QUICK REVIEW PSYCHIATRIC NURSING

Ego Defense Mechanisms

Denial Displacement Projection Undoing Compensation Symbolization

Substitution Introjection Repression Reaction formation Regression Dissociation Suppression

STAGES OF GRIEVING (Dying patient)

Denial Anger Bargaining Depression Acceptance

Bipolar Disorder Assessments

Disoriented, flight of ideas Lacks inhibitions, agitated Easily stimulated by environment Sexually indiscreet Affective disorder Maintain contact with reality Elation is defense against underlying depression Manipulative behavior results from poor selfesteem

Bipolar Disorder Implementations

Meet physical needs first Simplify environment Distract and redirect energy Provide external controls Set limits: escalating hyperactivity Use consistent approach Administer Lithium (help Manic Phase of Bipolar, keep hydrated) Increase awareness of feelings through reflection

Schizophrenia Assessments
Withdrawal from relationships and world Inappropriate display of feelings Hypochondriasis Suspiciousness Inability to test reality, regression Hallucinations Delusions Loose associations Short attention span Inability to meet basic needs: nutrition, hygiene

Schizophrenia Types
Disorganizedinappropriate behavior, transient hallucinations Catatonicsudden onset mutism, stereotyped position, periods of agitation Paranoidlate onset in life, suspiciousness, ideas of persecution and delusions

Schizophrenia Implementations
Maintain safetyprotect from erratic behavior With hallucinationdo not argue, validate reality, respond to feeling tone, never further discuss voices (dont ask to tell more about voices) With delusionsdo not argue, point out feeling tone, provide diversional activities Meet physical needs Establish therapeutic relationship

Schizophrenia Implementations
Institute measures to promote trust Engage in individual, group, or family therapy Encourage clients affect Accept nonverbal behavior Accept regression Provide simple activities or tasks

 Paranoid Assessments
Suspiciousness Cold, blunted affect Quick response with anger or rage

Paranoid Implementations
Establish trust Low doses phenothiazines for anxiety Structured social situations

Schizoid Assessments
Shy and introverted Little verbal interaction Few friends Uses intellectualization

Schizoid Implementations
Establish trust Low doses phenothiazines for anxiety Structured social situations

Schizotypal Assessments
Eccentric Suspicious of others Blunted affect Problems with perceiving, communicating

Schizotypal Interventions
Establish trust Low doses neuroleptics to decrease psychotic symptoms Structured social situations

Antisocial Assessments
Disregards rights of others Lying, cheating, stealing, promiscuous Lack of guilt Immature Irresponsible Associated with substance abuse

Antisocial Implementations
Firm limit-setting Confront behaviors consistently Enforce consequences Group therapy

Borderline Assessments
Brief and intense relationships Blames others for own problems Impulsive, manipulative Self-mutilation Women who have been sexually abused Suicidal when frustrated, stressed

Borderline implementations
Identify and verbalize feelings Use empathy Behavioral contract Journaling Consistent limit-setting Group therapy

Narcissistic Assessments
Arrogant lack of feelings and empathy for others Sense of entitlement Uses others to meet own needs Shallow relationships Views self as superior to others

Narcissistic Implementations
Mirror what client sounds like Limit-setting Consistency Teach that mistakes are acceptable

Histrionic Assessments
Draws attention to self Somatic complaints Temper tantrums, outbursts Shallow, shifting emotions Cannot deal with feelings Easily influenced by others

Histrionic Implementations
Positive reinforcement for other centered behaviors Clarify feelings Facilitate expression of feelings

Dependent Assessments
Passive Problem working independently Helpless when alone Dependent on others for decisions Fears loss of support and approval

Dependent Implementations
Emphasize decision-making Teach assertiveness Assist to clarify feelings and needs

Avoidant Assessments
Socially uncomfortable Hypersensitive to criticism, Lacks self-confidence Fears intimate relationships

Avoidant Implementations
Gradually confront fears Discuss feelings Teach assertiveness Increase exposure to small groups

Obssessive-compulsive Assessments High personal standards for self and others Preoccupied with rules, lists, organized Perfectionists Intellectualize

Obssessive-compulsive Implementations
Explore feelings Help with decision-making Confront procrastination Teach that mistakes are acceptable

Manipulative behavior Assessments

Unreasonable requests for time, attention, favors Divides staff against each other Intimidates others Use seductive or disingenuous approach

Manipulative Behavior Implementations Use consistent undivided staff approach Set limits Be alert for manipulation Check for destructive behavior Help client to see consequences of behavior

Acute Alcohol Intoxication

Drowsiness Slurred speech Tremors Impaired thinking Belligerence Loss of inhibitions

Acute Alcohol Implementations

Protect airway Assess for injuries Withdrawal assess IV glucose Counsel about alcohol use

Alcohol Withdrawal Assessments Tremors insomnia anxiety hallucinations

After Withdrawal Delirium Tremens Assessments Disorientation Paranoia Ideas of reference Suicide attempts Grand mal convulsions

Alcohol Withdrawal Implementations

Monitor vital signs, especially pulse Administer sedation, anticonvulsants, thiamine (IM or IV), glucose (IV) Seizure precautions Quiet, well-lighted environment Stay with patient

Chronic Alcohol Dependence Assessments Persistent incapacitation Cyclic drinking or binges Others in family take over clients role Family violence

Chronic Alcohol Dependence Implementations

Identify problems related to drinking Help client see problem Establish control of problem Alcoholics anonymous Antabuse Counsel spouse and children

