PSYCHIATRIC NURSING

Presented by: Dave Jay Sibi. Manriquez, RN

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

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

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

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

Methods to increase self-awareness:

Introspection Discussion Experience Role play

 Assessment (psychosocial processes )

Appearance , behavior or mood Speech , thought content and thought process Sensorium Insight and judgment Family relationships and work habits Level of growth and development

Common Behavioral Signs and Symptoms

Disturbances in perception
Illusion
misinterpretation of an actual external stimuli

Hallucinations
false sensory perception in the absence of external stimuli

PERCEPTION

PERCEPTION

PERCEPTION

PERCEPTION

PERCEPTION

 neologism coining of words that people do not understand

Disturbances in thinking and speech

Circumstantiality over inclusion of inappropriate thoughts and details Word salad incoherent mixture of words and phrases with no logical sequence
THINKING & SPEECH

 Verbigeration meaningless repetition of words and phrases Perseveration persistence of a response to a previous question Echolalia pathological repetition of words of others Aphasia speech difficulty and disturbance
Expressive , receptive or global
THINKING & SPEECH

 Flight of ideas- shifting of one topic from one subject to another in a somewhat related way Looseness of association-incoherent illogical flow of thoughts (unrelated way) Clang association sound of word gives direction to the flow of thought

THINKING & SPEECH

 Delusion persistent false belief, rigidly held

Delusions of grandeur: special /important in a way Persecutory: threatened Ideas of reference: situation/events involve them Somatic: body reacting in a particular way

THINKING & SPEECH

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

THINKING & SPEECH

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

THINKING & SPEECH

Disturbances of affect
Inappropriate disharmony between the stimuli and the emotional reaction Blunted affect severe reduction in emotional reaction Flat affect absence or near absence of emotional reaction Apathy dulled emotional tone

AFFECT

 Depersonalization feeling of strangeness from ones self Derealization feeling of strangeness towards environment Agnosia lack of sensory stimuli integration

AFFECT

Disturbances in motor activity

Echopraxia imitation of posture of others Waxy flexibility maintaining position for a long period of time Ataxia loss of balance Akathesia extreme restlessness

MOTOR ACTIVITY

 Dystonia- uncoordinated spastic movements of the body Tardive dyskinesia involuntary twitching or muscle movements Apraxia involuntary unpurposeful movements

MOTOR ACTIVITY

Disturbances in memory
Confabulation filling of memory gaps Dj vu something unfamiliar seems familiar Jamais vu- something familiar seems unfamiliar Amnesia memory loss (inability to recall past events)
Retrograde-distant past Anterograde immediate past Anomia lack of memory of items
MEMORY

Dynamics of Human Behavior

Behavior the way an individual reacts to a certain stimulus Conflict situation arising from the presence of two opposing drives

Need - organismic condition that requires a certain activity

Dynamics of Human Behavior

Personality
totality of emotional and behavioral traits that characterize the person in day to day living under ordinary conditions; it is relatively stable and predictable.

FORMATION OF PERSONALITY TEMPERAMENT

CHARACTER

biological-genetic template that interacts with our environment. a set of in-built dispositions we are born with mostly unalterable our nature. the outcome of the process of socialization, the acts and imprints of our environment and nurture on our psyche during the formative years (0-6 years and in adolescence). the set of all acquired characteristics we posses, often judged in a cultural-social context.

Sometimes the interplay of all these factors results in an abnormal personality

THEORIES OF PERSONALITY DEVELOPMENT

Freuds PSYCHOSEXUAL THEORY

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

 0-18 m0s ;oral mouth trust and discriminating 18 mos. 3 years ; anal bowels holding on or letting go Negativism and toilet training age 3 -6 years phallic ; genitals exploration and discovery ( inc. sexual tension) Gender identification and genital awareness Oedipus and Electra complex Castration anxiety and penis envy

 6-12 years latency (quiet stage) sexual energy diverted to play. Institution of superego: control of instinctual impulses 12 young adult genital ; reawakening of sexual drives relationships
Sexual maturation Sexual identity ,ability to love and work

Eric Ericksons PSYCHOSOCIAL THEORY

 0-12mos 1-3y 3-6 6-12 12-18

18-25 25-60 60 and above

TRUST vs. MISTRUST AUTONOMY vs. SHAME & DOUBT INDUSTRY vs. INFERIORITY INITIATIVE vs. GUILT IDENTITY vs. IDENTITY CONFUSION INTIMACY vs. ISOLATION EGO INTEGRITY vs. STAGNATION GENERATIVITY vs. DESPAIR

INFANCY
CONSISTENT MATERNAL CHILD INTERACTION TRUST INNER FEELING OF SELF WORTH HOPE

TODDLER
ALLOW EXPLORATION PROVIDE FOR SAFETY NO, NO NEGATIVISM OFFER CHOICES / REVERSE PSYCHOLOGY TOILET TRAINING 18 MOS.-BOWEL DAYTIME BLADDER: 2 yo NIGHTIME BLADDER: 3 yo REWARD W/ PRAISE AND AFFECTION INDEPENDENCE

PRE-SCHOOL
PROVIDE PLAY MATERIALS SATISFY CURIOSITY TEACH AND REINFORCE(HYGIENE,SOCIAL BEHAVIOR) SIBLING RIVALRY WILLPOWER

SCHOOL AGE
HOW TO DO THINGS WELL-SUPPORT EFFORTS CHUMS AND HOBBIES NEEDS TO EXCEL/ACCOMPLISH NEED FOR PRIVACY AND PEER INTERACTION COMPETENCE

ADOLESCENCE
MAKE DECISION,EMANCIPATION FROM PARENTS BODY IMAGE CHANGES NEED TO CONFORM BUT KEEP INDIVIDUALITY SELF - AWARENESS

YOUNG ADULT
COMMITMENT AND FIDELITY RESPONSIBILITY ACHIEVEMENT OF INDEPENDENCE

MIDDLE ADULTHOOD
SUPPORT-PERIOD OF ROLE TRANSITIONS

MIDLIFE CRISIS
ADJUSTMENT AND COMPROMISE MOST PRODUCTIVE AND CREATIVE ALTRUISM

LATE ADULTHOOD
SELF ACCEPTANCE SELF WORTH

WISDOM

Jean Piagets COGNITIVE THEORY

0-2 SENSORIMOTOR
REFLEXES IMITATIVE REPETITIVE BEHAVIOR SENSE OF OBJECT PERMANENCE AND SELF SEPARATE FROM ENVT. TRIAL AND ERROR RESULTS IN PROBLEM SOLVING

2-7Y PRE-OPERATIONAL
SELF-CENTERED,EGOCENTRIC CANNOT CONCEPTUALIZE OTHERS VIEW ANIMISTIC THINKING IMAGINARY PLAYMATE SYMBOLIC MENTAL REPRESENTATION CREATIVITY 2-4 PRE-CONCEPTUAL (PRE-LOGICAL) 4-7 INTUITIVE (UNDERSTANDING OF ROLES)

