Care of Clients with Maladaptive Patterns of Behavior

Unit II PRINCIPLES OF PSYCHIATRIC NURSING I. Contemporary Psyc iatric N!rsin" Practice A. The Biopsychosocial Model three separate, but interdependent, domains (biologic, psychological and social)

B. Professional Practice Legal authority to practice (license), granted by states and pro inces Professional standards set by professional nursing organi!ations (AP"A, #$P") %. $tandards of Psychiatric and Mental &ealth "ursing Practice '. Pro ides competent professional care through the helping role (. Performs)refines client assessments through the diagnostic and monitoring function *. Administers and monitors therapeutic inter entions +. ,ffecti ely manages rapidly changing situations -. #nter enes through the teaching-coaching function .. Monitors and ensures the /uality of health care practices 0. Practices 1ithin organi!ational and 1or2-role structures 3. Tools of Psychiatric "ursing Practice '. %linical 3ecision Ma2ing (. "ursing %are Plans *. %ritical Path1ays ,. #nterdisciplinary Approaches '. Multidisciplinary se eral disciplines pro iding different ser ices to patient (. #nterdisciplinary ser ices are not pro ided independently of each other. %hallenges of Psychiatric "ursing '. 5no1ledge de elopment, dissemination and application (. 6 ercoming stigma *. &ealth care deli ery system issues +. #mpact of technology

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II. T eoretic #asis o$ N!rsin" Practice A. Psychoanalytic Theories focuses on disco ering the causes of the client7s unconscious and repressed thoughts, feelings, and conflicts belie ed to cause an8iety and helping the client to gain insight into and resol e these conflicts and an8ieties. '. Sigmund Freud ('9-.:';*;) All human beha ior is caused and can be e8plained Personality components < id, ego, and superego Beha ior moti ated by subconscious thoughts and feelings, treatment in ol es analysis of dreams, ,go defense mechanisms Transference and countertransference Psychose8ual stages of de elopment a. 6ral $tage (= :'9 months) b. Anal $tage ('9 mos-* years) c. Phallic $tage (* : . years) d. Latency $tage (. : '( years)

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Care of Clients with Maladaptive Patterns of Behavior

e. >enital $tage ('( : (= years)

B. 3e elopmental Theories '. Erik Erikson (';=(:';;+) 3escribed eight stages of psychosocial development
STAGE & AGE # : #nfant =-' ## - Toddler (-* ### - Preschooler *-. #A - $choolage 0-'( A - Adolescence '(-'9 A# - Boung Adult The (=7s A## - Middle Adult Late (=7s to -=7s A### - 6ld Adult -=7s and beyond CRISIS Trust s. Mistrust SIGNFICANT RELT'S Mother

Autonomy s. $hame @ 3oubt

Parents

#nitiati e s.>uilt

4amily

#ndustry s.#nferiority

"eighborhood @ $chool Peer groups ?ole models Partners 4riends &ousehold Cor2mates Man2ind or DMy 2indE

,go-#dentity s.?ole%onfusion

#ntimacy s.#solation

>enerati ity s.$elfabsorption

#ntegrity s.3espair

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Jean Piaget ('9;.:';9=) 3escribed cognitive and intellectual development in children in four stages< a. $ensorimotor (=-( yrs) infants use sensory information gained through mouth and hands %ontemplati e recognition (. mos) ?epresentational intelligence)$ymbolic thought ('9 mos) b. Pre-operational ((-0 yrs) ,gocentricity Animation "on-conser ation c. %oncrete 6perational (0-'( yrs) %hild learns to relate e ents e en if it does not concern him %onser ation d. 4ormal 6perational ('(-'- yrs) Adult ?easoning Abstract thought

%. #nterpersonal Theories '. Harry Stack Sullivan (1892:19 9) ,stablished fi e life stages of personality de elopment that included the significance of interpersonal relationships 3escribed three de elopmental cogniti e modes< protota8ic, parata8ic, synta8ic Belie ed that unsatisfying relationships 1ere the basis for all emotional problems 3escribed the concept of therapeutic milieu or community Hildegard Peplau (19!9:1999" Leading nursing theorist and clinician de eloped the nurse#patient relationship 1ith phases and tas2s #dentified roles of the nurse< stranger, resource person, teacher, leader, surrogate, counselor 3escribed four le els of an8iety (mild, moderate, se ere, panic) still 1idely used no1

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3. &umanistic Theories '. $%raham &aslo' (1921:19(!" ) Hierarchy o* needs< basic physiologic needs, safety and security needs, lo e and belonging needs, esteem needs, self-actuali!ation +arl ,ogers (19!2:198("

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Care of Clients with Maladaptive Patterns of Behavior

) ,. +lient)centered therapy %oncepts of unconditional positi e regard, genuineness, and empathetic understanding

