TABLE OF CONTENTS

I. Psychiatric Nursing, 3
II. Basic Principles of Psychiatric Nursing, 3
III.3 Levels of Psychiatric Nursing (Levels of Health), 3
a. Primary, 3
b. Secondary, 4
c. Tertiary, 6
IV. Criteria of Mental Health, 6
V. Components of Assessment of Mental Status, 6
VI. DSM V (Diagnostic and Statistical Manual for Mental Health, 7
VII. Conceptual Models of Psychiatric Treatment, 7
VIII. Psychosocial Theory of Eric Erikson, 7
IX. Psychosexual (Psychoanalytical) Theory of Sigmund Freud, 7
a. Freudian Theory Component, 8
X. Essential Elements of Nurse-Client Contact, 9
XI. Four Phases of Nurse-Client Contact, 10
a. Pre-interaction/Pre-orientation, 10
b. Orientation, 10
c. Working Phase,11
d. Termination, 11

XII. Therapeutic Communication, 11

a. Therapeutic Communication Techniques, 11
b. Blocks to Therapeutic Communication, 12

XIII. Behavioral Therapy, 13

A. Terminologies, 13
a. Classical Conditioning, 13
b. Operant Conditioning, 14
c. Behavioral Treatments, 16
XIV. Group Therapy, 16
A. Definition, 16
B. Types of Groups, 16
C. Advantage of Group Therapy, 17
D. Principles of Group Therapy, 17
E. Phases of Group Therapy, 17
XV. Defense Mechanisms, 18
XVI. Anxiety, 20
A. Definition, 20
B. Major Assessment criterion for Measuring Degree of Anxiety, 20
C. Potential Nursing Diagnosis, 21
D. Nursing Intervention, 21

0
XVII. Types of Anxiety Disorder, 22
A. Phobia and Panic Disorder, 22
B. Obsessive-Compulsive Disorder, 22
C. Post Traumatic Stress Disorder, 23
D. Anxiolytic/Anti-Anxiety Drugs, 24
a. Benzodiazepine, 24
b. Barbiturates, 24
c. Atypical Anxiolytics, 25
XVIII. Psychotic Disorder: Schizophrenia, 25
A. Assessment Finding: General Signs, 25
B. Prioritized Nursing Diagnoses for all types of Schizophrenia, 27
C. Five Types of Schizophrenia, 27
D. Principle of Care in Schizophrenia, 28
XIX. Antipsychotics, 28
A. Phenothiazine, 28
B. Butyrophenones, 29
C. Thioxanthenes, 29
D. Atypical Anxiolytics, 29
E. Six Common Anticholinergic Side Effects of Antipsychotics, 29
F. Acute/Common side Effect for Prolonged use of Antipsychotics,30
G. Anti-Extrapyramidal Medications, 31
H. Adverse Effects of Antipsychotic Drugs, 31
XX. Affective/ Mood Disorder, 31
A. Types
I. Depressive Disorder, 31
a Antidepressants/ Thymoleptics, 34
i. Selective Serotonin Reuptake Inhibitors (SSRI), 34
ii. 2nd Generation Tricyclic Antidepressants (TCA), 35
iii. MAOI-Monoamine Oxidase Inhibitor, 36
iv. Electro Convulsive Therapy (ECT), 36
II. Bipolar Disorder, 38
a. Mood Stabilizers, 40
XXI. Psychosomatic/ Somatoform Disorder, 42
A. Psychosomatic Disorders, 42
B. Types of Somatoform Disorder/Psychosomatic Disorders, 43
XXII. Dissociative Disorder, 44
XXIII. Personality Disorders, 44
A. Cluster A: ODD/Eccentric, 45
a. Paranoid Personality Disorder, 45
b. Schizoid Personality Disorder, 45
c. Schizotypal Personality Disorder, 46
B. Cluster B: Dramatic/Erratic, 46
a. Antisocial Personality Disorder, 46
b. Borderline Personality Disorder, 47

1
 c. Histrionic Personality Disorder, 47
d. Narcissistic personality Disorder, 47
C. Cluster C: Anxious/ Fearful, 48
a. Obsessive-Compulsive Disorder, 48
b. Dependent Personality Disorder, 49
c. Avoidant Personality Disorder, 49
d. Passive-Aggressive Personality Disorder, 49
XXIV: Cognitive/ Organic Mental Disorder, 49
A. Delirium vs. Dementia, 50
B. Types of Dementia
C. Alzheimer’s Disease, 50
XXV. Eating Disorders, 55
A. Anorexia vs. Bulimia, 55
XXVI. Drug Addiction/Non-Alcoholic Substance Abuse, 57
A. Non-Alcoholic Abused Substances, 57
XXVII. Sexual Disorder/ Dysfunction, 59
XXVIII. Pervasive Developmental Disorder, 60
A. Autistic Disorder, 60
B. Attention Deficit Hyperactive Disorder, 61
C. Child Abuse, 61

2
 PSYCHIATRIC NURSING

 A specialized area of nursing practice employing theories of human behavior as its

science and purposely use of self as its art. Includes the continuous and comprehensive
services necessary for the promotion of optimal mental health, prevention of mental illness,
health maintenance, management and referral of mental and physical health problems, the
diagnosis and treatment of mental disorders and their sequela, and rehabilitation

BASIC PRINCIPLES OF PSYCHIATRIC NURSING

 Accept and respect the client regardless of his behavior.

 Limit or reject the inappropriate behavior but not the individual
 Encourage and support expression of feelings in a safe and non-judgmental
environment. Increase verbalization, decreases anxiety.
 Behaviors are learned.
 All behavior has meaning.

INTERDISCIPLINARY TEAM PRIMARY ROLES

 Psychiatrist: The psychiatrist is a physician certified in psychiatry by the

American Board of Psychiatry and Neurology, which requires 3-year residency,
2-years of clinical practice, and completion of an examination. The primary
function of the psychiatrist is diagnosis of, mental disorders and prescription of
medical treatments.
 Psychologist: The clinical psychologist has a doctorate (Ph.D.) in clinical
psychology and is prepared to practice therapy, conduct research, and interpret
psychological tests. Psychologists may also participate in the design of therapy
programs for groups of individuals.
 Psychiatric nurse: The registered nurse gains experience in working with clients
with psychiatric disorders after graduation from an accredited program of nursing
and completion of the licensure examination. The nurse has a solid foundation in
health promotion, illness prevention, and rehabilitation in all areas, allowing him
or her to view the client holistically. The nurse is also an essential team member
in evaluating the effectiveness of medical treatment, particularly medications.
Registered nurses who obtain a master’s degree in mental health may be certified
as clinical specialist or licensed as advanced practitioners, depending on
individual state nurse practice acts. Advanced practice nurses are certified to
prescribe drugs in many states.
 Psychiatric social worker: Most psychiatric social workers are prepared at the
master’s level, and they are licensed in some states. Social workers may practice
therapy and often have the primary responsibility for working with families,
community support, and referral.

3
  Occupational therapist: Occupational therapist may have an associate degree
(certified occupational therapy assistant) or a baccalaureate degree (certified
occupational therapist). Occupational therapy focuses on the functional abilities of
the client and ways to improve client functioning such as working with arts and
crafts and focusing on psychomotor skills.

 Recreation therapist: Many recreation therapists complete a baccalaureate

degree, but in some instances persons with experience fulfill these roles. The
recreation therapist helps the client to achieve a balance of work and play in his or
her life and provides activities that promote constructive use of leisure or
unstructured time.

 Vocational rehabilitation specialist: Vocational rehabilitation includes

determining clients’ interests and abilities and matching them with vocational
choices. Clients are also assisted in job-seeking and job-retention skills, as well as
pursuit of further education if that is needed and desired. Vocational rehabilitation
specialists can be prepared at the baccalaureate or master’s level and may have
different levels of autonomy and program supervision based on their education.

3 LEVELS OF PSYCHIATRIC NURSING (Levels of Health)

I. Primary Objective: PROMOTION & PREVENTION

A. Client and Family Teaching (Health Teaching)

1. Teaching adolescent in preventing contracting STDs

CHLAMYDIA: #1 STD in the U.S.

#1 Sign: Greenish & purulent urethral discharge.
PID (Pelvic Inflammatory disease) #1 cause of sterility in women

#1 Drug of choice Erythromycin

2nd drug of choice Cephalosporin

2. Teaching pregnant women relaxation techniques

Objective: to prevent complication in labor, fetal distress, perineal
laceration (also can be prevented by Kegel’s exercise)

4
 Stage I of labor (LAT-CAP)
L atent C chest breathing
A ctive A bdominal breathing
T ransitionalent P ant blow breathing

3. Teaching couples on contraceptives

BON (Barrier, Oral Contraceptive, Natural)
Barrier - CONDOM
Oral - Artificial
Natural - not for M A M (Malnourished, Anemics
& Menses irregular)
4. Conducting rape prevention classes is an example of primary level of prevention.

B. Herbal Medicines

C. Psychosocial Support – family/friends/peers

Needs most support (ASA): Addicts, Suicidal, Alcoholics,
Suicide = Mmajor depression, despair, hopeless, powerless

Prone: Mmale Age bracket prone for suicide

#1. Adolescent (identity crisis)
2. Elderly (ego-despair)
3. Middle age men (40 y.o. above)
4. Post partum depression (7 days/2-4 weeks)

D. Giving Vaccines

II. Secondary : Screening, Diagnosis & Immediate Treatment

A. Screening
> Denver Development Screening Test (DDST) #1 test for PDD

Pervasive Development Ddisorder (PPD)

1. Autism: Aage of onset (3 y.o.)

2. ADHD: Aage of onset (6 y.o.)
Diet: Finger Food (high caloric, high CHO)
Rx: Ritalin (Methylphenidate); dextroamphetamine (Dexedrine)
3. Conduct disorder: Aage of onset (6 y.o.)

B. Suicide Prevention/Intervention

5
 Impending signs of Suicide
1. Sudden elevation of mood/sudden mood swings
2. Giving away of prized possessions
3. Delusion of Omnipotence (divine powers)
Used by SS (Suicidal, Schizophrenia)
4. When the patient verbalizes that the 2nd Gen TCA is working.
less than 2-4 wks (telling a lie)

Suicide Interventions:
1. One-on-one supervision and monitoring
2. No suicide contract – 24 hrs monitoring
- Patient is required to verbalize suicidal ideas
3. Non metallic/plastic/sharp objects: ex. belts, curtains
4. Avoid dark places

C. Case Finding (Epidemics)/Contact Tracing (STDs)

D. Crisis Intervention

Objective: Tto return the client to its normal functioning or pre crisis level.
Duration: (4-6 wks)
Disorganization is a phase in the crisis state which is characterized by the feelings of great anxiety
and inability to perform activities of daily living

A patient in crisis is passive and submissive, so the nurse needs to be active and should direct the
paient to activities that facilitate coping.

Types of Crisis:

1. Developmental Maturation Crisis

- Adolescence (identity crisis)
- Mid-life crisis;
- Pregnancy
- Parenthood

2. Situational / Accidental crisis –

- Most common: Ddeath of a loved one
NSG DX: Ineffective Individual Ccoping/ Denial
- ex. murder, abortion , rape and fire

3. Adventitious – calamity, disaster

ex. World War I & II, epidemic, tsunami
In a DISASTER 1st assess/survey the scene

E. Emergency drugs and antidotes

6
DRUGS/ DISEASE Action / Effect ANTIDOTES
Heparin Anticoagulant Protamine Sulfate
Warfarin (Coumadin) Anticoagulant Vit. K
Mg Sulfate Anticonvulsants Calcium gluconate
Nubain (best), Morphine Narcotics Naloxone (Narcan)
Fibrinolytic / Thrombolytic Dissolves clot Amicar (Aminocaproic
acid)
*(Neuroleptic Malignant #1 Cardinal Sign : High Dantrolene (Dantrium),
Syndrome’s (NMS) Fever / Hyperthermia Bromocriptine (Parlodel)
Effect: antiparkinsonian,
anti-prolactin, antipsychotic
Hypertensive crisis (MAOI Antidepressant intoxication Ca channel blocker
intoxication) Suffix:(-dipine)
Anxiolytics, Sedatives – Sedative hypnotic/ Minor Flumazenil (Romazicon)
Suffix: zepam, -zolam tranquilizer
Tensilon (Endrophonium): Anticholinesterase & Miotic Atropine Sulfate (ATSO4)
Anticholinesterase
intoxication, Pilorcarpine
(Pilocar) intoxication :
Miotic

III. Tertiary Objective: Rrehabilitation, which start upon admission

A. Occupational Therapy –
- Usually use behavior modification for PDD (Pervasive
Developmental Disorders), anorexia & depression
- Also use fine motor rehabilitation for Post M.I. &
Post CVA
B. Vocational Skills (Entrepreneur skills)
C. Aftercare Support – follow-up.
Needed by: addicts & residual schizophrenia due to remission & exacerbation

7
 CRITERIA OF MENTAL HEALTH
(Jahoda, 1953; Staurt and Sundeen, 1995)

 Reality perception: Aability to test assumptions about the world by empirical thought;
includes social sensitivity (empathy)
 Growth, development, & self-actualization (by Maslow) which includes fully
functioning person” (by Rogers)
 Autonomy: Iinvolves self- determination, self- responsible for decisions, balance
between dependence and independence, and acceptance of the consequences of one’s
action
 Positive attitudes toward self; includes self-identity, self-acceptance, self-awareness,
belongingness, security and wholeness

COMPONENTS OF ASSESSMENT OF MENTAL STATUS

SENSORIUM: Consciousness? Orientation? Attention?
Concentration? Comprehension?
Example: Disorientation & Confusion ( Dementia)
APPEARANCE: Appropriateness? Grooming? Rigidity?
Mannerisms?
Example: Poor Grooming (Suicidal Patients, Schizophrenia
and Manic Depression)
AFFECT / MOOD: Appropriateness? Swing? Duration? Intensity?
Example: Flat Affect: Schizophrenia & Major Depression.
Seen also in Parkinson’s Disease & Myasthenia Gravis.
Labile Affect: Manic Depression or Bipolar Disorder
THOUGHT CONTENT: Self-concept? Areas of concern? Themes? Obsessions?
Delusions? Hallucinations?
Example: Ddelusion of grandeur (manic), delusion of
omnipotence ( schizophrenia), delusion of persecution &
delusion of reference (paranoid delusions)
THOUGHT PROCESS: Ability to understanding abstract/symbols?
Example: Mmagical thinking and animism of Schizotypal
personality
SPEECH: Coherency? Relevance? Meaning? Quality/Quantity?
Example : Slurring of Speech ( alcoholism) and pressured
speech (manic depression or bipolar disorder)

8
 DSM V (Diagnostic and Statistical Manual for Mental Health)

Axis I Clinical Syndrome (S&Sx)

II Personality Disorders
III Pathological Disorders
IV Environmental & Psychosocial stressors
V Global Functioning (assessment)]

CONCEPTUAL MODELS OF PSYCHIATRIC TREATMENT

 PSYCHOANALYTICAL/PSYCHOSEXUAL MODEL. (Freud); Focus- Intrapsychic

process (conflicts, anxiety, defense mechanisms, impulses).0
 BEHAVIORAL FRAMEWORK: Focus- learned behavior; Pavlov’s Theory: Classical
Conditioning; Skinner’s Theory: Operant Conditioning.
 INTERPERSOAL MODEL (Sullivan and Peplau); Focus- Interpersonal relationships
 PSYCHOSOCIAL THEORY (Erik Erickson); Focus-Psychosocial tasks
 EXISTENTIAL MODEL / HUMANISTIC MODEL (Rogers); Focus- Conscious human
experiences
 BIOMEDICAL MODEL (Meyer, Kraeplin, Frances); Focus – Disease approach,
syndromes, diagnoses, etiologies.

PSYCHOSOCIAL THEORY OF ERIC ERIKSON

 Most commonly used theory by health professionals.

 Describes the human cycle as a series of eight EGO developmental stages from birth to
death; Focus: PSYCHOSOCIAL TASKS throughout the life cycle.
 STAGES OF PSYCHOSOCIAL DEVELOPMENT:

AGE PSYCHOSOCIAL TASKS

Infancy (0-18 mo)
Toddler (18 mo-3 yrs)
Preschool Age (3-6 yrs)
School Age (6-12 yrs)
Adolescence (12-20 yrs)
Early Adulthood (20-35 yrs)
Middle Adulthood (35-65 yrs)
Later years / Old Age (65 yrs)
Trust vs. Mistrust
Autonomy vs. Shame and Doubt
Initiative vs. Guilt
Industry vs. Inferiority
Identity vs. Role confusion
Intimacy vs. Isolation
Generativity vs. Stagnation
Most common task of 40 y/o includes developing
responsibility over their own lives
Integrity vs. Despair
76 y/o male who has a good ego integrity is preoccupied w/
death

9
 PSYCHOSEXUAL (PSYCHOANALYTICAL) THEORY
OF SIGMUND FREUD

 Infancy: Oral Phase; Stage of the Id

 Toddler: Anal Phase; Stage of the Ego
 Preschooler: Phallic Phase; Stage of the Superego (conscience)
 Attachment of the child to the parent of the opposite sex and jealousy toward the
parent of the same sex
 Oedipal Complex: Attachment of the son to his mother and jealousy toward the
father.
 Electra Complex: Attachment of the girl to her father and jealousy toward the
mother.
 Schooler: Latency phase; Stage of the Strict Superego
 Adolescent: Genital phase

FREUDIAN THEORY COMPONENTS:

1. LEVELS OF AWARENESS:

Conscious
Subconscious
Watchman of the
Personality
Unconscious
The one who molds the personality
Storage bin of traumatic & meaningful
memories. True desires & motives are here.

 Conscious – Composed of past experiences, logical and governed by REALITY

PRINCIPLE; are remembered and easily recalled or available to the individual
 Subconscious – the Preconscious; composed of material that has been deliberately
pushed out of conscious level; helps repress unpleasant thoughts or feelings and can
examine or censor certain desires or thinking; can be recalled with some effort
 Unconscious – Composed of the LARGEST BODY OF MATERIAL- the thoughts,
memories and feelings that are repressed and not available to the conscious mind, not
logical and governed by PLEASURE PRINCIPLE – and since it is usually painful
and unacceptable to the individual, it cannot be deliberately brought unacceptable to the
individual, it cannot be deliberately brought back into awareness unless in disguised or
distorted form (dreams)

10
 2. SYSTEMS OF PERSONALITY, 3 AGENCIES OF THE MIND:

Three Elements of Personality

FUNCTION PRINCIPLE LANGUAGE PERSONALITY

Id -Animal -Pleasure “I want it when Infant/child
instinct Principle I want it.”
-Survival of the
fittest

Ego -Balances Reality “I can wait.” Adult

(Mediator) the Principle
desire of the Id
and Superego
The ego acts as the
integrator of the
personality.
Superego -Induces guilt Conscience “Thou shall Parent
 undoing Principle not.”

