FUNDAMENTAL CONCEPTS MENTAL HEALTH Is a state of emotional, psychological, and social wellness evidenced by: Satisfying interpersonal relationships

ps Effective behavior and coping Positive self-concept Emotional stability Self-awareness Factors Affecting Mental Health: MRS MATS Mastering the Environment Reality orientation Stress Management Maximizing Ones Potential Autonomy and Independence Tolerating Ones Uncertainties Self-esteem STRESS is any biopsychosocial (external or internal) experiences that one views as demanding, challenging, and threatening; Also char as: It is recurring. It is normal. It cannot be avoided. It is caused by a stressor. STRESSOR is any condition, event, or agent that increases the activity of the Sympathetic NS; Stress Adaptation Syndrome (SAS) GAS A R E 1. Stage I ALARM Activation of the SNS (or the Fight-or-Flight Response) Increase epinephrine, NE, and cortisol. Client is alert with increase anxiety. 2. Stage II RESISTANCE Hormone readjustment; Decrease in size and activity of the adrenal cortex; Increase use of defense mechanism; 1. Stage III EXHAUSTION Loss of ability to stop stress; Exaggerated defense-oriented behavior; Disorganized thinking and personality; May show signs of illusion, hallucination and delusions; Client may be stuporous or violent (PANIC) GRIEF is a powerful emotional reaction to a separation or loss from something that is/are very valuable;

is SELF-LIMITING; Stages of Death and Dying (Kubler-Ross) DABDA a. Denial b. Anger c. Bargaining d. Depression e. Acceptance Shes not dead! Shes still alive! Youre the reason shes dead!!! God, take me.. Spare her Im not hungry, I just want to be alone. At least she no longer have to suffer. He is in the presence of our Creator.

DENIAL ANGER BARGAINING DEPRESSION ACCEPTANCE

CONCEPT OF DEATH: TODDLER No specific concept of death yet. Reacts more to pain and discomfort; Separation anxiety may be felt; Focus is on the feelings of the parents; PRESCHOOL Death is like SLEEP; Or a form of PUNISHMENT; May use PLAY as a method of therapy; SCHOOL AGE Death is personified or as a final stage of life; May fear mutilation or punishment; Accept regressive or protest behavior from the client; Encourage verbalization of feelings;

1. ADOLESCENT Have MATURE understanding of death; May show strong emotions about death (sadness, silence, anger, withdrawn) Encourage verbalization of feelings; Respect need for privacy and expression of grief; 2. ADULT Death is disruption of lifestyle; Effects of death to significant others; 3. OLDER ADULT (Elderly) Emphasis on religious beliefs for comfort;

 Time for reflection, rest or peace; TRANSFERENCE 4. is the unconscious transfer of special feelings from a client to the nurse or therapist. COUNTERTRANSFERENCE Is the projection of the therapists feelings about a significant other to the patient during therapy; CRISIS Is an imbalance of the internal equilibrium that results from a stressor or threat to the patient; Client is in bad situation Problem-solving inadequate Cannot immediately neutralize the stressor CRISIS Types of Crisis: 1. Maturational growth and development (identity crisis, midlife crisis) 2. Situational unexpected events (death, loss) 3. Social major disaster (landslide, typhoon) Crisis is characterized by: 1. Self-limiting, only last for 4-6 weeks 2. Individualized - every person have their own reaction. 3. Person becomes passive and submissive. 4. Alteration in support system. Stages of a Crisis: (DIDA) 1. Denial first reaction; 2. Increase tension the person recognizes the crisis but continues to function; 3. Disorganization the person is pre-occupied to solve the conflict and alters his ADL; 4. Attempts to reorganize by using his coping mechanism; CRISIS INTERVENTION Aims to restore the person to a pre-crisis state of functioning; Focuses on resolving the immediate crisis; DEFENSE MECHANISMS Fight for stress DISPLACEMENT Transfer of feelings to a less threatening object rather than the one who provoke it DENIAL Failure to acknowledge an unacceptable trait or situation Alcoholics Battered wives Anorexia nervosa Drug dependents DISSOCIATION Psychological flight from self A type of amnesia Boss shouts at you, you shout at your subordinate Im not an alcoholic

REGRESSION REPRESSION RATIONALIZATION

INTELLECTUALIZATION

Return to an earlier developmental stage Unconscious forgetting of an anxiety provoking concept Illogical reasoning for a socially unacceptable trait sayang ang beer sa ref, kaya ko ininum Using only logical explanations without feelings or an affective component.

Return to thumbsucking Hindi ko maalala I drink because I dont want to waste the beer in the ref An examinee explains how she passed the NLE but hardly showed any emotion regarding the leakage. sasabunutan kita. . . ay kuklulutin lang kita ay pinatid kita, halika punta kita sa clinic Tulad niya hindi ako alcoholic, sila yon ako din Not just you, me too Hindi ko alam yan Angry at life, put anger in singing Biglang mangingig

REACTION FORMATION UNDOING

IDENTIFICATION PROJECTION

INTROJECTION

SUPPRESSION SUBLIMATION CONVERSION

COMPENSATION SUBSTITUTION

doing the opposite of your intention plastic Doing the opposite of what you have done due to guilt orocan, plastic, Tupperware Assume trait for personal, social, occupational role Attributing to others ones acceptable trait Pasa load Assume another persons trait as your own Conscious forgetting of an anxiety provoking concept Placing sexual energies toward a more productive endeavors Repressed angers put towards physical symptoms affecting nervous system leading to sensory numbness and motor paralysis Overachievement in one area to cover a defective part Replacing a difficult goal with a more accessible one

Pilay pero magaling kumanta Gusto ko Disneyland. Enchanted nalang.

Sino ka, Sino ako?

SELF - AWARENESS The nurses goal is to achieve authentic, open, and personal communication; The nurse must be able to examine personal feelings and reactions; A good understanding and acceptance of self allow the nurse to acknowledge a patients differences and uniqueness; QUADRANT 1

 Is the open quadrant; known to self and others QUADRANT 2 Is the blind quadrant; Known only to OTHERS, unknown to self. QUADRANT 3 Is the hidden quadrant; Known ONLY to self QUADRANT 4 Is the unknown quadrant; Unknown to the self and to others The following three principles help explain how the self functions: A change in any one quadrant affects all other quadrants. The smaller quadrant 1, the poorer the communication. When quadrant 1 is larger and other quadrants are smaller, interpersonal learning is significantly present. STEP 1 The goal of increasing self-awareness is to enlarge the area of quadrant 1 while reducing the size of the other three quadrants. To increase self-knowledge, it is necessary to listen to the self; The individual allows genuine emotions to be experienced, and identifies and accepts personal needs; STEP 2 Reduce the size of quadrant 2 by LISTENING TO AND LEARNING FROM OTHERS; As we relate to others, we broaden our SELF-PERCEPTIONS; Requires active listening and openness to the feedback others provide; STEP 3 Reduce the size of quadrant 3 by self-disclosing or revealing to others important aspects of the self; SELF-DISCLOSURE is both a sign of personality health and a means of achieving healthy personality; Sigmund Freud Father of Psychoanalysis Structure of Personality (Id, Ego, Superego)

PLEASURABLE PRINCIPLE Pain Avoidance Its all I DOMINANT SUPER EGO Obsessive - compulsive Anorexia Nervosa

UPER EGO hould not mall voice of God CONSCIENCE PRINCIPLE

I E

GO Xecutive Secretary

Impaired Reality Schizophrenia

REALITY PRINCIPLE LIBIDO sexual energy responsible for survival PSYCHOSEXUAL THEORY 1. ORAL STAGE 0 18 Months old Survival I want to eat, sleep, urinate, defecate ID formation Cry & Suck mouth Child Cries Feed the Infant Successful Ignore the Infant Unsuccessful Narcissistic

I
D mpulsive want to want PLEASURE eat drink urinate defecate

Dominant ID Mania Antisocial Narcissistic

Defense Mechanism: o FIXATION when a person is stuck in a certain developmental stage o REGRESSION return to an earlier developmental stage EGO is develop in the 6 month
th

S E

2. ANAL STAGE Ateen 3 years old (18 mos 3 y.o.) Toilet training

Bowel Control 18 months. Daytime Bladder Control 30 months. Nocturnal Bladder Control 36 months. Super Ego develop Toilet Training Good Mother Successful Bad Mother Unsuccessful

Identification boy associates with daddy, girl assoc. with mommy Castration fear of the little boy to daddy Penis Envy envy of little girl towards daddy

Dr. Karen Horney opposition to penis envy Level of Awareness o Conscious highest level of awareness o Preconscious Tip of the tongue o Unconscious deepest level of awareness Birth Trauma First traumatic experience of child REPRESSION unconscious forgetting of an anxiety provoking concept SUPRESSION conscious forgetting of an anxiety provoking concept

SE
Too Rigid Training Clean Organized Obedient OBSESSIVE COMPULSSIVE (Anal Retentive) Dirty Disorganized Disobedient ANTISOCIAL (Anal Expulsive)

BIG SE

4. LATENCY STAGE 6 12 years old Small SCHOOlatency SE Sexual energy is dormant Reading, Riting, Rithmetic Resolution of the oedipal complex; SUBLIMATION placing sexual energies toward a more productive endeavors

3. PHALLIC 3 6 y.o. Penis/ Vagina Parents is the significant person Called as Preschooler Physiologic homosexuality may also be seen in this stage.

5. GENITAL STAGE 12 y. o. above Sexual interest emerges as the person strives to develop satisfactory relationships with potential sex partners (intimacy) Corresponding with genital maturation which result to sexual awakenings; Gising Genital PSYCHOSOCIAL MODEL or Developmental Model; Established by Erik Erickson from Freuds psychoanalytical model; Spans the total life cycle from birth to death; Each stage of development is an emotional crisis involving positive and negative experiences; Life Stages I. Trust vs Mistrust (0 18 months of age) Child develops sense of trust or mistrust of others; Shares openly and relates to others; Interpersonal skills start to develop; II. Autonomy vs Shame and Doubt 18 months 3 y/o;

Oedipus Complex little boy loves mommy Electra Complex little girl loves daddy

 Child learns self-control or becomes very conscious and full of doubt; Negativistic attitude; Exhibits motor self-control and independence thru negativism; Parallel play is the social skill. III. Initiative vs Guilt (3 5 y/o) Child initiates spontaneous activities or develops fear of wrongdoing; Shows appropriate social behaviors; Curiosity and exploration; Social Skill: Cooperative Play IV. Industry vs Inferiority (6 12 y/o) Child develops the social and physical skills necessary to negotiate and compete in life; Acquisition of competence; Ability to cooperate and compromise; Identification with admired others (teachers, parents) V. Identity vs Role Diffusion ( 12 20 y/o ) Teenager either integrates childhood experiences into a personal identity; May develop self-doubts about sexual or occupational roles; Establish relationship with the opposite sex; Fidelity with friends; Also value importance of beauty or self-image; VI. Intimacy vs Isolation (18 25 or 30 y/o) The person develops commitment to work and to other people; Ability to give and receive love; Responsible sexual behaviors; VII. Generativity vs Stagnation (30 65 y/o) Productive, constructive, and creative activities; Personal and professional growth; Parental and societal responsibilities; Ability to care; VIII. Integrity vs Despair (65 years old to death) The person reviews life for meaning, fulfillment, and contributions made to the next generations; Sense of dignity and worth; Explores the philosophy of life; Have period of reminiscence; May result to regression and withdrawn; ERIK ERIKSON PSYCHOSOCIAL THEORY OF DEVELOPMENT Age + Affecting Major Factor 0-18 mos. Trust Mistrust Feeding 18 mos. 3 y.o. Autonomy Shame/ doubt Toilet Training AU nal TO ilet training NO favorite word

MY 3 6 y.o. 6 12 y.o. 12 20 y.o. 20 25 y.o. 25 45 y.o. 45 y.o. and above Initiative Industry Identity Intimacy Generativity Ego Integrity Guilt Inferiority Role confusion Isolation Stagnation Despair Independence In da-school Peer Love Parenting Reflection

