PSYCHIATRIC NURSING Benchmark Period in Psychiatric History Historical Perspective of the Treatment of Mental Illness

June Mellow focuses on clients psychosocial needs and strengths - argued that the nurse as the therapist is particularly suited to working with those with severe mental illness in the context of daily activities, focusing on the here and now to meet each persons psychosocial needs Psychiatric Nursing in the Philippines The National Center for Mental Health (NCMH) was established thru Public Works Act 3258. It was first known as INSULAR PSYCHOPATHIC HOSPITAL, situated on a hilly piece of land in Barrio Mauway, Mandaluyong, Rizal and was formally opened on December 17, 1928. This hospital was later known as the NATIONAL MENTAL HOSPITAL, given on November 12, 1986, it was given its present name thru Memorandum Circular No. 48 of the Office of the President. On January 30, 1987, NCMH was categorized as a Special Research Training Center and hospital under Department of Health. Today, NCMH has an authorized bed capacity of 4,200 and a daily average of 3,400 in-patients. It sprawls on a 46.7 hectare compound with a total of 35 Pavilions/Cottages and 52 Wards. The NCMH is a special training and research hospital mandated to render a comprehensive (preventive, promotive, curative and rehabilitative) range of quality mental health services nationwide. Standards of Mental Health Clinical Nursing Practice Standards of Care Standard I. Assessment The psychiatric-mental health nurse collects health data Standard II. Diagnosis The psychiatric-mental health nurse analyzes the data in determining diagnoses Standard III. Outcome Identification The psychiatric-mental health nurse identifies expected outcomes individualized to the client Standard IV. Planning The psychiatric-mental health nurse develops a plan of care that prescribes interventions to attain expected outcomes Standard V. Implementation The psychiatric-mental health nurse implements the interventions identified in the plan of care Standard Va. Counseling The psychiatric-mental health nurse uses counseling interventions to assist clients in improving or regaining their previous coping abilities, fostering mental health, and preventing mental illness and disability Standard Vb. Milieu Therapy

The psychiatric-mental health nurse provides, structures, and maintains a therapeutic environment in collaboration with the client and other health care providers

Standard Vc. Self-Care Activities The psychiatric-mental health nurse structures interventions around the clients activities of daily living to foster self-care and mental and physical well-being Standard Vd. Psychobiologic Interventions The psychiatric-mental health nurse uses knowledge of psychobiologic interventions and applies clinical skills to restore the clients health and prevent further disability Standard Ve. Health Teaching The psychiatric-mental health nurse, through health teachings assists clients in achieving satisfying, productive, and healthy patterns of living Standard Vf. Case Management The psychiatric-mental health nurse provides case management to coordinate comprehensive health services and ensure continuity of care Standard Vg. Health Promotion and Maintenance The psychiatric-mental health nurse employs strategies and interventions to promote and maintain mental health and prevent mental illness Standard VI. Evaluation The psychiatric-mental health nurse evaluates the clients progress in attaining expected outcomes MENTAL HEALTH State in the relationship of the individual and his environment in which the personality structure is relatively stable, and environmental stresses are within its absorptive capacity.(WHO) A positive state in which one is responsible, displays self-awareness, is self-directive, is worry-free and can cope with usual daily tension A state of complete physical, mental and social well-being and not merely the absence of disease Relative and dynamic concept. Not the same to all people Changes at different point in time. It is not static FACTORS THAT AFFECT MENTAL HEALTH Inherited characteristics genetic make-up Nurturing during childhood Life circumstances FACTORS INFLUENCING A PERSONS MENTAL HEALTH Individual factors vitality, finding meaning to life, biological makeup, emotional resilience, spirituality, sense of harmony in ones life Interpersonal factors Intimacy, helping others, effective communication, maintaining a balance of separateness and connection

Benchmark V: Decade of the Brain The 1990s declared the Decade of the Brain During this decade, a steep increase in brain research occurred that coincided with an increased interest in biologic explanations for mental disorders The Decade crystallized the fact that some behaviors are caused by biologic irregularities and not willful contraries, or worse The Decade brought back nursing into the mainstream of psychiatric care Psychiatric Nursing Practice Linda Richards Graduated in 1873 from New England Hospital for Women and Children in Boston Improved nursing care in psychiatric hospitals and organized educational programs in state mental hospitals in Illinois First psychiatric nurse Believed the mentally sick should be at least as well cared for as the physically sick Harriet Bailey - published the first psychiatric nursing textbook, Nursing Mental Diseases in 1920 Hildegard Peplau described the therapeutic nurse-client relationship with its phases and tasks and wrote extensively about anxiety The interpersonal dimension forms the foundation of nursing practice today

Social, Cultural factors access to adequate resources, sense of community, intolerance of violence

COMPONENTS OF MENTAL HEALTH Autonomy and Independence Individual follows guiding values and rules to live by Engage in independent action and thinking Consider the opinions and wishes of others Can work interdependently or cooperatively with others without losing his autonomy Maximizing ones potential Keep aiming Keep going Use talents Continually strive to grow Self-actualization Self esteem Accept strength and limitations Awareness of abilities and limitations Tolerating lifes uncertainties Positive outlook in life Face challenges life has to offer Optimism Have the courage to rise after falling Mastering the environment Learn to adopt or cope and relate Can deal with the environment Can influence the environment Being competent and creative Reality Orientation Distinguished real world from a dream Distinguished facts from fantasy Behave appropriately Act accordingly Stress management Tolerate life stresses Experience failure without devastation Cope and tolerate anxiety Resolve conflicts, stress and anxiety

Form close relationship with others Make decision pertaining to reality rather than fantasy Be optimistic & appreciate & enjoy life be independent or autonomous in thought and action Be creative, using varying approaches as they perform task or solve problem Consistent as they appreciate and respect the rights of others Displays willingness to listen and learn from others

Structured of personality- personal component Id, Ego, Super Ego

LEVELS OF AWARENESS Conscious aware at any time Pre-conscious can be retrieved rather easily through conscious part; tip of the tongue Unconscious repressed memories, passion, unacceptable urges; cant be recalled

SELF - AWARENESS Process by which the individual gains recognition of his or her own feelings, beliefs and attitudes The ability to recognize the nature of ones own behavior, attitude and emotion Key to self-understanding Help understand and accept the difference of others SELF CONCEPT part of self that lies within conscious awareness depends on how a person thinks he or she is viewed by others Good self-concept leads to self-acceptance SELF-ACCEPTANCE regards of oneself with realistic concept of strength and weakness, accept others easily Behaviors of a self-accepting person: Perserving Trusting and accepting others Seeing reality Minimizing weakness Increase strengths Learning from mistakes Reaching out to others Continuing growth towards self-actualization PSYCHODYNAMICS OF PERSONLITY PERSONALITY is the sum total of or whole being Aggregate of the physical and mental qualities of individual as it interacts in characteristic fashion Sum total of the persons distinctive character, behavior, attitude The way one carries himself Express through behavior Complex, dynamic and unique CONCEPT of PERSONALITY all behavior have meaning and is not determined by chance SIGMUND FREUD (1856 1939) Father of Psychoanalysis- all behaviour of human can be explain with cause Believed that vast majority of mental disorder were due to unresolved issues that originate in childhood

PERSONLITY STUCTURE ID source of all drives, instincts, reflexes, needs, genetic inheritance and capability to respond to wishes that motive us Present at birth Unlearned selfish source of libidal energy Operates on pleasure principle through the use of fantasy and images Compulsive with no sense of right or wrong Demands immediate satisfaction SIGNIFICANCE if id is not controlled effectively the individual function in antisocial; lawless manner or ways because his primitive drives or impulses are freely express Pleasure principle Its all about I Impulsive part EGO begins during the first 8 months of life and is fairly develop when the child reaches 2 years The self or the I Problem solver and reality tester Able to differentiate subjective experience, memory images and object reality Attempts to negotiate a solution with the outside world Controls and guides the action of individual Part of the personality that experiences anxiety and uses defense mechanism for protection Influenced by heredity, environmental factors and maturation SIGNIFICANCE if the individual does not develop a strong ego to arbitrate effectively between id and superego the individual will surely develop intrapersonal and interpersonal conflict Mediator Should be intact in reality SUPEREGO moral component of personality Consists of conscience (should-nots) and ego ideal (should) Operates both in the conscious and unconscious but operates mostly on the unconscious level Develops around 3-4 years and fairly develop at age 10 Formed and influence from the internalization of what parents teach their children regarding right or wrong through rewards and punishments SIGNIFICANCE if superego is so strong the life of the individual is dominated by its restriction on behavior, he or she is likely to be unhappy, inhibited and anxiety-guilt ridden. Individuals become inferior if he/she cannot live up to parental standards

Believes that crises is temporary

CHARACTERISTICS OF A PERSON WITH GOOD MENTAL HEALTH Have positive self-concept & relate well to people & their environment

Compose of moral and ethics and mores

Develop expressive language and symbolic play Intuitive phase (4-7) Egocentrism (seeing things from own point of view)

3.

CONCRETE OPERATIONAL STAGE (8 12 yr) Able to think more logically as concept of moral judgment, numbers, spatial relationship FORMAL OPERATION STAGE (12 adulthood) Develops adult logic Able to reason, form conclusion, plan for the future, think abstractly and builds ideas

4.

