Presented by: Dave Jay S. Manriquez, RN.

PSYCHIATRIC NURSING Introduction

MENTAL HEALTH balance in a persons internal li e and adaptation to realit!

Mental ILL Healt" state o i#balance c"aracteri$ed b! a disturbance in a persons t"ou%"ts& eelin%s and be"a'ior Ps!c"iatric nursin% interpersonal process ("ereb! t"e pro essional nurse practitioner &t"rou%" t"e t"erapeutic use o sel )art* and nursin% t"eories )science*& assist clients to ac"ie'e ps!c"osocial (ell bein%+ Core , interpersonal process Related Ter#s Mental "!%iene #easures to pro#ote #ental "ealt" & pre'ent #ental illness and su erin% and acilitate re"abilitation Main tool, t"erapeutic use o sel It re-uires sel .a(areness Met"ods to increase sel .a(areness, Introspection /iscussion E0perience Role pla!

Assess#ent )ps!c"osocial processes * Appearance & be"a'ior or #ood Speec" & t"ou%"t content and t"ou%"t process Sensoriu# Insi%"t and 1ud%#ent 2a#il! relations"ips and (or3 "abits Le'el o %ro(t" and de'elop#ent Co##on 4e"a'ioral Si%ns and S!#pto#s /isturbances in perception

Illusion #isinterpretation o an actual e0ternal sti#uli

Hallucinations alse sensor! perception in t"e absence o e0ternal sti#uli

/isturbances in t"in3in% and speec" neolo%is# coinin% o (ords t"at people do not understand Circu#stantialit! o'er inclusion o inappropriate t"ou%"ts and details 5ord salad inco"erent #i0ture o (ords and p"rases (it" no lo%ical se-uence 6erbi%eration #eanin%less repetition o (ords and p"rases Perse'eration persistence o a response to a pre'ious -uestion Ec"olalia pat"olo%ical repetition o (ords o ot"ers Ap"asia speec" di icult! and disturbance E0pressi'e & recepti'e or %lobal

2li%"t o ideas. s"i tin% o one topic ro# one sub1ect to anot"er in a so#e("at related (a! Looseness o association.inco"erent illo%ical lo( o t"ou%"ts )unrelated (a!* Clan% association sound o (ord %i'es direction to t"e lo( o t"ou%"t /elusion persistent alse belie & ri%idl! "eld /elusions o %randeur, special 7i#portant in a (a! Persecutor!, t"reatened Ideas o re erence, situation7e'ents in'ol'e t"e# So#atic, bod! reactin% in a particular (a!

8ealous, t"in3in% t"at t"eir partner is un ait" ul Eroto#anic, person& usuall! o "i%" status& is in lo'e (it" t"e client Reli%ious, illo%ical ideas about God and reli%ion e0"ibited b! e0tre#e or e0traneous be"a'ior

Mi0ed, co#bination o abo'e (it"out a predo#inant t"e#e Ma%ical t"in3in% pri#iti'e t"ou%"t process t"ou%"ts alone can c"an%e e'ents

Autistic t"in3in% re%ressi'e t"ou%"t process9 sub1ecti'e interpretations not 'alidated (it" ob1ecti'e realit! /ereis# unor%ani$ed t"in3in%

/isturbances o a ect Inappropriate dis"ar#on! bet(een t"e sti#uli and t"e e#otional reaction 4lunted a ect se'ere reduction in e#otional reaction 2lat a ect absence or near absence o e#otional reaction Apat"! dulled e#otional tone /epersonali$ation eelin% o stran%eness ro# one:s sel /ereali$ation eelin% o stran%eness to(ards en'iron#ent A%nosia lac3 o sensor! sti#uli inte%ration /isturbances in #otor acti'it! Ec"opra0ia i#itation o posture o ot"ers 5a0! le0ibilit! #aintainin% position or a lon% period o ti#e Ata0ia loss o balance A3at"esia e0tre#e restlessness /!stonia. uncoordinated spastic #o'e#ents o t"e bod! Tardi'e d!s3inesia in'oluntar! t(itc"in% or #uscle #o'e#ents Apra0ia in'oluntar! unpurpose ul #o'e#ents /isturbances in #e#or! Con abulation illin% o #e#or! %aps /;1< 'u so#et"in% un a#iliar see#s a#iliar 8a#ais 'u. so#et"in% a#iliar see#s un a#iliar A#nesia #e#or! loss )inabilit! to recall past e'ents* Retro%rade.distant past Antero%rade i##ediate past Ano#ia lac3 o #e#or! o ite#s

/!na#ics o Hu#an 4e"a'ior

4e"a'ior t"e (a! an indi'idual reacts to a certain sti#ulus Con lict situation arisin% ro# t"e presence o t(o opposin% dri'es

Need . or%anis#ic condition t"at re-uires a certain acti'it! /!na#ics o Hu#an 4e"a'ior Personalit! totalit! o e#otional and be"a'ioral traits t"at c"aracteri$e t"e person in da! to da! li'in% under ordinar! conditions9 it is relati'el! stable and predictable+ 2=RMATI=N =2 PERS=NALITY TEMPERAMENT biolo%ical.%enetic te#plate t"at interacts (it" our en'iron#ent+ a set o in.built dispositions (e are born (it" #ostl! unalterable our nature+ CHARACTER t"e outco#e o t"e process o sociali$ation& t"e acts and i#prints o our en'iron#ent and nurture on our ps!c"e durin% t"e or#ati'e !ears )>.? !ears and in adolescence*+ t"e set o all ac-uired c"aracteristics (e posses& o ten 1ud%ed in a cultural.social conte0t+ So#eti#es t"e interpla! o all t"ese actors results in an abnor#al personalit! THE=RIES =2 PERS=NALITY /E6EL=PMENT 2reud:s PSYCH=SE@UAL THE=RY

Libido inner dri'e Parts o bod! ocus o %rati ication Unsuccess ul resolution . i0ation Structures o personalit! Id, pleasure principle.instinct E%o, controls action and perception realit! principle Supere%o, #oral be"a'ior . conscience >.AB #>s 9oral #out" trust and discri#inatin% AB #os+ C !ears 9 anal bo(els "oldin% on or lettin% %o Ne%ati'is# and toilet trainin% a%e C .? !ears p"allic 9 %enitals e0ploration and disco'er! ) inc+ se0ual tension* Gender identi ication and %enital a(areness

=edipus and Electra co#ple0 Castration an0iet! and penis en'!

?.AD !ears latenc! )-uiet sta%e* se0ual ener%! di'erted to pla!+ Institution o supere%o, control o instinctual i#pulses AD !oun% adult %enital 9 rea(a3enin% o se0ual dri'es relations"ips Se0ual #aturation Se0ual identit! &abilit! to lo'e and (or3 Eric Eric3son:s PSYCH=S=CIAL THE=RY

>.AD#os A.C! C.? ?.AD AD.AB AB.DE DE.?> ?> and abo'e TRUST 's+ MISTRUST AUT=N=MY 's+ SHAME F /=U4T IN/USTRY 's+ IN2ERI=RITY INITIATI6E 's+ GUILT I/ENTITY 's+ I/ENTITY C=N2USI=N INTIMACY 's+ IS=LATI=N EG= INTEGRITY 's+ STAGNATI=N GENERATI6ITY 's+ /ESPAIR IN2ANCY C=NSISTENT MATERNAL CHIL/ INTERACTI=N TRUST INNER 2EELING =2 SEL2 5=RTH H=PE T=//LER

ALL=5 E@PL=RATI=N PR=6I/E 2=R SA2ETY GN=& N=H NEGATI6ISM =22ER CH=ICES 7 RE6ERSE PSYCH=L=GY T=ILET TRAINING AB M=S+.4=5EL /AYTIME 4LA//ER, D !o NIGHTIME 4LA//ER, C !o RE5AR/ 57 PRAISE AN/ A22ECTI=N IN/EPEN/ENCE PRE.SCH==L PR=6I/E PLAY MATERIALS SATIS2Y CURI=SITY TEACH AN/ REIN2=RCE)HYGIENE&S=CIAL 4EHA6I=R* SI4LING RI6ALRY 5ILLP=5ER SCH==L AGE H=5 T= /= THINGS 5ELL.SUPP=RT E22=RTS CHUMS AN/ H=44IES NEE/S T= E@CEL7ACC=MPLISH NEE/ 2=R PRI6ACY AN/ PEER INTERACTI=N C=MPETENCE A/=LESCENCE MAIE /ECISI=N&EMANCIPATI=N 2R=M PARENTS 4=/Y IMAGE CHANGES NEE/ T= C=N2=RM 4UT IEEP IN/I6I/UALITY SEL2 . A5ARENESS Y=UNG A/ULT

C=MMITMENT AN/ 2I/ELITY RESP=NSI4ILITY ACHIE6EMENT =2 IN/EPEN/ENCE MI//LE A/ULTH==/ SUPP=RT.PERI=/ =2 R=LE TRANSITI=NS MI/LI2E CRISIS

A/8USTMENT AN/ C=MPR=MISE M=ST PR=/UCTI6E AN/ CREATI6E ALTRUISM LATE A/ULTH==/ SEL2 ACCEPTANCE SEL2 5=RTH 5IS/=M 8ean Pia%et:s C=GNITI6E THE=RY >.D SENS=RIM=T=R

RE2LE@ES IMITATI6E REPETITI6E 4EHA6I=R SENSE =2 =48ECT PERMANENCE AN/ SEL2 SEPARATE 2R=M EN6T+

TRIAL AN/ ERR=R RESULTS IN PR=4LEM S=L6ING D.JY PRE.=PERATI=NAL SEL2.CENTERE/&EG=CENTRIC CANN=T C=NCEPTUALIKE =THER:S 6IE5 ANIMISTIC THINIING IMAGINARY PLAYMATE SYM4=LIC MENTAL REPRESENTATI=N CREATI6ITY D.L PRE.C=NCEPTUAL )PRE.L=GICAL* L.J INTUITI6E )UN/ERSTAN/ING =2 R=LES* J.ADY C=NCRETE =PERATI=NAL L=GICAL C=NCRETE TH=UGHT

IN/UCTI6E REAS=NING )SPECI2IC T= GENERAL* CAN RELATE& PR=4LEM S=L6ING A4ILITY REAS=NING AN/ SEL2.REGULATI=N AD.A4=6E, 2=RMAL =PERATI=NAL TH=UGHT Abstract t"in3in% Separation o antas! and act Realit! oriented /educti'e reasonin% Appl! scienti ic #et"od Ha'i%"urst:s /E6EL=PMENTAL TASIS

4ab! to earl! c"ild"ood Ri%"t ro# (ron% and Conscience Late c"ild"ood P"!sical s3ills& ("oleso#e attitude& social roles Conscience #oralit! and 'alues 2unda#ental s3ills in acade#ics Personal independence

Adolescence Se0ual social roles Relations"ips Independence and ideolo%! Earl! adult"ood Career Selectin% a #ate 2indin% Ci'ic or social responsibilit!

