AUTISM VS.

AD/HD
• A 7 year old child has attention
deficit hyperactivity disorder. The
child is most likely to exhibit
which of the symptoms?
A. restlessness, decreased attention
span and silence
B. hyperactivity, failure to complete
tasks and distractibility
C. impulsiveness, anhedonia and shyness

D. poor concentration, decreased

attention span and somatic
complaints
• Situation: A public health nurse during
one of her home visits to a postpartum
mother observed Noel, 5 years old
sitting by himself in the corner of the
room, rocking back and forth and
spinning his toy occasionally.
A child suffering from autism manifest
one of the following behaviors:
A. often shifts from uncompleted activity to
another
B. talks excessively
C. may indulge in repetitive play with fingers
and hands
D. has difficulty playing quietly
 AUTISM
• Living in their own world
• Appearance – flat (consistent)
• Behavior – ritualistic, repetitive
• Communication – echolalia, incomprehensible

NX: Impaired Verbal Communication

Impaired Social Interaction
Self Mutilation
Risk for Injury
 ADHD
Attention-deficit / hyperactive disorder –(I-H-
I)
• 7 years old and above
• Duration: 6 months and above
• Requires 2 settings: home and school

• Appearance: Dirty child

• Behavior: Clumsy, hyperactive, impatient
• Communication: talkative, bursts out

• Structure
• Setting limits
• Schedule
• Safety
 ADHD
• Important to distinguish ADHD from
normal, active behavior, behavioral
signs of psychosocial stressors,
inadequate parenting, or other
psychiatric disorders such as bipolar
disorder
• Can persist into adulthood
• Often diagnosed when child starts
school
 ADHD
• At school age, symptoms of ADHD begin to
interfere significantly with behavior and
performance:
– Fidgets constantly
– Makes excessive noise
– Normal environmental noises are distracting
– Cannot listen to directions or complete tasks
– Blurts out answers before questions are
completed
– Hurried, careless mistakes in schoolwork
– Loses or forgets homework assignments
– Fails to follow directions
– Peers may ostracize
 Treatment
Combination of pharmacotherapy with
behavioral, psychosocial, and educational
interventions
• (CARD)
• Stimulants: pemoline (Cylert)
amphetamine compound (Adderall),
methylphenidate (Ritalin), an
dextroamphetamine (Dexedrine), and
• Common side effects: insomnia, loss of
appetite, and weight loss or failure to
gain weight
 Strategies for Home and
School
• Therapeutic play techniques
• Offering consistent praise
• Using time-out
• Giving verbal reprimands
• Helping with parenting strategies

• Providing consistent rewards and

consequences for behavior
• Issuing daily report cards for behavior
• Give point systems for positive and negative
behavior
 Autism AD/HD
Etiology Growth & Decrease
Development, glucose; early
brain anoxia, malnutrition;
medications, prenatal
Appearance genetic
Clean, flat, act trauma;
Dirty, low
as deaf hereditary;
self-esteem,
social
Behavior Ritualistic, Clumsy,
insensitive to hyperactive,
pain, no fear to inattentive
death,
uncuddly, point
s to anything,
 Autism AD/HD
Communica Echolalia; Excessive
tion giggling laugh talking, burst
NX Impaired verbal out in class
Impaired
communication social
; impaired interaction;
social risk for injury
interaction; risk (directed to
for injury others)
Nursing (directed
Safety to safety
Priority self)
 Autism AD/HD
Nutrition Increase Increase in
nutrient calories,
requirement finger foods
Treatment Antipsychotic Ritalin,
drugs Dexedrine,
Milieu Stimulating Cylert
Non- (C-A-R-
environment D)
stimulating
Activity Non- Quiet, non-
competitive, competitive
Attitude monotonous
Active Kind firmness
therapy friendliness
• The parents asked what are the side
effects of Ritalin which was
prescribed for Rico:
• a. insomnia and palpitations
• b. crying and uncontrolled eating
• c. laziness and sleepiness
• d. extreme obedience
• A 7-year old is hospitalized with a
diagnosis of autism The nurse
observes the child upon admission.
Which of the following information
regarding his behavior would confirm
that he is an autistic child ?
A. lack of interest in inanimate object
B. dislike of routine
C. unresponsive to others
D. below average intelligence
• A child scores between 55 and 68 on
standardized intelligent quotient (IQ)
assessment test. The nurse is aware
that this degree of intellectual
impairment would be considered:
a. mild
b. severe
c. profound
d. moderate
Mental Retardation
 Mental retardation
• Subnormal general intellectual
functioning which originates during
the developmental period and is
associated with impairment of either
learning and social adjustment or
maturation or both.
 
