111basic Concepts in Psychiatric Nursing

BASIC CONCEPTS IN
PSYCHIATRIC NURSING
MENTAL HEALTH
Is a state of emotional, psychological,

and social wellness evidenced by
satisfying
personal
relationships,
effective behavior and coping, a
positive self concept, and emotional
stability.
COMPONENTS OF MENTAL
HEALTH (Johnson, 1997)
Autonomy and Independence

Maximizing Ones Potential
Tolerating Lifes Uncertainties
Self-esteem
Mastering the Environment
Reality Orientation
Stress Management
HEALTH AUTONOMY AND
INDEPENDENCE
The individual can look within for guiding

values and rules to live by.
The opinions and wishes of others are

considered but do not dictate the persons
decisions and behavior.
The person can work independently or

cooperatively with others without losing his
or her autonomy
HEALTH MAXIMIZING ONES
POTENTIAL
The person has an orientation toward

growth and self-actualization.
He or she is not content with the

status quo and continually and
continually strives to grow as a person.
HEALTH TOLERATING LIFES
UNCERTAINTIES
The person can face the challenges of

lifes day-to-day living with hope and a
positive outlook, despite not knowing
what lies ahead.
HEALTH SELF-ESTEEM
The person has realistic awareness of

his or her abilities and limitations.
COMPONENTS OF MENTAL HEALTH

MASTERING THE ENVIRONMENT
The person can deal with and influence

the environment in a capable,
competent, and creative manner.

REALITY ORIENTATION
The person can distinguish the real

world from a dream, fact from fantasy,
and act accordingly.

STRESS MANAGEMENT
The person can tolerate life stresses,

experience feelings of anxiety or grief
appropriately, and experience failure
without devastation.
He or she uses support from family

and friends to cope with crises,
knowing that the stress will not last
forever.
MENTAL ILL HEALTH
A state of imbalance characterized by

disturbance in a persons thoughts,
feelings and behavior.
MENTAL DISORDER (AMERICAN

PSYCHIATRIC ASSOCIATION, 1994)
Is a clinically significant behavioral or

psychological syndrome or pattern that
occurs in an individual and that is
associated with present distress (i.e.,
painful symptom) or disability (i.e.,
impairment in one or more important
areas
of
functioning)
or
with
a
significantly increased risk of suffering
death, pain, disability, or an important
loss of freedom.
PSYCHIATRIC NURSING
Interpersonal process whereby the professional

nurse practitioner through the therapeutic use
of self assists a family, group, or community to
promote mental health, to prevent mental
illness and suffering, to participate in the
treatment and rehabilitation of the mentally ill,
and if necessary to find meaning in these
experiences.
It is both a science and an art.
THE SCIENCE
IN PSYCHIATRIC NURSING
The use of different theories in the

practice of nursing serves as the
science of Psychiatric Nursing
THE ART
The therapeutic use of self is

considered as the art of Psychiatric
Nursing.
THE CORE
OF PSYCHIATRIC NURSING
The interpersonal process, that is, the

human-to-human relationship, is the
core of Psychiatric Nursing.
THE CLIENTS
The individual, the family, and

community, both mentally healthy
mentally ill, are considered as
clientele in Psychiatric Nursing.
the
and
the
MENTAL HYGIENE
It is the science that deals with

measures to promote mental health,
prevent mental illness and suffering
and facilitate rehabilitation.
SAMPLE BOARD QUESTION

NO.1
Which of the following is a generally

accepted component of mental health?
A) Autonomy
B) Absence of anxiety
C) Ability to control others
D) Happiness
ANSWER
Letter A
Rationale: According to Johnson, 1997,

autonomy and independence is one of
the components of mental health.

NO.2
A major predisposing factor of mental

illness in the home is?
A) Urbanization
B) Poverty
C) Political turmoil
D) Genetics
ANSWER
Letter B
Rationale: Poverty and domestic

abuses are some of the most common
causes of mental illness at home

NO.3
The science which deals with the

measures to promote mental health and
reduce incidence of mental illness is
known as?
A) Psychiatric Nursing
B) Psychology
C) Psychiatry
D) Mental Hygiene
ANSWER
Letter D
Rationale: Mental Hygiene is the

science that deals with measures to
promote mental health.
Psychiatric
Nursing is the interpersonal process
whereby the nurse assists the patient
to attain a state of mental health.

NO.4
Nursing as an interpersonal process is?

A) The science of nursing
B) The art of nursing
C) The core of nursing
D) The clientele of nursing
ANSWER
Letter C
Rationale: The core of Psychiatric

Nursing
is
the
human-to-human
relationship
or
the
interpersonal
process.

NO.5
Mental illness is?

A) Always hereditary in nature
B) Is manageable but is never treatable
C) A behavioral pattern associated with a
significantly increased risk of suffering
death, pain, disability, or an important
loss of freedom.
D) A state of emotional balance
ANSWER
Letter C
Rationale: Mental Illness is a clinically

significant
behavioral
or
psychological
syndrome or pattern that occurs in an
individual and that is associated with present
distress (i.e., painful symptom) or disability
(i.e., impairment in one or more important
areas of functioning) or with a significantly
increased risk of suffering death, pain,
disability, or an important loss of freedom.
THERAPEUTIC USE OF
SELF
THERAPEUTIC USE OF SELF
During therapeutic communication,

nurses
use
themselves
as
a
therapeutic tool
to
establish a
therapeutic relationship with the client,
to help the client grow, change, and
heal.
It is the main tool used by the nurse in

the practice of Psychiatric Nursing.
Using ones humanity personality, experiences,

values, feelings, intelligence, needs, coping
skills, and perceptions to help the client grow
and change is called THERAPEUTIC USE OF
ONES SELF (Northouse & Northouse, 1998).
It is the main tool used by the nurse in the

practice of Psychiatric Nursing.
It is the positive use of ones self in the process

of therapy
Hildegaard Peplau (1952), who described this

therapeutic use of self in the nurse-client
relationship, believed that nurses must have a
clear understanding of themselves to promote
their clients growth and to avoid limiting
clients choices to those valued by the nurse.
Therapeutic use
AWARENESS!!!
of
self
requires
SELF-
SELF-AWARENESS
Self-awareness means an understanding of

ones personality, emotions, sensitivity,
motivation, ethics, philosophy of life,
physical and social image, and capacities
(Campbell, 1980).
It is the process by which the nurse gains

recognition of his or her own feelings,
beliefs, and attitudes.
SELF-AWARENESS
The nurse needs to discover himself and what he believes

before trying to help others with different views.
Most of the time, the nurses values and beliefs will conflict with
those of the client, the nurse must learn to accept these
differences among people and view each client as a worthwhile
person regardless of the clients opinions and lifestyle.
Therefore,
OTHERS!
understand
YOURSELF
before
understanding
SELF-AWARENESS
The greater the nurses understanding of his or her own

feelings and responses, the better he or she can
communicate with and understand others.
One tool that is useful in learning more about oneself is

the JOHARI WINDOW (Luft, 1970), which creates a word
portrait of a person in four areas and indicates how well
a person knows himself or herself and communicates
with others.
FOUR QUADRANTS OF THE

JOHARI WINDOW
QUADRANT I
Open Public Self
Qualities
one
knows
about
oneself and others also know
QUADRANT II
Blind / Unaware Self
Qualities known only to others
QUADRANT III
Hidden / Private Self
Qualities known only to oneself
QUADRANT IV
Unknown
An empty quadrant to symbolize
qualities as yet undiscovered by

oneself or others
CREATING
A JOHARI WINDOW
First
Step
Appraise ones own qualities by creating a list of
those qualities:
Ones values
Attitudes
Feelings
Strengths
Behaviors
Accomplishments
Needs
Desires
Sad thoughts
CREATING A JOHARI WINDOW
Second Step
Find out how others perceive you by
interviewing others and asking them
to identify qualities they see in you,
both positive and negative.
CREATING A JOHARI WINDOW
Third Step
Compare lists and assign qualities to
the appropriate quadrants.

JOHARI WINDOW
If
Quadrant I is the
longest
list,
this
indicates the person is
open to others; a small
Quadrant I means the
person shares little
about
himself
or
herself with others

JOHARI WINDOW
If Quadrants I and III
are both small, the

person demonstrates
little insight.

JOHARI WINDOW
The
goal is to work
toward
moving
qualities
from
Quadrants II, III and IV
into
Quadrant
I
(qualities known to
oneself and others),
which indicates the
person is gaining selfknowledge and selfawareness.
METHODS USED TO INCREASE

SELF-AWARENESS
ROLE PLAY
Putting yourself in the clients situation allows you to think about his
or her thoughts, feelings and actions.
INTROSPECTION
Self-awareness can be accomplished through reflection, spending
time consciously focusing on how one feels and what one values or
believes.
Keep a diary that focuses on experiences and related feelings.
DISCUSSION
Talk with others about your own experiences and feelings and how
they feel about similar experiences.
Try to seek alternative points of view.
ENLARGING ONES EXPERIENCE

Being involved in new situations and experiences will uncover
qualities in yourself you might have not seen before.
CORE CONCEPTS ON
THE CARE OF THE
PSYCHOTIC PATIENT
COMMON BEHAVIORAL SIGNS

AND SYMPTOMS
Disturbances in Perception
Disturbances in Thinking
Disturbances in Affect
Disturbances in Motor Activity
Disturbances in Memory
DISTURBANCES IN
PERCEPTION
DISTURBANCES IN PERCEPTION:
ILLUSION
Misperception of an actual external

stimuli
Example
An electrical cord on the floor may
appear to be a snake!
DISTURBANCES IN PERCEPTION:
HALLUCINATION
False sensory perception in the absence of an

external stimuli
Perceptual experiences that do not exist in
reality
Example
A person may see angels hovering above
when nothing is there
A person may hear voices in a room
wherein he is alone
DISTURBANCES IN
THINKING
DISTURBANCES IN THINKING:
NEOLOGISM
Pathological coining of new words
These are words invented by the client

Example:
I am afraid of grittiz. If there are any

grittiz here, I will have to leave. Are you
a grittiz?
CIRCUMSTANTIALITY
Over inclusion of details.

Example:
Nurse: How have you been sleeping lately?
Client: Oh, I go to bed early, so I can get plenty of rest.
I like to listen to music or read before bed. Right now I
am reading a good mystery. Maybe I will write a mystery
someday. But is it isnt helping, reading I mean. I have
been getting only 2 or 3 hours of sleep at night.
WORD SALAD
Incoherent mixture of words and phrases.
This is a combination of jumbled words and

phrases that are disconnected or incoherent
and make no sense to the listener.
Example:
Corn, potatoes, jump up, play games, grass,
cupboard.
VERBIGERATION
Meaningless repetition of words and

phrases.
Example:
I want to go home, go home, go
home, go home.
PERSEVERATION
Persistence of a response to a previous question.

Example:
Client: I think people have been following me.
Nurse: Where do you live?
Client: At my place people have been following me.
Nurse: What do you like to do in your free time?
Client: Nothing because people are following me.
ECHOLALIA
Pathological repetition of words of others.
Example:
Nurse: Can you tell me how you are
feeling?
Client: Can you tell me how you are
feeling? how you are feeling?
FLIGHT OF IDEAS
Shifting of one topic from one subject

to another in a somewhat related way.
Excessive amount and rate of speech
composed of fragmented or unrelated
ideas.
LOOSENESS OF ASSOCIATION
Shifting of a topic from one subject to another in a

completely unrelated way.
Example:
Nurse: Do you have enough money to buy that candy bar?

Patient: I have a real yen for chocolate. The Japanese have all
the yen and have taken all of our money and marked it. You
know, you have to be careful of the Marxists because they are
friends with the Swiss and they have all the cheese and all the
watches and that means they have taken all the time. The worst
thing about Swiss cheese is all the holes. People have to be
careful about falling into holes.
CLANG ASSOCIATION
The sound of the word gives direction to the

flow of thought.
Examples:
I will take a pill if I go up to the hill but not if my
name is Jill, I dont want to kill.
I want to sing ping pong that song wong kong long
today, hey way.
DELUSION
False belief which is

knowledge and culture
inconsistent
with
ones
Examples:
The client may claim to be engaged to a famous
movie star or related to some public figure such
as claiming to be the daughter of the President of
the Philippines
May claim he or she has found a cure for cancer
DISTURBANCES IN
AFFECT
DISTURBANCES IN AFFECT:
INAPPROPRIATE AFFECT
Disharmony between the stimulus and

the emotional reaction.
BLUNTED AFFECT
Severe
reduction
emotional reaction.
Restricted
in
range of
emotional
feeling,
tone, or mood
FLAT AFFECT
Absence or near absence
of emotional reaction
Absence
of any facial
expression that would
indicate
emotions
or
mood
APATHY
Dulled emotional tone
Feelings of indifference toward people,

activities, and events
AMBIVALENCE
Presence of two opposing feelings.
Holding
seemingly
contradictory
beliefs of feelings about the same
person, event or situation
DEPERSONALIZATION
Feeling of strangeness towards oneself
Clients feel detached from their behavior

Although client can state his name correctly, he feels as if
his body belongs to someone else, or that his spirit is
detached from his body.
He may feel that his limbs are detached or that the size of
his body parts is changed, or he is unable to tell where his
body leaves off and the rest of the world begins
Patient describes the feeling of having stepped outside
their bodies and are observing themselves as detached
and foreign objects.
DEREALIZATION
Feeling of strangeness towards the environment
Environmental objects become smaller or larger, or

seem unfamiliar.
Individual feels that the outside world has changed:

Buildings may appear to be leaning
Everything may seem gray and dull
DISTURBANCES IN
MOTOR ACTIVITY
DISTURBANCES IN MOTOR
ACTIVITY:
ECHOPRAXIA
The
pathological
imitation of posture or
action of others.
Imitation
of
the
movements
and
gestures
of
another
person whom the client
is observing.
DISTURBANCES IN MOTOR
ACTIVITY:
WAXY FLEXIBILITY
Maintaining
the
desired position for
long periods of time
without
discomfort
even
when
it
is
awkward
or
uncomfortable.
DISTURBANCES IN
MEMORY
DISTURBANCES IN MEMORY:
CONFABULATION
Filling in of memory gaps to save face in an embarasing situation.

It is a confused persons tendency to make up a response to a
question when he cannot remember the answer
Example:
Nurse: Do you know Gemma? (referring to one of the residents at the

patients home)
Patient: Yes, I know her. I used to play cards with her husband.
Actually, Gemmas husband had been dead for many years and the
patient had never met him
AMNESIA
Inability to recall past events.
ANTEROGRADE AMNESIA
Loss of memory of the immediate past.
RETROGRADE AMNESIA
Loss of memory of the distant past.
DEJA VU
Feeling of having been to a place

which one has not yet visited.
JAMAIS VU
Feeling of NOT having been to a place

which one HAS VISITED.
A patient changes topics quickly while relating

his past psychiatric history. However, the
nurse is able to follow his thoughts. The
patients pattern of thinking is called?
A) Looseness of association
B) Flight of ideas
C) Clang association
D) Confabulation
ANSWER
Letter B
Rationale: Flight of ideas is the shifting

of a topic from one subject to another
in a somewhat related way. Looseness
of association is the shifting of a topic
from one subject to another in a
completely unrelated way.
A patient states, The sun is shining.

Where is my sun? I love Lucy. Let us
play ball. The patient is displaying?
A) Clang association
B) Flight of ideas
C) Derealization
D) Neologism
ANSWER
Letter B
Rationale: The patient is manifesting

flight of ideas
The main function confabulation

serves in patients with dementia, is to?
A) Lessen isolation
B) Protect their self-esteem
C) Control others
D) Enhance memory recall
ANSWER
Letter B
Rationale: Confabulation is the filling in

of memory gaps and it serves to
protect the patients self-esteem
A patient has mistakenly perceived a

coiled piece of wire as a snake. This is
an example of?
A) Illusion
B) Hallucination
C) Delusion
D) Confabulation
ANSWER
Letter A
Rationale: The patient misperceived an

actual external stimulus.
All of the following are disturbances in

thinking, EXCEPT?
A) Looseness of association
B) Hallucination
C) Delusion
D) Clang association
ANSWER
Letter B
Rationale:
Hallucination
disturbance in perception.
is
CORE CONCEPTS ON
THERAPEUTIC
COMMUNICATION
COMMUNICATION
COMMUNICATION
It is the interchange of information

between two or more people
It is the exchange of ideas or thoughts.
ELEMENTS OF
COMMUNICATION
Sender
Originator of the information
Message
Information being transmitted
Receiver
Recipient of information
Channel
Mode of communication
Feedback
Return response
Context
The setting of the communication
VARIABLES THAT INFLUENCE

COMMUNICATION
Perception
Experience of sensing, interpreting, and comprehending
the world in which the person lives
Values
Principles, standards of quality considered worthwhile or
desirable
Culture
The totality of socially transacted behavior patterns,
arts, beliefs, institutions, products of human work
characteristic of a community or population
LEVELS OF COMMUNICATION
Intrapersonal
Occurs when a person communicates within himself
Interpersonal
Takes place within dyads (groups of two persons) and in
small groups.
The level of person-to-person communication is the heart of
of psychiatric nursing
Public
Communication between a person and several other people
MODELS OF COMMUNICATION
Communication is an Act
Communication is an Interaction
Communication is a Transaction
COMMUNICATION IS AN ACT
It is something that a person is doing to another person

(example: person A talks to person B)
There is an attempt to transfer the thoughts or ideas of
one person into someone elses head.
It suggests that the receiver plays a passive role and
does not affect the communicator
When
misunderstandings
occur,
either
the
communicator is faulted for failing to send the correct
message or the receiver is faulted for having allowed
something to interfere with the transmission of a
correct message.
The model is, therefore, inadequate
COMMUNICATION IS AN
INTERACTION
It takes into account the process of

mutual influence.
When two people interact, they put

themselves into each others shoes.
It is a circular process in which the

participants
take
turns
at
being
communicator and receiver
COMMUNICATION IS A
TRANSACTION
It is viewed as a process of simultaneous mutual influence

rather than as a turn-taking event.
No one is labeled either as a communicator or receiver.
The
symbolic
interactionist
model
views
human
communication on the social, interpersonal level and accounts
for the whole persons involved in the process.
The participants are products of their social systems and
integral parts of it. Some events take place within the
participants (intrapersonal) and some take place between the
participants (interpersonal).
MODES OF COMMUNICATION
Verbal Communication
Non-verbal Communication
VERBAL COMMUNICATION:
THE SPOKEN WORD
Denotation
Connotation
Private and Shared meanings
THE SPOKEN WORD
Denotation
The meaning that is in general used
by most persons who share a
common language; the particular,
explicit, literal meaning of the word.
THE SPOKEN WORD
Connotation
Usually arises from a persons
personal experience
Suggests or implies something in
addition to the literal meaning
THE SPOKEN WORD
Private and Shared Meanings

For communication to take place,
meanings must be shared.
People labeled schizophrenic may
use language in an idiosyncratic way
or may use a private, unshared
language called neologisms.
NON-VERBAL MESSAGES
They carry more meaning than verbal

messages and involves the following:
Body movement or kinetics
Voice quality (pitch and range) and
non-language sounds (sobbing or
laughing)
NON-VERBAL
MESSAGES
They carry more meaning than verbal messages and involves
the following:
Proxemics use of personal or social space
Intimate Distance actual contact to 1.5 feet

Personal Distance 1.5 to 4 feet or 3 to 4 feet for interviews
Social Distance 4 to 12 feet
Public Distance 12 feet and beyond
Cultural Artifacts items in contact with interacting persons

that may act as non-verbal stimuli (i.e., clothes, cosmetics,
jewelry, cars)
CHARACTERISTICS OF
SUCCESSFUL COMMUNICATION
1) Feedback (return response)

If effective, may result in extension,
clarification or alteration of the original
communication
2) Appropriateness
The reply is fitting and relevant to the
communication; it is neither too much nor
too little
CHARACTERISTICS OF
SUCCESSFUL COMMUNICATION
3) Efficiency
The language used is understood
4) Flexibility
The absence
under-control
of
over-control
or
ESSENTIAL INGREDIENTS TO
FACILITATE COMMUNICATION
Respond with empathy
Respond with respect
Respond with genuineness
Respond with immediacy
Respond with warmth
THERAPEUTIC COMMUNICATION
An interpersonal interaction between the

nurse and client during which the nurse
focuses on the clients specific needs to
promote
an
effective
exchange
of
information
Skilled use of therapeutic communication

techniques helps the nurse understand and
empathize with the clients experience
GOALS OF THERAPEUTIC
COMMUNICATION
Establish a therapeutic nurse-client relationship
Identify the most important client concern at the

moment (the client-centered goal)
Assess the clients perception of the problem as it

unfolded.
This includes detailed actions (behaviors and messages) of

the people involved and the clients thoughts and feelings
about the situation, others, and self
Facilitate the clients expression of emotions
GOALS OF THERAPEUTIC
COMMUNICATION
Teach the client and family necessary self-care

techniques
Recognize the clients needs
Implement interventions designed to address the

clients needs
Guide the client toward identifying a plan of action

to a satisfying and socially acceptable resolution.
THERAPEUTIC
COMMUNICATION
TECHNIQUES
TECHNIQUES
Accepting
Focusing
Broad Openings
Formulating a Plan of
Consensual validation
Encouraging Comparison
Encouraging Description of
Perceptions
Encouraging Expression
Exploring
Action
General Leads
Giving Information
Giving Recognition
Making Observations
Offering self
TECHNIQUES
Placing Event in Time
Silence
or Sequence
Presenting Reality
Reflecting
Restating
Seeking Information
Suggesting
Collaboration
Summarizing
Translating into
Feelings
Verbalizing the Implied
Voicing Doubt
TECHNIQUES: ACCEPTING
Definition
Indicating reception
Examples
Yes
I follow what you said
Nodding
Rationale
An accepting response indicates the nurse has heard and followed
the train of thought.
It does not indicate agreement but is nonjudgmental.
Facial expression, tone of voice, and so forth also must convey
acceptance or the words will lose their meaning
TECHNIQUES: BROAD
OPENINGS
Definition
Allowing the client to take the initiative in introducing the topic
Examples
Is there something youd like to talk about?
Where would you like me to begin?
Rationale
Broad openings make explicit that the client has the lead in the
interaction.
For the client who is hesitant about talking, broad openings
may stimulate him or her to take the initiative
TECHNIQUES: CONSENSUAL
VALIDATION
Definition
Searching for mutual understanding, for accord in the meaning of
the words.
Examples
Tell me whether my understanding of it agrees with yours.
Are you using this word to convey that . .
Rationale
For verbal communication to be meaningful, it is essential that the
words being used should have the same meaning for all
participants.
Sometimes words, phrases, or slang terms have different
meanings and can be easily misunderstood.
TECHNIQUES: ENCOURAGING
COMPARISON
Definition
Helping the client to understand by looking at similarities and
differences.
Examples
Was it something like. . . ?
Have you had similar experiences?
Rationale
Comparing ideas, experiences, or relationships brings out many
recurring themes.
The client benefits from making these comparisons because he or
she might recall past coping strategies that were effective or
remember the he or she has survived a similar situation
TECHNIQUES:
ENCOURAGING DESCRIPTION OF
PERCEPTIONS
Definition
Asking client to verbalize what he or she perceives.
Examples
Tell me when you feel anxious
What is happening?
What does the voice seem to be saying?
Rationale
To understand the client, the nurse must see things from his or her
perspective.
Encouraging the client to describe ideas fully may relieve the
tension the client is feeling, and he or she might be less likely to
take action on ideas that are harmful or frightening.
TECHNIQUES: ENCOURAGING
EXPRESSION
Definition
Asking client to appraise the quality of his or her experience.
Examples
What are your feelings in regard to. . ?
Does this contribute to your distress?
Rationale
The nurse asks the client to consider people and events in
light of his or her own values.
Doing so encourages the client to make his or her own
appraisal rather than accepting the opinion of others.
TECHNIQUES: EXPLORING
Definition
Delving further into a subject or idea.
Examples
Tell me more about that.
Would you describe it more fully?
What kind of work?
Rationale
When clients deal with topics superficially, exploring can help them
examine the issue more fully.
Any problem or concern can be better understood if explored in depth.
If the client expresses an unwillingness to explore a subject, however,
the nurse must respect his or her wishes.
TECHNIQUES: FOCUSING
Definition
Concentrating on a single point.
Examples
This point seems looking at more closely.
Of all the concerns you have mentioned, which is most
troublesome?
Rationale
The nurse encourages the client to concentrate his or her energies
on a single point, which may prevent a multitude of factors or
problems from overwhelming the client.
It is also a useful technique when a client jumps from one topic to
another.
TECHNIQUES:
FORMULATING A PLAN OF
ACTION
Definition
Asking the client to consider kinds of behavior likely to be
appropriate in future situations.
Examples
What could you do to let your anger out harmlessly?
Next time this comes up, what might you do to handle it?
Rationale
It may be helpful for the client to plan in advance what he or
she might do in future similar situations.
Making definite plans increases the likelihood that the client
will cope more effectively in a similar situation
TECHNIQUES: GENERAL LEADS
Definition
Giving encouragement to continue.
Examples
Go on.
And then?
Tell me about it.
Rationale
General leads indicate that the nurse is listening and following what
the client is saying without taking away the initiative for the
interaction.
They also encourage the client to continue if he or she is hesitant
or uncomfortable about the topic.
TECHNIQUES: GIVING
INFORMATION
Definition
Making available the facts that the client needs.
Examples
My name is. . .
Visiting hours are. . .
My purpose in being here is. . .
Rationale
Informing the client of facts increases his or her knowledge
about a topic or lets the client know what to expect.
The nurse is functioning as a resource person
Giving information also builds trust with the client.
TECHNIQUES: GIVING
RECOGNITION
Definition
Acknowledging, indicating awareness.
Examples
Good Morning Ms. A. . .
Youve finished your list of things to do.
I notice that youve combed your hair.
Rationale
Greeting the client by name, indicating awareness of change, or
noting efforts the client has made all show that the nurse
recognizes the client as a person, as an individual.
Such recognition does not carry the notion of value, that is, of being
good or bad.
TECHNIQUES:
MAKING OBSERVATIONS
Definition
Verbalizing what the nurse perceives.
Examples
You appear tense.
Are you uncomfortable when . . ?
I notice that you are biting your lip.
Rationale
Sometimes clients cannot verbalize or make themselves
understood.
Or the client may not be ready to talk.
TECHNIQUES: OFFERING SELF
Definition
Making oneself available.
Examples
I will sit with you awhile.
I will stay here with you.
I am interested in what you think.
Rationale
The nurse can offer his or her presence, interest, and desire to
understand.
It is important that this offer is unconditional, that is, the client
does not have to respond verbally to get the nurses attention.
TECHNIQUES: PLACING EVENT IN TIIME
SEQUENCE
Definition
Clarifying the relationship of events in time.
Examples
What seemed to lead up to. . ?
Was this before or after?
When did this happen?
Rationale
Putting events in proper sequence helps both the nurse and client to see
them in perspective.
The client may gain insight into cause-and-effect behavior and
consequences, or perhaps some things are not related.
The nurse may gain information about recurrent patterns or themes in
the clients behavior relationship.
TECHNIQUES: PRESENTING
REALITY
Definition
Offering for consideration that which is real.
Examples
I see no one else in the room.
That sound was a car backfiring.
Your mother is not here. I am a nurse.
Rationale
When it is obvious that a client is misinterpreting reality, the nurse
can indicate what is real.
The nurse does this by calmly and quietly expressing the nurses
perceptions of the facts not by way of arguing with the client or
belittling his or her experience.
The intent is to indicate an alternative line of thought for the client
to consider, not to convince the client that he or she is wrong.
TECHNIQUES: REFLECTING
Definition
Directing client actions, thoughts, and feelings back to the client.
Examples
Client: Do you think I should tell the doctor?
Nurse: Do you think you should?
Client: My brother spends all my money and then has the nerve to ask for
more.
Nurse: This causes you to feel angry?
Rationale
Reflection encourages the client to recognize and accept his or her own
feelings.
The nurse indicates that the clients point of view has value, and that the
client has the right to have opinions, make decisions, and think
independently
TECHNIQUES: RESTATING
Definition
Repeating the main idea expressed.
Examples
Client: I cant sleep. I stay awake all night.
Nurse: You have difficulty sleeping.
Client: I am really mad. I am really upset.
Nurse: Youre really mad and upset.
Rationale
The nurse repeats what the client has said in approximately or nearly the
same words the client has used.
This restatement lets the client know that he or she communicated the
idea effectively.
This encourages the client to continue
Or if the client has been misunderstood, he or she can clarify his or her
thoughts.
TECHNIQUES:
SEEKING INFORMATION
Definition
Seeking to make clear that which is not meaningful or that
which is vague.
Examples
I am not sure that I follow.
Have I heard you correctly?
Rationale
The nurse should seek clarification throughout interactions
with clients.
Doing so can help the nurse to avoid making assumptions
that understanding has occurred when it has not.
It helps the client to articulate thoughts, feelings, and ideas
more clearly.
TECHNIQUES: SILENCE
Definition
Absence of verbal communication, which provides time for the client
to put thoughts or feelings into words, regain composure, or continue
talking.
Examples
Nurse says nothing but continues to maintain eye contact and
conveys interest
Rationale
Silence often encourages the client to verbalize provided that it is
interested and expectant.
Silence gives the client time to organize thoughts, direct the topic of
interaction, or focus on issues that are most important.
Much nonverbal behavior takes place during silence, and the nurse
needs to be, aware of the client and his or her own nonverbal
behavior.
TECHNIQUES:
SUGGESTING COLLABORATION
Definition
Offering to share, to strive, to work with the client for his or her
benefit.
Examples
Perhaps you and I can discuss and discover the triggers for
your anxiety.
Lets go to your room and I will help you find what you are
looking for.
Rationale
The nurse seeks to offer a relationship in which the client can
identify problems in living with others, grow emotionally, and
improve the ability to form satisfactory relationships.
The nurse offers to do things with, rather than for, the client
TECHNIQUES: SUMMARIZING
Definition
Organizing and summing up that which has gone before.
Examples
Have I got this straight?
Youve said that. .
During the past hour, you and I have discussed..
Rationale
Summarization seeks to bring out the important points of the
discussion and to increase the awareness and understanding of
both participants.
It omits the irrelevant and organizes the pertinent aspects of the
interaction.
It allows both client and nurse to depart with the same ideas and
provides a sense of closure at the completion of each discussion.
TECHNIQUES:
TRANSLATING INTO FEELINGS
Definition
Seeking to verbalize clients feelings that he or she expresses
only indirectly.
Examples
Client: I am dead.
Nurse: Are you suggesting that you feel lifeless?
Client: I am way out in the ocean.
Nurse: You seem to feel lonely or deserted.
Rationale
Often the client says, when taken literally, seems
meaningless or far removed from reality.
To understand, the nurse must concentrate on what the client
might be feeling to express himself or herself this way.
TECHNIQUES:
VERBALIZING THE IMPLIED
Definition
Voicing what the client has hinted at or suggested.
Examples
Client: I cant talk to you or anyone. It is a waste of time.
Nurse: Do you feel that no one understands?
Rationale
Putting into words what the client has implied or said indirectly
tends to make the discussion less obscure.
The nurse should be as direct as possible without being
unfeelingly blunt or obtuse.
The client may have difficulty communicating directly
The nurse should take care to express only what is fairly obvious;
otherwise the nurse may be jumping to conclusions or interpreting
the clients communication
TECHNIQUES: VOICING DOUBT
Definition
Expressing uncertainty about the reality of
the clients perceptions.
Examples
Isnt that unusual?
Really?
That is hard to believe.
TECHNIQUES: VOICING DOUBT
Rationale
Another means of responding to distortions of reality is
to express doubt.
Such expression permits the client to become aware
that others do not necessarily perceive events in the
same way or draw the same conclusions.
This does not mean the client will alter his or her point
of view, but at least the nurse will encourage the client
to reconsider or reevaluate what has happened.
The nurse neither agreed nor disagreed; however, he or
she has not let the misperceptions and distortions pass
without comment.
NON-THERAPEUTIC
COMMUNICATION
TECHNIQUES
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES
These
responses
cut
off
communication and make it more
difficult for the interaction to continue
It takes practice for the nurse to avoid

making these typical comments
NON-THERAPEUTIC
Advising
Giving Literal
Agreeing
Responses
Indicting the Existence
of an External Source
Interpreting
Introducing an
Unrelated Topic
Making Stereotyped
Comments
Belittling Feelings
Expressed
Challenging
Defending
Disagreeing
Disapproving
Giving Approval
NON-THERAPEUTIC
Probing
Requesting an
Reassuring
Explanation
Testing
Using Denial
Rejecting
NON-THERAPEUTIC
COMMUNICATION TECHNIQUES:
ADVISING
Definition
Telling the client what to do.
Examples
I think you should.
Why dont you?
Rationale
Giving advice implies that only the nurse knows
what is best for the client.
NON-THERAPEUTIC
AGREEING
Definition
Indicating accord with the client.
Examples
That is right.
I agree.
Rationale
Approval indicates the client is right rather than wrong.
This gives the client the impression that he or she is right because
of agreement with the nurse.
Opinions and conclusions should be exclusively the clients
When the nurse agrees with the client, there is no opportunity for
the client to change his or her mind without being wrong
BELITTLING FEELINGS
EXPRESSED
Definition
Misjudging the degree of the clients discomfort.
Examples
Client: I have nothing to live for. . . I wish I was dead
Nurse: Everybody gets down in the dumps. OR I have felt that way
myself.
Rationale
When the nurse tries to equate the intense and overwhelming
feelings the client has expressed to everybody or to the nurses
own feelings, the nurse implies that the discomfort is temporary,
mild, self-limiting, or not very important.
The client is focused on this or her own worries and feelings; hearing
the problems or feelings of others is not helpful.
NON-THERAPEUTIC
CHALLENGING
Definition
Demanding proof from the client.
Examples
But how can you be the President of the United States?
If you are dead, why is your heart beating?
Rationale
Often the nurse believes that if he or she can challenge the
client to prove unrealistic ideas, the client will realize there is
no proof and then will recognize reality.
Actually challenging causes the client to defend the delusions
or misperceptions more strongly than before.
NON-THERAPEUTIC
DEFENDING
Definition
Attempting to protect someone or something from verbal attack.
Examples
This hospital has a fine reputation.
I am sure your doctor has your best interests in mind.
Rationale
Defending what the client has criticized implies that he or she has
no right to express impressions, opinions, or feelings.
Testing the client that his or her criticism is unjust or unfounded
does not change the clients feelings but only serves to block
further communication
NON-THERAPEUTIC
DISAGREEING
Definition
Opposing the clients ideas.
Examples
That is wrong.
I definitely disagree with. . .
I do not believe that. . .
Rationale
Disagreeing implies the client is wrong
Consequently the client feels defensive about his or her
point of view or ideas.
NON-THERAPEUTIC COMMUNICATION
TECHNIQUES: GIVING APPROVAL
Definition
Sanctioning the clients behavior or ideas.
Examples
That is good.
I am glad that. .
Rationale
Saying what the client thinks or feels if good implies that the
opposite is bad.
Approval then, tends to limit the clients freedom to think, speak, or
act in a certain way.
This can lead to the clients acting in a particular way just to please
the nurse.
NON-THERAPEUTIC
GIVING LITERAL RESPONSES
Definition
Responding to a figurative comment as though it were a
statement of fact.
Examples
Client: They are looking in my head with a television camera.
Nurse: Try not to watch television. OR What channel?
Rationale
Often the client is at a loss to describe his or her feelings, so such
comments are the best he or she can do.
Usually it is helpful for the nurse to focus on the clients feelings in
response to such statements.
NON-THERAPEUTIC
INDICATING THE EXISTENCE OF
AN EXTERNAL SOURCE
Definition
Attributing the source of thoughts, feelings,
and behavior to others or to outside
influences.
Examples
What makes you say that?
What made you do that?
Who told you that you were a prophet?
INDICATING THE EXISTENCE OF AN
EXTERNAL SOURCE
Rationale
The nurse can ask, What happened? or
What events led you to draw such a
conclusion?
But to question What made you think that?
implies that the client was made or compelled
to think in a certain way.
Usually the nurse does not intend to suggest
that the source is external but that is often
NON-THERAPEUTIC
INTERPRETING
Definition
Asking to make conscious that which is unconscious; telling the
client the meaning of his or her experience.
Examples
What you really mean is. . .
Unconsciously you are saying. . .
Rationale
The clients thoughts and feelings are his or her own, not to be
interpreted by the nurse or for hidden meaning.
Only the client can identify or confirm the presence of feelings.
INTRODUCING AN UNRELATED
TOPIC
Definition
Changing the subject.
Examples
Client: I would like to die.
Nurse Did you have visitors last night?
Rationale
The nurse takes the initiative for the interaction away from
the client.
This usually happens because the nurse is uncomfortable,
does not know how to respond, or has a topic he or she would
rather discuss.
MAKING STEREOTYPED
COMMENTS
Definition
Offering meaningless cliches or trite comments.
Examples
It is for your own good.
Just keep your chin up
Just have a positive attitude and you will be better in no time.
Rationale
Social conversation contains many cliches and much meaningless
chit-chat.
Such comments are of no value in the nurse-client relationship.
Any automatic responses will lack the nurses consideration or
thoughtfulness.
NON-THERAPEUTIC
PROBING
Definition
Persistent questioning of the client.
Examples
Now tell me about this problem. You know I have to find out.
Tell me your psychiatric history.
Rationale
Probing tends to make the client feel used or invaded.
Clients have the right not to talk about issues or concerns if
they choose.
Pushing and probing by the nurse will not encourage the client
to talk.
NON-THERAPEUTIC
REASSURING
Definition
Indicating there is no reason for anxiety or other feelings of discomfort.
Examples:
I would not worry about that.
Everything would be alright.
You are coming along just fine.
Rationale
Attempts to dispel the clients anxiety by implying that there is not
sufficient reason for concern completely devalues the clients feelings.
Vague reassurances without accompanying facts are meaningless to the
client.
NON-THERAPEUTIC
REJECTING
Definition
Refusing to consider or showing contempt for the clients
ideas or behaviors.
Examples
Let us not discuss. . .
I do not want to hear about. . .
Rationale
When the nurse rejects any topic, he or she closes it off from
exploration.
In turn, the client will feel personally rejected along with his
or her ideas.
NON-THERAPEUTIC
REQUESTING AN EXPLANATION
Definition
Asking the client to provide reasons for thoughts, feelings,
behaviors, events.
Examples
Why do you think that?
Why do you feel that way?
Rationale
There is a difference between asking the client to describe what is
occurring or has taken place and asking him to explain why.
Usually a why question is intimidating.
In addition, the client is unlikely to know why and may become
defensive trying to explain himself or herself.
NON-THERAPEUTIC
TESTING
Definition
Appraising the clients degree of insight.
Examples
Do you know what kind of hospital this is?
Do you still have the idea that. . ?
Rationale
These types of questions force the client to try to recognize
his or her problems.
The clients acknowledgement that he or she does not know
these things may meet the nurses needs but is not helpful
for the client
NON-THERAPEUTIC
USING DENIAL
Definition
Refusing to admit that a problem exists.
Examples
Client: I am nothing.
Nurse: Of course you are something. Everybody is something.
Client: I am dead.
Nurse: Do not be silly.
Rationale
The nurse denies the clients feelings or the seriousness of the
situation by dismissing his or her comments without attempting to
discover the feelings or meaning behind them.
NON-VERBAL COMMUNICATION
This is transmitted with or without verbal

communication.
It is essential that the nurse become aware of
her own non-verbal communication in addition
to becoming skillful in identifying the clients
non-verbal communication.
Non-verbal communication provides clues about
the validity of the spoken words and congruency
with the clients behavior.
The phrase Actions speak louder than words is
generally accurate.
A
list
of
ways
in
which
non-verbal
communication is conveyed to others follows:
Tone of voice
Voice inflection
Facial Expression
Silence
Gestures
Mannerism
Posture
List
of
ways
in
which
non-verbal
communication is conveyed to others:
Eye contact
Rate of speech
A hurry up attitude
An I couldnt care less attitude
Physical appearance
Touch
Space
GUIDELINES FOR
IDENTIFYING THERAPEUTIC
RESPONSES IN THE BOARD
EXAM
GUIDELINES FOR IDENTIFYING

THERAPEUTIC RESPONSES IN
THE BOARD EXAM
Identify therapeutic and non-therapeutic phrases
Open-ended or Closed-ended question?
Avoid why questions and instead use what questions
Avoid false reassurances
Avoid focus on the nurse (use of the word I); or focus on the doctor.
Focus on the patient instead.
Use direct questions for suicidal cases
Avoid the Authoritarian Answer
THERAPEUTIC RESPONSES IN THE

BOARD EXAM: LOOK FOR
THERAPEUTIC PHRASES
The following are therapeutic

utilized by the nurse:
It seems
It sounds
I will sit with you
I will stay with you
I will check
Tell me
phrases

BOARD EXAM: LOOK FOR NONTHERAPEUTIC PHRASES
The use of labels is non-therapeutic
Thats good!
Thats bad!
Youre the best!
Youre the worst!

