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					PSYCHIATRIC NURSING

       Presented by:
 Dave Jay Sibi. Manriquez, RN
           Introduction
• MENTAL HEALTH – balance in a
  persons internal life and
  adaptation to reality

• Mental ILL Health – state of
  imbalance characterized by a
  disturbance in a persons thoughts,
  feelings and behavior
        Psychiatric nursing
• interpersonal process whereby the
  professional nurse practitioner ,through
  the therapeutic use of self (art) and
  nursing theories (science), assist clients
  to achieve psychosocial well being.
• Core : interpersonal process
             Related Terms
• Mental hygiene
  – measures to promote mental health ,
    prevent mental illness and suffering and
    facilitate rehabilitation
  – Main tool: therapeutic use of self
  – It requires self-awareness
• Methods to increase self-awareness:
  –   Introspection
  –   Discussion
  –   Experience
  –   Role play
• Assessment (psychosocial processes )
  – Appearance , behavior or mood
  – Speech , thought content and thought
    process
  – Sensorium
  – Insight and judgment
  – Family relationships and work habits
  – Level of growth and development
Common Behavioral Signs
    and Symptoms
   Disturbances in perception
• Illusion
  – misinterpretation of an actual external
    stimuli


• Hallucinations
  – false sensory perception in the absence of
    external stimuli




                                     PERCEPTION
PERCEPTION
PERCEPTION
PERCEPTION
PERCEPTION
 Disturbances in thinking and
           speech
• neologism – coining of words that
  people do not understand

• Circumstantiality – over inclusion of
  inappropriate thoughts and details

• Word salad – incoherent mixture of
  words and phrases with no logical
  sequence
                                THINKING & SPEECH
• Verbigeration – meaningless repetition
  of words and phrases
• Perseveration – persistence of a
  response to a previous question
• Echolalia – pathological repetition of
  words of others
• Aphasia – speech difficulty and
  disturbance
  – Expressive , receptive or global

                                  THINKING & SPEECH
• Flight of ideas- shifting of one topic
  from one subject to another in a
  somewhat related way
• Looseness of association-incoherent
  illogical flow of thoughts (unrelated
  way)
• Clang association – sound of word
  gives direction to the flow of thought


                               THINKING & SPEECH
• Delusion – persistent false belief, rigidly
  held
  – Delusions of grandeur: special /important
    in a way
  – Persecutory: threatened
  – Ideas of reference: situation/events
    involve them
  – Somatic: body reacting in a particular
    way


                                  THINKING & SPEECH
– Jealous: thinking that their partner is
  unfaithful
– Erotomanic: person, usually of high status,
  is in love with the client
– Religious: illogical ideas about God and
  religion exhibited by extreme or
  extraneous behavior
– Mixed: combination of above without a
  predominant theme



                                 THINKING & SPEECH
• Magical thinking – primitive thought
  process thoughts alone can change
  events
• Autistic thinking – regressive thought
  process; subjective interpretations not
  validated with objective reality
• Dereism – unorganized thinking




                               THINKING & SPEECH
     Disturbances of affect
• Inappropriate – disharmony between
  the stimuli and the emotional reaction
• Blunted affect – severe reduction in
  emotional reaction
• Flat affect – absence or near absence
  of emotional reaction
• Apathy – dulled emotional tone



                                 AFFECT
• Depersonalization – feeling of
  strangeness from one’s self
• Derealization – feeling of strangeness
  towards environment
• Agnosia – lack of sensory stimuli
  integration




                                  AFFECT
Disturbances in motor activity
• Echopraxia – imitation of posture of
  others
• Waxy flexibility – maintaining position
  for a long period of time
• Ataxia – loss of balance
• Akathesia – extreme restlessness




                                 MOTOR ACTIVITY
• Dystonia- uncoordinated spastic
  movements of the body
• Tardive dyskinesia – involuntary
  twitching or muscle movements
• Apraxia – involuntary unpurposeful
  movements




                              MOTOR ACTIVITY
    Disturbances in memory
• Confabulation – filling of memory gaps
• Déjà vu – something unfamiliar seems
  familiar
• Jamais vu- something familiar seems
  unfamiliar
• Amnesia – memory loss (inability to
  recall past events)
  – Retrograde-distant past
  – Anterograde – immediate past
  – Anomia – lack of memory of items
                                   MEMORY
Dynamics of Human Behavior
• Behavior – the way an individual
  reacts to a certain stimulus

• Conflict – situation arising from the
  presence of two opposing drives

• Need - organismic condition that
  requires a certain activity
Dynamics of Human Behavior
• Personality
  – totality of emotional and behavioral traits
    that characterize the person in day to day
    living under ordinary conditions; it is
    relatively stable and predictable.
         FORMATION OF
          PERSONALITY
• TEMPERAMENT
  – biological-genetic template that interacts with
    our environment.
  – a set of in-built dispositions we are born with
  – mostly unalterable
  – our nature.
• CHARACTER
  – the outcome of the process of socialization, the
    acts and imprints of our environment and nurture
    on our psyche during the formative years (0-6
    years and in adolescence).
  – the set of all acquired characteristics we posses,
    often judged in a cultural-social context.
• Sometimes the interplay of all these factors
  results in an abnormal personality
 THEORIES OF
PERSONALITY
DEVELOPMENT
       Freud’s
PSYCHOSEXUAL THEORY
• Libido – inner drive
• Parts of body –focus of gratification
• Unsuccessful resolution - fixation
• Structures of personality
  – Id: pleasure principle-instinct
  – Ego: controls action and perception –
    reality principle
  – Superego: moral behavior - conscience
• 0-18 m0s ;oral – mouth – trust and
  discriminating
• 18 mos. – 3 years ; anal – bowels –
  holding on or letting go
   – Negativism and toilet training age
• 3 -6 years phallic ; genitals –exploration
  and discovery ( inc. sexual tension)
   – Gender identification and genital
     awareness
   – Oedipus and Electra complex
   – Castration anxiety and penis envy
• 6-12 years – latency (quiet stage)
  sexual energy diverted to play.
  Institution of superego: control of
  instinctual impulses
• 12 – young adult – genital ;
  reawakening of sexual drives –
  relationships
  – Sexual maturation
  – Sexual identity ,ability to love and work
    Eric Erickson’s
PSYCHOSOCIAL THEORY
• 0-12mos        • TRUST vs. MISTRUST
• 1-3y           • AUTONOMY vs. SHAME &
                   DOUBT
• 3-6            • INDUSTRY vs. INFERIORITY
• 6-12           • INITIATIVE vs. GUILT
• 12-18          • IDENTITY vs. IDENTITY
                   CONFUSION
• 18-25          • INTIMACY vs. ISOLATION
• 25-60          • EGO INTEGRITY vs.
                   STAGNATION
                 • GENERATIVITY vs. DESPAIR
• 60 and above
            INFANCY
• CONSISTENT MATERNAL –CHILD
  INTERACTION – TRUST
• INNER FEELING OF SELF WORTH
• HOPE
            TODDLER
• ALLOW EXPLORATION
• PROVIDE FOR SAFETY
• “NO, NO” – NEGATIVISM
• OFFER CHOICES / REVERSE PSYCHOLOGY
• TOILET TRAINING – 18 MOS.-BOWEL
   – DAYTIME BLADDER: 2 yo
   – NIGHTIME BLADDER: 3 yo
• REWARD W/ PRAISE AND AFFECTION
• INDEPENDENCE
         PRE-SCHOOL
• PROVIDE PLAY MATERIALS
• SATISFY CURIOSITY
• TEACH AND
  REINFORCE(HYGIENE,SOCIAL
  BEHAVIOR)
• SIBLING RIVALRY
• WILLPOWER
        SCHOOL AGE
• HOW TO DO THINGS WELL-SUPPORT
  EFFORTS
• CHUMS AND HOBBIES
• NEEDS TO EXCEL/ACCOMPLISH
• NEED FOR PRIVACY AND PEER
  INTERACTION
• COMPETENCE
       ADOLESCENCE
• MAKE DECISION,EMANCIPATION FROM
  PARENTS
• BODY IMAGE CHANGES
• NEED TO CONFORM BUT KEEP
  INDIVIDUALITY
• SELF - AWARENESS
         YOUNG ADULT

