NOTES VI - PSYCHIATRIC NURSING PART 1

NOTES VI - PSYCHIATRIC NURSING PART 1

Introduction

MENTAL HEALTH balance in a persons internal life and adaptation to reality

Mental ILL Health state of imbalance characterized by a disturbance in a persons
thoughts, feelings and behavior
Psychiatric nursing

interpersonal process whereby the professional nurse practitioner ,through the therapeutic
use of self (art) and nursing theories (science), assist clients to achieve psychosocial well
being.

Core : interpersonal process

Related Terms

Mental hygiene
measures to promote mental health , prevent mental illness and suffering and facilitate
rehabilitation
Main tool: therapeutic use of self
It requires self-awareness

Methods to increase self-awareness:

Introspection
Discussion
Experience
Role play

Assessment (psychosocial processes )

Appearance , behavior or mood
Speech , thought content and thought process
Sensorium
Insight and judgment
Family relationships and work habits
Level of growth and development
Common Behavioral Signs and Symptoms
Disturbances in perception

Illusion
misinterpretation of an actual external stimuli

Hallucinations

false sensory perception in the absence of external stimuli

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

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

Jealous: thinking that their partner is unfaithful

Erotomanic: person, usually of high status, is in love with the client
Religious: illogical ideas about God and religion exhibited by extreme or extraneous
behavior
Mixed: combination of above without a predominant theme

Magical thinking primitive thought process thoughts alone can change events
Autistic thinking regressive thought process; subjective interpretations not validated with
objective reality

Dereism unorganized thinking

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 ones self
Derealization feeling of strangeness towards environment
Agnosia lack of sensory stimuli integration
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 dyskinesia involuntary twitching or muscle movements
Apraxia involuntary unpurposeful movements
Disturbances in memory

Confabulation filling of memory gaps

Dj vu something unfamiliar seems familiar
Jamais vu- something familiar seems unfamiliar
Amnesia memory loss (inability to recall past events)
Retrograde-distant past
Anterograde immediate past
Anomia lack of memory of items
Dynamics of Human Behavior

Behavior the way an individual reacts to a certain stimulus

Conflict situation arising from the presence of two opposing drives

Need - organismic condition that requires a certain activity

Dynamics of Human Behavior

Personality
totality of emotional and behavioral traits that characterize the person in day to day living
under ordinary conditions; it is relatively stable and predictable.
FORMATION OF PERSONALITY
TEMPERAMENT
biological-genetic template that interacts with our environment.
a set of in-built dispositions we are born with
mostly unalterable
our nature.
CHARACTER
the outcome of the process of socialization, the acts and imprints of our environment and
nurture on our psyche during the formative years (0-6 years and in adolescence).
the set of all acquired characteristics we posses, often judged in a cultural-social context.
Sometimes the interplay of all these factors results in an abnormal personality
THEORIES OF PERSONALITY DEVELOPMENT
Freuds
PSYCHOSEXUAL THEORY

Libido inner drive

Parts of body focus of gratification
Unsuccessful resolution - fixation
Structures of personality
Id: pleasure principle-instinct
Ego: controls action and perception reality principle
Superego: moral behavior - conscience

0-18 m0s ;oral mouth trust and discriminating

18 mos. 3 years ; anal bowels holding on or letting go
Negativism and toilet training age
3 -6 years phallic ; genitals exploration and discovery ( inc. sexual tension)
Gender identification and genital awareness
Oedipus and Electra complex
Castration anxiety and penis envy
6-12 years latency (quiet stage) sexual energy diverted to play. Institution of superego:
control of instinctual impulses

12 young adult genital ; reawakening of sexual drives relationships

Sexual maturation
Sexual identity ,ability to love and work
Eric Ericksons
PSYCHOSOCIAL THEORY

0-12mos
1-3y
3-6
6-12
12-18
18-25
25-60
60 and above
TRUST vs. MISTRUST
AUTONOMY vs. SHAME & DOUBT
INDUSTRY vs. INFERIORITY
INITIATIVE vs. GUILT
IDENTITY vs. IDENTITY CONFUSION
INTIMACY vs. ISOLATION
EGO INTEGRITY vs. STAGNATION
GENERATIVITY vs. DESPAIR
INFANCY

CONSISTENT MATERNAL CHILD INTERACTION TRUST

INNER FEELING OF SELF WORTH
HOPE
TODDLER
ALLOW EXPLORATION
PROVIDE FOR SAFETY
NO, NO NEGATIVISM
OFFER CHOICES / REVERSE PSYCHOLOGY
TOILET TRAINING 18 MOS.-BOWEL
DAYTIME BLADDER: 2 yo
NIGHTIME BLADDER: 3 yo

REWARD W/ PRAISE AND AFFECTION

INDEPENDENCE
PRE-SCHOOL

PROVIDE PLAY MATERIALS

SATISFY CURIOSITY
TEACH AND REINFORCE(HYGIENE,SOCIAL BEHAVIOR)
SIBLING RIVALRY
WILLPOWER
SCHOOL AGE

HOW TO DO THINGS WELL-SUPPORT EFFORTS

CHUMS AND HOBBIES
NEEDS TO EXCEL/ACCOMPLISH
NEED FOR PRIVACY AND PEER INTERACTION
COMPETENCE
ADOLESCENCE

MAKE DECISION,EMANCIPATION FROM PARENTS

BODY IMAGE CHANGES
NEED TO CONFORM BUT KEEP INDIVIDUALITY
SELF - AWARENESS
YOUNG ADULT

COMMITMENT AND FIDELITY

RESPONSIBILITY
ACHIEVEMENT OF INDEPENDENCE
MIDDLE ADULTHOOD
SUPPORT-PERIOD OF ROLE TRANSITIONS

MIDLIFE CRISIS
ADJUSTMENT AND COMPROMISE
MOST PRODUCTIVE AND CREATIVE
ALTRUISM
LATE ADULTHOOD

SELF ACCEPTANCE

SELF WORTH
WISDOM
Jean Piagets
COGNITIVE THEORY
0-2 SENSORIMOTOR

REFLEXES
IMITATIVE REPETITIVE BEHAVIOR
SENSE OF OBJECT PERMANENCE AND SELF SEPARATE FROM ENVT.
TRIAL AND ERROR RESULTS IN PROBLEM SOLVING
2-7Y PRE-OPERATIONAL
SELF-CENTERED,EGOCENTRIC
CANNOT CONCEPTUALIZE OTHERS VIEW
ANIMISTIC THINKING
IMAGINARY PLAYMATE SYMBOLIC MENTAL REPRESENTATION CREATIVITY
2-4 PRE-CONCEPTUAL (PRE-LOGICAL)
4-7 INTUITIVE (UNDERSTANDING OF ROLES)
7-12Y CONCRETE OPERATIONAL

LOGICAL CONCRETE THOUGHT

INDUCTIVE REASONING (SPECIFIC TO GENERAL)
CAN RELATE, PROBLEM SOLVING ABILITY
REASONING AND SELF-REGULATION
12-ABOVE: FORMAL OPERATIONAL THOUGHT

Abstract thinking
Separation of fantasy and fact
Reality oriented
Deductive reasoning
Apply scientific method
Havighursts
DEVELOPMENTAL TASKS

Baby to early childhood

Right from wrong and Conscience

Late childhood
Physical skills, wholesome attitude, social roles
Conscience morality and values
Fundamental skills in academics

Personal independence

Adolescence
Sexual social roles
Relationships
Independence and ideology

Early adulthood

Career
Selecting a mate
Finding Civic or social responsibility

Middle age
Achieving Civic or social responsibility
Adjusting to changes
Satisfactory career performance
Adjusting to aging parents
Adjusting to parental roles

Old age

Adjusting to changes
Establishing satisfactory living arrangements and affiliations
Kohlbergs
MORAL DEVELOPMENT/ THINKING/ JUDGEMENT

PRE-CONVENTIONAL (0-6)
PUNISHMENT AND OBEDIENCE
OBEDIENCE TO RULES TO AVOID PUNISHMENT

CONVENTIONAL ( 6-12 )

MUTUAL INTERPERSONAL EXPECTATIONS,RELATIONSHIPS AND CONFORMITY

SOCIAL SYSTEM AND CONSCIENCE MAINTENANCE
BEING GOOD IS IMPORTANT SELF RESPECT OR CONSCIENCE

POST CONVENTIONAL (12 18 Y)

PRIOR RIGHT OR SOCIAL CONTRACT
UNIVERSAL ETHICAL PRINCIPLE
ABIDE FOR COMMON GOOD
RATIONAL PERSON-VALIDITY OF PRINCIPLES-AND BECOME COMMITTED TO THEM
INNER CONTROL OF BEHAVIOR UNDERSTANDING THE EQUALITY OF HUMAN
RIGHTS AND DIGNITY OF HUMAN BEINGS AS INDIVIDUALS
Harry Stack Sullivans
INTERPERSONAL THEORY
INFANCY

NEED FOR SECURITY-INFANT LEARNS TO RELY ON OTHERS TO GRATIFY NEEDS

AND SATISFY WISHES, DEVELOPS A SENSE OF BASIC TRUST, SECURITY AND SELF
WORTH WHEN THIS OCCURS
TODDLERHOOD / EARLY CHILDHOOD

CHILD LEARNS TO COMMUNICATE NEEDS THROUGH USE OF WORDS AND

ACCEPTANCE OF DELAYED GRATIFICATION AND INTERFERENCE OF WISH
FULFILLMENT
PRE-SCHOOL
DEVELOPMENT OF BODY IMAGE AND SELF-PERCEPTION
ORGANIZES AND USES EXPERIENCES IN TERMS OF APPROVAL AND
DISAPPROVAL RECEIVED
BEGINS USING SELCTIVE INATTENTION AND DISASSOCIATES THOSE
EXPERIENCES THAT CAUSE PHYSICAL OR EMOTIONAL DISCOMFORT AND PAIN
SCHOOL AGE