The use of absolutes is non-therapeutic
Always
Never
None
All.

The use of commands is non-therapeutic

You need to
You must
You should

BOARD EXAM: USE OF OPEN-ENDED
QUESTIONS
Tell me, how do you feel, then follow it

up with I understand how you feel. I will
stay with you for awhile.

BOARD EXAM: USE OF CLOSED-ENDED
QUESTIONS
Use of Closed-ended questions is therapeutic

when dealing with:
Manic patients
This would discourage them from over-control of

the conversation
Rape or Crisis Victims
With their unstable condition, they may

misconstrue use of open-ended questions as
prying.

BOARD EXAM: USE OF WHY
QUESTIONS
The use of the question why is non-therapeutic

Example:
Client: I was speeding along the street and did not stop
at the sign
Nurse: Why were you speeding?
Rationale
Responses to why questions are considered
prying, violate the clients privacy and places the
client in a defensive position

BOARD EXAM: USE OF WHAT
QUESTIONS
The use of the question what is

therapeutic
What is happening?
What does the voice seem to be saying?
What transpired after that?

BOARD EXAM: AVOID FALSE
REASSURANCES
Examples:
I would not worry about that.
Everything would be alright.
You are coming along just fine.
Rationale
This response blocks the fears, feelings and other thoughts
of the client. Furthermore, vague reassurances without
accompanying facts are meaningless to the client

BOARD EXAM: USE OF THE WORD I
Example:
Client: Should I move from my home to
a nursing home?
Nurse: If I were you, Id go to a nursing
home, where youll get your meals
cooked for you
Rationale:
Therapeutic Communication is always client-centered, it is
never nurse-centered.

BOARD EXAM: USE OF THE WORD
YOU
Examples
Client: I am dead.
Nurse: Are you suggesting that you feel lifeless?
Client: I am way out in the ocean.
Nurse: You seem to feel lonely or deserted.
Rationale:
Therapeutic Communication is always
centered, it is never nurse-centered.
client-

BOARD EXAM: USE OF DIRECT
QUESTIONS FOR SUICIDAL PATIENTS
Nurse: Do you have any plans of killing

yourself?

BOARD EXAM:
AVOID THE AUTHORITARIAN ANSWER
Authoritarian Answer
Avoid statements like I think you
should. . I should know, I am the nurse
Rationale
Giving authoritarian answers implies
that only the nurse knows what is best
for the client
WHAT TO REMEMBER IN
Be empathetic and not just

sympathetic!
EMPATHY
Is the ability of the nurse to perceive the meanings

and feelings of the client and to communicate that
understanding to the client.
It is considered one of the essential skills a nurse
must develop
Being able to put himself on the clients shoes does
not mean that the nurse has had the same exact
experiences as the client
Nevertheless, by listening and sensing the
importance of the situation to the client, the nurse
can imagine the clients feelings about the
experience
EMPATHY
Both the client and the nurse give a gift of self

when empathy occurs the client by feeling safe
enough to share feelings, and the nurse by
listening closely enough to understand.
Empathy has been shown to positively influence

client outcomes
Clients tend to feel better about themselves when

the nurse is empathetic
EXAMPLE OF EMPATHY
Client: I am so confused! My son just visited and

wants to know where the safety deposit box key is.
Nurse: Youre confused because your son asked for
he safety deposit key. (Using reflection)
Nurse: Are you confused about the purpose of your
sons visit? (Using clarification)
Note that from these empathetic moments, a bond
can be established to serve as the foundation for the
nurse-client relationship
SYMPATHY
Feelings of concern or compassion one

shows for another.
By expressing sympathy, the nurse

may project his or her personal
concerns
onto
the
client,
thus
inhibiting the clients expression of
feelings
EXAMPLE OF SYMPATHY
Client: I am so confused! My son just visited and wants

to know where the safety deposit box key is.
Nurse: I know how confusing sons can be. My son
confuses me, too, and I know how bad that makes you
feel.
Note that the nurses feelings of sadness or even pity
could influence the relationship and hinder the nurses
abilities to focus on the clients needs.
Sympathy often shifts the emphasis on the nurses
feelings, hindering the nurses ability to view the clients
needs more objectively.

NO.1
These are communication techniques that

contribute to therapeutic relationship,
EXCEPT?
A) Active listening to what the patient
says
B) Labeling the patient
C) Encouraging expression of feelings
D) Clarifying
ANSWER
Letter B
Rationale: Labeling the patient is nontherapeutic.

NO.2
Which one of the following techniques used is

an example of giving a broad opening?
A) When did this happen to you?
B) Would you describe it in more detail?
C) Where would you like to begin?
D) I would like to spend time to talk with
you.
ANSWER
Letter C
Rationale: Giving a broad opening

provides an opportunity to the patient
to
choose
the
topic
of
the
conversation.

NO.3
A technique that enhances communication is

illustrated by one of the following statements:
A) Why do you feel this way?
B) It is for your own good.
C) I am sure he only meant to help you.
D) I would like to spend time with you.
ANSWER
Letter D
Rationale: Offering ones self facilitates

the development of rapport between
the nurse and the patient.

NO.4
Which of the following elements refers

to the setting of the communication?
A) Sender
B) Context
C) Receiver
D) Message
ANSWER
Letter B
Rationale: Context refers to the setting

of the conversation.

NO.5
Which of the following techniques of

communication is appropriate when
initiating a conversation?
A) Focusing
B) Use of silence
C) Giving broad opening
D) Reflecting
ANSWER
Letter C
Rationale:
Giving
broad
opening
provides an opportunity for the patient
to
choose
the
topic
of
the
conversation. Hence, it is appropriate
to use when initiating a conversation.
NURSE PATIENT
RELATIONSHIP
NURSE-PATIENT RELATIONSHIP
Series of interactions between the

nurse and the patient in which the
nurse assists the patient to attain
positive behavioral change
CHARACTERISTICS OF THE
Goal-directed
Focused on the needs of the patient
Planned
Time-limited
Professional
BASIC ELEMENTS OF THE

Trust
Rapport
Unconditional positive regard
Setting limits
Therapeutic communication
PHASES OF THE
Pre-orientation phase
Orientation phase
Working phase
Termination phase
PRE-ORIENTATION PHASE
Begins when the nurse is assigned to a

patient
Phase of Nurse-Patient Relationship in

which the patient is excluded as an actual
participant
Nurse feels certain degree of anxiety
PRE-ORIENTATION PHASE
Includes all of what the nurse thinks and

does before interacting with the patient
Tasks include data gathering, planning for

the first interaction
Major task is to develop self-awareness
ORIENTATION PHASE
Begins when the nurse and the patient interacts for the
first time
Parameters of the relationship are to be laid
Nurse begins to know about the patient
Tasks include establishing rapport, developing trust,

assessment (and formulation of a nursing diagnosis).
Major task is to develop a mutually acceptable contract
WORKING PHASE
It is highly individualized
More structured than the orientation phase
The longest and most productive phase of the nurse-patient

relationship
Limit-setting is employed
Tasks include planning and implementation
Major task is identification and resolution of the patients

problems
TERMINATION PHASE
It is a gradual weaning process
It is a mutual agreement
It involves feelings of anxiety, fear and loss
It should be recognized in the orientation phase
Tasks include evaluation
Major task is to assist patient to review what has been learned

and to transfer his learning to his relationship with others
TERMINATION PHASE
How to terminate?
Gradually decrease interaction time
Focus on future oriented topics
Encourage expression of feelings
Make the necessary referral
PROBLEMS AFFECTING THE

NURSE-PATIENT RELATIONSHIP TRANSFERENCE
Occurs when the client displaces onto the

nurse attitudes and feelings that the client
originally experience in other relationships
These patterns
unconscious
are
automatic
and

NURSE-PATIENT RELATIONSHIP TRANSFERENCE
Example:
An adolescent female client working
with a nurse who is about the same age
as the teens parents might react to the
nurse like she reacts to her parents.
She might experience intense feelings of
rebellion or make sarcastic remarks.

NURSE-PATIENT RELATIONSHIP COUNTERTRANFERENCE
Occurs when the nurse displaces onto the client

attitudes or feelings from his or her past.
Example:
A female nurse who has teenage children and
who is experiencing extreme frustration with an
adolescent client may respond by adopting a
parental or chastising tone.
The nurse is countertransfering her own attitudes

and feelings toward her children onto the client.
RESISTANCE
Development of ambivalent feelings

toward self-exploration

NO.1
The basis for a therapeutic nurse-patient

relationship begins with the nurses?
A) Sincere desire to help others
B) Sincere desire to help others
C) Self-awareness and understanding
D) Sound knowledge of Psychiatric
Nursing
ANSWER
Letter C
Rationale: Prior to the nurse helping

others, he should first have a thorough
awareness of himself.

NO.2
The nurse should introduce information about the

end of the nurse-patient relationship?
A) During the Orientation phase
B) As the goals of the relationship are reached
C) About one or two sessions before the last
meeting
D) When the patient is able to handle it
ANSWER
Letter A
Rationale: In the establishment of a

contract during the orientation phase,
information about the end of the
nurse-patient relationship must also be
included.

NO.3
The goal of the orientation phase of the nursepatient relationship is?

A) assist the patient to review what he has
learned
B) plan interventions to meet patients goals
C) formulating nursing diagnosis
D) facilitate expression of thoughts and
feelings
ANSWER
Letter C
Rationale: This provides the nurse with

a sense of direction.

NO.4
Which of the following is the most appropriate topic

during the orientation phase of nurse and patient
relationship?
A) patients perception of the reason of her being
hospitalized
B) identification of more effective methods of dealing
with stress
C) exploration of the patients inadequate coping skills
D) establishment of regular schedule for meeting
ANSWER
Letter D
Rationale: Establishment of a contract

is the major task of the nurse in the
Orientation phase.

NO.5
The nurse knows that a therapeutic

relationship is possible only when?
A) Emotional difficulties are identified
B) Mutual trust is achieved
C) Patients self-esteem is enlarged
D) Patient is motivated to change
ANSWER
Letter B
Rationale: Trust is the foundation of a

therapeutic nurse-patient relationship.
PRINCIPLES OF CARE IN
PSYCHIATRIC SETTINGS
The nurse views the patient as a

holistic
human
being
with
interdependent and interrelated needs.
The nurse accepts the patient as a

unique human being with inherent
value and worth exactly as he is.
The nurse should focus on the

patients strengths and assets and not
on his weakness and liabilities
The nurse views the patients behavior

non-judgmentally, while assisting the
patient to learn more adaptive ways of
coping
The nurse should explore the patient

behavior for the need it is designed to
meet
and
the
message
it
is
communicating.
The nurse has the potential for

establishing
a
nurse-patient
relationship with most if not all
patients.
The quality of the nurse-patient

relationship determines the degree of
change that can occur in the patients
behavior.
LEVELS OF
INTERVENTIONS IN
PSYCHIATRIC NURSING
PRIMARY LEVEL OF
PREVENTION
Interventions aimed at the promotion

of mental health and lowering the rate
of cases by altering the stressors.
Examples:
Health education
Information dissemination
Counseling
SECONDARY LEVEL OF
PREVENTION
Interventions that limit the severity of a disorder.
Has two components:

Case finding
Prompt treatment
Examples:
Crisis intervention
Administration of medications
TERTIARY LEVEL OF
PREVENTION
Interventions aimed at reducing the disability

after a disorder.
Has two components:

Prevention of complication
Active program of rehabilitation
Examples:
Alcoholics Anonymous
Occupational therapy

NO.1
Promotion of mental illness is best achieved by?

A) helping individuals use established successful
coping mechanisms
B) assisting individuals deal with physical
problems
C) helping individuals deal with physical problems
D) assisting individuals deal with family problems
ANSWER
Letter A
Rationale:
Strengthening
an
individuals coping mechanism is one
of the best ways to prevent mental
illness.

NO.2
A psychiatric nurse would be more likely

to work with people with mental disorders
in which of the following settings?
A) Shelters
B) Neighborhood centers
C) Prisons
D) All of these
ANSWER
Letter D
Rationale: Psychiatric nursing practice

is applicable in all healthcare settings.

NO.3
Which is an example
prevention strategy in
ward.?
of secondary
a psychiatric
A)
Monitoring
of
medication
administration
B) Monitoring of blood pressure
C) Assessing of skin problems
D) All of these
ANSWER
Letter D
Rationale: All the choices fall under the

category of prompt treatment

NO.4
Helping a patient find an alternative to

her home, which had been destroyed by a
fire, is an example of what level of
prevention strategy?
A) Primary
B) Secondary
C) Tertiary
D) Any of these
ANSWER
Letter C
Rationale: Providing assistance during

recovery
period
falls
under
rehabilitation, which is tertiary level of
prevention strategy

NO.5
Health education, communication and

information
dissemination
are
examples of activities under?
A) Health promotion
B) Rehabilitation
C) Case finding
D) Prompt treatment
ANSWER
Letter A
Rationale:
Health
education,
communication
and
information
dissemination are activities, which
promotes health.
CHARACTERISTICS OF A
PSYCHIATRIC NURSE
CHARACTERISTICS OF A
PSYCHIATRIC NURSE
Empathy
The ability to see beyond outward behavior
and sense accurately another persons inner
experiencing.
Genuineness / Congruence
Ability to use therapeutic tools appropriately
Unconditional Positive Regard

Respect
ROLES OF THE NURSE

IN PSYCHIATRIC
SETTINGS
ROLES OF THE NURSE IN

Ward Manager
Creates a therapeutic environment.
Socializing Agent
Assists the patient to feel comfortable
with others
Counselor
Listens to the patients verbalizations

Parent Surrogate
Assists the patient in the performance of
activities of daily living.
Patient Advocate
Enables the patient and his relatives to know
their rights and responsibilities
Teacher
Assists the patient to learn more adaptive
ways of coping

Technician
Facilitates the performance of nursing procedures
Therapist
Explores the patients needs, problems and
concerns through varied therapeutic means
Reality Base
Enables the patient to distinguish objective reality
and subjective reality

Healthy Role Model

Acts as a symbol of health by
serving as an example of healthful
living.
THE NERVOUS SYSTEM

AND HOW IT WORKS
BRAIN
The
brain is divided
into:
Cerebrum
Cerebellum
Brain Stem
Limbic System
CEREBRUM
The LEFT HEMISPHERE is the

center for logical reasoning and
analytic functions such as reading,
writing and mathematical tasks.
The RIGHT HEMISPHERE is the
center
for
creative
thinking,
intuition, and artistic abilities
CEREBRUM
CEREBRUM
Each
cerebral
hemisphere is divided
into four lobes:
Frontal
Parietal
Temporal
Occipital
FRONTAL LOBES OF CEREBRUM

These control the:
Organization
thought
Body movement
Memories
Emotions
Moral behavior
of

The frontal lobes:
Helps
regulate
arousal
Focus attention
Allow
problem
solving and decision
making to occur

Abnormalities
in
the
are
frontal
lobes
associated with:
Schizophrenia
Attention
Deficit
Hyperactivity
Disorder
Dementia
PARIETAL LOBES OF CEREBRUM

The parietal lobes are
involved with:
Interpreting
sensations of taste
and touch
Assisting in spatial
orientation
TEMPORAL LOBES OF CEREBRUM

These
function
centers for:
Hearing
Memory
Expressions
emotions
as
of
OCCIPITAL LOBES OF CEREBRUM

They assist in:
Coordinating
language generation
Visual interpretation
Depth perception
CEREBELLUM
It
is the center for

coordination
of
movements
and
postural adjustments
CEREBELLUM
Inhibited
transmission
of a neurotransmitter,
DOPAMINE, in this area
is associated with a
lack
of
smooth,
coordinated
movements
in
diseases
such
as
PARKINSONS DISEASE
and DEMENTIA
BRAIN STEM
This
includes
the
following:
Midbrain
Pons
Medulla Oblongata
MEDULLA OBLONGATA OF THE

BRAIN STEM
This contains the vital
centers for respiration

and
cardiovascular
function
PONS OF THE BRAIN STEM

This bridges the gap
both structurally and

functionally, serving as
a
primary
motor
pathway
MIDBRAIN OF THE BRAIN STEM

This includes most of the
RETICULAR
ACTIVATING
SYSTEM (RAS) and the
EXTRAPYRAMIDAL
SYSTEM (EPS).
The
RAS
influences
motor
activity,
sleep,
consciousness
and
awareness.
The
EPS
relays
information
about
movement
and
coordination from the
brain to the spinal nerves
LIMBIC SYSTEM
This
includes
following:
Thalamus
Hypothalamus
Hippocampus
Amygdala
the
THALAMUS OF THE LIMBIC SYSTEM

This regulates:
Activity
Sensation
Emotion
HYPOTHALAMUS OF THE LIMBIC

SYSTEM
This is involved with:
Temperature
regulation
Appetite control
Endocrine function
Sexual drive
Impulse
behavior
associated
with
feelings of anger,
rage and excitement
HIPPOCAMPUS AND AMYGDALA OF

THE LIMBIC SYSTEM
These
structures are
involved in emotional
arousal and memory.
LIMBIC SYSTEM
Disturbances
in the
limbic system have
been implicated in a
variety
of
mental
illnesses, such as:
The memory loss seen
in DEMENTIA
The poorly controlled
emotions and impulses
seen in PSYCHOTIC or
MANIC BEHAVIOR
NEUROTRANSMISSION
Neurons or nerve cells
communicate
information with each
other
by
sending
electrochemical
messages from neuron
to neuron, in a process
called
NEUROTRANSMISSION.
NEUROTRANSMISSION
Electrochemical messages pass from:
The dendrites
Through the cell body
Down the axon
Across the gaps between cells (SYNAPSE)
To the dendrite of the next neuron
NEUROTRANSMISSION
NEUROTRANSMITTERS
These
are chemical
substances
manufactured in the
neuron that aid in the
transmission
of
information throughout
the body
NEUROTRANSMITTERS
They either excite or
stimulate an action in
the cells (EXCITATORY)
or inhibit or stop an
action (INHIBITORY).
NEUROTRANSMITTERS
Neurotransmitters
fit
into a specific receptor
cells embedded in the
membrane
of
the
dendrite, just like a
certain key shape fits
into a lock
NEUROTRANSMITTERS
After
neurotransmitters
are
released into the synapse and
relay the message to the
receptor cells, they are either:
Transported back from the
synapse to the axon to be
store
for
later
use
(REUPTAKE);
are metabolized and
Or
inactivated
by
enzymes,
primarily
MONOAMINE
OXIDASE or MAO
MAJOR TYPES OF
NEUROTRANSMITTERS
TYPE OF
MECHANISM
NEUROTRANSMITTER
PHYSIOLOGIC EFFECTS
OF ACTION
DOPAMINE
Excitatory
Controls
complex
movements,
motivation,
cognition;
regulates
emotional response.
NOREPINEPHRINE
(NORADRENALINE)
Excitatory
Changes in attention, learning and

memory, sleep and wakefulness, mood
EPINEPHRINE
(ADRENALINE)
Excitatory
Fight-or-flight response
SEROTONIN
Inhibitory
Control of food intake, sleep and

wakefulness, temperature regulation,
pain
control,
sexual
behaviors,
regulation of emotion.
MAJOR TYPES OF
NEUROTRANSMITTERS
TYPE OF
MECHANISM OF
NEUROTRANSMITTER
ACTION
PHYSIOLOGIC EFFECTS
ACETYLCHOLINE
Excitatory or
Inhibitory
Sleep and wakefulness cycle; signals

muscles to become alert
NEUROPEPTIDES
Neuromodulators Enhance, prolong, inhibit, or limit the

effects of principal neurotransmitters
GLUTAMATE
Excitatory
Neurotoxicity results if levels are too

high
GAMMAAMINOBUTYRIC ACID
(GABA)
Inhibitory
Modulates other neurotransmitters
DOPAMINE
It is synthesized from the amino acid

tyrosine
It is implicated in Schizophrenia and other

psychoses, as well as movement disorders in
Parkinsons Disease
Antipsychotic medications work by blocking

dopamine receptors and reducing dopamine
activity
NOREPINEPHRINE
Excess norepinephrine has been implicated in a

variety of anxiety disorders.
Deficits in norepinephrine may affect memory

loss, social withdrawal and depression.
Some antidepressants block the reuptake of

norepinephrine, and others inhibit MAO from
metabolizing it.
SEROTONIN
It is derived from a dietary amino acid named

tryptophan.
It has been found to play a role in the delusions,

hallucinations, and withdrawn behavior in
schizophrenia.
Some antidepressants block serotonin reuptake,

thus leaving it available in the synapse for a
longer time, which results in improved mood.
HISTAMINE
The role of histamine in mental illness

is under investigation
Some
psychotropic
drugs
block
histamine, resulting in weight gain,
sedation and hypotension.
ACETYLCHOLINE
It is synthesized from dietary choline

found in red meat and vegetables.
Persons with Alzheimers Disease have

a decreased number of acetylcholinesecreting neurons
GAMMA-AMINOBUTYRIC ACID
(GABA)
Drugs that increase GABA function,

such as benzodiazepines, are used to
treat anxiety and induce sleep
GLUTAMATE
This is an excitatory amino acid that at

high levels can have major neurotoxic
effects.
This has been implicated in the brain

damage
caused
by
stroke,
hypoglycemia, sustained hypoxia or
ischemia, and some degenerative
diseases like Alzheimers Disease.
PSYCHOPHARMACOLOGY
PSYCHOPHARMACOLOGY
Terms used in describing drugs and drug

therapy important for the nurse to know:
Efficacy
Potency
Half-life
EFFICACY
This refers to the maximal therapeutic

effect that can be achieved by a drug.
POTENCY
This describes the amount of drug

needed to achieve that maximum effect
Drugs that have a low potency require

higher dosages to achieve efficacy
High-potency drugs achieve efficacy at

lower doses.
HALF-LIFE
This is the amount of time it takes for half of the

drug to be removed from the bloodstream.
Drugs with a shorter half-life may need to be

given 3 or 4 times in a day, but drugs with a
longer half-life may be given once a day.
The amount of time needed for a drug to leave

the body completely after it has been
discontinued is about five times its half-life.
PRINCIPLES THAT GUIDE

PSYCHOPHARMACOLOGIC TREATMENT
A medication is selected based on its

effect on the clients target symptom,
such as delusional thinking, panic
attacks, or hallucinations.
The effectiveness of the medication is

evaluated in large part by its ability to
diminish or eliminate the target
symptom.

Many psychotropic drugs must be

given in adequate dosages for a period
of time before their full effect is
realized.
Tricyclic antidepressants can require
4 to 6 weeks to provide optimal
therapeutic benefit.

The dosage of a medication is often

adjusted to the lowest dosage
effective for the client
Some higher dosages may be needed

to
stabilize
the
clients
target
symptoms, and lower dosages can be
used to sustain those effects over
time.

As a rule, elderly persons require lower

dosages of a medication to produce
therapeutic effects, and it may take
longer for a drug to achieve its full
therapeutic effect.

Psychotropic
medications
are
often
decreased gradually (tapering)rather than
abruptly discontinued.
This is due to potential problems with

rebound (temporary return of symptoms),
recurrence of the original symptoms, or
withdrawal (new symptoms resulting from
discontinuation of the drug)

Follow-up care is essential to ensure

compliance
with
the
medication
regimen, to make needed adjustments
in dosage, and to manage side effects.
WHAT THE NURSE NEEDS TO

KNOW ABOUT PSYCHOTROPIC
DRUGS
How the drug works
Its side effects
Contraindications
Interactions
Nursing interventions required for helping clients

manage the medication regimen
PSYCHOTROPIC DRUG
CATEGORIES
Antipsychotics
Antidepressants
Mood Stabilizers
Anti-anxiety Drugs
Stimulants
1) ANTIPSYCHOTIC DRUGS
ANTIPSYCHOTIC DRUGS
These are also known as NEUROLEPTICS
These are used to treat symptoms of

psychosis, such as delusions and
hallucinations.
They work by blocking the receptors of

the neurotransmitter Dopamine.
ANTIPSYCHOTIC DRUGS
Antipsychotic drugs are the primary medical treatment for

Schizophrenia and are also used in psychotic episodes of acute
mania, psychotic depression, and drug-induced psychosis.
Persons with dementia who have psychotic
sometimes respond to low doses of antipsychotics.
symptoms
Short-term therapy with antipsychotics may be useful for

transient psychotic symptoms, such as those seen in some
persons with borderline personality disorder.
TYPICAL ANTIPSYCHOTIC DRUGS

GENERIC
(TRADE)
NAME
FORMS
DAILY
DOSAGE
(mg)
EXTREME
DOSAGE
RANGE
(mg/day)
Chlorpromazi
ne
(Thorazine)
T, L, INJ
200 1600
25 2000
Perphenazine
(Trilafon)
T, L, INJ
16 32
4 64
Fluphenazine
(Prolixin)
T, L, INJ
2.5 20
1 60
Thioridazine
T, L
200 600
40 800
TYPICAL ANTIPSYCHOTIC DRUGS

GENERIC
(TRADE)
NAME
FORMS
DAILY
DOSAGE
(mg)
EXTREME
DOSAGE
RANGE
(mg/day)
Trifluoperazin
e (Stelazine)
T, L, INJ
6 50
2 80
Thiothixene
(Navane)
C, L, INJ
6 30
6 - 60
Haloperidol
(Haldol)
T, L, INJ
2 20
1 - 100
Loxapine
C, L, INJ
60 100
30 - 250
ATYPICAL ANTIPSYCHOTIC
DRUGS
GENERIC
(TRADE)
NAME
FORMS
DAILY
DOSAGE
(mg)
EXTREME
DOSAGE
RANGE
(mg/day)
Clozapine
(Clozaril)
150 500
75 - 700
Risperdone
(Risperdol)
28
1 16
Olanzapine
(Zyprexa)
5 15
5 - 20
MECHANISM OF ACTION OF
ANTIPSYCHOTIC DRUGS
The major action of all antipsychotics in the

nervous system is to block receptors for the
neurotransmitter dopamine.
The typical antipsychotic drugs are potent

antagonists (blockers) of dopamine receptors
D2, D3, and D4.
This makes them effective in treating target

symptoms
but
also
produces
many
extrapyramidal side effects.
ANTIPSYCHOTIC DRUGS
Newer, atypical antipsychotic drugs, such

as clozapine (Clozaril), are relatively weak
blockers of D2, which may account for the
lower incidence of extrapyramidal side
effects.
Atypical antipsychotics also inhibit the

reuptake of serotonin, which makes them
more effective in treating the depressive
aspects of Schizophrenia
SIDE EFFECTS OF
ANTIPSYCHOTIC DRUGS
Extrapyramidal Symptoms (EPS)

are serious neurologic symptoms
that are the major side effects of
antipsychotic drugs, which include:
Acute Dystonia
Pseudoparkinsonism
Akathisia
Tardive Dyskinesia
SIDE EFFECTS OF ANTIPSYCHOTIC

DRUGS EXTRAPYRAMIDAL SYMPTOMS
(EPS)
Blockade of D2 receptors in the midbrain region of

the brain stem is responsible for the development
of EPS
Therapies for the neurologic side effects of acute
dystonia, pseudoparkinsonism, and akathisia are
similar and include:
1) Lowering the dosage of the antipsychotic
2) Changing to a different antipsychotic
3) Administering anticholinergic medication
DRUGS USED TO TREAT

EXTRAPYRAMIDAL SIDE
EFFECTS
GENERIC
ORAL IM / IV DOSES DRUG CLASS
(TRADE) NAME DOSAGES
(mg)
(mg)
Amantadine
(Symmetrel)
100 bid or
tid
Dopaminergic
Agonist
Benztropine
(Cogentin)
1- 3 bid
12
Anticholinergic
Beperiden
(Akineton)
2 tid qid
Anticholinergic
Diazepam
(Valium)
5 tid
5 10
Benzodiazepin
e
25 50
Antihistamine
Diphenhydrami 25 50 qid
DRUGS USED TO TREAT

EXTRAPYRAMIDAL SIDE
EFFECTS
GENERIC
ORAL IM / IV DOSES DRUG CLASS
(TRADE) NAME DOSAGES
(mg)
(mg)
Lorazepam
(Ativan)
1 2 tid
Benzodiazepin
e
Procyclidine
(Kemadrin)
2.5 5 tid
Anticholinergic
Propranolol
(Inderal)
10 20 tid;
up to 40 qid
Beta-blocker
2 5 tid
Anticholinergic
Trihexaphenidyl
(Artane)

DRUGS (EPS) ACUTE DYSTONIA
This includes any of the following:

Acute muscular rigidity and cramping
A stiff or thick tongue with difficulty of
swallowing
In severe cases, laryngospasm and
respiratory difficulties.

Spasms or stiffness in
muscle groups can

produce
torticollis
(twisted
head
and
neck)

muscle groups can

produce opisthotonus
(tightness in the entire
body with the head
back and an arched
neck)

muscle groups can

produce an oculogyric
crisis (eyes rolled back
in a locked position)
TREATMENT FOR (EPS)

ACUTE DYSTONIA
Rapid relief is brought about by

immediate treatment with
anticholinergic drugs such as:
Intramuscular benztropine mesylate
(Cogentin)
Intramuscular or intravenous
diphenhydramine (Benadryl)
TREATMENT FOR (EPS)

ACUTE DYSTONIA
Recurrent dystonic reactions would

necessitate a lower dosage or a
change in the antipsychotic drug.
DRUGS (EPS)
PSEUDOPARKINSONISM
Drug-induced Parkinsonism or pseudoparkinsonism

have the following symptoms:
A stiff, stooped posture
Masklike facies
Decreased arm swing
A shuffling, festinating gait (with small steps)
Cogwheel rigidity (ratchet-like movements of joints)
Drooling
Tremor
Bradycardia
Coarse pill-rolling movements of the thumb and
fingers while at rest
TREATMENT FOR (EPS)

PSEUDOPARKINSONISM
Pseudoparkinsonism is treated by
changing
to
an
antipsychotic
medication that has a lower incidence
of EPS or by adding an oral
anticholinergic agent or amantadine .

DRUGS (EPS) AKATHISIA
Akathisia is reported by the client as an intense

need to move about
The client appears restless or anxious and

agitated, often with a rigid posture or gait and a
lack of spontaneous gestures.
This feeling of internal restlessness and the

inability to sit still or rest often leads clients to
discontinue their antipsychotic medication.
TREATMENT FOR (EPS)

AKATHISIA
Akathisia can be treated by a change

in antipsychotic medication or the
addition of an oral agent such as a
beta-blocker,
anticholinergic,
or
benzodiazepine.

DRUGS (EPS) TARDIVE DYSKINESIA
(TD)
TD is a syndrome of permanent, involuntary movements, is

most commonly caused by the long-term use of typical
antipsychotics.
Once it has developed, TD is irreversible.
Symptoms of TD include:
Involuntary movements of the tongue, facial and neck
muscles, upper and lower extremities, and truncal
musculature
Tongue-thrusting and protrusion, lip-smacking, blinking,
grimacing and other excessive, unnecessary facial
movements
TREATMENT FOR (EPS)

TARDIVE DYSKINESIA
Although TD is irreversible, its progression can be arrested by

decreasing or discontinuing the antipsychotic medication.
Preventing the occurrence of TD is done by keeping maintenance
dosages as low as possible, changing medications, and
monitoring the client periodically for the initial signs of TD.
Persons who have already developed signs of TD but who still
need to take antipshychotic medication are often given
clozapine, which has not yet been found to cause, or therefore
worsen, TD.
OTHER SIDE EFFECTS OF

ANTIPSYCHOTIC DRUGS
Neuroleptic Malignant Syndrome

Anticholinergic Side Effects

DRUGS NEUROLEPTIC MALIGNANT
SYNDROME (NMS)
NMS is a potentially fatal, idiosyncratic reaction to

an antipsychotic drug with the following symptoms:
Rigidity
High fever
Autonomic instability such as unstable blood
pressure, diaphoresis, pallor, delirium and
elevated levels of enzymes (particularly CPK).
Confusion
Being mute
Fluctuation from agitation to stupor

DRUGS NEUROLEPTIC MALIGNANT
SYNDROME (NMS)
Dehydration,
poor
nutrition,
and
concurrent medical illness all increase the
risk for NMS.
TREATMENT FOR
NEUROLEPTIC MALIGNANT SYNDROME
(NMS)
This includes the following:

Immediate
discontinuance
antipsychotic medications
of
all
Institution of supportive medical care

such as rehydration and hypothermia,
until the clients physical condition is
stabilized.

DRUGS ANTICHOLINERGIC SIDE
EFFECTS
Symptoms usually decrease after 3 4 weeks but do

not entirely remit and include the following:
Orthostatic hypotension
Dry mouth
Constipation
Urinary hesitance or retention
Blurred near vision
Dry eyes
Photophobia
Nasal congestion
Decreased memory
TREATMENT FOR
ANTICHOLINERGIC SIDE
EFFECTS
The client who is taking anticholinergic

agents for EPS may have increased
problems with anticholinergic side
effects, but some nutritional or overthe-counter remedies can ease these
symptoms
CLIENT TEACHING AND MEDICATION

MANAGEMENT: ANTIPSYCHOTIC
DRUGS
Drink sugar-free fluids and eat sugar-free hard candy

to ease the anticholinergic effects of dry mouth.
Avoid calorie-laden beverages and candy because they

promote dental caries, contribute to weight gain, and
do little to relieve dry mouth
Constipation can be prevented or relieved by

increasing intake of water and bulk-forming foods in
the diet and by exercising.

DRUGS
Stool softeners are permissible, but laxatives should

be avoided.
Use sunscreen to prevent burning and avoid long

periods of time in the sun. Wear protective clothing as
photosensitivity can cause a patient to burn easily.
Rising slowly from a sitting or lying position will

prevent falls from orthostatic hypotension or dizziness
due to a drop in blood pressure. Wait to walk until any
dizziness has subsided.

DRUGS
Monitor the amount of sleepiness or drowsiness you

experience. Avoid driving a car or performing other
potentially dangerous activities until your response
time and reflexes seem normal.
If you forget a dose of antipsychotic medication, take

it if the dose is only 3 to 4 hours late. If the missed
dose is more than 4 hours late or the next dose is
due, omit the forgotten dose.

