● Recent Stressors/Losses

NCM 117 ● Psychosocial/Psychiatric History

ー Coping skills and relationship
Psychiatric Laboratory ● Education
● Legal
Self Awareness ● Marital History
● Social History
● The process by which the nurse gains recognition of his or ● Support System
her own feelings, beliefs, and attitudes ● Insight
● Does not mean having to change one’s values or beliefs, ● Value-belief System
unless one desires to do so ー Spiritual values
● Personality – an internal contributing factor to the ● Special needs
development of self-awareness ● Discharge Goals
ー Extrovert ● Client Participation
○ Outgoing ● Elements of Psychiatric History
○ Likes to take charge of situations ● Mental Status Examination
○ Little difficulty socializing
ー Introvert Why is Assessment Crucial?
○ Quiet
○ Prefers to be a follower
○ Usually lets others initiate and direct interactions
● Open-minded – do not make decisions until they are aware
of all the facts pertaining to a certain situation
● Judgemental – inflexible and run the risk of neglecting the
perception of others Assessment Rating Scale that can be Applied to Patients Done by
● Emotionally stable – able to interact with others without Psychiatrists
displaying undue anger, fear, frustration, or other
inappropriate behavior ● Hamilton Anxiety Scale
ー Anxiety
● Beck Inventory/ Geriatric Depression Scale (GDS)/ Hamilton
Depression Scale
ー Depression
● Mania Rating Scale
ー Mania
● Brief Psychiatric Scale/Overall Psyche Scale

Nursing Process Applied to ●

ー Schizophrenia
Abnormal Involuntary Movement Scale/ Mini-Mental

Psychiatric Nursing Practice and ●

ー EPS effects
Alzheimer’s Disease Rating Scale

the Standards of Care ●

ー Cognitive Disorder
Eating Dso. Inventory/Body Attitude Test
ー Eating Disorder
Assessment ● Brief Drug Abuse Screen Test (B-DAST)
ー Substance Abuse
Principles & Techniques of Psychiatric Nursing Interview
● Global Assessment of Functioning
ー Level of Overall Function
● Establishing Boundaries
HOW?
ー Greet = ) Nursing Diagnosis
ー State the name of the patient
ー State your name ● Actual
ー Your background info ー Post trauma syndrome r/t overwhelming anxiety sec. To
ー Your ROLE rape or assault/ illness/ war or disaster as evidenced by
ー Patient’s ROLE reexperience (flashbacks), repetitive nightmares, intrusive
ー Schedule of interaction thoughts about traumatic events, excessive verbalization of
ー End of interaction the event
● Presenting Problem ● Potential or Risk Diagnosis
● Present Illness ー Risk for suicide r/t history of suicide or through verbal
● Family History remarks of harming self
● Medical History
 Which will be the PRIORITY?

🅰️ 🅱️
Post trauma syndrome r/t overwhelming Risk for suicide r/t
anxiety sec. To rape or assault/ illness/ war history of suicide or
or disaster as evidenced by reexperience through verbal
(flashbacks), repetitive nightmares, remarks of harming
intrusive thoughts about traumatic events, self

✅
excessive verbalization of the event

Imbalanced nutrition; less than the body Ineffective coping

Implementation

✅
requirements
● Counseling
ー “SPEAK less. LISTEN more.”
● Milieu Therapy
Outcome Identification and Planning ● Promotion of Self-care Activities
● Others:
Outcome Identification ○ Psychobiological interventions
■ Art, dance, music therapies
● Identification of expected client behaviors resulting from ○ Health Teachings
nursing interventions individualized to the client ○ Case Management
● Should be SMART ○ Health Promotion & Health Maintenance

Nursing Diagnosis Incorrect Outcome Correct Outcome General Nursing Considerations