Middle a%e Ac"ie'in% Ci'ic or social responsibilit! Ad1ustin% to c"an%es Satis actor! career per or#ance Ad1ustin% to a%in% parents Ad1ustin% to parental roles =ld a%e Ad1ustin% to c"an%es Establis"in% satis actor! li'in% arran%e#ents and a iliations Io"lber%:s M=RAL /E6EL=PMENT7 THINIING7 8U/GEMENT

PRE.C=N6ENTI=NAL )>.?*

PUNISHMENT AN/ =4E/IENCE =4E/IENCE T= RULES T= A6=I/ PUNISHMENT C=N6ENTI=NAL ) ?.AD * MUTUAL INTERPERS=NAL E@PECTATI=NS&RELATI=NSHIPS AN/ C=N2=RMITY S=CIAL SYSTEM AN/ C=NSCIENCE MAINTENANCE 4EING G==/ IS IMP=RTANT SEL2 RESPECT =R C=NSCIENCE

P=ST C=N6ENTI=NAL )AD AB Y* PRI=R RIGHT =R S=CIAL C=NTRACT UNI6ERSAL ETHICAL PRINCIPLE A4I/E 2=R C=MM=N G==/ RATI=NAL PERS=N.6ALI/ITY =2 PRINCIPLES.AN/ 4EC=ME C=MMITTE/ T= THEM INNER C=NTR=L =2 4EHA6I=R UN/ERSTAN/ING THE EMUALITY =2 HUMAN RIGHTS AN/ /IGNITY =2 HUMAN 4EINGS AS IN/I6I/UALS Harr! Stac3 Sulli'an:s INTERPERS=NAL THE=RY IN2ANCY NEE/ 2=R SECURITY.IN2ANT LEARNS T= RELY =N =THERS T= GRATI2Y NEE/S AN/ SATIS2Y 5ISHES& /E6EL=PS A SENSE =2 4ASIC TRUST& SECURITY AN/ SEL2 5=RTH 5HEN THIS =CCURS T=//LERH==/ 7 EARLY CHIL/H==/ CHIL/ LEARNS T= C=MMUNICATE NEE/S THR=UGH USE =2 5=R/S AN/ ACCEPTANCE =2 /ELAYE/ GRATI2ICATI=N AN/ INTER2ERENCE =2 5ISH 2UL2ILLMENT PRE.SCH==L /E6EL=PMENT =2 4=/Y IMAGE AN/ SEL2.PERCEPTI=N =RGANIKES AN/ USES E@PERIENCES IN TERMS =2 APPR=6AL AN/ /ISAPPR=6AL RECEI6E/ 4EGINS USING SELCTI6E INATTENTI=N AN/ /ISASS=CIATES TH=SE E@PERIENCES THAT CAUSE PHYSICAL =R EM=TI=NAL /ISC=M2=RT AN/ PAIN SCH==L AGE THE PERI=/ =2 LEARNING T= 2=RM SATIS2YING RELATI=NSHIPS 5ITH PEERS.USES C=MPETITI=N&C=MPR=MISE AN/ C==PERATI=N THE PRE.A/=LESCENT LEARNS T= RELATE T= PEERS =2 THE SAME SE@

A/=LESCENCE LEARNS IN/EPEN/ENCE AN/ H=5 T= ESTA4LISH SATIS2ACT=RY RELATI=NSHIPS 5ITH MEM4ERS =2 THE =PP=SITE SE@ Y=UNG A/ULTH==/ 4EC=MES EC=N=MICALLY& INTELLECTUALLY AN/ EM=TI=NALLY SEL2 SU2ICIENT LATER A/ULTH==/ LEARNS T= 4E INTER/EPEN/ENT AN/ ASSUMES RESP=NSI4ILITY 2=R =THERS SENESCENCE /E6EL=PS AN ACCEPTANCE =2 RESP=NSI4ILITY 2=R 5HAT LI2E IS AN/ 5AS AN/ =2 ITS PLACE IN THE 2L=5 =2 HIST=RY TREATMENT M=/ALITIES REM=TI6ATI=N THERAPY TREATMENT M=/ALITY THAT PR=M=TES E@PRESSI=N =2 2EELINGS THR=UGH INTERACTI=N 2ACILITATE/ 4Y /ISCUSSI=N =2 NEUTRAL T=PICS STEPS , cli#ate o acceptance creatin% brid%e to realit! s"arin% t"e (orld (e li'e in appreciation o (or3s o t"e (orld cli#ate o appreciation

tension

MUSIC THERAPY In'ol'es use o #usic to acilitate e0pression o eelin%s& rela0ation and outlet o PLAY THERAPY enables patient to e0perience intense e#otion in a sa e en'iron#ent (it" t"e use

o pla!

c"ildren e0press t"e#sel'es #ore easil! in pla!+ re'ealin% as re lection o c"ild:s situation in t"e a#il! pro'ide to!s and #aterials acilitate interaction obser'e and "elp c"ild resol'e proble#s t"rou%" pla! Group t"erap! Treat#ent #odalit! in'ol'in% t"ree or #ore patients (it" a t"erapist to relie'e e#otional di iculties& increase sel estee#& de'elop insi%"t & LEARN NE5 A/APTI6E 5AYS T= C=PE 5ITH STRESS and i#pro'e be"a'ior (it" ot"ers I/EAL B A> MEM4ERS MILIEU THERAPY Consists o treat#ent b! #eans o controlled #odi ication o t"e patient:s en'iron#ent to acilitate positi'e be"a'ioral c"an%e

Increase patient:s A(areness o eelin%s Sense o responsibilit! and Help return to co##unit! clients plan social and %roup interaction to3en pro%ra#s & open (ards and sel #edication are done 2AMILY THERAPY A METH=/ =2 PSYCH=THERAPY 5HICH 2=CUSES =N THE T=TAL 2AMILY AS AN INTERACTI=NAL SYSTEM PR=4LEM IS A 2AMILY PR=4LEM ocus on sic3 #e#bers be"a'ior as source o trouble 7 s!#pto# ser'e a unction or t"e a#il! #e#bers de'elop sense o identit! points out unction o t"e sic3 #e#ber or t"e rest o t"e a#il! PSYCH=ANALYTIC ocuses on t"e e0ploration o t"e unconscious& to acilitate identi ication o t"e patients de enses AN@IETY RESULTS 4ET5EEN C=N2LICTS =2 I/ AN/ EG= 4eco#es a(are o unconscious t"ou%"ts and eelin%s to understand an0iet! and de enses HYPN=THERAPY 6arious #et"ods and tec"ni-ues to induce a trance state ("ere patient beco#es sub#issi'e to instructions 4EHA6I=R M=/I2ICATI=N Application o learnin% principles in order to c"an%e #aladapti'e be"a'ior

4elie'es t"at ps!c"olo%ical proble#s are a result o learnin%

E'er!t"in% learned can be unlearned 4EHA6I=R M=/I2ICATI=N =PERANT C=N/ITI=NING Use o re(ards to rein orce positi'e be"a'ior Percei'ed and sel .rein orce#ent beco#es #ore i#portant t"an e0ternal rein orce#ent

/ESENSITIKATI=N Slo( ad1ust#ent or e0posure to eared ob1ects )p"obias* Periodic e0posure until undesirable be"a'ior disappears or lessens A6ERSI=N THERAPY An e0a#ple o be"a'ior #odi ication Pain ul sti#ulus is introduced to brin% about an a'oidance o anot"er sti#ulus End 'ie(, be"a'ioral c"an%e

=THER THERAPIES

HUM=R THERAPY To acilitate e0pression and en"ance interaction ACTI6ITY THERAPY Group interaction ("ile (or3in% on a tas3 to%et"er 4I=L=GICAL7 ME/ICAL THE=RY EM=TI=NAL PR=4LEM IS AN ILLNESS cause #a! be in"erited or c"e#ical in ori%in