7-12Y CONCRETE OPERATIONAL

LOGICAL CONCRETE THOUGHT INDUCTIVE REASONING (SPECIFIC TO GENERAL) CAN RELATE, PROBLEM SOLVING ABILITY REASONING AND SELF-REGULATION

12-ABOVE: FORMAL OPERATIONAL THOUGHT

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

Havighursts DEVELOPMENTAL TASKS

 Baby to early childhood

Right from wrong and Conscience

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

 Adolescence
Sexual social roles Relationships Independence and ideology

Early adulthood
Career Selecting a mate Finding Civic or social responsibility

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

Old age
Adjusting to changes Establishing satisfactory living arrangements and affiliations

Kohlbergs MORAL DEVELOPMENT/ THINKING/ JUDGEMENT

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

CONVENTIONAL ( 6-12 )
MUTUAL INTERPERSONAL EXPECTATIONS,RELATIONSHIPS AND CONFORMITY SOCIAL SYSTEM AND CONSCIENCE MAINTENANCE BEING GOOD IS IMPORTANT SELF RESPECT OR CONSCIENCE

 POST CONVENTIONAL (12 18 Y)

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

Harry Stack Sullivans INTERPERSONAL THEORY

INFANCY
NEED FOR SECURITY-INFANT LEARNS TO RELY ON OTHERS TO GRATIFY NEEDS AND SATISFY WISHES, DEVELOPS A SENSE OF BASIC TRUST, SECURITY AND SELF WORTH WHEN THIS OCCURS

TODDLERHOOD / EARLY CHILDHOOD

CHILD LEARNS TO COMMUNICATE NEEDS THROUGH USE OF WORDS AND ACCEPTANCE OF DELAYED GRATIFICATION AND INTERFERENCE OF WISH FULFILLMENT

PRE-SCHOOL
DEVELOPMENT OF BODY IMAGE AND SELFPERCEPTION ORGANIZES AND USES EXPERIENCES IN TERMS OF APPROVAL AND DISAPPROVAL RECEIVED BEGINS USING SELCTIVE INATTENTION AND DISASSOCIATES THOSE EXPERIENCES THAT CAUSE PHYSICAL OR EMOTIONAL DISCOMFORT AND PAIN

SCHOOL AGE
THE PERIOD OF LEARNING TO FORM SATISFYING RELATIONSHIPS WITH PEERSUSES COMPETITION,COMPROMISE AND COOPERATION THE PRE-ADOLESCENT LEARNS TO RELATE TO PEERS OF THE SAME SEX

ADOLESCENCE
LEARNS INDEPENDENCE AND HOW TO ESTABLISH SATISFACTORY RELATIONSHIPS WITH MEMBERS OF THE OPPOSITE SEX

YOUNG ADULTHOOD
BECOMES ECONOMICALLY, INTELLECTUALLY AND EMOTIONALLY SELF SUFICIENT

LATER ADULTHOOD
LEARNS TO BE INTERDEPENDENT AND ASSUMES RESPONSIBILITY FOR OTHERS

SENESCENCE
DEVELOPS AN ACCEPTANCE OF RESPONSIBILITY FOR WHAT LIFE IS AND WAS AND OF ITS PLACE IN THE FLOW OF HISTORY

TREATMENT MODALITIES

REMOTIVATION THERAPY
TREATMENT MODALITY THAT PROMOTES EXPRESSION OF FEELINGS THROUGH INTERACTION FACILITATED BY DISCUSSION OF NEUTRAL TOPICS STEPS : climate of acceptance creating bridge to reality sharing the world we live in appreciation of works of the world climate of appreciation

MUSIC THERAPY
Involves use of music to facilitate expression of feelings, relaxation and outlet of tension

PLAY THERAPY
enables patient to experience intense emotion in a safe environment with the use of play children express themselves more easily in play. revealing as reflection of childs situation in the family provide toys and materials facilitate interaction observe and help child resolve problems through play

Group therapy
Treatment modality involving three or more patients with a therapist to relieve emotional difficulties, increase self esteem, develop insight , LEARN NEW ADAPTIVE WAYS TO COPE WITH STRESS and improve behavior with others IDEAL 8 10 MEMBERS

MILIEU THERAPY
Consists of treatment by means of controlled modification of the patients environment to facilitate positive behavioral change Increase patients
Awareness of feelings Sense of responsibility and Help return to community

clients plan social and group interaction token programs , open wards and self medication are done

FAMILY THERAPY
A METHOD OF PSYCHOTHERAPY WHICH FOCUSES ON THE TOTAL FAMILY AS AN INTERACTIONAL SYSTEM PROBLEM IS A FAMILY PROBLEM focus on sick members behavior as source of trouble / symptom serve a function for the family members develop sense of identity points out function of the sick member for the rest of the family

PSYCHOANALYTIC
focuses on the exploration of the unconscious, to facilitate identification of the patients defenses ANXIETY RESULTS BETWEEN CONFLICTS OF ID AND EGO Becomes aware of unconscious thoughts and feelings to understand anxiety and defenses

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

BEHAVIOR MODIFICATION
Application of learning principles in order to change maladaptive behavior Believes that psychological problems are a result of learning Everything learned can be unlearned

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

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

AVERSION THERAPY
An example of behavior modification Painful stimulus is introduced to bring about an avoidance of another stimulus End view: behavioral change

OTHER THERAPIES
HUMOR THERAPY
To facilitate expression and enhance interaction

ACTIVITY THERAPY
Group interaction while working on a task together

 EMOTIONAL PROBLEM IS AN ILLNESS cause may be inherited or chemical in origin FOCUS OF TREATMENT IS MEDICATIONS AND ECT

BIOLOGICAL/ MEDICAL THEORY

BIOLOGICAL THERAPY
ELECTROCONVULSIVE THERAPY
Artificial induction of a grand mal seizure by passing a controlled electrical current through electrodes applied to one or both temples mechanism of action unclear voltage: 70 150 volts Duration: 0.5 2.0 seconds 6 to 12 treatments intervals of 48 hours

indicators of effectiveness occurrence of generalized tonic clonic seizures

 indications depression , mania and catatonic schizophrenia s/e: confusion, disorientation, short -term memory loss, seizure (30-60 sec) NPO prior Contraindications
Fever, pregnancy Inc ICP, fracture retinal detachment TB with hemoptysis cardiac d/o

consent needed Reorient after, supportive care

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

common complications:
loss of memory headache apnea fracture respiratory depression

Psychopharmacologic Therapy

Benzodiazepines
Indications
Anxiety Sedation/sleep Muscle spasm Seizure disorder Alcohol withdrawal syndromes

Benzodiazepines

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

Trade name
Xanax Librium Tranxene Valium Ativan Serax BuSpar

Benzodiazepines

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

Benzodiazepines

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

Possibly
Attention deficit/Hyperactivity d/o Post Traumatic Stress D/o Conduct d/o