Anxiety Exhibits decreased Verbalizes feeling calm,
anxiety relaxed, absence of ● Promoting health & safety
muscle tension & ● Monitoring medication schedules & effects
diaphoresis, practices ● Providing adequate nutrition/hydration
deep breathing
● Creating a nurturing, therapeutic environment
Ineffective Coping Demonstrates coping Makes own decision to ● Continuing to build trust, self-esteem & dignity
abilities attend group, interacts to ● Participating in therapeutic groups & activities
staff and personnels ● Developing client strengths & coping methods
● Improving communications & social skills
Hopelessness Expressing increased Makes plans for the
feelings of hope future, states “my kids ● Connecting family & community support systems
need me to be well” ● Preventing relapse through effective discharge planning

Planning
Evaluation
● Developing plan of care that is negotiated among the pt.,
nurse, family & interdisciplinary team & prescribes ● Evaluation of the client’s progress in attaining expected
evidence-based intervention to attain expected outcomes. outcomes.
● The Process: ● Compare the client’s current mental health state/condition w/
○ Meeting & working w/ client, family, treatment team the outcome statement.
○ Identifying priorities of care ● Consider all possible reasons why the client did not achieve
○ Coordinating & delegating responsibilities outcomes.
○ Making clinical decisions about the use of
psychotherapeutic, scientific principles using
Documentation
evidence-based practice
● Interdisciplinary standardized care plans
● Evaluation of the client’s changing condition
(NANDA) diagnosis
● Informed consent
● Clinical pathways
● Response to medication
● Ability to engage in treatment program
● Signs and symptoms (most critical suicidal/homicidal
tendencies)
● Client concerns
● Other critical incidents that occur
 ○ Heel of the Palm
Basic Life Support ■
INFANT
○ 30 chest compression × 2 artificial ventilation × 5
Basic Life Support cycles
○ 2 FIngers Flexing
● is a set of emergency procedures that consists of recognizing ➢ CPR DURATION (Adult/Infant): 2 MINUTES
RESPIRATORY and CARDIAC ARREST, and the proper COMPONENTS OF HIGH QUALITY CPR
application of CPR with or without AED (Automated ○ Adequate compression rate (100 – 120 compression per
External Defibrillator), FBAOM (Foreign Body Airway minute)
Obstruction Management) and RESCUE BREATHING or ○ Adequate compression depth (2 – 2.4 inches)
to maintain life until a victim recovers or ADVANCE LIFE ○ Allow complete chest recoil after each compression
SUPPORT is available ○ Minimize interruption in every compression: < 10 secs.
○ Avoid excessive ventilation
CPR ○ Correct hand placement
○ Correct compression site
● CPR (Cardiopulmonary Resuscitation)
ー A series of assessments and interventions using techniques
and maneuvers made to bring victims of cardiac &
respiratory arrest back to life.