2=CUS =2 TREATMENT IS ME/ICATI=NS AN/ ECT 4I=L=GICAL THERAPY ELECTR=C=N6ULSI6E THERAPY Arti icial induction o a %rand #al sei$ure b! passin% a controlled electrical current t"rou%" electrodes applied to one or bot" te#ples #ec"anis# o action unclear 'olta%e, J> AE> 'olts /uration, >+E D+> seconds ? to AD treat#ents inter'als o LB "ours indicators o e ecti'eness occurrence o %enerali$ed tonic clonic sei$ures

indications depression & #ania and catatonic sc"i$op"renia s7e, con usion& disorientation& s"ort .ter# #e#or! loss& sei$ure )C>.?> sec* NP= prior Contraindications 2e'er& pre%nanc! Inc ICP& racture retinal detac"#ent T4 (it" "e#opt!sis cardiac d7o consent needed Reorient a ter& supporti'e care #edications %i'en , Atropine sul ate, decrease secretions Succin!lc"oline )Anectine*, pro#ote #uscle rela0ation Met"o"e0ital Sodiu# ) 4re'ital *, ser'es as an anest"etic a%ent co##on co#plications, loss o #e#or! "eadac"e

apnea racture respirator! depression Ps!c"op"ar#acolo%ic T"erap! 4en$odia$epines

Indications An0iet! Sedation7sleep Muscle spas# Sei$ure disorder Alco"ol (it"dra(al s!ndro#es Generic Alpra$ola# C"lordia$epo0ide Clora$epate /ia$epa# Lora$epa# =0a$epa# 4usipirone Anti.an0iet! dru%s Trade na#e @ana0 Libriu# Tran0ene 6aliu# Ati'an Sera0 4uSpar Side e ects

/ro(siness7 sedation Ata0ia 2eelin%s o detac"#ent Increase irritabilit! and "ostilit! Antero%rade a#nesia Increased appetite F (ei%"t %ain Nausea Headac"e& con usion Anti.depressants Indications /epression 4ipolar depression Panic disorder 4uli#ia =bsessi'e.co#pulsi'e d7o Possibl! Attention de icit7H!peracti'it! d7o

Post Trau#atic Stress /7o Conduct d7o

Tric!clic )TCA* Generic Trade na#e A#itript!line Ela'il I#ipra#ine To ranil Tri#ipra#ine Sur#ontil Nortript!line Pa#elor Tra$odone /es!rel 4upropion 5ellbutrin Side e ects =rt"ostatic "!pertension

Antic"oliner%ic e ect /r! #out"& blurred 'ision& constipation& e0cessi'e s(eatin%& urinar! "esitanc!7 retention& tac"!cardia& a%itation& deliriu#& e0acerbation o %lauco#a Neurolo%ic e ects sedation& ps!c"o#otor slo(in%& poor concentration& ati%ue& ata0ia& tre#ors /ecrease libido and se0ual per or#ance

Generic Isocarbo0a$id P"enel$ine Tran!lc!pro#ine

Monoa#ine =0idase in"ibitors Trade na#e Marplan Nardil Parnate Side e ects Postural li%"t"eadedness Constipation /ela! e1aculation or or%as# Muscle t(itc"in% /ro(siness /r! #out" /ietar! restrictions C"eese& esp+ a%ed and #atured 2er#ented or a%ed protein Pic3led or s#o3ed is" 4eer& red (ine& s"err!9 li-uor F co%nac Yeast 2a'a or broad beans

4ee or c"ic3en li'er Spoiled7 o'erripe ruits9 banana peel !o%urt H!pertensi'e Crisis Si%ns Sudden ele'ation o 4P E0plosi'e "eadac"e& occipital #a! radiate rontall! Head F ace lus"ed Palpitations& c"est pain S(eatin%& e'er Nausea& 'o#itin% /ilated pupils& p"otop"obia Intracranial bleedin% Treat#ent Hold ne0t MA= dose /on:t let pt+ lie do(n IM c"lorpro#a$ine A>> #% 2e'er, #ana%e b! e0ternal coolin% tec"ni-ues Serotonin Reupta3e In"ibitors Generic Trade na#e 2luo0etine Pro$ac Sertraline Kolo t Paro0etine Pa0il 6enla a0ine E e0or Side e ects Nausea /iarr"ea Inso#nia /r! #out" Ner'ousness Headac"e Male se0ual d!s unction /ro(siness /i$$iness S(eatin% Mood stabili$in% dru%s

Indications Acute #ania 4ipolar prop"!la0is Possibl! 4uli#ia Alco"ol abuse A%%ressi'e be"a'ior sc"i$oa ecti'e

Mode o action Nor#ali$es t"e reupta3e o certain neurotrans#itters suc" as serotonin& norepinep"rine& acet!lc"oline and dopa#ine Reduces t"e release o norepinep"rine t"ru co#petition (it" calciu# E ects intracellularl! La% period, J.A> to AL da!s Lit"iu# carbonate Trade na#es Es3alit" Lit"otabs Lit"ane Lit"onate M=A, unclear9 inter ere (it" #etabolis# o neurotrans#itters9 alter Na transport in ner'es and #uscle cells Prelit"iu# (or3up Urinal!sis )4UN and creatinine* ECG& 24C& C4C Side e ects Earl! Nausea and diarr"ea Anore0ia 2ine "and tre#or )propranolol* T"irst& Pol!dipsia )dec+ crea& inc+ albu#in* Metallic taste 2ati%ue Let"ar%! Late 5ei%"t %ain acne Contraindications

4rain da#a%e7 C6 disease Epileps! Elderl!7 debilitated T"!roid and renal disease Se'ere de"!dration Pre%nanc! )Ast tri#ester*

Can au%#ent t"e e ects o anti.depressants Nursin% considerations T"erapeutic seru# le'el, >+E A+D #e-7L Maintenance le'el, >+? .A+D #e-7L To0ic Mild to #oderate, A+E to D #e-7L Moderate to se'ere, D D+E #e-7L Needs dial!sis, C #e- and abo'e Earl! si%ns o to0icit! Let"ar%!& #ild nausea& 'o#itin%& ine "and tre#ors& anore0ia& pol!uria& pol!dipsia& #etallic taste& ati%ue Late si%ns o to0icit! Ata0ia& %iddiness& tinnitus& blurred 'ision& pol!uria Nursin% considerations Lit"iu# le'els s"ould be c"ec3ed - D.C #os Seru# dra(n in t"e AM& ADH a ter last dose Co##on causes o inc+ le'els /ec+ Na inta3e /iuretic t"erap! /ec+ renal unctionin% 2FE loss Medical illness ='erdose NSAI/S Nursin% considerations /iet, ade-uate NaN and luid C% NaCl7 da! ?.B %lasses o HD= No ca eine No dri'in%, (ait or clinical e ect Mana%e#ent Moderatel! se'ere to0icit!

=s#otic diuresis, urea7 #annitol A#inop"!lline F PLR I6 Ade-uate NaCl Peritoneal7 "e#odial!sis Se'ere to0icit! Assess "0 -uic3l! Hold ne0t lit"iu# dose C"ec3 4P& rectal TO& RR& L=C& support =D =btain labs ECG E#etic& NGT la'a%e H!drate, E.?L7da! c PLR9 24C.C/U =t"er dru%s

Carba#a$epine )Te%retol* Side e ects /i$$iness Ata0ia Clu#siness Sedation /!sart"ria /iplopia Nausea F GI upset Preparation, li-& tab& c"e(able tab Nursin% considerations Assess dru% le'els - C.L da!s Monitor salt and luid inta3e A'oid alco"ol and non.prescription dru%s Re er dec+ in U= /on:t stop abruptl! C7I, pre%nanc! Ta3e (it" #eals =t"er dru%s 6alproic acid )/epa3ote& /epa3ene* Side e ects Nausea Hepato0icit! Neuroto0icit! He#atolo%ical to0icit! Pancreatitis Prep, tab& cap& sprin3les

M=A, inc+ le'els o GA4A9 in"ibits t"e kindling process or GsnoballH.li3e e ect seen in #ania F sei$ures Nursin% considerations T"erapeutic le'el, E> A>> u%7#L

/ose, A& >>> A&E>> #%7da! Monitor seru# le'els ADH a ter last dose To0ic e ects Se'ere diarr"ea& 'o#itin%& dro(siness& ##+ (ea3ness& lac3 o coordination Renal ailure& co#a& deat" Anti.ps!c"otic dru%s Indications Ps!c"otic s!#pto#s o sc"i$op"renia& acute #ania and depression Gilles de Tourette disorder Treat#ent.resistant bipolar disorder Huntin%ton:s disease and ot"er #o'e#ent disorder Possibl! Paranoid C"ild"ood ps!c"oses

M=A, bloc3 receptors o dopa#ine )/D& /C& /L* I unresponsi'e a ter ? (ee3s o t"erap!& anot"er class is tried

General considerations Cal#s (it"out producin% i#pair#ent o sleep Hi%" t"erapeutic inde0 Non addictin%& no tolerance A'oided in pre%nanc! TYPICAL, Hi%" Potenc! 2lup"ena$ine )Proli0in* Haloperidol )Haldol* T"iot"e0ene )Na'ane* Tri luopera$ine )Stela$ine* Moderate Potenc! Lo0apine )Lo0itane* Molindone )Moban* Perp"ena$ine )Trila on* Lo( Potenc! C"lopro#a$ine )T"ora$ine* C"lorprot"i0ene )Taractan* Mesorida$ine )Serentil*

T"iorida$ine )Mellaril* ATYPICAL Clo$apine )Clo$aril* Resperidone )Risperdal* =lan$apine )K!pre0a* Muetiapine )Sero-uel* Sertindole )Serlec:t* Kiprasidone )Keldo0*

Contraindications CNS depression, brain da#a%e& e0cess alco"ol7 narcotics Par3inson:s disease Aller%! 4lood d!scrasias Acute narro( an%le %lauco#a 4PH Side e ects H!potension Sedation /er#al and ocular s!ndro#e Neuroleptic #ali%nant s!ndro#e Antic"oliner%ic s!ndro#e Mo'e#ent s!ndro#e )E0trap!ra#idal S!ndro#e* Atropine ps!c"osis A%ranuloc!tosis Sei$ures

