BASIC CONCEPTS OF PSYCHIATRIC NURSING

WHAT IS MENTAL HEALTH?

ability to see oneself as others do

fit into the culture and society where one lives.

• a balance between a person’s internal life and adaptation to reality

• a state of well-being in which a person is able to realize his potentials

CHARACTERISTICS OF A MENTALLY HEALTHY PERSON

• Attitude of self acceptance—or the positive acceptance towards

oneself. It includes acceptance of self and self awareness. A person
must also have a sense of self identity, wholeness, belongingness,
security and meaningfulness.

• Growth, development and self-actualization-- The person seeks new

experiences to more fully explore aspects of oneself.

• Integration—a balance of what is expressed and what is repressed

between outer and inner conflicts. This can be measured in part by the
person’s ability to withstand stress, and cope with anxiety.

• Autonomous behavior—involves self-determination, a balance

between dependence and independence, and acceptance of the
consequences of one’s actions. It implies that the person should be
responsible for his decisions, actions, thoughts and feelings. As a
result, the person would develop respect of autonomy and freedom of
others.

• Perception of reality—this includes social sensitivity, respects for the

feelings and attitudes of others.

• Environmental mastery—enables the mentally healthy person to feel

success in an approved role in the society. The person can deal
effectively with the world, workout personal problems and obtain
satisfaction from life.

WHAT IS MENTAL ILLNESS?

inability to see oneself as others do.

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 • not having the ability to conform to the norms of the culture and
society.

• A state of imbalance characterized by a disturbance in a person’s

thoughts, feelings, and behavior. Poverty and abuses are the major
factors which increases mental illness in the home.

WHAT IS PSYCHIATRIC NURSING?

• An interpersonal process whereby the professional nurse practitioner

assists an individual, family, group or community through the
therapeutic use of the self to :

1. to promote mental health

2. prevent mental illness and suffering
3. participate in the treatment and rehabilitation of the mentally
ill

THERAPEUTIC USE OF THE SELF

• It is the main tool of the nurse in the practice of psychiatric nursing.

Main concepts focus on the positive use of the self in the process of
therapy and it requires self-awareness.

• By developing self-awareness and beginning to understand his

attitudes, the nurse can begin aspects of his personality, experiences,
values, feelings, intelligence, needs, coping skills and perceptions to
establish relationships with client. Therapeutic use of the self helps
the patient to grow, change and heal.

JOHARI’S WINDOW—is the basis of the therapeutic use of the self.

Q1—the open quadrant

Q1 Q2 Q2—the blind quadrant

Q3—the hidden quadrant

Q4—the unknown
quadrant
Q3 Q4

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PRINCIPLES THAT HELP EXPLAIN HOW THE SELF FUNCTIONS

1. A change in any quadrant affects all other quadrant.

2. The smaller the quadrant 1, the poorer the communication.

3. If interpersonal learning takes place, quadrant 1 will become larger

and one or more of the other quadrant will become smaller.

4. The goal of increasing self-awareness is to change area of quadrant

1 while reducing the size of other quadrants. This means that the
individual allows genuine emotions to be experienced, identifies
and accepts personal needs and moves the body in free and joyful
ways. It includes one’s thoughts, feelings, memories and impulses.

COMMUNICATION—refers to the reciprocal exchange of ideas between

or among persons.

MODES OF COMMUNICATION:

1. Verbal—occurs through words, spoken or written. It accurately

conveys information but it is less effective means of
communicating and it is only a small part of the total human
communication.

2. Nonverbal—includes all information that are relayed without the

use of spoken or written words, including clues from all of the five
senses.

TYPES OF NONVERBAL COMMUNICATION:

1. Vocal cues—nonverbal qualities of speech. Eg: pitch, tone of

voice, quality of voice, loudness or intensity. It also includes
laughing, groaning,, nervous coughing, and sounds of hesitation
such as “um” and “uh”. These are vital cues of emotion and can be
a powerful conveyor of information.

2. Action cues—body movements, automatic reflexes, posture, facial

expressions, gestures and mannerisms can be particularly
significant.

3. Object cues—speaker’s intentional and unintentional use of all

objects to convey meaning. Eg: dress, furnishings, or possessions
all communicate something about the speaker’s sense of self. It is a
less accurate way of conveying a message than other types of
nonverbal communication.
4. Space—provides another clue to the nature of the relationship
between two persons.
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FOUR ZONES OF SPACE

1. Intimate space—0 to 18 inches between people. This small degree

of separation between two people allows for maximum
interpersonal sensory stimulation. Example: parents with young
children, people who are whispering, sweethearts

2. Personal space—18 inches to 4 feet. Used for close relationship,

Visual sensation is improved. Example: family and friends who are
talking

3. Social space—9 to 12 feet. Less personal and less dependent. It

requires that speech be louder. Example: social, work and business
meetings

4. Public space—12 feet or more. Used in speech giving, and other

public occasions. Example: speaker and audience, small groups
and other informal functions

ELEMENTS OF COMMUNICATION

1. Sender—originator of information

2. Message—information being transferred

3. Receiver—recipient of information

4. Channel—mode of communication

5. Feedback—behavioral or verbal response of the receiver to the

sender

6. Context—setting which communication takes place

PRINCIPLES OF CARE IN PSYCHIATRIC SETTING

• 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 patient’s strengths and assets and not
on his weaknesses and liabilities.

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 • The nurse views the patient’s behavior non-judgmentally, while
assisting the patient to learn more adaptive ways of coping.

• The nurse should explore the patient’s behavior for the need it is
designed to meet and the message it is communicating.

• The nurse has the potentials 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 patient’s behavior.

LEVELS OF INTERVENTION IN PSYCHIATRIC NURSING

1. Primary level—interventions aimed at the promotion of mental

health and lowering the rate of cases by altering the stressors.
Example: health education

2. Secondary level—interventions that limit the severity of a

disorder. Example: case-finding, prompt treatment.

3. Tertiary—interventions aimed at reducing the disability after a

disorder. Example: prevention of complication, active program of
rehabilitation.

CHARACTERISTICS OF A PSYCHIATRIC NURSE

1. Empathy—the ability to sense beyond outward behavior and sense

accurately another person’s inner experiences.

2. Genuineness/Congruence—ability to use therapeutic tools

appropriately.

3. Unconditional positive regard

ROLES OF THE NURSE IN THE PSYCHIATRIC SETTING

1. Ward manager—creates therapeutic environment.

2. Socializing agent— assists the patient to feel comfortable with

others.

3. Counselor—listens to the patient’s verbalization of feelings.

4. Parent surrogate—assists the patient in the performance of

ADL’s.
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 5. Patient advocate—enables the patient and his relative to know
their rights and responsibilities.

6. Teacher—assists the patient to learn more adaptive ways of

coping.

7. Technician—facilitates the performance of nursing procedures.

8. Therapist—explores the patient’s needs, problems and concerns

through varied therapeutic means.

9. Role model—acts as a symbol of health by serving as an example

of healthful living.

THERAPEUTIC COMMUNICATION
• Is an interpersonal interaction between the nurse and the client during
which the nurse focuses on the client’s specific needs to promote an
effective exchange of communication

GOALS OF THERAPEUTIC COMMUNICATION

1. Establish a therapeutic nurse-client relationship

2. Identify the most important concern of the patient at that time

3. Assess the client’s perception of the problem as it unfolds

4. Facilitate the client’s expression of emotions

5. Teach the client and family necessary self-care skills

6. Recognize the client’s needs

7. Guide the client toward identifying the plan of action to a

satisfying and socially acceptable resolution

8. Implement interventions designed to address the client’s needs

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 THERAPEUTIC COMMUNICATION TECHNIQUES

1. Accepting—indicates that you are being receptive.

*Example: “Yes.”, “I know.”