COGNITIVE - BEHAVIORAL MODEL By Piaget; SENSORIMOTOR STAGE (birth 18 months) The child learns by IMITATION; Also by object permanence; B. PREOPERATIONAL STAGE ( 2 7 years old) Preconceptional Phase ( 2- 4 y/o) Learns using mental images and develops symbolic language and play (symbolism) Intuitive Phase ( 4 7 y/o) The child learns by separating disparate objects and events and also expands expressive language; Can give reason for belief and reactions but still prelogical; C. CONCRETE OPERATIONS (8 12 years old) Child can systemically organize thoughts and facts about the environment; Can apply rules to things that are seen and heard; Child begins abstract thinking; D. FORMAL OPERATIONS (12 adulthood) The person can think using conceptual, abstract operations, and CAN HYPOTHESIZE and evaluate solutions to the problems; MASLOWS HEIRARCHY OF NEEDS 1. Physiologic Needs o Air, food, water, shelter, rest, sleep, activity and temperature maintenance that are crucial for survival 2. Safety and Security Needs o Safe in physical and psychological aspects 3. Love and Belonging Needs o Giving and receiving affection, attaining a place in a group, maintaining the feeling of belonging 4. Self esteem Needs o Self esteem feelings of independence, competence and self respect o Esteem from others recognition, respect, appreciation 5. Self Actualization o Ones maximum potential and realize ones abilities and qualities BEHAVIORAL MODELS 1. Ivan Pavlov

Classical Conditioning Model Behavior is learned and retained by positive reinforcements; Behaviors that are inadequate or inappropriate must be replaced by more adaptive ones; All behavior are learned Food dog Salivation Bell Food Dog Salivation Bell Salivation

2. Peplau The nurse and the client must work together to assist client grow and to resolve problems; 3. Sullivan Behavior motivated by need to avoid anxiety and satisfy needs; 4. B.F. Skinner Operant Conditioning All behaviors are unlearned Reward (+ reinforcement) and Punishment (- Reinforcement) THERAPEUTIC COMMUNICATION Is an interactive process that occurs between the patient and the health professional; Focuses solely on the patients problem; Establishment of trust is the foundation of a nurse-client relationship; Techniques of Therapeutic Communication C SOAP ME FEG and SURE STROL CLARIFICATION Encourage client to make idea more understandable; Nurse: I dont understand what you mean. Could you explain it to me? SILENCE Client able to think about self or his problems; Does not feel any pressure to speak; Look into the eyes and listen to the client while he is talking; OFFERING SELF Offer to provide comfort to client by mere presence; Ill sit with you. Ill walk with you. Im here for you. ACCEPTING by nodding and following what client says; PRESENTING REALITY Reports events and situations as they really are; Client: I dont have a chance talking to my doctor. Nurse: I saw you and your doctor talking this morning Client: These voices are bothering. They want me to jump from the window. Nurse: There are no other people here. OR I dont hear any voices except for ours.

MAKING OBSERVATION Verbalize what you perceive; I notice that you cant sit still. I notice that something is bothering you. EMPATHY Showing or telling what you feel in relation to the clients suffering. I know what you feel I know this is hard for you. FOCUSING Encouraging the client to stay or focus on the topic; You were talking about your mother. You were saying that your.. EXPLORING Encourage client to express feelings or ideas deeply; Tell me more about you and your mother. How did you respond to.. GIVING RECOGNITION Indicate to client your awareness of him and his behaviors; Good morning, I noticed that you combed your hair today. I observed that youre behaving appropriately. SUGGESTING COLLABORATION Offer to work with client towards a specific goal; Client: I fail at everything I try. Nurse: May be we can figure out something together so that you can accomplish something you want to do. USING BROAD OPENINGS Encourage client to introduce the topic of conversation; or to start a conversation; Where shall we begin today? What are you thinking about? REFLECTING Direct clients questions or statements back to encourage expression of ideas and feelings; Client: Do you think I should talk to my doctor. Nurse: What do you want to talk about? ENCOURAGING DESCRIPTION Ask the client to verbalize his perception; What is happening to you right now? What are you doing in front of the window? SHARING PERCEPTIONS nurse describes his or her understanding of the patients f eelings and ideas; Nurse: I noticed that you have an unresolved feelings towards your mother. TRANSLATING INTO FEELINGS Encourage client to verbalize feelings expressed in another way; Client: I will never get better. Nurse: You sound rather hopeless and helpless.

RESTATING Repeat what client has said; Client: I dont want to take my medicines. Nurse: You dont want to take your medicines? OFFERING GENERAL LEADS Encourage client to continue discussing the topic; And then? or Go on Im listening. Tell me more about what you just said? LISTENING Blocks to Constructive Communication These are methods of communication that obstruct the process of therapeutic conversations (Non-therapeutic) BAD SCAR DROP B belittling feelings A agreeing / disagreeing D denial S stereotypical response C changing topic A approval / disapproval R reassuring D defending R requesting explanation O offering advise P probing Phases of Therapeutic Relationship A. ORIENTATION or Assessment or analysis; The nurse establishes trust with the client; The nurse assesses the client; Formulation of nursing diagnosis; Prioritization of the clients problems; The nurse and the client establish mutually agreed goals; Discussing the indications for termination; B. WORKING PHASE Pertains to planning and intervention; the nurse plans outcomes and related interventions to assist client to meet goals; The nurse facilitates the clients expression of problems, thoughts, and feelings; The nurse uses problem-solving approach; C. TERMINATION PHASE Pertains to evaluation; The nurse evaluates outcomes, reassess the problems, goals and interventions; Needs close attention to avoid destroying the benefits gained from the relationship;

The nurse and client express feelings regarding the termination of the interactions; The nurse observes the client for negative behaviors: Regression Anger Inappropriate expressions (laughter) The nurse evaluates the entire nurse-client relationship;

PSYCHOPHARMACOLOGY ANTI-PSYCHOTIC DRUGS Or neuroleptics or major tranquilizers; For acute and chronic psychosis; For bipolar I disorder, manic phase; Paranoid disorder; Severe nausea and vomiting*; Severe or pathologic hiccups*; Classification (Traditional or Typical Classification) 1. Chlorpromazine (Thorazine) - EARLIEST 2. Fluphenazine (Prolixin) 3. Thioridazine (Mellaril) 4. Trifluoperazine (Stelazine) 5. Haloperidol (Haldol) 6. Loxapine (Loxitane) Atypical Anti-psychotics: 1. Clozapine* (Clozaril) 2. Olanzapine* (Zyprexa) 3. Risperidone* (Risperdal) Mechanisms of Action: Blocks dopamine receptors in the nigrostriatal system causing pseudoparkinsonism; Inhibits dopamine receptors in the tubuloinfundibular system; Antagonizes serotonin receptors in the cerebral cortex (Risperidone) Typical Anti-psychotics Decrease dopamine Atypical Anti-psychotics Decrease serotonin Desired Effects of Antipsychotic Drugs: 1. CNS Effects a. sedation b. emotional quieting c. slowing of psychomotor functions 2. Modification of Psychiatric Symptoms a. Resolution of positive symptoms Hallucinations Illusions Delusions Excitement

 Suspiciousness b. Resolution of negative symptoms Accomplished by ATYPICAL antipsychotic agents 1. Attention deficit 2. Asocial behavior 3. Blunted or flat affect 4. Communication difficulties 5. Difficulty with abstraction SIDE EFFECTS A. PNS Effects (anticholinergic effects) B. PNS Effects (anti-adrenergic effects) 1. Orthostatic hypotension 2. Reflex tachycardia due to lower extremity vasodilatation; Anti-cholinergic effects are the same irregardless of what medication. A urinAry retention Blurring of vision due to dilated pupils. Constipation Dry mouth and nasal passages Elevated heart rate (tachycardia) C. CNS Effects (or EPSE) 1. Akathisia it is the most common EPSE; inability to sit still; px is restless, jittery or uneasy and may report a lot of nervous energy; Tx: Anticholinergic antiparkinson drugs (Artane, Biperiden, Cogentin) 2. Acute Dystonic Reactions (dystonia) rigidity of the muscles of the tongue, face, neck or back; results to abnormality in posture, gait or ocular movements; Torticollis Oculogyric crisis rolling of eyes backward in a fixed stare; Laryngeal-pharyngeal dystonia Tx: IM anticholinergic antiparkinson drug (Benztropine or Cogentin) 3. Tardive Dyskinesia (TD) potential permanent complication; refers to abnormal voluntary skeletal muscle movements usually jerky motion; appears after months or years of drug use but may occur sooner; caused by dopamine hypersensitivity and cholinergic deficit; anticholinergics may aggravate TD; usually affects the muscles of the mouth and face: 1. Lip smacking 2. Grinding of the teeth 3. Rolling or protrusion of the tongue 4. Tics 5. Excessive facial movements Grimacing and blinking Chewing and lateral jaw movement Puffing of the cheeks;

Tx:

Bromocriptine (Parlodel); Reduction of dose; Discontinuation of the drug; 4. Drug-induced Parkinsonism or pseudoparkinsonism; motor retardation (bradykinesia) and rigidity; difficulty in initiating or carrying out motor activity; shuffling gait; resting tremors of the hands and feet; hypersalivation; Tx: Dosage reduction Antiparkinson drug (Akineton) 5. Neuroleptic Malignant Syndrome is a rare but life-threatening reaction to neuroleptic drugs (1% of clients) 3-9 days after starting anti-psychotic (Haldol) manifestations: a. hyperthermia cardinal symptom. b. rigidity c. impaired consciousness d. hypertension e. cardiac arrhythmias Tx: Immediate discontinuation of the drug; Cooling blankets; Dantrolene or Bromocriptine 6. Other Side Effects a. Hyperglycemia b. Jaundice c. Blood dyscrasias or agranulocytosis (Clozapine) d. Orthostatic hypotension (Risperidone) e. Retinal pigmentation (Thioridazine) f. Galactorrhea and gynecomastia (Increase secretion of prolactin) g. Amenorrhea and impaired ejaculation h. Sun burn ANTI-PARKINSON DRUGS Major cause of EPS malfunction is a DEFICIENCY in the neurotransmitter DOPAMINE (substantia nigra) and a subsequent decrease in dopamine transmission in the basal ganglia; Mechanisms of Actions: Increases dopamine by increasing its precursor. Levodopa Carbidopa-levodopa (Sinemet) Stimulates the release of dopamine. Amantadine (Symmetrel)

 Increases the action of the dopamine receptors (Dopamine agonists) Bromocriptine (Parlodel) Pergolide (Permax) Blocks the metabolism of dopamine by inhibiting MAO type b. Selegiline (Eldepryl) Anti-parkinsons with anti-cholinergic properties. Benztropine (Cogentin) Biperiden (Akineton) Diphenhydramine (Benadryl) Ethopropazine (Parsidol) Procyclidine (Kemadrin) Trihexyphenidyl (Artane) ANTI-PARKINSON DRUGS CAPABLES Cogentin Artane Parlodel Akineton Benadryl Larodopa Eldepryl Symmetryl ANTIDEPRESSANTS DEPRESSION is caused by an imbalance or decreased availability of certain neurotransmitters (deficiencies of norepinephrine, serotonin, and possibly dopamine) Goals in the tx of Depression: 1. Reduce or remove all signs and symptoms of depression the most important. 2. Restore occupational and psychosocial function; 3. Reduce the incident of relapse and recurrence; A.TRICYCLIC ANTIDEPRESSANTS Blocks reuptake of norepinephrine and serotonin; Also increases receptor sensitivity to these neurotransmitter; Desirable Effects: Sedation. Others increase psychomotor activity. Improved appetite. Side Effects: Anti-cholinergic side effects Orthostatic hypotension Nursing Implications: Take medications at night. Reassure that symptoms will decrease in 2 - 4 weeks Increase fiber and fluid diet. Assess for adverse drug reactions.