Neuroleptic Mali%nant S!ndro#e A potentiall! atal& idios!ncratic reaction to an antips!c"otic dru% A>.D>P #ortalit! rate S0, ri%idit!& "i%" e'er& autono#ic instabilit! )4P& diap"oresis& pallor& deliriu#& ele'+ CPI*& con used or #ute& luctuate ro# a%itation to stupor =ccurs in t"e irst D (ee3s o t"erap! Ris3, "i%" dose o "i%".potenc! dru%s9 de"!dration& poor n0& concurrent #ed illness Mo'e#ent S!ndro#es A3at"isia

/!stonia

Tardi'e d!s3inesia 4rad!3inesia Par3insonis# =t"er s7e Atropine ps!c"osis )%eriatrics* H!peracti'it!& a%itation& con usion& lus"ed s3in& slu%%is" reacti'e pupils TTT, IM p"!sosti%#ine A%ranuloc!tosis )Clo$apine* =ccurs C.B (3s a ter Medical e#er%enc! s7s, e'er& #alaise& sore t"roat& leu3openia TTT, d7c& re'erse iso& antibiotics Sei$ures )Clo$apine* =ccurs in EP o patients9 TTT, /7c dru% Antic"oliner%ics 4en$tropine )Co%entin* Tri"e0!p"enid!l )Artane* 4iperiden )A3ineton* Proc!clidine )Ie#adrin*

Not (it"dra(n abruptl! Pro'ide cool en'iron#ent

ANTIPARIINS=NIAN ME/ICATI=NS Ad1unct to anti.ps!c"otic a%ents to balance dopa#ine7 acet!lc"oline in t"e brain s7e, %lauco#a& tac"!cardia& HPN& cardiac d0& ast"#a& duodenal ulcer A7e, blurred 'ision& p"otosensiti'it!& dro(siness& ort"ostatic "!potension& CH2& "allucinations

C=MM=N /RUGS, Tri"e0!p"enid!l )Artane* ben$tropine )Co%entin* 4iperiden )Co%entin* Sele%iline )Eldepr!l* Per%olide )Per#a0* ANTIHISTAMINE /ip"en"!dra#ine HCl )4ENA/RYL*

/=PAMINE RELEASING AGENT A#antadine )SYMMETREL* Nursin% considerations 4est ta3en a ter #eals A'oid dri'in% C"ec3 4P Alco"ol increases sedati'e e ects A'oid sudden position c"an%e /ru% is not (it"dra(n abruptl! PSYCHIATRIC /IS=R/ERS AN@IETY /IS=R/ERS

PANIC /IS=R/ERS SPECI2IC PH=4IA S=CIAL PH=4IA =C/ PTS/ ACUTE STRESS /IS=R/ER

GENERALIKE/ AN@IETY /IS=R/ER PANIC ATTACIS /iscrete period o intense ear or disco# ort in ("ic" at least L i t"e de'elop abruptl! and pea3 (it"in A> #ins, Palpitations& poundin% "eart& or accelerated HR S(eatin% Tre#blin% or s"a3in% Sensations o S=4 and s#ot"erin% 2eelin% o c"o3in%

s0

C"est pain or disco# ort Nausea or abd+ Pain 2eelin% di$$!& unstead!& li%"t"eaded or aint /ereali$ation or depersonali$ation 2ear o losin% control or %oin% cra$! 2ear o d!in% Parest"esias C"ills or "ot las"es

SPECI2ICQ PH=4IA R S=CIAL

E0cessi'e and unreasonable cued b! t"e presence or anticipation o a speci ic ob1ect or situation /e ense #ec" co##onl! used include repression and displace#ent 2ear o social per or#ance situations in ("ic" t"e person is e0posed to un a#iliar people or to possible scrutin! b! ot"ers =4SESSI=N C=MPULSI=N Recurrent and persistent t"ou%"ts& i#pulses& or i#a%es are e0perienced durin% t"e disturbance as intrusi'e and inappropriate Cause an0iet! or distress P0 3no(s t"at t"ese are 1ust product o one:s o(n #ind+ P0 eels dri'en to per or# repetiti'e be"a'iors or #ental acts in response to obsession or accordin% to t"e rules t"at one dee#s #ust be applied ri%idl!+ Ai#ed at reducin% an0iet! =4SESSI=N C=MPULSI=N 2ear o dirt F %er#s 2ear o bur%lar! or robber! 5orries about discardin% so#et"in% i#portant Concerns about contractin% a serious illness 5orries t"at t"in%s #ust be s!##etrical or #atc"in% E0cessi'e "and (as"in% Repeated c"ec3in% o door and (indo( loc3s Countin% and recountin% o ob1ects in e'er!da! li e Hoardin% o ob1ects E0cessi'e strai%"tenin%& orderin%& or o arran%in% t"in%s Repeatin% (ords or pra!ers silentl!

P=ST TRAUMATIC STRESS SYN/R=ME Person "as e0perienced& (itnessed or been con ronted (it" an e'ent t"at in'ol'ed actual or t"reatened deat" or serious in1ur!& or a t"reat to p"!sical inte%rit! Person ree0periences t"ese in t"e #ind

In'ol'es intense ear& "elplessness& or "orror and nu#bin% o %eneral responsi'eness )PSYCHIC NUM4ING* ACUTE GENERALIKE/ STRESS AN@IETY Meets t"e criteria or e0posure to a trau#atic e'ent and person e0periences C o t"e s0, sense o detac"#ent& reduced a(areness o one:s surroundin%s& dereali$ation& depersonali$ation& dissociated a#nesia

E0cessi'e an0iet! or (orr!& occurrin% in #ore da!s t"an not or at least ? #os& about a nu#ber o e'ents or acti'ities 2inds it di icult to control t"e (orr! M==/7 A22ECTI6E /IS=R/ERS

4IP=LAR /7= 4IP=LAR I, current or past e0perience o #anic episode& lastin% at least a (ee3& t"at is se'ere enou%" to cause e0tre#e i#pair#ent in social or occupational unctionin%+ MANIA, "!peracti'it! /EPRESSE/, e0tre#e sadness or (it"dra(al MI@E/ 4IP=LAR II, "0 o A or #ore #1 depressi'e episodes F at least A "!po#anic episode9 no #ania

MA8=R /EPRESSI6E /7= S least E s0 o sa#e D. (3 period (it" one bein% eit"er depressed #ood or loss o interest or pleasure+ Sin%le episode or recurrent =t"er s0, (t loss& inso#nia& ati%ue& recurrent t"ou%"ts o deat"& di#inis"ed abilit! to t"in3& ps!c"o#otor a%itation or retardation& eelin%s o (ort"lessness+

CYCL=THYMIC /7= H0 o D !rs o "!po#ania (it" nu#erous periods o abnor#all! ele'ated& e0pansi'e or irritable #oods+ /oes not #eet t"e criteria o #ania or depression+ /YSTHYMIC /7= S least D !rs o usuall! depressed #ood and at least A o t"e s0 o #1 depression (it"out #eetin% t"e criteria or it SEAS=NAL A22ECTI6E /7= /epression t"at co#es (it" s"ortened da!li%"t in all and (inter t"at disappears durin% sprin% and su##er+ /ealin% (it" Inappropriate 4e"a'iors AGGRESSI6E 4EHA6I=R Assist t"e client in identi !in% eelin%s o rustration and a%%ression Encoura%e t"e client to tal3 out instead o actin% out eelin%s o rustration Assist t"e client in identi !in% precipitatin% e'ents or situations t"at lead to a%%ressi'e be"a'ior /escribe t"e conse-uences o t"e be"a'ior on sel and ot"ers Assist in identi !in% pre'ious copin% #ec"anis#s Assist t"e client in t"e proble#.sol'in% tec"ni-ues to cope (it" rustration or a%%ression

/EESCALATI=N TECHNIMUES Maintain sa et! Maintain lar%e personal space and use nona%%ressi'e posture Use cal# approac" and co##unicate (it" a cal#& clear tone o 'oice )be asserti'e not a%%ressi'e /eter#ine ("at t"e client considers to be "is or "er need A'oid 'erbal stru%%les Pro'ide clear options t"at deal (it" be"a'ior Assist (it" proble#.sol'in% and decision #a3in% re%ardin% t"e options MANIPULATI6E 4EHA6I=RS Set clear& consistent& realistic& and en orceable li#its and co##unicate e0pected be"a'iors 4e clear about conse-uences associated (it" e0ceedin% set li#its

/iscuss be"a'ior in non1ud%#ental and nont"reatenin% #anner A'oid po(er stru%%les

Assist in de'elopin% #eans o settin% li#its on o(n be"a'ior SCHIK=PHRENIA c"aracteri$ed b! i#pair#ents in t"e perception or e0pression o realit! and b! si%ni icant social or occupational d!s unction+ =nce considered as a deadl! disease T"ere is lac3 o insi%"t in be"a'ior /0, late adolescence and earl! adult"ood AE.DE !+o+ )#en*9 DE.CE !+o+ )(o#en* =bsolete ter#, de#entia praeco0 T Gco%niti'e deterioration earl! in li eH Eu%ene 4leuler, sc"i$ GsplitH9 p"ren G#indH Ris3 actors Genetics, identical t(ins E>P& AEP or raternal t(ins 4ioc"e#ical actors /opa#ine "!pot"esis, o'eracti'e Serotonin i#balance /ecreased brain 'olu#e& enlar%ed 'entricles& deeper issures& and loss or underde'eloped brain tissue Ps!c"oanal!tic lac3 o trust durin% t"e earl! sta%es 5ea3 e%o /e enses, REPRESSI=N& REGRESSI=N& PR=8ECTI=N En'iron#ent in luences, po'ert!& lac3 o social support& "ostile "o#e en'iron#ent& isolation& unsatis actor! "ousin%& disruption in interpersonal relations"ips )di'orce or deat"*& 1ob pressure or une#plo!#ent Subt!pes

