PSYCHIATRIC NURSING, Ms. Ma.

Socorro Guan Hing

-

Definition: According to Travelbee is an interpersonal process whereby a professional nurse

practitioner assists the IFC to promote mental health, prevent mental illness, cope with the
experience of mental illness and suffering and if necessary find meaning in the experience.
o Interpersonal; -relationship among people nurse client relationship
o Process- systematic way of doing things
o Professional KSA
o Attitudes
Sensitive nurse is attuned to the needs of the client
Empathetic understand what the client feels
Sympathy subjective; pity the client
Consistent basic sameness; predictability; if client knows what to expect >>
reliance >> trust; we hold to our promises- builds trust
Flexible adjust and adapt to the situation
Hopeful
Revolving door syndrome admit discharge admit discharge
Trustworthy truthful to what he says
Accountability responsible for the client; answerable to the client
o Roles of the nurse
Teacher tell the SE of medications; know what to report; giving instructions
to participate in various activities
Socializing agent encourage client to participate; introduce a new topic for a
conversation
Withdrawn active friendliness
Paranoid passive friendliness be available
Technician technical skills of a nurse
Parent surrogate nurture the client; feed if with difficulty
Verbal limit setting stop! put the chair down.
Patient advocate fight for the rights of the clients
Rights of the client
o Free from harm- physical and psychological make environment
safe SOP
o Avoiding rejection
o Right
for
confidentiality

privileged
communication;
confidentiality circle: attending MD, RN, patient, guardian
o Privacy least intrusion should be done to the client; least
restrictive environment for client with freedom; dont guard
client one on one except if suicidal watcher pwede na
When to admit:
He hurts himself/. Others
Acutely ill needs hospitalization
o Free from unnecessary restraint to contain angry behavior
Assault cycle:
Verbalization
Time out client is told to go back to room and
remain there until he can control himself
Isolation room restraint application
Medicate the client

Verbal limit setting- tell the client clearly what he is

expected to do in a specific and concise manner; if
client has control he will follow
Restraint with MD orders
o If with clear danger no need for MD order;
document from the least restrictive approach
before applying restraint
Illegal detention restrained if there is no need
Counselor do not give advice; listen if client raises a problem or
concern, discuss it with client; cite alternatives; suggest on what to do;
teaching problem solving techniques
Ward manager coordinates client care- MD, RN and more ; adequate
staffing; ensure adequate supplies and equipment; ward is orderly and
clean
Researcher to develop theories, improve skills
Creator of a therapeutic environment milieu therapy
o Floor plan
o Facilities social hall
o Qualifications of staff
o Open communication
o Group effort all have concerted effort to attain goal
o Meetings among members of the patient and government:
patient government meeting
Staff meeting
Community meeting patient and staff
Appropriate leadership style: democratic
o Activities appropriate activity and timing
Manic more energy, short attention span, cant
concentrate; no competitive activities; engage in cleaning
activity, writing and brisk walking
o Norms and expectations
Safety no breakables, no curtain rods, no sharp objects;
no rosary allowed bracelet rosary lang
Independence - limit setting
Acceptance
Balance in the ward
Levels of Prevention
o Primary
Preventive with health risk
Promotive- no health risk
o Secondary curative
Sick ; prevent complications; early diagnosis; prompt treatment
institutionalization; pharmacotherapy acute illness
o Tertiary rehabilitative; sick and recovery; rehabilitation starts upon admission;
goal: optimize the function- highest na kayang abutin; not maximize
Therapeutic relationship / Helping relationship/ Corrective interpersonal experience/ one
on one relationship
o Therapeutic use of self
Interpersonal skills, communication skills, clinical skills

Self awareness is a must self understanding; know who you are; you can
control only what you know
Joharis window
You know and others know open window public self; introspection
Other know, you dont know closed window semi public self : listen
what others say about you ; sensitivity session positive and
constructive criticisms
You know, other dont know secret- hidden self private self; with
threat of being not accepted
Inner consciousness that you dont want to acknowledge inner self
psychoanalysis
Why self awareness? There is similarity among people; if the nurse
understand herself, she can understand others
When to develop? Start with pre-orientation. If client intrudes your
privacy do self awareness. What did I feel, why did I feel and what
can I do about this feeling.
Social VS Therapeutic relationship
o Social
Mutual approval
Mutual gratification of need
No structure no boundary and limit
Goal is for pleasure
o Therapeutic relationship
No need for approval
Client centered
Structured
Goal directed follow the contract
Phases of N-C relationship
o Pre orientation
Self awareness
Gather Initial info about the client how to approach client
o Orientation
Establish rapport, begin to build trust be consistent
Set a contract with the client expectations and parameters
Do the initial assessment of the client very crucial
Gives you cues and clues as basis for care plan
Routine assessment mental status exams
Appearance, reactions towards you, though content and process,
speech, judgment, sensorium
o Insight- why and what of condition ano pang ang dahilan bakit
kayo nandito?
Wala akong sakit, di ko alam No insight
Introduce yourself, call patient by name
o Working phases
Encourage verbalization of feelings client trusts you already
Assist patient to learn more socially acceptable behavior
Assist patient to learn more effective coping patterns - alternatives
Assist the client to develop insight
On going assessment of the client
Learning and corrective experience
Longest phase

 Problem solving occurs

Termination phase
Encourage verbalization of feelings that go with termination
Summarize what he learned in the relationship> let client bring these to
future relationship
Evaluate the outcome of the relationship- goal of termination phase
There should be closure of any relationship
When: as early as orientation phase
Sadness. Rejection normal feelings to express after termination
Impasse or blocks in the N-C relationship
o Resistance avoids things that are anxiety provoking in the relationship
Client refuses to talk to you, turns his back
Help the client resolve: make client aware of the situation
State your observations
o Transference
Shifting of feeling by patient from some significant in the past to the nurse
who is in the present
o Counter transference opposite of transference
o Inappropriate boundaries violation of limit and structure
Spend so much time, treat client as a friend, meet client after discharge,
accept gift from client
o Feeling of sympathy and encouraging dependency
Prevention: asses what client can do, let him do what he can do, assist client
in what he cannot do
o Non acceptance and avoidance
COMMUNICATION
o Reciprocal exchange of messages
o Components of communication
Sender >> message >> receiver >> feedback >> sender
o Context setting where communication takes place >> role >> content :
CONGRUENCE
o Channel of communication accessories that help us in communicating
o Different factors that affect communication: environment, age, sex, culture
o Modes of communication: congruence in verbal and non verbal communication
Verbal- spoken or written language
Non verbal body language, posture
No crossing of arms- distancing
Proxemics- distance
o Personal space 3-6 feet
Tone of voice and touch
o Techniques
Therapeutic if it builds, maintains and enhances relationship
Helps in the attainment of goals
Active listening listening to verbal and non verbal expression of client;
establish eye contact; assume position with arms on sides
Therapeutic silence keeping quiet; to give client time to think
Offering the self- making self available; ill just sit with you in awhile
Giving recognition acknowledging client; greeting client by name- builds the
esteem of client
Stating observation to be aware of what is happening; exactly what you saw
o

Broad opening- let the client choose what topic to discuss what are you
thinking? What is in your mind? Let client talk about what he wants to talk
about
Accepting technique interested, convey to the client that you are following;
does not follow that you are agreeing; it should not be an agreement
General leads more prompting
Go on, and then..
Giving information needs by the client to know; giving info what he wants to
know
Clarifying- making clear what is not understood
Ganon nga ba ang pagkakaintindi ko?
Exploring delve into a topic;
Tell me more about that.
Questioning open ended; avoid why questions- explanation; explore
>> resolution
Validating determine mutual understanding
Yung sinabi ng patient, same as what you understood?
Did I get you right when you said these?
Is that so?
Presenting reality present fact as it exist in external reality
Confronting cite discrepancy in clients behavior
Giving feedback or facilitative self disclosure role modeling you exemplify
desirable behavior that the client can imitate
Focusing- directing the client back to the topic to be pursued
Reflecting and Restating repeat what client said
Reflecting you direct back to the client what he said
Repeating to the client the feeling implied** >> empathize >>
verbalize the feeling
Restating saying at again
Exactly as he used them
Paraphrasing - repeat the idea, different set of words
Summarizing you give the summary gist of what you transpired during the
conversation; para mafeel niyo na may naaccomplish kayong dalawa sense
of accomplishment
Encouraging description
Placing events in time sequence chronological order to determine
relationships
Collaborating you work with the client; Let us
Non therapeutic
False reassurance re assure client not to worry
Do not worry you take it for granted
Belittling feelings you take the situation for granted
Approval you concede; disapprove you denounce the client
Moralizing or judging the client
Agreeing same thing what client is saying- no second thoughts ;
disagreeing- you oppose the client, you challenge the client
Giving advice impose what client need to do
Probing- explore beyond the clients desire what to explore
Defending protect another
Requesting explanation-WHY?
Giving literal response making the abstract concrete and literal

Changing the topic

The correct answer will usually contain one or both:
Giving correct information
Being empathetic and reflecting the patients feeling
Eliminate:
Authoritarian answers I want you to help me ambulate your daughter
Close-ended questions Do you discuss your problems with someone?
Why questions
Dont worry statement
Nurse focused answers I know from experience this is hard for you; instead,
this must be hard for you
Prioritization: SEA
Safety
Expression of feelings
Assisting in problem of solving
Paranoid client straight forward