Assess for suicide potential. Classifications: Tertiary Amines Imipramine (Tofranil) Amitriptyline (Elavil) Clomipramine (Anafranil) used in OCD. Secondary Amines Amoxapine (Asendin) Nortriptyline (Aventyl) Desipramine (Norpramin) Classifications Novel Cyclic Antidepressants Bupropion (Wellbutrin) Trazodone (Desyrel) Venlafaxine (Effexor)

B. SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI) Fewer side effects that TCA; First choice in treating depression. MOA: inhibits reuptake of serotonin in neurons which later increases the availability of serotonin in several neurons; Therapeutic lag time is approximately 1 4 weeks; Side Effects: GIT Symptoms Nausea Diarrhea Weight loss CNS Symptoms Headache Dizziness Tremors Nervousness Decreased libido and orgasms Nursing Implications: Avoid incorporating with MAOI because of the danger of serotonin syndrome (coma, hyperreflexia, hyperthermia, death) 14 days stopping MAOI and starting SSRI: 5 weeks stopping SSRI and starting MAOI; st Avoided during the 1 trimester of pregnancy. WOF: Increase activities and mood of patients because these are signs of suicidal ideations; Classification: Fluoxetine (Prozac) Fluvoxamine (Luvox) Paroxetine (Paxel) Sertraline (Zoloft)

C. MONOAMINE OXIDASE INHIBITORS (MAOI) Monoamine Oxidase involved in the metabolic decomposition and inactivation of amines (norepinephrine, dopamine and serotonin); Administered to hospitalized patients or px that can be closely monitored or supervised at home; It takes 2 4 weeks for these drugs to take effect; Side Effects: CNS Hyperstimulation Hypomania Agitation Insomnia Restlessness and euphoria Acute Anxiety Attack Hypertensive crisis (tachycardia, palpitations, occipital headache, chest pain, elevated BP, diaphoresis, and dilated pupils; sudden epistaxis) Nursing Implications: Take the medication EARLY IN THE DAY to avoid insomnia; Caution client to avoid OTC drugs because these contain AMINES and can cause HYPERTENSIVE CRISIS. Cold remedies Decongestants Antihistamines Sleeping aids Stimulants Instruct the px TO AVOID FOODS HIGH IN TYRAMINE (tyramine-restricted diet) Foods high in TYRAMINE: A aged cheese and avocado B bananas, beer C chocolate, coffee, chicken and pork liver D dried and preserved foods (pickles) E etc (yogurt, sausage) F fermented foods (beer, wine) Classifications: Phenelzine (Nardil) Tranylcypromine (Parnate) Moclobemide (Manerix) atypical MAOI. SSRI TCA MAOI

Male Erectile Dysfunction ANTI-MANIC DRUGS (Mood Stabilizers) LITHIUM Is used for manic phase of manic-depressive illness and refractory depression; The exact action of lithium is UNKNOWN; Substitute for Na in neurons altering the release and attachment of certain neurotransmitters in most neurons; Increases the reuptake of NE and serotonin; Lithium has a lag time of 7 10 days; Lithium is well absorbed from the GIT (via ORAL route) The typical dose for acute mania is 600 mg TID which produces a therapeutic blood dose of 0.6 1.2 mEq/L; Blood levels over 1.5 mEq/L can be toxic; Nursing Implications: WOF signs of early Li toxicity: Vomiting earliest; Diarrhea and Drowsiness Muscular weakness Lack of coordination Polyuria Client may have mild exercise or activities. Advise px not to drive during Li therapy; Advise px to practice balanced diet and salt intake; Increase Salt intake = decrease blood Li Decrease salt intake = increase blood Li For Li determination, blood must be drawn at least 8-12 hrs after the last dose and performed in the morning (every 3 4 months of Li intake) Take Li with meals to avoid nausea and vomiting; Increase fluid intake (2500-3000 ml) per day to reduce thirst and maintain normal fluid balance; PHARMA MOMENT LITHIUM L evel 0.6 1.2 mEq/L Increase urination Tremors, fine hand Hydration 3 L/day Increase Uu diarhea Mouth, dry ausea, vomiting, diarrhea Lithium Toxicity a+

Kidney Antidepressant Anticholinergic Side Effects (Syphathetic)

CARBAMAZEPINE (Tegretol) Used for px who do not respond to Li or for px Li is contraindicated; Used in px with bipolar disorders and for px with seizure disorders;

Thought to inhibit the small abnormal activity in the brain; Side Effects: Nausea and vomiting Anorexia Sedation and drowsiness Agranulocytosis

b. c. d. e. f. g.

Fatigue Decreased coordination Mental impairment Slow reflexes Confusion Respiratory depression***

VALPROIC ACID (Depakene) Is an anticonvulsant with antimanic property; Effective in px with bipolar disorders; Rapid acting and with less effect on cognition; Side Effects: Transient hair loss Weight gain Tremors GI Upset Thrombocytopenia ANTIANXIETY DRUGS Are also known as anxiolytics; Classified into: a. Benzodiazepines b. Sedative-Hypnotics Benzodiazepines are the major class of anxiolytics or minor tranquilizers; Are used in px: a. chronic anxiety b. acute anxiety or persons in crises c. presurgery d. panic attacks e. insomnia f. alcohol withdrawal syndrome g. bipolar disorders with Li therapy h. seizures Types of Benzodiaze PAM PAM 1. Diazepam (Valium) 2. Lorazepam (Ativan) 3. Clonazepam (Klonopin) 4. Oxazepam (Serax) for elderly. 5. Alprazolam (Xanax) 6. Chlordiazepoxide (Librium) 7. Clorazepate (Tranxene) 8. Buspirone (BuSpar) Adverse Drug Reactions: 1. CNS Depression a. Drowsiness

1. Anticholinergic side effects 3. Problems of dependence, withdrawal, and tolerance; a. Dependence or addiction the person must take the drug to feel normal; b. Withdrawal physical signs and symptoms that occur when the addictive substance is reduced or withheld; c. Tolerance the need to increase the amount of a substance to achieve the same effects; Nursing Interventions: Advise the px to avoid taking alcohol and other CNS depressants with the drug. WOF of overdose ( somnolence, confusion, coma, decreased reflexes, and hypotension) Advise the px to avoid driving; Monitor VS especially breathing; Sedative-Hypnotics Are also used in the treatment of anxiety, insomnia, and prevention of alcohol withdrawal syndrome; Barbiturates: Phenobarbital Secobarbital Pentobarbital Antihistamines: Diphenhydramine THERAPEUTIC LAG TIME Anti-psychotics TCA 2 4 weeks MAOI SSRI 1 4 weeks Lithium 7 10 days Clomipramine 2-3 months ELECTROCONVULSIVE THERAPY An electrical current (70-150 v) passes thru electrodes applied to the patients temple to induce a generalized tonic-clonic seizure (or Grand Mal) and unconsciousness; Is use when other traditional therapies failed; Length of application: 0.5 - 2 secs; Length of seizure: 30 - 60 secs; The cumulative effect of ECT is approx 220 - 250 secs.

Used to treat patients with depression, bipolar disorders, manic, and psychotic symptoms; The exact action of ECT remains unknown; Nursing Interventions: Obtain an informed consent from the patient, family, or legal representative of the patient; Teach the family and the patient about the treatment and what to expect like: Short-term memory loss resolve after 4-8 weeks; Disorientation Confusion Respiratory depression NPO post-midnight to prevent aspiration and vomiting; at least 8 hrs. Remove all prostheses including hairpins and dentures; Administer all preop meds as indicated like: AtSO4 to decrease oral and nasal secretions*; Succinylcholine muscle relaxant; Short-acting barbiturates* Does not affect seizure threshold Ex. Methohexital Vital signs must be monitored before and after the procedures; Tongue guard is inserted to prevent tongue injury during seizure; Monitor heart rate and rhythm, blood pressure, and EEG; Antidepressant no effect ECT ELECROCONVULSIVE THERAPY Pre o Informed consent o NPO 6 8 hours prior Meds o Atropine dry mouth o Barbituate Sedative o Succinylcholine muscle relaxant, prevent seizure Post o Side-lying lateral o S/E headache, dizziness, TEMPORARY MEMORY LOSS distinct sign 70 110 volts 20 30 seconds hour asleep post NEUROSIS I. is a maladaptive emotional state due to unresolved emotional conflict; OVERVIEW

II.

ANXIETY is a subjective feeling of vague apprehension due to real or perceived threat; is a NORMAL response to stress; Or may precede new experiences; ETIOLOGY 1. Biological Theory a. **GABA decrease; b. Norepinephrine increase; c. Serotonin increase; d. Dopamine increase; 2. Psychodynamic Theory Due to unresolved developmental conflicts; 1. Interpersonal Theory (by Sullivan) When expectations, approval, or needs are not met. 2. Behavioral Theory Anxiety is a learned response to combat stress; Kind of Anxiety (Freud) 1. Reality Anxiety - from external real threat; 2. Neurotic Anxiety - fear that instinct will cause one to do something that will cause punishment; 3. Moral Anxiety - guilt from a wrongdoing against the conscience; Levels of Anxiety: 1. Mild Anxiety associated with the tension of everyday life; the individual is alert and attentive (SNS is stimulated) perceptual field is increased; NO INTENSE FEELING BECAUSE SELF-CONCEPT NOT THREATENED With mild muscle tension; Interventions: - Discuss source of anxiety. - Problem solving to neutralize anxiety. - Teach the client to accept anxiety as normal. 1. Moderate Anxiety the focus is on immediate concerns; narrows the perceptual field; selective inattentiveness occurs; learning and problem-solving still take place; self-concept may be threatened (may have discomfort and irritability) may show moderate muscle tension with increase vitals, mydriasis, and sweating; Interventions: Decrease anxiety by ventilation of feelings, crying, or exercise. 2. Severe Anxiety a feeling that something bad is about to happen; With significant reduction in perceptual field;

All behavior is directed at relieving the anxiety; learning and problem-solving are not possible; May show: Hyperventilation Severe muscle tension Rapid pacing or walking Shouting and trembling Interventions: Stay with the client. Decrease anxiety and pressure. Use kind, firm, and simple directions. IM anxiolytics as ordered.

2. Dangle feet 3. Stand Up Gradually RELAXED ANXIETY Vague sense of impending doom

Gradually Tapered Dose

3. Panic Level of Anxiety associated with dread and terror and a sense of impending doom; the personality of the individual is disorganized; the individual is unable to communicate or function effectively; may experience loss of rational thoughts with distorted perception; May have: Fight or flight Freeze Helplessness Out of control (jump from windows) Rage, anger, and terror Interventions: Guide firmly or physically take control. IM anxiolytics as ordered. Restraints if needed (FOR SAFETY) ANXIETY Anticholinergic side effect Constipation Urinary Retention Dry Mouth Blurred Vision

Mild Moderate +1 +2 Widened acing Perceptual Field RN Meds Restless Enhanced Learning Capacity You Seem Restless

Severe Panic +3 +4 ont know what uicide to say/do afety IRECTIVE

Dont touch client Respi Alkalosis Bown Bag

Within 1 week Rebound phenomenon Seizure Abrupt Dependence Withdrawal

Anti-Anxiety Drowsy No Alcohol No Coffee Develop Orthostatic Hypotension Prevetion of O.H. 1. Sit Down

III. COPING WITH ANXIETY Coping Mechanisms any effort that will decrease the stress response; either a constructive or destructive mechanisms; they can be task-oriented to solve the problem; or defense-oriented to protect the pxs feelings; Type of Coping: 1. Adaptive coping for mild anxiety; 2. Pallative coping for moderate anxiety; 3. Maladaptive coping for severe anxiety; 4. Dysfunctional coping for panic level of anxiety; Type of Coping: 1. Adaptive solve the problem. Ex. If you have an exam you study or review. You PASSED with flying colors. 2. Pallative temporarily decrease the anxiety but does not solve the problem (allows the client to return to problem solving) Ex. If you have an exam. Go to the gym first then review. Youll PASS. 3. Maladaptive unsuccessful to decrease anxiety without attempting to solve the problem.

Ex. You have an exam Watch movies with friends first then cramming for review. Result of exam FAILED!!! 4. Dysfunctional not successful in reducing the anxiety or solving the problem; minimal functioning becomes difficult; Ex. You have an exam drinking spree with buddies.. When you wake up UMAGA NA. Result of exam . Asa ka pa. Eh di bagsak!!! Common Nursing Diagnosis: Ineffective individual coping*** Anxiety Impaired adjustment Risk for injury Risk for violence, self-directed or directed at others Fear Important Nursing Interventions: C calm environment A ask client to identify cause/s. L let client describe feelings. M monitor for suicide ideation. E expression of feelings. R release tension and energy (art therapy) 6 years old Assignments/ Homeworks No Assignments/ Homeworks You Think Teacher may get angry Anxiety I am sick MALINGERING pretending to be sick (Conscious) Absent SOMATOFORM > no pretension > no organic basis > unconscious

Tx:

Dyspnea Palpitations Chest pain Gastric distress - diarrhea Tremors Insomnia Restlessness Anxiolytics Psychotherapy

PANIC DISORDER The cause is usually cannot be identified; sudden onset, with feelings of intense apprehension, and dread; May be severe, recurrent, or intermittent lasting 5 30 minutes; Fear of losing control about themselves, going crazy, heart attack, or dying; Client may also experience physical symptoms similar to GAD; Treatment: a. Relaxation techniques b. Cognitive Behavioral Therapy c. Benzodiazepines Alprazolam (Xanax) d. *** Antidepressants Sertraline; Paroxetine; OBSESSIVE-COMPULSIVE DISORDER Characterized by episodes of obsession (unwanted, repetitive thought) and compulsion ( unwanted, repetitive action) that influence a persons life; Char by irrational, repetitive, ritualistic behaviors that the px uses in attempt to control the anxiety resulting from obsessions; Affects the ADL of the client; Anxiety occurs if O-C are resisted, and from being powerless to stop obsession. Compulsive behaviors are related to decrease or neutralize anxiety; Treatment: a. Behavioral techniques Desensitization Graded response Modeling of desired behaviors Cognitive therapy - to stop altered thought. b. Antidepressants ***Clomipramine (Anafranil); SSRIs. c. Anxiolytics PHOBIA An irrational fear of an object or situation that persists even though the px may recognize it as unreasonable; Associated with panic-level of anxiety if the object, situation, or activity cannot be avoided;

