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PSYCHIATRIC NURSING Interpersonal process whereby the professional nurse practitioner through the therapeutic use of self, * assist an individual, family, group or community to promote mental health, * to prevent mental illness and suffering, * to participate in the treatment and rehabilitation of the mentally ill and if necessary * to find meaning in these experiences. It is both a Science and an Art.

CORE of Psychiatric Nursing: Interpersonal Process ( Human to human Relationship Therapeutic use of Self the main tool of the nurse in the practice of psychiatric nursing - The positive use of ones self in the process of therapy - It requires self-awareness HISTORY

Linda Richards is called the first American Psychiatric nurse. She believed that the mentally sick should be at least as well cared for as the physically sick She graduated from the New England Hospital for Women and Children in Boston (1873) The first training of nurses to work with persons with mental illness was in 1882 at McLean Hospital in Waverly, Massachusetts. The nurses adapted medical-surgical principles to the care of clients with psychiatric disorders and treated them with tolerance and kindness. Somatic therapies for the treatment of mental disorders were developed. Treatment such as 1. insulin shock therapy (1935) 2. psychosurgery (1936) 3. electroconvulsive therapy (1937) In 1920, the first psychiatric nursing textbook Nursing Mental Diseases by Harriet Bailey > John Hopkins was the first school of nursing to include a course in psychiatric nursing in its curriculum (1913) > Hildegard Peplau (nursing theorist) shaped psychiatric nursing practice. He published Interpersonal Relations in Nursing (1952) and Interpersonal Techniques: The crux of Psychiatric Nursing (1962). She described the therapeutic nurse-client relationship. > June Mellow (nursing theorist) described her approach (Nursing Therapy) focusing on clients psychosocial needs and strengths (1986) > In 1973, the division of psychiatric and mental health practice of the American Nurses Association developed standard of care, which it revised in 1982, 1994 and 2000. > Standards of care are authoritative statements by professional organizations that describe the responsibilities for which nurses are accountable ANCIENT TIMES: - Punishments for sins and wrong doing - Viewed as either divine or demonic, depending on their behavior Aristotle (383-322 BC) relate disorders to physical disorders and his theory that amounts of blood, water and yellow and black bile in the body controlled the emotions. (corresponds with happiness, calmness, anger and sadness). Tx: blood-letting, starving, and purging (til 19th century) Early Christian Times (1-1000 AD) Mentally ill were viewed as possessed Tx: Priests performed exorcism. When failed they used more severe and brutal measures such as incarceration in dungeons, flogging and starving

Rennaisance (1300-1600)
Distinguished from criminals

1547 Hospital of St. Mary of Bethlehem was officially declared as hospital for the insane.

1775 charged for a fee for a privelege of viewing and ridiculating the inmates who
were seen as animal rather than human.

Period of Enlighnment (1790)

Philippe Pinel in France and William Tukes In England formulated the concept of ASYLUM. Insane no longer treated as less than human Human dignity upheld

Period of Scientific Study Sigmund Freud (1856-1939) studied the mind, its disorders and their treatment Emil Kraepelin (1856-1926) classify mental illness according to their symptoms Eugene Blueler (1857-1939) coined the term Schizophrenia

> Period of Psychotropic drugs - Lithium (1949) - Chlorpromazine (Thorazine) (1950) - MAOIs - Haloperidol (Haldol) - TCAs - Benzodiazepines > Community Mental Health (1963) - Individuals do not need to be hospitalized away from family and community; people have the right to be treated in their own community. > Decade of the Brain (1990) - An increase in funding for brain research, leading to new treatment strategies; has increased our understanding of mental disorders. BEHAVIORAL SCIENCES From the concept of Anthropology 1. All people are influenced by the culture into which they are born 2. Cultural factors including race, nationality and religion. 3. Groups that share a common race, nationality, religion, or language are known as ethnic groups. 4. Society as a whole frequently develops a fixed set of expected responses for certain ethnic group. 5. When each member of an ethnic group is expected to respond in a specific manner, the expected responses are called STEREOTYPES. 6. Cultural variability occurs in all stages of the life cycle: Child rearing, marriage patterns, health maintenance etc. From the Concept of Sociology 1. Every human society has institutions for the socialization of its members: a. Group establishes rules and code of conduct governing its members then these becomes the norms, values and mores of the group; b. Controls established through a system of rewards and punishment. 2. Development of society requires sanction of group members.

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3. A society is a reflection of all functional relationship that occur among its individual member. 4. Society or a group can change because of conflict among members. Examples of Conflict: a. Absence of certain members b. Introduction of new members c. A change in relationship d. Tension e. Integration ( learn about the others problem ) How to restore and resolve Conflict? - When people interact with one another and the group is dynamic (forceful) The primary group is the FAMILY Other Group :

CHANGES: Families become nuclear Altered male and female role pattern. Concepts from Neuroscience (Neurophysiologic Theory) 1. Neurobiologic system and their relationship to health and illness. 2. Knowledge gap still exist as to the specific mechanisms of causation for many psychiatric disorders. 3. There is no real division between ( the mind and body, the mental and physical, and the brain and thought ) 4. The Brain, like other organs, is vulnerable to disease. 5. Neuroscience encompasses Anatomy, Physiology, Biochemistry, Genetics, Neuro Imaging, Physics, Pharmacology, neurology, Neurosurgery, immunology, psychiatry, psychology, electronics, and Computer Science. Psychosocial Theories SIGMUND FREUD - Father of Psychoanalysis - Developed the psychoanalytic in the late 19th and early 20th century - He support the notion that all human behavior is caused and can be explained (deterministic theory. - Sigmund Freud believed that repressed (driven from conscious awareness) sexual impulses and desires motivate much human behavior - He also conceptualized Personality Structures. 3 Components: 1. Id reflects the innate desires such as pleasure seeking behavior, aggression and sexual impulses. - ID seeks instant gratification, causes impulsive, unthinking behavior and has no regards for rules or social convention. 2. Superego - part of a persons nature that reflects moral and ethical concepts, values and parental and social expectations. - Direct opposition to the ID 3. EGO is the balancing or mediating force between the ID and the superego. - Represents the mature and adaptive behavior that allows a person to function successfully. Ego Defense Mechanisms Defense Mechanism are automatic and usually unconscious processes or act by the individuals to: 1. Reduce or cope anxiety or fear. 2. Resolve emotional or mental conflict. 3. Protect ones self-esteem. 4. Protect ones sense of security.

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5. DM becomes pathologic when overused. 6. Used by both mentally healthy and mentally ill individuals. Common Defense Mechanisms 1. Compensation an attempt to overcome a real or imagined short coming, inferiority, inabilities and weaknesses. 2. Conversion emotional problems are converted to physical symptoms. 3. Denial failure to acknowledge an intolerable thought, feeling, experience or reality. 4. Displacement the redirection of feelings to a less threatening object. 5. Fantasy conscious distortion of unconscious feelings or wishes. 6. Fixation an unhealthy mechanism which is an arrest of maturation at certain stages of development. 7. Introjection symbolic assimilation or taking into oneself a love/hatred object. Derived from the word introject which means to take into or ingest. 8. Identification an individual integrates certain aspects of someone elses personality into ones own. 9. Intellectualization an overuse of intellectual concepts by an individual to avoid expression of feelings. 10. Projection attributing to others ones unconscious wishes/fear. - Literally means to throw away 11. Reaction-Formation expression of feelings that is the direct opposite of ones real feeling. - Also referred as overcompensation 12. Rationalization- an individual finds a justifiable cause and acceptable reasons just to be saved from an embarrassing and anxiety producing thoughts or situations. 13. Regression is the turning back to earlier patterns of behavior in solving personal conflicts. - Commonly seen to schizophrenic patients. 14. Repression it is the involuntary or unconscious forgetting of an unpleasant ideas or impulses 15. Suppression permits the individual to store away or consciously forget the unpleasant, painful and unacceptable thoughts, desires, experiences, and impulse. 16. Substitution replacing the desired unattainable goal with one that is attainable 17. Sublimation the redirection of unacceptable instinctual drive with one that is socially acceptable. 18. Symbolization less threatening object is used to represent another. 19. Undoing an attempt to erase an act, thought, feeling, guilt or desire. Freud also believed that the human personality functions at 3 levels of awareness: Conscious refers to the perceptions, thoughts and emotions that exist in persons awareness. Pre-conscious thoughts and emotions are not currently in the persons awareness but he or she can recall them with some effort. 3. Unconscious realm of thoughts and feelings that motivate a person even- though he or she is totally unaware of them. Stages of Psychosexual Development 1. Oral ( 0-18 months) area of gratification is the mouth. months) - Id present at birth; ego develops gradually from rudimentary structure present at birth. Pleasures: sucking activities like fingers, toes or nipples. Dissatisfaction : resurface at a later * overeating, smoking, nail-biting Nursing Implication: Provide oral stimulation by giving pacifiers. - Breastfeeding may provide more stimulation b. Do not discourage thumb sucking. 2. Anal Stage ( 18-36 months ) - childrens attention is focused on the anal region.

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Pleasure: Elimination Covers the ideal age for toilet training 2 Concepts: = holding on = letting go Possible Problem: - Compulsive need to be clean and orderly - Frugality and stinginess - Greed - Insistence on doing things at ones own rate at the expense of others. - Rigid training - Excessive messiness and disorderly habits. Nursing Implication: a. Help children achieve bowel and bladder control without undue emphasis on its importance. 3. Phallic / Oedipal (3-5 years) Pleasure: genital organ Activities associated with stroking and manipulating their sex organs - Oedipus complex - Electra complex - Concepts: onset of normal homosexuality Nursing Implications: Accept childs sexual interest Help the parents answer childs questions about birth or sexual differences. 4. Latency Stage ( 5-11 or 13 years ) Resolution of Oedipal Complex Disturbing behaviors are buried in the subconscious mind Period of calmness / stable period Formation of the superego Energies are absorbed by the concerns in school, peers, sports, and other recreational activites. Nursing Implication: Help the child have positive experiences, 6. Genital Stage (11-13 years old) Oedipal feelings are reactivated toward opposite sex ( capacity for orgasm ) The person is on his way in establishing a satisfying life of his own Nursing Implication: a. Provide appropriate opportunities for the child to relate with opposite sex. b. Allow child to verbalize feelings about new relationships. Erik Erikson Psychosocial Development Theory Childhood is very important in personality development Rejected Freuds attempt to describe personality solely on the basis of sexuality. Different tasks allows the person to achieve life virtues: love, wisdom, caring, hope, purpose and fidelity. STAGE 1 Period of Life Psychosocial Crisis Relationship with : Infancy, 0-18 months ( Hope ) : Trust Versus Mistrust : Maternal person

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Positive resolution : Reliance on the caregiver : Development of trust in the environment : Fear, anxiety and suspicion : Lack of care, both physical and psychological by caretaker leads to mistrust of environment

Negative resolution

Stage II Period of Life

: Toddler, 18 mos. To 3 yrs. ( Willpower) : Autonomy versus Shame and Doubt : Paternal person : Sense of self-worth : Assertion of choice and will : Environment encourages independence, leading to sense of pride : Loss of self-esteem : Sense of external control may produce self-doubt in others

Psychosocial Crisis Relationship with Positive Resolution

Negative Resolution

Stage III Period of Life Psychosocial Crisis Relationship with Positive resolution

Preschool, 3 6 years (Purpose) Initiative Versus Guilt Family Ability to learn to initiate activities, to enjoy achievements and competencies

Negative Resolution

- Inability to control newly developed power -Realization of potential failure leads to fear of punishment and guilt

Stage III Period of Life Psychosocial Crisis Relationship with Positive resolution Preschool, 3 6 years (Purpose) Initiative Versus Guilt Family Ability to learn to initiate activities, to enjoy achievements and competencies - Inability to control newly developed power -Realization of potential failure leads to fear of punishment and guilt

Negative Resolution

Stage IV Period of Life Psychosocial Crisis Schooler, 6-12 years (competence) Industry versus Inferiority

Relationship with Positive Resolution

Neighbors/School Learning the value of work Acquiring skills and tools of technology Competence helps to order life and make things work

Negative resolution

Repeated frustrations and failures lead to feelings of inadequacy and inferiority that may affect their view of life

Stage V P.O.L. P.C. Relationship with Pos. Resol.

Adolescent, 12 to 18 (Fidelity) Identity versus Role Confusion Peer Group Experiments with various roles in developing mature individuality

Neg. Resol.

Pressures and demands may lead to confusion about self

Stage VI P.O.L. P.C. Rel. with Pos. Resol.

Young Adult, 18-24 yrs, (Love) Intimacy versus Isolation Partners in Friendship A commitment with others Close heterosexual relationship and procreation

Neg. Resol.

Withdrawal from such intimacy, isolation, self-absorption and alienation from others.

Stage VII

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P.O.L. Middle Adult, 24-54 years (Care)

P.C.

Generativity versus Self-Absorption

Rel. with

Partner

Pos. Resol.

-The care and concern for the next generation -Widening interest in work and ideas Self-indulgence and resulting psychological impoverishment

Nsg. Resol. Nsg.

Stage VIII P.O.L.

Late Adult, 54 years to death, (Wisdom)

P.C. Rel. With Pos. Resol.

Integrity versus Despair Mankind - Acceptance of ones life - Realization of inevitability of death - Feeling of dignity and meaning of exixtence

Neg. Resol.

Disappointment of ones life and desperate fear of death

Jean Piaget Cognitive Development Theory SENSORIMOTOR (0-2 YEARS) Development proceeds from reflex activity to sensory motor learning. Begins to organize visual images and control motor responses. Pre-verbal stage PRE-OPERATIONAL STAGE (2-7 years) 2-4 years pre-conceptual: development proceeds from sensory motor learning to prelogical thought - the child learns language and symbols 4-7 years intuitive thought: the child is able to think in terms of class - the child is able to determine that individuals have roles CONCRETE OPERATIONAL STAGE 7-12 years development proceeds from pre-logical to logical concrete thought Ability to think of the possible consequences of actions FORMAL OPERATIONAL STAGE (12 to Adulthood) Full patterns of thinking Ability to use logic and symbolic processes (mathematical and scientific reasoning) Combinatorial thinking- multidimensional approach

Harry Stack Sullivan Interpersonal Model Focused on the role of the environment and interpersonal relations the most significant influences on a individuals development Anxiety is communicated interpersonally Hildegard Peplau (1909-1999) She developed the concept of therapeutic nurse-patient relationship STAGES/PHASES OF NPR: 1.Orientation Phase begins when the nurse and client meet and ends when the client begins to identify problems to examine. Nurse begins to build trust with the client. Nurse should listen closely to the clients history, perceptions, and misconceptions Provide support and empathy of pts feelings Major Task: to provide mutual agreement (contract) 2. Working Phase longest and most productive phase - identify perception to reality, support system and coping mechanisms. Major Task: Identification and resolution of the patients problems. Problems: Transference when the client unconsciously transfer to the nurse feelings he or she has for significant others. Countertransference 3. Termination Phase or the resolution phase Final stage Begins when the problems are resolved, and it ends when the relationship is ended. Evaluate the summary of progress Reinforce change and strength of the pt. Give rewards for cooperation Encourage about expression of feelings about termination of relationship Terminate the relationship without giving promises. > H. Peplau described the four levels of anxiety: a. mild, b. moderate, c. severe and; d. panic. Psychobiologic Model Focus is in mental illness as a biophysical impairment. Human behavior is influenced by genetics, biochemical alterations and function of brain and CNS. The stress response is a neuroendocrine response. MENTAL HYGIENE is the science that deals with measures to promote mental health, prevent mental illness and suffering and facilitate rehabilitation. Self-Awareness is the process of developing an understanding of ones own values, beliefs, thoughts, feelings, attitudes, motivations, prejudices, strengths and limitations and how these qualities affect others. JOHARIS WINDOW: portrait of a self in 4 areas. a. Open/Public Self b. Blind/ Unaware Self c. Hidden/Private Self d. Area of the Unknown Methods Used to Increase Self- Awareness

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Introspection Discussion Enlarging ones experience Role Play

BASIC CONCEPTS OF PSYCHIATRIC NURSING Principles of Care in Psychiatric Settings: The nurse views the patient as a Holistic human being with interdependent and interrelated needs. The nurse accepts the patient as a unique human being with inherent value and worth exactly as he is. The nurse should focus on the patients strengths and assets and not on his weakness and liabilities. The nurse views the patients behavior non judgmentally, while assisting the patient to learn more adaptive ways of coping. The nurse should explore the patients behavior for the need it is designed to meet and the message it is communicating. The nurse has the potential for establishing a nurse-patient relationship with most if not all patients. The quality of the nurse- patient relationship determines the degree of change that can occur in the patients behavior. Levels of Interventions in Psychiatric Nursing: Primary Interventions aimed at the promotion of mental health and lowering the rate of cases by altering the stressors. Ex. Health Education - Information Dissimination - Counseling Secondary interventions that limit the severity of a disorder. 2 Components: 1. Case Finding 2. Prompt treatment Ex: Crisis Intervention Administration of Medication Tertiary interventions aimed at reducing the disability after a disorder. 2 Components: 1. Prevention of complication 2. Active program of rehabilitation Ex: Alcoholics Anonymous Characteristics of a Psychiatric Nurse: 1. Empathy the ability to see beyond outward behavior and sense accurately another persons inner experiencing. 2. Genuineness/Congruence ability to use therapeutic tools appropriately. 3. Unconditional positive regard respect Role of the Nurse in Psychiatric Settings Ward Manager creates a therapeutic environment Socializing agent assists the patient to feel comfortable with others Counselor listens to the patients verbalization Parent surrogate assists the patient in the performance of ADL. Patient advocate enables the patient and his relatives to know their rights and responsibilities. Teacher assists the patient to learn more adaptive ways of coping. Technician facilitates the performance of nursing procedures.

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Therapist explores the patients needs, problems and concerns through varied therapeutic means. Reality base enables the patient to distinguish objective reality and subjective reality. Healthy Role Model acts as a symbol of health by serving as an example of healthful living Mental Health a state of emotional, psychological, and social wellness evidenced by satisfying relationships, effective behavior and coping, positive self- concept, and emotional stability. Factors Influencing Mental Health: 1. Individual or personal- biologic make-up, autonomy and independence, self-esteem, capacity for growth, sense of belonging, coping or stress management abilities. 2. Interpersonal or relationship effective communication, ability to help others, intimacy and a balance to separateness and connectedness. 3. Social/cultural or environmental factors sense of community, access to adequate resources, intolerance of behavior, mastery of the environment, and a positive, yet, realistic, view of ones world. Characteristics of a Mentally Healthy Person: According Jahoda 1.Self-acceptance and self awareness Self awareness the process by which a person gains recognition of his or her feelings, beliefs, and attitudes. - the process of developing an understanding of ones own values, beliefs, thoughts, feelings, attitudes, motivations, prejudices, strengths and limitation, and how these qualities affect. 2.Growth, development, and Self- Actualization - May mean that the individual seeks new experiences to more fully explore aspects of oneself. - Maslow (1958) and Rogers (1961) > Is adequately in touch with ones self and able to use the resources one has. > Has free access to personal feelings and can integrate them with thoughts and behaviors. > Can interact freely and openly with the environment. > Can share with other people and grow from such experiences. 3. Achieves a unifying, integrated outlook in life Integration is a balance between what is expressed, and what is repressed, between outer and inner conflicts. - Includes the regulation of emotional responses and a unified philosophy of life. 4. Self-determination or autonomy - A balance between dependence and independence, and acceptance of the consequences of ones action. - it implies that the person is self responsible for decisions, actions, thoughts, and feelings. 5. Perceives reality accurately Reality perception is the individuals ability to test assumptions about the world by empirical thought. - Mentally healthy person can change perceptions in light of new information Criteria: empathy or social sensitivity; a respect for the feelings and attitudes of others. 6. Exhibits environmental mastery - Enables a mentally healthy person to feel success in a approved role in society. - Person can deal effectively with the world, work out personal problems, and obtain satisfaction from life. - Person can cope, with loneliness, aggression and frustration without being overwhelmed - can cope with reciprocal relationship, can build new friendship and have satisfactory social group involvement. One is considered in a state of Mental Health if he/has the following:

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1. Self- awareness how the self feels, thinks, behaves, and senses at any given time. 2. Self- concept conscious awareness (attitude and ideas about self, life experience, knows and hold to be true about his/her identity). 3. Self- acceptance he knows his strengths and weaknesses. 4 ASPECTS OF SELF- CONCEPT 1. Body Image how to present ourselves to others physically affects how others perceive us socially and emotionally as well as intellectually. 2. Personal Identity perception of internal and external reality which includes thought / feelings / previous learning. 3. Self Esteem perception of worth 4. Role Performance (public roles) self representation to the outside world expressed through professional and social roles assumed in different situations such as family / school / work place. MENTAL HEALTH CONTINUUM ( Interpersonal adequacy Interpersonal competence ) to strike the balance between level of stressors and the available support. CONFLICT the result of the presence of two opposing or incompatible drives wherein the person is required to make a choice between possible responses.