Anti-depressants

Tricyclic (TCA)
Generic
Amitriptyline Imipramine Trimipramine Nortriptyline Trazodone Bupropion

Trade name
Elavil Tofranil Surmontil Pamelor Desyrel Wellbutrin

Anti-depressants

Side effects
Orthostatic hypertension Anticholinergic effect
Dry mouth, blurred vision, constipation, excessive sweating, urinary hesitancy/ retention, tachycardia, agitation, delirium, exacerbation of glaucoma

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

Decrease libido and sexual performance

Anti-depressants

Monoamine Oxidase inhibitors

Generic
Isocarboxazid Phenelzine Tranylcypromine

Trade name
Marplan Nardil Parnate

Anti-depressants

Side effects
Postural lightheadedness Constipation Delay ejaculation or orgasm Muscle twitching Drowsiness Dry mouth

Anti-depressants

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

Anti-depressants

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

Anti-depressants

 Treatment
Hold next MAO dose Dont let pt. lie down IM chlorpromazine 100 mg Fever: manage by external cooling techniques

Anti-depressants

Serotonin Reuptake Inhibitors

Generic
Fluoxetine Sertraline Paroxetine Venlafaxine

Trade name
Prozac Zoloft Paxil Effexor

Anti-depressants

Side effects
Nausea Diarrhea Insomnia Dry mouth Nervousness Headache Male sexual dysfunction Drowsiness Dizziness Sweating

Anti-depressants

Mood stabilizing drugs

Indications
Acute mania Bipolar prophylaxis

Possibly
Bulimia Alcohol abuse Aggressive behavior schizoaffective

Mood stabilizing

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

Lag period: 7-10 to 14 days

Mood stabilizing

Lithium carbonate
Trade names

Preparation: tab, cap, liq & Eskalith SR form Lithotabs Dose: 900 to 3600 mg/day Lithane Lithonate MOA: unclear; interfere with metabolism of neurotransmitters; alter Na transport in nerves and muscle cells

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

Mood stabilizing

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

Late
Weight gain acne

Mood stabilizing

Contraindications
Brain damage/ CV disease Epilepsy Elderly/ debilitated Thyroid and renal disease Severe dehydration Pregnancy (1st trimester) Can augment the effects of antidepressants

Mood stabilizing

Nursing considerations
Therapeutic serum level: 0.5 1.2 meq/L Maintenance level: 0.6 -1.2 meq/L Toxic
Mild to moderate: 1.5 to 2 meq/L Moderate to severe: 2 2.5 meq/L Needs dialysis: 3 meq and above

Early signs of toxicity

Lethargy, mild nausea, vomiting, fine hand tremors, anorexia, polyuria, polydipsia, metallic taste, fatigue

Late signs of toxicity

Ataxia, giddiness, tinnitus, blurred vision, polyuria

Mood stabilizing

Nursing considerations
Lithium levels should be checked q 2-3 mos Serum drawn in the AM, 12H after last dose Common causes of inc. levels
Dec. Na intake Diuretic therapy Dec. renal functioning F&E loss Medical illness Overdose NSAIDS

Mood stabilizing

Nursing considerations
Diet: adequate Na+ and fluid
3g NaCl/ day 6-8 glasses of H2O

No caffeine No driving: wait for clinical effect

Mood stabilizing

 Moderately severe toxicity

Management

Osmotic diuresis: urea/ mannitol Aminophylline & PLR IV Adequate NaCl Peritoneal/ hemodialysis

Severe toxicity
Assess hx quickly Hold next lithium dose Check BP, rectal T, RR, LOC, support O2 Obtain labs ECG Emetic, NGT lavage Hydrate: 5-6L/day c PLR; FBC-CDU

Mood stabilizing

Other drugs
Carbamazepine (Tegretol)
Side effects
Dizziness Ataxia Clumsiness Sedation Dysarthria Diplopia Nausea & GI upset 800 to 1200 mg/day

Preparation: liq, tab, chewable tab

Mood stabilizing

Nursing considerations
Assess drug levels q 3-4 days Monitor salt and fluid intake Avoid alcohol and non-prescription drugs Refer dec. in UO Dont stop abruptly C/I: pregnancy Take with meals

Mood stabilizing

Other drugs
Valproic acid (Depakote, Depakene)
Side effects
Nausea Hepatoxicity Neurotoxicity Hematological toxicity Pancreatitis

Prep: tab, cap, sprinkles

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

Mood stabilizing

Nursing considerations
Therapeutic level: 50 100 ug/mL Dose: 1, 000 1,500 mg/day Monitor serum levels 12H after last dose Toxic effects
Severe diarrhea, vomiting, drowsiness, mm. weakness, lack of coordination Renal failure, coma, death

Mood stabilizing

Anti-psychotic drugs
Indications
Psychotic symptoms of schizophrenia, acute mania and depression Gilles de Tourette disorder Treatment-resistant bipolar disorder Huntingtons disease and other movement disorder

Possibly
Paranoid Childhood psychoses

Anti-psychotic

 MOA: block receptors of dopamine (D2, D3, D4) If unresponsive after 6 weeks of therapy, another class is tried General considerations
Calms without producing impairment of sleep High therapeutic index Non addicting, no tolerance Avoided in pregnancy

Anti-psychotic

TYPICAL: High Potency

Fluphenazine (Prolixin) Haloperidol (Haldol) Thiothexene (Navane) Trifluoperazine (Stelazine)

Anti-psychotic

Moderate Potency
Loxapine (Loxitane) Molindone (Moban) Perphenazine (Trilafon)

Anti-psychotic

Low Potency
Chlopromazine (Thorazine) Chlorprothixene (Taractan) Mesoridazine (Serentil) Thioridazine (Mellaril)

Anti-psychotic

ATYPICAL
Clozapine (Clozaril) Resperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) Sertindole (Serlect) Ziprasidone (Zeldox)

Anti-psychotic

Contraindications
CNS depression: brain damage, excess alcohol/ narcotics Parkinsons disease Allergy Blood dyscrasias Acute narrow angle glaucoma BPH

Anti-psychotic

Side effects
Hypotension Sedation Dermal and ocular syndrome Neuroleptic malignant syndrome Anticholinergic syndrome Movement syndrome (Extrapyramidal Syndrome) New ! Atropine psychosis Agranulocytosis Seizures

Anti-psychotic

Neuroleptic Malignant Syndrome

A potentially fatal, idiosyncratic reaction to an antipsychotic drug 10-20% mortality rate Sx: TTT: dantrolene (Dantrium),
Bromocriptine (Parlodel) rigidity, high fever, autonomic instability (BP, diaphoresis, pallor, delirium, elev. CPK), confused or mute, fluctuate from agitation to stupor

Occurs in the first 2 weeks of therapy Risk: high dose of high-potency drugs; dehydration, poor nx, concurrent med illness

Anti-psychotic

Movement Syndromes
Akathisia Dystonia Tardive dyskinesia Bradykinesia Parkinsonism

Anti-psychotic

New !