Escape from Teacher PRIMARY GAIN (Behavior anxiety)

PSYCHOSOMATIC > Real pains/ illness > Real symptoms > 4 major types * Hypertension * Migraine Mama Care * Stress Ulcer * Asthma Attention SECONDARY GAIN

ANXIETY RELATED DISORDERS GENERAL ANXIETY DISORDER (GAD) Characterized by diffused, persistent, or unrealistic worry that rarely occurs by itself; Increase amount of inner energy consumed on controlling anxious feelings; Have used alcohol or other drugs to the point of dependence to control anxiety; Person may experience physical symptoms:

 a. Agoraphobia

Client will do anything just to avoid the phobic object regardless of the consequences; Types of Phobia: fear of being alone in open or public places where escape might be difficult or impossible; Client may not leave home;

1. Benzodiazepines 2. Antidepressants SSRI. Nursing Interventions: P provide safe environment for the client. T try to recall the traumatic event. S suicide precaution. D dont leave client alone. DISSOCIATIVE DISORDERS Is characterized by splitting off or removal from conscious awareness of some information, feeling, or mental function; Also associated with traumatic events and severe anxiety; Types of Dissociative Disorders: a. Dissociative Identity Disorder or multiple personality; existence of two or more fully developed distinct and unique personalities within the person; the personalities may take full control of the person one at a time; the personalities may or may not be aware of each other; the person is unable to recall important information; char by sudden transition from one personality to the other RELATED TO STRESS; dissociation is used as a method of distancing and defending self from anxiety and traumatic events; Clients with depersonalization disorder (like DID) are not admitted unless they are suicidal; GOAL: Integrate the personalities or memories so that they can coexist with the original personality. Psychotherapy Hypnosis Amobarbital sodium. b. Dissociative Amnesia inability to recall important personal information because it is anxiety provoking; memory impairment may be partial or complete; amnesia may be anterograde (recent information) or retrograde (past information); c. Dissociative (Psychogenic) Fugue Sudden travel away from home and assumes a new personality with inability to recall the past; This may occur suddenly for several hours or days; Follows severe psychosocial stress (marital quarrels, personal rejections, or natural disaster) It allows escape or flight from an intolerable situations. When the fugue state stops or lost .. the client returns home UNABLE to recall the fugue state.

a. Social Phobia fear of situations in which one might be embarrassed or criticized, and the fear of making fool of oneself; includes the fear of eating in public places, public speaking, or performing in public places; b. Specific Phobia a fear of a single object, activity, or situation such as snakes, closed spaces, and flying; Arachnophobia Aerophobia Acrophobia Aviophobia Claustrophobia Treatment: a. Behavioral techniques ***desensitization therapy of choice. b. Benzodiazepine Therapy

POSTTRAUMATIC STRESS DISORDER (PTSD) Grieving-like behaviors that result from a major and severe trauma like rape, assault, accident, fire, war, or natural disaster; Usually occurs AFTER a major traumatic events (usually after ONE month) Acute Stress Disorder anxiety during or immediate after a traumatic event (within 4 weeks or 1 month) May show physical manifestations: a. Flashbacks b. Insomnia and nightmares c. Eating problems d. Depression and isolation e. Hypervigilance and guilt about surviving the event; Types of PTSD: a. Acute less than 3 months after the event; b. Chronic 3 months or more after the event; c. Delayed at least 6 months after the event; Treatments: a. Psychotherapy b. Pharmacotherapy

Tx: Psychotherapy Anxiolytics SSRI Depersonalization Disorder An altered self-perception in which ones own reality is temporarily lost or changed; Feeling of self- detachment; The client may experience feelings of detachment but intact reality testing; To protect the client from an overwhelming stress; Tx: SSRI (Fluoxetine)

Migraine

Stress Ulcer

SOMATOFORM DISORDERS Complains of physical symptoms or illness for which no organic or physiologic cause can be identified; Evidence is present or presumption exists that the physical symptoms are connected to psychological factors or conflicts; With prolonged periods of diagnostic work ups with negative physical findings; The nurse or health team must never assume that patients are not sick. SOMATOFORM DISORDERS SOMATOFORM

BODY DYSMORPHIC DISORDER Preoccupation with an imaginary defect in ones physical appearance even though the person appears normal to others; Complaints of facial or body deformities; Client may have slight physical deformity but the reaction or preoccupation is out of proportion to the degree of deformity; Usually encountered during adolescence; Tendency to seek unnecessary surgery to correct the imaginary defect or minor flaws; May manifest with social impairment and altered work performance resulting from the clients desire to hide the imaginary defect; CONVERSION DISORDER Alteration or loss of functioning of a body part that is not related to any physical abnormalities (eg. Paralysis, blindness) Most symptoms are unconscious; HYPOCHONDRIASIS Morbid preoccupation with fear or belief that one has a serious disease based on personal interpretation of physical health; Paralysis Anosmia Blindness Aphonia Seizures Anesthesia or paresthesia No physical evidence of serious disease; Char by unwavering conviction of his/her illness; May show LA BELLE INDIFFERENCE. - Lack of concern regarding the severity of the above symptoms; - The client explains a severe disease calmly PAIN DISORDER Preoccupation with pain with no diagnostic findings as to the cause or intensity of pain; Pain that doesnt follow anatomical nervous system distribution; Have long history of several consultations with numerous doctors, use of drugs, or alcohol abuse; There is clear connection between a psychological stressor and onset of symptoms; With marked impairment in lifestyle and ADL; SOMATIZATION DISORDER

Nervous System CONVERSION DISORDER La Belle Indifference emotional disattachment from disability

Illusion of structural defect BODY DYSMHORPIC DISORDER

Minor Discomfort Interpreted as major illness HYPOCHONDRIASIS Maliit na butas, pinalalaki Favorite Past Time: Doctor Hopping Nursing Focus: Feelings PSYCHOSOMATIC DISORDERS Anxiety SNS BP Hypertension Vasoconstriction Cerebral Artery Left Gastric Artery PNS Bronchoconstriction Asthma

These individuals verbalize recurrent, frequent, and multiple somatic complaints for several years without physiologic cause; Begins before age 30; Clients usually see several physicians thru the years and even have exploratory and unnecessary surgeries; May also have social and occupational impairments; These pxs may have anxiety or depression; Or sleep disturbances, nervousness and experience suicidal ideation because of hopelessness about getting better; Common symptoms: Nausea and vomiting Dizziness Shortness of breath Dysmenorrhea Chest pain Other Types of Somatoform Disorders: 1. MALINGERING Intentional production of false or grossly exaggerated physical or psychological symptoms to get external compensation (leave, evading prosecution, compensation) May have no real symptoms or over exaggerated minor symptoms. 2. FACTITIOUS DISORDER aka Munchausens syndrome; When physical or psychological symptoms are intentionally produced or feigned TO GAIN ATTENTION; they may inflict injury to themselves to receive attention; Munchausens by proxy person inflicts injury or illness on SOMEONE else to gain attention or to be a hero; MOOD DISORDERS Associated with severe and painful sadness or abnormal elation; Changes a persons behavior, cognition, motivation, and emotions; Most common psychiatric diagnosis??? Also known as AFFECTIVE DISORDERS; Two Diagnostic Categories: 1. Major Depressive Disorder (MDD) A person experiences one or more episodes of depression with no manic or hypomanic manifestations; Twice as many women than men; Onset is usually early - mid 20s; 2. Bipolar Disorders A person experiences major depression with one or more manic or hypomanic episodes; Female and male ratio is the same; Onset is usually late 20s; MAJOR DEPRESSION

Etiologies: a. Biochemical Theory Altered or deficient levels of norepinephrine and serotonin are most often related to depression (Dopamine, Acetylcholine and GABA) Alterations in the functions of the hypothalamic-pituitary-adrenal system may cause depression; Alterations in the circadian rhythm (wake-sleep cycle) will cause problem with sleep patterns, arousal, activity, and hormonal secretions; b. Psychodynamic or Psychoanalytical Theory Depression occurs as a result of a persons ego loss in relationship to early life occurrences; Aggressive behavior inappropriately directed at self; Cognitive Theory Depression results when a person perceives all stressful situations as being negative; Interpersonal Theory Stated that persons difficulties, coping with individuals, life events, and life changes can be stressful and may lead to depression; Behavioral Theory Depression develops when one feels helpless and unworthy. Sociological Theory Stated that depression is caused by abnormal medical, social learning, stress, and response mechanism by an individual; Criteria for Major Depressive Disorder: 1. **Depressed mood. 2. **Anhedonia inability to experience or even imagine any pleasant emotion; 3. Sleep disturbances insomnia or hypersomnia; 4. Possible weight loss or weight gain. 5. Fatigue or energy loss. 6. Reduced recognition and concentration; 7. Psychomotor agitation increase or decrease activities; 8. Feelings of worthlessness or guilt; 9. Recurrent death or suicidal thoughts; 10. Symptoms must persists for a minimum of 2 weeks. A person must have at least 5/9, one of which is a depressed mood and/or anhedonia. Other symptoms of depression: 1. Apathy and sadness 2. Hopelessness and helplessness 3. Unworthiness and guilt 4. Anger 5. Decreased libido 6. Private verbal berating of self 7. Sudden crying without a cause 8. Dependency and Passiveness Nursing Diagnosis for MDD and Bipolars: 1. Ineffective individual coping

2. Hopelessness 3. Potential for injury 4. Potential for violence 5. Powerlessness 6. Altered nutrition 7. Sleep pattern disturbances 8. Impaired verbal communication Management: A. Nurse Interventions D drugs E expression of feelings P patient involvement in physical activities R reinforce decision making E nEvEr reinforce hallucination or delusions S suicide precaution S safe environment B. Pharmacotherapy 1. SSRI Fluoxetine (Prozac) 2. TCA Imipramine (Tofranil) 3. MAOI Phenelzine (Nardil) BIPOLAR DISORDERS Approximately 2 million people yearly suffer from bipolar disorders; Bipolar I disorders appear equally common among men and women; In men, the first episode is usually of manic manifestations; In women, it is depressive symptoms that come first before the manic signs; Characterized by episodes of mania and depression with periods of normal mood and activity in between; Also known as manic-depressive disorder; Clinical Manifestations of Mania: Denial**, distractibility, and delusions Resistance to treatment** Hyperactivity** Anorexia** Pleasurable activity involvement Irritability and insomnia Elevated mood Flight of ideas Loud and rapid speech Anger with labile mood Grandiosity or inflated self-esteem Types of Bipolar Disorders: 1. Bipolar I Disorder Has major depression and mania; Bipolar II Disorder The person has major depression and hypomanic rather than mania;

Hypomanic Episode Is almost similar to mania but with less severe level of impairment; Not severe enough to cause major problems in school, work, or home; Manic episodes only last at least 4 days in duration and does not warrant hospitalization; A. Nursing Management M - Maintain a safe environment. Monitor sleeping pattern. A - Always limit group activities. N - Never reinforce altered perceptions and delusions. I - Institute motor programs (running, walking) A - Avoid stimulants. Provide finger foods. B. Pharmacotherapy Lithium carbonate WOF signs of lithium toxicity. Carbamazepine Valproic acid Antianxiety drugs. **Antipsychotics for psychotic episodes during the manic phase of Bipolar I. PERSONALITY DISORDERS These are groups of psychiatric disorders that affects behavioral responses of an individual; Persons with this type of disorders are incapable of functioning effectively in the society; Patients are unaware of the adverse impacts of their behaviors; DSM-IV CLASSIFICATION Cluster A Odd/ Eccentric Aloof and emotionally distant from others; Behaviors are considered strange; 2. Paranoid Personality Disorder 3. Schizoid Personality Disorder 4. Schizotypal Personality Disorder Cluster B Dramatic / Erratic The individual is egocentric or self-centered; Little ability to understand anothers perspective; 1. Borderline Personality Disorder 2. Histrionic Personality Disorder 3. Antisocial Personality Disorder 4. Narcissistic Personality Disorder Cluster C Anxious / Fearful Appears overly anxious about various social and personal issues; Unusually concerned with the rules, procedures, and acceptance by others; 2. Dependent Personality Disorder

