Psychiatric Nursing

I. Basic Concepts in Psychiatric Nursing

Mental Health Mental Ill Health Psychiatric Nursing Interpersonal process whereby the professional nurse practitioner through the therapeutic use of self, assist an individual family, group or community to promote mental health, to prevent mental illness and suffering, to participate in the treatment and rehabilitation of the mentally ill and if necessary to find meaning in these experiences. Both a Science and Art Core of Psychiatric Nursing: -Interpersonal process Clientele: -Individual, family and the community - Both mentally healthy and mentally ill Main Tool of the Nurse -Therapeutic use of Self CONCEPTS Use of Self Therapeutic use of self Basic Principles Basis: Joharis Window Known to self Not Known to self Semi-public Self II Areas of the Unknown IV - positive use of ones self in the process of therapy - it requires self-awareness

Known to others

Public Self I Private self III

Not known to others

Goal: To increase quadrant I, decrease quadrant II and III Methods Used to Increase Self- Awareness 1. Introspection: -Viewing ones self as honestly as possible 2. Discussion: - Learning about oneself through association with others 3. Enlarging Ones Experience: - Engage in a particular activity and noting ones reaction to it.

4. Role playing: - A situation in which participants enact a role Core Concepts on the Care of the Psychotic Patient On Admission of the Client 1. 2. 3. 4. Priority Determine the reason why the client sought help Clients rights Initial assessment J O I M A T Common Behavioral Signs and Symptoms 1. Disturbance in perception: Illusion -misperception of an actual external stimuli Hallucination -false sensory perception in the absence of external stimuli Visual -seeing Tactile -feeling that there are some insects crawling on the skin 2. Disturbances in thinking Neologism - pathologic coining of words Circumstantiality - over inclusion of details Word Salad - incoherent mixture of words and phrases Verbigeration - incoherent mixture of word or phrases Perseveration - persistence of a response to a previous question Echolalia - pathological repetition of words Flight of ideas - shifting from of one topic from one subject to another in a somewhat related way Looseness of association - shifting of a topic from one subject to another in a completely unrelated way Clang association - the sound of the word gives direction to the flow of thought Delusion - false belief which is inconsistent with ones knowledge and culture 3. Disturbances of affect Inappropriate affect Blunted effect Flat affect Apathy Ambivalence Depersonalization Derealization 4. - disharmony between the stimuli and the emotional reaction - severe reduction in emotional reaction - absence or near absence of emotional reaction - dulled emotional tone - presence of two opposing feelings - feeling of strangeness towards ones self - feeling of strangeness towards the environment

Disturbances in Motor Activity Echopraxia - the pathological imitation of posture/action of others

Waxy flexibility maintaining the desired position for long periods of time without discomfort 5. Disturbances in memory Confabulation - filling in of memory gaps Amnesia- inability to recall past events Anterograde amnesia - loss of memory of the immediate past Retrograde amnesia - loss of memory of the distant past Dj vu - feeling of having been to a place which one has not yet visited Jamais vu - feeling of having been to a place which one has visited before Use of Appropriate Communication Techniques Communication: Reciprocal exchange of ideas between or among persons. Modes of communication: 1. Verbal - written/spoken 2. Non-verbal - posture, tone of voice, facial expression 3. Meta communication - based on role expectations/hidden meaning of words Elements of Communication Sender - originator of information Message - information being transmitted Receiver- recipient of information Channel - Mode of communication Feedback - return response Context - the setting of communication Criteria of successful communication Feedback Appropriateness Flexibility Efficiency Common Problems in Communication 1. 2. 3. 4. Dysfunctional communication Double bind communication Denotative vs. connotative meaning Incongruent communication

Techniques of Communication If your goal is: To initiate conversation: Giving broad opening Giving recognition To establish rapport and build trust: Giving information Use of silence To gather information: Focusing Validating

Reflecting Interpreting Restating To close a conversation: Summarizing How to Choose a Therapeutic Response in The Board Exam Establish Nurse Patient Relationship Nurse-Patient Relationship Series of interaction between the nurse and the patient in which the nurse assists the patient to attain positive behavioural change. 1. 2. Characteristics NPR Phases Social Relationship

