ECT, PHARMA, RAPE, SUICIDE

BIOPHYSICAL/SOMATIC INTERVENTIONS USES

A. ELECTROCONVULSIVE THERAPY
- Safe and effective treatment that may reduce symptoms
related to depression or mental illness
- During ECT, certain parts of the brain are stimulated using
small electric current
- effective treatment for depression
- electrodes are placed on the patient's scalp and a finely
controlled electric current is applied while the patient is under
general anesthesia. The current causes a brief controlled
seizure in the brain
- The usual course is 6-15 treatments scheduled 3x a
week(interval of 48 hours/treatment)
- Generally minimum of 6 treatments (improvement)
- It is believed that shock stimulates brain chemistry to correct
the chemical imbalance of depression.
1. For major depressive and bipolar depressive disorders especially
when psychotic symptoms are present.
2. For manic clients whose conditions are resistant to lithium and
antipsychotic medications
3. For clients with schizophrenia, schizoaffective syndromes and
psychotic clients.
INDICATIONS FOR USE
1. When antidepressant medications have no effect
2. When there is a need for a rapid definitive response such as
when the client is suicidal or homicidal
3. When the client is in extreme agitation or stupor
4. When the risks of other treatments outweigh the risk of ECT
5. When the client has a history of poor medication response, a
history of good ECT response
6. When the client prefers ECT as a treatment.

PRE-ECT EVALUATION PREPROCEDURE

- should include the following components: 1. Prepare patient by explaining procedure and telling patient about
potential temporary memory loss and confusion
o A thorough psychiatric history and examination, including 2. Informed consent, physical exam, lab work
history of response to ECT and other treatments
o A medical history and examination, with special attention to Commonly ordered tests prior to initiation of ECT include
cardiovascular, pulmonary, neurological, and the following:
musculoskeletal systems
o A history of dental problems and examination for loose or o Complete blood count
missing teeth o Serum chemistry
o A history of personal and family experiences with o Renal function
anesthesia o Electrocardiogram
o Urinalysis
TREATMENT FACILITIES o Chest radiograph (especially with cardiovascular or
- There should be a suite of 3 rooms pulmonary disease or history of smoking)
o Electroencephalogram (guided by history and
1. Pre ECT Room examination)
o Spinal radiograph (especially with known or suspected
2. ECT Room spinal disease)
- Which should be equipped with ECT machine and
accessories, an anesthetic appliance, suction 3. NPO after midnight for an early morning procedure or at least 4
apparatus, face masks, oxygen cylinders with hours prior to treatment
adjustable flow valves, curved tongue depressors, 4. Have patient void before ECT
mouth gags, resuscitation apparatus and emergency 5. Remove dentures, glasses, jewelry, fingernail polish, hairpins,
drugs contact lenses
- There should immediate access to a defibrillator 6. Baseline VS are taken
7. Administer preop meds if prescribed:
3. Recovery Room o Glycopyrrolate (Robinul) or Atropine sulfate given IM to
prevent the potential for aspiration and to minimize
• Maintenance ECT once a month may help decrease the relapse bradydysrhytmias in response to electrical stimulation.
rate for client with recurrent depression.
• ECT is not a permanent cure
• It is safe for pregnant women with no harm to fetus

CONTRAINDICATIONS
• Fever
• Cerebral aneurysm
• Cerebral Hemorrhage
• Brain Tumor
• Acute myocardial infarction
• Cardiac arrhythmias
• Congestive heart failure
• Aortic aneurysm
• TB with history of hemorrhage
• Pneumonia
• Recent fracture
• Retinal detachment
• Pregnancy (with complications)
• Aortic or cerebral aneurysms
• Congestive heart failure
• Osteoporosis
• M.I. or CVA(stroke) within the preceding 3-6 months

**Absolute contraindication to ECT – Increase ICP

- physiological rise in CSF that could lead to brain herniation

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ARTICLES REQUIRED TO ADMINISTER ECT
ARTICLES
Electrode paste and gel,
alcohol, saline
Electroencephalogram
Blood pressure apparatus,
stethoscope, pulse oximeter
Reflex hammer
Intravenous and venipuncture
supplies
Mouth gag ,tongue depressor
Stretcher with firm mattress
and side rails
Suction device
Ventilation equipment -
tubing mask, ambu bag, oral
airways, intubation
equipment, oxygen delivery
system
Emergency and other
medications needed by the
anesthesia staff
ROLE OF NURSE IN ECT
NURSING INTERVENTION
Remove metallic articles from
his/her body- example watch
bangle ring
Remove DENTURES
Remove lipstick, make up and
nail polish
Encourage patient to empty his
bladder and bowel
Give pre-medications as
ordered to the patient
transfer the patient to the ECT
Room on a well-padded bed
and placed in a comfortable
dorsal position
ECT TEAM
• Psychiatrist
• Anesthetist
• Trained Nurses
• Nursing aids
• ECT assistant
ECT, PHARMA, RAPE, SUICIDE
PURPOSES
Concentrated saline is a good
conductor of electricity, thereby
it facilitates in producing
convulsion.
To record electrical activity of
brain through surface
electrodes.
To monitor vital signs
To check muscle tone
IV Fluid, to introduce the
anesthetic drug
To prevent biting of tongue or
injury to lips
To prevent injury
To prevent the patient with
aspiration pneumonia
To prevent the patient from
respiratory and cardiac
complications
To handle the emergency
situation during the ECT
procedure.
RATIONALE
To prevent the electrical current
passing on unwanted areas.
Metal is a good conductor of
electricity.
To check for cyanosis. These
colors will mask the change in
the patient.
To reduce embarrassment after
the treatment. If the bladder is
full, he may spoil the bed due to
the relevant effect of the drug
To reduce anxiety
To prepare for the therapy. ECT
treatment is given in a dorsal or
supine position
DURING THE PROCEDURE
1. IV line inserted, EEG and ECG electrodes are attached
2. BP monitoring and pulse oximetry monitoring
3. May give muscle relaxants and short acting anesthesia and
barbiturates to prevent fractures
o Most common anesthetic agents - methohexital and
propofol
o The administration of muscle relaxant (e.g.
succinylcholine (Anectine) given IV prevents severe
muscle contraction during the seizure - preventing
damage to long bones and cervical vertebrae.
4. 100% oxygen by mask via positive pressure is administered
throughout the procedure.
o Because succinylcholine-paralyzes respiratory muscle
5. An airway or bite block is placed to prevent biting of the tongue
6. An electrical stimulus is administered(voltage is 70-150 volts and
is applied in 0.5 – 2 seconds) the seizure should last 30-60
seconds
PLACEMENT OF ELECTRODES
BILATERAL
• Most common, most effective and most cognitive dysfunction
• Each electrode placed 2.5 – 4 cm (1-1.5 inches) on the midpoint
on a line joining the tragus of the ear and the lateral canthus of
the eye
• in which the electrodes are placed on both sides of the head.
• This is designed to affect the entire brain
UNILATERAL
• Less cognitive effect may be clinically less effective
• Electrodes are places only on one side of head usually non-
dominant side
• in which one electrode placed on top of the head and the other
on one temple, usually the right.
• In this case, the current only passes through one side of the
brain.
POST PROCEDURE
1. Client will be transported to a recovery room with BP cuff and
oximeter in place, where oxygen, suction and other emergency
equipment are available.
o Position the client on side to prevent aspiration
2. Once the client is awake talk to the client and take his vital signs.
3. The client may be confused; provide frequent orientation (brief,
distinct, and simple) and reassurance.
o Describe what has occurred
o Allow the client to verbalize fears and anxieties related to
receiving ECT
4. Client returns to the unit when a 90% oxygen saturation is
maintained, VS are stable, and mental status is satisfactory
5. Assess the gag reflex prior to giving the client fluids, food or
medication.
COMMON COMPLICATIONS
• Loss of memory
• Headache
• Apnea
• Fracture
• Respiratory depression
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 ECT, PHARMA, RAPE, SUICIDE
B. PSYCHOPHARMACOLOGY
- is the scientific study of the effects drugs have
on mood, sensation, thinking, and behavior.

