PSYCHIATRIC NURSING A – wareness of self

• Focus in the care of clients with • Knowing and understanding oneself:

identifiable symptoms of mental illness
to institute immediate cure and care
and to prevent chronicity of the
disorder.
MENTAL HEALTH NURSING
• Focus on the well individuals to promote
mental health,
• Those that are at risk and those with
early symptoms of maladjustments to
prevent mental illness.
feelings, beliefs, prejudices
R – espect
• high or special regard to others
S – elf disclosure
- sharing oneself to others/ opening one’s
baggages to others
2. Therapeutic communication
SCOPES OF PYSCHIATRIC NURSING

WHO ARE AT RISK? 1. General setting (hospital, clinics, nursing

homes, homes & anywhere.)
1. Family hx
- includes care of client experiencing anxiety
2. Adolescent stage related to physical ailments and hospitalization
3. Abusing substance - Focus on the alleviation of emotional
sufferings or anxiety of client with physical
4. Victims or violence abuse
disorders
5. Belong to the disadvantage people
(homeless & poor) 2. Community setting

3. Psychiatric setting
6. Elderly stage & considered to be poor

7. Poor Access to health LEVELS OF PREVENTIVE CARE

2 IMPORTANT TOOLS IN PSYCHIATRIC NURSING 1. PRIMARY CARE

• prevent mental illness & promote mental

1. Therapeutic use of self
health
- Using oneself as a tool in the development of
nurse-patient-relationship (NPR) to meet clients • well client
emotional needs and resolve clients health 2. SECONDARY CARE
needs (EARS)
- sicked clients
2. therapeutic use of communication
Goals: Treatment & management of the
E – mpathy disease.
• The feeling that you understand and 1. Case finding/ surveying (demographic
share another person’s experience and profile)
emotions
2. Early detection of cases (screening)
3. Early recognition of symptoms and
implementation of intervention
4. Identifying available resources (referral)
5. Case Management
- Hospitalization, Psychotherapy, crisis
intervention, detoxifications & other treatment
modalities.
3. TERTIARY CARE
- rehabilitated client
Goal: empower pt to achieve the highest level
of functioning
II. PSYCHOTHERAPY
1. INDIVIDUAL THERAPY
- focus on clients exploration of feelings,
attitudes, thinking and behavior through
therapeutic relationship (OWE)
1. Orientation
2. Working
3. Ending/ Termination
- Therapeutic relationships helps clients
recognize their strengths, resources and
maladaptive responses.
2. FAMILY THERAPY
- Family therapy involves participation of the
client and his family members.
GOALS:
1. Understanding how family dynamics
contributed to the clients psychopathology
2. Restructuring maladaptive family behavorial
styles
3. Strengthening family problem solving
behaviors
3. GROUP THERAPY
- Group therapy compose of number of person
who gather in a face to face setting to
accomplish tasks that requires cooperation,
collaboration, or working together.
- Members are expected to contribute to the
group to benefits others (ALTTRUISM) and
receive benefit from others in return.
EXAMPLE OF GROUP THERAPY
1. PSYCHOEDUCATION GROUPS
- Education group is used to provide
information to members in a specific issues:
1.1 Stress Management
1.2 Medications Management
1.3 Assertiveness training
1.4 Conflict resolution
1.5 Anger Management
1.6 Problem Solving
2. SELF-HELP GROUP
- Self-help group are concerns about coping
with a specific problem or life crisis.
2.1 Alcoholic anonymous – Alcoholics
2.2 Al-Anon – wives of alcoholic
2.3 Ala-Teen – Children of alcoholics
2.4 Overeaters Anonymous – bulimia
2.5 One day at a time – grieving
3. SUPPORTIVE THERAPY GROUP
- Support groups are organized to help
members who shares a common problem to
cope with it..
3.1 Cancer or stroke victims
3.2 Person with AIDS
3.3 Family members of someone who has 3. ADVENTITIOUS CRISIS
committed suicide
Man made or Natural disaster.
3.4 Role reversion
WHAT IS CRISIS INTERVENTION?
3.5 Mother Against drunk driving (MADD)
• Are methods to help individuals who are
CASE MANAGEMENT incapacitated or severely disturbed by
current situation.
III. CRISIS INTERVENTION
WHAT ARE THE NURSING INTERVENTIONS?
WHAT IS CRISIS?
1. AUTHORITATIVE INTERVENTIONS
• When a persons anxiety is overwhelming
and the usual coping is no longer - Directing the person’s behavior by offering
effective. suggestions and course of actions

• The state is considered the turning point 2. FACILITATIVE INTERVENTIONS

in one’s life.
- Encouraging expression of feeding and
• WHY? concerns (debriefing)

• Because the person will respond to crisis III. TERTIARY CARE

in different ways:
• Rehabilitated client.
1. He will function as to the pre-crisis level,
Goal to empowerment patient to achieve the
2. He will function at a higher level (strong highest level of functioning possible
effective coping)
1. Prevention of relapse
3. He will function at a lower level (weak-
ineffective coping) - involve client in the treatment plan

- Family and community support

Remember CRISIS is SELF-LIMITING usually last - Health teaching disease, symptoms,

4-6 weeks. treatment.

WHAT ARE THE TYPES OF CRISIS? 2. Minimize chronic disability

1. MATURATIONAL CRISIS - Increase independency

- Anticipated events in the normal course of - Promote social function

life. - Promote personal growth
Ex. Getting married, having a baby, beginning 3. Restore clients optimal level of functioning.
a career, getting away from home.
- Vocational Training
2. SITUATIONAL CRISIS
- Job Placement
-Sudden events that threaten the individuals
integrity.

Ex. Death, sickness, loss of job

ULTIMATE GOAL IN TERTIARY PREVENTIVE CARE:
1. Recovery from illness
2. Reintegration to the community
CRITERIA FOR MENTAL HEALTH
P- Positive self concept
(self acceptance, self confidence, emotional
stability, self-directed)
R- Reality Perception ( real & fantasy)
A – Autonomous Behavior(independency)
I – Integrative capacity – resilience & hardiness
• Effective coping and behavior
• Resilience – ability to respond in a
healthy manner in any stressful situation
• Hardiness – ability to rest illness despite
of stressful situation
S – Self- Actualization and personal growth
E – Environment Mastery
• Satisfying interpersonal relationship
• Making use of available resources.
MENTAL HEALTH
• Is a state of emotional, psychological
and social wellness as evidence by:
P – ositive self concept
E – ffective coping and behavior emotional
stability
S – atisfying interpersonal relationship
MENTAL ILLNESS
• Health conditions marked by alterations
in thinking, mood or behavior that
interfere with the individual’s major
functioning:
A. Occupational functioning
- unable to perform ADL, role performance,
unable to work or go to social.
B. Social functioning
- Unable to develop a satisfying relationship
with others (isolated, withdrawn, paranoid,
narcissistic, aggressive etc.)
C. Emotional Functioning
- unable to express feelings effectively and
aggressively
-project/suppress feelings or aggressively
express feelings
- destroying things/properties, yelling or hurting
others
- unable to think rationally (committing suicide
or hurting others)
D. Psychological Functioning
-unable to think abstractly
-unable to cope with stress
- unable to solve problems effectively
E. Spiritual functioning
- faith in God is absence – no one to hold on –
when no one to turn to (hopeless or helpless)
WHY DO PEOPLE BECOME MENTALLY
A. BIOLOGICAL FACTORS
1.1 GENETIC FACTORS
-Children with mentally ill parents are more apt
to develop mental illness
1.2 NEUROSTRUCTURAL
- dysfunction / alterations of the brain
structures
1.3 NEUROCHEMICAL FACTOR
-imbalance of neurochemical of the brain
B. INDIVIDUAL FACTORS (PAIN)
P – oor physical health
A – any kind of loss
I – ineffective coping
- inability to distinguish reality from
fantasy
N – egative view of self
C. INTERPERSONAL FACTORS (FAIL)
F – aulty family interaction & nurturing
during childhood
A- bsence of sense of belongingness
I – neffective communication & interaction
(withdrawal from relationship)
L – oss of emotional control
D. ENVIRONMENTAL FACTORS (PAIN)
P – overty & Homelessness
• Presence of discrimination
A – buse and Violence
I – nability to make use of support and
community resources (Inadequate social
support)
N – egative view of the world
HOW IS MENTAL ILLNESS CLASSIFIES?
1. PSYCHOSIS
-loss of reality testing
-altered thought process
- disturbed sensory perception
Ex. Schizophrenia
2. NEUROSIS
- Has less severe symptoms
- Intact reality testing
Ex. Personality Disorder
• G – GUSTATORY – TASTE
• O – OLFACTORY
• V – VISUAL – SIGHT
• A – AUDITORY – HEARING
• T – TACTILE - TOUCH
3. ORGANICAL
- with specific underlying causes that result
to structural damage and cognitive
impairment.
Ex. Dementia
4. FUNCTIONAL
DSM IV-TR
• A TAXONOMY PUBLISHED BY APA
PURPOSES:
1. To provide a standard language or
nomenclature for all mental health professional
2. To present defining characteristics/
symptoms that differentiate specific diagnoses
3. To assist identifying the underlying causes of
disorder.
DSM IV- TR IS BASED ON A MULTI-AXIAL
CLASSIFICATION SYSTEM
AXIS 1 - Psychiatric disorder and other
conditions that may focus of clinical attention.
 S – chizophrenia and other psychotic MENTAL RETARDATION
disorders.
1. MILD (moron) 50-70 educable
-Substance Related disorder
2. MODERATE 35-40 trainable
A – nxiety and anxiety disorder
(IMBECILE)
D – epression and other mood disorder
3. SEVERE (idiot) 20-35 needs close
AXIS 2 – personality disorder and mental retardation Supervision
AXIS 3 – Current medical conditions that are
potentially relevant in understanding or managing 4. PROFOUND 20↓ needs custodial
the person’s mental SYMPTOMS.