Dynamics of Conflict: Conflict Increased Anxiety feelings of hopelessness, helplessness and isolation Perceived conflict increased Double increased anxiety 4 KINDS OF CONFLICT: 1. Approach approach in which the person wants to pursue two equally desirable but incompatible goals. 2. Approach avoidance in which the person wishes to both pursue and avoid the same goal. 3. Avoidance avoidance in which the person must choose between two undesirable goals. Because neither alternative seems beneficial, this is a difficult choice usually accompanied by much anxiety. 4. Double Approach Avoidance - often described as ambivalence. Mental Illness state of imbalance characterized by a disturbance in a persons thoughts, feelings, and behavior Poverty and abuses are major factors which increases the risk of mental illness in the home General Criteria to Diagnose Mental Disorders: Dissatisfaction with ones characteristics, abilities and accomplishments; Ineffective or unsatisfying relationships; Dissatisfaction with ones place in the world; Ineffective coping with life events; Lack of personal growth MAJOR SIGNS AND SYMPTOMS OF MENTAL ILLNESS: Disturbances in Perception (Sensory) - Illusion misperception of an actual external stimuli Hallucination false sensory perception in the absence of external stimuli TYPES:

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1. Auditory Hallucination most common type, involve hearing sounds, most often voices, talking to or about the client. Command hallucination voices demanding that the client take action, often to harm self or others, and are considered dangerous. 2. Visual Hallucination involve seeing images that do not exist at all. 3. Olfactory involve smells or odors 4. Tactile refer to sensations such as electricity running through the body or bugs crawling on the skin. 5. Gustatory- involve a taste lingering in the mouth or the sense that food tastes like something else. The taste maybe metallic or bitter or may be represented as a specific taste. 6. Cenesthetic report feeling of bodily functions that are usually undetectable 7. Kinesthetic client is motionless but reports the sensation of bodily movement Disturbances of Thoughts or in Thinking - Alogia a lack of any real meaning or substance in what the client says. Circumstantiality over inclusion of details Clang Association are ideas that are related to one another based on sound or rhyming rather than meaning. I will take a pill if I go up on hill but not if my name is Jill, I dont want to kill - Delusion false belief which is which is inconsistent with ones knowledge and culture. TYPES: Persecutory/Paranoid beliefs that others are planning to harm the client or are spying, following, rediculing, or belittling the client in some way. Grandiose characterized by the clients claim to association with famous people or celebrities or beliefs that he or she is famous or capable of great feats. 3. Religious delusion often center around the second coming of Christ or another significant religious figure or prophet. 4. Somatic delusion generally vague and unrealistic beliefs about the clients health or bodily functions. 5. Referential delusions or ideas of referance involves the clients belief that television broadcasts, music or newspaper articles have special meaning for him or her. - Dissociation a subconscious defense mechanism that helps person protect his or her emotional self from recognizing the full effects of some horrific or traumatic event by allowing the mind to forget or remove itself from the painful situation or memory. - Echolalia repitition or imitation of what someone else says; echoing what is heard. - Flight of Ideas shifting of one topic from one subject to another in a somewhat related way - Looseness of Association shifting of a topic from one subject to another in a completely unrelated way. - Neologism pathological coining of new words. Im afraid of grittiz. If there are any grittiz here, I will have to leave. Are you a grittiz? - Perseveration persistent adherence to a single idea or topic and verbal repitition of a sentence, phrase, or word, even when another person attempts to change topic - Verbigeration stereotyped repetition of words or phrases that may or may not have meaning to the listener. I want to swim, to swim, to swim, . - Word Salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the client. DISTURBANCES OF AFFECT Affect outward expression of the clients emotional state. - Inappropriate Affect displaying a facial expression that is incongruent with mood or situation; often silly or giddy regardless of circumstances. - Blunted Affect showing little or a slow-to-respond facial expression. - Flat Affect absence or near absence of emotional reaction. - Apathy feelings of indifference toward people, activities, and events.

14 Ambivalence holding seemingly contradictory beliefs or feelings about the same person, event, or situation. (two opposing feelings). Depersonalization feelings of being disconected from himself or herself; the client feels detached from his or her behavior. Derealization client senses that events are not real, when, in fact, they are. Labile rapidly changing or fluctuating, such as someones mood or emotions. Anhedonia having no pleasure or joy in life; losing any sense of pleasure from activities formerly enjoyed.

DISTURBANCES IN MOTOR: - Echopraxia pathological imitation of posture/action of others. - Waxy Flexibility maintenance of posture or position over time even when it is awkward or uncomfortable. DISTURBANCE IN MEMORY: - Confabulation client may make up answers to fill in memory gaps; usually associated with organic brain problems. - Amnesia partial or total inability to recall past information. Anterograde recent memory loss Retrograde remote memory loss / distant past memory Dj Vu feeling of having been to place which one has not yet visited. - Jamais Vu feeling of not having been to place which one has visited. Dementia - Gradual deterioration of intellectual functioning. - Results in the decreased of capacity to perform ADL. Other Behavioral Signs and Symptoms: Agitation severe anxiety associated with motor restlessness. Agnosia inability to recognize and interpret sensory stimuli. Akathisia subjective feeling of muscular tension, restlessness and pacing repeated sitting and standing. Ambivalence presence of two opposing feelings at the same time. Aphasia inability or difficulty to speak or recall words Apraxia inability to carry out specific task or activity Delirium refers to the acute change or disturbance in a persons: LOC, cognition, emotion, perception. Depression feeling of sadness Derealization feeling of strangeness towards the environment. Dysthymia persistent state of sadness. Elation / Euphoria a feeling of high degree of confidence, boastfulness and joy with increase motor activity. Narcolepsy sleep disorder characterized frequent irresistible urge to sleep with episodes of catalepsy. STRESS - pressure of varying degrees - a mental and physical response to stressor - is a wear or tear that life causes on the body - occurs when a person has difficulty dealing with life situations, problems and goals. - Accdng to Hans Selye, a psychological and physical response of the body that occurs whenever we must adapt to changing conditions, whether those conditions be real or perceived. Types of Stress: 1. Distress stress due to an excess of adaptive demands placed upon us. (this is the Bad stress) it lead to bodily and mental damage. 2. Eustress the optimal amount of stress which helps promote health and growth.

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3. Psychophysiological Stress mental upset that triggers a physiological stress response. It leads to psychosomatic illness. This is the most common type of stress and is the major factor in the onset of psychosomatic illness. STRESSOR - According to Selye, it is a positive or negative occurrence, or any emotion requiring response. 2 Classification of Stressor: 1. Maturational stressor experiences that are expected as a part of normal processes of growth and development in a given society. 2. Situational stressor less predictable and specific action are taken only when the threat is eminent or the event has occurred. Characteristics of Stress: 1. It is recurring 2. It is normal 3. It is brought about by stressor 4. It cannot be avoided SELYES STRESS ADAPTATION THEORY 1. Alarm Reaction impingement of stressor on individuals activates the preparation for FLIGHT or FIGHT. a. The Flight or Fight pathway is composed of three major areas: Amygdala, Hypothalamus, and Midbrain b. Electrical stimulation of these areas elicits rage behavior or flight. Bilateral lesioning ( destroying the three major areas can have a calming effect. Individuals experience an increase in alertness in order to focus on the immediate task or threat and to mobilize resources and defenses to concentrate on a particular stressor. Levels of Anxiety Mild to moderate Learning and Problem Solving can occur. Pathophysiology: Factor of Stress Message (nervous system) stimulate adrenal glands to secrete adrenaline and norepinephrine for fuel and organs (liver to convert glycogen stores to glucose for food ) to prepare for potential defense needs.

2.

Stage of Resistence Individuals strive to adapt to stress Increase use of coping and defense mechanisms Problem solving and learning are difficult but can be accomplished with assistance. Psychosomatic symptoms begin to develop. Level of Anxiety Moderate to severe If overwhelmed experience next stage Pathophysiology Digestive system reduces function to shunt blood to areas needed for defense. Lungs take in more air and the heart beats faster and harder so it can circulate highly nourished blood/ oxygenated blood to the muscles to defend the body by Fight, FLIGHT or freeze behaviors.

3. Stage of Exhaustion Result from the stress that last too long or it is overwhelming, or may result from the individuals total inability to cope. Anxiety Level Severe to Panic Defenses are EXAGGERATED AND DYSFUNCTION and personality becomes DISORGANIZED, thinking illogical decision making ineffective. DELUSIONS AND HALLUCINATIONS can occur with sensory misperception and greatly reduced orientation to reality. Individuals may become Violent, Suicidal or may be completely IMMOBILIZED. DEATH may occur Body stresses are depleted

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PROCESS OF ANXIETY Stressor Anxiety Neurochemical/Physiological Reaction Coping Behavior (Adaptive, Palliative, Maladaptive, and Dysfunction) COPING WITH ANXIETY Type of Coping Adaptive Palliative Maladaptive Dysfunctional Description Solves the problem that is causing the anxiety, so the anxiety is decreased. The patient is objective, rational and productive. Temporarily decreases the anxiety but does not solve the problem, so the anxiety eventually returns. Temporary relief allows the patient to return to problem solving. Unsuccessful attempts to decrease the anxiety without attempting to solve the problem. The anxiety remains. Not successful in reducing anxiety or solving the problem. Even minimal functioning becomes difficult, and new problems begin to develop.

MALADAPTIVE RESPONSES Anxiety is a vague feeling of dread apprehension Is a response to external or internal stimuli that can have behavioral, emotional, cognitive and physical symptoms. A subjective experience that can be detected only by the subjective behavior that result from it. A warning sign that person perceived danger, loss or threat a. health or the ability to perform the function b. self-esteem or self-respect c. self- control d. control or power over ones life e. status or prestige f. loved ones g. freedom or independence h. needs, goals, desires and expectations i. resources (emotional, physical, financial, spiritual, social and cultural. Theories of Origin/ Predisposing Factors: Psychoanalytic View Sigmund Freud (1969) identified two types of Anxiety 1. Primary Anxiety the traumatic state begins in the infant as a result of sudden stimulation and trauma of birth. It is a state of tension or drive produced by external causes. 2. Subsequent anxiety is the emotional conflict between two elements of the personality. This anxiety is due to the conflict between the ID and Superego. Interpersonal Views > Sullivan (1953) - Believed that through the close emotional bond between the mother and the child, anxiety is first convey by the mother to the infant who responds as if the mothering person were one unit.

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- He also believed that anxiety in later life arises when a person perceives that he or she will be viewed unfavorably or will lose the love of a valued person. Behavioral View Some theorist proposed that anxiety is a product of frustration caused by anything that interferes with attaining a desired goal. Anxiety may also arise through conflict that occurs when the person experiences two competing drives and may choose between them. It drives from 2 tendencies: 1. Approach (fight) tendency to do something or more toward something. 2. Avoidance (flight) is the opposite tendency; not to do something or not to move toward something. 6. Manipulation 7. Specific Situations a. Homicidal Or Assaultive reaction b. Masturbation

Common Behavioral Problems: 1. Anger 2. Combative-Aggressive Behavior 3. Confusion/Disorientation 4. Dependence 5. Hostility

Dysfunctional Pattern of Behavior (Saxton) Mosby 1. Withdrawal Behavior 5. Socially-Aggressive Behavior 2. Projective Behavior 6. Addictive Behavior 3. Aggressive Behavior 7. Self- Destructive Behavior 4. Anxiety-Based Behavior LEARNING Theories: Parental influence affects how a child responds to anxiety. The parents appropriate emotional response gives the child security and helps him learn constructive way of coping on his own.

BIOLOGIC Theories Genetic Theory - First degree relatives of clients with increased anxiety have higher rates of developing anxiety. Neurochemical Theory - Gamma-amino butyric acid (GABA) is the amino acid neurotransmitter believed to be dysfunctional in anxiety disorders. - GABA, an inhibitory neurotransmitter = anti anxiety agent that reduces cell excitability, thus decreasing the rate of neuronal firing. = GABA reduces anxiety and Norepinephrine increases it.

LEVELS OF ANXIETY and its NURSING MANAGEMENT: (Heldigard Peplau) 1. MILD ANXIETY (Alertness Level +1) is a sensation that something is different and warrants special attention. Psychological Responses wide perceptual field sharpened senses increased MOTIVATION effective problem solving increased learning activity irritability Physiologic Responses restlessness fidgeting GI butterflies Difficulty sleeping Hypersensitivity to noise

Key Nursing Interventions: (teaching) > Discuss source of anxiety (steps of learning)

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> Problem solving > Accept anxiety as natural; tolerate and benefit from it. * Use of Adaptive Coping Mechanism

2. MODERATE ANXIETY (Apprehension Level +2) is the disturbing feeling that

something is definitely wrong. Psychological Responses Perceptual field narrowed to immediate task Selectively attentive Cannot connect thoughts or events independently Increased use of automatisms Physiological Responses

muscle tension diaphoresis pounding pulse headache dry mouth high pitch voice faster rate of speech GI upset Frequent urination Startle reflex

- repeated fidgeting - difficulty concentrating - tangentiality - circumstantiality

* Coping mechanism (Palliative) Key Nursing Interventions: a. Speak in short, simple and easy-to-understand sentences b. Redirect client back to the topic if the client goes off on unrelated tangent. c. Decrease anxiety ventilation, crying, exercise d. Refocus attention relate feelings and behaviors to anxiety e. Oral medication if needed - creates a feeling that something bad is about to happen, or feeling of an impending doom. Psychological Responses Physiological Responses - fight and flight response sets in - severe headache - perceptual field reduced to one detail or scattered - nausea, vomiting, and diarrhea details - Trembling - cannot complete task - rigid stance - Cannot solve problems or learn effectively - vertigo -behavior geared toward anxiety relief and is - pale usually ineffective - tachycardia - doesnt respond to redirection - chest pain - feels awe, dread, or horror - dilated pupils and fixed vision - cries - Ritualistic behavior- Distorted perception - Disorientation - Difficulty focusing even with assistance - Delusions and hallucinations if prolonged - Flight of ideas - Suicidal/Homicidal ideations if prolonged - Ineffective reasoning and problem solving Use of Maladaptive Coping Mechanism Nurses Goal: To lower the persons anxiety level to moderate or mild before proceeding with anyone else Nursing Interventions:

3. SEVERE ANXIETY (Freefloating +3)

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1. Establish a trusting relationship open, trusting relationship Listen to patient and encourage to discuss their feelings of anxiety, hostility, guilt and frustration. Should answer patient questions directly and offer unconditional acceptance. Nurse should remain available and respect to patients personal space. 6-foot distance in small room may create the optimum condition for openness and discussion of fears. 2. Nurses self-awareness 3. Protecting and assuring the patient of his or her safety Determine the amount the patient can handle her stress Do not attack patients coping mechanism Do not argue with the patient 4. Modify the environment Assume a calm, quiet manner and lower environmental stimulation Limits the patient interaction with other client to minimize the contagious feelings of anxiety. 5. Encourage activity 6. Medication IM anti-anxiety medications

4. PANIC ANXIETY ( +4) feelings of helplessness and terror

Psychological Responses - perceptual field reduced to focus on self - cannot process any environmental stimuli out of contact with reality - distorted perceptions - doesnt recognize potential problem - cant communicate verbally > Clang associations >Neologisms > Word Salad - possible delusions and hallucination - may be suicidal - Disorganized or irrational reasoning and problem solving - Personality disorganization Physiological Responses - may bolt and run or totally immobile and mute - dilated pupils - increased blood pressure and pulse - Flight, fight, or Freeze

Use of DysfunctionalCoping Mechanism Key Nursing Interventions: a. clients safety is the primary concern b. Talk in a comforting manner even though the client cannot process what the nurse is saying. c. Go to small, quiet and non stimulating environment. d. Reassure the client that it is just anxiety and that it will pass, and that he or she is in safe place. e. Remain with the client until panic recedes. (last from 5 to 30 minutes) f. Administer anxiolytics. Nursing Intervention that could increase Anxiety: 1. Pressuring the patient to change prematurely. 2. Being judgmental. 3. Verbally disapproving patients behavior. 4. Asking the patient a direct question that bring defensiveness. TREATMENT STRATEGIES of ANXIETY DISORDERS: Cognitive Behavioral Treatment

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Aims: 1. Increasing activity. 2. Reducing unwanted behavior 3. Increasing pleasure 4. Enhancing social skills Anxiety Reduction 1. Relaxation Training decrease tension and anxiety. - Basic premise is that muscle tension is related to anxiety - Involves rhythmic breathing. 2. Systematic Relaxation involves relaxing voluntary muscles in an orderly sequence until the body as a whole, is relaxed. Techniques: patient seated in a comfortable chair with presence of soft music or pleasant visual cues----explain how anxiety is related to muscle tension----procedure should be described----deep breathing and exhaling slowly ---tension relaxation begins. 3. Meditation Components: A quiet environment A comfortable position A passive attitude A word or scene to focus on 4. Biofeedback - electrodes connected to the machine are attached to the patients forehead---brain waves, muscle tensions, temp, HR and BP ----the changes are communicated with the patient by auditory or visual means. 5. Systematic Desensitization Example: Construct a hierarchy of provoking or feared situations from 1 to 10, 1 is evoking little and 10 evoking intense or severe anxiety. In vitro, or imagined, desensitization, the patient proceeds with the imagined pairing of hierarchy items with the relaxed state, progressing from the least anxiety-provoking item to the most anxiety provoking item. In vivo, exposes the patient to real rather than imagined life situations 6. Interoceptive Exposure - Hierarchy is made of the specific symptoms that increase the patients anxiety. 7. Flooding patient is immediately exposed to the most anxiety-provoking stimulus instead of exposing gradually or systematically to a hierarchy of feared stimuli. Implosion imaginary event instead of a real life event. 8. Response Prevention - This technique is based on the concept that repeated exposure to an anxietyproducing stimulus without the presence of the anxiety reducing response will lead to anxiety reduction because the feared consequence does not occur. - Example: use of public restroom and engage in hand washing up to 20 times. 9. Eye Movement Desensitization --- Hypnosis COGNITIVE RESTRUCTURING: 1. Monitoring Thoughts and Feelings. Ex. DATE SITUATION Emotions

Automatic Thought

Rational response

Outcomes

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Describe actual event leading to unpleasant emotion Specify sad, anxious, angry etc. then rate from 1 100 Write automatic thoughts that precede the emotions then Rate Write rational response to automatic thoughts then rate Rerate belief in automatic thoughts

3. Questioning the Evidence 4. Examining alternatives 5. Decatastrophizing involves the therapist use of questions to more realistically appraise the situation. {Would it be terrible if that really took place. 6. Reframing turning negative messages into positive 7. Thought stopping teaching a patient to interrupt dysfunctional thoughts. c. Learning New Behavior 1. Modeling strategy used to form new behavior patterns, increase existing skills, or reduce avoidance skills, or reduce avoidance behavior in which the patient observes a person modeling adaptive behavior and is then encourage to imitate it. 2. Shaping introduces new behaviors that approximate the desired behavior. 3. Token Economy a form of positive reinforcement in which patients are rewarded for performing desired target behavior with tokens that they can use for desired purchases or activities. 4. Role Playing acting out of a particular situation. 5. Social Skills Training teaching smooth social functioning to those who do not manifest social skills, using the principles of guidance, demonstration, practice, feedback, resulting the acquisition of behaviors that will support community living. 6. Aversion Therapy reduces unwanted but persistent maladaptive behaviors by applying an aversive or noxious stimulus when that maladaptive behavior occurs. EX: Snap a rubber band on the wrist when being bothered by intrusive thoughts 7.Contingency Contracting a formal contract between the patient and the therapist defining what behaviors are to be changed and what consequences follow the performance of these behaviors. LEARNING NEW BEHAVIOR: Modeling strategy used to form new behavior patterns, increase existing skills, or reduce avoidance behavior in which the patiet observes a person modeling adaptive behavior and is then encourage to imitate it. Shaping introduces new behaviors by reinforcing behaviors that approximate the desired behavior. Token Economy a form of positive reinforcement in which patients are rewarded for performing desired target behavior with tokens that they can use for desired purchases or activities. Role Playing acting out of a particular situation. ANTIANXIETY DRUGS: EFFECT: Depress CNS including the thalamus, hypothalamus, limbic system and the reticular system. This effect increases the action of GABA, an inhibitory neurotransmitter. This leads to decreased incoming stimuli from the environment causing relaxation.

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A. Benzodiazepines are CNS depressant Ex: a. Alprazolam (Xanax) a. Chlordiazepoxide (Librium) b. Clonazepam (Klonopin) c. Chlorazepate (Tranxene) d. Diazepam (Valium) e. Flurazepam (Dalmane) f. Lorazepam (Ativan) g. Oxazepam (Serax) h. Temazepam (Restoril) i. Triazolam (Halcion) Mechanism of Action: - Benzodiazepines mediate the actions of amino acid GABA, the major inhibitory neurotransmitter in the brain. - Benzodiazepine produce their effect by binding to a specific site on the GABA receptor. A. Non Benzodiazepine Ex: Buspirone (BuSpar) believed to exert its anxiolytic effect by acting as a partial agonist at serotonin receptors, which decreases serotonin turnover. SIDE EFFECTS and Nursing Interventions: 1. Dry Mouth advice rinsing mouth with water often, eating sugarless hard candies, and chewing sugarless gum. 2. Ataxia (defective control and coordination of voluntary muscles, due to a lesion in the CNS which may be hereditary or caused by infection) provide assistance with ambulation. 3. Dizziness, drowsiness assist with ambulation and with getting in and out of bed. Caution about driving. 4. Nausea Take benzodiazepine with food. 5. Withdrawal symptoms that occurs after 12 hours of abstinence (increased anxiety, flulike symptoms and tremors) Contact prescriber Overdosage: somnolence, confusion, diminished reflexes, coma. Management: Flumazeril (Romazicon) benzodiazepam antagonist IV will reverse effects within 5 minutes. A patient being treated for overdose may experience agitation, restlessness, discomfort and anxiety. Major Interactions: Benzodiazepines are CNS depressants and interact addictively with other Depressants, Alcohol, MAOIs (Monoamine Oxidase Inhibitors, antihistamines, antipsychotics increase the sedative. CNS

Teachings: 1. It is not use for the minor stresses of everyday life. 2. Driving should be avoided until tolerance develops 3. Alcohol and other CNS depressants potentiate the effects of benzodiazepine. 4. Hypersensitivity to one Benzo may mean hypersensitivity to another. 5. These drug should not be stopped abruptly. Should be DC gradually over a period of 2-6 weeks. 6. Avoid ingesting substances that contain caffeine because they decrease the effect. ANXIETY DISORDERS Anxiety disorders are diagnosed when anxiety no longer functions as a signal of danger or a motivation for needed change but becomes chronic and permeates major portions of the persons life, resulting in maladaptive behaviors and emotional disability. - have many manifestations but anxiety is the key feature of each. Prevalence:

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More prevalent in women, people younger than 45 years, people who are divorced or separated and people of lower socioeconomic status. Types of Anxiety Disorders: Phobia Panic Disorder Obsessive-Compulsive Disorder (OCD) Generalized Anxiety Disorder (GAD) Acute Stress Disorder (ASD) Post- Traumatic Stress Disorder (PTSD) RELATED DISORDERS: 1. Anxiety Disorder due to a general medical condition. 2. Substance-induced Anxiety Disorder directly caused by drug abuse, a medication, or exposure to a toxin. 3. Separation Anxiety Disorder- excessive anxiety concerning separation from home or from persons/parents/caregivers to whom he is attached. ( occurs when it is no longer developmentally appropriate and before 18 years of age). 4. Adjustment Disorder GENERALIZED ANXIETY DISORDER A person with GAD worries excessively and feels highly anxious at least 50% of the time for 6 months or more Has three or more of the following symptoms: 1. uneasiness 4. fatigue 2. irritability 5. difficulty thinking 3. muscle tension 6. sleep alterations TREATMENT: Buspirone (BuSpar) SSRI antidepressants POST TRAUMATIC STRESS DISORDER Post traumatic Stress Disorder Disturbing pattern of behavior demonstrated by someone who has experienced a traumatic event. Example: natural disaster, combat or an assault, threat or death or serious injury and responded with intense fear, helplessness or terror. 3 Cluster of Symptoms: 1. Relieving the event persistently re-experiences the event through memories, dreams, flashbacks or reactions to external cues about the event. 2. Avoiding the reminders of event. 3. Being on guard or hyper-arousal signs of increased arousal are the following: insomnia, hyperarousal or hypervigilance, irritability or angry outburst. Symptoms occur 3 months or more after the trauma. Can occur at any age including childhood Dissociation is a subconscious defense mechanism that helps a person protects his or her emotional self from recognizing the full effects of some traumatic event by allowing the mind to forget or remove itself from the painful situation or memory.