THEORETICAL MODELS OF PATIENT CARE

- Biologic Model neurobiology
o Biochemical alterations
o Depressed- TCA; block reuptake nore and sero
- Cognitive model- thoughts- ideas, perspective, views affect behaviors
o Positive thought >> + behavior
o Depression pessimistic
o Cognitive therapy focus on positive thoughts
o Cognitive restructuring
- Social model
o Premise that environment affects behavior
o ENVIRONMENT is cause of maladaptive behavior
o Restructure the environment milieu therapy
- Behavioral model
o Learning theories behavior can be learned >> it could also be unlearned and
modified
o Learning acquisition
o Unlearned- extinction
o Learned- followed by something pleasant >> reward >> repetition
When to give the reward: immediate after activity pairing of behavior
Only adaptive behaviors should be awarded
o Withhold reward- negative reinforcer
o Behavior unpleasant >> AVERSION therapy
o Token economy reward the regularity of behavior
- Interpersonal Sullivan
o Premise that people affect other people
o Anxiety is communicable
o Provide experience that is therapeutic
o Therapeutic N-C relationship Peplau
- Existential or humanistic
o Does not consider the past; here and now; acknowledge the problem
- Psychodynamic
o Past experiences affect present behavior
o Psychoanalytic
o Developmental
- 3 levels of mental activity Freud
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o
o
o

Conscious awareness
What he is thinking now
Subconscious partly remembered, partly forgotten
Partly forgotten can be easily recalled
Unconscious cannot be easily remembered because they are painful and traumatic

FREUD
- Id- pleasure immediate gratification cannot wait
- Ego I/ Me emerged only if the infant knows that he is separated to the mother
o Infant >> I >> I baby has separation anxiety 8 months
o Balances the superego and id
o Defense mechanisms
- Superego sensor?
DEFENSE MECHANISMS blurs the problem for the tension to be relieved; if healthy, he should
solve the problem
- Suppression VS Repression
o Both forget
o S: purposely forget what is threatening
o R: unconscious forgetting
- Dissociation form of repression; aspects about the identity or the sense of self
- Isolation
o Behavior
o Defense mechanism separation of feeling from the thought of the event
- Regression VS fixation
o Both manifest behavior expected at an earlier stage of life
o R: goes back to the behavior expected at an earlier stage of development
o F: carries the behavior up to present stage; unable to outgrow behavior
alcoholism
- Identification vs introjection
o Both attempt to imitate- who we admire
o Identification: he integrates; dinadagdag lang niya sa kanya ung iba
o Introjections- he incorporates; he make a part of you; swallowing the person into
you
Used by suicidal client anger taking in
- Undoing negating, repairing something- obsessive compulsive disorder
- Reaction formation showing the exact opposite of what one feels, wishes or desires
- Compensation exaggerating a trait to cover for an inadequacy
- Conversion expressing ones feeling or conflicts through the body
- Symbolization attributing a meaning to an object to represent the unacceptable
- Substitution taking a more attainable goal because the original goal is not attainable
- Sublimation rechanneling socially unaccepted drives to something that is acceptable
- Rationalization Using a reason which is not the real reason to justify
- Denial refusal to acknowledge painful reality as if reality is not there
o Primary DM for alcoholics
- Displacement transfer of feeling to a less threatening object- ibinaling
- Projection throwing off; attributing to someone what one cannot acknowledge as his;
blaming
o Suspicious clients delusion of persecution papatayin niyo ako a!
CRISIS
- State of disequilibrium resulting from a stressful event or a perceived threat where the
individuals usual coping mechanisms become ineffective in dealing with it.
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Highly individualized.
Types
o Development transition; part of development; anticipated to happen
o Situational: External events; not part of development; cannot be anticipated; death
of someone- not traumatic
o Adventitious- man made or natural disaster; extraordinary
Rape, murder, hostage taking
3 balancing factors that will determine if a person will go into a crisis or not:
o Individuals perception of the event
o Situational support
o Coping mechanisms
EVENT >> assess the event>> perception of event >>
o Stressor >> coping, resources, support >> effective and adequate
o Not a stressor
Characteristics of crisis state
o Highly individualized
o Self limiting- 4-6 weeks; grief 6 months
o Short time management
o Rarely affects the individual without also affecting the significant others
o The person is amenable to suggestions
o Has a growth potential
Phases
o Pre crisis state of equilibrium >> stressful event >> ineffective coping / support
system lacking >> denial , ^ tension , feeling of fallen apart / state of
disorganization >> real crisis state >> attempt of reorganization ,trial and error >>
resolution

CRISIS INTERVENTION
- Active and directive approach
- Problem soling
- RN assist clients support system
- Steps
o Assess the situation - physical impact sa patient
o Assist the client to develop cognitive awareness of the event ano ang ibig sabihin
ng problema sa kanya?
o Assist the client in managing feelings
o Explore with the client the resources available
o Assist the client in action planning- we dont solve, we just assist
- Techniques
o Abreaction verbalization
o Clarification make client connect problem to his life
o Suggestion- influence client to take alternative
o Manipulation you use the positive point of the client to his advantage
o Reinforcement of behavior positive behavior should be recognized
o Support of defenses
o Raising self esteem
o Exploration of solution explore the advantages and disadvantages of values
RAPE and SEXUAL ASSAULT
- Rape- sexual act with penile penetration or any blunt object; without consent and against
the will
o Main motivation: strong feeling of inadequacy and helplessness
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o Make the client realize that it is not her fault.

Sexual assault
o Any other form of forced sexual contact (which does not qualify as rape)
Truths about rape
o It is an act of violence
o It is an act of domination and power power rape
o There are more females who are raped than males
o There are more acquaintances rape done.
Stages of recovery from trauma
o Acute phase or disorganization/ impact stage- rape trauma syndrome
Denial, helpless, feels dirty
Do not wash, douche and clean
Do not blame client if she washed or cleansed
Keep all evidences intact
Strong emotions talk about her feelings but let the client progress according
to her pace; allow patient to go through denial initially; assume attitude of
acceptance and empathy
Uphold the rights of the victim take consent done by MD; RN as witness
that there is no coercion
If below 12 statutory rape genital contacts only; no need for penetration
Vaginal smear
o Outward adjustment (recoil)
Client is composed already
Can be engaged in processing of the event.
There can still be internal turmoil
Needs client emotional support
o Resolution (organization)
If client has learned effective coping
Sexual dysfunction can be noted
PTSD complication
o Rape trauma syndrome sustained maladaptive response to rape
o Psychotherapeutic management of rape victims
Empathy, support and opportunity to process the event and intense feelings
Consider the rights of the rape victim
Nursing care

CHILD ABUSE
- Maltreatment of a child that ranges from violent physical attacks to passive neglect
- Types sexual, physical and emotional abuse
- Why abuse occurs?
o Individual factors he may use abusive act to feel adequate
- Dynamics underlying child abuse
o Individual factors
o Societal factors powerless end up helpless >> child and elderly; chronic poverty,
neglect
o Familial factors multi generational problem; generation to generation abused
happen in the family; how to assess: do a genogram to assess every generation
- Elements
o Abused
o Abuser
o Crisis
- Assessment we are mandated by RA 7610 anti child abuse law
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Physical abuse physical and behavioral indicators - commission

Bruises
Walts marka ng palo
Shaken child syndrome ALOC
Burns back, buttons, groin
Fractures
Always outside the house
Physical neglect- omission
Food, shelter, medical attention
Malnourished , begging behaviors
Child labor
No adequate clothing
Emotional abuse
Humiliated
Berated
With failure to thrive
Lags in physical development
Speech disturbances
Emotional manifestations of anxiety thumb sucking, nail biting and enuresis
Sexual abuse
Fondling of genitals
No menarche but with blood stain
Unusual vaginal discharge
Unusual knowledge about sex
Painful urination
Roles of the nurse
Primary consideration is the protection of the child. Report any suspected
case of child abuse.
Report only suspected abuse.
Report to police, barangay officials, DSWD, NGOs
The physical needs of the injured and neglected child must be met before
attempts are made to alter the familys pattern of functioning
Manage the psychological effects of abuse play therapy for children who
lack language facility to express- puppets, storytelling, dolls that represent
family

SPOUSE or PARTNER ABUSE

- Characteristic battered wife response to abuse
o Believes abuser will reform
o Fears leaving due to threat from abuser
o Learned helplessness
o Isolates self from other relationship
o Feels inadequate, accepts self blame low self esteem - assertiveness
o When to seek help: tension build up
o Phases
Tension build up minor abuses, accepts the situation
Serious battering stage
Honeymoon stage- sweet, husband is sorry
o Nursing diagnosis
Impaired skin integrity
Pain
Risk for injury
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Altered nutrition
Sleep pattern disturbance
Fear
Self esteem disturbance
Risk for violence
Ineffective individual or family coping
Nursing interventions
Intervention for the victim of abuse
Focus on preventing violent behavior
Interventions for the abuser
Interventions for the family