•
Causes:
1. congenital numerical deficiency or abnormal arrangement of
brain cells
• 2. birth injuries due to pelvic disproportions, premature births
or forceps delivery
• 3. infectious diseases e.g. german measles of the mother
during the first 3 months of pregnancy
• 4. infectious diseases during childhood e.g. meningitis or
encephalitis
• 5. endocrine deficiencies such as thyroid deficiency, known to
be the cause of cretinism
• 6. exposure to environmental deprivation, with poor housing
and economic and social conditions
• 7.  familial or hereditary causes
• 8. inborn errors of metabolism e.g. inability to metabolize
proteins, carbohydrates or fats
• 9.  genetic defects e.g. abnormalities in the genes and
chromosomes
 Physical Appearance
• small head; almond-shaped, downward
slanted eyes; thick lips.short fat hands with
usually one palmar line (simian crease);
yellow complexion
• tongue is flabby with deep groves and
fissures
• friendly and love to imitate others
• acute leukemia is more prevalent in them
• usually mouthbreathers and prone to
respiratory infections
• many die at an early age
• Temper tantrums
 Classification of mental
retardation according to IQ
CATEGORY IQ

Borderline 68-85

mild 52-67

moderate 36-51

severe 20-35

profound Under 20
 Mild (Educable/Moron)
• Can develop social communication skills;
minimal retardation in sensorimotor areas;
often not distinguished from normal until
late age (0-5 years)
• Can learn academic skills up to approximately
6th grade until late teens. Can be guided
toward social conformity, ‘educable’ (6-20
years)
• Can usually achieve social and vocational
skills adequate to minimum self-support
but may need guidance and assistance when
under unusual social or economic stress(21-
adult
 Moderate
(Trainable/Imbecile)
• Can talk or learn to communicate; poor
social awareness; fair motor development,
profits from training in self-help; can be
managed with moderate supervision (0-5)
• Can profit from training in social and
occupational skills; unlikely to progress
beyond second grade in academic subjects;
may learn to travel alone in familiar places
(6-20)
• May achieve self-maintenance in unskilled
or semi-skilled work under sheltered
conditions; needs supervision and guidance
when under mild social or economic stress
 Severe(Imbecile)
• Poor motor development; speech is minimal;
generally unable to profit from training in
self-help; little or no communication skills
(0-5)
• Can talk or learn to communicate; can be
trained in elemental health habits, profits
from systematic habit training (6-20)
• May contribute partially to self
maintenance under complete supervision;
can develop self-protection skills to a
minimal useful level in a controlled
environment (21-adult)
 Profound (Idiot)
• Gross retardation; minimal capacity for
functioning in sensorimotor areas;needs
nursing care (0-5)
• Some motor development present; may
respond to minimal or limited training in
self-help (6-20)
• Some motor and speech development;
may achieve very limited self-care;
needs nursing care (21-adult)
 Nursing Care
• Help parents accept diagnosis of
mental retardation
• Consider the
developmental/functional age, not the
chronological age
• Teach parents/caregivers that they
should:
– Protect the child from danger
– Make the child as independent as his condition
will permit
– Teach the child to refrain from holding their
mouths open as this gives them a dull
appearance
– Select attractive, well-fitting clothing,
hairstyle and good hygiene practices
– Eliminate the child’s undesirable social traits,
e.g. touching their noses and ears, scratching
– Refrain from scolding because it blocks
learning
– Recognize that temper tantrum as a child’s
attempt to meet some underlying emotional
needs
 Nursing Care
• Teach parents/caregivers that they should:
– When teaching the child:
» Demonstrate
» Use pictures for these are valuable
teaching aids
» Start teaching simple things, gradually
progressing to complex learning
experiences
» Teach only one thing at a time
» Repetition and patience are necessary
virtues
Conduct Disorder
 Conduct Disorder
• A complicated group of behavioral and
emotional problems in youngsters
• Repetitive and persistent pattern of
behavior in which the basic rights of
others or major age-appropriate social
norms are violated
• Appears in early or middle childhood as
oppositional defiant behavior
 4 Main Groupings:
• Aggression to people and animals
• Destruction of property
• Deceitfulness, lying or stealing
• Serious violations of rules
 Subtypes:
• Childhood-Onset Type
Symptoms before 10 years of age:
– Physical aggression toward others
– Disturbed peer relationships
– More likely to have persistent conduct disorder and to
develop antisocial personality disorder as adults