Legal Basis

● RA 10871
ー “An act requiring Basic Education Students to undergo
age-appropriate Basic Life Support Training”
● Health Emergency Management Bureau (HEMB) Goal
ー “At least one member of each household shall be trained in 2. When To Perform Rescue Breathing
BLS” ○Rescue Breathing
● RA 3815 ー A technique of delivering air into a person’s lungs to
ー Article 12. Section 4 of the Philippine Revised Penal Code supply him/her with the oxygen needed to survive.
Book 1: Any person who, while performing a lawful act ー It is when the patient has a positive pulse, but negative
with due care, causes an injury by mere accident without breathing.
fault or intention of causing it is exempted from criminal ー RULES IN RESCUE BREATHING: ALWAYS start
liability with a BLOW and END with a BLOW
WAYS TO VENTILATE THE LUNGS
Body Systems ○ Mouth to mouth
○ Mouth to nose
● Clinical Death: ○ Mouth to mouth and nose
○
Within 1 minute — Cardiac Irritability ○ Mouth to stoma
○
1-4 minute — Brain Damage not likely ○ Mouth to face shield
○
4-6 minute — Brain Damage possible ○ Mouth to mask
● Biological Death: ○ Bag valve mask | BVM
○ 6-10 minute — Brain Damage Very Likely ➢ Rescue breathing in ADULT is given in every 5 seconds:
○ Over 10 minute — Irreversible Brain Damaged Blow, 1002,1003, 1004 – 1
Blow, 1002,1003,1004 – 2
5 Important Things To Know About CPR Blow, 1002,1003,1004 – 3
Blow, 1002,1003,1004 – 4 … 24, BLOW
1. When To Start CPR (repeated in 24 cycles)
When you see a victim who is: ➢ Rescue Breathing in INFANT is given in every 3 seconds:
○ Unconscious and Unresponsive - “TAP” the patient on Blow, 1002, - 1
the shoulders Blow, 1002, - 2
○ No Breathing - (look for “Chest rise”) Blow, 1002, - 3
○ No Pulse - (check “Carotid pulse”) Blow, 1002, - 4 … 40, BLOW
➢ L-F-L (LOOK FOR LIFE) (repeated in 40 cycles)
ー Head-tilt chin-lift + Carotid pulse + Visual sweep + 10 3. When To Perform Recovery Position
seconds ○ It is when the victim has positive pulse and positive
■ ADULT breathing.
○ 30 chest compressions × 2 artificial ventilation × 5
cycles
 ○
Benefits of recovery position:
ー Aids in lung expansion
ー Draw out fluids from mouth
ー Assess patient’s back if there are other injuries
4. How To Use An AED
○ AED (Automated External Defibrillator)
ー Is a sophisticated, computerized device that can
analyze a heart rhythm and prompts the user to deliver
a shock when necessary. This device only require the
user to turn on the AED and follow the voice
instructions when prompted.
P - Power On
A - Attached Pads
A - Analyze
S - Shock
5. When To Stop CPR
○ S – spontaneous signs of circulation (Signs of Life) are
restored
○ T – turned over to another trained or authorized personnel
○ O – operator is already exhausted and can not continue to
do CPR
○ P – physician’s assumes responsibility
○ S – scene becomes unsafe (such as traffic, violence, etc. )
○ S – signed waiver to stop CPR (DNAR order)
WHEN NOT TO START CPR
○ Patient has irreversible signs of death (Rigor Mortis, Livor
Mortis, Decapitation).
○ No physiological benefits can be expected because the
vital functions have deteriorated.
○ Confirmed gestation of < 23 weeks or birth weight < 400
grams anencephaly.
○ Totally burned patient
FBAO
● FBAO (Foreign Body Airway Obstruction Management)
ー A condition when solid materials like chunked foods,
coins, vomitus, small toys etc. are blocking the airway.
Airway Obstruction
● Causes of Airway Obstruction:
1.Improper chewing of large pieces of food.
2.
Excessive alcohol intake:
a. Relaxation of tongue back into the throat.
b. Aspirated vomitus (stomach content)
3. Presence of loose upper and lower dentures.
4. For children who are running while eating.
5. For smaller children of hand to mouth stage who are left
unattended.
● Two Types of Airway Obstruction:
1. Anatomical Obstruction
2. Mechanical Obstruction
● Classification of Airway Obstruction:
○ Mild Obstruction
ー Good Air Exchange
ー Responsive and can cough forcefully
ー May wheeze between cough
○
Severe Obstruction
ー Poor or no air exchange
ー Weak or ineffective cough or no cough at all
ー High pitched noise while inhaling or no noise at all.
ー Increased Respiratory Difficulty
ー Cyanotic (Blue)
ー Clutching the neck with the thumbs & fingers making
the universal sign of choking.
ー Movement of air is absent
● How to Open an Airway:
○ Head-Tilt Chin-Lift Maneuver (Medical Case)
ー Tilt the head back with one hand and lift up the chin
with your other hand
○ Jaw-Thrust Maneuver (Trauma Case)
ー A technique that can be done by at least two highly
trained BLS providers (if suspected with cervical
trauma)
Universal Sign of Choking
● A sign wherein the victim is clutching his/her neck with one
or both hands & gasping for breath.
● ADULT
ー Mild Obstruction:
○ Position yourself (responder) on the side of the patient
to have a clear visual of obstructed food expelled
○ Have the patient cough until it is expelled
ー Severe Obstruction:
○ Position yourself at the back of the patient
○ Have the patient slightly spread the legs and have one
of your legs stay in between the patient's legs, while
the responder's other leg supports both your body's
weight
○ Perform 5 abdominal thrusts until the obstructed food
is expelled
○ (Abdominal thrust site: In between the navel and
epigastric region | Hand position: 'Bulge fist')
ー Unconscious
○ (Air bounces back: Obstructed | Air passess through:
No obstruction)
○ 30 chest compression + Head-tilt chin-lift + Blow +
(Air bounces back) + Retilt the head + Blow + (Air
bounces back) = Still obstructed
○ 30 chest compression + Head-tilt chin-lift + Blow +
(Air passess through) + Retilt the head + Blow + (Air
passess through) = No obstruction
〜 Look for life -> Perform CPR if necessary
● INFANT
ー Unconscious
○ (Air bounces back: Obstructed | Air passess through:
No obstruction)
 ○ 30 chest compression + Head-tilt chin-lift + Blow +
(Air bounces back) + Retilt the head + Blow + (Air First Aid
bounces back) = Still obstructed
○ 30 chest compression + Head-tilt chin-lift + Blow + ● First Aid – is the immediate medical care provided to the
(Air passess through) + Retilt the head + Blow + (Air patient to preserve life, prevent the condition from worsening,
passess through) = No obstruction or to promote recovery until medical services arrive.
〜 Look for life -> Perform CPR if necessary