Atropine psychosis (geriatrics)

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

Other s/e

Agranulocytosis (Clozapine)
Occurs 3-8 wks after Medical emergency s/s: fever, malaise, sore throat, leukopenia TTT: d/c, reverse iso, antibiotics

Seizures (Clozapine)
Occurs in 5% of patients; TTT: D/c drug

Anti-psychotic

Anticholinergics
Benztropine (Cogentin) Trihexyphenidyl (Artane) Biperiden (Akineton) Procyclidine (Kemadrin)
Not withdrawn abruptly Provide cool environment

Anti-psychotic

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

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

ANTIHISTAMINE
Diphenhydramine HCl (BENADRYL)

DOPAMINE RELEASING AGENT

Amantadine (SYMMETREL)

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

PSYCHIATRIC DISORDERS

ANXIETY DISORDERS
PANIC DISORDERS SPECIFIC PHOBIA SOCIAL PHOBIA OCD PTSD ACUTE STRESS DISORDER GENERALIZED ANXIETY DISORDER
ANXIETY DISORDERS

PANIC ATTACKS
Discrete period of intense fear or discomfort in which at least 4 if the ff sx develop abruptly and peak within 10 mins:
Palpitations, pounding heart, or accelerated HR Sweating Trembling or shaking Sensations of SOB and smothering Feeling of choking
ANXIETY DISORDERS

 Chest pain or discomfort Nausea or abd. Pain Feeling dizzy, unsteady, lightheaded or faint Derealization or depersonalization Fear of losing control or going crazy Fear of dying Paresthesias Chills or hot flashes

ANXIETY DISORDERS

SPECIFIC PHOBIA SOCIAL

Excessive and unreasonable cued by the presence or anticipation of a specific object or situation Defense mech commonly used include repression and displacement Fear of social performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others

ANXIETY DISORDERS

OBSESSION
Recurrent and persistent thoughts, impulses, or images are experienced during the disturbance as intrusive and inappropriate Cause anxiety or distress Px knows that these are just product of ones own mind.

COMPULSION
Px feels driven to perform repetitive behaviors or mental acts in response to obsession or according to the rules that one deems must be applied rigidly. Aimed at reducing anxiety

ANXIETY DISORDERS

OBSESSION
Fear of dirt & germs Fear of burglary or robbery Worries about discarding something important Concerns about contracting a serious illness Worries that things must be symmetrical or matching

COMPULSION
Excessive hand washing Repeated checking of door and window locks Counting and recounting of objects in everyday life Hoarding of objects Excessive straightening, ordering, or of arranging things Repeating words or prayers silently
ANXIETY DISORDERS

 Person has experienced, witnessed or been confronted with an event that involved actual or threatened death or serious injury, or a threat to physical integrity Person reexperiences these in the mind Involves intense fear, helplessness, or horror and numbing of general responsiveness (PSYCHIC NUMBING)

POST TRAUMATIC STRESS SYNDROME

ANXIETY DISORDERS

ACUTE STRESS
Meets the criteria for exposure to a traumatic event and person experiences 3 of the ff sx:
sense of detachment, reduced awareness of ones surroundings, derealization, depersonalization, dissociated amnesia

Excessive anxiety or worry, occurring in more days than not for at least 6 mos, about a number of events or activities Finds it difficult to control the worry

GENERALIZED ANXIETY

ANXIETY DISORDERS

MOOD/ AFFECTIVE DISORDERS

BIPOLAR D/O BIPOLAR I: current or past experience of manic episode, lasting at least a week, that is severe enough to cause extreme impairment in social or occupational functioning.
MANIA: hyperactivity DEPRESSED: extreme sadness or withdrawal MIXED

BIPOLAR II: hx of 1 or more mj depressive episodes & at least 1 hypomanic episode; no mania
MOOD DISORDERS

 MAJOR DEPRESSIVE D/O

@ least 5 sx of same 2- wk period with one being either depressed mood or loss of interest or pleasure. Single episode or recurrent Other sx: wt loss, insomnia, fatigue, recurrent thoughts of death, diminished ability to think, psychomotor agitation or retardation, feelings of worthlessness.

MOOD DISORDERS

 CYCLOTHYMIC D/O

DYSTHYMIC D/O

Hx of 2 yrs of hypomania with numerous periods of abnormally elevated, expansive or irritable moods. Does not meet the criteria of mania or depression. @ least 2 yrs of usually depressed mood and at least 1 of the sx of mj depression without meeting the criteria for it

SEASONAL AFFECTIVE D/O

Depression that comes with shortened daylight in fall and winter that disappears during spring and summer.
MOOD DISORDERS

Dealing with Inappropriate Behaviors

AGGRESSIVE BEHAVIOR Assist the client in identifying feelings of frustration and aggression Encourage the client to talk out instead of acting out feelings of frustration Assist the client in identifying precipitating events or situations that lead to aggressive behavior Describe the consequences of the behavior on self and others Assist in identifying previous coping mechanisms Assist the client in the problem-solving techniques to cope with frustration or aggression
MOOD DISORDERS

DEESCALATION TECHNIQUES Maintain safety Maintain large personal space and use nonaggressive posture Use calm approach and communicate with a calm, clear tone of voice (be assertive not aggressive Determine what the client considers to be his or her need Avoid verbal struggles Provide clear options that deal with behavior Assist with problem-solving and decision making regarding the options
MOOD DISORDERS

MANIPULATIVE BEHAVIORS Set clear, consistent, realistic, and enforceable limits and communicate expected behaviors Be clear about consequences associated with exceeding set limits Discuss behavior in nonjudgmental and nonthreatening manner Avoid power struggles Assist in developing means of setting limits on own behavior
MOOD DISORDERS

SCHIZOPHRENIA
characterized by impairments in the perception or expression of reality and by significant social or occupational dysfunction. Once considered as a deadly disease There is lack of insight in behavior Dx: late adolescence and early adulthood
15-25 y.o. (men); 25-35 y.o. (women)

Obsolete term: dementia praecox = cognitive deterioration early in life Eugene Bleuler: schiz split; phren mind
SCHIZOPHRENIA

Risk factors

Genetics: identical twins 50%, 15% for fraternal twins Biochemical factors

Psychoanalytic

Dopamine hypothesis: overactive Serotonin imbalance Decreased brain volume, enlarged ventricles, deeper fissures, and loss or underdeveloped brain tissue lack of trust during the early stages Weak ego Defenses: REPRESSION, REGRESSION, PROJECTION

Environment influences: poverty, lack of social support, hostile home environment, isolation, unsatisfactory housing, disruption in interpersonal relationships (divorce or death), job pressure or unemployment
SCHIZOPHRENIA

 Catatonic type

Subtypes

prominent psychomotor disturbances are evident. Symptoms can include catatonic stupor and waxy flexibility

Disorganized type
where thought disorder and flat affect are present together

Paranoid type
where delusions and hallucinations are present but thought disorder, disorganized behavior, and affective flattening are absent
SCHIZOPHRENIA

 Residual type
where positive symptoms are present at a low intensity only

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

SCHIZOPHRENIA

Symptoms
According to Bleuler: 4 As
Affect is inappropriate Associative looseness Autistic thinking Ambivalence

SCHIZOPHRENIA

Symptoms
Positive symptoms
delusions, auditory hallucinations and thought disorder and are typically regarded as manifestations of psychosis.