SUBSTANCE ABUSE
- 2 clinical subtypes
o Substance abuse

o Substance dependence
More serious
o Similarities of substance abuse/dependence
Regular use of the substance impairs function (cognitive. Physical etc) even
though pt knows nkakasama sa pt ang substance tinetake pa din nya; more
time to take and more time to get substance; takes the substance longer
than intended to; may have withdrawal symptoms substance specific
manifestations that occur upon the reduction or cessation of the substance
o Substance intoxication effect on the body CNS
CNS depressant decreased CNS
o Substance withdrawal
CNS depressant increased CNS
o Tolerance pt needs higher dose to bring about same effect
o Physical dependence patient nagwwithdrawal symptoms kapag wala na yung
substance
o Psychological dependency takes substance to avoid the unpleasant effects of
substance
- CNS stimulant
o Amphetamines
ADHD Ritaline
Narcolepsy decrease NREM
Shabu metamphetamine HCl
Obese clients
Benzadrine
Rizadrine
CI: thyroid problems, cardiac problems
Same effects as cocaine
o Cocaine
More expensive
Status symbol
Sniffing - nose
o Ecstasy
o Signs
Euphoria
Increase VS
Cardiorespiratory arrest
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Dilated pupils
Delusion and hallucinations
o Urine test asap after last day of taking drugs; up to 2-4 days; 5 days excreted; do
no dilute- false negative
o Momentary ecstasy RUSH wag lubayan ang pagtake
Shabu 8-12 hours; if not taken, Crashing >> psychological dependence
o Decrease appetite
o Decrease sleep insomnia
o Ecstacy MDMA methylene dioxymetamphetamine
With feeling of closeness or empathy among users
Club drug
Heightened sexuality > indiscriminate sexual acts
Withdrawal
Fatigability
Increase appetite
Increased tulog
o Given: antipsychotics
CNS depressant
o Alcohol
o Sedative or hypnotics
o Narcotics- opiods
Plant source: papaver somniferum
Derivative:
o Opium
o Heroine- mostly abused
o Codeine- cough syrup
o Morphine - analgesics
o Synthetic: Demerol analgesics
o Methadone
Effects
Causes euphoria
Can bring about sleepy languor masrap na tulog
Easy sensitivity to pain
Thought too slow need help in judgment
Pin point pupil life threatening
Decreased RR
Depressed DTR
Early manifestation of withdrawal
Runny nose
Teary eyes
Sneezing
Yawning
Piloerection
Muscle and abdominal cramps diarrhea; take warm showers
Dose should be tapered of
Narcotic opiate receptor blocker- to relieve craving Revia
Narcotic antagonist- narcan Naloxone
When withdrawing heroine- take methadone; does not make client sleepy
Hallucinogens or Psychotomimetics mind altering drugs
o Mescaline- natural
o LSD
o PCP anesthetic for animals
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Ketamine or Ketalar
Similar effect with ecstacy heightens sociality
Seeing self separating from body
Memory impairment
KHOLE experience
o Cannabinols
Plant cannabis sativa
Dagta potent form hashish
Increased appetite
If smoked red eyes
Prolonged use loss of motivation and poor judgement
Decrease in testosterone
o Can induce psychosis
o Effects
Distort sense of space- psychedelic
Warped appearance
Synesthesia blending of senses he smell color; could see odor
Bad trip frightening perception
Flash back experience hallucinations
Inhalants
o Nail polish removers
o Rugby
o Gasoline
o Solvents
o Generally cns depressants
o Mirthfulness- masayahin
o Hilarious
o Ulceration in the mouth
o

Alcoholism
- Etiology
o Biologic with genetic predisposition
o Psychodynamic fixation in oral stage
o Behavioral a learned behavior
o Social peer pressure
- Rehabilitation give up alcohol drinking friends
- Active ingredient: ethanol
- Blood alcohol concentrations/ level to behavioral manifestations of intoxications
o BAL behaviors
o Up to .1% - anxiety, euphoria, loud speech
o .05% loss of inhibition
o .1%-.15 slurred speech, motor in coordination, moodiness (LEGAL INTOXICATION)
o .2-.3 irritability, black out- memory impairment (cannot remember what he did
when he was drunk), tremor, ataxia, stupor
o .3 and up unconsciousness
- Liver metabolize 10ml per 90 minutes of whisky 1 glass of beer
- Stomach starts absorption of alcohol- small intestines
- Complications
o Gi
Malnutrition
Inflammations
o CNS
Due to deficiency in Vitamin B this should be supplemented
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Neuritis
Wenickes ataxia, ophthalmoplegia
Korsakoffs syndrome- confabulation falsifying to fill in the gap in
memory
o Reproductive
Impotence ; decrease testosterone
o CVS cardiomyopathy >> congestive heart failure
o FAS- pregnant
Nursing diagnosis
o Ineffective denial
o Ineffective individual coping
o Altered family process
o Anxiety
o Altered sensory perception- hallucinations and delusions
o Altered thought process
o Impaired verbal communication
o Sleep patterns disturbance
o Altered nutrition
o Self- esteem disturbance- low self esteem
o Alteration in social interaction
o Risk for violence
Enabling behavior and co-dependence behavior of relatives of alcoholics; kunsintidor
o Family therapy
Understanding the psychodynamics of substance dependence may be a basis for the
nurse client relationship
o Unresolved needs of early attachments
^ID
Strong oral tendencies
Demanding or manipulative
Decrease ego
Uses denial, rationalization and projection
o Denial - confront
Uses escape behavior provided by alcohol
Inferior feeling
We treat the behavior, not the diagnosis
Management
o Short term detoxification remove toxic effects of alcohol in the body
Do not let client to take alcohol done in a controlled environment
Admitted to the ward confiscate potential sources of alcohol mouthwash,
cologne, aftershave lotions, hand sanitizers, rubbing alcohol, elixir type of
cough syrup not allowed if taking disulfiram or antabuse
What to expect: withdrawal symptoms
Stage 1 6-8 hours after last drink
Stage 2 8-12 hours
Stage 3- 2 to 3 days late
Stage 4 2-5 days after Delirium tremens
How much alcohol have you taken in the last 48 hours? More alcohol,
more intense withdrawal manifestations will be; if with denial >>
underestimate the amount
Earliest- tremors, anxious, perspiration, hang over manifestations HA, nausea, vomiting, retching
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o
o

Stage 2 hallucinations- intensifying anxiety of the client give

anxiolytic such as Librium or valium
Stage 3- seizures life threatening
Stage 4- delirium tremens- complication of alcohol withdrawal
o CNS stimulating effect; cns irritability most extreme
o Unstable VS - ^BP CVA Clonidine or Catapress
o Excitability- non stimulating and quiet environment minimize
visitors and touching client; clustering
o Confusion and disorientation re-orient; well lighted
o Agitation motor counterpart of anxiety ; side rails up
o Hallucinations false sensory perceptions- visual; tactile ;
illusions misinterpretations of external stimuli- shadows on the
wall; reality presentation without arguing and disagreeing to the
client
o Seizure life threatening
o Blood shot eyes
o Monitor VS every hour or two
o Low pitched and calm approach
o Antipsychotics are not given have adverse effect decrease
convulsion threshold
o Anxiolytics- can prevent seizures
o Anti convulsants dilantin and magnesium sulfate
Goal: ensure the physiologic integrity and safety of the client
Long term rehabilitation
Foundation is abstinence
Give up Alcohol- Disulfiram Therapy (Aversion Therapy)
Acetaldehyde- ito yung meron kapag may hang over- hindi pa
kumpleto ang metabolism
MOA of disulfiram reaction: block the second enzyme aldehyde
dehydrogenase
Effects of disulfiram: NV, hypotension, DOB, MI
Caution: avoid anything that contains alcohol
It does not relieve the craving for alcohol it is deterrent to the client
Opiate receptor blocker- relieve craving for alcohol Previa Naltrexone
o AL + neurotransmitter >> endorphins / opiate like
Live a positive lifestyle way of life, what you do everyday
Rehabilitation goal: change in behavior through group therapy
From: Stressor >> anxiety >> alcohol >> decrease anxiety
To: stressors >> anxiety >> replacement with a more effective
adaptive coping >> decrease anxiety
Must give up denial first awareness
Group therapy for the alcoholic- alcoholic anonymous
Support group for the family of the alcoholics
o Al anon for the wife
o Ala teen for the children
Nursing interventions
Providing for physical and nutritional needs
Confrontation in relation to denial
Tough love- accept the person
Education
Group work
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Group therapy- collection of people with common goal and working to the
attainment of the common goal
Membership
o Size 8 to 10
o Nature homogenous or heterogenous
Stages of group development
o Initial phase orientation phase getting to know you;
clarification of goals
o Middle working phase; more coordinated; able to achieve goal
because of cohesiveness and unity
o Termination termination phase- summary of what have been
learned
Types
o Support group or maintenance group- maintain existing
strengths and behaviors rather than confront or change
behaviors
o Activity groups use a variety of techniques to facilitate self
expression, interaction and acceptance
Remotivation therapy discuss about a certain topic
o Psychoeducation groups to offer content and skills (medication,
stress/ anger management, problem solving, social skills)
o Self help groups = a homogenous group organized and led by
group members
Alcohol anonymous group
Yaloms therapeutic factors of GT
o Instillation of hope
o Universality hindi ako nagiisa
o Imparting information
o Altruism able to help
o Corrective recapitulation of primarily family group
o Development of socializing techniques
o Imitative techniques
o Catharsis - expression
o Cohesiveness
o Interpersonal learning