Catatonic type pro#inent ps!c"o#otor disturbances are e'ident+ S!#pto#s can include catatonic stupor and (a0! le0ibilit! Disorganized type ("ere t"ou%"t disorder and lat a ect are present to%et"er Paranoid type ("ere delusions and "allucinations are present but t"ou%"t disorder& disor%ani$ed be"a'ior& and a ecti'e lattenin% are absent

Residual type ("ere positi'e s!#pto#s are present at a lo( intensit! onl! ndi!!erentiated type

ps!c"otic s!#pto#s are present but t"e criteria or paranoid& disor%ani$ed& or catatonic t!pes "as not been #et S!#pto#s Accordin% to 4leuler, L A:s A ect is inappropriate Associati'e looseness Autistic t"in3in% A#bi'alence S!#pto#s

Positi'e s!#pto#s delusions& auditor! "allucinations and t"ou%"t disorder and are t!picall! re%arded as #ani estations o ps!c"osis+ Ne%ati'e s!#pto#s considered to be t"e loss or absence o nor#al traits or abilities E+G+ lat& blunted or constricted a ect and e#otion& po'ert! o speec" and lac3 o #oti'ation+ S!#pto#s Social isolation Catatonic be"a'ior "allucinations #nco"erence )#ar3ed looseness o association* $ero7 lac3 o interest& ener%! and initiati'e %b'ious ailure to attain e0pected le'el o de':t Peculiar be"a'ior "!%iene and %roo#in% i#paired Recurrent illusions and unusual perception e0periences &0acerbations and re#issions are co##on No or%anic actors accounts or t"e s!#pto#s

#nabilit! to return to baseline unctionin% a ter relapse ' ect is inappropriate Ns% /0, Abnor#al t"ou%"t process 4L=CIING, sudden cessation o a t"ou%"t in t"e #iddle o a sentence& unable to continue t"e train o t"ou%"t CIRCUMSTANTIALITY, be ore %ettin% to t"e point o ans(erin% a -uestion& t"e indi'idual %ets cau%"t up in countless details and e0planations C=N2A4ULATI=N L==SENESS =2 ASS=CIATI=N NE=L=GISM 5=R/ SALA/ Inter'entions Assess p"!sical needs Set li#its Maintain sa et! Initiate one.on.one interaction F pro%ress to s#all %roups Spend ti#e (it" clients Monitor or altered t"ou%"t process Maintain e%o boundaries& a'oid touc"in% Li#it ti#e o interaction 4e neutral /o not #a3e pro#ises t"at can:t be 3ept

Establis" dail! routines /o not G%o alon%H (it" t"e client:s delusions or "allucinations Pro'ide si#ple co#plete acti'ities Reorient Spea3 to t"e client in si#ple direct and concise #anner Set realistic %oals E0plain e'er!t"in% t"at is bein% done /ecrease sti#uli Monitor or suicide ris3

En'iron#ent Pro'ide sa e en'iron#ent Li#it sti#uli Ps!c"olo%ical Ttt 4e"a'ior t"erap!

Social s3ills trainin% Sel .#onitorin% Social ttt Milieu t"erap! 2a#il! t"erap! Group t"erap! )lon%.ter# ttt* Related ps!c"otic disorders SCHIK=A22ECTI6E /IS=R/ER sc"i$ N #ood disorder )#ania7 depression*

4RIE2 PSYCH=TIC /IS=R/ER sudden onset o ps!c"otic s!#pto#s& lasts less t"an D #os and client returns to pre#orbid le'el o unctionin% SCHIK=PHRENI2=RM /IS=R/ER sc"i$ s0 lastin% bet(een A #ont" and U?#os /ELUSI=NAL /IS=R/ER c"aracteri$ed b! pro#inent& nonbi$arre delusions PERS=NALITY /IS=R/ERS

CLUSTER A )odd F eccentric* paranoid& sc"i$oid& sc"i$ot!pal CLUSTER 4 )bad& dra#atic F erratic* antisocial& borderline& "istrionic& narcissistic CLUSTER C )an0ious F ear ul* a'oidant& dependent& =C/ CLUSTER A, =// F ECCENTRIC PARAN=I/ c"ronic "ostilit! pro1ected to ot"ers9 suspicious and #istrusts people Seen #ostl! in #en SCHIK=I/ social detac"#ent T GlonerH F Gintro'ertH Restriction o e#otions Attention i0ed on ob1ects rat"er t"an people 2unctions (ell in 'ocations SCHIK=TYPAL, interpersonal de icits Ma%ical t"in3in%& telepat"! Apparent in c"ild"ood or adolescence Inter'entions or PARAN=I/ /7= Asses or suicide ris3 A'oid direct e!e contact Establis" trustin% relations"ip Pro#ote increased sel .estee#

Re#ain cal#& nont"reatenin% and non1ud%#ental Pro'ide continuit! o care Respond "onestl! to t"e client 2ollo( t"ru on co##it#ents Pro'ide a dail! sc"edule o acti'ities Graduall! introduce client to %roups /o not ar%ue (it" delusions Use concrete& speci ic (ords

/o not be secreti'e (it" client /o not ("isper in presence o client Assure t"at t"e client (ill be sa e Pro'ide opportunit! to co#plete s#all tas3s Monitor eatin%& drin3in%& sleepin% and eli#ination patterns Li#it p"!sical contact Monitor or a%itation and decrease sti#uli as needed CLUSTER 4, ERRATIC& /RAMATIC& =R EM=TI=NAL ANTIS=CIAL S!n, sociopat"& ps!c"opat"ic F se#antic d7o Etiolo%!, Genetics inter ere in t"e de':t o positi'e interpersonal relations"ips 4rain da#a%e or trau#a Lo( socioecono#ic status 2ault! a#il! relations"ips, ne%lect Secondar! %ains AE.L> !+o+

Si%ns Lac3 o re#orse or indi erence to persons "urt I##ediate %rati ication 2ailure to accept social nor#s I#pulsi'it! Consistent irresponsibilit!

A%%ressi'e be"a'ior Rec3less be"a'ior t"at disre%ards t"e sa et! o ot"ers B>.V>P o all cri#e is co##itted b! antisocials )NIHM& D>>>* 4=R/ERLINE Latent& a#bulator! and aborti'e sc"i$op"renics 4et(een #oderate neurosis and ran3 ps!c"osis but -uite stable T"eories ault! separation ro# #ot"er9 parent and c"ild are bound b! %uilt Trau#a at AB #os )(ea3enin% o e%o* Un ul illed need or inti#ac!

Si%ns instabilit! I#pulsi'it!, unpredictable %a#blin%& s"opli tin%& se0 F substance abuse "!persensiti'it!& sel .destructi'e& pro ound #ood s"i ts unstable F intense relations /isturbance in sel concept Co##on in (o#en /e enses, denial& pro1ection& splittin%& pro1ecti'e identi ication

HISTRI=NIC Pattern o t"eatrical or o'ertl! dra#atic be"a'ior Si%ns /isco# ort ("en t"e client isn:t t"e center o attention Sel .dra#ati$ation and e0a%%erated e#otions uses p"!sical appearance& se0uall! seducti'e and pro'ocati'e be"a'ior E0cessi'el! i#pressionistic speec" lac3in% in detail )labile e#otions* Proble#s in dependence F "elplessness More re-uent in (o#en NARCISSISTIC E0a%%erated or %randiose sense o sel .i#portance /e'elop earl! in c"ild"ood Preoccupied (it" antasies o unli#ited success& po(er and beaut! Si%ns arro%ance& need or ad#iration& lac3 o e#pat"!&

seducti'e& sociall! e0ploitati'e& #anipulati'e =ccurs #ore in #en CLUSTER C, AN@I=US =R 2EAR2UL

A6=I/ANT Sensiti'e to re1ection& criticis#& "u#iliation& disappro'al& or s"a#e Inter eres (it" participation in occupational acti'ities& de':t o relations"ips& and ta3e personal ris3s social in"ibition& lon%s or relations"ips An0iet!& an%er and depression are co##on Social p"obia #a! occur Seen in A>P o clients in #ental clinics

/EPEN/ENT Lac3s con idence and unable to unction in an independent role Allo(s ot"er persons to be responsible o t"eir li'es Most re-uent personalit! disorder in t"e #ental "ealt" clinic sub#issi'e be"a'ior& lo( sel .estee#& inade-uate& "elpless

=4SESSI6E.C=MPULSI6E Preoccupied (it" rules F re%ulations& o'erl! concerned about tri'ial detail& e0cessi'el! de'oted to t"eir (or3 /epression is co##on Men are #ore a ected t"an (o#en UN/ER STU/Y PERS=NALITY /7= PASSI6E.AGGRESSI6E, sullen and ar%u#entati'e& resents ot"ers& resists ul illin% responsibilities& co#plains o bein% unappreciated /EPRESSI6E, %loo#!& broodin% pessi#istic& %uilt.prone& "i%"l! critical o sel and ot"ers& c"eerless+ Inter'entions Maintain sa et! a%ainst sel .destructi'e be"a'iors Allo( t"e client to #a3e c"oices and be as independent as possible Encoura%e t"e client to discuss eelin%s rat"er t"an act t"e# out Pro'ide consistenc! in response to t"e client:s actin% out /iscuss e0pectations and responsibilities (it" t"e client In or# t"e client t"at "ar# to sel & ot"ers& and propert! is unacceptable

