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ESTOLAS, RN
– A state of emotional, psychological and social
wellness evidenced by satisfying interpersonal
relationships, effective behavior and coping,
positive self-concept and emotional
stability.(Videbeck)
– Lifelong process of successful adaptation to a
changing internal and external environments.
– A clinically significant behavioral or psychological
syndrome or pattern that occurs in an individual
and that is associated with present distress,
increased risk of suffering, death, disability and
loss of freedom. (Videbeck)
– Loss of ability to respond to environment in ways
that are in accord with oneself and society.
• Accepts himself
• Perceives reality
• Mastery of self and environment
• Autonomy
• Unifying, integrated outlook in life
Theoretical Foundations
• Mental health-Psychiatric treatment
integrates concepts and strategies from
theories.
• Theoretical Models are used as guides for
treatments
• These theories attempt to explain human
behavior, health and mental illness
Theoretical Foundations
• Theoretical frameworks
– allow the systematic organization of knowledge
– guide data collection
– provide explanations for assessed behaviors
– guide care plan development
– provides rationales for interventions and
– determine evaluation criteria
– Guide research by providing assumptions to be
tested.
Theoretical Foundations
Psychosexual- Sigmund FREUD
Psychoanalytical Theory
Psychosocial Theory Erik ERIKSON
• Previous Hospitalizations
• Educational Background
• Occupational Background
• Social Patterns
• Sexual Patterns
• Interest and Abilities
• Substance Use and abuse
• Coping Abilities
• Spiritual Assessment
MENTAL STATUS EXAMINATION
• Personal Information
• Appearance
• Behavior
• Speech
• Affect and Mood
• Thought Process
• Perceptual Disturbances
• Cognition
• Test to Assess Cognitive Function
• Interpretation
Any score over 24 (out of 30) is effectively normal. The normal
value is also corrected for degree of schooling and age.
Low to very low scores correlate closely with the presence of
dementia, although other mental disorders can also result in
abnormal findings of the MMSE testing.
The presence of physical problems can also interfere with the
interpretation.
For example a patient that is physically unable to hear or read
the instructions properly, or has a motor deficit that affects his
writing and drawing skills.
Nature of Psychiatric Nursing
The DSM(DIAGNOSTIC STATISTICAL MANUAL)-TR
(TEXT REVISION) IV- APA (AMERICAN
PSYCHIATRIC ASSOCIATION)
– A taxonomy that describes all mental disorders,
outlining specific diagnostic criteria for each based
on clinical experience and research.
– Clinicians utilize this to diagnose psychiatric
disorders.
– Purpose of DSM-TR:
1. Standard nomenclature/ classification
2. Defining characteristics
3. Underlying cause of disorders
Nature of Psychiatric Nursing
The DSM-TR IV : Multi Axis Classification
AXIS I- Major Psychiatric Disorders
AXIS II- Mental Retardation and Personality
Disorders
AXIS III- Current Medical Condition
AXIS IV- Psychosocial and Environmental
Problems
AXIS V- Global Assessment of Function
Nature of Psychiatric Nursing
Historical People Worth Mentioning
1. Aristotle- the Humors
2. Freud- -Psychosexual theory
3. Kraeplin- symptomatic classification of
mental disorders.
4. Bleuler- coined “schizophrenia”
Nature of Psychiatric Nursing
Psychiatric Nursing in the Philippines
• GO and NGOs
• Mental health programs
Nature of Psychiatric Nursing
Psychiatric Nursing in the Philippines
Mental Health
State of well being, where a person can realize his
potential.
Mental Ill Health
Disturbance of thought, feelings and behavior.
Mental Disorder
Medically diagnosable illness.
Mental Hygiene
Science which deals with measures employed to
promote mental health.
Nature of Psychiatric Nursing
Scope of Nursing Practice
1) Disturbances in perception
Illusion
• Misinterpretation of an actual external stimuli.
Hallucinations
• False sensory perception in the absence of external
stimuli.
2) Disturbances in thinking and speech
Neologism
• Coining of words that people do not understand.
Circumstantiality
• Over inclusion of inappropriate thoughts and details.
Word salad
• Incoherent mixture of words and phrases with no logical
sequence.
Verbigeration
• Meaningless repetition of words and phrases.
Perseveration
• Persistence of a response to a previous question.
Echolalia
• Pathological repetition of words of others.
Aphasia
• Speech difficulty and disturbance
• Expressive , receptive or global
Magical thinking
• Primitive thought process thoughts alone can
change events.