GENERAL GUIDELINES REGARDING DRUG ADMINISTRATION IN

PSYCHIATRY
• The nurse should not administer any drug unless there is a
written order. Do not hesitate to consult the doctor when in doubt
any medication.
• All medications given must be charted on the patient‘s case
record sheet.
• In giving medication:
o Always address the patient by name and make certain of
his identification.
o Do not leave the patient until the drug is swallowed.
o Do not permit the patient to go to the bathroom to take
medication.
o Do not allow one patient to carry medicine to another.
• Stabilize dopamine output; preserve or enhance
ANTIPSYCHOTICS dopaminergic transmission when it is too low and reduce it
• Improve the thought process and the behavior of the client with when it is too high.
psychotic symptoms, especially the client with schizophrenia. • Antipsychotic drugs tend to block dopamine D2 receptors
• Blocks dopamine receptors in the basal ganglia of the brain, in the dopaminergic pathways of the brain. This means that
inhibiting transmission thereby reducing the psychotic dopamine released in these pathways has less effect.
symptoms. Excess release of dopamine in the mesolimbic pathway
o Indicated for acute and chronic psychosis. has been linked to psychotic experiences.

• Typical antipsychotics ( Traditional, First Generation) – SIDE EFFECTS OF ANTIPSYCHOTICS

developed between 1950 and 1990 • Dry mouth
o are more effective for positive symptoms of schizophrenia • Constipation
such as • Hypotension
▪ Hallucinations • Urinary retention
▪ Aggression • Increased heart rate
▪ Delusions • Extrapyramidal side effects (EXTRAPYRAMIDAL
SYNDROME)
o also block the chemoreceptor trigger zone and vomiting
center in the brain, producing an antiemetic effect. o Pseudoparkinsonism
- Mask like faces
• Atypical antipsychotics ( Second generation) - Developed - Dysphagia
from 1990 on - Drooling
o are more effective for the negative symptoms of
schizophrenia, such as o Dystonias
o Withdrawal - abnormal muscle tone producing spasms of tongue,
o Apathy face, and neck
o Alogia
o The effect of antipsychotic medications will be potentiated o Akathisia
when given with other medications acting on the CNS. - motor restlessness

CHARACTERISTICS: o Tardive dyskisneia

1. Reduced the risk for EPEs - involuntary movements of the mouth, tongue, trunk,
2. Increased effectiveness in treating negative symptoms extremities
3. Minimal risk of tardive dyskinesia (TD)
4. Reduced risk for elevated prolactin OTHER SIDE EFFECTS
• Drowsiness
GENERIC (TRADE) NAME FORMS ORAL DAILY • Blood dyscrasias – agranulocytosis (↓WBC)
DOSAGE • Pruritus
Conventional Antipsychotics • Photosensitivity
(1ST Generation) • Elevated blood glucose level
Chlorpromazine(Thorazine) T, L, Inj 200 – 1600 mg/day • Increased weight
Thiothixine(Navane) C, L, Inj 16 – 32 mg/day • Impaired body temperature regulation
Haloperidol(Haldol) T, L, Inj 2 – 20 mg/day • Gynecomastia
Atypical Antipsychotics (2nd • Lactation
Generation) • Orthostatic hypotension
Clozapine(Clorazil) T 150 – 500 mg/day
Quetiapine(Seroquel) T 300 – 600 mg/day
Dopamine system stabilizer) T 15 – 30 mg/day
Antipriprazole(Abilify)