AXIS 4 - Psychosocial and environment problems INTELLIGENT QUOTIENT (IQ)

that may affect the diagnosis, treatment and
prognosis of mental disorders. • 70 & BELOW- Feeblemindedness (MR)

EX. Negative life events, Interpersonal stress, • 70-79 – borderline deficiency

unemployment, lack of education, poverty. intelligence

AXIS 5 – Global assessment functioning • 80-89 dullness

• Use to assess the client’s overall level of • 110-119 superios intelligence

functioning on a scale of 0-100
• 140 & ABOVE – genius or almost genius.
• These information helps the health team
plan treatment and predict outcomes. EXAMPLES

• >91-100 • F20.0 - Paranoid schizophrenia

-Superior functioning in a wide range of • F20.1 – Disorganized schizophrenia

activities: • F20.2 – Catatonic Schizoprenia
-has (+) qualities • F20.3 – Undifferentiated Schizopreni
- Has (+) coping • F20.5 – Residual Schizoprenia
- NO symptoms of mental disorders • F20.8 – Other schizophrenia
> 41-50 • F31.2 – Bipolar Disorder Type 1
- one symptoms of impairment • F29.0 – Unspecified Non organic
- severe obsession rituals psychosis

- suicidal ideation • F06.8 – Other specified mental disorder

secondary to seizure disorder
> 1-10

- highly dangerous to self and others

- gravely disabled
 1. ADAPTIVE NORMAL DEFENSE MECHANISM

- Facing and finding solution to the • Helps individual to deal with reality
situation.
ANTICIPATION
2. LESS ADAPTIVE
• Planning ahead for realistic expectation
- Use defense Mechanism temporarily
COMPENSATION
3. MALADAPTIVE
• Making up for imagined handicapped
- Use defense mechanism excessively or deficiency

A. CONSTRUCTIVE COPING SUBLIMATION

1. TASK ORIENTED • Most constructive rechanneling socially

unacceptable behavior to a socially
- direct problem solving acceptable one.
2. DEFENSE ORIENTED
COMPROMISE
- Use of defense mechanism • Reciprocal give and take necessary in
B. DESTRUCTIVE COPING marry relationships

- avoids problem SUBSTITUTION

- use defense mechanism excessively • Taking something in place of the original

goal
DEFENSE MECHANISM
IDENTIFICATION
• Patterns of behaving or thinking that
person uses consciously or • Unconscious attempt to change oneself
unconsciously to: to resemble an admired person

1. Maintain a sense of being in control of RATIONALIZATION

the situation • Justifying one’s behavior to make
2. Lessen discomfort unacceptable feelings and behavior
acceptable.
3. Deal with stress
1. SOUR GRAPE
4. Decrease anxiety
- implies that what is sincerely wanted is
OVERUSE OF DEFENSE MECHANISM not worth trying after all.

- Stop individual to learn appropriate methods 2. SWEET LEMON

to resolve anxiety producing situations
- Inhibit emotional growth
- Lead to poor problem solving
- Implies that a person tries to convince
himself that what he has is exactly what
he wants.

- Create difficulty with a relationships

CONVERSION 1. PHYSICAL ISOLATION

• Transferring emotional conflict into - physical withdrawal from people to

physical symptoms prevent further hurt or damage to one’s
security
MALINGERING
2. EMOTIONAL ISOLATION
• Conscious fabrication of an ailments
- the process of separating an
DENIAL unacceptable feelings, ideas or impulses
• In acceptance of reality from one’s thought.

DISPLACEMENT REACTION FORMATION

• Releasing anger in a less threatening • Acting out behaviors apposite to what

way. one really feels

DISSOCIATION REGRESSION

• Blocking off anxiety provoking event • Returning to an earlier developmental

from the conscious mind stage

EX. AMNESIA FIXATION

INTELLECTUALIZATION • Psychosocial development ceased to

advance
• Excessive reasoning to obscure real
feeling SYMBOLISM

INTROJECTION • Conscious use of idea or subject to

represent another actual event or
• A type of identification in which the object.
individual incorporates the traits or
values of another to self REPRESSION

PROJECTION • Involuntary or unconscious forgetting

unacceptable thoughts from conscious
• Blaming others for unacceptable deeds mind.
or thoughts
SUPPRESION

• Conscious voluntary forgetting of

FANTASY unacceptable or painful ideas, thoughts
or feelings
• Gratification by imaginary
achievements and wishful thinking UNDOING