FREUDS PSYCHOSEXUAL STAGES OF DEVELOPMENT

HARRY STACK SULLIVANS INTERPERSONAL THEORY PERSONALITY behavior that can be observed within interpersonal relationship Personality development Infancy crying is used to establish contact with others Childhood language is used to assist with learning to delay the gratification of needs Juvenile period competition, compromise and cooperation are tools for developing relationship with others Preadolescence collaboration and the capacity for love assist in the development of relationship with same gender Early adolescence with sexual desire, facilitate learning to establish relationship with members of the opposite sex Later adolescence interdependence develop, learns to form lasting sexual relationship ANXIETY any painful feeling or emotion arising from social insecurity or blocks to getting biological needs satisfied SECURITY OPERATIONS a person uses to defend oneself against anxiety and ensure self-esteem Somnolent detachment use of sleep to avoid anxiety Apathy emotional detachment or numbing Selective inattention tuning out details associated with anxiety-producing situation Dissociation prevents situation from integrating into conscious awareness Converting anxiety to anger powerlessness is exchanged for a temporary feeling of power associated with anger directed outward 3 TYPES OF TENSION Tension of needs stemming from physiochemical requirement of life Tension of anxiety from interpersonal situation Tension of need for help

ERIK ERICKSONS DEVELOPMENTAL THEORY Each stage of development is an emotional crisis involving positive and negative experiences Growth/mastery of critical task results from having more positive experience than negative experience Allows for corrective emotional experience beyond 5 yrs of life

JEAN PIAGETS COGNITIVE THEORY Views intellectual development as result of constant interaction between environmental influences and genetically determined attributes 4 STAGES OF COGNITIVE DEVELOPMENT 1. SENSORIMOTOR STAGE (0 2 yr) Learns by exploring objects and events and by imitating Infants develop SCHEMATA (assimilation and accommodations incoming information) 2. PREOPERATION STAGE (2 7 yr) Preconceptual phase (2-4 yr) Learns by thinking images

SELF-SYSTEM develops relatively enduring patterns for avoiding or minimizing anxiety during interpersonal encounters and the meeting of biologic needs good me needs are satisfied bad me needs are unmet and anxiety persists not me anxiety is severe and information is not completely integrated into the personality on a conscious level

negative punishment involves withdrawing the reward to decrease a particular behavior

Behavioral treatments behavioral modification involves the use of various learned techniques to change maladaptive behavior, it is commonly used with clients who have anxiety disorders, substance abuse problems or other specific behavioral problems modeling refers to new behaviors that are learned by imitating the behavior of another person operant conditioning involves the use of tokens for desirable behavior

Behavioral Theories Key Concepts A behavioral framework is used to described a persons functioning in terms of identified behaviors people learn to be who they are because of environmental shaping behavior can be observed, described or recorded behavior is subject to reward or punishment changing ones environment can modify behavior maladaptive behaviors are learned through classical and operant conditioning; they may continue because they are rewarding to the individual maladaptive behaviors can be change without developing insight into the underlying concepts by altering the environment behavioral models posit that personality consist of learned behaviors and personality becomes synonymous with behavior if behavior changes, so does the personality Classical conditioning (Pavlovs theory) classical conditioning was developed by Ivan Pavlov he established that learning or conditioning can occur when a stimulus is paired with an unconditioned response a conditioned response is pairing of a stimulus with a response acquisition refers to the gaining of a learned response (once a response is learned, it continues) Extinction is the loss of learned response Operant conditioning (Skinners theory) developed by B. F. Skinner, operant conditioning involves the use of reinforce consequences to change the behavior positive reinforcement is a reward given to help continue the behavior negative reinforcement removes undesirable consequences to help continue the behavior positive punishment involves the use of aversive consequences to decrease a particular behavior

systemic desensitization involves gradually confronting a stimulus that evokes intense anxiety, it is useful in treating phobias the therapist initially teaches the client how to relax and begins a stimulus that causes mild anxiety the client learns to invoke the relaxation response when confronted with a stimulus the process continues until an intensely anxiety provoking stimulus no longer causes the client to feel anxious aversive therapy operates on the principle that unpleasant consequences result from undesirable behavior, it may be used in treatment of paraphilias biofeedback involves training techniques used to control physiologic responses such as stress response and its physiologic manifestations relaxation techniques are training techniques used to counteract anxiety symptoms assertiveness training incorporates techniques to overcome passivity or aggression in interpersonal situation

patterns of thinking leads to and perpetuates maladaptive behaviors the amount of perceived control over a situation affects how an individual responds to stressors and problems

Application to nursing In the behavioral framework, the nurse assesses both adaptive and maladaptive behaviors. The nurse and the client collaborate to identify behaviors that require change. As a member of the treatment team, the nurse uses various behavioral modification techniques to help the client. Cognitive Framework Key concepts the cognitive framework focuses on distorted or negative thought patterns that lead to maladaptive or symptomatic feelings and behaviors distorted thinking leads to and perpetuates maladaptive behaviors certain thought patterns can be identified as misperceptions

Treatments Cognitive therapy, a form of therapy developed by Aaron Beck, encompasses various treatment methods in which the therapist and client work closely to identify maladaptive thought patterns and develop alternate ways of thinking and behaving. This is often used in depression that stems from the individuals negative self concept, or exaggerated prolonged guilt, that result in automatic thoughts of self deprecation. The goal of the therapy is to diminish depressive symptoms by helping the client challenge and invalidate distorted thoughts through series of mental exercises and replace them with appropriate, realistic thoughts. In Rational-Emotive therapy developed by Albert Ellis, helps the client examine own irrational thoughts and behavior through verbal discussion followed by activities that allows the individuals to challenge the faulty beliefs by directly confronting the feared situation. This is useful in mild to moderate anxiety states In Gestalt therapy, based on the collective efforts of Fritz Perls and Paul Goodman, the therapist promotes the clients self awareness and increased self responsibility for meeting needs. In Becks Cognitive therapy, developed by Aaron Beck, the therapist teaches the client to identify and correct dysfunctional thoughts about the self, world and the future Cognitive techniques may be used: Cognitive restructuring change of maladaptive beliefs through positive self statements and refusing irrational beliefs Thought stopping constantly say STOP to maladaptive thoughts

Varieties of behavior A. Reflex action automatic response to a stimulus (blinking reflex, gag reflex) B. Goal oriented behavior presence of two factors: Presence of need within the individual Presence of goal outside the individual which is capable of producing a change in his internal condition and thus satisfying the need (e.g.. Hunger, anxiety)

Need an organismic condition which exist within an individual and which demands certain activity. It is a requirement for survival.

Humanistic Framework Key Concepts Humanistic framework focuses on the here and now current behaviors, issues and problems as well as spiritual values and meanings. human nature is viewed as positive and growth oriented, and existence involves search for meaning and authenticity Abraham Maslows theory of human motivation theory describes human needs that are organized according to levels in which individuals move on to higher needs as lower, more basic needs are met failure to develop ones potential leads to poor coping lack of self awareness and unmet needs interfere with feelings of security as well as with relationships fundamental human anxiety is fear of death which leads to existential anxiety Treatments Client centered therapy, developed by Carl Rogers is based on the belief that mental illness results from an individuals failure to develop fully as human being. Psychotherapy fosters the process of learning to be fully ones own self The therapist is genuine and without faade when relating to the client The clients behavior changes toward positive functioning when the therapist conveys acceptance, respect and genuine empathy for the client Existential therapy a form of talk therapy that focuses on life issues of freedom, helplessness, loss, isolation, aloneness, anxiety and death; through psychotherapy, the client discovers his own meaning of existence. MASLOWS HIERARCHY OF NEEDS Human motivation as a hierarchy of dynamic process or needs that are critical for the development of all humans Focused on human needs fulfilment, which is categorized into 6 incremental stages.

Biomedical Framework Key Concepts Physiologic, social and environmental factors can predispose to mental illness. Mental illness can be classified as in the multi axial DSM IV-TR Treatments Diagnostic work ups include detailed history and lab test as well as careful observation of current behavior Pharmacotherapy is a common treatment including g nurse patient interaction and milieu management. Eclectic Theory Eclectic varied; made up of parts from various sources choosing what is best or preferred from a variety of sources or styles Schizophrenia Possible causes: 1. Genetic 2. Organic 3. Biomedical theories 4. Psychological theories increased incidence among the lower socioeconomic groups 5. Unknown Mood Disorders Predisposing factors: 1. Medical Biological Theories a. Genetic higher incidence among individuals with relatives with the disorder b. Biochemical electrolyte imbalances, error in metabolism results in transposition of Sodium and Potassium within a neuron, low levels of NE, dopamine and serotonin Dynamics of Behaviour 1. Behavior refers to the way in which an organism responds to a stimulus All behaviors are meaningful and purposeful

Sources of Need Those which arise as a direct result of metabolic process (hunger and thirst) Those that results from a change in the persons relationship with his external environment (drop in room temperature)

Symbolic behavior talking, reading and thinking

CONFLICT The result o f the presence of two opposing or incompatible drives wherein the person is required to make a choice between the possible responses DYNAMICS OF CONFLICT Conflict anxiety feeling of hopelessness, helplessness and isolation perceived conflict increases anxiety STRESS and ANXIETY STRESS a stimulus or situation that produces distress and create physical and psychological demands on a person that requires coping and adapting CHARACTERISTICS OF STRESS It is recurring It is normal It cannot be avoided It is brought about by stressors STRESSOR any condition, agent, situation, feeling, thought or behavior which demands an increase in any activity within the ANS & CNS Perceptual field- thought, senses, orientation, concentration ANXIETY a response to internal conflict - feeling of uncertainty; uneasiness, apprehension or tension that a person experiences in response to an unknown object or situation Anxiety is describe as:THREAT Subjective experience Emotional pain Apprehension, fearfulness or a sense of powerlessness Warning signs of perceived danger or threat Emotional response that triggers behavior

Alerting and individual to prepare for self-defense Occurring in degrees Contagious Part of a process, not an isolated phenomenon

Use non-verbal language to demonstrate interests

CATEGORIES OF STRESS Normal anxiety healthy life force Motivates people to make & survive change Proportionate to actual events Acute anxiety Precipitated by an imminent loss or change that threatens an individuals sense of security Chronic anxiety the person has lived with the stress for a long time PRECIPITATING FACTORS OF ANXIETY Threats to biological integrity refers to the distortion in homeostasis ----temperature control Threat to self-esteem threat towards maintaining established views of self, values and patterns of behavior he uses to resists changes in self review Sense of isolation (alienation) Sense of insecurity (threat to identity) Sense of helplessness BEHAVIOR RESPONSE TO ANXIETY Anger Crying Withdrawal Forgetfulness Quarrelling Complaining Defensive behavior

INTERVENTIONS FOR SEVERE TO PANIC LEVELS OF ANXIETY Maintain a calm manner Always remain with the client Minimize environmental stimuli Use clear and simple statements and repetition Use a low pitched voice; speak slowly Reinforce reality Listen for themes in communication Attend physical and safety needs when necessary Set physical limit. Speak in a firm, authoritative voice. Provide opportunities for exercises Physical needs must be met to prevent exhaustion Assess need for medication or seclusion DEFENSE MECHANISM Protects people from painful awareness of feelings and memories that can provoke anxiety 5 IMPORTANT PROPERTIES OF DEFENSE MECHANISM 1. Defenses are major means of managing conflict and affect 2. Defenses are relatively unconsciousness 3. Defenses are discrete from one another 4. Although defenses are often the hallmark of major psychiatric syndrome, they are reversible 5. Defenses are adaptive as well as pathological MOST HEALTH DEFENSES Altruism emotional conflicts and stressors are dealt with by meeting the needs of others Sublimation unconscious process of substituting constructive and socially acceptable activity for strong impulses that are not acceptable in the original form. Humor deals with emotional conflict or stress by emphasizing the amusing or ironic aspects of the conflict or stressor. Suppression conscious denial of a disturbing situation or feeling INTERMEDIATE DEFENSES Repression exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness Displacement transfer of emotion associated with a particular person, object, or situation to another person, object, or situation that is non-threatening

