According to (A.P.

A) DSM 5 TR
PREPARED BY HENRY EVALLE
PSYCHIATRIC NURSING
- Is an interpersonal process whereby the professional nurse practitioner assists an individual, family and
community through the therapeutic use of self. To promote mental health and prevent / cope with the
experience of mental illness and suffering.
Interpersonal – interaction between two parties

1. Client – most important / main focus of the entire NPR (nurse-patient relationship)

2. Nurse – “active Listening”

Therapeutic use of Self - utilization of self to produce therapeutic effect to the client by using Therapeutic
Communication.

PSYCHOPHARMACOLOGY
- Focuses on Neurotransmitters –
- 3 majors neurotransmitters
o Mono Amines
 DOPAMINE
 SEROTONIN
 NOREPINEPHRINE
o Amino Acids
 GABA (Gamma Amino Butyric Acid)
o Choline
 ACETYLCHOLINE

ABNORMALITIES OF NEUROTRANSMITTERS

1. DOPAMINE

- Increase in Dopamine
o (+) signs of Schizophrenia
- Decrease in Dopamine
o Parkinson’s Disease – resting tremors / involuntary muscle movement or motor movement
o EPSE – Extrapyramidal Side Effects – involuntary motor problem

2. SEROTONIN

- Increase in Serotonin
o (-) signs of Schizophrenia
o Mania
- Decrease in Serotonin
o Major Depression
o Eating Disorder
o OCRD (Obsessive Compulsive Related Disorder)

3. NOREPINEPHRINE
- Increase Norepinephrine
o Mania
- Decrease Norepinephrine
o Major Depression

4. GABA

- Decrease GABA
o Anxiety Disorder

5. ACETYLCHOLINE

- Decrease Acetylcholine
o Dementia
o Alzheimer’s
o Parkinson’s

ANTIPSYCHOTICS
- given clients with Schizophrenia
- A.k.a NEUROLEPTICS / Major Tranquilizers / Ataractics / Psychic Energizers

3 types of Antipsychotics:

1. Typical – old / Traditional / Conventional

PRO-THO-ME-TRI-S-H

PRO – Prolixin
THO – Thorazine
ME – Mellaril
TRI – Trilafon
S – Stellazine
H – Haldol / Haloperidol

2. Atypical – New

C-RI-SE-Z

C – Clozaril
RI – Risperdal / Risperidol
SE – Seroquel
Z – Zyprexia

(1) TYPICAL (2) ATYPICAL

Time 1950’s - 1990’s –

 Thorazine Clozaril

Indication (+) signs of (-)(+) signs of

Schizophrenia Schizophrenia

MOA decrease decrease

Dopamine only Dopamine
and serotonin

EPSE very severe Mild / rare

EPSE

- Mild
- Moderate
- Severe
- Very Severe

3. DSS – Dopamine System Stabilizers – 2000’s

- Abilify (Aripiprazole)

Side Effects of Antipsychotics:

“A-E-I-O-U”

A – Anti Cholinergic Side Effects (ACSE)

- Agranulocytosis
- Amenorrhea

E - EPSE

I – Increase Prolactin Level

O – Other: Orthostatic Hypotension

- Photosensitivity
- Hepatotoxicity
- Teratogenic

U – umakyat ang timbang – weight gain / Hyperglycemia

A. ACSE “ABCDEF”

A – Absence of Sweat (Anhydrosis)

 B – Blurring of Vision
C – Constipation
D – Dry Mouth & Dilated Pupils (Mydriasis)
E – Elevated HR, (EHE) urinary retention
F – Fever

B. Agranulocytosis / Granulocytopenia / Leukopenia

- abnormal reduction of granulocytes in the blood

decrease WBC – decrease immune system

increase risk for infection = FATAL

- Most important Sign
o FEVER + sore throat
- Most common cause : Clozaril
Nursing Intervention – Monitor WBC Count
- Normal – 5000-10000 cell/cumm

C. Amenorrhea
- Absence of menstruation
Nursing Intervention: Family Planning

D. EPSE (Involuntary Motor / Muscle Problem

Meds: “ABCDEFS”
A – Artane, Akineton
B – Benadryl – most common most common
C – Cogentin – new DOC  Lesser SE
D – Dopamine Sinemet / Levodopa
E – Eldepril
F – Pergulide
S – Symmetrel

