PSYCHIATRIC NURSING

Introduction

MENTAL HEALTH balance in a persons internal life and adaptation to reality

Mental ILL Health state of imbalance characterized by a disturbance in a

persons thoughts, feelings and behavior
Psychiatric nursing

interpersonal process whereby the professional nurse practitioner ,through the

therapeutic use of self (art) and nursing theories (science), assist clients to achieve
psychosocial well being.

Core : interpersonal process

Related Terms

Mental hygiene

measures to promote mental health , prevent mental illness and suffering and
facilitate rehabilitation

Main tool: therapeutic use of self

It requires self-awareness

Methods to increase self-awareness:

Introspection
Discussion
Experience
Role play

Assessment (psychosocial processes )

Appearance , behavior or mood
Speech , thought content and thought process
Sensorium
Insight and judgment
Family relationships and work habits
Level of growth and development
Common Behavioral Signs and Symptoms
Disturbances in perception
Illusion
misinterpretation of an actual external stimuli

Hallucinations
false sensory perception in the absence of external stimuli

Disturbances in thinking and speech

neologism coining of words that people do not understand

Circumstantiality over inclusion of inappropriate thoughts and details

Word salad incoherent mixture of words and phrases with no logical sequence

Verbigeration meaningless repetition of words and phrases

Perseveration persistence of a response to a previous question

Echolalia pathological repetition of words of others
Aphasia speech difficulty and disturbance
Expressive , receptive or global

Flight of ideas- shifting of one topic from one subject to another in a somewhat
related way

Looseness of association-incoherent illogical flow of thoughts (unrelated way)

Clang association sound of word gives direction to the flow of thought

Delusion persistent false belief, rigidly held

Delusions of grandeur: special /important in a way
Persecutory: threatened
Ideas of reference: situation/events involve them
Somatic: body reacting in a particular way

Jealous: thinking that their partner is unfaithful

Erotomanic: person, usually of high status, is in love with the client
Religious: illogical ideas about God and religion exhibited by extreme or
extraneous behavior

Mixed: combination of above without a predominant theme

Magical thinking primitive thought process thoughts alone can change events

Autistic thinking regressive thought process; subjective interpretations not

validated with objective reality

Dereism unorganized thinking

Disturbances of affect
Inappropriate disharmony between the stimuli and the emotional reaction
Blunted affect severe reduction in emotional reaction
Flat affect absence or near absence of emotional reaction
Apathy dulled emotional tone
Depersonalization feeling of strangeness from ones self
Derealization feeling of strangeness towards environment
Agnosia lack of sensory stimuli integration
Disturbances in motor activity
Echopraxia imitation of posture of others
Waxy flexibility maintaining position for a long period of time
Ataxia loss of balance
Akathesia extreme restlessness
Dystonia- uncoordinated spastic movements of the body
Tardive dyskinesia involuntary twitching or muscle movements
Apraxia involuntary unpurposeful movements
Disturbances in memory
Confabulation filling of memory gaps
Dj vu something unfamiliar seems familiar
Jamais vu- something familiar seems unfamiliar
Amnesia memory loss (inability to recall past events)
Retrograde-distant past
Anterograde immediate past
Anomia lack of memory of items

Dynamics of Human Behavior

Behavior the way an individual reacts to a certain stimulus

Conflict situation arising from the presence of two opposing drives

Need - organismic condition that requires a certain activity

Dynamics of Human Behavior

Personality

totality of emotional and behavioral traits that characterize the person in day to
day living under ordinary conditions; it is relatively stable and predictable.
FORMATION OF PERSONALITY

TEMPERAMENT

biological-genetic template that interacts with our environment.

a set of in-built dispositions we are born with

mostly unalterable

our nature.

CHARACTER

the outcome of the process of socialization, the acts and imprints of our
environment and nurture on our psyche during the formative years (0-6 years and in
adolescence).

the set of all acquired characteristics we posses, often judged in a cultural-social

context.

Sometimes the interplay of all these factors results in an abnormal personality

THEORIES OF PERSONALITY DEVELOPMENT
Freuds
PSYCHOSEXUAL THEORY

Libido inner drive

Parts of body focus of gratification
Unsuccessful resolution - fixation
Structures of personality
Id: pleasure principle-instinct
Ego: controls action and perception reality principle
Superego: moral behavior - conscience
0-18 m0s ;oral mouth trust and discriminating
18 mos. 3 years ; anal bowels holding on or letting go
Negativism and toilet training age
3 -6 years phallic ; genitals exploration and discovery ( inc. sexual tension)

Gender identification and genital awareness

Oedipus and Electra complex
Castration anxiety and penis envy

6-12 years latency (quiet stage) sexual energy diverted to play. Institution of
superego: control of instinctual impulses

12 young adult genital ; reawakening of sexual drives relationships

Sexual maturation

Sexual identity ,ability to love and work

Eric Ericksons
PSYCHOSOCIAL THEORY

0-12mos
1-3y

3-6
6-12
12-18

18-25
25-60

60 and above
TRUST vs. MISTRUST
AUTONOMY vs. SHAME & DOUBT
INDUSTRY vs. INFERIORITY
INITIATIVE vs. GUILT
IDENTITY vs. IDENTITY CONFUSION
INTIMACY vs. ISOLATION
EGO INTEGRITY vs. STAGNATION
GENERATIVITY vs. DESPAIR

INFANCY
CONSISTENT MATERNAL CHILD INTERACTION TRUST
INNER FEELING OF SELF WORTH

HOPE
TODDLER

ALLOW EXPLORATION
PROVIDE FOR SAFETY
NO, NO NEGATIVISM
OFFER CHOICES / REVERSE PSYCHOLOGY
TOILET TRAINING 18 MOS.-BOWEL
DAYTIME BLADDER: 2 yo
NIGHTIME BLADDER: 3 yo
REWARD W/ PRAISE AND AFFECTION
INDEPENDENCE
PRE-SCHOOL
PROVIDE PLAY MATERIALS
SATISFY CURIOSITY
TEACH AND REINFORCE(HYGIENE,SOCIAL BEHAVIOR)
SIBLING RIVALRY
WILLPOWER
SCHOOL AGE
HOW TO DO THINGS WELL-SUPPORT EFFORTS
CHUMS AND HOBBIES
NEEDS TO EXCEL/ACCOMPLISH
NEED FOR PRIVACY AND PEER INTERACTION
COMPETENCE
ADOLESCENCE
MAKE DECISION,EMANCIPATION FROM PARENTS
BODY IMAGE CHANGES
NEED TO CONFORM BUT KEEP INDIVIDUALITY
SELF - AWARENESS
YOUNG ADULT

COMMITMENT AND FIDELITY

RESPONSIBILITY

ACHIEVEMENT OF INDEPENDENCE
MIDDLE ADULTHOOD
SUPPORT-PERIOD OF ROLE TRANSITIONS

MIDLIFE CRISIS

ADJUSTMENT AND COMPROMISE

MOST PRODUCTIVE AND CREATIVE

ALTRUISM
LATE ADULTHOOD

SELF ACCEPTANCE

SELF WORTH

WISDOM
Jean Piagets
COGNITIVE THEORY
0-2 SENSORIMOTOR

REFLEXES

INDUCTIVE REASONING (SPECIFIC TO GENERAL)

IMITATIVE REPETITIVE BEHAVIOR

SENSE OF OBJECT PERMANENCE AND SELF SEPARATE FROM ENVT.