ISOLATION • Engaging in a behavior that is

considered to be opposite of a previous
• Person blocked feelings associated with
unacceptable behavior.
unpleasant experience
 WHAT HAPPENS WHEN YOU FAIL TO COPE
WITH YOUR PRESENT SITUATION?
• You will be in CRISIS
WHAT IF YOU FAIL TO OVERCOME THE
CRISIS?
• It will result to your maladaptive patterns
of behavior or mental disorder.
HOW WOULD YOU KNOW THAT YOU HAVE
FAILING MENTAL HEALTH?
EARLY SIGNS OF FAILING MENTAL HEALTH
Decrease level of functioning
Sudden change in mood and behavior
(APILE)
A – nhedonia (Lack of pleasure)
A – nxiety
P – oor role performance
I – solation / withdrawn
L – oss of emotional control/ poor impulse
control / manipulative behavior
E – xcessive dependency
DISTRURBANCE IN AFFECT
1. MOOD – Emotional state
AFFECT – external symptoms of affect
1.1 INAPPROPRIATE AFFECT – disharmony
between thought and emotional response
1.2 FLAT AFFECT – No emotion attached to the
content of speech
1.2 BLUNT AFFECT – significant decrease
emotional response
1.3 LABILE AFFECT – change of emotion from
happiness to tearfulness in a very short period
of time.
1.4 EXAGERATED AFFECT
a. ELATED AFFECT – extreme and inappropriate
joyfulness
b. DEPRESSED AFFECT – pathologic feeling of
sadness
c. ANGRY – pathologic feeling of hostility
d. ANXIOUS – grieve feeling of apprehension
DISTURBANCES IN THOUGHTS
DELUSION – False belief that cannot be
corrected by reactions
1.1 DELUSION of GRANDEUR/ GRANDIOSE
DELUSION – belief that one is superior and
powerful
1.2 DELUSION of PERSECUTORY/PERSECUTORY
DELUSION
– belief that others are against him or will harm
him
IDEAS OF REFERENCE – belief that situation or
event in the environment are directly
projected into the client.
NIHILISTIC DELUSION – false belief that one
denies existence of self or part of self
THOUGHT BROADCASTING – false belief that
ones thought can be read by others
THOUGHT WITHDRAWAL – false belief that ones
thought is taken by others.
THOUGHT INSERTION – false belief that others
inserted thoughts or ideas into his mind
SELF DEPRECIATION – false belief that one feels
unworthy, ugly or sinful.
SOMATIC DELUSION – false belief pertaining to
body image or function
HYPOCHONDRIASIS – doctor shopper, morbid
belief that one is sick or likely to be sicked.
LOOSE ASSOCIATION
• Patient verbal production is impossible
to follow due to lack of organization.
WORD SALAD – extreme form of loose
association
CLANG ASSOCIATION – patient speaks in
rhymes.
NEOLOGISM – coining new words.
EX. “His BAGELSGELS is in the river”
THOUGHT BLOCKING – sudden stoppage of
thought without apparent reason.
FLIGHT OF IDEAS – over productivity of talk and
verbal skipping from one idea to another
POVERTY IDEAS – patient has few ideas and
focus only on negative aspects.
CIRCUMSTANTIALITY – patient provide a lot of
details before finally answering the question.
TANGENTIALITY- verbal production is not at all
related to question
OBSESSION – a persistent and irresistible thought that a
person is driven to think again and again
HYPOCHONDRIA – a morbid belief that in is sick
PERSEVERANCE – a tendency to emit the same DISTURBANCES IN MEMORY
verbal or motor response again and again AMNESIA – complete absence of memory
VERBIGERATION – constant repetition of same • ANTEROGRADE AMNESIA – forgetting recent
events
words
• RETROGRADE AMNESIA –forgetting further
events
DISTURBANCES IN PERCEPTION
PARAAMNESIA – incomplete absence of
ILLUSION – false interpretation of the external memory,
stimulus • CONFABULATION – fabricating stories to fill
HALLUCINATION – false sensory perceptions up lapses of memory because of
that occur in the absence of an actual anterograde amnesia
external stimuli • BLACKOUT – amnesia experienced by
G – ustatory – taste alcoholics about behavior during drinking
O – lfactory – Smell bouts.
WHAT ARE THE MANAGEMENT FOR MENTAL
V – isual – Sight
ILLNESS?
A – uditory – hearing
DRUGS
T – actile – touch
• Psychopharmacology
WORDS
DISTURBANCES IN MOTOR BEHAVIOR • Therapeutic Communication
CATATONIC STUPOR ENVIRONMENT
• RIGIDITY – client assumes position and • Milieu Therapy
will not move even when efforts is made • Psychotherapy
to change his position WHAT ARE THE MAJOR CATEGORIES OF
• WAXY FLEXIBILITY – client maintain PSYCHOTROPIC DRUGS?
• Antipsychotics
position which he has been originally
• Antidepresants
placed.
• Antimatic
CATATONIC EXCITEMENT
• Antianxiety
• HYPERACTIVITY – motor restlessness and • Anticholinergics
extreme/ over activity I. ANTIPSYCHOTIC DRUGS / NEUROLEPTICS
• IMPULSIVENESS – unpredictable and INDICATIONS:
sudden outburst of activity 1. Shizophrenia
• COMPULSION – unwanted urge to 2. Psychotic episodes of mania
perform repetitive actions 3. Psychotic depression
• AUTOMATISM 4. Drug induced psychosis
a. ECHOPRAXIA – repetition of the 5. Dementia with psychotic symptoms
actions of others. Blocks dopamine receptors in the post
b. ECHOLALIA – repetition of the words synaptic membrane and reduce dopamine
of others activity.
- STEREOTYPE TYPES:
a. MANNERSIM A. TYPICAL
- persistent motor behavior 1. CONVENTIONAL/ TRADITIONAL DRUGS
b. VERBIGERATION 2. Tx POSITIVE 5 OF SCHIZOPHRENIA
- constant repetition of same words - delusions
c. TICS & SPASM - hallucinations
- unconscious twitching or jerking of - disorganized thinking and behavior
muscles usually above the - disorganized speech
shoulder which are involuntary
 B. ATYPICAL K- emadrin (procyclidine)
1. New group of neuroleptic drugs A – rtane (trihexaphenidyl) 4-15mg/dl
2. Tx of positive & negative sx of A – mantadine (symmetry) 100-400mg
schizophrenia BID (Dopamin agonist)
- Alogia : Lack of language DYSTONIA/DYSTONIC REACTION
- Anergia : Lack of energy - Muscular rigidity and cramping
- Avolition : lack of motivation -tongue stickness or stiffness
- Asocial: lack of social skills - TORTICOLLIS (twisted head and neck)
- Apathy: lack of attention -OPISTHOTONUS (rigidity at the back of the
-Anhedonia: lack of interest or pleasure neck)
- Affective disturbances : Lack of emotional -OCULOGYRIC CRISIS (eyes relied back in a
response locked position)
C. DOPAMINE SYSTEM STABILIZER (DSS) SEVERE CASES OF DYSTONIA
- New generation antipsychotic drugs • Laryngospasm
- Use to stabilize dopamine output • Respiratory distress
approved by the FDA In November 2002 4. TARDRIVE DYSKINESIA
Ex: Arioiorazole (Abilify) - eye blinking
D. PALLIPERIDONE (Invega) - lip smacking
SELECTIVE NOREPINEPHRINE REUPTAKE - teeth grinding
INHIBITOR - tongue protruding
D- yserel (Trazadone) - Cheek puffing
E- ffexor (Ventafaxine) - body rocking
W- ellbutrin (Bupriopion) PREVENTION OF T.D
S-erzone (Nefazodone) 1. Maintain low dose
WHAT ARE THE EXTRAPYRAMIDAL SYMPTOMS 2. Change medication necessary
(EPS) 3. Monitor client periodically for initial signs
1. Akinisia / Pseudoparkinsonism of TD using the abnormal involuntary
-motor retardation movement scale (AIMS)
- salivation OTHER EFFECT OF ANTIPSYCHOTIC DRUGS
- hand tremors A. ANTICHOLINEGIC S/E – due to blockade of
- shuffling festinating gait acethylcoline
-mask like face -dry mouth/ eyes
2. Akathisia - constipation
- motor restlessness - retention
-pacing - photophobia
- inability to sit - urinary retention
- hand tremors - Blurred vision
- Rigid posture and gait Mgt – Manage side effects
3. Dystonia B. ENDOCRINE S/E
4. Tardive dyskinesia - Gynecomastia – increased prolactin
TREATMENT FOR EPS - Galactorhea
• Lower dosage of antipsychotic - Sexual dysfunction
• Change to a different antipsychotic - Menstrual problems
• Administer antocholinergics drugs Interventions: discuss with the client feeling and
C- ogentin *benztropin 2-6 mg/dl concern regarding effects on body image and
A- kineton (Bipenlen) 2-8 mc/dl feeling and anxiety
C. CARDIOVASCULAR ADVERSE EFFECT
1. Arrythmias, dysrythmias C. NEUROLEPTIC SYDROME (D CHAMP)
a. Assess radial and pulse D – Diaphoresis
b. Report feeling of light headness and C – Change in mental alertness (Stupor-coma_
dizziness H – Hyperthermia
2. Orhotatic hypotension • Hypertension/Hypotension (BP LABILITY)
a. Take baseline BP A – agitation, Tachycardia (>130 BPM)
b. Change position gradually Tachypnea (>25 BPM)
c. Monitor BP in different position M – Muscle rigidity
• (arm/abdomen like a board)
D. CENTRAL NERVOUS SYSTEM EFFECTS P – Pallor
- Head ache
- Dizziness II. ANTIDEPRESSANT DRUGS DESCRIPTION
- Sedation • Indications:
- Decreased mental alertness • Major depressive disorder
1. Headache may temporary until client will be • Bipolar type II
accustomed to medication • Depression secondary to other mental
2. May take medication at bedtime as advised disorders 9OCD, panic attacks, phobia,
by physician etc)
3. Caution on activities that needs mental • Blocks the reuptake of serotonin and
alertness norepinephrine into the pre-synaptic
E. DERMATOLOGIC EFFECT membrane.
- photosensitivity • USE ACROSS THE LIFESPAN
- Dermatitis 1. prescribed for adults and elderly
1. Avoid exposure to sunlight and cover 2. used for children and adolescence
exposed skin 3. not recommended during pregnancy and
2. Supervise personal hygiene lactation.
SERIOUS S/E CLASIFICATION OF II. ANTIDEPRESSANT DRUGS
A. AGRUNOLOCYTOSIS 1. TRICYCLIC ANTIDEPRESSANT (TCA)
SX. 2. SELECTIVE SEROTONIN REUPTAKE
1. Fever, sore throat/mouth, body malaise INHIBITOR (SSRI)
2. WBC level <2.0 3. MONOAMINE OXIDASE INHIBITOR
TX. (MAOI)
1. Monitor result of WBC 4. SELECTIVE NOREPINEPHRINE REUPTAKE
2. Notify physician INHIBITOR (SNRI)
3. Withhold further medication
4. Reverse isolation TRICYCLIC ANTIDEPRESSANT (TCA)
B. HEPATOTOXICITY • SAVE mr. TAN (2-6 weeks)
SX. S -Sinequan (doxepin)
1. Fever, nausea, jaundice, Abdominal pain A -Anafranil (clomiframin)
2. Abnormal liver function test (elevated enzymes)
V -Vivacil (protriptylline)
TX.
E -Elavil (amitriptyline)
1. Monitor result of liver function
2. Withhold any further medication
3. Notify physician T -tofranil (imipramine)
4. Increase client’s body resistance with A -Ascendin (amoxapine)
adequate rest, nutrition and fluids N -Norpramin (Deipramine)
 SELECTIVE SEROTONIN REUPTAKE INHIBITOR
• Therapeutic effect may occur to 2-3wks
P - Prozac (fluoxetine)
P - paxil ( paroxetine)
Z -luvox ( Fluvoxamine)
SERIOUS ADVERSE EFFECTS:
1. SEROTONIN SYNDROME
D - diaphoresis
D - Change mental status (confusion,
restlessness)
H - Hypertension, rigor
A - Acidosis, respiratory failure
M - Myoclonus ( muscle twitching),
tremors
• TX. FOR SEROTONIN SYNDROME
1. Pharmacology ( serotonin receptor
antagonist)
• Sansert (methysergide)
• Periactin ( cyproheeptadine)
2. Stop medication and notify physician
3. Admit client to ICU
4. Administer IV fluid
MONOAMINE OXIDASE INHIBITOR
• Therapeutic effect may occur2-4 wks
• Pa - Parnate ( tranylcypromine)
• Ma - Marplan ( Isocarboxadin)
• Na - Nardil ( phenelzine)
• S - Selegiline (EMSAN)
Note: avoid food and drink rich in tyramine
content to avoid hypertensive crisis.
Ex. Aged, fermented, preserved, prickled,
smoked, canned foods.
FOOD RICH IN TYRAMINE CONTENTS
• Aged cheese: cheddar cheese, swiss
cheese, bleu cheese
• Aged or fermented meats, rish or poultry:
salmon
• Chicken and beef liver pate
• Brewer’s yeast
• Red winers: Chianti, burgundy
• Herning: sausage, beef, salami, pepperoni