“ I follow what you said.”
Simply nodding

2. Using of Broad Openings—allowing the client to take the initiative to

introduce a topic.

*Example: “How are things going today?”

“How are you today?”
“Where do you want to start?”
“Is there something you’d like to talk about?”

3. Exploring—delving further into the subject or area.

* Example: “Tell me more about it.”

“Would you like to describe it more fully?”
“What kind of work?”

Important: Ask the client questions starting with WHAT,

WHEN, WHERE, HOW but NOT WHY!

4. Using of General Leads—giving encouragement to continue.

* Example: “Go on………..”

“And then…….”
“What else……”
“Tell me more..”

5. Focusing—concentrating on a single point.

* Example: “This topic needs more attention.”

“Of all the concerns you have mentioned, which is
the most troublesome?”

6. Active Listening—just to be there to listen. Eye contact is important.

7. Giving of Information—making available the facts that the client

needs.

* Example: “My name is……….”

“Visiting hours is.….”
“I’m here because…..”
“This medication is…”

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8. Clarification—if the patient said something which seems vague to
you, make an effort to ask him what he meant by it.

* Example: Patient: “I need to go to plung-plang!”

Nurse: “Just what do you mean by plung-plang?”

9. Making observations—verbalizing what the nurse perceives.

Sometimes the client may not be ready to speak.

* Example: “You appear tense.”

“You seem upset when we talk about your job.”
“I noticed that you are biting your lips.”
“I noticed you have combed your hair today.”

10. Offering the Self—making self available.

* Example: “I’ll sit with you for a while.”

“I’ll stay here with you for a moment.”
“I’m interested in your comfort.”

11. Presenting Reality—offering for consideration what is real.

* Example: Patient: “I can hear those voices again.”

Nurse: “I don’t hear the voices.”

Patient: “I see monsters at your back!”

Nurse: “I see no one else at my back.”

Patient: “Come here my daughter.”

Nurse: “I’m not your daughter, I’m Ana, your
Nurse for today.”

12. Restating—repeating the main idea of what the patient has said.

* Example: Patient: “I can’t sleep.”

Nurse: “You can’t sleep?”

Patient: “I’m really mad. I’m upset.”

Nurse: “You’re mad and upset?”

13. Using silence—absence of verbal communication which provides the

client the time to put thoughts and feelings into words. The nurse says
nothing but continues to maintain eye contact.

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14. Voicing Doubts—expressing uncertainty about reality of patient’s
perception.

* Example: Patient: “I’m the king of the world!”

Nurse: “Isn’t that unusual?”

Patient: “I’m the most beautiful girl in the entire

universe!”
Nurse: “Really!”

Patient: “I look like Brad Pitt.”

Nurse: “That’s hard to believe.”

15. Summarizing—recapping what has been talked about

*Example: “Have I got this correct?”

“You have said that…..”
“During the past hour, we have discussed..”

NON THERAPEUTIC COMMUNICATION TECHNIQUES

1. Advising—telling the client what to do.

*Example: “I think you should….”

“Why don’t you……..”

2. Agreeing—approval of what the patient has said. This indicates that

the patient is right.

*Example: “That’s right.”

“I agree.”

3. Belittling feelings—misjudging the patient’s discomfort

*Example: Patient: “I have nothing to live for.”

Nurse: “I feel that way myself.”

Patient: “I’d be better off dead.”

Nurse: “It’s up to you.”

4. Challenging—demanding proof from client.

*Example: Patient: “I’m the great Ferdinand Marcos.”

Nurse: “How can that be, he’s dead already.”

Patient: “I’m dead!”

Nurse: “If you’re dead, why are you breathing?”
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 5. Disagreeing—opposing client’s ideas.

*Example: “That’s wrong!”

“I definitely disagree!”
“I don’t believe that!”

6. Giving literal responses—responding to a comment as though facts

are real.

*Example: Patient: “I can see those spiders.”

Nurse: “Yeah, they sure are big ones.”

Patient: “You’re my long lost sister.”

“Nice seeing you again brother.”

7. Reassuring—making the client feel safe.

*Example: “Everything will be okay.”

“I wouldn’t worry about that.”
“You’re doing just fine.”
“You’ll be safe here.”

8. Rejecting—not addressing the needs of the patient.

*Example: “Let’s not discuss that.”

“I don’t want to hear about that.”
“I’m going to let the doctor talk to you about your
question.”

THE NURSE-PATIENT RELATIONSHIP (NPR)

• Series of interaction between the nurse and the patient wherein the
nurse assists the patient to attain positive behavioral change.

CHARACTERISTICS OF NPR

1. Goal oriented
2. Focused on the needs of the patient
3. Planned
4. Time-limited
5. Professional

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BASIC ELEMENTS OF NPR

1. Trust
2. Rapport
3. Unconditional positive regard
4. Setting limit
5. Therapeutic communication

PHASES OF NPR

1. Pre-orientation phase

• Begins when the nurse is assigned to the patient.

• The patient is excluded as an active participant.

• The nurse feels a certain degree of anxiety.

• It includes all that the nurse thinks and does before

interacting with the patient.

• MAJOR TASK of the nurse is self awareness

• OTHER TASK of the nurse is data gathering and planning

for the first interaction.

2. Orientation Phase

• Begins when the nurse and the patient meet for the patient.

• Parameters of the relationship is done.

• Explanation of roles is done during this phase which

includes the responsibilities and expectation of the patient
and nurse, with the expectations of both parties of what they
can and can’t do.

• The nurse begins to know the patient.

• MAJOR TASK of the nurse is to develop a mutually

acceptable contract.

• OTHER TASK of the nurse is to determine why the patient

sought help, establish rapport, and develop trust and
assessment.

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`
3. Working phase

• It is highly individualized.

• It is more structured than the orientation phase- meaning

most of the therapeutic work is done during this phase.

• It is the longest and most productive phase of NPR. The

nurse and the patient explore stressors and promote insight
in the patient by linking perceptions, thoughts, feelings and
actions. These insights should be translated into actions and
a change in behavior.

• Limit setting is employed.

• MAJOR TASK of the nurse is identification and resolution

of the patient’s problem. The nurse helps the patient master
anxieties, increase his independence, self responsibility and
develop constructive coping mechanisms

• OTHER TASK of the nurse is planning and implementation.

4. Termination phase

• It is the gradual weaning process since it is the most

difficult and important phase of the NPR. During this phase,
learning is maximized by the nurse and the patient.

• It is a mutual agreement. It is a time to exchange feelings

and memories and to evaluate the patient’s progress and
goal attainment.

• It involves feelings of anxiety, fear and loss.

• Termination should be recognized early during the

orientation phase.

• MAJOR TASK of the nurse is to assist the patient to review

what he has learned and transfer his learning to his
relationship with others.

• OTHER TASK is evaluation.

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WHEN TO TERMINATE NPR

• When goals have been accomplished.

• When the patient is emotionally stable.

• When the patient exhibits greater independence.

• When the patient is unable to cope with anxiety, separation, fear and
loss.

HOW TO TERMINATE NPR

• By gradually decreasing interaction time.

• By focusing on future oriented topics.

• By encouraging expression of feelings.

• By making necessary referrals.