A. Pre-Interaction Phase - begins when the nurse IS assigned/chooses a patient - phase of NPR in which patient is excluded as an active participant - nurse feels certain degree of anxiety - includes all of what the nurse thinks and does before interacting with the patient Major task of the nurse: to develop self-awareness Other tasks: data gathering, planning for first interaction B. Orientation Phase - when the nurse-patient interacts for the first time - parameters of the relationship are laid - nurse begins to know about the patient Major task: to develop a mutually acceptable contract Other tasks: determine why the patient sought help establish rapport, develop trust, assessment C. Working Phase - it is highly individualized - more structured than the orientation phase - the longest and most productive phase of the nurse-patient relationship - limit setting is employed Major task: identification and resolution of the patients problems Other tasks: Planning and implementation D. Termination Phase - it is a gradual weaning process - it is a mutual agreement - it involves feeling of anxiety, fear and loss

- it should be recognized in the orientation phase - it should be recognized in the orientation phase Major task: to assist the patient to review what he has learned and transfer his learning to his relationship with others. Other task: Evaluation When to terminate?

How to terminate?

Common Problems Affecting NPR 1. Transference - the development of an emotional attitude of the patient either positive or negative towards the nurse. 2. Resistance - development of ambivalent feelings towards self-exploration. 3. Counter Transference - as experienced by the nurse Initial Interventions Principles of Care in Psychiatric Settings 1. 2. 3. 4. 5. 6. 7. The nurse views the patient as a Holistic human being with interdependent and interrelated needs. The nurse accepts the patient as a unique being with inherent value and worth exactly as he is. The nurse should focus on the patients strengths and assets and not on his weakness and liabilities. The nurse views the patients behaviour non-judgmentally, while assisting the patient to learn more adaptive ways of coping. The nurse should explore the patients behaviour for the need it is designed to meet and message it is communicating. The nurse has the potential for establishing a nurse-patient relationship with most if not all patients. The quality of the nurse-patient relationship determine the degree of positive change that can occur in the patients behaviour.

Level of Interventions in Psychiatric Nursing Primary Interventions aimed at the promotion of mental health and lowering the rate of cases by altering the stressors. Secondary interventions that limits the severity of a disorder. 2 Components 1. 2. Case Finding Prompt treatment

Tertiary interventions aimed at reducing the disability after a disorder. 2 Components

1. 2.

Prevention of complication Active program of rehabilitation

Characteristics of a Psychiatric Nurse 1. 2. 3. Empathy the ability to see beyond outward behaviour and sense accurately another persons inner experience. Genuineness/Congruence ability to use therapeutic tools appropriately. Unconditional Positive Regard respect

Roles of the Nurse in Psychiatric Settings 1. Ward Manager Responsibility: 2. Socializing Agent Responsibility: 3. Counselor Responsibility: 4. Parent Surrogate Responsibility: 5. Patient Advocate Responsibility: 6. Teacher Responsibility: 7. Technician Responsibility: 8. Therapist Responsibility: 9. Reality Base Responsibility: 10. Healthy Role Model Responsibility: Types of Interventions 7.1 Biologic 7. 1. 1 Pharmacologic

II. Basic Concepts on Psychoparmacology

Neurons: Neurotransmitters: Classification of Psychopharmacologic Agents A. Major Tranquilizers/Antipsychotics: Indication: MOA: Examples: Haloperidol (Haldol) Fluphenazine ( Prolixin Prochlorperazine (Compazine) Chlorpromazine (Thorazine) Side effects: Blurred vision, dry mouth, tachycardia, palpitation, constipation, urinary retention

Skin: Photosensitivity BP: Orthostatic hypotension EPS: Extra Pyramidal Symptoms - Pseudoparkinsonism -pill-rolling tremor, mask-like face, cog-wheel rigidity, propulsive gait - Akathisia -restless leg syndrome - Dystonia - defect in muscle tone Adverse effect: 1. Tardive dyskinesia-lip smacking 2. Agranulocytosis 3. Hepatoxicity Principles of Nursing Care C H E C K B. Anti-Parkinsonian Agents: Indication: 2 Types: 1. Dopaminergic Drugs MOA: Examples: Amantadine (Symmetrel) Anticholinergic Drugs MOA: Trihexyphenidyl (Artane) Biperiden Hydrochloride (Akineton) Benztropine Mesylate (Cogentin) Diphenhydramine Hydrochloride (Benadryl)

2.