Negative symptoms
considered to be the loss or absence of normal traits or abilities E.G. flat, blunted or constricted affect and emotion, poverty of speech and lack of motivation.
SCHIZOPHRENIA

Social isolation Catatonic behavior Hallucinations Incoherence (marked looseness of association) Zero/ lack of interest, energy and initiative Obvious failure to attain expected level of devt Peculiar behavior Hygiene and grooming impaired Recurrent illusions and unusual perception experiences Exacerbations and remissions are common No organic factors accounts for the symptoms Inability to return to baseline functioning after relapse Affect is inappropriate
SCHIZOPHRENIA

Symptoms

Nsg Dx: Abnormal thought process

BLOCKING: sudden cessation of a thought in the middle of a sentence, unable to continue the train of thought CIRCUMSTANTIALITY: before getting to the point of answering a question, the individual gets caught up in countless details and explanations CONFABULATION LOOSENESS OF ASSOCIATION NEOLOGISM WORD SALAD
SCHIZOPHRENIA

Interventions

Assess physical needs Set limits Maintain safety Initiate one-on-one interaction & progress to small groups Spend time with clients Monitor for altered thought process Maintain ego boundaries, avoid touching Limit time of interaction Be neutral Do not make promises that cant be kept
SCHIZOPHRENIA

 Establish daily routines Do not go along with the clients delusions or hallucinations Provide simple complete activities Reorient Speak to the client in simple direct and concise manner Set realistic goals Explain everything that is being done Decrease stimuli Monitor for suicide risk
SCHIZOPHRENIA

 Environment
Provide safe environment Limit stimuli

Psychological Ttt
Behavior therapy Social skills training Self-monitoring

Social ttt
Milieu therapy Family therapy Group therapy (long-term ttt)
SCHIZOPHRENIA

Related psychotic disorders

SCHIZOAFFECTIVE DISORDER schiz + mood disorder (mania/ depression) BRIEF PSYCHOTIC DISORDER sudden onset of psychotic symptoms, lasts less than 2 mos and client returns to premorbid level of functioning SCHIZOPHRENIFORM DISORDER schiz sx lasting between 1 month and <6mos DELUSIONAL DISORDER characterized by prominent, nonbizarre delusions
SCHIZOPHRENIA

PERSONALITY DISORDERS
CLUSTER A (odd & eccentric)
paranoid, schizoid, schizotypal

CLUSTER B (bad, dramatic & erratic)

antisocial, borderline, histrionic, narcissistic

CLUSTER C (anxious & fearful)

avoidant, dependent, OCD
PERSONALITY D/O

CLUSTER A: ODD & ECCENTRIC PARANOID

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

SCHIZOID
social detachment = loner & introvert Restriction of emotions Attention fixed on objects rather than people Functions well in vocations

SCHIZOTYPAL: interpersonal deficits

Magical thinking, telepathy Apparent in childhood or adolescence
PERSONALITY D/O

Interventions for PARANOID D/O

Asses for suicide risk Avoid direct eye contact Establish trusting relationship Promote increased self-esteem Remain calm, nonthreatening and nonjudgmental Provide continuity of care Respond honestly to the client
PERSONALITY D/O

 Follow thru on commitments Provide a daily schedule of activities Gradually introduce client to groups Do not argue with delusions Use concrete, specific words

PERSONALITY D/O

 Do not be secretive with client Do not whisper in presence of client Assure that the client will be safe Provide opportunity to complete small tasks Monitor eating, drinking, sleeping and elimination patterns Limit physical contact Monitor for agitation and decrease stimuli as needed
PERSONALITY D/O

CLUSTER B: ERRATIC, DRAMATIC, OR EMOTIONAL

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

15-40 y.o.

PERSONALITY D/O

 Signs
Lack of remorse or indifference to persons hurt Immediate gratification Failure to accept social norms Impulsivity Consistent irresponsibility Aggressive behavior Reckless behavior that disregards the safety of others

80-90% of all crime is committed by antisocials (NIHM, 2000)

ANTISOCIAL PERSONALITY D/O

 BORDERLINE
Latent, ambulatory and abortive schizophrenics Between moderate neurosis and frank psychosis but quite stable Theories
faulty separation from mother; parent and child are bound by guilt Trauma at 18 mos (weakening of ego) Unfulfilled need for intimacy
BORDERLINE PERSONALITY D/O

 Signs
instability Impulsivity: unpredictable gambling, shoplifting, sex & substance abuse hypersensitivity, self-destructive, profound mood shifts unstable & intense relations Disturbance in self concept

Common in women Defenses: denial, projection, splitting, projective identification

BORDERLINE PERSONALITY D/O

 HISTRIONIC
Pattern of theatrical or overtly dramatic behavior Signs
Discomfort when the client isnt the center of attention Self-dramatization and exaggerated emotions uses physical appearance, sexually seductive and provocative behavior Excessively impressionistic speech lacking in detail (labile emotions)

Problems in dependence & helplessness More frequent in women

HISTRIONIC PERSONALITY D/O

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

Occurs more in men

NARCISSISTIC PERSONALITY D/O

 AVOIDANT

CLUSTER C: ANXIOUS OR FEARFUL

Sensitive to rejection, criticism, humiliation, disapproval, or shame Interferes with participation in occupational activities, devt of relationships, and take personal risks social inhibition, longs for relationships Anxiety, anger and depression are common Social phobia may occur Seen in 10% of clients in mental clinics
AVOIDANT PERSONALITY D/O

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

DEPENDENT PERSONALITY D/O

 OBSESSIVE-COMPULSIVE
Preoccupied with rules & regulations, overly concerned about trivial detail, excessively devoted to their work Depression is common Men are more affected than women

O-C PERSONALITY D/O

UNDER STUDY PERSONALITY D/O

PASSIVE-AGGRESSIVE: sullen and argumentative, resents others, resists fulfilling responsibilities, complains of being unappreciated DEPRESSIVE: gloomy, brooding pessimistic, guilt-prone, highly critical of self and others, cheerless.