DRUGS
If you have difficulty remembering

your medication, use a chart to record
doses when taken, or use a pill box
labeled with dosage times and/or days
of the week to help you remember
when to take medication.
SIDE EFFECTS OF ATYPICAL

ANTIPSYCHOTIC DRUGS CLOZAPINE
(Clozaril)
This drug produces fewer traditional side effects

than most typical antipsychotic drugs, but it has
the
potentially
fatal
side
effect
of
agranulocytosis.
This develops suddenly and is characterized by

fever, malaise, ulcerative sore throat, and
leukopenia.
This side effect can occur up to 24 weeks after

the initiation of therapy
TREATMENT OF AGRANULOCYTOSIS
DUE TO CLOZAPINE (Clozaril)
Blood samples should be taken weekly

to monitor the WBC count of patients
with agranulocytosis.
The drug
immediately
count drops
3,000.
must be discontinued
if the white blood cell
by 50% or to less than
2) ANTIDEPRESSANT DRUGS
ANTIDEPRESSANT DRUGS
Antidepressant drugs are

used in the treatment of:
Major depressive illness
Panic disorder
Other anxiety disorders
Bipolar depression
Psychotic depression
primarily
Although the mechanism of action is

not
completely
understood,
antidepressants somehow interact with
two neurotransmitters, norepinephrine
and serotonin, that regulate mood,
arousal, attention, memory processing
and appetite
These are divided into four groups
2A) Tricyclic and the related cyclic antidepressants
2B) Selective serotonin reuptake inhibitors (SSRIs)

2C) Monoamine Oxidase inhibitors (MAOIs)
2D) Other antidepressants such as venlafaxine
(Effexor),
bupropion
(Wellbutrin),
trazodone
(Desyrel), and nafozodone (Serzone)
The major interaction is with the

monoamine neurotransmitter systems in
the brain, particularly norepinephrine and
serotonin.
Both of these neurotransmitters are

released throughout the brain and help to
regulate arousal, vigilance, attention,
mood, sensory processing, and appetite.
Norepinephrine,
serotonin,
and
dopamine are removed from the
synapses after release by reuptake
into presynaptic neurons.
After
reuptake,
these
three
neurotransmitters are reloaded for
subsequent release or metabolized by
the enzyme Monoamine Oxidase
The cyclic antidepressants and venlafaxine block the

reuptake of norepinephrine primarily and serotonin to
some degree.
The Monoamine Oxidase Inhibitors (MAOIs) interfere

with enzyme metabolism.
The Selective Serotonin Reuptake Inhibitors (SSRIs)

block the reuptake of serotonin
2A) CYCLIC ANTIDEPRESSANT

DRUGS
CYCLIC ANTIDEPRESSANT
DRUGS DRUG
The cyclic antidepressants became

available in the 1950s and for years
were the first choice of drugs to treat
depression.
CYCLIC ANTIDEPRESSANTS
DRUG ALERT!!!
These are potentially lethal if taken in

an overdose.
Depressed or impulsive clients who are

taking these drugs need to have
prescriptions and refills in limited
amounts to decrease the risk.
DRUGS
GENERIC
(TRADE)
NAME
Imipramine
(Tofranil)
FORMS
USUAL DAILY EXTREME

DOSAGE
DOSAGE
(mg)
RANGE
(mg/day)
T, C, INJ
150 - 200
50 - 300
Despiramine
(Nopramin)
T, C
150 - 200
50 - 300
Amitryptiline
(Elavil)
T, INJ
150 - 200
50 - 300
Nortryptiline
C, L
75 - 100
25 - 150
DRUGS
GENERIC
(TRADE)
NAME
FORMS
USUAL DAILY EXTREME

DOSAGE
DOSAGE
(mg)
RANGE
(mg/day)
Trimipramine
(Surmontil)
150 - 200
50 - 300
Protriptyline
(Vivactil)
15 - 40
10 - 60
Maprotiline
(Ludiomil)
100 - 150
50 - 200
SIDE EFFECTS OF CYCLIC

The cyclic antidepressant drugs block cholinergic

receptors, resulting in anticholinergic effects such
as:
Dry mouth
Constipation
Urinary hesitancy or retention
Dry nasal passages
Blurred near vision
Agitation, delirium and ileus are more severe
anticholinergic side effects that may occur in the
elderly.
SIDE EFFECTS OF CYCLIC

Other common side effects include:

Sedation
Weight gain
Tachycardia
Sexual
dysfunction
is
frequently
reported by clients taking TCAs
2B) MONOAMINE OXIDASE

INHIBITOR (MAOI)
MONOAMINE OXIDASE
INHIBITORS (MAOIs)
The MAOIs were also discovered in the

1950s and were found to have a
positive effect on depressed persons.
The MAOIs have a low incidence of

sedation and anticholinergic effects
MONOAMINE OXIDASE
INHIBITORS
DRUG ALERT!!!
These are potentially lethal if taken in

an overdose.
Depressed or impulsive clients who are

taking these drugs need to have
prescriptions and refills in limited
amounts to decrease the risk.
MONOAMINE OXIDASE
INHIBITORS (MAOIs)
GENERIC
(TRADE) NAME
FORMS
USUAL DAILY EXTREME

DOSAGE
DOSAGE
(mg)
RANGE
(mg/day)
Phenelzine
(Nardil)
45 60
15 - 90
Tranylcypromi
ne
(Parnate)
30 - 50
10 - 90
Isocarboxazid
(Marplan)
20 - 40
10 - 60
SIDE EFFECTS OF MONOAMINE

OXIDASE INHIBITORS (MAOIs)
The most common side effects of MAOIs include:

Day-time sedation
Insomnia
Weight gain
Dry mouth
Sexual dysfunction
Sedation and insomnia are difficult to treat and

may necessitate a change in medication
SIDE EFFECTS OF MONOAMINE

Of particular concern with MAOIs is the potential

for a life-threatening hypertensive crisis if the
client ingests food containing tyramine.
The symptoms of this crisis are:

Severe hypertension
Hyperpyrexia
Tachycardia
Diaphoresis
Tremulousness
Cardiac Arrythmias
FOODS (CONTAINING TYRAMINE) TO

AVOID WHEN TAKING MONOAMINE
No mature or aged cheeses or dishes made

with cheese, such as lasagna, pizza. All cheese
is considered aged except cottage cheese,
cream cheese, ricotta cheese, and processed
cheese slices
No aged meats such as pepperoni, salami,

mortadella, summer sausage, beef logs, and
similar products. Make sure meat and chicken
are fresh and have been properly refrigerated.
FOODS (CONTAINING TYRAMINE) TO

AVOID WHEN TAKING MONOAMINE
No Italian broad beans (fava) pods or banana peel.

Banana pulp and all other fruits and vegetables are
permitted
Avoid all tap beers and microbrewery beer. Drink no

more than two cans or bottles of beer (including nonalcoholic beer) or 4 ounces of wine per day
No sauerkraut, soy sauce or soybean condiments, or

marmite (concentrated yeast).
INHIBITORS DRUG
INTERACTION
DRUG ALERT!!!
The following drugs can cause a potentially fatal drug

interaction when taken with MAOI antidepressants:
Other MAOI antidepressants

SSRI antidepressants
Certain cyclic compounds
Meperidine (Demerol)
Buspirone (BuSpar)
Dextromethorphan
General anesthetic
2C) SELECTIVE SEROTONIN

REUPTAKE INHIBITOR (SSRI)
SELECTIVE SEROTONIN
REUPTAKE INHIBITORS (SSRIs)
The SSRIs were first available in 1987 with the release

of fluoxetine (Prozac).
They have replaced the cyclic drugs as the first choice

in treating depression, because they equal in efficacy
and produce fewer troublesome side effects.
The SSRIs and clomipramine (cyclic antidepressant)

are effective in the treatment of ObsessiveCompulsive Disorder as well.
SELECTIVE SEROTONIN
GENERIC
(TRADE)
NAME
Fluoxetine
(Prozac)
FORMS
USUAL DAILY EXTREME

DOSAGE
DOSAGE
(mg)
RANGE
(mg/day)
C, L
20
50 - 80
Fluvoxamine
(Luvox)
150 - 200
50 - 300
Paroxetine
(Paxil)
20
10 - 50
Sertraline
100 - 150
50 - 200
SIDE EFFECTS OF SELECTIVE

SEROTONIN REUPTAKE INHIBITORS
(SSRIs)
Enhanced serotonin transmission can lead to several

common side effects such as:
Anxiety
Agitation
Akathisia or motor restlessness (treated with a betablocker such as propranolol or a benzodiazepine)
Nausea (take medications with food)
Insomnia which may continue to be a problem even if
the medication is taken in the morning (a sedative
hypnotic or low-dosage trazodone may be needed)
Sexual dysfunction or a diminished sexual drive or
difficulty achieving an erection or orgasm
SIDE EFFECTS OF SELECTIVE

SEROTONIN REUPTAKE INHIBITORS
(SSRIs)
Less common side effects include:

Sedation particularly with paroxetine or Paxil
(indicates need for a change to another
antidepressant)
Sweating (indicates need for change to another
antidepressant)
Diarrhea (manage with symptomatic treatment)
Hand tremor
(manage
with
symptomatic
Headaches
treatment)
DRUG INTERACTIONS FOR

SELECTIVE SEROTONIN
An uncommon but potentially serious drug interaction

called serotonin or serotonergic syndrome can result
from taking a MAOI and an SSRI at the same time
It can also occur if one of these drugs is taken too

close to the end of therapy with the other
Therefore, one drug must clear the persons system

before therapy with the other drug is initiated
DRUG INTERACTIONS FOR

SELECTIVE SEROTONIN
Symptoms of the serotonergic syndrome include:

Agitation
Sweating
Fever
Tachycardia
Hypotention
Rigidity
Hyperreflexia
In extreme reactions, even coma and death
could occur.
2D) OTHER ANTIDEPRESSANT

COMPOUNDS
OTHER ANTIDEPRESSANT
DRUGS
GENERIC
(TRADE)
NAME
FORMS
USUAL DAILY EXTREME

DOSAGE
DOSAGE
(mg)
RANGE
(mg/day)
Buproprion
(Wellbutrin)
200 300
100 450
Venlafaxine
(Effexor)
T, C
75 225
75 375
Trazodone
(Desyrel)
200 300
100 600
Nefazodone
300 600
100 - 600
SIDE EFFECTS OF OTHER

Sedation is caused by nefazodone, trazodone,

and mirtazapine
Headaches are brought about by nefazodone and
trazodone
Dry mouth and nausea are also brought about by
nefazodone
Loss of appetite, nausea, agitation and insomnia
are caused by Bupropion and venlafaxine
Dizziness, sweating and sedation may be brought
about by venlafaxine
SIDE EFFECTS OF OTHER

Sexual dysfunction is much less common

with the novel antidepressants, with one
notable exception : trazodone can cause
priapism (a sustained and painful erection
that necessitates immediate treatment and
discontinuation of the drug)
Priapism could result to impotence.

MANAGEMENT: ANTIDEPRESSANT
DRUGS
Minimize nausea by taking medication with food.
To reduce insomnia, take daily doses in the morning.

If this is not effective, ask the physician if a
medication for sleep is indicated. Do not use alcohol
to induce sleep, because this will worsen insomnia.
For diarrhea and headaches caused by the

medication,
take
over-the-counter
medications
approved by the physician.

DRUGS
Initial sedation effects generally lessen with time. If they

persist, talk to the physician about modifying the dose or
changing medications
For motor restlessness or hand tremor, ask the physician for a
medication such as propranolol (Inderal) or a benzodiazepine
Use calorie-free beverages or sugar-free candy to relieve dry
mouth. Avoid calorie-laden beverages, because they do not
alleviate dry mouth and may add to weight gain.

DRUGS
Try to get a balanced diet to avoid excess weight gain.

Exercise is also beneficial.
Increase your intake of water and bulk-forming foods

to prevent or relieve constipation. Stool softeners are
permitted. But laxatives should be avoided.
Do not drink alcohol while taking antidepressants

DRUGS
If problems with sexual drive or having

an erection or orgasm occur, discuss
them with the physician rather than
altering or stopping medication. Other
antidepressants may be appropriate.
If you miss a dose of the drug, follow

the directions given by your physician.
3) MOOD STABILIZING
DRUGS
MOOD STABILIZING DRUGS
These are used for the following:

To treat bipolar affective disorder by
stabilizing the clients mood
To avoid or minimize the highs and lows
that characterize bipolar illness
To treat the acute phases of mania
Lithium is the most established mood

stabilizer
Some
anticonvulsant
drugs
are
effective mood stabilizers such as:
Carbamazepine (Tegretol)
Valproic Acid (Depakene, Depakote)
Other
anticonvulsants,
such
as
gabapentin
(Neurontin)
and
lamotrigine (Lamictal), are being used
on a trial basis for mood stabilization
Occasionally, clonazepam (Klonopin),

an anti-anxiety agent, is also used to
treat acute mania.
Lithium
normalizes
the
neurotransmitters, such as:
Serotonin
Norepinephrine
Acetylcholine
Dopamine
reuptake
of
certain
Lithium also reduces the release of norepinephrine

through competition with calcium
Lithium produces its effects intracellularly rather than

within neuronal synapses.
Valproic Acid is known to increase levels of the

inhibitory neurotransmitter GABA.
Both anticonvulsants, Valproic Acid and

Carbamazepine, are thought to stabilize mood
by inhibiting the kindling process the
snowball-like effect seen when minor seizure
activity seems to build up into more frequent
and severe seizures.
In seizure management, anticonvulsants raise the level of

the threshold to prevent these minor seizures.
It is suspected that this same kindling process may also

occur in the development of full-blown mania, with
stimulation by more frequent minor episodes.
This explain why anticonvulsants are effective in the

treatment and prevention of mania as well.
DOSAGE OF MOOD STABILIZING

DRUGS - LITHIUM
Lithium is available in tablets, capsules,

liquid and a sustained release form but
NO PARENTERAL FORMS ARE AVAILABLE.
Daily dosages generally range from 900

mg to 3,600 mg.
More importantly, the serum Lithium

level should be about 1.0 mEq/L

DRUGS - LITHIUM
Serum Lithium levels of less than 0.5 mEq/L are

rarely therapeutic, and levels of more than 1.5
mEq/L are usually considered toxic.
The Lithium level should be monitored every 2 to

3 days while the therapeutic dosage is being
determined, then weekly.
When the clients condition is stable, the level

may need to be checked once a month or less
frequently.

DRUGS - ANTICONVULSANTS
Carbamazepine is available in liquid, tablet, and chewable

forms. Dosages usually range from 800 to 1,200 mg / day
and the extreme dosage is 200 to 2,000 mg / day.
Valproic acid is available in liquid, tablet, and capsule forms

and as sprinkles, with dosages raging from 1,000 to 1,500
mg / day and the extreme dosage is 750 to 3,000 mg / day
Serum drug levels, obtained 12 hours after the last dose of

the medication, are monitored for therapeutic levels of both
anticonvulsants.
SIDE EFFECTS OF MOOD STABILIZING

DRUGS - LITHIUM
Common side effects of Lithium therapy include:

Mild nausea (take medication with food) or
diarrhea
Anorexia
Fine hand tremors (use propranolol a beta
blocker)
Polydipsia
Polyuria
Metallic taste in the mouth
Fatigue or lethargy

DRUGS - LITHIUM
Weight gain and acne are side effects

that occur later in lithium therapy and
both are distressing for clients.
These are difficult to manage or
minimize and frequently lead to
noncompliance
TOXIC EFFECTS OF MOOD STABILIZING

DRUGS - LITHIUM
These include:
Severe diarrhea
Vomiting
Drowsiness
Muscle weakness
Lack of coordination
Untreated, these symptoms worsen and can lead

to renal failure, coma and death.
DRUG ALERT!!! - LITHIUM
When toxic signs occur, the drug

should be discontinued immediately.
If Lithium levels exceed 3.0 mEq/day,

dialysis may be indicated.

DRUGS - ANTICONVULSANTS
Side effects of carbamazepine and valproic acid include:

Drowsiness
Sedation
Dry mouth
Blurred vision
Carbamazepine may also cause rashes and othostatic

hypotension.
Valproic Acid may cause weight gain, alopecia and hand

tremors.
CLIENT TEACHING REGARDING

MEDICATION MANAGEMENT:
Have serum levels monitored periodically to

ensure therapeutic levels of the medication.
Take the medication with food to minimize

nausea.
For the fine hand tremors, ask the physician to

prescribe a beta-blocker such as propranolol
(Inderal).

To help minimize weight gain, get a balanced

diet and get regular exercise. Expect some
weight gain.
Minimize side effects of sedation and

drowsiness from anticonvulsant medications
by taking larger doses at bedtime and smaller
doses during the day.

Use calorie-free beverages and sugar-free

candy to relieve dry mouth. Avoid calorieladen beverages, because they do not
relieve dry mouth and stimulate more weight
gain.
If you are taking lithium, keep water intake

in a normal range and avoid heavy sweating,
because this decreases serum lithium levels
rapidly.
4) ANTIANXIETY DRUGS
(ANXIOLYTICS)
ANTIANXIETY
DRUGS
(ANXIOLYTICS)
These drugs are used to treat:
Anxiety and anxiety disorders

Insomnia
Obsessive-Compulsive disorder
Depression
Post-traumatic Stress disorder
Alcohol withdrawal
Benzodiazepines have proved to be the most effective in treating anxiety.
Buspirone is a non-benzodiazepine that is often used for relief of anxiety.
MECHANISM OF ACTION
ANTIANXIETY DRUGS (ANXIOLYTICS)
Benzodiazepines mediate the actions of the amino

acid GABA, the major inhibitory neurotransmitter in
the brain.
Benzodiazepines produce their effects by binding to a

specific site on the GABA receptor.
Buspirone is believed to exert its anxiolytic effect by

acting as a partial agonist at serotonin receptors,
decreasing serotonin turnover.
ANTIANXIETY DRUGS BENZODIAZEPINES

GENERIC
DAILY
(TRADE) NAME DOSAGE
RANGE
(mg)
HALF LIFE
(hours)
SPEED OF
ONSET
0.75 1.5
12 15
Intermediate
Chlordiazepoxid 15 100
e
(Librium)
50 100
Intermediate
Clonazepam
(Klonopin)
1.5 20
18 50
Intermediate
Chlorazepate
15 60
30 200
Fast
Alprazolam
(Xanax)
ANTIANXIETY DRUGS BENZODIAZEPINES

GENERIC
DAILY
(TRADE) NAME DOSAGE
RANGE
(mg)
HALF LIFE
(hours)
SPEED OF
ONSET
Flurazepam
(Dalmane)
15 30
47 100
Fast
Lorazepam
(Ativan)
28
10 20
Moderately
slow
Oxazepam
(Serax)
30 120
3 21
Moderately
slow
Temazepam
(Restoril)
15 30
9.5 20
Moderately
fast
DRUG ALERT!!! BENZODIAZEPINES
Benzodiazepines strongly enhance the

effects of alcohol
Clients should not drink alcohol when

taking benzodiazepines, or indeed any
psychotropic drug.
ANTIANXIETY DRUGS
NON-BENZODIAZEPINES
GENERIC
DAILY
(TRADE) NAME DOSAGE
RANGE
(mg)
Buspirone
(BuSpar)
15 30
HALF LIFE
(hours)
SPEED OF
ONSET
3 31
Very slow
PROBLEMS ENCOUNTERED WITH USE

OF BENZODIAZEPINES
Benzodiazepines have a tendency to cause physical

dependence.
Significant discontinuation symptoms occur when the

drug is stopped that often resemble the original
symptoms for which the client sought treatment.
This is especially a problem for clients with long-term

benzodiazepine use, such as those for panic disorder of
generalized anxiety disorder.
PROBLEMS ENCOUNTERED WITH USE

OF BENZODIAZEPINES
Benzodiazepines commonly cause psychological

dependence.
Clients fear the return of anxiety symptoms or

believe themselves incapable of handling anxiety
without the drugs.
This can lead to overuse or abuse of these drugs.
SIDE EFFECTS OF ANTIANXIETY DRUGS

- BENZODIAZEPINES
These are associated with CNS depression such as:

Drowsiness
Sedation
Poor coordination
Impairment of memory or clouded sensorium
When used for sleep, clients may complain of next-day
sedation or a hangover effect which is common among
benzodiazepines with a long half life.
SIDE EFFECTS OF ANTIANXIETY DRUGS

- NON-BENZODIAZEPINES
Common side effects from Buspirone

include:
Dizziness
Sedation
Nausea
Headache

ANTIANXIETY (ANXIOLYTIC) DRUGS
It is important for clients to know that antianxiety agents

are aimed at relieving symptoms, such as anxiety or
insomnia, but do not treat the underlying problems that
cause the anxiety.
Benzodiazepines strongly potentiate the effects of alcohol
One drink may have the effect of three drinks
Clients should not drink while taking benzodiazepines

Clients should be aware of decreased response time,

slower reflexes, and possible sedative effects of
benzodiazepines when attempting activities such as
driving or going to work. Drowsiness and sedation
usually decrease with time.
Benzodiazepine withdrawal can be fatal: once a

course of therapy has been started, benzodiazepines
should never be discontinued abruptly without the
supervision of the physician.

Take anxiolytic drugs only as prescribed.

Do not increase the dosage or take
extra doses even if your anxiety is
increased
without
consulting
the
physician
5) STIMULANTS
STIMULANT DRUGS
Stimulant drugs, specifically amphetamines, were first

used in the treatment of psychiatric disorders in the 1930s
for their pronounced effects of CNS stimulation.
Today, the primary use is for attention deficit /

hyperactivity disorder (ADHD) in children and adolescents,
residual attention deficit disorder in adults, and narcolepsy
(attacks of unwanted but irresistible daytime sleepiness
that disrupt a persons life).
STIMULANT DRUGS
The primary drugs used to treat ADHD

are the CNS stimulants:
methylphenidate (Ritalin)
pemoline (Cylert)
dextroamphetamine (Dexedrine)
STIMULANT DRUGS
Amphetamines and methylphenidate are often termed

indirectly acting amines because they act by causing
release of the neurotransmitters (norepinephrine,
dopamine, and serotonin) from presynaptic nerve
terminals, as opposed to having direct agonist effects
on the postsynaptic receptors.
They
also
block
neurotransmitters.
the
reuptake
of
these
DOSAGES OF STIMULANT DRUGS
For the treatment of narcolepsy in adults, both

dextroamphetamine
(Dexedrine)
and
methylphenydate (Ritalin) are given in divided
doses totaling 20 200 mg/day.
The higher doses may be needed because adults

with narcolepsy develop tolerance to the
stimulants, requiring more medication to sustain
improvement.
The dosages used to treat ADHD in children

vary widely depending on:
the physician
the age, weight and behavior of the child
the tolerance of the family for the childs
behavior

GENERIC (TRADE)
NAME
DOSAGE
Methylphenidate
(Ritalin)
Adults: 20-200 mg/day, orally, in divided doses

Children: 10-60 mg/day orally, in 2-4 divided doses
Dextroamphetamine
(Dexedrine)
Adults: 20-200 mg/day, orally, in divided doses

Children: 5-40 mg/day orally, in 2-3 divided doses
Pemoline
(Cylert)
Children: 37.5-112.5 mg/day orally, given once a

day in the morning
SIDE EFFECTS OF
STIMULANT DRUGS
The most common side effects of stimulants are:

Anorexia
Weight loss
Nausea
Irritability
Caffeine, sugar, and chocolate should be

avoided because they may worsen these
symptoms.
SIDE EFFECTS OF STIMULANT DRUGS
Less common side effects include:

Dizziness
Dry mouth
Blurred vision
Palpitations
SIDE EFFECTS OF
STIMULANT DRUGS
The most common long-term problem with

stimulants is the growth and weight
suppression that occurs in some children.
This can usually be prevented by taking

drug holidays on weekends, holidays, or
during summer vacation, which helps to
restore normal eating and growth patterns
CLIENT AND FAMILY TEACHING FOR

STIMULANT DRUGS
Never leave the supply of medication in

a place the child can reach to avoid
overdose
or
taking
additional
medication
Take the medication at meal time to

minimize nausea and anorexia.

STIMULANT DRUGS
Monitor the childs weight and height because growth

suppression can be a long-term consequence of
stimulant therapy.
Not giving the drugs during weekends during the
summer can help resume normal growth patterns.
Try a dosage schedule that provides a dose of

medication before beginning routine tasks of
concentration such as nightly homework.

STIMULANT DRUGS
Avoid beverages containing caffeine. Limit intake of

chocolate, sugar, or any other substance that increases
the childs activity level.
Alleviate dry mouth with calorie-free beverages or sugarfree candy.
Consult often with the school nurse or other person

responsible for giving medications at school.
Medications should be given in a manner that is not
intrusive, nor should it draw undue attention to the
child.
6) SENSITIZING DRUGS
DISULFIRAM (ANTABUSE)
Disulfiram is a sensitizing agent that

causes an adverse reaction when mixed
with alcohol in the body.
This agents only use is as a deterrent

to drinking alcohol in persons receiving
treatment for alcoholism.
ADVERSE REACTION WHEN

DISULFIRAM (ANTABUSE) MIXES WITH
ALCOHOL
Five to ten minutes after someone who is taking disulfiram
ingests alcohol, symptoms begin to appear:
Facial and body flushing from vasodilation
A throbbing headache
Sweating
Dry mouth
Nausea and vomiting
Dizziness and weakness
In severe cases, severe hypotension, confusion and even death.
Symptoms progress rapidly and last from 30 minutes to 2 hours.
DISULFIRAM (ANTABUSE)
Disulfiram inhibits the enzyme aldehyde

dehydrogenase, which is involved in the
metabolism of ethanol.
Acetaldehyde levels are then increased
from 5 to 10 times higher than normal,
resulting
in
the
disulfiram-alcohol
reaction
SIDE EFFECTS OF DISULFIRAM

(ANTABUSE)
Side effects of taking Disulfiram include:

Fatigue
Drowsiness
Halitosis
Tremor
Impotence
It can interfere with the metabolism of other drugs the

client is taking such as: phenytoin (Dilantin), isoniazid
(INH), warfarin (Coumadin), barbiturates, and long-acting
benzodiazepines such as diazepam and chlordiazepoxide.
CLIENT EDUCATION FOR PATIENTS

TAKING DISULFIRAM (ANTABUSE)
Many common products contain alcohol, such as:
Shaving cream
Aftershave lotion
Cologne
Deodorant
medications
such
as
cough
Over-the-counter
preparations
When used by the client taking disulfiram, these products
can produce the same reaction as drinking alcohol
The client must read product labels carefully and select
items that are alcohol-free
ELECTROCONVULSIVE
THERAPY (ECT)
ELECTROCONVULSIVE THERAPY
(ECT)
Involves application of electrodes to the

head of the client to deliver an electrical
impulse to the brain; this causes a seizure
It is believed that the shock stimulates brain

chemistry to correct the chemical imbalance
of depression
However, the mechanism of action of ECT is

unclear at present
FACTS ABOUT ELECTROCONVULSIVE

THERAPY (ECT)
Voltage of electrical current that is administered to
the client
70 150 volts
Length of electrical shock applied to the patient
About 0.5 to 2.0 seconds
Usual number of treatments needed to produce a
therapeutic effect
6 12 treatments
Frequency of treatments
There should be an interval of 48 hours for each
treatment

THERAPY (ECT)
Indicators of effectiveness of ECT

The occurrence of generalized tonicclonic seizure
Indications for ECT

Depression,
Mania,
Schizophrenia
Catatonic

THERAPY (ECT)
Contraindications to ECT
Fever
Increased intracranial tumor
TB with history of hemorrhage
Cardiac condition
Recent fracture
Retinal detachment
Pregnancy

THERAPY (ECT)
Need for consent prior to ECT

Yes, consent is needed

THERAPY (ECT)
Medications given to clients prior to ECT

Atropine sulfate
To decrease secretions
Anectine (Succinylcholine)
To promote muscle relaxation
Methohexital Sodium (Brevital)
Serves as an anesthetic agent

THERAPY (ECT)
Common complications of ECT

Loss of memory
Headache
Apnea
Fracture
Respiratory depression

NO.1
Mr. Bartes depression does not

antidepressant medication, and
orders electroconvulsive therapy
mechanism of action is?
improve with
the physician
(ECT).
ECTs
A) Similar to that of antidepressant drugs

B) Related to an increased production of chemicals
in the brain
C) Unclear at present
D) Related to the patients perception of ECT as
well-deserved punishment
ANSWER
Letter C
Rationale: The mechanism of action of

ECT is unclear at present

NO.2
Which of the following medications is

given to a patient before ECT, to
prevent aspiration?
A) Anectine
B) Brevital
C) Ritalin
D) Atropine sulfate
ANSWER
Letter D
Rationale: Atropine sulfate is given to

the patient, to decrease secretions to
prevent aspiration.

NO.3
Which of the following statements,

indicate a common side effect of ECT,
when a patient says:
A) I cannot sleep
B) I have a headache
C) I know you
D) I feel that my muscles are stiff
ANSWER
Letter B
Rationale: Headache is a common

complication of ECT

NO.4
An appropriate intervention
patient after ECT is to?
for
A) Check the consent

B) Re-orient the patient
C) Serve meals right away
D) Assist the patient to ambulate
ANSWER
Letter B
Rationale: Memory loss usually occurs

after ECT, so the nurse needs to reorient the patient

NO.5
Which of the following complaints

should the nurse address initially with
ECT?
A) I have a headache
B) I cannot breathe
C) I cannot remember anything
D) I am hungry
ANSWER
Letter B
Rationale: Respiratory depression can

occur after ECT due to the muscular
relaxation effect of Anectine, so assess
for respiration.
COMMON
PSYCHOTHERAPEUTIC
INTERVENTIONS
COMMON PSYCHOTHERAPEUTIC
INTERVENTIONS
Remotivation Therapy
Hypnotherapy
Music Therapy
Humor Therapy
Play Therapy
Behavior Modification
Group Therapy
Aversion Therapy
Milieu Therapy
Token Economy
Family Therapy
Desensitization
Psyhcoanalysis
Cognitive Therapy
REMOTIVATION THERAPY
Treatment modality that promotes

expression
of
feelings
through
interactions facilitated by discussion of
neutral topics
Reality orientation for rehabilitative

patients only and not for actively
psychotic patients
REMOTIVATION THERAPY
Five different steps:

Climate of acceptance
Welcome clients, introduce self to each other
Creating a bridge to reality
Orientation to topic
Sharing the world we live in
Discussion of the topic
Appreciation of the works of the world
Ask patient to reflect
Climate of appreciation
Express gratitude
MUSIC THERAPY
Involves the use of music to facilitate

relaxation, expression of feelings and
outlet of tension
PLAY THERAPY
Treatment modality which enables the

patient to experience intense emotion in
a safe environment with the use of play
Example: For victims of child abuse, give

dolls.
GROUP THERAPY
Treatment
modality
involving
therapeutic
interactions of three or more patients with a
therapist to relieve emotional difficulties,
increase self-esteem, develop insight and
improve behavior in relation with others
The minimum number of members in a group is

3, while the ideal number is 8 - 10
GROUP THERAPY
Types of Groups:
Therapeutic Group
To gain insight into their problems (i.e.

Alcoholics Anonymous)
Socialization group
To enhance interaction among patients
Life Review / Reminiscing Group
To lessen isolation
MILIEU THERAPY
Consists of treatment by means of

controlled modification of the patients
environment to facilitate positive
behavioral change
Nurse identifies what each patient

needs from the therapeutic milieu,
while keeping in mind the needs of the
larger patient group
FAMILY THERAPY
A method of psychotherapy which focuses on the total

family as an interactional system
Best suited for families where there is domestic violence
Goals include:
Enhancement of communication among family members
Mobilizing the familys inherent strengths
Strengthening family problem-solving behaviors
PSYCHOANALYSIS
A method of psychotherapy which focuses on the exploration of

the unconscious, to facilitate identification of the patients
defenses
Behavioral disorders are related to unresolved anxietyprovoking childhood experiences that are repressed into the
unconscious
Goal is to bring repressed experiences into conscious

awareness and to learn healthier means of coping with anxiety.
Utilizes dream analysis and free association (verbalization of

thoughts without censorship)
HYPNOTHERAPY
A therapeutic modality which involves

various methods and techniques to
induce a trans state where the patient
becomes submissive to instructions
HUMOR THERAPY
Involves the use of humor to facilitate

expression of feelings and to enhance
interaction
Therapeutic laughing lessens the high

levels of tension that often accompany
discussions of serious matters.
BEHAVIOR MODIFICATION
A therapeutic intervention involving the

application of learning principles in order
to change maladaptive behavior
It attempts to strengthen a desired

behavior or response by reinforcement,
either positive or negative.
Positive reinforcement
Example:
If the desired behavior is assertiveness,

whenever the client uses assertiveness skills
in a communication group, the group leader
provides positive reinforcement by giving the
client attention and positive feedback.
Negative reinforcement involves removing a

stimulus immediately after a behavior occurs so
that the behavior is more likely to occur again.
For example, if a client becomes anxious when

waiting to talk in a group, he may volunteer to
speak first to avoid the anxiety.
AVERSION THERAPY
An example of behavior modification in which a

painful stimulus is introduced to bring about an
avoidance of another stimulus with the end view of
facilitating behavioral change
Examples:
A patient snaps a rubber band on the wrist when
bothered by an intrusive thought
Covert sensitization
Patient imagines scenes that pair undesired behavior

with unpleasant consequences of overeating.
TOKEN ECONOMY
An example of behavior modification

technique which utilizes the principle
of rewarding desired behavior to
facilitate change
DESENSITIZATION
Periodic exposure of the individual to a

feared object, until the undesirable
behavior disappears or is lessened
COGNITIVE THERAPY
Short term structured therapy between the

patient and the therapist oriented towards
present problems and solutions.
The main focus of cognitive therapy is in

depression disorders to:
Increase activity
Reduce unwanted behavior
Increase pleasure
Enhancing social skills
COGNITIVE THERAPY
Anxiety Reduction
Relaxation Training
Systematic Desensitization
Cognitive Restructuring
Thought Stopping
Learning New Behavior

Token Economy

NO.1
A nurse consults the hospitals clinical nurse

specialist in psychiatric nursing about group
size. The nurse specialist will most likely say
that the optimal number of patients in each
group is?
A) 5
B) 10
C) 20
D) Unlimited
ANSWER
Letter B
Rationale: 8 10 patients is the

optimal number of patients in a group

NO.2
Milieu therapy involves?

A) Gathering together a member of a disturbed
patients community
B) Only immediate family members are involved in
affecting behavior changes in the patient
C) Emphasis on considering patient as a biophysical
and sociocultural being
D) Scientific manipulation of the environment that
influence improvement of patients behavior
ANSWER
Letter D
Rationale: Milieu therapy involves

scientific
manipulation
of
the
environment
that
can
influence
improvement of the patients behavior

NO.3
What is the main goal of milieu therapy?

A) Inclusion of the family in the therapy
B) Change inappropriate behavior
C) Patient-planned, patient-led activities
D) Staff-led decision-making process
ANSWER
Letter C
Rationale: In milieu therapy, patients

plan and lead activities rather than the
staff.

NO.4
In family therapy sessions, the nurse

should?
A) Serve as a leader
B) Focus on the sick member
C) Neutralize blaming by setting
contract
D) Use paradoxical communication
ANSWER
Letter C
Rationale: A contract is essential at the

beginning
of
therapy
to
make
expectations clear.

NO.5
Milieu activities which are initially

appropriate for schizophrenic patients
are the following, EXCEPT?
A) Basketball
B) Painting
C) Writing
D) Listening to music
ANSWER
Letter A
Rationale: Patients with schizophrenia

need activities that do not require
interaction, so solitary activities are
preferred over team activities.
DYNAMICS OF HUMAN
BEHAVIOR
NEED
It is an organismic condition which

requires a certain activity
STRESS
A broad class of experiences, in which a demanding

situation taxes a persons coping abilities
A non-specific response of the body to any kind of

demand made upon it (Hans Selye)
This non-specific response is called the General

Adaptation Syndrome (GAS) or the stress syndrome
Distress is known as unhealthy stress
Eustress is known as healthy stress
BEHAVIOR
Way in which an organism responds to

a stimulus
CONFLICT
Situation that arise from the presence

of two opposing drives.
BASIC CONCEPTS ON
THE PATIENT
PERSONALITY
The integration of those systems and

habits that represents an individuals
characteristic
adjustment
to
his
environment.
Personality
behavior
is
expressed
through
CHARACTERISTICS OF
PERSONALITY
Distinctiveness
Each individual is unique
Stability and Consistency

Personality is predictable
DETERMINANTS OF
PERSONALITY
Psychological
Type of climate at home
Cultural
Customs and traditions
Biological
Personality is not inherited
Familial
Parenting style
DIVISIONS OF THE MIND OR

LEVELS OF AWARENESS
Freud believed that the human personality

functions at three levels of awareness:
Conscious
Preconscious
Unconscious
DIVISIONS OF THE MIND /

LEVELS OF AWARENESS
CONSCIOUS
This refers to the perceptions, thoughts,

and emotions that exist in the persons
awareness such as being aware of
happy feelings or thinking about a loved
one
It is the part of the mind focused on

awareness

LEVELS OF AWARENESS
SUBCONSCIOUS
Preconscious thoughts and emotions are not

currently in the persons awareness, but he or she
can recall them with some effort.
It is the part of the mind that contains information

that can be recalled at will
For example, an adult remembering what he or

she did, thought, or felt as a child.

LEVELS OF AWARENESS
SUBCONSCIOUS
This
refers to the realm of thoughts and feelings that
motivate a person, even though he or she is totally

unaware of them.
This realm includes most defense mechanisms and

some instinctual drives or motivations.
It is the largest part of the mind; contains materials

and information that can never be recalled
PERSONALITY STRUCTURE
Sigmund
Freud
conceptualized
personality structure as having three
components:
Id
Superego
Ego
ID
Is the part of ones nature that reflects

basic or innate desires such as:
Pleasure-seeking behavior
Aggression
Sexual impulses
The id seeks instant gratification; causes

impulsive, unthinking behavior; and has
no regard for rules or social convention.
SUPEREGO
Is the part of
reflects moral
values, and
expectations
a persons nature that

and ethical concepts,
parental and social
Therefore, it is in direct opposition to

the id.
EGO
Is the balancing or mediating force between the

id and the superego.
It represents mature and adaptive behavior that

allows a person to function successfully in the
world.
Freud believed that anxiety resulted from the

egos attempts to balance the impulsive instincts
of the id with the stringent rules of the superego.
STRUCTURES
OF
PERSONALITY
ID
EGO
SUPEREGO
AGE AT WHICH
IT IS PRESENT
0 1 YEAR OLD 1 3 YEARS OLD 3 6 YEARS OLD
DIVISION OF
MIND
UNCONSCIOUS CONSCIOUS AND

UNCONSCIOUS
DESCRIPTION
NO SENSE OF
RIGHT OR
WRONG
UNCONSCIOUS
INTEGRATOR OF EGO IDEAL GIVES

PERSONALITY
REWARDS;
CONSCIENCE
GIVES
PUNISHMENT
THEORIES OF
PERSONALITY
DEVELOPMENT
THEORIES OF PERSONALITY
DEVELOPMENT
Freuds Psychosexual Theory
Eriksons Psychosocial Theory
Piagets Cognitive Theory
FREUDS THEORY OF
PSYCHOSEXUAL
DEVELOPMENT
FREUDS THEORY OF
PSYCHOSEXUAL DEVELOPMENT
Freud based his theory of childhood development on

the belief that sexual energy, termed libido, was the
driving force of human behavior
He proposed that children go through five stages of

psychosexual development
Oral
Anal
Phallic
Latency
Genital
FREUDS THEORY OF
PSYCHOSEXUAL DEVELOPMENT
Psychopathology
results
when
a
person has difficulty making the
transition from one stage to the next,
or when a person remains stalled at a
particular stage or regresses to an
earlier stage.
ORAL STAGE
Age
Birth to 18 months
Focus
Major site of tension and gratification is the mouth, lips and
tongue, includes biting and sucking activities
Id present at birth
Ego develops gradually from rudimentary structure present
at birth
Indicators of Fixation: smoking, chewing gum, voracious
eaters
ANAL STAGE
Age
18 36 months
Focus
Anus and surrounding area are major source of
interest
Acquisition of voluntary sphincter control (toilet
training)
Indicators
of Fixation: Parsimonious, punctual,
precise, obsessive-compulsive (overemphasized
cleanliness), passive-aggressive
PHALLIC OR OEDIPAL STAGE
Age
3 5 years
Focus
Penis is organ of interest for both sexes.
Masturbation is common
Penis envy (wish to possess penis) seen in girls;
oedipal complex (wish to marry opposite-sex parent
and be rid of same-sex parent) seen in boys and girls.
Indicators of Fixation: Exhibitionism due to fear of
castration
LATENCY STAGE
Age
5 11 or 13 years
Focus
Resolution of oedipal complex
Homosexual stage formation of gangs (boy-boy or
girl-girl)
Sexual drive channeled into socially appropriate
activities such as school work and sports
Formation of the superego
Indicators of Fixation: Chum-relationships or buddy,
Gender Identity Disorder or being uncomfortable with
gender
GENITAL STAGE
Age
11 13 years
Focus
Final stage of psychosexual development
Begins with puberty and the biologic capacity for
orgasm; involves the capacity for true intimacy
Area of gratification includes secondary sex
characteristics, reawakening of sexual drives.
Indicators of Fixation: Identity crisis
ERIKSONS THEORY OF
PSYCHOSOCIAL
DEVELOPMENT
ERIKSONS THEORY OF
PSYCHOSOCIAL DEVELOPMENT
In each stage, the person must

complete a life task that is essential to
his or her well-being and mental health.
These tasks allow the person to achieve

lifes virtues
ERIKSONS THEORY OF
PSYCHOSOCIAL DEVELOPMENT
In his view, psychosocial growth occurs in sequential

phases and each stage is dependent in completion of the
previous stage and life task
For example, in the infant stage, trust versus mistrust,
the baby must learn to develop basic trust (the positive
outcome) such that he or she will be fed and taken
cared of. The formation of trust is essential; mistrust,
the negative outcome of this stage, will impair the
persons development throughout his or her life.
1st Stage: TRUST VERSUS

MISTRUST (Infant)
Age
0 12 months
Virtue
Hope
Task
Viewing the world as safe and reliable;
relationships as nurturing, stable and dependable
Concept
If the needs of the child are consistently met, trust
develops
2nd Stage: AUTONOMY VERUS

SHAME AND DOUBT (Toddler)
Age
1 3 years
Virtue
Will
Task
Achieving a sense of control and free will
Concept
If toilet training is not hurried, autonomy
develops
3rd Stage: INITIATIVE VERSUS

GUILT (Pre-School)
Age
3 6 years
Virtue
Purpose
Task
Beginning development of a conscience;
learning to manage conflict and anxiety
Concept
If the childs sexual curiosity is handled
without anxiety, initiative develops
4th Stage: INDUSTRY VERSUS

INFERIORITY (School Age)
Age
6 12 years
Virtue
Competence
Task
Emerging confidence in own abilities; taking
pleasure in accomplishments
Concept
If the childs efforts at learning is supported,
industry develops
5th Stage: IDENTITY VERSUS

ROLE CONFUSION
(Adolescence)
Age
12 18 years
Virtue
Fidelity
Task
Formulating a sense of self and belonging
Concept
If the adolescents vocational decision is
supported, identity develops
6th Stage: INTIMACY VERSUS

ISOLATION (Young Adult)
Age
18 25
Virtue
Love
Task
Forming adult, loving relationships and
meaningful attachments to others
Concept
If the young adults decisions regarding love
relationships is supported, intimacy develops
7th Stage: GENERATIVITY

VERSUS STAGNATION (Middle
Adult)
Age
25 65 years
Virtue
Care
Task
Being creative and productive; establishing
the next generation
Concept
If an adult enjoys support from the family,
generativity develops
8th Stage: EGO INTEGRITY

VERSUS DESPAIR (Maturity)
Age
65 years and above
Virtue
Wisdom
Task
Accepting responsibility for ones self and life
Concept
If the elderly has a satisfying past
recollection, integrity develops
PIAGETS THEORY OF
COGNITIVE DEVELOPMENT
PIAGETS THEORY OF COGNITIVE

DEVELOPMENT
Piaget believed that human intelligence

progresses through a series of stages based
on age with the child at each successive
stage demonstrating a higher level of
functioning than at previous stages.
He also believed that biologic changes and

maturation were responsible for cognitive
development
PIAGETS THEORY OF
COGNITIVE DEVELOPMENT
Four stages of cognitive development:

Sensorimotor
Preoperational
Concrete Operations
Formal Operations
SENSORIMOTOR
Age
0 2 years
Concepts
The child develops a sense of self as separate
from the environment and the concept of object
permanence; that is, tangible objects dont
cease to exist just because they are out of sight
(example: peek-a-boo)
He or she begins to form mental images
Development proceeds from reflex activity to
sensorimotor learning
PREOPERATIONAL STAGE
Age
2 6 years
Concepts
The child develops the ability to express self with language,
understands the meaning of symbolic gestures, and begins
to classify objects
At 2 4 years, development proceeds from sensory motor learning

to prelogical thought (pre-conceptual)
The child learns language and symbols
At 4 6 years, the child is able to think in terms of class (intuitive)
The child is able to determine that individuals have roles
CONCRETE OPERATIONAL
STAGE
Age
6 12 years
Concepts
Development from pre-logical to logical
concrete thought
The child begins to apply logic to thinking,
understands spatiality and reversibility, and
is increasingly social and able to apply rules
Thinking is still concrete
FORMAL OPERATIONAL STAGE
Age
12 Adulthood
Concepts
The child is able to think abstractly and is
able to apply the scientific method
The child learns to think and reason in
abstract terms, further develops logical
thinking and reasoning, and achieves
cognitive maturity.