TRIAL AND ERROR RESULTS IN PROBLEM SOLVING

2-7Y PRE-OPERATIONAL

SELF-CENTERED,EGOCENTRIC

CANNOT CONCEPTUALIZE OTHERS VIEW

ANIMISTIC THINKING

IMAGINARY PLAYMATE SYMBOLIC MENTAL REPRESENTATION

CREATIVITY

2-4 PRE-CONCEPTUAL (PRE-LOGICAL)

4-7 INTUITIVE (UNDERSTANDING OF ROLES)

7-12Y CONCRETE OPERATIONAL

LOGICAL CONCRETE THOUGHT

CAN RELATE, PROBLEM SOLVING ABILITY

REASONING AND SELF-REGULATION
12-ABOVE: FORMAL OPERATIONAL THOUGHT
Abstract thinking
Separation of fantasy and fact
Reality oriented
Deductive reasoning

Apply scientific method

Havighursts
DEVELOPMENTAL TASKS

Baby to early childhood

Right from wrong and Conscience
Late childhood
Physical skills, wholesome attitude, social roles
Conscience morality and values
Fundamental skills in academics
Personal independence

Adolescence
Sexual social roles
Relationships
Independence and ideology
Early adulthood
Career
Selecting a mate
Finding Civic or social responsibility

Middle age
Achieving Civic or social responsibility
Adjusting to changes
Satisfactory career performance
Adjusting to aging parents
Adjusting to parental roles
Old age
Adjusting to changes
Establishing satisfactory living arrangements and affiliations
Kohlbergs
MORAL DEVELOPMENT/ THINKING/ JUDGEMENT

PRE-CONVENTIONAL (0-6)
PUNISHMENT AND OBEDIENCE
OBEDIENCE TO RULES TO AVOID PUNISHMENT

CONVENTIONAL ( 6-12 )

MUTUAL INTERPERSONAL EXPECTATIONS,RELATIONSHIPS AND

CONFORMITY

SOCIAL SYSTEM AND CONSCIENCE MAINTENANCE

BEING GOOD IS IMPORTANT SELF RESPECT OR CONSCIENCE

POST CONVENTIONAL (12 18 Y)

PRIOR RIGHT OR SOCIAL CONTRACT

UNIVERSAL ETHICAL PRINCIPLE

ABIDE FOR COMMON GOOD

RATIONAL PERSON-VALIDITY OF PRINCIPLES-AND BECOME

COMMITTED TO THEM

INNER CONTROL OF BEHAVIOR UNDERSTANDING THE EQUALITY OF

HUMAN RIGHTS AND DIGNITY OF HUMAN BEINGS AS INDIVIDUALS
Harry Stack Sullivans
INTERPERSONAL THEORY
INFANCY

NEED FOR SECURITY-INFANT LEARNS TO RELY ON OTHERS TO

GRATIFY NEEDS AND SATISFY WISHES, DEVELOPS A SENSE OF BASIC
TRUST, SECURITY AND SELF WORTH WHEN THIS OCCURS
TODDLERHOOD / EARLY CHILDHOOD

CHILD LEARNS TO COMMUNICATE NEEDS THROUGH USE OF WORDS

AND ACCEPTANCE OF DELAYED GRATIFICATION AND INTERFERENCE OF
WISH FULFILLMENT
PRE-SCHOOL

DEVELOPMENT OF BODY IMAGE AND SELF-PERCEPTION

ORGANIZES AND USES EXPERIENCES IN TERMS OF APPROVAL AND

DISAPPROVAL RECEIVED

BEGINS USING SELCTIVE INATTENTION AND DISASSOCIATES THOSE

EXPERIENCES THAT CAUSE PHYSICAL OR EMOTIONAL DISCOMFORT AND
PAIN
SCHOOL AGE

THE PERIOD OF LEARNING TO FORM SATISFYING RELATIONSHIPS

WITH PEERS-USES COMPETITION,COMPROMISE AND COOPERATION

THE PRE-ADOLESCENT LEARNS TO RELATE TO PEERS OF THE SAME

SEX
ADOLESCENCE

LEARNS INDEPENDENCE AND HOW TO ESTABLISH SATISFACTORY

RELATIONSHIPS WITH MEMBERS OF THE OPPOSITE SEX
YOUNG ADULTHOOD

BECOMES ECONOMICALLY, INTELLECTUALLY AND EMOTIONALLY

SELF SUFICIENT
LATER ADULTHOOD

LEARNS TO BE INTERDEPENDENT AND ASSUMES RESPONSIBILITY

FOR OTHERS
SENESCENCE

DEVELOPS AN ACCEPTANCE OF RESPONSIBILITY FOR WHAT LIFE IS

AND WAS AND OF ITS PLACE IN THE FLOW OF HISTORY
TREATMENT MODALITIES
REMOTIVATION THERAPY

TREATMENT MODALITY THAT PROMOTES EXPRESSION OF FEELINGS

THROUGH INTERACTION FACILITATED BY DISCUSSION OF NEUTRAL
TOPICS

STEPS :
climate of acceptance
creating bridge to reality
sharing the world we live in
appreciation of works of the world
climate of appreciation

MUSIC THERAPY
Involves use of music to facilitate expression of feelings, relaxation and outlet of

tension

PLAY THERAPY
enables patient to experience intense emotion in a safe environment with the use

of play

children express themselves more easily in play. revealing as reflection of childs

situation in the family

provide toys and materials facilitate interaction observe and help child resolve
problems through play
Group therapy

Treatment modality involving three or more patients with a therapist to relieve

emotional difficulties, increase self esteem, develop insight , LEARN NEW
ADAPTIVE WAYS TO COPE WITH STRESS and improve behavior with others

IDEAL 8 10 MEMBERS
MILIEU THERAPY

Consists of treatment by means of controlled modification of the patients

environment to facilitate positive behavioral change

Increase patients

Awareness of feelings

Sense of responsibility and

Help return to community

clients plan social and group interaction

token programs , open wards and self medication are done

FAMILY THERAPY

A METHOD OF PSYCHOTHERAPY WHICH FOCUSES ON THE TOTAL

FAMILY AS AN INTERACTIONAL SYSTEM

PROBLEM IS A FAMILY PROBLEM

focus on sick members behavior as source of trouble / symptom serve a function

for the family

members develop sense of identity

points out function of the sick member for the rest of the family
PSYCHOANALYTIC

focuses on the exploration of the unconscious, to facilitate identification of the

patients defenses

ANXIETY RESULTS BETWEEN CONFLICTS OF ID AND EGO

Becomes aware of unconscious thoughts and feelings to understand anxiety and

defenses
HYPNOTHERAPY

Various methods and techniques to induce a trance state where patient becomes
submissive to instructions
BEHAVIOR MODIFICATION

Application of learning principles in order to change maladaptive behavior

Believes that psychological problems are a result of learning

DESENSITIZATION
Slow adjustment or exposure to feared objects (phobias)
Periodic exposure until undesirable behavior disappears or lessens

Everything learned can be unlearned

BEHAVIOR MODIFICATION

OPERANT CONDITIONING

Use of rewards to reinforce positive behavior

Perceived and self-reinforcement becomes more important than external

reinforcement

AVERSION THERAPY
An example of behavior modification
Painful stimulus is introduced to bring about an avoidance of another stimulus
End view: behavioral change
OTHER THERAPIES
HUMOR THERAPY
To facilitate expression and enhance interaction
ACTIVITY THERAPY
Group interaction while working on a task together
BIOLOGICAL/ MEDICAL THEORY
EMOTIONAL PROBLEM IS AN ILLNESS
cause may be inherited or chemical in origin