3. Avoidant Personality Disorder 4. Obsessive-Compulsive Personality Disorder CLUSTER A PERSONALITY DISORDERS A. Paranoid Personality Disorder Individual is very secretive, suspicious, and dont trust others ; Conviction that other people are out to do me in Also very aloof, cold, and overly serious affect; Uses projection; Schizoid Personality Disorder Steadfast determination to remain distant and aloof; Preferred solitary activities; Lack of desire to develop social contacts (answer using words or phrases) Fearful of intimate relationships; Tend to fantasize or daydream; C. Schizotypal Personality Disorder Usually expressed unusual ideas and magical thinking; Inability to form and maintain age-appropriate relationships; May have transient psychotic symptoms but not sufficient to be diagnosed as schizophrenia; Ex. People with ESP; can see and talk with dead people (Sixth Sense) CLUSTER B PERSONALITY DISORDERS A. Antisocial Personality Disorder More common in males; Char by constant antisocial behaviors (robbery, theft, alcoholism, vandalism, etc.) Sustained history of irresponsibility, self-centeredness, and impulsiveness; Lack of remorse for ones destructive actions; Very manipulative and exploits others; Manifests with anger that results in hostile outburst; Potential for violence; Commonly uses rationalization; Tx: Group Psychotherapy Borderline Personality Disorder The px may be impulsive with splitting tendency and suicidal; With outburst of intense anger and rage; Emotionally labile and with unstable personality; Tendency for self-mutilation; Also are manipulative; Most commonly treated; Histrionic Personality Disorder Melodramatic, colorful, highly energetic, and seductive; Tendency to have shallow relationships; Self-centered character;

Wants to be the center of attention; Tendency to make many demands on others for reassurance; Narcissistic Personality Disorder More common in males; Inflated sense of self-importance; Feeling of entitlement for recognition; Feelings of worthlessness if not praised and admired by others; With labile affect; Tx: Group Psychotherapy CLUSTER C PERSONALITY DISORDERS B. Dependent Personality Disorder Relies on others to assume large areas of responsibilities for his life; Excessive need to be taken care of; Unassertive and passive; Fear of shame and criticism; Inability to take risks or to initiate anything; May show signs of depression and anxiety; B. Avoidant Personality Disorder Avoidance of any situation that could result in criticisms and shame; Px feels discomfort in social gatherings; Px may be shy and fearful (of rejection or disapproval) Afraid to enter into a relationship unless he/she feels secured and accepted; C. Obsessive-Compulsive Personality Disorder Preoccupation with orders, rules and regulations; Usually perfectionist and meticulous; Too busy working to have social life; Has difficulty in making decisions; Uses reaction formation, undoing, and displacement ; SCHIZOPRENIA Morel described schizophrenia before as dementia praecox (precocious senility); Bleuler later coined the term schizophrenia which means split mind (not split personality); 95% of clients with schizophrenia have a lifetime disease; It is the most common thought disorder; SUICIDE is the most common cause of premature death of these clients; Usually appears in late adolescent or early adulthood; Affects men and women almost equally; II. Theoretical Perspective A. Biological Theories 1. Biochemical Theory (Dopaminergic Hypotheses) Excessive dopaminergic activity in cortical areas causes acute positive symptoms of schizophrenia (HIDES) 2. Neurostructural Theory

Patients with schizophrenia have four structural changes in the brain: a. Cerebral ventricular enlargement. b. Cerebral atrophy c. Hypoplasia of the medial limbic structures. d. Decreased cerebral blood flow specially in the prefrontal cortex. Higher incidence of schizophrenia in patients with a diagnosed psychotic relative; Monozygotic twins have a higher incident rate compared to ordinary individuals; Identical twins have 50% risk; Fraternal twins have 15% risk; Prenatal exposure to influenza Minor malformations developing during early gestation Complications of pregnancy particularly during labor and delivery;

3. Genetic Theory 4. Perinatal Risk Factors

B. Developmental Theory The first stage (trust vs mistrust) is very important in the development of interpersonal relationship. A child deprived of nurturing, loving environment, neglected or rejected, is very vulnerable to mental disturbances; Therapeutic intervention focuses on the reestablishment of trust thru consistent, anxiety-free relationship; III. DSM-IV Criteria in the Diagnosis of Schizophrenia A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): 1. Delusions 2. Hallucinations 3. Disorganized speech (e.g., frequent derailment or incoherence) 4. Grossly disorganized or catatonic behavior 5. Negative symptoms (anergia, alogia) B. Social / Occupational Dysfunction: Manifestations of psychosis will significantly affect the level of functioning of the client. C. Duration Signs of the disturbance persist for at least 6 months. D. Schizoaffective and Mood Disorder Exclusion: The manifestations of psychosis are NOT secondary to other mental illness. E. Substance / General medical condition exclusion:

The manifestations of psychosis are NOT secondary to substance abuse (shabu use) or medical illness (delirium, typhoid psychosis) BLEULERS Four As 1. Affective Disturbance Inappropriate affective response does not match the circumstances; Blunted the response to certain circumstances is weakly appropriate; Flat inability to generate any affective response; Labile emotional tone changes quickly; 2. Autism preoccupation with the self with little concern for external reality; 3. Associative looseness the stringing together of unrelated topics with VAGUE connections; 4. Ambivalence simultaneous opposite feelings; Positive vs Negative Symptoms of Schizophrenia 1. Positive Symptoms (type I) believed to be caused by an increase in the amount of dopamine; Symptoms are additional of abnormal cognition and perception; Targeted by typical anti-psychotics (Haldol, Thorazine) Examples of Positive Symptoms: Hallucinations and hostility Illusions and ideas of reference Delusions Excitement Suspiciousness Bizarre behavior Agitation or tension Grandiosity HIDES BAG 2. Negative Symptoms (type II) Symptoms are essentially an absence or diminution of what should be ( lack of affect, lack of energy) May be related to: decrease amount of dopamine cerebral atrophy decreased cerebral blood flow increase serotonin; Targeted by ATYPICAL anti-psychotics (Clozapine, Olanzapine) Examples of Negative Symptoms: Alogia poverty of content; lack of meaning or substance in what he say; Anhedonia Asocial behavior Attention deficit Avolition lack of motivation; Blunted affect

Communication difficulties (echolalia, neologism, word salad, etc) Difficulty with abstraction; Objective vs Subjective Behavioral Manifestations: A. Objective Signs 1. Alterations in personal relationships. Poor attention span. Poor self care or grooming. Poor social communication. 2. Alterations of activity. Psychomotor agitation Echopraxia Catatonic rigidity Stereotype behaviors Subjective Signs: Autism and Ambivalence Blocking Clanging association and concrete thinking Delusions Retardation slow mental activity. Flight of ideas, mutism, and word salad. neoloGism invented words. Hallucination Illusions and ideas of reference Delusions fixed, false beliefs; 1. Somatic delusions 2. Delusion of grandiosity 3. Delusion of religion 4. Delusion of nehilism (dead) 5. Delusion of reference other people is talking about you. 6. Delusion of influence or control 7. Delusion of persecution 8. Paranoid delusions Subtypes of Schizophrenia (DSM-IV) 1. Paranoid extreme suspiciousness persecutory delusions auditory hallucinations Uses PROJECTION. ND: Potential for violence, directed to others or self. 2. Catatonic Increased purposeless motor activities Stuporous or waxy flexibility Rigid posturing behavior Mutism and negativism

Peculiar movements Echolalia or echopraxia Uses REPRESSION. ND: Impaired motor activities. 3. Disorganized / Hebephrenic With child-like behaviors Incoherent speech Disorganized behavior Unsystematized delusions Inappropriate or flat affect Abnormal social behavior uses REGRESSION. 4. Undifferentiated Grossly disorganized and incoherent behavior Severe hallucinations Prominent delusions Severely impaired level of functioning. Or if the clients manifestations will not fall under the three categories. 5. Residual Absence of psychotic symptoms although the px had previous schizophrenia; Functional level moderately impaired and the client cant keep a permanent job; Treatment: 1. Psychosocial Therapy Initially focuses on the patients physical safety; Helping px to become stronger than their symptoms Support the patient by abandoning maladaptive behaviors for more acceptable ones; Design a treatment plan to raise the patients functional level and to educate the family on how to respond appropriately to the patients behavior; 2. Pharmacotherapy Use of phenothiazines (Thorazine) and other neuroleptics; Adjunctive drugs such as antiparkinsons, anticholinergics, propranolol, and diphenhydramine may be used to control adverse drug reactions; 3. Combination Therapy Psychotherapy and pharmacotherapy; To build a stable psychological foundation and helping the patient accept responsibility for self care, develop social relationships, and vocational satisfaction; Nursing Diagnosis: 1. Altered thought process*** 2. Sensory/perception alteration*** 3. Potential for violence, directed to self or others; 4. Ineffective individual coping

5. 6. 7. 8. 9. 10. 2. Environment

Personal identity disturbance Impaired verbal communication Self-care deficit Impaired social interaction Nursing Interventions: Safety Remove any unsafe objects from the patients environment; Keep the px oriented to reality and 3 spheres; Minimize environmental stimuli; Communicate in clear, direct, and concise manner; Assist the px with grooming if needed; Allow the px to make decisions when appropriate; Acknowledge the pxs abilities and skills, and use them to reinforce teaching; Give positive reinforcement when the px voluntarily interacts with others; Encourage the px to participate in group activities; Validate the patients perceptions that are accurate and correct all misperceptions; Monitor the patients vital signs; Provide period for adequate sleep and diet; Control hyperactive psychomotor activity; WOF: adverse drug reactions (EPSE)

ffect appropriate, inappropriate, flat, blunt (incomplete emotion) mbivalence torn between 2 opposing forces utism ssociative Looseness Symptoms Negative Hypoactive Withdrawn Apathy Positive Hyperactive Sociable Flight of Ideas Talkative

3. Self-esteem 4. Social activities 5. Ego development 6. Homeostasis 7. Correct delusions Establish and maintain reality for the client. Teach the client to practice positive thinking and IGNORING delusions. 8. Correct hallucinations and illusions Help maintain reality. Engage px in reality-based activities such as card playing or occupational therapy. SCHIZOPHRENIA Ego disintegration Impaired reality perception Genetic vulnerability Stress Diathesis Model o Too much stress in the reality will lead client to escape it and go to the fantasy world Biological Theory o Dopamine level is High The exact cause is unknown Assess : Hallucination/ Illusions Nx Dx : Disturbed sensory perception Planning/ Implementation: Present reality Provide safety Evaluation : Improve sensory perception Assess : Content of Thought Nx Dx : Disturbed thought process Planning/ Implementation: Present reality Provide safety Evaluation : Improve thought process

Assess : Suspicious Nx Dx : Risk for other directive behavior Planning/ Implementation: Present reality Provide safety Evaluation : Eliminate/ minimize risk for other-directed violence

Assess : Suicidal Nx Dx : Risk for self directive behavior Planning/ Implementation: Present reality Provide safety Evaluation : Eliminate/ minimize risk for self-directed violence

Flight or Looseness

 I am going to the mall. Where is the light? Go here. Mineral Water. I am going to the mall. The mall is big. Big is the tree. The tree is tall.

Lets go to the garden

But if nothing in the preceeding intervention are seen Assess what the voices are saying SCHIZOPRENIA

Disorganized
Magical Thinking Believes to have a magical power I can turn you into a frog Echolalia I repeat what you say Parrots Echopraxia I repeat what you do Word Salad words, no rhyme Clang Association words with rhyme : Dunk, plank, sunk Neologism creation of new words Plinking, hustash Clarification done in case of neologism Delusion: Persecutory NBI is out to get me/ someone will harm the client Religious I am Jesus Christ Grandeur I am the queen of the world. Ideas of reference Nurses are talking about me. Concrete Association pilosopo what will you wear? clothes Thought Blocking

Catatonic
Ambivalence Waxy Flexibility o Iniwan na posture, ganun forever No favorite word Negativism

Paranoid
Suspicious Tendency to be violent MistrustScaredWithdrawn Nrsg. Int: Develop trust 1 to 1 short interaction frequent visit foods in sealed container meds wrapped for violent pt. Doors open Near the door Dont touch the pt. Eye contact 1 arms length away call reinforcement

Sad but smiles o Inappropriate affect No reaction o Flat affect Flight of ideas o HEBEPHRENIC Giggling Positive and Negative S/Sx

classified differentiated
Mixed classification Cant be classified 1st paranoid, then disorganized then catatonic, etc etc

Residual
No more positive s/sx, just withdrawn

Stimulus Visual Auditory Tactile

Halucinations Absent X X X

Illusion Present

In case of hallucinations do: Hallucinations Acknowledgment I know you the voices are real to you Reality orientation But I dont hear them Diversion

OTHER PSYCHOTIC DISORDERS A. Schizoaffective Disorder Is a psychosis characterized by both affective and schizophrenic symptoms with substantial loss of occupational and social functioning; Schizophrenic symptoms are dominant but are accompanied by major depressive or manic symptoms; Delusional Disorder Manifest symptoms similar to schizophrenia but with substantial differences exists: 1. DELUSIONS have basis in reality. 2. Have not met the criteria of schizophrenia. 3. Behavior is relatively normal other than their delusions. 4. Duration of symptoms is brief.