*continuation next page

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 ECT, PHARMA, RAPE, SUICIDE
INTERVENTIONS ANTIDEPRESSANT DRUGS
• Monitor vital signs • Used to treat major depression, panic disorder and other anxiety
• Monitor EPS, symptoms of neuroleptic malignant syndrome disorders, bipolar depression, and psychotic depression.
• Monitor urine output • Interact with the monoamine neurotransmitter systems in the
• Monitor serum glucose level brain, particularly the neurotransmitters norepinephrine and
• Administer the medication with food or milk to decrease gastric serotonin.
irritation
• For oral use, the liquid form might be preferred, because some SELECTIVE SEROTONIN REUPTAKE INHIBITOR(SSRI)
clients hide tablets to avoid taking them. • Action-inhibits CNS neuronal uptake of serotonin; acts as
• Avoid skin contact with the liquid concentrate to prevent contact stimulant counteracting depression and increasing motivation.
dermatitis • Indications:
• Protect the liquid concentrate from light o Depression
• Dilute the liquid concentrate with fruit juice o Obesity
• Inform the client that a full therapeutic effect of the medication o Bulimia
may not be evident for 3-6 weeks following initiation of therapy; o Obsessive compulsive disorders
however an observable therapeutic response may be apparent
after 7-10 days. ▪ Prozac
• Inform that client that some medications may cause harmless ▪ Paxil
change in urine color to pinkish brown. ▪ Luvox
▪ Zoloft
• Instruct the client to avoid alcohol or other CNS depressants
SIDE EFFECTS
INSTRUCT THE CLIENT TO
• Nausea and vomiting, cramping, diarrhea
• use sunscreen, hats, and protective clothing when outdoors.
• Dry mouth
• change positions slowly to avoid orthostatic hypotension
• Photosensitivity
• report signs of agranulocytosis, including sore throat, fever, and
malaise. • Insomnia, somnolence
• report signs of liver dysfunction, including jaundice, malaise, • Nervousness
fever, right upper abdominal pain • Headache, dizziness
• reduce gradually the dosage of the medication(when • Seizure activity
discontinuing) to avoid sudden recurrence of psychotic • Weight loss or gain
symptoms • Decrease libido
• Apathy
DRUGS USED TO TREAT EPS • Increase tremors
• Symmetrel • Increased sweating
• Akineton • CNS stimulation- including akathisia
• Valium
• Inderal NURSING CONSIDERSTIONS
• Ativan 1. Monitor VS-can potentially lower or increase BP
• Benadryl 2. Monitor weight
• Artane 3. Safety precautions-dizziness
4. Avoid alcohol
• Cogentin
5. Take in the AM to avoid insomnia
• Kemadrin
6. Given with a snack or meal to reduce risk of dizziness and
lightheadedness
7. Monitor the suicidal client, especially during improved mood and
increased energy levels.
8. Long term therapy-monitor liver and renal function.
9. Monitor WBC and neutrophil counts - discontinue if levels falls
normal
10. If priapism (painful, prolonged penile erection) occurs, withheld
medication and notify the physician

o The condition develops when blood in the penis becomes

trapped and is unable to drain. If the condition is not
treated immediately, it can lead to scarring and permanent
erectile dysfunction

11. Inform client about the possibility of decrease libido.

12. Instruct the client to

o change positions slowly to avoid a hypotensive effect.

o report any visual changes to physician

13. 13.Educate client- potential for discontinuation syndrome if

medication is stopped abruptly rather than tapered- GI
distress, movement problems, sleep disturbances.
14. 14.Be aware of the potential for serotonin syndrome
characterized by elevated temperature, elevated CPK, muscle
rigidity: this risk is greatly increased when SSRIs are given with
MAOIs. Thus, this medication combination is avoided.

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 ECT, PHARMA, RAPE, SUICIDE
TRICYCLIC ANTIDEPPRESSANTS(TCAs) MONOAMINO OXIDASE INHIBITORS(MAOIs)
• Actions:Inhibits presynaptic reuptake of neurotransmitters • Interferes with monoamine oxidase, allowing for increased
norepinephrine and serotonin; anticholinergic action at CNS and concentration of neurotransmitters in synaptic space, causing
peripheral receptors. stabilization of mood.
• Indications: Depression, obstructive sleep apnea
INDICATION
• May reduce seizure threshold
• Depression
• May reduce the effects of hypertensive agents
• Concurrent use with: ▪ Parnate
o MAOIs = causes hypertensive crisis ▪ Marplan
o alcohol or antihistamines = causes CNS depression ▪ Nardil

• Overdose is life threatening, necessitating immediate treatment SIDE EFFECTS

• Dry mouth
▪ Surmontil • Peripheral edema
▪ Pamelor • Anticholinergic effect
▪ Amitriptyline (Elavil) • Weight gain
▪ Norpramin • Gastrointestinal upset
▪ Tofranil • Delay in ejaculation
• Orthostatic hypotension
SIDE EFFECTS • Hypertensive crisis
• Cardiovascular disturbances- tachycardia, dysrhythmia • Hypertension
• Anticholinergic effects • Dizziness
• Photosensitivity • Restlessness
• Orthostatic hypotension • Daytime sedation
• Insomnia
• Sedation
• Weakness,lethargy
• Decreased or increased libido with ejaculatory and erection
• GI upset
disturbances.
• Anxiety, restlessness, irritability HYPERTENSIVE CRISIS
• Weight gain • severe hypertension
• hyperpyrexia
INTERVENTIONS • tachycardia
1. Instruct the client that the medication may take several weeks to • diaphoresis
produce the desired effect(client response may not occur until 2- • tremulousness
4 weeks after the first dose). • cardiac dysrhythmias
2. Monitor the suicidal client, especially during improved mood and • diplopia
increased energy levels • nausea
3. Monitor the patterns of daily bowel movement • dilated pupils, palpitations, constricting chest pain and altered mental
4. Assess for urinary retention status.
5. Long therapy- monitor renal and liver function test results
6. Administer with food or milk, if GI distress occurs o TYRAMINE REACTION
7. Administer the entire daily oral dose at one time, preferably - when taken with food containing tyramine or takes
bedtime. sympathomimetic drugs.
8. Instruct the client to avoid alcohol and nonprescription - The enzyme MAO is important to breakdown the tyramine
medication to prevent adverse medication interactions. in certain foods, its inhibition results in increase tyramine
9. Instruct the client to avoid driving and other activities serum levels- causing severe hypertension
requiring alertness until the response is known; sedation is
WHEN TAKEN WITH FOOD CONTAINING TYRAMINE:
expected in early therapy and may subside with time.
1. Mature/aged cheeses- lasagna, pizza. All cheese is considered aged
10. Do not abruptly stop taking the medication, it should be except cottage cheese, cream cheese, ricotta cheese and processed
tapered gradually. cheese slices.
11. Potential for medication interactions with OTC cold medication 2. Aged meats such as pepperoni, salami, mortadella, summer
exists. sausage, beef logs, meat extracts, and similar products.
12. Caution the client about photosensitivity and to take measures to 3. Italian broad beans(fava), bean curd(tofu), banana, avocado, over
prevent exposure to sunlight-wear sunscreen. ripe fruit
13. Encourage oral hygiene and the use of hard candies and mouth 4. All tap beers and microbrewery beer. Drink no more than 2 cans or
rinses to relieve dry mouth. bottles of beer( including non-alcoholic beer) or 4 ounces of wine /day
14. Encourage psychotherapy 5. Sauerkraut, soy sauce or soybean condiments, or
marmite(concentrated yeast)
6. Chocolate
7. Yogurt, sour cream, peanuts, Brewer's yeast, MSG
8. fruits such as raisins, avocados, bananas or figs (Tagalog
Name: Igos)