FOCUS OF TREATMENT IS MEDICATIONS AND ECT

BIOLOGICAL THERAPY

ELECTROCONVULSIVE THERAPY

Artificial induction of a grand mal seizure by passing a controlled electrical

current through electrodes applied to one or both temples

mechanism of action unclear

voltage: 70 150 volts

Duration: 0.5 2.0 seconds

6 to 12 treatments

intervals of 48 hours

indicators of effectiveness occurrence of generalized tonic clonic seizures

indications depression , mania and catatonic schizophrenia

s/e: confusion, disorientation, short -term memory loss, seizure (30-60 sec)
NPO prior
Contraindications
Fever, pregnancy
Inc ICP, fracture
retinal detachment
TB with hemoptysis
cardiac d/o
consent needed
Reorient after, supportive care
medications given :
Atropine sulfate: decrease secretions
Succinylcholine (Anectine): promote muscle relaxation

Methohexital Sodium ( Brevital ): serves as an anesthetic agent

common complications:
loss of memory
headache
apnea
fracture
respiratory depression

Psychopharmacologic Therapy
Benzodiazepines
Indications
Anxiety
Sedation/sleep
Muscle spasm
Seizure disorder
Alcohol withdrawal syndromes
Generic
Alprazolam
Chlordiazepoxide
Clorazepate
Diazepam
Lorazepam
Oxazepam
Busipirone

Anti-anxiety drugs
Trade name
Xanax
Librium
Tranxene
Valium
Ativan
Serax
BuSpar
Side effects

Drowsiness/ sedation
Ataxia
Feelings of detachment
Increase irritability and hostility
Anterograde amnesia
Increased appetite & weight gain
Nausea
Headache, confusion
Anti-depressants

Indications
Depression
Bipolar depression
Panic disorder

Bulimia
Obsessive-compulsive d/o

Possibly

Attention deficit/Hyperactivity d/o

Post Traumatic Stress D/o

Conduct d/o
Tricyclic (TCA)
Generic
Trade name
Amitriptyline
Elavil
Imipramine
Tofranil
Trimipramine
Surmontil
Nortriptyline
Pamelor
Trazodone
Desyrel
Bupropion
Wellbutrin
Side effects

Orthostatic hypertension

Anticholinergic effect

Dry mouth, blurred vision, constipation, excessive sweating, urinary hesitancy/

retention, tachycardia, agitation, delirium, exacerbation of glaucoma

Neurologic effects

sedation, psychomotor slowing, poor concentration, fatigue, ataxia, tremors

Decrease libido and sexual performance

Monoamine Oxidase inhibitors

Trade name
Marplan
Nardil
Parnate
Side effects
Postural lightheadedness

Generic
Isocarboxazid
Phenelzine
Tranylcypromine

Constipation
Delay ejaculation or orgasm
Muscle twitching
Drowsiness
Dry mouth
Dietary restrictions
Cheese, esp. aged and matured
Fermented or aged protein

Pickled or smoked fish

Beer, red wine, sherry; liquor & cognac
Yeast
Fava or broad beans
Beef or chicken liver
Spoiled/ overripe fruits; banana peel
yogurt
Hypertensive Crisis
Signs
Sudden elevation of BP
Explosive headache, occipital may radiate frontally
Head & face flushed
Palpitations, chest pain
Sweating, fever
Nausea, vomiting
Dilated pupils, photophobia
Intracranial bleeding
Treatment
Hold next MAO dose
Dont let pt. lie down
IM chlorpromazine 100 mg
Fever: manage by external cooling techniques
Serotonin Reuptake Inhibitors
Generic
Trade name
Fluoxetine
Prozac
Sertraline
Zoloft
Paroxetine
Paxil
Venlafaxine
Effexor
Side effects
Nausea
Diarrhea
Insomnia
Dry mouth
Nervousness
Headache
Male sexual dysfunction

Drowsiness
Dizziness
Sweating
Mood stabilizing drugs
Indications
Acute mania
Bipolar prophylaxis
Possibly
Bulimia
Alcohol abuse
Aggressive behavior
schizoaffective

Mode of action

Normalizes the reuptake of certain neurotransmitters such as serotonin,

norepinephrine, acetylcholine and dopamine

Reduces the release of norepinephrine thru competition with calcium

Effects intracellularly

Lag period: 7-10 to 14 days

Lithium carbonate

Trade names

Eskalith

Lithotabs

Lithane

Lithonate

MOA: unclear; interfere with metabolism of neurotransmitters; alter Na transport

in nerves and muscle cells

Prelithium workup

Urinalysis (BUN and creatinine)

ECG, FBC, CBC

Side effects

Early

Nausea and diarrhea

Anorexia

Fine hand tremor (propranolol)

Thirst, Polydipsia (dec. crea, inc. albumin)

Metallic taste

Fatigue

Lethargy

Late
Weight gain
acne

Contraindications
Brain damage/ CV disease
Epilepsy
Elderly/ debilitated
Thyroid and renal disease
Severe dehydration
Pregnancy (1st trimester)

Can augment the effects of anti-depressants

Nursing considerations

Therapeutic serum level: 0.5 1.2 meq/L

Maintenance level: 0.6 -1.2 meq/L

Toxic

Mild to moderate: 1.5 to 2 meq/L

Moderate to severe: 2 2.5 meq/L

Needs dialysis: 3 meq and above

Early signs of toxicity

Lethargy, mild nausea, vomiting, fine hand tremors, anorexia, polyuria,

polydipsia, metallic taste, fatigue

Late signs of toxicity

Ataxia, giddiness, tinnitus, blurred vision, polyuria

Nursing considerations
Lithium levels should be checked q 2-3 mos
Serum drawn in the AM, 12H after last dose
Common causes of inc. levels
Dec. Na intake
Diuretic therapy
Dec. renal functioning
F&E loss
Medical illness
Overdose
NSAIDS
Nursing considerations
Diet: adequate Na+ and fluid

3g NaCl/ day
6-8 glasses of H2O

No caffeine

No driving: wait for clinical effect

Management
Moderately severe toxicity
Osmotic diuresis: urea/ mannitol
Aminophylline & PLR IV
Adequate NaCl
Peritoneal/ hemodialysis
Severe toxicity
Assess hx quickly
Hold next lithium dose
Check BP, rectal T, RR, LOC, support O2
Obtain labs
ECG
Emetic, NGT lavage
Hydrate: 5-6L/day c PLR; FBC-CDU
Other drugs
Carbamazepine (Tegretol)
Side effects
Dizziness
Ataxia
Clumsiness
Sedation
Dysarthria
Diplopia
Nausea & GI upset
Preparation: liq, tab, chewable tab
Nursing considerations
Assess drug levels q 3-4 days
Monitor salt and fluid intake
Avoid alcohol and non-prescription drugs
Refer dec. in UO
Dont stop abruptly
C/I: pregnancy
Take with meals
Other drugs
Valproic acid (Depakote, Depakene)

Side effects
Nausea
Hepatoxicity
Neurotoxicity
Hematological toxicity
Pancreatitis
Prep: tab, cap, sprinkles

MOA: inc. levels of GABA; inhibits the kindling process or snoball-like effect
seen in mania & seizures
Nursing considerations

Therapeutic level: 50 100 ug/mL

Dose: 1, 000 1,500 mg/day

Monitor serum levels 12H after last dose

Toxic effects
Severe diarrhea, vomiting, drowsiness, mm. weakness, lack of coordination
Renal failure, coma, death
Anti-psychotic drugs
Indications
Psychotic symptoms of schizophrenia, acute mania and depression
Gilles de Tourette disorder
Treatment-resistant bipolar disorder
Huntingtons disease and other movement disorder

Possibly
Paranoid
Childhood psychoses

MOA: block receptors of dopamine (D2, D3, D4)

