COMPREHENSIVE PHASE

HANDOUTS
PSYCHIATRIC NURSING
Prepared By: Mr. Kevin Adre Fajardo
NOV 2023 Philippine Nurse Licensure Examination Review

MENTAL HEALTH

● According to the World Health Organization (WHO, 2020), mental health is a state of well-being in which an individual realizes his or her
own abilities, can cope with the normal stresses of life, can work productively, and is able to make a contribution to his or her community.
● “Mental health is like a violin with strings of interaction, behavior, affect and intellect. All these together may produce a pleasant or
stimulating melody or they may be discordant and irritating. The tune continually changes. No one is entirely mentally unhealthy and no
one is fully healthy at all times” - Ebersole and Hess,1985

3 ASPECTS OF PERSONALITY

1. ID

● inborn
● instinctive drives
● internal desires (urges)
● “I want” pleasure principle

2. EGO

● begins to develop between 4-6 mos.

● the “self”, “I” identity
● reality principle

3. SUPEREGO

● begins to develop between 3-6 years old

● determine right and wrong

Mind-Setting Implication Needs

Id (Infant) Pleasure principle Eat, drink, smoke, urinate, have sex

- Do what you want - unconscious

Ego (Adult) In touch with reality ● what is more beneficial

- Think before deciding conscious

Superego (Parent) Conscience Morally and ethically acceptable

- Is it good or bad? behavior
-conscience

Sigmund Freud’s Psychosexual Theory

● The theory supports the notion that all human behavior is caused and can be explained. Sexual impulses and desires motivate human
behavior.

PHASE/STAGE AGE FOCUS

Oral Birth to 18 Months

Anal 18 – 36 Months

Phallic/Oedipal 3 – 5 Years

Latency 6– 11 Years

Genital 12 – 18 Years

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ERIK ERIKSON

PSYCHOSOCIAL THEORY OF DEVELOPMENT

Age + - Affecting Major Factor

0-18 mos. Trust Mistrust Feeding

18 mos. – 3 y.o. Autonomy Shame/ doubt Toilet Training

AU nal
TO ilet training
NO favorite word
MY

3 – 6 y.o. Initiative Independent Guilt

6 – 12 y.o. Industry Inferiority In da-school

12 – 20 y.o. Identity Role Confusion Peer

20 – 25 y.o. Intimacy Isolation Love

25 – 45 y.o. Generativity Stagnation Parenting

45 y.o. and above Ego Integrity Despair Reflection

MASLOW’S HIERARCHY OF NEEDS

FOUR PHASES OF NURSE- CLIENT RELATIONSHIP (NCR)

A. Pre-interaction/Pre-orientation (For the Nurse)

- Stage of Self-Awareness 🡪 To prevent Counter Transference

#1 CORE VALUE OF Psychiatric Nursing

B. ORIENTATION (INITIATION)

T - rust and rapport

R - eflect on words

U - se of contract

S - tress confidentiality

T - herapeutic environment

*The start of termination phase: “Good morning, full name, RN, shift, session, date start & end.”

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Contract – 2 famous psychiatric contracts:

1. No suicide contract 🡪 Major depression = emergency

TWO definitions of no suicide contract:

A. 24 hrs monitoring

B. Verbalization to the nurse of all suicide ideas

2. Diet contract 🡪 Eating disorder

C. WORKING PHASE

Problem: EMOTIONAL ATTACHMENT Goal: RN (explore); Patient (verbalize) Transference – Patient to Nurse Countertransference – Nurse to Patient

S - elf concept ↑

O - rganize support system

L - ead to a plan of action

V - erbalization of feelings

E - ncourage independence

R - ealistic goal setting

*most difficult phase

D. TERMINATION

R - egression is common

I - ncrease independence

P - romote self-care

E - nvironmental support need

S/s: Regression: Temper tantrums, thumb sucking, apathy, fetal position when cry

Communication

● Exchange of information between 2 or more person

Essentials for a Therapeutic Communication:

● Genuineness
● Respect
● Empathy
● Attentive listening
● Trust (rapport)

ELEMENTS OF NON-VERBAL COMMUNICATION

1. KINETICS

● Body language
● Facial expressions, poise, posture, gait, movements, etc

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 ● Reflects mood

2. PARALANGUAGE

● Vocal cues

3. PROXEMICS

● space/ distance between sender and receiver

A. INTIMATE DISTANCE – up to 18 inches

B. PERSONAL SPACE – 18 inches to 4 ft.

C. SOCIAL SPACE – 9 to 12 ft.

D. PUBLIC SPACE – beyond 12 ft.

4. TOUCH

● Shows attempt to connect or relate

5. SILENCE

Therapeutic Communication Techniques

CLARIFYING

● I’m not sure I understand what you are trying to say.

