Psychiatric Nursing

A. Assessment
Psychiatric History: Chief Complaint
History Present of Illness
Past Health History
Family/Personal History
Mental Status Exam: Presentation (Appearance, Behavior, Attitude)
Stream of Talk
Emotion (Mood, Affect, Suicidal Ideation, Depersonalization)
Disturbance in Thinking (Thought Process and Thought Content)
Disturbance in Perception (Illusion and Hallucination)
Neurovegetative State
Gen. Sensorium & Intelligence (LOC, Memory, Gen Info, Concentration, Judgment)
Insight
Multiaxial System: I: Psychiatric condition except MR and PD
II: MR and PD
III: Medical Diagnosis
IV: Precipitating factor
V: Global Axial System
Physical Examination
Laboratory Tests

B. Neurotransmitters:
Excitatory: Dopamine
Epinephrine
Norepinephrine
Glutamate
ACH
Inhibitory: GABA
ACH
Serotonin

KEY EFFECTS: ↑Dopamine → Schizophrenia

↓ACH → Alzheimer’s
↑Norepinephrine → Mania
↓GABA → Anxiety Disorders
↓Serotonin → Depression

C. Defense Mechanisms
Alcoholism: Denial, Rationalization
Depression: Introjection
OCD: Undoing, Reaction Formation, Displacement
Mania: Projection
P. Schizo: Projection
C. Schizo: Repression
 D. Schizo: Regression
Antisocial: Displacement

D. Anxiety: ↓GABA
Classifications: Description S/Sx Interventions
M: Something warrants ↑Responses and Fx None
attention Restlessness
Focus: Heightened GI Butterflies

M: Something is wrong ↓Concentration Use of short, simple and direct

Focus: Task Agitation & Tension
Diaphoresis & bounding
pulse
Use of Automatisms
S: Something is distressing Scattering &Trembling
Focus: Detail ↑ V/s & Headache
↑ incoherent speech
Ritualistic Behavior
P: Something is incapacitating (-) communication
Focus: Self Bolt or remain immobile
(last for about 5-30 min)
statements.
Redirect to topic.
Goal: ↓anxiety
Low, calm voice
Even, deep breaths
Stay with client
Priority: Safety
Non-stimulating environment
Continue communication
Stay with client

1. Panic Disorder: Panic Level of Anxiety Priority: Safety and Privacy

Acute & Sudden Onset ↓anxiety: Breathing Exercises
Not more than an hour Guided Imagery
Intense and Recurrent Progressive Relaxation
Cause: unknown Therapy: Cognitive-Behavioral
2. GAD: Gradual Onset Relaxation Techniques
Exceeds 6 months
Not known cause
Excessive worrying
Results to Impaired
Function
Always preoccupied
Level: Moderate to Panic

3. ASD and PTSD: Acute: 2days – 4weeks after
the event
Post-Traumatic: 3mo –
years after event
Classic sign: Flashbacks and
Nightmares
Priority: Safety (esp with
Flasbacks)
Grounding Techniques: Reality
Orientation

4. OCD: Obsessions Identify underlying anxiety

Compulsions: Checking Behavior Therapy: Exposure
Cleaning Response
Counting Prevention
Does rituals: ↓anxiety Other relaxation techniques
5. Phobias: Persistent fear Behavioral Therapy:
Has anticipatory anxiety 1. Systematic Desensitization
Onset: Middle Adolescence 2. Flooding
Behavior: Avoidance Other Relaxation Techniques
Illogical and Intense
Agoraphobia, Specific,
Social

Anxiolytics: Atavax: elderly Considerations

Ativan: Prevent n/v 1. Avoid alcohol/brown
Anafranil: 1 week lag; no foods
addiction 2. Low starting dose
Buspar 3. High addictive
Klonopin potential
Librium 4. Taper: could lead to
Serax convulsions
Valium
Xanax: for phobis

E. Somatoform Disorders: (-) control of client

Somatization: symptoms are multiple
Conversion: deficits in sensory or motor function
Pain: Primary symptom of pain
Hypochondriasis: Preoccupation of dse: Disease Conviction and Phobia
Body Dysmorphic Disorder: Preoccupation with defect in physical appearance
Gains: Primary: Direct/External → Relief of anxiety, conflict, distress
Secondary: Personal/Internal → Attention, comfort
Interventions: Manage chief complaint
Improve quality of life: Promote routines
Express feelings
Coping Measures
Related D/o: Malingering: false/exaggerated symptoms; motivated by physical symptoms
Factitious: solely to gain attention; infliction of injury
Examples: 1. Munchausen Syndrome
2. Munchausen Syndrome by Proxy