DRUGS
• when used with SSRIs,certain cyclic compounds,
buspirone(Buspar),dextromethorphan, and opiate derivatives
such as meperidine.
• Antidote:5-10mg phentolamine mesylate(regitine)

• In a hypertensive emergency, the first goal is to bring down the blood

pressure as quickly as possible with intravenous (IV) blood pressure
medications to prevent further organ damage.
• Phentolamine Mesylate (phentolamine mesylate) is used as
an antidote for a hypertensive crisis.

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 ECT, PHARMA, RAPE, SUICIDE
INTERVENTIONS
1. Monitor BP frequently for hypertension.
2. Monitor for S/S of hypertensive crisis
3. If palpitations or frequent headache occurs withhold the
medication and notify the physician.
4. Administer with food if gastrointestinal distress occurs.
5. Instruct the client that the medication effect may be noted during
the first week of therapy, but maximum benefit may take up to 3
weeks.
6. Instruct the client to change positions slowly to prevent
orthostatic hypotension
7. Monitor for client compliance with medication administration
8. Instruct the client to carry a Medic Alert card indicating that a
MAOI medication is taken
9. Avoid administering the medication in the evening because
insomnia may result
10. When the medication is discontinued by the physician, it should
be discontinued gradually.
INTERVENTIONS
1. Monitor the suicidal client, especially during improved mood and
increased energy levels.
2. Administer with food to minimize GIT irritation
3. Instruct the client to maintain a fluid intake of 6-8 glasses of
water/day
4. Instruct the client to avoid excessive amounts of coffee, tea or
cola which have a diuretic effect
5. Instruct the client to maintain an adequate salt intake.
6. Do not administer diuretics while the client is taking lithium
INSTRUCT THE CLIENT
7. To avoid alcohol
8. That he may take a missed dose within the 2 hours of the
scheduled time; otherwise he should skip the missed dose and
take the next dose at the scheduled time
9. Not to discontinue taking the medication abruptly
10. That the therapeutic response will be noted in 1-3 weeks

MOOD STABILIZERS LITHIUM TOXICITY LEVELS

• Affect cellular transport mechanism and enhanced serotonin and
/or gamma-aminobutyric acid(GABA) function which are • Mild toxicity (serum lithium level is 1.5 mEq/L)
associated with food. o Apathy
o Lethargy
o Lithium o Diminished concentration
- is the most established mood stabilizer and is available o Mild ataxia
in tablets, capsules, liquid. No parenteral forms are o Coarse hand tremors
available. o Slight muscle weakness
- daily dosages(900-3,600mg)
- Therapeutic drug serum level of Lithium –( 0.6mEq/L- • Moderate toxicity (serum lithium level is 1.5 to 2.5 mEq/L)
1.2 mEq/L) o Nausea and vomiting
o Diarrhea (severe)
Serum Lithium levels should be monitored: o Slurred speech
a. Every 2-3/days while the therapeutic dose is determined o Mild to moderate ataxia and incoordination
b. Weekly o Tinnitus
c. Once a month- stable condition o Blurred vision
o Muscle twitching
SIDE EFFECTS: o Irregular tremor
• Mild nausea or diarrhea
• Anorexia ** If a patient developed diarrhea and vomiting, THE FIRST THING
• Fine hand tremor TO DO is HOLD the next dose and obtain an order for a stat serum
• Polydipsia lithium level
• Polyuria
• Metallic taste in the mouth • Severe toxicity (serum lithium level is greater than 2.5
• Fatigue or lethargy mEq/L)

EXAMPLES o Nystagmus
o Muscle fasciculations
Lithium preparations: o Deep tendon hyperreflxia
1. Lithium carbonate(Eskalith,Lithoboid) o Visual or actile hallucinations
2. Lithium citrate o Oliguria or anuria
o impaired level of consciousnes
Other mood stabilizers: o Tonic –clonic seizures ot coma, leading to death
1. Carbamazepine(Tegretol) o withhold lithium and notify the physician
2. Aripiprazole(Abilify) o monitor vital signs and level of consciousness
3. Valproic acid(Depakote) o monitor cardiac status
o prepare to obtain samples
Lithium modulates neurotransmitters • Lithium
- It inhibits excitatory neurotransmitters such as dopamine and • Electrolyte
glutamate, and promotes GABA-mediated neurotransmission. • BUN
• Creatinine level
Lithium inhibits dopamine neurotransmission • CBC
- During mania dopamine neurotransmission is increased. This o Monitor for suicidal tendencies
elevated state would cause down regulation of dopamine
receptors. A consequence of down regulation would be
decreased dopaminergic neurotransmission associated with
clinical depression.