ANXIETY AND OTHER RELATED DISORDERS

- Anxiety a subjective feeling of apprehension, dread or impending doom
- Anxiety VS fear
o Perceived by many fear
- Causes or etiology
o Biologic stimulation of autonomic NS
o Behavioral learned behavior
o Psychodynamic- caused by conflict and unacceptable desire and feeling
Conflict- presence of two opposing action drives- id and superego
o Interpersonal caused by people- Sullivan people affect people
- Characteristics
o Subjective
o Universally seen as unpleasant
o Both a stressor and an adaptation- not the best adaptation
o Form of energy cannot be seen but can be inferred
o Occurs in degrees mild, moderate, severe and panic
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Manifestations
o Psychomotor or physical
o Emotional
o Cognitive manifestations
o MILD - +1
Psychomotor
slight muscle tension
Slight fidgeting
Energetic
Good eye contact
Emotional
Occasional slight irritability
Confident
Cognitive
Alertness
Awareness of the surroundings
Concentration
Accurate perceptions
Attentiveness
Logical reasoning and problem solving
Client is at its best
o MODERATE +2
Psychomotor
Moderate muscle tension
Increased BP, PR, RR
Startle reflex
Slight perspiration
Difficulty sitting still for long
Periodic slow pacing
Increased rate of speech
Sporadic eye contact
Emotional
On edge keyed up
Increased irritability
Decreased confidence
Cognitive
Difficulty in concentrating
Easily distracted, can focuses with assistance
Narrowed perceptions
Decreased span of attention
Problem solving and reasoning with effort or assistance
Selective inattention- security operation
o SEVERE preparation for flight and fight response
Psychomotor
Preparation of body for F and F response
Extreme muscle tension
Increased perspiration
Continuous and rapid pacing, trembling
Loud and rapid speech
Poor eye contact
Somatic cymptoms
17

Emotional
Feeling of dread
Cognitive
Difficulty focusing even with assistance
Ineffective reasoning and problem solving
Disorientation

PANIC
Psychomotor
Actual flight, fight or immobilization
Suicide attempts or violence
Eyes fixed
Hysterical or mute
Incoherent
Emotional
Feeling overwhelmed
Cognitive
Disorganized perceptions
Disorganized or irrational reasoning and problem solving
Out of contact with reality
Personality disorganization

NEUROSIS abnormal anxiety

I.
Anxiety disorders
a. Obsessive Compulsive
b. Phobic
c. Generalized anxiety
d. Panic disorder
e. PTSD
II.
Causes
a. Biologic GABA- inhibitory NT- decrease>> dominance of excitatory
b. Psychodynamic conflict, unacceptable desire, wish or feeling >> ego will be
threatened >> protect itself >> REPRESSION pushes it back to the unconscious
mind
i. Present situation is related to the conflict >> nearly conscious re awakening
of this conflict that makes a person anxious >> behaviors to decrease
anxiety- manifestations of anxiety disorders
1. Sample: mamas boy >> repressed by ego >> marriage >> near
consciousness >> keep on thinking that he will be married >>
obsession repetitive thought >> engage in certain behaviors that are
repetitive inaayos yung damit pangkasal compulsion ineffective
coping because it makes the client dysfunctional
III.
Goal of intervention: client will demonstrate decreased anxiety
IV.
Disorders
a. OC repression and undoing; isolation- separation of feeling from the thought;
reaction formation
i. Intervention
1. Allow the client to do his compulsions.
2. Short term: demonstrate lessened number of compulsion
a. Setting limits time; dont be too rigid can be upset the client
i. Modify his schedule
ii. Diversionary activities- relaxing activities
18

1. Music therapy
2. Recreation therapy
3. Compulsive rigid and precise >> BAKING
measurement
4. Recognize well done activities to reinforce activities
5. Recognize positive behaviors
6. Assist client to have verbal outlet outlet that will
not use compulsion
3. Anxiolytics
4. Skin integrity impairment repetitive handwashing
a. Mild soap and emollient
b. Phobia irrational fear
i. Displacement, repression and symbolization, avoidance
ii. Real reason repressed- you do not know why
iii. Different types
1. Dog specific object specific phobia- simple phobia
2. Animals- zoophobia
3. Height- acrophobia ?
4. Disease- pathophobia
5. Thanatophobia- death
6. Social phobia- fear of being in situation that one can be embarrassed
or humiliated
a. Not attend parties, public speaking
7. Agoraphobia most resistant of all forms of phobia
a. Fear of open space cannot tolerate open parking area, open
highway
b. Fear of being alone
c. Fear of being in a situation where escape can be difficult
iv. Management
1. Accept the clients fear as real to him.
2. Do not denounce the client.
3. Let client get used to it. Involvement into the situation
4. Avoidance >> generates relief anxiety that rewards the voidance.
5. Systematic Desensitization gradual exposure to current situation;
least to most provoking
a. Imagine the situation
b. Make client see a picture.
c. See the real fearing situation very far
d. Nearer..
6. Implosive therapy flooding the client of the fearing situation; if client
can tolerate for sometime recognize behavior
c. GAD persistent worrying- 6 months
i. Anxiety is free flowing and diffuse; hindi nakaattach
ii. Can be moderate but continuous >> unplesant
d. Panic acute anxiety attack; sudden onset and short duration
i. 5-10 minutes; at most 1 hour; recurrent
ii. Variations
1. With agoraphobia fear of being alone
a. Why? When he is alone, he can have an attack no one can help
him
2. Without agoraphobia
a. With intense manifestations, hyperventilating dont let client to
be alone
b. Safe environment
c. Let client breathe to a brown bag
19

d. Parenteral anxiolytics
Thorough medical exam to rule out medical condition
after trauma
Person had not let go of the event
Living the life as a victim; not a survivor
Manifestations for atleast one month
1. Flash back relives the experience; nightmares
a. Nakaupo with far- away look; facial expression is in distress
2. Emotional numbness manhid; avoidance
3. Cannot eat, sleep, concentrate, feels guilty
iv. Management
1. Empathy and acceptance
2. Process the event progressive and intense
a. Parang desensitization progressive kung kaya ng client
b. Intense every detail
3. Grounding siya nakaground s past, iground mo siya sa present
a. When client is having flashbacks, call her name to ground her in
present
b. To realize that you are now in the present, not in the past
Nursing diagnosis
a. Risk for injury
b. Anxiety
c. Ineffective individual coping
i. Perception
ii. Coping
iii. Support
d. Powerlessness feels no power or control over the event; whatever that he does, he
cannot change the outcome anymore
e. Altered role performance - expectations
f. Sleep pattern disturbance
g. Self esteem disturbance
h. Fatigue for OCD
i. Decisional conflict
j. Skin integrity risk for impaired for OCD
Interventions
a. Assist in minimizing the clients anxiety
b. Provide for safety of the client
c. Assist in developing a more effective coping- psychotherapy
i. Awareness on the problem for the client to cope
ii. Problem solving very adaptive; for the problem to be resolve
1. Awareness and understanding of the problem
2. Assist the client to have alternatives
iii. Humor
iv. Diversional activities
v. Stress reduction techniques
d. Pharmacotherapy
i. Minor tranquilizers anxiolytics
1. Benzodiazepines
a. Valium Diazepam
b. Tranxene
c. Librium
d. Xanax - SA acute anxiety attack
e. Serax- SA
f. Ativan Lorazepam -SA
g. Dormicum Midazolam
iii.
e. PTSD
i.
ii.
iii.

V.

VI.

20

2. SE: CNS depressant

a. Sedation and drowsiness- safety
b. Orthostatic hypotension decrease of 20mmHg from baseline
i. HA, tachycardia
c. Anti cholinergic effects
i. Dry mouth adequate oral hygiene
1. Sour candy to stimulate salivation
ii. Constipation
iii. Urinary retention
iv. Blurring of vision- safety
d. Nausea medications with food
3. Adverse effect
a. Paradoxic excitement - reportable
4. Food restrictions
a. Alcohol
b. No coffee counter effect the medication no stimulants
5. Duration: no longer than 3 weeks >> can develop adverse effect
a. Potential for both physical and psychological dependence
6. Gradual withdrawal >> possible convulsion if not life threatening
7.
8. Expected outcome: decreased VS, muscle relaxation > evaluation
9.
e. Psychotherapy
i. Psychoanalysis only permanent cure; conflict is mid conscious to be
resolved
1. Achieved thru hypnosis- relaxation
a. Suggest client to talk brought to consciousness
2. Dream analysis
3. Catharsis verbalization
f. Milieu therapy- modify the environment
i. Quiet and non stimulating
g. Behavior modification
SOMATOFORM DISORDERS- body
I.
Dynamics- displacement, repression, conversion
a. Stressor (psychologic) >> Anxiety >> physical symptoms without organic basis
i. >> decrease anxiety (primary gain) direct advantage; relieved
responsibility; gratification is from within
ii. >> other advantages from the environment secondary gain
1. We should not gratify the secondary gain rewarding the secondary
gain
II.
Assessment all are characterized by physical symptoms
a. Physical manifestations vary depending upon the type of somatoform disorders
i. Somatization
1. Varied physical complaint iba ibang body part and systems are
involved
2. Pain that changes site
ii. Somatoform pain
1. Pain is the only manifestation intense and prolonged
2. Stationary pain and not proportionate to the cause
iii. Hypochondriasis
1. Morbid preoccupation
a. Morbid- illness
b. Preoccupation too much attention given to something
21

III.