Beha ioral Theories ) focuses on beha iors and beha ior changes rather than on e8plaining ho1 the mind 1or2s '. (. -van Pavlov (18 9#19./" 01 F1 Skinner (19! #199!" All beha ior is learned Beha ior has conse/uences (re1ard or punishment) ?e1arded beha ior tends to recur Positi e reinforcement increases the fre/uency of beha ior ?emo al of negati e reinforcers increases the fre/uency of beha ior %ontinuous reinforcement is the fastest 1ay to increase beha iorF random intermittent reinforcement increases beha ior more slo1ly but 1ith longer-lasting effect Treatment modalities based on beha iorism include %ehavior modi*ication2 token economy2 and systematic desensiti3ation

III. T e #io)o"ic Fo!n*ations o$ Psyc iatric N!rsin" A. Biologic Theories '. LA$ (. >A$ < >eneral Adaptation $yndrome (Hans Selye2 194/" + lin2ed stressful e ents and illness a. Alarm Phase b. ?esistance Phase c. ,8haustion Phase B. "eurobiologic Theories +entral 5ervous System '. Brain a. %erebrum di ided into t1o hemispheres 1ith four lobes each< 4rontal lobe, Parietal lobe, Temporal lobe, 6ccipital lobe b. %erebellum recei es and integrates information from all body areas to coordinate mo ement and posture c. Brain stem)Midbrain Pons, Medulla oblongata, Locus ceruleus, %ranial ner e nuclei * through '( d. Limbic system abo e the brain stem includes the Thalamus, &ypothalamus, Amygdala (. *. $pinal cord "er es that control oluntary acts

5eurotransmitters %hemical substances manufactured in the neuron to aid in transmission of information ,ither inhibitory or e8citatory '. (. *. +. -. .. 0. 9. 3opamine < control of comple8 mo ements, moti ation, cognition, regulation of emotional responses "orepinephrine < attention, learning, memory, sleep, 1a2efulness, mood regulation ,pinephrine < flight-or-fight response $erotonin < food inta2e, sleep, 1a2efulness, temp. regulation, pain control, se8ual beha iors, regulation of emotions &istamine < alertness, control of gastric secretions, cardiac stimulation, peripheral allergic responses Acetylcholine < sleep and 1a2efulness cycle, signals muscles to become alert >lutamate < an e8citatory amino acid >ABA < modulates other neurotransmitters

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Care of Clients with Maladaptive Patterns of Behavior

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0rain -maging 6echni7ues '. %omputed tomography (%T) (. Magnetic resonance imaging (M?#) *. Positron emission tomography (P,T) +. $ingle photon emission computed tomography ($P,%T) 88 M,"TAL #LL",$$ %A""6T B,T B, 3#A>"6$,3 C#T& T&,$, T,%&"#GH,$ AL6",. +auses o* &ental -llness '. >enetics and heredity (. Psychoimmunology *. #nfections I.. Psyc op armaco)o"y an* Ot er #io)o"ic Treatments Psychopharmacology and medication management are important in the treatment of many mental illnesses. A. Princip)es in /e*ications Use '. ,ffect on target symptom (. Ade/uate dosage for sufficient time *. Lo1est dose needed for maintenance +. Lo1er doses for the elderly -. Tapering rather than abrupt cessation to a oid rebound or 1ithdra1al .. 4ollo1-up care 0. $implify the regimen for increased compliance #. Antipsyc otic 0r!"s Hses < $chi!ophrenia, acute mania, psychotic depression, drug-induced psychosis, other psychotic symptoms Action < Treat psychotic symptoms, such as delusions and hallucinations, by bloc2ing dopamine receptors '. %on entional Antipsychotic 3rugs a. Phenothia!ines (Thora!ine, Proli8in, Mellaril, $tela!ine), "a ane, &aldol, Lo8itane, Moban b. $ide ,ffects < ,8trapyramidal side effects (,P$s) Pseudopar2insonism 3ystonia A2athisia Anticholinergic side effects Tardi e dys2inesia (T3) "euroleptic malignant syndrome ("M$) c. Pt. Teaching < Adhering to medication regimen Managing side effects (Thirst, %onstipation, $edation) Atypical Antipsychotic 3rugs a. %lo!aril, ?isperdal, Iypre8a, $ero/uel, >eodon b. $ide ,ffects < 4e1er ,P$s

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Care of Clients with Maladaptive Patterns of Behavior

Ceight gain Agranulocytosis (%lo!aril) < Adhering to medication regimen ?educing sugar and caloric inta2e %lo!aril Cee2ly CB% monitoring 3iscontinue medication and see2 care at first sign of infection

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c.