If unresponsive after 6 weeks of therapy, another class is tried

General considerations

Calms without producing impairment of sleep

High therapeutic index

Non addicting, no tolerance

Avoided in pregnancy
TYPICAL: High Potency
Fluphenazine (Prolixin)
Haloperidol (Haldol)
Thiothexene (Navane)
Trifluoperazine (Stelazine)

Moderate Potency
Loxapine (Loxitane)
Molindone (Moban)
Perphenazine (Trilafon)
Low Potency
Chlopromazine (Thorazine)
Chlorprothixene (Taractan)
Mesoridazine (Serentil)
Thioridazine (Mellaril)
ATYPICAL
Clozapine (Clozaril)
Resperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Sertindole (Serlect)
Ziprasidone (Zeldox)

Contraindications
CNS depression: brain damage, excess alcohol/ narcotics
Parkinsons disease
Allergy
Blood dyscrasias
Acute narrow angle glaucoma
BPH
Side effects

Hypotension
Sedation
Dermal and ocular syndrome
Neuroleptic malignant syndrome
Anticholinergic syndrome
Movement syndrome (Extrapyramidal Syndrome)
Atropine psychosis
Agranulocytosis
Seizures
Neuroleptic Malignant Syndrome
A potentially fatal, idiosyncratic reaction to an antipsychotic drug
10-20% mortality rate
Sx:
rigidity,
high fever,


autonomic instability (BP, diaphoresis, pallor, delirium, elev. CPK), confused or
mute, fluctuate from agitation to stupor

Occurs in the first 2 weeks of therapy

Risk: high dose of high-potency drugs; dehydration, poor nx, concurrent med
illness
Movement Syndromes

Akathisia

Dystonia
Tardive dyskinesia
Bradykinesia
Parkinsonism
Other s/e

Atropine psychosis (geriatrics)

Hyperactivity, agitation, confusion, flushed skin, sluggish reactive pupils
TTT: IM physostigmine

Agranulocytosis (Clozapine)
Occurs 3-8 wks after
Medical emergency
s/s: fever, malaise, sore throat, leukopenia
TTT: d/c, reverse iso, antibiotics

Seizures (Clozapine)
Occurs in 5% of patients; TTT: D/c drug
Anticholinergics
Benztropine (Cogentin)
Trihexyphenidyl (Artane)
Biperiden (Akineton)
Procyclidine (Kemadrin)

Not withdrawn abruptly

Provide cool environment

ANTIPARKINSONIAN MEDICATIONS

Adjunct to anti-psychotic agents to balance dopamine/ acetylcholine in the brain

s/e: glaucoma, tachycardia, HPN, cardiac dx, asthma, duodenal ulcer

A/e: blurred vision, photosensitivity, drowsiness, orthostatic hypotension, CHF,

hallucinations

COMMON DRUGS:
Trihexyphenidyl (Artane)
benztropine (Cogentin)
Biperiden (Cogentin)
Selegiline (Eldepryl)
Pergolide (Permax)

ANTIHISTAMINE
Diphenhydramine HCl (BENADRYL)

DOPAMINE RELEASING AGENT

Amantadine (SYMMETREL)
Nursing considerations
Best taken after meals
Avoid driving
Check BP
Alcohol increases sedative effects
Avoid sudden position change
Drug is not withdrawn abruptly
PSYCHIATRIC DISORDERS
ANXIETY DISORDERS

PANIC DISORDERS
SPECIFIC PHOBIA
SOCIAL PHOBIA
OCD
PTSD
ACUTE STRESS DISORDER

GENERALIZED ANXIETY DISORDER

PANIC ATTACKS

Discrete period of intense fear or discomfort in which at least 4 if the ff sx

develop abruptly and peak within 10 mins:

Palpitations, pounding heart, or accelerated HR

Sweating

Trembling or shaking

Sensations of SOB and smothering

Feeling of choking

Chest pain or discomfort

Nausea or abd. Pain

Feeling dizzy, unsteady, lightheaded or faint
Derealization or depersonalization
Fear of losing control or going crazy
Fear of dying
Paresthesias
Chills or hot flashes

SPECIFIC PHOBIA SOCIAL

Excessive and unreasonable cued by the presence or anticipation of a specific

object or situation

Defense mech commonly used include repression and displacement

Fear of social performance situations in which the person is exposed to unfamiliar

people or to possible scrutiny by others
OBSESSION COMPULSION

Recurrent and persistent thoughts, impulses, or images are experienced during the
disturbance as intrusive and inappropriate

Cause anxiety or distress

Px knows that these are just product of ones own mind.

Px feels driven to perform repetitive behaviors or mental acts in response to

obsession or according to the rules that one deems must be applied rigidly.

Aimed at reducing anxiety

OBSESSION
COMPULSION

Fear of dirt & germs

Fear of burglary or robbery

Worries about discarding something important

Concerns about contracting a serious illness

Worries that things must be symmetrical or matching

Excessive hand washing

Repeated checking of door and window locks
Counting and recounting of objects in everyday life
Hoarding of objects
Excessive straightening, ordering, or of arranging things
Repeating words or prayers silently

POST TRAUMATIC STRESS SYNDROME

Person has experienced, witnessed or been confronted with an event that involved
actual or threatened death or serious injury, or a threat to physical integrity

Person reexperiences these in the mind

Involves intense fear, helplessness, or horror and numbing of general

responsiveness (PSYCHIC NUMBING)
ACUTE
GENERALIZED
STRESS
ANXIETY

Meets the criteria for exposure to a traumatic event and person experiences 3 of
the ff sx:

sense of detachment,

reduced awareness of ones surroundings,

derealization,

depersonalization,

dissociated amnesia

Excessive anxiety or worry, occurring in more days than not for at least 6 mos,
about a number of events or activities

Finds it difficult to control the worry

MOOD/ AFFECTIVE DISORDERS

BIPOLAR D/O
BIPOLAR I: current or past experience of manic episode, lasting at least a week,
that is severe enough to cause extreme impairment in social or occupational functioning.

MANIA: hyperactivity

DEPRESSED: extreme sadness or withdrawal

MIXED

BIPOLAR II: hx of 1 or more mj depressive episodes & at least 1 hypomanic

episode; no mania

MAJOR DEPRESSIVE D/O

@ least 5 sx of same 2- wk period with one being either depressed mood or loss
of interest or pleasure.

Single episode or recurrent

Other sx: wt loss, insomnia, fatigue, recurrent thoughts of death, diminished

ability to think, psychomotor agitation or retardation, feelings of worthlessness.

CYCLOTHYMIC D/O

Hx of 2 yrs of hypomania with numerous periods of abnormally elevated,

expansive or irritable moods.

Does not meet the criteria of mania or depression.

DYSTHYMIC D/O

@ least 2 yrs of usually depressed mood and at least 1 of the sx of mj depression

without meeting the criteria for it

SEASONAL AFFECTIVE D/O

Depression that comes with shortened daylight in fall and winter that disappears
during spring and summer.
Dealing with Inappropriate Behaviors
AGGRESSIVE BEHAVIOR

Assist the client in identifying feelings of frustration and aggression

Encourage the client to talk out instead of acting out feelings of frustration

Assist the client in identifying precipitating events or situations that lead to

aggressive behavior

Describe the consequences of the behavior on self and others

Assist in identifying previous coping mechanisms

Assist the client in the problem-solving techniques to cope with frustration or

aggression
DEESCALATION TECHNIQUES

Maintain safety

Maintain large personal space and use nonaggressive posture

Use calm approach and communicate with a calm, clear tone of voice (be
assertive not aggressive

Determine what the client considers to be his or her need

Avoid verbal struggles

Provide clear options that deal with behavior

Assist with problem-solving and decision making regarding the options

MANIPULATIVE BEHAVIORS

Set clear, consistent, realistic, and enforceable limits and communicate expected
behaviors

Be clear about consequences associated with exceeding set limits

Discuss behavior in nonjudgmental and nonthreatening manner

Avoid power struggles

Assist in developing means of setting limits on own behavior

SCHIZOPHRENIA

characterized by impairments in the perception or expression of reality and by

significant social or occupational dysfunction.