COMMON PROBLEMS AFFECTING NPR

1. Transference—the development of an emotional attitude (either

positive or negative) of the patient towards the nurse.

2. Counter-transference—the development of an emotional attitude

(either positive or negative) of the nurse towards the patient.

3. Resistance—development of ambivalent feelings towards self

exploration.

MAJOR THEORIES OF PERSONALITY

• All people go through different stages in life from infancy to old age.
Each stage has its own character and offers its own unique
opportunities for growth.

SIGMUND FREUD— He is an Austrian psychiatrist and the founder of

psychoanalysis. He developed the theoretical formulation of the nature of
human personality.

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MAJOR COMPONENTS OF SIGMUND FREUD’S THEORY OF
PERSONALITY

A. Levels of Awareness
B. Agencies of the Mind
C. Concept of Anxiety and Defense Mechanisms
D. Psychosexual Stages of Development

A. LEVELS OF AWARENESS

1. Conscious—includes all experiences that are within a person’s

awareness, all intellectual, emotional and interpersonal aspects
of a person’s behavior that a person is aware of and able to
control. All information that is easily remembered and readily
available to the individual is in the conscious mind.

2. Preconscious—includes experiences, thoughts and feelings that

might not be in immediate awareness but can be recalled to
consciousness. It is also called subconscious.

3. Unconscious—refers to all memories, feelings and thoughts

that can never be recalled.

B. AGENCIES OF THE MIND

1. Id
• Operates on pleasure principle which refers to seeking
immediate reduction of anxiety.

• It operates on the “primary process” whereby the

individual indulges in hallucinating and forming an
object that will satisfy its needs in the attempt to
remove the tension. *Example: picturing an ice cold
soft drinks relieves the thirst for the moment.

• Reflects basic or innate desire of such as pleasure-

seeking behavior, aggression and sexual impulses.

2. Ego
• It is the executive decision maker

• The agency the is in touch with reality

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 • It operates on reality principle which determines
whether the experience is true or not and whether it has
external existence or not.
• Another function is problem solving.
• Balancing force between ID and superego

3. Superego
• The VOICE of GOD

• Reflects moral, ethical concepts, values, parental and

social expectations.

• It is the direct opposition of the ID

2 SUBSYSTEMS OF SUPEREGO

1. Conscience—refers to the capacity for self evaluation.

When moral codes are violated, the conscience punishes the
person by instilling guilt. A maladaptive example of this
behavior is seen in the extreme condition of depression, in
which people punishes himself for minor actions.

2. Ego ideal—what parents approve of and what they reward

the child for doing. Living up to one’s ego ideal results in
the person’s feeling proud and increases self-esteem.

C. CONCEPT OF ANXIETY AND DEFENSE MECHANISMS

ANXIETY—is the feeling of uneasiness, apprehension and

dread.

DEFENSE MECHANISMS— are methods of attempting to

protect the self and cope with emotionally painful thoughts,
feelings and events.

COMMON DEFENSE MECHANISMS

1. Repression—unconscious forgetting

• *Example: forgetting the name of a person for whom you

have intense negative feelings.

2. Displacement—ventilates feelings to a less threatening object

rather than who proved the fight.

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 • *Example: a husband who was reprimanded by the boss,
got home and kicked the dog.

3. Denial— is the failure to acknowledge something just like an

acceptable behavior or even situation.

• *Example: a drug addict says, “I don’t have a drug

problem.”

• An alcoholic says, “I can quit whenever I want to.”

4. Dissociation—the unconscious separation of painful feelings and

emotions from an acceptable idea, situation or object.

• *Example: a young woman talks about her husband’s

extensive gambling debts as if they were nothing to be
concerned about.

• A n adult remembers nothing of childhood sexual abuse

5. Regression—return to an early developmental stage where the

person feels safer.

• *Example: a person sleeping in a fetal position

• a boy who suddenly wets during the night after the

arrival of an older brother

6. Rationalization—illogical reasoning

• *Example: a student who failed her examination blames

her teacher’s poor lecture materials and teaching ways

• a young man said “I don’t really like the girl anyway”

instead of admitting that she was dumped by the same
girl

7. Reaction-formation—doing the exact opposite of what the person

really feels

• *Example: you greeted a neighbor when in fact you

despise her

• Miss Armi, who unconsciously hates her mother,

constantly tells the staff how wonderful her mother is

• An older brother who dislikes his younger brother sends

him a gift for the holiday

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8. Undoing—doing something good to make up for a wrong doing.

• *Example: a corrupt politician gives relief goods to the

victims of demolition

• After spanking her son, a mother bakes his favorite food

9. Identification—modeling behavior after someone else. This can be

conscious or unconscious attempt to model oneself after a
respected person.

• *Example: a six year old girl dresses up in her mother’s

dress, high heeled shoes, and make up

• a girl says, “When I grow up, I want to be just like my

mom.”

10. Projection—blaming others for one’s fault, escapegoating

• *Example: “Not me but them!”

• A man who is attracted to his friend’s wife,

unconsciously accuses his wife of flirting with his friend

• Karen states that she is using marijuana because her

boyfriend made her smoke it.

11. Introjection—accepting another person’s attitudes, beliefs and

values as one’s own.

• *Example: “Not only them but me.”

• While the mother is away, a young girl disciplines her

sister just like her mother.

• Without realizing it, the patient talks and acts just like her
therapist, analyzing other patients.

12. Suppression—conscious forgetting

• *Example: “I don’t want to talk about it anymore.”

• “I’m closing that chapter of my life already.”

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 13. Sublimation—channeling an impulse into a more productive
endeavor.

• Example: Satisfying sexual curiosity by conducting

sophisticated research about sexual endeavor.

• An adolescent arrested once for stealing later opens a

business that installs security systems in banks.

14. Conversion—anger, fear or anxiety converted to physical

manifestations or symptoms.

• *Example—Ana suddenly becomes blind upon knowing

that her mother died.

• A young girl who witnessed a tragic incident suddenly

becomes blind.

15. Compensation—counterbalancing of any defect of structure or

function. A person attempts to make up for real or imagined
deficiency.

• GMA is short in stature, but she is the president of the

Philippines.

• A man without hands and feet can paint using the mouth
efficiently.

D. SIGMUND FREUD’S PSYCHOSEXUAL STAGES OF DEVELOPMENT

1. 0-18 months —Oral Stage

• The baby is all mouth, getting gratification from sucking or

crying.

• The baby is all “Id” operating on the pleasure principle and

striving for immediate gratification of needs.

• During 4th to 5th month, the ego begins to emerge as the

infant see himself as a separate being from her mother. This
is the beginning of the sense of self.

• When the infant experiences satisfaction of basic needs, a

sense of trust is developed.

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 • If the oral stage is not successful, it will result to fixation
and narcissism.

2. 18 months to 3 years—Anal Stage

• Toilet training is vital.

• Child gains pleasure either by elimination of feces and from

their retention.

3. 3 to 6 years—Phallic Stage

• The child devotes much energy in examining their genitals,

masturbating and expressing interest in sexual matters.

• Boy falls for mommy—Oedipus complex.

• Boy imitates daddy—identification.

• Girl falls for daddy—Electra complex.

• Girl imitates mommy—identification.

• There is penis envy.

• Castration syndrome is present—fear of bodily mutilation.

4. 6 to 12 years—Latency stage

• Sexual energy is channeled to a more productive endeavor,

example is play or studies.

5. 12 years and above—Genital stage

• Emerges at adolescence with the onset of puberty.

Narcissism is redirected towards gratification involving
genuine interaction with other people.