• COMMITMENT AND FIDELITY

• RESPONSIBILITY

• ACHIEVEMENT OF INDEPENDENCE
     MIDDLE ADULTHOOD
• SUPPORT-PERIOD OF ROLE TRANSITIONS

• MIDLIFE CRISIS

• ADJUSTMENT AND COMPROMISE

• MOST PRODUCTIVE AND CREATIVE

• ALTRUISM
     LATE ADULTHOOD
• SELF ACCEPTANCE

• SELF WORTH

• WISDOM
   Jean Piaget’s
COGNITIVE THEORY
    0-2 SENSORIMOTOR
• REFLEXES
• IMITATIVE REPETITIVE BEHAVIOR
• SENSE OF OBJECT PERMANENCE AND
  SELF SEPARATE FROM ENVT.
• TRIAL AND ERROR RESULTS IN PROBLEM
  SOLVING
    2-7Y PRE-OPERATIONAL
• SELF-CENTERED,EGOCENTRIC
• CANNOT CONCEPTUALIZE OTHER’S VIEW
• ANIMISTIC THINKING
• IMAGINARY PLAYMATE – SYMBOLIC MENTAL
  REPRESENTATION – CREATIVITY
• 2-4 PRE-CONCEPTUAL (PRE-LOGICAL)
• 4-7 INTUITIVE (UNDERSTANDING OF ROLES)
       7-12Y CONCRETE
        OPERATIONAL
• LOGICAL CONCRETE THOUGHT
• INDUCTIVE REASONING (SPECIFIC TO
  GENERAL)
• CAN RELATE, PROBLEM SOLVING
  ABILITY
• REASONING AND SELF-REGULATION
    12-ABOVE: FORMAL
  OPERATIONAL THOUGHT
• Abstract thinking
• Separation of fantasy and fact
• Reality oriented
• Deductive reasoning
• Apply scientific method
     Havighurst’s
DEVELOPMENTAL TASKS
• Baby to early childhood
  – Right from wrong and Conscience
• Late childhood
  – Physical skills, wholesome attitude, social
    roles
  – Conscience morality and values
  – Fundamental skills in academics
  – Personal independence
• Adolescence
  – Sexual social roles
  – Relationships
  – Independence and ideology
• Early adulthood
  – Career
  – Selecting a mate
  – Finding Civic or social responsibility
• Middle age
  –   Achieving Civic or social responsibility
  –   Adjusting to changes
  –   Satisfactory career performance
  –   Adjusting to aging parents
  –   Adjusting to parental roles
• Old age
  – Adjusting to changes
  – Establishing satisfactory living
    arrangements and affiliations
      Kohlberg’s
MORAL DEVELOPMENT/
THINKING/ JUDGEMENT
• PRE-CONVENTIONAL (0-6)
  – PUNISHMENT AND OBEDIENCE
  – OBEDIENCE TO RULES TO AVOID
    PUNISHMENT
• CONVENTIONAL ( 6-12 )
  – MUTUAL INTERPERSONAL
    EXPECTATIONS,RELATIONSHIPS AND
    CONFORMITY
  – SOCIAL SYSTEM AND CONSCIENCE
    MAINTENANCE
  – BEING GOOD IS IMPORTANT SELF RESPECT
    OR CONSCIENCE
• POST –CONVENTIONAL (12 – 18 Y)
  – PRIOR RIGHT OR SOCIAL CONTRACT
  – UNIVERSAL ETHICAL PRINCIPLE
  – ABIDE FOR COMMON GOOD
  – RATIONAL PERSON-VALIDITY OF
    PRINCIPLES-AND BECOME COMMITTED TO
    THEM
  – INNER CONTROL OF BEHAVIOR
    UNDERSTANDING THE EQUALITY OF
    HUMAN RIGHTS AND DIGNITY OF HUMAN
    BEINGS AS INDIVIDUALS
   Harry Stack Sullivan’s
INTERPERSONAL THEORY
            INFANCY

• NEED FOR SECURITY-INFANT LEARNS TO
  RELY ON OTHERS TO GRATIFY NEEDS
  AND SATISFY WISHES, DEVELOPS A SENSE
  OF BASIC TRUST, SECURITY AND SELF
  WORTH WHEN THIS OCCURS
   TODDLERHOOD / EARLY
       CHILDHOOD
• CHILD LEARNS TO COMMUNICATE
  NEEDS THROUGH USE OF WORDS AND
  ACCEPTANCE OF DELAYED
  GRATIFICATION AND INTERFERENCE OF
  WISH FULFILLMENT
          PRE-SCHOOL
• DEVELOPMENT OF BODY IMAGE AND SELF-
  PERCEPTION
• ORGANIZES AND USES EXPERIENCES IN TERMS
  OF APPROVAL AND DISAPPROVAL RECEIVED
• BEGINS USING SELCTIVE INATTENTION AND
  DISASSOCIATES THOSE EXPERIENCES THAT
  CAUSE PHYSICAL OR EMOTIONAL
  DISCOMFORT AND PAIN
         SCHOOL AGE
• THE PERIOD OF LEARNING TO FORM
  SATISFYING RELATIONSHIPS WITH PEERS-
  USES COMPETITION,COMPROMISE AND
  COOPERATION
• THE PRE-ADOLESCENT LEARNS TO
  RELATE TO PEERS OF THE SAME SEX
        ADOLESCENCE
• LEARNS INDEPENDENCE AND HOW TO
  ESTABLISH SATISFACTORY
  RELATIONSHIPS WITH MEMBERS OF THE
  OPPOSITE SEX
    YOUNG ADULTHOOD
• BECOMES ECONOMICALLY,
  INTELLECTUALLY AND EMOTIONALLY
  SELF SUFICIENT
     LATER ADULTHOOD
• LEARNS TO BE INTERDEPENDENT AND
  ASSUMES RESPONSIBILITY FOR OTHERS
         SENESCENCE
• DEVELOPS AN ACCEPTANCE OF
  RESPONSIBILITY FOR WHAT LIFE IS AND
  WAS AND OF ITS PLACE IN THE FLOW OF
  HISTORY
TREATMENT
MODALITIES
REMOTIVATION THERAPY
• TREATMENT MODALITY THAT
  PROMOTES EXPRESSION OF FEELINGS
  THROUGH INTERACTION FACILITATED
  BY DISCUSSION OF NEUTRAL TOPICS
• STEPS :
  climate of acceptance
  creating bridge to reality
  sharing the world we live in
  appreciation of works of the world
  climate of appreciation
        MUSIC THERAPY
• Involves use of music to facilitate
  expression of feelings, relaxation and
  outlet of tension
       PLAY THERAPY
• enables patient to experience intense
  emotion in a safe environment with the
  use of play
• children express themselves more easily in
  play. revealing as reflection of child’s
  situation in the family
• provide toys and materials – facilitate
  interaction – observe and help child
  resolve problems through play
            Group therapy
• Treatment modality involving three or more
  patients with a therapist to relieve emotional
  difficulties, increase self – esteem, develop
  insight , LEARN NEW ADAPTIVE WAYS TO
  COPE WITH STRESS and improve behavior
  with others
• IDEAL 8 – 10 MEMBERS
         MILIEU THERAPY
• Consists of treatment by means of controlled
  modification of the patient’s environment to
  facilitate positive behavioral change
• Increase patient’s
  – Awareness of feelings
  – Sense of responsibility and
  – Help return to community
• clients plan social and group interaction
• token programs , open wards and self
  medication are done
        FAMILY THERAPY
• A METHOD OF PSYCHOTHERAPY WHICH
  FOCUSES ON THE TOTAL FAMILY AS AN
  INTERACTIONAL SYSTEM
• PROBLEM IS A FAMILY PROBLEM
• focus on sick members behavior as source of
  trouble / symptom serve a function for the
  family
• members develop sense of identity
• points out function of the sick member for
  the rest of the family
        PSYCHOANALYTIC
• focuses on the exploration of the
  unconscious, to facilitate identification of the
  patients defenses
• ANXIETY RESULTS BETWEEN CONFLICTS OF ID
  AND EGO
• Becomes aware of unconscious thoughts
  and feelings to understand anxiety and
  defenses
       HYPNOTHERAPY
• Various methods and techniques to
  induce a trance state where patient
  becomes submissive to instructions
 BEHAVIOR MODIFICATION
• Application of learning principles in
  order to change maladaptive
  behavior
• Believes that psychological problems
  are a result of learning
• Everything learned can be unlearned
 BEHAVIOR MODIFICATION
• OPERANT CONDITIONING
  – Use of rewards to reinforce positive
    behavior
  – Perceived and self-reinforcement
    becomes more important than external
    reinforcement

• DESENSITIZATION
  – Slow adjustment or exposure to feared
    objects (phobias)
  – Periodic exposure until undesirable
    behavior disappears or lessens
     AVERSION THERAPY
• An example of behavior modification
• Painful stimulus is introduced to bring
  about an avoidance of another
  stimulus
• End view: behavioral change
      OTHER THERAPIES
• HUMOR THERAPY
  – To facilitate expression and enhance
    interaction