EXPLORING

● Tell me more about your job./ Would you describe your responsibilities?

GIVING BROAD OPENINGS or ASKING OPEN-ENDED QUESTIONS

● Is there something you’d like to do?

ACCEPTING

● Yes, that must have been difficult for you.

ACKNOWLEDGING or GIVING RECOGNITION

● I noticed that you’ve fixed your bed.

ASKING DIRECT QUESTIONS

● How does your wife feel about your hospitalization?

● Yes, that must have been difficult for you.

ACKNOWLEDGING or GIVING RECOGNITION

● I noticed that you’ve fixed your bed.

ASKING DIRECT QUESTIONS

● How does your wife feel about your hospitalization?

INFORMING

● I’ll be your nurse for today, from 7:00 until 3:00 this afternoon.

REFLECTING

o Client: I do not want those medicines! pout

Nurse: You are unhappy of taking the medication

( Reflecting )

RESTATING

o Client: I can’t sleep, I stay awake all night.

Nurse: You can’t sleep at night. ( Restating )

SUMMARIZING

o During the past hour, we talked about your plans for the future, they include…

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 USING SILENCE

VOICING DOUBT

o I find that hard to believe.

NON-THERAPEUTIC and INEFFECTIVE COMMUNICATION

FALSE REASSURANCE.

JUDGING

DEFENDING

BELITTLING

STRESS

● state of physical and emotional imbalance ( Disequilibrium ) in response to threats, challenges, demand, unmet needs and lack of resources,
unsolved problems

GENERAL ADAPTATION SYNDROME (GAS) RESPONSE TO STRESS

STRESS MANAGEMENT

5 A’s

STRESS MANAGEMENT
● AVOID THE STRESSOR
● ALTER THE STRESSOR
● ACCEPT THE STRESSOR
● ADAPT TO THE STRESSOR
● ADOPT A HEALTHY LIFESTYLE

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 Anxiety

Mild

+1 Moderate

+2 Severe

+3 Panic

+4

Mild +1

● Widened
● Perceptual
● Field
● Restless
● Enhanced Learning
● Capacity
● “You Seem Restless”

Moderate

● +2
● acing
● RN Meds

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Severe

● +3
● ont know what
● to say/do
● IRECTIVE

Panic

● +4
● uicide
● afety

Drug of choice: Benzodiazepines Azapirones

Nursing education: Avoid ____________

Midazo ______

Alprazo ______

Diaze _____

Clonaze _____

Buspi _____

Ipsapi _____

Antidote: Fumazenil (Romazicon)

CRISIS

CRISIS and CRISIS INTERVENTION

● CRISIS - When coping mechanism are ineffective that results to disequilibrium.

TYPES OF CRISIS

● Situational – caused by unexpected event (Loss of a job / starting a new job, Death of a loved one)
● Adventitious / Social – caused by natural catastrophe (earthquake, fire, tornado)
● Maturational / Developmental – caused by expected events (menarche, marriage, pregnancy, retirement)

Duration of Crisis: 4 – 6 weeks (self-limiting)

Goal: To help patient return to pre-crisis level

Focus: Here and Now (GESTALT THERAPY)

● immediate problem, feelings, and solutions

Approach:

Directive – promote problem solving,

Supportive – encourage expression of feelings

Phobias

● an illogical, intense and persistent fear of a specific object or social situation

● Symptoms of a phobia are generally similar signs and symptoms to a panic attack

3 Categories of Phobias

1. Agoraphobia
2. Specific
3. Social Phobia

Defense Mechanism: Displacement and avoidance

Management: Flooding – sudden exposure to maximum stimulus

Systematic Desensitization – gradual exposure to the feared object

1st step: Let the client think and talk about the feared object

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 PTSD & Acute Stress Disorder

● Acute stress disorder ASD is a mental disorder that can occur within the first month following a traumatic event
● PTSD - Post Traumatic Stress Disorder if symptoms persist for over 1 month.

Psychotherapy

● Also called talk therapy is a way to help people with a broad variety of mental illnesses and emotional difficulties.
● Psychotherapy can help eliminate or control troubling symptoms so a person can function better and can increase well-being and healing.

Psychotherapy:

● Defusing – providing education on stress and stress management

● Debriefing – client is asked about their emotional reaction to an incident
● Exposure therapy – confronting trauma associated thoughts rather than avoiding
● Adaptive closure therapy (empty chair technique)
● Catharsis – releasing repressed emotions thru art and music

CBT - Cognitive Behavior Therapy

● CBT is a common type of psychotherapy (talk therapy).