• Sexual attraction, socialization, group activities and

preparation for marrying and raising a family begins to
manifest.

• By the end of the adolescence, the person becomes

transformed from what was originally a pleasure seeking
individual to a more reality oriented or socialized adult.

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 ERIK ERIKSON—he is an American psychoanalyst and a close
follower of Freud. He concentrated on the rational part of personality
or the ego.

ERIK ERIKSON’S PSYCHOSOCIAL STAGES OF DEVELOPMENT

1. 0-18 months—Trust Vs. Mistrust

• major factor—FEEDING

• SUCCESSFUL RESOLUTION (+)—Trust, faith and hope in

the environment develops.

• UNSUCCESSFUL RESOLUTION (−)—suspicion, difficulty

relating to other people.

2. 18 months to 3 years—Autonomy Vs. Shame and Doubt

• major factor—TOILET TRAINING

• (+) —sense of self control and adequacy, realistic self concept

and self-esteem.

• (−) —self doubt, feeling of being out of control of one’s life,

dependence on others for approval, denial of problems.

3. 3-6 years—Initiative Vs. Guilt

• major factor— INDEPENDENCE

• (+) —if sexual curiosity of the child is handled well without

anxiety, initiative develops. There’s ability to initiate one’s own
actions and activities, and there’s sense of purpose.

• (−) —Aggression, sense of inadequacy or guilt.

4. 6-12 years—Industry Vs. Inferiority

• major factor—SCHOOL

• (+) —ability to learn and work.

• (−)—a sense of inferiority, difficulty learning and working.

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 5. 12-18 years—Identity Vs. Role Confusion

• major factor—PEERS

• (+)—a sense of personal identity and fidelity.

• (−)—confusion about who one is

6. 18-25 years--- Intimacy Vs. Isolation

• major factor—LOVE

• (+)—ability to love deeply and commit oneself.

• (−)—emotional isolation and egocentricity.

7. 25-65 years—Generativity Vs. Stagnation

• major factor—PARENTING

• (+)—ability to give and care for others.

• (−)—inability to grow as a person.

8. 65 years and above—Integrity Vs. Despair

• major factor—REFLECTION

• (+)—sense of integrity and fulfillment, willingness to face death,

wisdom.

• (−)—dissatisfaction with life, denial of or despair over prospect

of death.

CONCEPTS ON THE CARE OF PSYCHOTIC PATIENTS

1. DISTURBANCES IN PERCEPTION

• Illusion—misperception of an actual stimuli

• Hallucination—false sensory perception in the absence of external

stimuli

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2. DISTURBANCES IN THINKING

• Neologism—pathological coining of new words.

• Circumstantiability—answers a question but only after giving

excessive unnecessary details

• Word salad—flow of unconnected words that has no meaning

• Perseveration—persistence of a response to a previous question.

Keeps on giving one answer.

• Verbigeration—meaningless repetition of words or phrases.

• Echolalia—pathological repetition of words of others.

• Flight of Ideas—excessive amount of rate of speech composed of

fragmented or unrelated ideas.

• Loose Associations—disorganized thinking that jumps from one

idea to another with little or no evident relation between the
thoughts.

• Clang Association—the sound of the word gives direction to the

flow of thought.

• Delusion—false belief which is inconsistent with one’s knowledge

and culture, fixed false belief not based in reality.

a. Delusional Grandeur—the individual thinks that he is

superior among others.

b. Delusional Persecution—the individual thinks that

someone is out to inflict him danger.

c. Ideas of Reference—the individual thinks that the

news is about him.

d. Erotomania—the individual thinks that everyone likes

him and has a crush on him

• Magical thinking—the individual practices the power that is

unreal.

• Concrete Association—loss of meta communication.

3. DISTURBANCES IN AFFECT
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 • Inappropriate affect—disharmony between the stimuli and
emotional reaction.

• Flat Affect—absence or near absence of emotional reaction.

• Ambivalence—presence of two opposing factors.

• Depersonalization—feeling of strangeness towards oneself.

• Derealization—feeling of strangeness towards the environment.

4. DISTURBANCES IN MOTOR ACTIVITY

• Echopraxia—the pathological imitation of posture or action of

others.

• Waxy Flexibility—maintaining the desired position for long

periods of time without discomfort.

5. DISTURBANCES IN MEMORY

• Confabulation—filling in of memory gaps.

• Amnesia—inability to recall past events.

a. Anterograde Amnesia—loss of memory of immediate

past.
b. Retrograde Amnesia—loss of memory of immediate
past.

• Déjà 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

already visited.

ELECTRO CONVULSIVE THERAPY (ECT)

23
 • It is a form of shock therapy administered by stimulation of cortex of
the brain, using an electrical apparatus with electrodes which fits the
temporal. It was introduced by Doctors Ugo Cerletti and Lucio Bini of
Rome, Italy in 1937.

• The goal is to produce grand mal seizure (tonic clonic). This

eventually resets the brain wave in a more appropriate way and
produces amnesia especially after a traumatic experience.

• The voltage of electrical current that is administered to the patient is

about 70 to 150 volts for about .5 to 1 second.

• The usual number of treatment needed to produce a therapeutic effect

is 6-12 treatments.

• There should be an interval of 48 hours for each treatment.

• Consent should be secured before performing the procedure.

INDICATIONS OF ECT

1. Major Depression
2. Manic Depressive reactions
3. Catatonic Schizophrenia
4. Acute breakdown

CONTRAINDICATIONS OF ECT

1. History of trauma, fracture

2. Increased intracranial pressure
3. Cardiac problems
4. TB with history of hemorrhage
5. Retinal detachment
6. Pregnancy

MEDICATIONS USED PRIOR TO ECT

1. Atropine sulfate

2. Anectine (Succinylcholine)

3. Methohexital Na (Brevital)

COMPLICATIONS OF ECT
1. Loss of memory
2. Headache
24
 3. Apnea
4. Fracture
5. Respiratory depression

COMMON PSYCHOTHERAPEUTIC INTERVENTIONS

APPLIED IN PSYCHIATRIC NURSING:

1. REMOTIVATION THERAPY—treatment modality that promotes

expression of feelings through interaction facilitated by discussion of
neutral topics.

2. MUSIC THERAPY—involves the use of music to facilitate relaxation,

expression of feelings and outlet of tension.

3. PLAY THERAPY—enables the patient to experience intense emotion

in a safe environment with the use of play.

4. GROUP THERAPY—involves therapeutic interactions of three or more

patients with a therapist to relieve emotional difficulties, increase self-
esteem, develop insight and improve behavior relation with others.
The minimum number of members is 3, while the ideal is 10.

5. MILIEU THERAPY—involves client interactions with one another,

example: practicing interpersonal skills, giving one another feedback
about behavior, and working cooperatively as a group to solve day to
day problems.

6. FAMILY THERAPY—form of group therapy in which the patient and

his family members participate. The goals include understanding how
family contribute to the client’s psychopathology, making use of
family’s strengths and resources, restructuring maladaptive family
behavioral styles, and strengthening family problem solving
behaviors.

7. PSYCHOANALYSIS—a method of psychotherapy which focuses on

the exploration of the unconscious. It focuses on discovering the
causes of the patients unconscious and repressed thoughts, feelings
and conflicts believed to cause anxiety and helping the client to gain
insight into and resolve this conflicts and anxieties.

8. HYPNOTHERAPY—involves various methods and techniques to

induce a state where the patient becomes submissive to instructions.

9. HUMOR THERAPY—involves the use of humor to facilitate

expression of feelings and enhance interaction.