Types of EPSE
1. Dystonia

- Involuntary rigidity of the muscles

- Face, neck, tongue, back, and extremities
- Earliest EPSE occur
- Occurs: 1-2 days
- Meds: ABC

2. Neuroleptic Malignant Syndrome (NMS)

- most rare EPSE (1%)

- unstable  most FATAL of ALL
 - most important sign: FEVER + muscle rigidity
- most common cause: HALDOL
- occurs 3-9 days after treatment
o DOC: Dantrolene Sodium

3. Pseudoparkinsonism

 “false” temporary
 Resting tremors
 Pill rolling
 Shuffling gait
- Bradykinesia - slow speech and slow movement
- Occurs – 1-3 weeks after the treatment
- Medication: ABC

4. Akathisia

- Inability to sit / stand still

- Ants in the Pants
- Most common of all EPSE
- Occurs 2-3 weeks after treatment
- MEDS: ABC

5. Tardive Dyskinesia

- Involuntary jerky movements

- Focuses – mouth
o Lip smacking
o Teeth grinding
o Tongue rolling
o Tongue Protrusion
- Occurs months – years after the treatment
- Irreversible EPSE
- DOC: Bromocriptine (Parlodel) – Dopamine Receptor Antagonist

E. Increase Prolactin Level

- Female  Galactorrhea
- Male  Gynecomastia
- Most common cause: Risperdal

F. Orthostatic Hypotension

- Sudden drop of BP when client changes his position form supine to sitting/ standing
- 5 mins. From sitting
- 5 mins from standing while holding side rails

G. Photosensitivity / Sunburn
 - Avoid sunlight / hot places  1st degree burns
- To avoid 1st degree burn – wear long sleeves, umbrella, wide hat, sunblock SPF– 15%, shades
- Common Cause: Thorazine

H. Hepatotoxicity – Liver

- Jaundice / Icterus
- Yellow skin / sclera
- Pale Color of Stool
- Dark colored urine
- FATAL

I. Teratogenic

- Nursing Intervention: Family planning

J. Weight gain & Hyperglycemia

- nursing intervention: Exercise

ANTIDEPRESSANTS
- MAJOR DEPRESSION
- A.k.a Thymoleptic / mood elevators

Goals for management of Depression:

1. Remove signs and symptoms of Depression
2. Restore Psychosocial Function
3. Prevent recurrence of Depression

3 Classifications

SSRI – Selective Serotonin Reuptake Inhibitor

- 1st line to treat major depression

- Lesser side effect
- Expensive

“PPLLZ CEL”

P – Prozac

P – Paxil

L – Luvox

L – Lexapro

Z – Zoloft
Cel – Celexa

- LAG period: 2-4 weeks

- Given: It depends upon the effects of the drugs
o Insomnia – Morning
o Nervousness – Morning
o Sedation – Evening

Side Effects:

- Weight loss
- Photosensitivity
- Headache and nervousness
- N&V
- Sexual dysfunction

TCA – Tricyclic Antidepressants

- 2nd line to treat MD

- Most sedation

“VP mo SI ATE”

V – Vivactyl

P – Pamelor

Si – Sinequan

A – Anafranil

T – Tofranil – 1950’s

E – Elavil – most CARDIOTOXIC

- Lag Period: 2-4 weeks

- Given: Evening – because most sedation

SIDE EFFECTS:

- Weight gain & Cardiotoxicity

- ACSE & Ataxia
- Eye pain & Nightmares
- Orthostatic Hypotension
- Sexual Dysfunction

MAOI- Mono-Amine Oxidase Inhibitor

- Last resort for treating MD / 3rd line

- Most side effects
- Pinaka mura na gamot
“Pa Ma Ma Na”

Pa – Parnate

Ma – Marplan

Ma – Manerix (Moclobemide) – NEW!