• ACTIVITY THERAPY
  – Group interaction while working on a task
    together
   BIOLOGICAL/ MEDICAL
         THEORY
• EMOTIONAL PROBLEM IS AN ILLNESS
• cause may be inherited or chemical in
  origin
• FOCUS OF TREATMENT IS MEDICATIONS
  AND ECT
    BIOLOGICAL THERAPY
• ELECTROCONVULSIVE THERAPY
  – Artificial induction of a grand mal seizure by
    passing a controlled electrical current through
    electrodes applied to one or both temples
  – mechanism of action – unclear
  – voltage: 70 – 150 volts
  – Duration: 0.5 – 2.0 seconds
  – 6 to 12 treatments
  – intervals of 48 hours
• indicators of effectiveness – occurrence of
  generalized tonic – clonic seizures
• indications – depression , mania and
  catatonic schizophrenia
• s/e: confusion, disorientation, short -term
  memory loss, seizure (30-60 sec)
• NPO prior
• Contraindications
  –   Fever, pregnancy
  –   Inc ICP, fracture
  –   retinal detachment
  –   TB with hemoptysis
  –   cardiac d/o
• consent needed
• Reorient after, supportive care
• medications given :
  – Atropine sulfate: decrease secretions
  – Succinylcholine (Anectine): promote
    muscle relaxation
  – Methohexital Sodium ( Brevital ): serves
    as an anesthetic agent
• common complications:
  –   loss of memory
  –   headache
  –   apnea
  –   fracture
  –   respiratory depression
Psychopharmacologic
      Therapy
                                     Benzodiazepines
           Benzodiazepines
• Indications
  –   Anxiety
  –   Sedation/sleep
  –   Muscle spasm
  –   Seizure disorder
  –   Alcohol withdrawal syndromes
                                 Benzodiazepines
      Anti-anxiety drugs
 Generic           Trade name
Alprazolam            Xanax
Chlordiazepoxide      Librium
Clorazepate           Tranxene
Diazepam              Valium
Lorazepam             Ativan
Oxazepam              Serax
Busipirone            BuSpar
                                        Benzodiazepines
             Side effects
• Drowsiness/ sedation
• Ataxia
• Feelings of detachment
• Increase irritability and hostility
• Anterograde amnesia
• Increased appetite & weight gain
• Nausea
• Headache, confusion
                                          Anti-depressants
           Anti-depressants
• Indications
  –   Depression
  –   Bipolar depression
  –   Panic disorder
  –   Bulimia
  –   Obsessive-compulsive d/o
• Possibly
  – Attention deficit/Hyperactivity d/o
  – Post Traumatic Stress D/o
  – Conduct d/o
                                Anti-depressants
          Tricyclic (TCA)
Generic            Trade name
Amitriptyline      Elavil
Imipramine         Tofranil
Trimipramine       Surmontil
Nortriptyline      Pamelor
Trazodone          Desyrel
Bupropion          Wellbutrin
                                                   Anti-depressants
              Side effects
• Orthostatic hypertension
• Anticholinergic effect
  – Dry mouth, blurred vision, constipation,
    excessive sweating, urinary hesitancy/
    retention, tachycardia, agitation, delirium,
    exacerbation of glaucoma
• Neurologic effects
  – sedation, psychomotor slowing, poor
    concentration, fatigue, ataxia, tremors
• Decrease libido and sexual
  performance
                                Anti-depressants
Monoamine Oxidase inhibitors
 Generic           Trade name
 Isocarboxazid     Marplan
 Phenelzine        Nardil
 Tranylcypromine   Parnate
                                Anti-depressants
            Side effects
• Postural lightheadedness
• Constipation
• Delay ejaculation or orgasm
• Muscle twitching
• Drowsiness
• Dry mouth
                                            Anti-depressants
        Dietary restrictions
• Cheese, esp. aged and matured
• Fermented or aged protein
• Pickled or smoked fish
• Beer, red wine, sherry; liquor & cognac
• Yeast
• Fava or broad beans
                         Hypertensive
•Tyramine
  Beef or chicken liver
                              Crisis
• Spoiled/ overripe fruits; banana peel
• yogurt
                                        Anti-depressants
          Hypertensive Crisis
• Signs
  – Sudden elevation of BP
  – Explosive headache, occipital may
    radiate frontally
  – Head & face flushed
  – Palpitations, chest pain
  – Sweating, fever
  – Nausea, vomiting
  – Dilated pupils, photophobia
  – Intracranial bleeding
                                          Anti-depressants
• Treatment
  –   Hold next MAO dose
  –   Don’t let pt. lie down
  –   IM chlorpromazine 100 mg
  –   Fever: manage by external cooling
      techniques
                             Anti-depressants
Serotonin Reuptake Inhibitors
  Generic       Trade name
 Fluoxetine     Prozac
 Sertraline     Zoloft
 Paroxetine     Paxil
 Venlafaxine    Effexor
                                 Anti-depressants
           Side effects
• Nausea         • Headache
• Diarrhea       • Male sexual
• Insomnia         dysfunction
• Dry mouth      • Drowsiness
• Nervousness    • Dizziness
                 • Sweating
                                Mood stabilizing
       Mood stabilizing drugs
• Indications
  – Acute mania
  – Bipolar prophylaxis
• Possibly
  –   Bulimia
  –   Alcohol abuse
  –   Aggressive behavior
  –   schizoaffective
                                            Mood stabilizing
• Mode of action
  – Normalizes the reuptake of certain
    neurotransmitters such as serotonin,
    norepinephrine, acetylcholine and
    dopamine
  – Reduces the release of norepinephrine
    thru competition with calcium
  – Effects intracellularly
• Lag period: 7-10 to 14 days
                                                 Mood stabilizing
          Lithium carbonate
• Trade names
   – Eskalith         Preparation: tab, cap, liq &
                      SR form
   – Lithotabs
                      Dose: 900 to 3600 mg/day
   – Lithane
   – Lithonate
• MOA: unclear; interfere with metabolism of
  neurotransmitters; alter Na transport in nerves
  and muscle cells
• Prelithium workup
  – Urinalysis (BUN and creatinine)
  – ECG, FBC, CBC
                                                     Mood stabilizing
                 Side effects
• Early
  –   Nausea and diarrhea
  –   Anorexia
  –   Fine hand tremor (propranolol)
  –   Thirst, Polydipsia (dec. crea, inc. albumin)
  –   Metallic taste
  –   Fatigue
  –   Lethargy
• Late
  – Weight gain
  – acne
                                     Mood stabilizing
         Contraindications
• Brain damage/ CV disease
• Epilepsy
• Elderly/ debilitated
• Thyroid and renal disease
• Severe dehydration
• Pregnancy (1st trimester)

• Can augment the effects of anti-
  depressants
                                                             Mood stabilizing
         Nursing considerations
• Therapeutic serum level: 0.5 – 1.2 meq/L
• Maintenance level: 0.6 -1.2 meq/L
• Toxic
   – Mild to moderate: 1.5 to 2 meq/L
   – Moderate to severe: 2 – 2.5 meq/L
   – Needs dialysis: 3 meq and above
• Early signs of toxicity
   – Lethargy, mild nausea, vomiting, fine hand
     tremors, anorexia, polyuria, polydipsia, metallic
     taste, fatigue
• Late signs of toxicity
   – Ataxia, giddiness, tinnitus, blurred vision, polyuria
                                               Mood stabilizing
         Nursing considerations
• Lithium levels should be checked q 2-3 mos
• Serum drawn in the AM, 12H after last dose
• Common causes of inc. levels
  –   Dec. Na intake
  –   Diuretic therapy
  –   Dec. renal functioning
  –   F&E loss
  –   Medical illness
  –   Overdose
  –   NSAIDS
                                         Mood stabilizing
       Nursing considerations
• Diet: adequate Na+ and fluid
  – 3g NaCl/ day
  – 6-8 glasses of H2O
• No caffeine
• No driving: wait for clinical effect
                                                 Mood stabilizing
                 Management
• Moderately severe toxicity
  –   Osmotic diuresis: urea/ mannitol
  –   Aminophylline & PLR IV
  –   Adequate NaCl
  –   Peritoneal/ hemodialysis
• Severe toxicity
  –   Assess hx quickly
  –   Hold next lithium dose
  –   Check BP, rectal T°, RR, LOC, support O2
  –   Obtain labs
  –   ECG
  –   Emetic, NGT lavage
  –   Hydrate: 5-6L/day c PLR; FBC-CDU
                                          Mood stabilizing
              Other drugs
• Carbamazepine (Tegretol)
  – Side effects
    • Dizziness           800 to 1200
    • Ataxia              mg/day
    • Clumsiness
    • Sedation
    • Dysarthria
    • Diplopia
    • Nausea & GI upset
  – Preparation: liq, tab, chewable tab
                                       Mood stabilizing
      Nursing considerations
• Assess drug levels q 3-4 days
• Monitor salt and fluid intake
• Avoid alcohol and non-prescription
  drugs
• Refer dec. in UO
• Don’t stop abruptly
• C/I: pregnancy
• Take with meals
                                              Mood stabilizing
              Other drugs
• Valproic acid (Depakote, Depakene)
  – Side effects
    • Nausea
    • Hepatoxicity
    • Neurotoxicity
    • Hematological toxicity
    • Pancreatitis
  – Prep: tab, cap, sprinkles
• MOA: inc. levels of GABA; inhibits the
  kindling process or “snoball”-like effect
  seen in mania & seizures
                                             Mood stabilizing
      Nursing considerations
• Therapeutic level: 50 – 100 ug/mL
• Dose: 1, 000 – 1,500 mg/day
• Monitor serum levels 12H after last dose
• Toxic effects
  – Severe diarrhea, vomiting, drowsiness,
    mm. weakness, lack of coordination
  – Renal failure, coma, death
                                           Anti-psychotic
       Anti-psychotic drugs
• Indications
  – Psychotic symptoms of schizophrenia,
    acute mania and depression
  – Gilles de Tourette disorder
  – Treatment-resistant bipolar disorder
  – Huntington’s disease and other
    movement disorder
• Possibly
  – Paranoid
  – Childhood psychoses
                                            Anti-psychotic
• MOA: block receptors of dopamine
  (D2, D3, D4)
• If unresponsive after 6 weeks of
  therapy, another class is tried
• General considerations
  – Calms without producing impairment of
    sleep
  – High therapeutic index
  – Non addicting, no tolerance
  – Avoided in pregnancy
                              Anti-psychotic
TYPICAL: High Potency

Fluphenazine (Prolixin)
Haloperidol (Haldol)
Thiothexene (Navane)
Trifluoperazine (Stelazine)
                          Anti-psychotic
  Moderate Potency

Loxapine (Loxitane)
Molindone (Moban)
Perphenazine (Trilafon)
                             Anti-psychotic
      Low Potency