LEVELS OF ANXIETY

INTERVENTIONS FOR MILD TO MODERATE LEVELS OF ANXIETY Help client to focus and sole problems with the use of communication techniques Help client identify anxiety Provide a calm presence Recognize the anxious persons distress Be willing to listen Evaluate effective past useful coping mechanism Assist in developing alternative solution to a problem Provide outlets from working off excess energy

Reaction formation unacceptable feelings or behaviors are kept out of awareness by developing the opposite behavior or emotion Somatization transforming anxiety on an unconscious level into a physical symptoms that has no organic cause Undoing consciously doing something to counteract or make up for a transgression or wrongdoing Rationalization justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanation that satisfy the teller as well as the listener

Intellectualization consciously or unconsciously using only logical explanation without ones feelings or an affective component Compensation consciously covering up for a weakness by overemphasizing or making up a desirable trait IMMATURE DEFENSES Passive aggression deals with emotional conflict or stressors by indirectly and unassertively expressing aggression towards another Acting-out behavior deals with emotional conflict or stressors by actions rather than reflections or feelings Dissociation unconscious separation of painful feelings and emotion from an unacceptable idea, situation or object Identification conscious or unconscious attempt to model oneself after a respected person Introjection unconsciously incorporating values & attitudes of others as if they were your own Devaluation emotional conflict or stressors are dealt with by attributing negative qualities to self or others Idealization attributing exaggerated positive qualities others Splitting the inability to integrate the positive and negative qualities of oneself or others into a cohesive image. Projection person unconsciously rejects emotionally unacceptable personal features and attributes to other people, objects or situation. Denial escaping unpleasant realities by ignoring their existence Regression unconscious return to an earlier and more comfortable developmental level ORGANIZATION OF THE NERVOUS SYSTEM BRAINSTEM regulates the internal organs and responsible for vital functions such as regulation of blood gases and the maintenance of BP Hypothalamus hunger, thirst and sex. - thought & emotions RAS allows human to sleep and carry out conscious mental activity Limbic system crucial role in emotional status and psychological function (norepinephrine, serotonin, dopamine

Maintenance of equilibrium Coordinates contraction

A second method of neurotransmitter inactivation is a little more complex. is a common target for drug action. NEUROTRANSMITTERS AND RECEPTORS

CEREBRUM responsible for mental activities and a conscious sense of being. Also responsible for language and the ability to communicate Cerebral cortex responsible for conscious sensation and the initiation of movement

Parietal cortex touch Temporal sound Occipital vision Frontal initiation of skeletal muscle contraction

Prefrontal cortex - responsible for thoughts, goal-oriented oriented behavior & inhibition - Seat of Personality

Basal ganglia regulation of movements Limbic system

Amygdala and hippocampus emotions, learning, memory and basic drives

NEUROTRANSMITTERS AND RECEPTORS

Conduction along a neuron involves the inward movement of sodium ions (Na) followed by the outward movement of potassium ions (K). When the current reaches the end of the cell, a neurotransmitter is released. The transmitter crosses the synapse and attaches to a receptor on the postsynaptic cell. The attachment of transmitter to receptor either stimulates or inhibits the postsynaptic cell the destruction of the action of the enzyme acetylcholinesterase on the neurotransmitter acetylcholine. Acetylcholinesterase is present at the postsynaptic membrane and destroys acetylcholine shortly after it attaches to nicotinic or muscarinic receptors on the postsynaptic cell. A full explanation of the various ways in which psychotropic drugs alter neuronal activity requires a brief review of the manner in which neurotransmitters are destroyed after attaching to the receptors. To avoid continuous and prolonged action on the post- synaptic cell, the neurotransmitter is released shortly after attaching to the postsynaptic receptor. Once released, the transmitter is destroyed in one of two ways. One way is the immediate inactivation of the transmitter at the postsynaptic membrane.

After interacting with the postsynaptic receptor, the transmitter is released and taken back into the presynaptic cell, the cell from which it was released. This process, referred to as the reuptake of neurotransmitter. Once inside the presynaptic cell, the transmitter is either recycled or inactivated by an enzyme within the cell. The monoamine transmitters norepinephrine, dopamine, and serotonin are all inactivated in this manner by the enzyme monoamine oxidase.

CEREBELLUM Coordinated muscle energy & activity

Therapeutic Communication

Clinical Interview - The client leads How to begin Setting private, safe Seating assume the same height, avoid face to face, avoid sitting without ready access to a door, avoid a desk barrier Introduction name, school, purpose, time limit How to start use open-ended question Guidelines: Speak briefly When you do not know what to say, SAY NOTHING When in doubt, focus on feelings Avoid advice Avoid relying on questions Pay attention to non-verbal cues Keep focus on the client Dynamics of therapeutic communication Interpretation of communication Themes in patients communication Content themes Mood themes Interaction themes Environmental consideration Physical consideration Kinesis consideration Effective tools in communicating

THERAPEUTIC RELATIONSHIP

Therapeutic relationship is consistently focused on the clients problem & needs

Factors that enhances growth in others 1. Genuineness self-awareness of ones feelings

2.

Empathy one understands the ideas expressed

Interference with therapeutic communication 1. Nurses fear and feelings Avoid personalizing what the patients say or do Ask question in a kind and matter-of-fact manner, by conveying empathy, and by reiterating a desire to help 2. Nurses lack of knowledge and insecurity Patients are usually more accepting when the nurse is honest about not knowing an answer and expresses a willingness to find answers 3. Ineffective responses Nurses must avoid premature conclusions Do not be preoccupied with what to say next, rather, listen to patient or they might be listening to THERAPEUTIC RELATIONSHIP Suspending value judgment Recognize their presence Identify how or where you learned these response to clients behavior Construct alternative ways to view the clients thinking and behavior

5 concepts of empathy Human trait Professional state communication process caring process special relationship

3.

Positive regard ability to view another person as being worthy of caring about & as someone who has strength & achievement potential

Helping client develop resources consistently encourage client to use their resources helps minimize the clients feeling of helplessness & dependency & also validates their potential for change

Establishing boundaries

Attitudes - the nurse takes the client & the relationship seriously Actions

Attending - foundation of interviewing - an intensity of presence or being with the client Non-verbal behaviors the reflect degree of attending 1. Nurses posture 2. Nurses degree of eye contact 3. Nurses body language Therapeutic techniques Therapeutic communication skills Use of silence Active listening 1. nurse carefully note what the client is saying verbally & nonverbally, as well as monitoring their own nonverbal response 2. Helps strengthens the clients ability to solve personal problems 3. The nurse communicates that the client is not alone, rather, the nurse is working along with the client Clarifying techniques 1. Helps both participants identify major differences in their frame of references, giving them the opportunity to correct misconception before these cause any serious misunderstanding. Degree of openness 1. Open-ended questions 2. Close-ended question 3. Indirect or implied question

Transference the process whereby a person unconsciously & inappropriately displaces onto individuals in his/her current life those patterns of behavior & emotional reaction that originated in relationship to significant figures in childhood; client-nurse Countertransference - the tendency of the nurse to displace onto the client feelings related to people in the nurses past; nurse-client Common countertransference reaction 1. Boredom (indifference) 2. Rescue 3. Overinvolvement 4. Overidentification misuse of honesty 5. Anger 6. Helplessness or hopelessness

The use of silence - a specific channel for transmitting and receiving messages Active listening Observing the clients non-verbal behaviors Listening to and understanding the person in the context of the social setting of his/her life Listening for false notes Providing the client with feedback information about himself/herself of which the client might not be aware Clarifying techniques Paraphrasing Restating Reflecting

STAGES OF NURSE PATIENT RELATIONSHIP 1. PREORIENTATION PHASE Goal: to establish a client database & assess own feelings regarding the client ORIENTATION PHASE

2.

Exploring

Goal: develop mutual trust, establish role of the nurse as significant other to the client Client recognizes needs & seek help Trustworthiness is built when the nurse is honest regarding intention, is consistent, and keeps promises Assess the degree of patients awareness of problems & the ability & motivation to change

3.

Talk about feelings directly then focus on coping more effectively with them Provide structure by limit setting WORKING PHASE

Manipulation Provide limit setting Help client express their needs directly to others Crying

Goal: identify & address clients problem Reality testing helps patient see reality more clearly & objectively compared with the past Limit setting intervention designed to prevent clients from harming themselves or others Nurses awareness of personal feelings & reaction to the client is vital for effective interaction with the client

Opportunity to live through & test out situations in a realistic way Opportunity to discuss interpersonal relationship in the unit among clients and between clients and staff Program carefully selected resocialization activities to prevent regression

4.

Unless a form of manipulation, allow client to cry Provide privacy Be quiet and unobtrusive

TERMINATION PHASE

Sexual innuendos or inappropriate touch Remind client these actions are inappropriate Denial & lack of cooperation Reality testing & supportive confrontation with denial Depressed affect, apathy, & psychomotor retardation Patience, frequent contact, and empathy Encourage hygiene, proper nutrition and gradual increase in activities Postponed major decisions until emotions have subsided Suspiciousness Communicate clearly, simply, and congruently. Clarify misinterpretation Provide simple rationale or explanations for rules, activities, occurrences, noises and requests Hyperactivity Patient should be in a quiet area, with minimal auditory & visual stimulation Remain calm, speak slowly and softly & respect patients personal space Give direction in a kind, simple but firm manner Transference & countertransference Nurses must be open and clear State action that they cannot meet patients need

Elements of milieu therapy 1. Safety Physical protection safety from physical harm Psychological safety nurses active intervention to prohibit verbal abuse, ridicule or harassment of patient

2.

Goal: assist client to review what was learned and to transfer learning interaction with others Attempt to make termination official and state feelings about the relationship Reasons for terminating the nurse-client relationship Symptom relief Improved social functioning Greater sense of identity Development of more adaptive behavior Accomplishment of the clients goals Impasses in therapy that the nurse is unable to resolve

Structure the physical environment rules & daily schedules of treatment activities Patient education lead by the nurse Opportunities for recreation Norms specific expectations of behavior that permeates the treatment environment Promotes safety & trust To create an environment that is more predictable & applicable to all who share the environment Limit settings should be set on acting-out behavior

3.

4.