• SIDE EEFECTS:
1. Anti-choline effects
2. Cardiovascular effects
3. Photosensitivity
4. GIT effect ( anorexia and nausea)
5. CNS effects ( sedation and fatigue)
III. ANTIMANIC DRUG DESCRIPTION
• INDICATIONS:
1. Bipolar disorder type1
2. Schizoaffective disorders
-Normalizes the reuptake of serotonin,
Ne, dopamine and acetycholine
• Check lithium level in the blood:
• 1st month- every 2-3 days
• weekly- until stable
• monthly- when stable
• Therapeutic level- 0.5 – 1. mEq/L
• Toxicity levels and can occur at
therapeutic level.
• CONTRAINDICATION
1. Hypersensitivity response to lithium
2. Renal disease
3. Thyroid disease
• SERIOUS SIDE EFFECTS:
4. Thyroid impairment
5. Renal impairment
• Perform thyroid and renal function tests
as baseline and monitor every 3-6
months for clients on long term lithium
therapy.
• Use of lithium may alter thyroid functions
usually 6-8 months of treatment
• Thyroid function test done as baseline
and every 6 months during tx of lithium
• Increase level of thyroid stimulating
hormone
• Anxiety, labile emotions, sleeping
difficulties
• Decrease level if thyroid stimulating
hormone
• Fatigue and depression
COMMON SIDE EFFECTS: NON BENZODIAZEPINES
1. GIT effects ( nausea, anorexia, diarrhea) • BusPar ( buspirone)
2. Fatigue and lethargy • Ambien ( zotpidem)
3. Weight gain
4. Polyuria Side effects ( SHiNeD)
5. Metallic taste S - Sedation
6. Tremors - remember side effects are H - Headache
maybe reasons for medication non- N - Nausea
compliance. D - Dizziness
• TOXIN EFFECTS (MAN is SAVeD)
M- muscle weakness BENZODIAZEPINES ( D LAST VIVE OF KIM,
N- Nausea HANNAH, AND REX)
S- slurred speech
A Agitation, ataxia D- dalmine ( flurazepam)
V- vomiting L- librium, ( chlordiazepoxide)
D- diarrhea, drowsiness A – Atrivan ( lorazepam)
• SEVERE TOXICITY (CRASH) S- Serax ( oxazepam)
T- Tranxene ( chlorazepate)
C - Coma
R - Renal failure V - Valium (diazepam)
A - Arrhythmia I - Inderal (propranolol)
S - Seizure V - Vistaril ( hydroxyzine)
H - Hypotension E - Equanil ( propanolol)
tx.: hemodialysis and treat symptoms
K - Klonopin (clonazepam)
PREVENTION OF LITHIUM TOXICITY H - Halcoin ( traizolam)
1. Caution use in clients with diarrhea, R - Restoril (temazepam)
polyuria, vomiting, profuse sweating, low X - Xanax (akprazolam)
salt diet.
2. Maintain adequate h20 inatke SIDE EFFECT OF BENZODIAZEPINES
3. Maintain adequate sodium intake D-rowsiness
2g/day I-Impaired memory
4. Replace fluid loss as necessary p- poor motor coordination
5. Report symptoms of toxicity s- sedation
6. Maintain appointments to monitor • 5 D’s
blood levels. D- dependence
7. Restricts a caffeine intake. D- driving and other hazardous activities
should be avoided
CLASSIFICATIONS OF ANTIANXIETY DRUGS D- drowsiness and sedation decreases
1. NON- BENZODIAZEPINE with time
• Acts a partial agonist decrease D- don’t stop benzodiazepine abruptly
serotonin turnover D- don’t drink alcohol beverages with
2. BENZODIAZIPINE antianxiety drugs.
• Mediate the actions of GABA (gamma
amino butyric acid)
Therapeutic communication
• Nurse pt interaction to promote
effective exchange of information to
work the client in the resolution of
his/her specific health needs &
problems.
Classification of communication
1. VERBAL – 10%
2. NON-VERBAL – 90%
Non-verbal communication has 3 categories:
a. KINESICS – body movements
b. PARALANGUAGE – voice tone
c. PROXEMICS – distance/space (respect
client’s personal space)
d. OTHERS:
• Observe autonomic physiologic
responses (ex. Increase respiration,
diaphoresis, pupil dilation, blushing,
paleness
• General appearance (ex. Hygiene,
grooming, dressing)
• Physical characteristics ( ht, wt,
physique, complexion)
Successful communication includes:
a. FEEDBACK – there should be an
accurate return response
b. APPROPRIATENESS – response should be
relevant
c. EFFICIENTCY – message & questions
should be clear, easy, simple &
concrete.
d. FLEXIBILITY – absence of overcontrol or
under-control
• OVER CONTROL
• deliberate prescribing response
• Encourage client to express feeling
& concerns
• UNDERCONTROL
• Participants do & say what they wish
to the extent of disregarding the
direction of conversation
• Direct/guide client to problem
solving.
GUIDELINES IN THERAPEUTI COMMUNICATION
TECHNIQUES
1. Focus the client’s feeling & concerns
2. Respond in such way that client feel
worthy & important
3. Direct or guide client to problem-solving
4. Focus on the verbal & non-verbal
communication
5. Always be honest, consistent &
congruent in your responses.
6. Remember the DON’T’S
THE DON’T’S
• ADVISING
• Telling the client what to do
• “I think you should _____________”
• “I really think you should give it a
try”
• AGREEING/DISAGREE
• Taking or opposing client’s ideas
• You are perfectly correct
• “I don’t believe what you had
said”
• AGPPROVING/DISAPPROVING
• Accepting or denouncing the
client’s behavior or idea
• “I like your blouse & slacks”
• “you fix your hair but it does not
suit you”
• ASKING WHY QUESTIONS
• BELITTLING FEELING EXPRESSSED
• Rejecting feeling expressed or
disregarding client’s feeling
• P “My husband left me. I have
nothing to live for. I wish was
dead”
• N “I felt that way too, when my
husband left me”, “I experience
the same at times”
• CHALLENGING
• Probing, prying, snooping
• P “ I’m the president of the US”
• N “how come you are the
president of US”
• CHANGING THE TOPIC
• Is introducing new topic
inappropriately
• Is a pattern that may indicate
anxiety
• CLOSED ENDED QUESTION (YES OR NO)
RESPONSE) EXCEPT WHEN CLARIFYING
OR VALIDATING
• FALSE REASSURANCE
• Is using cliché to reassure client
• Everything will be alright”
• GIVING PERSONAL OPINION
• “you have a lot of reason to live
for”
• GIVING LITERAL RESPONSES
• Figurative comment as though it
were a statement of fact
• P “they’re looking in my head w/
a television camera”
• N “what channel”
• GIVING ALUE JUDGEMENT
• Giving one’s opinion.
• Evaluating moralizing or implying
one’s values by using words such
as NICE, BAD, RIGHT, WRONG,
SHOULD. Etc.
• “you look good today you must
be feeling better today”
• INCONGRUENT COMMUNICATION
• Sending verbal & non-verbal
messages that contradict one
another.
• INTERNAL VALIDATION/INTERPRETING
• Is making an assumption about
the meaning of someone else
behavior w/o validation
• “You look good today. You must
be feeling better today”
• OVERLOADING
• Is taking rapidly changing
subjects too often& asking for
more information that cant be
absorbed at one time.
• UNDERLOADING
• Is remaining silent & unresponsive,
not picking up cues, & failing to give
feedback
OPEN ENDED – invites client to share personal
experience
• OPEN ENDED QUESTION (giving broad
opening)
• What would you like to discuss?
• What are your plan to the future?
• How will you approach your father?
• GENTLE COMMAND (encouraging
description of perceptions)
• Tell me something about your home
life?
• Share w/ me some of your hopes
about the therapy
• Describe for me the problems w/
your father
FOCUSED – used w/ a resistant client.
1. EXPLORING/FOCUSING
• Can you describe your feelings?
• Can you tell me about your boss?
• Can you tell me what the voices
are saying?
• This topic seems worth looking at
more closely
2. QUALITATIVE QUESTIONS
• How’s your appetite?
• How’s your job doing?
• How’s your mod been?
• How’s your sleep last night?
3. STATEMENT OF INQUIRY
• REFLECTING PARAPHARING
• You said you were only second in
your class? – what is youre feeling
about it?
• You seem to be saying that youre
viewed as the bad guy in your
family?
• Give me an example of being
the bad guy
• CLARIFY & VALIDATE clients
statement
• P “im crazy” (N “what do you
mean youre crazy”)
• P “I cant sleep I stay awake all
night” (N “you have difficulty
sleeping
4. EMPATHETICS STATEMENTS
• Making observation sharing
perceptions, seeking clarification
• It sounds like a troubling time for
you
• It looks like youre feeling sad
• Its difficult to end a marriage after
10 yrs
• Respond in such a way that client
feel worthy & important
• Youre worth my time
5. FACILITATORY STATEMENTS - Accepting
offering general leads
• ACCEPTING
• Conveying that nurse bears or
is interested in what the client is
saying yes or simple nodding
head
• OFFERING GENERAL LEAD
• Encouragement client to
continue the conversation
• Go on
• And then
• Tell me about it
CLOSE ENDED
• Helps obtain important facts or ask for
specific details & give information or
explanations
• CLOSED ENDED QUESTIONS (seeking
information)
• How long have you been hearing
voices?
• What medication are you taking?
• Are you feeling angry?
• I read your chart that you tried
suicide once before
OTHER USEFUL TECHNIQUES
• PRESENTING REALITY (ex. P “eggs are
flying saucer” N – “eggs are food to be
eaten
• MAKING OBSERVATION – Verbalizing
what the nurse perceives
(ex. You appear tense, ive notice that
biting your lips)
 • GIVING RECOGNITION – acknowledging
behavioral change or indicating
awareness
(ex. “you’ve comb your hair today”)
• SILENCE but express being there
• nurse says nothing but continues to
maintain eye contact & convey
interest acceptance
• ENCOURAGING EXPRESSION OF
FEELINGS – best response
• (ex. P “ I want to kill myself”, N “ tell
me about your feeling of wanting to
kill yourself”
• “tell me how you feel”
• ENCOURAGING DECRIPTION –
perception, asking the client what
he/she perceives
• (ex. “what does the voice seem to
be saying?”
• FEEDBACK – Directing clients actions
thoughts & feelings back to client
• (ex. P “do you think I should tell my
husband what happened?”
• N “ do you think you should tell your
husband ?”
• OFFERING SELF – making oneself
available
• (ex. “ I will stay here with you”
• I will accompany you in the
pantry”
NURSE – PATIENT RELATIONSHIP
THERAPEUTIC RELATIONSHIP – Is a helping
relationship between nurse & client
• Professional relationship
• Pt centered
• Time bounded
• Goal directed
• Structured – planned & follows a
sequence (establishing maintaining
termination)
PRE-ORIENTATION – Begin before the nurse’s
first contact w/ the client
1. SELF-AWARENESS
• The nurse should consider her
personal strength & limitations in
working w/ the client
2. GATHER CLIENT’S DATA - Baseline
information
A. ORIENTATION (establishing) – begins when
the nurse & client meet for the first time &
ends when the client begins to identify
problems to examine
1. Establish rapport & acceptance
(TRUST)
2. Establishing contract
3. Establishing boundaries
4. Beginning assessment
GOAL:
I. ORIENTATION PHASE
• T – Trust & rapport
• E – environmental therapeutic
• A – assessment (client’s strength
& weaknesses)
• C – contract (therapeutic)
• H – help client to communicate
II. WORKING (maintaining) – begins when
client’s problem is identified & ends
when the problem is re solved
1. Maintain the relationship
2. Working & resolving client’s
needs/concern
• P – Promotion of positive self-
concept
• R – realis goal setting
 • O – organize support system • ELEMENTS OF THERAPEUTIC
ENVIRONMENT /MILIEU THERAPY
• V – verbalization of feelings
includes:
• I – independency of effective
• Unit structure
coping skills
• Unit norms
• E – evaluation & redefining goals
as necessary • Limit setting