Side effects: Anticholinergic: blurred vision, constipation, orthostatic hypotension Adverse effects: Dry mouth, urinary retention, sore throat Principles of Nursing Care C H E C K C. Minor Tranquilizers/Anxiolytics Indications: MOA:

Examples: Diazepam (Valium) Chlordiazepoxide (Librium) Aprazolam (Xanax) Oxazepam (Serax) Chlorazepate Dipotassium (Tranxene) Side effects: Adverse effects: Principles of Nursing Care: C H E C K D. Antidepressants Common Types: 1. 2. 3. MOA: Examples: Imipramine (Tofranil) Amitriptyline (Elavil) Tranylcypromine (Parnate) Isocarboxazid (Marplan) Phenelzne (Nardil) Ritalin (Methylphenidate) Amphetamine (Benzedrine) Adverse effect: Cardiac arrhythmia, hypertensive crisis, growth suppression Side effect: Principles of Nursing Care: C H E C K Drug update: SSRI Selective Serotonin Reuptake Inhibitor - inhibits serotonin uptake Example: Fluoxetine (Prozac) Side effects : GI Discomforts Adverse effects: Tremors, decrease in libido E. Anti-manic agents 1. Lithium Carbonate Tricyclics MAO inhibitor Stimulants

MOA: C H E C K 2. Carbamazepine 7. 1. 2. Somatic Therapy Electro-convulsive Therapy MOA: Voltage: Duration: Number of treatment Frequency: Indicators of effectiveness: Indications: 1. 2. 3. Depression Mania Catatonic schizo

Contraindications: (relative) there is no absolute contraindication to ECT 1. Fever 2. ICP brain tumor 3. Cardiac 4. TB with history of hemorrhage 5. Recent fracture 6. Retinal detachment 7. Pregnancy Patient Preparation: Before the procedure: Consent: Physical exam: X-ray ECG EEG NPO Restrainments: Administration of Atropine SO4 Anectine (Succinylcholine) Methohexital Na (Brevital) During the procedure: Observe the patient tonic-clonic contraction After the procedure: Position Vital signs Reorient the patient Common complications: Memory loss, headache, fracture, apnea 7.2 Psychosocial Interventions

III. Common Psychotherapeutic Interventions

1. Remotivation therapy 5 Different Steps 1. 2. 3. 4. 5. 2. 3. 4. 5. 6. 7. 8. 9. Climate of acceptance Creating of bridge to reality Sharing the world we live in Appreciation of the works of the world Climate of appreciation

Music Therapy Play Therapy Group Therapy Psychodrama Milieu Therapy Family Therapy Psychoanalysis Hypnotherapy

10. Humor Therapy 11. Transactional Analysis 12. Behavior Modification 13. Aversion Therapy 14. Token Economy 15. Gestalt Therapy

IV. Dynamics of Human Behavior

Need is an organismic condition which requires a certain activity Stress pressure of varying degrees: Distress unhealthy stress Eustress healthy stress Behavior way in which an organism responds to a stimulus Conflict situation that arise from the presence of two opposing drives Types: Approach-Approach -both of each chosen have positive attributes Avoidance-Avoidance -negative attribute Approach-Attribute - choice have positive and negative attributes Double approach - avoidance

V. Basic Concepts on the Client

Personality - The integration of those systems and habits that represents an individuals characteristic adjustment to his environment - Expressed through behaviour.

2 Characteristics of Personality 1. Distinctiveness- each individual is unique 2. Stability and consistency personality is predictable Determinants: 1. Psychological - type of climate at home 2. Cultural - customs and traditions 3. Biological - personality is not inherited 4. Familial - parenting style 3 divisions of the mind: 1. Conscious - part of the mind that is focused on awareness 2. Subconscious - part of the mind that contains information that can be recalled at will. 3. Unconscious - largest part of the mind; contains materials and information that can never be recalled. Structures of Personality ID EGO SUPEREGO

Theories of Personality Development A. Freuds Psychosexual theory First to identify/classify the stages of development 0-18 mos: Oral Stage Area of Gratification: Indicators of Fixation: 18 mos 3 years: Anal Stage Area of Gratification: Indicators of Fixation: 3-6 years: Phallic Stage Area of Gratification: Indicators of Fixation: 6-12 years Latency: (Quiet Stage) Area of Gratification: Indicators of Fixation: 12 -21 years Genital Stage Area of Gratification: Indicators of Fixation: B. Eriksons Psychosocial Theory First to include adulthood as a stage of development 0.12 mos: Trust vs. Mistrust If the needs of the child is consistently met, trust develops.