THE PERIOD OF LEARNING TO FORM SATISFYING RELATIONSHIPS WITH PEERSUSES COMPETITION,COMPROMISE AND COOPERATION

THE PRE-ADOLESCENT LEARNS TO RELATE TO PEERS OF THE SAME SEX

ADOLESCENCE

LEARNS INDEPENDENCE AND HOW TO ESTABLISH SATISFACTORY

RELATIONSHIPS WITH MEMBERS OF THE OPPOSITE SEX
YOUNG ADULTHOOD

BECOMES ECONOMICALLY, INTELLECTUALLY AND EMOTIONALLY SELF

SUFICIENT
LATER ADULTHOOD

LEARNS TO BE INTERDEPENDENT AND ASSUMES RESPONSIBILITY FOR OTHERS

SENESCENCE

DEVELOPS AN ACCEPTANCE OF RESPONSIBILITY FOR WHAT LIFE IS AND WAS

AND OF ITS PLACE IN THE FLOW OF HISTORY
TREATMENT MODALITIES

REMOTIVATION THERAPY

TREATMENT MODALITY THAT PROMOTES EXPRESSION OF FEELINGS THROUGH

INTERACTION FACILITATED BY DISCUSSION OF NEUTRAL TOPICS

STEPS :
climate of acceptance
creating bridge to reality
sharing the world we live in
appreciation of works of the world
climate of appreciation
MUSIC THERAPY

Involves use of music to facilitate expression of feelings, relaxation and outlet of tension
PLAY THERAPY
enables patient to experience intense emotion in a safe environment with the use of play
children express themselves more easily in play. revealing as reflection of childs situation
in the family
provide toys and materials facilitate interaction observe and help child resolve
problems through play
Group therapy
Treatment modality involving three or more patients with a therapist to relieve emotional
difficulties, increase self esteem, develop insight , LEARN NEW ADAPTIVE WAYS TO
COPE WITH STRESS and improve behavior with others
IDEAL 8 10 MEMBERS
MILIEU THERAPY
Consists of treatment by means of controlled modification of the patients environment to
facilitate positive behavioral change
Increase patients
Awareness of feelings
Sense of responsibility and
Help return to community
clients plan social and group interaction
token programs , open wards and self medication are done
FAMILY THERAPY
A METHOD OF PSYCHOTHERAPY WHICH FOCUSES ON THE TOTAL FAMILY AS AN
INTERACTIONAL SYSTEM
PROBLEM IS A FAMILY PROBLEM
focus on sick members behavior as source of trouble / symptom serve a function for the
family
members develop sense of identity
points out function of the sick member for the rest of the family
PSYCHOANALYTIC
focuses on the exploration of the unconscious, to facilitate identification of the patients
defenses

ANXIETY RESULTS BETWEEN CONFLICTS OF ID AND EGO

Becomes aware of unconscious thoughts and feelings to understand anxiety and
defenses
HYPNOTHERAPY

Various methods and techniques to induce a trance state where patient becomes
submissive to instructions
BEHAVIOR MODIFICATION

Application of learning principles in order to change maladaptive behavior

Believes that psychological problems are a result of learning
Everything learned can be unlearned
BEHAVIOR MODIFICATION

OPERANT CONDITIONING
Use of rewards to reinforce positive behavior
Perceived and self-reinforcement becomes more important than external reinforcement

DESENSITIZATION
Slow adjustment or exposure to feared objects (phobias)
Periodic exposure until undesirable behavior disappears or lessens
AVERSION THERAPY

An example of behavior modification

Painful stimulus is introduced to bring about an avoidance of another stimulus
End view: behavioral change
OTHER THERAPIES

HUMOR THERAPY
To facilitate expression and enhance interaction

ACTIVITY THERAPY
Group interaction while working on a task together
BIOLOGICAL/ MEDICAL THEORY

EMOTIONAL PROBLEM IS AN ILLNESS

cause may be inherited or chemical in origin
FOCUS OF TREATMENT IS MEDICATIONS AND ECT
BIOLOGICAL THERAPY
ELECTROCONVULSIVE THERAPY
Artificial induction of a grand mal seizure by passing a controlled electrical current through
electrodes applied to one or both temples
mechanism of action unclear
voltage: 70 150 volts
Duration: 0.5 2.0 seconds

6 to 12 treatments
intervals of 48 hours
indicators of effectiveness occurrence of generalized tonic clonic seizures

indications depression , mania and catatonic schizophrenia

s/e: confusion, disorientation, short -term memory loss, seizure (30-60 sec)
NPO prior
Contraindications
Fever, pregnancy
Inc ICP, fracture
retinal detachment
TB with hemoptysis
cardiac d/o
consent needed
Reorient after, supportive care

medications given :
Atropine sulfate: decrease secretions
Succinylcholine (Anectine): promote muscle relaxation
Methohexital Sodium ( Brevital ): serves as an anesthetic agent

common complications:
loss of memory
headache
apnea
fracture
respiratory depression

NOTES VI - PSYCHIATRIC NURSING PART 2

NOTES VI - PSYCHIATRIC NURSING PART 2
Psychopharmacologic Therapy
Benzodiazepines

Indications
Anxiety
Sedation/sleep
Muscle spasm
Seizure disorder

Alcohol withdrawal syndromes

Anti-anxiety drugs
Generic
Alprazolam
Chlordiazepoxide
Clorazepate
Diazepam
Lorazepam
Oxazepam
Busipirone
Side effects

Trade name
Xanax
Librium
Tranxene
Valium
Ativan
Serax
BuSpar

Drowsiness/ sedation
Ataxia
Feelings of detachment
Increase irritability and hostility
Anterograde amnesia
Increased appetite & weight gain
Nausea
Headache, confusion
Anti-depressants

Indications
Depression
Bipolar depression
Panic disorder
Bulimia
Obsessive-compulsive d/o

Possibly

Attention deficit/Hyperactivity d/o

Post Traumatic Stress D/o
Conduct d/o
Tricyclic (TCA)
Generic
Amitriptyline
Imipramine
Trimipramine
Nortriptyline
Trazodone
Bupropion
Side effects

Orthostatic hypertension
Anticholinergic effect

Trade name
Elavil
Tofranil
Surmontil
Pamelor
Desyrel
Wellbutrin

Dry mouth, blurred vision, constipation, excessive sweating, urinary hesitancy/ retention,
tachycardia, agitation, delirium, exacerbation of glaucoma

Neurologic effects
sedation, psychomotor slowing, poor concentration, fatigue, ataxia, tremors

Decrease libido and sexual performance

Monoamine Oxidase inhibitors

Generic
Trade name
Isocarboxazid
Marplan
Phenelzine
Nardil
Tranylcypromine
Parnate
Side effects

Postural lightheadedness
Constipation
Delay ejaculation or orgasm
Muscle twitching
Drowsiness
Dry mouth
Dietary restrictions

Cheese, esp. aged and matured

Fermented or aged protein
Pickled or smoked fish
Beer, red wine, sherry; liquor & cognac
Yeast
Fava or broad beans
Beef or chicken liver
Spoiled/ overripe fruits; banana peel
yogurt
Hypertensive Crisis

Signs
Sudden elevation of BP
Explosive headache, occipital may radiate frontally
Head & face flushed
Palpitations, chest pain
Sweating, fever
Nausea, vomiting
Dilated pupils, photophobia

Intracranial bleeding

Treatment
Hold next MAO dose
Dont let pt. lie down
IM chlorpromazine 100 mg
Fever: manage by external cooling techniques
Serotonin Reuptake Inhibitors
Generic
Fluoxetine
Sertraline
Paroxetine
Venlafaxine
Side effects

Trade name
Prozac
Zoloft
Paxil
Effexor

Nausea
Diarrhea
Insomnia
Dry mouth
Nervousness
Headache
Male sexual dysfunction
Drowsiness
Dizziness
Sweating
Mood stabilizing drugs

Indications
Acute mania
Bipolar prophylaxis

Possibly
Bulimia
Alcohol abuse
Aggressive behavior
schizoaffective

Mode of action
Normalizes the reuptake of certain neurotransmitters such as serotonin, norepinephrine,
acetylcholine and dopamine
Reduces the release of norepinephrine thru competition with calcium

Effects intracellularly

Lag period: 7-10 to 14 days

Lithium carbonate

Trade names
Eskalith
Lithotabs
Lithane
Lithonate
MOA: unclear; interfere with metabolism of neurotransmitters; alter Na transport in nerves
and muscle cells

Prelithium workup
Urinalysis (BUN and creatinine)
ECG, FBC, CBC
Side effects

Early
Nausea and diarrhea
Anorexia
Fine hand tremor (propranolol)
Thirst, Polydipsia (dec. crea, inc. albumin)
Metallic taste
Fatigue
Lethargy

Late
Weight gain
acne
Contraindications

Brain damage/ CV disease

Epilepsy
Elderly/ debilitated
Thyroid and renal disease
Severe dehydration
Pregnancy (1st trimester)
Can augment the effects of anti-depressants
Nursing considerations
Therapeutic serum level: 0.5 1.2 meq/L
Maintenance level: 0.6 -1.2 meq/L
Toxic

