BIOPHYSICAL CONCEPT

CATEGORY: COGNITION
Obsessive compulsive Disorder
 Obsessive Compulsive Disorder (OCD)

• Can be present with other anxiety disorders

• Obsessions are recurrent and persistent thoughts, impulses, urges or images
– Experienced as intrusive and inappropriate and cause distress
–Patient is aware that they are a product of their mind
Compulsions are repetitive behaviors
–Patient is aware that they are a product of their mind
–common compulsions include: Hand washing, Ordering, Symmetry, Hair
pulling, Skin Picking, Checking, Praying, Counting, and Repeating words silently
• Significantly interfere with the person's functioning on the job, at school and/or
within social settings and relationships. 
 
 OCD
• COMPULSIONS
– Aimed at REDUCING anxiety
– Usually distress, shame about behavior
– Time consuming

– Person may say, I don’t know why I am doing this, or may say, I must
do this, I just must
 OCD Interventions

Medications:
First line: SSRIs (fluvoxamine, sertraline)
Second line: SNRI (venlafaxine)
Treatment-resistant OCD: second-generation antipsychotics (risperidone, quetiapine,
olanzapine)
For compulsions;
– If behaviors are not harmful, try not to call attention to the compulsive acts initially
– Do not force patient to stop compulsions, will result in ANXIETY
– Work with patient, to develop plan
• How often has obsessions
• How often has urge to do compulsions
• How to gradually reduce # of compulsions
• Substitute a physically safe behavior for harmful practices.
 Hoarding Disorder

• Persistent difficulty discarding of possessions regardless of actual value

• Distress associated with getting rid of the items
• Accumulation of possessions results in clutter/congestion of living spaces
• If living areas are uncluttered, it is because of a third-party intervention
• Most individuals with hoarding disorder (80-90%) also buy excessively and or
acquire free items(leaflets, items discarded by others)
• Interventions
Substitute a safe behavior (relaxation techniques, exercise, yoga, meditation…)
that can replace collecting behaviors.
Support groups
Assist patient with de-cluttering home environment
Pharmacology –anxiolytics/ anti-depressants
 somatic symptom Illnesses

• Somatization: Physical symptoms without a physiological basis

• Physical symptoms are precipitated by a psychological event
• The patient is not voluntarily able to control these symptoms (Not
intentionally produced)
Types of disorders
– Somatic symptom disorder is characterized by one or more physical
symptoms that have no organic basis
• Described as sickly
– Illness anxiety disorder, formerly hypochondriasis, is preoccupation
with the fear that one has a serious disease
• even though the results of tests (CAT scans, X rays, blood work…)
prove the disease is not there.
 Interventions: somatic symptom Illnesses

• Minimize the time and attention spent to discussing physical complaints

and refocus the patient on the psychological issues and give the patient a
specific amount of time they can talk about the physical complaint (5
minutes)
• Redirect to the psychological problems.
• The nurse can remind the patient that if the mind feels better so will the
body.
• Gradually connect anxiety to the physical complaints as the patient is
ready to tolerate this.
• Help client express emotions: journaling any other positive activities
• Teach coping strategies
SCHIZOPHRENIA
 SCHIZOPHRENIA

 Overview
 Risk Factors
 Etiology

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 ASSESSMENT

 Medical history
 Family History and relationships
 Substance Use and Abuse .
 Psychiatric History
 Labs and Diagnostics
 Psychometric Testing/DSM V

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 POSITIVE SYMPTOMS
 Thought Process and Content
 Delusions
 Hallucinations
 Illusions
 Concrete/Abstract
 Attention/Concentration
 Memory and Orientation
 Insight/ Judgment
 Calculation 12

 Level of Consciousness
 BEHAVIOR

 Impulsivity
 Catatonia
 Stupor
 Posturing
 Waxy Flexibility
 Ritualistic/Sterotypical
 Echopraxia

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 DISORGANIZED SPEECH
 Loose associations
 Flight of ideas
 Tangential
 Circumstantial
 Neologisms
 Word Salad
 Clang Associations
 Echolalia
 Mutism 14
 NEGATIVE SYMPTOMS
 Autistic
 Affect
 Alogia
 Avolition
 Anhedonia
 Ambivalence
 Apathy
 Anergia
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 Appearance
 COURSE OF THE ILLNESS

 Pro-dromal
 Acute
 Stable

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 PRO-DROMAL PHASE

 Slow and insidious

 Dysfunctions of thinking
 Misinterpretation of others
 Increased symbolic meaning
 Withdrawing
 Preoccupied with religion

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 ACUTE PHASE

 Psychotic symptoms
 Disorganization

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MAINTENANCE /STABLE/LONG
TERM PHASE