Interaction with client behaviors Violent behavior Stay out of striking distance Avoid touching clients without approval Change topic temporarily Suggest time out with patient Avoid being alone with patient Leave temporarily if patient is agitated Call for staff assistance Hallucinations Comment on behavior Provide reality but acknowledge behavior Assess the hallucination based on content of the messages Do not focus on hallucination once content is known Ignore the hallucination Delusions Clarify the meaning of the delusions then ignore Conflicting values Help client examine the effects or outcomes of their beliefs on their lives, relationship, and happiness Severe anxiety & incoherent speech Spend frequent, brief time with patients, offer support, and build trust

Reinforces the norms of making rules & expectations clear & encourage the milieu therapy concept---responsibility to self

5.

Balance the process of gradually allowing independent behavior in a dependent situation

Limit setting

Activity therapy Consists of a variety of recreational and vocational activities (recreational therapy, occupational therapy, music, art, and dance therapy) designed to test 7 examine social skills & serve as adjunct therapies Concept and principles 1. Socialization counters the regressive aspect of illness 2. Activities needs to be selected for specific psychosocial reason to achieve specific effects 3. Nonverbal means of expression as an additional behavioral outlet add a new dimension to treatment 4. Sublimation of sexual drives is possible through activities 5. Indication for activity therapy: clients with low self-esteem who are socially unresponsive Goals 6. 7. 8. 9. Encourage socialization in community & social activities Provide pleasurable activities Help client release tension and express feelings Teach new skills, help client find new hobbies

Milieu Management Consists of treatment by means of control modification of the clients environment to promote positive experiences

Purpose: helps patient recover from psychiatric & mental health problem

Characteristics of milieu therapy Friendly, warm, trusting, secure, supportive, comforting atmosphere throughout the unit An optimistic attitude about prognosis of illness Attention to comfort, food, and daily living needs; help with resolving difficulties related to tasks of daily living Opportunity for client to take responsibility for themselves and for the welfare of the unit in gradual steps Maximum individualization in dealing with clients

10.

Offer graded series of experience, from passive spectator role & vicarious experiences to more direct and active experience 11. Free and/or strengthen physical creative abilities 12. Increase self-esteem ANXIETY DISORDERS (flight of ideas) Group of conditions in which the affected person experiences persistent anxiety that the person cannot dismiss and that interferes with daily activities Etiology: excessive serotonin; low self concept, inadequate coping mechanism 1. Neurobiological hereditary, brain chemistry, developmental factors, disruption of the amygdala 2. Psychological - low self-esteem, shy or timid in childhood, critical parents, discomfort with aggression, abuse, violence, poverty Sympathetic parasympathetic Alert Relax Increase HR Decrease HR Increase RR Decrease RR Increase BP Decrease BP Oliguria Polyuria BV Dilated BV constricted Dilated pupils Constricted pupils constipation Diarrhea 4 levels of Anxiety Mild- alert Moderate- focus, increase alert Severe- scattered, disorganized Panic- loss of control, hallucination Interventions for Anxiety Calm Anxiety- Aware Listen Medications (Librium, Equanil, Atarax, Valium, Serax) Environment Reassurance A. GENERAL ANXIETY DISORDER Characterized by excessive chronic anxiety or worry & might concern everyday events Individuals have no control over anxiety & worrying becomes habitual Characteristics: restlessness. Fatigue, poor concentration, irritability, muscle tension, sleep disturbance, physical symptoms (dry mouth, upset stomach) Psychotropic mgt: 1. NPR reduce level of anxiety Goal: assist patient with developing adaptive, coping responses Promote trust Convey empathy

Psychopharmacology Antidepressants: SSRI. SSNRI Benzodiazepine short-acting Milieu mgt: Recreational activities Relaxation exercises, meditation & biofeedback CBT

Obsession persistent thoughts, impulses, images or desires that maybe trivial or morbid Recognize thoughts are irrational & senseless Compulsion repetitive stereotyped behavior that are performed in a particular manner in response to an obsession; Rituals Performed to prevent discomfort & to bind or neutralized anxiety It interferes with normal routines, occupational & social functioning Interferes with patients interpersonal relationship Etiology: genetic, increase brain activity in the frontal lobe & basal ganglia, serotonin dysregulation

Therapeutic touch & acupressure

B. PANIC DISORDERS recurrent panic attack & are worried about having more attacks

Panic attacks sudden, intense fear or discomfort and peaks at 10 minutes Feelings of impending doom

Types of panic disorder 1. Panic disorder with agoraphobia Feelings of terror that function is suspended, perceptual field is severely limited & misinterpretation of reality Personality disorganization Sign/symptoms: palpitations, chest pain, dyspnea, nausea, feelings of choking, chills & hot flashes 2. Panic disorder without agoraphobia

Psychotherapeutic mgt.: 1. NPR: Accept rituals permissively Avoid criticism or punishment, making demands, showing impatient positive feedback Allow extra time for slowness & clients action Help client verbalize feelings, solve problem & make decisions Protect from rejection by others & self-inflected harm Psychopharmacology: Antidepressant: o Clomipromine (anafranil) SSRI fluoxetine (Prozac), setraline (Zoloft), fluovoxamine (Luvox) & paroxetine (Plaxil) Milieu mgt.: Relaxation exercises & stress mgt. Recreational or social skills

Agoraphobia - intense, excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing or in which help might not be available if panic attack occurs Feared places are avoided e.g.. Outside, alone @ home, travelling in car, bus or plane, being on a bridge, riding in a elevator

CBT, problem-solving & communication or assertive training groups

Etiology: hereditary, trauma, life stress or trauma, disruption in the amygdala Psychotherapeutic mgt: 1. NPR: Reduce immediate anxiety stay physically close to patient, use simple sentences, firm voice, remove to smaller quiet room to minimize stimuli Patient education Cognitive restructuring Psychopharmacology: SSRI Benzodiazepine (clonazepam, lorazepam) immediate effect Milieu mgt.: gross motor activities diffuse energy C. OBSESSIVE COMPULSIVE DISORDER recurrent obsessions and compulsions that interfere with normal life

D. PHOBIC DISORDERS - Intense, irrational, persistent fear responses to an external object activity or situation Phobia response to experience anxiety & is characterized by a persistent fear of specific places or things types of phobias 1. Agoraphobia with history of panic disorders fear of being in public or open spaces places or situations in which escape might be difficult or help might not be available 2. Social phobia fear of being humiliated, scrutinized, or embarrassed in public 3. Specific phobia fear of a specific object or situation that is not either of the above 4. Acrophobia- heights

5.

Algophobia- pains

6. 7. 8.

Claustrophobia- crowds Pathophobia- diseases Monophobia- alone

3. Arousal symptoms arousal, anxiety, restlessness, irritability, disturbance in sleep, memory impairment or concentration PTSD outburst of anger, rage, survivor guilt 4. Other symptoms Anxiety or panic attack PTSD grief, depression, suicidal ideation or attempts, impulsive selfdestructive behavior, anxiety-relate disorders & substance abuse Psychotherapeutic mgt: prevent or minimize the symptoms 1. NPR: develop trust Nurse needs to be non-judgmental honest, emphatic, and supportive Teach dynamics of ASD & PTSD Exposure therapy & systematic desensitization Expressive therapy (art, music, poetry) facilitate externalizing painful emotions that are difficult to verbalize Crisis counselling

2.

Etiology: environment, genetic predisposition Psychotherapeutic mgt.: 1. NPR: Accept patient & their fears with a non-critical attitude Provide & involve patient in activities that do not increase anxiety but increase involvement, rather that promote avoidance Help client with physical safety and comfort Help patient recognize that their behavior is a method of avoiding anxiety Psychopharmacology: SSRI to reduce anxiety & depression & block panic attacks, if present Milieu mgt: Assertive training & goal-setting groups Social skills group to help redevelop social skills and decrease avoidance Behavior therapy systemic desensitization, flooding, exposure, and self-exposure E. ACUTE STRESS DISORDER & POST TRAUMATIC STRESS DISORDERS ( dreams, nightmares, flashbacks) - Develop after exposure to a clearly identifiable traumatic event that threatens the self, others, resources, and/or sense of control or hope ACUTE STRESS SYNDROME (suppression, disassociation, amnesia) 1d-2mos symptoms occur within 1 month of extreme stressor; includes dissociative symptoms (depersonalization, emotional detachment., dazed appearance, amnesia) POST STRESS DISORDER severe traumatic event that is not an ordinary occurrence e.g.. Rape, fire, flood, earthquake, tornado, bombing, plane crash, war, torture, kidnapping Diagnostic criteria 1. Dissociative symptoms & numbing Amnesia, depersonalization, derealization & awareness of surrounding, numbing, detachment or lack of emotional response Numbing of responses or reduced involvement with the external world

3.

4.
Psychopharmacology

Benzodiazepine (clonazepam, lorazepam) to reduce level of anxiety and fear. Help with sleep disturbance Clonidine & propanolol diminish the peripheral autonomic response associated with fear, anxiety & nightmare Lithium carbonate prescribed to patients experiencing explosive outburst SSRI (paroxetine, setraline, fluoxetine) decrease repetitive behaviors, disturbing images & somatic states TCA depression, adehonia & sleep disturbances Antipsychotic (respirodone) psychotic thinking 6. 5.

Clients constantly seek medical attention, undergo numerous tests; at risk for unnecessary surgery or drug abuse Pain disorder Associated with psychological factors like severe pain in one or more of anatomical sites that causes significant distress or impairment in functioning Pain is exaggerated or out of proportion Causes significant impairment in occupational or social functioning or causes marked distress Symptoms not intentionally produced or feigned Hypochrondiasis (unrealistic or exaggerated physical complaints) Worried & belief that they have serious disorders base on the misinterpretation of bodily signs & sensation for at least 6 months Preoccupation persists despite appropriate medical tests & reassurances Causes significant impairment in occupational or social functioning or causes marked distress Not inventing Conversion disorder (paralysis, blindness, loss of touch) Alteration in voluntary or motor sensory functioning that suggest neurological or medical condition Not due to malingering or factitious disorder and not culturally sanctioned Cannot be explained by gen. medical condition or effects of a substance Body dysmorphic disorder Individual is preoccupied with an imagined defect in appearance which are usually facial flaws. Dermatologist & plastic surgeon is often consulted May also exhibit obsessive compulsive traits & depressive syndrome Controls relationship through physical complaints Malingering -consciously stimulated to avoid unpleasant situation -inventing Inability of the CNS to regulate & interpret sensory input or to decrease communication between right & left hemisphere Hx of physical & sexual abuse witnessing violent acts in childhood, poor nurturing from family, lack of job, and social skills Need to be sick to relieve oneself of obligations & to gain attention Dissociation

Milieu mgt: Social activities Recreational & exercise program

Group therapy

Causes: 1. 2. 3. 4.