PERSONALITY D/O

Interventions
Maintain safety against self-destructive behaviors Allow the client to make choices and be as independent as possible Encourage the client to discuss feelings rather than act them out Provide consistency in response to the clients acting out Discuss expectations and responsibilities with the client Inform the client that harm to self, others, and property is unacceptable
PERSONALITY D/O

 Identify splitting behavior Assist the client to deal directly with anger Develop a written contract with the client Encourage the client to participate in group activities, and praise nonmanipulative behavior Set and maintain limits Remove the client from group situations in which attention-seeking behaviors occur Provide realistic praise for positive behaviors in social situations
PERSONALITY D/O

PSYCHOLOGICAL SEXUAL D/O

Hypoactive sexual disorder (asexuality) Sexual aversion disorder (avoidance of or lack of desire for sexual intercourse) Female sexual arousal d/o (failure of normal lubricating arousal response) Male erectile d/o Female orgasmic disorder Male orgasmic disorder Premature ejaculation
SEXUAL DISORDERS

Vaginismus Secondary sexual dysfxn Paraphilias Gender identity d/o PTSD due to genital mutilation or childhood sexual abuse Sexual dissatisfaction (non-specific) Lack of sexual desire anorgasmia Impotence STD

Other sexual problems

SEXUAL DISORDERS

 Infidelity Delay or absence of ejaculation, despite adequate stimulation Inability to control timing of ejaculation Inability to relax vaginal muscles enough to allow intercourse Inadequate vaginal lubrication preceding and during intercourse Burning pain on the vulva or in the vagina with contact to those areas
SEXUAL DISORDERS

 Unhappiness or confusion related to sexual orientation Persistent sexual arousal syndrome Sexual addict hypersexuality Post Ejaculatory Guilt Syndrome, the feeling of guilt after the male orgasm

SEXUAL DISORDERS

SEXUAL EXPRESSION
HETEROSEXUALITY HOMOSEXUALITY BISEXUALITY TRANSVESTISM

SEXUAL DISORDERS

PARAPHILIAS
EXHIBITIONISM: the recurrent urge or behavior to expose one's genitals to an unsuspecting person. FETISHISM: the use of non-sexual or nonliving objects or part of a person's body to gain sexual excitement. Partialism refers to fetishes specifically involving nonsexual parts of the body. FROTTEURISM: the recurrent urges or behavior of touching or rubbing against a nonconsenting person.
SEXUAL DISORDERS

 SEXUAL MASOCHISM: the recurrent urge or behavior of wanting to be humiliated, beaten, bound, or otherwise made to suffer. SEXUAL SADISM: the recurrent urge or behavior involving acts in which the pain or humiliation of the victim is sexually exciting. TRANSVESTIC FETISHISM: a sexual attraction towards the clothing of the opposite gender.
SEXUAL DISORDERS

 PEDOPHILIA: the sexual attraction to prepubescent or peripubescent children. VOYEURISM: the recurrent urge or behavior to observe an unsuspecting person who is naked, disrobing or engaging in sexual activities, or may not be sexual in nature at all.

SEXUAL DISORDERS

 Other paraphilias not otherwise specified ("Sexual Disorder NOS")

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

 SOMATIZATION D/O: hx of many physical complaints beginning before the age of 30 occurring over a pd of several yrs resulting in ttt being sought or significant occupational or social fxning. CONVERSION D/O: 1 or more sx of deficits affecting voluntary motor or sensory function suggesting a neurological or general medical condition; preceded by conflicts or stressors; cant be explained and sanctioned by cultural behavior.
Most common: blindness, deafness, paralysis, inability to talk La belle indifference

SOMATOFORM D/O

 HYPOCHONDRIASIS: preoccupation with fears of having, or ideas that one has, a serious dse based on the persons misinterpretation of bodily sx and persist despite appropriate medical eval and reassurance and has existed for @ least 6 mos. (e.g.:extensive use of home remedies) PAIN D/O: pain in 1 or more anatomical sites severe enough to warrant clinical attention and causes clinically significant distress or impairment in fxning.

Interventions Do not reinforce the sick role Discourage verbalization about physical symptoms by not responding with positive reinforcement Explore with the client the needs being met by the physical symptoms Convey understanding that the physical symptoms are real to the client Report and assess any new physical complaint
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EATING DISORDER BEHAVIORS

BINGE: rapid consumption of large quantities of food in a discrete period of time. (A: hundrends of Cal; B: thousands of Cal at a sitting) PURGE: Maladaptive eating regulation response that includes excessive exercise, forced vomiting, OCD Rx diuretics, diet pills, laxatives and steroids. FAST/ RESTRICT: Includes vegetarian diet eliminating all meat without substituting nonanimal sources of protein, OC about food choices, and eating habits.
EATING DISORDERS

ANOREXIA
Rare vomiting or diuretic/laxative abuse More severe wt loss Slightly younger More introverted Hunger denied Eating behavior may be considered normal and a source of esteem Sexually inactive Obsessional and perfectionist features dominate

BULIMIA
Frequent Less wt loss Slightly older More extroverted Hunger experienced Eating behavior considered foreign and source of distress More sexually active Avoidant, dependent, or borderline features as well as obsessional features
EATING DISORDERS

 Death from starvation (or suicide, in chronically ill) Amenorrhea

ANOREXIA BULIMIA complications

Death from hypokalemia or suicide Menses irregular or absent Drug and alcohol abuse, selfmutilation, and other behavioral problems

Fewer behavioral problems (these increase with level of severity)

EATING DISORDERS

DELIRIUM
The medical dx term that describes an organic mental disorder characterized by a cluster of cognitive impairments with an acute onset with a specific precipitating factor. Sx: diminished awareness of the environment, disturbances in psychomotor activity and sleepwake cycle. COGNITIVE: the mental process characterized by knowing, thinking, and judging.

COGNITIVE DISSONANCE: arises when 2 opposing beliefs exists at the same time. COGNITIVE DISTORTIONS: (+) or (-) distortions of reality that might include errors of logic, mistakes in reasoning, or individualized view of the world that do not reflect reality. Term: confusion = cognitive impairment
See dementia

COGNITIVE DISORDERS

DEMENTIA
The medical dx term that describes an organic mental d/o characterized by a cluster of cognitive impairments of generally gradual onset and irreversible without identifiable precipitating stressors. Types:
VASCULAR or MULTI-INFARCT VASCULAR WITH ALZHEIMERS DSE AD: most common DEMENTIA WITH LEWY BODIES: 2nd most common; neurofilament material PARKINSONIAN DEMENTIA AIDS DEMENTIA COMPLEX

COGNITIVE DISORDERS

 FRONTAL LOBE DEMENTIA or PICKS DSE: cytoplasmic collections; 3rd most common; loss of expressive language & comprehension CREUTZFELDT-JAKOB DSE: prion (proteinaceous infectious particles) = spongy brain; related to TSE & BSE in mad cow dse CORTICOBASAL DEGENERATION or HUNTINGTONS DSE/CHOREA: jerky movts SUPRANUCLEAR PALSY: clumping of protein tau = slow movt, weak eye movt (esp. downward), impaired walking COGNITIVE DISORDERS &balance

 Reversible Causes:
Subdural hematoma Tumor (meningioma) Cerebral vasculitis Hydrocephalus

Terms: disorientation, memory loss (sensory, primary, secondary, tertiary, working memory), confabulation, confusion Disturbing behaviors
Aggressive psychomotor Nonaggressive psychomotor Verbally aggressive Passive Functionally impaired: loss of ability to do self-care
COGNITIVE DISORDERS

DELIRIUM DEMENTIA

vs.
Gradual, chronic with continuous decline Normal LOC Labile affect Disoriented, confused Attention intact, sleep usually normal Memory impaired Disordered reasoning & calculation COGNITIVE DISORDERS

Rapid onset w/ wide fluctuations Hyperalert to difficult to arouse LOC Fluctuating affect Disoriented, confused Attention & sleep disturbed Memory impaired Disordered reasoning

DELIRIUM

vs.