IMBALANCE or ABNORMAL FUNCTIONING OF THE THREE ELEMENTS

OF PERSONALITY

↑Id + ↓SE = Conduct Ddisorder and Antisocial Personality Disorder

↓Id + ↑SE = Obsessive Compulsive Disorder

 ID: Psychoanalytic term for that part of the psyche that is UNCONSCIOUS, the
reservoir of INSTINCTS, primitive drives governed by the PLEASURE PRINCIPLE
and is SELF- CENTERED. The Ids says, “I want, what I want, when I want it”.
 EGO: Psychoanalytic term for that part of the psyche that is CONSCIOUS, The “I”
that is shown to the environment and most in touch with REALITY and the
MEDIATOR between the primitive, pleasure- seeking, instinctive drives of the ID and
the self- critical, prohibitive forces of the SUPEREGO and is directed by REALITY
PRINCIPLE. This is the thinking- feeling part of personality. The Ego says, “I would
want to have it if only I can afford it;” “Not now, I am not yet ready; perhaps next
week.”
 SUPEREGO: Psychoanalytic term for that part of the psyche that RESTRAINS,
controls, inhibits and prohibits impulses and instincts, is self- critical, and is called the
CONSCIENCE or EGO IDEAL. The Superego says, “I should not want that; It is not
good to even wish for it.”

11
 ESSENTIAL ELEMENTS OF A NURSE- CLIENT CONTRACT
1. Names of RN and patient 5. Purpose of a relationship
2. Roles of RN and patient 6. Meeting location / time
3. Responsibilities of RN and patient 7. Condition for termination
4. Goals / Expectations 8. Confidentiality

FOUR PHASES OF NURSE- CLIENT RELATIONSHIP (NCR)

A. Pre-interaction/Pre-orientation (For the Nurse)

- Stage of Self-Awareness  Tto prevent Counter Transference
#1 CORE VALUE OF Psychiatric Nursing

B. ORIENTATION (INITIATION)

Assessment of problems, needs, expectations of clients

Identify anxiety level of self and client
Set goals of relationship.
Define responsibilities of nurse and client. Stage of testing.
Establish boundaries of relationship. Stress confidentiality.

Contract – 2 famous psychiatric contracts:

1. No suicide contract  Mmajor depression = emergency

TWO definitions of no suicide contract:

A. 24 hrs monitoring
B. Vverbalization to the nurse of all suicide ideas

2. Diet contract  Eeating disorder

- The start of termination phase: “Good morning, full name, RN, shift, session, date
start & end.”

C. WORKING PHASE

 Promote acceptance of each other

 Accept client as having value and worth as a unique individual.
- Stage of resistance
- Counter transference phase
- Most difficult phase
-- NCP is on going
- Identification of the problem/exploration

12
 - The #1 Psychiatric Core Value is Consistency  Ffor manipulative patients
Be consistent to patient with: BAAAM COPS
B orderline C onduct d/o
A ntisocial O oral/eating disorder
A lzheimer’s P aranoid
A utistic S uicidal
 M anic
 Use therapeutic and problem- solving techniques
 Maintain PROFESSIONAL, therapeutic relationship
 Keep interaction reality- oriented- here and now
 Provide ACTIVE LISTENING and REFLECTION of feelings
 Use non- verbal communication to support client
 Recognize blocks to communication and work to remove them
 FOCUS on client’s:
 Confronting and working through identified problems
 Problems- solving skills
 Increasing independence
 Help client develop alternative, adaptive coping mechanisms

Personal biases (manifestation by counter-transference & vice versa) are seen

during working phase

D. TERMINATION
 Plan for termination of relationship early the relationship
- Stage of Separation Anxiety 
Signs & symptoms: Rregression: Ttemper tantrums, thumb sucking, apathy,
fetal position when crying.
- Phase of prognosis  Eevaluation
 Maintain boundaries
 Anticipate problems of termination:
 Increased dependency on the nurse
 Recall of previous negative experience- rejection, depression, abandonment, etc.
 Regressive behaviors
 Discuss client’s feelings and objectives achieved

THERAPEUTIC COMMUNICATION

 DEFINITION: Continuous, dynamic process of SENDING and RECEIVING

MESSAGES by various verbal or non- verbal means (words, signals, signs,
symbols) utilized in a goal- directed professional framework.

13
 THERAPEUTIC COMMUNICATION TECHNIQUES

a. Offering of self – safety, service, comfort

“I am here. I will sit here beside you.
I will lead you to the group therapy session.”
*Ursula, age 25, is found on the floor of the bathroom in the day treatment cleaning with moderate lacerations to both wrists.
Surrounded by broken glass, she sits staring blanking at her bleeding wrist while staff members call for an ambulance. The best
way the nurse should do is to approach Ursula slowly while speaking in the calm voice, calling her name and telling her that the
nurse is here to help her. This approach provides reassurance for a patient in distress.

b. Reflection: (mirror of feelings) “It must be difficult for you.” “You seem angry. You
seem concerned.”
When patient with symptoms of severe depression says to the nurse “I can’t talk; I have nothing to
say.” And continues being silent. The most appropriate response of the nurse is to say, “It may difficult
for you to speak at this time; perhaps you can do so at another time”. This response will convey that
the nurse is willing to wait for the patient’s readiness to engage in conversation.

Daughter of patient newly diagnosed w/ Alzheimer’s says, “I can’t be. Nobody in the family
is senile,” correct 5response of RN includes statement like, “It sounds as if you are shocked
over the diagnosis.”

c. Elaboration/Exploration
“Tell me more about your feelings”
“Everyone is on my back. My husband says, ‘I don’t do anything right,’ & my boss wants
me to do things differently.” RN’s response to elaborate feelings includes statement like,

“Have you discussed this with your husband about how to cope with these problems?
Tell me.”

Appropriate response for an 80 y/o who says, “I told my children that I’m ready to die.”
Includes statement like “Tell me about your feelings & I will stay w/ you.”

d. Clarification – used in neologism and word salad SAM (seen in Schizophrenia,

Alzheimer’s, Manic)

“What do you mean by…?” (Used in Neologism and word salad)

“I could not follow you.” –

(Used in flight of ideas and looseness of association)
“The ground is watching us.”, appropriate intervention includes clarify the meaning
of the word.

Brilliant & charming patient says, “I’ll be better off dead.” Best response of the RN
includes asking questions like, “Do you have plans of suicide”?

Pt says, “I’d like to take you out & give you a good show.” best response by the RN is
asking pt, “What do you mean by a good show?”

e. Reality Orientation/Reality Testing

- Nsg Dx: Altered Sensory Perception
- Delusion; Hallucination, Illusion & delusion
Client: “Help! Help! There are spiders on my back!”

14
 Nurse: “I don’t see spiders but for you that is real.”
Alcoholic pt with delirium tremens states, “There are spiders crawling on my back”.
The appropriate response of the nurse would be, “there are no spiders, its only part of
your illness”.

f. Giving Leads
“Aha..then…mmmh… go on… yes…”

g. Therapeutic Silence

h. Paraphrasing/restating – repeating
Repeats the MAIN IDEA; restate what the client says. (Patient: “I can’t believe I cannot
go home today.” Nurse: “You can’t believe that you can’t go home today?”)’

i. Summarizing – recap
Nurse: “Today you have described your understanding of how you feel when you are
upset with your son.”

j. Validation – interpret
Client: “I see a shadow.”
Nurse: “You’re frightened.”
A patient admitted to be listening to voices should be assessed by asking, “What does the voice
tells you?”
“I know that Prof. Draper tried to rape me, rape my mind...& he’s still trying to rape me”, correct of
RN includes questions like “Are you frightened being unable to control your thoughts?”
Post-menopausal woman says, “I’m pregnant by God in heaven.” Appropriate response by the
nurse includes statement like, “You believe something special happened to you?’

“It must be frightening to feel that way.” is an appropriate response for a suspicious pt
saying, “I think that my food is being poisoned”

RN’s correct response of pt w/. OCD who checks door 10-15 times includes statement
like, “It sounds as if you have much anxiety.”

k. Open-ended question / broad openings

Questions NOT answerable by ‘YES’ or ‘NO’; encourages further or broadened
communication.

“How are you?” “How’s your day?” “What are your favorite things?”

BLOCKS TO THERAPEUTIC COMMUNICATION

a. Never use why – it demands an explanation and also anxiety provoking

b. Closed Ended Question – questions answered by “yes” or “no”

15
 Note: Tthe only therapeutic closed-ended question  Ssuicidal pt.
“Are you planning to commit suicide?” – Confrontation

c. False Assurance
“Ddo not worry”  Tto patient who are dying & w/ incurable illness
“You have the best doctor; everything will be all right.”
“Relax that is nothing to worry about.”

d. Agree/disagree – never argue with client

“You are right in doing that.” / “You should not think that way.”

e. Belittling the patient – CHANGING THE SUBJECT

f. Non therapeutic silence/touch

g. Advising – never advise because they are sometimes persona; opinions

“I believe it would be better if you…”

h. Stereotyping

BEHAVIORAL THERAPY

A. TERMINOLOGIES
 STIMULUS: Aany event affecting an individual
 PROBLEM BEHAVIOR: Ddeficient, excessive, condemned, unwanted behavior
 OPERANT BEHAVIOR: Aactivities that are strongly influenced by events that
follow them.
 TARGET BEHAVIOR: Aactivities that the nurse wants to develop or accelerate
in the client.
 REINFORCER: Aa reward positively or negatively influences and strengthens
desirable behaviors.
 POSITIVE REINFORCER: Aa desirable reward produced by specific behavior
(TV time after doing homework)
 NEGATIVE REINFORCER: Aa negative consequence of a behavior (Spanking
child for wetting the floor)

A. Classical Conditioning (pairing of two stimuli in order to gain a new learning

behavior – by Ivan Pavlov)

1. Acquisition (newly acquired behavior or the by product of classical

conditioning).

16
 2. Extinction

B. Operant conditioning – Burrhus Skinner

- used in Behavior Modification

1. Positive reinforcement (Reward Orientation)

 Token Economy – use tokens as a source of reward.
Used in eating disorders and depression
> Token economy is also effective for toddlers

2. Negative Reinforcement (Punishment Orientation)

 Aversion Therapy/Aversion Technique

Behavioral Treatments

1. Desensitization – gradual exposure to the feared object

-- #1 treatment for phobia
2. Flooding/.Implosive Therapy – sudden exposure
3. Relaxation Technique – light stroking = labor
- Purse Lip Breathing Exercise = COPD/CAL (Chronic Airflow Limitation)
4. Biofeedback – mind over matter. Ex. HPN  ↓BP, palpitations, headache
5. Guided Imagery (Child) & Visualization (Adult)

GROUP THERAPY

A. DEFINITION: Psychotherapeutic processes that occur in formally organized groups

designed to change maladaptive or undesirable behavior.
Knowledge of therapeutic modalities enhances the performance of nursing interventions during therapy.
8-10 patients are the optimal number of patients in a group.

B. TYPES OF GROUPS

1. Structured
 Goals: Ppre- determined
 Format: Cclear and specific
 Factual material: Ppresented
 Leader: Rretains control

2. Unstructured
1. Goals: Nnot pre- determined. Responsibility for goal is shared by group and leader
2. Format: Discussion flows according to group members’ concern
3. Materials and topics are not pre- elected.
4. Leader: Nnondirective

17
 5. Emphasis: Mmore on FEELINGS rather than facts

C. ADVANTAGE OF GROUP THERAPY

1. Economical: Lless staff used.

2. Increased feelings of closeness Reduction on feelings of being alone.
3. With feedback group
 Corrects distortions of problems
 Builds self- image and self- confidence
 Increases reality- testing opportunities
 Gives info on how one’s personality and behavior appear to others
4. With opportunities for practicing alternative behaviors and methods of coping with
feelings
5. Provides attention to reality and provides development of insight into one’s
problems by expressing own experiences and listening to others in groups

D. PRINCIPLES OF GROUP THERAPY

1. Verbalization: Members express feelings and group reinforces appropriate

communication.
Desired outcome of group therapy includes verbalization of feelings rather than acting
them out
2. Activity: Provides stimuli to verbalization and expression of feelings.
3. Support: Members gain support from one another through interaction, sharing and
communication.
4. Change: Members have opportunity to try out new and desirable behaviors in group,
supportive setting to effect change.

E. PHASES OF GROUP THERAPY

1. Initial Phase
 Formation of group
 Setting and clarification of goals and expectations
 Initial meeting, acquaintance and interaction

2. Working Phase
 Confrontation between members→ Ccohesiveness
 Identification of problems→ Pproblem- solving processes
In a group therapy when one client says to another, “Maybe you’re taking on
someone else’s problems.” this shows that they are in the working phase

3. Termination Phase
 Evaluation of goals attainment
 Support for leave- taking

18
 In group therapy if a client says, “Leave me alone & get away from me.”, best action
of the RN is to maintain distance from the pt.
Behavior indicating that goal is met after socialization in a group therapy includes
participation of each group member telling the leader about specific problems

DEFENSE MECHANISMS

REPRESSSION SUPPRESSION
CONVERSION DISSOCIATION/SYMBOLIZATION
IDENTIFICATION INTROJECTION
SUBLIMATION COMPENSATION
RATIONALIZATION PROJECTION
DISPLACEMENT UNDOING
SPLITTING REACTION FORMATION
REGRESSION FIXATION
INTELLECTUALIZATION ACTING-OUT
DENIAL FANTASY

DEFENSE MECHANISMS

Legend: DM means Defense Mechanism

1. REPRESSION Involuntary recall painful or unpleasant thoughts or

feelings cause they are automatically & involuntarily
pushed into one’s unconsciousness.
FORGETFULNESS  Bblackout (alcoholic intoxication)
blocking (Alzheimer’s/Dementia)  Mmemory gaps 
Cconfabulation = making story to fill in memory gaps also
used by Wernicke’s Korsakoff’s = ↓ Vit. B1-thiamine,
 peripheral neuritis (tingling sensation)  ↓ B6
Pyridoxine, B9 folic acid, B12  P. anemia. Ex. Sexually
abused as a child blocks the experience from her
consciousness and is confused about inability to respond
sexually.
SUPPRESSION – used selective Willingly or voluntarily putting unacceptable thoughts or
inattention (moderate anxiety) feelings out of one’s mind with the ability to recall the
thoughts or feelings at will.

Ex. Voluntary forgetfulness or “I rather not talk about it,

right now!”
2. CONVERSION Transferring of mental conflict or emotional anxiety into
#1 DM: Ssomatic/somatoform physical symptom to release tension.
disease Ex. A soldier experiences sudden blindness after

19
 witnessing his best friend dying from a grenade blast;
Diarrhea before exam; suppress anger  HPN
DISSOCIATION Act of detaching of separating a strong emotionally
#1 DM: Mmultiple personality= charged conflict from one’s consciousness.
destruction of ego Ex. A woman raped found wandering a busy highway –
traumatic amnesia.
SYMBOLIZATION – unconscious; An object, idea, or act represents another through some
#1 DM: Pphobias common aspect and carries the emotional feeling
associated with the other.
Ex. Engagement ring symbol of love; phobias
3. IDENTIFICATION – external Unconsciously, people use it to identify with the
DM: Ppreschooler personality and traits of another. To preserve one’s ego or
self. Mimics/simulates external behavior , like fashion &
fads
Ex. Imitator, similar to role playing
INTROJECTION – INTERNAL Attributing to oneself the good qualities of another.
DM: Ddepression & counter Incorporate feelings & emotions, values & beliefs, traits
transference and personality. “ingestion, internalization”
Ex. Acting & dressing like Jesus Christ
4. SUBLIMATION Re-channeling of consciously intolerable or Socially
Unacceptable Behaviors or impulses into personally or
socially acceptable. Modify the issue, problem is still
present and connected
Ex. An aggressive person joins debate team (behavior
modification)++
COMPENSATION The act of making up for a real or imagined deficiency
with a specific behavior. Conscious or unconscious.
Problem is not connected.
Ex. An unattractive girl became a very good tennis player.
-+
5. RATIONALIZATION – object Most common ego DM. Unconsciously used to justify
#1 DM: Aanti-social disorder ideas, actions and/or feelings with good acceptable reasons
or explanation. Irrational/illogical excuses to escape
responsibility. Rationalization is justifying one’s actions which are based on
other motives. It is usually seen among alcoholics.
Ex. It wasn’t worth it; anyway, it is all for the best.
Student fails an exam, blames it on the poor lectures.
Temporarily alleviates anxiety.
PROJECTION – person Person rejects unwanted characteristics of self and assigns
#1 DM: Pparanoid them to others.Projection is attributing to others one’s unconscious
wishes/fear. Usually it is observed in paranoid patients.
Ex. Blaming others for own faults. “scapegoat”
6. DISPLACEMENT – higher to Mechanism that serves to transfer feelings such as
lower frustration, hostility or anxiety from one idea, person or
object to another.
Ex. Yelling at a subordinate after being yelled at by the
boss.

20
UNDOING OR RESTITUTION – Negation of previous consciously intolerable action or
lower to higher experience to reduce or alleviate feelings of guilt.
DM: Obsessive Compulsive Ex. Sending flowers after embarrassing her in public.
7. SPLITTING Viewing people as all good, and others as all bad
Impulsive = poor self-control
Ex. Hx of drug addicts & alcoholics
DM: Borderline (female)

REACTION FORMATION Person exaggerates or overdevelops certain actions by

#1 DM: Ppassive-aggressive displaying exactly the opposite behavior, attitude, or
personality disorder feeling from what he or she normally would show in a
given situation. OVERCOMPENSATION. Conscious
intent often altruistic. Procrastinate
Ex. Student hating her CI may act very courteously
towards her.
8. REGRESSION A. temporary retreat to past levels of behavior that
reduce anxiety, allow one to feel more comfortable. Ex. A
27 year old acts like a 17 y.o. on her first date with a
fellow employee; smoking at parties  chronic regression
FIXATION Permanent or persistence into later life of interests and
behavior patterns appropriate to an early age. Without
stressors
Ex. Chain smokers, alcoholics = oral fixation
9. INTELLECTUALIZATION The act of transferring emotional concerns into the
intellectual sphere. Exaggeration of intellect. Person uses
reasoning as a means to avoid confrontation. Ex. “Dear
John” Letter the groom is trying to figure out with his
room mate why his fiancée changed her mind – to avoid
confronting her.
ACTING - OUT Unconscious wish turned into reality
Ex. Molested child  wants to be comforted  becomes
psychologist = Oprah
10. DENIAL The unconscious refusal /avoidance to face thoughts,
#1DM: feelings, wishes, needs, and/or reality factors that are
Alcoholics, PTSD, incurable illness intolerable. Blocking the awareness of reality. Ex. “things
will get better, soon”
14 y/o girl who is undergoing dialysis says, “What’s good about this, is
that after it I will look good & thin.” This shows that the teen is
denying her chronic illness
Cancer patient saying, “You might have mixed my result with other
patients,” is showing denial

FANTASY Imagined events or mental images. Wishful thinking;

DM: Schizoid Temporary flight from reality to ↓ anxiety. Ex.
Daydreaming. (permanent flight from reality: autism)

ANXIETY

21
A. DEFINITION: Effective subjective response to an imagined or real internal or external threat.
□ Perceived SUBJECTIVELY by the conscious mind is as a painful, diffuse apprehension
or vague uneasiness, but the causative conflict or threats is not in the conscious mind
or awareness.
□ Low / mild level of anxiety is healthy and helps in individual growth and development.