• Adolescent-Onset Type
No behaviors of conduct disorder until
after 10 years of age:
– Less likely to be aggressive
– Have more normal peer relationships
– Less likely to have persistent conduct disorder or
antisocial personality disorder as adults
 Classifications:
• Mild- is applied if there are few, if any
conduct problems in excess of those required
for diagnosis, and if these cause only minor
harm to others (ex.lying, truancy)
• Moderate- applied when the number of
conduct problems and effect on others are
intermediate between “mild” and “severe”
(ex.vandalism, bullying, aggression to
animals)
• Severe- when many conduct problems exist
which are in excess of those required for
diagnosis or the conduct problems causes
considerable harm to others or property (ex.
Crimes, arson)
 Causes:
• School-related factors
• Parent psychological factors
(maternal depression, paternal
alcoholism, antisocial behavior)
• Divorce, marital distress and violence
• Family adversity
• Parent-child interactions
 Treatment:
• Early intervention is more effective;
prevention is more effective than
treatment:
– Preschool programs
– Parenting education
– Social skills training
– Family therapy
– Individual therapy
• Antipsychotics, lithium, or other mood
stabilizers such as carbamazepine
(Tegretol) or valproic acid (Depakote) for
labile moods or aggressive behavior
Oppositional Defiant Disorder
 Oppositional Defiant
Disorder
• A psychiatric behavior disorder that
is characterized by aggressiveness
and a tendency to purposely bother
and irritate (pattern of
stubbornness)
 Behavioral symptoms:
• Losing one’s temper
• Arguing with adults
• Actively defying requests
• Refusing to follow rules
• Deliberately annoying other people
• Blaming others for one’s own mistakes or
misbehaviors
• being touchy, easily annoyed
• Speaking harshly or unkind when upset
• Seeking revenge
• Having frequent temper tantrums
 Treatment
• Parent training
• Giving medication if there is
underlying other disorder
• Caregiver should take frequent
vacations
 Separation Anxiety
Disorder
• Excessive anxiety about separation
from home or loved ones, exceeding
what would be expected
• Results from combination of:
– Temperament traits (passivity,
avoidance, fearful or shy of novel
situations)
– Parenting behaviors that encourage
avoidance as a way to deal with unknown
situations
Treatment:
Parent education and family therapy
• The nurse is caring for several
patients who have eating disorder.
Based on appearance, how would the
nurse distinguish bulimic patient
from anorexic patients?
• a. by their teeth
• b. by the body size and weight
• c. by looking Mallory-Weiss tears
• d. the patients are indistinguishable
upon physical examination
• The nurse is caring for a bulimic
patients and an anorexic patient.
What cognitive characteristic would
be similar for both of these
patients:
• a. perfectionism, preoccupation with
food
• b. relaxed personality by preoccupied
by food
• c. no similarities
• d. preoccupations with exercise
• The nurse is aware that the signs
and symptoms that would be most
specific for diagnosing anorexia
nervosa are:
A. slow, pulse, 10% weight loss, and
alopecia
B. compulsive behaviors, excessive fears,
and nausea
C. excessive activity, memory lapses, and
an increased pulse
D. excessive weight loss, amenorrhea, and
abdominal distention
EATING DISORDERS
 ETIOLOGY
• Biological: increase levels of serotonin cause
inhibited appetite; also to anxious, rigid and
obssessional behaviors
• Sociocultural: “slim is beautiful”
• Family factors: twins
• Cognitive and behavioral: staying slim is
reinforced by attention given by other
people
• (Freud) 2 basic drives of humans: sexual and
eating- considered nurturing; anorexics
reject nurturing and the two appetites are
repulsive
• Eating disorders can be viewed
on a continuum: the anorexic eats
too little, the bulimic eats
chaotically, and the obese person
eats too much.
• Eating disorders overlap: 50%
of clients with anorexia exhibit
bulimic behavior, 35% of normal-
weight clients with bulimia have a
history of anorexia.
• More than 90% of clients with
eating disorders are female.
 Anorexia Bulimia
Etiology Psychological Familial,
(Freudian); internal
Socio-cultural;
Manifestatio gender
Lanugo, Dao ming
ns hypothermia, Su…
Behavior amenorrhea,
Diet, diet, Diet, diet,
parotitis
diet…die diet…vomit
Fear of weight Binge eating;
gain; purging; still
preoccupation on diet
Communica with food
Denial Verbalization
tion (knowledgeable of body
in nutrition) dysmorphic
 Anorexia Bulimia
Nx Nutrition Imbalance
Body Image nutrition more
disturbance than or less
Nx Priority Nutrition, than
Nutrition;
promote self- promote self-
Treatment / esteem
CBT; weight gain; esteem
CBT; weight
Therapy behavioral gain;
modification / behavioral
Kind Firmness modification /
Environment Stay with the Kind
Stay Firmness
with the
client one hour client one hour
after eating; after eating;
Don’t allow client Don’t allow
to go to toilet at client to go to
 Anorexia Nervosa
• Refusal or inability to maintain a
minimally normal body weight
• Intense fear of gaining weight or
becoming fat
• Significantly disturbed perception of the
shape or size of the body
• Steadfast inability or refusal to
acknowledge the seriousness of the
problem or even that one exists
 Anorexia Nervosa
• 85% or less of expected body weight
• Amenorrhea
• Preoccupation with food and food-related activities
• Restricting subtype loses weight dieting, fasting,
or excessively exercising
• Binge eating and purging subtype engages in binge
eating followed by purging
Onset and Clinical Course
• Typically begins between 14 and
18 years of age
• Ability to control weight gives
pleasure to the client
• Client may feel empty
emotionally and be unable to
identify or express feelings
• As illness progresses, depression
and labile moods are common
 Treatment: Anorexia
Nervosa
Setting depends on severity of illness:
• Medical management; risk of suicide
is significant
– Weight restoration
– Nutritional rehabilitation
– Rehydration
– Correction of electrolyte imbalances
– Supervised access to a bathroom to
prevent purging
Psychopharmacology
Amitriptyline (Elavil) and the
antihistamine cyproheptadine
(Periactin) can promote weight gain.
Olanzapine (Zyprexa) because of its
effect on body image distortions
Fluoxetine (Prozac) prevents relapse.
Psychotherapy
Family therapy
Individual therapy
 Bulimia Nervosa
• Characterized by recurrent episodes
of binge eating, then compensatory
behaviors to avoid weight gain (purging,
use of laxatives, diuretics, enemas,
emetics, fasting, excessive exercise)
• Binge eating is done in secret
• Client recognizes behavior as
pathologic, causing feelings of guilt,
shame, remorse, or contempt
• Usually normal weight
Onset and Clinical Course
• Begins at about age 18 or 19
• Binge eating begins after an
episode of dieting
• Between binges, eating may be
restrictive
• Food is hidden in the car, desk
at work, and secret locations
around the house
• Behavior may continue for years
before it is discovered
 Treatment: Bulimia
Nervosa
Most clients are treated on
outpatient basis:
Cognitive-behavioral therapy
Psychopharmacology
Antidepressants: desipramine
(Norpramin), imipramine (Tofranil),
amitriptyline (Elavil), nortriptyline
(Pamelor), phenelzine (Nardil), and
fluoxetine (Prozac)
• Theodore begins to experience
alcohol hallucinosis. The best nursing
intervention at this time is to:
A. keep the patient restrained in bed
B. check the patients BP every 15 minutes
and offer him juices
C. provide a quite environment &administer
medication as needed
D. restrain the patient & check his BP
every 30 minutes
• Which one of the following factors
will ensure the ability of an
alcoholic to abstain from alcohol?
• A. family support system