DEMENTIA
Disorganized, rich in content, delusional, paranoid No change in perception Poor judgment No insight Consistently poor & progressively worsens in MSE
COGNITIVE DISORDERS

Incoherent, confused, delusional, stereotyped Illusions, hallucinations Poor judgment Insight may be present in lucid moment Poor but variable in MSE

 Most common type of dementia Stages:

ALZHEIMERS DEMENTIA

MILD: impaired memory, insidious loses in ADL, subtle personality changes, socially normal MODERATE: obvious memory loss, overt ADL impairment, prominent behavioral difficulties, variable social skills, supervision needed SEVERE: fragmented memory, no recognition of familiar people, assistance needed with basic ADL, fewer troublesome behaviors, reduced mobility (4 As)
COGNITIVE DISORDERS

Symptoms
AGNOSIA: Difficulty recognizing wellknown objects APHASIA: Difficulty in finding the right word APRAXIA: Inability or difficulty in performing a purposeful organized task or similar skilled activities AMNESIA: Significant memory impairment in the absence of clouded consciousness or other cognitive symptoms
COGNITIVE DISORDERS

PSYCHIATRIC D/O IN CHILDREN MENTAL RETARDATION

PERVASIVE DEVTAL D/O
AUTISM RETTS D/O CHILDHOOD DISINTEGRATIVE D/O ASPERGERS D/O PDD NOS READING MATHEMATICS WRITTEN EXPRESSION ACADEMIC PROBLEM LEARNING D/O NOS
CHILDHOOD DISORDERS

LEARNING D/O

 MOTOR SKILLS D/O COMMUNICATION D/O

EXPRESSIVE LANGUAGE MIXED RECEPTIVE/EXPRESSIVE PHONOLOGICAL STUTTERING SELECTIVE MUTISM COMMUNICATION D/O NOS

MOVT & TIC D/O

DEVTAL COORDINATION TRANSIENT TIC
CHILDHOOD DISORDERS

CHRONIC MOTOR&VOCAL TIC TOURETTES D/O STEREOTYPIC MOVT D/O TIC D/O NOS
PICA RUMINATION FEEDING D/O ENURESIS ENCOPRESIS OTHER: BULIMIA, ANOREXIA
CHILDHOOD DISORDERS

DISORDERS OF INTAKE & ELIMINATION

 ADHD & DISRUPTIVE BEHAVIOR D/O

ADHD ADHD NOS CONDUCT D/O OPPOSITIONAL DEFIANT CHILD ANTISOCIAL DISRUPTIVE BEHAVIOR NOS

MOOD D/O

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

 ANXIETY D/O D/O OF RELATIONSHIP

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

CHILDHOOD DISORDERS

MENTAL RETARDATION
an IQ below 70, significant limitations in two or more areas of adaptive behavior (i.e., ability to function at age level in an ordinary environment), and evidence that the limitations became apparent in before 18 y.o. The following ranges, based on the Wechsler Adult Intelligence Scale (WAIS), are in standard use today: Class IQ Terms Profound Below 20 Idiot Severe 2034 Imbecile Moderate 3549 Moron Mild 5069 Borderline 7079
CHILDHOOD DISORDERS

RETTS D/O
Development is normal until 6-18 months, when language and motor milestones regress, purposeful hand use is lost Acquired deceleration in the rate of head growth (resulting in microcephaly in some) Hand stereotypes are typical and breathing irregularities such as hyperventilation, breath holding, or sighing are seen in many. Early on, autistic-like behavior may be seen Common in females
CHILDHOOD DISORDERS

CHILDHOOD DISINTEGRATIVE D/O or HELLERS SYNDROME

CDD has some similarity to autism, but an apparent period of fairly normal development is often noted before a regression in skills or a series of regressions in skills. characterized by late onset (>3 years of age) of devtal delays in language, social function and motor skills; skills apparently attained are lost
CHILDHOOD DISORDERS

ASPERGERS D/O
characterized by difference in language and communication skills, as well as repetitive or restrictive patterns of thought and behavior. Signs: unable to interpret or understand the desires or intentions of others and thereby are unable to predict what to expect of others or what others may expect of them
Narrow interests or preoccupation with a subject to the exclusion of other activities Repetitive behaviors or rituals Peculiarities in speech and language Extensive logical/technical patterns of thought Socially and emotionally inappropriate behavior and interpersonal interaction Problems with nonverbal communication Clumsy and uncoordinated motor movts

CHILDHOOD DISORDERS

CHRONIC MOTOR/ VOCAL TIC

TIC is a sudden, repetitive, stereotyped, nonrhythmic, involuntary movement (motor tic) or sound (phonic tic) that involves discrete groups of muscles. can be invisible to the observer (e.g. abdominal tensing or toe crunching)

CHILDHOOD DISORDERS

TOURETTES D/O
characterized by the presence of multiple physical (motor) tics and at least one vocal (phonic) tic; these tics characteristically wax and wane TTT: Neuroleptic medications
haloperidol (Haldol) pimozide (Orap)

CHILDHOOD DISORDERS

ADHD
Inattention: Failure to pay close attention to details or making careless mistakes when doing schoolwork or other activities Trouble keeping attention focused during play or tasks Appearing not to listen when spoken to Failure to follow instructions or finish tasks Avoiding tasks that require a high amount of mental effort and organization, such as school projects Frequently losing items required to facilitate tasks or activities, such as school supplies Excessive distractibility Forgetfulness Procrastination, inability to begin an activity Difficulties with household activities (cleaning, paying bills, etc.) Difficulty falling asleep, may be due to too many thoughts at night Frequent emotional outbursts Easily frustrated Easily distracted

Hyperactivity-impulsive behaviour Fidgeting with hands or feet or squirming in seat Leaving seat often, even when inappropriate Running or climbing at inappropriate times Difficulty in quiet play Frequently feeling restless Excessive speech Answering a question before the speaker has finished Failure to await one's turn Interrupting the activities of others at inappropriate times Impulsive spending, leading to financial difficulties

CHILDHOOD DISORDERS

 Frequently prescribed stimulants are methylphenidate (Ritalin and Concerta), amphetamines (Adderall) and dextroamphetamines (Dexedrine) Feingold diet which involves removing salicylates, artificial colors and flavors, and certain synthetic preservatives from children's diets.