Wernickes Syndrome Assessments

Confusion Diplopia, nystagmus Ataxia Apathy

Wernickes Syndrome Implementations

Thiamine (IM or IV) Abstinence from alcohol

Korsakoffs Psychosis Assessments

Memory disturbances with confabulation Learning problems Altered taste and smell Loss of reality testing

Korsakoffs Psychosis Implementations Balanced diet Thiamine Abstinence from alcohol

MEDICATIONS PYSCHIATRIC

ANTIPSYCHOTIC MEDICATIONS C O R C H F

Also called major tranquilizers/neuroleptic medications Improve the thought processes and the behavior of the client with psychotic symptoms. Typical antipsychotic (C-H-F) are good for POSITIVE symptoms (hallucination, delusion, aggression) Atypical antipsychotic medications (C-OR) are good for NEGATIVE symptoms (withdrawal, apathy, alogia)

ANTIPSYCHOTIC MEDICATIONS
Liquid form (mixed with fruit juice) is preferred than tablets (some clients hide the tablets) Full therapeutic effect occurs at 3-6 weeks. Observable response may occur at 7-10 days. May change the color of the urine to pinkish/red brown

ANTIPSYCHOTIC MEDICATIONS
The antipsychotic medications have ANTICHOLINERGIC and EXTR-PYRAMIDAL side effects.

 ANTICHOLINERGIC SIDE EFFECTS are usually ALL down EXCEPT for PULSE RATE! (Effect is TACHYCARDIA)

 EXTRA-PYRAMIDAL signs (EPS) are PD-ANT P D A N T

 TO REVERSE P-D-A, give ABC! (ABC mo lang yan!) Pseudo-parkinsonism Dystonia Akathisia

DEPRESSION
3 MAJOR GROUP of DRUGS for DEPRESSION are: Tricyclic anti-depressant (TCAs); Selective serotonin inhibitors (SSRIs) Monoamine oxidase inhibitors (MAOIs)

 MOST COMMON Tricyclic antidepressant (TCAs) are TAE-ICA T A E I C A

TCA
Blocks the reuptake of norepinephrine at the presynaptic neuron. NEVER take TCAs or SSRIs concurrently with MAOIs (leads to hypertensive crisis). Wait for 14 days before shifting from TCAs/SSRIs to MAOIs. Physostigmine is an antidote for anticholinergic toxicity

TCA
Therapeutic effect occurs at 2-4 weeks (observe patient for suicidal attempt at this period) Cardiac problems (dysrhythmias) are adverse reactions to the drug. ECG, cardiac monitor may be used.

TCA
Anticholinergic side effects should be addressed (D BUSS). Avoid alcohol and OTC Seizure threshold decreases, prone to seizures

SELECTIVE SEROTONIN INHIBITORS (SSRIs)

Inhibits serotonin reuptake and elicits antidepressant effect Avoid taking St. Johns Wort/MAOIs while taking SSRI (leads to serotonin syndrome; muscle rigidity, elevated CPK and temperature)

Most common SSRIs are S-P-F. Sertraline (Zoloft) Paroxetine (Paxil) Fluoxetine (Prozac) and bupropion (Wellbutrin) taken in AM to prevent insomnia

SSRI
Serotonin syndrome occurs when St. Johns wort/MAOIs are concurrently taken Should take the drug in AM if it causes insomnia Report PRIAPISM. Withhold the drug Instruct the client not to drive, change position gradually, and taper the dose gradually

MONOAMINE OXIDASE INHIBITORS (MAOIs)

Inhibits monoamine oxidize to increase the levels of norepinephrine and serotonin. These eventually improves the mood of depressed client The drug is ONLY given if TCAs, SRIs and even ECT were not effective.

MONOAMINE OXIDASE INHIBITORS (MAOIs)

1. AVOID amphetamines, TCA/SSRI, epinephrine, dopamine THYRAMINE-RICH foods, and vasoconstriction medications (may lead to hypertensive crisis)

 Most common MAOIs are the PaNa-Ma

 Monitor BP regularly. Withhold if with headache, neck stiffness/soreness and palpitations. (Hypertensive crisis is an adverse reaction, prepare to administer phentolamine; Regitine) Avoid thyramine-rich foods (ABC), TCA, SSRI, narcotics, Flexeril (muscle relaxant) Observable therapeutic effect occurs at 3 weeks (observe for suicidal attempt at this time)

 Avoid thyramine-rich foods (ABC), TCA, SSRI, narcotics, Flexeril (muscle relaxant) Observable therapeutic effect occurs at 3 weeks (observe for suicidal attempt at this time)

 Instruct patient to avoid caffeine and OTCs, and sudden change of position Should ALWAYS wear medic alert bracelet that MAOI is being taken

 COMMON FOODS HIGH in THYRAMINE (Should be avoided when taking MAIOs) ABCs MOST of them and those preserved foods or foods THAT REQUIRE BACTERIA/MOLD for their PREAPRATION/PRESERVATION

Alcohol/red wine/beer/sherry Avocado Banana, papaya or over ripe fruits Beef/chicken liver Brewers yeast Broad beans Caffeine-containing products Cheese (aged cheese NOT the cottage cheese)

And those PRESERVED FOODS Pickled herring Raisins Sausage, bologna, pepperoni, salami (Think of pizza) Sour cream Soy sauce Yogurt

END
Thank you