NO.1
Erikson described the psychosocial tasks of

the developing person in his theoretical
model. The primary developmental task of
the young adult (age 18 25) is?
A) Intimacy versus isolation
B) Industry versus inferiority
C) Generativity versus stagnation
D) Trust versus mistrust
ANSWER
Letter A
Rationale: The primary developmental

task of the young adult is intimacy
versus isolation

NO.2
Jen, 5 years-old has been brought to the

emergency room by their neighbor with
second degree burns at her right hand.
According to Freud, Jen is at what stage of
psychosexual development?
A) Latency
B) Oral
C) Anal
D) Phallic
ANSWER
Letter D
Rationale: The phallic stage of

development is from ages 3 through 6.

NO.3
Monica, a 19-year old college student

belongs to what stage of psychosexual
development?
A) Anal
B) Latency
C) Genital
D) Phallic
ANSWER
Letter C
Rationale: Age 12 to adulthood is the

genital
stage
of
development
according to Freud

NO.4
Three-year old Messiah belongs to what

stage of development?
1) Anal
2) Phallic
3) Sensorimotor
4) Pre-operational
A) 1,3
B) 1,4
C) 2,3
D) 2,4
ANSWER
Letter B
Rationale: In Freuds theory, age 1 3

belong to the anal stage while in
Piagets theory, age 2 7 belong to the
pre-operational stage

NO.5
A child who belongs to the phallic stage in

Freuds theory must develop which of the
following developmental tasks according
to Erickson?
A) Trust
B) Autonomy
C) Initiative
D) Industry
ANSWER
Letter C
Rationale: The phallic stage in Freuds

theory (age 3 6) corresponds to the
development of the developmental
task of initiative versus guilt in
Ericksons theory
CRISIS AND CRISIS

INTERVENTION
CRISIS
A crisis is a turning point in an individuals life that produces an

overwhelming emotional response
Individuals experience a crisis when they confront some life
circumstance or stressor that they cannot effectively manage
through use of their customary coping skills
A situation that occurs when an individuals habitual coping
ability becomes ineffective to meet demands of the situation
CHARACTERISTICS OF A CRISIS
STATE
Highly individualized
Lasts for 4 6 weeks
Person affected becomes passive and

submissive
Affects a persons support system
TYPES OF CRISES
Maturational or Developmental Crisis
Situational or Accidental Crisis
Social or Adventitious Crisis
MATURATIONAL OR
DEVELOPMENTAL CRISIS
Expected, predictable and internally

motivated events in the normal course of
life such as:
Leaving home for the first time
Getting married
Having a baby
Beginning a career
Growth
Parenthood
SITUATIONAL OR ACCIDENTAL
CRISIS
Unanticipated or sudden, unexpected,

unpredictable and externally motivated
events that threaten the individuals
integrity such as:
Death of a loved one
Loss of a job
Physical and emotional illness in the
individual family or member
Car accident
SOCIAL OR ADVENTITIOUS
CRISIS
Includes natural disasters and acts of

nature like:
Floods
Earthquakes
Hurricanes
War
Terrorist attacks
Riots
Violent crimes such as rape or murder
PHASES OF A CRISIS
Denial
Initial reaction
Increased Tension
The person recognizes the presence of a crisis and
continues to do activities of daily living
Disorganization
The person is pre-occupied with the crisis and is
unable to do activities of daily living
Attempts to Reorganize
The individual mobilizes previous coping mechanisms
CRISIS INTERVENTION
A way of entering into the life situation

of an individual, family, group, or
community to help them mobilize their
resources and to decrease the effect of
a crisis inducing stress
GOAL OF CRISIS INTERVENTION
To enable the patient to attain an

optimum level of functioning
TYPES OF CRISIS INTERVENTION
Authoritative Crisis Intervention
Facilitative Crisis Intervention
AUTHORITATIVE CRISIS
INTERVENTION
Are designed to assess the persons health status

and promote problem-solving such as:
Offering the person new information, knowledge
or meaning
Raising the persons self awareness by providing
feedback about behavior
Directing the persons behavior by offering
suggestions or courses of action
FACILITATIVE CRISIS
INTERVENTION
Aim at dealing with the persons needs for

empathetic understanding such as:
Encouraging the person to identify and
discuss feelings
Serving as a sounding board for the person
Affirming the persons self worth
PRIMARY ROLE OF THE NURSE

IN CRISIS
Active and directive, the nurse has to

assist the patient

NO.1
Nurse Apple attends to patients who are in crisis. The

goal of crisis intervention is to?
A) Assist the patient explore available and appropriate
resources in the community
B) Assist the patient develop awareness of her feelings
C) Assist the patient to achieve correct cognitive
perception of the situation
D) Assist the patient to seek new and useful adaptive
mechanisms within the context of her social support
system
ANSWER
Letter D
Rationale:
The
goal
of
crisis
intervention is to assist the patient to
seek
new
and
useful
adaptive
mechanisms within the context of her
social support system.

NO.2
This phase of crisis is characterized by

feelings of great anxiety and inability
to perform activities of daily living.
A) Disorganization
B) Reorganization
C) Attempt to escape the problem
D) Increased tension
ANSWER
Letter A
Rationale: Disorganization is the phase

of a crisis state which is characterized
by feelings of great anxiety and
inability to perform activities of daily
living.

NO.3
Which of the following would be most helpful

during the early stages of crisis intervention
A) Help the patient to understand the crisis
B) Encourage the patient to forget the experience
C) Assess her thoughts thoroughly
D) Protect the patient from potential harm
ANSWER
Letter A
Rationale: In crisis intervention, a

thorough understanding of the crisis is
necessary for appropriate planning

NO.4
The nurses role in crisis therapy

should be?
A) Non-directive and passive
B) Firm and confrontational
C) Active and directive
D) Calm and non-expressive
ANSWER
Letter C
Rationale: A patient in crisis is passive

and submissive so the nurse needs to
be active and directive to facilitate
coping.

NO.5
Which of the following is expected of a

person in crisis?
A) Be able to adjust in a week
B) Becomes submissive and passive
C) Takes the lead in problem-solving
D) Assists the nurse in decision-making
ANSWER
Letter B
Rationale: A patient in crisis is passive

and submissive.
RAPE
RAPE
Is a crime of violence and humiliation of the victim

expressed through sexual means
Rape is the penetration of an act of sexual intercourse

with a female against her will and without her consent,
whether her will is overcome by force, fear of force,
drugs, or intoxicants
It is also considered rape if the woman is incapable of

exercising rational judgment because of mental
deficiency or when she is below the age of consent.
RAPE
According to Republic Act 8353, it refers

to the insertion of the penis into the
mouth, vagina, anus of a victim
Insertion of any object into the mouth or

anus
It is generally considered as an act of

hostility, anger or violence
ESSENTIAL ELEMENTS
NECESSARY TO DEFINE AN ACT
OF RAPE
Use of threat / force
Lack of consent of the victim
Actual penetration of the penis into the

vagina
DIFFERENT KINDS OF RAPE
Anger Rape
Power Rape
Sadistic Rape
ANGER RAPE
Distinguished by physical violence and cruelty

to the victim
Rapist believes he is the victim of an unjust

society and takes revenge on others by raping
He uses extreme force and viciousness to

overcome the victim
This is done as a means of retaliation
POWER RAPE
The intent of the rapist is not to injure the victim but

to command and master another person sexually
The rapist has an insecure self-image and feelings

of incompetence and inadequacy
The rape is the vehicle for expressing power,

potency and might
This is done to prove ones masculinity
SADISTIC RAPE
Involves brutality
The use of bandage and torture is not an

expression of anger but necessary for the
rapists sexual excitement
The assault is often eroticized and is sexually

stimulating
This is done to express erotic feelings
WARNING SIGNS OF
RELATIONSHIP VIOLENCE
Emotionally abuses you (insults, makes belittling comments,

acts sulky or angry when you initiate an idea or activity)
Tell you with whom you may be friends or how you should
dress, or ties to control other elements of your life
Talks negatively about women in general
Gets jealous for no reason
Drinks heavily, uses drugs, or tries to get you drunk
WARNING SIGNS OF
Acts in an intimidating way by invading your

personal space such as standing too close or
touching you when you do not want him to
Cannot handle sexual or emotional frustration

without becoming angry
Does not view you as an equal; sees himself as

smarter or socially superior
WARNING SIGNS OF
Guards his masculinity by acting tough
Is angry or threatening to the point

that you have changed your life or
yourself so you wont anger him
RAPE TRAUMA SYNDROME
It refers to a group of signs and

symptoms experienced by a victim in
reaction to a rape
PHASES OF THE RAPE TRAUMA

SYNDROME
Acute
Phase
Characterized by shock, numbness and disbelief
Denial Phase
Characterized by the victims refusal to talk about the
event
Heightened Anxiety
Characterized by fear, tension, and nightmares
Stage of Reorganization
The victims life normalizes
NURSING CARE FOR RAPE

VICTIMS
In the emergency
emotional support
setting,
provide
immediate
The nurse should allow the woman to proceed at her

own pace and not rush her through any interview or
examination
Give as much control back to the victim as possible by

allowing her to make decisions, when possible, about
whom to call, what to do next, what she would like
done, etc.

VICTIMS
It is the victims decision about whether or

not to file charges and testify against the
perpetrator and the victim must sign
consent forms before any photographs of
hair and nail samples are taken for future
evidence
The priority in the care of a rape victim is

the preservation of evidence

VICTIMS
Prophylactic treatment for STDs is offered
Prophylaxis can be offered to prevent pregnancy
In some areas, HIV testing is strongly encouraged
Referrals to rape crisis centers are encouraged

NO.1
The initial treatment of a rape victim can

significantly affect the psychological impact the
assault will have on the victim.
The first
information elicited from a victim would be which
of the following?
A) the marital state of the victim
B) the victims perception of what occurred
C) whether or not the rapist was known to her
D) how she feels about having an abortion if she
becomes pregnant
ANSWER
Letter B
Rationale: Rape is a form of crisis. The

severity of a crisis situation depends
on the individuals perception of the
event.

NO.2
Rape is generally considered to be an

act of ?
A) Aggression
B) Bestiality
C) Exposure
D) Sexual passion
ANSWER
Letter A
Rationale:
Rape
is
generally
considered to be an act of aggression,
hostility and violence

NO.3
Which of the following is most

important for the emergency room
nurse to take?
A) Call the police
B) Call a psychiatrist
C) Provide emotional support
D) Offer protection from pregnancy
ANSWER
Letter C
Rationale: Initially, the provision of a

safe and supportive environment is
necessary

NO.4
The overall patient goal in rape counseling is

to help the victim?
A) Forget the incident and repress her feelings
in order to be able to carry on with her life
B) Identify the rapist in court
C) Accept her part in the rape
D) Acknowledge, face, and resolve the
reaction she is experiencing
ANSWER
Letter D
Rationale: Rape is a form of crisis. In

crisis intervention, the patient is
considered
as
the
primary
rehabilitator.

NO.5
Primary prevention of rape can be best

accomplished by which of the following?
A) Initiation of emergency measures after the
rape
B) Policewoman teaching a class on rape
prevention
C) Psychiatric hospitalization for the survivor
of rape
D) A lengthy jail sentence for the rapist
ANSWER
Letter B
Rationale: Conducting rape prevention

classes is an example of primary level
of prevention
SPOUSE OR PARTNER
ABUSE
SPOUSE OR PARTNER ABUSE
Is the mistreatment or misuse of one

person by another in the context of an
intimate relationship
The abuse can be emotional or

psychological, physical, sexual or a
combination (which is common)
Emotional or psychological abuse includes:
Name-calling
Belittling
Screaming
Yelling
Destroying property
Making threats
Refusing to speak to or ignoring the victim
Physical abuse includes the following:

Shoving
Pushing
Severe battering and choking and may
involve broken limbs and ribs, internal
bleeding, brain damage, even homicide
Sexual abuse include the following assaults

during sexual relations such as:
Biting nipples
Pulling hair
Slapping and biting
Rape
BATTERED WIFE SYNDROME
Cycle of domestic violence characterized by

wife-beating by the husband, humiliation and
other forms of aggression
The most common trait of abusive men is

low self-esteem
The most common trait of the abused

woman is dependence
CHARACTERISTICS OF ABUSIVE
HUSBANDS
They usually
families
come
They are immature, dependent and

non-assertive
They
have
inadequacy
strong
from
violent
feelings
of
PHASES OF SPOUSE OR
PARTNER ABUSE
Tension Building Phase

Involves minor battering incidents
Acute Battering Phase

More serious form of battering occurs
Aftermath / Honeymoon Phase

The husband becomes loving and gives
the wife hope
PRIORITY IN NURSING CARE

FOR THE ABUSED SPOUSE OR
PARTNER
Provision of shelter
DOs IN WORKING WITH VICTIMS

OF PARTNER ABUSE
Do ensure and maintain the clients confidentiality
Do listen, affirm, and say I am sorry you have

been hurt.
Do express: I am concerned for your safety.
Do tell the victim: You have the right to be safe

and respected.
DOs IN WORKING WITH VICTIMS

OF PARTNER ABUSE
Do recommend a support group or individual

counseling
Do identify community resources and

encourage the client to develop a safety plan
Offer to help the client contact a shelter, the

police, or other resources
DONTs IN WORKING WITH

VICTIMS OF PARTNER ABUSE
Dont disclose client communications

without the clients consent
Dont preach, moralize, or imply that you

doubt the client
Dont minimize the impact of the violence
Dont express outrage with the perpetrator

NO.1
Seeing a patient for the first time, the nurse notices bruises on her
upper arms and asks about them. After denying any problems, the
patient starts to cry and says, He didnt really mean to hurt me,
but I hate the kids to see. I am so worried about them. During the
interview, it would be most important for the nurse to determine?
A) The type and extent of abuse in the family
B) The potential of immediate danger to the patient and her
children
C) The resources available to the patient
D) Whether the patient wants to be separated from her husband
ANSWER
Letter B
Rationale: In domestic violence, the

priority is the patients safety

NO.2
When planning her care, which of the following is the

most important to the patient?
A) The phone number of the local crisis hotline
B) Referral to a psychotherapist
C) Referral to assertiveness training classes for women
D) No referral will be needed unless the battering
occurs against or is witnessed by an adult
ANSWER
Letter A
Rationale: Provision of support is an

essential component of the care of
battered women.

NO.3
In assessing a battered wifes method

of coping, which method would the
nurse least expect to find her using?
A) Assertiveness
B) Alcohol abuse
C) Self-blame
D) Suicidal thoughts
ANSWER
Letter A
Rationale: Battered women are usually

dependent and non-assertive

NO.4
Wife beaters will usually manifest?

A) Maturity
B) Low self-esteem
C) Assertiveness
D) Patience
ANSWER
Letter B
Rationale: Wife-beaters usually have

low self-esteem

NO.5
Abused women are more likely to become

receptive to nursing intervention during
the ?
A) Acute phase
B) Honeymoon stage
C) Tension building phase
D) Time between the acute phase and the
tension building phase
ANSWER
Letter D
Rationale: During this stage, the victim

is in a state of crisis and is therefore
more receptive to suggestions.
DONTs IN WORKING WITH

VICTIMS OF PARTNER ABUSE
Dont imply that the client is responsible for the

abuse
Dont recommend couples counseling
Dont direct the client to leave the relationship
Dont take charge and do everything for the client
CHILD ABUSE
CHILD ABUSE
Child abuse or mistreatment is

generally defined as the intentional
injury of a child
CHILD ABUSE
It can include any of the following:

Physical abuse or injuries
Neglect or failure to prevent harm
Failure to provide adequate physical
emotional care or supervision
Abandonment
Sexual assault or intrusion
Overt torture or maiming
or
TYPES OF CHILD ABUSE
Physical Abuse
Sexual Abuse
Neglect
Psychological Abuse

PHYSICAL ABUSE
Physical abuse of children often results from

unreasonably severe corporal punishment or unjustifiable
punishment such as hitting an infant for crying or soiling
his diapers
Intentional deliberate assaults on children include:
Burning
Biting
Cutting
Poking
Twisting limbs
Scalding with hot water

PHYSICAL ABUSE
The victim often has evidence of old

injuries
(e.g.,
scars,
untreated
fractures, multiple bruises of various
ages) that the history given by parents
does not explain adequately

SEXUAL ABUSE
Sexual abuse involves sexual acts performed by an adult

on a child younger than 18 years of age
Examples include:
Incest
Rape
Sodomy performed directly by the person or with an
object
Oral-genital contact
Acts of molestations such as rubbing, fondling, or
exposing the adults genitals

SEXUAL ABUSE
Sexual abuse includes:

Exploitation, such as:
Making, promoting, or selling
pornography involving minors
Coercion of minors to participate in
obscene acts

NEGLECT
Neglect is malicious or ignorant

withholding of physical, emotional, or
educational necessities for the childs
well-being

NEGLECT
Child abuse by neglect is the most prevalent type of

maltreatment and includes:
Refusal to seek health care or delay doing so;
Abandonment
Inadequate supervision
Reckless disregard for the childs safety
Punitive, exploitative, or abusive emotional treatment;
Spousal abuse in the childs presence
Giving the child permission to be truant (absent from
school)
Failing to enroll the child in school

PSYCHOLOGICAL ABUSE
Psychological abuse (emotional abuse) includes

Verbal assaults
Blaming
Screaming
Name-calling
Using sarcasm
Constant family discord

yelling, and chaos
Emotional deprivation
nurturing
Normal experiences that
security and self-worth
characterized by fighting,
or
withholding
affection,
engender acceptance, love,
CHARACTERISTICS OF ABUSIVE
PARENTS
They come from violent families
They were also abused by their parents
They have inadequate parenting skills
They are socially isolated because they dont trust anyone
The are emotionally immature
They have negative attitude towards the management of

the abused
WARNING SIGNS OF ABUSED

OR NEGLECTED CHILDREN
Serious injury such as fractures, burns,

lacerations with no reported history of trauma
or
Delay in seeking treatment for a significant injury
Child or parent gives a history inconsistent with

severity of injury, such as a baby with contre coup
injuries to the brain (shaken baby syndrome) that
the parent claim happened when the infant rolled
off the sofa

Inconsistencies or changes in the childs history

during the evaluation by either the child or the
adult
Unusual injuries for the childs age and level of

development, such as fractured femur on a 2
month old or a dislocated shoulder in a 2 year old

High incidence of urinary tract

infections; bruised, red, or swollen
genitalia; tears or bruising of rectum or
vagina
Evidence of old injuries not yet

reported, such as scars, fractures not
treated, multiple bruises that parent
cannot explain adequately
COMMON INDICATORS OF
CHILD ABUSE
Serious injuries in various stages of

healing
Healthy hair in various length
Apathy, no reaction
Depression
Excessive knowledge of sex
Self-esteem is low
PRIORITIES IN CHILD ABUSE
Republic Act 7610, the anti-child abuse law requires

reporting of suspected cases to authorities
Remember that the nurse does not have to decide with
certainty that abuse has occurred
Nurses are responsible for reporting suspected child
abuse with accurate and thorough documentation of
assessment data
Report cases to barangay officers, DSWD personnel,
police within 48 hours
PRIORITIES IN CHILD ABUSE
The first part of treatment for child

abuse or neglect is to ensure the
childs safety and well-being
Assistance of social service agencies

may be tapped

NO.1
In assessing an abusive situation, the nurse

would find what information most useful?
A) The interaction between the child and his
mother
B) The time of abuse
C) Presence of other children in the family
D) Age of the mother
ANSWER
Letter A
Rationale: The interaction between a

child and his mother provides a clue to
the kind of relationship that the child
has with his mother

NO.2
Which of the following actions would be

taken by hospital personnel when child
abuse is suspected?
A) Confront the mother
B) Notify the family
C) Notify the child protective service
D) Do nothing until the diagnosis is
certain
ANSWER
Letter C
Rationale: Hospital personnel are

required by law to report suspected
cases of child abuse.
ANXIETY
ANXIETY
A stage of uneasiness or discomfort experienced to

varying degrees
Is frequently coupled with doubts, fears, obsessions.
A feeling of terror or dread; the most uncomfortable

feeling a person can experience
An initial response to a psychic threat (Hildegard Peplau)
HILDEGARD PEPLAUS FOUR

LEVELS OF ANXIETY
Mild Anxiety
Moderate Anxiety
Severe Anxiety
Panic Anxiety
MILD ANXIETY
It is a positive state of heightened

awareness and sharpened senses,
allowing the person to learn new
behaviors and solve problems.
The person can take in all available

stimuli (enlarged perceptual field)
MODERATE ANXIETY
Involves a decreased perceptual field

(focus on immediate task only)
The person can learn new behavior or

solve problems only with assistance
Another person can redirect the person

to the task.
SEVERE ANXIETY
This involves feelings of dread or terror
The person cannot be redirected into a task;

he or she focuses only on scattered details
and
has
physiologic
symptoms
of
tachycardia, diaphoresis, and chest pain.
People with severe anxiety often go to

emergency departments, believing they are
having a heart attack.
PANIC ANXIETY
It involves loss of rational thought,

delusions,
hallucinations,
and
complete physical immobility and
muteness
The person may bolt and run

aimlessly, often exposing himself or
herself to injury.
SIGNS AND SYMPTOMS OF

ANXIETY
SIGNS AND MILD ANXIETY MODERATE
SEVERE
SYMPTOMS
PHYSICAL
COGNITIVE
ANXIETY
ANXIETY
PANIC
ANXIETY
Increased pulse Nausea

rate, respiratory Anorexia
rate, blood
Vomiting
pressure
Diarrhea
Pupillary
Constipation
dilation
Restlessness
Sweating
Signs and
symptoms
become the
focus of
attention
Attentive and
alert patient
Perceptual field Personality is

is greatly
disorganized
narrowed.
Focus of
attention is
trivial events
Narrowed
perceptual field
and selective
inattention
Signs and
symptoms of
exhaustion are
ignored
PRIORITY NURSING DIAGNOSES

FOR ANXIETY
Ineffective individual coping
Anxiety
PRINCIPLES OF NURSING CARE

IN ANXIETY
Calm
Administer medications
Listen to the patients concerns
Minimize environmental stimuli

NO.1
The nurse is aware that the two major types of

precipitating factors in anxiety are?
A) Fear of disapproval and shame
B) Conflicts involving avoidance and shame
C) Threats to ones biologic integrity and threats
to ones self-esteem
D) A persons poor health and poor financial
condition
ANSWER
Letter C
Rationale: The two major types of

precipitating factors to anxiety are:
threats to ones biologic integrity and
threats to ones self-esteem

NO.2
When working with a person who is anxious,

what is the overall goal of nursing
intervention?
A) Remove anxiety
B) Develop the persons awareness of anxiety
C) Protect the person from anxiety
D) Develop the persons capacity to tolerate
mild anxiety
ANSWER
Letter D
Rationale: The goal of intervention in

the care of the anxious patient is to
enable him to develop his capacity to
tolerate mild anxiety

NO.3
The nurse is caring for a patient with panic disorder and a

patient with a phobia.
What is one major difference
between those two disorders?
A) Specific precipitants are present with panic disorder
B) Specific precipitants are present with phobia
C) The symptoms are different for each disorder
D) Phobias are one cause of major depressive states
ANSWER
Letter B
Rationale: Specific
present with phobia
precipitants
are

NO.4
A man in his mid-forties complaints of severe

palpitations, sweating and intense fear when he had to
speak in public. Because his job entails lecturing in
auditoriums, what would the nurse suggest?
A) Behavior therapy with beta-adrenergic blockers
B) Quitting his job altogether
C) Telling jokes to reduce anxiety
D) Monoamine Oxidase inhibitors
ANSWER
Letter A
Rationale: A combination of behavioral

and somatic approaches is effective in
the management of anxiety

NO.5
An appropriate nursing diagnosis for a

patient with anxiety is which of the
following?
A) Self-esteem disturbance
B) Ineffective individual coping
C) Unilateral neglect
D) Altered thought process
ANSWER
Letter B
Rationale: Anxiety is one of the

defining characteristics of ineffective
individual coping.
EGO DEFENSE
MECHANISMS
EGO DEFENSE MECHANISMS
Freud believed that the self or ego used ego

defense mechanisms to protect the self and
cope with basic drives or emotionally painful
thoughts, feelings, or events.
Most ego defense mechanisms operate at the

unconscious level of awareness, so people are
not aware of what they are doing and often
need help to see the reality.
EGO DEFENSE MECHANISMS

Compensation
Rationalization
Conversion
Reaction Formation
Denial
Regression
Displacement
Repression
Dissociation
Resistance
Fixation
Sublimation
Identification
Substitution
Intellectualization
Suppression
Introjection
Undoing
Projection
COMPENSATION
Overachievement in one area to offset real

or perceived deficiencies in another area
Examples:
complex:
diminutive
man
Napoleon
becoming an emperor
Nurse with low self-esteem works double
shifts so her supervisor will like her
CONVERSION
Expression of an emotional conflict through the

development of a physical symptom, usually
sensorimotor in nature.
Example:
A teenager forbidden to see x-rated movies is
tempted to do so by friends and develops
blindness, and the teenager is unconcerned
about the loss of sight.
DENIAL
Failure to acknowledge an unbearable

condition; failure to admit the reality of a
situation, or how one enables the problem to
continue
Examples:
Diabetic eating chocolate candy
Spending money freely when broke
Waiting 3 days to seek help for severe
abdominal pain
DISPLACEMENT
Ventilation of intense feelings toward

persons less threatening than the one
who aroused those feelings.
Examples:
A person who is mad at the boss yells
at his or her spouse
A child who is harassed by a bully at
school mistreats a younger sibling.
DISSOCIATION
Dealing with emotional conflict by a

temporary alteration in consciousness or
identity
Examples:
Amnesia that prevents recall
yesterdays auto accident
An adult remembers nothing
childhood sexual abuse
of
of
FIXATION
Immobilization of a portion of the

personality resulting from unsuccessful
completion of tasks in a developmental
stage
Examples:
Never learning to delay gratification
Lack of a clear sense of identity as an
adult
IDENTIFICATION
Modeling actions and opinions of influential

others while searching for identity, or
aspiring to reach a personal, social, or
occupational goal.
Example:
Nursing student becoming a critical care
nurse because this is the specialty of an
instructor she admires.
INTELLECTUALIZATION
Separation of the emotions of a painful

event or situation from the facts
involved; acknowledging the facts but
not the emotions.
Example
Person
shows
no
emotional
expression when discussing serious
car accident.
INTROJECTION
Accepting another persons attitudes,

beliefs, and values as ones own.
Example:
A person who dislikes guns becomes
an avid hunter, just like a best
friend.
PROJECTION
Unconscious
blaming
of
unacceptable
inclinations or thoughts on an external
object.
Examples:
Man who has thought about same-gender
sexual relationship but never had one,
beats a man who is gay.
A person with many prejudices loudly
identifies others as bigots.
RATIONALIZATION
Excusing own behavior to avoid guilt,

responsibility, conflict, anxiety, or loss of
self-respect
Examples:
Student blames failure on teacher
being mean
Man says he beats his wife because
she does not listen to him.
REACTION FORMATION
Acting the opposite of what one thinks

or feels.
Examples:
Woman who never wanted to have
children becomes a super-mom.
Person who despises the boss tells
everyone what a great boss she is.
REGRESSION
Moving back to a previous developmental

stage in order to feel safe or have needs met
Examples:
Five-year-old asks for a bottle when new
baby brother is being fed.
Man pouts like a four-year-old if he is not
the center of his girlfriends attention.
REPRESSION
Excluding emotionally painful or anxietyprovoking thoughts and feelings from

conscious awareness
Examples:
Woman has no memory of the mugging
she suffered yesterday
Woman has no memory before age 7 when
she was removed from abusive parents.
RESISTANCE
Overt
or
covert
antagonism
toward
remembering
or
processing
anxietyproducing information.
Examples:
Nurse is too busy with tasks to spend time
talking to a dying patient
Person attends court-ordered treatment for
alcoholism but refuses to participate.
SUBLIMATION
Substituting a socially acceptable activity for

an impulse that is unacceptable
Examples:
Person who has quit smoking sucks on
hard candy when the urge to smoke arises.
Person goes for 15-minute walk when
tempted to eat junk foods.
SUBSTITUTION
Replacing the desired gratification with

one that is more readily available.
Example:
Woman who would like to have her
own children opens a day care
center.
SUPPRESSION
Conscious exclusion of unacceptable thoughts

and feelings from conscious awareness.
Examples:
A student decides not to think about a parents
illness in order to study for a test
A woman tells a friend she cannot think about
her sons death right now
UNDOING
Exhibiting acceptable behavior to make up for or

negate unacceptable behavior.
Examples:
A person who cheats on a spouse brings the
spouse a bouquet of roses.
A man who is ruthless in business donates large
amounts of money to charity

NO.1
When upset, the patient curls into a

fetal position in bed. The nurse judges
the patient to be exhibiting?
A) Fixation
B) Regression
C) Substitution
D) Symbolization
ANSWER
Letter B
Rationale: Regression is turning to an

earlier level of development in the face
of stress

NO.2
Family members often feel guilty that they are

not doing enough to the patient, so their
tendency is to blame the staff, nurses and
doctors. This defensive response is ?
A) Displacement
B) Rationalization
C) Projection
D) Sublimation
ANSWER
Letter C
Rationale: Projection is attributing to

others ones unconscious wishes or
fears. Usually it is seen in paranoid
patients.

NO.3
Alcoholics commonly use a defense

mechanism known as?
A) Denial
B) Regression
C) Displacement
D) Sublimation
ANSWER
Letter A
Rationale: Alcoholics usually use

denial, rationalization, projection and
isolation

NO.4
Rationalization is exemplified in one of the

following situations?
A) An applicant for a job develops fever on the day
of her personal interview
B) A student says, I did not get good grades
because the teacher does not like me.
C) An unfaithful husband gives a gift to his wife
after a heated argument
D) A patient says, I do not want to think about
my problems.
ANSWER
Letter B
Rationale: Rationalization is justifying

ones action which are based on other
motives.
It is usually seen among
alcoholics

NO.5
An example of maladaptive use of defense

mechanism is?
A) An individual resorts to drinking when
under stress to diffuse tension
B) A former drug addict helps in the
rehabilitation of drug users.
C) A short man excels in public speaking
D) A patient blames the nurse for his familys
unacceptable ways.
ANSWER
Letter A
Rationale: Drinking alcohol when under

stress makes a person at risk for
various disorders.
ANXIETY DISORDERS
ANXIETY DISORDERS
These are emotional illnesses characterized by fear,

autonomic
nervous
system
symptoms
and
avoidance behavior
They are diagnosed when anxiety no longer
functions as a signal of danger or a motivation for
needed change but becomes chronic and permeates
major portions of the persons life, resulting in
maladaptive behaviors and emotional instability
Anxiety disorders have many manifestations but
anxiety is the key feature of each
TYPES OF ANXIETY DISORDERS
Agoraphobia
Panic Disorder
Specific Phobia
Social Phobia
Obsessive-compulsive Disorder
Generalized anxiety Disorder
Acute Stress Disorder
Post-traumatic Stress Disorder
AGORAPHOBIA
Is anxiety about or avoidance of places

or situations from which escape might
be difficult or help might be
unavoidable
Fear of being alone in public places
SYMPTOMS OF AGORAPHOBIA
Avoids being outside alone or at home

alone
Avoids traveling in vehicles
Impaired ability to work
Difficulty meeting daily responsibilities
(e.g., grocery shopping, going to
appointments)
Knows response is extreme
MANAGEMENT OF
AGORAPHOBIA
Anti-anxiety medications
Social skills training

Teach them how to:
Ask questions
Give compliments
Maintain eye contact
Speak in a clear tone of voice
Avoid criticism
Avoid fidgeting
PANIC DISORDER
Is
characterized
by
recurrent,
unexpected panic attacks that cause
constant concern
Panic attack is the sudden onset

intense apprehension, fearfulness,
terror associated with feelings
impending doom
of
or
of
SYMPTOMS
OF
PANIC
DISORDER
A discrete episode of panic lasting 15 to 30 minutes with four or more
of the following:
Palpitations
Sweating
Trembling or shaking
Shortness of breath
Choking or smothering sensation
Chest pain or discomfort
Nausea
Derealization (sensing that things are not real) or depersonalization
(feelings of being disconnected from oneself
Fear of dying or going crazy
Paresthesias
Chills or hot flashes
MANAGEMENT OF PANIC
DISORDER
Relaxation exercises
Deep breathing
Cognitive behavioral techniques
COGNITIVE BEHAVIORAL
TECHNIQUES FOR PANIC
DISORDERS
Positive Reframing
Decatastrophizing
Assertiveness Training
POSITIVE REFRAMING
Turning negative messages into positive messages

The therapist teaches the person to create positive
messages for use during panic episodes
Instead of thinking, My heart is pounding. I think I am
going to die the client thinks, I can stand this. This is
just anxiety. It will go away.
The client can write down these messages and keep
them readily accessible such as in an address book,
wallet or calendar
DECATASTROPHIZING
Involves the therapists use of questions to more realistically

appraise the situation; the therapist may ask, What is the worst
thing that could happen? Is that likely? Could you survive that?
Is that as bad as you imagine?
The client uses thought-stopping and distraction techniques to
jolt himself from focusing on negative thoughts
Splashing the face with water, snapping a rubber band worn on
the wrist, or shouting are all techniques that can break the cycle
of negative thoughts
ASSERTIVENESS TRAINING
Helps the person take more control over life situations

Techniques help the person negotiate interpersonal
situations and foster self-assurance
They involve using I statements to identify feelings and
to communicate concerns or needs to others.
Examples include I feel angry when you turn your back
while Im talking, I want to have 5 minutes of your time
for an uninterrupted conversation about something
important
SPECIFIC PHOBIA
Is characterized by significant anxiety

provoked by a specific feared object or
situation
which
often
leads
to
avoidance behavior
SYMPTOMS OF SPECIFIC
PHOBIA
Marked anxiety response to the object

or situation
Avoidance or suffered endurance of
object or situation
Significant distress or impairment of
daily routine, occupation, or social
functioning
Adolescents and adults recognize their
fear as excessive or unreasonable.
MANAGEMENT OF SPECIFIC
PHOBIA
Systematic Desensitization
SYSTEMATIC OR SERIAL
DESENSITIZATION
The therapist progressively exposes the client

to the threatening object in a safe setting until
the clients anxiety decreases
During each exposure, the complexity and
intensity of exposure gradually increase but
each time the clients anxiety decreases.
The reduced anxiety serves as a positive
reinforcement until the anxiety is ultimately
eliminated
EXAMPLE OF SERIAL
DESENSITIZATION
For a client who fears flying, the therapist would encourage

the client to hold a small model airplane while talking about
his or her experiences
Later the client would talk about flying while holding a larger
model of an airplane
Later exposures might include walking past an airport, sitting
in a parked airplane, and finally taking a ride in the plane
Each sessions challenge is based on the success achieved in
the previous sessions
SOCIAL PHOBIA
Is characterized by anxiety provoked

by certain types of social or
performance situations, which often
leads to avoidance behavior
SYMPTOMS OF SOCIAL PHOBIA
Fear of embarrassment or inability to perform

Avoidance or dreaded endurance of behavior or
situation
Recognition that response is irrational or excessive
Belief that others are judging him or her
negatively
Significant distress or impairment in relationships,
work, or social life
Anxiety can be severe or panic level
MANAGEMENT OF SOCIAL
PHOBIA
Social Skills training
OBSESSIVE-COMPULSIVE
DISORDER
Involves obsession (thoughts, impulses

or images) that cause marked anxiety
and/or
compulsions
(repetitive
behaviors or mental acts) that attempt
to neutralize anxiety
SYMPTOMS OF OBSESSIVECOMPULSIVE DISORDER
Recurrent, persistent, unwanted, intrusive

thoughts, impulses, or images beyond worrying
about the realistic life problems
Attempts to ignore, suppress, or neutralize
obsessions with compulsions that are mostly
ineffective
Adults
and
adolescents
recognize
that
obsessions and compulsions are excessive and
unreasonable
DISORDER
OBSESSIONS
FEAR OF DIRT AND GERMS
FEAR
OF
ROBBERY
BURGLARY
COMPULSIONS
EXCESSIVE HAND WASHING
ORREPEATED CHECKING OF DOOR
AND WINDOW LOCKS
WORRIES ABOUT DISCARDINGCOUNTING AND RECOUNTING

SOMETHING IMPORTANT
OF OBJECTS IN EVERYDAY LIFE
WORRIES THAT THINGS MUSTEXCESSIVE

STRAIGHTENING,
BE
SYMMETRICAL
ORORDERING, OR ARRANGING OF
MATCHING
THINGS
MANAGEMENT OF OBSESSIVECOMPULSIVE DISORDER
Response prevention (delaying or

avoiding performance of the rituals)
Thought Stopping
GENERALIZED ANXIETY
DISORDER
Is characterized by at least six months

of persistent and excessive worry and
anxiety that interferes with a persons
life
It is also characterized by motor
tension, autonomic hyperactivity and
cognitive vigilance
SYMPTOMS OF GENERALIZED
ANXIETY DISORDER
Apprehensive expectations more days than not for 6

months or more about several events or activities
Uncontrollable worrying
Significant distress or impaired social or occupational
functioning
Three of the following symptoms:
Restlessness
Easily fatigued
Difficulty concentrating or mood going blank
Irritability
Muscle tension
Sleep disturbance
MANAGEMENT OF
GENERALIZED ANXIETY
DISORDER
Anti-depressants
Psychotherapy
ACUTE STRESS DISORDER
Is the development of anxiety,

dissociative, and other symptoms
within 1 month of exposure to an
extremely traumatic stressor
It lasts 2 days to 4 weeks
SYMPTOMS OF ACUTE STRESS

DISORDER
Exposure to traumatic event causing intense fear,
helplessness, or horror
Marked anxiety symptoms or increased arousal
Significant distress or impaired functioning
Persistent re-experiencing of the event
Three of the following symptoms:
Sense of emotional numbing or detachment
Dissociative amnesia (inability to recall important aspect
of the event)
Feeling dazed
Derealization
Depersonalization
MANAGEMENT OF ACUTE
STRESS DISORDER
Anti-depressant medications
Group therapy
POST-TRAUMATIC STRESS
DISORDER
Is characterized by the re-experiencing

of an extremely traumatic event,
avoidance of stimuli associated with
the event, numbing of responsiveness,
and persistent increased arousal
It begins within 3 months to years

after the event and may last a few
months or years
SYMPTOMS OF POSTTRAUMATIC STRESS DISORDER
Exposure to traumatic event involving intense fear, helplessness

or horror
Re-experiencing (intrusive recollections or dreams, flashbacks,
physical and psychological distress over reminders of the event)
Avoidance of memory-provoking stimuli and numbing of general
responsiveness (avoidance of thoughts, feelings, conversations,
people, places, amnesia, diminished interest or participation in
life events, feeling detached or estranged from others, restricted
affect, sense of foreboding)
SYMPTOMS OF POSTTRAUMATIC STRESS DISORDER
Increased arousal (sleep disturbance,

irritability or angry outbursts, difficulty
concentrating,
hypervigilance,
exaggerated startle reflex)
Significant distress or impairment
MANAGEMENT OF POSTTRAUMATIC STRESS DISORDER
Anti-depressant medications
Group therapy
PRIORITY NURSING DIAGNOSIS

FOR ANXIETY DISORDERS
PSYCHOPHARMACOLOGIC
MANAGEMENT OF POSTTRAUMATIC STRESS DISORDER
Anti-anxiety or anxiolytic drugs or

minor tranquilizers
Diazepam (Valium)
Oxazepam (Serax)
Chlordiazepoxide (Librium)
Chlorazepate
Dipotassium
(Tranxene)
Alprazolam (Xanax)
EFFECTS OF ANXIOLYTIC DRUGS
Decreased anxiety
Adequate sleep
WHEN TO ADMINISTER
ANXIOLYTIC DRUGS
Best taken before meals, food in the

stomach delays absorption
SIDE EFFECTS OF ANXIOLYTIC

DRUGS
Drowsiness
Sedation
Poor coordination
Impaired memory and clouded sensorium
CLIENT TEACHING ON
ANXIOLYTIC DRUGS
Avoid driving
Intake of alcohol and caffeine-containing

foods alter the effect of the drug
It potentiates the effect of alcohol
Administer separately, it is incompatible

with any drug.
WORKING WITH CLIENTS WITH

ANXIETY AND ANXIETY
DISORDERS
Remember that everyone suffers from stress

and anxiety occasionally that can interfere with
daily life and work
Avoid falling into the pitfall of trying to fix the
clients problems
Discuss any uncomfortable feelings with a more
experienced nurse for suggestions on how to
deal with your feelings toward these clients
Remember to practice techniques to manage
stress and anxiety in your life.
SITUATION
Leonora Cielo is the nurse manager of the oncology unit

on the 33rd floor of a large urban medical center.
Recently, she has been increasingly afraid of riding in
the elevator and of being in public places. This morning
she experienced shortness of breath, palpitations,
dizziness, and trembling while in the elevator. Leonora
was examined by an emergency department physician.