25
 10. BEHAVIOR MODIFICATION—a therapeutic intervention involving
the application of learning principles in order to change maladaptive
behavior.

11. TOKEN ECONOMY—an example of behavior modification technique

which utilizes the principle of rewarding for desired behavior to
facilitate change. B. F. Skinner theory.

12. SYSTEMATIC DESENSITIZATION—periodic exposure of the

individual to a feared object, until the undesirable behavior disappears
or is lessened.

13. COGNITIVE THERAPY—short term structured therapy between the

patient and the therapist oriented towards present problems and
solutions. The main focus is depressive disorders.

CRISIS AND CRISIS INTERVENTION

CRISIS—is a turning point in an individual’s life that produces an

overwhelming emotional response. It is a situation that occurs when an
individual’s habitual coping ability becomes ineffective to meet the demand
of the situation.

CHARACTERISTICS OF A CRISIS STATE

• It is highly individualized.
• It lasts for 4-6 weeks.
• The persons that are affected become passive and submissive.
• It affects the person’s support system.

TYPES OF CRISES

1. Maturational/Developmental crises—expected, predictable and

internally motivated. It occurs throughout the life cycle.

*Example: Puberty
Marriage
Parenthood

2. Situational crises—arise from external sources that precipitate a

crisis.

*Example: Loss of job

26
 Death of a loved one
Change in financial status
Pregnancy
Severe physical illness
Additional family members

3. Crises of disaster or Adventitious crises—are not part of everyday

life. They are unplanned and accidental in nature.

It comes from the following:

a. Natural disasters—floods, fires, earthquakes

b. National disasters—wars, riots, coup d’ etat

c. Crimes of violence—rape, murder, spouse and child abuse

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 preoccupied with the crisis and is

unable to do activities of daily living.

• Attempts to recognize—the individual mobilizes previous coping

mechanisms.

ANGER, HOSTILITY AND AGGRESSION

ANGER

• A normal human emotions, is a strong, uncomfortable, emotional

response to a real or perceived provocation.

• It results when a person is frustrated, hurt or afraid.

• Handled appropriately and expressed assertively, anger can be a

positive force that can resolve conflicts, solve problems and make
decisions.

• Although it is normal, it is often perceived as a negative feeling.

27
 • Some people try to express their anger by engaging in aggressive but
safe activities such as hitting a punching bag or yelling. Such is called
catharsis.

HOSTILITY AND AGGRESSION

• Also called verbal aggression, is an emotion expressed through verbal

abuse, lack of cooperation, violation of norms and rules or threatening
behavior.

• A person may express hostility when he feels threatened or powerless.

• Hostile behavior is intended to intimidate or cause emotional harm to

another, and can lead to physical aggression.

ABUSE AND VIOLENCE

ABUSE

• The wrongful use and maltreatment of another person

• Statistics show that abuse is perpetrated by someone known to the

victim.

• Victims of abuse can be a partner or a spouse, a child or an elderly.

BATTERED WIFE SYNDROME (BWS)

• A 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 women is dependence.

CHARACTERISTICS OF ABUSIVE HUSBAND

• They usually come from violent families.

• They are immature, dependent and non-assertive.

• They have a strong feeling of adequacy.

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PHASES OF BATTERED WIFE SYNDROME (BWS)

1. Tension building phase—involves minor battering incidents

HE:
• Has excessively high expectations of her

• Blames her for anything that goes wrong

• Does not try to control his behavior

• Is aware of his inappropriate behaviors but does denies it

• Verbal and minor physical abuse increases

• Afraid she will leave, he gets more possessive

• He gets more controlling

SHE:
• Is nurturing, compliant and tries to please him

• Denies the seriousness of the problem

• Feels she can control his behavior

• Tries to alter his behavior to stay safe

• Blames external factors, alcohol, work

• Takes minor abuse but she does not feel she deserves it

• May call for help as the tension becomes unbearable

2. Acute/serious battering incident—more serious form of incident.

HE:
• Is triggered by an internal, external event or substance

• Hits the wife in private

29
 • Will threaten more harm if she gets help

• Tries to justify his behaviors but does not understand what

happens

• Minimizes the severity of the abuse

SHE:
• May provoke it just to get over it (in cases of long term
battering)

• May call for help if afraid of being killed

• Has initial reaction of disbelief and denial

• Fears more abuse if the police comes, she may plead for them
not to arrest the husband

• Is anxious, ashamed, humiliated, sleepless, fatigued and

depressed

• Does not seek help for injuries for a day or more and lies about
the cause of injuries

3. Aftermath/honeymoon stage—the husband becomes loving and gives

the wife some hope.

HE:
• Is loving, charming, begging for forgiveness, making promises

• Truly believes he will never abuse again

• Feels that he taught her a lesson and she will not “act up” again

• Preys on her guilt to keep her trapped

SHE:
• Sees his loving behaviors as the real person and tries to make
up
• Wants to believe the abuse will never happen again
• Believes in the permanency of the relationship and gets trapped

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*Important: Priority nursing care for battered wife is provision of shelter

CHILD ABUSE

• Is the intentional injury of the child

• In can include physical abuse or injuries, neglect or failure to prevent

harm, failure to provide adequate physical or emotional care or
supervision

TYPES OF CHILD ABUSE

1. Physical abuse—results from unreasonably severe corporal

punishment like hitting, burning, biting, poking, twisting limbs or
scalding with hot water.

2. Sexual abuse—involves sexual acts performed by an adult to a

child younger than 18 years old. Examples include: incest, rape,
and sodomy performed by the person directly by the person or with
an object. Another type of sexual abuse involves exploitation such
as making, promoting and or selling pornography involving
minors.

3. Neglect—is ignorant withholding of physical, emotional or

educational necessities for the child’s well being.

4. Psychological or emotional abuse—includes verbal assault such

as blaming, screaming, name-calling and using sarcasm; constant
family discord characterized by fighting, yelling, chaos; and
emotional deprivation.

*Important: If a nurse suspects child abuse, she has to immediately contact

the child protective services.

ELDER ABUSE

• Is the maltreatment of older adults by family members or the

caretakers.

• It may include sexual abuse, psychological abuse, neglect, financial

exploitation, and denial of adequate medical treatment.
31
 • Most victims of elder abuse are 75 years and older, 60%-65% are
women

• Most cases of elder abuse occur when the elderly is dependent on

others for food, medical care and ADL’s.

RAPE

• Is a crime of violence and humiliation of the victim expressed

through sexual means

• Rape is the perpetration of an act of sexual intercourse with a

female against her will and without her consent.

• 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 (14 to 18 years)

• It requires only slight penetration of the outer vulva; full erection

and ejaculation is not necessary.

• The perpetrator uses threat or force

KINDS OF RAPE

1. Power rape—done to prove one’s masculinity

2. Anger rape—done as a means of retaliation

3. Sadistic rape—done to express erotic feelings

ASSESSMENT:

• Nursing assessment must include questions to determine current or

past sexual abuse.

32
 • To assess woman’s physical status, the nurse asks the victim to
describe what happened. If the woman can’t do so, the nurse may ask
needed questions gently and with care.

• To preserve possible evidence, the physical examination should occur

before the woman has showered, brushed her teeth, douched, changed
her clothes or had anything to drink.

NURSING DIAGNOSIS: Rape-trauma syndrome

NURSING INTERVENTIONS:

• Allow the victim to discuss feelings regarding the assault.

• Communicate knowledge and understanding of emotional responses

to sexual assault to help in the identification of feelings.