III. TERMINATION (terminating/separating) – • Unit modification

begins when the client problem is
• UNIT STRUCTURE includes:
resolved
• C – community meetings
• R – refer & transfer client to other
support system • A – ADL & active groups
• E – encourage client to discuss • P – physical exercise program
feelings about terminating
• Psycho-educational
• A – assess client emotional program
stability
• UNIT NORMS
• D – do not give false reassurance
that relationship will continue • Rules & policies

• Y – YOU identify & deal w/ • Dressing

separation issues. • Appearance
BARRIERS TO THERAPEUTIC RELATIONSHIP (Candy • Medication
TRIES)
• Visiting hour
• C – COUNTERTRANSFERRENCE – nurse
transfers feelings to client a significant • Telephone use
person in her life
• Individual responsibility
• T – TRANSFEERENCE – client transfer feeling to (independence nonviolent
nurse of a significant person on her life behavior physical & emotional
• R – RESISTANCE & AVOIDANCE – security respect privacy
development of ambivalent feelings for self acceptance
exploration or self disclosure
• LIMIT SETTING
• I – INAPRORPIATE BOUNDARIES – relationship
• Identifying acceptable &
should be maintained when the NPR
unacceptable noncompliance of
• E – ENCOURAGE DEPENDENY – encourage medications norms, inappropriate
independency sexual behaviors, others.
• S – SYMPHATY - empathy • Limit setting includes:
1. THERAPEUTIC ENVIRONMENT or MILIEU • Stating undesirable behavior
THERAPY
• Stating the effect or
• Purpose use of the environment to consequences of the behavior
enhance recovery/rehabilitation of in/her relationship to others
mentally ill pts
• Stating desirable behavior
 • Ex. “ I noticed that youre wearing
jun’s shirt. He might get angry. Let
me help you change into your
own shirt”
• UNIT MODIFICATION
• Purposeful arrangement of the
environment
• It seeks to identify & help change
potentially self-destructive or unhealthy
behavior.
• It funx on the idea that all behaviors are
learned & therefore can be unlearned.
• It can be beneficial in adults as well as
in children

• This includes physical BEHAVIOR THERAPY

arrangement of furniture, safety
• Depression
issues & orientation strategies.
• Anxiety
2. PSYCHOTHERAPHY
• Panic disorder
• It is a tx of mental or emotional
disorder of related bodily ailments by • Anger issues
psychological
• Eating disorder
• It is a tx of mental or emotional illness
by talking about problems than by • PTSD
using medicines or drugs • Bipolar disorder
• ILLNESS – specific condition that • ADHD
prevents your body or mind from
working normally (sickness, disease, • Phobias
ailment, disorders)
• OCD
• DISORDER – physical or mental
• Self-harm
condition that is not normal or
healthy (confuse, dishevel, • Substance abuse
disorganize, disturb upset.
TYPES OF BEHAVIOR THERAPY
1. INTERPERSONAL PSYCHOTHERAPY
• 2.1 COGNITIVE BEHAVIOR THERAPY
• It is tx modality that uses a therapeutic
• COGNITIVE THERAPY – focus on
relationship to modify the client’s
your moods & thoughts
feeling, attitudes, & behavior when
therapeutic communication forms the • BEHAVIORAL THERAPY – focus on
foundation your actions & behaviors.
• Ex. Nurse – pt relationship • CBT is centered around modifying
thought patterns in-order to change
• ATTITUDE – a feeling or way of thinking
mood & behavior
that affects a person’s behavior
(subjective) • CBT is based on the idea that negative
actions or feelings are the result of
• BEHAVIOR – the way a person acts,
current distorted beliefs or thoughts not
moves, reacts (objective)
unconscious forces from the past
2. BEHAVIORAL THERAPY
• CBT often requires only 10-20 sessions
• It is an umbrella a term for types of
• Therapist may asked you to keep
therapy that treat mental health
JOURNAL as part of CBT
disorders.
 • This will record your life events & your • People are taught to replace a
reactions thus helps you replace your fear response to phobia w/
negative thought patterns or relaxation responses
perception w/ more construction
1. Relaxation & breathing
• Learning to control & modify techniques
distorted thoughts & reactions
2. Gradual exposure to feared
• Learning to assess external object or situation
situations & reaction accurately
• 2.4 AVERSION THERAPY
• Practicing self talk
1. Often used to treat problems
• Using evaluation to reflect & such as substance abuse &
respond appropriately alcoholism

Disorders that can be treat by CBT 2. It is a form of behavior therapy

whereby NEGATIVE
• Antisocial behaviors
REINFORCEMENT is used to
• Conduct disorders change behavior: a stimulus
attractive to the client is paired
• Anxiety disorders (GAD, phobia) w/ paired w/ unpleasant event
• ADHD • 2.5 MODELLING
• Bipolar disorder 1. It is behavioral therapy whereby
• Depression the therapist acts as role model
for specific identified behaviors
• Personality disorder so that client learns through
• Schizophrenia imitation

• 3 . COGNITIVE THERAPY
• Sexual disorders
1. It is an active, directive, time
• Sleep disorders
limited, structured approach
• Social skill problems used to treat a variety of
disorders including depression,
• Substance abuse
anxiety disorders, phobias &
• 2.2 PLAY THERAPY panic disorder

• Tx is focus on what a child is 2. It is based on the principle that

uncomfortable expressing or how individuals feel & behave is
unable to express determined by how they think
about themselves, about the
• child may choose his/her own world & their place in it.
toys & play freely draw a picture
or use toys to create scene while • 4. FAMILY THERAPY
he/she is being assess/watch by
1. Understanding family dynamics &
the therapists
working on issues
• 2.3 SYSTEMDESENSITATION
• Relies on classnt.ical conditioning
& is often used to treat phobias
 • 5. Group therapy • Characterized by 2wks
duration of continuous
1. 5.1. psycho-education group
symptoms of depression
Provide information to
• DYSTHYMIA
members on a specific
issues • Characterized by low grade
depression of at least 2yrs
2. 5.2. self-help group
duraTion for more days than
Coping w/ a specific not
problem or life crisis
• BIPOLAR TYPE2 (DEPRESSED TYPE)
3. 5.3. supportive therapy group
• Characterized by one or 2
Shares a common major depressive episodes &
problem to cope w/ it. at least one or numerous
hypomanic episodes
MOOD DISORDDERS
• HYPOMANIC EPISODES
Mood disorder/affective disorders: mild to
extreme fluctuations in emotions & behaviors • Are distinct period of
persistent elevated expansive
• TYPES OF MOOD DISORDER or irritable more though at
1. Unipolar disorders least 4days.

2. Bipolar disorders OTHER RELATED DISORDER

• DEPRESSIVE DISORDERS (UNIPOLAR • MELACHOLIA – depressive generally

DISORDERS) seen in older population

1. Major depressive disorder • POST-PARTUM DEPRESSION – depression

seen after delivery
2. Dysthymia
• ATYPICAL DEPRESSION – depression seen
• BIPOLAR DISORDERS in younger generation, increased
appetite, hypersomnia, hypersensitivity
1. Bipolar manic type (type 1)
to interpersonal rejection
2. Bipolar depressed type (type2)
• SCHIZOAFFECTIVE DISORDER –
3. Cyclothymia. characterized by varying degrees of
symptoms of both schizophrenia &
• DEPRESSIVE DISORDER
mood disorders beginning in youth
• Major depressive disorder
• pts feel that are on a “chronic
• Bipolar type 2 – depressed type roller coaster ride” of symptoms
that are more often difficult to
• Dysthymia cope w/ than the individual
• Melancholia problem of either schizophrenia
or mood disorder
• Post-partum depression
SYMPTOMS OF DEPRESSION
• Atypical depression
• altered eating pattern
• Schizoaffective disorder
• decreased appetite (wt loss)
• MAJOR DEPRESSIVE DISORDER
• increased appetite (wt gain)
 • helpless, hopeless & worth THEORIES OF ETIOLOGY

• BIOLOGICAL FACTOR
• poverty of ideas
• Genetic
• psychomotor retardation (no energy &
motivation) • Neurochemical theory

• anhedonia (no feeling of pleasure) • Decrease serotonin &

poor concentration/decreased norepinephrine
attention • Neurophysiological
• recurrent thought of death (suicidal • Limbic system
ideation)
• Hypometabolism
• BIPOLAR TYPE 1
• Psychosocial factor
• Characterized by distinct period of
abnormally & persistently elevated. • BIOLOGICAL FACTORS
Expansive or irritable moderate least • Genetic
1 wk or more manic episodes usually
w/ a depressive episodes • Neurochemical theory