B. MAJOR ASSESSMENT CRITERION FOR MEASURING DEGREE OF ANXIETY :

Client’s ability to focus on what is happening to him in a situation.

□ Mild: The perceptual field is wide allowing the client to focus realistically on what is
happening to him. Alert senses, increased attentiveness, and increased motivation.
□ Moderate: Another word is selective inattention. The perceptual field narrows and the
client is able to partially focus on what is happening if directed to do so and can verbalize
feelings of anxiety.
□ Severe: The perceptual field is significantly reduced and the client may not be able to focus
on what is happening to him and may not be able to recognize or verbalize
anxiety. All senses affected; decreased perceptual field; drained energy;
Learning and problem-solving not possible. Start of sympathetic symptoms:
tachycardia, palpitations, hyperventilation (brown paper bag to prevent
Respiratory Alkalosis) and cold clammy skin.

□ Panic: The perceptual field is severely reduced and the client experiences feelings of panic
and dread. Client overwhelmed and helpless; personality may disintegrate →
hallucinations and delusions. Pathological conditions requiring immediate
intervention. Client may harm self or others.
A patient stating, “Sometimes I feel like I’m going crazy & losing control over myself,” is showing
symptoms of panic attack

POTENTIAL NURSING DIAGNOSES

□ Ineffective Individual Coping
□ Anxiety

C. NURSING INTERVENTION IMPLEMENTATON:

□ Identify anxious behavior and anxiety levels and institute measures to decrease anxiety at a
level where learning can occur.
□ Provide appropriate environment where environmental stress & stimulation are low (First
nursing action):
 Structured, NON-STIMULATING, uncluttered
 SAFE from physical exhaustion and harm.
□ STAY. Do not leave client alone. Recognize if additional help is needed. Provide physical
care if necessary.
□ Establish PERSON-TO-PERSON relationship and maintain an accepting attitude:
 ACCEPT client. Show willingness to LISTEN.
 Encourage, allow EXPRESION OF FEELINGS at clients OWN PACE avoid forcing
verbalization.

22
 □ Administer medication as directed and needed. The pharmacology therapy of choice is the
ANXIOLYTICS-reduces anxiety so client can participate in psychotherapy.
□Assist to cope with anxiety more effectively. Assist to recognize individual strengths
realistically
 Encourage measures to reduce anxiety: activities: relaxation techniques, exercises
(DANCING, WALKING, JOGGING), hobbies, talking with support groups,
desensitization treatment program
 Provide individual or group therapy to identify anxiety and new ways of dealing with it
and develop more effective coping interpersonal skills.
 If patient can be redirected back to the topic after he gets anxious while the RN gives discharge teaching, it is an
indication that discharge teaching can be resumed.

TYPES OF ANXIETY DISORDER

1. Phobia
2. Obsessive Compulsive
3. Post Traumatic Stress Disorder (PTSD)
4. Generalized Anxiety Disorder (GAD)
5. Panic Disorder

PHOBIA AND PANIC DISORDER

A. Extreme anxiety and apprehension experienced by an individual when confronted with feared
object/ situation; commonly begins in early twenty’s (young adult) as a result of childhood
environmental factors characterized by ORDER & RIGIDITY; use compensatory mechanism
of the psychoneurotic pattern of behavior and development of symptoms permits some
measure of social adjustment.
B. PRECIPITATING FACTOR: Pressures of decision-making regarding life-style in early
adult period
C. TYPES OF PHOBIA
 Agoraphobia: Ffear of being alone, fear of open spaces or PUBLIC places where help
would not be immediately available (trains, tunnels, crowds, buses)
A client with agoraphobia who is already able to go outside the house indicates a positive response to therapy.
Expected outcome for agoraphobia includes going out to see the mailbox
 Social phobia: Ffear of public speaking or situations in which public scrutiny may occur
 Simple phobia: Ffear of specific objects, animals or situations

D. NURSING IMPLEMENTATION
 Recognize the client’s feelings about phobic object/ situation
Specific precipitants are present with phobia
 Avoid confrontation and humiliation; Provide constant support (Stay with client
during an attack) if exposure to phobic object or situation cannot be avoided
 Do not focus on getting patient to stop being afraid

23
  Provide relaxation techniques
 Implement behavioral therapy: SYSTEMIC DESENSITIZATION (the #1 treatment for
PHOBIA) . Administer antidepressants as ordered

OBSESSIVE-COMPULSIVE DISORDER

A. A psychiatric disorder characterized by persistent, recurring anxiety-provoking thoughts and

repetitive acts; Unconscious control of anxiety by the use of rituals and thoughts
1. OBSESSION: Ppersistent, repetitive, uncontrollable thoughts
2. COMPULSION: Rrepetitive, uncontrollable acts of irrational behavior that serve NO
rational purpose → rigidity, rituals, inflexibility; the development of rituals permits some
measure of social adjustment
B. ASSESSMENT FINDINGS: Rritualistic, rigid, inflexible; with difficulty making decisions
and demonstrates striving at perfection; use verbal and intellectual defenses
C. NURSING IMPLEMENTATION:
 Provide for physical safety (1st); meet physical needs
 Accept, allow ritualistic activity; DO NOT INTERFERE with it; (The best time to
interfere with ritual is after client has completed it.) Accept behavior but set limits on
length and frequency of the ritual. Offer alternative activities; support attempts to reduce
dependency on the ritual; guide decisions
 Provide structured environment, minimize choices
 Provide socialization, group therapy
 Administer CLOMIPRAMINE (ANAFRANIL) as ordered
 A Tricyclic antidepressant used in phobias, anxiety and obsessive-compulsive disorder;
SIDE-EFFECTS/ ADVERSE REACTIONS: Ttachycardia, cardiac arrest, dizziness,
tremors, seizures, CONTRAINDICATIONS: Ppregnancy, hypersensitivity;
Interactions/Incompatibilities: Hypertensive crisis, convulsions, with MAOIs

POST-TRAUMATIC STRESS SYNDROME

A. A disorder following exposure to extreme traumatic event (wars, rape, natural catastrophes)
causing intense fear, recurring distressing recollections and nightmares

B. ASSESSMENT: 2 Cardinal Sign: FLASHBACK & NIGHTMARES. Images, thoughts,

feelings → intense fear and horror, sleep disturbances.
 Depression, or irritability or outburst of anger
 Exaggerated startle response; Poor impulsive control
 Avoidance; Inability to maintain intimacy; Hypervigilance

C. PRIORITY NURSING DIGNOSIS:

Altered Sleeping Patterns

24
 Altered Skin Integrity
Ineffective Individual Coping

D. NURSING INTERVENTATION
 Encourage VERBALIZATION about painful experience. Show empathy; be non-
judgmental; Help feel safe.
 Rational emotive-therapy; Allow to grieve
 Help client identify, label and express feelings safely
 Enhance support systems: Sself-help groups, family psychoeducation, and socialization.
In a rape victim, a statement like, “If I should not have worn that red panty, it wont happen to me”, shows denial

Statement of a rape patient who is beginning to resolve trauma includes, “I’m able to tell my friends about being raped.”
An RN needs further teaching about caring for a post-traumatic client when she keeps on asking the client to describe the
trauma that caused patient’s distress after recovering from a PTSD.

GENERALIZED ANXIETY DISORDER

A. Description
1. Generalized anxiety disorder is an unrealistic anxiety in which the cause can be
identified.
The two major types of precipitating factors for anxiety are: treats to one biologic integrity and treats to one’s self-esteem.
Anxiety is one of the defining characteristics of ineffective individual coping.
A patient with anxiety disorder may exhibit difficulty in coping.

2. Physical symptoms occur

B. Assessment
1. Restlessness and inability to relax
2. Episodes of trembling and shakiness
3. Chronic muscular tension
4. Dizziness
5. Inability to concentrate
6. Chronic fatigue and sleep problems
7. Inability to recognize the connection between the anxiety and the physical
symptoms
8. Focus on the physical discomfort

PANIC DISORDER
1. Description
a. The cause usually can not be identified.
b. Panic disorder produces a sudden onset with feeling of intense apprehension
and dread.
c. Severe, recurrent, intermittent anxiety attacks lasting 5 to 30 minutes occur.

2. Assessment
a. Choking sensation
b. Labored breathing
c. Pounding heart
d. Chest pain
e. Dizziness

25
 f. Nausea
g. Blurred vision
h. Numbness or tingling of the extremities
i. A sense of unreality and helplessness
j. A fear of being trapped
k. A fear of dying
L. Ffeelings of impending doom
3. Interventions
a. Attend to physical symptoms
b. Assist the client to identify the thoughts that aroused the anxiety and
identify the basis for these thoughts.
c. Assist the client to change unrealistic thoughts to more realistic thoughts.
d. Uuse cognitive restructuring.
e. Administer anti-anxiety medications as prescribed
A client in panic disorder showing dilated eyes, trembling & says, “I can no longer go further.” Should
be accompanied in her room & RN should stay w/ her for a while
The goal of intervention in the care of the anxious patient is to enable him to develop his capacity to tolerate mild
anxiety. A combination of behavioral and somatic approaches is effective in the management of anxiety.
Therapeutic communication appropriate to patient showing signs of panic disorder
includes providing a concrete direction

ANXIOLYTICS/ANTI-ANXIETY
Another word: Sedatives/Hypnotics/Minor Tranquilizer

For: Delirium, anti-anxiety, insomnia

ACTION: Increases GABA (gamma amino butyric acid)
USES: Major use to reduce anxiety; also induce sedation, relax muscles, inhibit convulsion;
Used in neuroses, psychosomatic disorders, functional psychiatric disorders. DO NOT modify
psychotic behavior.
Most commonly prescribed drugs in medicine
Greatest harm: Wwhen combined with ALCOHOL

I. Benzodiazepine Code: -ZEPAM/ZOLAM

Action: Aanticonvulsant, muscle relaxant & anxiolytic

Diazepam (Valium)* best for: Sstatus epilepticus , the best for delirium
tremens (alcohol & cocaine withdrawal)
Estazolam (Prosom)
Alprazolam (Xanax)
Chlorazepate (Tranxene)
Oxazepam (Serax)* the best in sundown syndrome (seen in Alzheimers)
Advantage: Nnot hepatotoxic
Lorazepam (Ativan)* 2nd drug for sundown syndrome
Triazolam (Halcion)* Anti-insomnia
Temazepam (Restoril)* Anti-insomnia
Flurazepam (Dalmane)* Anti-insomnia; do not stop abruptly  because
of rebound grand mal seizure

26
 Midazolam (Dormicum)
Prazepam (Centrax)
Chlordiazepoxide (Librium)* 2nd drug of choice for delirium tremens
Clonazepam (Klonopin)
Halazepam (Paxipam)

Side Effects: #1 Vital sign to be monitored: Respiratory Rate due to its

Lethal Side Effect; Respiratory Depression
1. Early  decrease LOC  Lethargic
Late/Fatal  decrease RR  Respiratory Depression  RR below 12
Avoid strenuous activities

Antidote for Benzodiazepine intoxication: FLUMAZENIL (ROMAZICON); an

anxiolytic antagonist

II. Barbiturates
Action: Uused as an anticonvulsant besides being a sedative

Code: TAL / AL

Secobarbital (seconal)
Phenobarbital (luminal)* commonly used anticonvulsant barbiturate
Methohexital (Brevital)
Amobarbital (Amital)

III Atypical Anxiolytics

Meprobamate (Equanil, Milltown)

Chloral Hydrate (Noctec)
Hydroxyzine (Atarax, Iterax, Vistaril)* anti emetic & antihistamine
Diphenhydramine (Benadryl)* Antiparkinsons, Antihistamine,
Anxiolytic (addictive)
Zolpidem (Ambien, Stillnox) sleeping aid

1. SIDE EFFECTS
 DROWSINESS (Do not drive; assistance w/ walking; NO alcohol)
 Mental confusion (Evaluate mood, sensorium, affect)
 Habituation and increased tolerance
 Withdrawal symptoms: high doses & prolonged use (>6mo)

27
 PSYCHOTIC DISORDER: SCHIZOPHRENIA

Definition: Ssevere impairment of mental & social functioning with grossly impaired reality
testing, sensory perception and with deterioration & regression of psychosocial functioning.

A. ASSESSMENT FINDINGS (GENERAL SIGNS)

THE FOUR A’s of SCHIZOPHRENIA ACCORDING TO BLEULER

A ASSOCIATIONS, LOOSE: Jjumping to different topics WITHOUT

association or relevance
AMBIVALENCE (Two opposing feelings toward others at the same time)
AUTISM (withdrawal from environment and others) → magical thinking,
neologism, aloofness)
AFFECT, FLAT (Inappropriate or no display of feelings)
#1 HALLUCINATION of Schizophrenia is Auditory.

THEORIES:
1. Iincreased dopamine –coming from the substancia nigra
2. Trauma  PTSD
3. Ddouble-bind theory  2 kinds of information/communication
4. Genetics 65% chances- if two parents are diagnose with schizophrenia
32.5% chances- if 1 parent is diagnosed with schizophrenia
5. Drug addicts and alcoholics: Hhigh probability for schizophrenia due to increase
Delusions & hallucination

DSM V Criteria for Schizophrenia:

Characterized by both (-) & (+) symptoms & social / occupational dysfunction for at
least SIX (6) months.
Patient with 5 admissions in 2 yrs is considered a chronic schizo.

(+) POSITIVE SIGNS OF SCHIZOPHRENIA: Ddue to EXCESS DOPAMINE

Do you know HILDDA PI?

Hallucination, Illusion, Looseness of Association, Delusion, Disorientation & Agitation

Paranoia & Insomnia
Schizophrenic patient says, “Pretty red dress, tomatoes are red…” is showing looseness of
association

28
 (-) NEGATIVE SIGNS OF SCHIZOPHRENIA: Ddue to LACK OF DOPAMINE

Remember your POOR A’s?

Poor judgment, Poor insight, Poor self care
Alogia, Anergia, Anhedonia

NURSING DIAGNOSIS FOR NEGATIVE SYMPTOMS OF

SCHIZOPHRENIA:
1. Alteration in Thought Process; 2. Alteration in Content of Thought

OTHER NEGATIVE SYMPTOMS:

All this signs & symptoms can also be seen in SAM (Schizophrenia, Alzheimer’s & Manic)

1. Neologism (creating NEW WORDS) vs. Word Salad (incoherent mixture of words)
2. Flight of Ideas (jumping from one RELATED topic to another): Ccommonly seen in
MANIC patients, also in Schizophrenia.
3. Verbigeration (meaningless repetition of action words (Verb)) vs. Perseveration
e.g. 1st stimulus  correct response
2nd & following stimulus  still responding to the 1st stimuli
4. Circumstantiality (beating around the bush; answers but delayed) vs. Tangentiality
(did not answer the stimulus/ question)
5. Clang association (use of rhymes in sentences) vs. Echolalia/Parroting & Echopraxia
(Commonly seen in AUTISM)

B. PRIORITIZED NURSING DIAGNOSES FOR ALL TYPES OF SCHIZOPHRENIA:

1. Risk for violence: Ddirected toward self or other (priority!!!)
2. Self-care deficit
3. Thought process, altered
4. Sensory/perceptual alterations ( related to illusion, delusion & hallucination)
5. Social isolation

C. 5 (FIVE) TYPES OF SCHIZOPHRENIA:

1. PARANOID: Presenting sign is

SUSPICIOUSNESS, ideas of persecution and delusions; sees environment as hostile and
threatening. REMEMBER the 4 P’s: Projection (#1 defense mechanism), Proxemics( 7

29
 feet away from the patient), Passive Friendliness (#1 attitude therapy: Nno touching, , no
whispering & laughing) , delusion of Persecution (#1 delusion of Paranoid Schizophrenia) ,
A patient who says,” The other staff members are laughing at my back.” shows a paranoid
delusion of schizophrenia.
Schizophrenic says, “Someone has placed a transistor in my brain,” correct interpretation shows
paranoid delusion
Statement like, “I don’t like to eat meat because animal produced foods are
Poisonous”, shows suspicious paranoid type schizophrenia.

Developmental Stage FIXATION: ORAL PHASE (TRUST vs. MISTRUST)

NURSING CONSIDERATION:
1. Consistency to build trust
2. Food: PACKED OR SEALED foods except canned goods: Nno metal
3. Social Isolation – no group session when schizophrenic
Paranoid who is suspicious saying, “This place is meant for bugs & prison,” In order to
encourage trust, the patient should be involved in the plan of care.

2. CATATONIC: With stereotyped position (catatonia) with waxy flexibility, mutism,

bizarre mannerism.
#1 Defense mechanism: Autism & mutism
#1 Cardinal Sign of Catatonia – waxy flexibility (cerea flexibilitas)

-Ssimilar in children with autism

- Most dangerous/serious type of schizophrenia– may die from dehydration

CATATONIC CHARACTERISTICS:
- Catatonic stupor – markedly slowed movement.
- Catatonic posturing- bizarre or weird positions
- Catatonic rigidity – cementation/stone-like position
- Catatonic negativism – resistance towards flexion & extension
- Catatonic hyperactivity or excitability:

PRIORITIZED NURSING DIAGNOSIS:

1. Fluid & Electrolyte Imbalance
2. Altered Nutrition less than body requirement
3. Self Care Deficit

3. DISORGANIZED: Another word is Hebephrenic. Characterized with inappropriate

behavior: Ssilly crying, laughing, regression, transient hallucinations (Auditory).
All behaviors are similar with toddlers since they are anal fixated.
Developmental Stage FIXATION: Anal Fixation
#1 Defense Mechanism: Regression & Fixation

4. UNDIFFERENTIATED or MIXED : Symptoms of more than one type of schizophrenia

30
 - has delusions & disorganized behavior but DOES NOT meet the critieria for the above
sub types alone. The #1 drug of choice is Fluphenazine (Prolixin decanoate)

5. RESIDUAL: No longer exhibits overt symptoms, no more delusions but still has negative
symptoms or odd beliefs or unusual perceptions.
Undifferentiated type chronic schizophrenia must be referred to a program promoting
social skills due to functional loss deficit.

D. PRINCIPLES OF CARE
1. Maintenance of safety: Protect from altered thought processes. Respond to feelings, and
not to delusions; Do not argue; Validate reality; remove from areas of tension
Suspiciousness & paranoid patient is threatening to the staff, the action of an RN that
shows a need for further teaching is when shegoes to the room of a pt. who yells,
“Everyone, out of here,”
Appropriate action of RN to a Schizophrenic who yells loudly, talks to wall and saying
“Don’t talk to me, bastard.” includes walking towards the pt & ask him who he is talking to.
2. Meeting of physical needs: May have to be fed / bathe initially
3. Establishment and maintenance of therapeutic relationship: Engage in individual therapy;
Promote trust; Encourage expression by verbalizing the observed; Offer presence-Tolerate
long silences
4. Implementation of appropriate family, group, social or diversional therapies
Patients with schizophrenia need activities that do not require interaction, so solitary activities are preferred over team activities.