1-3 years: Autonomy vs. Shame and Doubt If toilet training is not hurried, autonomy develops. 3-6 years: Initiative vs. Guilt If the childs sexual curiosity is handled without anxiety, initiative develops.

6-12 years: Industry vs. Inferiority If the childs efforts at learning is supported, industry develops. 12-18 years: Identity vs. Role Diffusion If the adolescents vocational decision is supported, identity develops. 18-25 years: Intimacy vs. Isolation If the adolescents decisions regarding love relationship is supported, intimacy develops. 25-65 years: Generativity vs. Stagnation If an individual enjoys support from the family, generativity develops. 65 onward: Integrity vs. Despair If the person has a satisfying past recollection, integrity develops. C. Piagets Cognitive Theory of Development. First to Focus on Cognitive Development 0-2 years: Sensory Motor Stage Development proceeds from reflex activity to sensory motor learning Child learns that he is separate from the environment Child learns the concept of object permanence 2-7 years: Pre-operational Stage 2-4 yrs: pre-conceptual development proceeds from sensory motor learning to pre-logical thought. The child learns language and symbols. 4-7 yrs: intuitive thought: The child is able to think in terms of class. The child is able to determine that individuals have roles. 7-12 years: Concrete Operational Stage Development proceeds from pre-logical concrete thought. 12 years to adulthood: Formal Operational Stage The child is able to think abstractly, able to apply the scientific method.

VI Crisis and Crisis Intervention

Crisis situation that occurs when an individuals habitual coping ability becomes ineffective to meet the demands of a situation. Characteristics: Types of Crisis: 1. Maturational/developmental crisis - expected, predictable and internally motivated. Example: growth 2. Situational/accidental - unexpected, unpredictable and externally motivated. Example: car accident 3. Social crisis - due to acts of nature Example: earthquake Crisis intervention A way of entering into the life situation of an individual, family, group, or community to help them mobilize their resources and to decrease the effect of a crisis inducing stress. Phases of Crisis Denial Increased tension initial reaction the person recognizes the presences of a crisis and continues to do activities of daily living.

Disorganization the person is preoccupied with the crisis and is unable to ADL. Attempts to reorganize individual mobilizes previous coping mechanism. Some Conditions Requiring Crisis Intervention 1. Rape

Some Facts of Rape: Ruthless Abusive Personal Experience Essential Elements Necessary to Define an Act of Rape 1. 2. 3. Use of threat/force Lack of consent of the victim Actual penetration of the penis into the vagina

Different Kinds of Rape Power Anger Sadistic Principles of Nursing Care:

Rape Trauma Syndrome (RTS) 1. acute phase 2. denial 3. heightened anxiety 4. stage of reorganization Battered Wife Syndrome (BWS) Characteristics of Abusive Husband: 1. They usually come from violent families 2. They are immature, dependent and non-assertive 3. They have strong feelings of inadequacy Phases 1. 2. 3. Tension building phase Acute battering incident Aftermath/honeymoon stage

Principles of Nursing Care:

Child Abuse Abuse Violence Neglect

- is what happens when an adult takes advantage of his authority over a child. - refers to the use of force. - lack of provision of those things which are necessary for the childs growth and development.

Physical abuse - abuse in the form of inflicting pain Emotional abuse - insult and undermining ones confidence Sexual abuse - abuse in the form of unwanted sexual contact Characteristic of Abusive Parents - they come from violent families - they were also abused by their parents - they have inadequate parenting skills - they are socially isolated because they dont trust anyone - they are emotionally immature - they have negative attitude towards the management of the abused Indicators of Child Abuse Principles of Nursing Care:

Where to report: Whom to report: Priority: Anxiety: Causes of Anxiety 2 classification factors 1. 2. Predisposing factor Factors that make you at risk Precipitating factor Factors that cause direct effect