NO.1
Which of the following behaviors would

the nurse expect to observe in the patient
with agoraphobia?
A) The patient is afraid of talking to other
people
B) The patient is afraid to leave her home
C) The patient is afraid of pain
D) The patient is afraid of fire
ANSWER
Letter B
Rationale: Agoraphobia is fear of being

alone in a particular place where
escape is difficult

NO.2
Leonora begins outpatient counseling sessions with a

psychiatric clinical nurse specialist. Which nursing
intervention would be most helpful in reducing
Leonoras anxiety level?
A) Psychoanalytically oriented psychotherapy
B) Group psychotherapy
C) Systematic desensitization
D) Referral for evaluation for electroconvulsive therapy
ANSWER
Letter C
Rationale: Systematic desensitization

is the treatment of choice for people
with phobia

NO.3
Because of the severity of Leonoras anxiety, the nurse

referred her to a psychiatrist for medication evaluation.
Which psychotropic drug regimen is most likely to be
prescribed on a short-term basis?
A) Diazepam (valium) 5 mg orally three times a day
B) Benztropine mesylate (Cogentin) 2 mg orally twice a day
C) Chlorpromazine hydrochloride (Thorazine) 25 mg orally
four times a day
D) Thioridazine hydrochloride (Mellaril) 100 mg orally four
times a day
ANSWER
Letter A
Rationale: An anxiolytic drug is the

drug of choice

NO.4
An appropriate nursing diagnosis for a

patient with phobia is?
A) Ineffective individual coping
B) Altered thought process
C) Sensory perceptual alteration
D) Self-esteem disturbance
ANSWER
Letter A
Rationale:
A patient with anxiety
disorder may exhibit difficulty in
coping

NO.5
Which of the following outcomes indicate a

positive response to therapy for a patient with
agoraphobia?
A) Patient experiences palpitation when going
out of the house
B) The symptoms occur only when triggered
C) The patient is able to visit the mailbox
D) The patient is able to entertain visitors
inside the house
ANSWER
Letter C
Rationale: The patients ability to go

outside the house indicates a positive
response to therapy.
PERSONALITY
DISORDERS
PERSONALITY
It can be defined as an ingrained, enduring pattern of

behaving and relating to self, others, and the environment;
personality includes perceptions, attitudes, and emotions
These behaviors and characteristics are consistent across a
broad range of situations and do not change easily
A person is usually not consciously aware of his personality
PERSONALITY DISORDERS
These are personality styles that are rigid and

maladaptive, causing significant personal
distress and impair social functioning.
These are diagnosed when personality traits

become inflexible and maladaptive and
significantly interfere with how a person
functions in society or cause the person
emotional distress.
ETIOLOGICAL FACTORS
Genetic Factors
Due to inherited traits
Temperamental Factors
Due to emotional climate at home
Biological Factors
Due to imbalance in hormones and neurotransmitters
Psychoanalytic Factors
Due to fixation at certain psychosexual stage of development
DSM-IV-TR PERSONALITY
DISORDER CATEGORIES
The Diagnostic and Statistical Manual of Mental Disorders Text Revision
of the American Psychiatric Association, in 2000, has made the following
classification of personality disorders:
Cluster A: Individuals whose behavior appears odd or eccentric
(paranoid, schizoid, and schizotypal personality disorders)
Cluster B: Individuals who appear dramatic, emotional, or erratic
(antisocial, borderline, histrionic, narcissistic)
Cluster C: Individuals who appear anxious or fearful (avoidant,
dependent, obsessive-compulsive)
CLUSTER A
Paranoid
Schizoid
Schizotypal
PARANOID PERSONALITY
DISORDER
Symptoms / Characteristics
Mistrust and suspicion of others
Guarded or hypervigilant and generally appear alert to
any impending danger
Restricted affect
Mood is labile, quickly changing from quietly suspicious
to angry or hostile
Responses become sarcastic for no apparent reason
Uses the defense mechanism of projection, which is
blaming other people, institutions or events for their
own difficulties
PARANOID PERSONALITY
DISORDER
Nursing Interventions
The nurse must approach these clients in a formal,
business-like manner and refrain from chit-chat and
jokes (serious and straightforward approach)
Involve the client in treatment planning

Because these clients need to feel in control, it is important to
involve them in formulating plans of care.
The nurse asks what the client would like to accomplish in
concrete terms.
Clients are more likely to engage in the therapeutic process if
they believe they have something to gain
SCHIZOID PERSONALITY
DISORDER
Detached from social relationships
They display a constricted affect and little, if any
emotion; aloof and indifferent, appearing emotionally
cold, uncaring,or unfeeling
Report no leisure or pleasurable activities because they
rarely experience enjoyment
Have a pervasive lack of desire for involvement with
others in all aspects of life
They do not have or desire friends, rarely date or
marry and have little or no sexual contact
Involve themselves more with things than people
SCHIZOID PERSONALITY
DISORDER
Focus on improved functioning of
the client in the community
Assist the client to find a case
manager one who can help the
client obtain services and health
care, manage finances, etc.
SCHIZOTYPAL PERSONALITY
DISORDER
Has social and interpersonal deficits
marked by acute discomfort with
and reduced capacity for close
relationships
Has
cognitive
or
perceptual
distortions
Possesses eccentric behavior
DISORDER
Clothes are ill fitting, do not match, and may be
stained or dirty
Cognitive distortions include ideas of reference
(events have special meaning for him), magical
thinking that he has special powers, unfounded
beliefs
Interpersonal relationships are troublesome and
may have only one significant relationship with
a first degree relative
DISORDER
Development of self-care skills
Nurse encourages client to establish
a daily routine for hygiene and
grooming
Improve community functioning and
provide social skills training
CLUSTER B
Antisocial
Borderline
Histrionic
Narcissistic
ANTISOCIAL PERSONALITY
DISORDER
Violation of the rights of others
Lack of remorse for behavior
Shallow emotions
Lying
Rationalization of own behavior
Poor judgment
Impulsivity
Irritability and aggressiveness
Lack of insight
DISORDER
Thrill-seeking behaviors
Exploitation
of
people
relationships
Poor work history
Consistent irresponsibility
in
DISORDER
Promote responsible behavior
Limit setting
State the limit in a matter-of-fact, nonjudgmental manner
Identify consequences of exceeding the limit
Identify expected or acceptable behavior
Consistent adherence to rules and treatment

plan
DISORDER
Consistent limit setting in a matter-of-fact, nonjudgmental manner is crucial to success

A client may approach the nurse flirtatiously and
attempt to gain personal information.
The nurse would use limit-setting by saying, It is not

acceptable for you to ask personal questions.
If you
continue, I will terminate our interaction. We need to use
this time to work on solving your job-related problems.
The nurse should not become angry or respond to the

client harshly or punitively
DISORDER
Confrontation
Point out problem behavior
Keep client focused on self, behavior
rather than justifying it.
DISORDER
Confrontation is a technique designed to manage

manipulative or deceptive behavior.
The nurse points out a clients problematic behavior while
remaining neutral and matter-of-fact; he or she avoids
accusing the client.
The nurse can also use confrontation to keep clients focused
on the topic and in the present
The nurse can focus on the behavior itself rather than on
attempts by clients to justify it.
DISORDER
Example of use of confrontation:

Nurse: Youve said youre interested in learning to
manage angry outbursts, but youve missed the
last three group meetings.
Client: Well, I can tell no one in the group likes
me. Why should I bother?
Nurse: The group meetings are designed to help
you and the others, but you cant work on issues if
you are not there.
DISORDER
Helping clients solve problems and
control emotions
Effective problem solving skills

Identifying the problem
Exploring alternative solutions and related
consequences
Choosing and implementing an alternative
Evaluating the results
Decrease impulsivity
DISORDER
Nursing Interventions:
Take time-out from a stressful situation
Leaving the area and going to a neutral

place to regain internal control helps
clients to avid impulsive reactions and
angry
outbursts,
regain
control
of
emotions and engage in constructive
problem-solving
DISORDER
Enhancing role performance
Identify barriers to role fulfillment
Decreasing and eliminating use of drugs
and alcohol
BORDERLINE PERSONALITY
DISORDER
Fear of abandonment, real or perceived
Unstable and intense relationships
Unstable self-image
Impulsivity or recklessness
Recurrent self-mutilating behavior or suicidal
threats or gestures
Chronic feelings of emptiness and boredom
Labile mood
DISORDER
Irritability
Polarized thinking about self and others
(splitting)
Impaired judgment
Lack of insight
Transient psychotic symptoms such as
hallucinations demanding self-harm
DISORDER
Promote clients safety
The nurse must always seriously consider suicidal ideation with

the presence of a plan, access to means for enacting the plan,
and self-harm behaviors and institute appropriate action
The nurse can encourage clients to enter a no self-harm contract,
in which a client promises to not engage in self-harm and to
report to the nurse when he or she is losing control
The nurse emphasizes that the no self-harm contract is not a
promise to the the nurse but is the clients promise to himself

to be safe
DISORDER
Helping clients to cope and control emotions
Clients often react to situations with extreme emotional

responses without actually recognizing their feelings
The nurse can help clients to identify their feelings and learn
to tolerate them without exaggerated responses such as
destruction of property or self-harm
Keeping a journal often helps clients gain awareness of
feelings.
The nurse can review journal entries as a basis for discussion
DISORDER
Helping clients to cope and control emotions
Another aspect of emotional regulation is decreasing impulsivity and

learning to delay gratification
When clients have an immediate desire or request, they must learn that it is
unreasonable to expect it to be granted without delay
Clients can use distraction such as taking a walk or listening to music to
deal with the delay or they can think about ways to meet needs themselves
Clients can write in their journals about their feelings when gratification
is delayed.
DISORDER
Cognitive Restructuring Techniques
These clients view everything, people
and situations, in extremes totally
good or totally bad.
Cognitive restructuring is a technique
useful in changing patterns of thinking
by helping clients to recognize negative
thoughts and feeling and to replace
them with positive patterns of thinking
DISORDER
Thought-stopping is a technique to alter the process of

negative or self-critical thought patterns such as I am
dumb, I am stupid, I cant do anything right.
When the thoughts begin, the client may actually
say, Stop! in a loud voice to stop the negative
thoughts
Later, a more subtle means such as forming a
visual image or a stop sign will be a cue to interrupt
the negative thoughts
DISORDER
The client then learns to replace recurrent,

negative thoughts of worthlessness with
more positive thinking
In positive self-talk, the client reframes
negative thoughts into positive ones: I
made a mistake, but it is not the end of the
world. Next time, I will know what to do.
DISORDER
Decatastrophizing is a technique that involves

learning to assess situations realistically rather
than always assuming a catastrophe will happen
The nurse asks, So what is the worst thing that
could happen? or Can you think of any
exceptions to that?
In this way, the client must consider other points
of view and actually think about the situation
DISORDER
Structure time
Feelings of chronic boredom and emptiness, fear

of abandonment, and intolerance of being alone
are common problems that lead to self-harm
Minimizing unstructured time
by planning
activities can help clients to manage time alone
Clients can make a written schedule that includes
appointments, shopping, reading the paper, or
going for a walk
HISTRIONIC PERSONALITY
DISORDER
With a pervasive pattern of excessive
emotionality and attention-seeking
Clients are overly concerned with impressing
others with their appearance
Dress and flirtatious behavior are not limited to
social situations or relationships but also occur
in occupational and professional settings
Clients are extroverts
DISORDER
Clients are emotionally expressive, gregarious, and effusive.
They often exaggerate emotions inappropriately: He is the
most wonderful doctor! He is so fantastic! He has changed
my life! to describe a physician she has seen once or twice.
In such a case, the client cannot specify why she views the
doctor so highly.
Expressed emotions, although colorful, are insincere and
shallow
DISORDER
Clients experience rapid shifts in mood and emotions
and may be laughing uproaringly one moment and
sobbing the next.
Thus their display of emotion may seem phony or
forced on observers
Clients are uncomfortable when they are not the center
of attention and go to great lengths to gain that status
Clients embarrass family members or friends by their
flamboyant hugging, kissing of someone newly
introduced, by sobbing over minor incidents
DISORDER
The nurse gives clients feedback about their social interactions
with others including manner of dress and nonverbal behavior.
Feedback should focus on appropriate alternatives not merely
criticism
The nurse might say, When you embrace and kiss other people
on first meeting them, they may interpret your behavior in a
sexual manner. It would be more acceptable to stand at least 2
feet away from them and to shake hands.
DISORDER
Teaching social skills and role-playing those skills in a
safe, non-threatening environment can help clients to
gain confidence in their ability to interact socially
The nurse must be specific in describing and modeling
social skills including establishing eye-contact, active
listening, and respecting personal space
It also helps to outline topics of discussion
appropriately for casual acquaintances, closer friends
or family and the nurse only.
DISORDER
Clients may be quite sensitive to discussing self-esteem and
may respond with exaggerated emotions.
It is important to explore personal strengths and assets and
give specific feedback about positive characteristics
Encouraging clients to use assertive communication, such
as I statements, may promote self-esteem and help them
to get their needs met more appropriately.
NARCISSISTIC PERSONALITY
DISORDER
Has a pervasive pattern of grandiosity (in fantasy or behavior), need for
admiration, and lack of empathy for others
They believe that they are superior, special and they demand special attention
They display an arrogant or haughty attitude

They view their problems as the fault of others
Underlying self-esteem is almost always fragile and vulnerable
They are hypersensitive to criticism and need constant attention, admiration
DISORDER
The nurse must use self-awareness skills to avoid the
anger and frustration that their behavior and attitude
can engender
Clients may be rude and arrogant, unwilling to wait, and
harsh and critical of the nurse. The nurse must not
internalize such criticism or take it personally
The goal is to gain cooperation of these clients with
other treatment as indicate
DISORDER
She sets limits to rude or verbally
abusive behavior and explains his or
her expectations from the clients.
CLUSTER C
Avoidant
Dependent
Obsessive-Compulsive
AVOIDANT PERSONALITY
DISORDER
Has a pervasive pattern of social
discomfort and reticence, low self-esteem
and
hypersensitivity
to
negative
evaluation
They fear rejection, criticism, shame or
disapproval
They remain aloof in their relationships
and feel inferior to others
DISORDER
These clients require much support and
reassurance from the nurse
The nurse can help them to explore
positive self-aspects, positive responses
from others, and possible reasons for selfcriticism
clients
to
practice
self Helping
affirmations and positive self-talk may be
useful in promoting self esteem
DISORDER
Other cognitive restructuring techniques such as
reframing and decatastrophizing can enhance self worth
Positive reframing means turning negative messages
into positive messages
Instead of thinking I will fail, the client thinks I may fail but I
will keep trying until I succeed.
Decatastrophizing involves the nurses use of questions

to realistically appraise the situation
What is the worst thing that could happen? Is that likely?

Could you survive that? Is that as bad as you imagine?
The client uses thought-stopping and distraction techniques to
jolt himself out of negative thoughts
DEPENDENT PERSONALITY
DISORDER
Has a pervasive and excessive need to be taken care of which leads
to submissive and clinging behavior and fears of separation
Has incessant demands for attention from others, lacks selfconfidence, needs excessive reassurance and advice
They are pre-occupied with excessive fears of being left alone to
care for themselves
They perceive themselves as unable to function outside a
relationship with someone who can tell them what to do
DEPENDENT PERSONALITY
DISORDER
The nurse must help the clients to express feelings of grief and
loss over the end of a relationship while fostering autonomy
and self reliance
Helping clients to identify their strengths and needs is more
helpful than encouraging the overwhelming belief that the
client cant do anything alone
Clients may need assistance in daily functioning like planning
menus, shopping, budgeting money, etc.
The nurse teaches problem-solving and decision-making skills
PERSONALITY DISORDER
Has a pervasive pattern of preoccupation with
perfectionism, mental and interpersonal control and
orderliness at the expense of flexibility, openness
and efficiency
They are formal, serious and answer questions with
precision and much detail
Clients check and recheck the details of any project
or activity
They have problems with judgment and decisionmaking specifically actually reaching a decision
They have low self-esteem and are always harsh,
critical, and judgmental of themselves; they believe
they could have done better regardless of how
well the job has been done
They have difficulty in relationships, few friends,
and little social life
They cannot tolerate lack of control
They have difficulty working collaboratively,
preferring to do it myself so it is done correctly
Nurses may be able to help clients to view
decision-making and completion of projects from a
different perspective
Rather than striving for the goal of perfection, clients

can set a goal of completing the project or making the
decision by a specified deadline
Helping clients to accept or to tolerate less-than-perfect
work or decisions made on time may alleviate some
difficulties at work or at home
Use of cognitive restructuring techniques
like decatastrophizing may challenge
some rigid and inflexible thinking
Encouraging clients to take risks, such as
letting someone else plan a family
activity, may improve relationships
Practicing negotiation with family or
friends may help them to relinquish some
of their need for control
OTHER RELATED DISORDERS
Depressive Personality Disorder
Passive Aggressive Personality

Disorder
DEPRESSIVE PERSONALITY
DISORDER
Has a pervasive pattern of depressive cognitions and
behaviors in various contexts but is much less severe
than major depression
They have a sad, gloomy, dejected affect
express
unhappiness,
cheerlessness,
They
hopelessness regardless of the situation
They repress or not express anger
Thinking is negative, pessimism for them is being
realistic
They blame themselves or others unjustly for
situations beyond anyones control
DISORDER
Self-esteem is quite low with feelings
of worthlessness and inadequacy
even when clients have been
successful.
Self-criticism often leads to punitive
behavior and feelings of guilt or
remorse
DISORDER
Assess for the possibility of self-harm. If the
client expresses suicidal ideation or has urges
for self-injury, the nurse must provide safety
precautions
Cognitive restructuring techniques such as
thought-stopping or positive self-talk can
enhance self-esteem
compliments
promotes
receiving
Giving
compliments, which further enhances positive
feelings
DISORDER
Giving factual feedback, rather than general praise, reinforces
attempts to interact with others and gives specific, positive
information about improved behaviors.
Oh, you are doing so well today is a general praise that does
not identify specific positive behaviors
You have talked to Mrs. Jones for 10 minutes even though it was
difficult. I know that took a lot of effort. is specific praise that
gives the client a clear message about what specific behavior was
effective and positive
PASSIVE AGGRESSIVE
Has a negative attitude and pervasive pattern of passive
resistance to demands for adequate social and occupational
performance
Loves to procrastinate and expresses anger through passivity
The negative attitude influences thought content: clients
perceive and anticipate difficulties
and disappointments
where none exists
They believe nothing good ever lasts
Ability to make decisions or judgments is impaired
PASSIVE AGGRESSIVE
They habitually resent, oppose, and resist
demands to function at a level expected by others.
This opposition occurs most frequently in work
situations but can also be evident in social
functioning
express
such
resistance
through
They
procrastination, forgetfulness, stubbornness, and
intentional inefficiency especially in response to
tasks assigned by authority figures.
PASSIVE AGGRESSIVE
The nurse can help clients examine the relationship between
feelings and subsequent actions
For example, a client may intend to complete a project at
work but then procrastinates, forgets or becomes ill and
misses the deadline. Or the client may intend to participate
in a family outing but becomes ill, forgets, or has an
emergency when it is time
By focusing on the behavior, the nurse can help the client to
see what is so annoying or troubling to others
PASSIVE AGGRESSIVE
The nurse can also help the client to
learn appropriate ways to express
feelings directly especially negative
feelings such as anger
Methods such as having the client write
about the feelings or role-play are
effective.
POINTS TO CONSIDER WHEN

WORKING WITH CLIENTS WITH
PERSONALITY DISORDERS
Talking to colleagues about feelings of frustration will help you

to deal with your emotional responses so you can be more
effective with clients
Clear, frequent communication with other health care
providers can help to diminish the clients manipulation
Do not take undue flattery or harsh criticism personally; it is a
result of the clients personality disorder
Set realistic goals and remember that behavior changes in
clients with personality disorders take a long time. Progress
can be very slow

NO.1
The nurse is caring for a patient who is

sarcastic and critical and often expresses
feelings that are the opposite of what he is
actually feeling. This patient is exhibiting
which type of behavior?
A) Passive
B) Aggressive
C) Passive - Aggressive
D) Assertive
ANSWER
Letter C
Rationale: Patients with passiveaggressive personality disorder loves

to procrastinate, expresses anger
through passivity

NO.2
The nurse is caring for a patient diagnosed with

paranoid personality disorder in an acute care facility.
Which intervention would the nurse use to control the
patients suspiciousness?
A) Keeping messages clear and consistent, while
avoiding deception
B) Providing pharmacologic therapy
C) Providing social interactions with others on the unit
D) Attending to the basic daily needs of the patient on
a consistent basis
ANSWER
Letter A
Rationale: Consistency should be

maintained when dealing with patients
with personality disorder.

NO.3
In caring for a patient who has antisocial

personality disorder. Which of the following
assessment findings should the nurse expect?
A) Manipulative behavior and inflated feelings
of self-worth
B) Manipulative behavior and inability to
tolerate frustration
C) Suicidal ideation and starvation
D) patterns of bulimia and starvation
ANSWER
Letter B
Rationale: Antisocial patients are

manipulative and have low tolerance
to frustration.

NO.4
In caring for a patient with borderline personality

disorder, which interventions should the nurse
perform?
A) Setting limits on manipulative behavior
B) Allowing the patients to set time limits
C) Using restraints judiciously
D) Encouraging acting out behavior
ANSWER
Letter A
Rationale: Setting limits prevents the

patient from manipulating the nurse.

NO.5
The nurse is performing an admission interview with the patient

who exhibits signs of narcissistic personality disorder. Which
behavior patters is most characteristic of narcissistic
personality disorder?
A) The patient has no close friends
B) The patient is reticent in social situations
C) The patient has grandiose sense of self-importance
D) The patient avoids work or school activities
ANSWER
Letter C
Rationale: Patients who are narcissistic

feel that they are special and they
demand special attention from others.

NO.6
In paranoid disorder, the part of the

personality that is weak is called?
A) Id
B) Ego
C) Superego
D) Not me
ANSWER
Letter B
Rationale: The ego acts

integrator of the personality
as
the

NO.7
A patient says he must wash his hands from 9:00 AM to 9:45

AM each day and therefore cannot attend 9:00 AM group
therapy sessions. Which concept does the nursing staff need to
keep in mind in planning nursing interventions for this patient?
A) Fears and tensions are often expressed in disguised form
through symbolic processes
B) Unmet needs are discharged through ritualistic behavior
C) Ritualistic behavior makes others uncomfortable
D) Depression underlies ritualistic behavior
ANSWER
Letter A
Rationale: The rituals performed by the

obsessive-compulsive patient is their
way of expressing fears and tensions.

NO.8
In interacting with a patient with an

antisocial personality disorder, what
would be the most therapeutic approach?
A) Reinforce the patients self concept
B) Gratify the patients inner needs
C) Give the patient the opportunity to test
reality
D) Provide external controls
ANSWER
Letter D
Rationale: Providing external controls

enables the nurse to set limits on the
patients behavior

NO.9
patient uses repetitive hand washing. To help
A
the
patient use less maladaptive means of handling stress,
the nurse could?
A) Provide varied activities on the unit, as change in
routine can break this ritualistic pattern
B) Give the patient ward assignment that do not require
perfection
C) Tell the patient changes in routine at the last minute to
avoid build up of anxiety
D) Provide an activity in which positive accomplishments
can occur so the patient can gain recognition
ANSWER
Letter D
Rationale:
Providing
positive
reinforcement for the desired behavior
can facilitate behavioral change.

NO.10
Which is an example of limit setting as an effective nursing

intervention in ritualistic hand washing behavior?
A) I dont want you to wash your hands so often anymore.
B) If you continue to wash your hands so frequently, the skin
on your hands will break down.
C) You may wash your hands before the group therapy
meeting if you wish, but not during the group therapy
D) The doctor wrote an order that you are to stop washing
your hands so often.
ANSWER
Letter C
Rationale: Allowing the obsessivecompulsive patient to perform his

rituals decreases the patients anxiety.
AUTISM
AUTISM
Is a disorder characterized by impairment in

communication
skills,
or
the
presence
of
stereotyped behavior, interests and activities with
associated impairment in social interactions
More common among boys
Usually diagnosed at age 2
It is treatable but not curable
MAIN PROBLEM IN AUTISM
Impaired interpersonal functioning
MOST ACCEPTABLE CAUSE OF

AUTISM
Biological Factors
Brain anoxia
Intake of drugs
MOST COMMON SIGNS AND

SYMPTOMS OF AUTISM
Resist normal teaching method

Silly laughing or giggling
Echolalia
Acts as deaf
No fear of danger
Insensitive to pain
Crying tantrums
Loves to spin objects
MOST COMMON SIGNS AND

SYMPTOMS OF AUTISM
Resists change in the routine

Not cuddly
Sustained odd play
Difficulty interacting with others
No eye contact
Wants blocks and not balls
Points to anything
Attachment to inanimate objects
COMMON PROBLEMS AND

APPROPRIATE MANAGEMENT
Tantrums
Involves head-banging
Place a helmet on the head
Communication
All vowels
Use of short sentences when talking to the child
Routines
Provide consistency
Risk for injury

NO.1
Autism can usually be diagnosed when

the child is about?
A) 2 years of age
B) 6 years of age
C) 6 months of age
D) 1 to 3 months of age
ANSWER
Letter A
Rationale: Autism is usually diagnosed

during the toddler stage

NO.2
The treatment of choice for an autistic

child probably will include?
A) Psychoanalysis
B) Behavior modification
C) Group therapy
D) Play therapy
ANSWER
Letter B
Rationale:
Behavior
modification
enables the nurse to modify the childs
maladaptive behavior

NO.3
When interacting with patients who have autistic

thinking and speaking patterns, what is likely to pose
the greatest difficulty for the nurse?
A) Showing acceptance for their incomprehensible acts
and verbalization
B) Ignoring their bizarre behavior
C) Speaking in a way that patients can understand
D) Determining which of the patients needs are being
met by their autistic expression.
ANSWER
Letter D
Rationale: Interacting with patients with

autistic thinking requires thorough analysis
of their speech patterns, the meanings of
their expressions and the relationship of
these to their covert needs. This situation
usually poses great difficulty on the part of
the nurse.

NO.4
In assessing the behavior of an autistic child, the

nurse notes that a symptom that characteristically
differentiates an autistic child from one with down
syndrome and that is?
A) Retardation of activity
B) Short attention span
C) Difficulty in responding to a nurturing relationship
D) Poor academic performance
ANSWER
Letter C
Rationale: Autistic children are usually

withdrawn

NO.5
Primary treatment goals to facilitate

recovery of an autistic child should
include all of the following, EXCEPT?
A) Developing self-confidence
B) Accepting healthy nurturance
C) Maintaining contact with reality
D) Encouraging the child to play with a
ball
ANSWER
Letter D
Rationale: Autistic children want to

play with blocks but not with balls.
MENTAL RETARDATION
MENTAL RETARDATION
The essential feature of mental retardation is belowaverage functioning (IQ less than 70) accompanied by
significant limitations in areas of adaptive functioning
such as communication skills, self care, home living,
social or interpersonal skills, use of community
resources, self-direction, academic skills, work, leisure,
and health and safety manifested before the age of 18.
It is not a mental illness
Main problem is inadequate mental functioning
LEVELS OF MENTAL
RETARDATION
LEVEL OF MENTAL
RETARDATION
INTELLIGENCE
QUOTIENT (IQ)
WHAT CAN BE
DONE
50 / 55 TO 70
EDUCABLE
MODERATE /
IMBECILE
35 / 40 TO 50 / 55
TRAINABLE
SEVERE / IDIOT
20 / 25 TO 35 / 40
NEEDS CLOSE
SUPERVISION
BELOW 20 / 25
NEEDS
CUSTODIAL CARE
MILD / MORON
PROFOUND
BASIS OF DIAGNOSIS OF
MENTAL RETARDATION
The Intelligence Quotient should not be the only criterion

used in making a diagnosis of Mental Retardation.
It should serve only to help in making a clinical judgment

of the patients adaptive behavioral capacity
This judgment should also be based on an evaluation of

the patients developmental history and present
functioning, social and emotional maturity
CAUSES OF MENTAL
RETARDATION
Congenital numerical deficiency or abnormal

arrangement of brain cells
Birth injuries due to pelvic disproportion,
premature births or forceps delivery
Rh blood-factor incompatibility between mother
and child
Infectious diseases, such as German measles of
the mother during the first three months of
pregnancy
Infectious diseases during childhood, such as
meningitis and encephalitis
CAUSES OF MENTAL
RETARDATION
Brain injuries occurring during childhood

Endocrine deficiencies, such as thyroid deficiency,
known to be the cause of cretinism
Exposure to environmental deprivation, with poor
housing and poor economic and social conditions.
Familial or hereditary causes
Inborn errors of metabolism, such as the inability to
metabolize proteins, carbohydrates or fats.
Genetic defects, such as abnormalities in genes and
chromosomes
PREVENTION OF MENTAL
RETARDATION
Adequate medical care during the prenatal period

and birth
Early detection of various disorders
Immunization against communicable diseases
Educating parents to understand the important
concepts of growth and development
Educating family members and society to accept
the mentally retarded
Better housing and living conditions
Improved nutrition through dietary requirement
instruction and meal planning
PREVENTION OF MENTAL
RETARDATION
Intellectual
stimulation
through
socialization, recreation, play and
learning
activities
for
affected
individuals
Genetic counseling
NURSING CARE FOR MENTALLY

RETARDED PATIENTS
Help parents accept a diagnosis of

mental retardation
Consider
the
developmental
functional
age
and
not
chronological age
or
the

RETARDED PATIENTS
Teach parents that they should:

Protect the child from danger
Make the child as independent as his condition
will permit
Teach the child small social graces and manners
which are a tremendous factor in helping to be
accepted by others

RETARDED PATIENTS

Teach the child to refrain from holding their mouths
open as this gives them a dull appearance
Select attractive, well-fitted clothing, hair style and
good hygiene practices
Eliminate the childs undesirable social traits, such as
touching their noses and ears, scratching, etc.

RETARDED PATIENTS

Teach the child only one thing at a time
Demonstrate what they teach, whenever possible
Use pictures, since these are valuable visual aids

RETARDED PATIENTS

Start teaching the child simple things, gradually
progressing to more complex learning experiences
Remember that patience
necessary virtues
and
repetition
are
Avoid prolonged teaching sessions since retarded

individuals easily become fatigued

RETARDED PATIENTS
Refrain from scolding because it blocks learning and instills fear
Give compliments as a motivating force
Not show fear themselves as this emotion will be transferred to

the child
Protect the child from teasing and taunting

RETARDED PATIENTS
Recognize a temper tantrum as a childs attempt to meet some

underlying emotional need such as attention, affection and
security or as the expression of the childs dislike for activity
Recognize that these children have a tendency to express

jealousy
Know that play activities are enjoyed and may be a teaching

experience.
PRINCIPLES OF NURSING CARE

FOR MENTALLY RETARDED
PATIENTS
Repetition
Role Modeling
Restructuring the Environment
FOCUS OF EDUCATION FOR

MENTALLY RETARDED PATIENTS
Reading
Writing
Basic Arithmetic

NO.1
A child scores between 55 and 68 on a

standardized
intelligent
quotient
(IQ)
assessment test. The nurse is aware that this
degree of intellectual impairment would be
considered?
A) Mild
B) Severe
C) Profound
D) Moderate
ANSWER
Letter A
Rationale: Mild retardation means an

I.Q. of 50 55 to approximately 70

NO.2
When a child is diagnosed as being moderately

retarded, it would be most helpful for the nurse to
suggest that the parents?
A) Offer simple, repetitive tasks
B) Concentrate on teaching, competitive situations
C) Offer challenging, competitive situations
D) Provide complete directions at the beginning of the
task to be carried out
ANSWER
Letter A
Rationale: Simple and repetitive tasks

facilitate learning

NO.3
Which of the following measures is of primary importance for

the parents with a young mentally retarded child at home?
A) Limit the amount of environmental stimulation to which the
child is exposed
B) Have the same parent teach the child new skills
C) Teach the child socially acceptable behaviors
D) Maintain a constant routine for daily activities
ANSWER
Letter D
Rationale:
Consistency
adjustment of the child.
facilitates

NO.4
A six year-old girl is recently diagnosed as mildly retarded.

