WHAT YOU SHOULD KNOW BEFORE THE PNLE

JULY 2012 PNLE PEARLS OF SUCCESS

PART 5: PSYCHIATRIC NURSING

A. Neurotransmitters 8. Agreeing: telling client know that you think, feel alike; nurse
verbalizes agreement
Dopamine Dopamine is generally excitatory and is 9. Disagreeing: letting client know that you do not agree; telling
synthesized from tyrosine, a dietary amino acid. client that you do not believe he is right
* Antipsychotic medications work by blocking 10. Probing: questioning client about a topic he has indicated he
dopamine receptors and reducing dopamine does not want to discuss.
activity. 11. Denial: refusing to recognize client’s perception
Norepinephrine It plays a role in mood regulation. 12. Changing topic: letting client know you do not want to discuss
Epinephrine Controls the fight-or-flight response in the a problem by introducing a new topic.
peripheral nervous system.
Serotonin The function of serotonin is mostly inhibitory, D. Defense Mechanism
involved in the control of food intake, sleep and
wakefulness, temperature regulation, pain  Denial: Refusal to acknowledge a part of reality
control, sexual behavior, and regulation of  Repression: threatening thoughts are pushed into the
emotions unconscious, anxiety and other symptoms are observed; client
Acetylcholine It can be excitatory or inhibitory. It is unable to have conscious awareness of conflicts or events that
synthesized from dietary choline found in red are source of anxiety
meat and vegetables and has been found to  Suppression: consciously putting a threatening / distressing
affect the sleep-wake cycle and to signal muscles thought out of one’s awareness
to become active.  Rationalization: Developing an acceptable, justifiable (to self)
Gamma- Is a major inhibitory neurotransmitter in the reason for behavior
Aminobutyric brain and has been found to modulate other  Reaction-formation: engaging in behavior that is opposite of
Acid (GABA) neurotransmitter systems rather than to provide true desires
a direct stimulus.  Sublimation: anxiety channeled into socially acceptable
behavior
 Compensation: making up for a deficit by success in another
field/area
B. Therapeutic Communications  Projection: placing own undesirable trait onto another;
blaming others for own difficulty
1. Silence: client able to think about self/problems; does not feel  Displacement: Directing feelings about one object/person
pressure or obligation to speak towards a less threatening object/person
2. Offering self: offer to provide comfort to client by presence.  Identification: taking onto oneself the traits of others that one
3. Accepting: Indicate nonjudgmental acceptance of client and his admires
perceptions by nodding and following what client says.  Introjection: symbolic incorporation of another into one’s
4. Giving recognition: indicate to client your awareness of him personality
and his behaviors.  Conversion: anxiety converted into a physical symptom that is
5. Making observations: verbalize what you perceive motor or sensory in nature
6. Encourage description: ask client to verbalize his perception  Symbolization: representing an idea or object by a substitute
7. Using broad openings: encourage client to introduce topic of object or sign
conversation  Dissociation: separation or splitting off of one aspect of mental
8. Offering general leads: encourage client to continue discussing process from conscious awareness
topic.  Undoing: behavior that is opposite of earlier unacceptable
9. Reflecting: direct client’s questions/ statements back to behavior or thought
encourage expression of ideas and feelings.  Regression: behavior that reflects an earlier level of
10. Restating: repeat what client has said. development. Adults hospitalized with serious illnesses
11. Focusing: encourage the client to stay on topic/point. sometimes will engage in regressive behaviors.
12. Exploring: encourage client to express feelings or ideas in more  Isolation: separating emotional aspects of content from
depth cognitive aspects of thought.
13. Clarification: encourage the client to make idea or feeling more  Splitting: viewing self, others, or situations as all good or all
explicit, understandable. bad.
14. Presenting reality: report events/situations as they really are.
15. Translating into feelings: encourage client to verbalize
E. Therapeutic Nurse-Patient Relationship
feelings expressed in another way.
16. Suggesting collaboration: offer to work with client towards
goal  Three (3) phases of nurse-client relationship

C. Non-Therapeutic Communications Orientation

1. Reassuring: telling the client there is no need to worry or be  Nurse explains relationship to client, defines both nurse’s
anxious. and client’s roles.
2. Advising: telling client what you believe should be done  Nurse determines what client expects from the
3. Requesting explanation: asking the client to provide reasons relationship and what can be done for the client.
for his feelings/behavior. The use of “WHY” questions should be  Nurse contracts with client about when and where future
avoided meetings will take place.
4. Stereotypical response: replying to client with meaningless  Nurse asses client and develops a plan of care based on
clichés appropriate nursing diagnoses.
5. Belittling feelings: minimizing or making light of client’s  Limits/termination of relationship are introduced (e.g.,
distress or discomfort “we will be meeting for 30 mins every morning while you
6. Approving: giving approval to client’s behavior or opinion are in the hospital.”)
7. Disapproving: telling client certain behavior or opinions do not
meet your approval