Identi ! splittin% be"a'ior

Assist t"e client to deal directl! (it" an%er /e'elop a (ritten contract (it" t"e client

Encoura%e t"e client to participate in %roup acti'ities& and praise non#anipulati'e be"a'ior Set and #aintain li#its Re#o'e t"e client ro# %roup situations in ("ic" attention.see3in% be"a'iors Pro'ide realistic praise or positi'e be"a'iors in social situations PSYCH=L=GICAL SE@UAL /7= H!poacti'e se0ual disorder )ase0ualit!* Se0ual a'ersion disorder )a'oidance o or lac3 o desire or se0ual intercourse* 2e#ale se0ual arousal d7o ) ailure o nor#al lubricatin% arousal response* Male erectile d7o 2e#ale or%as#ic disorder Male or%as#ic disorder Pre#ature e1aculation 6a%inis#us Secondar! se0ual d!s 0n Parap"ilias Gender identit! d7o PTS/ due to %enital #utilation or c"ild"ood se0ual abuse occur

%t(er se)ual proble*s Se0ual dissatis action )non.speci ic* Lac3 o se0ual desire anor%as#ia I#potence ST/

In idelit! /ela! or absence o e1aculation& despite ade-uate sti#ulation Inabilit! to control ti#in% o e1aculation Inabilit! to rela0 'a%inal #uscles enou%" to allo( intercourse Inade-uate 'a%inal lubrication precedin% and durin% intercourse 4urnin% pain on t"e 'ul'a or in t"e 'a%ina (it" contact to t"ose areas

Un"appiness or con usion related to se0ual orientation Persistent se0ual arousal s!ndro#e Se0ual addict "!perse0ualit! Post E1aculator! Guilt S!ndro#e& t"e eelin% o %uilt a ter t"e #ale or%as# SE@UAL E@PRESSI=N

HETER=SE@UALITY H=M=SE@UALITY 4ISE@UALITY TRANS6ESTISM

PARAPHILIAS E@HI4ITI=NISM, t"e recurrent ur%e or be"a'ior to e0pose oneWs %enitals to an unsuspectin% person+ 2ETISHISM, t"e use o non.se0ual or nonli'in% ob1ects or part o a personWs bod! to %ain se0ual e0cite#ent+ Partialism re ers to etis"es speci icall! in'ol'in% nonse0ual parts o t"e bod!+ 2R=TTEURISM, t"e recurrent ur%es or be"a'ior o touc"in% or rubbin% a%ainst a nonconsentin% person+

SE@UAL MAS=CHISM, t"e recurrent ur%e or be"a'ior o (antin% to be "u#iliated& beaten& bound& or ot"er(ise #ade to su er+ SE@UAL SA/ISM, t"e recurrent ur%e or be"a'ior in'ol'in% acts in ("ic" t"e pain or "u#iliation o t"e 'icti# is se0uall! e0citin%+ TRANS6ESTIC 2ETISHISM, a se0ual attraction to(ards t"e clot"in% o t"e opposite %ender+

PE/=PHILIA, t"e se0ual attraction to prepubescent or peripubescent c"ildren+

6=YEURISM, t"e recurrent ur%e or be"a'ior to obser'e an unsuspectin% person ("o is na3ed& disrobin% or en%a%in% in se0ual acti'ities& or #a! not be se0ual in nature at all+

Other paraphilias not otherwise specified )XSe0ual /isorder N=SX* telep"one scatalo%ia )obscene p"one calls* necrop"ilia )corpses* partialis# )e0clusi'e ocus on one part o t"e bod!* $oop"ilia)ani#als*

coprop"ilia ) eces* 3lis#ap"ilia )ene#as* urop"ilia )urine*

S=MAT=2=RM /7= S=MATIKATI=N /7=, "0 o #an! p"!sical co#plaints be%innin% be ore t"e a%e o C> occurrin% o'er a pd o se'eral !rs resultin% in ttt bein% sou%"t or si%ni icant occupational or social 0nin%+ C=N6ERSI=N /7=, A or #ore s0 o de icits a ectin% 'oluntar! #otor or sensor! unction su%%estin% a neurolo%ical or %eneral #edical condition9 preceded b! con licts or stressors9 can:t be e0plained and sanctioned b! cultural be"a'ior+ Most co##on, blindness& dea ness& paral!sis& inabilit! to tal3 GLa belle indi erenceH

HYP=CH=N/RIASIS, preoccupation (it" ears o "a'in%& or ideas t"at one "as& a serious dse based on t"e person:s #isinterpretation o bodil! s0 and persist despite appropriate #edical e'al and reassurance and "as e0isted or S least ? #os+ )e+%+,e0tensi'e use o "o#e re#edies* PAIN /7=, pain in A or #ore anato#ical sites se'ere enou%" to (arrant clinical attention and causes clinicall! si%ni icant distress or i#pair#ent in 0nin%+ Inter'entions /o not rein orce t"e sic3 role

/iscoura%e 'erbali$ation about p"!sical s!#pto#s b! not respondin% (it" positi'e rein orce#ent E0plore (it" t"e client t"e needs bein% #et b! t"e p"!sical s!#pto#s Con'e! understandin% t"at t"e p"!sical s!#pto#s are real to t"e client Report and assess an! ne( p"!sical co#plaint ne0t EATING /IS=R/ER 4EHA6I=RS 4INGE, rapid consu#ption o lar%e -uantities o ood in a discrete period o ti#e+ )A, "undrends o Cal9 4, t"ousands o Cal at a sittin%* PURGE, Maladapti'e eatin% re%ulation response t"at includes e0cessi'e e0ercise& orced 'o#itin%& =C/ R0 diuretics& diet pills& la0ati'es and steroids+ 2AST7 RESTRICT, Includes 'e%etarian diet eli#inatin% all #eat (it"out substitutin% nonani#al sources o protein& =C about ood c"oices& and eatin% "abits+ AN=RE@IA 4ULIMIA Rare 'o#itin% or diuretic7la0ati'e abuse More se'ere (t loss Sli%"tl! !oun%er More intro'erted

Hun%er denied Eatin% be"a'ior #a! be considered nor#al and a source o estee# Se0uall! inacti'e =bsessional and per ectionist eatures do#inate 2re-uent Less (t loss Sli%"tl! older More e0tro'erted Hun%er e0perienced Eatin% be"a'ior considered orei%n and source o distress More se0uall! acti'e A'oidant& dependent& or borderline eatures as (ell as obsessional eatures AN=RE@IA 4ULIMIA co#plications /eat" ro# star'ation )or suicide& in c"ronicall! ill* A#enorr"ea

2e(er be"a'ioral proble#s )t"ese increase (it" le'el o se'erit!* /eat" ro# "!po3ale#ia or suicide Menses irre%ular or absent /ru% and alco"ol abuse& sel .#utilation& and ot"er be"a'ioral proble#s /ELIRIUM T"e #edical d0 ter# t"at describes an or%anic #ental disorder c"aracteri$ed b! a cluster o co%niti'e i#pair#ents (it" an acute onset (it" a speci ic precipitatin% actor+ S0, di#inis"ed a(areness o t"e en'iron#ent& disturbances in ps!c"o#otor acti'it! and sleep.(a3e c!cle+ C=GNITI6E, t"e #ental process c"aracteri$ed b! 3no(in%& t"in3in%& and 1ud%in%+ C=GNITI6E /ISS=NANCE, arises ("en D opposin% belie s e0ists at t"e sa#e ti#e+ C=GNITI6E /IST=RTI=NS, )N* or ).* distortions o realit! t"at #i%"t include errors o lo%ic& #ista3es in reasonin%& or indi'iduali$ed 'ie( o t"e (orld t"at do not re lect realit!+ Ter#, con usion T co%niti'e i#pair#ent See de#entia /EMENTIA T"e #edical d0 ter# t"at describes an or%anic #ental d7o c"aracteri$ed b! a cluster o co%niti'e i#pair#ents o %enerall! %radual onset and irre'ersible (it"out identi iable precipitatin% stressors+ T!pes, 6ASCULAR or MULTI.IN2ARCT 6ASCULAR 5ITH ALKHEIMER:S /SE A/, #ost co##on /EMENTIA 5ITH LE5Y 4=/IES, Dnd #ost co##on9 neuro ila#ent #aterial PARIINS=NIAN /EMENTIA

AI/S /EMENTIA C=MPLE@

2R=NTAL L=4E /EMENTIA or PICI:S /SE, c!toplas#ic collections9 Crd #ost co##on9 loss o e0pressi'e lan%ua%e F co#pre"ension CREUTK2EL/T.8AI=4 /SE, prion )proteinaceous in ectious particles* T spon%! brain9 related to TSE F 4SE in #ad co( dse C=RTIC=4ASAL /EGENERATI=N or HUNTINGT=N:S /SE7CH=REA, 1er3! #o':ts SUPRANUCLEAR PALSY, clu#pin% o protein tau T slo( #o':t& (ea3 e!e #o':t )esp+ do(n(ard*& i#paired (al3in% Fbalance