F. Psychotic Disorders: BPD: 1day – 1month

Schizophreniform: 1 month – 6months
Schizophrenia: >6months
Schizoaffective: Psychotic + Mood
Shared Psychosis: sharing of similar delusion
Schizophrenia: ↓Dopamine
4A’s of Blueler: Ambivalence
Autism
Affective disturbance
Associational Disturbances
 Type Classic Symptoms Priority
Paranoid (+) Symptoms Safety (others)
Persecutory/Grandiose
Disorganized (+)/(-) Symptoms Nutrition/Circulation
Looseness of Associations
Inappropriate affect and actions
Catatonic (-) Symptoms ADL Assistance
Psychomotor disturbance:
agitation/markedly decreases
Undifferentiated Mixed Depends on presenting
Residual Recurrent symptoms

Antipsychotics

Typical EPS: Dystonia -azine

-affects Dopamine only Pseudoparkinsonism -eridol
-for (+) s/sx Akathisia
NMS: dangerous
TD: irreversible
Anticholinergic
Photosensitivity
Seizures
Atypical (almost all above but ↓EPS -apine
-affects Serotonin and tendencies) -idone
Dopamine Agranulocytosis
-for (+) and (-)
For Side Effects Akineton
Artane
Ativan
Benadryl
Beta-Blocker
Cogentin
Diazepam
Symmetrel

G. Mood Disorders
Types of Mood: Mania: elevated mood + loss of function
Hypomania: elevated mood
Depression: Depressed mood
Disorders: MDD
Bipolar I: mania + depression
Bipolar II: hypomania + depression
Dysthymia: Depression not quite of MDD
Cyclothemia: Hypomania

Mania Depression
Colorful Sad
Hyperactive Passive
 Talkative
Priority: Safety (others)
Non-stimulating Environment
Matter of Fact Approach
DOC: Lithium
Monotonous
Priority: Safety (client)
Stimulating Environment
Kind Firmness
DOC: Antidepressants

Pharmacology:

SSRI: prevent Fluoxetine (Prozac) Common: Prozac, Paxil, Zoloft

serotonin reuptake Sertraline (Zoloft)
Paroxetine (Paxil)
Citaprolam (Celexa)
Escitalopram (Lexapro)
TCA: prevent Amitriptyline (Elavil)
Norepinephrine and Amoxapine (Asendin)
serotonin reuptake Doxepin (Sinequan)
Imipramine (Tofranil)
Desipramine (Norpramine)
Nortriptyline (Pamelor)
MAOI: blocks Tranylcypromine (Parnate)
breakdown of Phenelzine (Nardil)
Norepinephrine, Isocarboxazid (Marplan)
Dopamine and
Serotonin
Lithium: exact Labs every 2-3days then
mechanism is weekly
unknown but affects Inhibit NE and dopamine
Na, K, Ca and Mg Therapeutic: 0.5-1.0 meq/L
functions as well as Has s/e: fine tremor,
Norepinephrine and anorexia,
Dopamine Mild nausea/diarrhea
Intoxication: unsteadiness,
n/v, weakness, drowsiness
Untreated: leads to renal
failure
Maintain sodium and water
Effect: 2-4 weeks
OD at am
Suicide Precautions
S/E: commonly CNS, GI
Common: Elavil, Tofranil,
Norpramin
Effect: 1-4 weeks
Administer at bedtime
s/e: CNS, GI, GU, CV,
photosensitivity
↑s/e: Hepatotoxic, GI, GU, CV,
Photosensitivity
Wash-out period of 5-6 weeks
before giving other
antidepressants
No tyramine-containing food
Other drugs: Carbamazepine
Valproic Acid
Gabapentin
Clonazepam

Therapies: Depression: ECT: (+) consent

Preop: remove dentures, jewelries, nail polish
Explain temporary memory loss
NPO for 6 hours and void before procedure
Premeds: short-acting anesthetic
muscle relaxant/paralytic (succinylcholine)
Complication: Respiratory Distress
Post-op: Monitor V/s and Orient to environment
Interpersonal Therapy
Behavioral Therapy
 Cognitive Therapy
Mania: Unhelpful because client does not have enough focus for any activity

H. Suicide: intentional act of killing oneself; cry for help

Assessment: Sex: Male (↑success) and Female (↑attempt)
Age: 15-45 y/o or above 45 y/o
Depression
Pt with previous attempts
Ethanol Use (Alcoholics)
Rationality: minimal
Social Support: minimal to none
Organized plan: higher risk
No family
Sickness: terminal stage
Nurse’s Role: Authoritarian
Priority: Safety: Support System List
Always under supervision (every 10 min if low lethality and always if very lethal)
Free room from dangerous materials
Establish no-suicide contracts

I. Personality Disorders

I. Odd or Eccentric
Paranoid Suspicious Straightforward
Schizoid Loner Promote communication
Schizotypal Weird Promote ADLs/social communication
II. Dramatic or Emotional
Antisocial Criminal Limitation and confrontation
Borderline Unstable Safety, coping
Histrionic Attention-seeker Social skill, factual feedback
Narcissistic Boastful Matter-of-fact, social communication
III. Anxious or Fearful
Avoidant Inferior Support, Cognitive Restructure
Dependent Submissive Increase Autonomy, self-reliance
OCPD Perfectionist Negotiation, timely decision
IV. Others
Depressive Depressed Increase self-esteem, safety
Passive- Intentionally Assist to examine and express
aggressive inefficient