● It helps clients reframe their thought processes in order to slowly cope with stress & anxiety, helping to treat many disorders from PTSD &
OCD, to eating disorders like anorexia & bulimia, and even depressive disorders.

Guided Imagery

● Guided imagery is a mind-body intervention where clients concentrate on mental images to help reduce stress, anxiety, & improve
concentration.

Group Therapy

GOAL:

● Reduce isolation & Communicate acceptance

PROBLEM:

● Allow the group to handle to talk about the issues.

Therapeutic Milieu

● This provides a safe & secure environment for clients that are in therapy. It’s basically the goal of every behavioral health or psych unit in
the clinical setting. Clients are encouraged to freely roam around in the social environment.

PERSONALITY DISORDERS

● A personality disorder is a way of thinking, feeling, and acting that goes against what people in the culture expect, causes distress or makes
it hard to function, and lasts for a long time.
● Personality disorders are ego-sync, which means that the person who has the disorder might not think they have a problem.

Narcissistic Personality Disorder

● Believes they are perfect

● Acts entitled, arrogant, & grandiose
● Relies on constant reinforcement & need for admiration = attempt to maintain self-esteem

Paranoid Personality Disorder

● Distrust & suspicion of others

● Intense need to control the environment

Histrionic Personality Disorder

1. Center of attention

2. Exaggerated or shallow emotional expression

3. Little tolerance for frustration & demands gratification

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4. Overly friendly & flirtatious

Dependent Personality Disorder

● Extreme dependency in a relationship & fear separation.

● PROGRESS

Borderline Personality Disorder

● Fear of being abandoned & uses manipulative behavior:

1. Cling to 1 favorite staff member

Antisocial Personality Disorder

● Impulsive, manipulates others for personal gain & lacks empathy.

Avoidant PD

● Shy, timid, inferiority complex

o avoid open forum
● Over sensitive to rejection/criticism

SCHIZOID

● I don’t want people

● Believes he can stand on his own
● Never had a best friend
● Avoid groups and social activities no enjoyment
● Cares more about computers and pets

Schizotypal Personality Disorder

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 OBSESSIVE-COMPULSIVE DISORDER (OCD)

● Obsessions = Excessive thoughts & impulses

● Compulsions = Repetitive “ritualistic behaviors”

NURSING MANAGEMENT

● Divert/ redirect the ritual to a productive activity

● Initially, allow patient to continue the rituals
● Engage patient in socia activities
● Set limits to patient’s ritual, but do not stop/interrupt a ritual

Dissociative Identity Disorder

● Dissociative identity disorder occurs when 2 or more identities rotate control over the client’s behavior.

NURSING MANAGEMENT

● Stay with patient

● Gather data about the patient
● Do not present all data, avoid flooding
● Explore stressors
● Ask the patient to relate the event
● Look for effective coping

SOMATOFORM DISORDERS

Somatic System Disorders

● SDD is a psychological disorder where clients have unexplained physical symptoms like abdominal pain, weakness, chest pain, shortness
of breath, & others.

SOMATOFORM DISORDERS

CONVERSION DISORDER BODY DYSMORPHIC DISORDER

HYPOCHONDRIASIS

● With physical symptoms, no organic cause

A. Malingering

B. Factitious

C. Factitious Disease by Proxy ( Munchausen’s Syndrome )

NURSING MANAGEMENT

● Rule out any possible organic of physiologic cause

● Attend to physical complaints
● Consistent care giver must be provided
● Encourage verbalization of feeling

EATING DISORDERS

Anorexia Nervosa Eating Disorders Bulimia

Diet, diet, diet Eating Pattern Eat, eat, vomit

<85% of expected body Weight Normal weight

3 mos. amenorrhea Menstruation Irregular menstruation

II. ANOREXIA NERVOSA

● Fear of obesity

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 ● Problem with the hypothalamus

ASSESSMENT:

a. Refusal to eat/ drink

b. Excessive exercise

c. Ferfectionist

d. Underweight/ 15% or less than IBW

e. Signs of malnutrition

-Bony prominence

-Amenorrhea for 3 periods

-Dry hair

-Lanugo

-Imbalance

-Poor skin turgor

g. Ensure Safety (suicidal)

III. BULIMIA NERVOSA/ BINGE AND PURGE SYNDROME

● Binge eating, followed by self-induced vomiting

ASSESSMENT:

● Hoarseness of voice
● Enlarged parotid glands
● Average weight
● Russel’s sign –calluses on knuckles
● Toothache- dental caries
● Metabolic acidosis and alkalosis
● Enema’s, diuretics and diet pills

MANAGEMENT

● Always Physiologic needs first!!!!