5. Symptoms may be due to substance or general medical conditions. Tx: Anti-psychotics C. Brief Psychotic Disorder Psychotic disturbances that last less than 1 month and are not related to other mental disorders, general medical conditions, or substance abuse; Tx: Anti-psychotics Schizophreniform Disorder Shows symptoms of typical schizophrenia and last at least 1 month but no longer than 6 months; Tx: Anti-psychotics COGNITIVE DISORDERS Cognitive abilities are processes that allow the person to make sense of experience and to interact productively with the environment; 1. Judgment 2. Attention 3. Perception 4. Orientation 5. Reasoning 6. Memory Char by deficit in memory or cognition that significantly changes a persons level of functioning; Also known as Organic Brain Disorders; DELIRIUM (acute brain syndrome) Deficiency in the capacity to maintain attention; With rapid onset and brief duration; Char by acute loss of conscious awareness; May lasts for hours or weeks and resolves in a few days (reversible); Causes: 1. Physical abuse 2. Infection - sepsis 3. Endocrine problems thyrotoxicosis 4. Trauma massive blood loss; 5. Abuse of substance Signs and Symptoms: 1. Prodromal signs Restlessness Anxiety Sleep disturbance Irritability 2. **Cloudy consciousness cardinal sign. 3. Apathy 4. Impaired cognition and memory defects 5. Disturbances in perception 6. Disorganized thought process Nursing Diagnosis:

1. **Risk for injury related to cognitive and psychomotor deficit. 2. Self-care deficit related to inability to carry out ADL. Nursing Interventions: **Follow treatment plan to relieve cause of delirium. 1. Reality orientation a. Call the px by name and keep a clock and calendar in plain view. b. Use very simple words and short sentences. c. Provide a safe and quiet environment; 3. Monitor vital signs. 4. Set limitations on inappropriate and harmful behaviors. 5. Provide adequate nutritional and fluid intake if tolerated; DEMENTIA (chronic brain syndrome) Char by memory impairment and insidious loss of intellectual ability; May be due to destruction of neurons in the brain; Etiology usually due to other NEUROLOGIC diseases: 1. Parkinsons Disease 2. Picks disease 3. Huntingtons chorea 4. Wernicke-Korsakoffs Syndrome 5. Alzheimers Disease **** DSM-IV Criteria for Dementia 1. Memory impairment (amnesia) 2. At least one of the ff cognitive disturbances: a. Aphasia language disturbance b. Apraxia inability to carry out motor activities despite intact motor function; c. Agnosia failure to recognize or identify objects despite intact sensory function; d. Disturbance in executive functioning (abstracting, planning, organizing) 3. Significant impairment in social or occupational functioning after the onset of illness. ALZHEIMERS DISEASE Is the most common type of dementia; Exact cause is UNKNOWN; Is a degenerative brain disease causing dementia that is progressive and most of the time irreversible; Usually begins after age 60 but early signs can be observed at age 40; Death may occur within five years after diagnosis (pneumonia or from other infections) More common in males; Char by microscopic brain changes: 1. Senile plaques** 2. Degeneration of neurons or neurofibrillary tangles ** 3. Cerebral atrophy **

4. Reduced level of acetylcholine:** Loss of neurons in the basal ganglia Increase action of acetylcholinesterase enzyme; As of Alzheimers Disease: aging amnesia agnosia aphasia apraxia aluminum deposition amyloid deposition antibodies abnormalities acetylcholine abnormality abnormality in chromosome 21 Clinical Manifestations of AD: - Memory loss (amnesia) and mood swings - Intolerance for activity - Depression - Anger - Helplessness and hopelessness - Incontinence and abnormal reflexes - Lack of self-care and home care - Altered sleep and arousal patterns - Numerous behavioral symptoms (hallucinations, delusions, dysphoria, apathy, agnosia, apraxia, aphasia) Nursing Diagnosis: - **High risk for injury - Altered thought process - Anxiety Nursing Interventions: 1. Ensure safety: - removing toys and other dangerous objects in the vicinity; - rearranging furniture and use of pads; 2. Support and meet the clients basic needs (food, shelter, clothing) 3. Encourage activities of daily living. 4. Provide sensory stimulation (reading, music) 5. Encourage life review or reminisce. 6. Use clear, short and concise communication. Pharmacotherapy: - Antipsychotics for psychotic symptoms; - Antidepressants SSRIs; Nortriptyline and Desipramine; - Antianxiety used for agitation, anxiety, and sleep disturbances; Buspirone Lorazepam

Oxazepam 2. Metabolic enhancers / Vasodilators - treat cognitive impairment; Hydergine 3. Nootropic agents used to enhance neuronal metabolic activity; Nootrophil 4. Donepezil (Aricept) and Tacrine (Cognex) acetylcholinesterase inhibitors; TO INCREASE ACH LEVEL; Aricept given once daily with low incidence of hepatotoxicity; SUBSTANCE ABUSE Causes maladaptive behaviors secondary to mood-altering substances; UPPERS Stimulation of SNS DOWNERS Depression of SNS Substance abuse is a widespread concern with broad social ramifications and personal consequences; May lead to addiction; Most commonly abused substances: 1. Alcohol 2. Opiates 3. Narcotics 4. Hallucinogens 5. Stimulants 6. Inhalants ALCOHOL - is considered as the leading abused substance; CIGARETTE is the most commonly abused substance by psychiatric patients; ALCOHOL ABUSE Alcohol is a CNS depressant that is rapidly absorbed into the bloodstream; Alcoholism is considered to be present when there is 0.1% or 10mL for every 1000mL of blood; Levels: .1 - .2% - slow coordination, slurred speech .2 - .3% - tremors, irritability, violence .3% and above - unconsciousness Effects of Alcohol Intake: 1. Aggression 2. Blackouts 3. Coordination problem 4. Difficulty walking (unsteady gait) 5. Experience slurred speech 6. F - polyuria 7. Gone are inhibitions 8. Hanep makapag-relax 9. Impaired attention, concentration, memory and judgment; An overdose or excessive alcohol intake in short period of time can result to (ABCD): Altered level of consciousness

 Breathing is depressed and vomiting Coma Death Wernicke - Korsakoffs Syndrome Char by amnesia, clouding of consciousness, confabulation (falsification of memory) and peripheral neuropathy; Results from inadequate amounts of THIAMINE (B1) and NIACIN, and the neurotoxic nature of alcohol; Tx: Vitamin B1 or B-complex replacement; Common Behavioral Problems: Denial Dependency Demanding Destructive Domineering Treatment: Symptoms of withdrawal usually begin 4 12 hours (6-8 hrs) after cessation or marked reduction of alcohol intake; May lasts up to 5 days; ALCOHOL WITHDRAWAL SYNDROME Stage I 6-8 hrs after last intake. Anxiety and anorexia Insomnia and tremors N/V and hyperactivity Increase pulse and BP Depression Stage 2 8-12 hrs after lasts intake. Confusion Gross tremors Nervousness Disorientation Auditory and visual hallucinations Illusions Nightmares Stage 3 12-48 hrs after last intake. Severe hallucinations Seizures (Dilantin) Stage 4 3 5 days after last ingestion. Confusion and delirium. Clouding of consciousness. Disorientation. Visual and tactile hallucinations.

Fever and increase BP. Tremors and tachycardia. Medical emergency. Alcohol withdrawal can be life-threatening, so detoxification needs to be accomplish under medical supervision; Safe withdrawal is usually accomplished by benzodiazepines: Lorazepam (Ativan) drug of choice; Diazepam (Valium) Disulfiram (Antabuse) Inhibits the breakdown of acetaldehydes by an enzyme (aldehyde dehydrogenase) Alcohol (Ethanol) Acetaldehyde + H2 Acetic acid CO2 + H2O (for excretion) The person who drinks alcohol while taking disulfiram will become ill: (DISULFIRAM OR ANTABUSE REACTION) 1. Sweating 2. Flushing of the neck and face 3. Tachycardia and palpitations 4. Hypotension 5. Throbbing headache 6. Nausea and vomiting 7. Dyspnea 8. Tremors 9. Weakness Disulfiram may also cause arrhythmias, MI, cardiac failure, seizures, coma, and death; The unpleasant effects to alcohol is intended to help stop alcohol drinking; Once disulfiram is started, the px must not take alcohol because of the danger of these adverse effects; ALCOHOLISM Etiology: Intergenerational Transmission From one generation to another generation Alcohol Blackout awake but unaware Confabulation inventing stories to self-esteem Denial I am not an alcoholic Dependence I cant live without it Enabling significant other tolerates abusers Another term CO DEPENDENCY TOLERANCE Substance to achieve a previous effect

DETOXIFICATION Withdrawal with MD supervision Check Alcohol, Mouthwash, Elixer void alcohol version therapy lcoholics Anonymous self help group ntabuse DISULFIRAM Never drink alcohol 12 hour interval/ 12 h last alcohol intake B1 Vitamin Deficiency or else: nausea, vomiting and hypotension Wernickes Encephalopathy motor Complications Korsakoffs Psychosis memory Delirium Tremens 24 72 h after last dose of alcohol untreated withdrawal syndrome ormocation bugs crawling under the skin amily Therapy mother, father, brother FETAL ALCOHOL SYNDROME (FAS) Is the result of alcohols inhibiting effects on fetal development during the first trimester of pregnancy; Pregnant women who drink alcohol run the risk of seriously harming their unborn child; Characteristics: 1. Microcephaly 2. Severe mental retardation 3. Stillborn SEDATIVES, HYPNOTICS, and ANXIOLYTICS These are CNS depressants; Intoxication symptoms: (SIC LULI) 1. Slurred speech and stupor 2. Impaired verbal communication 3. Coma 4. Lack of coordination 5. Unsteady gait 6. Labile mood 7. Impaired attention or memory 8. Benzodiazepines when taken orally are rarely fatal (ONLY causes lethargy and confusion) Barbiturates (Parenteral or oral) can be lethal when taken in overdose (2 10 g can be fatal) 1. Coma 2. Respiratory arrest 3. Cardiac failure 4. Death Withdrawal Symptoms:

1. Usually occurs 6 8 hrs after cessation of some benzodiazepines; 2. Manifested by: 1. Autonomic hyperactivity a. Increase PR b. Increase BP c. Increase RR d. Increase in temperature 2. Hand tremors 3. Anxiety 4. Nausea 5. Insomnia 6. Psychomotor agitation Detoxification from sedatives, hypnotics, and anxiolytics often manage by TAPERING the amount of drugs the client receives over a period of days or weeks; Barbiturates can cause fetal abnormalities because these can cross the placental barrier; - Infants born to mothers who take barbiturates during the last trimester of pregnancy can experience withdrawal symptoms postpartum; OPIOIDS Are popular drugs because these desensitize the person to both physiologic and psychological pain and induce a sense of euphoria and well-being; Examples: 1. Morphine* 2. Opium* 3. Meperidine (Demerol)* 4. Codeine 5. Hydrocodone 6. Methadone drug of choice during detoxification. 7. Heroin* OPIOID INTOXICATION happen after the initial euphoric feeling: 1. Pinpoint pupils* 2. Apathy 3. Respiratory depression 4. Uncoordinated movements 5. Lethargy and listlessness 6. Attention and memory impairment 7. Slurred speech 8. NALOXONE (opioid antagonist) - is the treatment of choice for toxicity; NOT FOR DETOXIFICATION; 9. It reverses all the signs of opioid toxicity by blocking the neuroreceptors affected by opioids; 10. Immediately improves pxs respiration and consciousness; Withdrawal develops when (1) drug intake ceases or is (2) markedly decreased, or it can also be (3) precipitated by the administration of naloxone: 1. Craving

2. 3. 4. 5. 6. 7. 8. 9.