• B. can help himself

• C. expresses regret about drinking
too much alcohol
• D. overcoming the denial that he has
an alcohol problem
• The nurse is talking to the patient
about amphetamine, cocaine and
caffeine. How would the nurse
classify this substance?
• a. opiates
• b. analgesics
• c. stimulants
• d. depressants
Which assessment findings indicate
chronic cocaine use?
• a. craving for sweets
• b. lack of coordination
• c. pinpoints pupil
• d. nasal septum deterioration
 CHEMICAL
DEPENDENCE
Alcohol Abuse
Substance Abuse
 Substance Dependence
• maladaptive pattern of substance use leading
to clinically significant impairment or distress
as manifested by three or more of the
following, occurring at any time in the same 12
month period
– Tolerance
– Withdrawal
– Substance is often taken in larger amounts or over
a longer period than intended
– Persistent desire or unsuccessful effort to cut
down
– Time is spent in activities necessary to obtain the
substance, use the substance or recover from its
effects
– Important social, occupational or recreational
activities are given up or reduced because of
substance use.
• Intoxication is use of a substance that results
in maladaptive behavior
• Withdrawal syndrome refers to the negative
psychological and physical reactions that occur
when use of a substance ceases or dramatically
decreases
• Detoxification is the process of safely
withdrawing from a substance
• Substance abuse is using a drug in a way that is
inconsistent with medical or social norms and
despite negative consequences
• Substance dependence includes problems
associated with addiction such as tolerance,
withdrawal, and unsuccessful attempts to stop
using the substance
• Blackout drinking in which the person
continues to function but has no conscious
awareness of his or her behavior at the
time nor any later memory of the behavior
• As the person continues to drink, he or she
often develops a tolerance for alcohol;
that is, he or she needs more alcohol to
produce the same effect
• After continued heavy drinking, the person
experiences a tolerance break, which
means that very small amounts of alcohol
will intoxicate the person
• The later course of alcoholism, when the
person’s functioning definitely is affected,
is often characterized by periods of
abstinence or temporarily controlled
drinking
Alcohol Abuse
 Ethanol

Alcohol dehydrogenase (enzyme)

hydrogen acetaldehyde(toxic)

Bypass source of aldehyde dehydrogenase

Energy in the liver
acetic acid (non
toxic)
• One drink= 1 oz 86 proof “hard liquor”= 5 oz
glass of table wine= 12oz can/bottle of beer
• Legal limit= 5-6 drinks (non tolerant)
• Beer=4% alcohol
• Wine=12% alcohol
• Liquor=40-50% alcohol
• Healthy body can metabolize 10ml of alcohol
every 90minutes
• Tolerant drinker- 10-12 drinks before
intoxication
 CAGE
QUESTIONNAIRE
• Cutting Down –Have you ever felt you
should cut down on your drinking?
• Annoyance-Have people annoyed you by
criticizing your drinking?
• Guilty- Have you ever felt guilty about
your drinking
• Eye opener- Have you ever had a drink
first thing in the morning to steady your
nerves or get rid of hang-over?
*2-3 yes answers to these questions
strongly suggest dependence on alcohol
 Alcohol Abuse
• Alcohol is a legal substance
• A central nervous system depressant
• A disease that can be arrested but
not cured.
• Used with other substance
 ALCOHOLISM
• Intergenerational Transmission
• Awake but unaware
• Blackout
• Confabulation
• Denial, dependence
• Enabling, co-dependence
• Tolerance increases

• Detoxification - doctor
 ALCOHOLISM
• Avoid alcohol during therapy
• Aversion therapy
• Antabuse – disulfiram
• Belongings – check for alcohol, mouthwash,
elixir etc.
• B1 deficiency
• Complication
– Wernicke’s Encephalopathy (Motor)
– Korsakoff’s Psychosis (Mind)
• Delirium Tremens
• Formication
 Principles of Nursing
Care
• Provide a well-lighted room
• DAT; Vitamin B1; Glucose
• Monitor v/s