Re'ersible Causes, Subdural "e#ato#a Tu#or )#enin%io#a* Cerebral 'asculitis H!drocep"alus Ter#s, disorientation& #e#or! loss )sensor!& pri#ar!& secondar!& tertiar!& (or3in% #e#or!*& con abulation& con usion /isturbin% be"a'iors A%%ressi'e ps!c"o#otor Nona%%ressi'e ps!c"o#otor 6erball! a%%ressi'e Passi'e 2unctionall! i#paired, loss o abilit! to do sel .care /ELIRIUM 's+ /EMENTIA Rapid onset (7 (ide luctuations H!peralert to di icult to arouse L=C 2luctuatin% a ect /isoriented& con used Attention F sleep disturbed Me#or! i#paired /isordered reasonin% Gradual& c"ronic (it" continuous decline Nor#al L=C Labile a ect /isoriented& con used Attention intact& sleep usuall! nor#al Me#or! i#paired /isordered reasonin% F calculation /ELIRIUM 's+ /EMENTIA Inco"erent& con used& delusional& stereot!ped Illusions& "allucinations Poor 1ud%#ent

Insi%"t #a! be present in lucid #o#ent Poor but 'ariable in MSE ne0t /isor%ani$ed& ric" in content& delusional& paranoid No c"an%e in perception Poor 1ud%#ent No insi%"t Consistentl! poor F pro%ressi'el! (orsens in MSE ALKHEIMER:S /EMENTIA Most co##on t!pe o de#entia

Sta%es, MIL/, i#paired #e#or!& insidious loses in A/L& subtle personalit! c"an%es& sociall! nor#al M=/ERATE, ob'ious #e#or! loss& o'ert A/L i#pair#ent& pro#inent be"a'ioral di iculties& 'ariable social s3ills& super'ision needed SE6ERE, ra%#ented #e#or!& no reco%nition o a#iliar people& assistance needed (it" basic A/L& e(er troubleso#e be"a'iors& reduced #obilit! )L A:s*

S!#pto#s AGN=SIA, /i icult! reco%ni$in% (ell.3no(n ob1ects APHASIA, /i icult! in indin% t"e ri%"t (ord

APRA@IA, Inabilit! or di icult! in per or#in% a purpose ul or%ani$ed tas3 or si#ilar s3illed acti'ities AMNESIA, Si%ni icant #e#or! i#pair#ent in t"e absence o clouded consciousness or ot"er co%niti'e s!#pto#s PSYCHIATRIC /7= IN CHIL/REN MENTAL RETAR/ATI=N PER6ASI6E /E6:TAL /7= AUTISM RETT:S /7= CHIL/H==/ /ISINTEGRATI6E /7= ASPERGER:S /7= P// N=S LEARNING /7= REA/ING MATHEMATICS 5RITTEN E@PRESSI=N ACA/EMIC PR=4LEM LEARNING /7= N=S

M=T=R SIILLS /7= C=MMUNICATI=N /7= E@PRESSI6E LANGUAGE MI@E/ RECEPTI6E7E@PRESSI6E PH=N=L=GICAL STUTTERING SELECTI6E MUTISM C=MMUNICATI=N /7= N=S M=6:T F TIC /7= /E6:TAL C==R/INATI=N TRANSIENT TIC CHR=NIC M=T=RF6=CAL TIC T=URETTE:S /7= STERE=TYPIC M=6:T /7= TIC /7= N=S /IS=R/ERS =2 INTAIE F ELIMINATI=N PICA RUMINATI=N 2EE/ING /7= ENURESIS ENC=PRESIS =THER, 4ULIMIA& AN=RE@IA A/H/ F /ISRUPTI6E 4EHA6I=R /7= A/H/ A/H/ N=S C=N/UCT /7= =PP=SITI=NAL /E2IANT CHIL/ ANTIS=CIAL /ISRUPTI6E 4EHA6I=R N=S M==/ /7= M8 /EPRESSI6E /7= 4IP=LAR I =R II /YSTHYMIC MI@E/ EPIS=/E HYP=MANIC EPIS=/E M==/ /7= /UE T= ME/ICAL C=N/ITI=N SU4STANCE.IN/UCE/ M==/ /7=

AN@IETY /7=

/7= =2 RELATI=NSHIP SEPARATI=N AN@IETY REACTI6E ATTACHMENT =2 IN2ANCY =R EARLY CHIL/H==/ PARENT.CHIL/ RELATI=NAL PR=4LEM SI4LING RELATI=NAL PR=4LEM PR=4LEMS RELATE/ T= A4USE =R NEGLECT MENTAL RETAR/ATI=N an IM belo( J>& si%ni icant li#itations in t(o or #ore areas o adapti'e be"a'ior )i+e+& abilit! to unction at a%e le'el in an ordinar! en'iron#ent*& and e'idence t"at t"e li#itations beca#e apparent in be ore AB !+o+ T"e ollo(in% ran%es& based on t"e 5ec"sler Adult Intelli%ence Scale )5AIS*& are in standard use toda!, Class #+ ,er*s Pro ound 4elo( D> Idiot Se'ere D>CL I#becile Moderate CELV Moron Mild E>?V 4orderline J>JV RETT:S /7= /e'elop#ent is nor#al until ?.AB #ont"s& ("en lan%ua%e and #otor #ilestones re%ress& purpose ul "and use is lost Ac-uired deceleration in t"e rate o "ead %ro(t" )resultin% in #icrocep"al! in so#e* Hand stereot!pes are t!pical and breat"in% irre%ularities suc" as "!per'entilation& breat" "oldin%& or si%"in% are seen in #an!+ Earl! on& autistic.li3e be"a'ior #a! be seen Co##on in e#ales CHIL/H==/ /ISINTEGRATI6E /7= or HELLER:S SYN/R=ME C// "as so#e si#ilarit! to autis#& but an apparent period o airl! nor#al de'elop#ent is o ten noted be ore a re%ression in s3ills or a series o re%ressions in s3ills+ c"aracteri$ed b! late onset )YC !ears o a%e* o de':tal dela!s in lan%ua%e& social unction and #otor s3ills9 s3ills apparentl! attained are lost ASPERGER:S /7= c"aracteri$ed b! di erence in lan%ua%e and co##unication s3ills& as (ell as repetiti'e or restricti'e patterns o t"ou%"t and be"a'ior+ Si%ns, unable to interpret or understand t"e desires or intentions o ot"ers and t"ereb! are unable to predict ("at to e0pect o ot"ers or ("at ot"ers #a! e0pect o t"e# Narro( interests or preoccupation (it" a sub1ect to t"e e0clusion o ot"er acti'ities Repetiti'e be"a'iors or rituals Peculiarities in speec" and lan%ua%e

E0tensi'e lo%ical7tec"nical patterns o t"ou%"t Sociall! and e#otionall! inappropriate be"a'ior and interpersonal interaction Proble#s (it" non'erbal co##unication Clu#s! and uncoordinated #otor #o':ts

CHR=NIC M=T=R7 6=CAL TIC ,#C is a sudden& repetiti'e& stereot!ped& nonr"!t"#ic& in'oluntar! #o'e#ent )#otor tic* or sound )p"onic tic* t"at in'ol'es discrete %roups o #uscles+ can be in'isible to t"e obser'er )e+%+ abdo#inal tensin% or toe crunc"in%* T=URETTE:S /7= c"aracteri$ed b! t"e presence o #ultiple p"!sical )#otor* tics and at least one 'ocal )p"onic* tic9 t"ese tics c"aracteristicall! (a0 and (ane TTT, Neuroleptic #edications "aloperidol )Haldol* pi#o$ide )=rap* A/H/ #nattention: 2ailure to pa! close attention to details or #a3in% careless #ista3es ("en doin% sc"ool(or3 or ot"er acti'ities Trouble 3eepin% attention ocused durin% pla! or tas3s Appearin% not to listen ("en spo3en to 2ailure to ollo( instructions or inis" tas3s A'oidin% tas3s t"at re-uire a "i%" a#ount o #ental e ort and or%ani$ation& suc" as sc"ool pro1ects 2re-uentl! losin% ite#s re-uired to acilitate tas3s or acti'ities& suc" as sc"ool supplies E0cessi'e distractibilit! 2or%et ulness Procrastination& inabilit! to be%in an acti'it! /i iculties (it" "ouse"old acti'ities )cleanin%& pa!in% bills& etc+* /i icult! allin% asleep& #a! be due to too #an! t"ou%"ts at ni%"t 2re-uent e#otional outbursts Easil! rustrated Easil! distracted "yperactivity-i*pulsive be(aviour 2id%etin% (it" "ands or eet or s-uir#in% in seat Lea'in% seat o ten& e'en ("en inappropriate Runnin% or cli#bin% at inappropriate ti#es /i icult! in -uiet pla! 2re-uentl! eelin% restless E0cessi'e speec" Ans(erin% a -uestion be ore t"e spea3er "as inis"ed 2ailure to a(ait oneWs turn Interruptin% t"e acti'ities o ot"ers at inappropriate ti#es I#pulsi'e spendin%& leadin% to inancial di iculties