Types of Dissociative disorders: a. Dissociative Amnesia the client cannot remember important personal information usually of a traumatic stressful nature. b. Dissociative fugue the client has episodes of suddenly leaving the home or place at work without any explanation, traveling to another city, and being unable to remember his or her past or identity. He or she may assume a new identity.

24 c. Dissociative Identity Disorder (formerly, multiple personality disorder). The

client display two or more distinct identities or personality states that recurrently take control of his/her behavior. This is accompanied by inability to recall important personal information. d. Depersonalization disorder the client has persistent or recurrent feelings of being detached from his or her mental processes or body. This is accompanied by intact reality testing; the client is not psychotic or out of touch with reality. APPLICATION OF THE NURSING PROCESS: Assessment: A) Background: Reveals that the client has the history of trauma or abuse B) General Appearance and Motor Behavior: Often appears hyper-alert and react to even small environmental noises with a startle response. Maybe very uncomfortable is the client too close physically and may require greater distance or personal space. May appear anxious or agitated and may have difficulty sitting still or may sit very still, seemingly to curl up with arms around knees. C) Mood and Affect Nurse must remember that a wide range of emotions is possible, e.g. from passivity to anger. May appear frightened or scared, or agitated and hostile depending on his or her experience. When experiences a FLASHBACK, the patient appears terrified and may cry, scream or attempt to hide or runaway. When the client is DISSOCIATING, he or she may speak in different tone of voice or appear numb with a vacant stare. Report intense rage or anger or feeling dread inside and unable to identify any feelings or emotions. D) Thought Process and Content Report reliving the trauma nightmares or flashbacks Intrusive, persistent thought about the trauma interfere on client focus on ADL. Report hallucinations or buzzing voices in their head Report fantasies in which they take revenge on their abuser.

E) Sensorium and Intellectual Processes Oriented to reality except if the client is experiencing flashback or dissociative episodes. With Memory Gaps period for which they have no clear MEMORIES. May be short or extensive and are usually related to the time of abuse or trauma. F) Judgment and Insight Clients ability to make decisions or solve problems may be impaired. G) Self- Concept Low Self-Esteem Believe they are bad people who somehow deserve or provoke the abuse. Think they are unworthy and damage Think they are going crazy and are out of control with no hope of regaining control. See themselves as helpless, hopeless, and worthless.

H) Roles and Relationships Great deal or difficulty with all types of relationships.

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I) Problems with authority figures- being unable to make directions from another or have another monitor her performance. Close relationship are difficult- because clients ability to TRUST is severely compromises. Avoidant behavior. Physiologic Consideration Difficulty sleeping Overeating or lack of appetite Use alcohol or other drugs.

OUTCOME IDENTIFICATION 1. The client will be physically safe. 2. The client will distinguish between ideas of self harm and taking action on those ideas. 3. The client will demonstrate healthy, effective ways of dealing with stress. 4. The client will express emotions nondestructively. 5. The client will establish a social support system in the community. INTERVENTION: 1. Promoting the clients safety priority. Assess the client potential for self harm and suicide and take action accordingly. Nurse and treatment team must provide safety measures when the client cannot do so. Nurse can talk with the client about the difference between having self harm thoughts and taking action on those thoughts Help the client develop plan for going to safe place when having destructive thoughts or impulses so that he or she can calm down and wait until they pass.

1. Helping the client cope with stress and emotions.

Use GROUNDING TECHNIQUE to help client who is dissociating or experiencing a flashbacks. Reorient the client by saying John, Im here with you, my name is Roland, Im the nurse working with you today. You are in the hospital?, today is Monday, July 2, 2007. Can you open your eyes and look at me? John, my name is Roland Validates clients feeling of fear but try to increase contact to reality: I know this is frightening to you, but you are safe now What are you feeling? What are you touching? do you feel your feet on the floor? During dissociative experience or flashback, help client change body position but do not grab or force client to stand up. Use supportive touch when client responds well to it. Teach deep breathing and relaxation techniques Use distraction techniques such as physical exercises, listening to music, talking with others to engaging in a hobby or enjoyable activities. Help to make a list of activities and keep materials client on hand to engage client when feelings are intense. 2. Help the client promote in self-esteem. Refer to client as survivor rather than a victim allows the client to think they are strong enough to survive their ordeal. Establish social support system in the community- local hotline crisis, friends and family. Medication: Paroxetine (Paxil) Sertraline (Zoloft)

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ACUTE STRESS DISORDER Is similar to PTSD in that the person experienced a traumatic situation but the response is more dissociative. Onset is within 4 week after event and duration is 2 days to 4 weeks Assessment: History of exposure to traumatic event Avoidance of stimuli related to trauma ( feelings, thoughts, people, conversations, places, activities) and distress when exposed to reminders of the traumatic event. Increased arousal or anxiety: sleep disturbance, hypervigilance, startle response, irritability, decreased concentration. Flashbacks re- experiencing and relieving the event through dreams, nightmares, illusions. Impairment in functioning occupational, social, family. Dissociative symptoms: a. absence of emotions, numbing, detachment- may not be able to show emotions such as affection. b. Daze decreased awareness of surroundings c. Amnesia d. depersonalization Cross sensitization overreaction to other stimuli that resemble the original traumatic event. Defense Mechanism: denial, suppression, and repression. Nursing Intervention: 1. Desensitization through gradual exposure to stressful stimuli. 2. Medications: 3. Nursing Interventions: a. Strengthen survivors sense of control over their lives. > Familiarizing the individuals with the symptoms of PTSD and their basis. > Teaching coping skills that channel anger and manage stress. > Assisting with activities of daily living (ADL) and basic self- care skills. > Allowing the survivors to make as many decisions as possible, based on their ability. b, Create a sense of safety. c. Provide support. Help survivor to grieve over their losses so they can move forward in their lives. d. Assist in forming meaningful goals and connections with other people. PANIC DISORDER Composed of discrete episodes of panic attacks, that is 15-30 minutes of rapid, intense, escalating anxiety in which the person experiences great emotional fears as well physiologic discomfort. Displays four or more of the following symptoms: palpitations, sweating, tremors, shortness of breath, sense of suffocation, chest pain, nausea, abdominal distress, dizziness, paresthesias, chills or hot flashes. Panic disorder is diagnosed when a person has recurrent unexpected panic attack followed by a least 1 month of persistent concern or worry about future attacks Onset of panic disorder peaks in late adolescence and the mid-30s. A person with panic disorder experiences this emotional and physiologic responses without this stimulus.

TREATMENT: Treated with COGNITIVE-BEHAVIORAL techniques deep breathing and relaxation and medication such as: e. SSRIs antidepressants (Selective Serotonin Reactive Inhibitors) f. Tricyclic antidepressant

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g. Benzodiazepines h. Antihypertensive drugs (catapres propanolol)

APPLICATION OF THE NURSING PROCESS: Assessment History: Client usually seeks treatment for panic disorder after he or she has experienced several panic attacks. Client may report, I feel like Im going crazy, I thought I was having a heart attack, but the doctor says its anxiety. Usually the client cannot identify any trigger for these events. General Appearance and Motor Behavior: May appear entirely normal Automatism automatic, unconscious mannerism, may be apparent.. Examples: tapping fingers, twisting hair- geared towards anxiety relief. Moods and Affect Anxious, worried, tense, depress, serious or sad. Express anger at his or herself Derealization (sensing that things are not real) Thought Processes and Content During a panic attack, the client may become overwhelmed, believing that he or she is dying, losing control or going crazy. May even consider suicide Worry about the next panic attack Sensorium and Intellectual Processes May become confused and disoriented during the panic attack. Self Concept Client often make self-blaming statements such as I cant believe Im so weak and out of control or I used to be a happy well-adjusted person. Roles and Relationships Typically avoids people, places and events associated with previous panic attack Physiologic and self Care Concerns With problems on sleeping and eating Experience loss of appetite or eat constantly OUTCOME IDENTIFICATION 1. The client will be free from injury. 2. The client will verbalize feelings 3. The client will sleep at least 6 hours per night. 4. The client will demonstrate use of effective coping mechanism. 5. The client will demonstrate effective use of methods to manage anxiety response 6. The client will verbalize a sense of personal control. 7. The client will establish adequate nutritional intake. INTERVENTION:

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Provide a safe environment and ensure clients privacy during the attack- if the environment is over stimulating, the client should move into a less stimulating place (a quiet place reduces anxiety and provides privacy for the client) Remain in the client during a panic attack- to calm her down and to assess client behaviors and concern. Talk to client in a calm reassurance voice Teach the client to use relaxation technique- deep breathing exercises, guided imagery Help the client to use cognitive restructuring techniques. Engage client to explore how to decrease stressors and anxiety-provoking situations. OBSESSIVE-COMPULSIVE DISORDER OBSESSION are recurrent, persistent intrusive and unwanted thoughts, images, or impulses that cause markedly anxiety and interfere with interpersonal, social or occupational function. COMPULSION are realistic or repetitive behaviors or mental acts that a person carries out continuously in an attempt to neutralize anxiety.

Obsessive-compulsive disorder (OCD) is diagnosed only when these thoughts, images and impulses consume the person or he or she is compelled to act out the behavior to a point at which they interfere with personal, social and occupational function. OCD can start in childhood especially in males

TREATMENT: B. Behavior Therapy Exposure- involves assisting the client to deliberately confront the situations and stimuli that he or she usually avoids. Response Prevention focuses on delaying or avoiding performance of rituals. MEDICATION: Clomipramine (Anafranil) a drug of choice, it decrease obsession and alleviate rituals. APPLICATION OF THE NURSING PROCESS: Assessment: A. History: Client usually seeks treatment only when obsession becomes too overwhelming, compulsions interfere with daily living or both. Most treatment is outpatient. The client reports that rituals began many years before; some begin early as childhood. B. General Appearance and Motor Behavior Client seems tense, anxious, worried, and fretful. Overall appearance is unremarkable; that is, nothing observable seems to be out of the ordinary C. Mood and Affect Clients report ongoing, overwhelming feelings of anxiety is response to obsessional thoughts, images, or urges. Look sad and anxious. D. Thought Processes and Content Client describes the obsessions as arising from nowhere during the middle of normal activities. E. Sensorium and Intellectual Processes

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There is intact intellectual functioning The client may describe difficulty concentrating or paying attention when obsessions are strong. No impairment of memory or sensory functioning.

F. Judgment and Insight Recognizes that obsession is irrational but he or she cannot stop them Client can make sound judgment (I know the house is safe) but cannot act on them. When anxiety overwhelms, client will engage in ritualistic behavior G. Self Concept Clients voices concern that he or she is going crazy. There is feeling of powerlessness to control the obsession or compulsion that contributes to low self-esteem. H. Roles and Relationship Relationship suffers as family and friends tire of repetitive behavior, and the client is less available to them. I. Physiologic and Self-Care Considerations Have trouble sleeping Loss of appetite or unwanted weight loss Personal hygiene may suffer

OUTCOME IDENTIFICATION: 1. The client will complete daily routine activities within a realistic time frame. 2. The client will demonstrate effective use of relaxation techniques. 3. The client will discuss feelings with another person. 4. The client will demonstrate effective use of behavior therapy techniques. 5. The client will spend less time performing rituals. INTERVENTION: 1. Offer encouragement, support, and compassion. 2. Be clear with the client that you believe he or she change. 3. Encourage the client to talk about feelings, obsessions and rituals. 4. Gradually decrease time for the client to carry out ritualistic behavior. 5. Assist the client to use exposure and response prevention behavioral techniques. 6. Encourage client to use techniques to manage and to tolerate anxiety responses. 7. Assist client to complete daily routine and activities. PHOBIAS 1. 2. 3. Is an illogical, intense, persistent fear of a specific object or social situation that cause extreme distress and interferes with normal functioning. Usually do not result from past, negative experiences 3 Categories of phobia Agoraphobia Acute anxiety on crowd and fear of being alone. Specific phobia irrational fear of an object or situation Social phobia anxiety provoked by certain social or performance situations. Diagnosis of phobic disorder is made only when the phobic behavior significantly interferes with the persons life by creating marked distress or difficulty in interpersonal or occupational functioning.

Categories of Specific phobia: 1. Natural environmental phobias fear of storm, water, height, or other natural phenomena.

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2. Blood-injection phobia fear of seeing ones own or others blood, traumatic injury, or an invasive medical procedure such as an injection. 3. Situational phobia- fear of being in a specific situation such as a bridge, tunnel, elevator, small room, hospital or airplane. 4. Animal phobia fear of animal or insects (usually a specific type). Often this fear develops in childhood and can continue through adulthood in both men and women. Cats and dogs are the most common phobic objects. 5. Other types of specific phobias: for example, fear of getting lost while driving if not able to make all right turns (and no left turns) to get to ones destination. usually occur in childhood or adolescent. Social Phobia is also known as social anxiety disorder. Person becomes severely anxious to the point of panic or incapacitation when confronting situations involving people. Example: Making speech, attending a social engagement alone, interacting with the opposite sex or with strangers, and making complaints. Fear is rooted in low self esteem and concern about others judgment. Fears on looking socially inept, appearing anxious, or doing something embarrassing such as burping or spilling food. Other social phobias: fear of eating in public, using public bathrooms, writing in public, or becoming the center of attention. Peak age of onset is middle adolescence. TREATMENT: 1. Behavioral Therapy Systematic Desensitization- in which the therapist progressively exposes the client to the threatening object in a safe setting until the clients anxiety decreases. Example: fear of flying, airplane, walk in the airport, taking a short ride in a plane.

Flooding form of rapid desensitization in which a behavioral therapist confronts the client with phobic object (either a picture or the actual object) until it no longer produces anxiety. = Because the clients worst fear has been realized and the client did not die, there is a little reason to fear the situation anymore. = This method is highly anxiety producing and should be conducted only by a trained psychotherapist under controlled circumstances and with the client consent. 2. MEDICATION: No pharmacological intervention PSYCHOPHYSIOLOGIC RESPONSES

Psychosomatic Disorders (Psychophysiologic Disorders) = refer to disorders characterized by somatic complaints for which the organic cause could be demonstrated and are the result of emotional conflict. General Characteristics 1. Involves organ system innervated by the ANS. 2. Physiologic changes involved are those that usually accompany emotional response but more intense autonomic nervous system sustained. 3. Symptoms are thus physiologic rather than symbolic, the effect being expressed through the viscera. 4. May produce structural organic changes if psychosomatic symptoms persist. 5. Somatic symptoms afford generous secondary gains. The nurse and other health team must never assume that patient with PPD are not sick.

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Theories of psychopathology 1. Repressed conflict/events and leads to increase in the patients level of anxiety. 2. A certain personality type (type A) is particularly prone to the development of certain physical illness. 3. This theory places emphasis on the symbolism of illness. 4. Organ weakness theory: All humans have one body system that is relatively less healthy than the other. 5. Patient with psychophysiologic disorder often have needs for dependency, attention, love and security. * When these needs cannot be met the person clings unconsciously to this disability as means of achieving satisfaction.

6. Psychophysiologic Disorders:
ORGAN/SYSTEM G.I.T Cardiovascular Respiratory Integumentary Musculoskeletal DISORDER - Peptic Ulcer - Essential hypertension - Bronchial asthma - ALLERGIC Dermatitis - Arthritis Masochistic Behavior

Concept in Giving Nursing Care 1. Persons who develop psychophysiologic disturbances have unconscious emotional conflict that increases their anxiety and interferes with their effectively meeting their needs. 2. The physical illness is the result of an expression of this unconscious conflict and serves as a means of lowering anxiety level. 3. The physical illness is real in that those are demonstrable organic changes that may be life-threatening. Nursing Care: 1. The nurse must fully understand and accept the fact that these people are physically ill and that these symptoms may reach in life-threatening proportion. 2. During the acute episode of illness meeting the physical needs of the client is for primary importance. 3. It must be understood that many of the clients feelings unacceptable to him and therefore acceptance of him and his feelings by the nurse is of primary importance. 4. The nurse carries out attitude that she believes the individual will get better if he merely exerted more control over his emotion. SOMATOFORM DISORDERS

= Expression of needs through body language: Symbolic repressed feeling is related with over-excited organ. It is characterized as the presence of physical symptoms that suggest a medical condition without a demonstrable organic basis. These are chronic and recurrent, so progress toward treatment outcomes can be slow and difficult. Coping Technique: To gain attention Rationalization * Punishing of self and others

3 Central features of Somatoform disorders: 1. Physical complaints suggest major medical illness but have no demonstrable organic basis. 2. Psychological factors and conflicts seem important initiating, exacerbating, and maintaining the symptoms. 3. Symptoms or magnified health concerns are not under the clients conscious control.

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ETIOLOGY: Psychosocial theorists believe that people with somatoform disorders keep stress, anxiety, or frustration inside rather than expressing them outward. This is called internalization. When clients express these internalized feelings and stress through physical symptoms is called Somatization Internalization and Somatization are both unconscious defense mechanism Physical symptoms worsen when they experienced another conflicts or emotional stress The worsening of physical symptoms helps them to meet psychological needs for security, attention, and affection through primary and secondary gains. PRIMARY GAINS is the direct benefit clients experience such as relief from anxiety, conflicts, or distress. e.g. If the client is physically sick, she doesnt have to deal with problems with the children SECONDARY GAINS is the personal benefit derived from illness, such as special attention or comfort received from others. e.g. receiving back rub, being brought tea or breakfast in bed. Types of Somatoform: 1. Body Dysmorphic Disorder Preoccupation with some imagined defect in appearance in a normal appearing person. E.g. Nose is too large or the teeth 2. Conversion Disorder (Conversion reaction) An unconscious process through which the anxiety is converted into physical and physiologic symptoms. Usually unexplained sudden deficit of sensory or motor function (blindness, paralysis) - tends to develop during adolescence or early adulthood but may occur at any age. - More common among women - Patients with this disorder may have feelings of guilt, unexpressed anger, frustrations and low self esteem. Nursing Intervention: a. Focus on anxiety reduction symptoms will be relieved when anxiety is relieved. - diversional activities and administration of anti-anxiety medications. b. Matter of fact attitude. c. Relaxation training d. Psychotherapy e. Hypnotherapy c. Hypochodriasis Morbid preoccupation with body functions or fear of serious disease. Motive is unrecognizable or unconscious. They may interpret normal body sensations as signs of disease. Also known as Disease phobia Six Major Criteria: 1. Preoccupation with having a serious disease based on misinterpretation of physical symptom. 2. This conviction that he is ill is maintained despite medical reassurance that nothing is wrong. 3. Preoccupation that is not as intense or distorted as delusional disorder or as restricted as body dysmorphic disorder. 4. Preoccupation that causes significant distress and impaired social and occupational functioning. 5. Disorder duration of at least 6 months; and 6. The symptoms are not caused by anxiety, somatoform, and major depressive disorders.

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Nursing Intervention: 1. Establish trust and show empathy. 2. Reassure client and family that there is no medical illness by showing laboratory results, x-ray findings, and other tangible evidence but acknowledge the symptoms as real for the person and discuss with the patient that they are caused by a disease fear. 3. Exposure techniques. 4. Explore alternative coping skills-identity stressors. 5. Set limits on the time spent with the client because of the tendency of the client to manipulate. 6. Do not provide secondary gain, do not focus on the symptoms during interaction with the patient but encourage verbalization of feelings. 7. Diversional activity. 8. Medications SSRI (fluoxetine {prosac}, paroxetine {paxil}, and fluvoxamine maleate {luvox}).

d. Somatization disorder (Briquets Syndrome)

Somatization = is defined as the transference of mental experiences and states into bodily symptoms. Somatization Disorder = Somatic complaints of several years duration for which medical attention has been sought but that are apparently not due to any physical disorder. = Occurs before age 30 and runs a chronic course. = Characterized by multiple physical symptoms which includes a combination of pain, gastrointestinal, sexual and pseudoneurologic symptoms. DIAGNOSTIC Criteria: onset of physical complaints before age 30 a history of pain affecting at least four different body parts two or more GI symptoms at least one sexual or reproductive system at least one neurologic symptom (excluding pain) the diagnosis is supported by the dramatic nature of the complaints and the patients exhibitionistic, dependent, manipulative, and sometimes suicidal behavior. ***Undifferentiated somatoform disorder Symptoms: Nausea and vomiting, intolerance to several different food, erectile/ejaculation problems, irregular menses, excessive menstrual bleeding, blindness, seizures, deafness, paralysis, difficulty swallowing/breathing, dissociative symptoms such as amnesia, Dizziness, Shortness of breath, Dysmenorrhea and chest pain, headache, sexual intercourse (dyspareunia), painful urination (dysuria). Key Feature: La belle indifference Nursing Intervention: a. Usually, the treatment is calm, firm, supportive relationship. b. Avoid judgmental approach and such comments as There is nothing wrong with you, or Everything is alright. c. Matter of fact manner about the diagnosis but acknowledge the symptoms as real and distressing to the patient. Provide symptomatic care. d. Provide empathy. Reassure that although he has an impairing condition, it is not life threatening and inform the patient of the different therapies available e. Set limits.

e. Pain disorder (Psychalgia)

Primary physical symptom of pain, which generally is unrelieved by analgesics and greatly affected by psychological factors in terms of onset, severity, exacerbation, and maintenance. General Characteristic:

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1. Physical symptoms without organic basis. Examples: blindness, seizures, paralysis, anosmia, aphonia, Coordination disturbance, Anesthesia or paresthesia 2. La Belle indifference Lack of concern regarding the severity of the above symptoms. 3. Doctor hopping 4. Excessive use of analgesic with minimal relief from pain 5. Assumption of an invalid role. 6. Impairment in social and occupational functioning due to pre-occupation with physical complaints. Nursing Intervention: Same as Conversion Disorder Somatization = is defined as the transference of mental experiences and states into bodily symptoms. Somatization Disorder = Somatic complaints of several years duration for which medical attention has been sought but that are apparently not due to any physical disorder. Occurs before age 30 and runs a chronic course. Symptoms: Nausea and vomiting, intolerance to several different food, erectile/ejaculation problems, irregular menses, excessive menstrual bleeding, blindness, seizures, deafness, paralysis, difficulty swallowing/breathing, dissociative symptoms such as amnesia, Dizziness, Shortness of breath, Dysmenorrhea and chest pain, headache, sexual intercourse (dyspareunia), painful urination (dysuria) RELATED DISORDERS: a. Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms. - motivated by external incentives such as avoiding work, evading criminal prosecution, obtaining financial compensation, or obtaining drugs. b. Factitious Disorder (Munchausen syndrome) occurs when a person intentionally produces or feigns physical or psychological symptoms solely to gain attention. - People with factitious disorder may even inflict injury on themselves to receive attention. - A variation of factitious disorder is Munchausen syndrome by proxy, occurs when a person inflicts illness or injury on someone else to gain the attention of emergency medical personnel or to be a hero for saving the victim. SLEEP DISORDERS 4 STAGES of SLEEP 1. The time period immediately after falling asleep, during which the person is responsive to environmental stimuli and cerebral activities continues; last about 10 minutes. 2. The time period when the person is beginning to relax, cerebral activity slows down, with hearing being the last to go, and the individual falls asleep. 3. The time period when the person becomes more relaxed, blood pressure, respiration and pulse decrease, metabolism slows down, and gastrointestinal activity increases. 4. The period beginning about 30 minutes after the person has fallen asleep; it is marked by deep sleep, very relaxed muscles, an increase in the release of growth hormones, and a very few REM. Within 10-30 minutes after stage 4 begins, REM becomes prominent; the persons pulse, respiration and blood pressure rise, and vivid dreams occur which can often be recalled upon awakening. This REM sleep lasts about 20 minutes and the person then returns to stage 2 and the cycle is repeated. COMMON DISORDERS OF SLEEP

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Insomnia = difficulty in falling asleep, intermittent sleep or early awakening from sleep. It is the most common of all sleep disorder and it is believed that insomnia usually results from anxiety and stress. Certain Measures that have been used with success by at least some insomniacs: Eat high-protein food before bedtime, such as cheese or milk. Observe a regular bedtime hour and avoid naps during the day and evening. Leave the bed and bedroom when awake. Try to sleep only when sleepy and not when wakeful. Avoid stimulating activity before bedtime. Include exercise in each day but not before bedtime Using relaxation and meditation techniques before attempting to sleep. The use of drugs has not proven to be a satisfactory solution, it may make matters worse and dependency on drugs develop.

a. Somnambolism = sleepwalking, is more common in children than in adults.