An important aspect in nursing care of a mildly mentally
retarded child is to?
A) Encourage her parents to concentrate on the child rather
than on the condition at this time
B) Delay extensive diagnostic studies until the child is older
C) Modify the childs environment to promote independence
and impulse control
D) Provide one-to-one tutorial education and minimize peer
interaction
ANSWER
Letter C
Rationale: Restructuring the childs

environment prevents injury and
promotes independence

NO.5
Nursing intervention that focus on the

cognitively impaired child most emphasize
providing the child and family with support
and education that are directed toward?
A) Finding a cure
B) Optimal development
C) Identifying the problem
D) Curing major symptoms
ANSWER
Letter B
Rationale: The primary goal of care for

the cognitively impaired child is to
promote optimal development.
ATTENTION DEFICIT
HYPERACTIVITY DISORDER
(ADHD)
ATTENTION DEFICIT
HYPERACTIVITY DISORDER
(ADHD)
A disorder characterized by:

Inattentiveness
Over-activity
Impulsiveness
A common disorder among boys
Occurs before the age of 7
MAIN PROBLEMS IN ADHD
Inattention
Hyperactivity
Impulsivity
COMMON ETIOLOGICAL
FACTORS
Neurologic impairment
Pre-natal trauma
Early malnutrition
Frontal lobe hypoperfusion
Use of drugs by the mother during pregnancy

ADHD
Subdivided into:
Inattentive behaviors
Hyperactive and Impulsive behaviors

ADHD - INATTENTIVE
BEHAVIORS
Misses details
Makes careless mistakes
Has difficulty sustaining attention
Does not seem to listen
Does not follow-through on chores or homework
Has difficulty with organization
Avoids tasks requiring mental effort
Often loses necessary things
Is easily distracted by other stimuli
Is often forgetful in daily activities

ADHD - HYPERACTIVE /
IMPULSIVE BEHAVIOURS
Fidgets
Often leaves a seat, (e.g., during a meal)
Runs or climbs excessively
Can not play quietly
Is always on the go; driven
Talks excessively
Blurts out answers
Interrupts
Cant wait for turn
Is intrusive with siblings and playmates
PSYCHOPHARMACOLOGY FOR
ADHD
Stimulant Drugs
Methylphenidate (Ritalin) drug of
choice
Dextroamphetamine (Dexedrine)
Amphetamine (Adderall)
STIMULANT DRUGS USED TO

TREAT ADHD
GENERIC (TRADE)
NAME
DOSAGE (mg/day)
NURSING
CONSIDERATIONS
Methylphenidate
(Ritalin)
10 60 in 3 4Monitor
for
appetite
divided doses
suppression
and
growth
delays
Give regular tablets after
meals
Alert client that full drug effect
takes 2 days
Dextroamphetamine
(Dexedrine)
5 40 in 2 3 dividedMonitor for insomnia

doses
Give last dose in early
afternoon
Monitor
for
appetite
suppression
Alert client that full drug effect
takes 2 days
NURSING CARE FOR ADHD
Ensuring the clients safety and that of others

Stop unsafe behavior (priority
diagnosis is RISK FOR INJURY)
nursing
Provide close supervision

Give clear directions about acceptable and
unacceptable behavior
Improved role performance

Give positive feedback for meeting
expectations
Manage the environment (e.g., provide
a quiet place free of distractions for
task completion)
Simplifying instructions and directions

Get the childs full attention
Break complex tasks into small steps
Allow breaks
Structured daily routine

Establish a daily schedule
Minimize changes
Client / Family education and support

Listen to parents
frustrations
feelings
and

NO.1
A 7 year-old child has attention deficit

hyperactivity disorder. The child is most likely to
exhibit which of the following?
A) Restlessness, decreased attention span and
distractability
B) Hyperactivity, somatic complaints, and
distractability
C) Impulsiveness, anhedonia and shyness
D) Poor concentration, decreased attention span
and somatic complaints
ANSWER
Letter A
Rationale: ADHD is characterized by

Inattention,
Hyperactivity
and
Impulsivity

NO.2
An 8 year-old boy has recently been diagnosed with

attention deficit hyperactivity disorder by his
pediatrician. He and his parents come to the pediatric
clinic together. Which of the following behaviors would
the nurse be most likely to observe from the child?
A) Lethargy
B) Preoccupation with body parts
C) Very poor skills
D) Short attention span
ANSWER
Letter D
Rationale: ADHD is characterized by

Inattention,
Hyperactivity
and
Impulsivity

NO.3
In providing care to a school-age child with attention-deficit

hyperactivity disorder, the most effective intervention
would be to?
A) Increase environmental stimulation and peer interaction
B) Administer drug therapy (i.e., methyphenidate or Ritalin)
and use behavior modification
C) Provide parental education and diet therapy
D)
Encourage
delayed
achievement
of
normal
developmental tasks
ANSWER
Letter B
Rationale: Ritalin is the drug of choice

for ADHD because it increases
attention span

NO.4
Which nursing diagnosis is most applicable for a child

with ADHD?
A) Ineffective family coping related to ineffective
parenting
B) Potential for injury related to impulsivity
C) Impaired verbal communication related to mutism
D) Altered thought processes related to impaired reality
ANSWER
Letter B
Rationale: The priority needs of a child

with ADHD are safety and provision of
adequate nutrition

NO.5
Which medication side effects is

typically the greatest concern of
parents with children with ADHD?
A) Dizziness
B) Headache
C) Increased appetite
D) Delayed physical growth
ANSWER
Letter D
Rationale: Ritalin, the drug of choice

for ADHD causes growth suppression,
insomnia and suppression of appetite.
EATING DISORDERS
EATING DISORDERS
For many, eating symbolizes parental nurturing

the love and care that are the prototype of and a
basis for all future intimate relationships
For some, however, eating creates anxiety

because of its association with unsatisfactory and
unpleasant parent-child interactions.
Clearly, food and eating have greater individual

and cultural meaning and importance than
merely an activity undertaken to sustain life.
ANOREXIA NERVOSA
ANOREXIA NERVOSA
This is a life-threatening eating disorder characterized by:

the clients refusal or, inability to maintain a minimally
normal body weight
intense fear of gaining weight or becoming fat
significantly disturbed perception of the shape or size of
the body
steadfast inability or refusal to acknowledge the
seriousness of the problem or even that one exists
ANOREXIA NERVOSA
Clients with anorexia nervosa have:

A body weight that is 85% less than
expected for their age and height
Experienced
amenorrhea for at
least three consecutive cycles
A preoccupation with food and foodrelated activities

ANOREXIA NERVOSA
Fear of gaining weight or becoming fat even

when severely underweight (Main Sign)
Body image disturbance
Amenorrhea
Depressive symptoms such as depressed mood,

social withdrawal, irritability, and insomnia

ANOREXIA NERVOSA
Preoccupation with thoughts of food
Feelings of ineffectiveness
Inflexible thinking
Strong need to control the environment

ANOREXIA NERVOSA
Limited spontaneity
emotional expression
and
overly
restrained
Complaints of constipation and abdominal pain
Cold intolerance
Lethargy

ANOREXIA NERVOSA
Emaciation
Hypotension, hypothermia and bradycardia
Hypertrophy of salivary glands

ANOREXIA NERVOSA
Elevated BUN
Electrolyte imbalances
Leukopenia and mild anemia
Elevated liver function studies
BULIMIA NERVOSA
Is an eating disorder characterized by:

Recurrent episodes (at least twice a
week for 3 months) of binge eating
(consuming a large amount of food,
far greater than most people eat at a
time, in a discrete period of usually 2
hours or less)
BULIMIA NERVOSA
Is an eating disorder characterized by:

eating
followed
by
inappropriate
Binge
compensatory behaviors to avoid weight gain such
as:
Purging (compensatory behavior designed to eliminate

food by means of self-induced vomiting, misuse of
laxatives, enemas, and diuretics)
Fasting
Excessively exercising

BULIMIA NERVOSA
Recurrent episodes of binge eating
Compensatory behavior such as self-induced

vomiting, misuse of laxatives, diuretics, enema or
other medications, or excessive exercise
Self-evaluation overly influenced by body shape

and weight
Usually within normal weight range, possible

underweight or overweight

BULIMIA NERVOSA
Restriction of total calorie consumption between binges,

selecting low-calorie foods while avoiding foods perceived to
be fattening are likely to trigger a binge
Depressive and anxiety symptoms
Possible substance use involving alcohol or stimulants
Loss of dental enamel

BULIMIA NERVOSA
Chipped, ragged, or moth eaten appearance of

the teeth
Increased dental caries
Menstrual irregularities
Dependence on laxatives
Esophageal tears

BULIMIA NERVOSA
Fluid and electrolyte abnormalities
Metabolic alkalosis (from vomiting) or

metabolic acidosis (from diarrhea)
Mildly elevated serum amylase levels
RISK FACTORS FOR EATING DISORDERS
DISORDER
BIOLOGIC
RISK
FACTORS
DEVELOPMENTAL FAMILY RISK

RISK FACTORS
FACTORS
SOCIOCULTURAL
RISK
FACTORS
Anorexia
Nervosa
Obesity; dieting Issues of developing Family lacks

Cultural ideal of
at an early age autonomy and
emotional
being thin;
having control over support;
media focus on
self and
parental
beauty,
environment;
maltreatment; thinness,
developing a unique cannot deal with fitness,
identity;
conflict
preoccupation
dissatisfaction with
with achieving
body image
the ideal body
Bulimia
Nervosa
Obesity; early
dieting;
possible
serotonin and
norepinephrine
Self-perceptions of Chaotic family Same with

being overweight, with loose
above, weightfat, unattractive, and boundaries;
related teasing
undesirable;
parental
dissatisfaction with maltreatment
COMMON NURSING DIAGNOSES

RELATED TO EATING
DISORDERS
Body image disturbance
Self-esteem disturbance
NURSING INTERVENTIONS FOR

ANOREXIA NERVOSA
Promote improved nutrition assume a calm, matter-of-fact attitude
and positive expectation of the client, meeting minimal nutritional
goals is non-negotiable.
Tube or IV feedings
Weigh daily, record intake and output, observe client during
meals and bathroom activities
Avoid discussing food, recipes, restaurants and eating
Provide a pleasant meal time environment and adopt realistic
expectations of how much the client will eat

ANOREXIA NERVOSA
Promote improved nutrition

Frequent, small meals are more acceptable
Set time limit of about one-half hour to forestall
mealtime marathon (protracted meals during
which the client eats little)
Collaborate with a dietitian
Acknowledge and recognize efforts of clients who
meet weight gain goals but avoid praise or flattery
Behavior modification therapy can help

ANOREXIA NERVOSA
Promote effective individual coping
The best way is to involve the clients in their own treatment
planning
Give clients the opportunity to practice problem solving.
Demonstrate positive belief in clients abilities to regain
healthy functioning and a willingness to tolerate mistakes
Set firm, clear limits to provide the secure environment
needed to learn more effective coping behaviors
Explore clients feelings about their families, their roles in the
family and their autonomy within the family system

BULIMIA NERVOSA
Promoting effective coping with anxiety

help them recognize events that
create anxiety and to avoid binging and
purging in response to anxiety
Promoting improved fluid volume
Promoting effective individual coping

BULIMIA NERVOSA
Promoting effective individual coping

It is important for clients to identify situations or
patterns of events that precede episodes of binging
and purging.
They need to learn effective ways
feelings and assertive techniques to
interactions in the future
Promoting effective family coping
of expressing
diminish guilt

NO.1
The nurse is monitoring a patient diagnosed with anorexia

nervosa. In addition to monitoring the patients eating, the
nurse should do which of the following after meals?
A) Encourage the patient to go for a walk to get some exercise
B) Prevent the patient from using the bathroom for 2 hours after
eating
C) Tell the patient to lie down for 2 hours after eating
D) Instruct the patient to get plenty of exercise
ANSWER
Letter B
Rationale: Preventing the patient from

using the bathroom for 2 hours after
eating, prevents the patient from
inducing vomiting

NO.2
The nurse is caring for a patient who has

bulimia.
What treatment option is most
effective?
A) Antidepressant
B) Cognitive behavior therapy
C) Anti-depressants and cognitive-behavior
therapy
D)
Total
parenteral
nutrition
and
antidepressants
ANSWER
Letter C
Rationale: Combination of somatic and

behavioral
treatment
modalities
facilitates treatment of the disorder

NO.3
The nurse is caring for a bulimic patient and an

anorexic patient. What cognitive characteristics
would be similar for both of these patients?
A) Perfectionism and pre-occupation with food
B) Relaxed personality, but pre-occupied with food
C) No similarities
D) Pre-occupation with exercise
ANSWER
Letter A
Rationale:
Patients
with
eating
disorders are usually high achievers,
perfectionists and pre-occupied with
food.

NO.4
Psychologically, bulimic differs from an anorexic

patient through awareness that her behavior is?
A) Acceptable
B) Abnormal
C) Easy to control
D) Physically dangerous
ANSWER
Letter B
Rationale: Bulimic patients are usually

aware of their abnormal behavior

NO.5
The primary objective in the treatment of

anorexia is to?
A) Enable the patient to eat and gain
weight
B) Decrease anxiety to stimulate appetite
C) Help patient to select food she likes
D) Cure her anorexia condition and eat
ANSWER
Letter A
Rationale: Anorexic patients usually

suppress their appetite, which makes it
difficult for the nurse to convince them
to eat.
SEXUAL DISORDERS
GENDER IDENTITY
This is an individuals personal or

private sense of identity as female or
male
It develops from an interaction of

biology, identity imposed by others
and self-identity
GENDER ROLES
Refers to learning and performing

socially accepted sex behaviors, i.e.,
taking on a feminine or masculine role
Proponents of andogeny (flexibility in

gender roles), however, view most
characteristics
and
behaviors
as
human qualities that should not be
limited to a specific gender
TRANSSEXUALISM
Is a gender identity disorder in which a

person has consistently strong feelings
of being trapped in a body of a wrong
sex.
PARAPHILIAS
A group of psychosexual disorders characterized by

unconventional sexual behaviors
These are abnormal expressions of sexuality
They are not, by definition, pathologic
They only become so when severe, insistent,

coercive and harmful to the self or others
NON-COERCIVE PARAPHILIAS
Fetishism
Autoerotic Asphyxia
Sexual Masochism
Transvestitism
NON-COERCIVE PARAPHILIAS FETISHISM
Sexual arousal elicited by inanimate

objects (shoes, leather, rubber) or
specific body parts (feet, hair)
NON-COERCIVE PARAPHILIAS AUTOEROTIC ASPHYXIA
Constriction of the neck to enhance a

masturbation experience; often leads
to accidental death
NON-COERCIVE PARAPHILIAS SEXUAL MASOCHISM
Erotic
interest
in
receiving
psychological or physical pain, real or
fantasized
NON-COERCIVE PARAPHILIAS TRANSVESTITISM
Using the apparel of the opposite sex
COERCIVE PARAPHILIAS
Exhibitionism
Voyeurism
Frotteurism
Obscene Phone Callers / Telephone
Scatologia
Pedophilia
Urophilia
Coprophilia
Sadism
COERCIVE PARAPHILIAS EXHIBITIONISM
Intentional exposure of the genitals to

a stranger or unsuspecting person
May be accompanied by arousal and

masturbation either during or after the
exposure
VOYEURISM
Secret observation of an unsuspecting

person (usually a woman) engaged in
a private act, e.g., undressing or
having sex.
The voyeur often masturbates during

or after the viewing
COERCIVE PARAPHILIAS FROTTEURISM
Intense sexual arousal elicited by

rubbing the genitals against a nonconsenting person
OBSCENE PHONE CALLERS
Calling a non-consenting person and

making sexual noises, using profanity,
attempting to seduce, or describing
sexual activity.
The caller often masturbates during or

after the call
PEDOPHILIA
Sexual interest in a child
Behavior
ranges
from
exposure,
voyeurism, and explicit talk to
touching, oral sex and intercourse
UROPHILIA
Urinating on the sexual partner
COERCIVE PARAPHILIAS COPROPHILIA
Smearing feces on the partner
SADISM
Erotic interest in inflicting physical pain
OTHER FORMS OF PARAPHILIA
Anningulus
Cunnillingus
Fellatio
Partialism

ANNILINGUS
Tongue brushing of the anus

CUNNILLINGUS
Tongue brushing of the vulva

FELLATIO
Inserting the penis into the mouth

PARTIALISM
Inserting the penis into the other parts

of the body
TYPE OF THERAPY PERFORMED

ON PATIENTS WITH PARAPHILIAS
therapeutic
intervention
involving
the
A
application of learning principles in order to
change maladaptive behavior
A method of attempting to strengthen a desired
behavior or response by reinforcement , either
positive or negative
Positive reinforcement is given to the client who

exhibits the desired behavior
Negative reinforcement involves removing a stimulus
immediately after a (positive) behavior occurs so that
the behavior is more likely to occur again
TYPE OF THERAPY PERFORMED

ON PATIENTS WITH
PARAPHILIAS
Aversion Therapy
An example of behavior modification in which
a painful stimulus is introduced to bring about
avoidance of another stimulus with the end
view of facilitating behavioral change
Token Economy
example
of
behavior
modification
An
technique which utilizes the principle of
rewarding desired behavior to facilitate
change.
SEXUAL ADDICTION
The frequency of sexual activity can be viewed on a

continuum, with most people falling in the middle
range
Some have sex frequently in a way that enhances

their lives; others have sex infrequently and report
contentment and satisfaction
A sexual pattern that falls at either extreme of the

continuum, however can signal problems.
SEXUAL ADDICTION
Is a disorder in which the central focus of life is sex

People with these addictions spend 50% or more of all waking hours
dealing with sex, from fantasy to acting out behavior.
Acting out behavior is often victimless, e.g., overindulging in
masturbation, fetishism, pornography use, or commercial telephone
sex; or visiting prostitutes
Victimizing behaviors (those with a non-consenting partner) are less
frequent and include obscene phone calls, frotteurism, voyeurism,
exhibitionism, child sexual abuse and rape
SEXUAL ADDICTION
Sexual addiction is not simply the frequent enjoyment of

sexual behaviors; rather, it is a progressive disease in which
sex is used to numb pain.
The pay off is the same as in any other addiction, i.e., an

intensely pleasurable, short-lived release from pain, and an
escape from the problems of daily life.
The consequences are the same in the addicts life and

eventually becomes unmanageable
SEXUAL ADDICTION
Many sexual addicts grew up in homes where

they were emotionally, physically, or sexually
abused
Most of them suffer from low self-esteem and

believe themselves unlovable.
They have desperate need for love and they

equate sex with proof of love.
SEXUAL ADDICTION
The components have the hallmarks of

obsessive-compulsive behavior:
Preoccupation
Spends hours thinking or obsessing about

sex and is so time consuming that the
person cannot fulfill work, school, or
family responsibilities
SEXUAL ADDICTION

Ritualization
The individual engages in specific

behaviors done just the right way and
in the same sequence at the right time.
The ritual seems to control anxiety; once
addicts begin a ritual, they cannot stop
until the cycle is completed
SEXUAL ADDICTION

Compulsivity
The individual cannot control sexual

behavior and this behavior becomes the
most important aspect of life
SEXUAL ADDICTION

Shame and Despair
At the end of the cycle, the person

experiences guilt and shame at the loss of
control. The pain of despair creates the
need to begin the cycle all over again. Like
other addicts, these individuals want to stop
their behavior, promise to stop, try to stop
and are unable to stop without treatment.
ON PATIENTS WITH SEXUAL

ADDICTION
therapeutic
intervention
involving
the
A
application of learning principles in order to
change maladaptive behavior
A method of attempting to strengthen a desired
behavior or response by reinforcement , either
positive or negative
Positive reinforcement is given to the client who

exhibits the desired behavior
Negative reinforcement involves removing a stimulus
immediately after a (positive) behavior occurs so that
the behavior is more likely to occur again
SEXUAL DYSFUNCTIONS
These are problems or difficulties with sexual expression classified
according to the phase of the sexual response cycle that is affected
This does not include dissatisfaction problems
Contributory factors actually implicate past and current factors:
Lack of sex education
Internalization of the teaching that sex is dirty or sinful
Parental punishment for normal exploration of ones genitals
Severe trauma such as rape or child sexual abuse
SEXUAL DYSFUNCTIONS
Contributory factors actually implicate

past and current factors:
Negative feelings like guilt anxiety,
anger which interfere with the ability
to experience pleasure and joy
SEXUAL DYSFUNCTION
Fear of failure in sexual performance

often becomes a vicious cycle, i.e.,
fear of failure creates actual failure,
which in turn, produces more fear.
CLASSIFICATIONS OF SEXUAL
DYSFUNCTION
Disorders of Sexual Desire
Arousal Disorders
Orgasm Disorders
DISORDERS OF SEXUAL DESIRE

Inhibited Sexual Desire
Persistently low interest or a total lack of interest in
sexual activity
Sexual Aversion Disorder
Severe distaste for sexual activity or the thought of
the sexual activity, which then leads to a phobic
avoidance of sex
The most common cause of sexual aversion disorder
is childhood sexual abuse or adult rape
Increased Sexual Interest
Symptomatic of the manic phase of a bipolar disorder
AROUSAL DISORDERS
Physiologic responses and subjective sense

of excitement experienced during sexual
activity
Female Sexual Arousal Disorder
Lack of vaginal lubrication
Male Sexual Arousal Disorder
Occurs when the man has erection problems

during 25% or more of sexual interactions;
cannot attain a full erection or loses erection
prior to orgasm (impotence / erectile inhibition)
ORGASM DISORDERS
Inhibited Female Orgasm / Frigid
Woman is totally incapable of responding sexually
Sexual response stops before orgasm occurs
Pre-orgasmic
Women who have never experienced an orgasm
Secondarily Non-Orgasmic
They have had orgasm in the past but are not currently
experiencing them
Situationally Non-orgasmic
Have orgasms in some situations but not in others
ORGASM DISORDERS
Inhibited Male Orgasm

Male can maintain an erection for long periods
(e.g., an hour or more) but has extreme difficulty
ejaculating
Could be organic, e.g., spinal cord injuries,
multiple sclerosis, due to drugs or may be
psychogenic (fear of pregnancy, performance
pressure, fear of losing control, anxiety and guilt
about engaging in sexual activity)
ORGASM DISORDERS
Rapid Ejaculation
One of the most common dysfunction among men
Refers to the absence of voluntary control of ejaculation
Probably due to:
Inability to perceive his arousal level accurately

Lowered sensory threshold due to infrequent sexual activity
Early conditioning as a result of hurried masturbation or
hurried sexual intercourse
Extreme anxiety during sexual interaction, resulting in
ejaculation triggered by the SNS
SEXUAL PAIN DISORDERS
Vaginismus
Involuntary spasms of the outer one third of the
vaginal muscles making penetration of the
vagina painful and sometimes impossible.
is
mainly
psychophysiologic:
as
Cause
protection against real or imagined pain;
history of sexual trauma; emotional conflict
SEXUAL PAIN DISORDERS
Dyspareunia
Pain during
intercourse
or
immediately
after
Could be due to skin irritations,

vaginal infection, estrogen deficiency,
or drugs; pelvic disorders, such as
endometriosis, scar tissue, tumors
PROBLEMS WITH SEXUAL

SATISFACTION
These are more related to the

emotional tone of the relationship than
the physiologic response
May be situational, due to lack of

extragenital satisfaction, related to the
relationship difficulties, due to lack of
intimacy
NURSING CARE FOR SEXUAL

DYSFUNCTIONS
Reduce anxiety and fear
Accurate identification of feelings is the first step
Help the client identify one anxiety-producing situation
within their sexual interactions
The nurse and client may analyze the situation to discover
negative anticipatory thoughts that may be the source of the
anxiety.
Review how the client has handled anxiety in the past and
evaluate the range and effectiveness of this past coping
behavior, then explore alternative coping behaviors

DYSFUNCTIONS
Decrease spiritual distress

Because the origin of spiritual
distress is the lack of intimacy or
connection
within
a
sexual
relationship, the goal of nursing care
is to help clients achieve and
maintain a level of intimacy each
partner finds comfortable

DYSFUNCTIONS
Promote more effective family coping

Apart from setting specific times to share feelings, and belief,
some couples need training in more effective communication
skills.
Teach couples to avoid the you language, which evokes a defensive

response and results in arguments, and encourage use of the I
language, which expresses personal thoughts, feelings and needs.
Example of You language
You only have sex on your mind. You are a pervert
Example of I language
I am concerned because we seem to have different expectations of

how often we would like to make love.

DYSFUNCTIONS
Promote comfort with personal identity

A multidisciplinary approach is most
effective in helping transsexuals adjust to
their situation
Family and friends need support and
counseling to reintegrate this person into
their lives as a person of the other sex

DYSFUNCTIONS
Promote effective role performance

Refer sexual addicts to self-help groups
and specialized professional therapy
Recovery is a long-term process facilitated
by individual, group, couple, family, and
family-of-origin therapy

DYSFUNCTIONS
Promote
patterns
non-coercive
sexuality
If practiced with an adult consenting

partner
requires
no
nursing
intervention except for client and
partner education and possible
couple
negotiation
about
the
behavior

DYSFUNCTIONS
Decrease violence against the self and others

The most important nursing education regarding
autoerotic asphyxia is community education
Therapy for sex offenders is a specialized area that
should not be taken lightly
Behavior modification techniques, group therapy,
hypnosis could be used

DYSFUNCTIONS
Decrease pain
Thorough physical examination is
necessary to find and treat the organic
cause of the pain
Vaginismus is treated with education,
dilators and supportive psychotherapy

DYSFUNCTIONS
Increase knowledge
Teach clients sexual anatomy and
the sexual response cycle
Encourage couples to talk with one
another
about
their
individual
responses
SEX THERAPY
Common components
Information and education about sexual functions
Experiential and Sensory Awareness
Therapist helps clients to recognize feelings of anxiety,

anger and pleasure by tuning into bodily cues
Insight
Therapist attempts to learn and understand what is causing

and perpetuating the sexual problem
SEX THERAPY
Common components
Cognitive Restructuring
Clients identify and re-evaluate their nonsexual fears about sexual interaction
Behavioral Interventions
Focus is on changing the non-sexual behavior

that contributes to sexual problems
Assertiveness training, communication training,
stress-reduction exercises and problem-solving
techniques
SCHIZOPHRENIA
SCHIZOPHRENIA
The term schizophrenia (split mind) was coined by

Bleuler to describe a lack of integration of the
patients functions
There is disharmony between the patients thinking,
feeling and acting.
Schizophrenia causes distorted and bizarre thoughts,
perceptions, emotions, movements and behavior.
It cannot be defined as a single illness; rather it is
thought of as a syndrome or disease process with
many different varieties and symptoms
SCHIZOPHRENIA
The main problem in schizophrenia is

Altered Thought Process
The most acceptable theory on the

cause of schizophrenia is the Biologic
Theory which says that schizophrenia
is due to increased dopamine.
CHARACTERISTICS OF PATIENTS
WITH SCHIZOPHRENIA
Patients are usually of the asthenic or

slender, lightly muscled body type
They tend to be introverted, deficient in their

affective response ability, self conscious,
retiring, moody and sensitive
Thought processes are disorganized and

disturbed; emotion may be lacking or
disassociated from the content of thought
WITH SCHIZOPHRENIA
There is failure in adapting to objective reality with its

everyday problems, situations and demands and in forming
satisfactory relationships with others
Instead of recognizing and adapting to the inevitable
frustrations and problems of living, they utilize the
mechanism of denial and withdraw from reality
The patients abstract ability becomes impaired to the
extent that he cannot conceptualize or form logical
conclusions
WITH SCHIZOPHRENIA
Patient acts out in ways which would

ordinarily be subject to social restraint
Delusions and hallucinations are

accessory symptoms which serve to
fulfill denied wishes and to free the
patient from intolerable feelings of
guilt and anxiety.
TYPES OF SCHIZOPHRENIA
Paranoid Type
Catatonic Type
Disorganized Type
Undifferentiated Type
Residual Type
SCHIZOPHRENIA
PARANOID TYPE
Characterized by persecutory (feeling

victimized or spied on) grandiose
delusions,
hallucinations,
and
occasionally,
excessive
religiosity
(delusional religious focus) or hostile
and aggressive behavior.
SCHIZOPHRENIA
CATATONIC TYPE
Characterized by marked psychomotor disturbance, either

motionless or excessive motor activity.
Motor immobility may be manifested by catalepsy (waxy
flexibility) or stupor
Excessive motor activity is apparently purposeless and is
not influenced by external stimuli
Other features include negativism, mutism, peculiarities of
voluntary movement, echolalia, and echopraxia
SCHIZOPHRENIA
CATATONIC TYPE
Catatonic Stupor
Marked decrease
and/or reduction
activity or mutism
in
in
reactivity to
spontaneous
the environment
movement and
Catatonic Negativism
Apparently motive-less resistance to all instruction or
attempts to be moved
Catatonic Rigidity
Maintenance of a rigid posture against efforts to be
moved
SCHIZOPHRENIA
CATATONIC TYPE
Catatonic Excitement
Excited motor activity, apparently
purposeless and not influenced by
external stimuli
Catatonic Posturing
Voluntary
assumption
inappropriate posture.
of
SCHIZOPHRENIA
DISORGANIZED TYPE
Incoherence, marked loosening of

associations, or grossly disorganized
behavior
Flat or grossly inappropriate affect
Does not meet the criteria for the

catatonic type
SCHIZOPHRENIA
UNDIFFERENTIATED TYPE
Characterized by mixed schizophrenic symptoms

(of other types) along with disturbances of
thought, affect and behavior
Prominent delusions, hallucinations, incoherence

or grossly disorganized behavior
Patients whose manifestations cannot be fitted

into one or the other types
SCHIZOPHRENIA
RESIDUAL TYPE
Absence of prominent delusions,

hallucinations, incoherence or grossly
disorganized behavior
SCHIZOPHRENIA
RESIDUAL TYPE
Continuing evidence of the disturbance, as indicated by

2 or more of these residual symptoms:
Marked social isolation or withdrawal
Marked impairment in role functioning as wageearner, student or homemaker
Marked peculiar behaviors
Marked impairment in personal hygiene and grooming
Odd beliefs or magical thinking, influencing behavior
and inconsistent with cultural norms.
Marked lack of initiative, interest
COMPARISON OF DIFFERENT
TYPES OF SCHIZOPHRENIA
CATATONIC TYPE DISORGANIZED
TYPE
Onset
PARANOID TYPE
Acute
Insidious
Abrupt
Abnormal Motor
Behavior
Bizarre Behavior
Suspiciousness
Ideas of reference
Repression
Regression
Projection
Priority Nursing
Diagnosis
Impaired Motor
Activity
Impaired Social
Functioning
Potential for injury

directed at others
Priority Nursing
Care
Circulation
Nutrition
Assistance with
ADL
Nutrition
Safety
Distinguishing
Feature
Defense
Mechanism
CRITERIA FOR PROGNOSIS OF

SCHIZOPHRENIA
Favorable Prognosis
Good socialization
Late / acute onset
Adequate support system
Family history of mood disorder
CRITERIA FOR PROGNOSIS OF

SCHIZOPHRENIA
Unfavorable Prognosis
Poor / no socialization
Early and insidious onset
Few / no support system
History of chronicity / many relapses
THEORIES OF CAUSATION OF
SCHIZOPHRENIA
Biologic
Genetic Theories
Schizophrenics
inherit
a
genetic
vulnerability for the disease
Relatives
of schizophrenics have a
greater chance of developing the disease
Concordance rates for schizophrenia are
consistently higher for monozygotic than
for dizygotic twins
SCHIZOPHRENIA
Biologic
Biological Theories
The dopamine hypothesis is the most

widely held and extensively studied
biochemical mechanism thought to
underlie schizophrenia
SCHIZOPHRENIA
Biologic
Brain Structure
Ventricular size has been found to be

significantly
larger
in
chronic
schizophrenics
SCHIZOPHRENIA
Psychological Theories
Information Processing Deficit
Attention and Arousal
Either hypo- or hyper-
SCHIZOPHRENIA
Family Theories
Defect in family interaction
disordered family communication
Familys Emotional Tone is highly

critical, hostile or over involved
FUNDAMENTAL SIGNS AND

SYMPTOMS OF SCHIZOPHRENIA
AS IDENTIFIED BY BLEULER
Associative Looseness
Autism
Apathy
Ambivalence
The symptoms of schizophrenia are divided into

two major categories:
Positive or hard symptoms / signs, which
include delusions, hallucinations, and grossly
disorganized thinking, speech and behavior
Negative or soft symptoms / signs such as flat
affect, lack of volition, and social withdrawal or
discomfort
SYMPTOMS OF
SCHIZOPHRENIA
Medication can control the

symptoms, but frequently the
symptoms
persist
after
symptoms have abated
positive
negative
positive
POSITIVE OR HARD SYMPTOMS OF

SCHIZOPHRENIA
Ambivalence
Flight of ideas
Associative Looseness
Hallucinations
Delusions
Ideas of Reference
Echopraxia
Perseveration
POSITIVE OR HARD SYMPTOMS

OF SCHIZOPHRENIA
AMBIVALENCE
Holding
seemingly
contradictory
beliefs or feelings about the same
person, event or situation

OF SCHIZOPHRENIA
ASSOCIATIVE LOOSENESS
Fragmented or poorly related thoughts

and ideas

OF SCHIZOPHRENIA DELUSIONS
Fixed false beliefs that have no basis in

reality

OF SCHIZOPHRENIA ECHOPRAXIA
Imitation of the movements and

gestures of another person whom the
client is observing.

OF SCHIZOPHRENIA - FLIGHT
OF IDEAS
Continuous flow of verbalization in

which the person jumps rapidly from
one topic to another

OF SCHIZOPHRENIA
IDEAS OF REFERENCE
False impressions that external events

have special meaning to the person

OF SCHIZOPHRENIA PERSEVERATION
Persistent adherence to a single idea or topic; verbal repetition of a
sentence, word, or phrase; resisting attempts to change the topic
Example:
NEGATIVE OR SOFT SYMPTOMS OF

SCHIZOPHRENIA
Alogia
Catatonia
Anhedonia
Flat Affect
Apathy
Lack of Volition
Blunted Affect
NEGATIVE OR SOFT SYMPTOMS

OF SCHIZOPHRENIA - ALOGIA
Tendency to speak very little or to

convey little substance of meaning
(poverty of content)

OF SCHIZOPHRENIA ANHEDONIA
Feeling no joy or pleasure from life or

any activities or relationships

OF SCHIZOPHRENIA - APATHY
Feelings of indifference toward people,

activities, and events

OF SCHIZOPHRENIA - BLUNTED
AFFECT
Restricted range of emotional feeling,

tone, or mood

OF SCHIZOPHRENIA CATATONIA
Psychologically induced immobility

occasionally marked by periods of
agitation or excitement; the client
seems motionless, as if in a trance

OF SCHIZOPHRENIA - FLAT
AFFECT
Absence of any facial expression that

would indicate emotions or mood

OF SCHIZOPHRENIA - LACK OF
VOLITION
Absence of will, ambition, or drive to

take action or accomplish tasks
GENERAL SIGNS AND

1) Perceptual changes
Perceptions may either be heightened or blunted
May occur in all the senses, or in just one or two
1a) Illusions
Clients misperceives or exaggerates stimuli in the external

environment
1b) Hallucinations (hallmark of schizophrenia)
Subjective perception of something that does not exist in the

external environment
May be visual, olfactory, gustatory, tactile, or auditory
GENERAL SIGNS AND

2) Disturbances in thought
The thinking is nudged or unclear
Thoughts
are
disconnected
or
disjointed
Connections between one thought and
another are vague
Examples:
2a) Clang Associations
2b) Delusions
CLANG ASSOCIATIONS
Are ideas that are related to one

another based on sound or rhyming
rather than meaning.
Example: I will take a pill if I go up to

the hill but not if my name is Jill, I dont
want to kill.
DELUSIONS
Disturbances in the content rather than the

form of thought
Fixed false beliefs about ones environment or
event occurring in it
Types of delusions
Persecutory or Paranoid Delusions
Grandiose Delusions
Religious Delusions
Somatic Delusions
Referential Delusions or Ideas of Reference
PERSECUTORY / PARANOID
DELUSIONS
Involves the clients belief that others are planning

to harm the client or are spying, following, ridiculing,
or belittling the client in some way.
Sometimes the client cannot define who these others
are.
Examples:
The client may think that food has been poisoned or that
rooms are bugged with listening devices
Sometimes the persecutor is the government or other
powerful organization
Occasionally, specific individuals, even family members may
be named as the persecutor
GRANDIOSE DELUSIONS
Are characterized by the clients claim to association with
famous people or celebrities, or the clients belief that he
or she is famous or capable of great feats
Examples:
The client may claim to be engaged to a famous movie
star or related to some public figure such as claiming
to be the daughter of the President of the Philippines
May claim he or she has found a cure for cancer
RELIGIOUS DELUSIONS
Often center around the second coming of Christ or another

significant religious figure or prophet
These religious delusions appear suddenly as part of the
clients psychosis and are not part of his or her religious
faith or that of others
Examples:
Client claims to be the Messiah or some prophet sent from God

Believes that God communicated directly to him or her
He or she has a special religious mission in life or special
religious powers
SOMATIC DELUSIONS
Are generally vague and unrealistic beliefs

about the clients health or bodily functions
Factual information or diagnostic testing does

not change these beliefs
Examples
A male client may say that he is pregnant
A client may report decaying intestines or
worms in the brain
REFERENTIAL DELUSIONS /
IDEAS OF REFERENCE
Involve the clients belief that television

broadcasts, music, or newspaper articles have
special meaning for him or her
Examples:
The client may report that the president was
speaking directly to him on a news broadcast
or that special messages are sent through
newspaper articles
GENERAL SIGNS AND SYMPTOMS

OF SCHIZOPHRENIA
3) Changes in communication
Clients have difficulty responding appropriately to
events and people they encounter because of their
distorted perceptions, impaired ability to sort and
assimilate
these
perceptions,
and
difficulty
communicating responses clearly
Examples:
3a) Thought Disorganization
3b) Thought Blocking
3c) Tangential Communication
3d) Circumstantial Communication
3e) Alogia
THOUGHT DISORGANIZATION
Responses are inappropriate to the

situation
THOUGHT BLOCKING
Difficulties articulating a response or

stops mid-sentence as if they are stuck
Clients may suddenly stop talking in

the middle of a sentence and remain
silent for several seconds to one
minute
TANGENTIAL THINKING
Veering into unrelated topics and never answering

the original question
Example:

Client: Oh, I try to sleep at night. I like to listen to
music to help me sleep. I really like country-western
music best. What do you like? Can I have something
to eat pretty soon? I am hungry!
Nurse: Can you tell me how you have been sleeping?
CIRCUMSTANTIAL
COMMUNICATION
Circumstantiality may be evidenced if the client gives
unnecessary details or strays from the topic but eventually
provides the requested information
Example:
Client: Oh, I go to bed early, so I can get plenty of rest. I
like to listen to music or read before bed. Right now I am
reading a good mystery. Maybe I will write a mystery
someday. But is it isnt helping, reading I mean. I have
been getting only 2 or 3 hours of sleep at night.
ALOGIA
Poverty of content describes the lack of

any real meaning or substance in what
the client says
Example:
Nurse: How have you been sleeping
lately?
Client: Well, I guess, I do not know,
hard to tell.
GENERAL SIGNS AND

4) Disruptions in emotional responses
Restricted
or
inappropriate
expression or emotion
GENERAL SIGNS AND SYMPTOMS

OF SCHIZOPHRENIA
5) Motor Behavior Changes
Disorganized behavior and catatonia (manifested
by unusual body movement or lack of movement)
Examples:
5a) Catatonic Excitement
The client moves excitedly but not in response to
environmental influences
5b) Catatonic Posturing
Clients hold bizarre postures for a period of time
5c) Stupor
Client holds the body still and is unresponsive to the
environment
GENERAL SIGNS AND

6) Self care deficits
They neglect to bathe, change clothes or
attend to minor grooming tasks
Some show little awareness of current fashion
styles
Wearing clothing that makes them look out of
place is also seen
GENERAL SIGNS AND

7) Activity Intolerance
This
is
brought
about
by
ambivalence about where to sit or
what to eat
GENERAL SIGNS AND

8) Altered Thought Processes
Examples:
8a) Magical Thinking
8b) Thought Insertion
8c) Thought Withdrawal
8d) Thought Broadcasting
MAGICAL THINKING
Belief that events can happen simply

because one wishes them to happen.
THOUGHT INSERTION
They may state that others are placing

thoughts in their mind or in their head
against their will
THOUGHT WITHDRAWAL
They may state that others are taking

their thoughts out of their head
THOUGHT BROADCASTING
They may state that they believe

others can hear their thoughts
They believe that thoughts are

transmitted to others via radio,
television or other means but not
directly by the client
GENERAL SIGNS AND