Admission assessment of a Schizophrenic client reveals auditory hallucination, and drinking more than 6 L
of water daily for past weeks, priority focus should be hyponatremia.
Desired efficacy of treatment in schizophrenic patient who is mute & immobilized includes standing up when RN enters
the room.

ANTIPSYCHOTICS

Another word: Neuroleptic / Major Tranquilizers

USES: Schizophrenia, acute mania, depression and organic conditions; Non-psychiatric cases:
Nausea and vomiting, pre-anesthesia, intractable hiccups.
Antipsychotics can only decrease the positive symptoms of schizophrenia, but not the negative symptom such as ambivalence.

Action: ↓ delusion, hallucinations, looseness of association

to decrease levels of dopamine in the substantia nigra

31
 I. Phenothiazine Code: AZINE
Fluphenazine (Prolixin)*
Acetophenazine (Tindal)
Pherphenazine (Trilafon)
Promazine (Sparine)
Chlorpromazine (Thorazine)*#1 that causes photosensitivity/photophobia;
Side effects: Ccauses also red orange urine
In liquid form is usually put in a chaser  Chaser: 60- 100 ml
juice (prone or tomato); to prevent constipation & contact
dermatitis; taken with straw (bite straw & sip)

Mesoridazine (Serentil)
Thioridazine (Mellaril)* ceiling dose/day: 800 mg  Adverse Effect:
Rretinitis pigmentosa
Prochlorperazine (Compazine)* #1 commonly used anti emetic
Compazine causes anticholinergic side effects
Trifluoperazine (Stelazine)

II. Butyrophenones Code: PERIDOL

Haloperidol (Haldol, Serenase)* #1 drug used for extreme violent behavior
Instruct patient taking Haldol to wear sunscreen
Droperidol (Inapsine)

III. Thioxanthenes Code: THIXENE

Chlorprothixene (Taractan
Thiothixene (Navane)

IV. Atypical Antipsychotics Code: DONE / ZAPINE or APINE

Olanzapine (Zyprexia)
Clozapine (Clozaril) #1 that causes Agranulocytosis & Blood Dyscrascia
“I will need to monitor my blood level to continue my medication.” shows a correct
understanding of a patient while taking Clozaril.
Loxapine (Loxitane)
Risperidone (Risperidone) #1 drug for Korsakoff’s psychosis
Molindone (Moban)

Aripiprazole (Abilify) newest antipsychotic drug

32
SIX COMMON ANTICHOLINERGIC SIDE EFFECTS OF ANTIPSYCHOTICS

(Anticholinergic effects are drug actions of antipsychotic drugs because they BLOCK
MUSCARINIC CHOLINERGIC RECEPTORS)

CODE: BUCO PanDan – anticholinergic S/Es

1. Blurring of Vision - ↑ sympathetic reaction (don’t operate machinery);

Mydriatic – pupil dilate  sympa  ↑ IOP  don’t use in glaucoma

2. Urinary Retention – (Post Partum, Autonomic Dysreflexia, paraplegia)

Nursing Interventions:
1. Provide Privacy – give bed pan
2. Sounds of dripping water – faucet
3. Intermittent cold & warm compress

3. Constipation
Nursing Interventions:
1. Prevent constipation ↑ fiber (residue) AG or roughage,
prune/pineapple/papaya juice/ fruits
2. ↑ OFI
3. ↑exercise

4. Orthostatic Hypotension/Postural Hypotension

- take BP in supine, Fowler’s & standing position. Difference of BP 15-20 mm Hg below
S/Sx: Ppallor, dizziness
Nursing consideration: Slowly change position
Told patient to dangle feet first before standing

5. Pan Photosensitivity (photophobia)

Nursing Intervention:
1. Use sun glasses, sun block, long sleeves or/and umbrella
Patients taking antipsychotic should be instructed to wear wide brimmed hat when
going outside

6. Dan Dry mouth/ Xerostomia

Prioritized Nursing Intervention:
Give (1) ice chips, (2) chewing gum, (3) sips of water

33
ACUTE/COMMON SIDE-EFFECTS FOR PROLONGED USED OF ANTIPSYCOTICS

Extrapyramidal Symptoms (EPS) Common Signs & Symptoms:

Definition of EPS: Rreversible side effect (except TARDIVE DYSKINESIA), which is a

result of neurological dysfunction of the Extrapyramidal System.
Patients taking with prolonged antipsychotic medications should always be assessed for symptoms of extrapyramidal symptoms.

1. Akathisia –another word: Mmotor restlessness  1-6 wks

Signs of motor restless: Foot tapping, finger fidgeting, can’t sit down for more
than 15 minutes and pacing back & forth.
Patient is unable to remain still
Drug of Choice: CODE: CBA

#1 Cogentin (Benztropine Mesylate)

#2 Benadryl (Diphenhydramine Hcl)
#3 Akineton (Biperiden Hcl)

2. Dystonia – #1 cardinal Sign: Ooculogyric crisis = involuntary rolling of eyeballs, neck

shoulder, jaw and throat spasm (dysphagia)  2-5 days
Drug of Choice: CODE: CBA

#1 Cogentin (Benztropine Mesylate)

#2 Benadryl (Diphenhydramine Hcl)
#3 Akineton (Biperiden Hcl)

3. Pseudoparkinsonism - another word: Ddrug-induced Parkinsonism – #1 sign: Ppill--

rolling tremors. Other signs: Mmask-like face, flat affect, shuffling gait or festinating gait,
cogwheel rigidity.
DRUG OF CHOICE:
#1 Artane (trihexyphenydyl)
#2 Amantadine ( Symmetrel) can also be used in Chicken pox, also an ANTI VIRAL

4. Tardive Dyskinesia – Starts with T: TONGUE (tongue rolling & tongue protrusion)
lip smacking, tongue rolling, protrusion of the tongue, vermicular or vermiform tongue
rolling  irreversible. This is an EMERGENCY!!!
Symptoms of tardive dyskinesia include fly catcher’s mouth, tongue thrusting, facial grimacing,
puckering of cheeks, and drooling of saliva.
--administer Artane, Benadryl, Cogentin, Antiparkinsonian drug

34
 5. Akinesia – absence of kinetic movements

ANTI- EPS MEDICATION

CODE: PACABBA
- Usually they are anticholinergic & antiparkinsonian drugs

Procyclidine (kemadryl, kemadrin)

Artane ( trihexyphenydyl)
Cogentin (Benztropine mesylate)
Akineton (biperiden Hcl)
Bromocriptine (Parlodel)
Benadryl (Diphenhydramine)
Amantadine (Symmetrel)

ADVERSE EFFECT OF ANTIPSYCHOTIC DRUGS:

Neuroleptic Malignant Syndrome RARE, LIFE-THREATENING : (EXTREME

EMERGENCY): #1 Cardinal Sign is High fever, tremors, tachycardia, tachypnea,
sweating, hyperkalemia, stupor, incontinence, renal failure, muscle rigidity (Discontinue
all drugs STAT; ventilation; hydration; nutrition; renal dialysis; hydrotherapeutic
measures). Elevated blood pressure and diaphoresis are indicative of Neuroleptic malignant syndrome, which is a medical
emergency.
ANTIDOTE: Dantrolene (Dantrium) or Bromocriptine (Parlodel)
Bromocriptine is both an Antiparkinsons & Anti prolactin

AFFECTIVE / MOOD DISORDERS

MODELS OF CAUSATION: Genetic; Aggression turned inward; Objects loss;

Personality disorganization; Cognitive: Hhopelessness; Learned helplessness-
hopelessness; Behavioral: Lloss of positive reinforcement; Biological: Ddecreased
serotonin and norepinephrine *; Life stressors; and Integrative: chemical, experiential,
behavioral variables

DEPRESSION: An abnormal extension or over elaboration of sadness and grief; oldest

and most frequently described psychiatric illness; a pathologic grief reaction experienced
by an individual who does not mourn
 The term depression is used in varied ways: a sign, symptom, syndrome, emotional
state, reaction, disease or clinical entity.
 May be mild, moderate, severe, with (uncommon) or without psychotic features

35
I. TYPES: Depressive Disorders, Manic-Depressive (Bipolar) Disorders, Suicidal
Behavior

A. DEPRESSIVE DISORDERS: Depressive episode with no manic episodes

1. Major depression, single episode
2. Major depression, recurrent: Rrepeated episodes of major sadness or depression
separated by long intervals, occurring in clusters or increasing with age*
3. Dysthymia: Cchronic depressive mood problems occurring in the absence of a major
depressive or organic or psychotic diagnosis.

DIFFERENTIATION/CATEGORY:
Moderate Depression – crying at night
- Dysthymia – painful depression for 2 years
*Severe Depression – Crying at early morning, depression less than 2weeks
*Major Depression – Severe depression for more than 2 weeks
* - both of them have the same characteristics

 BEHAVIORS COMMONLY ASSOCIATED WITH DEPRESSION

a. Affective: Anger, anxiety, apathy, bitterness, hopelessness, helplessness, sense of
worthlessness, low self-esteem, denial of feelings
b. Physiological: Ffatigue, backache, anorexia, vomiting, headache, dizziness,
insomnia, chest pain, constipation, weight change, abdominal pains*
c. Cognitive: Confusion, indecisiveness, ambivalence, inability to concentrate,
pessimism, loss of interest, self-blame
d. Behavioral: Altered activity level, over-dependency, psychomotor retardation,
withdrawal, poor hygiene, agitation, irritability, tearfulness
In a depressed patient, hostility is turned towards the self, while in manic patient, hostility is turned
towards the environment.
Depression in children results to anhedonia (energy loss & fatigue, decreased interest in
previously enjoyed activities) like playing alone during recess.

 DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSION: At least five of the following,

most of the day, nearly daily, for 2 weeks:
1. Early morning depression 6. Feelings of worthlessness &
2. Loss of interest or pleasure ambivalence (fear of death vs. fear living) *
(ANHEDONIA)* 7. Self care deficit*
3. Insomnia* 8. History of suicide*
4. Psychomotor retardation (slow mov’t) 9. Weight loss or gain
5. Fatigue or loss of energy (anemia) 10. Flat affect*
11. Constipation*

PREDISPOSING FACTORS:
1. Single, Annulled & Divorced
2. Loss of loved one (situational crisis)
3. SAD – Seasonal Affective Disorder – common on winter season (Nov.-Feb.) or intimate
months

36
 Seasonal depression occurs during winter and fall this is due to abnormal melatonin
metabolism.
Intervention for pt with seasonal affective disorder (SAD) during a depressed mood
includes the use of broad spectrum light in high activity area. This produces high
intensity color like broad day light.
Also instruct the pt that the light source must be 3 ft away from the eye
4. Caucasians/Afro-Americans/Asians*
5. Alcoholics/Drug addicts*
A 66 y/o American men, no hobby, no friend, retired 6 yrs ago, no money & has history of
alcohol abuse is at risk for suicide
6. Protestants
7. Incurable Illness*
8. Post partum depression
9. Schizophrenia*

Prone: Mmale Age bracket prone for suicide

#1. Adolescent (identity crisis)
2. Elderly (ego-despair)
3. Middle age men (45 y.o. above)
4. Post partum depression (7 days/2-4 weeks)

Suicide and Self-destructive Behavior

Suicide is never a random act. Whether committed impulsively or after painstaking consideration
the act has both a message and a purpose. In general the purpose or reason for suicide is to
escape; to get away or end an intolerable situation, crisis, difficulty, or relationship, e.g., escaping
a terminal illness, avoiding being a burden to others, resolving an untenable family situation, or to
avoid punishment or exposure of socially or personally unacceptable behavior.

Self-destructive behavior is action by which people emotionally, socially and physically damage or
end their lives. Typical behavior are biting one’s nails, pulling one’s hair scratching or cutting
one’s wrist. A complete suicide is the most violent self-destructive behavior.

Levels of self-destructive behavior:

1. Chronic self-destructive behavior – e.g. smoking, gambling, self-mutilation

2. Suicidal threat – a threat more serious than a casual statement of suicidal intent and
accompanied by behavioral changes, e.g., mood swings, temper outbursts, decline in school
or work performance
3. Suicidal gesture – more serious warning signal than a threat that maybe followed a suicidal
act that is carefully planned to attract attention without seriously injuring the subject
4. Suicidal attempt – a strong and desperate call for help involving a definite risk.

Cognitive styles of suicidal patients:

37
 1. Ambivalence. They have 2 conflicting desires at the same time: T to live and to die.
Ambivalence accounts for the fact that a suicidal person often takes lethal or near-lethal
action but leaves open the possibility for rescue.
2. Communication. Some, people cannot express their needs or feelings to others, or when
they do, they do not obtain the results they hope for. For them, suicide becomes a clear
and direct, if violent, form of communication.

Demographic Variables – suicide rates are higher among the following:

1. Single people
2. Divorced, separated or widowed
3. People who are confused about their sexual orientation
4. People who have experienced a recent loss: divorce, loss of job, loss of prestige, loss of
social status or who are facing the threat of criminal exposure
5. Caucasians, Eskimos and Native Americans
6. Protestants or those who profess no religious affiliation

Clinical variables:

1. People who have attempted suicide before

2. People who have experienced the loss of an important person at some time in the past or
the loss of both parents early in life, or the loss of or threat of their spouse, job, money or
social position
3. People who are depressed or recovering from depression or a psychotic episode
4. Those with physical illness, particularly when the illness involves an alteration of body
images or lifestyle
5. Those who abuse alcohol or drugs
6. Those who are recovering from a thought disorder combined with depressed mood and / or
suicidal ideation ( hallucinations that tell them to kill or harm themselves)

Management – people bent on suicide almost always give either verbal or nonverbal clues of their
intent. They actually make a powerful attempt to communicate to others their hurt ad desperation.
They are crying out for help.

1. A lethality assessment scale (Table 2) is an attempt to predict the likelihood of suicide.

Table 2: Lethality Assessment Scale

Key to Scale Danger to Self Typical Indicators

1 No predictable risk of Has no notion of suicide

immediate suicide or history of attempts,
has satisfactorily social
support network, and is

38
 in close contact with
significant others

2 Low risk of Person has considered

immediate suicide suicide with low lethal
method; no history of
attempts or recent serious
loss; has satisfactorily
support network; no
alcohol problems;
basically wants to live

3 Moderate risk of Has considered suicide

immediate suicide with high lethal method
but no specific plan or
threats; or has plan with
low lethal method ,
history of low lethal
attempts, with
dysfunctional family
history and reliance on
Valium or other drugs for
stress relief; is weighing
the odds between life and
death

4 High risk of Has current high lethal

immediate suicide plan, obtainable means,
history of previous
attempts, has a close
friend but is unable to
communicate with him or
her a drinking problem; is
depressed and wants to
die

5 Very high risk of Has current high lethal

immediate suicide plan with available
means, history of high

39
 lethal suicide attempts, is
cut off from resources; is
depressed and uses
alcohol to excess, and is
threatened with a serious
loss, such as
unemployment or divorce
or failure in school age
more in elderly and
adolescents

General guidelines – the general task of the nurse is to work with the client to stop the
constricted processing of suicidal thinking long enough to allow the client and the family to
consider alternatives to suicide.

a. Take only threat seriously

b. Talk about suicide openly and directly
c. Implement basic suicide precautions:

 Check on the client at least every 15 minutes or require the client to

remain in public places
 Stay with the client while all medications are taken
 Search the client’s belongings for potentially harmful objects. Make the
search in the client’s presence and ask for the client’s assistance while
doing so
 Check articles brought in by visitors
 Allow the client to have regular food tray but check whether the glass or
any utensils are missing when collecting the tray
 Allow visitors and telephone calls unless the client wishes otherwise
 Check that visitors do not potentially dangerous objects in the room

d. In addition to the above, maximum suicide precautions mean:

 Provide one-to-one nursing supervision. The nurse must be in the room

with the client at all times
 Maintain the client’s safety in the least restrictive manner possible
 Do not allow the client to leave the unit for test or procedures
 Serve the client’s meals in an isolation tray that contains no glass or metal
silverware

40
 e. Expect that the client will be experiencing shame, and work to assists the client
toward self- acceptance
f. Relieve the client’s obvious immediate distress
g. Find out what, in the client’s view, the most pressing need is
h. Assume a nonjudgmental, caring attitude that does not engender self-pity in the
client
i. Ask why the client chose to attempt suicide at this particular moment. The answer
will shed light on the meaning suicide has for this patient and may provide
information that can lead to other helpful interventions
j. Decide if a no-harm, no suicide contract will be used
k. Be careful not to encourage staff behaviors that give clients or staff members a false
sense of security
l. Do not make unrealistic promises
m. Encouraged the client to continue daily activities and self-care as much as possible
n. Decide with the client which family members and friends are to be contact and by
whom
o. Be prepared to deal with family members who may be confused, angry or
uninterested
p. Evaluate the client’s need for medication
q. Evaluate the plan developed in collaboration with the client and arrange for
appropriate follow-up
r. Monitor your personal feelings about the client and decide how they may be
influencing your clinical work
s. Work with other team members to evaluate the issues fully
t. Do a body examination
u. Recognize that people can and have hanged or strangled themselves with shoelaces,
brassiere straps, pantyhose, robe belts, etc.

2 LETHAL METHODS OF SUICIDE:

1. Low-risk = slashing of the radial pulse (more o females)
2. High-risk = drowning, gun shot, hanging, jumping from a very high
place/building, overdose of tranquilizer (Midazolam & Dormicum)

SUICIDAL BEHAVIORS:

SUICIDAL GESTURE: Ddirected toward the goal of receiving attention rather than
actual self-destruction; b) SUICIDAL THREAT: Ooccurs before the overt suicidal
activity takes place: “Will you remember me when I am gone,” “Take care of my
children”; c) SUICIDAL ATTEMPTS: Aany self-directed actions taken by the individual
that will lead to death if not interrupted. A most suicidal person has made a specific plan,
and has the means readily available.
Best question to be asked after a patient who recovers from an overdose of pills includes
asking “Do you still want to end your life?”