• Provide anticipatory guidance regarding common physical,

psychological and social responses.

• Explore relationship with significant others. Encourage the victim to

discuss the situation with trusted and supportive people.

• Advise the patient of the potential for STD’s or pregnancy. Help in

identifying health care provider and offer to accompany to the medical
examination.

• Support decision making and active problem solving. Plan for follow
up phone contact for a few days.

EVALUATION:

• The patient will resume his or her usual lifestyle and social
relationship

ANXIETY AND ANXIETY DISORDERS

ANXIETY
• is the vague sense of impending doom
33
• is a subjective emotional response to stress

• is distinguished from fear, which is feeling afraid by a clearly

identifiable external stimulus that represents danger to a person

• is unavoidable in life and can serve many positive functions such as

motivating a person to take action to resolve a crisis

LEVELS OF ANXIETY

1. Mild Anxiety
• Preparation of the body for constructive action.

• Slight muscle tension.

• Energetic.

• Good eye contact.

• Occasional slight irritability.

• Feeling challenged, confident

• Alert, aware of the surroundings. Concentration.

• Accurate perceptions. Logical reasoning and problem solving.

INTERVENTIONS:
a. Discuss source of anxiety

b. Problem solving strategies

c. Accept anxiety as natural; tolerate and benefit from it.

2. Moderate Anxiety
• Increased blood pressure, pulse and respirations.

• Slight perspiration, difficulty sitting still.

34
 • Periodic slow pacing.

• Increased rate of speech and there’s sporadic eye contact.

• Increased irritability and decreased confidence.

• Difficulty concentrating, easily distracted but can focus with

assistance

• Problem solving and reasoning with effort or assistance.

INTERVENTIONS:
a. Decrease anxiety by ventilation, crying and exercise.

b. Refocus attention. Relate feelings and behaviors and

feelings to anxiety then use problem solving.

c. Give oral medications if needed- anxiolytics

3. Severe Anxiety
• Preparation of the body for fight or flight.

• Extreme muscle tension and perspiration

• Continuous rapid pacing.

• Loud, rapid speech.

• Poor eye contact. There’s sleep disturbance.

• Extreme discomfort, feeling of dread.

• Difficulty focusing even with assistance.

• Flight of ideas, ineffective reasoning and problem solving.

• Suicidal or homicidal ideations if prolonged

INTERVENTIONS:
a. Decrease anxiety, stimuli and pressure.

b. Use kind, firm, simple directions.

35
 c. Use time out.

d. IM injections if needed--anxiolytics

4. Panic
• Actual fight or flight or immobilization.

• Suicide attempts or violence.

• Hysterical or mute.

• Feeling overwhelmed and out of control.

• Desperation. Feeling totally drained.

• Disorganized perception, irrational reasoning and problem

solving.

• Out of contact with reality.

INTERVENTIONS:
a. Guide firmly or physically take control.

b. IM medications--anxiolytics

c. Restraint the person if needed.

ANXIETY DISORDERS AND THEIR SYMPTOMS

1. AGORAPHOBIA—avoidance or places or situations from which

escape might be difficult or help might be unavailable.
• Avoids being outside or at home alone.
• Avoids traveling in vehicles.
• Impaired ability to work.
• Difficulty meeting daily responsibilities (shopping, going to
appointments)
• Admits response is extreme

2. PANIC DISORDER—characterized by recurrent panic attacks

• Panic lasting for 15 to 30 minutes with palpitations, sweating,

smothering sensation, chest pain, nausea, derealization or
depersonalization.
• There’s fear of dying or going crazy; chills or hot flashes.

36
3. SPECIFIC PHOBIA—characterized by significant anxiety provoked by
a specific feared object or situation, which often leads to avoidance
behavior.

• Panic when confronted with the feared object

• Persistent fear of specific things, places or situations
• Disruption of social or work life

4. SOCIAL PHOBIA—characterized by anxiety provoked by certain types

of social or performance situations, which often leads to avoidance
behavior.

• Fear of embarrassment or inability to perform

• Belief that others are judging her negatively
• Impairment in relationships, work or social life

5. GENERALIZED ANXIETY DISORDER—characterized by at least 6

moths of persistent and excessive worry and anxiety.

• Uncontrollable worrying

• 3 of the following symptoms: restlessness, easily fatigued, mind

going blank, irritability, muscle tension, sleep disturbance

• Impaired social functioning

6. POSTTRAUMATIC STRESS DISORDER-- a group of symptoms that

develop after a traumatic event. This may involve death, injury,
witnessing a tragic event that result in death or serious injury of
another person. In PSTD, ordinary coping behaviors fail to relieve the
anxiety.
• Diaphoresis, dyspnea, GI upset, hypertension, tachycardia

• Anger, self-hatred, anxiety, depression

• Avoidance of people or places involved in the trauma
• Difficulty sleeping
• Difficulty concentrating, flashbacks and nightmares of traumatic
experience

7. OBSESSIVE-COMPULSIVE DISORDER—involves obsessions

(thoughts) that cause marked anxiety and/or compulsions (acts) that
attempt to neutralize the behavior.

37
 • Controls anxiety through extreme orderliness, cleanliness or
punctuality
• Needs to be in control
• Is excessively devoted to work and productivity
• Is over conscientious
• Is reluctant to delegate tasks to others

PERSONALITY DISORDERS—CLUSTER A, B, AND C

CLUSTER A

1. Schizotypal Personality Disorder

• Has some cognitive and perceptual distortion, may have ideas

of reference, magical thinking, and preoccupation with ESP
• Maybe viewed as odd in speech and behavior
• Has poorly developed social skills
• Has uncomfortable relationships
• Clothes are ill fitting, do not match and maybe dirty or stained
• Clients often provide unsatisfactory answers to questions, but
coherent
• Clients often experience great anxiety especially around
unfamiliar persons
• Mistrust of others, bizarre thinking and ideas, and unkempt
appearance makes it difficult for these clients to get and keep
jobs

2. Paranoid Personality Disorder

• Uses projection-blames others for own difficulties

• Extremely suspicious of other’s motives
• Is very private
• Expects to be exploited or harmed by others
• Reads hidden meanings into harmless remarks or events
• Doesn’t forgive insults or injuries
• Questions other’s loyalty
• During stress, they may manifest psychotic symptoms
• Is aloof, and may maintain considerable distance from the nurse
• Mood maybe labile
• May appear guarded and hyper vigilant
3. Schizoid Personality Disorder

• Is emotionally cold and detached

38
 • Is withdrawn
• Can’t form warm and spontaneous relationships
• Usually lives alone or in parents home
• Has little need for friendship or intimacy
• Has a solitary lifestyle
• May report no leisure or pleasurable experience
• Has difficulty expressing and experiencing emotions
• Often involved with computers or electronics

CLUSTER B

1. Narcissistic Personality Disorder

• Can’t empathize with others due to intense need for love and
admiration
• Demands much time and attention from others
• Feels special
• Is arrogant and envious
• Expects to be recognized as superior without commensurate
achievements
• Is grandiose
• Views their problems as fault of others
• Hypersensitive to criticisms
• At work, they are ambitious and confident
• They believe that only special and privileged people can
appreciate their unique qualities or are worthy of their friendship

2. Histrionic Personality Disorder

• Uses attention seeking behaviors

• Overly concerned with physical appearance, may overdress
• Can’t tolerate delayed gratification
• Has a seductive appearance or behavior
• Becomes anxious when limits are placed on attention seeking
behaviors
• Has rapid shifts in moods and emotions
• May ignore old friends when introduced to someone who looks
more interesting