Once considered as a deadly disease

There is lack of insight in behavior

Dx: late adolescence and early adulthood

15-25 y.o. (men); 25-35 y.o. (women)

Obsolete term: dementia praecox = cognitive deterioration early in life

Eugene Bleuler: schiz split; phren mind

Risk factors
Genetics: identical twins 50%, 15% for fraternal twins

Biochemical factors

Dopamine hypothesis: overactive

Serotonin imbalance

Decreased brain volume, enlarged ventricles, deeper fissures, and loss or

underdeveloped brain tissue
Psychoanalytic

lack of trust during the early stages

Weak ego

Defenses: REPRESSION, REGRESSION, PROJECTION

Environment influences: poverty, lack of social support, hostile home environment,
isolation, unsatisfactory housing, disruption in interpersonal relationships (divorce
or death), job pressure or unemployment
Subtypes

Catatonic type

prominent psychomotor disturbances are evident. Symptoms can include catatonic

stupor and waxy flexibility

Disorganized type

where thought disorder and flat affect are present together

Paranoid type

where delusions and hallucinations are present but thought disorder, disorganized
behavior, and affective flattening are absent

Residual type

where positive symptoms are present at a low intensity only

Undifferentiated type

psychotic symptoms are present but the criteria for paranoid, disorganized, or
catatonic types has not been met
Symptoms
According to Bleuler: 4 As

Affect is inappropriate

Associative looseness

Autistic thinking

Ambivalence
Symptoms

Positive symptoms

delusions, auditory hallucinations and thought disorder and are typically regarded
as manifestations of psychosis.

Negative symptoms

considered to be the loss or absence of normal traits or abilities

E.G. flat, blunted or constricted affect and emotion, poverty of speech and lack of
motivation.
Symptoms

Social isolation

Catatonic behavior

Hallucinations

Incoherence (marked looseness of association)

Zero/ lack of interest, energy and initiative

Obvious failure to attain expected level of devt

Peculiar behavior

Hygiene and grooming impaired

Recurrent illusions and unusual perception experiences

Exacerbations and remissions are common

No organic factors accounts for the symptoms

Inability to return to baseline functioning after relapse

Affect is inappropriate
Nsg Dx: Abnormal thought process

BLOCKING: sudden cessation of a thought in the middle of a sentence, unable to

continue the train of thought

CIRCUMSTANTIALITY: before getting to the point of answering a question, the

individual gets caught up in countless details and explanations

CONFABULATION

LOOSENESS OF ASSOCIATION

NEOLOGISM

WORD SALAD
Interventions

Assess physical needs

Set limits

Maintain safety

Initiate one-on-one interaction & progress to small groups

Spend time with clients

Monitor for altered thought process

Maintain ego boundaries, avoid touching

Limit time of interaction

Be neutral

Do not make promises that cant be kept

Establish daily routines

Do not go along with the clients delusions or hallucinations
Provide simple complete activities
Reorient

Speak to the client in simple direct and concise manner

Environment
Provide safe environment
Limit stimuli

Set realistic goals

Explain everything that is being done
Decrease stimuli
Monitor for suicide risk

Psychological Ttt
Behavior therapy
Social skills training
Self-monitoring
Social ttt
Milieu therapy
Family therapy
Group therapy (long-term ttt)
Related psychotic disorders
SCHIZOAFFECTIVE DISORDER schiz + mood disorder (mania/ depression)

BRIEF PSYCHOTIC DISORDER sudden onset of psychotic symptoms, lasts less

than 2 mos and client returns to premorbid level of functioning

SCHIZOPHRENIFORM DISORDER schiz sx lasting between 1 month and

<6mos

DELUSIONAL DISORDER characterized by prominent, nonbizarre delusions

PERSONALITY DISORDERS

CLUSTER A (odd & eccentric)

paranoid, schizoid, schizotypal

CLUSTER B (bad, dramatic & erratic)

antisocial, borderline, histrionic, narcissistic

CLUSTER C (anxious & fearful)

avoidant, dependent, OCD

CLUSTER A: ODD & ECCENTRIC
PARANOID
chronic hostility projected to others; suspicious and mistrusts people
Seen mostly in men
SCHIZOID

social detachment = loner & introvert

Restriction of emotions
Attention fixed on objects rather than people
Functions well in vocations
SCHIZOTYPAL: interpersonal deficits
Magical thinking, telepathy
Apparent in childhood or adolescence
Interventions for PARANOID D/O
Asses for suicide risk
Avoid direct eye contact
Establish trusting relationship
Promote increased self-esteem
Remain calm, nonthreatening and nonjudgmental
Provide continuity of care
Respond honestly to the client
Follow thru on commitments
Provide a daily schedule of activities
Gradually introduce client to groups
Do not argue with delusions
Use concrete, specific words

Do not be secretive with client

Do not whisper in presence of client
Assure that the client will be safe
Provide opportunity to complete small tasks
Monitor eating, drinking, sleeping and elimination patterns
Limit physical contact
Monitor for agitation and decrease stimuli as needed
CLUSTER B: ERRATIC, DRAMATIC, OR EMOTIONAL
ANTISOCIAL
Syn: sociopath, psychopathic & semantic d/o
Etiology:
Genetics interfere in the devt of positive interpersonal relationships
Brain damage or trauma
Low socioeconomic status

Faulty family relationships: neglect

Secondary gains
15-40 y.o.

Signs
Lack of remorse or indifference to persons hurt
Immediate gratification
Failure to accept social norms
Impulsivity
Consistent irresponsibility
Aggressive behavior
Reckless behavior that disregards the safety of others

80-90% of all crime is committed by antisocials (NIHM, 2000)

BORDERLINE

Latent, ambulatory and abortive schizophrenics

Between moderate neurosis and frank psychosis but quite stable
Theories
faulty separation from mother; parent and child are bound by guilt
Trauma at 18 mos (weakening of ego)
Unfulfilled need for intimacy

Signs
instability
Impulsivity: unpredictable gambling, shoplifting, sex & substance abuse
hypersensitivity, self-destructive, profound mood shifts
unstable & intense relations
Disturbance in self concept

Common in women

HISTRIONIC
Pattern of theatrical or overtly dramatic behavior
Signs

Defenses: denial, projection, splitting, projective identification

Discomfort when the client isnt the center of attention

Self-dramatization and exaggerated emotions
uses physical appearance, sexually seductive and provocative behavior
Excessively impressionistic speech lacking in detail (labile emotions)
Problems in dependence & helplessness
More frequent in women

NARCISSISTIC
Exaggerated or grandiose sense of self-importance
Develop early in childhood
Preoccupied with fantasies of unlimited success, power and beauty
Signs
arrogance, need for admiration,
lack of empathy,
seductive, socially exploitative, manipulative
Occurs more in men