Psychoanalytic theory Anxiety is caused by a conflict between the Id and the Superego Interpersonal Theory Cause of anxiety is fear of interpersonal rejection Behavioral Theory Anxiety is a product of frustration Learning Theory Exposure to early life fearful experiences causes anxiety Conflict theory Presence of opposing drives Biologic Theory Anxiety may accompany physical ailments/diseases Family Studies Anxiety can run in families Precipitating factors Threat to ones biological integrity

e. g. surgery Threat to ones self system e. g. insult Signs and Symptoms of Anxiety Signs and Symptoms Physical Mild PR, RR, Pupillary dilatation, sweating Attentive and alert Moderate nausea, anorexia, vomiting, diarrhea, constipation, restlessness narrowed perceptual field and selective inattention use of any defense mechanism available Severe S/Sx becomes the focus of attention perceptual field is greatly narrowed; focus of attention is trivial events defense mechanisms operate to prevent panic, amnesia, and dissociation Panic S/Sx of exhaustion are ignored personality disorganized

Cognitive

Emotional

Minimal use of defenses

defense mechanisms fail

Nursing Diagnosis Principles of Nursing Care: BE C-ALM A-DMINISTER MEDICATIONS L-ISTEN M-INIMIZE ENVIRONMENTAL STIMULI Defense Mechanisms: Unconscious, specific intrapsychic adaptive efforts which are employed by the individual to resolve emotional conflict and to cope with anxiety Characteristics: It is automatic It is not the defense mechanism that is pathological but it is the frequent use of it Used by both mentally healthy and mentally ill individuals Types: Compensation - an attempt to overcome a real or imagined shortcoming Conversion - emotional problems are converted to physical symptoms Denial - failure to acknowledge an intolerable thought, feeling, experience or reality Displacement - the redirection of feelings to a less threatening object Dissociation - detachment of certain activities from normal consciousness which then function alone Fantasy - conscious distortion of unconscious feelings or wishes Fixation - arrest of maturation at certain stages of development Isolation - cutting of or blunting of an unacceptable aspect of a total experience Introjection - symbolic assimilation or taking into ones self a love/hatred object Identification - conscious patterning of ones self from another person Intellectualization - over use of intellectual concepts by an individual to avoid expression of feelings Projection - attributing to others ones unconscious wishes/fears Reaction formation - expression of feelings that is the direct opposite of ones real feelings Rationalization - justifying ones actions which are based on other motives Regression - returning to an earlier level of development in the face of stress

Repression - unconscious forgetting Suppression - conscious forgetting Substituting - replacing the desired unattainable goal with one that is attainable Sublimation - the channelling of unacceptable instinctual drive with one that is acceptable Symbolization - less threatening object is used to represent another Undoing - an attempt to erase an act, thought, feeling or desire Anxiety Disorders Panic Attacks Intervention: Agoraphobia Intervention: Social Phobia Intervention: Simple Phobia Intervention: Obsessive-compulsive behaviour Intervention: General Anxiety Disorder Intervention: Post-traumatic Stress Disorder Intervention: Nursing Diagnosis Drug of Choice:

VII. Personality Disorders

Etiological Factors 1. Genetic Factors 2. Temperamental Factors 3. Biological Factors 4. Psychoanalytic Factors Types: Borderline - fears separation; impulsive; unstable but intense relationships Hypochonriacal Anti-social - habitually breaks the law; with low self-esteem; lacks sense of guilt. Dependent - incessant demands for attention from others Schizoid withdrawn, last to catch up in fashion, introvert, aloof Shizotypal bizarre behaviour, silly laughter Histrionic overly concerned with physical appearance, attention seeking behaviour Extrovert Avoidant fears rejection Paranoid extreme mistrust and suspiciousness Passive-Aggressive loves to procrastinate, expresses anger through passivity Emphatic Narcissistic (self-love), believe that they are special and they demand special attention Obsessive-Compulsive repetitive thoughts and action, perfectionist, inflexible, rigid Nursing diagnoses; 1. Ineffective individual coping 2. Self- esteem disturbance Principles of Nursing Care 1. consistency 2. limit setting

VIII Autism
Treatable but not curable More common among boys Usually diagnosed at age 2 Main Problem: Interpersonal functioning Most Acceptable Cause: Biological factors brain anoxia, intake of drugs Signs and symptoms 1. resist normal teaching method 2. silly laughing or giggling 3. echolalia 4. acts as if deaf 5. no fear of danger 6. insensitive to pain 7. crying tantrums 8. loves to spin objects 9. resists change in the routine 10. not cuddly 11. sustained odd play 12. difficulty interacting with others 13. no eye contact 14. wants blocks not ball 15. points to anything 16. attachment to inanimate objects Management of priority problems Tantrum - involves headbanging = place a helmet on the head Communication all vowels = use build up and break down Routines consistency Nursing diagnosis: Potential for injury