Lithium promotes GABAergic neurotransmission

- The Neurotransmitter That Dissolves Anxiety and Improves
Sleep.
- GABA is the brain's main inhibitory neurotransmitter. It keeps the
brain from becoming overactive and promotes calm relaxation.

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 ECT, PHARMA, RAPE, SUICIDE
ANTIANXIETY /ANXIOLYTIC MEDICATIONS STIMULANTS
• Depress the CNS, thereby increasing the effects of GABA,which • Increases agitation and activities in adults, have a calming effect
produces relaxation and may depress the limbic system. on children with ADHD and increases alertness and sensitivity to
• Benzodiazepines have anxiety-reducing, sedative-hypnotic, stimuli.
muscle relaxing and anticonvulsant action. • Uses: To treat ADHD, residual attention deficit disorder in adults
• Benzodiazepines are contraindicated in clients with acute and narcolepsy.
narrow-angle glaucoma and should be used cautiously in
children and older clients. o Narcolepsy is a chronic sleep disorder characterized by
• Abrupt withdrawal of benzodiazepine can be potentially life overwhelming daytime drowsiness and sudden attacks of
threatening and withdrawal should be done under medical sleep
supervision
▪ Methypenidate(Ritalin)
▪ alprazolam (Xanax) panic, generalized anxiety, phobias, ▪ Amphetamine(Addrenal)
social anxiety, OCD. ▪ Dextroamphetamine(Dexedrine)
▪ clonazepam (Klonopin) panic, generalized anxiety,
phobias, social anxiety.
▪ diazepam (Valium) generalized anxiety, panic, phobias.
▪ lorazepam (Ativan) generalized anxiety, panic, phobias.
▪ oxazepam (Serax) generalized anxiety, phobias.

SIDE EFFECTS
• daytime sedation
• dizziness
• drowsiness
• poor coordination
• hypotension
• Constipation
• Urinary incontinence
• Impaired memory

INTERVENTIONS
INTERVENTIONS
Instruct the client: 1. Monitor for CNS side effects
1. To avoid alcohol 2. Obtain a baseline ECG
2. To monitor for responses such as agitation, trembling, and 3. Monitor the BP
tension 4. Instruct the child and parents that the last dose of the day should
3. To monitor visual disturbances because the medication can be taken at least 6 hours before bedtime to prevent insomnia
worsen glaucoma 5. Monitor height and weight(particularly in children)
4. Not to discontinue the medication abruptly. 6. Instruct the client and parents that a drug free period(drug
5. To avoid tasks that require alertness until the response to holidays) may be prescribed to allow growth of the child if the
medication is established medication has caused growth retardation
BARBITURATES AND SEDATIVE-HYPNOTICS
• Depress the reticular activating system by promoting the
inhibitory synaptic action of the neurotransmitter GABA
• Used for short term treatment of insomnia or for sedation to
relieve anxiety, tension, and apprehension

Barbiturates
▪ Amobarbital (Amytal)
▪ Secobarbital(Seconal)
▪ Butabarbital(Butisol)
▪ Pentobarbital(Nembutal

Sedative-hypnotics
▪ Chloral hydrate(Aquachloral)
▪ Meprobamate(Miltown)
▪ Eszopiclone(Lunesta)
▪ Paraldehyde(Paral)

INTERVENTIONS

Instruct the client:

1. To avoid alcohol
2. To avoid driving or operating hazardous equipment if drowsiness
or dizziness occurs.
3. For insomnia-Take medication 30 minutes before bedtime Avoid
taking with a heavy meal to help absorption
4. Not to discontinue the medication abruptly.
5. When taking chloral hydrate, take the medication with food and a
full glass of water ,fruit juice or ginger ale to prevent gastric
irritation

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 ECT, PHARMA, RAPE, SUICIDE
STRESS 3. CHRONIC STRESS
• is the wear and tear that life causes on the body. It • most harmful type of stress
• occurs when the person has difficulty dealing with life situations, • develops over a long period of time.
problems, and goals. Each person handles stress differently. • are likely lead to final breakdown
• It helps us to stay focused, energetic, and alert
CAUSES
3 STAGES OF REACTION TO STRESS • Trauma
• Personal (ongoing poverty)
1. Alarm reaction stage • Family (a dysfunctional family, or an unhappy marriage
- stress stimulates the body to send messages from the • Work issues.
hypothalamus to the glands and organs to prepare for • Ignoring signs of acute and episodic acute stress.
potential needs.
SYMPTOMS
2. Resistance stage • Violence
- the digestive system reduces function to shunt blood to • heart attack
areas needed for defense.
• stroke
• suicide
3. Exhaustion stage
- occurs when the person has responded negatively to anxiety • cancer
and stress: body stores are depleted or the emotional
components are not resolve, resulting in continual arousal of
the physiologic response. STRESS CAN BE CAUSED BY A VARIETY OF DIFFERENT
COMMON LIFE EVENTS,

PERSONAL • illness or injury

• pregnancy and becoming a
parent
• bereavement
• long-term health problems
• organizing a complicated
event, like a group holiday
• everyday tasks such as
travel or household chores

FRIENDS AND FAMILY • getting married or civil

partnered
TYPES OF STRESS • going through a break-up or
getting divorced
1. ACUTE STRESS • difficult relationships with
• is short-term and is the most common parents, siblings, friends or
• acceptable in small amounts children
• being a carer for a friend or
CAUSES relative who needs lots of
a. Presssure support.
b. Demands
EMPLOYMENT AND STUDY • losing a job
SYMPTOMS
• long-term unemployment
• Anxiety
• retiring
• Headaches
• exams and deadlines
• heartburn,
• difficult issues at work
• rapid heartbeat
• starting a new job.
For example - recent argument that has caused upset
HOUSING • housing problems such as
the stress will be reduced or removed
poor living conditions, lack of
once these are resolved.
security or homelessness
2. EPISODIC ACUTE STRESS • moving house
• people who are always in hurry • problems with neighbors.
• short tempered and can be considered hostile MONEY • worries about money or
• person with too many commitments and poor organization benefits
• can also lead to high blood pressure and heart disease • poverty
• debt.
CAUSES
a. People who already suffer from ongoing acute stress
b. people with pessimistic personalities