 Intensity of psychosis diminishes

 Illness becomes less disruptive and easier to manage
 Management in the community
 Develop a trusting therapeutic relationship in order to:
 Enhance social skills
 Medication management
 Psycho-educational material
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 PLAN
 Disturbed Thought Process
 Short Term Goal
 Patient states thoughts are less intense and less frequent with
medications and nursing interventions within 48 hours.
 Patient discussed concrete events not delusions for 5 minutes
twice a shift within 24 hours.
 Long Term Goal
 Patient demonstrates two coping skills that minimize delusional
thoughts within two weeks.
 PLAN

 Disturbed Sensory Perception

 Short Term Goal
 State using a scale (1-10) that the voices are less disturbing or
less distracting within 72 hours.
 Long Term Goal
 Patient will demonstrate tasks that distract self from the
hallucinations within two weeks.
 PLAN

Defensive Coping-Paranoia
 Short Term Goal
 Focus on reality-based activity for 15 minutes with
medications and nursing intervention within 48 hours.
 Long Term Goal:
 Demonstrate 2 techniques that decrease suspiciousness on
own within 2 weeks.
 
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 PLAN

Impaired Social Interaction

 Short Term Goal
 Engage in 1 activity with nurse by the end of 48 hours.
 Long Term Goal
 Participate in 1-2 group activities with minimal
encouragement within 2 weeks.

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 INTERVENTIONS

 Thought Processes
 Sensory Perception
 Defensive Coping-Paranoia

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 INTERVENTIONS

 Social Interaction
 Self Care
 Intake/ Sleep/ Hygiene
 Safety
 INTERVENTIONS

 Communication
 Patient Centered Care/Caring
 PHARMACOLOGY
ANTI-PSYCHOTICS

Typicals Atypicals
 Targets positive  Targets positive and negative
symptoms symptoms
 Can make negative  Fewer motor side effects
symptoms worse
 Numerous side effects

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 PSYCHOPHARMACOLOGICAL
ANTI-PSYCHOTICS TYPICAL AND ATYPICAL
 Actions/Intended Effects
 General Side Effects
 Sedation
 Anticholinergic effects
 Weight gain
 Photosensitivity
 Decreased Seizure threshold
 Orthostatic hypotension
 Galactorrhea/amenorrhea
 Sexual dysfunction
 PSYCHOPHARMACOLOGICAL
ANTI-PSYCHOTICS TYPICAL AND ATYPICAL

 Other Side effects

 Reversible Extrapyramidal System (EPS)
 Acute Dystonic Reaction
 Akathisia
 Pseudo-parkinsonism
 PSYCHOPHARMACOLOGICAL
ANTI-PSYCHOTICS TYPICAL AND ATYPICAL

Other Side effects

 Irreversible Extrapyramidal Side Effects (EPS )
 Tardive dyskinesia (TD)
Toxic Effects
 Neuroleptic Malignant Syndrome (NMS)
 Contraindications
 Teaching
ANTI-PSYCHOTIC MEDICATION LIST

Atypical Typical
Clozaril (clozapine) ** Haldol (haloperidol)
Risperdal (risperidone) Prolixin (fluphenazine)
Zyprexa (olanzepine) Trilafon (perphenazine)
Seroquel (quetiapine)
Geodon (ziprasidone) Typicals
Abilify (aripiprazole) Targets positive
symptoms
Can make negative
symptoms worse
Atypicals Numerous side effects
Targets positive and
negative symptoms
Fewer motor side effects
 EVALUATION
 The patient states that the voices are no longer interfering
with day-to-day tasks.
 Delusions no longer interfere with patients’ ability to
function in family, social, work situations.
 Patient will engage in pre-crisis level of self care.
 Patient uses appropriate social skills in interactions.
 Patient demonstrates decreased suspicious behaviors when
interacting with others.

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DELIRIUM
 OVERVIEW/ RISK FACTORS

 Overview
 Abrupt onset
 Fluctuating levels of consciousness
 Reversible
 Risk Factors
 Age
 Severity of illness
 Terminal illness
 Dementia
Feature DELIRIUM
ONSET Abrupt, Acute, days to weeks
DURATION Days to weeks
REVERSIBLE Yes
ATTENTION/STABILITY/LEVEL Unable to focus and changes
OF CONSCIOUSNESS from hour to hour/Fluctuating
HALLUCINATIONS Yes
ORIENTATION Disoriented to place, and/or
time
COURSE Gradually clears once causes
are treated.
 ASSESSMENT: DELIRIUM
 Underlying Cause of Illness
 Symptoms
 Cognitive
 Attention
 Level of Consciousness
 Reality Testing
 Orientation
 Memory
 Language
 Thought Processes
 Personality
 Psychomotor Behavior
 Emotional Disturbance
 ASSESSMENT

 Labs and Diagnostics

 Psychometric Tools/ DSM
 PLAN

 Confusion
 Short Term Goal
 Patient will respond without fear to staff's efforts to
communication techniques within 24 hours.
 Long Term Goal
 Patient will return to pre-morbid cognitive functioning
within two weeks.
 INTERVENTIONS