Mild to moderate: 1.5 to 2 meq/L

Moderate to severe: 2 2.5 meq/L
Needs dialysis: 3 meq and above
Early signs of toxicity
Lethargy, mild nausea, vomiting, fine hand tremors, anorexia, polyuria, polydipsia, metallic
taste, fatigue
Late signs of toxicity
Ataxia, giddiness, tinnitus, blurred vision, polyuria
Nursing considerations
Lithium levels should be checked q 2-3 mos
Serum drawn in the AM, 12H after last dose
Common causes of inc. levels
Dec. Na intake
Diuretic therapy
Dec. renal functioning
F&E loss
Medical illness
Overdose
NSAIDS
Nursing considerations

Diet: adequate Na+ and fluid

3g NaCl/ day
6-8 glasses of H2O

No caffeine
No driving: wait for clinical effect
Management
Moderately severe toxicity
Osmotic diuresis: urea/ mannitol
Aminophylline & PLR IV
Adequate NaCl
Peritoneal/ hemodialysis
Severe toxicity
Assess hx quickly
Hold next lithium dose
Check BP, rectal T, RR, LOC, support O2
Obtain labs
ECG
Emetic, NGT lavage
Hydrate: 5-6L/day c PLR; FBC-CDU
Other drugs

Carbamazepine (Tegretol)
Side effects

Dizziness
Ataxia
Clumsiness
Sedation
Dysarthria
Diplopia
Nausea & GI upset
Preparation: liq, tab, chewable tab
Nursing considerations

Assess drug levels q 3-4 days

Monitor salt and fluid intake
Avoid alcohol and non-prescription drugs
Refer dec. in UO
Dont stop abruptly
C/I: pregnancy
Take with meals
Other drugs

Valproic acid (Depakote, Depakene)

Side effects

Nausea
Hepatoxicity
Neurotoxicity
Hematological toxicity
Pancreatitis
Prep: tab, cap, sprinkles

MOA: inc. levels of GABA; inhibits the kindling process or snoball-like effect seen in
mania & seizures
Nursing considerations

Therapeutic level: 50 100 ug/mL

Dose: 1, 000 1,500 mg/day
Monitor serum levels 12H after last dose
Toxic effects
Severe diarrhea, vomiting, drowsiness, mm. weakness, lack of coordination
Renal failure, coma, death
Anti-psychotic drugs

Indications
Psychotic symptoms of schizophrenia, acute mania and depression

Gilles de Tourette disorder

Treatment-resistant bipolar disorder
Huntingtons disease and other movement disorder

Possibly
Paranoid
Childhood psychoses

MOA: block receptors of dopamine (D2, D3, D4)

If unresponsive after 6 weeks of therapy, another class is tried
General considerations
Calms without producing impairment of sleep
High therapeutic index
Non addicting, no tolerance
Avoided in pregnancy
TYPICAL: High Potency
Fluphenazine (Prolixin)
Haloperidol (Haldol)
Thiothexene (Navane)
Trifluoperazine (Stelazine)
Moderate Potency
Loxapine (Loxitane)
Molindone (Moban)
Perphenazine (Trilafon)
Low Potency
Chlopromazine (Thorazine)
Chlorprothixene (Taractan)
Mesoridazine (Serentil)
Thioridazine (Mellaril)
ATYPICAL
Clozapine (Clozaril)
Resperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Sertindole (Serlect)
Ziprasidone (Zeldox)
Contraindications

CNS depression: brain damage, excess alcohol/ narcotics

Parkinsons disease
Allergy
Blood dyscrasias

Acute narrow angle glaucoma

BPH
Side effects

Hypotension
Sedation
Dermal and ocular syndrome
Neuroleptic malignant syndrome
Anticholinergic syndrome
Movement syndrome (Extrapyramidal Syndrome)
Atropine psychosis
Agranulocytosis
Seizures
Neuroleptic Malignant Syndrome
A potentially fatal, idiosyncratic reaction to an antipsychotic drug
10-20% mortality rate
Sx:
rigidity,
high fever,
autonomic instability (BP, diaphoresis, pallor, delirium, elev. CPK), confused or mute,
fluctuate from agitation to stupor
Occurs in the first 2 weeks of therapy
Risk: high dose of high-potency drugs; dehydration, poor nx, concurrent med illness
Movement Syndromes

Akathisia
Dystonia
Tardive dyskinesia
Bradykinesia
Parkinsonism
Other s/e

Atropine psychosis (geriatrics)

Hyperactivity, agitation, confusion, flushed skin, sluggish reactive pupils
TTT: IM physostigmine

Agranulocytosis (Clozapine)

Occurs 3-8 wks after

Medical emergency
s/s: fever, malaise, sore throat, leukopenia
TTT: d/c, reverse iso, antibiotics

Seizures (Clozapine)
Occurs in 5% of patients; TTT: D/c drug
Anticholinergics
Benztropine (Cogentin)
Trihexyphenidyl (Artane)
Biperiden (Akineton)
Procyclidine (Kemadrin)

Not withdrawn abruptly

Provide cool environment
ANTIPARKINSONIAN MEDICATIONS
Adjunct to anti-psychotic agents to balance dopamine/ acetylcholine in the brain
s/e: glaucoma, tachycardia, HPN, cardiac dx, asthma, duodenal ulcer
A/e: blurred vision, photosensitivity, drowsiness, orthostatic hypotension, CHF,
hallucinations

COMMON DRUGS:
Trihexyphenidyl (Artane)
benztropine (Cogentin)
Biperiden (Cogentin)
Selegiline (Eldepryl)
Pergolide (Permax)

ANTIHISTAMINE
Diphenhydramine HCl (BENADRYL)

DOPAMINE RELEASING AGENT

Amantadine (SYMMETREL)

Nursing considerations
Best taken after meals
Avoid driving
Check BP
Alcohol increases sedative effects
Avoid sudden position change
Drug is not withdrawn abruptly

NOTES VI - PSYCHIATRIC NURSING PART 3

NOTES VI - PSYCHIATRIC NURSING PART 3

PSYCHIATRIC DISORDERS
ANXIETY DISORDERS

PANIC DISORDERS
SPECIFIC PHOBIA
SOCIAL PHOBIA
OCD
PTSD
ACUTE STRESS DISORDER
GENERALIZED ANXIETY DISORDER
PANIC ATTACKS
DISCRETE PERIOD OF INTENSE FEAR OR DISCOMFORT IN WHICH AT LEAST
4 IF THE FF SX DEVELOP ABRUPTLY AND PEAK WITHIN 10 MINS:
Palpitations, pounding heart, or accelerated HR
Sweating
Trembling or shaking
Sensations of SOB and smothering
Feeling of choking

Chest pain or discomfort

Nausea or abd. Pain
Feeling dizzy, unsteady, lightheaded or faint
Derealization or depersonalization
Fear of losing control or going crazy
Fear of dying

 Paresthesias
Chills or hot flashes

SPECIFIC PHOBIA SOCIAL

EXCESSIVE AND UNREASONABLE CUED BY THE PRESENCE OR

ANTICIPATION OF A SPECIFIC OBJECT OR SITUATION

DEFENSE MECH COMMONLY USED INCLUDE REPRESSION AND

DISPLACEMENT

FEAR OF SOCIAL PERFORMANCE SITUATIONS IN WHICH THE PERSON IS

EXPOSED TO UNFAMILIAR PEOPLE OR TO POSSIBLE SCRUTINY BY OTHERS
OBSESSION

COMPULSION

RECURRENT AND PERSISTENT THOUGHTS, IMPULSES, OR IMAGES ARE

EXPERIENCED DURING THE DISTURBANCE AS INTRUSIVE AND
INAPPROPRIATE

CAUSE ANXIETY OR DISTRESS

PX KNOWS THAT THESE ARE JUST PRODUCT OF ONES OWN MIND.
PX FEELS DRIVEN TO PERFORM REPETITIVE BEHAVIORS OR MENTAL ACTS
IN RESPONSE TO OBSESSION OR ACCORDING TO THE RULES THAT ONE
DEEMS MUST BE APPLIED RIGIDLY.

AIMED AT REDUCING ANXIETY

OBSESSION

COMPULSION

FEAR OF DIRT & GERMS

FEAR OF BURGLARY OR ROBBERY
WORRIES ABOUT DISCARDING SOMETHING IMPORTANT
CONCERNS ABOUT CONTRACTING A SERIOUS ILLNESS
WORRIES THAT THINGS MUST BE SYMMETRICAL OR MATCHING
EXCESSIVE HAND WASHING
REPEATED CHECKING OF DOOR AND WINDOW LOCKS
COUNTING AND RECOUNTING OF OBJECTS IN EVERYDAY LIFE
HOARDING OF OBJECTS
EXCESSIVE STRAIGHTENING, ORDERING, OR OF ARRANGING THINGS
REPEATING WORDS OR PRAYERS SILENTLY

POST TRAUMATIC STRESS SYNDROME

PERSON HAS EXPERIENCED, WITNESSED OR BEEN CONFRONTED WITH AN
EVENT THAT INVOLVED ACTUAL OR THREATENED DEATH OR SERIOUS INJURY,
OR A THREAT TO PHYSICAL INTEGRITY
PERSON REEXPERIENCES THESE IN THE MIND
INVOLVES INTENSE FEAR, HELPLESSNESS, OR HORROR AND NUMBING OF
GENERAL RESPONSIVENESS (PSYCHIC NUMBING)

ACUTE
STRESS

GENERALIZED
ANXIETY

MEETS THE CRITERIA FOR EXPOSURE TO A TRAUMATIC EVENT AND

PERSON EXPERIENCES 3 OF THE FF SX:
sense of detachment,
reduced awareness of ones surroundings,
derealization,
depersonalization,
dissociated amnesia

EXCESSIVE ANXIETY OR WORRY, OCCURRING IN MORE DAYS THAN NOT

FOR AT LEAST 6 MOS, ABOUT A NUMBER OF EVENTS OR ACTIVITIES

FINDS IT DIFFICULT TO CONTROL THE WORRY

MOOD/ AFFECTIVE DISORDERS

BIPOLAR D/O
BIPOLAR I: current or past experience of manic episode, lasting at least a

week, that is severe enough to cause extreme impairment in social or

occupational functioning.