41
 IMPENDING SIGNS OF SUICIDE:

1. Sudden elevation of mood/sudden mood swings*

When a depressed patient suddenly becomes cheerful, it means that the patient is recovering
from depression and is in danger of committing suicide.
2. Giving away of prized possessions*
3. Delusion of Omnipotence (divine powers)
Used by SS (Suicidal, Schizophrenia)
4. When the patient verbalizes that the 2nd Gen TCA is working.
less than 2-4 wks ( telling a lie)

 Suicidal attempts are common when client is strong enough to carry out a suicidal
plan, usually 10-14 days after start of medication, and after ECT

USUAL TIME FOR SUICIDE:

1. Early in the morning RATIONALE: Tthe depression at this time is HIGH
2. In between nursing shifts RATIONALE: Nnurses at this time are very busy

NURSING DIAGNOSIS: (common) Risk/Potential for Injury Directed to Self

STEP BY STEP PRIORITIZE NURSING INTERVENTIONS:

1. One-on-one nursing monitoring/intervention (never leave the client)*

2. Do not leave the patient for the 1st 24 hrs. (No suicide contract)*
3. Offering of self (best therapeutic communication)*
4. No metallic objects
5. No sharp objects
6. Needs stimulus – bright room Rationale: to see suicidal acts
7. Avoid religious music (increases guilt) and love songs = non-suggestive song is needed
8. Check for impending signs of suicide = sudden elevation of mood;
#1 – sudden mood swings
A female patient who becomes euphoric for no apparent reason shows a behavior that indicates recovery
from depression, which increases the risk for suicide.
9. Activities focus on self-care
10. Join group therapy
Depressed patients usually turn their hostile feelings towards themselves. Providing an activity that serves as an outlet for these
aggressive feelings will make the patient feel less guilty.
During family therapy, a mother asks, “How long will my daughters have suicidal thoughts?”
appropriate response of the RN- ‘’ Your daughter will go on to view suicide as a way of
coping.”
11. Monitor in giving medication – do not leave patient after giving medication for 30
minutes. Check under the tongue & pillow
12. Monitor patient in CR, between shift & during endorsement
13. #1 Attitude Therapy: Kind Firmness
14. Step by step Tx: ANTIDEPRESSANT another word is THYMOLEPTICS
1st SSRI (Selective Serotonin Reuptake Inhibitor) A
2nd Second Gen. TCA

42
 3rd MAOI
4th ECT (last resort)
15. Meet physical needs:
Promote eating, rest, elimination
Promote self-care whenever appropriate / possible
16. Support self-esteem:
Warm and consistent care
Being patient with client’s slowness
Simple tasks that increase success and self-esteem and imply confidence in
capabilities
Example: Self care activities that will not easily tire the patient. Rationale:
Depressed patients have fatigue.
17. Decrease social withdrawal: Ssit with client during quiet times; introduce to others
when ready
The priority focus for a suicidal patient in the ER with a slash in her wrist is her physiologic homeostasis.
Assess attempt for suicide in a 16 y/o girl who is eating & sleeping poorly since break-up
and saying,” My life is ruined now.”

ANTIDEPRESSANTS or THYMOLEPTICS

I. SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)

Usually the FIRST LINE of drug. RATIONALE: FEWER SIDE EFFECTS

Action: Balance Serotonin – gradual effect (usually 2 weeks)
Effect: 2 wks.
Code: XETINE/ODONE

Fluoxetine HCl (Prozac) – dry mouth (xerostomia)

Paroxetine HCl (Paxil)
Trazodone (Desyrel)) – adverse effect: Ppriapism (prolonged use)
Nefazodone (Serzone)
Fluvoxamine (Luvox)
Sertraline (Zoloft) – causes GI upset (diarrhea, insomnia): always with meals
Venlafaxine (Effexor)
Citalopram (Celexia)

Common Side Effects:

1. Weight Loss
2. Insomnia (single am dose)

Nursing Considerations:
1. Ffor insomnia:
a. Induce sleep thru: 1. Wwarm bath (systemic effect)
2. Warm milk/banana (active substance: tryptophan)
3. Massage
b. Give meds in single AM dose

43
 Antidepressants are best taken after meals

II. SECOND GENERATION TRICYCLIC ANTI DEPRESSANT

Action: Increases norepinephrine and/or serotonin levels in CNS by blocking their

uptake by presynaptic neurons or it balances Serotonin & Epinephrine levels.

Effect: 2-4 wks.

Code: PRAMINE/TRYPTILLINE

Clomipramine HCl (Anaframil) #1 for OCD*

Imipramine (Tofranil)* the best drug for enuresis
Amitryptilline (Elavil)
Protryphilline (Vivactil)
Maprotilline (Ludiomil)
Norpramine (Desipramine) #1 antidepressant for elderly depression.
RATIONALE: Ffewer anticholinergic S/E
Nortryptilline (Pamelor, Aventyl)
Trimipramine ( Surmontil)
Buproprion (Wellbutrin) 400 mg/day*(ceiling dose) EXCESS INTAKE:
Ggrand mal seizure
Doxepine (Sinequan)
Amoxapine (Asendin)

Common Side Effects: 1. Sedation (at night)

2. Weight gain

Nursing Consideration: 1. Give meds at night

# 1 adverse effect – cardiac dysrhythmias

#1 screening test before taking TCA – ECG
When a depressed client taking TCA shows no improvement in the symptoms, the nurse must anticipate the
physician to discontinue TCA after two weeks and start on Parnate.
Nursing intervention before giving the drug includes checking the BP.

III. MAOI – MONO AMINE OXIDESE INHIBITOR

ACTION: Psychomotor stimulator or psychic energizers; block oxidative deamination of
naturally occurring monoamines (epinephrine, NOREPINEPHRINE, serotonin) → CNS
stimulation

Effect: 2 weeks

CODE: PAMMANA
Parnate (tranylcypromine)
Marplan (Isocarboxacid)
Mannerix (Moclobemide) *the newest MAOI
Nardil (Phenelzine SO4)

44
 CONTAINDICATIONS: TYRAMINE + MAOI = HYPERTENSIVE CRISIS
1. Tyramine rich-food, high in Na & cholesterol Hypertensive Crisis
1. Aged cheese (except cottage cheese, cream cheese),
Cheddar cheese and Swiss cheese are high in tyramine and should be
avoided.
2. Canned foods such as sardines, soy sauce & catsup
3. Organ meats (chicken gizzard & liver) & Process foods
(salami/bacon) ↑ Na
3. Red wine (alcohol)
4. Soy sauce
5. Cheese burger
6. Banana, papaya, avocado, raisins (all over ripe fruits except apricot)
7. Yogurt, sour cream, margarine;
8. Mayonnaise
9. OTC decongestants
10. Pickled foods, Pickled herring
Foods contraindicated in MAOI therapy includes figs, bologna, chicken liver, meat tenderizer, ,
sausage, chocolate, licorice, yeast, sauerkrauts, Food safe to give includes fresh fish, Cream, Yogurt,
Coffee, Chocolate , Italian green beans, sausage, yeast,

Antidote: CALCIUM CHANNEL BLOCKERS (-DIPINE)

1. Verapamil (Calan)
2. Phentolamine (Regitine)  also the #1drug for Pheochromocytoma (tumor in
the medulla)

IV. ELECTROCONVULSIVE THERAPY (ECT)

ECT is passing of an electric current through electrodes applied to one or both temples to
artificially induce a grand mal seizure for the safe and effective treatment of depression.
ECT’s mechanism of action is unclear at present

Advantages: Quicker effects than antidepressants; Safer for elderly; 80 % improvement rate of
major depressive episode with vegetative aspects

- Best therapy for major depression (last resort)

- Invasive
- Induction of 70-150 volts of electricity in).5-2secs. Then, it is followed by a
grand-mal seizure lasting 30-60 secs.
- 6-12 treatments, “every other day”

- Before ECT a major depressed client undergo the ff meds:

1. SSRi (Selective Serotonin Reuptake Inhibitor inhibitor) –2 wks
2. Antidepressants  TCA 2nd Generation – 2-4 wks
3. MAOi – 2 wks

45
 4. ECT (last resort)

Side Effects:
1. Temporary RECENT Memory Loss –
ANTEROGRADE amnesia
Intervention: Rre-orient client to 3 spheres
2. confusion/disorientation – (usually 24 hours)
3. Headache  ↑ 02 demand, ↑ cerebral hypoxia
4. Muscle spasm
5. Wt. gain (stimulate thalamic/limbic  appetite)

Contraindicated:

1. PPPP – Post MI, Post CVA, pacemaker, pregnant women

2. Neurologic problem  Alzheimer’s, degenerative disorder
3. Brain tumor, weakness of lumbosacral spine

A. Legal/Pre-Nursing Responsibilities: Preparation: Similar to preparing a client for surgery:

1. Informed Consent – if client is coherent, if not a guardian may sign the consent forms.
2. No metallic objects
3. No nail polish to check peripheral circulation
4. No contact lenses it may adhere to the cornea
5. Wash & dry hair

6. Give following medications BEFORE ECT:

a. Atropine sulfate – anticholinergic
PRIMARY purpose – to dry secretions and prevent aspiration
SECONDARY purpose – to prevent bradycardia (vagolytic)
b. Phenobarbital (Luminal), Methohexital (barbiturate Na) -
minor tranquilizer also an anticonvulsant
c. Succinylcholine (Anectine) – muscle relaxant
7. Priority vs. to focus ABC; check RR 12 less; LOC
8. Before ECT  supine position; after ECT  side-lying
9. Have patient VOID before giving ECT

46
Nursing Diagnosis:
1. Risk for Airway Obstruction/aspiration
2. Risk for Injury
3. Impaired/Altered Cognition/LOC

Nursing Intervention

5 S in Seizure 1. Safety (#1 objective)

2. Side-lying (#1 Position)
3. Side rails up
4. Stimulus ↓ (no noise & bright lights)
5. Support the head with a pillow AFTER the seizure

 FIRST & TOP priority: Ensure a patent airway. Side-lying after removal of airway.
Observe for respiratory problems
 Remain with client until alert. VS q 5 min until stable.
 REORIENT: Ttime, place (unit), person (nurse); Reassure regarding confusion and
memory loss. Same RN before & after.

B. BIPOLAR DISORDERS: With one or more manic episodes, with or without a major
depressive episode

1. Bipolar, depressive: Mmost recent or current behavior displaying major depression

2. Bipolar, manic: Mmost recent or current behavior displaying overactive, agitated
behavior
3. Bipolar, mixed: Rrapid intermingling of depressed and manic behavior
4. Cyclothymania: Nnumerous occurrences of abnormally depressed moods over a period
of at least 2 years
5.
 MANIA: Mood that is elevated, expansive, or irritable
Manic behavior is a defense against depression since the individual attempts to deny
feelings of unworthiness and helplessness.

MANIC EPISODE:
Neurotransmitter imbalance: * 1. Norepinephrine 2. Serotonin

BEHAVIORS COMMONLY ASSOCIATED WITH MANIA

a. Affective: Eelation/ euphoria, lack of shame, lack of guilt, humorous,

intolerance of criticism, expansiveness, inflated self-esteem*
b. Physiological: Dehydration, inadequate nutrition, needs little sleep, weight
loss*

47
 c. Cognitive: Ambitiousness, denial of realistic danger, distractibility,
grandiosity, flight of ideas, lack of judgment. *
d. Behavioral: Aggressiveness, provocativeness, excessive spending, hyperactivity,
poor grooming, irritability, argumentative*

DIAGNOSTIC CRITERIA FOR A MANIC EPISODE: At least 3 of the following for

at least 1 week:

1. Delusion of Grandeur – over self-worth, inflated self-esteem

RATIONALE: Aa defense to mask feelings of depression & inadequacies
2. Insomnia
3. Flight of ideas
4. Excessive involvement in pleasurable activities without regard for negative
consequences
5. Flight of ideas – talkative/pressured speech/pressure to keep talking
Tell manic pt to speak more slowly to make a sense if he keeps on moving one subject to another.

6. Hyperactive & Distractibility

8. Easily Agitated
9. Manipulative
10. Increased Metabolism
11. Poor impulse control – impulsive
12. Violent/aggressive/hypersexual
13. Pressured speech

NURSING DIAGNOSIS:

1. Risk/ Potential for Injury directed to others /or to self

2. Fluid & Electrolytes Imbalances
3. Fluid Volume Deficit

NURSING INTERVENTIONS:

1. Accept client; reject behavior

2. Provide consistent care
3. Set limits of behavior/external controls
*One staff to provide controls
*Do not leave alone in room when hyperactivity is escalating
*Explain restrictions on behavior
*Do not encourage performance/jokes
*Approach in a calm, collected, non-argumentative manner

48
 4. Distract and redirect energy: Cchoose physical activities using large movements until
acute mania subsides (dancing, walking with staff)
Meet nutritional needs: Hhigh-calorie FINGER FOODS and fluids to be carried while
moving. Prone to become fatigue, so, give finger foods: potato chips, bread, raisin, and
sandwich. SHORTCUT: ALL HIGH CALORIC & HIGH CARBOHYDRATE DIET or
ALL BAKERY PRODUCTS!!!
Tuna sandwich & apple are appropriate food for bipolar manic
A Husband of 36 y/o bipolar manic type says, “My wife hasn’t eaten or slept for days.” The RN should place a priority focus on
physical condition.
Encourage rest: Ssedation PRN, short PM naps
7. Avoid ACTIVITIES that increases attention span such as chess, bingo, scrabble...
8. Avoid CONTACT SPORTS: Bbasketball, gym, strenuous activities & Increase
perspiration!!
ACCEPTABLE ACTIVITIES: Bbrisk walking, punching bag, raking leaves, tearing
newspaper.
9 Productive activities: Ggardening, finger painting, household chores,
Activity for Manic Bipolar includes raking leaves (quiet physical, constructive, productive) to increase self-esteem;
competitive is not safe.
10. Less environmental stimulus: Nno bright lights, do not touch
11. Encourage OFI: Bbecause of Lithium and increased metabolism
12. Check Lithium intoxication
SELECTED SITUATIONS AND INTERVENTIONS:

A. Disturbing the Group Session

1. Separate the patient from the group, REMEMBER don’t touch the patient
Touching the patient may increase AGITATION.
2. Setting of limits – “matter of fact” (#1 Attitude therapy for manipulative patients)
Patient in acute manic phase begins to disrobe, appropriate nursing action includes removing patient
from group meeting & accompany him to his room

B. Aggressive Reaction
1. Decrease environmental stimulation
A pt who is pt watching TV suddenly throws the pillows & chair, immediate action
is to place pt in seclusion.
“Staff 1st used a lesser means of control for less success.” Shows a documentation
that indicates a pt’s right is being safeguarded during aggressive reactions.

C. Violent Patients
1. Move to the door fast and call the crisis management team

D. Swearing
1. Setting of Limits
2. Give avenues for verbalization/expression vs. Physical violence

MOOD STABILIZERS (ANTIMANIC DRUGS): LITHIUM

For: (Mood disorder specifically Mania (Bipolar Disorder)

49
USES: Elevate mood when client is depressed; dampen mood when client is in manic; used
in acute manic, bipolar prophylaxis; ACTS by reducing adrenergic neurotransmitter levels
in cerebral tissue through alteration of sodium transport → affects a shift in intraneural
metabolism of NOREPINEPHRINE

Action: ↓ hyperactivity and balance or stabilize the mood

Effect: 1 wk.

CODE: LITH

Lithium CO3 – Eskalith, Lithane, Lithobid

Lithium Citrate – Cibalith - S

Therapeutic Serum Level:

= 0.5-1.5 mEq (local/CGFNS)
= 0.6 – 1.2 mEq (NCLEX)
a. Early in therapy: Serum levels measured q 2-3 times per week; 12 hours after the
last dose. Long-term: q 2-3 months. Before lithium is begun baseline RENAL,
CARDIAC, and THYROID status obtained.

Antidote: 1. DIAMOX (ACETAZOLAMIDE) carbonic anhydrase inhibitor (for open

angle glaucoma)
2. MANNITOL (Osmitrol) osmotic diuretics  Action to ↑ urine output, ↓
cerebral edema
3. MNGT. OF OVERDOSE: Induce emesis / lavage; airway; dialysis for severe
intoxication
4. . If patient forgets a dose, he may take it if he missed dosing time by 2
hours; if longer than 2 hours, skip the dose and take the next dose. NEVER
DOUBLE A DOSE!!!

Nursing Considerations:
1. Before extracting Lithium serum level  Lithium fasting 12 hrs  check vital signs
2. Avoid diuretics to prevent hyponatremia
3. Avoid strenuous exercise/activities  gym works
4. Avoid sauna baths
5. Avoid caffeine  because it is a diuretic
6. For hypernatremia  AVOID Na CO3
7. Avoid taking soda and/or soda drinks
8. ↑ OFI – 3 L /day; ↑ Na – 3mg/day
A patient who is talking lithium must be placed in a normal sodium (3 gms.) , high fluid diet (3 L of water). This is done to
facilitate excretion of lithium from the body.

50
 A. Increase Na = ↓ Lithium effect
For hypernatremia  AVOID Na CO3
Avoid taking soda and/or soda drinks
When the lithium level falls below 0.5, the patient will manifest signs and symptoms of mania.

B. Decrease Na = ↑ Lithium intoxication  MORE dangerous!!!!

AVOID the 2 dangerous “D”: diuretics & dehydration
Avoid diuretics to prevent hyponatremia
Avoid strenuous exercise/activities  gym works
Avoid sauna baths (EXCESSIVE PERSPIRATION)
Avoid caffeine  because it is a diuretic

Stages in Lithium Intoxication

I. Early/Initial/Mild: 1.5 mEq

- Nausea, vomiting & anorexia
- Diarrhea
- Gross hand tremors
- Abdominal cramps  hypocalcemia  metabolic alkalosis
(Prolong vomiting  metabolic acidosis)

II. Moderate: 1.6 – 2.4 mEq

Symptoms are 2x the initial signs

III. Severe: ↑ 2.5 mEq

1. Nnystagmus, tactile, olfactory & visual hallucination
2. POA (Polyuria, Oliguria, Anuria)  ARF (Kidney problem)
Lithium is nephrotoxic & teratogenic
3. Grand Mal Seizure  Cerebral hypoxia  ↓LOC  COMA  death

PSYCHOSOMATIC / SOMATOFORM DISORDERS

A. PSYCHOSOMATIC DISORDERS: Wwithout any organic or REAL physiological

“OBJECTIVE” symptoms.
 Emotional stress may exacerbate or precipitate an illness.
 The way an individual reacts to stress depends on his physiological and psychological
make-up.
 Structural changes may take place and pose threat to life.
 Defense mechanisms include REPRESSION, PROJECTION, CONVERSION and
INTROJECTION.
 Synergistic relationship exists between repressed feelings and overexcited organs.

51
  Somatoform disorders result in impaired social, occupational and other areas of
functioning.

PSYCHOPHYSIOLOGIC DISORDER: with real symptoms!

Physical symptoms whose etiologies are in part precipitated by psychological factors and may
involve any organ system.

 Cardiovascular: Hypertension, Tachycardia

 Gastrointestinal: Peptic Ulcer, ulcerative colitis, Colic
 Respiratory: Asthma, Hyperventilation, Common colds, Hay fever
 Skin: Blushing, Flushing, Perspiring, Dermatitis
 Nervous: Chronic fatigue, Migraine headaches, Exhaustion
 Endocrine: Dysmenorrhea, Hyperthyroidism
 Musculoskeletal: Cramps
 Others: Obesity, hyperemesis gravidarum

NURSING CARE: Holistic or TOTAL – physical and emotional

Understand that PHYSICAL SYMPTOMS ARE REAL and that the client is not faking and
the TREATMENT OF PHYSICAL PROBLEMS DOES NOT RELIEVE EMOTIONAL
PROBLEMS Develop nurse-client relationship:
 Respect the client and his problems.
 Help to express feelings, Allow client to feel in control
 Let client meet dependency needs.
2. Help to work through problems and learn new coping mechanism.