● Fluid and electrolyte imbalance
● After eating stay with the client for 1 hour and accompany when going to the comfort room
● Meal contract
● Weight gain for the client

THERAPIES FOR EATING DISORDERS

● PHARMACOTHERAPY

a. Appetite stimulant (Periactin)

b. Anti-depressant (Tofranil)

Neurotransmitters

● Dopamine/ Epinephrine /Norepinephrine

● Serotonin –
● GABA – Gamma-Aminobutyric acid

PSYCHOTIC DISORDERS

Schizophrenia

What is Schizophrenia?

● A long-term mental disorder involving a deteriorating breakdown in the relation between thought, emotion, and behavior.
● The earlier the onset, the worse the prognosis.

Possible Causes of Schizophrenia

1. Genetic

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 2. Neuroanatomic/Neurochemical

3. Immunovirologic

CLASSIFICATION OF SCHIZOPHRENIA

1. DISORGANIZED-aka Hebephrenic

Essential features:

Characterized with inappropriate behavior: Silly crying, laughing, regression, transient hallucinations (Auditory)

Defense Mechanism: Regression

Anal Fixation

5 (FIVE) TYPES OF SCHIZOPHRENIA:

2. PARANOID:

● Presenting sign is SUSPICIOUSNESS, ideas of persecution and delusions. REMEMBER the 4 P’s:
● Projection (#1 defense mechanism),
● Proxemics( 7 feet away from the patient),
● Passive Friendliness (#1 attitude therapy: No touching, , no whispering & laughing) ,
● Persecutory delusion(#1 delusion of Paranoid Schizophrenia) ,

*Nursing Diagnosis: Alteration in nutrition: Less than body requirement

Nursing Goal: to meet the patient’s daily nutritional requirements

Nursing Interventions:

a. Do not force patient to eat foods that he refuses

b. You may do any of the following:

1. Allow client to buy foods

2. Allow client to prepare his own food

3. Offer packaged foods except canned foods

*Nursing Diagnosis: Non-compliance with therapy

Nursing Interventions:

a. Explain to the client the reason for administering the drug

b. Administer drugs in the same form always

c. Do not hide tablets

3. CATATONIC

Essential features: psychomotor disturbances

● waxy flexibility(cerea flexibilitas) rigidity, posturing, negativism,mutism

Defense Mechanism: Autism and mutism

CATATONIC CHARACTERISTICS:

● Catatonic stupor – markedly slowed movement.

● Catatonic posturing- bizarre or weird positions
● Catatonic rigidity – cementation/stone-like position
● Catatonic negativism – resistance towards flexion & extension
● Catatonic hyperactivity or excitability

4. UNDIFFERENTIATED or MIXED: Symptoms of more than one type of schizophrenia

● The #1 drug of choice is Fluphenazine (Prolixin decanoate)

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5. RESIDUAL: No longer exhibits overt symptoms, no more delusions but still has negative symptoms

Positive Symptoms - clear symptoms, visibly displayed and Thought

Negative Symptoms - non-active symptoms

PSYCHOMOTOR DISTURBANCES

P POSTURING

A PRAXIA

W AXY FLEXIBILITY

E CHOPRAXIA

R IGIDITYRAXIA

2. ECHOPRAXIA

MOOD/AFFECT DISTURBANCES

1. APATHY

2. FLAT SPEECH

3. BLUNT AFFECT

4. INAPPROPRIATE AFFECT

5. AMBIVALENCE

6. EUPHORIA

7. LABILE

8. MELANCHOLIA

9. ALEXITHYMIA

Disorganized Speech & Thought

1. Loose associations: rapid shift of thought with no logical connection

2. flight of ideas: rapid shift of thought with logical connection

2. Neologisms: making up imaginary words

3. Clang associations: listing rhyming words together that make no sense

4. Word Salad: mixing words together that have no meaning except to the client

5. Concrete thinking: taking a statement literally.

6. Tangentiality: speaking of unrelated topics that do not correlate to the main discussion.

7. Echolalia: repetition of words they hear from someone else

8. Perseveration: repeating the same words and phrases when answering different questions

● Verbigeration – repeating phrases

● Stilted language – use of flowery words

a. Illusion – false perception of actual external stimuli

b. Hallucination – false sensory perception in the absence of external stimuli

Note: Illusions and hallucinations can be visual, tactile, auditory, gustatory, or olfactory

c. Delusion – the false belief that is inconsistent with one’s knowledge and Culture

Delusions

Delusions of Reference:

● This song has a secret message just for me”

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 Delusions of Control:

● “I do not go online, that's how the NBI controls you”

Delusions of Grandeur:

● ”I have a very important meeting with the President today”

Persecutory (paranoid) delusions:

● “The hospital food is trying to poison me”

Management

● Hallucination must be recognized

● Assess the content
● Reality presentation
● Divert the attention
● Engage in reality-based activity
● Reintegrate with the milieu
● TALK BACK to the voices