• Long term therapy

– Support system –
• Alcoholic Anonymous
• Alanon
• Alateen
 Principles of Nursing
Care
• Family therapy
• Provide safety: alcohol free
environment
• Increase self-esteem
• Resocialization
 Common medications:
• Antabuse
• Vit. B1 or thiamine
• Valium
• Magnesium sulfate
• Multivitamins
• anticonvulsants
 Stages of Alcohol
Withdrawal
• I 8 hours after the last drink
– Mild tremors, tachycardia, increased BP,
diaphoresis, nervousness
• 2 8-12 hours after the last drink
– Gross tremors, hyperactivity, profound
confusion, loss of appetite, insomnia, weakness
disorientation, illusions, hallucinations and
delusions
• 3 12-48 hours after the last drink
– * severe hallucinations, grand mal seizures
• 4 3-4 days after the last drink
– Delirium tremens, confusion, agitation,
hallucinations, insomnia and tachycardia
 CODEPENDENCY
• An over responsible behavior-doing for
others what they just as well do to
themselves
• Women or wives of alcoholics
• Codependent individuals find themselves:
1. Attempting to control someone else’s
drinking
2. Spending inordinate time thinking
about the alcoholic person
3. Covering up the person’s drinking or
lying
4. Feeling responsible for the person’s
 CODEPENDENCY
5. Feeling guilty for the alcoholic’s
behavior
6. Avoiding family and social events
because of concerns or shame about the
alcoholic’s behavior
7. Allowing moods to be influence by the
alcoholic
8. Assuming the alcoholic’s duties and
responsibilities
9. Often bailing the alcoholic out of
financial or legal problems
• . A young man is being assessed for
early sign of narcotic withdrawal ,
which include:
a. yawning and perspiring
b. drowsiness and fruity odor to the
breath
c. syncope and pulse deficit
d. bradycardia and headache
UPPERS AND DOWNERS
UPPER DOWNERS
Cocaine Marijuana
Hallucinogens Alcohol
Amphetamines Barbiturates
Opiates
Narcotics

HEROIN
CODEINE
MORPHINE
 Sedatives, Hypnotics,
and Anxiolytics
• Central nervous system depressants
• Benzodiazepines alone, when taken
orally in overdose, are rarely fatal,
but the person will be lethargic and
confused
• Barbiturates, in contrast, can be
lethal when taken in overdose. They
can cause coma, respiratory
arrest, cardiac failure, and death
• Withdrawal symptoms in 6 to 8 hours
or up to 1 week
• Withdrawal syndrome is characterized
by symptoms opposite of the acute
effects of the drug:
– Autonomic hyperactivity (increased pulse,
blood pressure, respirations, and
temperature), hand tremor, insomnia,
anxiety, nausea, and psychomotor agitation;
seizures and hallucinations occur rarely in
severe benzodiazepine withdrawal
• Detoxification from sedatives,
hypnotics, and anxiolytics is managed by
tapering the amount of the drug
Stimulants (Amphetamines,
Cocaine, Others)
• Central nervous system stimulants
• Overdoses can result in seizures and coma
• Withdrawal occurs within hours to several days
• Withdrawal syndrome:
– Dysphoria accompanied by fatigue, vivid and
unpleasant dreams, insomnia or hypersomnia,
increased appetite, and psychomotor
retardation or agitation; withdrawal symptoms
are referred to as “crashing”--the person may
experience depressive symptoms, including
suicidal ideation, for several days
• Stimulant withdrawal is not treated
pharmacologically
 Cannabis (Marijuana)
• Used for its psychoactive effects
• Excessive use of cannabis may produce
delirium or cannabis-induced psychotic
disorder; overdoses of cannabis do not
occur
• Withdrawal symptoms:
– Insomnia, muscle aches, sweating, anxiety, and
tremors
• Effects are treated symptomatically
 Opioids
• Central nervous system depressants
• Overdose can lead to coma, respiratory
depression, pupillary constriction,
unconsciousness, and death
• Withdrawal:
– Short-acting drugs: begins in 6 to 24 hours;
peaks in 2 to 3 days and gradually subside in
5 to 7 days
– Longer-acting drugs: begins in 2 to 4 days,
subsiding in 2 weeks
opioids stimulate opioid receptors

endorphins (neurotransmitter
mediating pain attracted)

increase pain threshold

euphoria (better than sex)

Heroin-more commonly abused narcotic
(fat-binding)
-becomes morphine in the brain,
trapped, sustained euphoria
Narcotics- risk for AIDS due to
needle sharing
Respiratory depression
Sensitivity to CO2 stimulation by the
medullary center for respiration
– Primary cause of death

PNS effects: constipation, decreased

gastric, biliary and pancreatic
secretions, urinary retention,
hypotension, reduced pupil size
Pinpoint pupils-sign of narcotics
overdose
AIDS- common because of needle
sharing
 Symptom pattern of respiratory depression:

Person becomes stuporous

Sleeps(Skin is wet and warm )