It does not occur during REM sleep, but does occur during stages lll and lV of NREM. Therefore, it is generally relatively easy to awaken a sleepwalker. The danger for somnanbolist is that he may suffer injury. Measure to avoid danger: Provide safe environment such as using secure locks on doors. Drug such as Diazepam (Valium)= suppress stage-lV sleep, and effective in deceasing sleepwalking episodes cause. Nocturnal enuresis involuntary urination that occurs while a person is sleeping. Diurnal enuresis involuntary urination when a person is awake. Measure to assist in preventing bed wetting limit fluid intake for several hours before bedtime empty the bladder prior to bedtime wakening the youngster during the night for voiding c. Sleep apnea and snoring d. Narcolepsy = an uncontrollable desire to sleep. It is considered to be a neurologic disorder. e. Sleep talking = it appears that almost everyone talks in his sleep at some time. It occurs prior to REM sleep and rarely presents a problem, unless the talking interferes with rest of persons sharing the same room. ABUSE AND VIOLENCE Domestic Violence Requiring Crisis Intervention

b. Eneuresis = involuntary urination. It occurs during NREM with unknown

RAPE According to R.A. 8353, it refers to the insertion of the penis into the mouth, vagina, anus of a victim. Insertion of any object into the mouth or anus. It is generally considered as an act of hostility, anger or violence. Non consensual sexual penetration of an individual, obtained by force or threat, or in cases in which the victim is not capable of consent.

Kinds of Rape Power done to prove ones masculinity, virility and competence 1. Precipitated by incident that activates the offenders feelings of inadequacy and insecurity.

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2. The offender forces the victim to become weak, helpless and submissive, the exact qualities he despises in himself. 3. Subduing the victim to submit to his sexual demands gives the offender a sense of power, security, strength, mastery, and control. 4. Every rape is an exciting adventure because the offender sees it as a test of his manhood and strength. 5. During the rape, the offender finds little or no gratify and is disappointed because it did not went through the way he fantasized it to be. Anger done as a means of retaliation 1. Rape was used as a means of expressing anger, hatred and contempt against the victim, who represents those women who wronged him at some point of his life. 2. This type of rape is impulsive, often committed at the time the victim is angry, frustrated and depressed. 3. Rapist who commits this type of rape reported that they did not feel sexually aroused at the time of offense. He committed rape as a means to vent his anger and hostility, to retaliate back for wrong he perceives has been done against him. 4. It may lead to homicide. Sadistic done to express erotic feelings 1. Occurs because the offender feels the need to inflict pain and torment on his victim to achieve sexual satisfaction. Aggression becomes a sexual expression and a source of sexual gratification. 2. The offender is intensely excited and finds intense pleasure in the victims torment, anguish, distress, and suffering. Impulsive/ Opportunistic Rape may occur in conjunction with other antisocial acts such as during a robbery. Silent rape syndrome Is a maladaptive reaction to rape The victim: Fails to disclose information about the rape Is unable to resolve feelings about the sexual assault Results to increase anxiety and may develop a sudden phobic reaction. Rape Trauma Syndrome (RTS) Refers to a group of signs and symptoms experienced by a victim in reaction to rape. Phases: Actual Phase shock, numbness, disbelief Denial refusal to discuss the event Heightened anxiety fear, tension, nightmares Stage of reorganization

Phases of Rape Trauma Syndrome 1. Disorganization occurs just after the incident and the victim experiences anger, guilt, embarrassment, humiliation, denial, shock, disbelief, fear of death, multiple physical and somatic complaints and a wish for revenge. Emergency Care: If a victim calls the hospital reporting rape tell her not to shower, bathe, douche or change clothing and go to hospital at once. In the ER provide privacy and offer comfort be nonjudgmental Assist in pelvic examination to collect evidence ( hair, semen, fingernails scraping, fibers, stains). Preserve any evidence and proper documentation. Treat physical injuries Inquire about LMP, the contraception being used and if rapist used condom. Nursing Intervention:

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The nurse should be aware of her own personal feelings about rape. Be aware of the emotional responses at different stages development: Stay with the victim: the focus during the initial stage is on the victims need for physical safety and emotional security. Provide prophylactic antibiotic therapy Encourage the victim to speak about the rape incident. Reassure victim the information given will be treated confidential. Encourage expressing negative emotions and feelings. Anti-anxiety medications.

2. Reorganization - Occurs several days or weeks after when the victim begin the
struggle to adapt. Grief over losses resolves slowly. Common Fears/ Phobia of Rape victims: a. Fear of being indoors if rape occurs indoor. b. Fear of the outdoors if raped occurred outside c. Fear of Crowds d. Fear of being alone e. Fear of people around the victim while the persons engages in daily activities f. Fear of sexual activity especially if victim has no prior sexual experience Nursing Intervention: Provide a list of community and legal resources Long term counseling Psychotherapy for irrational fears and phobias FAMILY VIOLENCE According to The National Research Councils Panel on Understanding and Preventing Violence in the United States defines Family Violence as all violent behavior that occur within a household. These includes: Spouse Assault Physical and Sexual Assault Sibling Assaults Physical and Sexual Assaults of other relatives who reside in the household TYPES OF ABUSE: Physical : pushing, hitting, throwing Psychological : verbal degrading Sexual : wife, child, friend, stranger Neglect: medical, physical, psychological Abused Persons: Wives Husbands Children Elderly CHARACTERISTICS OF ABUSER: Profile a parent of a soon to be born Low self-esteem Uses Alcohol or drugs Projects anger Anxious Depressed Has come form abusive household Is socially isolated

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Impulsive, immature Guilt

CHARACTERISTIC OF ABUSED PERSONS: Sleep disorders such as nightmares Headaches Anxiety Suicidal Ideation Substance Abuse Disruptive behavior at home, school, work Teen runaway behavior LONG TERM EFFECTS OF FAMILY ABUSE: Survivors of famiy abuse often share special profiles that are characterized by four (4) Oppositional traits or polarities.

1. Naivete vs.Cyanism or suspiciousness. The survivor may hold a joyful all will be

well view of the world or an extremely negative one. The nave optimism reflects the survivors denial of the abuse and the wish it had not ever happened. Cyanism or suspiciousness reflects the victims recognition of the abuse and generalization of cruelty and manipulativeness of the abuser to others and to the world in general. their abusers, who sometimes relegate them to subhuman status. However, survivors may also feel important, as if they had been chosen for special, if horrible, treatment.

2. Worthlessness vs. specialness. Victims may feel worthless due to humiliation from

3. Self-punitive vs. self indulgent behavior. This polarity mimics the abusers pattern
of first punishing, then indulging the victim. It may also reflect survivor self hatred and feelings that they deserved to be abused. Alternately, or at the same time, victims may reward themselves because they feel deprived or self-pitying. 4. Intense dependency vs. excessive caretaking. Abusers often foster the dependency through forced isolation and appeals to the victim for sympathy. victims

Battered Wife Syndrome (BWS) A form of cyclic 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 Women: Dependent personality disorder. Have difficulty leaving abusive relationships because of financial and emotional dependence on the abuser and the risk of suffering increased violence and death.

Characteristic of Abusive Husbands They usually come from violent families They are immature, dependent and non-assertive They have strong feelings of inadequacy Phases of BWS Tension building phase - involves minor battering incidents Acute battering incident more serious form of battering Aftermath/honeymoon stage the husband becomes loving and gives the wife a hope. Types of Partner Abuse: 1. Isolation controlling what she does, who she sees and talks to, where she goes.

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2. Intimidation putting her in fear buy using looks, actions, gestures or loud voice, smashing things, destroying her property, 3. Using male privilege treating her like a servant, making all the big decisions, and acting like the master of the castle. 4. Threats - Making and / or carrying out threats to hurt her emotionally, threatening to take the children, to commit suicide or report her to welfare agency. 5. Using Children Making her feel guilty about the children; using the children to give messages; using visitation as a way to harass her. 6. Sexual Abuse Making her abuse in sexual acts against her will, physically attacking the sexual parts of her body; treating her like a sex object. 7. Economic Abuse trying to keep her from getting or keeping a job; making her ask for money; giving her an allowance; taking her money. 8. Emotional Abuse Putting her down or making her feel bad about herself, calling her names, making her think sheis crazy, playing mind games. Priority in the care of the battered wife Provision of shelter

Treatment and Intervention: A woman can obtain a restraining order (protection order) from her county of residence that legally prohibits the abuser from approaching or contacting her. Battered womens shelter can provide temporary housing and food for abused women and their children when they decide to leave the abusive relationship. Individual psychotherapy or counseling, group therapy, or support and selfhelp groups can help abused women deal with their trauma and begin to build new, healthier relationship. Child abuse Is an act of omission of responsibility or commission in which intentional harm is inflicted on a child.

What is Abuse? = is what happens when an older adult takes advantage of his authority over a young child. What is Violence? = refers to the use of force. What is neglect? = lack of provision of those things which are necessary for the childs growth and development. Components of Omission: Child abandonment leaving the child physically Child neglect lack of provision of those things which are necessary for the childs growth and development Characteristics of Abusive Parents: They come from violent families They were also abused by their parents They have inadequate parenting skills They are socially isolated because they dont trust anyone They are emotionally immature They have negative attitude towards the management of the abused Types of Commission/ Types of Child abuse 1. Physical Abuse - Is an intentional physical harm inflicted on a child by a parent or other persons. 2. Emotional Abuse (Psychological abuse) insult and undermining ones confidence. Includes verbal assaults, such as blaming, screaming, name-calling, and using sarcasm.

40 3. Sexual abuse abuse in the form of unwanted sexual contact performed by an

adult on a child younger than 18 years.

4. Neglect is malicious or ignorant withholding of physical, emotional, or educational

necessities for the childs well being. A type of maltreatment and includes refusal to seek health care or delay doing so; abandonment; inadequate supervision; reckless disregard for the childs safety; punitive, exploitative or abusive emotional treatment; spousal abuse in the childs presence; giving the child permission to be truant; or failing to enroll child in school. TYPE Physical Abuse j. k. l. m. n. o. p. q. Manifestations Pattern of bruises wells at varying stages of healing, bald patches on the scalp, lacerations Burns (cigarette, scald, rope) Unexplained fractures and dislocations Withdrawn or aggressive behavior Unusual fear of parent or desire to please parent Incongruence between explanation and injury Pain and itching of genitals Difficulty walking and sitting Bruised and bleeding genitals Stains, blood on underwear, change in performance in school Pregnancy Venereal disease Reports sexual assault Withdrawn or aggressive behavior Unusual sexual behaviors Appearance: poor hygiene Inadequate weight gain Consistent hunger Inconsistent school attendance Medical and physical problems unattended Fatigue Withdrawn Substance Abuse

Sexual Abuse

Physical Neglect

Emotional Neglect

Low self-esteem Hypochondriasis Developmental lag Sleep disorders or neglect Behavioral extremes

Republic act 7610 (Anti Child Abuse Law) Required reporting of suspected cases Report cases to the nearest authorities within 48 hours (Barangay officers, DSWD personnel, police) Treatment and intervention: To ensure the childs safety and well being Removing the child from the home Interview parent and child separately in privacy: ask in detail about symptoms Treat injuries A thorough psychiatric evaluation Provide referral for assistance and therapy Play therapy Family therapy, if reuniting the family is feasible. Parents may require psychiatric or substance abuse treatment

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If the child is unlikely to return home, foster care services may be indicated. ELDER ABUSE = is the maltreatment of older adults by family members or caretakers. It may include physical and sexual abuse, psychological abuse, neglect, self-neglect, financial exploitation, and denial of adequate medical treatment. Most victims of elder abuse are 75 years or older, and 60-65% are women. When the elder has multiple, chronic mental and physical health problems, and when she is dependent on others for food, medical care, and various activities of daily living. A psychiatric disorder or substance abuse also may aggravate abuse of elders. Clinical picture: Have bruises or fractures May lack needed eyeglasses or hearing aids May be denied foods, fluids, or medications May be restrained in a bed or chair. The abuser may use the victims financial resources for his own pleasure, while the elder cannot afford food or medications. Abusers may withhold medical care itself from the elder with acute or chronic illness. Self-neglect involves the elders failure to provide for himself/herself.

Types and Possible Indicators of Elder Abuse 1. Abuse inflicting of pain, injury or mental anguish Physical abuse indicator Frequent, unexplained injuries Reluctant to seek medical treatment Disorientation or grogginess indicating misuse of medications Psychological or emotional abuse indicators Helplessness Hesitance to talk openly Anger and agitation Withdrawal and depression Financial abuse indicators Signatures on checks that differ from the elders Recent change in will or power of attorney Missing valuable belongings that are not just misplaced Lack of television, clothes, or personal items that are easily affordable.

2.Neglect lack of provision of services necessary for physical and mental health. Neglect indicators Dirt, fecal or urine smell, or other health hazards in the elders living environment. Rashes, sores, or lice on the elder Untreated medical condition, malnourished or dehydrated Inadequate clothing

3. Self Neglect the person chooses to avoid medical care or other services that would promote optimal functioning. Indicators of self-neglect Inability to manage personal finances. Inability to manage activities of daily living such as personal care, shopping, housework.

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Wandering, refusing needed medical attention, isolation, substance abuse Failure to keep needed medical appointments Confusion, memory loss, unresponsiveness Lack of toilet facilities

4. Exploitation illegal or improper use of the individuals resources. Warning indicators for caregiver Elder is not given opportunity to speak for self, to have visitors, or to see anyone without the presence of the caregiver. Attitudes of indifference or anger toward the elder Blaming the elder for his/her illness or limitations Defensiveness Has history of family violence or alcohol or drug problems.

Treatment and intervention: Assess for signs of abuse and neglect Relieving the caregivers stress and providing additional resources may help to correct the abusive situation and leave the caregiving relationship intact. Report cases of abuse and neglect as mandated by all states. Assess for dysfunctional family systems Removal of the elder or caregiver is necessary, if the neglect or abuse is intentional and designed to provide personal gain (access to the victims financial resources). KEY POINTS: Women and children are the most likely victims of abuse and violence. Characteristics of violent families include an intergenerational transmission process, social isolation, power and control, and the use of alcohol and other drugs. Spousal abuse can be emotional, physical and sexual, or all three. Women have difficulty leaving abusive relationships because of financial or emotional dependence on the abuser. Child abuse includes neglect, physical, emotional, and sexual abuse. Elder abuse includes physical and sexual abuse, psychological abuse, neglect, exploitation, and medical abuse. Survivors of abuse and trauma often experience guilt and shame, low self esteem, substance abuse, depression, post-traumatic stress disorder, and dissociative disorders. PTSD is a response to a traumatic event. It includes flashback, nightmares, insomnia, mistrust, avoidance behavior, and intense psychological distress. Dissociation is a defense mechanism that protects the emotional self from the full reality of abusive or traumatic events during and after those events. Survivors of trauma and abuse may be admitted to the hospital for safety concerns or stabilization of intense symptoms such as flashbacks or dissociative episodes. The nurse can help the client to minimize dissociative episodes or flashbacks through grounding techniques and reality orientation. GRIEF AND LOSS Experiences of loss are normal and essential in human life. All people grieve when they experience lifes changes and losses Grief is the focus of treatment To support and care for the grieving client, the nurse must understand the phases and cultural responses to loss.

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GRIEF refers to the subjective emotions and affect that are a normal response to the experience of loss. GRIEVING is also known as bereavement BEREAVEMENT refers to the process by which a person experiences the grief. It involves the content (what a person thinks, says, and feel) and the process of (How a person thinks, says, and feels). ANTICIPATORY GRIEVING is when people facing an imminent loss begin to grapple with the very real possibility of the loss or death in the near future. MOURNING is the outward expression of grief. Rituals of mourning include: having a wake, sitting shivah, holding religious ceremonies and arranging funerals. LOSS anticipated or actual removal or absence of a valued object or person. Types of losses. Examples of losses related to specific human needs in Maslows hierarchy are as follows: 1. Physiologic loss: amputation, loss of adequate air exchange or pancreatic functioning. 2. Safety loss: loss of safe environment, loss of psychological safety secondary to broken trust between client and provider. 3. Loss of security and a sense of belonging: the loss of loved one affects the need to love and to be loved; loss accompanies changes in relationships such as birth, marriage, divorce, illness, and death; a person may lose roles within a family or group as relationship changes. 4. Loss of self-esteem: any change in how a person is valued at work or in relationships can threaten his need for self-esteem. Change in self-perception can challenge sense of self-worth. A loss to function and the self-perception and worth tied to that role may accompany the death of a loved one. 5. Loss related to self-actualization: an external and internal crisis that blocks or inhibits striving toward fulfillment may threaten personal goals and individual potentials. A change in goals or direction will precipitate an inevitable period of grief as the person gives up a creative thought to make room for new ideas and directions. (losing the hope of marriage and family, giving up plans to attend graduate school). KUBLER-ROSS Stages of Dying/Grief: 1. Denial initial response to protect the self from anxiety No not me, Its not true, Its not possible May continue to make impractical/unrealistic plans May comment that a mistake has been made about the diagnosis of terminal illness May appear normal and continued ADL as if nothing wrong May not conform with the advised treatment regimen Adaptive Response crying, verbal denial Maladaptive Response absence of reaction such as crying 2. Anger individual feel that they are victims of incompetence or a vengeful God, fate, and circumstances. Why me, What did I do to deserve this May anger overtly ( being irritable, impatient, critical, verbally abusive) 0r covertly ( neglecting self,, not eating, not going to check-ups, committing suicide, drinking alcohol.) Adaptive Response verbal expression Maladaptive persistent guilt or low self esteem, aggression, self destructive ideation or behavior. 3. Bargaining the person try to exhibit good behavior, make up for perceived wrong doings or other engage in behaviors that would please God so he will be given more time an extension of life or granted recovery. Yes, me but If I live until Christmas Adaptive Response : bargains for treatment control, express wish to be alive for specific events in the near future.

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Maladaptive Response: Bargains for unrealistic activities or events in the distant future anymore and the person grieves for himself and those he will leave behind, for the things that he can no longer accomplish or experience. Yes, Im dying Withdrawn, has no energy and interest to interact Cries Makes few demands Adaptive Response: crying, withdrawing from interaction Maladaptive Response: self destructive actions, despair

5. Depression occurs when the reality of loss or impending loss cannot be ignored

6. Acceptance occurs when the person has come to peace with himself and others.

Yes, I am ready Stage of affective void Only persons who are highly significant to him stimulates a reaction. Others are merely toler ated. Makes realistic preparation Adaptive Response: may wish to be alone, limit visitors, limit conversation, complete personal and family business.

Reaction of Children to Death: Infant and Toddlers: Live only in present Are only concerned only with separation from mother, being alone, abandoned Can sense sadness in others and may feel guilty due to magical thinking Healthy toddlers may insist on seeing other long after that persons death Preschool See death as temporary, a type of sleep or separation Cannot differentiate death and separation See life as concrete, they know the word dead but do not see the finality Fear separation from parents Dying children may regress in their behavior School-Age Have concept of time, causality and irreversibility of death They fear mutilation, pain abandonment Will ask directly if they are dying Interested in death ceremony, may make request for own ceremony Feel death is punishment 5-6 years old: see death as something other experience, believe death as reversible not final, begin to accept death as a fact. 6-9: identify death with old people, may personify death 9-10: accept that everyone must die May know they are going to die but feel comforted by having parents and loved ones with them. Adolescence May express anger at impending death Have an accurate understanding of death May wish to do something for friends and family, to leave something behind May wish to plan own funeral TYPES OF GRIEF: 1. Anticipatory grief occurs before a death. 2. Normal grief occurs when a persons emotional and behavioral responses are in accordance with the expected norms within his culture, social traits, social status and relationship to that which has been lost.