 MANIA: hyperactivity
DEPRESSED: extreme sadness or withdrawal
MIXED
BIPOLAR II: hx of 1 or more mj depressive episodes & at least 1 hypomanic

episode; no mania

MAJOR DEPRESSIVE D/O

@ least 5 sx of same 2- wk period with one being either depressed mood

or loss of interest or pleasure.

Single episode or recurrent
Other sx: wt loss, insomnia, fatigue, recurrent thoughts of death,

diminished ability to think, psychomotor agitation or retardation, feelings of

worthlessness.

CYCLOTHYMIC D/O
Hx of 2 yrs of hypomania with numerous periods of abnormally elevated,

expansive or irritable moods.

Does not meet the criteria of mania or depression.

DYSTHYMIC D/O
@ least 2 yrs of usually depressed mood and at least 1 of the sx of mj

depression without meeting the criteria for it

SEASONAL AFFECTIVE D/O
Depression that comes with shortened daylight in fall and winter that

disappears during spring and summer.

Dealing with Inappropriate Behaviors

AGGRESSIVE BEHAVIOR

ASSIST THE CLIENT IN IDENTIFYING FEELINGS OF FRUSTRATION AND

AGGRESSION

ENCOURAGE THE CLIENT TO TALK OUT INSTEAD OF ACTING OUT FEELINGS

OF FRUSTRATION

ASSIST THE CLIENT IN IDENTIFYING PRECIPITATING EVENTS OR SITUATIONS

THAT LEAD TO AGGRESSIVE BEHAVIOR

DESCRIBE THE CONSEQUENCES OF THE BEHAVIOR ON SELF AND OTHERS

ASSIST IN IDENTIFYING PREVIOUS COPING MECHANISMS
ASSIST THE CLIENT IN THE PROBLEM-SOLVING TECHNIQUES TO COPE
WITH FRUSTRATION OR AGGRESSION
DEESCALATION TECHNIQUES

MAINTAIN SAFETY
MAINTAIN LARGE PERSONAL SPACE AND USE NONAGGRESSIVE POSTURE
USE CALM APPROACH AND COMMUNICATE WITH A CALM, CLEAR TONE OF
VOICE (BE ASSERTIVE NOT AGGRESSIVE

DETERMINE WHAT THE CLIENT CONSIDERS TO BE HIS OR HER NEED

AVOID VERBAL STRUGGLES
PROVIDE CLEAR OPTIONS THAT DEAL WITH BEHAVIOR
ASSIST WITH PROBLEM-SOLVING AND DECISION MAKING REGARDING THE
OPTIONS
MANIPULATIVE BEHAVIORS
SET CLEAR, CONSISTENT, REALISTIC, AND ENFORCEABLE LIMITS AND
COMMUNICATE EXPECTED BEHAVIORS
BE CLEAR ABOUT CONSEQUENCES ASSOCIATED WITH EXCEEDING SET
LIMITS
DISCUSS BEHAVIOR IN NONJUDGMENTAL AND NONTHREATENING MANNER
AVOID POWER STRUGGLES

 ASSIST IN DEVELOPING MEANS OF SETTING LIMITS ON OWN BEHAVIOR

SCHIZOPHRENIA

CHARACTERIZED BY IMPAIRMENTS IN THE PERCEPTION OR EXPRESSION OF

REALITY AND BY SIGNIFICANT SOCIAL OR OCCUPATIONAL DYSFUNCTION.

ONCE CONSIDERED AS A DEADLY DISEASE

THERE IS LACK OF INSIGHT IN BEHAVIOR
DX: LATE ADOLESCENCE AND EARLY ADULTHOOD
15-25 y.o. (men); 25-35 y.o. (women)

OBSOLETE TERM: DEMENTIA PRAECOX = COGNITIVE DETERIORATION

EARLY IN LIFE

EUGENE BLEULER: SCHIZ SPLIT; PHREN MIND

Risk factors

GENETICS: IDENTICAL TWINS 50%, 15% FOR FRATERNAL TWINS

BIOCHEMICAL FACTORS

Dopamine hypothesis: overactive

Serotonin imbalance

Decreased brain volume, enlarged ventricles, deeper fissures, and

loss or underdeveloped brain tissue
PSYCHOANALYTIC

lack of trust during the early stages

Weak ego

Defenses: REPRESSION, REGRESSION, PROJECTION

ENVIRONMENT INFLUENCES: POVERTY, LACK OF SOCIAL SUPPORT,

HOSTILE HOME ENVIRONMENT, ISOLATION, UNSATISFACTORY HOUSING,
DISRUPTION IN INTERPERSONAL RELATIONSHIPS (DIVORCE OR DEATH),
JOB PRESSURE OR UNEMPLOYMENT

Subtypes
CATATONIC TYPE
prominent psychomotor disturbances are evident. Symptoms can include

catatonic stupor and waxy flexibility

DISORGANIZED TYPE
where thought disorder and flat affect are present together

PARANOID TYPE
where delusions and hallucinations are present but thought disorder,

disorganized behavior, and affective flattening are absent

RESIDUAL TYPE

where positive symptoms are present at a low intensity only

UNDIFFERENTIATED TYPE

psychotic symptoms are present but the criteria for paranoid, disorganized,
or catatonic types has not been met

Symptoms
ACCORDING TO BLEULER: 4 AS
Affect is inappropriate
Associative looseness
Autistic thinking
Ambivalence

Symptoms
POSITIVE SYMPTOMS
delusions, auditory hallucinations and thought disorder and are typically

regarded as manifestations of psychosis.

NEGATIVE SYMPTOMS
considered to be the loss or absence of normal traits or abilities
E.G. flat, blunted or constricted affect and emotion, poverty of speech and

lack of motivation.

Symptoms
SOCIAL ISOLATION
CATATONIC BEHAVIOR
HALLUCINATIONS
INCOHERENCE (MARKED LOOSENESS OF ASSOCIATION)
ZERO/ LACK OF INTEREST, ENERGY AND INITIATIVE
OBVIOUS FAILURE TO ATTAIN EXPECTED LEVEL OF DEVT
PECULIAR BEHAVIOR
HYGIENE AND GROOMING IMPAIRED
RECURRENT ILLUSIONS AND UNUSUAL PERCEPTION EXPERIENCES
EXACERBATIONS AND REMISSIONS ARE COMMON
NO ORGANIC FACTORS ACCOUNTS FOR THE SYMPTOMS
INABILITY TO RETURN TO BASELINE FUNCTIONING AFTER RELAPSE
AFFECT IS INAPPROPRIATE
Nsg Dx: Abnormal thought process

BLOCKING: SUDDEN CESSATION OF A THOUGHT IN THE MIDDLE OF A

SENTENCE, UNABLE TO CONTINUE THE TRAIN OF THOUGHT

CIRCUMSTANTIALITY: BEFORE GETTING TO THE POINT OF ANSWERING A

QUESTION, THE INDIVIDUAL GETS CAUGHT UP IN COUNTLESS DETAILS AND
EXPLANATIONS

CONFABULATION
LOOSENESS OF ASSOCIATION
NEOLOGISM
WORD SALAD
Interventions

ASSESS PHYSICAL NEEDS

SET LIMITS
MAINTAIN SAFETY
INITIATE ONE-ON-ONE INTERACTION & PROGRESS TO SMALL GROUPS
SPEND TIME WITH CLIENTS

 MONITOR FOR ALTERED THOUGHT PROCESS

MAINTAIN EGO BOUNDARIES, AVOID TOUCHING
LIMIT TIME OF INTERACTION
BE NEUTRAL
DO NOT MAKE PROMISES THAT CANT BE KEPT
ESTABLISH DAILY ROUTINES
DO NOT GO ALONG WITH THE CLIENTS DELUSIONS OR HALLUCINATIONS
PROVIDE SIMPLE COMPLETE ACTIVITIES
REORIENT
SPEAK TO THE CLIENT IN SIMPLE DIRECT AND CONCISE MANNER
SET REALISTIC GOALS
EXPLAIN EVERYTHING THAT IS BEING DONE
DECREASE STIMULI
MONITOR FOR SUICIDE RISK

ENVIRONMENT
Provide safe environment
Limit stimuli

PSYCHOLOGICAL TTT
Behavior therapy
Social skills training
Self-monitoring

SOCIAL TTT
Milieu therapy
Family therapy

 Group therapy (long-term ttt)

Related psychotic disorders

SCHIZOAFFECTIVE DISORDER SCHIZ + MOOD DISORDER (MANIA/
DEPRESSION)
BRIEF PSYCHOTIC DISORDER SUDDEN ONSET OF PSYCHOTIC SYMPTOMS,
LASTS LESS THAN 2 MOS AND CLIENT RETURNS TO PREMORBID LEVEL OF
FUNCTIONING
SCHIZOPHRENIFORM DISORDER SCHIZ SX LASTING BETWEEN 1 MONTH
AND <6MOS
DELUSIONAL DISORDER CHARACTERIZED BY PROMINENT, NONBIZARRE
DELUSIONS