a coma develops,

accompanied by respiratory depression and hypoxia

skin becomes cold and clammy

pupils dilate

DEATH
• Withdrawal symptoms:
– Anxiety, restlessness, aching back and legs,
cravings, nausea, vomiting, dysphoria,
lacrimation, rhinorrhea, sweating, diarrhea,
yawning, fever, and insomnia
• Withdrawal does not require
pharmacologic intervention
• Administration of Naloxone (Narcan) is
the treatment of choice
• Methadone can be used as a replacement
for heroin, serving to reduce cravings
 Hallucinogens
• Distort reality and produce symptoms similar to
psychosis, including hallucinations (usually visual)
and depersonalization
• Toxic reactions to hallucinogens (except PCP) are
primarily psychological; overdoses as such do not
occur. PCP toxicity can include seizures,
hypertension, hyperthermia, and respiratory
depression
• Hallucinogens can produce flashbacks that may
persist for a few months up to 5 years
• Treatment is supportive:
– Isolation from external stimuli; physical restraints; (for
PCP) medications to control seizures and blood pressure;
cooling devices; mechanical ventilation
Drug Length of Detoxifica Withdrawal Intoxicati
acute tion Signs and on
detoxific agents symptoms
ation
Alcoho 3-5 days Librium, Anxiety, Loss of
l Serax, sweats, inhibition
Valium, tremors,
VIstaril flushed face,
irritability,
Valiu Slow Librium, sleepiness,
Agitation, Relaxatio
m drug Valium confusion,
insomnia, n
taper, up seizures,
convulsions, Euphoria
delirium
Pheno to 2
Slow Librium, ataxia, nausea, None
barbit weeks
drug phenobar vomiting, Natural
al taper, 2- bital hypertension
with postural Synthetic
4 weeks
hypotension,
psychotic
Drug Length of Detoxifica Withdrawal Intoxicati
acute tion Signs and on
detoxific agents symptoms
ation
Heroin 3-5 days Methadon Yawning, High
Morphi 3-5 days e or other dilated pupils, ecstasy,
ne tapering gooseflesh, relaxation
3-5 days
opiate or vomiting, , euphoria
Demer 2 weeks
non- diarrhea, runny
ol + opiate nose, and eyes,
Metha withdraw sleeplessness,
done al anxiety,
regimens irritability,
Amph 3-5 days Not elevated blood
General fatigue, Rush,
etami required pressure
apathy, and high
nes pulse, craving
depression, fatigue
for narcotics
drowsiness,
irritability,
paranoia
Drug Length of Detoxifica Withdrawal Intoxicati
acute tion Signs and on
detoxific agents symptoms
ation
Marijua 2-3 days Not Few signs of Euphoria,
na (metaboli required withdrawal, ecstasy
tes craving for with no
remain marijuana, anxiety
the body general anxiety
up to 2 and
weeks) restlessness
Withdrawal effects:
Alcohol – tremors
Narcotics – yawning
Hallucinogens – perceptual / sensory disturbance
Marijuana – amotivational syndrome
Amphetamines - anxiety
 Intervention:
• Behavioral Modification
• Detoxification
• Family Marital Therapy
• Self Help Groups
• Medication
 Withdrawal Effects
• Perceptual and sensory disturbance
( hallucinogens )
• Amotivational Syndrome ( marijuana )
• Yawning ( narcotics )
• Anxiety ( amphetamine )
• Tremors ( alcohol )
 Cardinal signs
• Narcotics: pupillary constriction,
decreased BP
• Stimulants: pupillary dilation,
increased BP, paranoia
• Hallucinogen : Bloodshot eyes, dry
mouth, cravings for junk foods
• Sedatives: tremors, sedation
 Substance Abuse in Health
Professionals
Warning signs of abuse include:
• Poor work performance, frequent absenteeism, unusual
behavior, slurred speech, isolation from peers
• Incorrect drug counts
• Excessive controlled substances listed as wasted or
contaminated
• Reports by clients of ineffective pain relief from
medications, especially if relief had been adequate
previously
• Damaged or torn packaging on controlled substances
• Increased reports of “pharmacy error”
• Consistent offers to obtain controlled substances from
pharmacy
• Unexplained absences from the unit
• Trips to the bathroom after contact with controlled
substances
• Consistent early arrivals at or late departures from work
for no apparent reason
• Situation: Mr. Albert, a 45 year old
married man has been alcoholic for
three years. He voluntarily sought
admission to the rehabilitation center
for detoxification. He started drinking
when he was terminated from his work
abroad.
Due to his drinking problem, his family
life deteriorated. The nurse identifies
on eof the following as an appropriate
nursing diagnosis:
A. ineffective individual coping
B. altered health maintenance
C. ineffective family coping
D. disturbance in self-esteem
• The nurse should be alert for signs
of Korsakoff’s syndrome which are
manifested in one of the following
symptoms:
A. delusions and ideas of reference
B. hallucination and suspiciousness
C. insomnia and confabulation
D. delusions and flight of ideas
• Korsakoff’s syndrome is due. Mr.
Albert is suited for what
supplement?
• A. ascorbic acid
• B. Vitamin A
• C. Thiamine
• D. Vitamin D
• A treatment modality best suited
for Mr. Albert is on eof the
following therapies:
• A. family therapy
• B. marital therapy
• C. behavior therapy
• D. group therapy
• Marijuana is classified as:
A. Hallucinogen
B. narcotic
C. sedative- hypnotic
D. psycho-stimulant
• A client informs his nurse therapist that
he has been convicted for breaking and
entering into homes and stealing women’s
undergarments. Further questioning by
the nurse reveals that the client requires
these items in order to become sexually
aroused. Based on this information, the
nurse suspects the client is experiencing
the psychosexual disorder of:
A. voyeurism
B. frotteurism
C. fetishism
D. sexual masochism
• Answer: C
• Rationale: Fetishism refers to the use of an
object, foot apparel, for sexual arousal. Voyeurism
involves the act of observing unsuspecting
individuals, usually strangers, who may be naked or
in the process of disrobing. Frotteurism involves
intense, recurrent fantasies of, and/or actual
touching and rubbing the genitalia against a non-
consenting person, in association with sexual
arousal. The behavior usually occurs in crowded
places, and the individual usually fantasizes an
exclusive, caring relationship with the victim.
Sexual masochism involves the act of being
humiliated, bound, beaten and otherwise made to
physically suffer for purposes of sexual
stimulation.
Sexual Disorders
 PARAPHILIA
• A condition in which the sexual
instinct is expressed in ways that are
socially prohibited or are biologically
undesirable
• Bisexuality sexual attraction to members of the
opposite sex and the same sex
• Masochism experiencing sexual attraction, urges
or arousal when receiving pain (hypoxyphilia)
• Sadism experiencing sexual attraction, urges or
arousal when giving pain
• Frotteurism pleasure from rubbing genitals
against unconsenting victim
• Pedophilia sexual pleasure with children below 13
• Necrophilia sexual pleasure with the dead
• Voyerism experiencing intense pleasure from
watching people undress
• Transvestism cross dressing with the opposite
sex
• Transexualism going from one sex to another
•Telephone Scatologia
•Zoophilia
•Bestiality
•Exhibitionism
 Sexual Dysfunctions
Excitement Orgasm
• Sexual aversion disorder
• Orgasm disorder
• Hypoactive sexual desire
• Erectile dysfunction