2re-uentl! prescribed sti#ulants are #et"!lp"enidate )Ritalin and Concerta*& a#p"eta#ines )Adderall* and de0troa#p"eta#ines )/e0edrine* 2ein%old diet ("ic" in'ol'es re#o'in% salic!lates& arti icial colors and la'ors& and certain s!nt"etic preser'ati'es ro# c"ildrenWs diets+ C=N/UCT /7= repetiti'e and persistent pattern o be"a'ior in ("ic" t"e basic ri%"ts o ot"ers or #a1or a%e.appropriate societal nor#s or rules are 'iolated& AGGRESSI=N T= PE=PLE F ANIMALS /ESTRUCTI=N =2 PR=PERTY /ECEIT2ULNESS =R THE2T SERI=US 6I=LATI=NS =2 RULES 4e%innin% be ore a%e AC =PP=SITI=NAL /E2IANT c"aracteri$ed b! an on%oin% pattern o disobedient& "ostile& and de iant be"a'ior to(ard aut"orit! i%ures t"at %oes be!ond t"e bounds o nor#al c"ild"ood be"a'ior Si%ns Losin% te#per Ar%uin% (it" adults Re usin% to ollo( t"e rules /eliberatel! anno!in% people 4la#in% ot"ers Easil! anno!ed An%r! and resent ul Spite ul or e'en re'en%e ul ne0t SU4STANCE A4USE E0cessi'e or un"ealt"! use o substances& suc" as alco"ol& tobacco or dru%s& or use o products suc" as ood Ter#s, T=LERANCE, t"e declinin% e ect o t"e sa#e dru% dose ("en it is ta3en repeatedl! o'er ti#e HA4ITUATI=N, a ps!c"olo%ical dependence o t"e use o a dru% A//ICTI=N, t"e biolo%ical and7 or ps!c"olo%ical be"a'iors related to substance dependence 5ITH/RA5AL SYMPT=MS, result ro# a biolo%ical need t"at de'elops ("en t"e bod! beco#es adapted to "a'in% an addicti'e dru% in t"e s!ste#9 occurs ("en seru# le'els decrease A//ICTI=N ALC=H=L, blood alco"ol le'els o >+AP )A>>#% alco"ol7dl o blood* or "i%"er 5ITH/RA5AL

Anore0ia An0iet! Easil! startled H!peralertness HPN Inso#nia Irritabilit! 8er3! #o':t Possibl!, "allucinations& illusions or 'i'id ni%"t#ares Sei$ures )J.LB "rs a ter cessation* Tac"!cardia tre#ors

5ITH/RA5AL /ELIRIUM A%itation Anore0ia An0iet! /eliriu# /iap"oresis /isorientation (it" luctuatin% le'els o consciousness 2e'er )A>> to A>C 2* Hallucinations and delusions Inso#nia Tac"!cardia and HPN /isul ira# )Antabuse* t"erap! Nursin% care =btain in o about dru% t!pe and a#ount consu#ed Assess '7s Re#o'e unnecssar! ob1 ro# en'iron#ent Pro'ide one.on.one super'ision i necessar! Pro'ide a -uiet& cal# en'iron#ent (it" #ini#al sti#uli Maintain orientation Ensure sa et! Use restraints Pro'ide p"!sical needs Pro'ide ood and luids as tolerated Ad#inister #edications Collect blood and urine sa#ples or dru% screenin% SP=USE A4USE 4atterin% precipitates A,L suicide atte#pts o all (o#en 5i'es e0plain t"e in1uries as bein% sel .in licted or accidental P"ases Tension.buildin%, series o s#all incidents t"at leads to beatin% Acute beatin% p"ase, (i e beco#es ob1ect o assault be"a'ior

 Lo'in% p"ase, batterer is re#orse ul and assures spouse t"at "e (ill not "ar# "er a%ain+ T"is leads to reconciliation+

M!t"s T"e! belie'e t"at i t"e! tr! not to anta%oni$e (it" t"eir "usband& "e (ill c"an%e+ E orts to coerce t"e (i e out o t"e 'icti# role can be ruit ul+ 2acts 5o#en sta! in relations"ips (it" #en ("o batter because t"e! eel %uilt! or responsible o t"e "usband:s be"a'ior 5i e de'elops little sense o sel .(ort"& i##obili$ed and unable to re#o'e sel ro# t"e relations"ip+ Assess#ent, in1uries& ot"er e'idence Inter'entions, (it" consent CHIL/ A4USE

PHYSICAL 4ATTERING EM=TI=NAL SE@UAL NEGLECT

EL/ERLY A4USE A 'ariet! o be"a'iors t"at t"reaten t"e "ealt"& co# ort& and possibl! t"e li'es o t"e elderl!& includin% p"!sical and e#otional ne%lect& e#otional abuse& 'iolation o personal ri%"ts& inancial abuse& and direct p"!sical abuse+ Co##onl! co##itted b! care %i'ers+ SE@UAL A4USE Co#ponents Se0ual Misuse, inappropriate se0ual acti'it! Rape, t"ere is actual penetration Incest, re ers to t"e relations"ip bet(een t"e 'icti# and abuser blood relati'e or step parent role Inter'entions C"ildren, t"ru pla! or role pla!in% (it" puppets Pre'ention o urt"er se0ual abuse ne0t C=MPLETE/ SUICI/E Sel .in licted deat"

LE6ELS =2 SUICI/E Ideation, t"ou%"t Atte#pt, acted upon but ailed

Co#pleted

CHEMICAL RESTRAINT CHEMICAL RESTRAINTS, Medications used to restrict t"e patient:s reedo# o #o'e#ent or or e#er%enc! control o be"a'ior but are not a standard treat#ent or t"e p0:s #edical or ps!c"iatric condition+ PHYSICAL RESTRAINTS, Are an! #anual #et"od or p"!sical or #ec"anical de'ice attac"ed to or ad1acent to t"e p0:s bod! t"at "e or s"e cannot easil! re#o'e and t"at restricts reedo# o #o'e#ent or nor#al access to one:s bod!& #aterial or e-uip#ent+ SECLUTI=N AN/ RESTRAINTS SECLUTI=N, t"e in'oluntar! con ine#ent o a person alone in a roo# ro# ("ic" t"e person is p"!sicall! pre'ented ro# lea'in%+ No t"erapeutic e'idence ot"er t"an a last resort to ensure sa et!+ E'idence su%%est t"at it adds to urt"er trau#a and p"!sical "ar#

GUI/ELINES All "ospital sta ("o "a'e direct contact (it" t"e p0 s"ould "a'e on%oin% education and trainin% in t"e proper use o seclusion and restraints and ot"er alternati'es P"!sician or licensed practitioner s"ould e'aluate need (it"in A "our a ter t"e initiation o t"is inter'ention+ Ma0 o L "ours or adults& D "ours or a%es V.AJ& and A "our or c"ildren under V !rs =rders #a! be rene(ed or DL "rs be ore anot"er ace to ace e'aluation Continuous assess#ent& #onitorin% and e'aluation9 recorded Good nursin% care 2or bot" restrained and secluded, constant #onitorin% ace to ace or b! bot" audio and 'ideo e-uip#ent+ P0 s"ould be released ASAP =THER GUI/ELINES SECLUSI=N Roo# s"ould allo( obser'ation and co##unication (it" p0 Re#o'e all ite#s t"at p0 #i%"t use to "ar# sel /ocu#ent, rationale& response to inter'ention& p"!sical condition& ns% care& F rationale or ter#ination RESTRAINTS Gi'e support F reassurance Position in anato#ical position Pri'ac! is i#portant '7s F Circulation c"ec3 S"ould be released - D"rs A'oid t!in% to t"e side rails o bed Assist in periodic c"an%e in bod! positions

TERMINATING THE INTER6ENTI=N As soon as #et t"e criteria or release

Re'ie( (it" p0 t"e be"a'ior t"at precipitated t"e inter'ention F p0:s capacit! to e0ercise control o'er be"a'ior /E4RIE2ING, re'ie(in% t"e acts related to an e'ent F processin% t"e response to t"e#9 can be used a ter an! stress ul e'ent ne0t THERAPEUTIC IMPASSES Are bloc3s in t"e pro%ress o t"e nurse.pt relations"ip

onesel

Pro'o3es intense eelin%s in bot" t"e nurse and patient RESISTANCE TRANS2ERENCE C=UNTERTRANS2ERENCE 4=UN/ARY 6I=LATI=NS RESISTANCE Reluctance or a'oidance o 'erbali$in% or e0periencin% troublin% aspects o

E%, suppression or repression& intensi ication o s0& sel .de'aluation or "opelessness& intellectual in"ibitions& actin% out or irrational be"a'ior& super icial tal3& intellectual insi%"t7 intellectuali$ation& trans erence reactions+ TRANS2ERENCE Unconscious response in ("ic" t"e p0 e0periences eelin%s and attitudes to(ard t"e nurse t"at (ere ori%inall! associatated (it" ot"er si%ni icant i%ures in "is or "er li e+ H=STILE TRANS2ERENCE, an%er and "ostilit!& resistance /EPEN/ENT TRANS2ERENCE, sub#issi'e& subordinate and re%ards t"e nurse as a %od.li3e i%ure9 'ie(s relations"ip as #a%ical 5"at do !ou doZ

LISTEN CLARI2Y RE2LECT

E@PL=RE7 ANALYKE C=UNTERTRANS2ERENCE Created b! t"e nurse:s speci ic e#otional response to t"e -ualities o t"e patient9 inappropriate in t"e conte0t& content and intensit! o e#otion9 nurses identi ! t"e p0 (it" indi'iduals ro# t"eir past& and personal needs

T!pes, Reactions o INTENSE lo'e or carin% /is%ust or "ostilit! An0iet!& o ten in response to resistance b! t"e p0

E%+ /i icult! e#pat"i$in% 2eelin%s o depression be ore or a ter t"e session Carelessness about i#ple#entin% t"e contract /ro(siness durin% t"e sessions Encoura%e#ent o t"e p0:s dependenc! Ar%u#ents (it" t"e p0 Personal or social in'ol'e#ent (it" t"e p0 Se0ual or a%%ressi'e antasies to(ard t"e p0 Tendenc! to ocus on onl! one aspect or (a! o loo3in% at in or#ation presented b! t"e p0 Atte#pts to "elp t"e p0 (it" #atters not related to t"e identi ied nursin% proble#s 2eelin%s o an%er or i#patience because o t"e p0:s un(illin%ness to c"an%e /rea#s about or preoccupation (it" t"e p0