9) Unusual speech patterns
Examples:
9a) Clang Associations
9b) Neologisms
9c) Verbigeration
9d) Echolalia
9e) Stilted Language
9f) Perseveration
9g) Word Salad
CLANG ASSOCIATIONS
Are ideas that are related to one

another based on sound or rhyming
rather than meaning.
Example: I will take a pill if I go up to

the hill but not if my name is Jill, I dont
want to kill.
NEOLOGISMS
These are words invented by the client

Example:
I am afraid of grittiz. If there are any

grittiz here, I will have to leave. Are you
a grittiz?
VERBIGERATION
This is the stereotyped repetition of

words or phrases that may or may not
have meaning to the listener.
Example:
I want to go home, go home, go home,

go home.
ECHOLALIA
This is the clients imitation

repetition of what the nurse says.
or
Example:
Nurse: Can you tell me how you are
feeling?
Client: Can you tell me how you are
feeling? how you are feeling?
STILTED LANGUAGE
This is the use of words or phrases that

are flowery, excessive, and pompous
Example:
Would you be so kind, as a

representative of Florence Nightingale,
as to do me the honor of providing just
a wee bit of refreshment, perhaps in the
form of some clear spring water?
PERSEVERATION
Persistent adherence to a single idea or topic; verbal repetition of a
sentence, word, or phrase; resisting attempts to change the topic
Example:
WORD SALAD
This is a combination of jumbled words

and phrases that are disconnected or
incoherent and make no sense to the
listener.
Example:
Corn, potatoes, jump up, play games,

grass, cupboard.
OTHER DISORDERS RELATED

TO SCHIZOPHRENIA
1) Delusional
Similar to schizophrenia because they hold
unusual bizarre beliefs and cannot be
reasoned with regarding these beliefs.
Unlike schizophrenic clients, delusional clients
do not have persistent hallucinations
Delusions have a basis reality

Hallucinations are not a dominant feature
Behavior is within normal range except in relation
to delusion
Behavior does not meet criteria for schizophrenia
OTHER DISORDERS RELATED TO

SCHIZOPHRENIA
2) Psychotic disorders not elsewhere classified
2a) Schizophreniform Disorder
The duration of all symptoms (acute and residual) is less than six
months and a return to normal functioning is possible. (Note that 6
months is the amount of time necessary to meet the diagnostic
criteria for schizophrenia)
2b) Schizoactive Disorder
Dominant schizophrenic symptoms are accompanied at some, but

not all times by a major depressive or manic syndrome
There is a mood disorder in the form of either depression or mania
OTHER DISORDERS RELATED TO

SCHIZOPHRENIA
2) Psychotic disorders not elsewhere classified
2c) Brief Reactive Psychosis
Psychotic symptoms appear shortly after a stressful event

or a series of stressful events
2d) Induced Psychotic Disorder
A delusional system develops because of a close

relationship with a person who already has a psychotic
disorder with delusions
Also known as folie a deux, two people share a similar
delusion.
MEDICATIONS USED IN
SCHIZOPHRENIA
Drug Classification
Antipsychotics or neuroleptics
Conventional antipsychotics
These are dopamine antagonists
Atypical antipsychotics
Newer schizophrenic drugs which are both
dopamine and serotonine antagonists
CONVENTIONAL
ANTIPSYCHOTICS
Chlorpromazine (Thorazine)
Trifluoperazine (Trilafon)
Fluphenazin (Prolixin)
Thioridazine (Mellaril)
Mesoridazine (Serentil)
Thiothixene (Navane)
Haloperidol (Haldol)
Loxapine (Loxitane)
Molindone (Moban)
Perphenazine (Etrafon)
Trifluoperazine (Stelazine)
ATYPICAL ANTIPSYCHOTICS
Clozapine (Clozaril)
Risperidone (Risperdol)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Ziprasidone (Geodon)
EFFECTS OF ANTIPSYCHOTICS
Prescribed primarily for efficacy in

decreasing psychotic symptoms like
delusions, hallucinations and looseness
of association
They do not cure schizophrenia, they

only manage the symptoms of the
disease
WHEN TO ADMINISTER
ANTIPSYCHOTIC MEDICATIONS
Best taken after meals
SIDE EFFECTS OF
1) Extrapyramidal Side Effects or EPS
Reversible
movement
disorders
which include:
Dystonic Reactions
Pseudoparkinsonism
Akathisia
Tardive Dyskinesia
DYSTONIC REACTIONS
They appear early in the course of treatment and are

characterized by spasms in discrete muscle groups such as the
neck muscles (torticollis) or eye muscles (oculogyric crisis)
These spasms may also be accompanied by protrusion of the
tongue, dysphagia and laryngeal/pharyngeal spasm that can
compromise the clients airway
Acute treatment consists of diphenhydramine (benadryl) given
either intramuscularly or intravenously or benzotropine
(Cogentin) given intramuscularly
DYSTONIC REACTIONS
Nursing
considerations
reactions include:
for
dystonic
Administering medications as ordered

Assessing for their effectiveness
Reassuring client if frightened.
PSEUDOPARKINSONISM
Includes shuffling gait, masklike facies, muscle

stiffness (continuous) or cogwheeling rigidity (rachetlike movements of joints), drooling, and akinesia
(slowness and difficulty initiating movements.
These symptoms appear in the first few days after

starting the medication
Treatment of pseudoparkinsonism is achieved by both

dopaminergic drugs and anticholinergic drugs
PSEUDOPARKINSONISM
Dopaminergic Drugs
Amantadine (Symmetrel)
Levodopa
Levodopa-Carbidopa (Sinemet)
PSEUDOPARKINSONISM
Anticholinergic Drugs
Trihexyphenidyl (Artane)
Biperiden Hydrochloride (Akineton)
Benzotropine Mesylate (Cogentin)
Diphenhydramine
Hydrochloride
(Benadryl)
AKATHISIA
This is characterized by restless movement, pacing, inability to

remain still, and the clients report of inner restlessness.
Described by patients as I feel as if I have ants in my pants.
Akathisia usually develops when the antipsychotic is started or

when the dose is increased
Beta-blockers such as propranolol have been most effective in

treating akathisia, while benzodiazepines like diazepam have
provided some success as well.
TARDIVE DYSKINESIA
A late appearing side-effect characterized by
abnormal involuntary movements such as lip
smacking, tongue protrusion, chewing, blinking,
grimacing, and choreiform movements of the
limbs and feet
This is irreversible once it has appeared
TARDIVE DYSKINESIA
Decreasing or discontinuing the medication can
arrest the progression.
Clozapine (Clozaril) has not been found to cause
this side effect
consideration
includes
proper
Nursing
assessment and subsequent reporting to the
physician
SIDE EFFECTS OF
2) Seizures
These are infrequent side effects of
antipshychotic medications
The notable exception is Clozapine
These may be associated with high
doses of the medication
Treatment is a lowered dosage or a
different antipsychotic medication
SIDE EFFECTS OF
3) Seizures
Nursing consideration includes:
Stopping the medication;

Notifying the physician;
Protecting client from injury;
Providing reassurance and privacy for client
after seizure
SIDE EFFECTS OF
3) Neuroleptic Malignant Syndrome
This is a serious and frequently fatal condition seen
in those being treated with antipsychotic medications
It is characterized by muscle rigidity, high fever,
increased muscle enzymes (particularly CPK), and
leukocytosis (increased leukocytes)
This is treated by stopping the medication
SIDE EFFECTS OF
4) Neuroleptic Malignant Syndrome
Nursing considerations include:
Stopping the medication
Notifying the physician immediately of
its signs and symptoms
SIDE EFFECTS OF
4) Agranulocytosis
Clozapine has the potentially fatal side
effect of agranulocytosis (failure of the
bone marrow to produce adequate white
blood cells)
develops
suddenly
and
is
This
characterized by fever, malaise, ulcerative
sore throat, and leukopenia
SIDE EFFECTS OF
4) Agranulocytosis
May not be manifested immediately but can occur
as long as 18 to 24 weeks after initiation of
therapy.
Drug must be discontinued immediately
Weekly white
necessary
blood
cell
counts
(CBC)
are
SIDE EFFECTS OF
4) Agranulocytosis
Nursing
considerations
include
stopping
the
medication
and
notifying the physician immediately
of its signs and symptoms
OTHER SIDE EFFECTS OF ANTIPSYCHOTIC

MEDICATIONS AND THEIR NURSING
CONSIDERATIONS
SIDE EFFECTS
NURSING CONSIDERATIONS
Sedation
Caution about activities requiring client
to be fully alert such as driving a car
Photosensitivity
Caution client to avoid sun exposure;

advise client when in the sun, to wear
protective clothing and sun-blocking
lotion
Weight Gain
Encourage
balanced
diet
with
controlled
portions
and
regular
exercise; focus on minimizing gain
Dry mouth
(anticholinergic
Use ice chips or hard candy for relief
OTHER SIDE EFFECTS OF ANTIPSYCHOTIC

MEDICATIONS AND THEIR NURSING
CONSIDERATIONS
SIDE EFFECTS
NURSING CONSIDERATIONS
Constipation
(anticholinergic
symptom)
Increase fluid and dietary fiber intake; client may

need a stool softener if unrelieved
Blurred vision
(anticholinergic
symptom)
Assess side effect, which should improve with

time; report to physician if no improvement
Urinary Retention
(anticholinergic
symptom)
Instruct client to report any frequency or burning

with urination; report to physician if no
improvement over time
NURSING CARE FOR

SCHIZOPHRENIA
Promote adequate communication
1)
Attend seriously to the client since he

perceives nuisances of the nurses
behavior
If a client complains of physical

symptoms such as stomach distress,
consider the symptoms as real until there
is evidence otherwise.
NURSING CARE FOR

SCHIZOPHRENIA
2) Promote compliance with medical regimen
Administer prescribed medications
Observe client behavior for therapeutic effects
Maintaining therapeutic blood levels is important
Monitor side effects of drugs
NURSING CARE FOR

SCHIZOPHRENIA
2) Promote
regimen
compliance
with
medical
Teach client about the therapeutic and

possible untoward effects of drugs
Help client to take action to prevent
untoward effects
NURSING CARE FOR

SCHIZOPHRENIA
2) Promote compliance with medical regimen
Evaluate clients subjective response to the drug and attitude
towards continued use. Compliance may be affected because:
They do not understand the administration instruction

They are so disorganized to follow instruction
The side effect of major tranquilizers are too uncomfortable
NURSING CARE FOR

SCHIZOPHRENIA
3) Assist with grooming and hygiene
Intervention begins by establishing clear
expectations.
Frequency and timing
should be specified in writing
power
struggles
regarding
Avoid
completion of tasks. If initial prompts do
not work, leave the client alone for a short
period
NURSING CARE FOR

SCHIZOPHRENIA
4) Promote organized behavior
The first rule is to go slowly and keep
calm
Clients with disorganized
require direction and limits
their actions more effective
directed.
behavior
to make
and goal
NURSING CARE FOR

SCHIZOPHRENIA
5) Promote social interaction and activity
The clients effort to withdraw from
social contact stem from past
relationship failures and fear of
rejection
NURSING CARE FOR

SCHIZOPHRENIA
6) Social skills training
Provide structure by clearly setting times
for group meetings, beginning and ending
each session with a statement of goals
and recapping what the group has
accomplished
Address social skills that are essential to
functioning in the milieu
NURSING CARE FOR

SCHIZOPHRENIA
6) Social skills training
Do not assume periods of quiet or inactivity are
due to laziness or lack of interest
Help client find activities that are intrinsically
rewarding or some social tangible reward yet
are within their capacities
NURSING CARE FOR

SCHIZOPHRENIA
7)
Promote
reality-based
perceptions
as
hallucinations and illusions often frighten clients
Reassure client of their safety
Protect them from physical harm as they respond
to their altered perceptions
Intervene quickly by giving additional doses of
phychotropic medications or placing the client in
a quiet room
NURSING CARE FOR

SCHIZOPHRENIA
7)
Promote
reality-based
perceptions
as
hallucinations and illusions often frighten clients
Validate reality I know the voices are real to
you but no one else can hear them. No one
means to harm you.
Help clients to distinguish reality from the
hallucinatory experience
NURSING CARE FOR

SCHIZOPHRENIA
7) Promote reality-based perceptions as hallucinations
and illusions often frighten clients
Make brief frequent contacts with the client to
interrupt the hallucinatory cycle and to maintain trust
Encourage the client to attend to stimuli in the
environment such as conversation rather than to
internal stimuli. Example: Greg, listen to me rather
than to the sound you hear.
NURSING CARE FOR

SCHIZOPHRENIA
7) Promote reality-based perceptions as
hallucinations and illusions often frighten
clients
Help the client in activities that require
cognitive or verbal involvement
Support coping strategies that the client has
identified as personally effective in reducing
hallucinations
NURSING CARE FOR

SCHIZOPHRENIA
7) Promote reality-based perceptions as hallucinations
and illusions often frighten clients
If needed, teach the client that the hallucination are
part of the disease process
Help the client monitor events or interactions that
increase the hallucinations
Protect the client and others who might be harmed
by the clients acting on hallucinated commands.
NURSING CARE FOR

SCHIZOPHRENIA
8) Intervene with delusions
Do not argue with their general beliefs
Focus on the reality-based aspects of their
communications
Protect them from acting on their delusion in a
way that might harm themselves or others
Observe for stressors that precipitate the
delusion and help the client to avoid or
eliminate these stressors
NURSING CARE FOR

SCHIZOPHRENIA
9)
Promote
responses
congruent
emotional
10) Promote family understanding and

involvement

NO.1
Which of the following is not

characteristic of the patient with
paranoid schizophrenia?
A) Delusions
B) Hallucinations
C) Decreased sensitivity
D) Ideas of reference
ANSWER
Letter C
Rationale:
Paranoid
schizophrenia
patients
are
usually
extremely
sensitive.

NO.2
Which defense mechanism is most

characteristic of the patient with
paranoid schizophrenia?
A) Undoing
B) Projection
C) Rationalization
D) Suppression
ANSWER
Letter B
Rationale: Paranoid patients usually

project their mistrust to others.

NO.3
Thiodazine (Mellaril), an antipsychotic, is

usually effective in treating all but one of the
following symptoms of schizophrenia. Which
symptom will not be affected by this drug?
A) Agitation
B) Hallucinations
C) Delusions
D) Ambivalence
ANSWER
Letter A
Rationale: Antipsychotics can only

decrease the positive symptoms of
schizophrenia. Agitation is a negative
symptom

The nurse is caring for a patient with disorganized schizophrenia.
NO.4
The patient is responding well to therapy but has had limited social
contact with others.
appropriate?
Which of the following interventions is most
A) Discourage the patient from interacting with others because if his

efforts fail, it will be too traumatic for him
B) Encourage the patient to attend a party thrown for the residents
of the facility
C) Encourage the patient to participate in one-on-one interactions
D) Encourage the patient to place a personal advertisement in the
local newspaper but not reveal his main identity
ANSWER
Letter C
Rationale: Participation in one-on-one

interactions helps the patient in
establishing beginning social contact
with others.

NO.5
A 27 year-old female has been admitted to the inpatient

psychiatric unit with diagnosis of catatonic schizophrenia. She
appears weak and pale. The nurse would expect to observe
which behavior in the patient?
A) Scratching cat-like motions of the extremities
B) Exaggerated suspiciousness, excessive food intake
C) Stuporous withdrawal, hallucinations and delusions
D) Sexual preoccupation and word salad
ANSWER
Letter C
Rationale: Catatonic schizophrenia is

usually manifested by stuporous
withdrawal, hallucinations, delusions,
waxy flexibility and catatonic rigidity.
MOOD DISORDERS
MOOD / AFFECTIVE DISORDERS
A group of psychiatric diagnoses characterized by

disturbances in emotional and behavioral response
patterns ranging from elation and agitation to extreme
depression and a serious potential for suicide.
Group of disorders characterized by a decreased or entire

loss of control over mood
The mood disturbance may occur in different patterns of

severity, duration, alone or in combination
COMMON ETIOLOGICAL
THEORIES OF MOOD
DISORDERS
1) Genetic Theory
If one parent has a bipolar disorder,
there is 25% chance of transmission
to the child
2) Aggression Turned Inward Theory
Overdeveloped superego leads
depression
to
COMMON ETIOLOGICAL
THEORIES OF MOOD
DISORDERS
3) Object Loss theory
Loss of parent before age 11 increases the
risk for depression
4) Personality Organization Theory
oral-dependent,
Obsessive-compulsive,
hysterical
personalities
have
higher
predisposition to mood disorders
COMMON ETIOLOGICAL
THEORIES OF MOOD DISORDERS
5) Cognitive Theory
Mood disorder results from negative
views of the self, the future, and
negative interpretation of experiences
6) Learned Helplessness Theory
Mood disorder is caused by a belief that
one has no control over his environment
COMMON ETIOLOGICAL
THEORIES OF MOOD
DISORDERS
7) Psychoanalytic Theory
Mania is a defense against an underlying
depression
Depression is due to a rigid superego
8) Biologic Factor
Mania is related to increased norepinephrine
while
depression
is
related
to
low
norepinephrine
COMMON PRECIPITATING
FACTORS OF MOOD DISORDERS
Loss of a loved one

Major life events
Roles strain
Decreased coping resources
Physiological changes
DIFFERENT TYPES OF MOOD

DISORDERS
The two main types of mood disorders are:

Depression
Characterized by anergia (lack of energy),

exhaustion, agitation, noise intolerance, and
slowed thinking process
Bipolar Disorders
Diagnosed when a persons mood cycles

between extremes of mania and depression
SUBTYPES OF DEPRESSIONS
Major Depression
Dysthymic Depression
Depression Not Otherwise Specified
MAJOR DEPRESSION
Severe depression which lasts for at

least 2 weeks during which the person
experiences a depressed mood or loss
of pleasure in nearly all activities
MAJOR DEPRESSION
In addition, four of the following symptoms are present:

Changes in appetite or weight
Changes in sleep
Changes in psychomotor activity
Decreased energy
Feelings of worthlessness or guilt
Difficulty thinking, concentrating or making decisions
Recurrent thoughts of death or suicidal ideation, plans, or
attempts.
These symptoms must be present every day for 2 weeks and
result in significant distress or impair social, occupational or
other important areas of functioning
DYSTHYMIC DEPRESSION
It is less severe than major depression
It is characterized by at least 2 years

of depressed mood for more days than
not with some additional less severe
symptoms that do not meet the
criteria for a major depressive episode
DEPRESSION NOT OTHERWISE

SPECIFIED (DNOS)
Depression that lasts for 2 days to 2

weeks
SUBTYPES OF BIPOLAR
DISORDERS
Manic
Hypomanic
Bipolar I
Bipolar II
Cyclothymia
MANIA
The diagnosis of manic episode or mania requires at

least 1 week of unusual and incessantly heightened,
grandiose or agitated mood in addition to three or
more of the following symptoms:
Exaggerated self-esteem
Sleeplessness
Pressured speech
Flight of ideas
Reduced ability to filter extraneous stimuli
MANIA
The diagnosis of manic episode or mania requires at least 1

week of unusual and incessantly heightened, grandiose or
agitated mood in addition to three or more of the following
symptoms:
Distractability
Increased activities with increased energy
Multiple, grandiose high-risk activities involving poor
judgment and severe consequences such as spending
sprees, sex with strangers, and impulsive investments
HYPOMANIC
Less severe than mania
Lasts for at least 4 days
BIPOLAR I
With history of mania
The patient exhibits:

Manic episodes
Periods of normal behavior
Periods of profound depression
BIPOLAR II
No history of mania
The patient exhibits:

Depression
Normal behavior
At least one hypomanic episode, but
NOT manic
CYCLOTHYMIA
Characterized by
two
numerous periods of both
symptoms that do not
criteria for bipolar disorder
years of
hypomanic
meet the
Numerous episodes of hypomania and

depressed mood that lasts for at least
two years
DIFFERENCE BETWEEN MANIA

AND DEPRESSION
Appearance
Behavior
MANIA
DEPRESSION
Colorful
Sad
Highly driven,
Hyperactive
Passivity
Psychomotor
retardation
Communication Talkative (Flight of

Ideas)
Nursing
Diagnosis
Nursing Care
Monotonous
speech
Risk for injury

directed at others
Risk for injury:

Self-directed
Safety
Safety
DIFFERENCE BETWEEN MANIA

AND DEPRESSION
Treatment of
Choice
Milieu Therapy
Appropriate
Activity
Attitude Therapy
MANIA
DEPRESSION
Lithium
ECT
Non-stimulating
Stimulating
Quiet Type
Avoid competitive
Monotonous
activity
Example: counting
Matter of fact
(attitude of
casualness)
Kind Firmness
MEDICATIONS USED IN MANIA
Drug Classification
Antimanic Medications
Lithium Carbonate
Anticonvulsant Medications
Used as mood stabilizers
LITHIUM CARBONATE
It is a salt contained in the human body
Its mechanism of action is not known but it is

thought to work in the synapses to hasten
destruction of catecholamines (dopamine and
norepinephrine),
inhibit
neurotransmitter
release, and decrease the sensitivity of postsynaptic receptors.
EFFECTS OF LITHIUM
CARBONATE
It decreases hyperactivity
WHEN TO TAKE LITHIUM

CARBONATE
IMPORTANT POINTS ON LITHIUM

CARBONATE
Lithium is not metabolized; rather, it is

reabsorbed by the proximal tubule and
excreted in the urine
Periodic serum lithium levels are used to

monitor the clients safety and to ensure that
the dose given has increased the serum
lithium level to treatment level or reduced it
to maintenance level.
IMPORTANT POINTS ON LITHIUM

CARBONATE
There is a narrow range of safety among

maintenance levels (0.5 to 1.0 mEq/L),
treatment levels (0.8 to 1.5 mEq/L) and
toxicity levels (1.5 mEq/L and above)
It is important to asses for signs of toxicity

and ensure that clients and their families
have this information prior to discharge.
SYMPTOMS AND INTERVENTIONS OF

LITHIUM TOXICITY
SERUM LITHIUM SYMPTOMS OF INTERVENTIONS
LEVEL
LITHIUM
TOXICITY
1.5 2.0 mEq/L Nausea
andWithhold
next
vomiting, diarrhea,dose;
call
reduced
physician. Serum
coordination,
lithium levels are
drowsiness,
ordered and doses
slurred
speech,of
lithium
are
muscle weakness usually suspended
for a few days or
the
dose
is
reduced
SYMPTOMS AND INTERVENTIONS

OF LITHIUM TOXICITY
SERUM LITHIUM LEVEL SYMPTOMS OF LITHIUM
TOXICITY
2.0 3.0 mEq/L
INTERVENTIONS
Ataxia, agitation, blurredWithhold future doses, call

vision, tinnitus, giddiness,physician,
stat
serum
choreoathetoid
lithium level.
Gastric
movements,
confusion,lavage may be used to
muscle
fasciculation,remove oral lithium; IV
hyperreflexia, hypertoniccontaining
saline
and
muscles,
myoclonicelectrolytes used to ensure
twitches,
pruritus,fluid
and
electrolyte
maculopapular
rash,function and maintain renal
movement of limbs, slurredfunction.
speech, large output of
dilute urine, incontinence
of bladder of bowel, vertigo
SYMPTOMS AND INTERVENTIONS

OF LITHIUM TOXICITY
SERUM LITHIUM LEVEL SYMPTOMS OF LITHIUM
TOXICITY
3.0 mEq/L and above
INTERVENTIONS
Cardiac
arrythmia,All
of
preceding
hypotension,
peripheralinterventions plus lithium
vascular collapse, focal orion excretion is augmented
generalized
seizures,with use of aminophylline,
reduced
levels
ofmannitol,
or
urea.
consciousness from stuporHemodialysis may also be
to coma, myoclonic jerksused to remove lithium
of muscle groups, andfrom
the
body.
spasticity of muscles
Respiratory,
circulatory,
thyroid
and
immune
systems are monitored
and assisted as needed.
CLIENT TEACHING FOR LITHIUM

CARBONATE
Clients should drink adequate water (approximately

3 liters per day) and continue with the usual amount
of dietary table salt (3 grams per day).
Having too much salt in the diet because of

unusually high salty foods or the ingestion of saltcontaining antacids can reduce receptor availability
for lithium and increase lithium excretion, so the
lithium level will be too low.

CARBONATE
If there is too much water, lithium is diluted and the

lithium level will be too low to be therapeutic.
Drinking too little water or losing fluid through

excessive sweating, vomiting, or diarrhea will increase
the lithium level, which may result in toxicity.

CARBONATE
Monitoring daily weights and the balance

between intake and output and checking
for dependent edema can be helpful in
monitoring fluid balance.
The physician should be contacted if the

client has diarrhea, fever, flu, or any
condition that leads to dehydration

CARBONATE
It takes 10 14 days before therapeutic effect of

lithium becomes evident
Antipsychotics are administered during the first two

weeks to manage the acute symptoms of mania until
lithium takes effect
Anticonvulsants could also be used as mood stabilizers
Mannitol is administered if lithium toxicity occurs
ANTICONVULSANTS USED AS
MOOD STABILIZERS
GENERIC (TRADE)
NAME OF
ANTICONVULSANT
SIDE EFFECTS
NURSING
IMPLICATIONS
Carbamazepine (Tegretol) Dizziness,

hypotension,Assist client to rise slowly
ataxia, sedation, blurredfrom sitting position
vision, leukopenia, rashes Monitor gait and assist as
necessary
Report
rashes
to
physician
Divalproex (Depakote)
Ataxia,
drowsiness,Monitor gait and assist as
weakness,
fatigue,necessary
menstrual
changes,Provide rest periods
dyspepsia,
nausea,Give with food
vomiting, weight gain, hair
Establish
balanced
loss
nutrition
ANTICONVULSANTS USED AS
MOOD STABILIZERS
GENERIC (TRADE)
NAME OF
ANTICONVULSANT
SIDE EFFECTS
NURSING
IMPLICATIONS
Lamotrigine (Lamictal)
Dizziness,
ataxia,
coordination,from sitting position
sedation,
headache,Monitor gait and assist as
weakness,
fatigue,necessary
menstrual changes, soreProvide rest periods
throat
Topiramate (Topamax)
Dizziness,
anxiety,
ataxia,from sitting position
incoordination, confusion,Monitor gait and assist as
sedation, slurred speech,necessary
tremor, weakness
Orient client

MANIA
Provide for clients physical safety and safety of those

around the client
The nurse assess clients directly for suicidal ideation and
plans or thought of hurting others
Clients in the manic phase have little insight into their
anger and agitation and how their behaviors affect
others. They often intrude into others space, take
others belongings without permission, or appear
aggressive in approaching others. This behavior can
threaten or anger people who then retaliate
It is important to monitor the clients whereabouts and
behaviors frequently.

MANIA
Set limits on clients behavior when needed and

remind client to respect distances between self and
others.
The nurse may say: John, you are too close to my
face.
Please stand back 2 feet. or It is
unacceptable to hug other clients. You may talk to
others, but do not touch them.
When setting limits, it is important to clearly identify

the unacceptable behavior and convey the expected
appropriate behavior
NURSING INTERVENTIONS FOR MANIA
Use
short
simple
communicate
sentences
to
Clients with mania have short

attention span, so he nurse uses clear
,
simple
sentences
when
communicating

MANIA
Keep channels of communication open with clients,

regardless of speech patterns (pressured, rapid,
circumstantial, rhyming, noisy or intrusive with flight of
ideas)
The nurse can say, Please speak more slowly, I am
having trouble following you.
The nurse patiently and frequently repeats this
request during conversation because clients will
return to rapid speech

MANIA
Clarify
the
communication
meaning
of
clients
When speech includes flight of ideas, the

nurse can ask clients to explain the
relationship between topics for example,
What happened then? or Was that
before or after you got married?

MANIA
Set limits regarding taking turns

speaking and listening and giving
attention to others when they need it

MANIA
Frequently provide finger foods that are

high in calories and protein (sandwiches,
protein bars, fortified shakes)
Manic clients may be too busy to sit
down and eat, or they may have such
poor concentration that they fail to stay
interested in food for very long

MANIA
Promote rest and sleep by decreasing

environmental stimulation
The
nurse
provides
a
quiet
environment
without
noise,
television, or other distractions.

MANIA
Establishing a bedtime routine, such as

tepid bath may help clients to calm
down enough to rest

MANIA
Protect the clients dignity when inappropriate behavior occurs

Clients may lose sexual inhibitions resulting in provocative and risky behaviors.
Clothing may be flashy or revealing, or clients may undress in public. They may
engage in unprotected sex with virtual strangers. Clients may ask staff members
or other clients for sex, graphically describe sexual acts, or display their genitals.
The nurse handles such behavior in a matter-of-fact, non-judgmental

manner
For example, Mary, lets go to your room and find a sweater.
It is important to treat clients with dignity and respect despite their

inappropriate behavior. It is not helpful to scold or chastise them.
REVIEW OF MAJOR SYMPTOMS

OF DEPRESSIVE DISORDER
Depressed mood
Anhedonism (decreased attention to and

enjoyment
from
previously
pleasurable
activities)
Unintentional weight change of 5% or more in

a month
Change in sleep pattern

Agitation or psychomotor retardation
Tiredness
Worthlessness or guilt inappropriate to

the situation (possibly delusional)

Difficulty thinking, focusing, or making

decisions
Hopelessness, helplessness
suicidal ideation
and/or
TREATMENT MODALITIES FOR

DEPRESSIVE DISORDERS
Electroconvulsive Therapy
Psychopharmacology
Cyclic antidepressants
Monoamine oxidase inhibitors
Selective serotonin reuptake
inhibitors
(ECT)
Involves application of electrodes to the

head of the client to deliver an electrical
impulse to the brain; this causes a seizure
It is believed that the shock stimulates brain

chemistry to correct the chemical imbalance
of depression
However, the mechanism of action of ECT is

unclear at present
FACTS ABOUT
(ECT)
Voltage of electrical current that is administered to
the client
70 150 volts
Length of electrical shock applied to the patient
About 0.5 to 2.0 seconds
Usual number of treatments needed to produce a
therapeutic effect
6 12 treatments
Frequency of treatments
There should be an interval of 48 hours for each
treatment

THERAPY (ECT)
Indicators of effectiveness of ECT

The occurrence of generalized tonicclonic seizure

THERAPY (ECT)
Indications for ECT

Depression, Mania, Catatonic Schizophrenia
Contraindications to ECT
Fever
Increased intracranial tumor
TB with history of hemorrhage
Cardiac condition
Recent fracture
Retinal detachment
Pregnancy

THERAPY (ECT)
Need for consent prior to ECT

Yes, consent is needed
FACTS ABOUT
(ECT)
Medications given to clients prior to ECT

Atropine sulfate
To decrease secretions
Anectine (Succinylcholine)
To promote muscle relaxation
Methohexital Sodium (Brevital)
Serves as an anesthetic agent
FACTS ABOUT
(ECT)
Common complications of ECT

Loss of memory
Headache
Apnea
Fracture
Respiratory depression
REVIEW OF BIOLOGIC FACTOR

ON DEPRESSIVE DISORDERS
Depression is related to low levels of

norepinephrine (particularly in brain
synapses)
PSYCHOPHARMACOLOGY FOR
DEPRESSIVE DISORDERS
Cyclic Antidepressants
Selective Serotonin Reuptake Inhibitors
Monoamine Oxidase Inhibitors
MECHANISM OF ACTION
The precise mechanism of action by which antidepressants

produce their therapeutic effects is not known, but much is
known about their action on the CNS.
The
major
interaction
is
with
the
monoamine
neurotransmitter systems in the brain, particularly
norepinephrine and serotonin.
Both of these neurotransmitters are released throughout the
brain, and help to regulate arousal, vigilance, attention,
mood, sensory processing and appetite
MECHANISM OF ACTION
Norepinephrine and serotonin are

removed from the synapses after
release by reuptake into presynaptic
neurons.
After reuptake, norepinephrine and
serotonin are reloaded for subsequent
release or metabolized by the enzyme
Monoamine Oxidase (MAO).
MECHANISM OF ACTION
The Selective Serotonin Reuptake Inhibitors block the

reuptake of serotonin
The Cyclic Antidepressants block the reuptake of

norepinephrine and serotonin to some degree
The Monoamine Oxidase Inhibitors (MAOIs) interfere

with enzyme metabolism of norepinephrine
These class of medications permits norepinephrine to

linger longer in synapses to increase its levels there.
TRICYCLIC ANTIDEPRESSANTS
(TCAs)
Amitriptyline (Elavil)
Amoxapine (Asendin)
Doxepin (Sinequan)
Imipramine (Tofranil)
Despiramine (Norpramine)
Nortriptyline (Pamelor)
EFFECTS OF TCAs
Prevents
the
reuptake
of
norepinephrine, increases appetite and
produces adequate sleep
WHEN TO ADMINISTER TCAs
Best given after meals
SIDE EFFECTS OF TCAs
The cyclic antidepressants block cholinergic receptors,

resulting in anticholinergic effects such as dry mouth,
constipation, urinary hesitancy or retention, dry nasal
passages, and blurred near vision
More severe anticholinergic effects, such as agitation,

delirium, and ileus, may occur particularly in adults
Hypotention, sedation, weight gain, tachycardia, and

sexual dysfunction are common side effects
IMPORTANT POINTS ON THE

USE OF TCAs
Therapeutic effects may become evident only after 2

3 weeks of intake; they have a lag period before
reaching a serum level that begins to alter symptoms
Check the blood pressure as they cause hypotension
Check the heart rate as they cause cardiac arrythmias

USE OF TCAs
TCAs are contraindicated in severe

impairment of liver function and in
myocardial infarction (acute recovery
phase)
They cannot be given concurrently

with MAOIs

USE OF TCAs
Because of their anticholinergic side effects, TCAs must

be used cautiously in patients with glaucoma, benign
prostatic hypertrophy, urinary retention or obstruction,
diabetes mellitus, hyperthyroidism, cardiovascular
disease, renal impairment or respiratory disorders
Overdosage occurs over several days and results in

confusion, agitation, hallucinations, hyperpyrexia and
increased reflexes
MONOAMINE OXIDASE
INHIBITORS
Isocarboxazid (Marplan)
Phenelzine (Nardil)
Tranylcypromine (Parnate)
EFFECTS OF MAOIs
Functions as antidepressants resulting

into increased appetite and adequate
sleep
WHEN TO ADMINISTER MAOIs
SIDE EFFECTS OF MAOIs
The most common side effects of MAOIs

include daytime sedation, insomnia, weight
gain, dry mouth, orthostatic hypotension
and sexual dysfunction.
The sedation and insomnia are difficult to

treat and may necessitate a change in
medication
SIDE EFFECTS OF MAOIs
Of particular concern with MAOIs is the potential for a lifethreatening hypertensive crises if the client ingests food that
contains tyramine or takes sympathomimetic drugs
Because the enzyme monoamine oxidase is necessary to break
down the tyramine in certain foods, its inhibition results to
increased serum tyramine levels, which causes severe
hypertension,
hyperpyrexia,
tachycardia,
diaphoresis,
tremulousness, and cardiac dysrythmias
FOODS (CONTAINING
TYRAMINE) TO AVOID WHEN
TAKING MAOIs
Mature or aged cheeses or dishes made with

cheese, such as lasagna or pizza. All cheese is
considered aged except cottage cheese, cream
cheese, ricotta cheese, and processed cheese slices
Aged meats such as pepperoni, salami, mortadella,

summer sausage, beef logs, and similar products.
Make sure meat and chicken are fresh and have
been properly refrigerated
FOODS (CONTAINING
TYRAMINE) TO AVOID WHEN
TAKING MAOIs
Italian broad beans (fava) pods or banana peel.

Banana pulp and all other fruits and vegetables
are permitted
All tap beers and microbrewery beer. Drink no

more than two cans or bottles of beer (including
non-alcoholic beer) or 4 ounces of wine per day
Sauerkraut, soy sauce or soybean condiments or

marmite (concentrated yeast)

USE OF MAOIs
It takes 2 3 weeks before initial therapeutic effect

become noticeable as it also has a lag period before
they reach therapeutic levels
Monitor the blood pressure
There should be at least a two-week interval when

shifting from one anti-depressant to another. Because
of the lag period a washout period is recommended
between the time the MAOI is discontinued and
another class of antidepressant is started
MAOI DRUG INTERACTIONS
The following drugs cause potentially fatal interactions with

MAOIs
Amphetamines
Ephedrine
Fenfluramine
Isoproterenol
Meperedine
Phenylephrine
Phenylpropanolamine
Pseudoephedrine
SSRIs
TCAs
Tyramine
SELECTIVE SEROTONIN
These are the newest category of antidepressants

that are effective for most clients
Their action is specific to serotonin reuptake

inhibition
These drugs produce few sedating, anticholinergic

and cardiovascular side effects, which makes
them safer for use in children and older adults
SELECTIVE SEROTONIN
Because of their low side effects and relative

safety, people using SSRIs are more apt to be
compliant with the treatment regimen than
clients using more troublesome medications.
Insomnia decreases in 3 to 4 days, appetite

returns to a more normal state in 5 to 7 days, and
energy returns in 4 to 7 days.
In 7 to 10 days, mood, concentration, and interest

in life improves
SELECTIVE SEROTONIN REUPTAKE INHIBITORS

(SSRIs)
GENERIC
(TRADE) NAME
SIDE EFFECTS
NURSING IMPLICATIONS
Fluoxetine (Prozac)
Headache,
nervousness,Administer in AM (if nervous) or
anxiety,
sedation,
tremor,PM (if drowsy)
sexual dysfunction, anorexia,Monitor for hyponatremia
constipatin, nausea, diarrhea,Encourage adequate fluids
weight loss
Report sexual difficulties to
physician
Sertraline (Zoloft)
Dizziness, sedation, headache,Administer in PM if client is

insomnia,
tremor,
sexualdrowsy
dysfunction,diarrhea, dry mouthEncourage use of sugar free
and throat, nausea, vomiting,beverages or hard candy
sweating
Drink adequate fluids
Monitor hyponatremia; report
sexual difficulties to physician
Paroxetine (Paxil)
Dizziness, sedation, headache,Administer with food

insomnia, weakness, fatigue,Administer in PM if client is
constipation, dry mouth anddrowsy
throat,
nausea,
vomiting,Encourage use of sugar free
diarrhea, sweating
hard candy or beverages
Encourage adequate fluids
Citalopram (Calexa)
Drowsiness,
sedation,Monitor for hyponatremia
insomnia, nausea, vomiting,Administer with food
weight
gain,
constipation,Administer dose at 6PM or later
diarrhea
Promote balanced nutrition and

DEPRESSION
Provide for safety of the client and others

The first priority is to determine if the client with
depression is suicidal
If a client has suicidal ideation or hears voices
commanding him to commit suicide, measures
to provide a safe environment are necessary
The nurse asks additional questions to
determine the lethality of the intent and plan
Suicide precautions (removal of harmful items,
increased supervision) are instituted.