• CYCLOTHYMIA • Increase serotonin,

norepinephrine, acethylcholine,
• Characterized by periods of
dopamine
hypomanic & depressive episodes
that do not meet the criteria for • Neurophysiological
major depressive disorder
• Limbic system dysfunx
SYMPTOM OF MANIA
• Psychosocial factor
• HYPERPRODUCTIVITY
THEORIES OF ETIOLOGY
• Racing thoughts
• PSYCHOSOCIAL THEORY
• Flight of ideas • Imaged or real
• EXPANSIVE MOOD • Loss of loved person or object

• Hyperactivity • Faulty family interaction

• Distractibility • PSYCHOSOCIAL THEORY

• Mask of depression
• Extreme energy
SAD PERSON’S SCALE
• Altered sleep
pattern(decreased) • S – SEX

• A – AGE <19 & 45>

• Altered eating pattern
(decreased) • D – DEPRESSION – this is a good prediction

• EUPHORIA/ELATION • P – Previous attempt – major indicator

• E – ethanol (alcohol) used

• Feeling “high”, ecstatic, on top
of the world up in the clouds • R – rational thinking impaired

• DELUSION OF GRANDEUR • S – social support lacking

• O – organized plan
• INCREASE SELF-ESTEEM
• N – no spouse
•
• S – sickness
BEHAVIORAL CLUES OF IMPENDING SUICIDE NURSING INTERVENTION
• Change in pts behavior DEPRESSION MANIA
• Improved mood 10-14 days after talking 1. PHYSICAL NEEDS 1. PHYSICAL NEEDS
antidepressant
• provide • provide
• Finalizes business or personal affairs
adequate adequate
• Gives away valuable posseessions nutrition & nutrition &
hydration hydration
• Withdraws social activities & plan

• Has death plan/leaves note • assess wt • prevent

exhaustion
• Makes direct or indirect statements • prevent
constipation • encourage
• (“I may not be around then”) rest
• inc. exercise
• (“I will not be needing it where I am going”)
• short nap
• hygiene
SUICIDAL ASSESSMENT • sedation PRN
2. let client
• IDEATION – “are you thinking about express 2. LIMIT SETTING
killing yourself” feelings on
• PLAN – “do you have a plan of killing unacceptable
3. environment
yourself” behavior
• stimulating
• METHOD – “how do you plan to kill 3. ENVIRONENT
yourself” • safety
• Non-
(remove
• ACESS – “how would you carry out this stimulating
objects)
plan?” • Safety
• institute
• WHERE - “where would you kill yourself?” (remove
suicide
excess
• WHEN – “when do you plan to kill precaution
furnitures)
yourself?” 4. ACTIVITIES –
4. ACTIVITIES –
• TIMING – “what day or time of day do repetitive,
gross physical
you plan to kill yourself?” task . ex
activities. Ex.
folding
PSYCHIATRIC CONDITIONS W/ HIGH INCIDENCE Brisk walking.
laundry –
OF SUICIDE promote
• M – major depression completion
of ADL by
• A – alcoholism providing
enough time
• D – drug addiction
& assisting
• P – panic disorder/post traumatic client when
disorder necessary

• A – anorexia nervosa TREATMENT

• L – low impulse behavior 1. PSYCHOPHARMACOLOGY

• S – schizophrenia & schizoaffective
2. ECT
disorder
3. PSYCHOTHERAPY
 ELECTROCONVULSIVE THERAPY NURSING RESPONSIBILITIES

• ECT involves introduction of electrical current to the • Inform client

bain through an electrode attached to client’s
• Secure consent
temporal region.
• Complete physical exam
• It produces grandma seizures
• Cardiopulmonary & neurological exam
• Clients are usually given series of 6-15 tx 3x a wk
• Dental records
• Maximum benefit is achieved in 12-15 tx
• Preparation of the procedure
2 FORMS OF ECT
• Room
1. UNILATERAL
• ECT machine
• Electrodes is attached to either sides
• Emergency equipment & drugs
• Results in less memory loss but more tx may be
• PRE- ECT
needed
• NPO 6-8hrs/post midnight
2. BILATERAL
• Take v/s
• Electrodes are attached to both sides
• Dry client
• Results in more rapid improvement but w/ increase
short memory loss • Remove nail polish

INDICATIONS • Place client in a supine position comfortably

in bed w/ firm mattress
• Severely depressed
• Remove jewelries
• Actively suicidal
• Loosen clothing’s
• Does not respond to antidepressant
• Empty the bladder

• Intolerable drug side effects • Move bowel

• Prevent relapse of depression • Administer pre-medication as prescribe by

the physician.
CONTRAINDICATION
• Muscle relaxant (succinylcholine –
• HPN anectine)

• CVD • Short acting anesthesia

• COPD • Atrophine sulphate

• Fever • DURING ECT

• Brain tumor • Stay w/ the client

• Fracture & Glaucoma • Provide emotional support

• Assess any complications

 • POST ECT
• Position client in a lateral position
• Assess any injury
• Take v/s
• Stay w/ the client & orient as the client
will experience confusion& short term
memory impairment
• Offer food if client is fully awake &
when gag reflex returns
SCHIZOPHRENIA – is a group of disorder characterized
by altered thinking feeling perception & behavior
• Men tend to bet diagnosed bet 18-25
• Women are diagnosed most frequently
between 25-35
THEORIES OF ETIOLOGY
1. BIOLOGICAL FACTORS
a. Genetic predisposition
• 1st degree relatives are 10x
greater riskd for schizophrenia
b. Neurochemical imbalances
• Dopaminergic dysfunx
c. Neuroanatomic or structural dysfunx
• Frontal lobe hypometabolism
• Thinner cortex of the medial
temporal lobe
2. PSYCHOSOCIAL FACTORS
a. Poverty/homelessness
b. Difficulty resting
c. Affective blunting
d. Difficulties w/ decision making
e. Self concept changes
f. Ineffective coping
g. Loss of family relationships
TYPES OF SCHIZOPHRENIA
1. DISORGANIZED
• Onset: early usually <18y/o & insidious
• Behavioral pattern: withdrawn
• Defense mechanism: regression
• Characteristics: impaired ADL,
inappropriate behavior, silly smile &
laughter, somatic delusions.
NURSING INTERVENTION
• Promote self care & independency
• Promote socialization
• Provide safe & simple activities
• Involve in therapeutic activities (re-motivation
activities)
• Use active friendliness
CARE OF CLIENT WHO IS HALLUCINATION
• Maintain accepting attitude
• Assess type of hallucination
• Do not argue w/ pt about reality of
hallucination
• Point out reality if possible
• Encourage discussions of reality-based interest
• Comment on feeing tone of hallucination
• Ex. that must be frightening to you
• Encourage diversional activities & activities w/c
pt can gain sense of mastery. Ex. Playing cards,
artwork
CARE CLIENT W/ DELUSIONS 3. CATATONIC SCHIZOPHRENIA

• Allow pt to verbalize the delusions • Onset: no specific age & usually acute &
precipitated by emotionally disturbing
• Do not argue w/ pt
experience
• Do not reinforce delusions by validationg them
• Behavioral pattern: withdrawn
• Focus on potential real concern of pt
• Defense mechanism: repression
• Provide activities to divert attention from delusions
• Types: catatonic stupor
• Provides solitary activities then may progress to
noncompetitive games or activities • Catatonic excitement

2. PARANOID SCHIZOPHRENIA NURSING MANAGEMENT

• Onset: late onset usually 30-35y/o & is a. Provide safety

sudden/acute
b. Promote nutrition & hydration
• Behavior pattern: suspicious
c. Prevent bowel & bladder problem
• Defense mechanism: projection
d. Minimize circulatory tone
• Characteristics: extreme suspiciousness,
ideas of reference, delusion of persecution, 4. UNDIFFERENTIATED SCHIZOPHRENNIA
auditory hallucination, unpredictable
violence • Symptoms of more than one type of
schizophrenia
NURSING INTERVENTION
• Does not meet the criteria for paranoid
1. Give client ample personal space – to enhance
his/her sense of security disorganized or catatonic

2. Use no demand attitude – making demands & being 2. RESIDUAL SCHIZOPHRENIA

authoritative increases the client’s suspiciousness
• Hx of at least one psychotic episode but
3. Use passive friendliness w/ limited overt psychotic behavior

4. Develop trust – be reliable & consistent • Negative symptoms persist or 2 or more

positive symptoms are present in
5. Provide safety for others & client
attenuated form such as odd beliefs
• Approach client in a non-threatening
manner OTHER RELATED DISORDERS

• Never whisper 1. SCHIZOAFFECTIVE DISORDER

• Never hold complicated objects 2. DELUSIONAL DISORDER

• Provides solitary safe & relatively simple • Non-bizarre delusion of at least 1month
activities duration

6. Focus on client’s nutrition 3. SCHIZOPHRENIFORM

• Characterized by the presence of

symptoms of schizophrenia
 • BREIF PSYCHOTIC DISORDERS LEVELS OF ANXIETY

• Characterized by the presence of • MILD ANXIETY

symptoms of schizophrenia at least
once) • PERCEPTION

• Duration of at least 1day but less than 1 • Increased/widens

month returns to pre-illness level of • Enlarged perceptual field
functioning
• BEHAVIORAL CHANGES
• SHARED PSYCHOTIC DISORDERS
• Alert/aware
• Delusion is similar in content to that of
the other person • Energetics

• PSYCHOTIC DISORDERS DUE TO A GENERAL • Attention increased

MEDICAL CONDITION
• Can solved problem
• Evidence from hx, physical exam or lab
studies that disturbance is a result of • Learning is effective
the physiologic consequences of a
• PHYSIOLOGICAL CHANGES
general medication condition/disorder
• Slight discomfort
• SUBSTANCE INDUCED PSYCHOTIC
DISORDER • Restlessness