PERSONALITY DISORDERS

CLUSTER A (ODD & ECCENTRIC)

paranoid, schizoid, schizotypal

CLUSTER B (BAD, DRAMATIC & ERRATIC)

antisocial, borderline, histrionic, narcissistic

CLUSTER C (ANXIOUS & FEARFUL)

avoidant, dependent, OCD
CLUSTER A: ODD & ECCENTRIC

PARANOID
chronic hostility projected to others; suspicious and mistrusts people
Seen mostly in men

SCHIZOID
social detachment = loner & introvert
Restriction of emotions

 Attention fixed on objects rather than people

Functions well in vocations

SCHIZOTYPAL: INTERPERSONAL DEFICITS

Magical thinking, telepathy
Apparent in childhood or adolescence
Interventions for PARANOID D/O

ASSES FOR SUICIDE RISK

AVOID DIRECT EYE CONTACT
ESTABLISH TRUSTING RELATIONSHIP
PROMOTE INCREASED SELF-ESTEEM
REMAIN CALM, NONTHREATENING AND NONJUDGMENTAL
PROVIDE CONTINUITY OF CARE
RESPOND HONESTLY TO THE CLIENT
FOLLOW THRU ON COMMITMENTS
PROVIDE A DAILY SCHEDULE OF ACTIVITIES
GRADUALLY INTRODUCE CLIENT TO GROUPS
DO NOT ARGUE WITH DELUSIONS
USE CONCRETE, SPECIFIC WORDS

Do not be secretive with client

DO NOT WHISPER IN PRESENCE OF CLIENT

ASSURE THAT THE CLIENT WILL BE SAFE
PROVIDE OPPORTUNITY TO COMPLETE SMALL TASKS
MONITOR EATING, DRINKING, SLEEPING AND ELIMINATION PATTERNS
LIMIT PHYSICAL CONTACT
MONITOR FOR AGITATION AND DECREASE STIMULI AS NEEDED

CLUSTER B: ERRATIC, DRAMATIC, OR EMOTIONAL

ANTISOCIAL
Syn: sociopath, psychopathic & semantic d/o
Etiology:
Genetics interfere in the devt of positive interpersonal relationships
Brain damage or trauma
Low socioeconomic status
Faulty family relationships: neglect
Secondary gains
15-40 y.o.

SIGNS
Lack of remorse or indifference to persons hurt
Immediate gratification
Failure to accept social norms
Impulsivity
Consistent irresponsibility

 Aggressive behavior
Reckless behavior that disregards the safety of others

80-90% OF ALL CRIME IS COMMITTED BY ANTISOCIALS (NIHM, 2000)

BORDERLINE

Latent, ambulatory and abortive schizophrenics

Between moderate neurosis and frank psychosis but quite stable
Theories
faulty separation from mother; parent and child are bound by guilt
Trauma at 18 mos (weakening of ego)
Unfulfilled need for intimacy
SIGNS
instability
Impulsivity: unpredictable gambling, shoplifting, sex & substance abuse
hypersensitivity, self-destructive, profound mood shifts
unstable & intense relations
Disturbance in self concept

COMMON IN WOMEN
DEFENSES: DENIAL, PROJECTION, SPLITTING, PROJECTIVE IDENTIFICATION

HISTRIONIC
Pattern of theatrical or overtly dramatic behavior

 Signs
Discomfort when the client isnt the center of attention
Self-dramatization and exaggerated emotions
uses physical appearance, sexually seductive and provocative behavior
Excessively impressionistic speech lacking in detail (labile emotions)
Problems in dependence & helplessness
More frequent in women

NARCISSISTIC
Exaggerated or grandiose sense of self-importance
Develop early in childhood
Preoccupied with fantasies of unlimited success, power and beauty
Signs
arrogance, need for admiration,
lack of empathy,
seductive, socially exploitative, manipulative
Occurs more in men

CLUSTER C: ANXIOUS OR FEARFUL

AVOIDANT
Sensitive to rejection, criticism, humiliation, disapproval, or shame
Interferes with participation in occupational activities, devt of

relationships, and take personal risks

social inhibition, longs for relationships
Anxiety, anger and depression are common
Social phobia may occur

 Seen in 10% of clients in mental clinics

DEPENDENT
Lacks confidence and unable to function in an independent role
Allows other persons to be responsible of their lives
Most frequent personality disorder in the mental health clinic
submissive behavior, low self-esteem, inadequate, helpless

OBSESSIVE-COMPULSIVE
Preoccupied with rules & regulations, overly concerned about trivial detail,

excessively devoted to their work

Depression is common
Men are more affected than women

UNDER STUDY PERSONALITY D/O

PASSIVE-AGGRESSIVE: SULLEN AND ARGUMENTATIVE, RESENTS OTHERS,
RESISTS FULFILLING RESPONSIBILITIES, COMPLAINS OF BEING
UNAPPRECIATED
DEPRESSIVE: GLOOMY, BROODING PESSIMISTIC, GUILT-PRONE, HIGHLY
CRITICAL OF SELF AND OTHERS, CHEERLESS.

Interventions

MAINTAIN SAFETY AGAINST SELF-DESTRUCTIVE BEHAVIORS

ALLOW THE CLIENT TO MAKE CHOICES AND BE AS INDEPENDENT AS
POSSIBLE

ENCOURAGE THE CLIENT TO DISCUSS FEELINGS RATHER THAN ACT THEM

OUT

PROVIDE CONSISTENCY IN RESPONSE TO THE CLIENTS ACTING OUT

DISCUSS EXPECTATIONS AND RESPONSIBILITIES WITH THE CLIENT
INFORM THE CLIENT THAT HARM TO SELF, OTHERS, AND PROPERTY IS
UNACCEPTABLE
IDENTIFY SPLITTING BEHAVIOR
ASSIST THE CLIENT TO DEAL DIRECTLY WITH ANGER
DEVELOP A WRITTEN CONTRACT WITH THE CLIENT
ENCOURAGE THE CLIENT TO PARTICIPATE IN GROUP ACTIVITIES, AND
PRAISE NONMANIPULATIVE BEHAVIOR
SET AND MAINTAIN LIMITS
REMOVE THE CLIENT FROM GROUP SITUATIONS IN WHICH ATTENTIONSEEKING BEHAVIORS OCCUR
PROVIDE REALISTIC PRAISE FOR POSITIVE BEHAVIORS IN SOCIAL
SITUATIONS

PSYCHOLOGICAL SEXUAL D/O

HYPOACTIVE SEXUAL DISORDER (ASEXUALITY)
SEXUAL AVERSION DISORDER (AVOIDANCE OF OR LACK OF DESIRE FOR
SEXUAL INTERCOURSE)

 FEMALE SEXUAL AROUSAL D/O (FAILURE OF NORMAL LUBRICATING

AROUSAL RESPONSE)
MALE ERECTILE D/O
FEMALE ORGASMIC DISORDER
MALE ORGASMIC DISORDER
PREMATURE EJACULATION

VAGINISMUS
SECONDARY SEXUAL DYSFXN
PARAPHILIAS
GENDER IDENTITY D/O
PTSD DUE TO GENITAL MUTILATION OR CHILDHOOD SEXUAL ABUSE
OTHER SEXUAL PROBLEMS

SEXUAL DISSATISFACTION (NON-SPECIFIC)

LACK OF SEXUAL DESIRE
ANORGASMIA
IMPOTENCE
STD
INFIDELITY
DELAY OR ABSENCE OF EJACULATION, DESPITE ADEQUATE STIMULATION
INABILITY TO CONTROL TIMING OF EJACULATION
INABILITY TO RELAX VAGINAL MUSCLES ENOUGH TO ALLOW INTERCOURSE
INADEQUATE VAGINAL LUBRICATION PRECEDING AND DURING
INTERCOURSE
BURNING PAIN ON THE VULVA OR IN THE VAGINA WITH CONTACT TO
THOSE AREAS
UNHAPPINESS OR CONFUSION RELATED TO SEXUAL ORIENTATION

 PERSISTENT SEXUAL AROUSAL SYNDROME

SEXUAL ADDICT
HYPERSEXUALITY
POST EJACULATORY GUILT SYNDROME, THE FEELING OF GUILT AFTER THE
MALE ORGASM

SEXUAL EXPRESSION
HETEROSEXUALITY
HOMOSEXUALITY
BISEXUALITY
TRANSVESTISM

PARAPHILIAS
EXHIBITIONISM: THE RECURRENT URGE OR BEHAVIOR TO EXPOSE ONE'S
GENITALS TO AN UNSUSPECTING PERSON.
FETISHISM: THE USE OF NON-SEXUAL OR NONLIVING OBJECTS OR PART OF
A PERSON'S BODY TO GAIN SEXUAL EXCITEMENT. PARTIALISM REFERS TO
FETISHES SPECIFICALLY INVOLVING NONSEXUAL PARTS OF THE BODY.
FROTTEURISM: THE RECURRENT URGES OR BEHAVIOR OF TOUCHING OR
RUBBING AGAINST A NONCONSENTING PERSON.
SEXUAL MASOCHISM: THE RECURRENT URGE OR BEHAVIOR OF WANTING
TO BE HUMILIATED, BEATEN, BOUND, OR OTHERWISE MADE TO SUFFER.
SEXUAL SADISM: THE RECURRENT URGE OR BEHAVIOR INVOLVING ACTS IN
WHICH THE PAIN OR HUMILIATION OF THE VICTIM IS SEXUALLY EXCITING.
TRANSVESTIC FETISHISM: A SEXUAL ATTRACTION TOWARDS THE
CLOTHING OF THE OPPOSITE GENDER.
PEDOPHILIA: THE SEXUAL ATTRACTION TO PREPUBESCENT OR
PERIPUBESCENT CHILDREN.
VOYEURISM: THE RECURRENT URGE OR BEHAVIOR TO OBSERVE AN
UNSUSPECTING PERSON WHO IS NAKED, DISROBING OR ENGAGING IN
SEXUAL ACTIVITIES, OR MAY NOT BE SEXUAL IN NATURE AT ALL.