SYMPTOMS
• tension headache
• hypertension
• chest pain

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SIGNS AND SYMPTOMS OF STRESS OVERLOAD WAYS TO CREATE A STRESS FREE WORK ENVIRONMENT
• Reduce personal stress
• COGNITIVE SYMPTOMS • Live in the present
o Memory problems • Be yourself
o Inability to concentrate • Assign tasks evenly
o Poor judgment • Create realistic goals
o Seeing only the negative • Plan ahead – Proper time management
o Anxious or racing thoughts o Get an organizer and use it
o Constant worrying o Schedule everything
o Include classes, study time, projects, tests, work and play
• EMOTIONAL SYMPTOMS
o Depression or general unhappiness • Don’t procrastinate - to keep delaying something that must be
o Anxiety and agitation done, often because it is unpleasant or boring
o Moodiness, irritability, or anger • Create an open dialogue
o Feeling overwhelmed • Communicate with coworkers
o Loneliness and isolation
• Walk around
o Other mental or emotional health problems
• Stress balls
• Work as a team
• PHYSICAL SYMPTOMS
o Aches and pains • Share responsibilities
o Diarrhea or constipation • Take a break
o Nausea, dizziness
o Chest pain, rapid heart rate REWARD YOUR SELF
o Loss of sex drive • Reward things I need to get done with things I love
o Frequent colds or flu • Example: 10 minutes of TV, phone, etc. after 50 minutes of
studying
• BEHAVIORAL SYMPTOMS • Example: after two hours of studying 30 minutes of exercise
o Eating more or less
o Sleeping too much or too little FIND REASON TO LOVE YOUR LIFE
o Withdrawing from others
o Procrastinating or neglecting responsibilities TREATMENT
o Using alcohol, cigarettes, or drugs to relax • Self-help – connect with others
o Nervous habits (e.g. nail biting, pacing) • Medications
o Therapies that may help to induce relaxation include
WAYS TO DEAL WITH STRESS aromatherapy or reflexology.

1. Set aside time each day to relax CRISIS INTERVENTION

• Read a book, comic book
• Meditate CRISIS
• Deep breathing • is a temporary state of severe emotional disorganization caused
by failure of coping mechanisms and lack of support.
2. Find something pleasant
• Sew o The ability for decision making and problem solving is
• Paint inadequate.
• Play basketball o Treatment is aimed at assisting the client and the family
trough the stressful situation.
3. Positive reinforcement
CHARACTERISTICS
• Creating positive thoughts
• Temporary state of disequilibrium precipitated by the event
4. Rest • Highly individualize
• Try to get the recommended amount of sleep each night • Self limiting usually 4-6 weeks
• Put your head down • Person becomes passive and submissive.
• Affects a person support system.
5. Exercise • Crisis can promote growth and new behaviors
• Stretch
• Yoga 4 STAGES OF CRISIS
• Pilates 1. Exposure to stressor
2. Increased anxiety when customary coping is ineffective
• Run
3. Increased efforts to cope;
4. Disequilibrium and significant distress
6. Ask for help
• Sharing responsibilities
• Delegating tasks
• Saying NO to doing more tasks than you can handle
• Brainstorming ideas
• Seek professional help if stress symptoms continue or get
worse.

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TYPES: CRISIS INTERVENTION
- is a method of providing assistance to those affected by a crisis
1. MATURATIONAL/DEVELOPMENTAL CRISIS in which the immediate problem is resolved and psychological
- relates to developmental stages and associated role equilibrium is restored.
changes, predictable/expected events in the normal course
of life POTENTIAL NURSING DIAGNOSIS
a. Individual coping, ineffective
o leaving home for the first time b. Powerlessness
o getting married c. Grieving, dysfunctional
o having a baby
o beginning a career PLAN/IMPLEMENTATION
o retirement 1. Goal-directed, focus on the here and now
2. Focus on the client’s immediate problems
2. SITUATIONAL/ACCIDENTAL CRISIS 3. Explore nurse’s and client’s understanding of the problem
- unanticipated or sudden events that threatens the individual
integrity. a. Define the event(client may truly not know what has
precipitated the crisis)
o Death of a love one b. Confirm nurse’s perception by reviewing with client
o Loss/change of a job c. Identify the factors that are affecting problem solving
o Physical or emotional illness in the individual or family d. Evaluate how realistically client sees the problems or
member concerns
o Change in financial status
o Divorce 4. Help client become aware of feelings and validate them
o Abortion
a. Acknowledge feelings. Ex. “This must be a painful situation
3. ADVENTITIOUS CRISIS for you”
- disaster /event that is not part of everyday life and is b. Avoid blaming client for problems and concerns
unplanned and accidental. c. Encourage ventilation with nurse to relieve anxiety
- It may result from a natural disaster or catastrophic event. d. Tell client he will feel better, but it may take 1 or 2 months

o flood 5. Develop a plan

o earthquake
o hurricanes a. Encourage the client to make as many arrangements as
o war possible(avoid dependence)
o terrorist b. Write out information, since comprehension is impaired,
o attacks e.g. Referrals
o riot c. Maximize client’s situational support
o fire
o violent crimes (rape, murder, assault, spouse and child 6. Find new coping skills and manage feelings
abuse, kidnapping)
a. Focus on strengths and present coping skills
PSYCHOLOGICAL FIRST AID (PFA) b. Encourage client to form new social outlets,reaching out to
- is comforting someone who in distress and helping them feel others
safe and calm. c. Facilitate future planning

• Assessing needs and concerns. o Ask client “What would you like do?” “Where would
• Protecting people from further harm. you like to go from here?”
• Providing emotional support. o Give referrals when needed, family counselling,
• Helping to provide immediate basic needs, such as food and vocational counselling
water, a blanket or a temporary place to stay.