- It can lessen Hypertensive Crisis

Na – Nardil

- Lag Period: 2-4 weeks

- Given: Morning

SIDE EFFECTS:

- Insomnia
- Hypertensive Crisis
o TYRAMINE rich food should be avoided
“ABCDEFG”
o A – Aged Cheese, Avocado
o B – Banana
o C – Caffeine (soda, coffee, energy drink)
o D – Dry foods
o E – Embotido (meat, raisins, cheese, hotdog, ham, carrots)
o F – F (P)izza. Papaya, Fermented food (yakult, Yogurt, all alcohol beverages)
o G – Gravy, Ginseng

UNIQUE S/Sx of Hypertensive Crises:

1. Severe Sweating
2. Severe Nausea and vomiting
3. Occipital Headache
4. Sore Neck & Stiff Neck
MEDS / DOC: Phentolamine (5mg) IV – Non-Selective Alpha Adrenergic Antagonist

ST. JOHN WORT – Herbal

- Can treat Major depression

- ADHD (Attention Deficit Hyperactive Disorder)

NOTE:
 - Do not mix different Antidepressant Drugs  can cause serotonin syndrome (FATAL)
- Best time to commit suicide is during the drug intake  increase neurotransmitter

ANTIMANIC
- For Manic Patients (elevated mood)

Unique Sign: Pleasure Principle (Sex Addicts)

- A.k.a Mood stabilizers

- Lag time: 7-10 days
- Meds: “ES – TE – DE”

ES – Eskalith (Lithium)  1950’s

TE – Tegretol (Carbamazepine)  for pregnant Manic

DE – Depakene (Valproic Acid)  can cause neural tube defect

Therapeutic Dose:

- 300-600mg TID

Therapeutic Blood Lithium Level:

- 0.5-1.5 meqs/ liter  OLD

- 0.6-1.2 meqs / liter  NEW!

Contraindications of Lithium:

- Heart Problem
- Liver Cirrhosis
- Renal Failure
- Lithium Allergy
- Cancer
- Pregnant
- Dehydration
- Parkinson’s
- Epilepsy

Relationship of Na and Li:

- Inversely Proportional
- Increase Na , Decrease Li  Effectiveness
- Decrease Na , Increase Lithium  Lithium Toxicity
Meds Given for Lithium toxicity: “DAMU”
D – Di-amox
A – Aminophylline
M – Mannitol
U – Urea

Meds that alters Lithium Level (DL)

D – Diuril
L – Lasix

Signs/symptoms of Lithium Toxicity: SEVERE

- Diarrhea
- Vomiting
- Diaphoresis
- Muscle weakness
- Coarse tremors

HENRY’S Lithium Precaution:

H – Herbal Tea / Milktea

E – Excessive Exercise

N – Nescafe (Coffe)

R – Red bull, sting, cobra

Y – you should avoid hot places

S – Salt intake /day  2-3gms without condiments

- Water intake/ day  2-3Liter

Other Antimanic Drugs:

- Gabapentin
- Topamax
- Trileptal
- Lamictal

ANTIANXIETY
- A.k.a Anxiolytics / Minor Tranquilizers / Benzodiazepines
- Other Purpose: “P-A-R-I-S”
o P – Pre- operative medications
 Diazepam (Valium)
o A – Alcohol Withdrawal Syndrome
 Librium (Chlordiazepoxide)
o R – Restraints
 Diazepam (Valium)
o I – Insomnia
 Diazepam (Valium)
o S – Seizure
 Lorazepam (Ativan)
Medications: “LIBRE – TRANSPO – BUS”
- Librium - 1950’s
- Transxene
- Buspar
-zepam -zolam

diazepam triazolam
 Lorazepam midazolam

oxazepam – alprazolam
elderly people

clonazepam

Side / Adverse Effects: “RAD”

R – Respiratory Depression
A – Altered LOC (CNS Depression)
D – Dependency  very addicting drugs

Nursing Intervention: “RAD”

R – RR – monitors
A – Avoid Activities: Avoid operating machines, driving, swimming
D – Decrease the dosage of the drug GRADUALLY before stopping it  TAPERING

ANTIDEMENTIA / ANTIALZHEIMERS
- Aka Anticholinesterase / Choline sterase inhibitor
Medication: “CARE”
C – Cognex – 1945  OLD
A – Aricept –DOC
R – Razadyne / Reminyl
E – Exelon