 OTHER PARAPHILIAS NOT OTHERWISE SPECIFIED ("SEXUAL DISORDER

NOS")
telephone scatalogia (obscene phone calls)
necrophilia (corpses)
partialism (exclusive focus on one part of the body)
zoophilia(animals)
coprophilia (feces)
klismaphilia (enemas)
urophilia (urine)

SOMATOFORM D/O

SOMATIZATION D/O: HX OF MANY PHYSICAL COMPLAINTS BEGINNING

BEFORE THE AGE OF 30 OCCURRING OVER A PD OF SEVERAL YRS RESULTING
IN TTT BEING SOUGHT OR SIGNIFICANT OCCUPATIONAL OR SOCIAL FXNING.

CONVERSION D/O: 1 OR MORE SX OF DEFICITS AFFECTING VOLUNTARY

MOTOR OR SENSORY FUNCTION SUGGESTING A NEUROLOGICAL OR
GENERAL MEDICAL CONDITION; PRECEDED BY CONFLICTS OR STRESSORS;
CANT BE EXPLAINED AND SANCTIONED BY CULTURAL BEHAVIOR.
Most common: blindness, deafness, paralysis, inability to talk
La belle indifference

 HYPOCHONDRIASIS: PREOCCUPATION WITH FEARS OF HAVING, OR IDEAS

THAT ONE HAS, A SERIOUS DSE BASED ON THE PERSONS
MISINTERPRETATION OF BODILY SX AND PERSIST DESPITE APPROPRIATE
MEDICAL EVAL AND REASSURANCE AND HAS EXISTED FOR @ LEAST 6 MOS.
(E.G.:EXTENSIVE USE OF HOME REMEDIES)
PAIN D/O: PAIN IN 1 OR MORE ANATOMICAL SITES SEVERE ENOUGH TO
WARRANT CLINICAL ATTENTION AND CAUSES CLINICALLY SIGNIFICANT
DISTRESS OR IMPAIRMENT IN FXNING.

INTERVENTIONS
DO NOT REINFORCE THE SICK ROLE
DISCOURAGE VERBALIZATION ABOUT PHYSICAL SYMPTOMS BY NOT
RESPONDING WITH POSITIVE REINFORCEMENT
EXPLORE WITH THE CLIENT THE NEEDS BEING MET BY THE PHYSICAL
SYMPTOMS
CONVEY UNDERSTANDING THAT THE PHYSICAL SYMPTOMS ARE REAL TO
THE CLIENT
REPORT AND ASSESS ANY NEW PHYSICAL COMPLAINT
next

EATING DISORDER BEHAVIORS

BINGE: RAPID CONSUMPTION OF LARGE QUANTITIES OF FOOD IN A

DISCRETE PERIOD OF TIME. (A: HUNDRENDS OF CAL; B: THOUSANDS
OF CAL AT A SITTING)

PURGE: MALADAPTIVE EATING REGULATION RESPONSE THAT INCLUDES

EXCESSIVE EXERCISE, FORCED VOMITING, OCD RX DIURETICS, DIET PILLS,
LAXATIVES AND STEROIDS.

FAST/ RESTRICT: INCLUDES VEGETARIAN DIET ELIMINATING ALL MEAT

WITHOUT SUBSTITUTING NONANIMAL SOURCES OF PROTEIN, OC ABOUT
FOOD CHOICES, AND EATING HABITS.
ANOREXIA

BULIMIA

RARE VOMITING OR DIURETIC/LAXATIVE ABUSE

MORE SEVERE WT LOSS
SLIGHTLY YOUNGER
MORE INTROVERTED
HUNGER DENIED
EATING BEHAVIOR MAY BE CONSIDERED NORMAL AND A SOURCE OF
ESTEEM
SEXUALLY INACTIVE
OBSESSIONAL AND PERFECTIONIST FEATURES DOMINATE
FREQUENT
LESS WT LOSS
SLIGHTLY OLDER
MORE EXTROVERTED
HUNGER EXPERIENCED
EATING BEHAVIOR CONSIDERED FOREIGN AND SOURCE OF DISTRESS
MORE SEXUALLY ACTIVE
AVOIDANT, DEPENDENT, OR BORDERLINE FEATURES AS WELL AS
OBSESSIONAL FEATURES
ANOREXIA
BULIMIA
complications

DEATH FROM STARVATION (OR SUICIDE, IN CHRONICALLY ILL)

 AMENORRHEA
FEWER BEHAVIORAL PROBLEMS (THESE INCREASE WITH LEVEL OF
SEVERITY)

DEATH FROM HYPOKALEMIA OR SUICIDE

MENSES IRREGULAR OR ABSENT
DRUG AND ALCOHOL ABUSE, SELF-MUTILATION, AND OTHER BEHAVIORAL
PROBLEMS
DELIRIUM
THE MEDICAL DX TERM THAT DESCRIBES AN ORGANIC MENTAL DISORDER
CHARACTERIZED BY A CLUSTER OF COGNITIVE IMPAIRMENTS WITH AN ACUTE
ONSET WITH A SPECIFIC PRECIPITATING FACTOR.
SX: DIMINISHED AWARENESS OF THE ENVIRONMENT, DISTURBANCES IN
PSYCHOMOTOR ACTIVITY AND SLEEP-WAKE CYCLE.
COGNITIVE: THE MENTAL PROCESS CHARACTERIZED BY KNOWING,
THINKING, AND JUDGING.
COGNITIVE DISSONANCE: arises when 2 opposing beliefs exists at the
same time.

COGNITIVE DISTORTIONS: (+) or (-) distortions of reality that might include

errors of logic, mistakes in reasoning, or individualized view of the world that
do not reflect reality.

Term: confusion = cognitive impairment

See dementia

DEMENTIA

THE MEDICAL DX TERM THAT DESCRIBES AN ORGANIC MENTAL D/O

CHARACTERIZED BY A CLUSTER OF COGNITIVE IMPAIRMENTS OF GENERALLY
GRADUAL ONSET AND IRREVERSIBLE WITHOUT IDENTIFIABLE PRECIPITATING
STRESSORS.

TYPES:
VASCULAR or MULTI-INFARCT
VASCULAR WITH ALZHEIMERS DSE

 AD: most common

DEMENTIA WITH LEWY BODIES: 2nd most common; neurofilament material
PARKINSONIAN DEMENTIA
AIDS DEMENTIA COMPLEX

FRONTAL LOBE DEMENTIA or PICKS DSE: cytoplasmic collections; 3rd most

common; loss of expressive language & comprehension

CREUTZFELDT-JAKOB DSE: prion (proteinaceous infectious particles) =

spongy brain; related to TSE & BSE in mad cow dse

CORTICOBASAL DEGENERATION or HUNTINGTONS DSE/CHOREA: jerky

movts
SUPRANUCLEAR PALSY: clumping of protein tau = slow movt, weak eye

movt (esp. downward), impaired walking &balance

REVERSIBLE CAUSES:
Subdural hematoma
Tumor (meningioma)
Cerebral vasculitis
Hydrocephalus

TERMS: DISORIENTATION, MEMORY LOSS (SENSORY, PRIMARY,

SECONDARY, TERTIARY, WORKING MEMORY), CONFABULATION, CONFUSION

DISTURBING BEHAVIORS
Aggressive psychomotor
Nonaggressive psychomotor
Verbally aggressive

 Passive
Functionally impaired: loss of ability to do self-care
DELIRIUM

vs.

DEMENTIA

RAPID ONSET W/ WIDE FLUCTUATIONS

HYPERALERT TO DIFFICULT TO AROUSE LOC
FLUCTUATING AFFECT
DISORIENTED, CONFUSED
ATTENTION & SLEEP DISTURBED
MEMORY IMPAIRED
DISORDERED REASONING
GRADUAL, CHRONIC WITH CONTINUOUS DECLINE
NORMAL LOC
LABILE AFFECT
DISORIENTED, CONFUSED ATTENTION INTACT, SLEEP USUALLY NORMAL
MEMORY IMPAIRED
DISORDERED REASONING & CALCULATION
DELIRIUM

vs.