Chlopromazine (Thorazine)
Chlorprothixene (Taractan)
Mesoridazine (Serentil)
Thioridazine (Mellaril)
                          Anti-psychotic
     ATYPICAL
Clozapine (Clozaril)
Resperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Sertindole (Serlec’t)
Ziprasidone (Zeldox)
                                         Anti-psychotic
         Contraindications
• CNS depression: brain damage, excess
  alcohol/ narcotics
• Parkinson’s disease
• Allergy
• Blood dyscrasias
• Acute narrow angle glaucoma
• BPH
                                        Anti-psychotic
            Side effects
  • Hypotension
  • Sedation
  • Dermal and ocular syndrome
  • Neuroleptic malignant syndrome
  • Anticholinergic syndrome
  • Movement syndrome (Extrapyramidal
    Syndrome)
! • Atropine psychosis
New


  • Agranulocytosis
  • Seizures
                                                        Anti-psychotic
 Neuroleptic Malignant Syndrome
• A potentially fatal, idiosyncratic reaction to
  an antipsychotic drug
• 10-20% mortality rate
• Sx:                 TTT: dantrolene (Dantrium),
  – rigidity,           Bromocriptine (Parlodel)
  – high fever,
  – autonomic instability (BP, diaphoresis, pallor,
    delirium, elev. CPK), confused or mute, fluctuate
    from agitation to stupor
• Occurs in the first 2 weeks of therapy
• Risk: high dose of high-potency drugs;
  dehydration, poor nx, concurrent med illness
                          Anti-psychotic
     Movement Syndromes
• Akathisia
• Dystonia
• Tardive dyskinesia
• Bradykinesia
• Parkinsonism
                                                     Anti-psychotic
              New
              !     Other s/e
• Atropine psychosis (geriatrics)
  – Hyperactivity, agitation, confusion,
    flushed skin, sluggish reactive pupils
  – TTT: IM physostigmine
• Agranulocytosis (Clozapine)
  –   Occurs 3-8 wks after
  –   Medical emergency
  –   s/s: fever, malaise, sore throat, leukopenia
  –   TTT: d/c, reverse iso, antibiotics
• Seizures (Clozapine)
  – Occurs in 5% of patients; TTT: D/c drug
                                 Anti-psychotic
         Anticholinergics

      Benztropine (Cogentin)
      Trihexyphenidyl (Artane)
      Biperiden (Akineton)
      Procyclidine (Kemadrin)

• Not withdrawn abruptly
• Provide cool environment
 ANTIPARKINSONIAN MEDICATIONS
• Adjunct to anti-psychotic agents to balance
  dopamine/ acetylcholine in the brain
• s/e: glaucoma, tachycardia, HPN, cardiac
  dx, asthma, duodenal ulcer
• A/e: blurred vision, photosensitivity,
  drowsiness, orthostatic hypotension, CHF,
  hallucinations
• COMMON DRUGS:
  –   Trihexyphenidyl (Artane)
  –   benztropine (Cogentin)
  –   Biperiden (Cogentin)
  –   Selegiline (Eldepryl)
  –   Pergolide (Permax)
• ANTIHISTAMINE
  – Diphenhydramine HCl (BENADRYL)
• DOPAMINE RELEASING AGENT
  – Amantadine (SYMMETREL)
• Nursing considerations
  –   Best taken after meals
  –   Avoid driving
  –   Check BP
  –   Alcohol increases sedative effects
  –   Avoid sudden position change
  –   Drug is not withdrawn abruptly
PSYCHIATRIC
 DISORDERS
   ANXIETY DISORDERS
• PANIC DISORDERS
• SPECIFIC PHOBIA
• SOCIAL PHOBIA
• OCD
• PTSD
• ACUTE STRESS DISORDER
• GENERALIZED ANXIETY DISORDER

                      ANXIETY DISORDERS
         PANIC ATTACKS
• Discrete period of intense fear or
  discomfort in which at least 4 if the ff sx
  develop abruptly and peak within 10
  mins:
  – Palpitations, pounding heart, or
    accelerated HR
  – Sweating
  – Trembling or shaking
  – Sensations of SOB and smothering
  – Feeling of choking
                               ANXIETY DISORDERS
– Chest pain or discomfort
– Nausea or abd. Pain
– Feeling dizzy, unsteady, lightheaded or
  faint
– Derealization or depersonalization
– Fear of losing control or going crazy
– Fear of dying
– Paresthesias
– Chills or hot flashes


                              ANXIETY DISORDERS
 SPECIFIC→ PHOBIA ← SOCIAL
• Excessive and        • Fear of social
  unreasonable cued      performance
  by the presence or     situations in which
  anticipation of a      the person is
  specific object or     exposed to
  situation              unfamiliar people or
• Defense mech           to possible scrutiny
  commonly used          by others
  include repression
  and displacement


                              ANXIETY DISORDERS
 OBSESSION               COMPULSION
• Recurrent and          • Px feels driven to
  persistent thoughts,     perform repetitive
  impulses, or images      behaviors or mental
  are experienced          acts in response to
  during the               obsession or
  disturbance as           according to the
  intrusive and            rules that one
  inappropriate            deems must be
• Cause anxiety or         applied rigidly.
  distress               • Aimed at reducing
• Px knows that these      anxiety
  are just product of
  one’s own mind.
                                ANXIETY DISORDERS
  OBSESSION                  COMPULSION
• Fear of dirt & germs       • Excessive hand washing
• Fear of burglary or        • Repeated checking of
  robbery                      door and window locks
• Worries about              • Counting and
  discarding something         recounting of objects in
  important                    everyday life
• Concerns about             • Hoarding of objects
  contracting a serious      • Excessive straightening,
  illness                      ordering, or of
• Worries that things must     arranging things
  be symmetrical or          • Repeating words or
  matching                     prayers silently


                                      ANXIETY DISORDERS
  POST TRAUMATIC STRESS
        SYNDROME
• Person has experienced, witnessed or
  been confronted with an event that
  involved actual or threatened death or
  serious injury, or a threat to physical
  integrity
• Person reexperiences these in the mind
• Involves intense fear, helplessness, or
  horror and numbing of general
  responsiveness (PSYCHIC NUMBING)


                            ANXIETY DISORDERS
        ACUTE                   GENERALIZED
        STRESS                    ANXIETY
• Meets the criteria for   • Excessive anxiety or
  exposure to a              worry, occurring in
  traumatic event and        more days than not
  person experiences         for at least 6 mos,
  3 of the ff sx:            about a number of
  – sense of                 events or activities
    detachment,
  – reduced awareness      • Finds it difficult to
    of one’s                 control the worry
    surroundings,
  – derealization,
  – depersonalization,
  – dissociated amnesia

                                   ANXIETY DISORDERS
MOOD/ AFFECTIVE DISORDERS
• BIPOLAR D/O
   – BIPOLAR I: current or past experience of
     manic episode, lasting at least a week,
     that is severe enough to cause extreme
     impairment in social or occupational
     functioning.
     • MANIA: hyperactivity
     • DEPRESSED: extreme sadness or withdrawal
     • MIXED
  – BIPOLAR II: hx of 1 or more mj depressive
    episodes & at least 1 hypomanic episode;
    no mania


                                   MOOD DISORDERS
• MAJOR DEPRESSIVE D/O
 – @ least 5 sx of same 2- wk period with one
   being either depressed mood or loss of
   interest or pleasure.
 – Single episode or recurrent
 – Other sx: wt loss, insomnia, fatigue,
   recurrent thoughts of death, diminished
   ability to think, psychomotor agitation or
   retardation, feelings of worthlessness.



                               MOOD DISORDERS
• CYCLOTHYMIC D/O
  – Hx of 2 yrs of hypomania with numerous
    periods of abnormally elevated, expansive
    or irritable moods.
  – Does not meet the criteria of mania or
    depression.
• DYSTHYMIC D/O
  – @ least 2 yrs of usually depressed mood
    and at least 1 of the sx of mj depression
    without meeting the criteria for it
• SEASONAL AFFECTIVE D/O
  – Depression that comes with shortened
    daylight in fall and winter that disappears
    during spring and summer.