POSSIBLE TOPICS ON PSYCHIATRIC NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming July 2012 PNLE
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY 2012 PNLE PEARLS OF SUCCESS
PART 5: PSYCHIATRIC NURSING
Working Phase
 Client’s problems and needs are identified and explored as
nurse and client develop mutual acceptance.
 Client’s dysfunctional symptoms, feelings, or interpersonal
relationships are identified.
 Therapeutic techniques are employed to reduce anxiety
and to promote positive change and independence
 Goals are evaluated as therapeutic work proceeds, and
changed as determined by client’s progress.
Termination Phase
 Relationship and growth in nurse and client are
summarized
 Client may become anxious and react with increased
dependence, hostility, or withdrawal.
 These reactions are discussed with client.
 Feelings of nurse and client concerning termination
should be discussed in context of finiteness of
relationship.
Transeference: occurs when client transfers
conflicts/feelings from past to the nurse.
Example: client becomes overly dependent, clinging to nurse
who represents (unconsciously to client) the nurturing client
desires from own mother.
Countertranseference: occurs when nurse responds to
client emotionally, as if in a personal, not
professional/therapeutic relationship.
Example: Nurse is sarcastic and judgmental to client who has a
history of drug abuse. Client represents (unconsciously to
nurse) the nurse’s brother who has abused drugs.
F. Anxiety
 Experienced as a sense of emotional or physical
distress as the individual responds to an unknown
threat or thwarting of unmet needs.
 Levels of Anxiety
Mild Increased awareness; ability to solve problems,
learn; increase in perceptual field; minimal muscle
tension.
Moderate Optimal level for learning, perceptual field narrows
to pay attention to particular details, increased
tension to solve problems or meet challenges.
Severe Sympathetic nervous system (flight/fight
response): increase in BP, pulse and respirations;
narrowed perceptual field, fixed vision, dilated
pupils, can perceive scattered details or only one
detail; difficulty in problem solving.
Panic Decrease in VS (release of sympathetic response),
distorted perceptual field, inability to solve
problems, disorganized behavior, feelings of
helplessness/terror.
 Nursing Interventions:
 Determine the level of client’s anxiety by
assessing the verbal and non-verbal behaviors
and physiologic symptoms.
 Determine cause of anxiety with client.
 Stay with client.
 Reduce anxiety by remaining calm yourself, use
silence, or speak slowly and softly.
 Help client recognize own anxious behavior.
POSSIBLE TOPICS ON PSYCHIATRIC NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming July 2012 PNLE
 Provide outlets (e.g., talking, psychomotor
activity, crying, tasks)
 Provide support and encourage client to find
ways to cope with anxiety.
 In panic state nurse must make decisions.
 Do not leave client alone.
 Encourage ventilation of thoughts and
feelings.
 Use firm voice and give short, explicit
directions (e.g., “sit in this chair. I will sit
here next to you”).
 Engage client in motor activity to reduce
tension (e.g., “We can take a brisk walk
around the day room. Let’s go”).
G. Bipolar Disorder
 Characterized by hyperactivity and euphoria that may
become sarcasm or hostility
 Assessment findings
 Hyperactivity to the point of physical exhaustion
 Flamboyant dress/makeup
 Sexual acting out
 Impulsive behaviors
 Flight of ideas: inability to finish one thought before
jumping to another
 Loud, domineering, manipulative behavior
 Distractibility
 Dehydration, nutritional deficits
 Delusions of grandeur
 Possible short-term depression (risk for suicide)
 Hostility, aggression
 Nursing Intervention:
 Determine what client is attempting to tell you; use
active listening.
 Assist client in focusing on a topic
 Offer finger foods, high-nutrition foods, and fluids.
 Provide quite environment, decrease stimuli
 Stay with client, use silence
 Remove harmful objects
 Be accepting of hostile statements.
 Do not argue with client
 Use distraction to diver client from behaviors that
are harmful to self or others.
 Administer medications as ordered and observe for
effects/side effects.
 Teach clients early sings of toxicity
 Maintain fluid and salt intake
 Avoid diuretics
 Monitor lithium blood levels