• Symptoms developed during or • GI butterflies

w/in 1 month of substance
intoxication or withdrawal, or • Difficulty sleeping
medication used related to the
• INTERVENTION
disturbance
• Engage in goal directed activities
ANXIETY & ANXIETY DISORDER
• MODERATE ANXIETY
Anxiety is considered normal when it is appropriate to
the situation • PERCEPTION

Anxiety becomes abnormal when it is excessive, chronic • Decreased/narrowed

& results to impairment in the individual’s major
• Selective inattention
functioning & usually manifest unusual behaviors.
• BEHAVIORAL CHANGES
• Panic w/o reason
• Difficulty in concentration
• Irrational fear of objects
• Easily distracted
• Uncontrollable repetitive actions
• Attention span decreased
• Theorist believed that non-satisfying relationships,
unfulfilled needs, unmet developmental Tasks, etc. • Pacing/restlessness
produce anxiety, w/c is the basis for all emotional
• Cannot connect thoughts or events
problems independently
• PHYSIOLOGICAL CHANGES • Increased BP, RR, CR

• Pounding pulse • Chest pain

• Higher voice pitch • Severe headache & vertigo

• Diarrhea
• Increase rate of speech
• Tremors
• Frequent urination
• Pale/faint
• Nervous mannerisms
• Dilated pupils
• Clammy hands
• SEVERE ANXIETY NURSING MGT
• Diaphoresis
• Decrease anxiety
• Muscle tension
• Relaxation technique
• GI distress
• Reduce environmental stimuli
• Headache
• Stay or walk w/ person who is upset
• Dry mouth
• Listen
• MODERATE ANXIETY
• Administer intramuscular anxiolytics
• NURSING MGT
• PANIC ANXIETY
➢ Refocus attention
• PERCEPTION
➢ Supervise client in solving
problems & learning new things • Disorganized (sabog/waral)

➢ Administer oral anxiolytics as • BEHAVIORAL

prescribed
• May bolt & run or immobile

• SEVERE ANXIETY • May become hysterical or mute

• PERCEPTION • Disorganized thinking

• Distorted(magulo) • Irrational reasoning

• BEHAVIORAL • Feeling overwhelmed & out of control

• Confused • Suicidal

• Impaired judgment decision making & • Hallucination/delusion

problem solving
• PHYSIOLOGICAL
• Absence of abstract reasoning • Same w/ severe anxiety

• Difficulty focusing even w/ assistance • SOB

• S/S becomes the focus of attention • Hyperventilation

• COPING DYSFUNCTIONAL • INTERPERSONAL THEORY

• Defense mechanisms fail ➢ The higher the lvel of anxiety to

communicate & solve the lower the ability of
• NURSING MGT the communicate & solve the problems &
the greater chance for anxiety disorders to
• Provide safety because the person
develop.
cannot perceive potential harm.
ANXIETY DISORDERS – is diagnosed when anxiety
• Continuously talk w/ the person in a
becomes chronic & impairs individual’s major funx
comforting manner even though the
resulting to maladaptive behavior & emotional disability
client cannot process what you are
saying 1. PHONIA/PHOBIC DISORDER

• Reduce environmental stimuli • A – specific irrational fear

• Remain w/ the person until panic • DM – displacement, repression,

subsides/abate (panic can last from 15- projection,
30 mins)
• 1. AGORAPHOBIA – fear of open spaces,
• UNDERLYING CAUSE OF ANXIETY: fear of being alone in public places

• BIOLOGIC FACTOR • 2. SOCIAL PHOBIA – avoid social

situations because of fears of being
➢ Genetic
humiliated or embarrassed
➢ Neurochemical
• 3. SPECIFIC PHOBIA – persisten
- GABA – anxiety disorders irrational fear other than the above.

- Norepinephrine – panic disorder GAD, TYPES OF PHOBIC DISORDER

PTSD
• AGROPHOBIA – ht
- Serotonin – panic disorder, GAD, OCD
• ANDROPHOBIA – storms
• GABA believed to be dysfunctional in
• CLAUSTROPHOBIA – enclosed places
anxiety disorders
• KAKORRHAPHOBIA – failure
• GABA reduces anxiety & norepinephrine
increase it, researchers believe that • NYCTOPHOBIA – nights/ dark places
problem w/ the regulation of these
neurotransmitters occur in anxiety disorder • OCHLOPHOBIA – CROWDS

• PSYCHODYNAMIC • PHOTOPHOBIA – light

• PSYCHOANALYTICL/INTRAPSYCHIC THEORY • AILUROPHOBIA – cats

➢ Defense mechanisms are cognitive • ALGOPHOBIA – pain

distortions that a person uses
unconsciously to maintain a sense of • ASTRAPHOBIA – storms
being in control of situation to lessen • BELONOPHOBIA – needles
discomfort to deal w/ stress.
 • BRONTOPHOBIA – thunder 2. PANIC ATTACK/PANIC DISORDER

• CLAUSTROPHOBIA – enclosed places • A sudden onset apprehension or terror

that last for 15-30 mins
• CYNOPHOBIA – dogs
• Afer attack it is allowed by 1month of
• ENTOMOPHOBIA – insect one or more the ff. symptoms
• GENOPHOBIA – DIRT • 1. Persistent concerns of having
another attack
• HEMATOPHOBIA – BLOOD
• Feeling of “going crazy” losing control,
• KAKORRHAPHOBIA – FAILURE
or having heart attack
• MICROPHOBIA – GERMS
• 3. Significant change in behavior – panic
• MYSOPHOBIA – contamination/germs disorder w/ agoraphobia.

• NYCTOPHOBIA – NIGHTS/DARK PLACES NURSING MGT

• OCHLOPHOBIA – CROWDS. • Provide safety

• OPIDIOPHOBIA – SNAKE • Continuously talk w/ the person in a comforting

manner.
• PATHOPHOBIA – DISEAASE
• Reduce environmental stimuli
• PHONOPHOBIA – LOUD NOISES
• Remain environment stimuli
• PHOTOPHOBIA – LIGHT
• Remain with the person until panic subsides
• PYROPHOBIA – FIRE (panic can last 15-30 mins)

• TAPHOPHOBIA – BEING BURRIED ALIVE GENERALIZED ANXIETY DISORDERS

• TOPOPHOBIA – STAGE FRIGHT • A: non-specific, excessive & uncontrollable w/c

may last over days for 6months
• XENOPHOBIAA - FEAR OF STRANGERS
• Individual w/ GAD typically anticipate disasters
• ZOOPHOBIA – ANIMAL
& overly concern about everyday matters such
NURSING MGT as:

• EXPOSURE THERAPY • Health issues

• Systematic desensitization – gradual • Money

exposure to the feared object
• Work difficulties
• Implosive therapy/flooding technique –
• Death
abrupt exposure to the feared object.
• Family problem
• Positive self-talk
• Assessment • NURSING INTERVENTION

• Fatigue • Discuss self harm thoughts

• Insomnia/decreased appetite • Use distraction techniques

• Poor concentration/forgetting • Refers client as “survivor” & not
• DOB
a “victim”

• Tremors • Promote social & community

support
• Sweating
• OBSSESSIVE COMPULSICE DISORDER
• NURSING MGT
• A repetitive thoughts (obsession) &
• Relaxation
action (compulsion)
• Isometric exercise
• Common onsessions
• Progressive muscle relaxation
• Violence
• Positive self talk
• Wealth
• Distraction techniques
• Power
• Rubber band, counting objects,
counting backward from 100 by • Sex
threes.
• Contaminations
• Increase physical activities to release energy
• Cleanliness
• Ex. Stationary bicycling
• Common compulsions
• POST-TAUMATIC STRESS DISORDER
• Checking
• A re-experiencing extreme traumatic
events/ stressors through FLASHBACKS • Handwashing arranging
& NIGHTMARES
• Counting
• DM – avoidance of symptoms
• Touching
at least 1-3 months
• Cleaning
• Chronic: onset of symptoms at
least 3-6 months • NURSING INTERVENTIONS
• Delayed: onset of symptoms at • P – psychopharmacology. SSRI & TCA
least 6months or beyond after teach client about medication as part of
stress the tx plan
• Acute stress disorders • A – allow client time to perform rituals
• Onset of symptoms at least 2 • C – convey acceptance of the client,
days to 1month despite ritualistic behavior
 • E – expression of feelings • Benzodiazepine

• D – diversional therapy – encourage • Xanax

limit setting on ritualistic behaviors as
• Non-benzodiazepine
part of the established tx plan.
• BuSpar
• Keep journal – assist client in listing of
the objects & places that triggers • SSRI
anxiety as part of exposure-response
• Paxil
prevention program
• Zoloft
REMEMBER:
• GAD
• Intervention
• Non-benzodiazepine
• Mild – engage in goal directed activities
• BuSpar
• Moderate – refocus attention
• SSRI
• Severe – decrease anxiety
• PROZAC
• Panic – provide safety
• PAXIL
• Principles of mgt:
• ZOLOFT
• Be: C – calm
• Alpha-adrenergic agonist
• A – administer medications • Inderal (propranolol)

• L – listen to the pts concern • OCD

• M – minimize environmental • Benzodiazepine

stimuli
• Xanax
• Panic disorder
• Non-benzodiazepine
• Benzodiazepine
• BuSpar
• Xanax
• TCA
• Klonopin
• Anafranil
• Valium
• Klonopin
• SSRI
• SSRI
• Prozac
• Paxil
• Zoloft
• Zoloft
• TCA
• Prozac
• Tofranil
• Luvox
• Phobia
MALADAPTIVE PATTERNS OF BEHAVIOR • SYPTOMS