IX. Mental Retardation

IQ less than 70 Not a mental illness Main problem: Inadequate mental functioning Age of Onset: 18 years old Causes: Maternal infection Exact gestational age is not reached (premature) Nutritional deficiency Toxoplasmosis Anoxia Lead poisoning Recent infection measles Environmental factors Thyroid deficiency Alcoholic Mother RH Incompatibility Damage to brain from various causes AIDS Toxemia Inherited factor Opiate intoxication

Neurological/neurodevelopment impairment Levels of Mental Retardation 1. Mild/Moron 2. Moderate/Imbecile 3. Severe/Idiot 4. Profound Nursing diagnosis: Principles of Nursing Care: 1. Repetition 2. Role Modeling 3. Restructuring Focus of Education: Reading, writing, basic arithmetic IQ: 50/55-70 Educable IQ: 35/40 -50/55 Trainable IQ: 20/25 -35/40 Needs close supervision Below 20-25 Needs custodial care

X. Attention Deficit Hyperactivity Disorder

Common in boys Usually diagnosed before age 7 Main problem: Inattention, hyperactivity, and impulsivity Causes: Neurologic impairment Pre-natal trauma Early malnutrition Frontal lobe-hypoperfusion Use of drug by mother Signs and symptoms: Difficulty remaining seated Easily distracted by extraneous stimuli Fidgeting Interrupts/intrudes on others Child exhibits hyperactivity Indulges in destructive behaviour Talks excessively Nursing diagnosis: Potential for injury Principles of Nursing Care: Nutrition: Safety: Drug of Choice: Methylphenidate (Ritalin)

XI. Eating Disorders

Common among females (adolescents) Most common cause: Psychological factors Individual factors (conflict about growing up) Parental factors (domineering parents) Socio-cultural factors Anorexia Main sign: fear of gaining weight

Amenorrhea No organic factor accounts for weight loss Obviously thin but feels fat Refusal to maintain normal body weight Epigastric discomfort X symptoms (peculiar symptoms) Intense fear of gaining weight Always thinking of food Bulimia Binge eating Under strict dieting or vigorous exercise Lacks control over eating binges Induced vomiting Minimum of 2 binge eating episode a week for 2 months Increased/persistent concern of body size/shape Abuse of diuretics and laxatives Nursing diagnosis: Body image disturbance/self-esteem disturbance Ineffective individual coping

Principles of Nursing Care: 1. Monitor patients weight 2. Oral hygiene 3. Stay with the patient during mealtime and within 2 hours after meals 4. encourage the patient to remain in a public place after meals 5. behaviour modification

XII. Sexual Disorders

Cause: Psychological factors, unresolved oedipal complex Paraphilia a term which generally refers to abnormal sexual behaviour Types: Sexual Stimulus Exhibitionism - publicly showing the genitals Fetishism - from inanimate objects Anilingus - tongue brushing the anus Cunnilingus - tongue brushing the vulva Fellatio - inserting the penis into the mouth Partialism - inserting the penis into the other parts of the body Pedophilia - sexual intercourse with a child Urophilia - urinating on the partner Coprophilia - smearing feces on the partner Masochism - sexual gratification from experiencing pain Sadism - inflicting pain Telephone scatologia - sex on phone Voyeurism - sexual gratification by seeing others in the nude Frotteurism - rubbing the genitalia to the body parts Transvestism - using the apparel of the opposite sex Nursing diagnosis: Altered sexual functioning Principles of Nursing Care: 1. Limit setting 2. Behavior Modification