CLUSTER C: ANXIOUS OR FEARFUL

AVOIDANT

Sensitive to rejection, criticism, humiliation, disapproval, or shame

Interferes with participation in occupational activities, devt of relationships, and

take personal risks

social inhibition, longs for relationships

Anxiety, anger and depression are common

Social phobia may occur

Seen in 10% of clients in mental clinics

DEPENDENT
Lacks confidence and unable to function in an independent role
Allows other persons to be responsible of their lives
Most frequent personality disorder in the mental health clinic
submissive behavior, low self-esteem, inadequate, helpless

OBSESSIVE-COMPULSIVE

Preoccupied with rules & regulations, overly concerned about trivial detail,
excessively devoted to their work

Depression is common

Men are more affected than women

UNDER STUDY PERSONALITY D/O

PASSIVE-AGGRESSIVE: sullen and argumentative, resents others, resists

fulfilling responsibilities, complains of being unappreciated

DEPRESSIVE: gloomy, brooding pessimistic, guilt-prone, highly critical of self

and others, cheerless.
Interventions

Maintain safety against self-destructive behaviors

Allow the client to make choices and be as independent as possible

Encourage the client to discuss feelings rather than act them out

Provide consistency in response to the clients acting out

Discuss expectations and responsibilities with the client

Inform the client that harm to self, others, and property is unacceptable

Identify splitting behavior

Remove the client from group situations in which attention-seeking behaviors

Assist the client to deal directly with anger

Develop a written contract with the client

Encourage the client to participate in group activities, and praise nonmanipulative

behavior

Set and maintain limits

occur

Provide realistic praise for positive behaviors in social situations

PSYCHOLOGICAL SEXUAL D/O
Hypoactive sexual disorder (asexuality)
Sexual aversion disorder (avoidance of or lack of desire for sexual intercourse)
Female sexual arousal d/o (failure of normal lubricating arousal response)
Male erectile d/o
Female orgasmic disorder
Male orgasmic disorder
Premature ejaculation
Vaginismus
Secondary sexual dysfxn
Paraphilias
Gender identity d/o
PTSD due to genital mutilation or childhood sexual abuse

Other sexual problems

Sexual dissatisfaction (non-specific)

Lack of sexual desire

anorgasmia
Impotence
STD

Infidelity

Unhappiness or confusion related to sexual orientation

Delay or absence of ejaculation, despite adequate stimulation

Inability to control timing of ejaculation
Inability to relax vaginal muscles enough to allow intercourse
Inadequate vaginal lubrication preceding and during intercourse
Burning pain on the vulva or in the vagina with contact to those areas

Persistent sexual arousal syndrome

Sexual addict
hypersexuality
Post Ejaculatory Guilt Syndrome, the feeling of guilt after the male orgasm
SEXUAL EXPRESSION
HETEROSEXUALITY
HOMOSEXUALITY
BISEXUALITY
TRANSVESTISM

PARAPHILIAS

EXHIBITIONISM: the recurrent urge or behavior to expose one's genitals to an

unsuspecting person.

FETISHISM: the use of non-sexual or nonliving objects or part of a person's body

to gain sexual excitement. Partialism refers to fetishes specifically involving nonsexual
parts of the body.

FROTTEURISM: the recurrent urges or behavior of touching or rubbing against a

nonconsenting person.

SEXUAL MASOCHISM: the recurrent urge or behavior of wanting to be

humiliated, beaten, bound, or otherwise made to suffer.

SEXUAL SADISM: the recurrent urge or behavior involving acts in which the
pain or humiliation of the victim is sexually exciting.

TRANSVESTIC FETISHISM: a sexual attraction towards the clothing of the

opposite gender.

PEDOPHILIA: the sexual attraction to prepubescent or peripubescent children.

Other paraphilias not otherwise specified ("Sexual Disorder NOS")

telephone scatalogia (obscene phone calls)
necrophilia (corpses)
partialism (exclusive focus on one part of the body)
zoophilia(animals)
coprophilia (feces)
klismaphilia (enemas)
urophilia (urine)

VOYEURISM: the recurrent urge or behavior to observe an unsuspecting person

who is naked, disrobing or engaging in sexual activities, or may not be sexual in nature at
all.

SOMATOFORM D/O

SOMATIZATION D/O: hx of many physical complaints beginning before the age

of 30 occurring over a pd of several yrs resulting in ttt being sought or significant
occupational or social fxning.

CONVERSION D/O: 1 or more sx of deficits affecting voluntary motor or

sensory function suggesting a neurological or general medical condition; preceded by
conflicts or stressors; cant be explained and sanctioned by cultural behavior.

Most common: blindness, deafness, paralysis, inability to talk

La belle indifference

HYPOCHONDRIASIS: preoccupation with fears of having, or ideas that one has,

a serious dse based on the persons misinterpretation of bodily sx and persist despite
appropriate medical eval and reassurance and has existed for @ least 6 mos.
(e.g.:extensive use of home remedies)

PAIN D/O: pain in 1 or more anatomical sites severe enough to warrant clinical
attention and causes clinically significant distress or impairment in fxning.
Interventions

Do not reinforce the sick role

Discourage verbalization about physical symptoms by not responding with

positive reinforcement

Explore with the client the needs being met by the physical symptoms

Convey understanding that the physical symptoms are real to the client

Report and assess any new physical complaint

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EATING DISORDER BEHAVIORS

BINGE: rapid consumption of large quantities of food in a discrete period of time.

(A: hundrends of Cal; B: thousands of Cal at a sitting)

PURGE: Maladaptive eating regulation response that includes excessive exercise,

forced vomiting, OCD Rx diuretics, diet pills, laxatives and steroids.

FAST/ RESTRICT: Includes vegetarian diet eliminating all meat without

substituting nonanimal sources of protein, OC about food choices, and eating habits.
ANOREXIA
BULIMIA

Rare vomiting or diuretic/laxative abuse

More severe wt loss

Slightly younger

More introverted

Hunger denied

Eating behavior may be considered normal and a source of esteem

Sexually inactive

Obsessional and perfectionist features dominate

Frequent

Less wt loss

Slightly older

More extroverted

Hunger experienced

Eating behavior considered foreign and source of distress

More sexually active

Avoidant, dependent, or borderline features as well as obsessional features

ANOREXIA
BULIMIA
complications

Death from starvation (or suicide, in chronically ill)

Amenorrhea

Fewer behavioral problems (these increase with level of severity)

Death from hypokalemia or suicide
Menses irregular or absent
Drug and alcohol abuse, self-mutilation, and other behavioral problems
DELIRIUM

The medical dx term that describes an organic mental disorder characterized by a

cluster of cognitive impairments with an acute onset with a specific precipitating factor.

Sx: diminished awareness of the environment, disturbances in psychomotor

activity and sleep-wake cycle.

COGNITIVE: the mental process characterized by knowing, thinking, and

judging.

COGNITIVE DISSONANCE: arises when 2 opposing beliefs exists at the same

time.
COGNITIVE DISTORTIONS: (+) or (-) distortions of reality that might include
errors of logic, mistakes in reasoning, or individualized view of the world that do not
reflect reality.

Term: confusion = cognitive impairment

See dementia
DEMENTIA

The medical dx term that describes an organic mental d/o characterized by a

cluster of cognitive impairments of generally gradual onset and irreversible without
identifiable precipitating stressors.