Restlessness and rhinorrhea Anxiety with aching backs and legs Nausea and vomiting Dysphoria and diarrhea Sweating Fever Insomnia Lacrimation

CRANDS FIL Heroin Withdrawal: STRICY Sneezing Tears Restlessness Irritability Coryza Yawning Methadone - is used to replace opioid during detoxification to reduce signs and symptoms of withdrawal; STIMULANTS (Amphetamines, Cocaine, Ecstasy ) Also known as uppers; These drugs excite the CNS; The effects of these drugs, even though they are different, are the virtually same; These drugs have limited clinical indications and a high potential for abuse; Amphetamines are commonly used before to lose weight (ex. IONAMINE) Cocaine and ecstasy have NO clinical use and is highly addictive; Commonly used as a recreational drug because of intense and immediate feeling of euphoria; Intoxication from stimulants develops rapidly: 1. Super active 2. Talkative 3. Impaired judgment 4. Mabilis pumayat (weight loss) 5. Unhappiness or anger 6. Loss of appetite (anorexia) 7. Anxiety 8. The presence of hallucinations and illusions 9. Euphoria Physiologic effects: a. Tachycardia b. Elevated BP c. Dilated pupils d. Diaphoresis with chills e. Nausea f. Chest pain and Confusion g. Cardiac arrhythmias

Cocaine users may also report bugs crawling beneath the skin (FORMICATION) and foul smells; Nasal septum perforation is associated with chronic snorting cocaine and is due to extreme vasoconstriction which impedes blood supply to the nasal septum causing necrosis; Cocaine or Stimulant Withdrawal: Occurs within a few hours to several days; Manifestations: ( D MANIPIS) a. Depressive symptoms b. Marked dysphoria feeling of unhappiness and anger; c. Agitation d. Nightmares e. Increase appetite f. Psychosis g. Increase suicidal ideations h. Sleeping disturbances CANNABIS (Marijuana) From Cannabis sativa, a hemp plant for making ropes and cloth; contain DELTA-9 TETRAHYDROCANNABINOL (THC) - the active substance; Marijuana upper leaves, flowering tops, and stems of the plant; Hashish is the dried resinous exudates from the leaves of the female plant; Cannabis most of the time is smoked like cigarettes but it can be eaten (brownies) Therapeutic use of cannabis: 1. Lowers IOP 2. ** Relieves nausea and vomiting associated with cancer chemotherapy (dronabinol, nabilone) 3. Anorexia and weight loss of AIDS Cannabis Intoxications: 1. Begins to act less than 1 minute after inhalation; 2. Peak levels occur in 20 30 minutes and lasts at least 2 - 3 hours; 3. Symptoms of Cannabis Intoxication: 4. Tachycardia 5. Hypotension 6. Eye redness 7. Psychotic symptoms (hallucinations) 8. Abnormal motor coordination 9. Short-term memory loss 10. Inappropriate laughter (laughing trip) 11. Social withdrawal 12. Increase appetite (food trip) 13. Disorientation, delirium, and dysphoria Treatment is usually symptomatic and overdose does not occur ( because easily excreted ) Withdrawal symptoms are usually not present when sudden cessation is performed;

HALLUCINOGENS Also referred to as psychotomimetics or psychedelics; Are substances that distort the users perception of reality and produce symptoms similar to psychosis; Used to treat chronic alcoholism and reduction of cancer pain and PLP; Two basic groups: 1. Natural a. Mescaline peyote from cactus; b. Psilocybin psilocin from mushrooms; c. Cannabis Synthetic a. LSD lysergic acid diethylamide b. STP dimethoxy-4-methylamphetamine c. Pencyclidine (PCP) most potent; d. DMT dimethyltryptamine e. MDA - methylenedioxyamphetamine f. Hallucinogen intoxication is marked by a variety of maladaptive behavioral or psychological changes: 2. Hallucinations 3. Anxiety 4. Paranoid ideation 5. Depression and dangerous behaviors 6. Ideas of reference 7. Toxic reactions to hallucinogens (except PCP) are primarily psychological and overdose usually will not occur; Psychotic reactions are best managed by: 1. Isolation from external stimuli. 2. Using physical restraints if necessary for the CLIENTS SAFETY. INHALANTS Are diverse groups of drugs that are inhaled for their effects: 1. Anesthetics 2. Nitrates 3. Organic solvents a. Gasoline b. Glue c. Paint thinner d. Spray paint e. Inhalants can cause significant brain damage, PNS damage, and liver disease; Inhalants may cause acute toxicity: 1. Respiratory depression 2. Anoxia 3. Vagal stimulation 4. Arrhythmias 5. Death ( due to bronchospasm, cardiac arrest, suffocation, or aspiration)

6. Treatment consist of supporting respiratory and cardiac functions until the substance is removed from the body; There are no withdrawal or detoxification procedures for inhalants; EFFECTS OF SUBSTANCE ABUSE 1. Decrease number of social friends. 2. Reduction of leisure activities. 3. Erosion of spiritual values and moral standards. 4. Abnormal physical functions. 5. Mounting family tension and mental deterioration. 6. Sexual and occupational problems. EATING DISORDERS ANOREXIA NERVOSA is a disorder characterized by compulsive resistance to eat and maintain body weight; Common in adolescent and young adult 12 18 years of age; With a mortality rate of 15 20%; Majority of cases are females; Clients usually die of severe malnutrition; Most of them are experiencing DENIAL (unconscious refusal to admit their disease) May be triggered by: adolescent crisis unconscious fear of growing up excessive concern and fear of obesity elevated feelings for self-control Manifestations of Anorexia Nervosa: Hypothermia, and hypotension Anemia with bradycardia/tachycardia. Nutritional deficiency (malnutrition) Obvious weight loss ( 15% or more of original body weight ) *** Resistance to eat (fear of eating) Electrolyte imbalance (hypoK and hypoNa) Keep high performance in school and sports Social withdrawal with poor individual coping Increase in size of salivary gland (hypertrophy) Amenorrhea (absence of at least 3 consecutive menstrual cycle) Nursing Diagnosis: Altered nutrition: less than body requirements Disturbed body image Ineffective individual coping Ineffective family coping Fluid and Electrolyte imbalance BULIMIA

A syndrome char by recurrent binge eating with lack of control and followed by purging (vomiting, use of laxatives or diuretics, or vigorous exercise) May also manifest with pica (or eating non-nutritious foods such as plaster, paint, clay, or sand) Common among adolescent and young adults 17-23 years old; More common among women; Tend to be episodic with remissions and relapse; Most clients know their illness; Is predispose to have depression; May have discord with family relationship; There is a profound history of obesity in the family; Manifestations: 1. Body and weight conscious. 2. Unusual, extroverted, and impulsive individuals. 3. Lability in weight (due to binge-eating and long hours of fasting) 4. Induced purging after binge-eating. 5. Multiple dental staining 6. I - Electrolyte imbalance (hyponatremia, hypokalemia, and hypochlorinemia) 7. Engages in vigorous exercises. 8. Signs of depression. Nursing Diagnosis: 1. Altered nutrition: less than body requirements 2. Ineffective family coping 3. Ineffective individual coping 4. Personal identity disturbance Nursing Interventions for Eating Disorders: 1. Weigh client daily. 2. Encourage verbalization of feelings. 3. Increase self-esteem. 4. Go observe for signs of purging and depression. 5. Help clients reestablish proper eating behavior. 6. Monitor caloric intake. 7. Electrolyte monitoring regularly. EATING DISORDERS 18 mos. 3 y.o. Toilet Training Clean Obedient Organized Thought 6 y.o. class valedictorian/ model student social inactive/ no BF weighing

I Am Fat Self Esteem Diet, Diet, Diet Anorexia Nervosa Eating Disorders Eating Pattern Diet, diet, diet Weight <85% of expected body Menstruation 3 mos. ammenorhea Karen Carpenter

Bulimia Eat, eat, vomit Normal weight Irregular menstruation Dao Ming Xi Da Ming Sugat/ suka Vomiting Dental caries Wounded knuckles Metabolic alkalosis Metabolic acidosis

Vomiting Fluid Volume Deficit ARRHYTHMIA (fatal complication) Diarrhea Interventions Restore fluid and electrolyte balance Collaborative regarding menu contract Target weight gain After meals: stay 30 mins 1 hour SEXUAL DISORDERS These are disorders that are related to human sexuality due to psychophysiological causes; Types: 1. Alteration in gender identity 2. Alteration in sexual orientation 3. Alteration in sexual behavior 4. Alteration in sexual functioning 5. Painful sexual disorders ALTERATION IN GENDER IDENTITY 1. Transsexualism Persistent discomfort about ones sex assignment; Caused by confused learning about gender roles; Feeling of being trapped in the wrong body; With intense feeling or preoccupation about transsexual surgery; 2. Gender Identity Disorder of Childhood Persistent and intense distress at ones sexual identity; Client insists that he/she is an opposite sex; Assertion that he/she will grow up to have transsexual surgery; 3. Nontranssexual Cross Gender Disorder

Feeling

Behavior

Persistent discomfort about ones sex but with no preoccupation with getting rid of the genitalia; ALTERATION IN SEXUAL ORIENTATION 1. Ego-Dystonic Homosexuality Weak heterosexual arousal with desire to have heterosexual relationship; Client experience inappropriate homosexual arousal pattern; ALTERATION IN SEXUAL BEHAVIOR 1. Sexual Acting Out With disturbed conduct or poor impulse control; Have extramarital affairs and promiscuous individuals; With high sexual drive; Presence of inadequate coping and interpersonal skills; 2. Paraphilia Sexual urges or fantasies that are directed toward nonhuman objects, pain to self, partner, or children, or other non-consenting individuals; This may be asymptomatic; Behavior often followed by guilt, shame, low self-esteem, or anxiety; Not due to other mental disorder; ALTERATION IN SEXUAL FUNCTIONING 1. Sexual Dysfunction individual is unsatisfied in his sexual function; 2. Hypoactive sexual desire absence of sexual fantasies and desires; 3. Sexual aversion avoidance of genital sexual contact with a partner; 4. Sexual arousal disorder Failure to attain and maintain erection in males; Lack of lubrication in females; Persistent or recurrent lack of subjective sense of sexual excitement and pleasure; PAINFUL SEXUAL DISORDERS 1. Vaginismus an involuntary vaginal spasm at penetration; Protection against anticipated pain associated with sexual trauma, intense guilt, or high religion offense; 2. Dyspareunia painful sexual intercourse; NURSING DIAGNOSIS 1. Altered sexuality patterns 2. Ineffective individual coping 3. Altered family process 4. Anxiety 5. Potential for violence: self-induced or to others. NURSING INTERVENTIONS: 1. Sexuality belief and values discussion. 2. Encourage to discuss feelings of guilt, remorse, anger, and loneliness. 3. X explain to the client the institution of suicidal precaution. OVERVIEW OF SUICIDE

SUICIDE Verbal I wont be a problem anymore This is my last day on earth Ill soon be gone Who will commit Suicide? Sex Male (more successful)/ female (hesitant) Age 15 24 y/o or above 45 Depression Patient with previous attempt ETOH ethanol - alcoholics Rirrational Social support lacking Organized plan greater risk No family Sickness, terminal SUICIDE TRIAD Loss of spouse Loss of job Aloneness Is Patient is SUICIDAL; nurse should: DIE Direct question Are you going to commit suicide? Irregular interval of visit to pt. room Early AM and period of endorsement the time pts commit suicide Best approach for suicidal pt. : Direct approach Nursing Management: Close surveillance Hospital area majority sucide will happens at: weekends 1- 3 am Sunday Weekend less staff personnel Early AM every one is asleep Give simple task. Dont give complex may cause depression ex. Jigsaw Water plants Wash the dishes except sharps is the 9 leading cause of death in the US; Among the three leading causes of death for those aged 15-34 years old; Females are higher to COMMIT suicide; Men are 4x higher to COMPLETE SUICIDE than females;
th

Non Verbal Take this ring, its yours (giving of valuable) Sudden change in mood

SUICIDE Or self-inflicted death; outcome of a persons inability to deal with catastrophic stress (depression) Suicide most often is the result of depression, diagnosed or not; Suicide may occur in children, adolescent, or adult populations; Suicidal ideation includes a persons thoughts regarding suicide; Suicidal gestures non-lethal self-injury acts like: 1. Cutting of skin areas 2. Burning of skin 3. Ingestion of poisonous substances or drugs Suicidal gestures may be considered as ATTENTION-SEEKING measures and MAY NOT LEAD to serious attempts or completion; Suicidal threats are persons verbal statements that may declare their intent to commit suicide; Threats OFTEN PRECEDE an actual suicide attempt; Suicide attempt is the actual implementation of a self-injurious act with the purpose of ending a persons life; The death by suicide of a psychiatric client is of particular importance to the nurse because of opportunities for assessment and interventions; (HIGH) Risk Factors for Completed Suicide: 1. Caucasian and Native Americans 2. Living alone single, divorced, widow/er 3. Age 40-60 and older 4. Male sex 5. Prior suicide attempts 50-85% 6. Substance use (alcoholism, drugs) 7. Hopelessness and helplessness 8. Unemployed or financial problems 9. General medical illness terminal cancer 10. Severe anhedonia

3. 4. 5. 6.