 Assist in dressing, bathing
 Set limits on disruptive behaviors.
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY 2012 PNLE PEARLS OF SUCCESS
PART 5: PSYCHIATRIC NURSING
Mood Stabilizing Drugs
 Lithium Carbonate normalizes the reuptake neurotransmitters
such as serotonin, norepinephrine, acetylcholine, and
dopamine.
 Initial dose levels: 600mg tid to maintain blood serum
level of 1.0-1.5 mEz/L; blood serum levels should be
checked 12 hours after last dose, twice a week.
 Maintenance dosage levels: 300mg tid/qid, to maintain
a blood serum level of 0.6-1.2mEq/L; checked monthly.
 Toxicity when blood levels higher than 2.0 mEq/L:
tremors, nausea and vomiting, thirst,
polyuria, coma, seizures, cardiac arrest
H. Disorders of Perceptions
 Illusions, stimulus in the environment of
misperceived
 Delusions, fixed, false set of beliefs that are real to
client
 Grandiose: false belief that client has power, wealth,
or status or is famous person
 Persecutory: false belief that client is the object of
another’s harassment of harmful intent.
 Somatic: false belief that client has some
physical/physiologic defect
 Ideas of Reference, belief that events or behaviors
of others relate to self.
 Hallucinations, sensory perceptions that have no
stimulus in environment most common
hallucinations are auditory and visual.
Nursing Intervention:
 Avoid arguing
 Determine client’s need
 Reduce anxiety
 Present reality
 After therapeutic relationship has been
established, you can express doubt about
delusions, hallucinations to client.
 Direct client’s attention to non-threatening
topics.
I. Depression
 Characterized by loss of ambition, lack of interest in
activities and sex, low self-esteem, and feelings of
boredom and sadness.
 Nursing Assessment:
 Feelings of helplessness, hopelessness, worthlessness
 Reduction in normal activities or agitation
 Slowing of body function/elimination
 Loss of appetite
 Inappropriate guilt
 Self-deprecation, low self-esteem
 Inability to concentrate, disordered thinking
 Poor hygiene
 Slumped posture
 Crying, ruminating
 Dependency
 Depressed children: possible separation anxiety
 Elderly clients: possible symptoms of dementia
 Nursing Interventions
 Monitor I&O
 Weigh client regularly
 Maintain a schedule of regular appointment
 Remove potentially harmful articles
POSSIBLE TOPICS ON PSYCHIATRIC NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming July 2012 PNLE
 Contract with client to report suicidal ideation,
impulses, plans: check client frequently
 Assist with dressing, hygiene, and feeding
 Encourage discussion of negative/positive
aspects of self
 Encourage change to more positive topics if
self-deprecating thoughts persist
 Administer antidepressant medications as
ordered:
Anti Depressant Drugs
 Tricyclic Antidepressants (TCAs)
 Effectiveness increased by antihistamine, alcohol,
benzodiazepines, effectiveness decreased by
barbiturates, nicotine, vitamin C
 Monoamine Oxidase Inhibitors (MAOIs)
 Effectiveness increased with antipsychotic drugs,
alcohol, meperidine
 Avoid foods containing tyramine (e.g., beer, red
wine, aged cheese, avocados, caffeine, chocolate, cour
cream, yogurt); these foods or MAOIs taken with
TCAs may result in hypertensive crisis
 Be sure client swallows medication. If side effects
disappear suddenly, cheeking/hoarding may have
occurred.
 Antidepressant medications do not take effect for 2-3
weeks. Encourage client to continue medication even
if not feeling better. Be aware of suicide potential
during this time.
 SSRIs
 venlafaxine, nefazodone, and bupropion are often
better choices for those who are potentially suicidal
or highly impulsive
 However, SSRIs are only effective for mild to
moderate depression.
J. Schizophrenia
 Characterized by disordered thinking, delusions,
hallucinations, depersonalization (feeling of being
strange, not oneself), impaired reality testing
(psychosis), and impaired interpersonal
relationships.
 Nursing Assessment:
 Four A’s
1. Affect: flat, blunted
2. Associative looseness: verbalizations are
disorganized
3. Ambivalence: cannot choose between
conflicting emotions
4. Autistic thinking: thoughts on self, extreme
withdrawal, unable to relate to outside world
 Any changes in thoughts, speech, affect
 Ability to perform self-care activities, nutritional
deficits
 Suicide potential
 Aggression
 Regression
 Impaired communication