Types:

VASCULAR or MULTI-INFARCT

VASCULAR WITH ALZHEIMERS DSE

AD: most common

DEMENTIA WITH LEWY BODIES: 2nd most common; neurofilament material

PARKINSONIAN DEMENTIA

AIDS DEMENTIA COMPLEX

FRONTAL LOBE DEMENTIA or PICKS DSE: cytoplasmic collections; 3rd

most common; loss of expressive language & comprehension

CREUTZFELDT-JAKOB DSE: prion (proteinaceous infectious particles) =

spongy brain; related to TSE & BSE in mad cow dse

CORTICOBASAL DEGENERATION or HUNTINGTONS DSE/CHOREA:

jerky movts

SUPRANUCLEAR PALSY: clumping of protein tau = slow movt, weak eye

movt (esp. downward), impaired walking &balance

Reversible Causes:

Subdural hematoma

Tumor (meningioma)

Cerebral vasculitis

Hydrocephalus

Terms: disorientation, memory loss (sensory, primary, secondary, tertiary,

working memory), confabulation, confusion

Disturbing behaviors

Aggressive psychomotor

Nonaggressive psychomotor

Verbally aggressive

Passive

Functionally impaired: loss of ability to do self-care

DELIRIUM
vs.
DEMENTIA

Rapid onset w/ wide fluctuations

Hyperalert to difficult to arouse LOC

Fluctuating affect
Disoriented, confused
Attention & sleep disturbed
Memory impaired
Disordered reasoning
Gradual, chronic with continuous decline
Normal LOC
Labile affect
Disoriented, confused Attention intact, sleep usually normal
Memory impaired
Disordered reasoning & calculation
DELIRIUM
vs.
DEMENTIA

Incoherent, confused, delusional, stereotyped

Illusions, hallucinations

Poor judgment

Insight may be present in lucid moment

Poor but variable in MSE

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Disorganized, rich in content, delusional, paranoid
No change in perception
Poor judgment
No insight
Consistently poor & progressively worsens in MSE
ALZHEIMERS DEMENTIA
Most common type of dementia

Stages:

MILD: impaired memory, insidious loses in ADL, subtle personality changes,

socially normal

MODERATE: obvious memory loss, overt ADL impairment, prominent

behavioral difficulties, variable social skills, supervision needed

SEVERE: fragmented memory, no recognition of familiar people, assistance

needed with basic ADL, fewer troublesome behaviors, reduced mobility (4 As)

Symptoms
AGNOSIA: Difficulty recognizing well-known objects
APHASIA: Difficulty in finding the right word

APRAXIA: Inability or difficulty in performing a purposeful organized task or

similar skilled activities

AMNESIA: Significant memory impairment in the absence of clouded

consciousness or other cognitive symptoms

PSYCHIATRIC D/O IN CHILDREN

MENTAL RETARDATION
PERVASIVE DEVTAL D/O
AUTISM
RETTS D/O
CHILDHOOD DISINTEGRATIVE D/O
ASPERGERS D/O
PDD NOS
LEARNING D/O
READING
MATHEMATICS
WRITTEN EXPRESSION
ACADEMIC PROBLEM
LEARNING D/O NOS
MOTOR SKILLS D/O

COMMUNICATION D/O
EXPRESSIVE LANGUAGE
MIXED RECEPTIVE/EXPRESSIVE
PHONOLOGICAL
STUTTERING
SELECTIVE MUTISM
COMMUNICATION D/O NOS

MOVT & TIC D/O

DEVTAL COORDINATION
TRANSIENT TIC

CHRONIC MOTOR&VOCAL TIC

TOURETTES D/O
STEREOTYPIC MOVT D/O
TIC D/O NOS

DISORDERS OF INTAKE & ELIMINATION

PICA
RUMINATION
FEEDING D/O
ENURESIS
ENCOPRESIS

OTHER: BULIMIA, ANOREXIA

ADHD & DISRUPTIVE BEHAVIOR D/O

ADHD
ADHD NOS
CONDUCT D/O
OPPOSITIONAL DEFIANT
CHILD ANTISOCIAL
DISRUPTIVE BEHAVIOR NOS
MOOD D/O
MJ DEPRESSIVE D/O
BIPOLAR I OR II
DYSTHYMIC
MIXED EPISODE
HYPOMANIC EPISODE
MOOD D/O DUE TO MEDICAL CONDITION
SUBSTANCE-INDUCED MOOD D/O

ANXIETY D/O

D/O OF RELATIONSHIP

SEPARATION ANXIETY

REACTIVE ATTACHMENT OF INFANCY OR EARLY CHILDHOOD

PARENT-CHILD RELATIONAL PROBLEM

SIBLING RELATIONAL PROBLEM

PROBLEMS RELATED TO ABUSE OR NEGLECT

MENTAL RETARDATION

an IQ below 70, significant limitations in two or more areas of adaptive behavior

(i.e., ability to function at age level in an ordinary environment), and evidence that the
limitations became apparent in before 18 y.o.

The following ranges, based on the Wechsler Adult Intelligence Scale (WAIS), are
in standard use today:

Class
IQ
Terms
Profound
Below 20
Idiot
Severe
2034
Imbecile
Moderate
3549
Moron
Mild
5069
Borderline
7079
RETTS D/O

Development is normal until 6-18 months, when language and motor milestones
regress,

purposeful hand use is lost

Acquired deceleration in the rate of head growth (resulting in microcephaly in

some)

Hand stereotypes are typical and breathing irregularities such as hyperventilation,

breath holding, or sighing are seen in many.

Early on, autistic-like behavior may be seen

Common in females
CHILDHOOD DISINTEGRATIVE D/O or HELLERS SYNDROME

CDD has some similarity to autism, but an apparent period of fairly normal
development is often noted before a regression in skills or a series of regressions in skills.

characterized by late onset (>3 years of age) of devtal delays in language, social
function and motor skills; skills apparently attained are lost
ASPERGERS D/O

characterized by difference in language and communication skills, as well as

repetitive or restrictive patterns of thought and behavior.

Signs: unable to interpret or understand the desires or intentions of others and

thereby are unable to predict what to expect of others or what others may expect of them

Narrow interests or preoccupation with a subject to the exclusion of other

activities

Repetitive behaviors or rituals

Peculiarities in speech and language

Extensive logical/technical patterns of thought

Socially and emotionally inappropriate behavior and interpersonal interaction

Problems with nonverbal communication

Clumsy and uncoordinated motor movts

CHRONIC MOTOR/ VOCAL TIC

TIC is a sudden, repetitive, stereotyped, nonrhythmic, involuntary movement

(motor tic) or sound (phonic tic) that involves discrete groups of muscles.

can be invisible to the observer (e.g. abdominal tensing or toe crunching)

TOURETTES D/O

characterized by the presence of multiple physical (motor) tics and at least one
vocal (phonic) tic; these tics characteristically wax and wane

TTT: Neuroleptic medications

haloperidol (Haldol)

pimozide (Orap)
ADHD
Inattention:

Failure to pay close attention to details or making careless mistakes when doing
schoolwork or other activities

Trouble keeping attention focused during play or tasks

Appearing not to listen when spoken to

Failure to follow instructions or finish tasks

Avoiding tasks that require a high amount of mental effort and organization, such
as school projects

Frequently losing items required to facilitate tasks or activities, such as school

supplies

Excessive distractibility

Forgetfulness

Procrastination, inability to begin an activity

Difficulties with household activities (cleaning, paying bills, etc.)