Autistic thinking
• Regressive thought process
Subjective interpretations not validated with objective
reality.
Flight of ideas
• Shifting of one topic from one subject to another in a
somewhat related way.
Looseness of association
• Incoherent ,illogical flow of thoughts(unrelated way).
Clang association
• Sound of word gives direction to the flow of thought.
Delusion
• Persistent false belief,rigidly held.
• Delusions of grandeur- special /important in a way
• Persecutory-threatened
• Ideas of reference-situation/events involve them
• Somatic- body reacting in a particular way
3) Disturbances of affect
Inappropriate
• Disharmony between the stimuli and the emotional
reaction.
Blunted affect
• Severe reduction in emotional reaction.
Flat affect
• Absence or near absence of emotional reaction.
Apathy
• Dulled emotional tone.
Depersonalization
• Feeling of strangeness from one’s self.
Derealization
• Feeling of strangeness towards environment.
Agnosia
• Lack of sensory stimuli integration.
4) Disturbances in motor activity
Echopraxia
• Imitation of posture of others.
Waxy flexibility
• Maintaining position for a long period of time.
Ataxia
• Loss of balance.
Akathesia
• Extreme restlessness.
Dystonia
• Uncoordinated spastic movements of the body.
Tardive dyskenisia
• Involuntary twitching or muscle movements.
Apraxia
• Involuntary unpurposeful movements.
5) Disturbances in memory
Confabulation
• Filling of memory gaps
Déjà vu
• 2nd time-like feeling
Jamais vu
• Not having been to the place one has been
before.
Amnesia
• Memory loss (inability to recall past events)
Retrograde-distant past
Anterograde – immediate past
Anomia – lack of memory of items
Therapeutic Relationships
• This is a nurse-client interaction that is
directed toward enhancing the client’s well-
being (Isaacs)
• A relationship established between a health
care professional and a client for the purpose
of assisting the client to solve his problems
Therapeutic Relationships
• The nurse- patient relationship is
characterized by a helping process
– The nurse and client work together for his
benefit
– The nurse uses herself therapeutically and this is
achieved by self-awareness
Therapeutic Relationships
• The nurse- patient relationship
– Respect the client and vale as individual
– Holistic care
– Maintain appropriate limits
– Covey empathy not sympathy
– Maintain honest and therapeutic communication
– Encourage expression of feelings
Therapeutic Relationships
ELEMENTS OF THE THERAPEUTIC RELATIONSHIP
• Contract
• Boundaries
• Confidentiality
• Therapeutic Behaviors
Therapeutic Relationships
ELEMENTS OF THE THERAPEUTIC RELATIONSHIP
Therapeutic Behaviors
1. Genuineness = sincerity and honesty
2. Concreteness= ability to identify client’s
feelings
3. Respect= shown through consideration of
patient as unique being
4. Self- exploration and self disclosure
Therapeutic Relationships
PHASES OF THE THERAPEUTIC RELATIONSHIP
1. Pre-Interaction- Pre-orientation
2. Orientation- Interaction
3. Working
4. Termination
Therapeutic Relationships
Phase Nursing Activities
Pre-interaction Nurse obtains data from
secondary sources
Interaction- Orientation Nurse establishes trust, assess
client, establishes mutual
agreement
Working Nurse assists the client to
meet goals and resolve
problems
Termination Nurse and client express
feelings about termination,
observes regressive behaviors
and evaluates NCR
Orientation
• Establishment of goals, rules, boundaries
etc..