Confusion
 Communication
 Environment
 Agitation
Physical
Caring
Teaching
Safety
 EVALUATION

 The patient has returned to baseline level of

functioning in all affected areas.
DEMENTIA
 OVERVIEW

 Dementia
 Gradual and progressive
 Global decline
 Irreversible
ETIOLOGY: DEMENTIA
ETIOLOGY: DEMENTIA

 Plaques
ETIOLOGY: DEMENTIA
Tangles
 RISK FACTORS

 Dementia
 Age
 Genetics
 Lack of Exercise
 Nutrition
 Metabolism
Feature DEMENTIA

ONSET Slow, gradual (years)

DURATION Years

REVERSIBLE No

ATTENTION Able to focus until late in the illness

HALLUCINATIONS Only in late phase

LEVEL OF Alert until late phase

CONSCIOUSNESS

ORIENTATION Orientation intact initially, gradually loses orientation

to place and time. Orientation to person lost in late
phase.
COURSE Slow, progressive deterioration in all cognitive
functions
 “A GLOBAL DECLINE IN COGNITIVE
FUNCTIONING”

 Characteristics
 Cognitive
 Attention
 Level of Consciousness
 Reality Testing
 Orientation
 Memory
 Language
 Calculation
 Thought Processes
 ASSESSMENT

 Denial, confabulation, perseveration, avoidance

 Tools
STAGES OF ALZHEIMER’S DISEASE

Stage 1-Early
Disorientation about time
Difficulty with judgment
Depression and anxiety
Stage 2-Middle
New information can not be retained
Remote memory loss
Stage 3-Late
Hyperorality
Hyperetamorphosis
 ASSESSMENT

 Labs and Diagnostics

 Abuse and Neglect
 PLAN

Risk of Injury
 Short Term Goal: With nursing intervention patient will
remain free from injury immediately.
 Long Term Goal: With guidance and environmental
manipulation patient will not hurt himself/herself
within three weeks.
 PLAN

Self-Care Deficit
Short Term Goal: Participate in step-by-step instructions for bathing,
dressing, grooming, eating and toileting with nursing assistance and
guidance within 48 hours.
Long Term Goal: Patient will participate in self-care at optimal level
with supervision and guidance with evaluations of patients’ abilities
every two weeks.

Impaired Memory
Short Term Goal: Patient will be involved with their milieu within 48
hours of admission with nursing assistance.
Long Term Goal: Patient will be able to communicate to his/her
optimal ability using visual/verbal cues with assistance of care providers.
 INTERVENTIONS

 Risk of Injury
 Wandering
 Injuries/ Accidents
 Driving
 Medication administration
 Cooking
 INTERVENTIONS
 Self Care Deficit
 Nutrition
 Toileting
 Constipation
 Sleep
 Dressing/Bathing
 Mobility
 INTERVENTIONS

 Impaired Memory
 Reminiscence
 Safety
 Catastrophic Reactions.
 Inappropriate Behavior
 Labile
 Personality Changes
 INTERVENTIONS

 Confusion
 Communication
 Caring
 Culture/Spirituality
 PSYCHO-PHARMACOLOGY-
CHOLINESTERASE INHIBITOR

 Action
 Intended
 Side Effects
 Toxic Effects
 Teaching
 Drugs:
 Tacrine (THA, Cognex), Galantamine (Reminyl),
Rivastigmine (Exelon), Donepezil (Aricept)
 PSYCHO-PHARMACOLOGY-
NEUROTRANSMITTER INHIBITOR

 Action
 Intended Effects
 Side Effects
 Toxic Effects
 Teaching
 Drugs:
 Memantine (Namenda)
 OTHER PSYCHO-PHARMACOLOGY

 Anti-Inflammatory
 Anti-Cholesterol
 Buspar/Benzodiazepines
 Trazodone
 Antipsychotics
 Anti-Depressants
 Mood Stabilizer
 INTERVENTIONS

 Teaching
 Course of the Illness
 Grieving
 Unacceptable Feelings
 INTERVENTIONS

 Caregiver
 Self care
 Physical and Psychological
 Exhaustion
 Respite
 Support Groups
 Resources
 Financial
 Legal
 Placement
 EVALUATION

 Evaluation should be directed at maximizing quality of life and

maximizing function and must be adjusted throughout the
course of dementia.
 IndicatorDepression Delirium Dementia
DEPRESSION VS. DELIRIUM VS. DEMENTIA

Onset Relatively Rapid Rapid Slow

Duration Short or long Brief Progressive
Level of No change Decreased / No change
Consciousness fluctuates
Thinking Slow, difficulty Disorganized Eventually disappears
with decisions
EARLY LATE
Short-term Short and long
Memory Loss Short term Short term
Speech Normal or slow Slurred; rambling; Normal aphasic
irrelevant

Psychosis Sometimes Sometimes none Sometimes

Mood Depressed Anxious; fearful; Anxious labile,
irritable depression restless,
agitated