                                  MOOD DISORDERS
Dealing with Inappropriate Behaviors
AGGRESSIVE BEHAVIOR
• Assist the client in identifying feelings of
  frustration and aggression
• Encourage the client to talk out instead of
  acting out feelings of frustration
• Assist the client in identifying precipitating
  events or situations that lead to aggressive
  behavior
• Describe the consequences of the behavior
  on self and others
• Assist in identifying previous coping
  mechanisms
• Assist the client in the problem-solving
  techniques to cope with frustration or
  aggression
                                  MOOD DISORDERS
DEESCALATION TECHNIQUES
• Maintain safety
• Maintain large personal space and use
  nonaggressive posture
• Use calm approach and communicate with
  a calm, clear tone of voice (be assertive not
  aggressive
• Determine what the client considers to be his
  or her need
• Avoid verbal struggles
• Provide clear options that deal with behavior
• Assist with problem-solving and decision
  making regarding the options
                                 MOOD DISORDERS
MANIPULATIVE BEHAVIORS
• Set clear, consistent, realistic, and
  enforceable limits and communicate
  expected behaviors
• Be clear about consequences
  associated with exceeding set limits
• Discuss behavior in nonjudgmental and
  nonthreatening manner
• Avoid power struggles
• Assist in developing means of setting
  limits on own behavior
                           MOOD DISORDERS
         SCHIZOPHRENIA
• characterized by impairments in the
  perception or expression of reality and by
  significant social or occupational
  dysfunction.
• Once considered as a deadly disease
• There is lack of insight in behavior
• Dx: late adolescence and early adulthood
  – 15-25 y.o. (men); 25-35 y.o. (women)
• Obsolete term: dementia praecox =
  “cognitive deterioration early in life”
• Eugene Bleuler: schiz “split”; phren “mind”

                                      SCHIZOPHRENIA
                     Risk factors
•       Genetics: identical twins 50%, 15% for fraternal
        twins
•       Biochemical factors
    –     Dopamine hypothesis: overactive
    –     Serotonin imbalance
    –     Decreased brain volume, enlarged ventricles, deeper
          fissures, and loss or underdeveloped brain tissue
•       Psychoanalytic
    –     lack of trust during the early stages
    –     Weak ego
    –     Defenses: REPRESSION, REGRESSION, PROJECTION
•       Environment influences: poverty, lack of social
        support, hostile home environment, isolation,
        unsatisfactory housing, disruption in interpersonal
        relationships (divorce or death), job pressure or
        unemployment

                                               SCHIZOPHRENIA
                Subtypes
• Catatonic type
  – prominent psychomotor disturbances are
    evident. Symptoms can include catatonic
    stupor and waxy flexibility
• Disorganized type
  – where thought disorder and flat affect are
    present together
• Paranoid type
  – where delusions and hallucinations are
    present but thought disorder, disorganized
    behavior, and affective flattening are
    absent
                                 SCHIZOPHRENIA
• Residual type
  – where positive symptoms are present
    at a low intensity only
• Undifferentiated type
  – psychotic symptoms are present but
    the criteria for paranoid,
    disorganized, or catatonic types has
    not been met


                             SCHIZOPHRENIA
                  Symptoms
According to Bleuler: 4 A’s
  –   Affect is inappropriate
  –   Associative looseness
  –   Autistic thinking
  –   Ambivalence




                                SCHIZOPHRENIA
                Symptoms
• Positive symptoms
  – delusions, auditory hallucinations and
    thought disorder and are typically
    regarded as manifestations of psychosis.
• Negative symptoms
  – considered to be the loss or absence of
    normal traits or abilities
  – E.G. flat, blunted or constricted affect and
    emotion, poverty of speech and lack of
    motivation.

                                  SCHIZOPHRENIA
                    Symptoms
•   Social isolation
•   Catatonic behavior
•   Hallucinations
•   Incoherence (marked looseness of association)
•   Zero/ lack of interest, energy and initiative
•   Obvious failure to attain expected level of dev’t
•   Peculiar behavior
•   Hygiene and grooming impaired
•   Recurrent illusions and unusual perception
    experiences
•   Exacerbations and remissions are common
•   No organic factors accounts for the symptoms
•   Inability to return to baseline functioning after
    relapse
•   Affect is inappropriate

                                          SCHIZOPHRENIA
 Nsg Dx: Abnormal thought process
• BLOCKING: sudden cessation of a thought in
  the middle of a sentence, unable to
  continue the train of thought
• CIRCUMSTANTIALITY: before getting to the
  point of answering a question, the individual
  gets caught up in countless details and
  explanations
• CONFABULATION
• LOOSENESS OF ASSOCIATION
• NEOLOGISM
• WORD SALAD

                                  SCHIZOPHRENIA
Interventions
•   Assess physical needs
•   Set limits
•   Maintain safety
•   Initiate one-on-one interaction & progress to
    small groups
•   Spend time with clients
•   Monitor for altered thought process
•   Maintain ego boundaries, avoid touching
•   Limit time of interaction
•   Be neutral
•   Do not make promises that can’t be kept
                                    SCHIZOPHRENIA
• Establish daily routines
• Do not “go along” with the client’s
  delusions or hallucinations
• Provide simple complete activities
• Reorient
• Speak to the client in simple direct and
  concise manner
• Set realistic goals
• Explain everything that is being done
• Decrease stimuli
• Monitor for suicide risk
                              SCHIZOPHRENIA
• Environment
  – Provide safe environment
  – Limit stimuli
• Psychological Ttt
  – Behavior therapy
  – Social skills training
  – Self-monitoring
• Social ttt
  – Milieu therapy
  – Family therapy
  – Group therapy (long-term ttt)

                                SCHIZOPHRENIA
   Related psychotic disorders
• SCHIZOAFFECTIVE DISORDER schiz +
  mood disorder (mania/ depression)
• BRIEF PSYCHOTIC DISORDER sudden
  onset of psychotic symptoms, lasts less
  than 2 mos and client returns to
  premorbid level of functioning
• SCHIZOPHRENIFORM DISORDER schiz sx
  lasting between 1 month and <6mos
• DELUSIONAL DISORDER characterized
  by prominent, nonbizarre delusions
                              SCHIZOPHRENIA
PERSONALITY DISORDERS
•CLUSTER A (odd & eccentric)
 – paranoid, schizoid, schizotypal
•CLUSTER B (bad, dramatic &
 erratic)
 – antisocial, borderline, histrionic,
  narcissistic
•CLUSTER C (anxious & fearful)
 – avoidant, dependent, OCD
                           PERSONALITY D/O
       CLUSTER A: ODD &
• PARANOID
           ECCENTRIC
  – chronic hostility projected to others; suspicious
    and mistrusts people
  – Seen mostly in men
• SCHIZOID
  –   social detachment = “loner” & “introvert”
  –   Restriction of emotions
  –   Attention fixed on objects rather than people
  –   Functions well in vocations
• SCHIZOTYPAL: interpersonal deficits
  – Magical thinking, telepathy
  – Apparent in childhood or adolescence

                                        PERSONALITY D/O
 Interventions for PARANOID D/O
• Asses for suicide risk
• Avoid direct eye contact
• Establish trusting relationship
• Promote increased self-esteem
• Remain calm, nonthreatening
  and nonjudgmental
• Provide continuity of care
• Respond honestly to the client

                          PERSONALITY D/O
• Follow thru on commitments
• Provide a daily schedule of
  activities
• Gradually introduce client to
  groups
• Do not argue with delusions
• Use concrete, specific words


                          PERSONALITY D/O
• Do not be secretive with client
• Do not whisper in presence of client
• Assure that the client will be safe
• Provide opportunity to complete small
  tasks
• Monitor eating, drinking, sleeping and
  elimination patterns
• Limit physical contact
• Monitor for agitation and decrease
  stimuli as needed

                             PERSONALITY D/O
    CLUSTER B: ERRATIC,
  DRAMATIC, OR EMOTIONAL
• ANTISOCIAL
  – Syn: sociopath, psychopathic & semantic
    d/o
  – Etiology:
    • Genetics interfere in the dev’t of positive
      interpersonal relationships
    • Brain damage or trauma
    • Low socioeconomic status
    • Faulty family relationships: neglect
    • Secondary gains
  – 15-40 y.o.
                                       PERSONALITY D/O
• Signs
  – Lack of remorse or indifference to persons
    hurt
  – Immediate gratification
  – Failure to accept social norms
  – Impulsivity
  – Consistent irresponsibility
  – Aggressive behavior
  – Reckless behavior that disregards the
    safety of others
• 80-90% of all crime is committed by
  antisocials (NIHM, 2000)
                            ANTISOCIAL PERSONALITY D/O
• BORDERLINE
 – Latent, ambulatory and abortive
   schizophrenics
 – Between moderate neurosis and
   frank psychosis but quite stable
 – Theories
   •faulty separation from mother; parent
    and child are bound by guilt
   •Trauma at 18 mos (weakening of ego)
   •Unfulfilled need for intimacy


                         BORDERLINE PERSONALITY D/O
• Signs
  – instability
  – Impulsivity: unpredictable gambling,
    shoplifting, sex & substance abuse
  – hypersensitivity, self-destructive, profound
    mood shifts
  – unstable & intense relations
  – Disturbance in self concept
• Common in women
• Defenses: denial, projection, splitting,
  projective identification

                             BORDERLINE PERSONALITY D/O
• HISTRIONIC
  – Pattern of theatrical or overtly dramatic
    behavior
  – Signs
    • Discomfort when the client isn’t the center of
      attention
    • Self-dramatization and exaggerated emotions
    • uses physical appearance, sexually seductive
      and provocative behavior
    • Excessively impressionistic speech lacking in
      detail (labile emotions)
  – Problems in dependence & helplessness
  – More frequent in women
                                HISTRIONIC PERSONALITY D/O
• NARCISSISTIC
  – Exaggerated or grandiose sense of self-
    importance
  – Develop early in childhood
  – Preoccupied with fantasies of unlimited
    success, power and beauty
  – Signs
    • arrogance, need for admiration,
    • lack of empathy,
    • seductive, socially exploitative, manipulative
  – Occurs more in men


                               NARCISSISTIC PERSONALITY D/O
  CLUSTER C: ANXIOUS OR
        FEARFUL
• AVOIDANT
 – Sensitive to rejection, criticism, humiliation,
   disapproval, or shame
 – Interferes with participation in
   occupational activities, dev’t of
   relationships, and take personal risks
 – social inhibition, longs for relationships
 – Anxiety, anger and depression are
   common
 – Social phobia may occur
 – Seen in 10% of clients in mental clinics

                               AVOIDANT PERSONALITY D/O
• DEPENDENT
 – Lacks confidence and unable to function
   in an independent role
 – Allows other persons to be responsible of
   their lives
 – Most frequent personality disorder in the
   mental health clinic
 – submissive behavior, low self-esteem,
   inadequate, helpless




                          DEPENDENT PERSONALITY D/O
• OBSESSIVE-COMPULSIVE
 – Preoccupied with rules & regulations, overly
   concerned about trivial detail, excessively
   devoted to their work
 – Depression is common
 – Men are more affected than women




                               O-C PERSONALITY D/O
 UNDER STUDY PERSONALITY D/O
• PASSIVE-AGGRESSIVE: sullen and
  argumentative, resents others, resists
  fulfilling responsibilities, complains of
  being unappreciated
• DEPRESSIVE: gloomy, brooding
  pessimistic, guilt-prone, highly critical of
  self and others, cheerless.