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY 2012 PNLE PEARLS OF SUCCESS
PART 5: PSYCHIATRIC NURSING
Antipsychotic Drugs
 Also known as neuroleptics, are used to treat the symptoms
of psychosis, such as the delusions and the hallucinations.
 Antipsychotic’s work by blocking receptors of the
neurotransmitter, dopamine.
 Newer, atypical antipsychotic drugs such as clozapine
(Clozaril) are relatively weak blockers of D2, which may
account for the lower incidence of extrapyramidal side
effect
 Extrapyramidal Symptoms
a. Dysthonic reactions
 Sudden contractions of face, tongue, extraoccular
muscles
 Administer antiparkinson agents prn (e.g.,
benztropine (cogentin) 1-8mg or dipenhydramine
(benadryl) 10-50mg), which can be given PO or IM
for faster relief; trihexyphendil (artane) 3-15mg PO
only, can also be used prn).
 Remain with client; this is a frightening experience
and usually occurs when medication is started
b. Parkinson syndrome
 Occurs within 1-3 weeks
 Tremors, rigid, posture, masklike facial appearance
 Administer antiparkinson agents prn
c. Akathisia
 Motor restlessness
 Need to keep moving
 Administer antiparkinson agents
 Reduce medications to see if symptoms decrease
 Determine if movement is under voluntary control
d. Tardive dyskinesia
 Irreversible involuntary movements of tongue, face,
extremities
 May occur after prolonged use of antipsychotics
e. Neuroleptic malignant syndrome
 Occurs days/weeks after initiation of treatment in
1% of clients
 Elevated VS, rigidity, and confusion followed by
incontinence, mutism, opisthotonos, retrocollis, renal
failure, coma, and death
 Discontinue medication, notify physician, monitor VS,
electrolyte balance, I&O
 Nursing Interventions:
 Offer self in development of therapeutic
relationship
 Use silence
 Set time for interaction with client
 Encourage reality orientation but understand
that delusions/hallucinations are real to client.
 Assist with feeding/dressing as necessary
 Check on client frequently; remove potentially
harmful objects
 Contract with client to tell you when anxiety is
becoming so high that loss of control is possible
 Administer antipsychotic medications as
ordered; observe for effects
K. Suicide
 Ideation: verbalization of wish to die
POSSIBLE TOPICS ON PSYCHIATRIC NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming July 2012 PNLE
 Gestures: engaging in nonlethal behaviors
 Actions: engaging in behaviors or planning to
engage in behaviors that have potential to cause
death
WHO WILL COMMIT SUICIDE? SAD PERSON
S- ex - Male (more successful); female (hesitant)
A- ge – 15-25 y/o or above 45 y/o
D- epression
P- atient with previous attempts (will try again)
E- thanol (Alcoholics)
R- ational (opposite)
S- ocial support (lacks)
O- rganized plan (greater risk)
N- o family
S- ickness (terminal stage)
 Nursing Assessment
Verbal cues
 Overt: I’m going to kill myself
 Disguised: I have the answer to my problems
Behavioral cues
 Giving away prized possessions
 Getting financial affairs in order, making a will
 Suicidal ideation/gestures
 Indication of hopelessness, depression
 Behavioral and attitudinal change
 Nursing Intervention
 Contract with client to report suicide attempt
 Assess suicide risk
 Keep client under constant observation
 Remove any objects that can be used in suicide
attempt
 Therapeutic intervention
Support aspect of wish to live
Use one-to-one nurse/client relationship
Allow client to express feelings
Provide hope
Provide diversionary activities
Utilize support groups
 Following a suicide
Encourage survivor to discuss client’s
death, their feelings and fears
Provide anticipatory guidance to family
Hold staff meetings to ventilate feelings
L. Eating Disorders
 Bulimia Nervosa: binge eating; the ingestion of large
amount of food in short amount of time, often
followed by self-induced vomiting.
 Anorexia Nervosa: refusal to eat or aberration in
eating patterns resulting in severe emaciation that
can be life threatening.
 Nursing Assessment
 Weight loss of 15% or more of original body weight
 Electrolyte imbalance
 Depression
 Pre-occupation with being thin; inability to recognize
degree of own emaciation (distorted body image).
 Social withdrawal and poor family and individual
coping skills.
 History of high activity and achievement in
academics, athletics.
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY 2012 PNLE PEARLS OF SUCCESS

