturbance in the way in which one’s bodyweight, o Observe signs of purging 1-2 hours after meals
shape or size is experienced  Provide accurate information on nutrition and discuss
 In females, absence of menses of at least 3 realistic and healthy diet
consecutive cycles  Help the client identify emotions and develop non-
 Inability or refusal to acknowledge the seriousness of food related strategies
the problem o Convey warmth and sincerity
 Onset: 12-15; 17-21 years of age o Ask the client to identify feelings
o Assist the client to change stereotypical beliefs
Etiology  Assist in identifying at least three positive
 Cultural pressure characteristics
 Serotonin imbalance → controls appetite and the  Teach patient about their illness
satiety control center  Behavior modification: reward increase in weight
 Family patterns with meaningful privileges
o Perfectionist  Identify patient’s non weight related interests to
o Does not permit verbalization of feelings reduce anxiety and refocus attention
o Marital problems
BULIMIA NERVOSA
Clinical Presentation
 Low weight Symptoms
 Amenorrhea  Recurrent episodes of binge eating
 Yellow skin  Feeling of lack of control over eating behaviors
 Cold extremities during the eating binges
 Peripheral edema  Recurrent inappropriate compensatory behavior in
 Muscle weakening order to prevent weight gain, such as self-induced
 Constipation vomiting
 Low T3 and T4  Binge eating and inappropriate eating behaviors
 Hypotension  Persistent over concern with body shape and weight
 Bradycardia
Clinical Presentation
 Hypokalemia
 Binge and purging behaviors
 Anemia
 Have depressive signs and symptoms
 Pancytopenia
 Disturbed home life
 Decreased bone density
 Major concerns
o Interpersonal relationships
SIGNS RELATED TO PURGING BEHAVIORS
o Self-concept
Gastrointestinal o Impulsive behaviors
 Chemical dependence is also common
  Normal to slightly low
 Dental carries
 Parotid swelling
 Gastric swelling and rupture
 Calluses or scars on the hand
 Peripheral edema
 Hypokalemia, hyponatremia

Management:
 Trust
 Help patient identify feelings associated with binge-
purge behaviors
 Accept patient as a worthwhile human being
because they are often ashamed of their behavior
 Encourage patient to discuss positive qualities about
themselves
 Teach about bulimia nervosa
 Encourage to explore interpersonal relationships
 Encourage patients to adhere to meal and snack
schedules
 Encourage the patent to approach the staff if they
feel like binging or purging
 Encourage to attend group sessions
 Encourage family therapy
 Encourage participation in art, recreation and
occupational therapy
 Encourage the patient to describe their body image
at different ages of their lives