PHASES OF CRISIS

1. Denial
- external precipitating event, initial reaction,

2. Increased Tension
- the person recognizes the presence of a crisis and continues
to do activities of daily living. Increased feelings of anxiety.

3. Disorganization
- the person is preoccupied with crisis and is unable to do
activities of daily living (ADL).Emergence of physical
symptoms, relationship problems.

4. Attempts to reorganize
- the individual mobilizes previous coping mechanisms.

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LOSS, GRIEF, DYING AND DEATH GRIEF
• refers to subjective emotions and affect that are normal response
LOSS to the experience of loss.
- occurs when a valued person, object or situation is changed or • It occurs with loss caused by separation as well as loss caused
made inaccessible so that its value is diminished or removed. by death.
• Ex: divorce loss of job, house, pet.
TYPES OF LOSSES: • It is a process that varies from person to person.
• Actual
- a type of loss that can be recognized by others as well as by STAGES OF GRIEF
the person sustaining the loss.
- Examples: Loss of a limb, of a spouse, of a valued object 1. Shock and disbelief
such as money, loss of a job. - refusal to accept the loss, followed by a stunned or numb
- A woman who has a mastectomy response. Difficulties with decision making, emotional
outbursts, denial and isolation.
• Perceived
- is felt by the person but is intangible to others. 2. Experiencing the loss
- Examples: Loss of youth, financial independence, a valued - survivor may feel angry at the love one who died or may feel
environment, Loss of confidence guilt about the death.

• Physical and Psychological • Bargaining or depression or both may occur in this

- directly related to actual and perceived losses are these 2 stage
losses.
- Examples: A person who loses an arm in car accident 3. Reintegration
suffers from both of these losses because of the loss of the - survivor begins to reorganize his or her life and accepts the
arm & the loss that may be caused by an altered self-image reality of the loss.
& the inability to return to his or her job.
- These losses are simultaneous. GRIEF PROCESS

• Anticipatory
- A type of loss in which a person displays loss and grief
behaviors for a loss that has yet to take place.
- Examples: Often seen in families of patients with serious
and life-threatening illnesses, and serves to lessen the
impact of the actual loss of a family member.
• Maturational
- This type of loss is experienced as a result of natural
developmental processes.
- Examples:
- The first child may experience a loss of status when her
sibling is born.
- Also, happens when sending children off to kindergarten or
college.
- Loss of childhood dreams, the loss felt in adolescents when
a romance fails, loss felt when leaving family home for
college or marriage and establishing a home of one’s own
- As an individual ages, they experience menopause and loss
of hair, teeth, hearing, sight, and “youth.”
- Apply maturational loss to different stages in a person’s life.
• Situational
- A type of loss experienced as a result of an unpredictable
event, including traumatic injury, disease, death, or national
disaster.
- Sudden death of a loved one, or the unemployed person
who suffers low self-esteem
• 4-8 Weeks - acute grief, the first phase, generally is resolve
• 3-6 months - active symptoms of grief (depressed mood,
changes in sleep or appetite),presence of anxiety, social
isolation, and preoccupation with the loss
• 1-2 years - the complete mourning
Dysfunctional grieving
- is a delayed, exaggerated, prolonged or inappropriate response
to loss
- Wife - “My husband was my everything, I can’t go on without
him”
- NURSE may respond: “His death is a big loss to you”
MOURNING (PAGLULUKSA)
- Is the outward and social expression of loss.Conventional
manifestation of sorrow experienced by one, especially related to
death
- May be dictated by cultural and religious beliefs
BEREAVEMENT (PANGUNGULILA)
- is the period of grief and mourning after a death.
- part of the normal process of reacting to a loss.
- may experience grief as a mental, physical, social or emotional
reaction. Mental reactions can include anger, guilt, anxiety,
sadness and despair.
INTERVENTIONS
• Focus on the here and now
• Provide support to family when loved one dies
• Provide family privacy
• Encourage verbalization of feelings
• Facilitate expressions of anger & rage
• Emphasize strengths
• Increase ability to cope

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STAGES OF GRIEF and DYING (Elizabeth Kubler-Ross) ASSESSMENT

a. Denial Stages of crisis

- shock & disbelief regarding the loss a. Acute reaction lasts 3-4 weeks
b. Reorganization is long term
b. Anger
- may be expressed toward God, relatives, friends, or health Common responses to rape
care providers a. Self blame, embarrassment
b. Phobias, fear of violence, death, injury
c. Bargaining c. Anxiety, insomnia
- occurs when the person ask God or fate for more time to d. Wish to escape, move, relocate
delay the individual loss e. Psychosomatic disturbances

d. Depression 1. Female client:

- results when awareness of the loss becomes acute
a. Obtain the date of the last menstrual period.
e. Acceptance b. Determine the form of the birth control used and the last
- occurs when the person shows evidence of coming to terms act of intercourse before rape.
with death. Communication and intervention during this c. Determine the duration of the intercourse, orifices violated
stage are mainly nonverbal, as when the client gestures to and whether penile penetration occurred.
hold the nurse’s hand. d. Determine whether condom was used by the perpetrator