                                PERSONALITY D/O
               Interventions
• Maintain safety against self-destructive
  behaviors
• Allow the client to make choices and be as
  independent as possible
• Encourage the client to discuss feelings
  rather than act them out
• Provide consistency in response to the
  client’s acting out
• Discuss expectations and responsibilities with
  the client
• Inform the client that harm to self, others,
  and property is unacceptable
                                  PERSONALITY D/O
• Identify splitting behavior
• Assist the client to deal directly with
  anger
• Develop a written contract with the
  client
• Encourage the client to participate in
  group activities, and praise
  nonmanipulative behavior
• Set and maintain limits
• Remove the client from group situations
  in which attention-seeking behaviors
  occur
• Provide realistic praise for positive
  behaviors in social situations
                            PERSONALITY D/O
PSYCHOLOGICAL SEXUAL D/O
• Hypoactive sexual disorder (asexuality)
• Sexual aversion disorder (avoidance of
  or lack of desire for sexual intercourse)
• Female sexual arousal d/o (failure of
  normal lubricating arousal response)
• Male erectile d/o
• Female orgasmic disorder
• Male orgasmic disorder
• Premature ejaculation
                              SEXUAL DISORDERS
•   Vaginismus
•   Secondary sexual dysfxn
•   Paraphilias
•   Gender identity d/o
•   PTSD due to genital mutilation or childhood
    sexual abuse

Other sexual problems
•   Sexual dissatisfaction (non-specific)
•   Lack of sexual desire
•   anorgasmia
•   Impotence
•   STD


                                    SEXUAL DISORDERS
• Infidelity
• Delay or absence of ejaculation,
  despite adequate stimulation
• Inability to control timing of ejaculation
• Inability to relax vaginal muscles
  enough to allow intercourse
• Inadequate vaginal lubrication
  preceding and during intercourse
• Burning pain on the vulva or in the
  vagina with contact to those areas

                              SEXUAL DISORDERS
• Unhappiness or confusion related to
  sexual orientation
• Persistent sexual arousal syndrome
• Sexual addict
• hypersexuality
• Post Ejaculatory Guilt Syndrome, the
  feeling of guilt after the male orgasm



                             SEXUAL DISORDERS
   SEXUAL EXPRESSION
• HETEROSEXUALITY
• HOMOSEXUALITY
• BISEXUALITY
• TRANSVESTISM




                    SEXUAL DISORDERS
           PARAPHILIAS
• EXHIBITIONISM: the recurrent urge or
  behavior to expose one's genitals to an
  unsuspecting person.
• FETISHISM: the use of non-sexual or
  nonliving objects or part of a person's
  body to gain sexual excitement.
  Partialism refers to fetishes specifically
  involving nonsexual parts of the body.
• FROTTEURISM: the recurrent urges or
  behavior of touching or rubbing
  against a nonconsenting person.
                              SEXUAL DISORDERS
• SEXUAL MASOCHISM: the recurrent urge
  or behavior of wanting to be
  humiliated, beaten, bound, or
  otherwise made to suffer.
• SEXUAL SADISM: the recurrent urge or
  behavior involving acts in which the
  pain or humiliation of the victim is
  sexually exciting.
• TRANSVESTIC FETISHISM: a sexual
  attraction towards the clothing of the
  opposite gender.

                           SEXUAL DISORDERS
• PEDOPHILIA: the sexual attraction to
  prepubescent or peripubescent
  children.
• VOYEURISM: the recurrent urge or
  behavior to observe an unsuspecting
  person who is naked, disrobing or
  engaging in sexual activities, or may
  not be sexual in nature at all.




                            SEXUAL DISORDERS
• Other paraphilias not otherwise
  specified ("Sexual Disorder NOS")
  – telephone scatalogia (obscene phone
    calls)
  – necrophilia (corpses)
  – partialism (exclusive focus on one part of
    the body)
  – zoophilia(animals)
  – coprophilia (feces)
  – klismaphilia (enemas)
  – urophilia (urine)

                                 SEXUAL DISORDERS
        SOMATOFORM D/O
• SOMATIZATION D/O: hx of many physical
  complaints beginning before the age of 30
  occurring over a pd of several yrs resulting in
  ttt being sought or significant occupational
  or social fxning.
• CONVERSION D/O: 1 or more sx of deficits
  affecting voluntary motor or sensory function
  suggesting a neurological or general
  medical condition; preceded by conflicts or
  stressors; can’t be explained and sanctioned
  by cultural behavior.
  – Most common: blindness, deafness, paralysis,
    inability to talk
  – “La belle indifference”
• HYPOCHONDRIASIS: preoccupation
  with fears of having, or ideas that one
  has, a serious dse based on the person’s
  misinterpretation of bodily sx and persist
  despite appropriate medical eval and
  reassurance and has existed for @ least
  6 mos. (e.g.:extensive use of home
  remedies)
• PAIN D/O: pain in 1 or more anatomical
  sites severe enough to warrant clinical
  attention and causes clinically
  significant distress or impairment in
  fxning.
Interventions
• Do not reinforce the sick role
• Discourage verbalization about
  physical symptoms by not responding
  with positive reinforcement
• Explore with the client the needs being
  met by the physical symptoms
• Convey understanding that the
  physical symptoms are real to the client
• Report and assess any new physical
  complaint
         » next
        EATING DISORDER
           BEHAVIORS
• BINGE: rapid consumption of large quantities
  of food in a discrete period of time. (A:
  hundrends of Cal; B: thousands of Cal at a
  sitting)
• PURGE: Maladaptive eating regulation
  response that includes excessive exercise,
  forced vomiting, OCD Rx diuretics, diet pills,
  laxatives and steroids.
• FAST/ RESTRICT: Includes vegetarian diet
  eliminating all meat without substituting
  nonanimal sources of protein, OC about
  food choices, and eating habits.
                                 EATING DISORDERS
 ANOREXIA                        BULIMIA
• Rare vomiting or          • Frequent
  diuretic/laxative abuse   • Less wt loss
• More severe wt loss       • Slightly older
• Slightly younger          • More extroverted
• More introverted          • Hunger experienced
• Hunger denied             • Eating behavior
• Eating behavior may         considered foreign and
  be considered normal        source of distress
  and a source of esteem    • More sexually active
• Sexually inactive         • Avoidant, dependent,
• Obsessional and             or borderline features
  perfectionist features      as well as obsessional
  dominate                    features
                                     EATING DISORDERS
 ANOREXIA          BULIMIA
       complications
• Death from            • Death from
  starvation (or          hypokalemia or
  suicide, in             suicide
  chronically ill)      • Menses irregular or
• Amenorrhea              absent
                        • Drug and alcohol
• Fewer behavioral        abuse, self-
  problems (these         mutilation, and
  increase with level     other behavioral
  of severity)            problems


                                EATING DISORDERS
                    DELIRIUM
• The medical dx term that describes an organic
  mental disorder characterized by a cluster of
  cognitive impairments with an acute onset with a
  specific precipitating factor.
• Sx: diminished awareness of the environment,
  disturbances in psychomotor activity and sleep-
  wake cycle.
• COGNITIVE: the mental process characterized by
  knowing, thinking, and judging.
  – COGNITIVE DISSONANCE: arises when 2 opposing beliefs
    exists at the same time.
  – COGNITIVE DISTORTIONS: (+) or (-) distortions of reality that
    might include errors of logic, mistakes in reasoning, or
    individualized view of the world that do not reflect reality.
  – Term: confusion = cognitive impairment
             » See dementia


                                            COGNITIVE DISORDERS
               DEMENTIA
• The medical dx term that describes an
  organic mental d/o characterized by a
  cluster of cognitive impairments of
  generally gradual onset and irreversible
  without identifiable precipitating stressors.
• Types:
  – VASCULAR or MULTI-INFARCT
  – VASCULAR WITH ALZHEIMER’S DSE
  – AD: most common
  – DEMENTIA WITH LEWY BODIES: 2nd most
    common; neurofilament material
  – PARKINSONIAN DEMENTIA
  – AIDS DEMENTIA COMPLEX