TYPES OF SOMATOFORM DISORDERS / PSYCHOSOMATIC DISORDERS

1. CONVERSION DISORDER: Presence of physical symptoms with NO identified

physical etiology.
CHARACERISTICS: #1 Sign “ Labelle Indifference”
a. Can take the form of blindness, deafness, paralysis or any other physical conditions but
with no organic basis.
b. Client derives primary and secondary gains from the physical symptoms.

ASSESS FOR: TWO GAINS IN CONVERSION DISORDER

Primary gain.
REPRESSION: Keeps internal need or conflict out of awareness.
SYMBOLISM: Symptom has symbolic value to client.
Secondary gain. (Not connected to the primary gain)
Additional advantages: Ssympathy, attention, avoidance.
Reinforces maladjusted behavior.

NURSING INTERVENTION:
Do’s: Divert attention from symptom; Provide social and recreational activities;
Reduce pressure on client; Control environment

52
 Don’ts: Confront client with his illness; Feed into secondary gains through
anticipating client needs.

2. HYPOCHONDRIASIS Preoccupation with an imagined illness with no observable

symptoms and no organic changes.
#1 Sign is “DOCTOR SHOPPING”: Inability to accept reassurance even after
exhaustive testing activities as going from doctor to doctor to find cure.

ASSESS FOR
 Preoccupation with body functions or fear of serious disease misinterpretation and
exaggeration of physical symptoms
 Adoption of sick role and invalid life-style; signs of severe regression
 Lack of interest in environment history of repeated absences from work
 If the client is MALINGERING: Ddeliberately making up illness to prolong
hospitalization; ‘faking illness’

Nursing Intervention:
 Show acceptance of the client.
 Prepare for, assist in complete medical workup to reassure client and rule and medical
problems
 Psychotherapy, family therapy and group therapy:
A combination of somatic and behavioral treatment modalities facilities treatment of the disorder.
o Meet physical needs giving accurate information and correcting misconception.
o Demonstrate friendly, supportive approach but NOT focusing on the
illness.
o Provide diversionary activities that build self-esteem.
o Help client refocus on topics other than the illness.
o Assist client understand how he uses illness to avoid dealing with his problems.
DEFENSE MECHANISMS IN SOMOTOFORM DISORDERS: Denial, Projection,
Conversion, and Introjection

DISSOCIATIVE DISORDERS

A. DEFINITION: Psychiatric disorder involving disruption in the usually integrated

functions of consciousness, identity, memory, or perception of the environment; Client
attempts to deal with anxiety by BLOCKING certain areas out of the mind or deeply
REPRESSING traumatic events, or by PSYCHOLOGICAL RETREAT from reality; A
condition NOT of organic origin and usually occurs as a result of some very painful
experience
B. ASSESSMENT FINDINGS:
 AMNESIA: Sselective or generalized and continuous loss of memory

53
  FUGUE: Sstate of dissociation involving amnesia and actual PHYSICAL FLIGHT –
transient disorientation where client is unaware that he has traveled to another location
(Client does not remember period of fugue.)
 DEPERSONALIZATION: Aalteration in perception or experience of self, sense of
detachment from self, as if self is NOT REAL
 DISSOCIATIVE IDENTITY DISORDER ( MULTIPLE PERSONALITY) : Donated
by two or more personalities, each of which controls the behavior while in the
consciousness
C. NURSING IMPLEMENTATION:
 Assess what form the dissociative disorder is manifesting and degree of interference in
ADL, lifestyle, and interpersonal relations
 Reduce anxiety-producing stimuli
 Redirect client’s attention away from self; increase socialization / diversional activities
 Support modalities of treatment:
o Abreaction: aAsssisting in the recall of past, painful experiences
o Hypnosis; cognitive restructuring
o Behavioral therapy
o Psychopharmacology: Anti-anxiety, antidepressant

Most appropriate intervention for Dissociative Personality Behavior includes encouraging to chart
alternative personality.

PERSONALITY DISORDERS

A. DEFINITION: Borderline state of personality characterized by defects in its development

or by pathologic trends in its structure; premorbid personality of individuals resembling the
compensatory mechanisms associated with the pathologic counterpart.

B. PREDISPOSING FACTORS & CAUSATION

1. Biological predisposition  malnutrition, neurologic defects & congenital predisposition
2. Development of maladaptive behavior
3. Freudian fixation

GENERAL CHARACTERISTICS:
1. Denial
2. Maladaptive behavior  inflexible
3. Minor stress poor tolerance  mood disturbance
4. in reality
5. Not caused by physiological pattern
- Attitude  can be changed
- Immature
- do not adjust to environment

54
 3 CLUSTERS OF PERSONALITY DISORDERS
1. Cluster A Disorders: Odd / Eccentric
a. Paranoid b. Schizoid c. Schizotypal
2. Cluster B Disorders: Dramatic / Erratic
a. Histrionic b. Narcissistic c. Antisocial d. Borderline
3. Cluster C Disorders: Anxious/ Fearful
a. Dependent b. Avoidant c. Passive Aggressive d. Obsessive Compulsive

CLUSTER A: ODD / ECCENTRIC

A. Paranoid Personality Disorder

CHARACTERISTICS: Code (MOST OF THEM STARTS WITH LETTER “P”)

- suspicious, distrustful  oral fixation
- Loneliness  suspicious/mistrust  pathologic jealousy, hypersensitive
#1 DEFENSE MECHANISM: Projection
#1 NURSING DIAGNOSIS: Social Isolation
#1NURSING CONSIDERATION/INTERVENTIONS:
1. Passive Friendliness  no eye contact, mo touch, no laughing/giggling, non
whispering
2. Consistency
3. Proxemics: 7 feet away from the patient

B. Schizoid Personality Disorder

CHARACTERISTICS:
- Socially distant, detached, low IQ
- introvert, loner, aloof, humorless
- avoids close relationships with family, friends, peers
- Flat affect  indifferent to praise
- Functional when works alone; more interested on objects
Shy, introverted since childhood but with fair contact with reality
Autistic thinking, dreaming, emotional detachment, avoidance of meaningful
interpersonal relationships, cold and detached
#1 NURSING DIAGNOSIS: Social Isolation\

C. Schizotypal Personality Disorder

- Similar with schizophrenia
CHARACTERISTICS:
- Odd, eccentric, lowest IQ
- Magical thinking, e.g., superstitiousness, telepathy
- Ideas of reference or delusion of reference
- Cold/aloof  limit social contact=social anxiety
- Peculiarity in speech but no looseness of association
- may develop into schizophrenia or other psychotic disorders

55
 - Withdrawn, unattached, odd and eccentric,
- Diminished affective (blunted/inappropriate affect) and intellectual skills, vague, over
elaborate speech
- Frequent part of vagabond or transient groups of society
#1 NURSING DIAGNOSIS: Social Isolation

CLUSTER B: DRAMATIC/ ERRATIC

A. Antisocial Personality Disorder

- 15-40 y.o, mostly in males
- History of conduct disorder (6-11 yo)

THEORIES: Ggenetic/hereditary
Physical/Sexual abuse
Low socioeconomic status  maladaptive behaviors
CHARACTERISTICS:
- Impulsive, aggressive, manipulative
- Low self-esteem
- lack remorse
- hates rule/regulations, authority figures
- coprolalia (bad words)
- Kills, cheats, steals, rapes, destroys
- #1 Defense Mechanism: Rrationalization
- Underdeveloped superego; lack of guilt, conscience and remorse; unable to learn
from experience or punishment
- Life-long disturbances that conflict with laws and customs
- Unable to postpone gratification, immature, irresponsible
- Randomly acting out aggressive egocentric impulses on society; reckless, unlawful,
disregard for right of others.
- Steals, cheats, lies
- Appears charming, intellectual, smooth talker
- Antisocial patients have low tolerance to frustration.

NURSING INTERVENTION/CONSIDERATION:
1. SETTING OF LIMITS – “matter of fact,” voice not high nor low, does not say please.
Setting of limits prevent the patient from manipulating the nurse.
2. Consistency is a must regarding rules & regulation.
Efficacy of treatment is achieved for an antisocial if the patient is able to respect
nurse’s & other patients boundaries.
Positive outcome for antisocial personality disorder includes adherence to rule of hospital unit
Interventions that can be appreciated by antisocial include exchanging tokens for any privilege

B. Borderline Personality Disorder

- Mostly in females

56
THEORIES: Ffaulty parent-child relationship; dysfunctional family
Trauma; physical/sexual abuse (18 months)  low ego
Unfulfilled need of intimacy

CHARACTERISTICS:
- Impulsive, self-destructive, unstable
- Self-mutilation & suicidal
Therapeutic measure to prevent self-mutilation in borderline includes behavioral contract.
The purpose of behavioral contract in borderline is to limit use of unhealthy defense
mechanisms
- Unpredictable behavior (gambling, shopping, sex, substance abuse)
- Disturbance in self-concept: Iidentity
- #1 DEFENSE MECHANISM: Ssplitting
“You’re the only nurse who understands me.” This statement is shown in a patient with
borderline behavior.
- Identity disturbance with chronic feelings of emptiness (Anhedonia)
- Marked mood swings and impulsive unpredictable behavior with potential
for self-destruction.
- Intense, brief, unstable interpersonal relationships with impulsiveness,
manipulation, physical fights and temper tantrums
A borderline patient indicates an improvement when she state, “I ran around the block
rather than cutting myself”.
Borderline personality with a history of cutting her wrist shows an intense & a changeable
affect during the middle phase of nurse-pt relationship. The patient says, "You’re a smart
nurse. I want to be just like you.” This statement shows Transference
A patient borderline state, “You’re a phony. You don’t know what happened to me.”
Best response of the nurse will be, “I’ll ensure what is necessary will be done to you
Intervention for borderline d/o includes setting of limits through saying, “The policy of the unit is that, ‘You can’t
leave in the unit in 1st 24 hrs.’”

C. Histrionic Personality Disorder

- More common in women, 2-3 % of the population

THEORY: Llacks Electra complex (no father figure)

Papa’s girl

CHARACTERISTICS:

- Emotional, dramatic, theatrical

- wants to be the center of attention
- Manipulative, Sexually seductive or provocative
- Exaggeration of emotion, Style of speech is excessively impressionistic
- Labile emotion, Positive: Ccreative, imaginative
- Extroverted, manipulative, vain with behavior directed toward gaining attention to self;
- Emotionally unstable; uses somatic complaints to avoid responsibility

D. Narcissistic Personality Disorder

57
 - Usually Men
- Another: Mmetrosexual

CHARACTERISTICS:
- Vanity in personal appearance
- Exaggerated or grandiose sense of self-importance
- Boastful, egotistical, superiority complex
- preoccupied with fantasies: Ppower, success, beauty
- Excessive admirations; envies other, arrogant, lack of empathy
-Overblown sense of importance, grandiosity; with strong need for attention and
admiration from others

CLUSTER C: ANXIOUS / FEARFUL

A. Obsessive –Compulsive Personality Disorder

- More in women
- Obsession – irresistible thought, Compulsion – irresistible action

THEORIES: Genetic: Serotonin imbalance

Anal fixation  strict toilet training
Overpowering mother

CHARACTERISTICS:
- Cardinal Signs: RITUALISTIC
- #1 DEFENSE MECHANISM: Undoing, Repression, Symbolization
# 1 Ritual: handwashing

Other Ritualistic behaviors: 4 C’s:

Controlling  perfectionism
Collects or hoarding
Cleaning
Checking

 Rigid, over-conscientious, perfectionist, inflexible, cold affect

 Driven by obsessive concerns
 Sets high standards for self and others
 Preoccupied with details, rules and organization

STEP TO STEP PRIORITY NURSING DIAGNOSIS:

Altered Sleeping Patterns
Altered Skin Integrity
Ineffective Individual Coping

PRIORITY NURSING INTERVENTIONS:

58
1. Give appropriate time to do rituals to decrease anxiety
In OCD, intervention includes giving an extra ½ hr to the pt to do the ritual before starting
the task.
Question most likely to elicit response for treatment of compulsive hand washing
includes asking “how much has the symptom interfered with your daily activities?”
2. Do not abruptly stop rituals
3. Setting of limits  avoid manipulative and controlling behaviors
4. TX: Tricyclics – antidepressants  balance serotonin and norepinephrine
Effects: 2-4 wks.
Clomipramine (Anaframil) #1 drug of choice for OC
Imipramine (Toframil) 2nd drug of choice
An oriented group therapy is indicated for OCD

B. Dependent Personality Disorder

- Most common personality disorder for Acute wife battering syndrome
- Co-dependency  enabling
Statement of pt that indicates ability to care for self after being victim of domestic
violence includes a statement like, “I have a car key & money hidden outside the
house.”
Battered wife should be referred to shelter

Batterers are violent, loving & remorseful (dual personality)

Wife batterer has low-self esteem
Honeymoon episodes in acute wife battering syndrome showing statement of
reconciliation includes, “Mama, pls. get these red flowers. I love you & I’ll never do it
again.”

CHARACTERISTICS:
- Submissive, clinging
- lacks self-confidence, low self-esteem, helpless, good follower
- Lacks self-confidence, helpless when alone, preoccupied with fear of being alone
- Fails to make decisions and accept responsibility→ induces others to
take responsibility
A pt with Dependent personality who shows ineffective decision making should have
setting of limits & make behavioral contract on its daily activities.

C. Avoidant Personality Disorder

CHARACTERISTICS:
- Shy, timid, inferiority complex
- avoid open forum
- Over sensitive to rejection/criticism
- Social withdrawal = inept
- Depression, anxiety, anger are common
- Withdrawn, loner, lacks self-confidence; with feelings of discomfort/timidity
when with others
-Unwilling to get involved with others and in situations where negative evaluation,
rejection and failure are a possibility

59
 C. Passive Aggressive Personality Disorder

CHARACTERISTICS:
- insecure  backbiter  plastic
- loves to procrastinate, cant finish a task
- Patients with passive-aggressive personality expresses anger through passivity.
#1 Defense Mechanism: Rreaction formation
.
Goal of nurse in Passive Aggressive Personality includes verbalization of anger when
needed
Goal of Care for Passive Aggressive includes verbalization of feelings of anger when the
need arises.

COGNITIVE / ORGANIC MENTAL DISORDERS

I. COGNITIVE/PSYCHIATRIC DISORDERS
 With organic etiology
 With deficits in COGNITION and MEMORY
 Effects: Cchanges in levels of functioning and disturbed behavior
 MOST COMMON AREAS OF DIFFICULTY (JOCAM)
J – Judgment (impaired)
O – Orientation (confused/disoriented; illusion/hallucination)
C – Confabulation (filling in memory gaps)
A – Affect (mood changes, depression, tearful, withdrawn)
M- Memory (Impaired especially for names and recent events – compensated by
confabulation and circumstantiality)

DELIRIUM VERSUS DEMENTIA

Delirium Dementia

Acute in onset Chronic / Gradual in onset

Reversible irreversible
#1 sign: Clouding of consciousness #1 Sign: Progressive memory
Or grand mal / tonic-clonic seizure Loss

Causes: Hyperthermia, sepsis such as Causes: Uunknown

(idiopathic)
Encephalitis, meningitis, drug induced

60
 Withdrawal (alcohol & cocaine withdrawal)

SYMPTOMS OF DELIRIUM

* Difficulty with attention

* Easily distractible
* Disoriented
* May have sensory disturbances such as illusions,
Misinterpretations or hallucinations
* Can have sleep – wake cycle disturbances
* Changes in psychomotor activity
* May experience anxiety, fear, irritability, euphoria,

TYPES OF DEMENTIA

Pick’s Disease: Similar picture to DAT, but with frontal lobe symptoms (personality changes) and
reactive gliosis.

Vascular/Multi-infarct Dementia: Ppatchy cognitive deterioration (dependent on infarct site)

appearing within 1 years of vascular injury; common in men and earlier in onset.

Huntington’s Disease: Autosomal dominant (chromosome 4) disorder with both motor (chorea,
gait disturbance, slurred speech) & cognitive changes (dementia)

Creutzfeldt-Jacob Disease: Dementia due to prions (infectious particle without DNA or RNA);
rapidly progressive from vague somatic complaints to ataxia, dementia then death.

Parkinson’s Disease:
 Dopamine in the basal ganglia & extra-pyramidal system causes tremors (pill-rolling &
resting), bradykinesia, cogwheel rigidity, shuffling gait, mask-like fascies.
 Progresses to depression & dementia, treated with L-dopa
Nursing care for the patient with dementia is geared towards maintaining existing functions by minimizing regression.

61
 Place an alarm signal to know that the pt is attempting to exit in a dementia client who used to wander away
from acute facility.

ALZHEIMER’S DISEASE

 Degenerative disease of the central nervous system characterized by premature senile

retardation. Degenerative disorder of the cerebral cortex.
 The etiology of Alzheimer’s disease is unknown
 The most common non- traumatic cause of dementia is Alzheimer’s disease at 65, 10%
of the population has Alzheimer’s; by 85, the percentage increases to half. Multi-infarct
dementia is the second most common cause of non – traumatic dementia.

 NATURE: Gradual, progressive; Onset: Usually after 65 (2-4%); may begin at 40-65;
may die within 2 yrs or 8-10 yrs if with total care. The main pathology is the of presence
of senile plaques that destroys neurons leading to decreased acetylcholine.

 The primary need of a patient with Alzheimer’s is Reorientation.

4 CARDINAL SIGNS OF ALZHEIMER’S

1. Agnosia – sensory–inability to recognize objects/subjects

Patient with agnosia is unable to recognize persons.
st to forget:
1 Tthe name of an object
2nd to forget is the function of an object
2. Apraxia – sensory-inability for purposeful mov’t. ex. Tremors
3. Amnesia – 1st amnesia to appear: Aanterograde amnesia –recent memory
2nd amnesia to appear: Retrograde – past
Tx: Reminiscing Group Therapy
4. Aphasia – sensory-inability for speech and communication

Predisposing/Contributing Factors: Psychiatric Mental Health Nursing 3rd edition by Mary C.

Townsend
Exact cause unknown but several hypothesis were introduced; (pg 342-343)
1) Acetylcholine Alteration: Ddecrease in acetylcholine reduces the amount of
neurotransmitter which results in disruption of cognitive process.
2) Accumulation of Aluminum: Sstudies show that aluminum accumulates in damaged areas of
the brain.
3) Alterations in the Immune System: Aantibodies are being produced in the brain which
causes a reaction against self it is called autoimmune.
4) Head Trauma: Head injuries
5) Genetic Factor: Pattern of inheritance

THREE STAGES OF ALZHEIMERS

62
Early stage (Forgetfulness Stage: Mild)

The first symptom of Alzheimer’s disease is Progressive memory loss. This is followed by
disorientation, personality changes, language difficulty, and other symptoms & dementia.
The patient can compensate for the memory loss but the family may notice personality changes
and mood swing. Recent memory is affected including the ability to learn new information.
Managing daily living activities becomes progressively more difficult. The patient may notice
difficulty balancing his checkbook and may forget where he put things. Forgetfulness: loose
things; forget names, short-term memory loss, and the individual is aware of the intellectual
decline. Early Confusion: Symptoms of confusion begins and concentration may be interrupted.
Individual may forget major event in personal history such as birthday of his/her child:
experience declining activity to perform task; individual may deny memory loss. Findings that
are observed in the early stages of Alzheimer’s disease are inappropriate affect, disorientation
to time, paranoia, memory loss, and an impaired judgment.