Synesthesia – mixing of senses (hears the color, sees the sound, tastes the words)

DELUSION – false belief

Management:

● Clarification the meaning

● Acknowledge the feelings
● Voice doubt
● Engage in reality-based activities

PARANOID CLIENT

● Passive Friendliness
● Develop trust
● Involve the client in planning
● SEALED CONTAINER (for food and medicine)
● Avoid staring, whispering, and giggling
● Respect personal space (not less than _______)
● Maintain professional tone (use simple, direct, concise words)

Antipsychotics

● These are medications, also known as neuroleptics, which are used to treat the symptoms of psychosis such as the delusions and
hallucinations seen in schizophrenia, schizoaffective disorder, and the manic phase of bipolar disorder.
● Works by blocking the receptors for the neurotransmitter: Dopamine

Common Examples

● 1st Generation Antipsychotics: Chlorpromazine (Thorazine), Haloperidol (Haldol)

● 2nd Generation Antipsychotics: Clozapine (Clozaril), Risperidone (Risperdal), Quetiapine (Seroquel) Olanzipine (Zyprexa)
● New Generation (Dopamine System Stabilizers): Aripiprazole

Extra Pyramidal Syndrome

● Pseudoparkinsonism
● Acute Dystonia (
● Akathisia

Neuroleptic Malignant Syndrome

Tardive Dyskinesia

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DEFENSE MECHANISMS – protect ego and decrease anxiety

DISPLACEMENT • Transfer of feelings to a less threatening object rather than the one who provoke it

DENIAL • Failure to acknowledge an unacceptable trait or situation

DISSOCIATION • Psychological flight from self

• A type of amnesia

REGRESSION • Return to an earlier developmental stage

REPRESSION • Unconscious forgetting of an anxiety provoking concept

RATIONALIZATION • Illogical reasoning for a socially unacceptable trait

REACTION FORMATION • doing the opposite of your intention

• plastic

UNDOING • Doing the opposite of what you have done due to guilt

IDENTIFICATION • Assume trait for personal, social, occupational role

PROJECTION • Attributing to others one’s acceptable trait

• Pasa load

INTROJECTION • Assume another person’s trait as your own

SUPPRESSION • Conscious forgetting of an anxiety provoking concept

SUBLIMATION • Placing sexual energies toward a more productive endeavors

CONVERSION • Repressed angers put towards physical symptoms affecting nervous system leading to
sensory numbness and motor paralysis

COMPENSATION • Overachievement in one area to cover a defective part

Intellectualization – acknowledging the facts but not the

emotions

SUBSTITUTION • Replacing a difficult goal with a more accessible one

Splitting acknowledging the facts but not the

emotions

EGO DEFENSE MECHANISMS

Rationalization – Distortion of Man says he beats his wife because she does not listen
facts, unjustifiable excuse to him

Intellectualization – Person shows no emotional expression when discussing

acknowledging the facts but not serious car accident
the
emotions

NEURODEVELOPMENTAL DISORDERS

Autism Spectrum Disorder

Pathophysiology

● ASD is a developmental disorder that impairs a child’s ability to communicate and interact.
● The cause of autism is unknown.

Routines & Consistency

● Give a schedule of daily activities

● Routines & Consistency
● Maintain daily routines when possible
● Avoid making acute changes in their environment

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Signs & Symptoms

● Does not maintain eye contact

● Does not Interact with gestures
● Like being cuddled & plays alone
● Respond to questions
● Display nonverbal behavior
● Delay in language development

Repetitive

● Actions “Ritualistic behavior”

● Words (echolalia)

PREVENT OVERSTIMULATION

● Limit number of visitors & choices

● Private room away from the nurse’s station

Management

● Give a written schedule of daily activities NCLEX TIP

● Aggressive behavior: distract the child & ask them to blow up a balloon
● Increased risk for injury

Communication

1. Eye contact first (before speaking)

2. Simple language

3. Child repeats back what was said

4. Offer praise upon task completion

Management:

● Expressive therapy drawing, muscic etc

● Enhanced communication
● Improved social interaction
● Safety

ADD/ADHD

Pathophysiology

● ADD - Attention Deficit Disorder

● ADHD - Attention Deficit Hyperactivity Disorder

ADD/ADHD

● The brain has low levels of the neurotransmitters dopamine & norepinephrine which help the brain focus on reward vs. risk and control
impulsivity & mood, making clients with ADHD more likely to have anxiety & substance abuse problems.