PART 5: PSYCHIATRIC NURSING

 Amenorrhea

 Nursing Interventions:
 Monitor VS N. Child Abuse
 Measure I&O
 Weigh client 3 times/week at the same time  Nursing Assessment:
(check to be sure client has not hidden heavy
objects or water loaded before being weighed, Physical Abuse Sexual Abuse
weigh in hospital gown). Pattern of bruises/welts Pain/itching of genitals
 Do not comment on weight loss or gain. Burns (cigarette, scald, rope) Bruised/bleeding genitals
 Set limits on time allotted for eating. Unexplained Stains/blood on underwear
 Record amount eaten. fractures/dislocations Withdrawn or aggressive
Withdrawn or aggressive behavior
 Stay with client during meals, focusing on behavior Unusual sexual behaviors
client, not on food. Unusual fear of parent/desire to
 Accompany client to bathroom for at least ½ please parent
hour after eating to prevent self-induced
vomiting.  Nursing Interventions
 Individual/family therapy may be necessary.  Provide SAFETY ENVIRONMENT
 Encourage client to express feelings.  Provide nursing care specific to
 Help client to set realistic goal for self and to physical/emotional symptoms
reduce need for being perfect.  Conduct interview in private with child and
 Encourage client to discuss own body image; parent/s separated
present reality; do not argue with client.  Inform parent/s of requirement to report
 Teach client relaxation techniques. suspected abuse.
 Help client identify interests and positive  Do not probe for information or try to prove
aspects of self. abuse
 Be supportive and nonjudgmental
M. Alcohol Withdrawal Syndrome  Provide referrals for assistance and therapy

 Alcohol consumption reduce/discontinued

following continuous consumption for many days or
longer
 Withdrawal is progressive and has four stages:
 At least 8hrs after last drink: symptoms
include mild tremors, tachycardia, increased
BP, diaphoresis, nervousness.
 gross tremors: hyperactivity, profound
confusion, loss of appetite, insomnia, weakness,
disorientation, illusions, auditory and visual
hallucinations.
 12-48 hours after last drink: symptoms
include (in addition to those found in I and II)
severe hallucinations, grand mal seizures.
 3-5 days after last drink (24-72 hours if
untreated): delirium tremens, confusion,
agitation, severe psychomotor activity,
hallucinations, insomnia, tachycardia.
 Withdrawal may last less than a week or may evolve
into alcohol withdrawal delirium (delirium
tremens).

POSSIBLE TOPICS ON PSYCHIATRIC NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming July 2012 PNLE
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY 2012 PNLE PEARLS OF SUCCESS
PART 5: PSYCHIATRIC NURSING
O. Personality Disorders
Personality Symptoms / Characteristics
Disorder
Paranoid Mistrust & suspicions of others;
guarded, restricted affect
Schizoid Detached from social relationships;
restricted affect; involved with
things more than people
Schizotypal Acute discomfort in relationships;
cognitive or perceptual distortions;
eccentric behavior
Antisocial Disregard fro rights of others, rules,
and laws
Borderline Unstable relationships, self-image,
and affect; impulsivity; self-
mutilation
Histrionic Excessive emotionality and
attention seeking
Narcissistic Grandiose; lack of empathy; need
for admiration
Avoidant Social inhibitions; feelings of
inadequacy; hypersensitive to
negative evaluation
Dependent Submissive and clinging behavior;
excessive need to be taken care of
Obsessive- Preoccupation with borderlines;
compulsive perfectionism, and control
Depressive Pattern of depressive cognitions
and behaviors in a variety of
contexts
Passive-aggressive Pattern of negative attitudes and
passive resistance to demands for
adequate performance in social and
occupational situations
POSSIBLE TOPICS ON PSYCHIATRIC NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming July 2012 PNLE
Nursing Interventions
Serious, straightforward approach; teach client to
validate ideas before taking action; involve client in
treatment planning
Improve client’s functioning in the community; assist
client to find case manager
Develop self-care skills; improve community
functioning; social skills training
Limit setting; confrontation; teach client to solve
problems effectively and manage emotions of anger or
frustration
Promote safety; help client to cope and control
emotions; cognitive restructuring techniques; structure
time; teach social skills
Teach social skills; provide factual feedback about
behavior
Matter-of-fact approach; gain cooperation with needed
treatment; teach client any needed self-care skills
Support and reassurance; cognitive restructuring
techniques; promote self-esteem
Foster client’s self-reliance and autonomy; teach
problem-solving and decision-making skills; cognitive
restructuring techniques
Encourage negotiation with others; assist client to make
timely decisions and complete work; cognitive
restructuring techniques
Assess self-harm risk; provide factual feedback; promote
self-esteem; increase involvement in activities
Help client to identify feelings and express them directly;
assist client to examine own feelings and behavior
realistically