CHILDHOOD DISORDERS

CONDUCT D/O
repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated,
AGGRESSION TO PEOPLE & ANIMALS DESTRUCTION OF PROPERTY DECEITFULNESS OR THEFT SERIOUS VIOLATIONS OF RULES
Beginning before age 13

CHILDHOOD DISORDERS

OPPOSITIONAL DEFIANT
characterized by an ongoing pattern of disobedient, hostile, and defiant behavior toward authority figures that goes beyond the bounds of normal childhood behavior Signs Losing temper Arguing with adults Refusing to follow the rules Deliberately annoying people Blaming others Easily annoyed Angry and resentful Spiteful or even revengeful
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CHILDHOOD DISORDERS

SUBSTANCE ABUSE
Excessive or unhealthy use of substances, such as alcohol, tobacco or drugs, or use of products such as food Terms:
TOLERANCE: the declining effect of the same drug dose when it is taken repeatedly over time HABITUATION: a psychological dependence of the use of a drug ADDICTION: the biological and/ or psychological behaviors related to substance dependence WITHDRAWAL SYMPTOMS: result from a biological need that develops when the body becomes adapted to having an addictive drug in the system; occurs when serum levels decrease
SUBSTANCE ABUSE

ADDICTION
ALCOHOL: blood alcohol levels of 0.1% (100mg alcohol/dl of blood) or higher
WITHDRAWAL
Anorexia Anxiety Easily startled Hyperalertness HPN Insomnia Irritability Jerky movt Possibly: hallucinations, illusions or vivid nightmares Seizures (7-48 hrs after cessation) Tachycardia tremors
SUBSTANCE ABUSE

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

Disulfiram (Antabuse) therapy

SUBSTANCE ABUSE

Nursing care
Obtain info about drug type and amount consumed Assess v/s Remove unnecssary obj from environment Provide one-on-one supervision if necessary Provide a quiet, calm environment with minimal stimuli Maintain orientation Ensure safety Use restraints Provide physical needs Provide food and fluids as tolerated Administer medications Collect blood and urine samples for drug
SUBSTANCE ABUSE

SPOUSE ABUSE
Battering precipitates 1:4 suicide attempts of all women Wives explain the injuries as being selfinflicted or accidental Phases
Tension-building: series of small incidents that leads to beating Acute beating phase: wife becomes object of assault behavior Loving phase: batterer is remorseful and assures spouse that he will not harm her again. This leads to reconciliation.
ABUSE

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

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

Assessment: injuries, other evidence Interventions: with consent

ABUSE

CHILD ABUSE
PHYSICAL BATTERING EMOTIONAL SEXUAL NEGLECT

ABUSE

ELDERLY ABUSE
A variety of behaviors that threaten the health, comfort, and possibly the lives of the elderly, including physical and emotional neglect, emotional abuse, violation of personal rights, financial abuse, and direct physical abuse. Commonly committed by care givers.

ABUSE

SEXUAL ABUSE
Components
Sexual Misuse: inappropriate sexual activity Rape: there is actual penetration Incest: refers to the relationship between the victim and abuser blood relative or step parent role

Interventions
Children: thru play or role playing with puppets Prevention of further sexual abuse
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ABUSE

COMPLETED SUICIDE
Self-inflicted death LEVELS OF SUICIDE
Ideation: thought Attempt: acted upon but failed Completed

SUICIDE

CHEMICAL RESTRAINT
CHEMICAL RESTRAINTS: Medications used to restrict the patients freedom of movement or for emergency control of behavior but are not a standard treatment for the pxs medical or psychiatric condition. PHYSICAL RESTRAINTS: Are any manual method or physical or mechanical device attached to or adjacent to the pxs body that he or she cannot easily remove and that restricts freedom of movement or normal access to ones body, material or equipment.

SECLUTION AND RESTRAINTS

SECLUTION: the involuntary confinement of a person alone in a room from which the person is physically prevented from leaving.
No therapeutic evidence other than a last resort to ensure safety. Evidence suggest that it adds to further trauma and physical harm

 GUIDELINES

All hospital staff who have direct contact with the px should have ongoing education and training in the proper use of seclusion and restraints and other alternatives Physician or licensed practitioner should evaluate need within 1 hour after the initiation of this intervention. Max of 4 hours for adults, 2 hours for ages 9-17, and 1 hour for children under 9 yrs Orders may be renewed for 24 hrs before another face to face evaluation Continuous assessment, monitoring and evaluation; recorded Good nursing care For both restrained and secluded: constant monitoring face to face or by both audio and video equipment. Px should be released ASAP

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

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

TERMINATING THE INTERVENTION

As soon as met the criteria for release Review with px the behavior that precipitated the intervention & pxs capacity to exercise control over behavior DEBRIEFING: reviewing the facts related to an event & processing the response to them; can be used after any stressful event
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THERAPEUTIC IMPASSES
Are blocks in the progress of the nursept relationship Provokes intense feelings in both the nurse and patient
RESISTANCE TRANSFERENCE COUNTERTRANSFERENCE BOUNDARY VIOLATIONS

RESISTANCE
Reluctance or avoidance of verbalizing or experiencing troubling aspects of oneself Eg: suppression or repression, intensification of sx, self-devaluation or hopelessness, intellectual inhibitions, acting out or irrational behavior, superficial talk, intellectual insight/ intellectualization, transference reactions.

TRANSFERENCE
Unconscious response in which the px experiences feelings and attitudes toward the nurse that were originally associatated with other significant figures in his or her life.
HOSTILE TRANSFERENCE: anger and hostility, resistance DEPENDENT TRANSFERENCE: submissive, subordinate and regards the nurse as a god-like figure; views relationship as magical

What do you do?

LISTEN CLARIFY REFLECT EXPLORE/ ANALYZE

COUNTERTRANSFERENCE
Created by the nurses specific emotional response to the qualities of the patient; inappropriate in the context, content and intensity of emotion; nurses identify the px with individuals from their past, and personal needs Types: Reactions of INTENSE love or caring Disgust or hostility Anxiety, often in response to resistance by the px

 Eg.

Difficulty empathizing Feelings of depression before or after the session Carelessness about implementing the contract Drowsiness during the sessions Encouragement of the pxs dependency Arguments with the px Personal or social involvement with the px Sexual or aggressive fantasies toward the px Tendency to focus on only one aspect or way of looking at information presented by the px Attempts to help the px with matters not related to the identified nursing problems Feelings of anger or impatience because of the pxs unwillingness to change Dreams about or preoccupation with the px