DEMENTIA

INCOHERENT, CONFUSED, DELUSIONAL, STEREOTYPED

ILLUSIONS, HALLUCINATIONS
POOR JUDGMENT
INSIGHT MAY BE PRESENT IN LUCID MOMENT
POOR BUT VARIABLE IN MSE

next

 DISORGANIZED, RICH IN CONTENT, DELUSIONAL, PARANOID

NO CHANGE IN PERCEPTION
POOR JUDGMENT
NO INSIGHT
CONSISTENTLY POOR & PROGRESSIVELY WORSENS IN MSE
ALZHEIMERS DEMENTIA

MOST COMMON TYPE OF DEMENTIA

STAGES:

MILD: impaired memory, insidious loses in ADL, subtle personality

changes, socially normal

MODERATE: obvious memory loss, overt ADL impairment, prominent

behavioral difficulties, variable social skills, supervision needed

SEVERE: fragmented memory, no recognition of familiar people, assistance

needed with basic ADL, fewer troublesome behaviors, reduced mobility (4
As)

Symptoms
AGNOSIA: DIFFICULTY RECOGNIZING WELL-KNOWN OBJECTS
APHASIA: DIFFICULTY IN FINDING THE RIGHT WORD
APRAXIA: INABILITY OR DIFFICULTY IN PERFORMING A PURPOSEFUL
ORGANIZED TASK OR SIMILAR SKILLED ACTIVITIES
AMNESIA: SIGNIFICANT MEMORY IMPAIRMENT IN THE ABSENCE OF
CLOUDED CONSCIOUSNESS OR OTHER COGNITIVE SYMPTOMS

NOTES VI - PSYCHIATRIC NURSING PART 4

NOTES VI - PSYCHIATRIC NURSING PART 4

PSYCHIATRIC D/O IN CHILDREN

MENTAL RETARDATION
PERVASIVE DEVTAL D/O
AUTISM
RETTS D/O
CHILDHOOD DISINTEGRATIVE D/O
ASPERGERS D/O
PDD NOS

LEARNING D/O
READING
MATHEMATICS
WRITTEN EXPRESSION
ACADEMIC PROBLEM
LEARNING D/O NOS

MOTOR SKILLS D/O

COMMUNICATION D/O
EXPRESSIVE LANGUAGE
MIXED RECEPTIVE/EXPRESSIVE
PHONOLOGICAL
STUTTERING

 SELECTIVE MUTISM
COMMUNICATION D/O NOS

MOVT & TIC D/O

DEVTAL COORDINATION
TRANSIENT TIC

CHRONIC MOTOR&VOCAL TIC

TOURETTES D/O
STEREOTYPIC MOVT D/O
TIC D/O NOS

DISORDERS OF INTAKE & ELIMINATION

PICA
RUMINATION
FEEDING D/O
ENURESIS
ENCOPRESIS
OTHER: BULIMIA, ANOREXIA

ADHD & DISRUPTIVE BEHAVIOR D/O

ADHD
ADHD NOS
CONDUCT D/O

 OPPOSITIONAL DEFIANT
CHILD ANTISOCIAL
DISRUPTIVE BEHAVIOR NOS

MOOD D/O
MJ DEPRESSIVE D/O
BIPOLAR I OR II
DYSTHYMIC
MIXED EPISODE
HYPOMANIC EPISODE
MOOD D/O DUE TO MEDICAL CONDITION
SUBSTANCE-INDUCED MOOD D/O

ANXIETY D/O
D/O OF RELATIONSHIP
SEPARATION ANXIETY
REACTIVE ATTACHMENT OF INFANCY OR EARLY CHILDHOOD
PARENT-CHILD RELATIONAL PROBLEM
SIBLING RELATIONAL PROBLEM
PROBLEMS RELATED TO ABUSE OR NEGLECT

MENTAL RETARDATION
AN IQ BELOW 70, SIGNIFICANT LIMITATIONS IN TWO OR MORE AREAS OF
ADAPTIVE BEHAVIOR (I.E., ABILITY TO FUNCTION AT AGE LEVEL IN AN
ORDINARY ENVIRONMENT), AND EVIDENCE THAT THE LIMITATIONS BECAME
APPARENT IN BEFORE 18 Y.O.
THE FOLLOWING RANGES, BASED ON THE WECHSLER ADULT
INTELLIGENCE SCALE (WAIS), ARE IN STANDARD USE TODAY:
CLASS

IQ

PROFOUND
SEVERE
MODERATE
MILD

BELOW 20
2034
3549

TERMS
IDIOT
IMBECILE
MORON

5069

BORDERLINE

7079

RETTS D/O

DEVELOPMENT IS NORMAL UNTIL 6-18 MONTHS, WHEN LANGUAGE AND

MOTOR MILESTONES REGRESS,

PURPOSEFUL HAND USE IS LOST

ACQUIRED DECELERATION IN THE RATE OF HEAD GROWTH (RESULTING IN
MICROCEPHALY IN SOME)

HAND STEREOTYPES ARE TYPICAL AND BREATHING IRREGULARITIES SUCH

AS HYPERVENTILATION, BREATH HOLDING, OR SIGHING ARE SEEN IN MANY.

EARLY ON, AUTISTIC-LIKE BEHAVIOR MAY BE SEEN

COMMON IN FEMALES
CHILDHOOD DISINTEGRATIVE D/O or HELLERS SYNDROME
CDD HAS SOME SIMILARITY TO AUTISM, BUT AN APPARENT PERIOD OF
FAIRLY NORMAL DEVELOPMENT IS OFTEN NOTED BEFORE A REGRESSION IN
SKILLS OR A SERIES OF REGRESSIONS IN SKILLS.
CHARACTERIZED BY LATE ONSET (>3 YEARS OF AGE) OF DEVTAL DELAYS
IN LANGUAGE, SOCIAL FUNCTION AND MOTOR SKILLS; SKILLS APPARENTLY
ATTAINED ARE LOST

ASPERGERS D/O
CHARACTERIZED BY DIFFERENCE IN LANGUAGE AND COMMUNICATION
SKILLS, AS WELL AS REPETITIVE OR RESTRICTIVE PATTERNS OF THOUGHT
AND BEHAVIOR.

 SIGNS: UNABLE TO INTERPRET OR UNDERSTAND THE DESIRES OR

INTENTIONS OF OTHERS AND THEREBY ARE UNABLE TO PREDICT WHAT TO
EXPECT OF OTHERS OR WHAT OTHERS MAY EXPECT OF THEM
Narrow interests or preoccupation with a subject to the exclusion of other
activities

Repetitive behaviors or rituals

Peculiarities in speech and language

Extensive logical/technical patterns of thought

Socially and emotionally inappropriate behavior and interpersonal

interaction

Problems with nonverbal communication

Clumsy and uncoordinated motor movts

CHRONIC MOTOR/ VOCAL TIC

TIC IS A SUDDEN, REPETITIVE, STEREOTYPED, NONRHYTHMIC,
INVOLUNTARY MOVEMENT (MOTOR TIC) OR SOUND (PHONIC TIC) THAT
INVOLVES DISCRETE GROUPS OF MUSCLES.
CAN BE INVISIBLE TO THE OBSERVER (E.G. ABDOMINAL TENSING OR TOE
CRUNCHING)

TOURETTES D/O
CHARACTERIZED BY THE PRESENCE OF MULTIPLE PHYSICAL (MOTOR) TICS
AND AT LEAST ONE VOCAL (PHONIC) TIC; THESE TICS CHARACTERISTICALLY
WAX AND WANE
TTT: NEUROLEPTIC MEDICATIONS
haloperidol (Haldol)
pimozide (Orap)

ADHD
INATTENTION:
FAILURE TO PAY CLOSE ATTENTION TO DETAILS OR MAKING CARELESS
MISTAKES WHEN DOING SCHOOLWORK OR OTHER ACTIVITIES

TROUBLE KEEPING ATTENTION FOCUSED DURING PLAY OR TASKS

APPEARING NOT TO LISTEN WHEN SPOKEN TO

FAILURE TO FOLLOW INSTRUCTIONS OR FINISH TASKS

AVOIDING TASKS THAT REQUIRE A HIGH AMOUNT OF MENTAL EFFORT

AND ORGANIZATION, SUCH AS SCHOOL PROJECTS

FREQUENTLY LOSING ITEMS REQUIRED TO FACILITATE TASKS OR

ACTIVITIES, SUCH AS SCHOOL SUPPLIES

EXCESSIVE DISTRACTIBILITY

FORGETFULNESS

PROCRASTINATION, INABILITY TO BEGIN AN ACTIVITY

DIFFICULTIES WITH HOUSEHOLD ACTIVITIES (CLEANING, PAYING BILLS,

ETC.)

DIFFICULTY FALLING ASLEEP, MAY BE DUE TO TOO MANY THOUGHTS AT

NIGHT

FREQUENT EMOTIONAL OUTBURSTS

EASILY FRUSTRATED

EASILY DISTRACTED

HYPERACTIVITY-IMPULSIVE BEHAVIOUR

FIDGETING WITH HANDS OR FEET OR SQUIRMING IN SEAT

LEAVING SEAT OFTEN, EVEN WHEN INAPPROPRIATE

RUNNING OR CLIMBING AT INAPPROPRIATE TIMES

DIFFICULTY IN QUIET PLAY

FREQUENTLY FEELING RESTLESS

EXCESSIVE SPEECH

ANSWERING A QUESTION BEFORE THE SPEAKER HAS FINISHED

FAILURE TO AWAIT ONE'S TURN

INTERRUPTING THE ACTIVITIES OF OTHERS AT INAPPROPRIATE TIMES

IMPULSIVE SPENDING, LEADING TO FINANCIAL DIFFICULTIES

 FREQUENTLY PRESCRIBED STIMULANTS ARE METHYLPHENIDATE (RITALIN

AND CONCERTA), AMPHETAMINES (ADDERALL) AND DEXTROAMPHETAMINES
(DEXEDRINE)
FEINGOLD DIET WHICH INVOLVES REMOVING SALICYLATES, ARTIFICIAL
COLORS AND FLAVORS, AND CERTAIN SYNTHETIC PRESERVATIVES FROM
CHILDREN'S DIETS.