Persistent avoidance of situation, activities and people, thoughts and feelings Denial, repression & suspension Feel detached or estrange from family & friends withdrawal depression Lost interest in activities, hopelessness Change in sleep pattern

F. SOMATOFORM DISORDERS (with physical complaints) - Characterized by the presence of physiologic complaints or symptoms, which are not under voluntary control & no demonstrable organic finding and physiologic bases -anxiety alone Types of somatoform disorders 1. Somatization disorder Conversion of mental states or experiences into bodily symptoms associated with anxiety Recurrent, frequent & multiple somatic complaints for several years without physiologic cause

Impulsive behavior, sudden life change 2. Reexperiencing the trauma & intrusive memories hallucinations (PTSD)

Psychotherapeutic mgt. 1. NPR: Use matter-of-fact caring approach Encourage patient to verbalize & describe feeling Use positive reinforcement & set limits Be consistent Use diversion by including patient patients in milieu activities and recreational games

Do not push awareness of or insight into conflicts or problems

3.

Psychopharmacology: SSRI to treat anxiety and depression Milieu mgt: Relaxation exercises meditation and CBT Family therapy G. DISSOCIATIVE DISORDER disturbances in the normally well-integrated continuum of consciousness, memory, identity, and perception -inability to recall extensive amount of important personal information

Depersonalization disorder involves an altered sense of self, so that the individual feel unreal or strange or believe that danger is not happening to then or to someone else Reality testing remains intact Dissociative identity disorder existence of 2 or more identities or personalities that take control of the persons behavior with its own patterns of relating, perceiving, and thinking The person or host us unaware of the other personalities, but the other alters might be aware of each other to varying degrees

Impairment in communication & imaginative activity Impairment in social interaction Markedly restricted, stereotypical patterns of behavior, interest and activities

a.

4.

Childhood & Adolescent psychiatric disorders Aspergers disorders a severe developmental disorder characterized by major difficulties in social interaction & restricts & unusual interest & behavior Use monotone speech and rigid language They cannot understand jokes and are taken advantage easily Inability to show empathy to others but want to meet people & make friends Have an obsession with facts about circumscribed and odd topics Attention deficit/hyperactivity disorder (ADD/ADHD) characterized by inattention, impulsiveness, and overactivity in school 9before 7 years old) Causes: Environmental exposure perinatal insults, head injury, psychosocial adversity, lead poisoning, and diet Genetic and hereditary factors Dysfunction in the frontal lobe Characteristics of ADHD Inattention Difficulty paying attention in tasks or play Does not seem to listen, follow through or finish tasks Does not pay attention to details & makes careless mistakes Is easily distracted, lose things, & is forgetful in daily activities Childhood & Adolescent psychiatric disorders Hyperactivity Fidgets, is unable to sit still or stay seated in school or at other times Runs & climbs excessively in inappropriate situations Has difficulty playing quietly in leisure activities Acts as if driven by a motor, constantly on the go Talks excessively Impulsivity Blurts out answer before question has been completed Has difficulty waiting for own turn Interrupts, intrudes in others conversation & games

Dissociation the removal from conscious awareness of painful feelings, memories, thoughts, or aspects of identity Unconscious defense mechanism that protects an individual from the emotional pain of experiences or conflicts that have been repressed Defense mechanism: repression

Defense mechanism: repression papalit-palit ng identity

Causes: traumatic events Inability to recall important personal information usually of a traumatic or stressful nature The disorder is often associated with exposure to traumatic event common during disaster and wartime Sexual abuse during childhood Psychopathology: an escape mechanism from memory of painful experiences or devoid of emotional satisfaction. There is little or no participation of the conscious personality so the person is unable to recall Types of dissociative disorders 1. Dissociative amnesia Sudden inability recall important information of one or more episodes not associated with organic disorders usually of a traumatic or stressful nature

Psychotherapeutic mgt. 1. NPR: Establish trust & support, provide caring and empathy Assist in gathering data about feelings, conflicts, or situations that patient experienced Ensure client safety Provide nondemanding, simple routine Confirm identity of client and orientation to time & place Encourage client to do things for self and make decision about routine tasks Milieu mgt: Individual therapy Task-oriented group OT and art therapy Cognitive therapy

b.

Self-help groups

Localized amnesia- occurs in a few hours after traumatic experience Selective amnesia- inability to recall past events General amnesia inability to recall events of ones entire life Continuous- inability to recall after a specific events up to and including present

2.

Dissocialise fugue sudden, unexpected travel away from home or some other location with the assumption of a new identity or a confusion about ones identity Fugue states is characterized amnesia; consequently, patients do not remember what happened. wala sa sarili Temporary strange alterations

Childhood & Adolescent psychiatric disorders Risk factors: Genetic factor Social & environment severe marital discord, low socioeconomic status, large family & overcrowding, parental criminality maternal psychiatric disorder, traumatic life event, sexual/physical abuse Psychosocial factor Biochemical factors alterations of neurotransmitters (decrease in norephhinephrine & serotonin Temperament a style of behavior a child habitually uses to cope with the demands & expectations of the environment Types of childhood mental disorders 1. Pervasive development disorders a. Autistic disorder b. Characterized by impairment in social interaction, communication and restricted repertoire of activity & interest c. Usually first observed before 3 years of age d. Sign & symptoms

Nursing Dx Risk for injury Impaired social interaction Ineffective individual Risk for violence for self-directed or directed to others Nursing intervention Establish trust Talk to client about safe & unsafe behavior use clear, honest straightforward communication Assess the frequency & severity of accidents Provide supervision for potentially dangerous Assist the client, parent or caregivers to make the distinction between accidental & purposeful incident Childhood & Adolescent psychiatric disorders Give instruction slowly using simply giving instruction Ask client to repeat exercise or instruction before beginning a task Administer stimulant in the morning to maximize effectiveness for daytime activity Help parents decrease their feelings of guilt & blame Maintain a safe environment at home & in school Oppositional defiant disorder enduring pattern of disobedience, argumentative, explosive angry outburst, low frustration tolerance, and a tendency to blame others for quarrels or accidents Recurrent pattern of negativistic, disobedient, hostile , defiant behavior towards authority figures with serious violation of basic rights of others Exhibit persistent testing of limits, an unwillingness to give in or negotiate, and a refusal to accept blame for misdeeds Behavior do not violate the rights of others Conduct disorder characterized by persistent pattern of behavior in which the rights of others & age-appropriate societal norms or rules are violated. Predisposing factors: ADHD, oppositional child behaviors, parental rejection, inconsistent parenting with harsh discipline, early institutional living, frequent shifting of parental figures, large family size, absence of father or alcoholic father, antisocial & drug-dependent family members, & association with a delinquent group

c.

Anxiety disorders 1. Separation anxiety disorders excessively anxious when separated from or anticipating a separation from their home or parental figures 2. Most children will express worry about harm or permanent loss of the mother or major attachment figure 3. Characteristics: Excessive distress when separated from or anticipating separation from home or parental figure Excessive worries that one will be lost or kidnapped or that parental figures will be harmed Fear of being home alone or in situation without other significant adults Refusal to sleep unless near a parental figure & refusal to sleep away from home Refusal to attend school or other activities without a parental figure Physical symptoms as a response to anxiety 4. Nursing interventions: Assess the quality of the relationship between child & parents or caregivers for evidence of anxiety, conflicts or difficulty of fit between childs and parents temperament assess the childs previous & current ability to separate from parents or caregivers Protect the child from panic levels of anxiety by acting as parental surrogate Accept regression but giving emotional support to help child progress again Increase childs self-esteem & feelings of competence in the ability to perform , achieve, influence the future Help child accept and work through traumatic events or losses 5. Psychopharmacology: antihistamines, anxiolytics and antidepressants 6. Cognitive therapy, behavior modification

Interacts with others without expecting them to meet all needs Seeks a balance of work & play Accomplishes goals Defines & expresses spirituality

1.

PERSONALITY DISORDERS Personality sum total of the persons distinctive character, behavior, attitudes, the way one carries himself , the way one communicate An enduring pattern of behavior that is considered to be both conscious and unconscious and reflects a means of adapting to a particular environment & it cultural, ethnic and community standards (Carson) Healthy personality: Sees his or her own strengths weaknesses Identifies his or her own boundaries Recognizes interaction & thoughts that lead to strong emotions such as joy or anger

Personality disorder enduring pattern of inner experience & behavior that deviates markedly from the expectation of the individuals culture, is pervasive & inflexible, has an onset in adolescence or early adulthood, is stable over time, & lead to distress or impairment (APA, 2000) Etiology of PD Theorist PD is related to unsuccessful mastery of task in early stages of development that can lead to anxiety Behaviorist Developmentalist believe that PD originates in early childhood experiences (negative experiences) Genetic cmponents Stressful environment CRITERIA FOR A PERSONALITY DISORDER CLUSTER A DISORDERS (ODD, ECCENTRIC) a. Paranoid personality disorder These individuals interpret other people's motives as threatening resulting in an increase in anxiety & the need for vigilance Characterized by distrust & suspiciousness toward others, based on the belief (unsupported by evidence) that others want to exploit, harm, or deceive the person & often act in defense of a fragile self-concept They demonstrate jealousy, controlling behaviors, and unwillingness to forgive Common in men than women Irritable and stubborn prejudice With ideas of reference Blunted affect , humorless and serious Fear in confiding in others Hold grudges towards others Easily get angry if they are threatened Emotionally cold in appearance but are acceptable of close relationship to few b. Defense mechanism: projection c. Nursing interventions: -serious communication -involvement in all activities d. Nursing guidelines may carry or conceal weapons Schizoid personality disorder (Socially distant and detached) Individuals with this disorder lacks personal & social relationship. They are detached from others & withdraws from interaction hypersensitive

b.

Examples of behaviors: physically aggressive, have poor peer relationships & shows little concern for others & lack of guilt or remorse

Childhood & Adolescent psychiatric disorders

Introverted since childhood, rarely have close friends Use autistic thinking, daydreaming are more gratifying They respond with short answers to questions & do not initiate spontaneous conversation They are reality-oriented but maintain fair contact with others They function in a solitary occupation but shows indifference to praise or criticism from others Can be a precursor to schizophrenia or delusion disorder Usually fantasized things but still in reality Defense mechanism: INTELLECTUALIZATION DSM IV criteria 1. Lacks desire for close relationship or friends 2. Choose to be alone 3. Lack sexual experience 4. Avoid activities 5. Appears cold and detached Nursing guideline: 1. Avoid being too nice or friendly 2. Do not try to increase socialization 3. Develop interpersonal relationship 4. Give minimal task 2.

c.