Plateau
• Premature ejaculation
• Sexual arousal • Gender identity
• Sexual Pain disorder
 GENDER IDENTITY
DISORDER
• A strong and persistent cross-gender
identification
• Involves discomfort with one’s sex or the gender
role of that sex
• In Children:
4. stated desire or insistence that he or she is the
other sex
5. In boys, dressing in female attire; in girls, wearing
only masculine clothing.
6. Make-believe play or fantasies of being the other
sex
7. Prefers playmates of the other sex.
• In adolescents and adults:
2. Stated desire to be the other sex
3. Frequently passes as the other sex
4. Desires to be treated as the other
sex
5. Conviction that he or she has typical
feelings and reactions of the other
sex
 SEXUAL ADDICTION
• 50% or more of waking hours spent
on sexual fantasies/activities
• Impairs daily functioning
• With or without a partner
• Cycle- preoccupation, rituals,
compulsion, shame & guilt, anxiety
 Intervention
• Psychotherapy
• Individual therapy
• Group Psychotherapy
• Social skills training
• Treatment of co-morbid physical and psychiatric
features
• Hormonal treatments
• Medications
• Anti-androgen drugs (Medroxyprogesterone
acetate and Cyproterone acetate)
• In the initial interview with a 64-year
old man who has primary dementia of
the Alzheimer’s type and his wife ,
which of these data should be
obtained in order to plan his care?
a. his occupational skills
b. his normal daily routine
c. the quality of maternal relationship
d. whether there is a history of
dementia in his family
• Which of the following nursing
interventions minimizes confusion
and disorientation in the patient
with Alzheimer’s disease (AD)?
A. reasoning with the patient
B. using reality orientation
C. following a regular routine
D. using restraints to promote physical
safety
• Answer: C
• Rationale: A calm, predictable environment
which limits external stimuli and allows for
a regular routine helps to support the
patient’s cognitive function. Attempting to
reason with the patient or using reality
orientation may increase anxiety without
promoting function. Using memory aids and
offering clear and simple explanations may
help to reduce confusion and disorientation
while promoting security. Restraints are
avoided if at all possible as they may
increase agitation.
Delirium & dementia
 Delirium
Delirium: a syndrome that
involves disturbance of
consciousness accompanied by a
change in cognition
• Acute and fluctuating
• Difficulty paying attention,
distractibility, and disorientation
• Sensory disturbances include illusions,
misinterpretations, hallucinations
• Disturbances in sleep/wake cycle, anxiety, fear,
irritability, euphoria, apathy
• Risk factors: hospitalization for
general medical conditions, older
acutely ill clients, severe
physical illness, older age, and
baseline cognitive impairment
• Etiology: almost always results
from an identifiable physiologic,
metabolic, or cerebral
disturbance or disease or from
drug intoxication or withdrawal
 Psychopharmacology and
Other Medical Treatment
• If quiet and resting, no medication
needed for delirium
• If experiencing psychomotor
agitation, sedation with an
antipsychotic may prevent
inadvertent self-injury
• Delirium induced by alcohol
withdrawal is treated with
benzodiazepines
• Adequate food and fluid
• Physical restraints only when
necessary
 Dementia
• Dementia involves multiple
cognitive deficits, primarily
memory impairment, and at least
one of the following:
– Aphasia
– Apraxia
– Agnosia
– Disturbance in
executive functioning/Kluver-Bucy like
syndrome (agraphia, hyperorality,
hypermetamorphosis)
• Dementia is progressive
 Treatment and Prognosis
• Acetylcholine precursors, cholinergic
agonists, and cholinesterase inhibitors
such as tacrine (Cognex), donepezil
(Aricept), rivastigmine (Exelon), and
galantamine (Reminyl) temporarily slow
the progress of dementia (CARE)
• Alternatives: Gingko Biloba, Huperzine A,
Melatonin
• Symptomatic treatment of behaviors
such as delusions, hallucinations,
outbursts, and labile moods, which vary
among clients
 Delirium Vs Dementia
Delirium Dementia
Etiology Substance degenerative
intoxication;
medical condition,
Onset post-anesthesia
Usually sudden Usually
gradual
Course Usually brief with Usually long-
return to usual term and
level of progressive,
functioning occasionally
maybe
arrested or
 Delirium Dementia
Population Young and Exclusive
affected old alike among elderly
Sensorium Clouded Clear
Memory Impaired; Impaired;
immediate, remote, recent
recent memory loss
memory
Perception loss
Illusion and Illusion
Hallucinatio Delusion
n Hallucination
Shadow
Speech and
Incoherent Difficult in
monsters finding words
 Delirium Dementia
Prognosis Reversible Irreversible