CONDUCT D/O
REPETITIVE AND PERSISTENT PATTERN OF BEHAVIOR IN WHICH THE BASIC
RIGHTS OF OTHERS OR MAJOR AGE-APPROPRIATE SOCIETAL NORMS OR
RULES ARE VIOLATED,
AGGRESSION TO PEOPLE & ANIMALS
DESTRUCTION OF PROPERTY
DECEITFULNESS OR THEFT
SERIOUS VIOLATIONS OF RULES

Beginning before age 13

OPPOSITIONAL DEFIANT

CHARACTERIZED BY AN ONGOING PATTERN OF DISOBEDIENT, HOSTILE,

AND DEFIANT BEHAVIOR TOWARD AUTHORITY FIGURES THAT GOES BEYOND
THE BOUNDS OF NORMAL CHILDHOOD BEHAVIOR
SIGNS
Losing temper
Arguing with adults
Refusing to follow the rules
Deliberately annoying people
Blaming others
Easily annoyed
Angry and resentful

 Spiteful or even revengeful

SUBSTANCE ABUSE

EXCESSIVE OR UNHEALTHY USE OF SUBSTANCES, SUCH AS ALCOHOL,

TOBACCO OR DRUGS, OR USE OF PRODUCTS SUCH AS FOOD

TERMS:
TOLERANCE: the declining effect of the same drug dose when it is taken
repeatedly over time
HABITUATION: a psychological dependence of the use of a drug
ADDICTION: the biological and/ or psychological behaviors related to
substance dependence
WITHDRAWAL SYMPTOMS: result from a biological need that develops
when the body becomes adapted to having an addictive drug in the system;
occurs when serum levels decrease
ADDICTION

ALCOHOL: BLOOD ALCOHOL LEVELS OF 0.1% (100MG ALCOHOL/DL OF

BLOOD) OR HIGHER
WITHDRAWAL
Anorexia
Anxiety
Easily startled
Hyperalertness
HPN
Insomnia
Irritability
Jerky movt
Possibly: hallucinations, illusions or vivid nightmares
Seizures (7-48 hrs after cessation)
Tachycardia
tremors

 WITHDRAWAL DELIRIUM

Agitation
Anorexia
Anxiety
Delirium
Diaphoresis
Disorientation with fluctuating levels of consciousness
Fever (100 to 103 F)
Hallucinations and delusions
Insomnia
Tachycardia and HPN
Disulfiram (Antabuse) therapy

Nursing care

OBTAIN INFO ABOUT DRUG TYPE AND AMOUNT CONSUMED

ASSESS V/S
REMOVE UNNECSSARY OBJ FROM ENVIRONMENT
PROVIDE ONE-ON-ONE SUPERVISION IF NECESSARY
PROVIDE A QUIET, CALM ENVIRONMENT WITH MINIMAL STIMULI
MAINTAIN ORIENTATION
ENSURE SAFETY
USE RESTRAINTS
PROVIDE PHYSICAL NEEDS
PROVIDE FOOD AND FLUIDS AS TOLERATED
ADMINISTER MEDICATIONS
COLLECT BLOOD AND URINE SAMPLES FOR DRUG SCREENING
SPOUSE ABUSE

BATTERING PRECIPITATES 1:4 SUICIDE ATTEMPTS OF ALL WOMEN

WIVES EXPLAIN THE INJURIES AS BEING SELF-INFLICTED OR ACCIDENTAL
PHASES
Tension-building: series of small incidents that leads to beating

 Acute beating phase: wife becomes object of assault behavior

Loving phase: batterer is remorseful and assures spouse that he will not
harm her again. This leads to reconciliation.

MYTHS
They believe that if they try not to antagonize with their husband, he will
change.
Efforts to coerce the wife out of the victim role can be fruitful.

FACTS
Women stay in relationships with men who batter because they feel guilty
or responsible of the husbands behavior
Wife develops little sense of self-worth, immobilized and unable to remove
self from the relationship.

 ASSESSMENT: INJURIES, OTHER EVIDENCE

INTERVENTIONS: WITH CONSENT
CHILD ABUSE

PHYSICAL BATTERING
EMOTIONAL
SEXUAL
NEGLECT
ELDERLY ABUSE
A VARIETY OF BEHAVIORS THAT THREATEN THE HEALTH, COMFORT, AND
POSSIBLY THE LIVES OF THE ELDERLY, INCLUDING PHYSICAL AND EMOTIONAL
NEGLECT, EMOTIONAL ABUSE, VIOLATION OF PERSONAL RIGHTS, FINANCIAL
ABUSE, AND DIRECT PHYSICAL ABUSE.
COMMONLY COMMITTED BY CARE GIVERS.

SEXUAL ABUSE
COMPONENTS
Sexual Misuse: inappropriate sexual activity
Rape: there is actual penetration
Incest: refers to the relationship between the victim and abuser blood

relative or step parent role

INTERVENTIONS
Children: thru play or role playing with puppets
Prevention of further sexual abuse
next

COMPLETED SUICIDE
SELF-INFLICTED DEATH
LEVELS OF SUICIDE
Ideation: thought
Attempt: acted upon but failed
Completed

CHEMICAL RESTRAINT

CHEMICAL RESTRAINTS: MEDICATIONS USED TO RESTRICT THE PATIENTS

FREEDOM OF MOVEMENT OR FOR EMERGENCY CONTROL OF BEHAVIOR BUT
ARE NOT A STANDARD TREATMENT FOR THE PXS MEDICAL OR PSYCHIATRIC
CONDITION.

PHYSICAL RESTRAINTS: ARE ANY MANUAL METHOD OR PHYSICAL OR

MECHANICAL DEVICE ATTACHED TO OR ADJACENT TO THE PXS BODY THAT
HE OR SHE CANNOT EASILY REMOVE AND THAT RESTRICTS FREEDOM OF
MOVEMENT OR NORMAL ACCESS TO ONES BODY, MATERIAL OR EQUIPMENT.
SECLUTION AND RESTRAINTS
SECLUTION: THE INVOLUNTARY CONFINEMENT OF A PERSON ALONE IN A
ROOM FROM WHICH THE PERSON IS PHYSICALLY PREVENTED FROM LEAVING.
No therapeutic evidence other than a last resort to ensure safety.
Evidence suggest that it adds to further trauma and physical harm

GUIDELINES
All hospital staff who have direct contact with the px should have ongoing
education and training in the proper use of seclusion and restraints and other
alternatives
Physician or licensed practitioner should evaluate need within 1 hour after
the initiation of this intervention.

 Max of 4 hours for adults, 2 hours for ages 9-17, and 1 hour for children
under 9 yrs
Orders may be renewed for 24 hrs before another face to face evaluation
Continuous assessment, monitoring and evaluation; recorded
Good nursing care
For both restrained and secluded: constant monitoring face to face or by
both audio and video equipment.
Px should be released ASAP
OTHER GUIDELINES

SECLUSION
Room should allow observation and communication with px
Remove all items that px might use to harm self
Document: rationale, response to intervention, physical condition, nsg
care, & rationale for termination

RESTRAINTS
Give support & reassurance
Position in anatomical position
Privacy is important
v/s & Circulation check
Should be released q 2hrs
Avoid tying to the side rails of bed
Assist in periodic change in body positions

TERMINATING THE INTERVENTION

AS SOON AS MET THE CRITERIA FOR RELEASE
REVIEW WITH PX THE BEHAVIOR THAT PRECIPITATED THE INTERVENTION &
PXS CAPACITY TO EXERCISE CONTROL OVER BEHAVIOR
DEBRIEFING: REVIEWING THE FACTS RELATED TO AN EVENT &
PROCESSING THE RESPONSE TO THEM; CAN BE USED AFTER ANY STRESSFUL
EVENT

THERAPEUTIC IMPASSES
ARE BLOCKS IN THE PROGRESS OF THE NURSE-PT RELATIONSHIP
PROVOKES INTENSE FEELINGS IN BOTH THE NURSE AND PATIENT
RESISTANCE
TRANSFERENCE
COUNTERTRANSFERENCE
BOUNDARY VIOLATIONS

RESISTANCE
RELUCTANCE OR AVOIDANCE OF VERBALIZING OR EXPERIENCING
TROUBLING ASPECTS OF ONESELF
EG: SUPPRESSION OR REPRESSION, INTENSIFICATION OF SX, SELFDEVALUATION OR HOPELESSNESS, INTELLECTUAL INHIBITIONS, ACTING OUT
OR IRRATIONAL BEHAVIOR, SUPERFICIAL TALK, INTELLECTUAL INSIGHT/
INTELLECTUALIZATION, TRANSFERENCE REACTIONS.

TRANSFERENCE
UNCONSCIOUS RESPONSE IN WHICH THE PX EXPERIENCES FEELINGS AND
ATTITUDES TOWARD THE NURSE THAT WERE ORIGINALLY ASSOCIATATED
WITH OTHER SIGNIFICANT FIGURES IN HIS OR HER LIFE.
HOSTILE TRANSFERENCE: anger and hostility, resistance
DEPENDENT TRANSFERENCE: submissive, subordinate and regards the

nurse as a god-like figure; views relationship as magical

What do you do?

LISTEN
CLARIFY
REFLECT
EXPLORE/ ANALYZE

COUNTERTRANSFERENCE

CREATED BY THE NURSES SPECIFIC EMOTIONAL RESPONSE TO THE

QUALITIES OF THE PATIENT; INAPPROPRIATE IN THE CONTEXT, CONTENT AND
INTENSITY OF EMOTION; NURSES IDENTIFY THE PX WITH INDIVIDUALS FROM
THEIR PAST, AND PERSONAL NEEDS

TYPES: REACTIONS OF INTENSE

love or caring
Disgust or hostility
Anxiety, often in response to resistance by the px

EG.
Difficulty empathizing
Feelings of depression before or after the session
Carelessness about implementing the contract
Drowsiness during the sessions
Encouragement of the pxs dependency
Arguments with the px

 Personal or social involvement with the px

Sexual or aggressive fantasies toward the px
Tendency to focus on only one aspect or way of looking at information
presented by the px
Attempts to help the px with matters not related to the identified nursing
problems
Feelings of anger or impatience because of the pxs unwillingness to
change
Dreams about or preoccupation with the px