DEATH AND DYING 2. Shame,embarrassment and humiliation

• Avoidance behavior 3. Anger and revenge
• Inability to express feelings when in denial 4. Afraid to tell others because of fear of not being believe
• Feelings of guilt
• Withdrawal MALES
• Lonely, frightened • may be sexually abused as children - phedophiles
• may occur between gay partners or strangers (most prevalent in
INTERVENTIONS institutions such as prison)
• Support staff having feelings of loss • May have more difficulty of disclosure
• Keep communication open
• Allow expression of feelings
• Focus on the here and now Rape trauma syndrome (RTS) is the psychological
• Let patient know he/she is not alone trauma experienced by a rape victim that includes disruptions to
normal physical, emotional, cognitive, and interpersonal behavior.
• Provide comforting environment
• Be attentive to need for privacy
• Sleep disturbance
• Provide physically comforting care e.g. Back rubs
• Loss of appetite
• Give sense of control and dignity
• Fears, anxiety, phobias, suspicion
• Respect patient wishes
• Decrease in activities and motivation
HOSPICE CARE • Disruptions in relationships with partner,family,friends
- is holistic care for patients dying or debilitated and not expected • Self-blame, guilt, shame
to improve. • Lowered self esteem, feelings of worthlessness
- focuses on holistic care of patients actively dying or not expected • Somatic complaints
to improve. It helps patients face death with dignity and comfort.
- Euthanasia refers to the deliberate ending of a life.. INTERVENTIONS
1. Perform the assessment in a quiet, private area.
RAPE TRAUMA 2. Stay with the victim
3. Assess the victim’s stress level before performing treatments and
RAPE procedures.
- is a type of sexual assault usually involving sexual intercourse or 4. Victim should not shower,bathe,douche(female) or change
other forms of sexual penetration carried out against a person clothing until an examination is performed.
without that person's consent. 5. Obtain written consent for the examination, photographs,
laboratory tests, release of information, and laboratory samples.
DATE RAPE (Acquaintance rape) 6. Asssist with female pelvic examination and obtain specimens to
• in most cases the victim is female and knows the perpetrator detect semen (the pelvic examination may trigger a flashback of
• the rape takes place in the context of an actual or potential the attack), a shower and fresh clothing should be made
romantic or sexual relationship between the parties available to the client after examination.
7. Preserve any evidence. (clothing, hair samples)
The perpetrator 8. Treat physical injuries and provide client safety.
- may use physical or psychological intimidation to force a victim to 9. Document all events in the care of the victim.
have sex against their will 10. Reinforce to the victim that surviving the assault is most
- has sex with a victim who is incapable of giving consent, for important; if the victim survived the rape, he or she did exactly
example, because they have been incapacitated by alcohol or what is necessary to stay alive.
other drugs 11. Prophylactic treatment for sexually transmitted disease is
offered. HIV testing is strongly encouraged. Victims are
encouraged to engaged in safe sex practices until the results of
HIV testing are available.
12. Refer the victim to crisis intervention and support groups.

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SUICIDE ANALYSIS
• Understanding self destructive behavior
• It is the intentional act of killing oneself.
a. Attempts to cope fail, leaving the client with low self esteem and feelings
• Suicidal ideation - thinking about killing oneself of hopelessness and helplessness
b. Client feels guilty and overwhelmed in response to precipitating event,
a. Active suicidal ideation and may see suicide as a relief
c. Ambivalence about suicide may lead to cry for help or attention.
• when a person thinks about and seek ways to commit d. Aggression and rage turned toward self (introjection) or into an attempt
suicide.(more lethal than passive) to punish others
e. Most common as depression is lifting
b. Passive suicidal ideation o 10-14 days after antidepressant medication begun
o New signs of energy improvement
• when a person thinks of wanting to die or wishes he/she
were dead but has no plans to cause his/her death. POTENTIAL NURSING DIAGNOSIS

DSM-5, THERE ARE FIVE PROPOSED CRITERION SUICIDAL Violence: self directed, risk for
BEHAVIOR DISORDER, WITH TWO SPECIFIERS
Plan/Implementation:
1. Implement measures for depression
2. Be alert for signs of destructive behavior (suicide/homicide assessment)
3. Remove all potentially dangerous items
4. Provide for a strong therapeutic relationship to increase client self-worth

a. Establish authoritative and credible matter of fact manner to increase

confidence
b. Place on one to one observation and stay with client to help control
self-destructive impulses
c. Let the client know that the nurse will assist in seeking every possible
resource to ease troubles
d. Relieve client’s feeling of embarrassment, e.g. “ I see you are upset.
You are wise to seek help.”

5. Discuss all behaviour with team members

a. Note indirect clues as cry for help, e.g. presence of pills

b. Observe for sudden increased energy level as indication of possible
impending suicide attempt
c. Note increase in anxiety, insomnia
ASSESSMENT
6. Give client a sense of control other than through suicide
1. Symptoms same as in depression
2. Behavioral clues of impending suicide: a. Assist with problem solving and decision making
b. Develop and use a suicidal contract
c. Avoid excess support, as this encourage dependency and eventual
• Any sudden change in the patient’s behavior feelings of abandonment
• Becomes energetic after period of depression
• Improved mood for 10-14 days after taking 7. Provide family therapy where indicated
antidepressant may mean suicidal plans made a. Avoid taking client’s side as family is not direct cause of suicidal urge.
• Finalizes business or personal affairs b. Look for scapegoating or acting out of family destructiveness.
• Gives away valuable possessions or pets
8. Intervene quickly and calmly during actual attempts
• Withdraws from social activities and plans
• Appears emotionally upset a. Remove the harmful objects from the client(razor, ropes) without
• Presence of weapons, razors, pills inflicting harm to self and /or client.
• Has death plan b. Stay by the client’s side and reassure the client that you are there to
help
• Leaves a note c. Avoid judgemental remarks or interpretations. “Why did you do this?”
• Makes direct or indirect statements (e.g. “ I may not be
around then.”) 9. Contract patient

a. “No suicide,” “No harm,” or “No self-injury” contracts are made

between psychiatric health care professionals and patients who are
admitted to a psychiatric unit with depression and/or suicide ideation
or self injurious acting out
b. Patients agree to contact nurse if they have an impulse to be self
destructive
c. Patient is asked to abide by the signed contract
d. Patient is periodically reminded of the contract
e. Limit setting lets patient know that self destructive acts are not
permitted
f. Staff members will do anything within power to prevent patient self
destruction

EVALUATION
• Has self- inflicted injury been avoided?
• Have self-destructive tendencies decreased?

PREDISPOSING FACTORS
a. Male over 50 years old
b. Age range 15-19 years old
c. Client with poor social attachments; isolation
d. Clients with previous attempts
e. Clients with personality disorders
f. Psychotic individuals with command hallucinations to kill
themselves
g. Overwhelming precipitating events
1. Terminal or degenerative disease(cancer, CKD)
2. Death or loss of a loved one through divorce or separation
3. Financial loss, job loss, school failure

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