Levels of Perceptual field Remarks/ assessment Nursing intervention

Anxiety
MILD (+1) INCREASE (PF) - HEALTHY - Relaxation technique
- Best for learning  Deep breathing
- Very sharp and alert  Music therapy
 Eating
 Meditation / Yoga
- Verbalization of feelings
MODERATE (+2) Narrow  going down PF - Selective inattention - Refocus the client
- Decrease focus - Can give anxiolytics
initially
- ROUTE: ORAL
SEVERE (+3) Greatly reduced PF - Rapid pacing K.I.S.S
- Hyperventilation
- Tremors
- Palpitations
- Shouting / screaming - Keep it short and simple
- Difficulty in instructions
communication - Can give Anxiolytics
- Fixed vision (Tulala) - Route: IM

PANIC (+4) Loss/ Block PF - Loss of rational - SAFETY

thoughts - Can give Anxiolytics
- Loss of - Route: IM
communication
- Feeling of impending
doom
- Tunnel Vision
- Violent
ANXIETY DISORDERS

A. Separation Anxiety Disorder (SAD)

o Excessive & persistent anxiety or fear concerning separation from home or to those
whom the individual is attached` to.
- Fear from separation from Home
- Children: at least 1 month
- Adult – 6 months
Nursing Intervention of SEPANX:
F – Family Therapy / support system
E – Encourage Verbalization
A - Anxiolytics
R – Relaxation Technique
S – SAFETY & Stay with the client
B. Selective Mutism
- A person who is normally capable of speech does not speak in specific situation to specific
people
- Selective Mutism usually co-exist with extreme shyness or strong social anxiety
- Common to children – 5y/o for at least 6 mos.
- Trusted: MAMA/ Mother
Nursing Intervention: “MUTE”
M – Medication: Anxiolytics
U – Understand the child’s situation
T – Therapy: Play / Family / Group Therapy
E – Encourage the child to talk/speak slowly (SHAPING)
Operant Conditioning - reward and punishment
C. Phobia
- intense or irrational fear of objects, things, places, events, situation, animals and
person .
- Level of Anxiety: Severe-panic type
Types of Phobia
1. Agoraphobia – fear of being alone in an open or public space where escape is impossible
MONOPHOBIA – fear of being alone
2. Social Phobia – fear of situation that may cause shame or embarrassment
3. Simple Phobias / Specific Phobia
- Acrophobia – heights
- Arachnophobia – spiders
- Xenophobia – strangers
- Claustrophobia – close space
 - Monophobia –being alone
Defense Mechanism: Symbolization / Displacement
Nursing Intervention: “PHOBIA”
P – Phobia attacks: stay with the client
H – Health teaching
- Systematic Desensitization – gradual exposure to the phobic exposure
- Flooding – abrupt/ sudden exposure
O – Offer relaxation Technique
B –Bervalization / Catharsis
I – Important: Safety
A – Anxiolytics

D. Panic Attacks
- intermittent occurrence of panic level of anxiety
P – Palpitations
A – Agitations
N – Numbness/ nervousness  most important sign
I – Intense Fear
C – Chest Pain

G – Generalized Anxiety D/O (GAD)

- Free floating anxiety disorder
- Persistent worrying of two or more life events for at least 6 months.
- Ex: Problema ko … Problema ko yun
o Problema mo – Problem ko

GAD PANIC

Continous continuity of Intermittent

anxiety

Moderate to Level of Anxiety PANIC

severre

overuse of PRONe to overuse of

substance abuse anxiolytics

Anxiolytics DOC Prozac

Psycho, individ, MGT Psycho, individ,
bahevioral bahevioral
therapy therapy

OBSESSIVE COMPULSIVE AND RELATED DISORDERS (OCRD)

5 types of OCRD: “OBETH”

O - Obsessive Compulsive Disorder

B - Body Dysmorphic Disorder

E- Excoriation Disorder

T - Trichotillomania Disorder

H – Hoarding Disorder

A. OCD

O – OBSESSION - unwanted repetitive thoughts / thinking that increases level of anxiety

C – COMPULSION - unwanted repetitive actions that decreases level anxiety = RITUAL  X ADL’s

D – Decrease Serotonin Level

- during – Toddler Age: because of MOTHER  strict toilet training  Erik ERICKSON theory