• Rapport is built
• Identify expectations
• Trust is gained
• Assessment is done
• Goals are defined
• Contract is made
Working/Exploration/Identification
• Problems are identified
• Solutions are explored, applied and
evaluated
• Nurse assists the client to develop coping
skills, positive self concept and independence
• Promote insight and the use of adaptive
coping mechanisms
Termination/Resolution
• Nurse terminates the relationship based on
mutually agreed goals when these are
already achieved
• Focus of this stage is growth that has
occurred
• Client may become anxious and reacts
• Nurses must help patient resolve the anxiety
and ends the relationship professionally
Therapeutic Communication
• Therapeutic communication
– Dynamic process of exchanging information
– Composed of verbal and non-verbal techniques
that the nurse uses to focus on the client’s needs
Therapeutic Relationships
Therapeutic communication : ELEMENTS
1. Sender- the source of message
2. Message- the information transmitted
3. Receiver- recipient of message
4. Feedback- receiver’s response to the
message
Therapeutic Relationships
NON VERBAL COMMUNICATION
1. Proxemics- the physical space between the
sender and receiver
2. Kinetics- the body movements such as
gestures, facial expressions and
mannerisms
3. Touch- intimate physical contact
Therapeutic Relationships
NON VERBAL COMMUNICATION
4. Silence
5. Paralanguage- voice quality (tone, inflection)
or how a message is delivered
Therapeutic Relationships
VERBAL COMMUNICATION
• Use of therapeutic communication
techniques
• Effective communication should be
therapeutic, appropriate, simple, adaptive,
concise and credible
Therapeutic Communication
Open ended questions
Focus on FEEELINGS
State behaviors observed
Reflect, restate, rephrase
Neutral responses
Therapeutic Communication
Offering self I am here to help you
PERSONAL= 1 ½ to 4 ft
SOCIAL= 4 to 12 ft
PUBLIC= 12 to 15 ft
Psychiatric Nursing Process
• Applies to all clients
• Utilizes unique process for psychological
assessment
• Similar to other types of nursing process
approaches
Psychiatric Nursing Process
• Nursing ASSESSMENT
Nursing History
Physical Examination including the Neurological
examination
Laboratory Examination
Psychiatric Nursing Process
• Nursing ASSESSMENT
– Refers to the scientific process of identifying a
patient’s psychosocial problems, strengths an
concerns
– Interview is done to acquires broad information
about a client
Psychiatric Nursing Process
• MENTAL STATUS ASSESSMENT
– Level of consciousness
– General appearance
– Behavior
– Speech
– Mood and affect
– Judgment
– Memory
– insight
Psychiatric Nursing Process
• MENTAL STATUS ASSESSMENT
– Observation of mood and affect
– Assessment of thought, sensorium and
intelligence
– Speech and content
– Assess developmental status and family-cultural-
spiritual background
Psychiatric Nursing Process
• MENTAL STATUS ASSESSMENT
– Emotional status
– Cognitive assessment
– Socio-cultural assessment
Psychiatric Nursing Process
• Physical Examination
– Observation for key signs
• Diagnostic Tests
– CT, MRI, PET, EEG
– Laboratory tests= CBC, Electrolytes, Drug levels
Psychiatric Nursing Process
– Other diagnostic tests
• Beck depression inventory
• Minnesota multiphasic personality inventory
• Draw-a person test
• Sentence completion test
• Thematic aperception test
Psychiatric Nursing Process
• Nursing Diagnoses
– Anxiety
– Ineffective coping- individual, family
– Fatigue
– Fear
– Sleep pattern disturbance
– Altered thought process
– Etcetera
Psychiatric Nursing Process
• Nursing Objectives
• Short term goals are set for immediate
problems, feasible and within client's
capabilities
• Long term goals are related to discharge
planning and prevention of recurrence of
symptoms
Psychiatric Nursing Process
• Nursing Objectives: The client will:
– Participate in treatment program
– Becomes oriented to three spheres and exhibit
reality-based behaviors
– Recognize reasons for behavior
– Maintain self-care activities
Psychiatric Nursing Process
• Nursing Interventions
– Use of therapeutic communication
– Therapeutic Groups
– Psychotherapy: Family, Milieu, Behavioral
modification, Crisis intervention,
Psychopharmacology
– Electroconvulsive therapy
Psychiatric Nursing Process
• Nursing Evaluation
– Determine if goals are met by collecting data and
comparing them to baseline
– Clients’ behavior should demonstrate optimal
orientation to reality and interaction with others
appropriately
Treatment Modalities
1. Therapeutic Environment- Milieu
2. Therapeutic Groups
3. Crisis intervention
4. Family therapy
5. Behavioral modification
6. Cognitive therapy
7. Psychotherapy
Therapeutic environment
• Research has documented that the
environment in which the mentally ill person
is treated is a major factor in enhancing or
impeding the therapeutic effects of other
treatment modalities
Therapeutic environment
Characteristics of a Therapeutic environment
1. The clients’ physical needs are met
2. The client is respected
3. Decision making authority is clearly defined
4. Client is protected from injury (self and
others)
Therapeutic environment
Characteristics of a Therapeutic environment
5. Clients are allowed freedom of choice
commensurate to his ability to decide