IV.

V.

VI.

c. With tendency for client to misinterpret manifestations as

manifestations of a serious illness
2. Doctor hopping
iv. Conversion
1. Alteration or loss in motor and sensory
2. Neurological symptoms are noted
a. Witness blind
3. Physical symptoms are symbolic of the conflict
4. La belle indifference beautiful indifference client is not upset with
the manifestations- differential diagnosis
v. Body dysmorphic disorder disorder characterized by preoccupation with a
defect imagined or very slight- part of hypochondriasis
Common characteristics of physical symptoms
a. Real (not fake)- accepting the patient; MOF attitude
b. Occur unconsciously (not deliberate) hindi sinasadya na siya ay magkasakit
c. No underlying structural or organic basis not a medical condition
i. Management: anti anxiety and stress reduction techniques
d. With primary and secondary gain
e. Malingering conscious simulation of an illness- not a somatoform disorder
i. Fake
ii. Deliberate
Nursing diagnosis
a. Chronic pain
b. Ineffective coping
c. Disturbed body image how he perceives his physical appearance or physical
function
d. Self care deficit
e. Altered role performance
Goals:
a. To make the client as functional as his condition will allow to improve the quality of
life
i. Let client do what he can realistically do
b. To relieve symptoms anxiolytics and stress reduction technique guided imagery
i. GI- imagine a very nice place or very pleasant; coach the client as what he is
suppose to imagine
c. Do not push awareness of or insight into conflicts or problems >> uses body as a
way of coping
i. Use benefit of blindness for a while since he cannot move on
d. To encourage expression of emotional feeling- not about complaints
e. To assist in learning more effective coping strategies for long term basis
f. Short term be aware of the problem
Management
a. Psychotherapy
b. Anti anxiety and antidepressants
c. Stress management techniques
i. GI
ii. Meditation
1. Capacity to concentrate
2. Relaxed position
3. Environment conducive for concentration
iii. Progressive muscle relaxation
1. Alternately tense and relax muscle

DISSOCIATIVE DISORDER unconscious forgetting; forgetting identity

22

I.
II.
III.

IV.
V.

VI.

VII.

VIII.

D. Amnesia loses identity

D. Fugue loses identity and travels to other place and assumes different identity
Dissociative identity disorder: Several personality; shift from one personality to
another; not aware of other personality; they have been victims of abuse- assumes the
personality of the abuser
Depersonalization disorder- state of trance like or dream like; with co-morbidity with
other conditions schizophrenia
Diagnosis
a. Ineffective coping
b. Disturbed thought process
c. Disturbed personal identity
i. PI- ability to distinguish self from non self
Goals of care integrate the personalities or memories
a. Establish trust and support
b. Ensure patient safety
c. Reduce self harm and violence
Treatment
a. Milieu therapy
b. Psychotherapy
c. Psychoanalysis to reintegrate the self
Decreased functioning of ego

PSYCHOPHYSIOLOGIC DISORDERS psychological factors affecting medical condition

I.
Prolonged stress >> stimulate the physiological effects under the pituitary-adrenal axis
>> body symptoms with structural or organic changes >> primary gain (decrease
anxiety), secondary gain (attention, dependency)
II.
With period of remission and exacerbations
III.
Organ vulnerability theory weak part will suffer
a. Vascular system HA, HPN, angina, migraine
b. Respiratory asthma
c. GI- PUD, ulcerative colitis
d. MS- RA
e. Endocrine DM
IV.
Predisposition as to personality type
a. Migraine- perfectionist
b. Essential HPN- weak personality, CAD - aggressive
c. Bronchial asthma dependent
d. PUD type A
e. Ulcerative colitis hindi assertive >> defecating the enemy
f. Dermatitis
g. RA masochist, self sacrificing
V.
Management
a. Priority is to manage the physical symptoms positive diagnostic exams
b. Assist the client to find alternative outlets of anxiety
c. Learn a more effective way of coping to prevent exacerbations
PSYCHOTIC DISORDERS
I.
Psychosis -Inability to distinguish what is real and not
II.
Neurosis- abnormal anxiety
III.
Schizophrenia thought disorder; bipolar disorder mood disorder
a. Disintegration in persons thoughts, behavior
b. Biologic cause
i. Genetic predisposition
ii. Biochemical alteration
23

c. Psychodynamic
i. Faulty parent child relationship
ii. Faulty communication
iii. Dysfunctional relationship
d. Assessment
i. 4As Bleulers 4A
1. Affect- apathy, inappropriate
a. External manifestation of emotion; temporary
b. Apathy walang affective response
c. Affect adequacy
i. Restricted affect- less than normal
ii. Less than restricted blunt affect
iii. Less than blunt- flat (apathy)
2. Ambivalence two opposing feelings at the same time
3. Associative looseness though process disturbance how a person
connect his thoughts; no logical sequence; incoherent speec
4. Autism- self absorption; client who pays attention to external
stimulation may sariling mundo
5. Auditory hallucinations- client hears when there is nothing to be heard;
common among schizophrenic clients
ii. DSM criteria at least 2 of the ff for at least 6 months
1. Positive symptoms
a. Delusions false beliefs projection as a defense mechanism;
altered thought process
i. Fixed and false belief
ii. Delusion of grandeur one is an exalted person ;
motivation or underlying need: feelings of inadequacy and
low self esteem listen to the content, enhancing esteem
of the client
iii. Persecution or paranoia others are plotting against him;
at risk for violence; do not leave client stand by
1. Verbal content sarcastic, obscene words
intensifying emotions
iv. Religious delusion- religion content
v. Reference things are referring to him- talk loud enough
to be heard by the client
vi. Control external force is controlling him God made me
do it.
vii. Thought insertion- others can put thoughts in his minds
viii. Thought withdrawal others can remove thought in his
mind
ix. Thought Broadcast- client believes others know what he is
thinking off
x. Somatic delusion- body is changing in some way
xi. Nihilistic - Body or parts does not exist
b. Hallucination false sensory perception
i. Altered sensory perception
c. Disorganized speech
i. Word salad jumble of words put together kapatid puti
inis tatay
ii. Clang association rhyming words are put together
broom boom
iii. Neologism coining of new words
iv. Perseveration same response to different stimuli
24

v. Verbigeration - walang narinig pero inuuli ulit niya

vi. Echolalia may narinig muna bago inulit ulit
d. Grossly disorganized or catatonic behavior regressed behavior
i. Catatonic- motor manifestations due to mental illness
1. Immobile
2. Hyperactivity
3. Bizarre postures
2. Negative symptoms
a. Alogia poverty of speech; impoverished speech- one or two
words; cannot expound on thoughts
b. Anhedonia no sense of pleasure
c. Avolition No motivation
d. Anergia
e. Asocial
f. Inattention
e. Types
i. Paranoid delusion and hallucinations; most kempt; at risk to be violent
ii. Disorganized type- most regressed and unkempt
1. Disorganized speech
2. Grossly disorganized
iii. Catatonic catatonic behavior; most acute
1. Does not move Stupor
2. Not moving, stiff Rigidity
3. Not moving, opposite ang ginagawa Negativistic Type
4. Excitement- nagwawala, nagtatakbo
5. Bizaare posture- Posturing
6. Waxy Flexibility assumes and maintains position that has been
imposed
iv. Residual - Negative symptoms
v. Undifferentiated - Mixture
f. One month or less- brief psychotic disorder
g. Longer than 1 month, less than 6 months shizophreniform
h. Common nursing diagnosis
i. Risk for violence self directed command hallucinations
ii. Potential or risk for other directed violence
iii. Altered thought process delusion and looseness of association; for concrete
thinking
iv. Sensory perceptual alteration- hallucinations
v. Personality identity disturbance
vi. Impaired verbal communication catatonic: mutism
vii. Social isolation
viii. Self care deficit: nutrition , grooming catatonic and disorganized
ix. Altered nutrition less than body requirement
x. Ineffective coping
i. Management
i. Psychotherapeutic management
ii. Promote safety of client and others.
iii. Establish therapeutic relationship
1. Withdrawn patient catatonic and schizophrenic, disorganized = active
friendliness- spend time with client, maintain distance, short and
frequent interactions
2. Suspicious client passive friendliness you do not make pilit yourself,
do not make a promise that you cannot fulfikll
iv. Use therapeutic communication

25

v.

vi.
vii.
viii.