Hanging Drowning Carbon monoxide poisoning Overdose with certain drugs (alcohol, barbiturates, and other CNS depressants, ASA, valium) 7. Wrist cutting 8. Ingestion of poisonous substances 3. Rescue A person who deliberately attempts to deceive would-be rescuers has a high lethal potential; The more detailed the plan, the more lethal and accessible the method; The more effort to block rescuers, the greater the chance for a successful suicide; Nursing Diagnosis: Ineffective individual coping Potential for violence: self-directed Fear Anxiety Nursing Interventions: Assess and evaluate client for suicidal risk to develop a reasonable plan of care. Suspect suicidal ideation in most depressed clients. Inquire directly about the frequency and content of suicidal ideations. The nurse will not provoke suicide. The nurse will convey concern, worth of the client, and a sense of understanding. To plan nursing care. Evaluate clients access to a means of suicide to block the access. Develop a formal no suicide contract with the client. Advise the client to discontinue drugs and/or alcohol intake.

Assessment of Suicidal Patients: It is important for the nurse to be able to assess the suicidal potential of mentally ill clients because of higher risk in committing suicide; Plan The more developed the plan, the greater risk of suicide; Impulsive suicide attempts can also result in death but generally are less often lethal because of lack of planning; 2. Method Some methods of suicide are more lethal than others; One important factor in determining the lethality of a method is the time between initiation and the delivery of the lethal impact of the method; Ex. GSW is more lethal than drowning or suffocation; Types of Methods: 1. Gunshot 2. Jumping from high places

DEVELOPMENTAL DISORDERS A. MENTAL RETARDATION Or Cognitive Developmental Delay; Is defined by IQ BELOW 70 before 18 y/o that is accompanied by impairments in performing age-expected activities in daily living; 3% of the US population are considered MR; Most mentally retarded are in the MILD range; The causes of MR: 1. Specific Downs syndrome most common. Fragile X syndrome Phenylketonuria 2. Multifactorial causes Congenital anomalies

 Perinatal trauma Postnatal trauma Postnatal infections DSM-IV Classification of Mental Retardation LEVELS OF MENTAL RETARDATION Profound o < 20 o thinks like an infants o cant be trained o stay with the patient Severe o 20 35 Moderate o 35 50 o can be train o mental age is 2 7 y/o o pre-operational stage Mild o 50 70 o mental age is 7 12 o educable o can go to school Borderline o 70 - 90 Normal o 90 100

Down syndrome is one of the most widely known syndromes associated with MR; Clinical Manifestations: 1. Characteristic facial anomalies and others. a. Brachycephaly b. Epicanthal folds c. Flat nasal bridge d. Low-set ears e. Oblique palpebral fissures f. Protruding tongue ero 2 y/o g. Simean crease of palms ensorimotor 2. Congenital heart defects VSD, TOF, PDA evere 3. Mental retardation 4. Hypotonia Modera e 5. Growth retardation Fragile X Syndrome hirtyfive C. 50 nd 2 most common identifiable cause of MR; rainable Most common inherited cause; wo 7 y/o Dx made during mid-childhood; Clinical Manifestations: 1. Mild to moderate MR 2. Elongated face, prominent ears, macrocephaly, high-arched palate; 3. Macroorchidism at puberty 4. Autism 5. Attention deficit, hyperactive 6. Self-mutilating or self-injurious behaviors; D. Turners Syndrome MILD MR capable of EDUCATION; rare genetic disorder found among females; - Mental age of 8 12 years old; nd There is an absence of a normal 2 sex chromosomes; - Can learn to read, write, achieve vocational skills, and Genetic analysis reveals a 45,X chromosome constitution; function in the society; Clinical Manifestations: MODERATE MR the client is TRAINABLE; 1. The most prevalent: - Mental age of 3 7 years old; a. Short stature, webbed neck, low posterior hairline, - Can learn the activities of daily living; edema of the hand and feet; - Can be trained to work; b. Broad chest with inverted or underdeveloped nipples; SEVERE MR the client is barely trainable; c. Immature reproductive organs, primary amenorrhea - Mental age 0 -2 years old; AUTISTIC DISORDER - Totally dependent and in need of custodial care; Char by detachment from reality when self-preoccupation and self-involvement - May say few words; are predominant; - With uncoordinated motor movements; Strong genetic contributions but the exact cause remains UNKNOWN; PROFOUND MR mental age of young infant; Others suggest: - Requires full-time care; o increase level of serotonin - No academic skills; o abnormal serotonin receptors; - No fine or gross motor skills; Most are mentally retardate; B. DOWN SYNDROME (TRISOMY 21) Onset is usually at 30 months of age; Is the most common identifiable cause of MR;

AUTISM Autistic Savant autistic with a special talent Assess Appearance flat affect, consistent movement Behavior repetitive, ritualistic Communication echolalia, incomprehensible Nx Dx Impaired verbal communication Impaired social interaction Self mutilation Risk for injury Planning/ Implementation Maslows hierarchy of needs Constancy, promote safety Evaluation Expressive therapy drawing, muscic etc Enhanced communication Improved social interaction Safety Clinical Manifestations: o Profoundly disturbed social relatedness; o Constant delay in the developmental profile; o Aloof and indifferent to others; o Prefers inanimate objects than human contacts; o Temper tantrums o Language is delayed and deviant: Abnormal intonation Pronoun reversals Echolalia o Stereotypical behaviors Rocking Hand flapping Extraordinary insistence on sameness Preoccupation with peculiar interests (fans, aircons) Nursing Interventions: o Maintain a consistent and familiar environment. o Set consistent and firm limits for behaviors. o Encourage verbalization of feelings and concerns. o Prevents destructive behaviors. o Provide routine for ADLs. Pharmacologic Tx: o Haloperidol (Haldol) - to decrease or relieve: Temper tantrums Aggressiveness Self-injury

Hyperactivity Stereotypical behaviors o Naltrexone o Clomipramine o Clonidine o Stimulants DISRUPTIVE BEHAVIOR DISORDERS ATTENTION-DEFICIT HYPERACTIVITY DISORDER Is char by inattention, impulsiveness, and overactivity; Is a relatively common among SCHOOL-AGED CHILDREN (2-11%); The exact etiology is STILL UNKNOWN; Experts suggest that dysfunction of the frontal lobe; May occur together with learning disabilities; Possible Etiologies: 1. Environmental exposures a. Perinatal insults b. Head injury c. Psychosocial adversity d. Lead poisoning 2. Food additives and history of allergies. 3. Genetic predisposition especially among identical and fraternal twins. ATTENTION DEFICIT HYPERACTIVE DISORDER Onset : 7 y.o. and below Duration : 6 months and above Settings : 2 House and school Id Dominant : Mom or RN will act as superego ADHD Glucose Frontal Lobe impaired judgement ADHD S/Sx Ritalin Frontal Lobe Judgement ADHD S/Sx (stimulant) Assess Appearance dirty Behavior clumsy, impatient, easily distracted, hyperactive Communication talkative, blurts out in class

Nx Dx Risk for injury Impaired social interaction Planning/ Implementation tructure separate room for eating, playing, sleeping and etc chedule time for everything et limits afety

Evaluation Minimize Risk for Injury Improved social interaction Safety Residual ADHD grows up not antisocial Meds: Ritalin, dexedrin, pemoline, adderal Best time to give: once a day: AFTER MEALS: prevent lost of appetite Dont give at bedtime STIMULANT causes insomnia Give 6 hours prior bedtime if bid MAIN PROBLEMS OF ADHD:*** I Inattention H Hyperactivity I Impulsivity NURSING DIAGNOSIS: Risk for injury.*** Management: 1. Multidisciplinary approach (environmental and behavioral) is the treatment of choice. 2. Pharmacotherapy CNS STIMULANTS work for 70-75% of ADHD (only for children older than 7 years old) Effective in decreasing motor activities and increasing attention span and concentration; *** Methylphenidate (Ritalin) most common; Dextroamphetamine (Dexadrin) Pemoline (Cylert) Clonidine (Catapres) TCAs (Imipramine, desipramine, nortriptyline) TIC DISORDERS Term used to describe several disorders that are characterized by motor and/or vocal tics; TIC is a sudden, rapid, recurrent, non-rhythmic, stereotyped motor movement or vocalization; Tics can be suppressed for a period of time but not indefinitely; Tics are exacerbated by stress and diminished during sleep and when the person is engaged in an absorbing activity; Motor Tics typically rapid, jerky movements of the eyes, face, neck, and shoulders; Vocal Tics most common are throat clearing, grunting, or other repetitive noises; Echolalia Palilalia Coprolalia

TOURETTES SYNDROME is a chronic idiopathic movement disorder that is char by the presence of multiple motor and vocal tics for more than 1 year; May experience all types of tics in his lifetime; Will lead to significant impairment on social, academic, or occupational functioning; May feel ashamed and self-conscious; Rare and more common among BOYS than girls; Onset usually by age 7 years; Dx: Haloperidol (Haldol)

ABUSE Wrongful use and maltreatment of another person (spouse, partner, child, or elderly) May lead to: Physical injuries Psychological injuries Victims of abuse may also show: Upset Numb Agitation Withdrawn low self-esteem Aloof Domestic violence goes undisclosed for months or years (due to FEAR OF THE ABUSER) Char of a Violent Family: 1. Social Isolation Do not invite others into their home or tells others what is going on; Threat from the abuser; 2. Abuse of Power and Control Abuser is almost always in a position of power and control over the victim; Physical, economic, or social power; 3. Alcohol and Drug Abuse Abuser commonly uses alcohol or drugs; Alcoholism is also present in 50% of abused women; Alcohol and drugs are also associated with date rape; 4. Intergenerational transmission process Family violence is a learned response; 1/3 of abusive men grew from a violent family or with history of abuse; SPOUSE OR PARTNER ABUSE Is the maltreatment or misuse of one person by another in the context of an intimate relationship; 90 95% of domestic violence victims are WOMEN; Pregnancy increases violence in a relationship; This can be:

1. Psychological or emotional abuse Name-calling Belittling Shouting Destroying properties Threats Refusing to speak to the victim 2. Physical Abuse Shoving Pushing Battering Choking Fractures Homicide 3. Sexual Abuse During sex; Biting nipples Pulling hair Slapping Hitting Rape Char of an Abuser: 1. inAdequacy 2. Isip Bata (immature) 3. pUr problem-solving skills 4. low Self-esteem 5. jEalous and possessive 6. act is Rewarding Why women stay with their abusive husbands? 1. DEPENDENCY - is the most common reason. 2. Cycle of Violence CYCLE OF VIOLENCE Violent behavior 1. Violent Behavior Explodes in violent / abusive attack; 2. Period of Remorse Or Honeymoon Period Regret and apology Im sorry. It will never happen again. Promise Buys gifts, flowers, jewelries, etc. Wife believes her husband. May start from weeks to months. Then becomes frequent. 3. Tension Building Stage Arguments again ensue; Silence No complaints

Assess for signs of abuse CHILD ABUSE or child maltreatment; Intentional injury to a child; May include: Physical abuse and injuries Neglect or failure to prevent harm Failure to provide care Abandonment Sexual assault Torture Types of Child Abuse: Physical Emotional Neglect Sexual Physical Abuse Usually due to corporal punishment; Hitting and Burning Biting and Cutting Poking Twisting limbs Scalding with hot water Evidence of old injuries (healed fx) and multiple bruises of various stages. Stop crying Diumebs ka na naman... Emotional Abuse Verbal assaults Constant family violence Withholding affection and love Neglect Is the most common type of maltreatment; Refused or delay to seek medical help. Abandonment Inadequate supervision Disregard for safety Spousal abuse in childs presence Failure to enroll to school Sexual Abuse 75% of cases involve father-daughter incest; Rape Sodomy Molestation Exploitation of minors Char of Parents (in Child Abuse)

Lack of parenting skills Lack of understanding in childrens needs Lack of money Lack of education With history of child abuse Warning Signs of Abused Children: A Absence of trauma but with serious injuries (fracture, burns, lacerations) B Bruised, red, swollen, teared genitalia (vagina and anal) U Unusual injuries for age and development (Femoral fx in a 2 month old) S Switching and inconsistencies in childs history. E Evidence of old injuries.*** D Delay in seeking treatment for severe injury. Nursing Interventions: Ensure the childs safety and well-being. Thorough psychiatric evaluation. Establish trust to help child deal with trauma of abuse. Use play therapy to express his feelings. Refer to social works.