Manifestat Disoriented to Early:

ions time and place personality
Emotionally change,
unstable altered
Speech is language
rumbling and pattern,
irrelevant neglect of
Extreme personal
distractibility appearance &
Sundowning hygiene
Progressive:
Wandering,
 Delirium Dementia
Interventi Safety Safety
ons Structure Consistency
Set limits Clear verbal
Communicate communicati
with simple on
words and in Reorientatio
short phrases n to reality
 Manifestations Nursing Responsibilities
Memory loss • Always re-orient patient as to time,
person, place and activities being
done.
•Encourage patient to tell stories of
earlier years.
•Place familiar objects in
surroundings.
Disorientation • Make use of calendars, clocks and
signs that are visible.
•Provide proper functioning of
eyeglasses and hearing aids.
•Provide for presence of familiar
personal objects in room.
Restlessness • Convey warmth and
and agitation reassurance.
•Orient to time, person
and place.
• Communication has to
be simple, clear and
direct.
Depression, •
•Expectations should be
Assist in routine
mood lability explained
activities. simply and
completely.
• Involve patient in
simple and repetitive
tasks, especially one
that involves helping
someone..
Perceptual • Orient to reality.
disturbances • Decrease sensory stimuli.
• assess source of
perceptual disturbances
and redirect attention to
other things.
• If severe, may give
Incontinence antipsychotic drugs.
• Display pictures or signs
on bathroom doors to
provide visual clues.
•Place patient near the
toilet or supply a commode
nearby.
• Limit amount of fluid
during night time.
 Nursing Interventions
• Always identify yourself and call the
person by name.
• Speak slowly; use face-to-face
contact
• Encourage reminiscing therapy
• Keep the client’s room well lit and
bring familiar objects from home.
• Provide for safety measures (e.g. hot
H20, medic alert bracelet, driving
etc)
• End of Module 2

THANK YOU!
• . Countertransference is:
• A. The patient’s feeling or reaction
toward the therapist.
• B. The therapist’s feelings or
reactions towards the patient.
• C. Underlying meaning in group
interaction.
• D. The content of an interaction
• . What is the number of treatments for
ECT?
• A. 2-3 times a week, 6 to 12 treatments
B 5 times a week, 6 to 12 treatments
• C 3-4 times a week, with hair spa &
treatment
• D. 3-6 treatments a week, 6 to 12
treatments
•  
• Situation: Mercy, a 43 year old married
woman was referred to the psychiatric
clinic by her physician She has insomnia,
anxiety, fatigue and loss of interest in her
usual activities which started after her
husband left her.
• . This crisis is:
• A. Situational
• B. Adventitious
• C. Developmental
• D. Incidental
• The appropriate nursing diagnosis for
Mercy is:
• A. Impaired Social Interaction
• B. Disturbed Thought process
• C. Impaired Verbal Communication
• D, Ineffective Individual Coping
• In crisis intervention, the nurse’s
role should be:
• A. Active and directive
• B. Non-directive and passive
• C. Firm and directive
• D. Calm and non-aggressive
• Crisis Intervention therapy is
characterized by one of the following
features:
• A. Focuses on solving the immediate
problem
• B Aims to resolve a situational crisis
only
• C. It is a long term process
• D. Aims to correct a pathological
state
• Situation: Joan, 40 years old, scheduled for
mastectomy, starts to complain of
palpitation, dizziness, nausea and cannot
express what she wants.
• Joan was given an antianxiety drug which is
one of the following:
• A. Imipramine (Tofranil)
• B. Chlorpromazine (Thorazine)
• C. Halloperidol (haldol)
• D. Diazepam ( valium)
• A client with a diagnosis of
schizophrenia repeatedly says to the
nurse, “no moley jandu’. This is an
example of:
• A. echolalia
• B concretism
• C. a neologism
• D. paleologic thinking
• When making an assessment of a
client’s hallucination, the nurse
realizes that the most common type
of hallucination is:
• A. visual
• B. tactile
• C. auditory
• D. olfactory
• The best indication of effective crisis
counseling for Mercy is she has:
• A. Visited her relatives and friends
• B. Worked through her feelings of grief
over her son’s death
• C. Resumed her previous routines and
activities
• D. Developed a closer relationship with her
friends
• A young client is admitted to the
hospital with a diagnosis of acute
schizophrenia. The family relates
that one day the client looked at a
linen sheet on a clothesline and
thought it was a ghost The nurse
recognize that was:
• A. an illusion
• B delusion
• C. confabulation
• D. hallucination