* Response of nursing assistant to an Alzheimer’s patient that Needs Further Teaching includes
a statement like, “How many glasses of water did you drink today?” - Anterograde amnesia.

Middle stage (Wandering Stage/Sundown syndrome)

The patient is increasingly disoriented and completely unable to learn and recall new information.
He may wander or become agitated or physically aggressive. He may have bladder incontinence
and may require assistance with activities of daily living. Individual may be unable to recall major
life events even the name of spouse. Disorientation in the surroundings is common and the person
may be unable to recall the day, season, and year. Sleeping becomes a problem. Symptoms worsen
in the evening known as “SUNDOWNING.

Late stage (Kluver Bucy like Syndrome)

The patient may be unable to walk and is completely dependent on caregivers. He’s totally
incontinent of bowel and bladder. He may even be unable to swallow and is at risk for
aspiration. He’s unable to speak intelligibly. In the late stages of Alzheimer’s disease it is better
to go along with the patient’s reality rather than confront him with logical reasoning. Asking close
ended simple questions that relate to his reality is non-threatening and calming. Note that the
nurse’s response in a way that is congruent is the main concern. The individual may not recognize
family members. There may be problems of immobility.

Nursing Diagnosis: Risk for trauma

63
Nursing Intervention: 1) Milieu Therapy is needed: a CONSISTENT UNCHANGING &
FAMILIAR ENVIRONMENT IS NEEDED to decrease
chances of disorientation & confusion.
In milieu therapy, patients plan and lead activities rather than the staff.
Millieu therapy involves scientific manipulation of the environment that can influence
improvement patient’s behavior
2) Store frequently used items within reach.
3) Keep bed in unelevated position with soft padding if client has
history of seizure and keep the rails up.
A confused Alzheimer’s patient who gets out of bed several times must be provided with
a safe environment like placing a hand rails for the patient to hold.
Bed of confused Alzheimer’s patient must always have its side rails up.
4) Assign room near nurses’ station.
5) Assist patient with ambulation.
6) Keep dim light on at night. Decrease environmental stimulus.
7) If patient is a smoker, stay with him/her at all times.
8) Frequently orient patient to time, place and situation.
9) If patient is prone to wander, provide an area in which the client is
safe to wander.
10. Family counseling about Alzheimer’s disease includes checking
that pt is wearing ID bracelet when going out at all times
11. Soft restrain may be required if the client is disoriented and
hyperactive as ordered by the physician.
12. Provision of simple, structured environment, ↓ choices
Consistency and ROUTINE in care to increase security; Brief,
frequent contacts; reinforce reality-oriented comments
Ample time and patience to allow client to talk / complete tasks
using associative patterns to improve recall: simplicity,
focusing, repeating, summarizing.
Allow REMINISCING of past life / exploits / achievements.
Reminiscing helps lessen the patient’s loneliness.
13. Wear the Medical Alert Bracelet – (name, Address, Tel #,
Diagnosis, Medication)
14. Avoid afternoon naps, avoid caffeine, TV & radio remote
15. REMEMBER THE 3 C’s for Alzheimer’s to DECREASE
DISORIENTATION: Color, Calendar, Clock

Nursing Diagnosis: Altered thought process

Nursing intervention: 1) Frequently orient the patient to reality.

64
Sensory stimulation for elders helps to increase pt’s arousal
2) Keep explanation simple and use face-to-face interaction. Speak
slowly and do not shout. In caring for elderly w/ Alzheimer’s use
short & simple words & face him while you are talking.
3) Discourage rumination of delusional thinking. Talk about real people
and real events.
4) Monitor for medication side effects.
5) Use soft tone, simple sentences, and a slow,
calm manner when speaking to a person with Alzheimer’s
disease. If he doesn’t understand you, repeat yourself using the
same words. Your nonverbal communication is more important
than your actual spoken message. Don’t a hurried tone, which will
make the patient feel stressed. Move slowly and maintain eye
contact.

Nursing Diagnosis: Self-care deficit

Nursing Intervention: 1) Identify self-care deficit and provide assistance.
Urinary incontinence in patient with Alzheimer’s can be controlled
by decreasing fluid intake at night time
2) Allow plenty of time for the patient to perform task.
3) Provide guidance and support for independent actions by talking
the patient through the task.
4) Provide structure schedule of activities that does not change
from day to day.
5) ADLs should follow home routine as closely as possible.
6) Provide client’s nutritional needs, safety and security. .
7. Give foods high in carbohydrates to an Alzheimer’s who refuses
to eat his meal
In an Alzheimer’s caregiver class, the nurse tells the student that the reason why pt’s do not take a bath is
that they cant remember anymore if they have taken the bath already.

Screening Test: MS Brunner and Suddarth (pg 160)

1) Electroencephalography
2) Computed tomography
3) Magnetic Resonance Imaging

Confirmative Test: MS Brunner and Suddarth (pg 160)

Cerebral biopsy after death.
Complication: MS Brunner and Suddarth (pg 158)
1) Infection
2) Malnutrition

65
 Best Drug: Anticholinesterase:I increases ACH (acetylcholine) levels
MS Brunner and Suddarth (pg 160)
Tacrine hydrochloride (Cognex)
Donezepil (Aricept)
Rivastigmine (Exelon)

DRUG STUDY:
No cure or definitive treatment exists for Alzheimer’s disease. However, three drugs,
tacrine (Cognex), rivastigmine (Exelon), and donepizel (Aricept), have been approved by
the Food and Drug Administration to improve cognitive function in patients with mild to
moderate Alzheimer’s disease.

Tacrine hydrochloride (Cognex)-monitor patient for liver toxicity

Tacrine hydrochloride (Cognex)-enhances acetylcholine uptake in the brain, thus
maintaining memory skills for a period of time.

SUMMARIZED DRUGS USED TO TREAT DEMENTIA

NAME DOSAGE RANGE AND NURSING

ROUTE CONSIIDERATION

Tacrine (Cognex) 40 – 160 mg orally per day Monitor liver enzymes for
divided into 4 doses hepatotoxic effects.
Monitor for flu – like
symptoms.

Donepezil (Aricept) 5 – 10 mg orally per day Monitor for nausea,

diarrhea, and insomnia.
Test stools periodically for
GI bleeding.

Rivastigmine (Exelon) 3 – 12 mg orally per day Monitor for nausea,

divided into 2 doses vomiting, abdominal pain,
and loss of appetite.

Galantamine (Reminyl) 16 – 32 mg orally per day Monitor for nausea,

66
 divided into 2 doses vomiting, loss of appetite,
dizziness, and syncope.

BEST HERBAL DRUG FOR ALZHEIMERS:

Enhancing memory with ginkgo biloba

Ginkgo biloba, a plant extract, contains several ingredients that many believe can slow
memory loss in people with Alzheimer’s disease, Research has shown that ginkgo
produces arterial, venous, and capillary dilation, leading to improved tissue
perfusion and blood flow. Adverse effects are uncommon but may include GI upset or
using anticoagulants.

EATING DISORDERS

#1 CAUSE: Unknown
#1 Personality Disorder of Eating Disorders: Obsessive Compulsive Personality

THEORIES OF CAUSATION:
1. Behavioral: Aattention-seeking by rejecting foods; manipulation to gratify needs
2. Family interaction: Aambivalent feelings towards mother; overprotection, rigidity, lack
of personal boundaries and independence; use of anorexia to avoid interpersonal conflicts.
The issue of CONTROL is a central one for the client with anorexia nervosa. It is believed
that symptoms are caused by stressor that the adolescent perceives as a loss of control in
some aspect of her life. Controlling intake and weight gain is a way the client establishes a
sense of control over her life.
3. Psychoanalytic: Rregression to oral and anal developmental stage to avoid adolescent
sexuality and independence
4. Medical: Ggenetic predisposition, increased catecholamines, hypothalamus dysfunction

ANOREXIA BULIMIA
- Amenorrhea  lanugo - Binge/purge syndrome
Binge eating: Eating increased amounts of
high calorie food in a short period of time.
-2 binge-eating episodes or more per week
for 3 months

- ↓ 15-20% ideal weight - fluctuation of body weight

Defective defense mechanism: Denial There is ACCEPTANCE

Poor to fair prognosis - good prognosis  acceptance
- Bulimic patients are usually aware of

67
 their abnormal behavior.

CHARACTERISTICS CHARACTERISTICS
- vegetarian - carbohydrate, ↑ caloric fast foods
- All are females - 4 % are Boys
- Adolescent 11-17 yo - young adults
- hoards/collects food - loves to cook
- strenuous exercise -abuses laxatives/enema
- introvert - extrovert
- Patient’s with eating disorders are usually high achievers,
perfectionist and preoccupied with food.

OTHERS:
Refusal to take meals → dramatic weight loss
Anorexic patients usually suppress their appetite, which makes it
difficult for the nurse to convince them to eat.
Resistance to treatment; difficulty accepting
nurturance & caring
Feelings of loneliness and isolation
Hypotension, bradycardia, hypothermia
Secondary sexual organ atrophy; amenorrhea
Reduced metabolism, reduced hormonal
functioning; hypoglycemia; electrolyte
imbalance
Hyperactivity; Constipation; Leukopenia
Skin problem: Hyperkeratosis (overgrowth of
horny layer of epidermis) Complications:
- esophageal varices
- dental carries
Complications: - callous finger
#1 Cause of death: cardiac dysrrhythmia --. - chipmunk face
Hypokalemia  ECG  ST segment depression
& Prominent U wave
STEP BY STEP NURSING DIAGNOSIS:
1. F/E imbalance
2. Fluid volume deficit – hypovolemic shock
STEP BY STEP NURSING DIAGNOSIS: 3.Altered Nutrition less than body
1. F/E imbalance requirement
2. Fluid volume deficit – hypovolemic shock
3. Altered Nutrition less than body requirement
4. Altered Body Image
Change of body image causes difficulty in self-esteem.
Long term treatment for anorexia/bulimia includes
outpatient family therapy sense of control over herself is
a positive outcome in eating disorder.

68
 NURSING INTERVENTION FOR EATING DISORDERS

1. DIETARY THERAPY → restoration and stabilization of nutritional and fluid balance

a. Feedings: Ooral, IV or tubes; monitor hydration and electrolytes
An anorexic patient with high urine specific gravity must be encouraged to have an increase fluid intake
b. Caring and nurturance when possible
c. Provide education 1) on growth & development and normal nutrition 2) Limit
setting: Bbased on weight gain or loss, grant or restrict privileges; use behavioral
contract to enforce limits
2. ASSESS AND EVALUATE:
 Weight and % of normal body weight loss; weighing 3x a week: Ssame time,
clothing and weighing scale. Limit activity based on weight gain: For wt. Loss –
complete bed rest; gain less than 100 g- with bathroom privileges; more than 200 g-
may ambulate in the hospital
 Eating patterns: Aamount, type of foods, time and place of eating, whether food is
forced or followed by vomiting; Provide surveillance 30 min. to 1 hr after meals
 Preventing the patient from using the bathroom for 2 hours after eating, prevents the patient from inducing vomiting.
 Presence of anemia, hypotension, bradycardia, amenorrhea
 Interpersonal relationships
3. PROVIDE A STRUCTURED ENVIRONMENT that offers safety and comfort and helps
DEVELOP INTERNAL CONTROL→ reduces need to control by self-starvation.
4. Help client accept eating problem and set realistic, attainable short-term goals
5. Provide support is developing better outlets for emotional expression; Encourage outside
interests not related to food
6. Provide teaching on therapeutic diet: Bbalanced, calories restriction to effect WEIGHT
GAIN (1-2 pound per week)
7. Offer PRAISE for progress; accept lapses (behavior modification)
8. Instruct and support in behavioral modification program: 1) Control speed of eating –
chewing food well; 2) Self monitoring w/ food diary; & 3) Praise/reinforce compliance
Best discharge plan for anorexic teen includes attending a support group

69
 DRUG ADDICTION/NONALCOHOLIC SUBSTANCE ABUSE

SUBSTANCE ABUSE TERMS AND DEFINITTIONS

TERMS
DEFINITIONS

Psychoactive substance A substance that affects a person’s mood

or behavior

Substance abuse Continued use of a psychoactive

substance despite the occurrence of
physical, psychological, social, or
occupational problems

Substance dependence A range of physiologic, behavioral, and

cognitive symptoms indicating that a
person persists in using the substance,
ignoring serious substance-related
problems

Physiologic dependence The body’s physical adaptation to a drug,

whereby withdrawal symptoms occur if
the drug is not used

Psychological dependence The emotional need or craving for a drug

either for its effect or to prevent the
occurrence of withdrawal symptoms

Addiction A compulsion, loss of control, and

progressive pattern of drug use;
characterized by behavioral changes,
impaired thinking, unkept promises to
stop usage, obsession with the drug,
neglect of personal needs, decreased
tolerance, and physiologic deterioration

70
Polysubstance abuse Concurrent use of multiple drugs

Intoxication An altered physiologic state resulting

from the use of a psychoactive drug

Overdose Accidental or deliberate consumption of a

drug in a dose larger than is ordinarily
used, resulting in a serious toxic reaction
or death

Tolerance Tolerance is the need for the increasing

amount of a substance to produce its
desired effect. It also refers to the
decreasing effect of the drug.

A state whereby the effect of a drug is

Cross-tolerance decreased and greater amounts are
required to achieve the desired effect
because the person has become tolerant to
a similar drug

Any factor that increases the likelihood of

Predisposition an event occurring

The ability of one drug to increase the

Potentiation activity of another drug when taken at the
same time

Any use of a drug that deviates from

Drug misuse medical or socially acceptable use

71
 The coexistence of a major psychiatric
Dual diagnosis illness and a psychoactive substance
abuse disorder

An acute situation in which a person

Blackout experiences a period of memory loss
for actions as a direct result of using
drugs or alcohol

Discontinuation of a substance by a
Withdrawal person who is dependent on it

The process of withdrawing a person

Detoxification from an addictive substance in a safe
manner

The amount of a drug that produces a

Toxic dose poisonous effect

The tendency to relapse into a former

Recidivism pattern of substance use and associated
behaviors

The return to a normal state of health,

Recovery whereby the person does not engage in
problematic behavior and continues to
meet life’s challenges and personal goals

Complete abstinence from drugs while

Sobriety developing a satisfactory lifestyle

Voluntarily refraining from activities

Abstinence or the use of substances that cause
problems in the physiologic,
psychological, social, intellectual, and

72
 spiritual arenas of a person’s life

A. ASSESSMENT FINDINGS
● History. Academic or job failures, marital failures, stealing to support habit,
personality change, violent acting out
● Physical Examination: Mmalnutrition; abdominal cramps; diaphoresis, yawning,
lacrimation, rhinorrhea 10 hours after the last opiate injection; needle marks on
arms along path of a vein (wearing of long- sleeves); nasal discharge with nasal
septum perforation (cocaine)
● Social: Inability to maintain ADL and fulfill role responsibilities and obligations

B. NURSING DIAGNOSES, POTENTIAL:

● Altered health maintenance/nutrition related to chemical dependence; lack of interest

in food
● High Risk for Violence: Ddirected toward self or others related to feelings of
suspicion or distrust; intake of mind-altering substances; misinterpretation of stimuli
● Defensive Coping related to denial of problem; projection of responsibility or blame;
rationalization of failures

NON-ALCOHOLIC ABUSED SUBSTANCES

DRUG SX OF ABUSE/ SX OF TREATMENT

INTOXICATION WITHDRAWAL
OPIATE or Euphoria → Chills and Naloxone (NARCAN) the
NARCOTICS: Anxiety → PERSPIRATION #1 antidote for Opioids or
A CNS depressant can cause Sadness → Tremors Narcotic intoxication
decreased blood pressure,
pulse, respiration, and Insomnia
temperature. Narcotic Withdrawal
causes muscle ache, METHADONE for
1. Demerol rhinorrhea, anxiety Heroin Withdrawal :
2. Morphine 1st 12-72 hrs:
3. Codeine -sleep disturbances,
piloerection, irritability,
4. Nalbuphine tremors, weakness,
diarrhea, muscle spasm
(legs), abdominal pain, VS
changes, decreased self-
esteem, depression

Lacrimation
(Watery eyes)
HEROIN- (Horse, Marked respiratory RUNNY NOSE
smack, junk, Smack,

73
,Horse and Fine depression YAWNING
China) PinpointPupils , ↑ BP
Hyperpyrexia Dilated pupils
Ventricular dysrhythmia Cramps
Muscle SPASM
Nausea, VOMITING
Panic, diaphoresis,
and weight
loss/anorexia

ANXIOLYTICS: Slurred speech Fatigue Sodium

Minor Respiratory Anxiety bicarbonate → excretion
tranquilizers depression ↓ BP and Depression Activated charcoal, gastric
Valium PR ↑ BP and PR lavage
Librium Ataxia/ impaired Tachycardia
Barbiturates- coordination Tremors
(Downes, rainbows, Drowsiness Convulsions
pink ladies) Seizures, Coma Delirium
Phenobarbital ↓ Memory Hallucinations
Nembutal Anxiety
Insomnia
STIMULANTS Euphoria Depression Activated charcoal, use
(Upper, meth, Agitation Fatigue gastric lavage
speed, pep, pills, ↑ BP, PR, RP, Temp Apathy
crystal, Ice, Hyperactivity, dilated Disorientation
Uppers, Crank pupils, Grandiosity Irritability
Amphetamines Hypervigilance, Altered sleep
Dexedrine Euphoria, Appetite
Methamphetamine suppression, Personality
changes, Antisocial
behavior

Cocaine (Oral, Nasal septum Cocaine is Cocaine use leads to

Injected, Inhaled) perforation characterized by, dopamine deficiency.
“Coke” vivid dreams and Amino acid therapy is
“Crack” Irritability, Seizure hypersomnia or utilized to facilitate
“Snow” Coma, Insomnia, insomnia and restoration of depleted
“Blow” Dilated pupils psychomotor neurotransmitters.
“Lady” agitation.
“Powder” Psychosis similar to
paranoid
schizophrenia

74
Hallucinogens: LSD Hallucination None Small doses of Valium
(acid) (PCP :Oral, Incoherence
Injected, Inhaled) ↑ confusion
Angel dust, Hog, Dilated pupils
rocket fuel) ↑ BP, Temp
Delirium, Mania,
Agitation
Convulsions
Coma
Cannabis #1 sign RED EYES Hyperactivity Most effects wear off in 5-
Derivatives: (irritated conjunctiva) Insomnia 8 hr ‘ talk down’ client
Marijuana (mary Fatigue Dry mouth
jane, joint, grass, Conjunctival Sexual arousal
weed, Pot, Hash, Congestion Visual hallucinations
Weed) ↑ appetite
Euphoria
Relaxed inhibition
Dilated pupils
Psychosis

Another word for alcohol is “Booze” “Brew”

GENERAL PRINCIPLES OF CARE: ALCOHOL DETOXIFICATION

3 A’s = Alcohol Withdrawal  Aversion Therapy (Punishment)

Antabuse (Disulfiram) = no effect unless mixed with alcohol
Action: Iinhibit Antabuse effect Acetaldehyde dehydrogenase
> Dosage: Acute phase = 500 mg in 1st 2 wks.
Maintenance Phase = 250 mg & ↓
>Prohibited Household items with alcohol: mouthwash, cough syrup/elixir, vinegar,
fruitcake, shaving cream, astringent, and toner, acetone/nail polish
Cough medicines and other over-the-counter medicines are alcohol-based and may cause antabuse reaction when it is combined
with antabuse.
Antabuse may worsen renal damage thus it is contraindicated for patients with renal problems.