45 3. Complicated grief sets in when the emotional and behavioral responses are

prolonged, overwhelming and maladaptive. Commonly occurs if: Loss is sudden such as to accident and suicide a loved ones death is sudden A lot of suffering occurred before the death of a loved one: murder Conflict or strain in the relationship of the deceased and survivor Presence of other loses and grief from previous loses is not yet resolved The dead is a child Lack of support system Very intense grief

Signs of Complicated Grief: Isolation and withdrawal Severe or prolonged depression Violent behavior Suicidal ideation Workaholism Addictive behavior Swift replacement of the lost relationship Avoidance of any reminder of or imitation of the deceased People who are vulnerable to complicated grieving include those with the following characteristics: 1. Low self-esteem 4. Previous suicide threats or attempts 2. Low trust in other 5. Absent or unhelpful family members 3. Previous psychiatric disorder 6. Ambivalent, dependent, or insecure attachment to the deceased person Types of Complicated Grief: 1. Chronic Grief prolonged grief 2. Delayed Grief conscious or unconscious repression of feelings of loss by the survivor to avoid pain (working excessively, avoiding to talk about the loss or becoming unduly concern with the problems of others) 3. Exaggerated Grief - occur when the survivor engages in self- destructive behaviors in an attempt to find relief from his spiritual or emotional pain (self destructive tendencies seen in excessive alcohol drinking, suicidal ideation or unsafe sexual practices). 4. Masked Grief occurs when the grief of the survivor is interfering with his normal life already without the survivor knowing it. ( manifested by avoidance to engage in new relationships, to show affection, or making hurtful comments). 5. Disenfranchised Grief occurs when a survivor is prevented from openly acknowledging his loss because the relationship with the deceased was unacceptable or marginalized. = Is a grief over a loss that is not or cannot be acknowledged openly, mourned publicly, or supported socially. 3 categories: that can result in disenfranchised grief: 1. A relationship has no legitimacy 2. The loss itself is not recognized 3. The griever is not recognized. A nurse may experience disenfranchised grief. For example, she works in areas involving organ donation or transplantation. The daily intensity of relationships between nurses and client/families creates strong bonds among them. DIMENSIONS OF GRIEVING The nurse must use a holistic model of grieving that encompasses: 1. Cognitive dimension 4. Behavioral dimension 2. Emotional dimension 5. Physiologic dimension 3. Spiritual dimension

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Cognitive Responses to Grief The pain that accompanies grieving results from disturbance in the persons belief. The loss disrupts the basic assumptions about lifes meaning and purpose. Grieving after causes a person to change belief about and the world such as perceptions of the worlds benevolence, the meaning of life as related to justice, and a sense of destiny or life path. Other changes in thinking and attitude include reviewing and ranking values, becoming wiser, shedding illusions about immortality, viewing the world more realistically, and re-evaluating religious or spiritual beliefs. Emotional Responses to Grief Anger, sadness, and anxiety are the predominant emotional response to loss. The grieving person may direct anger and resentment toward the dead person and his health practices, family members, or health care provider or institutions. The nurse might hear common reactions as follows: He would have stopped smoking years ago. If I had taken him to the doctor earlier, this might not have happened. It took you too long to diagnose his illness. Spiritual Responses to Grief The grieving person may become disillusioned and angry with God or other religious figure such as the priest ( Margaret Vignette) Finding explanation and meaning through religious or spiritual beliefs, the client may begin to identify positive aspects of grieving (comfort, hope and strength in spiritual beliefs) Behavioral Responses to Grief Behavioral responses to grief are often the easiest to observe. The nurse can give supportive guidance for the clients exploration of emotionally and cognitively rough terrain. The nurse must provide the context of acceptance in which the client can explore his behavior. Example: 1. Client is still functioningphase of numbness. 2. Tearfully sobbing, crying uncontrollably, showing great restlessness, and searching phase of yearning and seeking. 3. Drug or alcohol abuse indicates a maladaptive behavioral response, suicide and homicide attempts to be extreme responsePhase of disorganization. 4. Participates in activities and reflection that are personally meaningful and satisfying phase of reorganization. Physiologic Responses to Grief May complain of insomnia, headache, impaired appetite, weight loss, lack of energy, palpitation, indigestions, and changes in the immune and endocrine system. Sleep disturbances are among the most frequent and persistent bereavement associated symptoms. Nursing Intervention for Persons in Grief Show empathy. Help the survivor to identify and express feelings, allow to cry and listen to their verbalizations. Use open-ended statements that encourage verbalization. Offer comfort. Encourage the survivor to talk about life without the deceased. When the person has recovered, grief may occur again. Prepare that person that may pain may resurface again. Refer to support groups, for counseling. Cultural Considerations

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Each culture, defines specific acceptable ways to exhibit shock and sadness, display anger, and mourn. Cultural awareness of the rituals for mourning can help nurses understand an individuals or familys behavior. AFRICAN AMERICAN - public prayer, black clothing, and decreased social activity MUSLIM AMERICAN - has 3 steps of burial procedure 1. washing the dead body 2. dressing the dead 3. positioning of the body HAITAN AMERICAN - They practice VODUN (voodoo) called root medicine - VODUN- is the practice of calling on a group of spirits with whom one periodically makes peace during specific events in life. CHINESE AMERICAN - Burning incense and reading scripture are ways to assist the spirit of the deceased in the afterlife journey. - The Buddhists ( do meditation) - For 1 year after death they place bowls of food on a table for the spirit JAPANESE AMERICAN - Bathe the deceased with warm water and dress the body in a white Kimono after purification rites. - For 2 days, family and friends bearing gifts may visit or offer money for the deceased while saying prayers and burning incense. FILIPINO AMERICAN - Wearing black clothing or armbands - Family and friends place wreaths on the casket and drape a broad black cloth on the home of the deceased. - Family members commonly place announcement in local newspaper asking for prayers and blessings on the soul of the deceased. VIETNAMESE AMERICAN (BUDDHISTS) - bathe the deceased and dressed in black clothes - they put few grains of rice in the mouth and place money with the deceased so that he can buy drink as the spirit moves on in the afterlife. - The body is displayed for viewing in the home before burial. When friends enter, music is played as a way to warm the deceased of the arrival. HISPANIC AMERICAN - they pray for the soul of the deceased during a novena (9-day devotion) and a rosary (devotional prayer) - they manifest luto (mourning) by wearing black or black and white and keeping a subdued manner. Like no watching TV, going to the movies, listening to the radio, or attending the dances or other social events. - Friends and relatives bring flowers and crosses to decorate the grave. - Lighting candles and blessings the deceased during a wake in the home. NATIVE AMERICAN (more than 500 Natives American tribes in U.S.) - They perform ceremonies of baptism for the spirit of the deceased seems to help ward off depression that those grieving may experience. Cherokee tribe- viewing death as a state of unconditional love in which the spirit of the deceased remains present. Encourages movements towards lifes purpose of being happy and living in harmony with nature and others Navajo tribe believes in and fears ghost; death signifies the end of all that is good so they must avoid touching the body of the deceased. Dakota believe in a happy after life called the land of the spirit, they believe that proper mourning is essential not only for the soul of deceased but also to protect members of the community. - To designate the end of mourning, they hold ceremony at burial grounds where they cover the grave with a blanket or cloth for making clothes and later give the cloth to a tribe member. They serve a dinner during which they sing, make speeches, and give away money. ORTHODOX JEWISH AMERICAN

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They stay with a dying person so that the soul does not leave the body while the person is alone. To leave the body alone after death is disrespectful. The family of the deceased may request to cover the body with a sheet. The eyes should be closed and the body should remain covered and untouched until family, a rabbi, or a Jewish undertaker can begin rites. Although organ donation is permitted, autopsy is not allowed; burial must occur within 24 hours unless delayed by the Sabbath. SUICIDE Suicide= is the intentional act of killing oneself. It is common in people with mood disorders especially Depression, Bipolar disorder, Schizophrenia, Substance Abuse, Post Traumatic Stress disorder, and Borderline Personality disorder. FACTORS: 1. Chronic Medical Illness: A) Cancer B) HIV/AIDs C) Diabetes D) CVAs E) Head and Spinal cord injury 2. A) C) E) Environmental factor: Isolation B) Recent loss Lack of social support D) Unemployment Critical life events F) Family history of Depresssion or suicide

3. Behavioral factor: A) Impulsivity B) Unstable lifestyle C) Erratic or unexplained changes from usual behavior. SUICIDAL IDEATION= means thinking about killing oneself. TYPES: 1. Active suicide ideation = thinks and seeks the way to commit suicide. 2. Passive suicide ideation = thinks and wanting to die or wishes she were dead but has no plan to cause her death. 3. Attempted suicide = a suicidal act that either failed or was incomplete (because someone recognized the suicide attempt as a cry for help and responded or the person was discovered and rescued) RISK FACTOR: SEX (more female attempts suicide but more male commits suicide) The higher suicide rates for men are partly the result of the method chosen like: 1. Shooting 2. Hanging 3. Jumping from a high place. For women: They are more likely to overdose on medication. Assessment: Those with a relative who commit suicide are at risk for suicide: the closer the relationship, the greater the risk because it offers a sense of permission or accepting of suicide as a method of escaping a difficult situation. This familiarity and acceptance also is believed to contribute to copycat suicide by teenagers. Warnings of suicidal intent Often people contemplating suicide have ambivalent and conflicting feelings about their desire to die. They frequently reach out to others help. Example: a client might say, I keep thinking about taking my entire supply of medications to end it all (direct) or I just can take it anymore (indirect).

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Asking clients directly about thought of suicide is important. Example: are you thinking of suicide? Risky behavior: Some suicidal people in treatment describe placing themselves in risky or dangerous situations such as speeding in a blinding rainstorm or when intoxicated. Some use the Russian roulette OUTCOME IDENTIFICATION: The client will be safe from harming self or others The client will engage in a therapeutic relationship. The client will establish a non-suicide contract. The client will create a list of positive attributes The client will generate, test, and evaluate realistic plans to address underlying issues.

INTERVENTION: Using an authoritative role. The nurse assumes an authoritative role to help clients stay safe. Example, a client may want to be alone in her room to think privately. This is not allowed while she is at increased risk for suicide. > Ask direct questions. Providing a safe environment: a. Monitor round the clock but in at irregular basis b. Remove dangerous items that can be used by the client c. Make sure there are there are no old medication or guns, if the patient is at home Initiating a no-suicide contract The client agrees to keep themselves safe and to notify staff at the first impulse to harm themselves. Creating a support system list The nurse makes a list of specific names and agencies that the clients can call for support. Family Response: Significant others may feel guilty for not knowing how desperate the suicidal person was, angry because the person did not seek their help or trust them, ashamed that their loved one ended his life with a socially unacceptable act, and sad about being rejected. Nurse Response: The nurse must convey the belief that the person can be helped and can grow and change. The nurse does not blame the clients or act judgmentally when asking about the details of a planned suicide. The nurse uses a nonjudgmental tone of voice and monitors his body language and facial expressions to make sure not to convey disgust or blame. Nevertheless nurses also must realize that no matter how competent and caring interventions are, a few clients will still commit suicide. A clients suicide can be devastating to the staff members who treated him especially if they have gotten to know the person and his family well over time. Even with therapy, staff members may end up leaving the health care facility or the profession as a result. Mental Health Promotion: They suggest that promotion of protective factors would improve the mental health of adolescents (reduction in suicide risk) The protective factors include

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1. 2. 3. 4. Close-parent child relationship Academic achievement Family life stability Connectedness with peers and others outside the family

Screening for early detection of risk factor, such as 1. Family strife, parental alcoholism or mental illness 2. History of fighting and access to weapons in the home MOOD DISORDERS Mood disorders, are also called affective disorders, are pervasive alterations in emotions that are manifested by Depression, Mania, or both. These interfere with a persons life, plaguing him or her with drastic and long-term sadness, agitation, or elation. Accompanying self-doubt, guilt, and anger alter life activities especially those that involved self-esteem, occupation and relationships. History: Archeologists have found holes drilled into ancient skulls to relieve the evil humors of those suffering from sad feelings and strange behaviors Babylonians and ancient Hebrews believed that overwhelming sadness and extreme behavior were sent to people through the will of God or other divine beings. King Saul, King Nebuchadnezzar, and Mosses suffered overwhelming grief of heart, unclean spirits, and bitterness of soul (symptoms of depression) Abraham Lincoln and queen Victoria had recurrent episodes of depression Until mid-1950s no treatment was available to help people with serious depression or mania. While there are still no cures for mood disorders, effective treatments for both depression and mania are now available. Are the most common psychiatric diagnoses associated with suicide and one of the most important risk factors for it is depression. Increased risk for suicide and suicide attempts are those clients with schizophrenia, substance use disorders, antisocial and borderline disorders, and panic disorders. CATEGORIES OF MOOD DISORDERS Primary mood disorders are major depressive disorder and bipolar disorder (formerly called manic-depressive illness) a. Major depressive episode lasts at least 2 weeks. With 4 symptoms as 1. Change in appetite or weight, sleep, or psychomotor activities 2. Decreased energy 3. Feelings of worthlessness or guilt 4. difficulty thinking, concentrating, or making decisions; or recurrent thoughts of death or suicidal ideation, plans or attempts. Some people also have delusions and hallucinations, the combination is referred to as psychotic depression b. Bipolar disorder is diagnosed when a persons mood cycles between extremes of mania and depression. Mania = is a distinct period during which mood is abnormally and persistently elevated, expansive, irritable (last for 1 week). Symptoms are: 1. Inflated self-esteem or grandiosity; decreased need for help. 2. Pressured speech = unrelenting, rapid, often loud talking without pauses. 3. Flight of ideas = racing thoughts, often unconnected; distractibility; increased involvement in goal-directed activity or psychomotor agitation; and excessive involvement in pleasure-seeking activities with a high potential for painful consequences. Some exhibits delusions and hallucinations. Hypomania = a period of abnormally and persistently elevated, expansive, or irritable mood lasting 4 days. With same symptoms of mania. The difference is that hypomania episodes do not impair the persons ability to function ( he

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may be productive) and there are no psychotic features (delusions and hallucinations). Mixed episode (rapid-cycling) is diagnosed when the person experience both mania and depression (every day for 1 week)

Bipolar disorders are described as: Bipolar I disorder one or more manic or mixed episodes usually accompanied by major depressive episodes Bipolar II disorder one or more major depressive episode accompanied by at least one hypomanic episode.

Some people bipolar disorder may experience a euthymic or normal mood and
affect between extreme episodes or they may have a depressed mood swing following a manic episode before returning to a euthymic mood. For some, euthymic periods between extreme are quite short. For others euthymia lasts months or even years. RELATED DISORDERS With symptoms that are less severe or of shorter duration includes: 1. Dysthymic disorder = characterized by at least 2 years of depressed mood for more days than not with some additional less severe symptoms that do not meet the criteria for a major depressive episode. 2. Cyclothymic disorder = by 2 years of numerous periods of both hypothymic symptoms that do not meet the criteria for bipolar disorder. 3. Substance-induced mood disorder = characterized by a prominent and persistent disturbance in mood that is judged to be a direct physiological consequence of ingested substances such as alcohol, other drugs, or toxins. 4. Mood disorder due to general medical condition= characterized by a prominent and persistent disturbance in mood that is judged to be a direct physiological consequence of a medical condition such as degenerative neurological conditions, cerebrovascular disease, metabolic or endocrine conditions, autoimmune disorders, HIV infections, or certain cancers. Some disorders that involve changes in mood include: 1. Seasonal affective disorder (SAD) With 2 subtypes 1. Winter depression or fall-onset SAD= they experience increased sleep, appetite, and carbohydrate cravings; weight gain; interpersonal conflict; irritability; and heaviness in the extremities beginning in late autumn and abating in spring and summer. 2. Spring onset SAD = less common with symptoms of insomnia, weight loss, and poor appetite lasting from late spring or early summer until early fall. 2. Postpartum or maternity blues are frequent normal experience after delivery of a baby characterized by labile mood and affect, crying spells, sadness, insomnia, and anxiety. Symptoms begin 1 day after delivery, usually peak in 3-7 days and disappear rapidly with no medical treatment. 3. Postpartum depression meets all criteria for a major depression episode with onset within 4 weeks of delivery. 4. Postpartum psychosis = is a psychotic episode developing within 3 weeks of delivery beginning with fatigue, sadness, emotional lability, poor memory, and confusion and progressing to delusions, hallucinations, poor insight and judgment, and loss of contact with reality. It requires immediate treatment. ETIOLOGY Most recent research focuses on chemical biologic imbalances as the cause

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Psychosocial stressors and interpersonal events appear to trigger certain physiologic and chemical changes in the brain, which significantly alter the balance of neurotransmitters. Effective treatment addresses both the biologic and psychosocial components of mood disorders The nurse needs a basic knowledge of both perspectives when working with clients experiencing these disorders. THEORIES 1. Biologic Theories A) Genetic theories = First-degree relatives of people with bipolar disorder have 3% 8% risk of developing bipolar disorder compared with a 1% risk in the general population. B) Neurochemical theories = influences of neurotransmitters (chemical messengers) focus on serotonin and norepinephrine as the two major biogenic amines implicated in mood disorders. Serotonin has many roles in behavior: mood, activity, aggressiveness and irritability, cognition, pain, biorhythms, and neuroendocrine process (growth hormone, cortisol and prolactin levels are abnormal in depression) Deficits of serotonin, its precursor tryptophan or a metabolite of serotonin found in the blood or CSF occur in people with depression Positron emission tomography scans demonstrate reduced metabolism in the frontal cortex, which may promote depression. Norepinephrine levels may be deficient in depression and increased in mania. Catecolamine energizes the body to mobilize during stress and inhibits kindling Kindling = the process by which seizure activity in a specific area of the brain is initially stimulated by reaching a threshold of the cumulative effects of stress, low amounts of electric impulses, or chemicals such as cocaine that sensitize nerve cells and pathways Anticonvulsants inhibit kindling. C) Neuroendocrine influences Mood disturbances have been documented in people with endocrine disorders such as those of the thyroid, adrenal, parathyroid, and pituitary. Elevated glucocorticoid activity is associated with the stress response, and evidence of increased cortisol secretion is apparent in about 40% of clients with depression with the highest rates found among older clients. Postpartum hormone alterations precipitate mood disorders such as postpartum depression and psychosis. About 5-10% of people with depression have thyroid dysfunction (elevated Thyroid stimulating hormone. 2. Psychodynamic Theories Psychological/ psychodynamic views explain depression from 3 general themes: 1. Adverse early life experiences = early losses, maternal inconsistency, the giving and withholding of love by caregiver, and various types of abuse are the causative agents for depression 2. Intrapsychic conflict = refers to the conflicts people have when they have mixed emotions about a behavior, event, or situation. Example: an individual who has been brought up to refrain from sexual activity, but who also has strong urges to experience sex, has a conflict. To refrain from sexual activity increases sexual frustration and to engage in sexual activity may cause anxiety, guilt, and fear. Persistent unsuccessful resolution of these conflicts can lead to depression. 3. Reactions to life events = Loss of loved one, of a job, of self-esteem, and loss of familiar surroundings. It is normal to react to loss with grief and sadness; it is abnormal to overreact 3.Sociological theory = it uses the medical, social learning, stress, and antipsychiatric models to explain the development of depression

53 1. Medical model = supports the idea that depression is a disease that can be treated

through medical interventions such as medications, nutritional therapy, and electroconvulsive shock treatments 2. Social learning = indicated that depression occurs when a person learns, through repetitive experiences, to cope with stress in a negative manner 3. Stress model = have contended that the development of depression is related to the interactions of a persons experiences, perceptions, social support, biopsychosocial weakness and occurrence of stress. 4. Antipsychiatric model = supports the premise that depression is a persons normal adaptive response to cope with aversive socioeconomic and political situations and should not be vied as abnormal. Cultural Considerations Children with depression often appear cranky. They may have school phobia, hyperactivity, learning disorders, failing grades, and antisocial behaviors. Adolescents with depression may abuse substances, join gangs, engage in risky behavior, be underachievers, or drop out of school In adults, manifestations of depression can include substance abuse, eating disorders, compulsive behaviors such as workaholism and gambling, and hypochondriasis. Older adults who are cranky and argumentative may actually depressed. MAJOR DEPRESSIVE DISORDER

Typically involves 2 or more weeks of a sad mood or lack of interest in life activities
with at least 4 other symptoms of depression such as: anhedonia and change in weight, sleep, energy, concentration, decision-making, self-esteem and goals. Common in women and has a 1.5 to 3 times greater incidence in first-degree relatives Incidence of depression decreases with age in women and increases with age in men Single and divorced people have the highest incidence. Depression in prepubertal boys and girls occurs at an equal rate. Onset: untreated ( 6-24 months), 50-60% people who have one episode of depression will have another, after the 2nd episode (70% chance of recurrence). GENERAL APPEARANCE Looks sad and sometimes looks ill Posture often slouched with head down and minimal eye contact. With psychomotor retardation ( slow body movement, slow cognitive processing, and slow verbal interaction) Responses to questions may be minimal with only one or two words. Latency of responses (takes 30 seconds to respond to a question. May answer some questions with I dont know because they are too fatigued and overwhelmed to think of an answer or respond in any detail. May exhibit signs of agitation or anxiety, wringing their hands and having difficulty sitting still. Have psychomotor agitation (increased body movement and thought) such as pacing, accelerated thinking, and argumentativeness. Describe themselves as hopeless, helpless, down, and anxious. May say, they are a burden on others, a failure at life, or may make other similar statements. Easily frustrated, angry at themselves and can be angry at others. They experience anhedonia (lack of the capacity to enjoy normally enjoyable experiences) May be apathetic (not caring about self, activities, or much of anything) May be flat with no emotional expressions. They are overwhelmed by noise and people who might make demands on them, so they withdraw from the stimulation of interaction with others. THOUGHT PROCESS AND CONTENT

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They experience slowed thinking process With severe depression, they may not respond verbally to questions. They tend to be negative and pessimistic in their thinking. They make self-deprecating remarks, criticizing themselves harshly (focused on failure or negative attributes). They tend to ruminate (repeatedly going the same thoughts) Those with psychotic symptoms, they have delusions, believed that they are responsible for all the tragedies and miseries in the world. Have thought of dying or committing suicide. The nurse may ask directly Are you thinking about suicide? or What suicidal thoughts are you having? Most of them will readily admit to suicidal thinking

SENSORIUM AND INTELLECTUAL PROCESS They are oriented to person, time and place. Those with psychotic symptoms or are withdrawn from their environment, experience difficulty with orientation. Their ability to respond questions are limited thus assessing general knowledge is difficult. Memory impairment is common Have extreme difficulty concentrating or paying attention. If psychotic, they may hear degrading and belittling voices, or may order them to commit suicide. JUDGMENT AND INSIGHT Impaired judgment because they cannot use their cognitive abilities to solve problems or to make decisions. Cant make decisions because of their extreme apathy or their negative belief that it doesnt matter anyway. Insight may be intact, if clients have been depressed previously Some have very limited insight and are totally unaware of their behavior, feelings, or even their illness. SELF-CONCEPT Reduced greatly their sense of self-esteem. Often use phrases such as good for nothing or just worthless to describe themselves. Believes that others would be better off without them, which leads to suicidal thoughts. ROLE AND RELATIONSHIPS Have difficulty fulfilling roles and relationships. Have problems going to work or school and seem unable to carry out their responsibilities. On family responsibilities, they are less able to cook, clean or care for children. Due to inability to fulfill roles, they become more convinced of their worthlessness for being unable to meet life responsibilities. Depression can cause great strain in relationships. They avoid social and family relationships because they feel overwhelmed, experience no pleasure from interactions, and feel unworthy Withdrawn from relationships, the strain increases. PHYSIOLOGIC AND SELFCARE CONSIDERATIONS Weight loss due to lack of appetite or disinterest in eating. Have sleep disturbance Lose interest in sexual activities (men often experience impotence. Some neglect personal hygiene (due to lack of interest or energy) Constipation due to decreased food and fluid intake as well as inactivity. May cause dehydration. II Data Analysis Nursing diagnoses commonly established for the client with depression include the following: Risk for Suicide

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Ineffective Role Performance Imbalanced Nutrition: Less than Body Requirements Self Care Deficit Anxiety Chronic Low Self-Esteem Ineffective Coping Disturbed Sleep Pattern Hopelessness Impaired Social Interaction TREATMENT AND PROGNOSIS A) Psychopharmacology 1. Selective Serotonin Reuptake Inhibitors (SSRIs). > Antidepressants, and are effective for most clients. > Produce few sedating, anticholinergic, and cardiovascular side effects (safer to use in children and older adults) > Insomnia decreases in 3 to 4 days. > Appetite returns to the normal state in 5 to 7 days > Energy returns in 4 to 7 days Example: - Fluoxetine (Prozac) - Citalopram (Celexa) - Sertraline (Zoloft) - Escitalopram (Lexapro) - Paroxetine (Paxil) 2.Cyclic antidepressants > Tricyclics- for the treatment of depression (mid-1950s), the oldest antidepressants. > Relieve symptoms of hopelessness, helplessness, anhedonia, inappropriate guilt, suicidal ideation, and daily mood variations (cranky in the morning and better in the evening) 3.Tetracyclic Antidepressants A) Amoxapine (Asendin) may cause extrapyramidal syndrome, tardive dyskinesia and neuroleptic malignant syndrome > It increases appetite and cause weight gain and craving for sweets. B) Malprotiline (Ludiomil) carries a risk of seizures, severe constipation and urinary retension, stomatitis > Central nervous system depressants can increase the effect of this drug.

