PSYCHIATRIC NURSING General appearance, Attitude & Behavior, Posture, Gait, Activity, facial Expressions, Mannerism AUTOMATISM Repeated

purposeless, behavior often indicative of anxiety, such as drumming of fingers, twisting locks of hair WAXY FLEXIBILITY Maintenance of posture or position over time when it is awkward and uncomfortable. DYSKINESIA a permanent condition marked by uncontrollable lip smacking , grimacing and tongue movement. A. General Appearance attribute and behavior A. Attribute: a. Unkept b. Disbeveled (untidy) c. Clean d. Neat e. Unusual B. Attire: a. Appropriate b. Seductive c. Loud d. Meticulous (particular) e. Untidy f. Atypical (Uncommon) C. Gait Manner of Walking a. Normal b. Parkinson c. Shuffling gait (walk without liftng the feet) d. Unusual D. Motor Activity a. Unremarkable b. Agitated c. Hyperactive d. Pacing a particular style of walking e. Handwringing E. Facial Expression a. Characteristics

1.Smiling tense 2.Alert 3.Worried 4.Sad 5.Tearful 6.Happy 7.Angry suspicious 8.Frightened 9.Distant b. Moods and Affect 1. EUPHORIC is a state of mood usually marked by an almost bubbly enthusiastic joyfulness 2. EUTHYMISM refers to a normal mood as subjectively deprived by the patient which appears appropriate to the current situation 3. SAD/DEPRESSION is subjectively defined, feeling of sadness, helplessness 4. LABILE Fluctuating mood from depressed and crying to euphoria 5. ELATED Extreme feelings of happiness and well being which in the pathological state, is beyond what would be typical of most individuals in the particular situation. This often seen in manic. 6. AFFECT a. BLUNTED AFFECT showing little to slow - to respond facial expression b. BROAD AFFECT displaying a full range of emotional expressions c. FLAT AFFECT showing no facial expressions d. INAPPROPRIATE AFFECT displaying a facial expressions that is incongruent with mood or situation, often silly or giddily regardless of circumstances e. RESTRICTED AFFECT displaying one type of expression usually 7. HISTRIONIC Characterized by adaption of exaggerated mannerism. Gestures and descriptions are after theoretical seductive or highly excited. 8. ANXIOUS a. Tense and worried b. Rapid heart beat c. Sweaty palms

d. Shortness of breath e. The patient may be aware or unaware of the reasons for his affective state. 9. ANGRY

Thought Process and Content THOUGHT PROCESS - how the client thinks THOUGHT CONTENT what the client actually says CIRCUMSTANTIAL THINKING a client eventually answers questions but only after giving excessive unnecessary detail DELUSION a fixed false belief not based in reality 1. THOUGHT CONTROL, BROADCASTING AND INSERTION A feeling that an outside person or force a. Thought Control controlling his thought b. Broadcasting able to hear his thought c. Insertion - putting thought in his mind 2. INFLUENCE a. Suffering from delusion of influence will state that they feel that an outside force is influencing their behavior or their thinking 3. PARANOID divided into two types a. PERSECUTORY a. A person with persecutory delusions will related fears that other people or outside agencies are plotting against him to do him harm b. GRANDIOSE b. exaggerated content of themselves 4. SOMATIC most commonly seen in cases of affective d/o esp. with psychotic depression Ex. Worms eating his brain

FLIGHT OF IDEAS Excessive amount and rate of speech composed of fragmental or unrelated ideas IDEAS OF REFERENCE Clients inaccurate interpretation that general events are personally directed to him or her LOOSE ASSOCIATIONS Disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts. TANGENTIAL THINKING

Wandering off topics and never providing the information requested THOUGHT BLOCKING Stopping abruptly THOUGHT BROADCASTING THOUGHT WITHDRAWAL A delusion belief that others are talking the clients thought s away and the client is powerless to stop it WORD SALAD Flaw of unconnected words that convey no meaning to the listener. CHARACTERISTICS OF TALKS AND STREAMS OF THOUGHT Description emphasis on form of either than of clients verbal communication Loudness flows, speed, quality logic level of coherence

2. Character Talk 1. MUTISM patients refusal to talk 2. LOGICAL - able to think sensibly 3. SPONTANEOUSLY speech is organized 4. PRESSURED SPEECH 5. DELIBERATE goal directed and proceed to normal pace 3. Organization of Talk 1. PERSEVERATION characterized by repetition of speech movement or an idea over which an individual has no control 2. HALTING hesitant or done with frequent irregular pauses. 3. INCOHERENT - not clearly expressed or well thought 4. FRAGMENT there is loss of unity 5. RUMINATIONS to think carefully and at length about something 6. CONFABULATION to give fictitious accounts of past events believing they are true/Dementia or KORSAKOFF SYNDROME 7. NEOLOGISM inventing words or phrases that only be understand arrangement of words or syllables is a nonsense fashion 8. ECHOLALIA repeats the patients speech or question 9. VERBIGERATION - repeats word again and again 10. CLANG ASSOCIATION makes frequently rhymes or in severe cases may only in rhymes Content OF THOUGHTS Disturbances include: 1. ILLUSIONS misconceptions of external stimuli

2. DEPERSONALIZATION sense of feeling unreal strange or unfamiliar or emotionally numb 3. DEREALIZATION sense of reality surroundings or situations 4. OBSESSIONS maladaptive persistent patterns of thoughts 5. COMPULSIONS maladaptive urges to act on impulse 6. PREOCCUPATION voluntary attention given to repetitive thoughts that center on particular ideas associated with affective importance 7. PHOBIAS irrational fear FANTASIES AND DAYDREAMS - Unrealistic and impractical idea b. SENSORIUM and INTELLECTUAL PROCESS i. ORIENTATION recognition of time, place, person and self ii. MEMORY 1. Remote - access patient memory for important events that occured 2. Recent recalls events, hours and weeks 3. Immediate have just occurred and which covers a time span of second to minutes or called immediate memory iii. ABILITY TO CONCENTRATE ability to concentrate by asking the client to perform certain task iv. ABSTRACT THINKING 1. SIMILARITIES a. Ability to make the most abstract b. SENSORY PERCEPTUAL ALTERATION a. HALLUCINATION sensory perception that have no stimuli i. Auditory Hallucination such as hearing voice when no one else around b. JUDGEMENT and INSIGHT i. JUDGEMENT refers to the ability to interprets one environment ii. INSIGHT the ability to understand the true nature of ones situation and accept same personal responsibility for that situation

h. PHYSIOLOGIC AND SELF-CARE CONSIDERATION

SLEEP PATTERN 1. Normal Sleep feeling rested and refreshed 2. Hypersomnia Increase number of hours of sleep used as an escape mechanism from psychological stress 3. Insomnia difficulty of sleeping a. Early b. Late c. MIXED EATNG PATTERN 1. Anorexia Nervosa life threatening disorder 2. Bulimia Nervosa eating d/o characterized by recurrent episodes of binge eating followed by inappropriate compensatory to avoid wt gain

PSYCHOLOGIAL TEST Two Basic 1. Intelligence Test Evaluate client cognitive abilities and intellectual functioning 2. Personality Test Reflect the clients personality in areas such as self concept

OPEN/ PUBLIC WINDOW Qualities one knows about oneself and othes also know

BLIND/UNAWARE SELF Qualities known to others

JOHARI WINDOW UNKNOWN an empty quadrant to symbolize qualities as yet undiscovered by oneself or others

HIDDEN/ PRIVATE to oneself

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