Effect of Antabuse with Alcohol

1. Nausea & Vomiting

2. Diarrhea
3. Intense headache
4. Abdominal cramps

> Short term objective for an alcoholic: Tto stop/cut denial

75
 Long term objective: Abstinence (similar with STD/HIV/AIDS)

> # 1 group therapy for Alcoholics

(12 step recovery program – AA (Alcoholic Anonymous)
for victims of alcoholics: AL-ANON
for alcoholic teens: ALATEEN
Correct response of an RN to alcoholic patient who says, “I don’t want to attend group meeting, I don’t
need their alcoholic advice.” Is a statement like,“ The group activity may not seem helpful to you but you
can help them.”

> Screening Questions for alcohol abuse:

1. When was the last time you have taken alcohol?
2. How much alcohol have you taken for the last 24-48 hrs?
In a detoxification unit, the nurse asks the pt when was the last time he drink alcohol to determine
the onset of alcohol withdrawal syndrome.

Goal in alcohol detoxification includes maintaining maximum physical integrity during withdrawal
period.

Statement of a pt who is alcoholic and undergoing detoxification saying, “I can quit whenever I want.” shows
denial

CAGE SCREENING QUESTION FOR AN ALCOHOLIC

C cut down alcohol (Do you need to cut down alcohol?)
A annoyed (Are you annoyed when someone will ask you “Are you an alcoholic?)
G guilty (Are you guilty of taking too much alcohol?)
E eye opener (stimulant) Do you use an eye opener early in the morning to decrease the
after effects of alcohol?

3 Stages of Alcohol Intoxication

I. Alcohol Serum Level = 0.04 -0.05%

> unsteady gait
> ↓ social & sexual inhibition

II. ASL = 0.08-0.1 or 100 mg/dl

> slurring of speech
> Fruity odor  similar to ketoacidosis
> Legal intoxication

III. ASL = 0.15-0.2 – severe alcohol intoxication

> 4 Common Complications with History of Alcoholism

1. Liver Cirrhosis
2. Gastritis  inflammation
3. Pancreatitis
4. Wernicke’s Korsakoff’s  peripheral neuritis  lack of Vit. B1 (thiamine)

76
 (Sx: Ttingling sensation/numbness of extremities: Aavoid electric blankets!)
Wernicke’s’ psychosis is due to thiamine deficiency.
Confabulation or making up of stories is one of the initial manifestations of Korsakoff’s syndrome.

Two categories of Wernicke’s Korsakoff’s:

A. Wernicke’s Aphasia / Receptive Aphasia: Pproblems in interpretation (temporal lobe)

B. Korsakoff’s Psychosis – irreversible (the best drug is Risperidone (Risperdal): Iit has
Decrease extrapyramidal symptoms (EPS)
4 Stages of Alcohol Withdrawal

I. Early/Initial – Fine tremors, restlessness, tachycardia, diaphoresis, hyperventilation &

nervousness
Symptoms of alcohol withdrawal is observed when the cup rattles to the side
when the patient stirs his coffee

II. Hallucination – #1 hallucination of Alcohol withdrawal is TACTILE

Nursing diagnosis for patient with delirium tremens who says, “There are bugs in my bed crawling over me” is
Altered Thought Process

2. Visual hallucination
Intervention: > Use lampshade to ↓ shadow (illusions)
Leaving a light on the patient’s room will decrease visual hallucinations, which frequently occur in
alcohol withdrawal syndromes.
 Shadow stimulates hallucination
 don’t leave the patient (Offering of self)
Assigning a staff to the patient promotes safety especially during withdrawal episodes.

III. Pre-seizure/RUM FITS

Impending signs of Seizure

1. Epigastric pain (early sign in eclampsia)
2. High pitch cry/projectile
3. Eye pain/periorbital pain (scotomas) usually in eclampsia
4. Headache & Aura- ↑ ICP
5. Restlessness  cerebral hypoxia = ↓ 02 & glucose

IV. Delirium Tremens

Active Seizure = Grand mal/Tonic-Clonic
Delirium tremens is initially manifested by anxiety, restlessness, illusions, hallucinations and elevated
vital signs.
Observation indicating a need to be included during endorsement to next shift in an alcoholic patient in the
ER include observations of becoming fearful (delirium tremens)

DRUGS CAUSING DELIRIUM

77
Anticonvulsants
Anticholinergics
Antidepressants
Antihistamines
Antipsychotics
Aspirin
Barbiturates
Benzodiazepines
Cardiac glycosides
Cimetidine (Tagamet)
Hypoglycemic agents
Insulin
Narcotics
Propranolol (Inderal)
Reserpine
Thiazide diuretics

MOST COMMON CAUSES OF DELERIUM

Physiologic or metabolic Hypoxemia, electrolytes disturbances, renal

or hepatic failure, hypo- or hyperglycemia,
dehydration, sleep deprivation, thyroid or
glucocorticoid disturbances, thiamine or
vitamin B12 deficiency, vitamin C, niacin,
or protein deficiency, cardiovascular shock,
brain tumor, head injury, and exposure to
gasoline, paint solvents, insecticides, and
related substances

Infection Systemic: Ssepsis, urinary tract infection,

pneumonia
Cerebral: Mmeningitis, encephalitis, HIV,
syphilis

Drug-related Intoxication: Aanticholinergics, lithium,

alcohol, sedatives, and hypnotics
Withdrawal: Aalcohol, sedatives, and
hypnotics
Reactions to anesthesia, prescription
medication or illicit (street) drugs

78
 COMMONLY USED ANTICONVULSANTS

1. Valium (Diazepam)  best drug for delirium tremens

2. Librium (Clordiazepoxide)
Positive) outcome of Librium in alcoholic depressed woman includes an observation that
client can pick an object on floor w/ smooth coordination
3. Klonopin (Clonazepam) 
4. Phenytoin (Dilantin)  best anticonvulsant for children
SE: Ggingival hyperplasia & red orange urine
Intervention: Mmassage the gums & use soft bristle toothbrush
Adverse Effect: Blood dyscrasia- thrombocytopenia S/SX: Bbleeding of the gums
Lab test: Pplatelet count = 150,000-400,000; if ↓100,000-
active bleeding
Special Considerations: The only COMPATIBLE I.V. Solution for
Phenytoin (dilantin) is NSS (Normal Saline Solution)

5. Carbamazepine (Tegretol): Anticonvulsant  trigeminal neuralgia (tic douloureux)

A/E: Agranulocytosis/neutropenia – S/Sx: Ssore throat -
Neutrophils 54-56 %

6. Valproic Acid (Depakene/Depakote) therapeutic serum level: 40-100 mcg.

Adverse Reaction: Hepatotoxic (assess SGPT or ALT)

7. Ethosuccimide (zarontin)
Chlordiazepoxide (Librium), multivitamins, thiamine and folic acid help decrease withdrawal symptoms.

GENERAL PRINCIPLES OF CARE: DETOXIFICATION/OVERDOSE

A. Maintain airway: Iintubation (keep airway on hand), suction
B. Start IV line
C. Monitoring: BP, respiration, pulse, temperature, LOC
D. Prevent and control seizures; Keep in calm, quiet environment
E. Check for trauma, protect from injury
A pt taking phencyclidine (PCP), shouts & walks back & forth, appropriate nursing intervention
includes seclusion, staying w/ the pt, and decreasing stimuli.
F. Administer ordered drugs; Detoxify / treat overdose-
 NALOXONE (NARCAN) – Pure antagonist to narcotics-induces withdrawal and
stimulates respiration; DRUG OF CHOICE when in doubt the substance used because
NALOPHINE (NALLIN), a partial antagonist to narcotics, will ↑ respiratory depression if
barbiturates have also been used
 METHADONE – drug substitute used for acute withdrawal and long-term maintenance;
changes an illegal to a legal drug, which is administered under supervision.
 Antidepressants block the ‘high’ from stimulant abuse
G. Nutrition: Hhigh-calorie, high-protein, high-vitamin

79
 SEXUAL DISORDERS / DYSFUNCTION

A. SEXUAL DISORDER: Ddeviations in sexual behavior; sexual behaviors that are directed
toward anything other than consenting adults or are performed under unusual circumstances
and are considered abnormal
B. PARAPHILIA: Sexual fantasies or urges that are directed toward nonhuman objects, the pain
to self or partner, or children and other nonconsenting individuals.
1. EXHIBITIONISM: Sexual gratification from exposing genitalia
2. FETISHISM: Sexual gratification from an inanimate object (usually clothing material)
substituted for the genitals
3. FROTTEURISM: Sexual gratification from toughing or rubbing against a nonconsenting
person (usually in crowds, public transportation)
4. MASOCHISM: Sexual gratification from self-suffering used as an accompaniment of the
sexual act or substitute for it
5. PEDOPHILIA: Sexual gratification from children
6. SADISM: Sexual gratification from inflicting pain or cruelty to others used as an
accompaniment of the sexual act or a substitute for it
7. TRANSVESTISM: Sexual gratification from wearing clothes of the opposite sex
8. VOYEURISM: Sexual gratification from watching the sexual play / act of others
9. ZOOPHILIA: Sexual gratification from animals
C. SEXUAL DYSFUNCTION: Generalized or situational, acquired or lifelong inhibition or
interference with any of the phases of the sexual responses which may be due to psychogenic
factors alone or psychogenic and biologic combined.
D. NURSING DIAGNOSES
1. Anxiety related to threat to security and fear of discovery
2. Anxiety related to conflict between sexual desires social norms
3. Sexual dysfunction related to actual or perceived sexual limitations
4. Sexual dysfunction related to inability to achieve sexual satisfaction without the use of
paraphilic behaviors
5. Potential for infection related to frequent changes in sexual partners or sadistic or
masochistic acts
6. Potential for injury / violence related to sexual behavior and retaliation for sexual behaviors

E. GENERAL PRINCIPLES OF CARE

1. Acceptance NOT of the behavior but of the client who is in emotional pain
2. Protection of the client from others
3. Setting limits on the sexual acting out
4. Supporting of self-esteem: Aavoidance of punitive remarks or responses
5. Provision of diversional activities

PERVASIVE DEVELOPMENTAL DISORDERS

80
 CODE: ACA
Autism, Conduct Disorder, Attention Deficit Hyperactive Disorder (ADHD),

AUSTITIC DISORDER

A. A type of developmental disorder for an unknown; probable underlying problem: failure to

develop satisfactory relationships with significant adults
- mostly males
- talented in music or math
- # 1 screening test – DDST (Denver Developmental Screening Test)
- Autism is usually diagnosed during the toddler stage.
CHARACTERISTICS:
1. Blank stare
2. Rrepetitive movement: head banging  padded room/helmet
3. Llikes to follow bright moving objects
4. Ccatatonic
5. Ttemper tantrums
6. Cclings to inanimate objects
B. ASSESSMENT FINDINGS:
1. Disturbance in sense of self-identity, in ego system formation: Iinability to distinguish
between self and reality / environment → speaks of self in the third person
2. Withdrawal from reality.
3. Lacks meaningful relationship with outside world; turns to inanimate objects and self-
centered activities for security
4. Personality alteration – adaptive, inhibitory, steering mechanisms due to profound
interference in intellect
5. SEVERE AUTISM – Severe apathy, Association looseness, Autistic thinking, Poor grasp
of reality, Ambivalence, Poor communication skills, Poor interpersonal relations, Poor
intellectual functioning
C. NURSING DIAGNOSIS: Potential for Injury

D. NURSING IMPLEMENTATION:

1. Provide consistent, routine ADL in familiar environment

2. Set consistent and firm limits for his behavior
3. Make physical contact on a regular basis. Accept the client’s need to push but still
maintain regular contact.
4. Prevent acts of self-destructive behavior
5. Provide appropriate therapy:
● Removal from home, if necessary; consistent loving home care is still favored over
hospitalization; consistent care giver; never leave alone; and always provide safety.
● Psychotherapy: Pplay, group, individual therapy
Primary treatment goal to facilitate the recovery of an autistic child should include playing with blocks not with balls .
Occupational Therapy #1  behavior modification #2
Behavior modification in an autistic child enables the nurse to modify the child’s maladaptive behavior.
● Pharmacology: Tranquilizers and amphetamines to reduce symptoms

81
 Caring autistic children requires specialized skills.

ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

A. Disruptive behavioral disorder evident before 7 years old and lasting at least 6 months and
characterized by hyperactivity and inattentiveness

THEORIES: ↑ Norepinephrine, ↑ Serotonin

- #1 Screening Test  DDST

CHARACTERISTICS:
1. Hyperactive  could not sit and stay in 15 minutes
2. ↑metabolism  fatigue
3. handwriting not legible
4. Easily agitated by noise & color (orange/yellow)

B. ASSESSMENT
1. Severe inattentiveness with or without hyperactivity
2. Short attention span
3. Excessive impulsiveness
4. Squirming and fidgeting
5. Hyperactive  could not sit and stay in 15 minutes
2. ↑metabolism  fatigue
3. handwriting not legible
4. Easily agitated by noise & color (orange/yellow)
C. NURISNG IMPLEMENTATION:
1. Set realistic, attainable goals
2. Provide firm, consistent discipline with opportunities to experience satisfaction and success
3. Provide a structured environment-
● With a balance of energy expenditure and quiet time
● With learning experience utilizing child’s ability
● With exercise in perceptual-motor coordination
● With LESS STIMULATION
The priority needs of the child with ADHD are safety and provision of inadequate nutrition.
Catching attention of a child with ADD includes getting him to look at his mom & give him simple
directions.
4. Administer drugs as ordered: RITALIN (methylphenidate) or dextroamphetamine sulfate

5. #1 Therapy: Occupational Therapy using behavior modification

2. DIET: ↑caloric content – finger foods
3. Vitamin B Complex ↑ appetite
4. Do not mix Caffeinated food/drinks with ACA/alcohol
5. Tx: 1. RITALIN (Methylphenidate: BEST GIVEN AFTER BREAKFAST)
Always with meals
Ritalin, the drug of choice for ADHD causes growth suppression, insomnia and suppression of appetite.
Psychostimulant – to increase attention span
2. Dextroamphetamine (Dexedrine)

82
 3. Pemoline (Cylert) very hepatotoxic!!!
4. Stratera ( Atomoxetine) newest psychostimulant!!
Contraindication: Ddo not give below 6 yo  hepatotoxic  SGPT
Stratera, a drug for ADD/ADHD enhances catecholamine effect.
Statement like, “My son is able to accomplish his task better,” indicates efficacy of the drug.

CHILD ABUSE

A. DEFINITION: Physical abuse and emotional neglect; may include sexual abuse
B. CAUSE: Exact-unknown; Present in all socioeconomic levels
C. ASSESSMENT:
● Obvious physical injuries, disturbance on parent-child interaction (Absence of PROTEST
on admission of a toddler is a sign of abuse.)
● Inconsistency of declaration of the type, location, cause of injury, discovery of undeclared /
unreported fractures
● Malnutrition / failure to thrive / emotional neglect
● Sexual abuse signs: Ggenital bruises, lacerations; STDs
 History: Parents who were abused as kids
○ Other characteristics of abusive parents: 1) Tend to be young, immature, dependent; 20
Low in self- esteem 3) Lacks identity 4) Expect child to provide them with love and care
(PERSONAL ROLE THEORY of causation) 5) With incorrect concept of what the child
is, and can do 6) With inadequate resources and support system
Abusive parents usually have low-self-esteem and has little social involvement.
Child abuse is common in the lower socio-economic class.
The interaction between the abuse child and a mother provides a clue to the kind of relationship that this child has with his
mother.
In working with the mother of abused child, therapeutic use of self requires self awareness initially, therefore the nurse has to
deal with her feelings first.
Attendance to a parenting class is a step towards learning parenting skills, which are lacking in abusive parents.

D. POTENTIAL NURSING DIAGNOSES

1) Impaired Skin Integrity 2) Infective Family Coping
E. NURSING IMPLEMENTATION
 FIRST: Meet physical needs; treat injuries
 MANDATORY: REPORTING of suspected cases to appropriate agency (SAVE
EVIDENCES; TAKE PICTURES)
Notify the legal authorities about reports of a battered 7 y/o girl is part of the responsibilities
of an RN

83
  EMOTIONAL SUPPORT to child: PLAY THERAPY to express feelings;
NONJUDGMENTAL ATTITUDE toward parents
 ROLE MODELING for parents who are encouraged to care for child
 DOCUMENTATION of ACTUAL FINDIGNS not interpretation nor opinion

POSSIBLE INDICATORS OF ELDER ABUSE

Physical abuse indicators

 Frequent, unexplained injuries accompanied by a habit of seeking medical assistance from

various locations
 Reluctance to seek medical treatment for injuries, or denial of their existence
 Disorientation or grogginess indicating misuse of medications
 Fear or edginess in the presence of family member or caregiver

Psychological or Emotional abuse indicators

 Helplessness
 Hesitance to talk openly
 Anger or agitation
 Withdrawal or depression

Financial abuse indicators

 Unusual or inappropriate activity in bank accounts

 Signatures on checks that differ from the elder’s
 Recent changes in will or power of attorney when elder is not capable of making those
decisions
 Missing valuable belongings that are no just misplaced
 Lack of television, clothes, or personal items that are easily affordable
 Unusual concern by the caregiver over the expense of the elder’s treatment when it is not
the caregiver’s money being spent

84
Neglect indicators

 Dirt, fecal or urine smell, or other health hazards in the elder’s living environment
 Rashes, sores, or lice on the elder
 Elder has an untreated medical condition is malnourished or dehydrated not related to a
known illness
 Inadequate clothing

Indicators of self-neglect

 Inability to manage personal finances, such as hoarding, squandering, or giving away

money while not paying bills
 Inability to manage activities of daily living such as personal care, shopping, housework
 Wandering, refusing needed medical attention , isolation, substance use
 Failure to keep needed medical appointments
 Confusion, memory loss, unresponsive
 Lack of toilet facilities, living quarters infested with animals or vermin

Warning indicators from caregiver

 Elder is not given opportunity to speak for self, to have visitors, or to see anyone without
the presence of the caregiver
 Attitudes of indifference or anger toward the elder
 Blaming the elder for his or her illness or limitations
 Defensiveness
 Conflicting accounts of elder’s abilities, problems, and so forth
 Previous history of abuse or problems with alcohol or drugs.

85
86