Schizotypal personality disorder (odd and eccentric) Individuals with this disorder may have behavior similar to those of someone with schizophrenia, however psychotic episode are infrequent & less severe Near schizophrenia but still in reality Paranoid ideation: discrimination

Characteristics: similar to schizoid but not severe 1. Ideas of reference 2. With magical thinking/odd beliefs leading to interpersonal difficulties 3. Problems in thinking, communicating and perceiving 4. Has eccentric appearance and shows evidence of magical thinking or perceptual distortion that are not clear delusions or hallucination 5. Sensitive to behavior of other people especially rejection & anger 6. Speech may be difficult to follow the individual develops a personalized style with vague association 7. Socially inept Nursing guideline

Offer support like kindness Be calm, non-threatening in all or approaches 3. Respect clients need for social isolation cannot tolerate group therapy 4. Speak in a gentle manner to encourage to get involve in group activities 5. Be aware of clients suspiciousness & employ appropriate intervention 6. Assist & teach the client about social skills & appropriate behavior to improve his interpersonal relationship CLUSTER B CRITERIA (DRAMATIC, EMOTIONAL, ERRATIC) a. Antisocial personality disorder (manipulative) Has consistent disregard for others with exploitation & repeated unlawful actions. Unable to postpone gratification, selfish and irresponsible Generally manipulative, does not feel guilty, sorrow & not loyal Charming, intellectual and smooth talkers They repeatedly neglect responsibilities, tell lies and perform destructive or illegal acts, without developing any insight into predictable consequences Hostile, unable to follow rules Diagnose before age 15 as conduct disorder Criteria for Antisocial PD 1. Violate rights of others 2. Engage in illegal activities 3. Aggressive behavior 4. Lack of guilt or remorse 5. Irresponsible in work & with finances 6. Impulsiveness 7. Recklessness

1.

2.

c.

6. Avoid moralizing Borderline personality disorders Characterized by impulsiveness, unpredictable, unstable moods Desperately seek relationship to avoid feeling abandoned Chronic sense of boredom Overspending, promiscuity, overeating Problems with identity & self-image

history of substance abuse & multiple or dramatic suicidal gesture, risk of suicide and mutilation Manipulative and dependent Emotional lability Defense mechanism: projection Etiology:

d.

Etiology: genetics, environment, family environment (unstable parent child realationship Nursing guidelines 1. Prevent or reduce untoward effects of manipulation (flattery, seductiveness, instilling guilt) by setting limits 2. Encourage client to verbalize feeling 3. Be firm, steadfast and consistent in dealing with patients behavior and reinforcing rules & policies 4. Help client be aware of the consequences of their behavior 5. Explain & point out the effects of their behavior towards others

Inadequate regulation of serotonin & dopamine & other transmitters Parents may cling to the child and prevent autonomy, individual or parent withdraws support & attention making the child confuse Pharmacologic mgt: Neuroleptic drugs (3-12 wks) Lithium Valporic acid Carbamazepine Benzodiazepine Nursing guidelines Set realistic goals, use clear action word Be aware of manipulative behaviors Provide clear & consistent boundaries & limits Use clear 7 straightforward communication Avoid rejecting or rescuing Assess for suicidal & self-mutilating behavior Narcissistic personal disorder (boasful/superioritycomplex) Individuals with this disorder display grandiosity about his performance and achievement Arrogant, extrovert Believe to be special with need to be admired Feel intense shame & fear that if they are bad, they will be abandoned Afraid of their own mistakes, as well as the mistakes of others.

Defense mechanism: rationalization Nursing guidelines: Supportive confrontation Remain neutral; avoid engaging in power struggle or becoming defensive in response to the clients disparaging remarks Convey unussuming self-confidence Point out reality

e.

Tell client no one is perfect Histrionic personality disorder Individual with this disorder are characterized by excessive emotional attention seeking behavior and are dramatic and ego-centric Seductive, flamboyant and shallow use speech to impress others Needs to be the center of attention Impulsive and melodramatic Demands the best of everything and can be very critical

Nursing guidelines Be friendly, gentle, reassuring approach Help client to confront fears gradually Support & direct client in accomplishing short-term goals

c.

Relaxation techniques Obsessive-compulsive personality disorder

Perfectionist and inflexible Overly strict & often set standards for themselves that are too high Preoccupied with details, rules, trivial and procedures Difficult to express emotions or warmth They try to control partner in a relationship Serious, affect is constricted and would speak in monotone voice Defense mechanism: intellectualization, rationalization, reaction-formation Etiology: early parent-child relationship Nursing guidelines: Help client make decision encourage follow-through behaviors Encourage leisure activities Guard against engaging in power struggle with client Confront clients procastination and intellectualization

Related factors: mother-child relationship Nursing guidelines: Understand seductive behavior as a response to distress Keep communication & interaction professional, despite temptation to collude with the client in a flirtatious & misleading manner Encourage & model the use of concrete & descriptive rather that vague & impressionistic language

3.

Teach and role-model assertiveness CLUSTER C DISORDERS (ANXIOUS, FEARFUL) a. Dependent personality disorder (submissive) pervasive & excessive need to be taken care of that leads to submissive and clinging behavior & fears of separation (APA, 2000) Extreme dependency in a close relationship, with an urgent search to find a replacement when one relationship ends - they are afraid to be alone They want others to make decision for them they need direction and reassurance They feel the need to be rewarded if they do good deeds for others To avoid conflict they become passive, conceal sexual feelings and anger Nursing guidelines: Increase responsibility for self in daily livings Be assertive Encourage client to verbalize feeling Be aware of countertranference b.
Avoidant personality disorder (shy/ with inferiority complex) These clients are timid, socially uncomfortable, with self care and withdrawn Social inhibition and avoidance of all situation that require interpersonal contact Hyeprsensitive to criticism Uncertain and lacks confidence and afraid to ask question or speak in public

MOOD DISORDERS Mood a persons state of mind exhibited through feeding & emotions (APA, 2001) Mood disorders extreme change in mood that presents problems in daily functioning - alteration in effect or mood that occurs when an individual experience exaggerated feeling for a prolong period of time that is psychologically, physically & socially unacceptable Causes: Genetics Biochemistry Personality Environment 1. Types of depression: MAJOR DEPRESSIVE DISORDER (MDD) Characterized by 1 or more major depressive episodes, which are defined as at least 2 weeks by depressive mood or less of interest accompanied by at least 4 additional symptoms of depression Signs/behavior a. Depressed mood most of the day b. Anhedonia

Significant weight loss or gain (5% wt. in month) d. Insomia or hypersomia (2 hrs in 1 month) e. Increase or decrease motor activities f. anergia g. Feelings of worthlessness or inappropriate guilt (may be delusional) h. Recurrent thoughts of death or suicidal ideation i. Decrease concentration or indecisiveness Characteristics a. Disregards grooming, cleanliness & personal appearance b. Stooped posture & dejected facial expression c. Dishevelled, downcast, lacking eye contact & tearful d. Agitated Specifiers: a. Atypical depression occurs in younger population Increase appetite or wt. gain, hypersomnia, leaden paralysis & extreme sensitivity to interpersonal rejection b. Melancholic depression older adults Anhedonia & inability to be cheered up Depression worse in AM Early AM awakening Psychomotor retardation or agitation Significant anorexia or wt loss Excessive or inappropriate guilt c. Catatonic features psychomotor attraction including immobility, excessive motor activities, mutism, echolalia or echopraxia, inappropriate posturing negativism d. Postpartum depression mood disturbance that occurs during the first 30 days post partum e. Psychotic depression delusions & hallucination Delusion of guilt, delusions of deserved punishment, somatic delusions, nihilistic delusion, & delusion of poverty f. Seasonal affective disorder (SAD) occur in conjunction with a seasonal change Psychopharmacological mgt. a. SSRIs b. Tricyclics c. Antidepressant d. MAOIs Nursing guidelines: a. Establish trust

c.

2.

Nonjudgmental & friendly approach Use silence & stay with patient Avoid challenging or testing the client Do not argue Divert patients attention b. Bolster self-esteem c. Be amphatic d. Point out or reward small visible accomplishment e. Do not embarrass patient f. Never reinforce hallucination, delusions or irrational beliefs g. Encourage verbal expressions of anger h. Provide non-threatening one-to-one relationship i. Guide patient to appropriate decisions by using problem solving DYSTHMIC DISORDER Patient is depressive mood for at least 2 years With poor appetite or over-eating Insomia or hypersomia Low energy or fatigue Low self-esteem Poor concentration or difficulty making decisions Feelings of hopelessness Difference between MDD & DD (duration & severity) Patient may engage in activities to generate excitement may turn to substance abuse or food Patients do not readily recognize their symptoms as abnormal MANIC DISORDERS STAGES OF MANIA Mild elation or hypomaniac (4 days) Affect feeling of happiness, confidence Thought flight of ideas, inflated self-esteem Behavior always on the go, increase sexual drive Acute manic episodes Intensified symptoms Mood disturbance & lability Enthusiastic & intrusive Hyperactivity Flight of ideas Distractibility

c.
d.

Depressive episodes hypersomia, hyperphagia, wt. gain, leaden paralysis, little energy BIPOLAR DISORDER

Nutrition & sleep issues

Bipolar I disorder experiences swings between manic episodes and major depression; manic episodes Bipolar II disorder characterized by 1 or more depressive episodes accompanied by at least one hypomanic episodes; depressive Cyclothymic disorders a swing between a hypomanic and depressive symptom; numerous periods of hypomanic sx and depressive sx Major depressive- 6mos+; exhibits 5+ sx of major depressive episodes Dysthymic depressive- not sever; no ssx; usually sensitive and have intense feelings of guilt; (-) perceptions, cognitive therapy Behavior of bipolar disorder Objective behavior Disturbance of speech, social, interpersonal & occupational relationship, activity & appearance Speech rapid, pressured, loud, easily distracted Altered social, interpersonal & occupational relationship Subjective behavior Alteration of affect euphoric, grandiosity, labile Alteration of perception delusion & hallucination Nursing responsibilities Use matter of fact tone Clear, concise direction & comments remarks should be simple & brief Limit setting Reinforcement of reality Respond to legitimate complaints Redirect patient into more healthy activities Provide for can be eaten easily Assess amount of sleep & rest Provide quiet place to sleep Structure activities during the day Do not drink caffeine at bedtime Psychopharmacology Lithium Anticonvulsant & atypical antipsychotics Milieu mgt. Safety Consistency among staff Reduction of environmental stimuli Dealing with patient who are escalating Reinforcement of appropriate hygiene & dress

Electroconvulsive therapy (ECT) - if the pt. Cannot tolerate the anti-depressive drugs -if the anti-depressive drugs is not effective anymore -procedures: consent, procedure, npo 8hrs, premeds (succinylcholine), remove metals, supine position (vertebral fracture) Post ECT: temporary loss of memory

Manic Onset before 30mins Mood: elevated Expansive Irritable Speech: loud Rhyming Clanging Vulgar Wt. Loss Grandiose Distracted Hyperactive Decrease need for sleep Flight of ideas Begins suddenly Escalates over several days

Depressive Previous manic episodes Dysphoric Depressive Despairing Decrease pleasure Negative views Fatigue Decrease appetite Constipation Insomnia Suicidal preoccupation May be agitated or have movement Retardation

1.