Signs & Symptoms

1. Hyperactivity “restless”

2. Inattention “reduced ability to focus”

3. Impulsiveness “excessive talking”

4. Low self-esteem & impaired social skills

Causes & Risk Factors

● Head trauma: TBI (traumatic brain injury)

● Children who have had a serious head injury are more likely to develop ADHD later on in age.

ATTENTION DEFICIT DISORDER

● Onset : 7 y.o. and below

● Duration : 6 months and above
● Settings : 2 House and school
● Id Dominant : Mom or RN will act as superego

ADHD Meds

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Drug names:

● Methylphenidate
● Amphetamine mixture
● (brand: Ritalin)
● (brand: Adrenal)
● Dextroamphetamine
● Stimulants

Indication:

Given to treat:

● ADHD in children & adolescents & even narcolepsy

KEY POINT

● Loss of Appetite & Weight

● Loss of Sleep
o Restlessness
o Give last dose NO LATER than 6PM
● Improvements in school work

Residual ADHD grows up not antisocial

Meds: Ritalin, dexedrin, pemoline, adderal Best time to give: once a day: AFTER MEALS: prevent loss of appetite

Don’t give at bedtime 🡪 STIMULANT 🡪 causes insomnia Give 6 hours prior bedtime if bid

KEY POINT

● PRIORITY nursing assessments

o Monitor BP
o MONITOR and report height, weight trends with HCP
● Reversal Agent: Alprazolam

MOOD DISORDERS

Bipolar Disorders – Types

Bipolar 1 Bipolar 2 Manic d/o Major d/o Cyclothymia Dysthymia

Mania

Hypomania

Normal

Hypo Dep

Major Depression

Depression

Mental Health "Psychiatric Care"

Pathophysiology

● Major Depressive Disorder (MDD) also called clinical depression is when a client experiences a severe depressed mood, loss of enjoyment
in life, low energy & few other critical signs and symptoms. Everything is low & slow, it is thought to be from low levels of
neurotransmitters within the brain.

Neurotransmitters

● Low Serotonin
● Low Dopamine
● Low Norepinephrine

Signs & Symptoms

Diagnosis: 5 or more symptoms

1. Depressed mood (hopeless, empty)

2. Anhedonia (loss of joy/ interest in life)

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 3. Weight loss (anorexia) or Wt. Gain

4. Psychomotor retardation or Agitation

5. Insomnia or hypersomnia (sleeping too much)

6. Fatigue (Anergia)

7. Feelings of worthlessness or Guilt

8. Difficulty in concentration

9. Suicidal thoughts (Recurrent)

1. Continuous one-to-one observation

2. Semi-private room (near nurses’ station)

● Remove harmful objects from the room

● Supervise during meals
● Reassess: changes in suicidal thoughts
● Clear plans of the future involving personal goals, family, & friends

Diet

1. Small “frequent” meals

2. High calorie foods & fluids

3. Stay with client during meals

4. Weekly weighing

Antidepressants - 4 Rules

1. Increased risk of suicide

2. Slow Onset & SLOW taper off

3. NEVER Mix

● SSRI + St John’s Wort or MAOI + Antidepressant (TCA, SSRI, SNRI)

4. ALL psych drugs

● Decrease BP (slow position changes)

● Cause weight changes

Antidepressants

● Primarily used in the treatment of major depressive illness, anxiety disorders, the depressed phase of bipolar disorder, and psychotic
depression.

3 Major Groups and Common Examples:

1. Tricyclic Antidepressants (TCA) – Examples: Imipramine (Tofranil), Doxepin (Sinequan), Amitriptyline (Elavil)

2. Selective Serotonin Reuptake Inhibitors (SSRI) – Examples: Fluoxetine (Prozac), Sertraline (Zoloft), Citalopram (Celexa)

3. Monoamine Oxidase Inhibitors (MAOI) – Examples: Phenelzine (Nardil), Tranylcypromine (Parnate), Isocarboxazid (Marplan)

SELECTIVE SEROTONIN REUPTAKE INHIBITOR

Action: Prevent reuptake of serotonin increasing the availability of serotonin in the body.

● Serotonin syndrome
● Side effects but Suicide risk
● Rigid muscle and Restless
● I to 4 weeks only

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PROZAC, CELEXA, ZOLOFT

TRICYCLIC ANTI DEPRESSANT

Action: Prevents the reuptake of norepinephrine and serotonin increasing these neurotransmitters in the body..