6. Nursing Personnel remain constant and
assignments are stable
7. Emphasis is placed on social interaction
between clients and staff
Therapeutic Modalities
Milieu therapy
– Total environment has an effect on the person’s
behavior- physical, emotional, relationships
Purposes of therapy
1. Improve client’s behavior
2. Involve client in decision making
3. Increase autonomy and communication
4. Set structure of unit and behavioral limits
Therapeutic Modalities
Milieu therapy
• The surrounding is made positive to effect
behavioral changes in the prescribed
directions
• Goals of milieu therapy: to help patient
develop sense of self-esteem, personal
growth, improve ability to relate to others
and return to the community better
prepared
Therapeutic modalities
Milieu therapy
– The nurse involves the client in decision making
– The nurse promotes the involvement of staff in
care
– Social skills are developed and sense of
community is fostered
Therapeutic Groups
– A treatment approach in which the entire milieu
is used as treatment
– This includes the physical environment and the
others clients
Therapeutic Groups
Group Therapy
– Involves meaningful interaction between
members of a group as they relate their personal
experiences to each other
– The main objective is for each group member to
examine his own behavior and relationship. The
group can influence to change his behavior and
relationships
Therapeutic Groups
• Groups of clients meet with one or more
therapists to work together to solve client
problems
Therapeutic Groups
• Purposes
– To increase self-awareness
– To improve interpersonal relationships
– To make changes in behavior
– To enhancing group teaching and learning
Therapeutic Groups
• Structure of the Therapeutic Group
– One leader chosen by the group
– Members
– Size is usually 10
– Physical arrangement
– Time and place of meeting
Therapeutic Groups
Phases of group development
1. Beginning phase
– Info given, anxiety heightened
2. Middle phase
– Confrontation, cohesiveness, trust and self-
reliance
3. Termination phase
– Goals of the group are achieved
– Individuals leave the group when work is done
Therapeutic modalities
CRISIS
• A disturbance caused by a precipitating event
such as perceived loss, a threat of loss or a
challenge that is perceived as a threat to self.
Therapeutic modalities
CRISIS
Can be classified as to maturational crisis,
situational crisis or adventitious crisis
– Maturational= role changes
– Situational= loss of job, death
– Adventitious= fires, earthquakes and floods
– In a crisis, the person’s usual methods of coping
are INEFFECTIVE, resulting in increasingly greater
levels of anxiety.
Therapeutic Modalities
• Characteristics of Crisis:
– It is sudden
– It is short term may last for 4-6 weeks
– Individualized
– The person becomes dependent and
overwhelmed
Therapeutic Modalities
Factors that can produce crisis
• 1. Hazardous EVENTS
• 2. Threat to the individual’s equilibrium
• 3. Inadequate coping skills
Therapeutic Modalities
• Projection
• Blame is attached to
others or to
environment for
unacceptable thoughts,
mistakes, etc
Ego Defense Mechanisms
• Rationalization • JUSTIFICATION of
certain BEHAVIORS by
faulty logic/reasons
• Reaction Formation
• Acting OPPOSITELY to
the way they feel
Ego Defense Mechanisms
• Regression • Resorting to an earlier,
more comfortable level
of functioning that is
less demanding
• Repression
• Unconscious
mechanism of keeping
threatening desires or
thoughts from
becoming CONSCIOUS
Ego Defense Mechanisms
• Sublimation • Re-channeling of
aggressive energies
into socially acceptable
activities
• Substitution
• Replacement of a
highly valued object by
a LESS valuable or
acceptable and
available object
Ego Defense Mechanisms
• Undoing • Actions or words
designed to cancel
some disapproved
thoughts, impulses , or
acts in which the
person relieves GUILT
by making reparation
Disturbances in 2 or more of the following:
• Cognition (thinking about self, people, &
events).
• Affectivity (range, intensity, lability, &
appropriateness of emotional response)
• Interpersonal functioning
• Impulse control
192
Type Characteristics
193
• Suspicious of others
• Doubt trustworthiness or loyalty of friends &
others.
• Fear of confiding in others.
• Suspicious, without justification, of spouse’s
or sexual partner’s fidelity.
• Interpret remarks as demeaning or
threatening.
• Hold grudges toward others.
• Become angry & threatening when they
perceive they are attacked by others.
194
• Lacks desire for close relationships or friends
• Chooses solitary activities; a lifelong loner
• Little interest in sexual experiences
• Avoids activities
• Appears cold & detached
• Lacks close friends
• Appears indifference to praise or criticism
196
• Ideas of reference
• Magical thinking or odd beliefs
• Unusual perceptual experience, including bodily
illusion
• Odd thinking & vague, stereotypical, over
elaborate speech
• Suspicious
• Blunted or inappropriate affect
• Odd or eccentric appearance or behavior
• Few close relationships
• Excessive social anxiety
197
Type Characteristics
Antisocial Disregard of others’ rights without
guilt
Borderline Problems with self-identity, IPRs,
mood shifts, & self-destructiveness.