J. Eating Disorders: a sign of needing control in an uncontrollable environment

Anorexia Nervosa: Amenorrhea
Need for control
Occupation with food
Result to decreased functioning
Emaciated and exercises
X – maintenance of IBW
 Impaired insight
Altered Nutrition: Priority
Treatment: Below 18 years old: Family Therapy
Above 18 years old: Individual or cognitive-behavioral therapy
Weight restoration
Nutrition Rehabilitation
Fluid and electrolyte stabilization
Bulimia Nervosa: Binge eating
Usually normal in weight
Lacks control
Induce vomiting (purging)
May abuse drugs
Intact Insight
Aspiration risk
Treatment: Cognitive-Behavioral Therapy
General Mngt: Environment
Absence of nodules
Thirst
Indigestion
No signs of malnutrition
Goal: Increase weight

K. Substance Abuse
Abuse: problem in functioning
failure with major obligations
results in physical hazard/legal problems
Dependence: problem with addiction
tolerance and withdrawal
increase in usage
aggression and cravings
Intoxication: due to over ingestion
Withdrawal: due to cessation
Stages: Preoccupation/anticipation
Binge/Intoxication
Withdrawal
Classifications:Depressant: Alcohol, Cannabis, Opioids, Sedative, Anxiolytics, Hypnotics
Stimulants: Caffeine, Cocaine, Nicotine
Hallucinogens: Amphetamines, PCP
Alcohol: Stages: Loss of Inhibition
Lack of Coordination
Aggression
Overdose
Withdrawal: starts at 4-12 hrs; peaks on 2nd day and stops by 5th day
rebound over-excitement
 Management: Abstinence: goal
Life coping skills
Codependence: manage
Openly express feelings
Health Teachings
Offer support
Look-out for relapse
Pharma: withdrawal: Benzodiazepine (DOC: Librium)
aversion therapy: Disulfiram
Treatment: Community settings
Sedatives/Hypnotics/Anxiolytics: Benzodiazepine: Overdose is rarely fatal; ↓LOC
Mngt: gastric lavage & charcoal; dialysis (with severe)
Barbiturates: Lethal
Mngt: ICU (Lavage and dialysis)
Withdrawal: Increase of Sympathetic activity
Detoxification: Tapering
Marijuana: Can have medicinal uses
Alcohol-like high
No overdose
No withdrawal
Acts within 1 min till 2-3 hours
Blood-shot eyes
Impaired coordination: intoxication
Severe use: delirium and psychosis
Opioids: Opioid antagonist: Naloxone (Narcan)
Pain-free sensation leads to euphoria
Intoxication: constricted pupils
Overdose: respiratory depression
Initial withdrawal: cravings and restlessness
Don’t require meds for withdrawal
Stimulants: used medically for ADHD; except for cocaine
Intoxication: rapid; ↑sympathetic response
Withdrawal and detoxification: ↓sympathetic response lasting from a few hours to days
depression and suicidal ideation
no meds; only symptomatic mngt
Cocaine (classic): perforated septum
Hallucinogens: distort reality; has psychotic manifestations
Physiologic: ↑TPrBP, Pupil size, reflexes
Intoxication: behavioral and pysh changes
No overdose and Withdrawals; Only flashbacks that persist up to 5 years
Symptomatic Management
Inhalant: Paints, Gasoline, correction fluid, cleaners, etc
Intoxication: ↓coordination → stupor and coma
 Toxicity: Respiratory and cardiac problem (supportive management)
No withdrawal/detox

H. Violence and Abuse

1. Family: Social Isolation
Abuse of power and substances
Intergenerational transmission
2. Partner: Psychological (emotional) or Physical (may include sexual)
Cycle: Tension-building
Violent Behavior
Period of remorse (honeymoon)
Abuser: ↓self-esteem/↓coping
Abused: Dependency
Report ASAP (RA 9262)
Priority: Safety
3. Child: May be sexual, neglect, psychological
Assessments: An inconsistent history
Bruising of rectum/genitalia
Unusual injury for age
Serious injury without trauma
Existence of frequent UTI
Delay with treatment and unreported injury
Priority: Safety (Report suspected case in 48 hrs; RA 7610)
Remove child from home
Trust is crucial
Therapy: Play
4. Elderly: May be physical, neglect, psychological and financial
Assessment: Elder doesn’t speak for self
Lots of unreported injury
Dehydrated/malnourished
Existence of health hazards & unpaid bills
Reluctance to report
Management: Unintentional: Relieve caregiver’s stress; Provide information
Intentional: Remove from home
5. Rape and Sexual Assault:
RA 9262. Section 31 Health worker’s responsibilities with suspected/confirmed rape:
1. Documentation and record
2. Free of charge medical certificate
3. Notice of right and possible remedies (Offering options)
Assessments: Physical exam before hygiene
Clothing placed inside paper bag
Ask for description of event
Treatment: Supportive/group therapy
Prophylactic for STD’s