4. Atypical Antidepressants = are used when the client has an inadequate response
to or side effects fro SSRIs. A) Venlafaxine blocks the reuptake of serotonin, norepinephrine, and dopamine (weakly) B) Bupropion for smoking cessation C) Nefazodone inhibits the reuptake of serotonin and norepinephrine and has few side effects. it can be used in clients with liver and kidney disease. D) Mirtazapine (Remeron) = also inhibits the reuptake of serotonin and norepinephrine, has few sexual side effects, but has higher incidence of weight gain, sedation and anticholinergic side effects 5. Monoamine oxidase inhibitors (MAOIs) Is used infrequently because of potentially fatal side effects and interactions with numerous drugs. The most serious side effect is hypertensive crisis, a threatening condition that can result when a client taking MAOs ingest tyramine-containing food and fluids or other medication. Symptoms are occipital headache, hypertension, nausea, vomiting, chills, sweating, restlessness, nuchal rigidity, dilated pupils, fever and motor agitation. These can lead to hyperpyrexia, cerebral hemorrhage, and death. Example:

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Other Medical treatment and Psychotherapy 1. Electroconvulsive Therapy (ECT) 2. Psychotherapy. Combination of psychotherapy and medication is considered the most effective treatment for depressive disorders. A) Interpersonal therapy B) Behavior therapy C) Cognitive therapy IV Intervention Provide a safe milieu and protect the client from self injury. Institute suicide precautions if indicated. Begin a therapeutic relationship by spending non-demanding time with the client. Provide a structured environment to mobilize the patient by: a. Allow time to finish task b. Initiate activities with the client c. Maintain consistency in schedule and activities Establish adequate nutrition and hydration. Promote rest and sleep. Encourage the client to verbalize and describe emotions. Work with the client to manage medications and side effects. Providing client and family teaching for depression: 1. Teach about the illness of depression. 2. Discuss the importance of support groups and assist in locating resources. 3. Teach about the benefits of therapy and follow-up appointments. 4. Teach the action, side effects, and special instructions regarding medications.

V Evaluation That client feels safe and not experiencing uncontrollable urges to commit suicide. Participation in therapy and medication compliance produces more favorable outcomes. Being able to identify signs of relapse and to seek treatment immediately can significantly decrease the severity of a depressive episode.

BIPOLAR DISORDER Bipolar disorder involves extreme mood swings from episodes of mania to episode of depression. It ranks second only to the major depression as a cause of worldwide disability. Young men early in the course of their illness are at highest risk for suicide (especially those with a history of suicide attempts or alcohol abuse. Occurs almost equally among men and women. Commonly in highly educated people. Difference between Major Depressive Disorders from Bipolar Disorder In Major Depressive Disorders, there is gradual descent into and back from depression can last 6 to 24 months (2 years). __________________________________________Normal mood (euthymia) __________________________________________Depression (dysthymia) While in BIPOLAR Disorder (3 categories)

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1. Bipolar disorder mixed or cycle = cycles alternate between periods of depression, back to normal behavior (euthymia) then to mania. 2. Bipolar manic = the person is in prolonged manic state for at least one week duration. The mood is abnormally elevated, expansive or irritable with three or more of the following: grandiosity, insomnia, verbosity, flight of ideas, distractibility, psychomotor agitation, excessive involvement with pleasurable activities without regard for consequences. 3. Bipolar depressed = cycle alternates between depression and normal (euthymic) behavior for at least 2 weeks duration, with a change in level of functioning plus five or more of the following: change in weight, insomnia, psychomotor agitation or retardation, fatigue, worthless feelings, inappropriate guilt, difficulty of concentration, death thoughts, suicidal ideation or attempt. ____________________________________________________Mania ____________________________________________________Normal mood ____________________________________________________Depression 1 2 3 Onset and Clinical Course The very early onset of bipolar Children who have been diagnosed with ADHD ( Attention Deficit/ Hyperactivity Disorder) Early 20s mean age for the first manic episode Other starts older than 50 years GENERAL APPEARANCE AND MOTOR BEHAVIOR Client experience psychomotor agitation and seem to be in perpetual motion; sitting still is difficult. These movements make clients exhausted or injure themselves. They may wear clothing that is brightly colored, flamboyant, attention-getting, and perhaps sexually suggestive ( a lot of jewelry, hair ornaments, heavy make-up) Pressured speech (hallmark symptom) which means unrelenting rapid and often loud speech without pauses. MOOD AND AFFECT Have periods of euphoria, exuberant activity, grandiosity and false sense of wellbeing. Has projection of all-knowing and all-powerful image (unconscious defense against underlying low self-esteem) Some manifest an angry, verbally aggressive tone and are sarcastic and irritable especially when others set limit on their behavior. With labile mood and with periods of loud laughter may alternate with episodes of tears. THOUGHT PROCESS AND CONTENT Have flight of ideas (cant connect concepts and jump from one subject to another). They may unable to communicate thoughts or needs in ways that others understand. They start many projects but cannot carry any to completion. Talk nonstop about the plans and projects to anyone, insisting on the importance of accomplishing these activities. They do not consider risks or personal experience, abilities, or resources. (shopping using credit cards excessively while unemployed and broke. With grandiosity (may claim to be the President, a famous TV/Movie star, or even God or a prophet). SENSORIUM AND INTELLECTUAL PROCESSES They are oriented to person and place but rarely to time. May claim to have many abilities that they do not possess. The ability to concentrate or to pay attention is grossly impaired.

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If psychotic, she may experience hallucinations JUDGMENT AND INSIGHT Are easily angered and irritable and strike back at what they perceive as censorship by others because they impose no restrictions on themselves. They are impulsive and rarely think before acting or speaking which makes their judgment poor. Insight is limited because they believe they are fine and have no problems. They blame any difficulties on others. SELF-CONCEPT Have exaggerated self-esteem and they believe they can accomplish anything. Rarely discuss their self-concept realistically ROLES AND RELATIONSHIPS They have trouble at work or school (not attending) and are too distracted and hyperactive to pay attention to children or ADLs They may begin many tasks or projects but they complete few. They have a great need to socialize but little understanding of their excessive, overpowering, and confrontational social interactions. Usual mood is elation (overjoyed) and with labile emotions (unstable emotions and fluctuates readily between euphoria and hostility. They cannot postpone or delay gratification. PHYSIOLOGIC AND SELF-CARE CONSIDERATIONS Can go days without sleep or food and not even realize they are hungry or tired. Often ignore personal hygiene as boring when they have more important things to do. They may throw away possessions or destroy valued items. They may even injure themselves and tend to ignore or be aware of health needs that can worsen. II Data Analysis Nursing diagnosis commonly established for clients in the manic phase are: Risk for Other-Directed Violence > Noncompliance Risk for Injury > Self-Care Deficit Imbalance Nutrition: Less than Body Requirement > Chronic Low Self-Esteem Ineffective Coping > Disturbed Sleep Pattern Ineffective Role Performance Treatment PSYCHOPHARMACOLOGY Involves a lifetime regimen: either an antimanic agent (lithium) or anticonvulsants used as mood stabilizer. In the acute stage of mania or depression exhibits psychotic (with delusions, hallucinations, and illusions), an antipsychotic agent is administered. LITHIUM Is a salt contained in the human body; it is similar to gold, copper, magnesium, manganese, and other trace elements. Is a salt that has greater affinity (similar) for receptor sites than Sodium Chloride. Sodium chloride helps to restore water imbalance (diuretics) Also could partially or completely mute the cycling toward bipolar depression. Response rate in acute mania is 70-80%. Also stabilize bipolar disorder by reducing the degree and frequency of cycling or eliminating manic episodes. Not only competes for salt receptor sites but also affects calcium, potassium, and magnesium ions as well as glucose metabolism

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Action peaks in 30 minutes -4 hours for regular form and 4-6 hours for the slowrelease form. It crosses the blood-brain barrier and placenta and is distributed in sweat and breast milk. Not recommended during pregnancy, it may lead to first trimester developmental abnormalities. May give antipsychotic or antidepressants in combination with lithium to reduce the symptoms. It can cause renal disease Has poorer response to client with early-onset bipolar disorder and early-onset alcoholism. May give anticonvulsants instead of lithium ANTICONVULSANTS Used to treat seizure disorders. Have proven helpful in stabilizing the moods of people with bipolar illness. ANTICONVULSANTS USED AS MOOD STABILIZERS 1. Carbamazepine (Tegretol) * Used for grand mal and temporal lobe epilepsy as well as trigeminal neuralgia. * Clients taking Carbamazepine need to have serum level checked regularly to monitor for toxicity and determine if the drug has reached therapeutic level (4-12 ug/ml) 2. Valproic acid (Depakote) * Known as divalproex sodium and sodium valproate. * Used for simple absence and mixed seizures, migraine prophylaxis, and mania. * As baseline and ongoing liver function test, serum ammonia levels, platelet and bleeding time to monitor therapeutic level (50-125 ug/ml). 3. Gabapentin (neurontin), Lamotrigine (Lamictal), Topiramate (Topamax) * Used less frequently than Valpoic acid. * Value ranges for therapeutic levels are not established. 4. Clonazepam (Klonopin) * An anticonvulsant and a benzodiazepine (major tranquillizers) * Used in simple absence and minor motor seizures, panic disorder, and bipolar disorder * Physiologic dependence can develop with long-term use. * This drug may be used in conjunction with Lithium or other mood stabilizers but is not used alone to manage bipolar disorder. PSYCHOTHERAPY It is useful in the mildly depressive or normal portion of the bipolar cycle. It is not useful during acute manic stage because the persons attention span is brief and he can gain little insight during times of accelerated psychomotor activity. Psychotherapy combined with medication can reduce the risk of suicide and injury, provide support to the client and family, and help the client to accept the diagnosis and treatment plan. III Outcome Identification The client will not injure self and others. The client will establish a balance rest, sleep and activity The client will establish adequate nutrition, hydration, and elimination The client will participate in self-care activities. The client will evaluate personal qualities realistically. The client will engage in socially appropriate, reality-based interaction The client will verbalize knowledge of his illness and treatment. IV Intervention: Provide for clients physical safety and safety of those around client: Set limits on clients behavior when needed. Remind the client to respect distances between self and others. Use short, simple sentence to communicate. Clarify the meaning of clients communication.

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Frequently provide finger foods that are high in calories and protein. Promote rest and sleep. Protect the clients dignity when inappropriate behavior occurs Channel clients need for movement into socially acceptable motor activities. Managing medications. Provide client and family teachings for the client with Mania 1. Teach about Bipolar illness and ways to manage the disorders. 2. Teach about the medication management including the need for periodic blood work and management of side effects. 3. For clients taking Lithium, teach about the need for adequate salt and fluid intake and seeking medical care for vomiting and diarrhea. 4. Educate the client and family about risk-taking behavior. 5. Teach about behavioral sign of relapses and how to seek treatment in early stages. SCHIZOPHRENIA Schizophrenia a serious psychiatric disorder characterized by impaired communication, loss of contact to reality and deterioration from a previous level of functioning.

from the Greek roots schizein (, "to split") and phrn, phren- (, -, "mind")

Historical Perspective: Morel (1856) the first psychiatrist to describe the psychiatric symptoms of schizophrenia. He named the disorder dementia praecox. Kahlbum (1868) describe catatonia Hecker (1870) described hebephrenia Emil Kraepelin (1896) described paranoia and categorized paranoia, hebephrenia and catatonia under dementia praecox. He believed that the cause of schizophrenia is biologic in nature, as a result of neuropathology Eugene Bleuler (1908) a Swiss Psychiatrist introduced the term schizophrenia and viewed it as a serious disruption of the mind, a splitting of the mind. He believed that the cause of schizophrenia can be explained by using Freuds psychoanalytical model.

is a psychiatric diagnosis that describes a mental disorder characterized by abnormalities in the perception or expression of reality. It most commonly manifests as auditory hallucinations, paranoid or bizarre delusions or disorganized speech and thinking in the context of significant social or occupational dysfunction. Onset of symptoms typically occurs in young adulthood Peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women. Diagnosis is based on the patient's self-reported experiences and observed behavior. No laboratory test for schizophrenia currently exists.

4 As Manifestations: according to E. Bleuler 1. 2. 3. 4. Associative looseness Autism Affect Inappropriateness Ambivalence

* Auditory hallucination TWO MAJOR CATEGORIES OF THE SYMPTOMS:

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1. Positive or Hard symptoms/signs which include delusions, hallucinations, and grossly disorganized thinking, speech and behavior. Ambivalence Associative looseness Delusions Echopraxia Flight of Ideas Hallucinations Ideas of reference Perseverations

2. Negative of Soft Symptoms/signs such as flat affect, lack of volition and social withdrawal or discomfort. Alogia Anhedonia Apathy Blunted/flat affect Catatonia Avolition

TYPES OF SCHIZOPHRENIA: 1. Schizophrenia, Paranoid type: characterized by persecutory or grandiose delusion, hallucinations, and, occassionally, excessive religiosity or hostile and aggressive behavior. Prognosis: Good Defense Mechanism: Projection Nursing Interventions: Priority: Safety of Others Offer sealed foods/unopened medicines Never displace outbursts of emotions Explain procedure in simple ways Never argue with the patient

2. Schizophrenia, Disorganized type: characterized by grossly inappropriate or flat affect, incoherence, loose associations and extremely disorganized behavior. Prognosis: Poor Defense Mechanisms: Regression Nursing Interventions: Assist with ADL Encourage activity Present reality

3. Schizophrenia Catatonic type: characterized by marked psychomotor disturbance, either motionless or excessive motor activity. Motor immobility may be manifested by catalepsy (waxy flexibility) or stupor. Excessive motor activity is apparently purposeless and is not influenced by external stimuli. Other features include extreme negativism, mutism, peculiarities of voluntary movement, echolalia and echopraxia.

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Prognosis: Good Defense Mechanism: Repression Nursing Interventions: Priority: Nutrition and circulation Provide distraction Encourage activity

4. Schizophrenia, Undifferentiated: characterized by mixed schizophrenic symptoms along with disturbances of thought, affect, and behavior. 5. Schizophrenia Residual type: characterized by at least one previous, though not a current episode, social withdrawal, flat affect and looseness of association RELATED DISORDERS: Schizophreniform disorder the client exhibit the symptoms but for less than the 6 months necessary to meet the diagnostic criteria for schizophrenia. Social or occupational functioning may or may not be impaired. Schizoaffective disorder the client exhibits the symptoms of psychosis and at the same time, all the features of a mood disorder, either depression or mania Delusional disorder - the client has one or more non bizarre delusions that is, the focus the delusion is believable. Psychosocial functioning is not markedly impaired, and behavior is not obviously odd or bizarre. Brief Psychotic disorder the client experiences the sudden onset of at least one psychotic symptom such as delusion, hallucinations, or disorganized speech or behavior, which last from one day to 1 month. The episode may or may not have identifiable stressor or may follow childbirth. Shared Psychotic disorder (folie a deux)- two people share a similar delusion. The person with this diagnosis develops this delusion in the context of a close relationship with someone who has psychotic delusion.

ETIOLOGY: BIOLOGIC FACTORS 1. Genetic Factors Twins Identical Twin have 50% risk for schizophrenia while Fraternal twin have 15 % risk Children with one biologic parent with schizophrenia has a 15% risk; risk rises if both biologic parents have schizophrenia. 2. Neuroanatomic Scientist studied the brain structure (neuroanatomy) and activity (neurochemical) of people with schizophrenia with the development of non invasive imaging techniques such as CT Scan, MRI, and Positron Emission Tomography (PET) in the past 25 years. Findings: have relatively less brain tissue and CSF. CT scan shown enlarged ventricles in the brain and cortical atrophy PET studies suggest that glucose metabolism and oxygen are diminished in the frontal cortical structures of the brain. Research consistently shows decreased brain volume and abnormal brain function in the temporal and frontal areas of person with schizophrenia.

3. Neurochemical Factors Implicated the action of dopamine, serotonin, norepinephrine, acetylcholine, glutamate and several neuromodulary peptides.

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Excess dopamine as the cause which was developed based on two observations. ( First, drugs that increase activity in the dopaminergic system such as levodopa and amphetamine, sometimes induced a paranoid psychotic reaction similar to schizophrenia. Second, drugs blocking the postsynaptic dopamine receptors reduced psychotic symptoms; in fact the greater the ability of the drug to block dopamine receptors, the more effective it is in decreasing symptoms of schizophrenia. More recently, serotonin, has been included among the leading neurochemical factors affecting schizophrenia. Newer atypical antipsychotic such as clozapine (clozaril) are both dopamine and serotonin antagonists which dramatically reduce psychotic symptoms and ameliorate the negative signs of schizophrenia.

4. Immunovirologic Factors: Popular theories have emerged that exposure to a virus or the bodys immune response to a virus could alter the brain physiology of people with schizophrenia. Cytokines may have a role in the development of major psychiatric disorders such as schizophrenia. Infections in pregnant women as possible origin. Higher rates of schizophrenia among children born in crowded areas in cold weather, conditions that are hospitable to respiratory ailments.

TREATMENT Antipsychotic or neuroleptic medications prescribed primarily for their efficacy in decreasing psychotic symptoms. They do not cure schizophrenia; rather, they are used to manage the symptoms of the disease.

the older or conventional antipsychotic medications are dopamine antagonist. It targets the positive signs of schizophrenia, but no observable effect on the negative signs. The newer or atypical antipsychotic medications are both dopamine and serotonin antagonists. It does not only diminish positive symptoms; for many clients, they also lessen the negative signs of lack of volition and motivation, social withdrawal and anhedonia.

Maintenance Therapy - available in depot injection form, wherein the vehicle is sesame oil that is why it is absorbes slowly over time into the clients system. 1. Fluphenazine (Prolixin) in decanoate and enanthate preparations. 2. Haloperidol (Haldol) in decanoate Effects of the drugs last 2-4 weeks, eliminating the need for daily oral antipsychotic medication The duration of action is 7-28 days for fluphenazine and 4 weeks for haloperidol Not suitable for the management of acute episodes of psychosis SIDE EFFECTS:

Serious neurologic side effects include extrapyramidal side effects (acute dystonic reactions, akathisia, parkinsonism); tardive dyskinesia, seizures and neuroleptic malignant syndrome. Non-neurologic side effects include weight gain, sedation,

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photosensitivity and anticholinergic symptoms such as dry mouth, blurred vision, constipation, urinary retention, and orthostatic hypotension.

1. Extrapyramidal side effects: are reversible movement disorders induced by

neuroleptic medications. a. Dystonic reaction characterized by spasms in discrete muscle groups such as the neck muscle (torticollis) or eye movement (oculogyric crisis) accompanied by protrusion of the tongue, dysphagia, and laryngeal /pharyngeal spasm that can compromise the clients airway causing a medical emergency. Acute Treatment: Diphenhydramine (Benadryl) given either intramuscularly or intravenously, or Benzotropine (Cogentin) given intramuscularly. Other drugs: Trihexyphenidyl (Artane) Biperiden (Akineton) Amantadine (Symmetrel) Diazepam (Valium) Lorazepam (Ativan) Propanolol (Inderal)

b. Psuedoparkinsonism or neuroleptic-induced parkinsonism include shuffling gait, mask-like facies, muscle stiffness (continuous) or cogwheeling rigidity (ratchet-like movements of joints), drooling, and akinesia (slowness and difficulty initiating movement). Acute Treatment: same as dystonic reactions c.Akathisia is characterized by restless movement, pacing, inability to remain still, and the clients report of inner restlessness. Acute Treatment: Betablockers such as Propanolol

2.

Tardive Dyskinesia is a late-appearing side effect characterized by abnormal involuntary movement such as lip smacking, tongue protrusion, chewing, blinking, grimacing, and choreiform movements of the limbs and feet. Abnormal Involuntary Movement Scale (AIMS) is used to observed in several positions and the severity of symptoms is rated from 0 to 4. AIMS can be administered every 3-6 months. Notify the physician so that the client dosage or drug can be changed to prevent advancement of T.D. 3. Seizures infrequent side effect, incidence is only 1%. Treatment: lower dosage or a different antipsychotic

4.