Narcissistic Over-evaluation of self, arrogance, &
indifference to the criticism of others
Histrionic Dramatic behaviors, attention seeking,
& superficiality
198
• Deceitfulness as seen in lying or conning others
• Engages in illegal activities
• Aggressive behavior; violence
• Lack of guilt or remorse
• Irresponsible in work & with finances
• Impulsiveness
• Reckless disregard of safety for self or others
• Insensitivity
201
• Before age 15, these behaviors are diagnosed as
conduct disorder.
• DUI, substance abuse, domestic violence ie; child
abuse, wife abuse. -> meet clients at court/prison
• History is more important than mental status
assessment.
• Seems no conscience, irresponsible, immature &
dependent.
• Nursing care- set firm limits & be consistent in
confronting behaviors & enforcing unit rules.
• Frantic avoidance of abandonment; real or
imagined
• Unstable & intense IPR; Identity disturbances
• Impulsivity; Affective instability
• Recurrent suicidal behavior or self-mutilating
behavior – to express feelings of
anger/frustration
• Rapid mood shifts
• Chronic feelings of emptiness
• Transient dissociative & paranoid symptoms
203
• Uncertain about his self-image, career goals,
personal values, & sexual orientation
• Unhealthy R & in short-term intimate R
• For client’s impulsivity – Nurse’s self awareness
and set limit are important.
• Pt alternates between overidealization &
devaluation of individuals ie falls in love with the
perfect person and shortly can find no redeeming
quality in the formerly idealized person.
• Manipulation & dependency commonly occur. Pt
has great difficulty in being alone & therefore
seeks intense but brief relationships
• tend to view themselves as victims and assume
little responsibility for their problems
• Grandiose self-importance
• Fantasies of unlimited power, success, or brilliance
• Believes he/she is special or unique; Needs to be
admired
• Sense of entitlement (i.e., deserves to be favored or
given special treatment)
• Takes advantage of others for own benefit
• Lacks empathy
• Envious of others or others are envious of him/her
• Arrogant or naughty
205
• Family may complained “The pt never really
seemed to see me as a person with my own
thoughts and problems.”
• Needs to be center of attention
• Displays sexually seductive or provocative behaviors
• Shallow, rapidly shifting emotions
• Uses physical appearance to draw attention
• Uses speech to impress others but is lacking in depth
• Dramatic expression of emotion
• Easily influenced by others
• Exaggerates degree of intimacy with others
207
Type Characteristics
Dependent Submissiveness, helplessness, fear of
responsibility, & reliance on others for
decision making.
Avoidant Timidity, social withdrawal behavior,
& hypersensitivity to criticism.
Obsessive- Indecisiveness, perfectionism,
compulsive inflexibility, & difficulty expressing
feelings.
208
• Unable to make daily decisions without much advice
& reassurance.
• Needs others to be responsible for important areas of
life.
• Seldom disagrees with others because of fear of loss
of support or approval.
• Problem with initiating projects or doing things on
own because of little self-confidence.
• Performs unpleasant tasks to obtain support from
others.
• Anxious or helpless when alone because of fear of
being unable to care for self.
• Urgently seeks another relationship for support &
care after a close R ends.
• Preoccupied with fear of being alone to care for self.
209
• Avoids occupations involving interpersonal contact
because of fears of disapproval or rejection.
• Uninvolved with others unless certain of being liked.
• Fears intimate Rs due to fear of shame or ridicule.
• Preoccupied with being criticized or rejected in social
situations.
• Inhibited & feels inadequate in new interpersonal
situations.
• Believes self to be socially inept, unappealing, or
inferior to others.
• Very reluctant to take risks or engage in new
activities due to possibility of being embarrassed.
211
AVOIDANT
• A pervasive pattern of social interaction,
feeling of inadequacy, and hypersensitivity to
negative evaluation, beginning by early
adulthood and present in variety of context.
• Preoccupied with details, rules, lists, organization.
• Perfectionism that interferes with task
completion.
• Too busy working to have friends or leisure
activities.
• Over conscientious & inflexible.
• Unable to discard worthless or worn-out objects.
• Others must do things his/her way in work or task
related activity.
• Reluctant to spend and hoards money.
• Rigid and stubborn.