If the patient is unresponsive… Common Day-to-Day Medical Emergency Incidents /

Patient is not breathing… Injuries
Patient has no pulse…
Proceed with CHEST COMPRESSIONS right away! (for 2 mins.) Fainting
Push Hard! Push Fast!
The earlier you compress, the more chances of survival! ● What to do:
Time is critical! (0-6 minutes / Golden Time) ー Loosen the patient’s clothing
ー Provide enough ventilation
“Next to creating a life, the finest thing a man can do is SAVE one.” ー Elevate the feet of the patient (above the patient’s heart)
—Abraham Lincoln ー Once recovered, put the patient in a sitting position
ー Introduce “sugar” (candy, coke, juice, etc.)
CPR Algorithm
Headache
1. Wear PPE
2. Scene size up ● What to do:
3. Introduce yourself ー Drink plenty of water
4. Check for responsiveness of the patient (unresponsive) ー Rest
5. Call for help (Activate EMS) ー Apply cold compress on the painful area
6. Check for breathing and circulation simultaneously (LOOK ー Avoid stressors
FOR LIFE) ● When to seek medical care:
7. Proceed with chest compressions ー If headache persists
8. Once the patient recovers → RECOVERY POSITION or if ー Headache with stiff neck
EMS arrives turnover the responsibility to the responding ー Headache with numbness and weakness of arms or legs
agency and difficulty speaking
ー Headache after head injury
Things To Know ー Headache with difficulty breathing

● The human body has a built-in first aid system. Seizure / Convulsion
● Tissue repair and regeneration within the body are influenced
by VITAMIN C. It helps and improves the immune system. ● Uncontrolled rapid shaking
● Muscles and tissues repair rejuvenate as we SLEEP and take ● Muscle relaxes and contracts repeatedly (involuntary
in PROTEIN. movements)
● Drinking water is essential for maintaining good health and ● Drooling or foaming of the mouth
well-being. Here are some of the benefits of drinking an ● Staring blankly (absence seizure)
adequate amount of water: ● Victim may not remember
ー Hydration, support digestion, weight management, ● What to do:
detoxification, skin health, joint health, brain function, ー Keep patients away from hazards
regulates body temperature, boosts energy levels, supports ー Provide adequate breathing space
heart health and kidney function. ー Support the head and neck
● The A-B-C of Life ー Note the duration, recurrence and interval
ー Airway ー Place the patient in a recovery position after the episode
ー Breathing ー Stay with the patient until help arrives
ー Circulation ● DONTs:
● Rule of 3s of Survival ー Do not place anything by mouth
○ The body can survive without air: 3 minutes ー Do not make the person stop from convulsing
○ The body can survive without water and food: 3 days ー Do not put anything by mouth until the patient is fully
○ The body can survive with water only: 3 weeks awake
○ The body can survive extreme heat/cold: 3 hours
○ The body can survive severe bleeding: 3 minutes
 Nosebleed Jellyfish / Sea Urchin Sting