XIII. Schizophrenia
Split Mind

Not a single disease but a combination of disorders Main Problem: Signs and Symptoms: 1. Associative looseness 2. Autism 3. Apathy 4. Ambivalence 5. Auditory Hallucination Most acceptable theory on the cause of Schizophrenia, Biologic Theory Signs and Symptoms Social isolation Catatonic behaviour Hallucination Incoherent/marked looseness of association Zero/lack of interest, energy, and initiative Obvious failure to attain expected levels of development Peculiar behaviour Hygiene and grooming are impaired Recurrent illusions and unusual perceptual experiences Exacerbation and remissions are common No organic factor accounts for signs or symptoms Inability to return to baseline functioning after each relapse Affect is inappropriate Different Types Catatonic Onset Distinguishing feature Defense mechanism Nursing diagnosis Priority nursing care Prognosis Acute Abnormal motor behavior Repression Impaired motor activity Circulation Nutrition Good Disorganized Insidious Bizarre behavior Regression Impaired social functioning Assistance with ADL Poor Paranoid Abrupt Suspiciousness and ideas of reference Projection Potential for injury directed at others Nutrition and Safety Good

Other types:

Undifferentiated Residual with minimal symptoms

Criteria for Prognosis Favorable Prognosis

Unfavorable Prognosis

1. 2. 3. 4.

Good socialization Late/acute onset Adequate support system Family history of mood disorder

1. 2. 3. 4.

Poor/no socialization Early and insidious prognosis Few//no support system History of chronicity/many relapses

XIV. Mood Disorders

Predisposing Factors: Genetic: If one parent ahs bipolar disorder, 25 percent chance of transmission to the child.

Aggression turned inward theory: overdeveloped superego Object loss theory: loss of parent before age 11 Personality Organization Theory: Obsessive-Compulsive theory, Oral dependent, hysterical personalities have higher predisposition to mood disorders.

Cognitive Theory:

Mood disorder results from (-) view of self, (-) view of future, (-) interpretation of experience Mood disorder is caused by a belief that one has no control over his environment Mania is a defense against an underlying depression Depression due to rigid SE Mania is cause by increased norepinephrine while depression is cause by low norepinephrine

Learned Helplessness Theory: Psychoanalytic Theory:

Biologic Factor: Precipitating Factors 1. 2. 3. 4. 5. Loss of a loved one Major life events Roles strain Decreased coping resources physiological changes

Types of Mood Disorders 1. Depression A. Major Depression-severe, lasts for at least 2 weeks B. Dysthymic Depression-less severe (2 years) C. DNOS lasts for 2 days 2 weeks Bipolar Disorders A. Manic-severe, lasts for at least 1 week B. Hypomanic-lasts for at least 4 days C. Bipolar I with history of mania Bipolar II with no history of mania D. Cyclothymic numerous episodes of hypomania and depressed mood that lasts for at least 2 years Signs and symptoms:

2.

Appearance Behavior

Mania Colorful Highly driven, hyperactive

Depression Sad Passivity/Psychomotor retardation

Communication Talkative (Flight of ideas) Monotonous Nursing Diagnosis Nursing Care Risk for injury directed at others Lithium Risk for injury to self ECT Stimulating Monotonous activity e. g. counting Kind firmness

Milieu Therapy Non-stimulating Activity

Quiet Type Avoid competitive

Attitude therapy Matter of Fact (attitude of casualness) Suicide Ultimate form of self-destruction cry for help Major intervention: Risk Factors Prevention Listen

Sex (more female attempts at suicide but more males commit suicide) Unsuccessful previous attempt Identification with a family member who committed suicide Chronic Illness (e.g. Cancer) Depression/Dependent personality Age (18-25 and 40)/Alcoholism Lethality of previous attempt/Losses Nursing Diagnosis: Risk for self-directed injury Nursing Care: 1. 2. 3. 4. One-on-one monitoring Frequent unscheduled rounds Avoid use of metals and glass utensils Monitor for the signs of impending suicide (e.g. giving away of prized possession)

XV. Conditions Common in the Elderly

Delirium Disorientation Acute Involves young and old Clouded sensorium Reversible Good prognosis Dementia Loss/impairment of memory Chronic Exclusive in the elderly Clear sensorium Irreversible Poor prognosis

Alzheimers disease: Irreversible

Main pathology: presence of senile plaques-destroys neurons (decreased acethylcholline) Signs and symptoms: Aphasia-inability to talk Agnosia- inability to recognize object Apraxia-inability to perform ADL Amnesia/Memory Loss/Mnemonic disturbance 3 phases 1. 2. 3. Forgetfulness Phase-difficulty of remembering appointments Advance Phase-difficulty of remembering past events but not recent events Terminal Phase-death occurs in 1 year