Neuroleptic Malignant Syndrome is a serious and frequently fatal condition characterized by muscle rigidity, high fever, increased muscle enzymes (particularly CPK) and leukocytosis (increased leukocytes). 0.1 to 1% chance Treatment: Stop the medication 5. Agranulocytosis - failure of the bone marrow to produce adequate WBC. Characterized by fever, malaise, ulcerative sore throat, and leukopenia. Not manifested immediately but can occur as long as 18-24 weeks after the initiation of therapy. Treatment:

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a. Discontinue the drug stat. b. weekly WBC count for the first 6 months then every 2 weeks thereafter. Psychosocial Treatment: 1. 2. 3. 4. Individual and Group therapy Family Therapy Family Education Social Skills Training

General Appearance, Motor Behavior, and Speech Some appear normal in terms of being dresses Others exhibit bizarre or odd behavior Appear disheveled and unkempt with no obvious concern for their hygiene Client may be restless and unable to sit still, exhibit agitation and pacing or appear unmoving (catatonia) Stereotypic behavior Echopraxia accompanied by rambling speech Exhibit psychomotor retardation May be almost immobile, curled into a ball (fetal position) Exhibit waxy flexibility Speech may be slowed or accelerated in rate and volume, may speak in whisper or hushed tones or may talk loudly or yell Exhibit unusual speech pattern: word salad and echolalia Mood and Affect May have flat affect or blunted affect Mask-like facial expression Affect may also be described as silly, characterized by giddy laughter for no apparent reason Exhibit inappropriate expression or emotions incongruent with the context of situation Anhedonia

Thought Process and Content Thought blocking Thought broadcasting Thought withdrawal Thought insertion May exhibit tangential and circumstantial thinking May also exhibit alogia Delusions

Sensorium amd Intellectual Process With difficulty on abstract thinking Demonstrate poor intellectual functioning During episodes of psychosis, clients are commonly disoriented to time and sometimes place Exhibit the most extreme form of disorientation which is depersonalization Hallucinations which is one of the hallmark symptom of schizophrenia which involves the five senses and bodily sensations Judgment and Insight Judgment is frequently impaired Severely impaired insight

Self Concept

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lack of ego boundaries as evidenced by depersonalization, derealization and ideas of reference. May believe that they are fused with another person or object, may not recognize body parts as their own or may fail to know whether they are male or female. Roles and Relationships Social isolation is prevalent Has problem with trust and intimacy With low self esteem Lacks motivation Difficulty fulfilling family roles

Physiologic and Self Care Considerations With inattention to hygiene and grooming Clients may fail to recognize sensations such as hunger or thirst, and food or fluid intake may be inadequate Occasionally develop polydipsia, which lead to water intoxication Serum sodium levels can become dangerously low, leading to seizure Sleep problems are common May not correctly perceive or acknowledge physical cues such as fatigue DATA ANALYSIS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Risk for Other-Directed Violence Risk for Suicide Disturbed Thought Processes Disturbed Sensory Perception Disturbed Personal Identity Impaired Verbal Communication Self- Care deficits Social Isolation Deficient Diversional Activity Ineffective Health Maintenance Ineffective therapeutic Regimen Management

OUTCOME IDENTIFICATION 1. 2. 3. 4. 5. The The The The The client client client client client will will will will will not injure self and others establish contact with reality. interact with others in the environment. express thoughts and feelings. participate in prescribed therapeutic environment.

Treatment Outcome for Continued Care after the Stabilization of Acute Symptoms: 1. The client appointments.) 2. The client 3. The client 4. The client needs. 5. The client will participate in the prescribed regimen (including medications and follow up will maintain adequate routine for sleeping, food, and fluid intake. will demonstrate independence in self-care activities. will communicate effectively with others in the community to meet his or her will seek or accept assistance to meet his needs when indicated.

Nursing Interventions: 1. 2. Promoting safety of client and others and right to privacy and dignity. Establishing therapeutic relationship by establishing trust.

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Using therapeutic communication (clarifying feelings and statements are disorganized and confused). 4. Interventions for delusions. Do not openly confront the delusion or argue with the client. Establish and maintain reality for the client Use distracting techniques. Teach the client positive self-talk, positive thinking and to ignore delusional beliefs. 5. Interventions for hallucinations client listening to 6. Help present and maintain reality by frequent contact and communication with the Elicit description of hallucination to protect client and others. Engage client in reality based activities such as card playing, occupational therapy or music.

Coping with socially inappropriate behaviors.

Redirect the client away from problem situations. Deal with inappropriate behavior in a nonjudgmental and matter-of-fact manner; give factual statements; do not scold. Reassure others that clients inappropriate behavior or comments are not his or her fault (without violating clients confidentiality.) Try to reintegrate the client into the treatment milieu as soon as possible. Do not make the client feel punished for inappropriate behaviors. Teach social skills through education, role modelling and practice.

7.

Suspiciousness/ Paranoia The first step and the most important is to establish a trusting relationship. Establish regular time and place of meeting; be consistent. Use one to one relationship initially. Gradually increase interaction but avoid competitive activities Do not argue and be nonjudgmental with regards to hallucinations, delusions and feelings, ideas expressed by the patient Be honest and matter of fact Make mutual expectations and promises clear, abide by them Avoid talking and laughing when client can see you but not hear you Give rationales or explanations for rules, activities, occurences, noises and request Do not force to participate in activies If client thinks the food is poisoned: give him foods in sealed containers and open them in front of the client, do not mix medicine with clients food beverages without the client knowing it and seeing when you mixed them, do not touch clients food without him seeing it, do not change the expected menu of the client without informing him first. Be calm when talking to patient Do not touch client without approval. 8. Client and family teachings.

Drink sugar-free fluids and eat sugar-free hard candy to ease the anticholinergic effects of dry mouth. Avoid calorie-laden beverages and candy they promote dental caries, contribute to weight gain and do little to relieve dry mouth. Constipation can be prevented or relieved by increasing intake if water and bulkforming foods in the diet and exercising. Stool softeners are permissible, but laxatives should be avoided.

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Use sunscreen to prevent burning. Avoid long periods of tie in the sun and wear protective clothing. Rising slowly from a lying or sitting position will prevent falls from orthostatic hypotension or dizziness due to a drop in blood pressure. Wait until any dizziness have subsided before walking. Monitor the amount of sleepiness or drowsiness the client experience. Avoid driving a car or performing other potentially dangerous activities until your response time and reflexes seen normal. If you forgot a dose of antipsychotic medication, take it if the dose is only 3-4 hours late. If the missed dose is more than 4 hours late or the next dose is due, omit the forgotten dose. If you have difficulty remembering you medication, use a chart to record doses when taken, or use a pill box labeled with dosage times and/or days of the week to help you remember when to take the medication. Personality Disorders Includes perceptions, attitudes and emotions Defined as an ingrained enduring pattern of behaving and relating to self, others, and the environment. Compose of temperament and character Temperament refers to biologic processes of sensation, association, and motivation that underlie the integration of skills and habits based on emotion. Character consists of concepts about the self and the external world. Personality Disorders Diagnosed when personality traits become inflexible and maladaptive and significantly interfere with how a person functions in society or cause the person emotional distress. Diagnosis of PD is based on two or more deviations on the following 1. Ways of perceiving and interpreting self, other people, and events. (cognition) 2. Range, intensity, lability, and appropriateness of emotional response (affect) 3. Ability to control impulses or express behavior at the appropriate time and place (impulse control) Categories of Personality Disorders Cluster A includes people whose behavior appear odd or eccentric and includes paranoid, schizoid, and schizotypal personality disorders. Cluster B includes people who appear dramatic, emotional or erratic and includes antisocial, borderline, histrionic, and narcissistic personality disorders. Cluster C includes people who appear anxious or fearful and includes avoidant, dependent, and obsessive-compulsive personality disorders. Signs and symptoms of cluster A (odd, eccentric) personality disorders Paranoid personality disorder More common in men than women 0.5%-2.5% of the general population Belief that others are lying, cheating, exploiting or trying to harm you Perception of hidden, malicious meaning in benign comments Inability to work collaboratively with others Emotional detachment Hostility toward others Defense Mechanism Used: Projection Nursing Interventions: Approach in a formal, business-like manner and refrain from social chitchat or jokes Involve in formulating their plans of care Teach client to validate ideas before taking action. Schizoid personality disorder Occurs 0.5% - 7% of the general population Fantasizing rich and extensive

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Extreme introversion self absorbed and loner Emotional distance, even from family members lack of desire for involvement with others in all aspects of life. Fixation on your own thoughts and feelings indecisive and lack future goals and direction Emotional detachment marked difficulty experiencing and expressing emotions particularly anger and aggression

Nursing Interventions: Improve clients functioning in the community - Nurse can make referrals to social services or appropriate local agencies for assistance. Assist client to find case manager that can help the client to obtain services and health care, manage finances, and so on. Schizotypal personality disorder 3%-5% of the population; slightly common in men than women Indifference to and withdrawal from others "Magical thinking (experience transient psychotic episodes in response to stress) the idea that you can influence people and events with your thoughts Odd appearance, elaborate style of dressing (unkempt, clothes often ill-fitting, do not match and stained and dirty), speaking (coherent but may be loose and bizarre) and in interacting with others Belief that messages are hidden for you in public speeches and displays Suspicious or paranoid ideas anxious to strangers Development of self-care skills - establish a daily routine for hygiene and grooming Improve community functioning - Ask client to make a list of people in the community with whom they must have contact (telephone or written) Social skills training to help clients to talk clearly with others and to reduce bizarre conversations. Signs and symptoms of cluster B (dramatic, emotional) personality disorder Histrionic personality disorder 2-3% of the gen.popul. Excessive sensitivity to others' approval Attention-grabbing, often sexually provocative clothing and behavior - Speech is usually colorful and theatrical, full of superlative adjectives Excessive concern with your physical appearance False sense of intimacy with others refer almost all acquaintances as dear Constant, sudden emotional shifts Have variety of vague physical complaints or relate exaggerated versions of physical illness Nursing Interventions: Teach social skills Provide factual feedback about behavior should focus on appropriate alternatives, not merely criticism Narcissistic personality disorder 1-2% in general population; mostly in men Inflated sense of and preoccupation with your importance, achievements and talents (sense of entitlement) Constant attention-grabbing and admiration-seeking behavior Inability to empathize with others Excessive anger or shame in response to criticism Manipulation of others to further your own desires Nursing Interventions:

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Matter-of-fact approach Teach client any needed self-care skills. Antisocial (formerly, sociopathic, psychopathic or dyssocial personality disorder) personality disorder Only 3% of the general population; common in men Onset: is in childhood and adolescence Hx: childhood= enuresis, sleep walking and syntonic act of cruelty - adolescence engaged in lying, vandalism, sexual promiscuity Chronic irresponsibility and unreliability and substance abuse Lack of regard for the law and for others' rights Persistent lying and stealing Aggressive, often violent behavior Lack of remorse for hurting others Lack of concern for the safety of yourself and Nursing Interventions: 1. Stating the behavioral limit (describing the unacceptable behavior) 2. Identifying the consequences if the limit exceeded 3. Identifying the expected or desired behavior. Confrontation (matter-of-fact) - Point out problem behavior - Keep client focused on self Teach the client to solve problems effectively and manage emotions of anger and or frustration Problem Solving Skills: 1. Identifying the problem 2. Exploring alternative solutions and related consequences 3. Choosing and implementing alternatives 4. Evaluating the results. Borderline personality disorder About 2-3% of the general population, 3x common in women 8-10% commit suicide Five times more common in those with first-degree relative Difficulty controlling emotions or impulses Frequent, dramatic changes in mood, opinions and plans Stormy relationships involving frequent, intense anger and possibly physical fights (tend to idealize and adore others) Fear of being alone despite a tendency to push people away-tend to use traditional objects Feeling of emptiness inside Tend to have psychotic features during intense stress Suicide attempts or self-mutilation Nursing Interventions Promoting clients safety - No-self-harm contract - Safe expression of feelings and emotions Helping the client to cope and control emotions - identifying feelings - Journal entries - Delaying gratification Cognitive restructuring techniques - Thought stopping and decatastrophising Limit setting and confrontation Signs and symptoms of cluster C (anxious, fearful) personality disorders Avoidant personality disorder Hypersensitivity to criticism or rejection Self-imposed social isolation (reluctant to anything perceived risky) Extreme shyness in social situations, though you strongly desire close relationships

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Nursing Interventions: Support and reassurance Cognitive restructuring Reframing and decatastrophising Promote self-esteem Dependent personality disorder 15% of the population; 3x more often in female Excessive dependence on others to meet your physical and emotional needs Tolerance of poor, even abusive treatment in order to stay in relationships Unwillingness to independently voice opinions, make decisions or initiate activities Intense fear of being alone Urgent need to start a new relationship when one has ended Nursing Interventions: Foster clients self-reliance and autonomy Teach problem solving and decision making skills Cognitive restructuring technique Obsessive-compulsive personality disorder Excessive concern with order, rules, schedules and lists Perfectionism, often so pronounced that you can't complete tasks because your standards are impossible to meet Inability to throw out even broken, worthless objects Inability to share responsibility with others Inflexibility about the "right" ethics, ideas and methods Compulsive devotion to work at the expense of recreation and relationships Financial stinginess Discomfort with emotions and aspects of personal relationships that you can't control Nursing Interventions Encourage negotiation with others Assist client to make timely decisions and complete work Cognitive restructuring technique Depressive Personality Disorder Char. by a pervasive pattern of depressive cognitions and behaviors in various contexts. Occurs equally in both female and male Similar behavior with MDD, but less severe Nursing Interventions Assess whether there is risk for self-harm Encourage to involve in activities or engaged with others. Provide factual feedback Promote self esteem Passive-Aggressive Personality Disorder - 1-3% of the general population - Slightly , prevalent in female than male - Love procrastinate - Express anger through passivity Medications: Antidepressants. Doctors commonly prescribe selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac, Sarafem), sertraline (Zoloft), citalopram (Celexa), paroxetine (Paxil), nefazodone, and escitalopram (Lexapro), or the related antidepressant venlafaxine (Effexor) to help relieve depression and anxiety in people with personality disorders. Less often, monoamine oxidase inhibitors such as phenelzine (Nardil) and tranylcypromine (Parnate) may be used Anticonvulsants. These medications may help suppress impulsive and aggressive behavior. Your doctor may prescribe carbamazepine (Carbatrol, Tegretol) or valproic acid (Depakote). Your doctor may also prescribe topiramate (Topamax), an anticonvulsant that's being studied as an aid in managing impulse-control problems Antipsychotics. People with borderline and schizotypal personality disorders are at risk of losing touch with reality. Antipsychotic medications such as risperidone

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(Risperdal) and olanzapine (Zyprexa) can help improve distorted thinking. For severe behavior problems, doctors may prescribe haloperidol (Haldol). Other medications. Doctors sometimes prescribe anti-anxiety medications such as alprazolam (Xanax) and clonazepam (Klonopin) and mood stabilizers such as lithium (Eskalith, Lithobid) to relieve symptoms associated with personality disorders.

ELECTOCONVULSIVE THERAPY 2 TYPES OF ECT: 1. Unmodified ECT- no medications are given prior to treatment 2. Modified ECT with medications prior to the treatment a) Atropine SO4 to decrease secretions/ minimize aspiration and decreases vagal stimulation b) Anectine (Succinylcholine) to promote muscle relaxation c) Methohexetal Sodium (Brevital) serves as an anesthetic agent. Ultra acting barbiturates and induces a light coma preceding delivery of ECT. It requires consent Usually given at 70-150 volts for about .5-2 seconds Effectivity: 6-12 treatments with at least 48 hour interval Indicator of effectiveness: tonic-clonic seizure

INDICATIONS of ECT: Depression Mania Catatonic schizophrenia CONTRAINDICATIONS: Fever Increased ICP Cardiac conditions TB with history of hemorrhage * Age below 18 y.o. * Retinal detachment * Pregnancy

Before the procedure: Diagnostic procedures: X-ray, ECG, EEG Drugs if Modified (Atropine SO4, Anectine, Methohexital Na) Check Vital signs No dentures, hairpins or nail polish During the procedure: Observe for tonic-clonic seizure After the procedure: Position Check vital signs Reorient the client Watch out for complications: Memory loss, Headache, Apnea, Respiratory depression, and fracture. DELUSION DISORDER Clients with schizophrenia usually experience delusions (fixed, false beliefs with no basis in reality) in the psychotic phase of the illness. A common characteristic of schizophrenic delusions are direct, immediate, and total certainty with which the client holds these beliefs Initially, the nurse assesses the content and depth of the delusion to know what behaviors to expect and to try to establish reality for the client. When eliciting information about the clients delusional beliefs, the nurse must be careful not to

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support or challenge them. The nurse might ask the client to explain what he or she believes by saying Plain explain that to me or Tell me what youre thinking about that. Types of Delusion 1. Persecutory/paranoid delusions- involve the clients belief that others are planning to harm the client or are spying, following, ridiculing, or belittling the client in some way. Sometimes the client cannot define who these others are. Example: The client may think that food has been poisoned or that rooms are bugged with listening devices. Sometimes the persecutor is the government, FBI, or other powerful organization. Occasionally, specific individuals, even family members, may be named as the persecutor. 2. Grandiose delusion are characterized by the clients claim to association with famous people or celebrities, or the clients belief that he or she is capable of great feats. Examples: The client may claim to be engaged to a famous movie star or related to some public figure, such as claiming to be the daughter of the president of the United States, or he or she may claim to have found a cure for cancer. 3. Religious delusions often center around the second coming of Christ or another significant religious figure or prophet. These religious delusions appear suddenly as part of the clients psychosis and are not part of his or her religious faith or that of others. Examples: Client claims to be the Messiah or some prophet sent from God; believes that God communicates directly to him or her, or that he or she has a special religious mission in life or special religious powers. 4. Somatic delusion are generally vague and unrealistic belief about the clients health or bodily functions. Factual information or diagnostic testing does not change these beliefs. Examples: A male client may say that he is pregnant, or a client may report decaying intestines or worms in the brain. 5. Referential delusion or ideas of reference involves the clients belief that television broadcasts, music, or newspaper articles have special meaning for him or her. Examples: The client may report that the president was speaking directly to him on a news broadcast or that special messages are sent through newspaper articles. Cognitive Disorders Cognition is the brains ability to process, retain, and use information. Cognitive abilities include reasoning, judgment, perception, attention, comprehension, and memory. These are essential for many important tasks, including making decisions, solving problems, interpreting the environment, and learning new information. A cognitive disorder is a disruption or impairment in these higher-level functions of the brain. They can cause people to forget the names of immediate family members, to be unable to perform daily household tasks, and to neglect personal hygiene. Types 1. Amnestic disorders 2. Delirium 3. Dementia Delirium Is a syndrome that involves a disturbance of consciousness accompanied by a change in cognition. famous or

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It develops over a short period, sometimes a matter of hours, and fluctuates, or changes, throughout the course of the day. Clients have difficulty paying attention, are easily distracted and disoriented , and may have sensory disturbances such as illusions, misinterpretations, or hallucinations. Examples: An electrical cord on the floor may appear to them to be a snake (illusion). They may mistake the banging of a laundry cart in the hallway for a gunshot (misinterpretation). They may see angels hovering above when nothing is there (hallucination). Clients may experience disturbances in the sleep-wake cycle, changes in psychomotor activity, and emotional problems such as anxiety, fear, irritability, euphoria, or apathy Etiology: results from an identifiable physiologic, metabolic, or cerebral disturbance or disease from drug intoxication or withdrawal. Drugs causing delirium: anesthesia, anticonvulsants, anticholinergics, antidepressants, antihistamines, antihypertensives, aspirin, insulin, narcotics, steroids The most common causes of delirium: Physiologic or metabolic, infection and drug related. Treatment: To identify and treat the causal or contributing medical conditions. Some causes such as head injury or encephalitis may leave clients with cognitive, behavioral, or emotional impairment even after the underlying cause resolves. Dementia is a mental disorder that involves multiple cognitive deficits, primarily memory impairment, and at least one of the following cognitive disturbances Clients have Aphasia (deterioration of language function), Apraxia (impaired ability to execute motor functions despite intact motor abilities, Agnosia ( inability to recognize or name objects despite intact sensory abilities) and disturbance in executive functioning or inability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior. Impair social or occupational functioning and represent a decline from previous functioning. Memory impairment is the prominent early sign of dementia. Difficulty learning new material and forget previously learned material. Example: forgetting where certain objects were placed or that food is cooking on the stove. Client forgets the names of adult children, their lifelong occupation, and even their names. Clients may exhibit echolalia (echoing what is heard) or palilalia (repeating words or sounds over and over) May also underestimate the risks associated with activities or overestimate their ability to function in certain situation. (driving or parking) Comparison of Delirium and Dementia Indicators Delirium Dementia Onset Rapid Gradual and insidious Duration Brief (hours to days) Progressive deterioration Level of consciousness Impaired, fluctuates Not affected Memory Short term memory Short-then-long term memory impaired, impaired eventually destroyed Speech May be slurred, Normal in early stage, progressive rambling, pressured aphasia in later stage And irrelevant Thought process Temporary disorganized Impaired thinking, eventually loss of Thinking abilities Perception Visual or tactile Often absent, but can have paranoia, hallucinations, hallucinations, illusions delusions Mood Anxious, fearful if Depressed and anxious in early stage,

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If hallucinating; Weeping, irritable labile mood, restless pacing, angry outbursts in later stages

Etiology: it is not known whether dementia causes decreased metabolic activity or if decreased metabolic activity results in dementia. Other causes of dementia are related to infections such as human immuno-deficiency virus (HIV), infection or Creutzfeldt-Jakob disease. Most common type of dementia and their known or hypothesized causes 1. Alzheimers disease is progressive brain disorder that has a gradual onset but causes an increasing decline in functioning, including loss of speech, loss of motor function, and profound personality and behavioral changes such as paranoia, delusions, hallucinations, inattention to hygiene, and belligerence 2. Vascular dementia has symptoms similar to those of alzheimers disease, but onset is abrupt, and rapid change in functioning. Computed tomography or magnetic resonance imaging usually shows multiple vascular lesions of the cerebral cortex and subcortical structures resulting from the decreased blood supply to the brain. 3. Picks disease a degenerative brain disease that particularly affects the frontal and temporal lobes and results in a clinical picture similar to that of Alzheimers disease. Early signs include personality changes, loss of social skills and inhibitions, emotional blunting, and language abnormalities. 4. Creutzfeldt Jakob disease CNS disorder that develops in adults 40-60 years of age. It involves altered vision, loss of coordination or abnormal movements, and dementia that usually progresses rapidly (a few months). The cause of the encephalopathy is an infectious particle resistant to boiling, some disinfectants (e.g.; formalin, alcohol), and ultraviolet radiation. Pressured autoclaving or bleach can inactivate the particle. 5. HIV infection result directly from invasion of nervous tissue by HIV or from other acquired immuno-deficiency syndrome-related illnesses such as toxoplasmosis and cytomegalovirus. These can result in a wide variety of symptoms ranging from mild sensory impairment to gross memory and cognitive deficits to severe muscle dysfunction. 6. Parkinsons disease slowly progressive neurologic condition characterized by tremor, rigidity, bradykinesia, and postural inability. 7. Huntingtons disease an inherited, dominant gene disease that primary involves cerebral atrophy, demyelination, and enlargement of the brain ventricles. 8. Head trauma repeated head injury may lead to progressive dementia ( e.g. from boxing or any sports) Treatment: Changes in diet Exercise Control of hypertension or diabetes Antidepressants (for depressive symptoms), Antipsychotics such as haloperidol (Haldol), olanzapine (Zyprexa), risperidone (Risperdal), and quetiapine (Seroquel) to manage psychotic symptoms of delusions, hallucinations, or paranoia. Lithium carbonate, carbamazepine (tegretol), and valproic acid (Depakote) help to stabilize affective lability and to diminish aggressive outburst. Benzodiazepines are used cautiously because they may cause delirium and can worsen already compromised cognitive abilities. Amnestic disorder A disturbance in memory that results directly from the physiologic affects of a general medical condition or the persisting effects of a substance such as alcohol or other drugs. Are similar to those with dementia in terms of memory deficits, confusion, and problems with attention. But they do not have multiple cognitive deficits seen in dementia such as aphasia, apraxia, agnosia, and impaired executive functions.