Difficulty falling asleep, may be due to too many thoughts at night

Frequent emotional outbursts

Easily frustrated

Easily distracted
Hyperactivity-impulsive behaviour

Fidgeting with hands or feet or squirming in seat

Leaving seat often, even when inappropriate

Running or climbing at inappropriate times

Difficulty in quiet play

Frequently feeling restless

Excessive speech

Answering a question before the speaker has finished

Failure to await one's turn

Interrupting the activities of others at inappropriate times

Impulsive spending, leading to financial difficulties

Frequently prescribed stimulants are methylphenidate (Ritalin and Concerta),

amphetamines (Adderall) and dextroamphetamines (Dexedrine)

Feingold diet which involves removing salicylates, artificial colors and flavors,
and certain synthetic preservatives from children's diets.
CONDUCT D/O

repetitive and persistent pattern of behavior in which the basic rights of others or
major age-appropriate societal norms or rules are violated,

AGGRESSION TO PEOPLE & ANIMALS

DESTRUCTION OF PROPERTY

DECEITFULNESS OR THEFT

SERIOUS VIOLATIONS OF RULES

Beginning before age 13

OPPOSITIONAL DEFIANT

characterized by an ongoing pattern of disobedient, hostile, and defiant behavior

toward authority figures that goes beyond the bounds of normal childhood behavior

Signs

Losing temper

Arguing with adults

Refusing to follow the rules

Deliberately annoying people

Blaming others

Easily annoyed
Angry and resentful
Spiteful or even revengeful
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SUBSTANCE ABUSE

Excessive or unhealthy use of substances, such as alcohol, tobacco or drugs, or

use of products such as food

Terms:

TOLERANCE: the declining effect of the same drug dose when it is taken
repeatedly over time

HABITUATION: a psychological dependence of the use of a drug

ADDICTION: the biological and/ or psychological behaviors related to substance

dependence

WITHDRAWAL SYMPTOMS: result from a biological need that develops when

the body becomes adapted to having an addictive drug in the system; occurs when serum
levels decrease
ADDICTION

ALCOHOL: blood alcohol levels of 0.1% (100mg alcohol/dl of blood) or higher

WITHDRAWAL

Anorexia

Anxiety

Easily startled

Hyperalertness

HPN

Insomnia

Irritability

Jerky movt

Possibly: hallucinations, illusions or vivid nightmares

Seizures (7-48 hrs after cessation)

Tachycardia

tremors

WITHDRAWAL DELIRIUM
Agitation
Anorexia
Anxiety
Delirium
Diaphoresis
Disorientation with fluctuating levels of consciousness
Fever (100 to 103 F)
Hallucinations and delusions
Insomnia
Tachycardia and HPN
Disulfiram (Antabuse) therapy

Nursing care

Obtain info about drug type and amount consumed

Assess v/s

Remove unnecssary obj from environment

Provide one-on-one supervision if necessary

Provide a quiet, calm environment with minimal stimuli

Maintain orientation

Ensure safety

Use restraints

Provide physical needs

Provide food and fluids as tolerated

Administer medications

Collect blood and urine samples for drug screening

SPOUSE ABUSE

Battering precipitates 1:4 suicide attempts of all women

Wives explain the injuries as being self-inflicted or accidental

Phases

Tension-building: series of small incidents that leads to beating

Acute beating phase: wife becomes object of assault behavior

Loving phase: batterer is remorseful and assures spouse that he will not harm her
again. This leads to reconciliation.

Myths
They believe that if they try not to antagonize with their husband, he will change.
Efforts to coerce the wife out of the victim role can be fruitful.

Facts

Women stay in relationships with men who batter because they feel guilty or
responsible of the husbands behavior

Wife develops little sense of self-worth, immobilized and unable to remove self
from the relationship.

Assessment: injuries, other evidence

Interventions: with consent

CHILD ABUSE

PHYSICAL BATTERING
EMOTIONAL
SEXUAL
NEGLECT
ELDERLY ABUSE

A variety of behaviors that threaten the health, comfort, and possibly the lives of
the elderly, including physical and emotional neglect, emotional abuse, violation of
personal rights, financial abuse, and direct physical abuse.

Commonly committed by care givers.

SEXUAL ABUSE

Components

Sexual Misuse: inappropriate sexual activity

Rape: there is actual penetration

Incest: refers to the relationship between the victim and abuser blood relative or
step parent role

Interventions

Children: thru play or role playing with puppets

Prevention of further sexual abuse

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COMPLETED SUICIDE

Self-inflicted death

LEVELS OF SUICIDE

Ideation: thought

Attempt: acted upon but failed

Completed
CHEMICAL RESTRAINT

CHEMICAL RESTRAINTS: Medications used to restrict the patients freedom of

movement or for emergency control of behavior but are not a standard treatment for the
pxs medical or psychiatric condition.

PHYSICAL RESTRAINTS: Are any manual method or physical or mechanical

device attached to or adjacent to the pxs body that he or she cannot easily remove and
that restricts freedom of movement or normal access to ones body, material or
equipment.
SECLUTION AND RESTRAINTS

SECLUTION: the involuntary confinement of a person alone in a room from

which the person is physically prevented from leaving.

No therapeutic evidence other than a last resort to ensure safety.

Evidence suggest that it adds to further trauma and physical harm

GUIDELINES

All hospital staff who have direct contact with the px should have ongoing
education and training in the proper use of seclusion and restraints and other alternatives

Physician or licensed practitioner should evaluate need within 1 hour after the
initiation of this intervention.


Max of 4 hours for adults, 2 hours for ages 9-17, and 1 hour for children under 9
yrs

Orders may be renewed for 24 hrs before another face to face evaluation

Continuous assessment, monitoring and evaluation; recorded

Good nursing care

For both restrained and secluded: constant monitoring face to face or by both
audio and video equipment.

Px should be released ASAP

OTHER GUIDELINES

SECLUSION

Room should allow observation and communication with px

Remove all items that px might use to harm self

Document: rationale, response to intervention, physical condition, nsg care, &

rationale for termination

RESTRAINTS

Give support & reassurance

Position in anatomical position

Privacy is important

v/s & Circulation check

Should be released q 2hrs

Avoid tying to the side rails of bed

Assist in periodic change in body positions

TERMINATING THE INTERVENTION

As soon as met the criteria for release

Review with px the behavior that precipitated the intervention & pxs capacity to
exercise control over behavior

DEBRIEFING: reviewing the facts related to an event & processing the response
to them; can be used after any stressful event

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THERAPEUTIC IMPASSES

Are blocks in the progress of the nurse-pt relationship

Provokes intense feelings in both the nurse and patient

RESISTANCE
TRANSFERENCE
COUNTERTRANSFERENCE
BOUNDARY VIOLATIONS
RESISTANCE
Reluctance or avoidance of verbalizing or experiencing troubling aspects of

oneself

Eg: suppression or repression, intensification of sx, self-devaluation or

hopelessness, intellectual inhibitions, acting out or irrational behavior, superficial talk,
intellectual insight/ intellectualization, transference reactions.

TRANSFERENCE

Unconscious response in which the px experiences feelings and attitudes toward

the nurse that were originally associatated with other significant figures in his or her life.

HOSTILE TRANSFERENCE: anger and hostility, resistance

DEPENDENT TRANSFERENCE: submissive, subordinate and regards the nurse

as a god-like figure; views relationship as magical

What do you do?

LISTEN
CLARIFY
REFLECT
EXPLORE/ ANALYZE

COUNTERTRANSFERENCE

Created by the nurses specific emotional response to the qualities of the patient;
inappropriate in the context, content and intensity of emotion; nurses identify the px with
individuals from their past, and personal needs

Types: Reactions of INTENSE

love or caring

Disgust or hostility

Anxiety, often in response to resistance by the px

Eg.

Difficulty empathizing

Feelings of depression before or after the session

Carelessness about implementing the contract

Drowsiness during the sessions

Encouragement of the pxs dependency

Arguments with the px

Personal or social involvement with the px

Sexual or aggressive fantasies toward the px

Tendency to focus on only one aspect or way of looking at information presented

by the px

Attempts to help the px with matters not related to the identified nursing problems

Feelings of anger or impatience because of the pxs unwillingness to change

Dreams about or preoccupation with the px