 School age : common MALE

 Adolescent stage: common FEMALE

NURSING INTERVENTION

O – Offer & allow rituals: initially

C – Contract: Limit Setting
D – Diversional Activity, Cognitive Behavioral Therapy (CBT)
DOC: TCA – Anafranil - 1st
SSRI – Luvox – 2nd
DEFENSE MECHANISM: “ DOCU”
Obsession - Displacement
Compulsion – Undoing

B. BODY DYSMORPHIC DISORDER (BDD)

- characterized by an imaginary defect which appears normal to other

- Adolescent Stage
- common among FEMALE
NURSING INTERVENTION: “MASK”
M – Mirror manipulation
- to increase public self-awareness
A – Anti- Depressant: SSRI (PPLLZ-Cel)
S – Self – esteem increase
K – Cognitive behavioral therapy (CBT)

C. EXCORIATION / DERMTOMIMANIA

- SKIN PICKING DISORDER

- Uncontrolled & repeated scratching of the skin because of high anxiety or boredom, resulting to
skin lesions for at least 6 mos.
- In skin picking: they use rubbing, squeezing, lancing/ cutting & biting.
Common Site: face, Arms, Hands
Sexual Preference: FEMALE

NURISNG INTERVENTION: “ SKIN”

S – SSRI
K – CBT
I – instruct to is Unna Sleeves
N – Needs Supervision & Dermatological Skin Care

D. TRICHOTILLOMANIA - HAIR PULLING d/o

- Uncontrolled & repeated pulling out of one’s own hair, resulting in hair loss for at least 6 mos.
Common Site: Scalp, eyelids, eyebrow & pubic region
Sexual Preference: Female
*RITUAL: eating the hair

NURSING INTERVENTION: “hair”

H – hair pulling : CBT
A- Anti- Depressant: SSRI
I – Instruct Diversional Activities & Relaxation Technique
R – Ritual: Strict Supervision

E. HOARDING DISORDER

- persistent difficulties discarding or parting with possessions, regardless of their actual value, resulting
in the accumulation of possessions that congest and clutter active living areas for at least 6 months

Sexual Preference: Female

NURSING INTERVENTION: “HOARD”

H – Hygiene
O – Offer cognitive – behavioral
A – Anti- Depressant: SSRI
R – Requires: Safety
D – Diversional Activity

MOOD DISORDER / AFFECT

MAJOR BIPOLAR DISORDER
DEPRESSION

Most - depress - depress

important mood / mood( 1mon
sign severe th) + mood
sadness elevation
(1month)
- mood swing
Age of - early mid - Early
Onset 20’s adulthood
- 20-25 y/o - 15-25 y/o
Sexual - FEMALE - Equally
Preference distributed

DOC - SSRI - Depressed –

SSRI
- Mood
Elevation -
LITHIUM

I. MAJOR DEPRESSION

- characterized by severe sadness + anhedonia  inability to feel pleasure / happiness

Without episodes of mania/ hypomania
- “all depress clients r potentially suicidal
- Cause: unknown
- NT: decrease serotonin
- Confirmation: 2 weeks / 14 days
S/SX: “DEPRESS”
D – DEPRESS / severe sadness & ANHEDONIA
E – INSOMNIA / Hypersomnia
P – PHYSICAL ACTIVITY DECREASE
R – Recurrent suicidal thought
E – Excessive Guilt / Conscience
S – Self-esteem decrease (hopeless , helpless, worthless)
S – self- blaming  introjection
II. BIPOLAR DISORDER
- Characterized by severe sadness + episodes of mania and hypomania
- 2 types of Bipolar Disorder
o BIPOLAR I – MD to MANIA: complete mood swing
o BIPOLAR II - MD to HYPOMANIA
NURSING INTERVENTION: “SAFE”
S - Safety: suicidal tendencies 
o sudden change in mood / behavior
o verbalization of suicidal plans
o giving prize possession
- catharsis
- putting away harmful object
- irregular but frequent visits
A – Anti Depressant – SSRI  TCA  MAOI
F – Food, hygiene, rest & sleep
E – ECT  Last Resort