                                  COGNITIVE DISORDERS
– FRONTAL LOBE DEMENTIA or PICK’S DSE:
  cytoplasmic collections; 3rd most
  common; loss of expressive language &
  comprehension
– CREUTZFELDT-JAKOB DSE: prion
  (proteinaceous infectious particles) = spongy
  brain; related to TSE & BSE in mad cow
  dse
– CORTICOBASAL DEGENERATION or
  HUNTINGTON’S DSE/CHOREA: jerky mov’ts
– SUPRANUCLEAR PALSY: clumping of
  protein tau = slow mov’t, weak eye mov’t
  (esp. downward), impaired walking
  &balance                        COGNITIVE DISORDERS
• Reversible Causes:
  –   Subdural hematoma
  –   Tumor (meningioma)
  –   Cerebral vasculitis
  –   Hydrocephalus
• Terms: disorientation, memory loss (sensory,
  primary, secondary, tertiary, working
  memory), confabulation, confusion
• Disturbing behaviors
  –   Aggressive psychomotor
  –   Nonaggressive psychomotor
  –   Verbally aggressive
  –   Passive
  –   Functionally impaired: loss of ability to do self-care

                                        COGNITIVE DISORDERS
  DELIRIUM                      vs.
DEMENTIA
• Rapid onset w/ wide       • Gradual, chronic
  fluctuations                with continuous
• Hyperalert to difficult     decline
  to arouse LOC             • Normal LOC
• Fluctuating affect        • Labile affect
• Disoriented,              • Disoriented,
  confused                    confused Attention
• Attention & sleep           intact, sleep usually
  disturbed                   normal
• Memory impaired           • Memory impaired
• Disordered                • Disordered
  reasoning                   reasoning &
                              calculation DISORDERS
                                    COGNITIVE
 DELIRIUM           vs.       DEMENTIA
• Incoherent,             • Disorganized, rich in
  confused, delusional,     content, delusional,
  stereotyped               paranoid
• Illusions,              • No change in
  hallucinations            perception
• Poor judgment           • Poor judgment
• Insight may be          • No insight
  present in lucid        • Consistently poor &
  moment                    progressively
• Poor but variable in      worsens in MSE
  MSE
                                 COGNITIVE DISORDERS
  ALZHEIMER’S DEMENTIA
• Most common type of dementia
• Stages:
 – MILD: impaired memory, insidious loses in
   ADL, subtle personality changes, socially
   normal
 – MODERATE: obvious memory loss, overt
   ADL impairment, prominent behavioral
   difficulties, variable social skills,
   supervision needed
 – SEVERE: fragmented memory, no
   recognition of familiar people, assistance
   needed with basic ADL, fewer
   troublesome behaviors, reduced mobility
   (4 A’s)
                             COGNITIVE DISORDERS
              Symptoms
• AGNOSIA: Difficulty recognizing well-
  known objects
• APHASIA: Difficulty in finding the right
  word
• APRAXIA: Inability or difficulty in
  performing a purposeful organized
  task or similar skilled activities
• AMNESIA: Significant memory
  impairment in the absence of clouded
  consciousness or other cognitive
  symptoms
                            COGNITIVE DISORDERS
      PSYCHIATRIC D/O IN
             CHILDREN
• MENTAL RETARDATION
• PERVASIVE DEV’TAL D/O
  –   AUTISM
  –   RETT’S D/O
  –   CHILDHOOD DISINTEGRATIVE D/O
  –   ASPERGER’S D/O
  –   PDD NOS
• LEARNING D/O
  –   READING
  –   MATHEMATICS
  –   WRITTEN EXPRESSION
  –   ACADEMIC PROBLEM
  –   LEARNING D/O NOS

                                CHILDHOOD DISORDERS
• MOTOR SKILLS D/O
• COMMUNICATION D/O
  –   EXPRESSIVE LANGUAGE
  –   MIXED RECEPTIVE/EXPRESSIVE
  –   PHONOLOGICAL
  –   STUTTERING
  –   SELECTIVE MUTISM
  –   COMMUNICATION D/O NOS
• MOV’T & TIC D/O
  – DEV’TAL COORDINATION
  – TRANSIENT TIC

                              CHILDHOOD DISORDERS
  –   CHRONIC MOTOR&VOCAL TIC
  –   TOURETTE’S D/O
  –   STEREOTYPIC MOV’T D/O
  –   TIC D/O NOS
• DISORDERS OF INTAKE & ELIMINATION
  –   PICA
  –   RUMINATION
  –   FEEDING D/O
  –   ENURESIS
  –   ENCOPRESIS
  –   OTHER: BULIMIA, ANOREXIA
                                 CHILDHOOD DISORDERS
• ADHD & DISRUPTIVE BEHAVIOR D/O
  –   ADHD
  –   ADHD NOS
  –   CONDUCT D/O
  –   OPPOSITIONAL DEFIANT
  –   CHILD ANTISOCIAL
  –   DISRUPTIVE BEHAVIOR NOS
• MOOD D/O
  –   MJ DEPRESSIVE D/O
  –   BIPOLAR I OR II
  –   DYSTHYMIC
  –   MIXED EPISODE
  –   HYPOMANIC EPISODE
  –   MOOD D/O DUE TO MEDICAL CONDITION
  –   SUBSTANCE-INDUCED MOOD D/O

                                CHILDHOOD DISORDERS
• ANXIETY D/O
• D/O OF RELATIONSHIP
  – SEPARATION ANXIETY
  – REACTIVE ATTACHMENT OF INFANCY OR
    EARLY CHILDHOOD
  – PARENT-CHILD RELATIONAL PROBLEM
  – SIBLING RELATIONAL PROBLEM
  – PROBLEMS RELATED TO ABUSE OR NEGLECT




                          CHILDHOOD DISORDERS
    MENTAL RETARDATION
• an IQ below 70, significant limitations in two or more
  areas of adaptive behavior (i.e., ability to function
  at age level in an ordinary environment), and
  evidence that the limitations became apparent in
  before 18 y.o.
• The following ranges, based on the Wechsler Adult
  Intelligence Scale (WAIS), are in standard use today:
• Class              IQ                Terms
Profound           Below 20            Idiot
Severe             20–34               Imbecile
Moderate           35–49               Moron
Mild               50–69
Borderline         70–79

                                     CHILDHOOD DISORDERS
              RETT’S D/O
• Development is normal until 6-18 months,
  when language and motor milestones
  regress,
• purposeful hand use is lost
• Acquired deceleration in the rate of head
  growth (resulting in microcephaly in some)
• Hand stereotypes are typical and breathing
  irregularities such as hyperventilation, breath
  holding, or sighing are seen in many.
• Early on, autistic-like behavior may be seen
• Common in females
                                 CHILDHOOD DISORDERS
CHILDHOOD DISINTEGRATIVE
D/O or HELLER’S SYNDROME
• CDD has some similarity to autism, but
  an apparent period of fairly normal
  development is often noted before a
  regression in skills or a series of
  regressions in skills.
• characterized by late onset (>3 years
  of age) of dev’tal delays in language,
  social function and motor skills; skills
  apparently attained are lost
                            CHILDHOOD DISORDERS
           ASPERGER’S D/O
• characterized by difference in language and
  communication skills, as well as repetitive or
  restrictive patterns of thought and behavior.
• Signs: unable to interpret or understand the desires
  or intentions of others and thereby are unable to
  predict what to expect of others or what others may
  expect of them
   – Narrow interests or preoccupation with a subject to the
     exclusion of other activities
   – Repetitive behaviors or rituals
   – Peculiarities in speech and language
   – Extensive logical/technical patterns of thought
   – Socially and emotionally inappropriate behavior and
     interpersonal interaction
   – Problems with nonverbal communication
   – Clumsy and uncoordinated motor mov’ts


                                          CHILDHOOD DISORDERS
CHRONIC MOTOR/ VOCAL TIC
• TIC is a sudden, repetitive, stereotyped,
  nonrhythmic, involuntary movement
  (motor tic) or sound (phonic tic) that
  involves discrete groups of muscles.
• can be invisible to the observer (e.g.
  abdominal tensing or toe crunching)




                            CHILDHOOD DISORDERS
        TOURETTE’S D/O
• characterized by the presence of
  multiple physical (motor) tics and at
  least one vocal (phonic) tic; these tics
  characteristically wax and wane
• TTT: Neuroleptic medications
  – haloperidol (Haldol)
  – pimozide (Orap)




                             CHILDHOOD DISORDERS
                                  ADHD
Inattention:                                  Hyperactivity-impulsive behaviour
• Failure to pay close attention to details   • Fidgeting with hands or feet or
    or making careless mistakes when            squirming in seat
    doing schoolwork or other activities
• Trouble keeping attention focused           • Leaving seat often, even when
    during play or tasks                        inappropriate
• Appearing not to listen when spoken to      • Running or climbing at
• Failure to follow instructions or finish      inappropriate times
    tasks                                     • Difficulty in quiet play
• Avoiding tasks that require a high          • Frequently feeling restless
    amount of mental effort and
    organization, such as school projects     • Excessive speech
• Frequently losing items required to         • Answering a question before
    facilitate tasks or activities, such as     the speaker has finished
    school supplies                           • Failure to await one's turn
• Excessive distractibility                   • Interrupting the activities of
• Forgetfulness                                 others at inappropriate times
• Procrastination, inability to begin an
    activity                                  • Impulsive spending, leading to
                                                financial difficulties
• Difficulties with household activities
    (cleaning, paying bills, etc.)
• Difficulty falling asleep, may be due to
    too many thoughts at night
• Frequent emotional outbursts
• Easily frustrated
• Easily distracted                                     CHILDHOOD DISORDERS
• Frequently prescribed stimulants are
  methylphenidate (Ritalin and
  Concerta), amphetamines (Adderall)
  and dextroamphetamines (Dexedrine)
• Feingold diet which involves removing
  salicylates, artificial colors and flavors,
  and certain synthetic preservatives
  from children's diets.