3. Borderline Personality Disorder

39
 • Has poorly developed sense of self and is easily influenced by
others
• Struggles with overwhelming feelings of anger and anxiety
• Has intense fear of abandonment
• May commit suicide as a form of intense anger or a form of self-
punishment
• May cling and ask for help one minute then become angry, act
out, and reject all offers of help the next minute.
• Needs others around to maintain sense of self (you + me = self)

4. Antisocial Personality Disorder

• Is aggressive and impulsive

• Acts out conflicts
• Has no regard for rules and norms
• Takes no responsibility for outcomes of own behavior
• Blames others when things go wrong
• Must have immediate gratification
• Believes others are unreliable
• Must have immediate gratification
• Disregards the truth
• Has a poor work history
• Can’t sustain a monogamous relationship

CLUSTER C

1. Dependent Personality Disorder

• Characterized by an intense need to be taken care of

• Remains in an abusive relationship
• Is often pessimistic and self critical, easily hurt by others
• Falls apart if significant other leaves or dies
• Doesn’t trust own judgment, feels incapable of managing on
own
• Needs excessive reassurance and advise
• Lacks self confidence

2. Obsessive Compulsive Personality Disorder

• Controls anxiety through extreme orderliness, cleanliness and

punctuality
• Needs to be in control
• Is excessively devoted to work and productivity

• Is overly conscientious

40
 • Is reluctant to delegate task to others

3. Avoidant Personality Disorder

• Remains aloof in relationships

• Wants friendship but can form them only if assured of not getting
hurt. Doesn’t like surprises
• Is preoccupied with fear of being criticized or rejected in social
situations
• Feels inferior to others

EATING DISORDERS

ANOREXIA NERVOSA—the client deliberately starves herself or

engages in binge eating and purging. The client wants to be as thin as
possible and refuses to maintain an appropriate weight. A key clinical
finding is a refusal to sustain weight at or above minimum requirements
for age and height.

• Denies that eating pattern is abnormal

• Loses significant amount of body weight
• Is perfectionist
• Copes with stress by starving self
• Denies feeling fatigued
• Exercises compulsively
• Tightly controls food intake
• Feels powerful over abstaining from food
• Secretive
• Overwhelmed by fear of losing control
• High achiever

NURSING DIAGNOSIS:

• Imbalanced nutrition
• Disturbed body image
• Chronic low self-esteem

41
DRUG THERAPY:

• Anti-anxiety agents (Xanax)

• Antidepressants (Tofranil)
• SSRI: fluoxitine (Prozac)

IMPLEMENTATION:

• Obtain a complete physical assessment.

• Make a contract for amount of food to be eaten.

• Provide one on one support before, during and after meals to foster
a strong NPR.

• Prevent the client from using the bathroom for 90 minutes after
eating.

• Encourage verbal expression of feelings.

• Help the client identify coping mechanisms for dealing with

anxiety.

• Help the client learn ways to satisfy personal, unmet needs.

• Weigh the client once a week at the same time of the day using the
same scale.

• Discuss the client’s perception of appearance. Explain that she has

the right to think of herself as beautiful.

BULIMIA NERVOSA—is characterized by episodic bingeing on food,

followed by purging in the form of vomiting.

• Recognize that eating pattern is abnormal.

• Keeps weight within normal range.
• Copes with stress by bingeing.
• Admits feeling fatigued.
• May or may not exercise strenuously.
• Is unable to control food intake.
• May abuse alcohol.
• May be suicidal after bingeing.
• Secretive with food.
• Low self-esteem may prevent achievement.

42
NURSING DIAGNOSIS:

• Imbalanced nutrition
• Anxiety
• Powerlessness

DRUG THERAPY:

• SSRI

IMPLEMENTATION:

• Perform a complete physical assessment.

• Explain the purpose of nutritional contract.

• Avoid power struggles around food.

• Prevent the client from using the bathroom for two hours after eating.

• Provide one on one support before, during and after meals.

• Encourage the client to express feelings.

SOMATOFORM DISORDERS

CONVERSION DISORDER—exhibits symptoms that suggest a physical

disorder, but observation and evaluation can’t determine a physiologic
cause. The onset of symptoms is preceded by psychological trauma, conflict,
and the physical symptoms are the manifestations of the conflict.

• Aphonia
• Blindness
• Deafness
• Dysphagia
• Impaired balance and coordination
• Loss of touch sensation
• Lump in the throat
• Paralysis
• Seizures
• Urinary incontinence

43
NURSING DIAGNOSIS

• Ineffective individual coping

• Anxiety

DRUG THERAPY

• Benzodiazepines: alprazolam (Xanax), lorazepam (Ativan)

IMPLEMENTATION

• Maintain safe environment.

• Establish a supportive acceptance of the client but keep the focus

away from the symptoms.

• Review all laboratory and diagnostic study results.

• Encourage the patient to identify any emotional conflicts occurring

before the onset of the symptoms.

• Promote social interaction

• Review teaching topics with the client and family.

HYPOCHONDRIASIS—the client is preoccupied by fear of the serious

illness, despite medical assurance of good health. The client interprets all
physical sensations as serious illness, impairing his ability to function
normally.

• Abnormal focus on bodily functions and sensations.

• Anger, frustration, depression.
• Frequent visits to doctors and specialists despite assurance from
health care providers that the client is healthy.
• Intensified physical symptoms around sympathetic people.
• Rejection of the idea that the symptoms are stress related.
• Use of symptoms to avoid difficult situations.

44
NURSING DIAGNOSES

• Deficient knowledge
• Ineffective individual coping
• Ineffective health maintenance

DRUG THERAPY

• Benzodiazepine: lorazepam (Ativan)

• Tricyclic antidepressants: imipramine (Tofranil), doxepin (Sinequan)

IMPLEMENTATION

BODY DYSMORPHIC DISORDER

• Preoccupation with an imagined or exaggerated defect in physical

appearance such as thinking one’s nose is too large or teeth are
crooked and unattractive.

CHILD AND ADOLESCENT DISORDER

ATTENTION DEFICIT HYPERACTIVITY DISORDER

• Previously called Attention Deficit Disorder. The child displays long-

term behaviors such as hyperactivity, impulsiveness and inattention.
Males are affected more frequently than females.

ASSESSMENT FINDINGS:

• Climbs, runs, talks excessively

• Decreased attention span
• Difficulty organizing tasks and activities
• Difficulty waiting for turns
• Easily distracted
• Fails to give close attention to school works or activities
• Fails to listen when spoken to directly
• Unable to follow directions

45
NURSING DIAGNOSES:

• Impaired Social Interaction

• Ineffective Family Coping
• Risk for Injury
• Risk for deficient parenting

DRUG THERAPY:

• Methylphenidate (Ritalin)
• Atomoxetine (Straterra)

IMPLEMENTATION:

• Monitor growth.—if the child is receiving methylphenidate, growth

maybe slowed

• Give one simple instruction at a time so the child can successfully

complete the task.—promotes self-esteem

• Give one medication in the morning and at lunch.—avoids interfering

with night sleep

• Ensure adequate nutrition—hyperactivity and medications may cause

increased nutrient needs

• Reduce environmental stimuli—decreases destruction

• Formulate a schedule for the child—provides consistency and routine

EVALUATION:

• The child can focus and do his task better.

AUTISTIC DISORDER

• A severe impairment of reciprocal interaction skills, communication

and restricted stereotypical behavioral patterns.