2.

EATING DISORDERS ANOREXIA NERVOSA fear of gaining wt. Limit their intake or refuse to eat but do not lose their appetite Perfectionist & introvert with self-esteem & peer relationship problems Clinical manifestation/behaviors Restricters (fasting) Vomiters-purgers

3.

Distortion of self-esteem

Normal or slightly

Delirium state of extreme excitement Disorientation, incoherence Visual or olfactory hallucination Exhaustion, dehydration, injury even death Basic syndromes of bipolar disorders Manic episodes elevated, expansive or irritable mood Hypomanic episodes less, severe level of impairment

Induction of vomiting 7 excessive use of laxative or diuretics denies concern dental problems uncontrollably eat large amounts of food substance abuse

Avoids people Rigid excersie program Hyperactive

Competitive, compulsive, obsessive

a. b.

family conflict

Non-purging- excessive exercise/ laxative use Clinical manifestation/behavior Secretive about behavior

Amenorrhea ( 3 consecutive cycle) Hypotension, bradycardia, hyponatremia Dry skin with lanugo Delayed gastric emptying Slow peristalsis----constipation Dehaydration (15% loss of BW) Refeeding syndrome (3D, Decrease appetite, depressed,denial) Pitting edema Osteopenis or osteoporosis Cardiac arrythmias (50% cause of death) Bizaare behavior regarding fool & eating Feel abandoned or inadequate Depression, irritability, social withdrawal, lessened sex drive & obsession symptoms

4Ms (multivitamins, minerals, megace, marinol)

Binge eating (2x/wk for 3mos) F/E abnormalities Use of laxatives Use of ipecac syrup Menstrual irregularities Dental carries Russels sign Loss of control over eating Anxious & feeling weakness Angry & agitated or depressed Mod disorders Substance abuse

SCHIZOPHRENIA (split mind) Schizophrenia mental disorder characterized by disturdance in thought & sensory perception & deterioration in psychosocial functioning -serious mental disorder -increase dopamine level Biochemical therapy Perinatal therapy Decrease O2 during pregnancy -ego is destroy Psychotic delusions, any prominent hallucinations, disorganized speech or disorganized catatonic behavior (APA, 2000) Comorbidity Substance abuse Depressive symptoms Anxiety disorders Theory Dopamine hypothesis Alternative biochemical hypothesis structural cerebral abnormalities, reduced gray matter, increase ventricular brain ratio Genetics Autoimmune Double bind communication 2 messages that contradict each other are sent causing the child to be confused on what action to engage in which immobilize the child & results to anxiety Birth & pregnancy complication, viral infxn, poor nutrition or starvation, exposure to toxin Stress development/family Weak ego Vitamin deficiency vitamins B1, B6, B12, vit. C Precipitating factors Emotional - marital problem

1. 2. 3. 1. 2. 3. 4. 5. 6. 7. 8. 9.

Etiology Biologic factors increase serotonin A culture of thinness, relational orientation of women Genetic component Family environment Odd eating habits & emphasis on appearance Rejection of food & wt. loss as a positive reinforcement Childhood sexual abuse Regression to a prepubertal state Fear of being out of control Defense mechanism: REACTION FORMATION

Self induce vomiting (purging) Etiology Low serotonin activity Inherited Cycles of low self-esteem, extreme concerns about body shape & wt., strict dieting, binge eating & compensatory behavior Ambivalence Feel unworthy of nurturing Psychotherapeutic mgt Medical stabilization Wt. restoration Help patient reestablish appropriate eating behavior Elevate self-esteem Medical treatment IV lines & feeding tubes Nursing guidelines Convey warmth & sincerity Listen emphatically Be honest Set appropriate behavioral limit Assist patient in identifying their qualities Collaborate with patient Teach patient about disorders Determine patients weight with their back on the scale Initiate behavioral modification Express emotions assertively Help patient identify & express bodily sensation identify non-weight related interest Psychopharmacology Anxiolytics Atypical antipsychotics
Antidepressants - SSRI (Tofranil) TCAs (Prozac)

BULIMIA NERVOSA (binge eating) Intermittent binge period and periods of restrictive eating Loss of control over eating Anxious & feeling of weakness before eating while binging Angry & agitated or depressed Mood disorders Substance sbuse

Self-induce vomiting Excessive exercise Uncontrolled cravings Purging Binge Laxative use Substance abuse

Somatic pregnancy, physical illness 3. May be none 4 As (Eugene Bleuler) Affect outward manifestation of a persons feelings & emotion flat, blunted, inappropriate bizarre affect Associative looseness haphazard & confused thinking manifested in jumbled & illogical speech & reasoning Autism thinking that is not bound to reality but reflects the private perceptual world of the individual delusions, hallucination, neologism Ambivalence simultaneously holding 2 opposing emotions, attitudes, ideas, or wishes towards the same person situation or object Phases of schizophrenia 1. Pre morbid- no s/sx

1. 2.

Types: Purging

2. 3. 4. 5.

Prodromal- insomnia, tension and withdrawal Onset- s/sx recognized Progressive- s/sx fully recognizable Chronic/relapse- repeated episodes, (-) s/sx relapse

Common symptoms of schizophrenia 1. Delusions false fixed beliefs that cannot be corrected by reasoning 2. Hallucinations sensory perception for which no external stimulus exist 3. Illusions misinterpretation of environmental stimuli 4. Depersonalization feeling of the individual that the self has been changed or altered 5. Affective flattening absence of emotional response 6. ambivalences Hallucination A (4As) R (rel is alter) Delusion Common delusions in schizophrenia Delusions of reference everything that is occurring in the environment has significance to oneself 2. Delusion of persecution false belief that one is being singles out for harm by others someone is platting against him/her 3. Somatic delusion appearance or functioning of ones body is altered 4. Grandiose delusion false belief that one is a very powerful & important person 5. Nihilistic delusion I am dead 6. Delusions of influence one is controlled by others or outside force Jealousy false belief that ones mate in unfaithful; may have so-called proof Symptoms of loose association 1. Neologism 2. Echolalia 3. Word salad 4. Clang association 1.

Diagnostic Characteristics -evidence of atleast 2 or more of the ff: Hallucination Delusion psychosis (-) s/sx Inappropriate/disorganized speech -s/sx should be seen in a pt. More than 6mos -s/sx should not be caused of substance abuse or medical condition

4.

UNDIFFERENTIATED TYPE characterized by atypical symptoms that do not meet the criteria for other subtypes Characteristics symptoms Prognosis is favorable Atypical symptoms (+) (-) disorganized

5.

2 diagnostic categories Type I schizophrenia (+) s/sx, gen. Acute, responds to antipsychotic drugs Type II schizophrenia (-) s/sx has low in onset

RESIDUAL TYPE Continuing evidence of negative symptoms without characteristic symptoms of schizophrenia (-) s/sx + atleast 1 (+) s/sx (-) symptoms w/o characteristic symptoms of schizo

1.

SCHIZOPHRENIA SUBTYPES PARANOID TYPE (projection) Experience persecutory or grandiose delusion & auditory hallucination Suspicious (build trust) Hallucination (auditory) Anger/agitation (setting limit) Violence (safety) Extremely experience persecution (grandiosity)

Dis FLIES Organized Catatonic- WIRE Residual Undifferentiated- atypical sx Paranoid- SHAVE Assessment Objective Sx Less concerned with their appearance Introspection & apathy Anergia Inadequate interpersonal communication Hostility Withdrawal Psychomotor agitation or inactive or catatonic Subjective Sx Hallucnation Illusion Paranoid thinking Thoiught disorder Delusions Confusion, incoherent speech, clouding, & a sense of going crazy Inappropriate, flattened, blunted, or labile affect Psychopharmacology Stabilize acute symptoms Maintain therapeutic plasma levels Typical antipsycotics Haloperidol (Haldol) Chlorpromazine (Thorazine) Thiothixene (Navane) Atypical antipsychotics Clozapine (Clozaril) Respirodone (Respiradol) Olanzopine (Zyprexa) Milieu mgt. For disruptive patients: Set limits

1.

2. 3.

3 broad clinical symptoms Positive symptoms Reflects the presence of overt psychotic or distorted behavior Negative symptoms reflect a dimunition or loss of normal function Disorganized symptoms presence of confused thinking, incoherent or disorganized speech & disorganized behaviour (+) increase dopa with energy (treated by antipsychotic drug) Suicidal ideation (no self harm contact) Hallucination/hyperactivity Excitement Pressured speech Hostility (setting limit) Excessive agitation Rude Delusions disorganized Confusion Attention deficit Repetitive movement Disorganized speech Inappropriate speech

2.

(-) decrease dopa w/o energy Anhedonia (pleasure) Avolution (socialization) Anergia (energy) Affect (blunt/flat) Ay(eye) contact is poor

CATATONIC TYPE psychomotor disturbances Motoric immobility, waxy flexibility or stupor Excitement (excessive motor activity) Extreme negativism or mutism ---- withdrawal Peculiar movements Echolalia or echopraxia Waxy flexibility (can stay longer in one position) Inappropriate action (echolalia(last word heard), echopraxia(action)) Rigidity Eye contact is poor DISORGANIZED TYPE most severe prognosis, disintegration of personality & is withdrawn, disorganized speech, disorganized behavior, flat or inappropriate affect Flat affect Losseness of association Inappropriate affect Extremely disorganized Schizophrenic features (delusion, hallucination)

3.

Frequently observe escalating patients to intervene Modify the environment to minimize objects that can be used as weapons Be careful in stating what the staff will do if a patient acts out When using restraints, provide for safety by evaluating the patients status of hydration, nutrition, elimination, & circulation

Provide safe & relatively simple activities for these patients

a. b.