● Two – four weeks

● Check for the higher incidence of side effects (anticholinergic)
● Assess for suicide

ASENDIN, NORPRALAMIN, TOFRANIL, SINEQUAN, ANAFRANIL, AVENTYL, VIVACTIL, ELAVIL

MONOAMINE OXIDASE INHIBITORS

Antidepressant 🡪 no effect 🡪 ECT

ELECTROCONVULSIVE THERAPY

Pre

● Informed consent
● NPO 6 – 8 hours prior

Meds

● Atropine - dry mouth, oral secretion

● Barbituate – Sedative
● Succinylcholine - muscle relaxant, prevent seizure

Post

● Side-lying – lateral

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 ● S/E
● Most common: confusion
● headache, dizziness,
● TEMPORARY MEMORY LOSS 🡪 distinct sign

Nursing Intervention

5 S in Seizure

1. Safety (#1 objective)

2. Side-lying (#1 Position)

3. Side rails up

4. Stimulus ↓ (no noise & bright lights)

5. Support the head with a pillow AFTER the seizure

● FIRST & TOP priority: Ensure a patent airway. Side-lying after removal of airway. Observe for respiratory problems
● Remain with client until alert. VS q 5 min until stable.
● REORIENT: Time, place (unit), person (nurse); Reassure regarding confusion and memory loss. Same RN before & after.

POINTS TO REMEMBER

Electric Current 70 – 150 volts

Duration of Administration 0.5 – 2 seconds

Frequency of Treatment 2 – 3 treatments weekly

Total Number of Treatments 6 – 12 ECT therapy

Side Effect: Seizure Lasts 30 secs. To 1 min. or slightly longer

( tonic – clonic )

Indications for Electroconvulsive Therapy

1. Severe depression
2. Treatment-resistant depression
3. Severe mania
4. Catatonia
● Life-threatening priority: Monitor for aspiration and respiratory status

SUICIDE

Verbal Non Verbal

• I won’t be a problem anymore • Take this ring, it’s yours (giving of valuable)
• This is my last day on earth • Sudden change in mood
• I’ll soon be gone

Who will commit Suicide?

● Sex – Male (more successful)/ female (hesitant)

● Age – 15 –24 y/o or above 45
● Depression
● Patient with the previous attempt
● ETOH – ethanol – alcoholics
● Rirrational
● Social support lacking
● Organized plan greater risk
● No family Sickness, terminal

Best approach for suicidal pt.: Direct approach

Nursing Management: Close surveillance

Hospital area majority sucide will happens at:

● weekends 1- 3 am Sunday
● Weekend less staff personnel

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 ● Early AM everyone is asleep

Hospital area majority suicide will happens at:

● weekends 1- 3 am Sunday
● Weekend less staff personnel
● Early AM everyone is asleep

SUICIDE PRECAUTIONS

Bipolar Disorder

What is Bipolar Disorder?

● Mania: “A mood disorder marked by hyperactive wildly optimistic state”

● Depression: “The feeling of severe despondency and dejection”

Signs & Symptoms

● More energy & Mood Swings

● Agitation
● Non-stop talking & Flight of ideas
● Insomnia
● Attention span

BI-POLAR, MANIC

● Lithium: undergo the first kidney test and check for blood levels
● Level: 0.6 – 1.2 meq/L

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 ● Increase urination
● Toxicity watch/out tremors, fine hand
● Hydration should be within normal limits
● Hypothyroidism - inhibits thyroidal iodine uptake
● Increase
● Uu (diarrhea)
● Mouth dry

SIGNS OF LITHIUM TOXICITY

● Nausea, vomiting, diarrhea

● **** WAIT FOR 2 – 4 WEEKS BEFORE LITHIUM THERAPY TAKES EFFECTS

NURSING DIAGNOSIS:

1. Risk/ Potential for Injury directed to others /or to self

2. Fluid & Electrolytes Imbalances

3. Fluid Volume Deficit

NURSING INTERVENTIONS:

1. Accept client; reject behavior

2. Provide consistent care

3. Set limits of behavior/external controls

4. Distract and redirect energy: (dancing, walking with staff)

5. Meet nutritional needs: High-calorie FINGER FOODS and fluids to be carried while moving. (potato chips, bread, raisin, and sandwich)

Encourage rest: Sedation PRN, short PM naps

Tips:

*Increase perspiration!!)

*Brisk walking, punching bag, raking leaves, tearing newspaper

*Gardening, finger painting, household chores,

Competitive is not safe

*Tuna and apple sandwich

SHORTCUT: ALL HIGH CALORIC & HIGH CARBOHYDRATE DIET or ALL BAKERY PRODUCTS!!!