DEPRESSION
Begin a therapeutic relationship by spending nondemanding time with the client

Clients may be unable to sustain a long interaction, so
several shorter visits help the nurse to asses status and
to establish a therapeutic relationship
The nurses presence conveys genuine interest and
caring. Silence can convey that clients are worthwhile
even if they are not interacting.
My name is Sheila, I am your nurse today. Im going to
sit with you for a few minutes. If you need anything, or
if you would like to talk, please tell me.
After time has elapsed, the nurse would say, I am
going now. I will be back in an hour to see you again.

DEPRESSION
Promote completion of activities of daily living by assisting the
client only as necessary
The nurse asks the client to perform a global task, Martin, it is
time to get dressed.
If a client cannot respond to the global request, the nurse
breaks the task into smaller segments. Clients with depression
can become overwhelmed easily with a task that has several
steps. The nurse can use success in small, concrete steps as a
basis to increase self-esteem and to build competency for a
slightly more complex task the next time.

DEPRESSION
Establish adequate nutrition and hydration

The nurse can explain that beginning to eat will help
stimulate appetite
Food offered frequently and in small amounts can
prevent overwhelming clients with a large meal that
they feel unable to eat
Sitting up with clients during meals can promote eating
Monitoring food and fluid intake may be necessary until
clients are consuming adequate amounts

DEPRESSION
Promote rest and sleep

This may include the short-term use of
sedatives or giving medication in the evening
if drowsiness or sedation is a side-effect.
It is also important to encourage clients to
remain out of bed and active during the day
to facilitate sleeping at night
It is important to monitor the number of hours
client sleep as well as if they feel refreshed on
awakening

DEPRESSION
Encourage the client to verbalize and describe emotions
Clients with depression are often overwhelmed by the intensity of
their emotions
Talking about these feelings can be beneficial.
Initially, the nurse encourages the clients to describe in detail how
they are feeling
Sharing the burden with another person can provide some relief
The nurse can listen attentively, encourage clients, and validate
the intensity of their experience.

DEPRESSION
Work with the client to manage

medications and their side effects.

NO.1
The nurse knows that sadness typically

accompanies grief and depression.
Which
affect changes indicate major depressions?
A) Fear, timidity and lack of interest around
B) Withdrawal, negative attitude, and little or
no eye contact
C) Lack of initiative, dominating personality,
and defensiveness
D) Irritability, apathy and self-doubt
ANSWER
Letter D
Rationale:
Depression
is
usually
manifested by irritability, apathy, selfdoubt, sadness and psychomotor
retardation.

NO.2
Which nursing approach would be best for a patient with

symptoms of severe depression?
A) Allow the patient time for quiet thought; remain silent
B) Ask the patient to join the nurse and the other patients
in the TV lounge
C) State that the nurse would like to go with a patient for a
short walk around the outside grounds, and assist the
patient with his or her coat
D) Give the patient a choice of recreational activities.
ANSWER
Letter C
Rationale: Walking is a therapeutic

activity for a patient with mood
disorder. Providing assistance to the
patient
conveys
a
feeling
of
importance.

NO.3
Which nursing approach is important in

depression?
A) Providing motor outlets for aggressive,
hostile feelings.
B) Protecting against harm to others
C) Reducing interpersonal contacts
D) De-emphasizing preoccupation with
elimination, nourishment and sleep
ANSWER
Letter A
Rationale: Depressed patients usually

turn their hostile feelings towards
themselves. Providing an outlet for
these aggressive feelings will make the
patient feel less guilty.

NO.4
When a patient with symptoms of severe depressions

says to the nurse, I cant talk; I have nothing to say.
And continues being silent, what should the nurse say?
A) Say, Alright, you do not have to talk. Let us play
cards instead.
B) Explain that talking is an important sign of getting
well and that the patient is expected to do so
C) Be silent until the patient speaks again
D) Say, It may be difficult for you to speak at this time,
perhaps you can do so at another time.
ANSWER
Letter D
Rationale: This response will convey

that the nurse is willing to wait for the
patients readiness to engage in a
conversation.

NO.5
When assessing patients who are in a depressed

episode and those who are exhibiting a manic
episode of bipolar mood disorders.
Which
characteristics common to both episodes of the
disorder is the nurse likely to note?
A) Suicidal tendency
B) Underlying hostility
C) Delusions
D) Flight of ideas
ANSWER
Letter B
Rationale: In the depressed patient,

hostility is turned towards the self. In
the manic patient, hostility is turned
towards the environment.

NO.6
An extremely hyperactive patient exhibiting manic behavior is

admitted to the hospital. In view of the patients elated state,
the nurse should arrange for the patient to be in a room
A) With another patient who is very quiet
B) That will provide a great deal of stimuli
C) That has had most of the furniture removed
D) With another patient experiencing similar behavior
ANSWER
Letter C
Rationale:
The
priority
hyperactive patient is safety
for

NO.7
A hyperactive, manic patient might be redirected

therapeutically by?
A) Asking the patient to guide other patients in
group games
B) Encouraging the patient to tear pictures out of
magazines for a scrapbook
C) Suggesting the patient initiate social activities
on a unit with other patients
D) Encourage the patient to write a short story
ANSWER
Letter B
Rationale: This provides the patient an

opportunity
to
rechannel
excess
energy into a more productive activity.

NO.8
A patient who has a history of bipolar disorder

(manic) demonstrates grandiosity. The best
interpretation of this behavior is that the
patient is?
A) Afraid of talking to other people
B) Manifesting conceit
C) Compensating for low self-esteem
D) Deliberately attempting to intimidate
others
ANSWER
Letter C
Rationale: Delusions of grandeur is the

patients way of compensating for poor
self-esteem.

NO.9
Which of the following food selections

is appropriate for a manic patient?
A) Cheeseburger
B) Rice toppings
C) Chicken soup
D) Potato chips
ANSWER
Letter A
Rationale: High calorie finger foods

which the patient can carry around as
he moves is the most appropriate
selection for a manic patient.

NO.10
An individual who is on a psychiatric unit and has a

diagnosis of depression makes all of the following remarks
to the nurse during her hospitalization.
Which one
suggests an improvement in her condition?
A) I am making a plan to organize child care for parents
while they attend services at my church.
B) My room mate does not show any consideration. She is
always turning the lights on at any hour of the night.
C) I know who is boss and I cooperate to the best of my
ability.
D) Let me wash the bathroom floor.
ANSWER
Letter A
Rationale: At the height of depression,

patients
usually
have
difficulty
conceptualizing
activities.
The
patients plan to organize child care
indicates
that
his
ability
to
conceptualize is working.
This
indicates recovery from depression.
SUICIDE
SUICIDE
It is the intentional act of killing

oneself
It is the ultimate form of selfdestruction
It is a cry for help
SUICIDE
Suicidal thoughts are common in

people with mood disorders, especially
depression
In the United States, men commit

approximately 72% of suicides, which
is roughly 3 times the rate of women,
although women are 4 times more
likely than men to attempt suicide.
SUICIDE
The higher suicide rates for men are

partly the result of the method chosen
(e.g., shooting, hanging, jumping from
a high place).
Women are more likely to overdose on

medication
RISK FACTORS FOR SUICIDE
Clients with psychiatric disorders who are

at increased risk for suicide include:
Depression
Bipolar disorder
Schizophrenia
Substance abuse
Post-traumatic stress disorder
Borderline personality disorder
Environmental factors that increase suicide

risk include:
Isolation
Recent Loss
Lack of social support
Unemployment
Critical life events
Family history of depression or suicide
A history of suicide attempts increases

risk for suicide.
The first two years after an attempt
represent the highest risk period,
especially the first three months.
Those with a relative who committed suicide are

at increased risk for suicide: the closer the
relationship, the greater the risk
One possible explanation is that the relatives
suicide offers a sense of permission or
acceptance of suicide as a method of
escaping a difficult situation
THEORETIC FOUNDATIONS OF
SUICIDE
Psychodynamic theories
According to Freud is a conflict between the
instinct for life and the instinct for death
Suicide occurs
predominates.
when
the
wish
for
death
Others view suicide as an aggression intended for

others turned inward against the self
SUICIDE
Sociologic Theories
The social and cultural contexts in which the
individual lives influence the expression of
suicidality. There are four types:
Egoistic Suicide
The individuals ties to the community are too
loose or tenuous, and the individual is not
interested in maintaining his or her relationship
with the community
SUICIDE
Sociologic Theories
Anomic Suicide
An individual experiences the aloneness
or estrangement that occurs when there
is a precipitous deterioration in ones
relationship with the society
SUICIDE
Sociologic Theories
Fatalistic Suicide
An individual is excessively regulated,

or there are no personal freedoms or no
hope (e.g., suicide of slaves)
SUICIDE
Sociologic Theories
Altruistic Suicide
Rules of customs demand suicide under

certain conditions, or selfinflicted
suicide is honorable
LEVELS OF SELF-DESTRUCTIVE
BEHAVIOR
Chronic self-destructive behavior

Smoking, gambling, self-mutilation
Suicidal threat
A threat more than a casual statement
of suicidal intent and accompanied by
behavioral
changes,
e.g.,
mood
swings, temper outbursts, decline in
school or work performance
LEVELS OF SELF-DESTRUCTIVE
BEHAVIOR
Suicidal gesture
More serious warning signal than a threat
that may be followed by an act that is
carefully planned to attract attention
without seriously injuring the subject
Suicidal attempt
A strong and desperate call for help
involving a definite risk
FAMILY CHARACTERISTIC OF
SUICIDAL PATIENTS
Poor family history or tendencies

Early trauma
Rigid, disorganized or dysfunctional
family system
Disturbed parent-child relationship
Unresolved loss
History of abuse
COGNITIVE STYLES OF
SUICIDAL PATIENTS
Ambivalence
They have two conflicting desires at
the same time: to live and to die
Ambivalence accounts for the fact that
a suicidal person often takes lethal or
near-lethal action but leaves open the
possibility for rescue.
COGNITIVE STYLES OF
SUICIDAL PATIENTS
Communication
Some people cannot express their needs or
feelings to others, or when they do, they do
not obtain the results they hope for.
For them, suicide becomes a clear and
direct, if violent, form of communication
DEMOGRAPHIC VARIABLES
Suicide rates are higher among the following:

Single people
Divorced, separated or widowed
People who are confused about their sexual orientation
People who have experienced a recent loss: divorce, loss of
job, loss of prestige, loss of social status or who are facing the
threat of criminal exposure
Caucasians, Eskimos and native Americans
Protestants or those who profess no religious affiliation
SUICIDAL IDEATION
Means thinking about killing oneself
Active suicidal ideation is when a person thinks

about and seeks ways to commit suicide
Passive suicidal ideation is when a person thinks

about wanting to die or wishes he or she were
dead but has no plans to cause his or her death
People with active suicidal ideation are considered

more potentially lethal
LETHALITY ASSESSMENT SCALE
A scale used in an attempt to predict

the likelihood of suicide

KEY TO SCALE
1
DANGER TO
SELF
TYPICAL
INDICATORS
No predictable riskHas no notion of

of
immediatesuicide or history
suicide
of attempts, has
satisfactory social
support network,
and is in close
contact
with
significant others

KEY TO SCALE
2
DANGER TO
SELF
TYPICAL
INDICATORS
Low
risk
ofPerson
has
immediate suicide considered suicide
with low lethal
method; no history
of attempts or
recent
serious
loss;
has
satisfactory
support network;
no
alcohol
problems;

KEY TO SCALE
3
DANGER TO
SELF
TYPICAL
INDICATORS
Moderate risk ofHas

considered
immediate suicide suicide with high
lethal method but
no specific plan or
threats; or has
plan
with
low
lethal
method,
history
of
low
lethal
attempts,
with
tumultuous
family history and
reliance on valium
or other drugs for

KEY TO SCALE
4
DANGER TO
SELF
TYPICAL
INDICATORS
High
risk
ofHas current high
immediate suicide lethal
plan,
obtainable means,
history of previous
attempt, has a
close friend but is
unable
to
communicate with
him;
has
a
drinking problem;
is depressed and

KEY TO SCALE
5
DANGER TO
SELF
TYPICAL
INDICATORS
Very high risk ofHas current high

immediate suicide lethal plan with
available means,
history of high
lethal
suicide
attempts; is cut off
from resources; is
depressed; uses
alcohol to excess;
and is threatened
with a serious loss
such
as
unemployment or
GUIDE QUESTIONS IN
LETHALITY ASSESSMENT
Does the client have a plan? If so, what is it? Is

the plan specific?
Are the means available to carry out this plan?

(For example, if the person plans to shoot himself,
does he have access to a gun and ammunition?)
If the client carries out the plan, is it likely to be

lethal? (For example, a plan to take 10 aspirin
tablets is not lethal; a plan to take a 2-week
supply of a tricyclic antidepressant is.)
GUIDE QUESTIONS IN
LETHALITY ASSESSMENT
Has the client made preparations for death such

as giving away prized possessions, writing a
suicide note, or talking to friends one last time?
Where and when does the client intend to carry

out the plan?
Is the intended time a special date or anniversary

that has meaning for the client?
WHAT IS THE PRIORITY

NURSING DIAGNOSIS IN
SUICIDE
Risk for injury Self directed
NURSING CARE FOR SUICIDAL

PATIENTS
Provide one-on-one monitoring
Have frequent unscheduled rounds
Avoid use of metals and glass utensils
Monitor for the signs of impending

suicide
MAJOR INTERVENTIONS FOR

SUICIDAL PATIENTS
Prevention
Listen

NO.1
A 19 year-old patient is brought to the

emergency room because she slashed her
wrists. What is the nurses first concern?
A) Stabilization of physical condition
B) Determination of antecedent, causal
factors relevant to the wrist slashing
C) Reduction of anxiety
D) Obtaining a detailed nursing history
ANSWER
Letter A
Rationale: The priority for the patient

is her physiologic homeostasis

NO.2
Which characteristic should the nurse recognize as

common in a person engaged in gradual selfdestructive behavior such as in obesity, drug
addition, and smoking?
A) Acceptance of death wish
B) Denial of possibility of death
C) Ability to control own behavior
D) Ignorance of the consequences of own behavior
ANSWER
Letter B
Rationale: Self-destructive behavior

usually is related to the patients
denial of the possibility of death

NO.3
A patient relates to the nurse, I was going to kill

myself last night.
What is the best initial
response of the nurse?
A) Say nothing.
Wait for the patients next
comment
B) What were you going to do this time?
C) Have you felt this way before?
D) You seem upset. I am going to be here with
you. Perhaps you will want to talk about it.
ANSWER
Letter D
Rationale: This response facilitates free

expression of feelings.

NO.4
Which feeling is the nurse likely to identify as

the antecedent of self-destructive behavior?
A) Omnipotence
B) Grandiosity
C) Low self-esteem
D) Self-satisfaction
ANSWER
Letter C
Rationale: Low self-esteem causes

depression. When depression begins
to lift, the patient may now have
enough energy to carry out a suicidal
plan.

NO.5
In planning patient care, a nurse need to know

that self-destructive behavior may be
interpreted as the?
A) Directing hostile feelings toward self
B) Directing hostile feelings toward others
C) Directing hostile feelings toward
internalized love object
D) Internalized on the fear of death
an
ANSWER
Letter C
Rationale: Suicide can be related to

directing of hostile feelings toward an
internalized love object.

NO.6
It would be important to the nurse to

implement definite suicide precautions for
a depressed patients mood change
suddenly to one of ?
A) Cheerfulness
B) Psychomotor retardation
C) Agitation
D) Hostility
ANSWER
Letter A
Rationale: When a depressed person

suddenly becomes cheerful, it means
that the patient is recovering from
depression and is in danger of
committing suicide.
SAMPLE
BOARD
QUESTION
NO.7
Ursula, 25, is found sitting on the floor of a bathroom with moderate
lacerations to both wrists. With broken pieces of glass around her, she
stares blankly at her bleeding wrists while friends call for an
ambulance. How should a nurse approach Ursula initially?
A) Enter the room quietly and move beside her to assess her injuries
B) Call for back-up before entering the room and restraining her.
C) Move as much glass away and then quietly sit next to her
D) Approach her slowly and in a calm voice call her name and tell her
that the nurse is here to help her
ANSWER
Letter D
Rationale: This approach provides

reassurance for a patient in distress
SAMPLE BOARD QUESTION NO.8
Ursula is taken to the hospital and admitted on emergency basis for 72 hours, as provided by
state law. Ursula says to the admitting nurse, I am not staying here. I was a little upset
and did a stupid thing. I want to live. Which response is most appropriate?
A) Unfortunately, you have no right to leave at this time. You must be evaluated further.
B) Cutting your wrist certainly was a stupid thing to do. What are you trying to accomplish
anyway?
C) You have been admitted on an emergency basis and can be held by 72 hours. You have
the right to consult the lawyer about your admission.
D) I can see youre upset. Why dont you try to relax? You can explain to the physician
what upset you. If what you say is true, youll be released sooner.
ANSWER
Letter C
Rationale: This response provides

orientation to the patient about the
present situation

NO.9
Determining Ursulas suicide potential during the

mental status examination involves assessing
several factors, the most significant of which is her?
A) History of previous attempts
B) Suicide plan
C) Emotional state
D) Self-esteem
ANSWER
Letter B
Rationale: The presence of a definite

plan increases the risk for suicide.

NO.10
A female patient who is on a psychiatric unit is being observed

for signs of suicidal intent. Which of these behaviors by the
patient is most likely a sign of suicidal risk?
A) She continuously falls asleep after midnight
B) She has constant body aches without organic cause
C) She becomes euphoric for no apparent reason
D) She restricts her interpersonal contacts to staff who care for
her.
ANSWER
Letter C
Rationale: The patients behavior

indicates recovery from depression,
which increases the risk for suicide.
ALZHEIMERS DISEASE
ALZHEIMERS DISEASE
An organic mental disorder defined as

a chronic, progressive condition that is
the major cause of degenerative
dementia seen in the elderly
The main pathology is the presence of

senile plaques that destroys neurons
leading to decreased acetylcholine
COMPARISON OF DELIRIUM AND

DEMENTIA
INDICATOR
DELIRIUM
DEMENTIA
Onset
Rapid
Gradual and insidious
Duration
Brief (hours to days)
Progressive deterioration
Level of
Consciousness
Impaired, fluctuates
Not affected
Memory
Short-term
impaired
Speech
May be slurred,rambling,Normal
in
early
stage,
pressured, irrelevant
progressive aphasia in later
stage
Thought
Processes
Temporarily disorganized Impaired thinking, eventual loss

of thinking abilities
Perception
Visual
or
tactileOften absent, but can have
hallucinations, delusions paranoia,
hallucinations,
memoryShort-term
then
memory impaired,
destroyed
Long-term
eventually
4As OF ALZHEIMERS DISEASE
Aphasia
Loss of language ability
Initially there is difficulty in finding words
There is deterioration of language function and
exhibits palilalia (echoing sounds) and echoing
words
Eventually, there is loss of all verbal ability

Apraxia
Loss of purposeful movement without loss of muscle power or

coordination in general
Ability to conceptualize or perform motor tasks deteriorates
There is difficulty in pursuing complex tasks or become so

obsessed with an aspect of an act that they cannot complete it.
The client loses the ability to perform self-care activities
Agnosia
Loss of sensory ability to recognize objects
Initially, has difficulty recognizing
objects like chairs and tables
everyday
In the later stages, cannot recognize even loved

ones or their own body parts.
Amnesia
Mnemonic disturbances or memory loss
In the initial stages, there is recent memory loss such
as forgetting food cooking on the stove
In later stages, there is remote memory loss such as
forgetting names of children, occupation
Eventually there is profound memory loss of both
recent and past events
STAGES OF ALZHEIMERS
DISEASE
Early or Forgetfulness Stage
Second or Advanced Stage
Final or Terminal Stage
EARLY OR FORGETFULNESS
STAGE
Has difficulty remembering names and

appointments and may forget where
things are placed
Have problems with spatial orientation
Shows affect changes and

emotionally unstable at times
seems
SECOND
OR ADVANCED STAGE
Cognitive deficits are present
May last from 2 12 years

Memory for past events may still exist, but the person has no recall
of recent ones.
Orientation and concentration are affected and has increasing
difficulty comprehending everyday events
There is restlessness at night and increased aphasia, apraxia and
agnosia
Former social habits are forgotten
FINAL OR TERMINAL STAGE
Lasts for several months to 5 years
There is severe disorientation, psychotic symptoms
Kluver-Busy-like syndrome (hyperorality, blunting of emotions,

bulimia, attempt to touch every object in sight) occurs
Eventually becomes bedridden, emaciated and helpless
Death results from pneumonia, malnutrition or dehydration
PREDISPOSING FACTORS IN
ALZHEIMERS DISEASE
Genetics
In 10% to 20%, runs in the family
Viral
Aluminum
Vitamin B12 deficiency
Related with Downs syndrome
Possible defect in the immune system
Disrupted biochemical pathways and other
metabolic (glucose) abnormalities
DRUGS THAT SLOW THE

PROGRESS OF DEMENTIA
NAME OF
CHOLINESTERASE
INHIBITOR
DOSAGE RANGE AND

ROUTE
NURSING
CONSIDERATIONS
Tacrine (Cognex)
40 160 mg orally perMonitor liver enzymes for

day divided into 4 doses hepatotoxic effects
Monitor
for
flu-like
symptoms
Donepezil (Aricept)
5 10 mg orally per day
Rivastigmine (Exelon)
3 12 mg orally per dayMonitor
Monitor
for
nausea,
diarrhea, and insomnia
Test stools periodically for
GI bleeding
for
nausea,
NURSING CARE FOR

ALZHEIMERS PATIENTS
Promote normal motor behavior

Living areas must be well lit and furniture left in the
same place
Safety bars installed near toilets, showers, and tubs
Teach safe use of walkers and wheelchairs
clients
using
tranquilizers
and
Evaluate
antidepressants for postural hypotension
Avoid crowds or large open spaces without
boundaries
NURSING CARE FOR

ALZHEIMERS PATIENTS
Maintain self-care
Allow the client to do as much as
possible unassisted
Remind client about daily grooming
Remind client about grooming and
personal hygiene
Use mouth swabs with dilute hydrogen
peroxide if client resists mouth care
Total bed care
NURSING CARE FOR

ALZHEIMERS PATIENTS
Promote adequate sleep

Allow sleepless clients to wander in a
confined area until they are tired
Make sure room is lighted and without
shadows
Leave a radio on to provide more stimulation
NURSING CARE FOR

ALZHEIMERS PATIENTS
Support knowledge processes
Support optimal verbal expression

Call the client by name, approach in a
clear view and give simple directions
Support optimal role performance

Client must be viewed as an active
family member
NURSING CARE FOR

ALZHEIMERS PATIENTS
Promote optimal patterns of

elimination
Toileting routine is essential
Promote optimal nutritional status
NURSING CARE FOR

ALZHEIMERS PATIENTS
Support optimal memory function

Gently orient client
Do not argue about verbal discrepancies. Rather,
direct client towards areas of interest that are
familiar and pleasurable
Music therapy
Drug therapy
NURSING CARE FOR

ALZHEIMERS PATIENTS
Promote optimal orientation

Structure environment to support
cognition
Hearing or visual aids are necessary to
prevent sensory loss or distortion
Easy to read clocks, orientation boards
and consistent daily routine
Do not quiz the client
NURSING CARE FOR

ALZHEIMERS PATIENTS
Support appropriate conduct or impulse control

Client functions best in an environment where
stimulation is controlled and sensory overload is
prevented
Changes must be done slowly
Call client by name, approach in full view and
refrain from touching client
Requests should be simple and non-demanding
NURSING CARE FOR

ALZHEIMERS PATIENTS
Maintain optimal attention span

Repeat requests as needed
Speak in simple phrases, loud enough to be heard
and reinforce meaning with non-verbal gesture
Lower clients anxiety level by moving slowly,
speaking clearly and providing new information
slowly
NURSING CARE FOR

ALZHEIMERS PATIENTS
Maintain optimal perceptual functioning

A quiet environment with soft music prevents
sensory overload
When speaking with the client, stand or sit so that
you are in direct view
First giving a verbal warning, touch the clients
shoulder or hands, and slowly and clearly explain all
procedures.
Use touch with caution
Sometimes a very soothing touch can overexcite the
client, who may respond by striking out
NURSING CARE FOR

ALZHEIMERS PATIENTS
Maintain optimal perceptual functioning

When responding to hallucination
Simply state that you understand that these
thoughts seem very real but that you do not
experience the same thoughts
Do not argue or ask client to elaborate
Give assurance that these thoughts will go
away

NO.1
When a patient has dementia, it is most important that

the nurse plan the daily activities to?
A) Be highly structured
B) Be changed each day to meet the patients need for
variety
C) Be simplified as much as possible to avoid problems
with decision-making
D) Provide many opportunities for making choices to
simulate the patients involvement and interest
ANSWER
Letter A
Rationale:
A
highly
structured
environment decreases the burden of
decision making for the patient.

NO.2
What will the nurse most commonly note in the

clinical picture of dementia?
A) Memory loss for events of the distant past
B) Quarrelsome behavior directly related to the
extent of lack of blood supply to the brain
C) Increased resistance to change
D) Ability to perform ADL
ANSWER
Letter C
Rationale: Increased resistance to

change is a common manifestation of
dementia

NO.3
An important part of the nursing care

for a patient with dementia would be?
A) Minimizing regression
B) Correcting memory loss
C) Rehabilitating toward independent
functioning
D) Preventing further deterioration
ANSWER
Letter A
Rationale: Nursing care for the patient

with dementia is geared toward
maintaining existing functions by
minimizing regression.

NO.4
The patient is in the early stage of Alzheimers disease and

his adult son attended an appointment at the community
health center. The nurse is reading the autopsy report of a
patient who recently died. The report reveals senile plaques,
neurofibrillary tangles, and atrophy. These changes are
characteristic of which illness?
A) Meningitis
B) Delirium tremors
C) Neurosyphilis
D) Alzheimers disease
ANSWER
Letter D
Rationale: Alzheimers disease is

characterized by presence of senile
plaques, neurofibrillary tangles, and
atrophy of the brain.

NO.5
While conversing with the nurse the son

states, I am tired of hearing about how
things were 30 years ago. This statement
indicates?
A) A lack of knowledge of the disease
B) Unusual behavior in the father
C) His fathers level of anxiety
D) His fathers antagonism toward him
ANSWER
Letter A
Rationale: Patients with

usually talk about the past
dementia

NO.6
The nurse discusses the possibility of the patient attending day

treatment for patients with Alzheimers disease. The best
rationale the nurse would give for day treatment is that
A) The patient would have more structure for his day
B) The staff are excellent in the treatment they offer to the
patients
C) The patient would benefit from increased social interaction
D) This will decrease burden on the family
ANSWER
Letter C
Rationale: Attending day treatment

increases social interaction for the
demented patient.

NO.7
Three of the following statements are true

Alzheimers disease. Which one is inaccurate?
about
A) There is degeneration of the cortex and atrophy of the

cerebrum
B) Death usually occurs 1 to 10 years after onset
C) There is progressive deterioration of intellectual function
and change in personality and behavior
D) The etiology of this disease is well-known and
documented in research findings.
ANSWER
Letter D
Rationale: The etiology of Alzheimers

disease is unknown

NO.8
Mrs. Reyes, 72, with Alzheimers disease, has difficulty

remembering where her room is on the unit. Which of the
following would best help her alleviate this problem?
A) Paint the door to her room light pink
B) Assign her a peer who will help her find her room
C) Print her name in large letters on the door to her room
D) Assign her a room next to the nurses station so the staff can
assist her as necessary
ANSWER
Letter C
Rationale: Printing the patients name

in large letters on the door to her room
provides reorientation for the patient.

NO.9
Mang Nano, 75, was diagnosed as having

primary
degenerative
dementia
of
the
Alzheimers type. Alzheimers disease is a ?
A) Functional disorder
B) An irreversible condition
C) Generally reversible condition
D) Delirious state
ANSWER
Letter B
Rationale: Alzheimers
dementia, is irreversible
disease,

NO.10
One of the important areas of concern for

the staff and family in the care of Mang
Nano is his safety. An appropriate nursing
diagnosis would be?
A) Impaired physical mobility
B) Altered thought process
C) Impaired verbal communication
D) Potential for injury
ANSWER
Letter D
Rationale: Due to cognitive and

memory deficits, a patient with
Alzheimers disease is at risk for injury.

NO.11
The nurse should include in her health

teaching that Mang Nanos progressive loss of
memory leads to inability to recognize family
members. This sign of Alzheimers disease is
known as?
A) Apraxia
B) Mnemonic disturbance
C) Agnosia
D) Aphasia
ANSWER
Letter C
Rationale: Agnosia is inability

recognize objects and persons.
to
ALCOHOLISM
ALCOHOLISM
A state of physical and psychological dependency on

alcohol manifested by an individuals inability to refrain
from drinking or to control his consumption of alcohol
World Health Organization definition
A chronic disease or a disorder characterized by
excessive alcohol intake
and interference in the
individuals health, interpersonal relationship and
economic functioning
Considered to be present when there is 0.1% or 10 ml for
every 1,000 ml of blood
DYNAMICS OF ALCOHOLISM
Social drinking may progress to abuse
The reliance on excessive drinking as a means of

dealing with personal tension and discomfort clearly
suggests the psychological factors play a key role in the
development of alcohol abuse.
Alcohol being a depressant aids in the relaxing of the

individual and releases inhibitions
Following a drinking episode, the alcohol abuser is

often overwhelmed with feelings of remorse and guilt
PHASES OF PROGRESSION OF
ALCOHOLISM
1) Pre-alcoholic Phase
Starts with social drinking until tolerance begins
to develop
2) Prodromal Phase
Alcohol becomes a need; blackouts occur; denial
begins to develop
3) Crucial Phase
Cardinal symptoms of alcoholism develops (loss of
control over drinking)
4) Chronic Phase
The person becomes intoxicated all day
ETIOLOGICAL THEORIES OF
ALCOHOLISM
1) Psychoanalytic Theories
Due to fixation in the oral stage of development
2) Learning Theories
Due to a learned behavior
3) Biological Theories
Due to inherited traits
4) Socio-cultural Theories
Due to effects of mass media
MANIFESTATIONS OF
DIFFERENT BLOOD LEVELS OF
ALCOHOL
BLOOD LEVEL
MANIFESTATION
0.1% TO 0.2%
Low coordination
0.2% TO 0.3%
Presence of ataxia,
tremors, irritability,
stupor
EFFECTS OF ALCOHOL
A sedative anesthetic, alcohol is

absorbed in the small intestine;
approximately 95% is broken down by
the liver, the rest is excreted through
the lungs, the kidneys and skin.
Generally, a person can metabolize 10

ml of alcohol or 1 ounce of whiskey
every 90 minutes
EFFECTS OF ALCOHOL
If taken in exceedingly high doses, it

can depress respiration and cause
death.
Intoxication occurs when a persons

blood alcohol level is 0.10% or more
EFFECTS OF ALCOHOL
Simple intoxication lasts less than 12 hours and is usually

followed by a hangover with unpleasant symptoms
(nausea, vomiting, gastritis, headache, fatigue, sweating,
thirst, vasomotor instability) occurring approximately 4 6
hours after alcohol ingestion. The cause is uncertain but
the symptoms are attributed to hypoglycemia and the
accumulation of lactic acid and acetaldehyde in the blood.
Alcoholic hallucinosis
Auditory hallucinations reported
hours after heavy drinking.
approximately
48
POSSIBLE OUTCOMES OF
ALCOHOLISM
Brain damage
Alcoholic hallucinosis
Death
COMMON BEHAVIORAL
PROBLEMS OF ALCOHOLIC
PATIENTS
Denial
Dependency
Demanding
Destructive
Domineering
COMMON DEFENSE
MECHANISMS UTILIZED BY
ALCOHOLICS
Denial
Rationalization
Isolation
Projection
STAGES OF ALCOHOL
WITHDRAWAL SYNDROME
1) Tremulousness
Occurs during the drinking period up
to 2 hours afterward.
There is anxiety, agitation and
irritability
As
it
progresses,
tremors,
tachycardia and diaphoresis are
exhibited
STAGES OF ALCOHOL
WITHDRAWAL SYNDROME
2) Hallucinations
Begins 12 48 hours after the
person stops drinking
Gastrointestinal
symptoms
of
nausea, vomiting, diarrhea and
anorexia are present
STAGES OF ALCOHOL
WITHDRAWAL SYNDROME
Delirium tremens
A condition of severe memory disturbance,
agitation, anorexia and hallucinations
Begins a few days after drinking stops and
ends within 1 5 days
There is elevated temperature, severe
diaphoresis, hypertension and tachycardia
Behavioral symptoms include confusion
with disorientation, agitation, tremors, and
alterations in sensory perception.
COMMON WITHDRAWAL SIGNS

AND SYMPTOMS
Hallucinations (visual and tactile)
Increased vital signs
Tremors
Sweating and seizures
COMMON WITHDRAWAL
SYNDROMES EXPERIENCED BY
ALCOHOLICS
SYNDROME
DELIRIUM
TREMENS
CAUSE
ONSET
Faulty
Acute
metabolism
of alcohol
KORSAKOFFS Thiamine
Chronic
PSYCHOSIS
and Niacin
deficiency
ESSENTIAL
FEATURE
OTHER SIGNS AND

SYMPTOMS
Delirium
Increased vital signs

Visual and tactile
hallucinations
Coarse tremors
Memory
Disturbances
Retrograde amnesia
Anterograde amnesia
Confabulation
PHARMACOLOGIC TREATMENT
OF ALCOHOLIC PATIENTS
Vitamin B1 (Thiamine) is often prescribed to prevent or to treat
Wernickes syndrome and Korsakoffs syndrome, which are neurologic
conditions that can result from heavy alcohol use.
Vitamin B12 (Cyanocobalamin) and folic acid are often prescribed for
clients with nutritional deficiencies
Alcohol withdrawal is managed with a benzodiazepine anxiolytic agent,
which is used to suppress the symptoms of abstinence.
The most commonly used benzodiazepines are lorazepam,
chlordiazepoxide and diazepam.
PHARMACOLOGIC TREATMENT
OF ALCOHOLIC PATIENTS
Disulfiram (Antabuse) may be prescribed to help deter clients from drinking.
If a client taking disulfiram drinks alcohol, a severe adverse reaction occurs with flushing, a
throbbing headache, sweating, nausea and vomiting.
In severe cases, severe hypotension, confusion, coma, and even death may result
The client must avoid a wide variety of products that contain alcohol such as cough syrup,
lotions, mouthwash, perfume, aftershave, vinegar and vanilla and other extracts.
The client must read product labels carefully because any product containing alcohol can
produce the symptoms.
DRUG USED
USE
DOSAGE
NURSING
DRUGS
FOR ALCOHOLIC
PATIENTS
CONSIDERATIONS
Lorazepam
(Ativan)
Alcohol
withdrawal
2 4 mg every 2 Monitor vital signs and

4 hours prn
global assessments for
effectiveness; may cause
dizziness and drowsiness
Chlordiazepoxide Alcohol
withdrawal
(Librium)
50-100 mg, repeat Monitor vital signs and

in 2-4 hours if
global assessments for
necessary, not to effectiveness; may cause
exceed 300 mg/day dizziness and drowsiness
Disulfiram
(Antabuse)
Maintain
500 mg/day for 1-2 Teach client to read labels
abstinence
weeks, then 250
to avoid products with
from alcohol mg/day
alcohol
Thiamine (Vitamin Prevent or

B1)
treat
100 mg/day
Teach client about proper

nutrition

ALCOHOLIC PATIENTS
1) Using confrontation strategies
Several family members, friends, etc., can speak
calmly and slowly with minimal emotion.
Present facts by saying, You have alcohol on your
breath, or You have slurred speech
The next step requires them to make clear and
direct statements about consequences Either
you get help now or you will have to leave your
job.

ALCOHOLIC PATIENTS
2)
Avoiding
non-therapeutic
communication
The nurse should avoid the role of
rescuer, patsy and prosecutor and
function in the role of a nonjudgmental problem solver who
points out the consequences of the
behavior.

ALCOHOLIC PATIENTS
3) Make use of educating video tapes
and talks by recovered alcoholics
4) Referral and self-help groups

ALCOHOLIC PATIENTS
5) Encourage lifestyle changes.
Nurses can help clients discuss ways to
alter
their
destructive
habits
by
suggesting different coping strategies
and by encouraging clients to discover
new interests and capabilities within
themselves.
Recognizing that relapses are always a
threat, nurses may set up contracts with
the client.
CONCEPT OF LOSS
STAGES OF GRIEF / GRIEVING
Shock, Numbness, Disbelief

Searching behavior
Yearning and Protest

Anger towards God
Anguish, Disorganization and Despair

Reality of the loss is accepted
Identification stage
A family member imitates some
characteristics of the dead person
Reorganization / Restitution
Life normalizes
STAGES OF DEATH / DYING
Denial
No, not me!
Anger
Why me?
Bargaining
If only.
Depression
Stage of silence
Acceptance
Yes, it is me

FOR THE GRIEVING / DYING

FOR THE GRIEVING / DYING
Be physically present
Be non-judgmental
Encourage verbalization of feelings
Allow the patient to cry
Recognize your own thoughts about death and

dying
THANK YOU !!!

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BASIC CONCEPTS IN

Is a state of emotional, psychological,

Autonomy and Independence

The individual can look within for guiding

The opinions and wishes of others are

The person can work independently or

The person has an orientation toward

He or she is not content with the

The person can face the challenges of

The person has realistic awareness of

COMPONENTS OF MENTAL HEALTH

The person can deal with and influence

COMPONENTS OF MENTAL HEALTH

The person can distinguish the real

COMPONENTS OF MENTAL HEALTH

The person can tolerate life stresses,

He or she uses support from family

MENTAL ILL HEALTH

A state of imbalance characterized by

MENTAL DISORDER (AMERICAN

Is a clinically significant behavioral or

Interpersonal process whereby the professional

It is both a science and an art.

The use of different theories in the

The therapeutic use of self is

The interpersonal process, that is, the

The individual, the family, and

It is the science that deals with

SAMPLE BOARD QUESTION

Which of the following is a generally

Rationale: According to Johnson, 1997,

SAMPLE BOARD QUESTION

A major predisposing factor of mental

Rationale: Poverty and domestic

SAMPLE BOARD QUESTION

The science which deals with the

Rationale: Mental Hygiene is the

SAMPLE BOARD QUESTION

Nursing as an interpersonal process is?

Rationale: The core of Psychiatric

SAMPLE BOARD QUESTION

Mental illness is?

Rationale: Mental Illness is a clinically

THERAPEUTIC USE OF SELF

During therapeutic communication,

It is the main tool used by the nurse in

THERAPEUTIC USE OF SELF

Using ones humanity personality, experiences,

It is the main tool used by the nurse in the

It is the positive use of ones self in the process

THERAPEUTIC USE OF SELF

Hildegaard Peplau (1952), who described this

Self-awareness means an understanding of

It is the process by which the nurse gains

The nurse needs to discover himself and what he believes

The greater the nurses understanding of his or her own

One tool that is useful in learning more about oneself is

FOUR QUADRANTS OF THE

qualities as yet undiscovered by

CREATING A JOHARI WINDOW

CREATING A JOHARI WINDOW

FOUR QUADRANTS OF THE

FOUR QUADRANTS OF THE