For withdrawn patients: Arrange non-threatening activities that involve these patient in doing something Arrange furniture in a semicircle or around a table Help client to participate in decision making Reinforce appropriate grooming & hygiene Provide psychosocial rehabilitation For suspicious patients: Be matter-of-fact Staff members should not laugh or whisper around patients unless patient can hear what is being said Do not touch suspicious patients without warning Be consistent in activities Maintain eye contact For patient with impaired communication: Be patient & do not pressure patient to make sense Do not place patient in group activities that would frustrate them, damage self-esteem, or over-tax their abilities Provide opportunities for purposeful psychomotor activity For patient with hallucinations: Attempt to provide distracting activities Discourage situation in which patient talk to others about their disordered perception Monitor television selection Monitor for command hallucination that might increase the potential for patient to become dangerous Have staff members available in the dayroom so that patient can talk to real people about real people or real events Safety Acknowledge Reality Stronger stimulus For disorganized patients: Remove disorganized patient to a less stimulating environment Provide a calm environment

Nursing guidelines Build a therapeutic alliance with patient Be calm Accept patient Keep promises Be honest Do not reinforce hallucinations or delusions Do not touch patient without warning Reinforce positive behaviors Avoid competitive activities Do not embarrass patient Allow & encourage verbalization of feelings SCHIZOPHRENIA LIKE DISORDERS Schizoaffective disorders Uninterruptive period of illness during which at some point the patient experiences a MDD, manic or mixed episodes along with the negative symptoms of schizophrenia In the absence of prominent mood symptoms, patient exhibits delusion or hallucination (2wks) Schizophreniform disorder Patient exhibits features of schizopohrenia for more than 1 month - <6 months No impaired social or occupational function Brief psychotic disorder Onset of at least 1 or more positive symptoms of psychosis

c.
Type of Crisis

Perception of precipitating event is realistic rather than destored Situational supports (ex. Family, friends) Coping mechanism that alleviate anxiety

Developmental crisis - occurs from transition from one stage of maturation to another in the life cycle Situational crisis occurs to a sudden, unexpected event in an individual life. These events is all about experiences of loss.

1.

Adventitious crisis occurs in response to severe trauma or natural disaster. These crisis can affect individuals, communities and even nation Sequence of Crisis Development 1. Pre-Crisis period individual has emotional equilibrium Crisis period individual has the subjective experience of being upset, failure of usual coping mechanism, symptoms are expereinced 3. Post-Crisis period resolution of crisis Symptoms common in individual experiencing crisis

2.

2.

Physical symptoms somatic complaints Cognitive symptoms confusion, difficulty concentrating, racing thoughts, inability to make decisions Behavioral symptoms disorganization, impulsive, angry outburst, withdrawal from social interaction Emotional symptoms anxiety, anger, guilt, sadness, depression, paranoia, suspicion, helplessness, powerlessness

3.

4.

Occur at least 1 day - <month then full recovery Psychotic disorder due to a general medical condition Presence of prominent hallucination or delusion determined as resulting from the direct physiologic effect of a specific medical condition
CRISIS It is an overwhelming reaction to a threatening situation in which an individuals usual problem-solving skills and coping responses are inadequate for maintaining psychological equilibrium General Consideration Crisis occurs in all individuals at one time or another Crisis is not necessarily pathological, it can provide stimulus for growth & learning Crisis is time limited and is usually resolve one way or another in a brief period (4-6 weeks) a. Successful crisis resolution occurs when functioning is restored or enhanced through new learning b. Unsuccessful crisis resolution is when functioning is not restored to pre-crisis level, and the individual experiences decreased level of functioning Individuals perception of the problem determine the crisis. Each individual has unique response to the problem Balancing factors are important in predicting outcomes for the individual responding to a crisis

1. 2. 3.

Management of Crisis: Crisis Intervention 1. Assistance Assistance for an individual affected by a crisis Assistance for groups or communities affected by crisis Mobile crisis team interdisciplinary teams provide services to groups of communities affected by crisis Disaster response team teams have an organized plan to provide help to large segments of the population affected by natural disaster Critical incident stress debriefing assistance is directed at groups of professional such as hospital personnel, police and firemen, who have been involved in a crisis situation.

4. 5.

2.

Role of the Nurse Nurse provides direct services to people in crisis and serve as members of crisis intervention teams

In acute and chronic hospital setting assist individuals and families responding to the crisis of serious illness, hospitalization and death In community setting provide assistance to individuals and families in developmental and situational crisis Nurses working with a particular group of client should anticipate situations in which crisis may occurs. They also collaborate with other health team members to help an individual resolve crisis

Intoxication: ingestion of substance that results in abductive behavior Withdrawal:s/sx that manifest after the effect of the substance Detoxification: process to eliminate the substance being ingested Tolerance: increasing the amt. Of substance to achieve the max effect Blackout: person cannot remember things during substance intoxication Confabulation: making up stories Dependence: person cannot work without substance ingestion Alcoholic- induced persisting amnestic disorder Alcohol Intoxication Slurred speech Unsteady gait Impaired memory and judgement Flushing Drowsiness Tremors Belligerence Loss of inhibitions Constricted pupils if severe: coma, respi dep., death Alcohol Withdrawal Sweating Shaking G.I symptoms o Liver (cirrhosis) o Pancreas(monitor CBG) DOC: Librium and Valium Untreated: DELIRIUM TREMENS o Seizures (Seizure prec.(padded tongue dep., suction machine,O2, Valium or diazepam) o Hallucination (DOC: thorazine/antipsychotic) Antabuse (DISULFIRAM) Alcoholic anonymous (Major Goal:ABSTINENCE) o Evaluation: no. Of days of abstinence Two differ. CNS assoc. With alcoholism o Korsakoffs Psychosis- form of amnesia characterized by short-term memory loss disorientation, inability to learn new skills and exhibit confabulation. -There is a degenerative changes in the hypothalamus bec. Of a deficiency in Vit B complex, especially thiamine B6 and B12 o Wernicks Psychosis- inflammatory hemorrhagic degenerative condition of the brain caused by a thiamine deficiency in which lesions occur in the hypothalamus, mammillary bodies and tissues surrounding ventricles and aqueducts Clinical symptoms include: Double vision Involuntary and rapid eye movements Lack of muscular coordination Decreased mental function

Alcohol Abuse Individual who is in the state of alcohol of alcohol abuse exhibits one or more of the following symptoms in a 12mos period. Recurrent drinking of alcohol resulting in a failure to fulfil major role obligations at home, school or work

Recurrent drinking in situations in which it is physically hazardous Continued use of despite having persistent or recurrent social or interpersonal problems caused by alcoholism

Principles of crisis intervention the goal of crisis intervention is to return the individual to pre-crisis level of functioning Emphasis is on strengthening and supporting healthy aspects of individuals functioning A problem-solving approach is use in a systematic manner Assessing the individuals perception to problem assessing strengths and weaknesses of the individual and family support system Planning specific outcomes or goals based on priorities Providing direct intervention Evaluation outcome and results of intervention Use the framework of Maslows hierarchy of needs to determine the priorities for intervention Physical resources necessary for survival Social resources necessary for regaining sense of belonging Psychological resources necessary for regaining selfesteem Role of crisis intervention worker includes: Establishes rapport and communities hope and optimism Assumes an active, directive role if necessary

Alcohol Dependence Individual who is in the state of alcohol dependence experiences distress and exhibits 3 or more of the following symptoms during a 12mos period A need of an increased amts. Of alcohol to achieve desired effects Continued use of alcohol to relieve or avoid withdrawal symptoms

Intake of alcohol is in larger amt or over a longer period of time than was intended.

Make suggestions and offer alternatives

Alcohol intoxication An individual is in the state of alcohol intoxication if seen with the following behavioural changes after the recent ingestion of alcohol: o Nystagmus o Unsteady gait o Slurred speech o Impaired memory o Impaired judgment o Impaired attention span o Fighting o Irritability o Mood changes o Stupor or coma o Increased verbalization o Impaired social functioning Alcohol Withdrawal Occurs when an individual abruptly stops drinking after alcohol has become a necessity of life to maintain functioning Generally, the individual is in the state of alcohol withdrawal if the following clinical symptoms are experienced within several hours to few days after the cessation or reduction of heavy and prolonged alcohol used: o Autonomic hyperactivity o Grand mal seizures o Psychomotor agitations and anxiety o Increased hand tremors o Sleep disturbances (insomnia and nightmares) o Illusions and transient hallucinations (visual/tactile/auditory) o Eleve\ated temperature higher than 100F Shadows are misinterpreted and any noises or quick movements are perceived exaggeratedly

Lecture: Terminologies

Serious medical complications may occur if the client is left untreted S/sx:

o Lacrimation o Diarrhea o Rhinorrhea o Yowning o Fever o Insomnia o Anxiety o Restlessness o Craving Opiod(pain reliever) Legal drugs: morphine, Demerol, hydromorphone, oxycodone, methadone Illegal drugs: heroin and normethadone Narcan (naloxone) Opiod antagonist Blocks the effect of opiod for 72 Alcohol Related Disorders System Common effects and complications G.I Acute gastritis, pancreatitis, cirrhosis of the liver, hepatitis, esophageal varices, haemorrhoids, ascites Respi Respi dep and depresse cough reflex Cardio Hypertension, weakened heart muscles and heart failure Repro Prostitis or fetal alcohol\ syndrome or abnormalities in the newbornheart defects, mental retardation and abnormal shape heads and limbs caused by maternal drinking during pregnancies CNS Depression, gait changes and peripheral neuropathy Others Deficiencies of vit. A, D, K due to poor nutritional status, anemia, increased susceptibility to infection, bruises and bleeding tendencies due to decreased RBC and WBC and abnormal bone marrowing functioning Opiod related disorders Substances that are included in this classification are morphine, heroin, penctazone, and codeine or methadone Opiates are narcotic drugs that induces sleep, suppress coughing and alleviate pain Opiates are abused to help relieve withdrawal symptoms or to feel good Opiates users usually experience reduced feelings of hunger, thirst, pain and sexual desire Acute overdose may experience symptoms such as decreased or slow respirations, constricted pupils and a rapid, weak pulse The person is in the state of opiates withdrawal if the following symptoms are experienced within 12-16 hours after the las dose: o Yawning o Tremors o Diarrhea o Nausea and vomiting o Restlessness o Dilated pupils o Sneezing o Goose bumps o Rhinitis o Watery eyes

o Diaphoresis o Loss of appetite o Muscle cramps o Irritability The above symptoms may subside in 5-10days if no treatment occurs