214
• Anxiety
• High risk for self-mutilation
• Hopelessness
• Impaired communication
• Ineffective individual coping
• Self-esteem disturbance
• Social isolation
216
Nursing Care
• Nurse-Patient relationship – trust, empathy,
authenticity
• Focus on specific behaviors, distress to self
or others or both & awareness of
dysfunctional & self-defeating patterns
• Case management – stress reduction &
crisis intervention
• Assertive training; Social skill training
• Psychobiological therapy (with caution)
• Milieu therapy – setting limits
217
Conclusion
• Personality traits -> individualization
• Disorder = rigid, dysfunctional, distress
• Distress come from others’ reaction to or
behaviors toward that person -> evoke
interpersonal conflict
• Usually have more than one DSM diagnosis
• Long-term hospitalization is unnecessary
• Limit setting – multidisciplinary work
• Px - have a fairly good prognosis only with
therapy
218
Substance-Related Disorders
225
Introduction
• Epidemiology - # 1 health problem in the US ->
effects on cost, quality of life, society
• Types - Alcohol, tobacco, other drugs ie opium,
heroin, codeine, synthetic narcotics.
• Cigarettes and alcohol – gateway drugs
• History – medical use, social use, illegal use
• Central nervous system (CNS) was affected
• Substance dependency – Client experiences
tolerance and withdrawal symptoms
226
Substance
• Prescribed medications
– Ritalin
– OxyContin
• Over-the-counter cough, cold, sleep, and diet
medication.
• Narcotics
– Heroin
– Morphine
– Demerol
– Methadone.
• Inhalants
• Hallucinogen
– Marijuana, LSD, PCP…
• Stimulants
– Cocaine
– Amphetamines
227
Other Substance & Trends
• Club drugs ie MDMA (ecstasy), GHB, Rohypnol,
ketamine, methamphetamine, LSD
• CNS depressants ie. Valium, phenobarbital
• Steroids
• 1960 – hallucinogens, amphetamines
• 1970 – heroin, marijuana, sedatives
• 1980 – cocaine – injection, smoking
228
Terminology
• Dependence
– physical & psychological
• Codependence
– an emotional, psychological and behavioral
pattern of coping that an individual develops as a
result of prolonged exposure to a dysfunctional
pattern of behavior within the family.
– The individual experiences difficulty with identity
development and set in functional boundaries
which lead to taking care of others rather than self.
229
• Tolerance
– May be influenced by the enzyme ie French
• Cross-tolerance
– A condition in which tolerance to one drug often results in a
tolerance to chemically similar drugs.
• Withdrawal
– Abstinence syndrome.
– Physical signs and symptoms that occur when the addictive
substance is reduced or withheld .
• Dual diagnosis
232
Etiology
• Biological theories
– Genetic predisposition
• Psychological theories
– Psychoanalytic theories
– Interpersonal theories
• Family theories
– Family system theory
• Learning theories
– Positive effect of mood alternations
– Media reinforcement
– Peer pressures
• Psychosocial and behavioral factors increase the
client’s vulnerability to drug or alcohol abuse.
233
Age & Substance Use
Marijuana 10 % 37 %
Cocaine 2 % 8 %
234
Perinatal Concerns
• 25-30% of women expose their children to
nicotine in utero
• 3 out of every 5 women of childbearing age
drink alcohol
• 10% of women of childrearing age use an illicit
drug
• Substances = teratogens -> malformations in
the fetus, intrauterine growth retardation,
subtle mental and behavioral deficits.