1. For concrete thinking do not be abstract in your speech; direct and

simple
2. For incoherence- clarify and say, I dont understand what you said,
please clarify it.
3. For mutism magsalita ka; conscious pero ayaw magsalita; spend time
with client short but frequent; do not provoke the client; strt on
neutral topics before personal things
Do not reinforce D and H
1. Do not argue about delusions
2. Do not reinforce hallucinations can be done by exploring the content;
you can only know the content but do not explore
3. If a patient is acting odd and the nurse suspects he or she is
hallucinating, the patient should be asked about it.
4. Help patient to identify the stressors that might precipitate
hallucinations or delusions
5. Focus on real people and real events
Physiologic and self care considerations circulation, nutrition, hygiene
1. Catatonic NGT at a later time
Deal with socially appropriate behaviors
Pharmacologic management
1. Antipsychotic Neuroleptics- major tranquilizers
a. MOA: blocks dopamine receptors at the post synaptic area
b. Expected outcome: decrease D and H
c. Mouth check side of cheek and under the tongue >> for
compliance
d. Phenothiazine
i. Thorazine
ii. Mellaril
iii. Trilafon
iv. Nozinan
v. Stelazine
vi. Compazine
vii. Prolixin Flufenazine decanoate Modecate- long acting
form (injectable) 3-4 weeks effects
e. Butyrophenone
i. Haldol
ii. Serenace
f. Atypical
i. Risperdal - risperidone
ii. Clozaril
iii. Zeldox
iv. Seroquel quetiapine ***
v. Abilify
vi. Olanzapine -Zyprexia
g. SE
i. CNS depression
ii. OH
iii. Anticholinergic effects
iv. GI upset after meals
v. Endocrine changes
1. Gynecomastia
2. Amenorrhea
3. Explain that these are SE
vi. Photosensitivity
26

1.
2.
vii. EPS
1.
2.
3.
4.

Protect skin from sun

Walk on shady part of street

High incidence with HALDOL

Akathesia fidgeting restlessness hindi mapakali
Akinesia- feeling of weakness and muscle fatigue
Dystonia protrusion of tongue, opisthotonus,
oculogyric crisis nakatirik lang yung mata
5. Pseudoparkinsonism
a. Pill rolling tremors
b. Mask like facies
c. Shuffling gait
d. Muscle rigidity
e. Inclined forward posture
6. Anti EPS drugs
a. Akineton Biperiden
b. Artane
c. Cogentin- Benztropine
d. Symmetrel or amantadine
e. BENDARYL ***

h. AE

j.

i. Decrease in convulsion threshold

ii. Clozaril at risk for blood dyscrasias
1. Leucopenia reason to stop the drug
2. CBC result
3. Spontaneuous bleeding
4. Mouth sores
5. Elevated temperature with no obvious RTI
iii. Tardive dyskinesia
1. Form of EPS
2. Irreversible
3. Lip smacking, cheek puffing, nguya ng nguya wala
namang kinakain
iv. NMS
1. Hyperthermia above 49-41C
2. Muscle stiffness
3. Severe sweating palpitations
4. Can lead to stupor coma death
ix. Therapeutic milieu
Rehabilitation
i. Compliance to treatment
ii. Independence in activities of daily living
iii. Social skills assistance
iv. Develop more effective coping patterns
1. Thru role playing or rehearsal of new behavior to test the new
behavior***
v. Dealing with future hallucinations
1. Keep yourself busy
2. Ignore his visions and voices to hear
3. Thought stopping client wills himself to stop

GRIEF AND GRIEVING

I.
Normal reaction to real and anticipated loss
II.
Phases Kobler Ross
a. Denial
27

III.

b. Anger
c. Bargaining trade off or exchange; attempt to delay the loss
d. Depression - sad
e. Acceptance
Engel:
a. Shock and disbelief >> awareness of the pain >> acceptance

MAJOR DEPRESSIVE DISORDER

I.
Causes or etiology
a. Cognitive cause: negative mental set, pessimistic
b. Biologic: decrease NE, S; ^MAO- causes destruction of NE and S (endogenous)
c. Psychodynamic unresolved conflict, debilitating life experience, reaction to life
events (exogenous) situation with a theme of loss
i. DLE- early life traumatizing loss; oral need ungratified
II.
Seasonal affective disorders- winter months; light therapy
III.
Dynamics of MDD
a. Loss >> helplessness and abandonment >> anger or hostility >> increase SE >>
guilty and worthlessness >> internalized hostility kikimkimin yung galit >>
depression >> introjections of hostility (suicide)- risk for violence
IV.
Assessment
a. At least 5 of the criteria for a minimum of 2 weeks
i. Sadness
ii. Loss interest anhedonia
iii. Worthlessness/ excessive or inappropriate guilt self depreciation
iv. Psychomotor disturbance slow
v. Diminished ability to concentrate and indecisiveness
vi. Somatic
1. Appetite disturbances no appetite
2. Sleep disturbance insomnia
a. Initial insomnia- matagal na nakahiga, hindi dalawin ng antok
b. Middle insomnia - Mababaw ang tulog at paggising gising
c. Terminal have slept in early part of life but in early morning, he
wakes up and cannot go back to sleep
vii. Recurrent thoughts of death
viii. Suicide when there is lifting already mood >> energized to put into action
the plan
V.
Nursing diagnosis
a. Altered nutrition
b. Anxiety
c. Ineffective individual coping
d. Hopelessness
e. Powerlessness
f. Self care deficit
g. Altered role performance
h. Social isolation
i. Sleep pattern disturbance
j. Risk for violence, self directed SUICIDE
k. Constipation
VI.
Management
a. If suicidal >> priority
b. Provide safety
c. Assess whether suicidal or not
i. Talks about it directly or indirectly
1. I want to die
2. My family will be better off without me
28

d.

e.
f.

g.
h.

i.
j.
k.
l.
m.

n.

o.

3. I would like to rest because I am tired of my life

ii. Are you saying that you want to die? asked by nurse ask direct question
iii. Giving valuables
iv. May find client having harmful objects blade in his wallet, electric cord in
bag
v. Written a farewell note
vi. Put into order his affairs
vii. Change in behavior
viii. Change in mood- lifting of depression
Assess the lethality assessment how determined or deadly is the client?
i. Criteria
1. Plan if there is a plan, more likely to pursue the plan
2. Ask about the means high lethality strangulation ; cutting the risk
low lethality
3. Recent loss
4. Age
a. Adolescent- developmental crisis + situational crisis
b. Elderly they feel that they are useless
5. Sex
a. Male > female
b. Females attempt
c. Male successful
6. Marital status
a. Single, widow, widower > married lack of support
7. Drug user knows what to mix to make a potent formula
8. Client had a previous attempt part of assessment
a. If failed, he could do it again
Monitor client one on one monitoring; close watching; with companion RTC
i. Low lethality check client every 15 minutes
Enter into a NO SUICIDE CONTRACT
i. While he is in the ward, he will not hurt himself
ii. Not a 100% assurance
iii. Go to the nurse when he feels like hurting himself
Plastic utensils, no breakables
Promote a therapeutic relationship
i. Accept patient
ii. Spend time with client
iii. Respond to anger therapeutically kind firmness repetitive monotonous non
gratifying activity
1. Box of coins to catch
Focus on the clients strength
Active friendliness
Art therapy
Music therapy
Create a scheduled and structures but non-demanding environment simplified; no
decision making is required; dont ask the client what activity you want to do today
have a schedule
Promote independence by encouraging patient to perform ADLS
i. Eating sit with the client; if didnt eat direct the client; if ayaw pa rin
spoon feed
Medications
i. Antidepressants
1. Decrease NE and S
2. TCAs- blocks the re-uptake of NE and S; -going back of NT from the
post synaptic to pre synaptic area
29

a.
b.
c.
d.
e.
f.

Tofranil***
Elavil
Norpramine
Anafranil
Dozepin
Disadvantage: have delayed effect- 2-4 weeks; 3-4 weeksinform client to continue medications
3. SSRI specific serotonin reuptake inhibitor
a. S- stimulate tachycardia, irritable, hypomanic episode > report
b. Prozac
c. Zoloft
d. Luvox
e. Paxil
4. MAOI
a. Parnate
b. Nardil
c. Marplan
d. SE- same as TCA
e. OH except taken with tyramine rich fopods >> HPN crisis
i. Tyramine can only be metabolized by MAO
ii. ^Amine ephedrine like effect vasopressor effect
iii. Check BP, HA, tachycardia >> validate again
iv. Tyramine rich foods: processed foods, age cheese
1. ROT: fresh foods are not tyramine rich except
banana, avocado, chicken liver, beef liver
5. Atypical anti depressants
a. Effexor
b. Depresil
c. Remeron mirtazipine
d. Lexapro
ii. ECT
1. 70-150 volts to bring about seizures
2. Neurochemical and neurophysiologic >> similar to the effect of
antidepressants
3. Indications
a. Severe depression- did not respond to medications
b. Acutely suicidal client delayed effects of medications
c. Schizophrenic but did not respond to antipsychotic- catatonic
and paranoid
d. Maniac did not respond to meds
4. CI
a. Cardiac problems ECG to be done first
b. Organic mental disorders- tumor, aneurysms- do EEG
c. With fracture
d. High BP
e. Pregnancy
f. Active bleeding tendency CBC agranulocytosis and
leucopenia
5. Psychological and physical preparations
a. NPO 6-8 hours; 4-6 hours
b. Hospital gown-loose clothing
c. Remove good conductors of electricity
d. Nothing to shave off
e. Void to prevent accidental voiding during the ECT
f. Mouth gag to prevent biting the tongue during ECT
30