Nursing Diagnosis: Altered thought processes Nursing Care: Calendar Clock (frequent orientation) Color Consistency (one nurse to lessen confusion)

XVI. Substance Abuse and Substance Dependence

Substance Abuse: use of a substance for other than its legitimate medical purpose Substance Dependence: physiological and psychological dependence of the body on a substance as evidenced by tolerance and withdrawal Tolerance: need for an increasing amount of the substance to produce its desired effect or it refers to the declining effect of the drug. Withdrawal: syndrome or a group of symptoms experienced by the patient when the amount of the substance is reduced or when the intake is stopped. Alcoholism Definition: WHO- alcoholism is a chronic disease or a disorder characterized by excessive alcohol intake and interference in the individuals health, interpersonal relationship and economic functioning. Alcoholism considered to be present when there is 1% or 10 ml for every 1000 ml of blood. What happens at level: .1-.2% (low coordination) .2-.3% (presence of ataxia, tremors, irritability, stupor) .3 and above (unconsciousness) Theories of Causation 1. 2. 3. 4. Psychoanalytic Theories Learning Theories Biological Theories Socio-Cultural Theories

Progression of Alcoholism 1. 2. Pre-alcoholic Phase starts with social drinking tolerance begins to develop Prodromal Phase Alcohol becomes a need, blackouts occur; denial begins to develop

3. 4.

Crucial Phase cardinal symptoms of alcoholism develops (loss of control over drinking) Chronic Phase the person becomes intoxicated all day

Outcome: Brain Damage Alcoholic Hallucinosis Death Common Behavioral problems of the Alcoholic Patient Denial Dependency Demanding Destructive Common Withdrawal Signs and Symptoms Hallucinations Increased vital signs Tremors Sweating and Seizure Criteria Cause Onset Essential feature Other S/Sx D. Tremens Faculty metabolism of alcohol Acute Delirium Korsakoff Psychosis Thiamine & Niacin deficiency Chronic Memory disturbances Confusion Opthalmoplegia Ataxia Thiamine def. Chronic Wernickes P. Thiamine deficiency Domineering

Vital Signs Retrograde A Visual and tactile Anterograde A Coarse tremors Confabulation Korsakoffs P.

Long terms of care Community resources Other coping means aside from denial Personal responsibility for not drinking Isolation Nutrition Vitamin B & C, CHO diet Group therapy Nursing diagnosis: Ineffective individual coping Principles of Nursing Care: 1. Well-lighted room 2. DAT 3. Monitor vital signs 4. Administration of glucose 5. Vitamins Drug of choice: Disulfiram (Anti-abuse) delays the metabolism of alcohol Avoid: Mouth wash Over the counter cold remedies Food sauces made up of wine Fruit flavoured extracts

Aftershave lotion Vinegar Skin products Commonly Abused Substances Substance a. Stimulants Amphetamine (shabu)Weight loss, hyperactivity depression Euphoria Cocaine b. Narcotics Heroin c. Hallucinogens LSD dilated pupils & hallucinations none pinpoint pupils, drowsiness piloerection & runny nose perforated nasal septum psychomotor agitation Physical signs Withdrawal Effect

Nursing Diagnosis: Ineffective individual coping Nursing interventions for substance abusers: Behavior Modification (Firmness-matter of fact) Detoxification Antihypertensive; anti-anxiety- administered to patients who are abusing stimulants Anti-anxiety; anti-depressants- administered to patients who are abusing depressants Anti-anxiety (Librium), disulfiram (anti-abuse);- administered to patients who are abusing alcohol

XVII. Concept of Loss

Grief/Grieving-George Engel 1. 2. 3. 4. 5. Shock, Numbness, Disbelief- Searching behaviour Yearning and Protest anger towards God Anguish, Disorganization, and Despair reality of the loss is accepted Identification stage- a family member imitates some characteristics of the dead person. Reorganization/restitution- life normalizes

Death/Dying: Elizabeth Kubler-Ross Stages: Denial No, Not me! Anger - Why me? Bargaining- If only Depression silence Acceptance Yes, its me. Nursing Diagnosis: Ineffective individual coping Nursing Care: 1. 2. Be physically present Be non-judgmental

3. 4. 5.

Encourage verbalization of feelings Allow the patient to cry Recognize your own thoughts about death and dying