235
Fetal Alcohol Syndrome (FAS)
• Low birth weight
• Certain facial characteristics ie. microcephaly,
microthalmia, short palpebral fissures, poorly
developed philtrum, thin upper lip, short nose,
small chin, flattening of the maxillary area
• Neurological abnormalities ie developmental
and/or intellectual delays; it is a preventable
cause of mental retardation
• Fetal Alcohol Effect (FAE)- Less severe cases
236
Other problems of FAS & FAE
• Other organs – heart, hearing, visual, dental,
genital anomalies
• Hyperactivity, poor coordination, short
attention spans, dependency, social
withdrawal, impulsivity…
• Co-morbidity
• Depression, anger, suicidal ideation, antisocial
behaviors
• Preventable health problem for children
237
Adolescent Substance Abuse
• Health & social problem
• School drop-out
• Victim of abuse – child/parental, sexual
• Experienced trouble with law
• Suicide attempts
• Feelings of inferiority, history of mental
problems
238
Signs of Adolescent Drug Use
• Sudden behavioral changes
• Sweating, especially at night
• Needle marks
• Inebriation (intoxicated, drunk)
• Change in nutritional intake
• Nasal congestion
• Rhinorrhea with cocaine use
• School problems
239
Warning Ss of Teen Sub. Abuse
Physical Fatigue, health complaints, red/glazed
eyes, lasting cough
Emotional Personality, mood change, irritability,
irresponsible behavior, depression…
Family Arguments, breaking rules,
withdrawing
School Decreased interest, neg. attitude, drop
in grades, absences, truancy
Social Problems with law, changes to less
problems conventional styles in dress and music
240
Prevention of
Adolescent substance Use
• Positive role modeling
• Reinforce positive behaviors
• Support – cope with social pressure
• Establish normative expectations
• Help to anticipate pressures
• Involve in life skills training programs
• Open communication
241
Alcohol Abuse
• Body damage - brain cell -> neurological S/S Liver,
G-I, muscle, heart, sexual function …
• Blackouts –
• Wernicke’s syndrome - intact intellectual function
but poor memory, ataxia, confusion, vit B deficiency
• Korsakoff’s syndrome – disorientation
• Alcohol withdrawal syndrome (AWS) -
• Alcohol withdrawal delirium - Delirium
tremens (DT) – confusion, disorientation,
hallucination, tachycardia, tremor, …
242
Wernicke’s Encephalopathy
243
Korsakoff Syndrome
• Difficulty in acquiring new information or learning
new skills
• Lack of insight into their deficit
• Amnesia
• Impaired short term memory
• Tendency for confabulation
• Apathy
• Inattention
• Impaired fine motor skills
• Impaired sense of smell
• Talkative an repetitive behaviors
244
Treatment of WKS
• IV or IM thiamine
• Medications
– Cholinersterase inhibitors
– Atypical antipsychotics
– SSRI
• Alcohol cessation
• Dietary consumption
245
Clinical Description
• Denial
• Dependence – compulsive use
• Abuse – dysfunction in work, …
• Intoxication
• Withdrawal
• Delirium
• Psychotic disorders
246
• Denial – N’s role - to question why they feel
threatened to help them to gain insight.
• Dependence – use of the drug is no longer under
control, & continue to use despite adverse
effects.
• Abuse- recurrent use -> failure to manage work,
school, or home roles, hazardous situation
• Withdrawal – physiological, behavioral ,
cognitive, and affective symptoms that occur
after reduction or discontinuance of a drug that
has been used heavily over a long period of time.
• Alcohol Withdrawal – tremulousness,
nervousness, anxiety, anorexia, nausea, vomiting,
insomnia, sleep disturbances, rapid pulse, high
bp, profuse perspiration, diarrhea, fever,
unsteady gait, difficulty concentrating, craving
Alcohol-related Disorders
Alcohol Alcohol withdrawal Substance induced
intoxication delirium
• Slurred speech • Nausea/vomiting • Impaired
• Incoordination • Anxiety consciousness
• Unsteady gait • Hallucination • Cognitive change
• Nystagmus • Sweating (memory,
• Attention/ • Psychomotor disorientation,
memory agitation hallucination)
impairment • Grand mal seizure • Short period of
• Stupor or • Hand tremor time/fluctuates
coma • Evidence of sub.
abuse
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Alcohol
• Detoxification – 3Ss-
–Secure environment
–Sedation
–Supplements
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CNS Depressant - Narcotics
• Opioids – endorphin agonist, euphoria
• Increasing pain threshold, reducing anxiety and
fear
• Decreased pulmonary ventilation/esp. elders
• Respiratory depression in neonates/preg
• Withdrawal is rarely fatal, but painful
– ie yawning, tearing, rhinorrhea, sweating, flushing,
tachycardia, tremor, restlessness, irritability, muscle
spasm, fever, nausea, diarrhea, vomiting, repetitive
sneezing, abdominal cramps, backache
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CNS depressant - Barbiturates
• Medical – relieve anxiety, produce sleep,
anesthesia, epilepsy, soften withdrawal from
heroin
• Narrow therapeutic index
• Classification- ultrashort (30’-3h), short (3-4h),
intermediate (6-8h), long (10-12h)
• Intoxication: unsteady gait, slurred speech,
sustained nystagmus, confusion, irritability,
insomnia
• Tolerance
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• Narrow therapeutic index- lethal dose being
only slightly higher than the therapeutic dose
• Barbiturates with short to intermediate
duration have the highest abuse potential i.e.
amobarbital( Amytal), pentobarbital
(Nembutal), and seconbarbital (Seconal).