6. Types
a. Without sedative- unmodified ECT
b. Modified ECT with pre medications
i. IV pentothal or brevital Na to sedate
ii. Atropine sulfate prevent aspiration
iii. Anectine or succinylcholine HCl- muscle relaxant
1. Too much relax >> respiration muscles >>
aspiration
7. Who applies the electrodes in temple: MD
8. Nurse assistant during the procedure and observe reaction
9. Desired outcome
a. Tonic clonic phases of convulsion same as with epilepsy
10.Right after seizure turn to sides prevent aspiration >> check RR
rerspiration depression
11.Client will be asleep- check VS every 15 minutes until stable
12.Re orient client
13.Check for gag reflex
BIPOLAR DISORDER
I.
With manic episodes
II.
If depressed all manifestations of MDD
III.
Manic episode
IV.
Etiology
a. Biologic genetic
i. Manic - ^S,NE; intracellular Na is increased very excitable cells
b. Psychodynamics
i. Manic as defense against depression >> do not acknowledge that he is
depressed
ii. ^ID >> denial of depression >> reaction formation >> anger >>
externalized >> manic
V.
Manifestations manic
a. Elevated expansive mood/ irritable mood of at least 1 week and at least 3 of the ff:
i. Pleasurable activities laughs a lot, buying spree, hypersexual
ii. ^ in goal directed activities
iii. ^ psychomotor agitation lakad ng lakad >> exhaustion poor prognosis
iv. Inflated self esteem or grandiosity feeling of inadequacy
v. Pressure of speech - nagkakapatong ang sinasabi / loquacious speech
productive and speech di nauubusan ng sinasabi
vi. Flight of ideas or feeling that thoughts are racing
vii. Distractability attention span is very short
viii. Somatic manifestations- nutrition and sleep less no time to eat
ix. Sarcastic they want to hide their own vulnerability; manipulative and
demanding
VI.
Nursing diagnosis
a. Risk for violence
b. Risk for injury
c. Altered nutrition less than body requirements
d. Ineffective individual coping
e. Self care deficit
f. Self esteem disturbance
g. Sleep pattern disturbance
h. Impaired social interaction
i. Altered role performance
VII.
Interventions
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a. Safety for client and others

i. ROT: ^environmental stimuli for client = ^ hyperactive client
ii. Decrease environmental stimuli room farthest from the station
1. Simple room and preferable single room from client
iii. Low pitched and calm approach
b. Limit setting
c. Establish eye contact but do not stare intimidating
d. Wag mas mataas sa kanya kailangan kalevel mo ang patient
e. Side ang kamay with palms up huwag sa likod
f. Verbalize
g. Time out
h. Medicate
i. Verbal limits
j. Restraints
k. When restraining look for help in the crisis team
i. Tell the client why he will be surrounded
ii. Surround the client
iii. Timing to hold client from the back to divert attention
l. Ensure that nutritional and fluid balance needs are met finger foods, foods on the
run, high caloric, high CHON
i. Burger, hotdog, fries
ii. Fluids lithium carbonate- SE polyuria; toxic to renal tubules
m. Use short, simple sentences to communicate
n. Set limits but respond to legitimate complaints
i. Kapag lumabas na nakahubad go back to room
ii. If masturbating go back to room
o. Channel excessive energy into socially acceptable motor activities
i. Writing, cleaning, brisk walking
p. Reinforce reality delusion of grandeur
q. Lithium carbonate
i. Blocks the release and facilitates the reuptake of NE and S; replaces the Na in
the intracellular
ii. There is a affinity with Na and lithium
iii. Needs to be maintained if stopped relapse
iv. Therapeutic serum level 0.6-1.2mEq/L
1. Below 0.5 not therapeutic
2. ^1.5 toxic
v. Regular blood test- serum lithium determination - once every two months
vi. Teach client SE and AE
1. SE and E
a. Fine tremors SE
b. Gross tremors AE
c. Nausea- SE
d. Vomiting earliest manifestation of toxicity AE
e. Diarrhea - AE
f. DHN take fluids upto 3 liters- SE
g. Anuria, oliguria and insipidus AE
h. Gi upset SE after meals
i. Tinnitus = AE
j. Motor incoordination - AE
k. Ataxia AE
l. Confuison AE
m. 3-4mEq/ L organ damage
n. Not allowed to pregnant
o. Regular diet
32

2. Avoid diuretics
vii. Client should not skimp with lithium wag magtitipid; kapag sobra excrete;
kasama ang lithium
COGNITIVE DISORDERS
1.
Organic mental disorders
2.
Affect consciousness, memory, orientation, attention, perception and landuage
disturbance
3.
Delirium acute confusional state
a. Causes
i. Physical illness
1. CHF, uremia, PNM, metabolic disorders, CVA, DHN, infection
ii. Prescription drugs
1. Polypharmacy with drugs with anticholinergic effects
a. Antipsychotic, antihistamine, anti HPN, cardiovascular drugs like
digoxin and diuretics, cimetidine, parkinsonism
4.
Dementia progressive cognitive deterioration
a. Causes
i. Reversible like:
1. Encephalopathy
2. Infections like syphilis
3. Toxic conditions due to substances like alcohol and metal
ii. Non reversible
1. Multi infarct dementia
2. AD
3. PD
4. Picks D
5. Huntingtons chorea - genetic
5.
Delirium
a. Disturbances in LOC with reduced ability to focus, sustain or shift attention
b. Changes in cognition
c. Develops over a short period of time and with a tendency to fluctuate during the
course of the day
i. More intense at bedtime sun downing
6.
Dementia
a. Memory impairment- amnesia may progressively deteriorate
b. 1 or more of the ff disturbances
i. Aphasia, apraxia, agnosia,
ii. Disturbances in executive functions (planning, organizing, sequencing,
abstracting),
iii. Cognitive deficits can cause significant impairment in social and occupational
function
7.
Alzheimers disease
a. Etiology
i. Genetic predisposition
ii. Unknown but with various theories like genetic, toxin, infection, cholinergic
deficit, structural
b. Biologic- acetylcholine- cholinesterase blockers- to minimize deterioration more
quality life
i. Tacrine cognex
ii. Exelon
iii. Aricept
c. Viral
d. Toxic substances aluminum
e. Structural changes
33

i. Neurofibrillary tangles and neuritic plaques nagkabuhol buhol na nerve

fibers senile block dead neurons>> cerebral atrophy
f. Stages
i. Mild stage 2-3 years
1. Amnesia forgetfulness is the hallmark; recent memory first; remote
memory still intact
2. Other cognitive difficulties problem in DM, judgment, reasoning
3. Repetitive questioning
4. Does not want change something new and recent
5. Cannot remember upto last week
6. Maintain consistent environment same >> routine >> predictable
>> knows what to expect
ii. Moderate stage 3-4 years
1. Disoriented and confused
2. Sleep disturbances
3. Wandering
4. The 3 other As
a. Apraxia loss of purposeful body movements self care deficit
safety becomes a priority ; direct client step by step; dont leave
the client unsupervised ; wag mong gawing ang mga bagay na
kaya niya pang gawin, lalong magddeteriorate
b. Agnosia- loss of sensory ability to recognize hindi niya maname yung mga bagay na alam niya before
c. Aphasia loss of language ability
i. Receptive- cannot understand what you were saying and
wht to answer- mute
ii. Expressive first to appear difficulty in finding words to
say; give client to think of what to say, talk at eye level
iii. Severe 5-10 years
1. Personality and emotional changes irritable and violent
2. Deterioration in all areas of function
g. Nursing diagnosis
i. Risk for injury- priority
ii. Altered thought process- memory, confusion, disorientation
iii. Impaired communication
iv. Impaired socialization
v. Altered role performance
vi. Self care deficit
vii. Sleep pattern disturbance
viii. Low esteem
ix. Caregiver role restrain
h. Management
i. Promote safety and protection from injury
1. Rubberized floor
2. No moving objects- gulong
3. Bed yung tama lang
4. Thermoregulation
5. Allow client to wander but he must not be allowed to access the main
door
a. If lost- he should be properly identified; may ID and contact
number
ii. Structure environment and routine
iii. Promote adequate sleep, proper nutrition, hygiene and activity

34

iv.
v.
vi.
vii.
viii.
ix.