SECLUSION

Informed consent: ___________________

Room: lockable and observable from the outside

Purpose: RESTORATIVE, NOT PUNITIVE

Goal: to help client regain self-control

Monitoring: one-on-one monitoring on the first hour

Environment: less stimulated environment (no visitors and phone calls allowed)

RESTRAINT

Doctor’s order (Application): _________________

Informed consent: _________________________

Proper Application:

● 6 to 8 staff members required

● Adequate circulation must be ensured

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 ● Anchor on a stable part of the bed

Doctor’s order (removal): ____________________

Proper Removal:

Temporary – alternately, one at a time, for 10 minutes every 2 hours

Permanent – alternately one at a time

ALCOHOLISM

● Etiology: Intergenerational Transmission

● From one generation to another generation

Alcohol

Blackout 🡪 awake but unaware

Confabulation 🡪 inventing stories to ↑ self-esteem

Denial 🡪 “I am not an alcoholic” Dependence 🡪 “I can’t live without it”

Enabling 🡪 significant other tolerates abusers

Another term CO – DEPENDENCY

TOLERANCE ↑ Substance to achieve a previous effect

DETOXIFICATION

● Withdrawal with MD supervision

● Check Alcohol, Mouthwash, Elixer

● void alcohol
● version therapy
● lcoholics Anonymous 🡪 self help group
● ntabuse

● 1 Vitamin Deficiency

● omplications

● elirium Tremens

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 ● ormocation 🡪 bugs crawling under the skin
● amily Therapy 🡪 mother, father, brother

> 4 Common Complications with History of Alcoholism

1. Liver Cirrhosis

2. Gastritis 🡪 inflammation

3. Pancreatitis

4. Wernicke’s Korsakoff’s 🡪 peripheral neuritis 🡨 lack of Vit. B1 (thiamine)

(Sx: Tingling sensation/numbness of extremities: Avoid electric blankets!)

Wernicke’s’ psychosis is due to thiamine deficiency.

Confabulation or making up of stories is one of the initial manifestations of Korsakoff’s syndrome.

Two categories of Wernicke’s Korsakoff’s:

A. Wernicke’s Aphasia / Receptive Aphasia:

● Problems in interpretation (temporal lobe)

B. Korsakoff’s Psychosis – irreversible (the best drug is Risperidone (Risperdal):

● It has Decrease extrapyramidal symptoms (EPS)

4 Stages of Alcohol Withdrawal

I. Early/Initial – Fine tremors, restlessness, tachycardia, diaphoresis, hyperventilation & nervousness

WITHDRAWAL SYMPTOMS

a. 6-8o
● after last drink
● tremors
● headache
● increase BP/ Hypertension
● palpitation
● agitation
● insomnia

b. 12-24o

● after last drink

● convulsions
● hallucinations

c. 36-48o

● Delirium Tremens

IV. Delirium Tremens

● Active Seizure = Grandmal/Tonic-Clonic

● Delirium tremens is initially manifested by anxiety, restlessness, illusions, hallucinations and elevated vital signs.

DETOXIFICATION (DRYING OUT)

● Process of assisting an individual to go through withdrawal safely and successfully

● Disulfiram (Antabuse)
● AVOID:vanilla,vinegar,aftershave lotion,mouthwash,polish remover,backrub ointment,cologne,isoprophyl alcohol)

Effect of Antabuse with Alcohol

1. Nausea & Vomiting

2. Diarrhea

3. Intense headache

4. Abdominal cramps

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> Short term objective for an alcoholic: To stop/cut denial

Long term objective: Abstinence (similar with STD/HIV/AIDS)

Drug Abuse Mental Health "Psychiatric Care"

PHARMA MOMENTS

SUBSTANCE ABUSE

Downers (AMBON INE)

● Alcohol
● Marijuana
● Barbituates
● Opiates
● Narcotics

● Uppers (CHA)
● Cocaine
● Hallucinogen
● Amphetamines

Opiate plus Cocaine = sustained high!!!!!!

● Morphine
● Codeine
● Heroine

NARCAN 🡪 antidote

DETOXIFICATION 🡪 withdrawal with MD Supervision METHADONE

OVERDOSE

Alcohol Cocaine

Coma Seizure

SEXUAL DISORDERS

● Paraphilia
● Sadism
● Masochism
● Pedophilia
● Fetishism
● Voyeurism
● Frotteurism
● Telephone Scatologia

NURSING MANAGEMENT FOR SEXUAL DISORDERS

1. Self-awareness on the part of the nurse

2. Clarify sexual values
3. Behavior therapies
4. Accept person but not the act

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 5. Engage patient in productive activity

PERSONALITY DEVELOPMENT THEORIES

THEORISTS THEORIES

1. Sigmund Freud Personality structures and Psychosexual Theory

2. Erik Erickson Psychosocial

3. Jean Piaget Cognitive Development

4. Harry Stuck Sullivan Interpersonal

5. Kohlberg Moral Development

6. Adolf Meyer Psychobiology

7. Alfred Adler Individual Psychology

8. Carl Jung Introvert vs. Extrovert

9. Carl Rogers Client - Centered

10. Otto Rank Birth Trauma Theory

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