• It is most common in boys than in girls and is identified no later than

3 years of age.

ASSESSMENT FINDINGS:
46
 • Displays little eye contact and makes few facial expressions towards
others.
• Doesn’t use gestures to communicate and doesn’t relate to peers and
parents.
• Lacks spontaneous enjoyment, has no moods or emotional affect.
• Likes to play with blocks and not balls.
• Not cuddly.
• Has little intelligible speech.
• Engages in stereotyped motor behavior such as hand flapping, body
twisting, worst of all head banging.

NURSING DIAGNOSES:

• Risk for injury

• Impaired Social Interaction
• Ineffective Family Coping

DRUG THERAPY:

• Haloperidol (Haltom); risperidone (Risperdal)—for temper tantrums,

aggressiveness, self injury, hyperactivity and stereotyped behaviors

• Naltrexone (ReVia); clomipramine (Anafranil)—to diminish self

injury, hyperactive and obsessive behaviors

IMPLEMENTATION:

• Comprehensive and individualized treatment including special

education and language therapy.

CONDUCT DISORDER

• Characterized by persistent antisocial behavior in children and

adolescents that significantly impairs their ability to function in social,
academic and occupational areas.

• Symptoms are clustered in 4 areas: aggression to people and animals;

destruction of property; deceitfulness and theft; and serious violation
of rules.

• People with conduct disorder have little empathy for others, have low
self-esteem, poor frustration tolerance, and temper outbursts.

47
 • It is frequently associated with early sexual behavior, drinking,
smoking and use of illegal substances.

• Is classified as : Minor—includes lying, staying out late without

permission. Moderate—vandalism and theft. Severe—forced sex,
cruelty to animals, use of weapons, robbery.

NURSING DIAGNOSIS

• Ineffective Coping
IMPLEMENTATION:

• Encourage the client to discuss feelings.—initial step toward dealing

with problems in appropriate manner.

• Give positive feedback for discussions—increases the likelihood of

continued performance.

• Tell the client that he is accepted as a person, although a particular

behavior is not acceptable—the client needs support to increase self
esteem.

• Teach the client about limit setting—explain how limits can be

beneficial.

• Help the client to practice problem solving process with daily

situations—his abilities and skills will increase with practice.

ALZHEIMERS DISEASE

• Impairment of cognitive functioning, memory and personality. The

dementia or forgetfulness occurs gradually but with continuous
decline and damage is irreversible.

ASSESSMENT FINDINGS:

• Forgetfulness—inability to recall factual information and events.

• Inability to learn new things or recall previously learned materials.
• Noticeable changes in mental status and personal appearance.
• History of getting lost—wandering behavior.
• There’s memory gap—inability to complete activities of daily living.
• There’s poor judgment.

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NURSING DIAGNOSES:

• Impaired Memory
• Self-care Deficit
• Caregiver Role Strain

DRUG THERAPY:

• Anticholinesterase agent—donepezil (Aricept), tarring (Cognex),

Memantine (Namenda)

IMPLEMENTATION:

• Provide opportunities for reminiscence (One-on-one, or small group)

—usually an enjoyable activity.

• Use written cues (calendar, notebook, lists)—decreases need of

clients to recall appointments and activities without assistance.

• Establish routine of activities and structured environment.—less

demand on memory function.

• Provide simple directions—clients can’t remember complicated ones.

• Do not rush the patient to do things.—to maximize independent

functions

• If the patient is to be cared for at home, instruct the family to install

alarms at all exit doors.—provide for client’s safety.

SCHIZOPHRENIA

• Causes distorted and bizarre thoughts, perceptions, emotions,

movements and behavior.

• Usually diagnosed in late adolescence or early adulthood.

TYPES OF SCHIZOPHRENIA

1. Paranoid type—characterized by persecutory or grandiose

delusions, hallucinations, hostile and aggressive behavior.

2. Disorganized Type—characterized by grossly inappropriate or flat

affect, incoherence, loose associations and extremely disorganized
behavior.
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 3. Catatonic Type—characterized by marked psychomotor
disturbance, either motionless or excessive motor activity. Motor
immobility maybe manifested by catalepsy or stupor. Other
features include extreme negativism, mutism, echolalia, and
echopraxia.

4. Undifferentiated Type—characterized by mixed schizophrenic

symptoms along with disturbances of thought, affect and behavior.

5. Residual Type—characterized by at least one previous though not

a current episode: social withdrawal, flat affect, and loose
associations.

NURSING DIAGNOSES:

• Disturbed Thought Processes

• Ineffective Individual Coping
• Self-care Deficit

TREATMENT:

• ECT
• Family therapy
• Milieu therapy

DRUG THERAPY

• Antiparkinsons agent—Benztropine (Cogentin), Trihexyphenidate

(Artane), Biperiden (Akineton), Amantadine (Symmetrel), Diazepam
(Valium), Lorazepam (Ativan)—for EPS or extra pyramidal side
effect

a.Extrapyramidal side effects

1. Dystonia—toticollis and oculogyric crisis

2. Pseudoparkinsonism—shuffling gait, mask like facies,

cofwheels rigidity, droolings, and akinesia.

3. Akathisia

b.Tardive dyskinesia

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 c.Neuroleptic Malignant Syndrome

• Antipsychotic drugs—fluphenazine (Zyprexia), Olanzapine

(Risperdol),thioridazine(Mellaril), Chlorpromazine (Thorazine),
Haloperidol (Haldol)

IMPLEMENTATION:

• Provide skin care—patients who are taking antipsychotics have

photosensitivity.Providing skin care prevents skin breakdown.

• Monitor intake and output—body weight may decrease as a result of

inadequate intake.

• Monitor for adverse effects of antipsychotic drugs—early

identification can help diminish client’s anxiety about these
symptoms.

• When discussing care, give short and simple explanations at the

client’s level of understanding—to increase cooperation.

• Provide appropriate measures to ensure client’s safety and explain to

the client why you are doing so.—implementing and explaining safety
measures can promote trust and decrease anxiety while increasing
the client’s sense of security.

• Promote a trusting relationship—to create safe environment in which

the client can practice social interaction.

BIPOLAR DISORDER

• Involves extreme mood swings from episodes of mania to episodes of

depression.

• During manic phases: Clients are euphoric, grandiose, energetic and

sleepless. They have poor judgment and rapid thoughts, actions and
speech. Major symptoms of mania are the following:

1. Heightened mood, grandiose.

2. Exaggerated self-esteem.
3. Sleeplessness.
4. Pressured speech.
5. Flight of ideas.
6. Easily distracted.
7. High risk activities.

• During depressed phases, mood, behavior are the same as in people

diagnosed with major depression.

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 • If a person’s first episode of the bipolar illness is a depressed phase,
she might be diagnosed as having major depression and a diagnosis of
a bipolar disorder will not be made until the person experiences a
manic episode.

• It occurs equally among men and women. It is more common in

highly educated people.

NURSING DIAGNOSIS

• Risk for Injury

• Risk for Other Directed Violence
• Imbalanced Nutrition—Less than the body requirement
• Ineffective Coping
• Noncompliance
• Ineffective Role Performance
• Self-care Deficit
• Disturbed Sleep Pattern

DRUG THERAPY:

• Antimanic agent (Lithium)

• Anticonvulsants like carbamazine (Tegretol), gabapentin (Neurontin),

topiramate (Topamax)

IMPLEMENTATION:

• Providing for safety.

• Providing therapeutic communication.

• Promoting appropriate behaviors.

• Managing medications.

• Providing family and client teaching.

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