1. Time away iwan mo muna siya, balik ka after 30 minutes then

encourage her gain para kumain.
2. Sleep insomnia- do not give sedative at once >> can make patient
more drowsy and more risk for injury; if needed ang sedative- give it
judiciously
3. Delirium sa araw tulog, sa gabi gising
Promote something to do, somewhere to live, someone to love
1. Horticulture planting
2. Reminiscing activity early stage recent memory
Promote interaction and involvement
Provide emotional support
Family or caregiver support
Memory enhancers reorientation tools
1. Calendar, clock, nametag, nameplate
Assess first the condition

EATING DISORDERS
1. Anorexia nervosa starvation client will not eat because of self imposed starvation
a. Poor insight with her eating behavior
b. Causes
i. Biologic decreased S give anti depressants
ii. Psychodynamic
1. With dysfunctional family relationship >> unmeshed type of family
parents are domineering and controlling; protective >> he has
lost control over life >> helpless >> control something >> mouth
>> control over life
2. Manipulation control others
3. She thinks she is fat >> disturbed body image >> wants to lose
weight >> afraid of gaining weight >> client will not eat /
strenuous exercise / diuretics and laxatives / loves to cook
4. Conflicts when growing up too much stressors if you did not eat,
you will not develop the stressors at that age
iii. Social theory
1. Thin is in
c. Assessment
i. Starvation loss weight 15 to 85% of ideal weight >> cachexia
ii. Decrease VS decrease BMR
iii. Decrease FSH and LH amenorrhea for 3 consecutive menses
iv. DHN
v. Fluid and electrolyte imbalance hypoK- cardiac function, hypoNa
vi. Lanugo
d. Stressor >> anxious >> starvation to relieve anxiety >> decrease anxiety:
ineffective coping
e. Achievers, good girl in the family, perfectionist
f. ND
i. Altered NTN less than body requirements
ii. Disturbed body image
iii. Low self esteem
iv. Anxiety
v. Ineffective coping
vi. Disturbed parent child relationship
g. Goal:
i. client will regain her nutritional state best parameter- weight taking OD
1. Early morning, before breakfast, same amount of clothing
35

ii. Increase self esteem

iii. Expression of feeling journal writing
iv. Discharged if regained 15- 85% of lost
h. Management
i. Behavior modification contract whatever that is served, should be taken
30 minutes; 1-2 lbs per week
1. Needs a contract she manipulates
a. Set limits if client engages in starvation
ii. Let client stay in public place
2. Bulimia Nervosa
a. Binge eating
b. Good insight with her eating behavior
c. Binge episode of taking in large amount of food over a short period of time
d. Dynamics
i. Neurochemical depression; decreased S anti depressant
ii. Gives importance to body shape and size
e. Assessment
i. Weight a little below or above the IBW
f. ND
i. NTN
ii. Low self esteem
iii. Ineffective coping
g. Management
i. Set limit to the overeating- adhere to meal schedule- dietician
ii. Facilitate verbalization
iii. Rehabilitation: help client connect; undergo cognitive behavior therapy
PERSONALITY DISORDERS
I.
Aggregate or sum total of physical and mental qualities of a person as he interacts
-----------II.
Developed by genetic, culture
III.
Traits and characteristics; pattern of relationship and behavior >> too rigid or flexible
>> impaired function in social and occupational
IV.
Ego syntonic traits- synchronizes with the ego >> not distressed >> Poor insight
V.
Fixated at certain stage development
VI.
Cluster a odd and eccentric
a. Schizoid shy and timid, introvert, few friends, prefer to be alone, engage in fantasy
and solitary activity, aloof; pre morbid personality of schizophrenic
b. Schizotypal shy and timid but has some delusions not excessive; with magical
thoughts and powers
c. Paranoid does not trust easily, questions loyalty, does not give info, thinks others
are deliberately annoying him, aloof, does not want to be criticized
VII.
Cluster b dramatic, erratic and emotional
a. Antisocial- lack SE control, poor value systems, very lenient learning, inconsistent
discipline, parents are alcoholic and antisocial; persistently violate right of others;
always in police stations for criminal acts; does not feel guilty for wrong acts; very
demanding and manipulative; exploitation from others COCO MARTIN of TAYONG
DALAWA
b. Borderline- either good or bad child; SPLITTING; bad child tantamount to
abandonment(fear) CLING- she gives her all to someone for as long as hindi siya
iiwan; involves in self destruction
c. Histrionic hysterical personality AIRIZ; overly reactive and dramatic; exaggerates
things, describes things in colorful way; OA
36

VIII.

IX.

d. Narcissistic self loving; exaggerated sense of self; she is the best; needs to be
admired; envious type; she wants to be praised
Cluster C anxious and fearful type
a. Dependent depends on others for DM and problem solving, cannot make decision
for himself; follow the flow of tide; low self esteem; lack of confidence, stupid
b. Avoidant avoids relationship, afraid rejection
c. OC personality disorder person is very meticulous, organized, devoted to work in
the expense of pressure; wants things to happen the way he wants, very rigid
Management
a. Withdrawn AF
b. Passive Friendliness- paranoid
c. Manipulative MOF
d. No medications

CHILDHOOD DISORDERS
I.
Autistic pervasive disorders
a. Biologic
i. Genetic
ii. PKU
b. Manifestations
i. Impairment in social interactions
ii. Want inanimate objects- security objects
iii. Not capable of establishing eye contact
iv. Disturbed personal identity
v. Unable to distinguish self and non self uses third person
vi. Repetitive activities head banging, spin around without feeling dizzy, flapping
vii. May have peculiar response to the environment client does not want change;
no reaction to environment
viii. With fantasy world
ix. Does not pay attention to NTN
c. Management
i. Optimize function
ii. Consistent
iii. Accepting
iv. Safe
v. Reality based
vi. Haldol
II.
Separation anxiety disorder
a. SA- normal during first stage of development
b. Separation individuation phase
c. Child has been overprotected; not given experience to be independent
d. Play therapy
e. If with school phobia gradually expose systematic desensitization
III.
ADHD
a. Etiology
i. Genetic
ii. Biochemical Ritalin use; improves attention span of child paradoxic effect
1. Used of foods with preservatives use fresh foods
iii. Minimal brain disorder
iv. Psychosocial factors very loving parents before, then ngayon laging
magkaaway na >> upset client
b. Manifestation
i. Inattention distractibility
ii. Impulsivity
iii. Hyperactivity
37

IV.

V.

c. Diagnosed: first day of class

d. Management
i. Limit setting by calling attention without scolding the child
ii. Non stimulating environment
iii. If in school
1. Activities should be broken down into shorter activities
2. Teach the client what is not acceptable
3. Praise positive behavior
iv. Ritalin give in AM; after meals
1. SE- insomnia
2. Do not give in very young children growth retardation
Conduct Disorder
a. Antisocial disorder for 18 years old and above
b. Manifestations
i. Violations of age related norms school norms
ii. Gang fights
iii. Engage in burglary
iv. Engage in drugs
c. Psychotherapy
Mental retardation sub average intellectual capacity
a. IQ average 90-110
b. Etiology
i. prenatal causes- german measles in first trimester
1. Malnourished
2. PKU
3. Chromosomal aberrations trisomy 21
4. Hydrocephaly
5. anencephaly
ii. Perinatal causes
1. Cerebral anoxia
2. Multiple birth siya ung last na pinanganak
3. Placenta previa
4. Vacuum extraction
5. Forceps delivery
iii. Post natal causes
1. Infections
2. Meningitis
3. Encephalitis
iv. Environmental factors***
1. Lack of sensory stimulation
2. Falls
3. Eats the paint of her crib with lead
c. Classification
i. Profound below 20-25
ii. Severe 25-29-40
1. MA: 0-3; partially contribute to self care
iii. Moderate 40-54-55
1. MA: 3-8; if made to study, can attain grade 2; roam around; trainablechild can learn unskilled and semi skilled work needs some assistance
iv. Mild 55-70
1. MA : 8-12; capable of reaching grade 6; may be educated in vocational
skills at most; needs assistance but not over protected; need to be taught,
needs a lot of patience, routine and repetition; simple to complex; visual
aids; may have difficulty in speech; difficulty using joints involve parents
v. 70-89- borderline MR >> slow learners
38

vi. Optimize function highest na kaya niyang

developmental age and not the chronological age

abutin

mental

age

or

SEXUAL DYSFUNCTIONS
I.
Self awareness
II.
Knowledge
III.
Ability to communicate
IV.
Behaviors to attain the physiologic requirements in sex acts
V.
Sexual appetite or sexual desire seeking out and responding to the sex act
VI.
Persistent and recurrent lack of desire for the sex act sexual desire disorder
VII.
Have sexual desire, but have dislike in sex- sexual aversion disorder
VIII. Arousal initial physiologic response to the sex act
a. Male erection erectile dysfunction
b. Female frigidity sexual arousal disorder
IX.
Orgasm
a. Failure >> orgasmic disorder
X.
Premature ejaculation early ejaculation
XI.
Management
a. Any medical or biological cause for this disorder
b. Psychological >> psychotherapy
XII.
Paraphilias or sexual de- sexual behaviors person engages in certain sexual behaviors
satisfies her instinct in a way that is socially unacceptable or biologically unacceptable
a. Cyber sex- voyeurism
b. Transvestism susuotin yung damit ng opposite sex- cross dressing
i. This brings arousal and satisfaction
c. Fetishism - Personal effects on opposite sex - symbols
d. Pedophilia Preferences children
i. Below age 13
ii. Age gap of 5 years
e. Zoophilia- animal partner
f. Incest- relatives
g. Pyromania fire
h. Klismaphilia- Enema
i. Necrophilia- dead
j. Anal intercourse 2 adult males sodomy
k. Male and boy- pederasty
l. Rubbing frotteurism
m. Sex phone or obscene words Scatologia
n. Satyriasis- excessive coitus for male
o. Nymphomia- excessive coitus for female
p. Fellacio oral stimulation of males
q. Cunnilingus oral stimulation of females
r. Voids on the partner urophilia
s. Defecates on partner - coprophilia

39