III. MANIA
- extreme or exaggerated
- Euphoric that leads to acceleration of physical & mental activity that affects the ADL’s, mood
elevation  Risk for injury r/t others
- “all manic client can be violet”
- Cause: unknown
- NT: increase serotonin & norepinephrine
- Confirmation: 1 week / 7 days
- DM: Denial – 1st
- Reaction formation – 2nd
SIGNS & SYMPTOMS: “MANICS”
M – Mood elevation / elevated mood/ euphoria, manipulated, mayabang / grandiosity
A – Ayaw matulog , they have limitless energy
N – Nananakit (violent) , neologism
I – increase activity
C – Cannot concentrate (easily distracted) / Clang Association – rhyming of words
S – Sex addicts & all other pleasurable activity = ID / shifting rapidly from one topic to another topic
( flight of ideas)

NURSING INTERVENTION: “MANIAS”

M – Madaling hawakan / kainin / finger foods
A – Anti Manic Drug – (Es – Te – De)
Lithium - DOC
N – non – competitive & non-contact sport
I – iwas sa concentration na work / activity Ex: Chess
A – Allow rest / sleep
S – Safety / solitary activity – nag iisa lang – holticulture / gardening

Other Mood Disorders:

Disruptive Mood Dysregulation Disorder (DMDD) AKA PEDIATRIC BIPOLAR DISORDER
- 6-18 YEARS OLD
- 19 pataas = BIPOLAR DISORDER
- School age : Male
- Adolescent: Female
- Temper outburst / tantrums
- Severe irritability 3-4x a
- Overreaction to stimuli week in
- Most of the time they feel angry 1 year
- violent
NURSING INTERVENTION “SISA”

S – SUPPORT SYSTEM “family”

I – individual therapy / play therapy
S – Safety
A - anti depressants (SSRI) - lungkot
Lithium – mood elevation – saya
Premenstrual Dysphoric Disorder (PMDD)

- is a more SEVERE form of premenstrual syndrome (PMS)

- EXTREME mood shifts that can disrupt your work and ADL’s
- PMDD usually begin 7-10 days before your period starts and continue for the first few days that
you have your period

Signs and Symptoms:

1. Physiological / Physical
- bloating
- Breast tenderness
- Headache
- Joint or muscle pain
- Fatigue or low energy
- Easily get bruises
- Pimples / acne
2. AFFECTIVE / MOOD
- Extreme & unstable mood swing
- Severe sadness /depression
- Hopelessness
- Suicidal thoughts
3. BEHAVIOR
- Increase Anxiety
- Feeling out of control
- diff. to think/ focus & comm.
- irritability & anger
- difficulty to sleep
- lack of interest in ADL’s / relationship
- verbal / physical aggressive
- food cravings

NURSING INTERVENTION “MENS”

M – MEDS SSRI & pill hormones (danzol & zoldex
E – Encourage verbalization of feelings
N – Nutritional supplements (Vit. B & calcium
S – Support System
THOUGHT DISORDER / PSYCHOSIS
SCHIZOPHRENIA
H – Hallucinations – Perception
- Without things
I – Illusion – Perception
- With things
D - Delusion - Thought (worst)

Aka: dementia Precox (old)

- Split mind (new)
Cause: unknown
Age: 15-25 LA -EA
Sexual Preference: Equally Distributed

Confirmation of Schizophrenia:
2 weeks to <1 month HID : Brief Psychotic D/ O
1 month - <6 mos. HID: Schizopreniform
>6mos HID: Schizophrenia

Nursing Diagnosis:
1. for Hallucination
- Impaired sensory Perception
2. for illusion
- impaired Sensory Perception
3. for Delusion
- Altered thought Process
(+) sign of (-) sign of SChiz
schizophrenia

Hallucination Apathy /
anhedonia

Illusion Blunted & flat

affect

Delusion Communication
Disturbance

Excitement

Suspiciousness

Bizarre Behavior

Agitation

Grandiosity

EUGENE BLEULER 4A’S of Schizophrenia

1. Affect
- blunted
- inappropriate
- flat
- labile
- latent
2. Autism - socially withdrawn
3. Ambivalence – 2 opposite feeling at the same time
4. Associative Looseness – stringing together of unrelated topics
NURSING INTERVENTION:
S - SAFETY
A – ANTI PSYCHOTIC
P – Physiologic Needs (food, rest & sleep, hygiene)
E – Environment (milieu)
T – Trust – consistency, availability, reliability (CAR)
Y – you should orient the client to reality. (ego)