Pt. Teaching

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"e1->eneration Antipsychotic 3rugs a. Aripipra!ole (Abilify) b. $ide ,ffects < &eadache An8iety "ausea c. Pt. Teaching < Adhering to medication regimen

C. Anti*epressant 0r!"s Hses < MaJor depression, panic disorder and other an8iety disorders, bipolar depression, psychotic depression Action < #nteract 1ith the monoamine neurotransmitter systems in the brain, particularly the neurotransmitters norepinephrine and serotonin '. $$?# Antidepressant 3rugs a. fluo8etine (Pro!ac), paro8etine (Pa8il), sertraline (Ioloft), citalopram (%ele8a), escitalopram (Le8apro) b. $ide ,ffects < An8iety Agitation A2athisia "ausea #nsomnia $e8ual dysfunction (anorgasmia)impotence) c. Pt Teaching < Ta2e in the morning Ta2e 1ith food Propanolol gi en for a2athisia T%A Antidepressant 3rugs a. imipramine (Tofranil), desipramine ("orpramin), amitriptyline (,la il), do8epin ($ine/uan), clomipramine (Anafranil) b. $ide ,ffects < Anticholinergic (blurred ision, urinary retention, dry mouth, constipation) 6rthostatic hypotension $edation Ceight gain Tachycardia $e8ual dysfunction c. Pt Teaching < Ta2ing in the e ening Hsing caution 1hen dri ing MA6# Antidepressant 3rugs a. phenel!ine ("ardil), tranylcypromine (Parnate), isocarbo8a!id (Marplan) b. $ide ,ffects < $edation #nsomnia Ceight gain 3ry mouth 6rthostatic hypotension $e8ual dysfunction &ypertensi e crisis 1ith e8cessi e tyramine or sympathomimetic drugs c. Pt Teaching < 4ollo1ing tyramine-free diet (a oid aged cheeses, aged meats, beer and 1ine, sauer2raut, soy) A oiding sympathomimetic drugs Hsing caution 1hen dri ing

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0. /oo* Sta1i)i2in" 0r!"s '. lithiumF anticon ulsant medications (carbama!epine (Tegretol), alproic acid (3epa2ote), lamotrigine (Lamictal), gabapentin ("eurontin) (. Hses < Bipolar disorder *. Action < Act on the neurotransmitters of the brain +. $ide ,ffects < Lithium "ausea, 3iarrhea, Anore8ia 4ine hand tremor Polydipsia Polyuria 4atigue Ceight gain Acne -. Pt Teaching < Lithium Ta2en 1ith food &a ing monthly blood le els dra1n '( hours after last dose (maintain therapeutic le els bet1een =.-:'.- m,/)L) E. Antian3iety 0r!"s '. ben!odia!epinesF buspirone (Bu$par)

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Care of Clients with Maladaptive Patterns of Behavior

(. *. +. Hses < Action < $ide ,ffects < An8iety disorders, insomnia, 6%3, depression, PT$3, alcohol 1ithdra1al Moderate the actions of >ABA Tolerance and dependence 3ro1siness $edation Poor concentration #mpaired memory %louded sensorium Hsing caution during dri ing due to slo1er refle8es and response time "e er discontinuing abruptly as 1ithdra1al can be fatal A oiding alcohol

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Pt Teaching <

F. Stim!)ant 0r!"s '. methylphenidate (?italin), pemoline (%ylert), de8troamphetamine (. Hses < A3&3, residual A33 in adults, and narcolepsy *. Action < %ause release of neurotransmitters +. $ide ,ffects < Anore8ia Ceight loss "ausea #rritability -. Pt Teaching < A oiding caffeine, sugar, and chocolate Ta2ing after meals Long-term use can cause dependency G. 0is!)$iram '. Antabuse (. Hses < A ersion therapy for treatment of alcoholism *. Action < %auses an ad erse reaction 1hen alcohol is ingested +. $ide ,ffects < 4atigue 3ro1siness &alitosis Tremor #mpotence -. Pt Teaching < A oiding alcohol (including products such as sha ing cream, aftersha e, cologne, many 6T% meds) 4amily should ne er administer 1ithout the personKs 2no1ledge H. C!)t!ra) Consi*erations ,thnic bac2grounds influence responses to some psychotropic medications< '. African Americans respond more rapidly to antipsychotic and tricyclic antidepressant medications than do 1hites and ha e a greater ris2 of side effects (. Asians metaboli!e antipsychotic @ tricyclic antidepressants more slo1ly, re/uiring lo1er doses to produce the same effects *. &ispanics re/uire lo1er doses of antidepressants than 1hites to achie e desired effects +. Asians and African Americans re/uire lo1er doses of lithium than 1hites to produce desired effects .. Ot er T erapies A. %risis #nter ention (>erald %aplan, ';.+) $tages of %risis< '. ,8posure to stressor (. #ncreased an8iety 1hen customary coping is ineffecti e *. #ncreased efforts to cope +. 3ise/uilibrium and significant distress Types of %rises< '. Maturational (. $ituational *. Ad entitious %risis state lasts + to . 1ee2s. 6utcome is either return to pre ious functioning le el, impro ed coping, or decreased coping. %risis inter ention techni/ues are authoritati e and facilitati e. A balance of both types is most effecti e.

B. Psychiatric Mental &ealth "ursing #nter entions

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