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Stroke or other cerebrovascular events, head injuries, and neurotoxic exposure such as carbon monoxide poisoning, chronic alcohol ingestion, and vitamin B12 or thiamine deficiency. Alcohol-induced amnestic disorder results from a chronic thiamine or vit B deficiency and is called Korsakoffs syndrome. Substance Abuse and Substance Dependence Substance abuse use of a substance for other than its legitimate medical purpose Substance dependence physiological and psychological dependence of the body on a substance as evidenced by tolerance and withdrawal. Substance tolerance need for an increasing amount of the substance to produce its desired effect or it refers to the declining effect of the drug. Withdrawal syndrome or a group of symptoms experienced by the patient when the amount of the substance is reduced or when the mistake is stopped. Habituation a psychological dependence on the use of a drug. Withdrawal symptoms: There are symptoms manifested by the body when abstaining or decreasing the dosage of certain substance. Patient may manifest Psychosis while withdrawing. Alcoholism -> (WHO) is a chronic disease or a disorder characterized by excessive intake of alcohol and interference in the individuals health, interpersonal relationship and economic functioning. It alters the health, career, and financial status Normal alcohol level = 0% (for a normal person) Alcoholic Blood Alcohol level = 0.6 1% Is also considered as a mal-adaptive coping mechanism and 100% to cause liver cirrhosis. Development of alcoholism: 0.1 - 0.2% - for a normal person, it can cause drowsiness, dizziness and low coordination. There is disturbance in balance. 0.2- 0.3% - presence of ataxia, tremors, irritability, stupor 0.3% and above - loss of consciousness Progression: Pre-alcoholic Phase starts with social drinking; tolerance begins to develop Prodromal Stage alcohol becomes a need; blockouts occur; denial begins to develop Crucial cardinal symptoms of alcoholism develops (loss of control over drinking) Chronic Phase the person becomes intoxicated all day. Outcome: Brain damage Alcoholic hallucinosis Death Major Defense Mechanisms: 1. Denial 3) Rationalization 2. Projection 4) Isolation Most common withdrawal symptoms of alcoholics: C confusion H hallucinations (visual and tactile) Antidote for Alcoholism: I - increase in vital signs 1. Librium } T - tremors 2. Tranxene } Benzodiazepines/ S seizures/sweating (diaphoresis) 3. Xanax } minor tranquilizers Behavioral problems: > Denial > Dependency > Demanding > Destructive > Domineering

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Nursing Diagnosis: Ineffective Individual coping. Other management or treatment: 1. Group therapy (Alcohol Anonymous Group) 2. Behavior therapy 3. Ventilation of feelings Long term Goal: *abstaining from alcohol (ABSTINENCE)

Alcohol Withdrawal: Occurs when an individual abruptly stops drinking after alcohol has become a necessity of life to maintain functioning. Symptoms include: autonomic hyperactivity sleep disturbance (insomnia) grand mal seizures illusions / hallucinations psychomotor agitation and anxiety hyperthermia increased hand tremors tachycardia (impending delirium tremens) Alcohol Withdrawal Delirium: * Delirium Tremens -> Increased alcohol level in the blood, reaching the brain, causing delirium. * experienced within 24-72 hours after the last intake: > agitation > restlessness > elevated vital signs > hyperalertness > hallucinations and illusions > incoherent speech * serious medical complications may occur if the client is left untreated Korsakoffs Psychosis -> deficiency in NIACIN and THIAMINE (important in memory function) a. decrease in Niacin and thiamin can cause memory disturbance manifested as confabulation and amnesia (antero and retro) b. Characterized by: short-term memory loss, disorientation, inability to learn new skills, confabulation. c. Deficiency in Vit. B complex, especially B1 and B12 Wernickes Encephalopathy -> an inflammatory hemorrhagic degenerative condition of the brain caused by Vitamin B1 deficiency. Symptoms include: double vision involuntary and rapid eye movements lack of muscular coordination decreased mental function Nursing Diagnosis: Ineffective individual coping Principles of Nursing Care: well lighted room diet as tolerated monitor vital signs administration of glucose Vitamins (multivitamin, Vitamin B-complex, Vitamin C) Alcohol Detoxification: Drug of Choice: Disulfiram (Antabuse) it delays the metabolism Avoid alcohol containing products

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3 Ss of detoxification: Safety, sedation and supplement Instruct the patient to avoid: > Mouth wash > Over the counter cold remedies > food sauces made up of wine > Fruit flavored extracts > Aftershave lotions > Vinegar > Skin products DRUG-RELATED DISORDERS Addiction - The condition of having established the practice of yielding that is habit forming to the extent that discontinuing the practice causes severe physiological and psychological symptoms. - In health care, a state in which therapeutic use of an addictive drug to control such symptoms as intractable pain has created a dependence wherein discontinuing the drug would result in severe distress symptoms. Cocaine-Related Disorders (Stimulants) Cocaine is a white powdered stimulant substance Usually sniffed, snorted, smoked in a pipe or injected into a vein or subcutaneous tissue. Poor mans cocaine: Shabu (sha-boo) Signs of use: panic attacks, insomnia, loss of appetite, impaired thinking, cocaine psychosis, agitation, dilation of the pupils, diaphoresis, and increased V/S Classic sign: Perforated nasal septum Can cause a sudden heart attack even in healthy young people. Leads to dopamine deficiency. Amino acid therapy is utilized to facilitate restoration of depleted neurotransmitters. Withdrawal from cocaine is characterized by severe depression, fatigue, vivid dreams and hypersomnia or insomnia and psychomotor agitation. * Cannabis-Related Disorder (Cannabinoids) Example: Marijuana Can act as stimulant or depressant and is often considered to be a mild hallucinogen with some sedative properties. Is not physically addicting but may lead to psychological dependence. Plant: cannabis sativa Active component is Tetrahydocannabinol Routes of use: orally (capsules, tablets, on sugar cubes) with food Smoked in a pipe or rolled as cigarette. Acts within 15 minutes Effects lasts approximately 2-4 hours Physiologic symptoms include: Psychologic effects: increased appetite > Hallucinations with acute psychotic effect, excitement manage with anti psychotics drowsiness > Illusions lowered body temperature > Trip (can kill and feels capable of flying) depression - managed with downers unsteady gait reduced coordination and reflexes inability to think clearly impaired judgment

79 Classic sign: bloodshot eyes

In large doses, it may cause: Hallucination, suicidal ideations, and delusions of invulnerability. Long-Term Goals: Community resources * Nutrition Other coping means aside from denial * Group therapy Personal responsibility for not drinking/ drugs taking Isolation Downers NARCOTICS => (OPIATES) < Depressants (respiratory problem) Examples: *Demerol *Nubain *Heroine ----------antidote is METADONE *Morphine sulfate *Codeine * Paregoric Acid (program as a replacement for Heroin for gradual desensitization.It has the same effect as heroin but with less side effects, it blocks euphoric effect of heroin and eiminates craving Side effects of NARCOTICS: N- nausea and vomiting A- abdominal pain R- restlessness C- coreza symptoms (flu-like symptoms, teary eyes) Note: narrowed pupils (pin O- on the next day (becomes aggressive and destructive) point pupils, it decreases T- tremors Vital signs. I - irritable C- cold and hot flushes S- sweating/diaphoresis => initial sign of narcotic intoxication (headache) Others: papillary constriction, euphoria, respiratory problems-CNS depression), cardioproblem. Common manifestation of narcotic withdrawal: Yawning and diaphoresis CNS STIMULANTS: Uppers (cardio-problem) Examples: Methampethamine HCL (shabu)-(Ionamin) Cocaine

* Caffaine * Ecstacy (party)

Antidote for CNS Stimulants: no need for an antidote because they are short acting and it wears off after 2-4 hours. Signs and symptoms / side effects: Increased V/S (LBM) Note: Dilated pupils Cardiovascular problems (palpitations) Euphoria The effect of ecstacy is 10x than the effect of SHABU People taking ecstacy has an effect of dehydration = increase fluid intake. Hyperactive Loss of appetite/ weight loss Depression most dangerous side effect and can cause suicide (Management is Antidepressant)

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Dangerous effect of Cocaine: Deviated nasal septum Cardio problem (Myocardial Infarction) Respiratory problem

HALLUCINOGENS => Downers ---- note: Dilated pupils It produces flashbacks. Craving for the drugs Example: LSD- Lysergic Acid Diethylamide (produces mind-changing experiences) PCP Pheny cyclidine Sings and Symptoms: Euphoria and escape reality. Psychological effect: anxiety, depression, paranoid ideation, ideas of reference, fear of losing ones mind, and potentially dangerous behavior such as jump out a window and believed he can fly (Jones, 2005) Treatment: isolation from external stimuli and physical restraints (for safety of client and others.) Toxic reactions: aggression and suicide --- Treatment: supportive. Management for all substance abuse: Long term goal: Abstinence! > Counseling > Individual therapy > Group therapy > Family therapy

> Sport system > Referral

Treatment: > supportive therapy and manage the side effect. Eating Disorders A. Anorexia nervosa= syndrome of self-starvation; cause is emotional disturbance which cause emaciation and physical problem. 1. Negative behavior due to power struggle with family over pressure to it. 2. Morbid fear of obesity or has fear in gaining weight. Not a disturbance in appetite but distorted body image perception related to disturbance in sense of identity and autonomy. Symptoms: a. Weight loss 25 0/0 original weight b. Delayed sexual development (amennorhea) c. Physical symptoms ( decrease BP, decrease therapy, decrease protein) d. Refusal to eat- report Not being hungry although actual feeling of hunger do not cease until late in the disorder. e. Preoccupation with food. Prepare a lot for friends but refuses to eat. f. Extensive exercising. B. Bulimia= Binge and purge syndrome Characteristics 1. Rapid consumption of a large amount of food in a discrete period of time. 2. A feeling of lack of control over eating behavior. 3. Engage in self-induced vomiting, use of laxative, diuretic, strict dieting or fasting or vigorous. 4. The person abuse that the behavior is abnormal. 5. Experience depression after each episode. Symptoms: a. Binges are usually solitary and secret. May consume as many as 11,500 calories in one episode. b. Binge is viewed as pleasurable but is followed by intense self- criticism. * Medical Complications 1. Esophagitis 5. Dehydration 2. Esophageal rupture 6. Dental resume

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3. Dilatation, rupture of stomach 4. Arrhythmias 7. Fungal infestation

Predisposing Factors Ego development is retarded. Individual remains in the dependent position. Disorder in the neuroendocrines within the hypothalamus. Family dynamics Families consist of positive father, a domineering mother and an overly dependent child. There is high value place on perfectionism in this family, and the child feeds he must satisfy these standards. Nursing Care 1. If patient is unable to maintain adequate oral intake, feeding may be given per nasogastric tube. 2. Behavior modification. Focus is placed on emotional issues rather than food and eating. 3. A limit in mealtime (30 minutes) should be imposed. 4. Observe for at least 1 hour following meals. 5. Strict documentation of I and O. 6. Weight daily 7. Do not discuss food or eating with client once protocol has been established 8. Initially allows patients to maintain dependent role to decrease anxiety. Encourage independence only when trust has been established and condition has proved.

C. Pica = Persistent eating of non-nutritive substances such as clay, paint, plastic or

starch Incidence: Occurs one or two years of age easy persist to adolescence and adulthood. SEXUAL DISORDERS Sexuality- is the result of biologic, psychological, social and experimental factors that mold an individuals sexual development, self-concept, body image and behavior. Phases of the Sexual Response Cycle Desire the ability, interest and willingness to receive sexual stimulation Excitement / Arousal result of psychological stimulation. Example is fantasizing during the desire phase and foreplay which involves petting and fondling of erogenous zones or areas of the body that are particularly sensitive to erotic stimulation. Myotonia begins (increased muscular contractions and decreased relaxation, tonic muscle spasm) Plateau - Myotonia becomes pronounced: Grimacing occurs. The heart rate and BP continue to increase as well as the respiration. Orgasm formerly termed as climax. It is the shortest stage in the sexual response cycle. It occurs when stimulation proceeds through the plateau stage to a point where the body suddenly discharges accumulated sexual tension. Resolution phase the final phase of sexual response. When the organs and body systems gradually return to the unaroused state. Sexual dysfunction Disorders Sexual Desire Disorders: have little or no sexual desire or have an aversion to sexual contact. Sexual Arousal Disorder: individuals cannot complete the physiologic requirements for sexual intercourse. Example: Women cannot maintain lubrication Men cannot maintain erection Orgasm Disorders: Inability to achieve orgasm phase Example: Premature ejaculation

82 Sexual Pain Disorders: individuals suffer genital pain (dyspareunias)

Example: Vaginismus

Paraphilia (Sexual Deviation) A term which generally refers to abnormal sexual behavior It last for 6 months leading to distress or impairment to functioning. Examples: Anilingus - tongue brushing the anus Bestiality or Zoophilia - contact with the animals Coprophilia smearing feces on the partner Cunnillingus tongue brushing the vulva Exhibitionism (Exhibitorism) Involves exposing ones genitals to unsuspecting strangers. The victims are usually women or children. They are stimulated by the effect of shocking the victim. Fellatio inserting the penis into the mouth Fetishism inanimate/ non-living objects or articles Frotteurism ( Frottage) touching or rubbing against the unsuspecting people. Usually occurs in crowded places where escape is into the crowd is possible. Masochism Sexual gratification from experiencing pain. Involves the acts of being humiliated beaten, restrained, or otherwise made to suffer. Necrophilia involves the use of corpses. Partialism inserting the penis into the other parts of the body Pedophilia use of prepubertal children. It could be an actual sexual act or a fantasy. The child is generally 13 years of age or younger. Sadism inflicting pain. Telephone Scatogia Involves telephoning someone and making lewd, obscene remarks or conversation. AKA (also known as) sex on phone. Transvestism sexual excitement through wearing the clothing of a woman Urophilia urinating on the partner. Voyeurism Act of observing unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity includes cyber-voyeurism. Gender Identity Disorder AKA transexualism Believe that they were born as the wrong sex Leads to persistent discomfort and feels inappropriate in the role of the assigned sex. Nursing Intervention: Attitude: Accepting Empathic Non-judgmental Accept his feelings related to sexuality Have a private area to discuss fears or concerns about sexuality Intervene to discuss self-esteem issues, anxiety, guilt, and empathy for victims. Employ limit setting Referral to the correct clinic. DISORDERS COMMONLY DIAGNOSED TO CHILDREN 1. AUTISM = Characterized by: impairment in communication skills Presence of stereotyped behavior, interests and activities. Associated with impairment on social interactions treatable but not curable

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more common among boys usually diagnosed at age 2, after 3 years there is screaming and bangs the head Main problem: interpersonal functioning Most acceptable cause: Biologic factors- brain anoxia, intake of drugs > Wants blocks > Acts as deaf > Resist normal teaching method/routine > No fear of danger > Insensitive to pain > No eye contact > Giggling or silly laughing > resists change in routine > Destructive and aggressive at times (self &

Signs and Symptoms Odd play Not cuddly Echolalia changes Crying tantrums Head towards anything Inanimate object attachment Loves to spin objects / self Difficulty interacting with others Uses people as tools others) = = = = = =

it is a spectrum disorder (severe low IQ--- High IQ) 50% may never develop language 75% have mental retardation 20-25 % develop seizure a few able to live normal functional lives it is a lifelong developmental disability

Nursing Interventions (starts at home) Environment: safe and consistent Encourage the client to participate for self-care Speak calmly when giving instructions Use simple words or phrases Repeat instructions as necessary Glutten diet no wheat, rice, process foods, canned goods. Brown rice can be. Haloperidol symptomatic relief for hyperactivity, stereotypical and self- destructive behavior 2. MENTAL RETARDATION- is not a mental illness but a problem of inadequate mental functioning. Onset: 18 months IQ: below 70 Manifested by sub-average intellectual functioning in: Communication * Home living * Health and safety Self-care * Social skills Causes: HIV /AIDS / Rubella infection > Opiate intoxication Alcoholic mother > Nutritional deficiency (lack in Folic Acid) Thyroid deficiency > Anoxia Excessive lead poisoning > Toxemia (pregnancy-induced hypertension) Damage to the brain > Environmental factors Neurological / neurodevelopmental impairment > Severe RH incompatibility Premature (did not reached the exact gestational age) Levels/degree of retardation: Level IQ Mild / Moron 51-70 Moderate / Imbecile 36-50 Implication Difficulty adapting to school Educable-needs assistance Poor awareness of needs of others Trainable needs moderate supervision

* * * *

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Severe / Idiot Profound 20 35 Below 20 * Unable to learn academic skills * Poor motor development and minimal speech * Needs complete and close supervision Has minimal capacity for sensorimotor function Needs custodial care with a totally Structured environment

Principles of Nursing Care Protective care Education of the family Their involvement is an important factor in the plan of promotion progress and to minimize the stress. Repetition Role modeling Restructuring Focus of Education : Reading, Arithmetic, Writing 3. ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) > Common in boys and usually diagnosed before age 7 > Problems: Inattention, hyperactivity and impulsivity Causes: Intranatal Factors Signs and symptoms: (ONE) Obstinacy, Negativism and Egocentrism (FAT) Fighting syndrome, Aggressiveness, Tolerance is low (DEFICIT) Difficulty concentrating, Excessive talking, Fidgeting, Interrupts/Intrudes on others, Child exhibits hyperactivity, Indulges in destructive behavior, temper tantrums Signs and Symptoms Negativism > Difficulty concentrating Egocentrism > Excessive talking Fighting syndrome > Interrupt/intrudes on others Aggressiveness > Child exhibits hyperactivity Tolerance is low > Temper tantrums Nursing Diagnosis: Potential for injury Principles of nursing care: Provide nutrition and safety Environment: Structured and enable appropriate reaction to the environmental stimuli Plan a firm and consistent environment in which limits and standards are set. Intervention of ADHD 1. combination of medication 2. behavioral interventions 3. parental education 4. special educational assistance is needed to help with academic achievement. Drug of choice: Methylphenidate (Ritalin) 4. Learning disorders is diagnosed when a childs achievement in reading, mathematics, or written expression is below that expected for age, formal education, and intelligence. 5. Motor skills disorders this disorder becomes evident as a child attempts to crawl or walk or as an older child tries to dress independently or manipulate toys such as building blocks. There is developmental coordination disorder 6. Communication disorders

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* Expressive language disorder - involves an impaired ability to communicate through verbal and sign language. The child has difficulty learning new words and speaking in complete and correct sentences; his or her speech is limited. * Mixed receptive and expressive language disorder includes the problems of expressive language disorder along with difficulty understanding (receiving) and determining the meaning of words and sentences. * Phonologic disorder involves problems with articulation (forming sounds that are part of speech). * Stuttering a disturbance of the normal fluency and time patterning of speech. Common in boys than in girls. Treatment: Speech and language therapists (to improve their communication skills). Teach the parents to continue speech therapy activities at home. 7. Pervasive developmental disorders (Autistic Disorders) * Autistic disorder (displays little eye contact) * Retts disorder (occurs exclusively in girls, she loses motor skills and begins show stereotyped movements instead. Also loses interest in the social environment, and severe impairment of expressive and receptive language becomes evident as she grows older). * Childhood disintergrative disorder (marked regression in multiple areas of functioning after at least 2 years after apparent normal growth and development). The onset is between 3 and 4 years. Have same social and communication deficits and behavioral patterns seen with autistic disorder. Occurs more often in boys than in girls * Aspergers disorder same impairment of social interaction but there are no language or cognitive delays. Rare disorder occurs more often in boys 8. Feeding and eating disorders (during infancy and early childhood) * Pica (persistent ingestion of non nutritive substance such as paint, hair, cloth, leaves, etc * Ruminating disorder (repeated regurgitation and rechewing of food) * Feeding disorder of infant or early childhood (failure to eat adequately, common in boys) 9. Tic disorders * Tourettes disorders (involves multiple motor tics one or more vocal tics which occurs many times a day for more than 1 year, more common in boys at 7 years of age). Usually treated successfully with atypical antipsychotic medications. * Chronic motor or tic disorder Either the motor or the vocal tic is seen. * Transient tic disorder- involve single or multiple vocal or motor tics, but the occurrent last no longer than 12 months. 10. Elimination disorders (cause impairment for the child based on the response of parents, the level of self-esteem, and the degree of ostracism by peers. * Functional encopresis intentional/ involuntary defecation * Functional enuresis intentional / involuntary micturition or urination Other disorders of infancy, childhood, or adolescence separation anxiety disorder = are miserable away from home and may fear never seeing their homes or loved ones again.

Selective mutism = persistent failure to speak in social situations where speaking is expected, such as school. Children may communicate by gestures, nodding or shaking the head or occasionally one-syllable vocalizations in a voice different from their natural voice. They are excessively shy, socially withdrawn or isolated, they may have temper tantrums (common in girls) Reactive attachment disorder

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= begins before 5 years of age and is associated with grossly pathologic care such as parental neglect, abuse, or failure to meet the childs basic physical or emotional needs. Repeated changes of caregivers, or multiple foster care placements, also can prevent the formation of stable attachments. Stereotypic movement disorder = associated with many genetic, metabolic, and neurologic disorders and often accompanies mental retardation. Include waving, rocking, twirling objects, biting fingers, banging the head, biting or hitting oneself, or picking at the skin or body orifices.