● What to do: ● What to do:

ー Have the patient sit down in a comfortable position with ー Remove victim’s clothing
the head and upper body lean forward ー Rinse affected area with vinegar as soon as possible for 30
ー Pinch the victim’s nose; have the patient breath through seconds
the mouth, for 10-15 minutes ー Pain should be treated with warm water immersion when
● Apply ice pack on the nose bridge – forehead possible
ー Do it for 10-15 minutes ー Use seawater in washing the injury to dilute the toxin
● Reassess the injury; if bleeding persists, do it again for ー Monitor victim’s condition
another 15 minutes ー Bring victim to hospital
ー If bleeding still persists, bring the victim to the nearest ● What not to do:
hospital ー Remove but do not touch the tentacles
ー Do not use fresh water or ice
Diarrhea ー Do not rub the affected area
ー Do not apply pressure
● What to do:
ー Promote rehydration: Land Animal Bites
○ Give water / Oresol solution
○ 1 liter of water + ½ tsp of salt + 6 tsp of sugar ● Cause direct damage to skin and soft tissues
○ Do not drink coffee, milk (dairy products) or alcoholic ● Causes of infection:
beverages ー Tetanus
○ Do not take medications for diarrhea unless prescribed ー Rabies
by the doctor ● What to do:
○ Do not give spicy, greasy or fatty foods ー Wash bitten area with soap & water
● When to seek medical help: ー Do not induce bleeding
ー LBM for more than 3 times ー Control bleeding
ー Bloody, black or oily looking stool ー Cover wound with sterile or clean dressing
ー Dizziness, weakness and muscle cramps ー Bring victim to the nearest health care facility or animal
bite center
Hyperventilation
Muscle Cramps
● Hyperventilation is a self-correcting condition.
● What to do: ● What to do:
ー Reassure the patient that you are there to help – make sure ー Rest the affected area
the patient stays calm ー Rehydrate plenty of fluids and electrolytes
ー Loosen the patient’s clothing and have him/her sit down
ー Introduce deep breathing exercises (inhale from the nose –
exhale from the mouth) ● What not to do:
ー The “Paper bag” method is optional ー Massage the area while muscle cramps are happening
ー Constant patient monitoring ー Adding pressure to the affected area – by stretching

Musculoskeletal Injuries Burn

● Fracture – broken bone ● What to do

● DONTs ー Clean running water on the affected area (to clean the
ー Do NOT try to re-align a limb if you suspect a fracture wound and alleviate pain)
ー Do NOT try to put back an exposed bone ー Apply burn ointment
ー Do NOT massage the affected area ー Continuous wound care
● What to do: ー Drink plenty fluids
ー R – Rest / Immobilize ● What not to do:
ー I – Ice / Cold packs ー Pick the blister’s
ー C – Compress ー Do not apply ice directly to the wound
ー E – Elevate ー Do not use cotton balls or loose fibers
● If an injured extremity is blue or extremely pale, activate ー Do not use toothpaste
EMS immediately
ー Apply ice on the injured are for 15-20 minutes for every 1
to 2 hours during the first 24 hours
 Extreme Bleeding

● What is “Life-threatening” Bleeding?

ー Blood that is spurting out of the wound
ー Blood that won’t stop coming out of the wound
ー Blood that is pooling on the ground
ー Loss of all or part am arm or leg
ー Patient is already confused or unconscious due to bleeding
● What to do:
ー Immediately CONTROL THE BLEEDING by applying
DIRECT PRESSURE
ー Transfer the patient immediately to the nearest hospital

Wound Care

Heart Attack Symptoms

● C – Chest pain
● R – Radiates (neck, jaw, back)
● U – Unrelieved pain with (Nitro)
● S – Sweating (cold sweat)
● H – Hard to breathe
● I – Increased heart rate
● N – Nausea / vomiting
● G – Gloom and doom (impending doom)