Stimulant - Cocaine
• Medical – relief for altitude sickness, anesthetics,
• Block norepinephrine & dopamine reuptake
• CNS & PNS effects – euphoria, alertness, anorexia,
sexual stimulation
• Derivatives: crack, rock
• Physical dependence is less severe
• Psychological dependence is intense
• Highs (+ reinforcement) & lows ( - reinforcement)
• Cocaine-induced depression, suicide
• Death – caused by meta. & resp. acidosis, and
hyperthermia, prolonged seizure, tachyarrhythmias
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Stimulant - Amphetamine
• Speed, ice, crank, poor person’s cocaine
• Medical – ADD, narcolepsy, obesity
• CNS effects – wakefulness, alertness, heightened
concentration, energy, euphoria, insomnia, amnesia,
restlessness, agitation,
• PNS effects- palpitations, tachycardia, hypertension
• Amphetamine-induced psychosis
• Facilitate excretion by acidification of urine
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Hallucinogen
• Natural & synthetic
• Heighten awareness of reality or cause a
terrifying psychosis-like reaction, distortions in
body image, sense of depersonalization, loss of
the sense of reality, panic, anxiety, confusion,
paranoid reaction
• Altered perception -> unable to perform simple
tasks or lead to violent behaviors
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Dual Diagnosis
• Comorbidity – 2 or more disorders in the same
person
• Dual diagnosis- 2 initial unrelated disorders
that interact and cause increased
manifestations of the other disorder
• Personality disorders – higher incidence – 47%
of antisocial; 2/3 of borderline; 4.5-15%
above the norm in Schizophrenia
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Etiology of Dual Diagnosis
• Substance use -> calmer, feel better, less
anxious, decrease the intensity of
hallucinations.
• Compare with using antipsychotics – less
uncomfortable side effects
• Increase social acceptance, feeling of
autonomy or power -> self-esteem
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Tx for Dual Dx
• Multifaceted & multidisciplinary – case
management, ind/gr therapy, skill training,
vocational counseling, …
• N-Pt Relationship – knowledgeable, skilled,
nonjudgmental, empathic
• Monitoring – S/s of withdrawal
• Milieu therapy – set limits
• Psychopharmacology - compliance
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Impaired Professionals
• Incidence: 5% - chemical abuser
• 8-10% (or higher) -chemically dependent
• Common profile
– Family hx of sub abuse, depression, sexual abuse
– Academically and professionally successful
– Divorced
– Received professional treatment for sub abuse
– Regularly attends recovery self-help groups
• Report to supervisor immediately
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Common Nursing Diagnoses
• Anxiety
• Ineffective individual coping/ self-care
• Altered health maintenance/ nutrition/
sensory-perception/ family process,
• Risk for injury/infection
• Impaired communication/ social interaction
• Violence, potential for
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Substance Abuse Problems Needing
Collaboration
• 53% of drug abusers have at least 1 serious
psychiatric problem
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Pharmacological Treatment
• Alcoholism
– Naltrexone (Trexan, ReVia) –
– Disulfiram (Antabuse) –
• Opiod addict
– Methadone (Dolophine)
– L-alpha Acetylmethadol (LAAM)
– Naltrexone (Trexan, ReVia)
– Clonidine
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Pharmacological Treatment (II)
• Stimulant dependence –
– Dopaminergic drugs ie. Amantadine (Symmetrel),
bromocriptine (Parlodel)
– Anticonvulsants ie carbamazepine (Tegretol)
– TCA ie desipramine (Norpramine)
• Hallucinogen dependence –
– Diazepam (Valium)
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Supplementary Treatment
• Sedatives
– Benzodiazepine ie Librium, Valium
– Phenobarbital
• Thiamine (Vit B1)
• Folic Acid
• Magnesium sulfate
• Anticonvulsant
• Multivitamins
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N-Pt Relationship
• Trust - communication
• Support – minimizes anxiety
• Consistency – objective & nonjudgmental
• Continually assess
– Presence of predictable defense style
– Psychophysiological responses
• Referral – local resources/ community
agencies
265
Milieu Therapy
• Drug-free – safety, structure, norms, limit setting
• Motivation
– Dependency vs. face the consequences
• 3Cs – Family members
– did not cause the disease,
– cannot control it,
– cannot cure it
• Belongingness – significant relationship, social
skills,
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Interdisciplinary Interventions
• Breaking through defenses - denial
• Understanding and accepting the disorder
• Identification with peers
• Development of hope
• Re-socialization
• Developing self-esteem and self-worth
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DELIRIUM