                              CHILDHOOD DISORDERS
            CONDUCT D/O
• repetitive and persistent pattern of
  behavior in which the basic rights of
  others or major age-appropriate
  societal norms or rules are violated,
  –   AGGRESSION TO PEOPLE & ANIMALS
  –   DESTRUCTION OF PROPERTY
  –   DECEITFULNESS OR THEFT
  –   SERIOUS VIOLATIONS OF RULES
      • Beginning before age 13


                                  CHILDHOOD DISORDERS
  OPPOSITIONAL DEFIANT
• characterized by an ongoing pattern of
  disobedient, hostile, and defiant behavior toward
  authority figures that goes beyond the bounds of
  normal childhood behavior
• Signs
   – Losing temper
   – Arguing with adults
   – Refusing to follow the rules
   – Deliberately annoying people
   – Blaming others
   – Easily annoyed
   – Angry and resentful
   – Spiteful or even revengeful
            » next
                                   CHILDHOOD DISORDERS
      SUBSTANCE ABUSE
• Excessive or unhealthy use of substances,
  such as alcohol, tobacco or drugs, or use of
  products such as food
• Terms:
  – TOLERANCE: the declining effect of the same
    drug dose when it is taken repeatedly over time
  – HABITUATION: a psychological dependence of
    the use of a drug
  – ADDICTION: the biological and/ or psychological
    behaviors related to substance dependence
  – WITHDRAWAL SYMPTOMS: result from a biological
    need that develops when the body becomes
    adapted to having an addictive drug in the
    system; occurs when serum levels decrease
                                    SUBSTANCE ABUSE
                  ADDICTION
• ALCOHOL: blood alcohol levels of 0.1%
  (100mg alcohol/dl of blood) or higher
  – WITHDRAWAL
     • Anorexia
     • Anxiety
     • Easily startled
     • Hyperalertness
     • HPN
     • Insomnia
     • Irritability
     • Jerky mov’t
     • Possibly: hallucinations, illusions or vivid nightmares
     • Seizures (7-48 hrs after cessation)
     • Tachycardia
     • tremors
                                               SUBSTANCE ABUSE
– WITHDRAWAL DELIRIUM
  • Agitation
  • Anorexia
  • Anxiety
  • Delirium
  • Diaphoresis
  • Disorientation with fluctuating levels of
    consciousness
  • Fever (100 to 103 F)
  • Hallucinations and delusions
  • Insomnia
  • Tachycardia and HPN
– Disulfiram (Antabuse) therapy

                                    SUBSTANCE ABUSE
Nursing care
• Obtain info about drug type and amount
  consumed
• Assess v/s
• Remove unnecssary obj from environment
• Provide one-on-one supervision if necessary
• Provide a quiet, calm environment with minimal
  stimuli
• Maintain orientation
• Ensure safety
• Use restraints
• Provide physical needs
• Provide food and fluids as tolerated
• Administer medications
• Collect blood and urine samples for drug
                                  SUBSTANCE ABUSE
          SPOUSE ABUSE
• Battering precipitates 1:4 suicide attempts of
  all women
• Wives explain the injuries as being self-
  inflicted or accidental
• Phases
  – Tension-building: series of small incidents that
    leads to beating
  – Acute beating phase: wife becomes object of
    assault behavior
  – Loving phase: batterer is remorseful and assures
    spouse that he will not harm her again. This leads
    to reconciliation.
                                           ABUSE
• Myths
  – They believe that if they try not to antagonize with
    their husband, he will change.
  – Efforts to coerce the wife out of the victim role
    can be fruitful.
• Facts
  – Women stay in relationships with men who batter
    because they feel guilty or responsible of the
    husband’s behavior
  – Wife develops little sense of self-worth,
    immobilized and unable to remove self from the
    relationship.
• Assessment: injuries, other evidence
• Interventions: with consent
                                            ABUSE
      CHILD ABUSE
•PHYSICAL BATTERING
•EMOTIONAL
•SEXUAL
•NEGLECT



                      ABUSE
        ELDERLY ABUSE
• A variety of behaviors that threaten the
  health, comfort, and possibly the lives
  of the elderly, including physical and
  emotional neglect, emotional abuse,
  violation of personal rights, financial
  abuse, and direct physical abuse.
• Commonly committed by care givers.




                                 ABUSE
          SEXUAL ABUSE
• Components
  – Sexual Misuse: inappropriate sexual
    activity
  – Rape: there is actual penetration
  – Incest: refers to the relationship between
    the victim and abuser blood relative or
    step parent role
• Interventions
  – Children: thru play or role playing with
    puppets
  – Prevention of further sexual abuse
          » next
                                      ABUSE
    COMPLETED SUICIDE
• Self-inflicted death

• LEVELS OF SUICIDE
  – Ideation: thought
  – Attempt: acted upon but failed
  – Completed




                                     SUICIDE
    CHEMICAL RESTRAINT
• CHEMICAL RESTRAINTS: Medications used to
  restrict the patient’s freedom of movement
  or for emergency control of behavior but are
  not a standard treatment for the px’s
  medical or psychiatric condition.
• PHYSICAL RESTRAINTS: Are any manual
  method or physical or mechanical device
  attached to or adjacent to the px’s body
  that he or she cannot easily remove and
  that restricts freedom of movement or
  normal access to one’s body, material or
  equipment.
SECLUTION AND RESTRAINTS
• SECLUTION: the involuntary
  confinement of a person alone in a
  room from which the person is
  physically prevented from leaving.
  – No therapeutic evidence other than a last
    resort to ensure safety.
  – Evidence suggest that it adds to further
    trauma and physical harm
• GUIDELINES
  – All hospital staff who have direct contact with the
    px should have ongoing education and training
    in the proper use of seclusion and restraints and
    other alternatives
  – Physician or licensed practitioner should evaluate
    need within 1 hour after the initiation of this
    intervention.
  – Max of 4 hours for adults, 2 hours for ages 9-17,
    and 1 hour for children under 9 yrs
  – Orders may be renewed for 24 hrs before another
    face to face evaluation
  – Continuous assessment, monitoring and
    evaluation; recorded
  – Good nursing care
  – For both restrained and secluded: constant
    monitoring face to face or by both audio and
    video equipment.
  – Px should be released ASAP
        OTHER GUIDELINES
• SECLUSION                  • RESTRAINTS
  – Room should allow          – Give support &
    observation and              reassurance
    communication with         – Position in
    px                           anatomical position
                               – Privacy is important
  – Remove all items that
    px might use to harm       – v/s & Circulation
    self                         check
                               – Should be released
  – Document: rationale,         q 2hrs
    response to
                               – Avoid tying to the
    intervention, physical       side rails of bed
    condition, nsg care, &
                               – Assist in periodic
    rationale for                change in body
    termination                  positions
       TERMINATING THE
        INTERVENTION
• As soon as met the criteria for release
• Review with px the behavior that
  precipitated the intervention & px’s
  capacity to exercise control over
  behavior
• DEBRIEFING: reviewing the facts related
  to an event & processing the response
  to them; can be used after any stressful
  event
         » next
 THERAPEUTIC IMPASSES
• Are blocks in the progress of the nurse-
  pt relationship
• Provokes intense feelings in both the
  nurse and patient
  –   RESISTANCE
  –   TRANSFERENCE
  –   COUNTERTRANSFERENCE
  –   BOUNDARY VIOLATIONS
            RESISTANCE
• Reluctance or avoidance of
  verbalizing or experiencing troubling
  aspects of oneself
• Eg: suppression or repression,
  intensification of sx, self-devaluation or
  hopelessness, intellectual inhibitions,
  acting out or irrational behavior,
  superficial talk, intellectual insight/
  intellectualization, transference
  reactions.
       TRANSFERENCE
• Unconscious response in which the px
  experiences feelings and attitudes
  toward the nurse that were originally
  associatated with other significant
  figures in his or her life.
  – HOSTILE TRANSFERENCE: anger and
    hostility, resistance
  – DEPENDENT TRANSFERENCE: submissive,
    subordinate and regards the nurse as a
    god-like figure; views relationship as
    magical
    What do you do?
•LISTEN
•CLARIFY
•REFLECT
•EXPLORE/ ANALYZE
COUNTERTRANSFERENCE
• Created by the nurse’s specific emotional
  response to the qualities of the patient;
  inappropriate in the context, content and
  intensity of emotion; nurses identify the px
  with individuals from their past, and personal
  needs
• Types: Reactions of INTENSE
   – love or caring
   – Disgust or hostility
   – Anxiety, often in response to resistance by
     the px
• Eg.
  – Difficulty empathizing
  – Feelings of depression before or after the session
  – Carelessness about implementing the contract
  – Drowsiness during the sessions
  – Encouragement of the px’s dependency
  – Arguments with the px
  – Personal or social involvement with the px
  – Sexual or aggressive fantasies toward the px
  – Tendency to focus on only one aspect or way of
    looking at information presented by the px
  – Attempts to help the px with matters not related
    to the identified nursing problems
  – Feelings of anger or impatience because of the
    px’s unwillingness to change
  – Dreams about or preoccupation with the px

				
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