SOMATOFORM DISORDERS PAIN: at least 4 different sites head, abdomen, joints,

back, chest, extremities, rectum, menstruation, sexual
• Is a disorder characterized by presence of intercourse, urination
physical symptoms that suggest a medical
conditions w/o organic basis. • GASTROINTESTINAL SYMPTOMS: at
least 2 sx: N/V, bloating, diarrhea, foo
ESTIOLOGY
intolerance.
I. BILOGOGIC THEORIES
• SEXUAL SYMPTOMS: at least 1 sx:
a. Genetic sexual indifference, erectile dysfunx,
ejaculatory dysfunx, irregular menses,
b. Biochemical changes – comorbid w/ excessive bleeding during
other psychiatric problems such as menstruation, vomiting throughout
depression & panic pregnancy

c. Neuropathologic theory – • PSUEDONEUROLOGIC SYMPTOMS: at

hypometabolism /dysfunx of certain least 1 sx:
brain areas
• Conversion symptoms
II. PSYCHOLOSOCIAL THEORIES
• Paralysis or localized weakness,
a. CONVERSION – neurologic & motor difficulty swallowing or lump in
symptoms the throat, blindness, double
vision, deafness, loss of pain
b. SOMATIZATION – physiologic symptoms
sensation
c. Use as coping
• Dissociative symptoms
d. PRIMARY GAIN – are the direct external
benefits that being sick provides relief • Amnesia, fainting or loss of
of anxiety, conflict or distress consciousness

e. SECONDARY GAIN – are the internal or II. CONVERSION DISORDER

personal benefits received from others • Involves unexplained, usually sudden
because one is sick. deficits in sensory or motor funx
TYPES OF SOMATOFORM DISORDER
• LA BELLE INDIFFERENCE – a lack of
I. SOMATIZATION DISORDER concern or distress despite of
neurologic disorder
• Characterized by multiple physical
symptoms that has no pathologic basis • MGT – acknowledge symptoms – traet
the conversion symptoms as real
• Symptoms are combination of pain, GI, symptoms
sexual & pseudo-neurologic

• Symptoms interfere w/ individual’s funx

 III. PAIN DISORDER
• Primary physical symptom is pain ex.
Headache & musculoskeletal pain
• Common in woman than men
• Co-morbid w/ depression & anxiety
• Nursing intervention
i. Help client identify strategies to
relieve pain
ii. Identify stressors
IV. HYPOCHODRIASIS
• Disease conviction – preoccupation w/
fear that one has serious disease
• Disease phobia - pre-occupation w/
fear that one develop serious disease
V. BODY DYSMORPHIC DISORDER
• Preoccupation w/ an imagined or
exaggerated defect in physical
appearance
VI. OTHER RELATED DISORDER
• MALINGERING – in fabrication of
physical or psychological symptoms
FACTITIOUS DISORDER
a. MUCHAUSEN’S SYNDROME
- Intentional production of physical or
psychological symptom solely to gain
attention
b. MUNCHAUSEN’S SYNDROME BY PROXY
NURSING INTERVENTION
1. Establish a routine activity
2. Proper nutrition, rest & exercise
3. Relationship between stress coping & physical
symptoms
4. Relaxation techniques: guided imagery, deep
breathing, music. Etc.
5. Promote social interactions
6. Keeping a journal
7. Limit primary & secondary gain
TREATMENT
PHARMACOLOGY – to treat co-morbid psychiatric
disorders
a. SSRI – fluoxetine, sertraline, paroxetine
b. TCA – tofranil (imipramine)
c. MAOI – phenelzine (nardil), Chronic pain
d. SNRI – venlafaxine (effexor), duloxetine
(Cymbalta), welbutrin.
EVALUATION
1. Client verbalized insight into the dynamics of
the disease process including primary &
secondary gain
2. Recognize relationship between stress coping &
physical symptoms
3. The client decreased physical attention seeking
complaints
Dissociative disorders
• Disorders that occurs in extreme stress or
trauma resulting to memory loss
• ONSET: sudden or gradual & the course may be
long term or transient
• DM DISSOCIATION – removal of conscious
awareness of painful feelings, memories,
thoughts, or aspect of identify.
TYPES OF DISSOCIATICVE DISORDERS
1. Dissociative amnesia
- Loss memory of important personal
information, often of trauma or
stressful nature
2. Dissociative fugue
- Sudden unexpected travel away from
home or ones place of work w/ loss of
memory about the past & confusion
about personal identity
- In severe but rare cases the individual
may assume a whole new identity
 3. Disassociation identity disorders ( multiple
personality disorders)
- Presence of two or more distinct sub
personality
- At least two of these sub personalities
take control of the persons behaviors
NURSING INTERVENTIONS
1. Provide safety
2. Reduce anxiety
3. Expression of feelings
4. Promote coping.
DISORDERS IN CHILDREN
• CONDUCT DISORDER
• Persistent antisocial behavior in children &
adolescents that significantly impairs their
ability to funx in social, academic or
occupational funx.
CONDUCT DISORDERS CLASSIFCATION
• MILD – less conduct problems & cause minor
harm to others (ex. Lying, truancy, running
away from home
• MODERATE – conduct problems increases &
increase amount of harm to others. (ex.
Vandalism, sexual harassment, use of weapons.
• SEVERE – conduct problems are greater w/
considerable harm to others (ex. Rape, robbery,
burglary, homicide, parricide, use illegal
substances
CONDUCT DISORDERS TREATMENT
• PRE-SCHOOL AGE
o Parental educations about growth &
development.
o Parental support during crisis.
• SCHOOL AGED CHILDREN - Family therapy
o Parental education
o Social skills training to improve peer
relationships.
o Improve academic performance
increase ability to comply w/ demands
from authority figures
• ADOLENCE – individual therapy
o Conflict resolution
o Anger management
o Teaching social skills
• MEDICATION may be used for specific
symptoms
1. Antipsychotic – aggression
2. Lithium – labile mood
3. Carbamazepine – mood stabilizer
4. Valproic acid (Depakote) – mood stabilizer
CONDUCT DISORDERS NURSING INTERVENTION
• DECREASE VIOLENCE
o Set limitation on client’s inappropriate
behavior
o Use behavioral contract
• INCREASE COMPLIANCE TO TX PLAN
o Provide consistency w/ clients tx
o Provide routine schedule of ADL
• IMPROVE COPNG SKILLS
o Teach client & practice problem solving
skills
o Behavioral therapy
o Self-monitoring – diary/journal
o Positive reinforcement of appropriate
behavior
• PROMOTE SELF-ESTEEM
o Encourage independency (making
decision w/ guidance)
o Show acceptance, interest & respects
• PROMOTE SOCIAL SKILLS
o Teach age-appropriate social skills
o Role-model & practice social skills
• PROVIDE CLIENT & FAMILY EDUCATION
OPPOSITIONAL DEFIANT DIORDER
- Most common psychiatric diagnosis of pre-
school children characterized by
uncooperative, defiant & hostile behavior
toward authority figures w/o major
antisocial violations.
- Is diagnosed when behaviors are frequent &
intense & cause dysfunx in social, academic
& work situations
 - As the child progresses through
development, ODD tends to be associated
w/ co-morbid diagnosis of ANXIETY &
MOOD disorders
AUTISM
- Also called mindblindedness
- Incidence common in boys
- Onset: identified usually by 18mos &not later
than 3y/o
- Characteristic: impairment of reciprocal
interaction skills
- Etiology: unknown but could be genetic factor
AUTISM SYMPTOMS
1. Difficulty w/ social interactions
- Unaffectionate
- Inappropriate attachment to objects
- Lack of interest in the environment
- Inappropriate laughing or giggling
- May avoid eye contact
2. Difficulty w/ communication
- Delayed or absent of language
development (echolalia)
- Doesnot use language to communicate
instead may use gestures
- Difficulty in expressing needs
3. Stereotype behavior
- S – sustained repetitive motor
movements
➢Spin objects or self
➢Rocking
➢Hand or finger flapping
➢Body twisting
HOW IS AUTISM DIAGNOSED?
• For the 1st 2yrs of life, the child should be
checked for the ff development deficits:
o 12mos: no babbling, pointing or
gesturing
o 18mos: no single word spoken
o 24mos: no two-word spontaneous
expressions
o Loss of any language or social skills at
any age
TX FOR AUTISIM
• Reduce behavioral symptoms
o Reduce temper tantrums,
aggressiveness, self-injury, hyperactivity
& stereotyped behaviors
1. Haloperidol (Haldol)
2. Risperidone (Risperdal)
o Diminish self-injury & hyperactive
obsessive behaviors
1. C – catapres (clonidine)
2. A – anafranil (clomipramine)
3. R – ReVia (naltrexone)
• Promote learning & development
o Special education: highly structured
program focusing on the development
of social skills, language, self-care &
school performance
o Family therapy: parental education
ATTENTION DEFICIT HYPERACTIVE DISORDER
• Characterized by:
o H – hyperactivity
o I – inattentiveness
o D – distractibility & impulsivity
• Common among boys
• Usually identified & diagnosed when the child
begins pre-school
ATTENTION DEFICIT HYPERACTIVE DISORDER (ADHD)
A – academic performance is poor
D – disruptive & intrusive behavior
H – hyperactive & impulsive behavior
1. Inability to sit still
2. Fidgets
3. Run or climbs excessively
4. Often on the go
5. Talks excessively
6. Blurts out answer/interrupts
conversation
7. Cant wait for turns is markedly affected
D – difficulty sustaining attention & concentration
TX FOR ADHD interferes w/ relationship & occupational
functioning.
PSYCHOPHARMACOLOGY (CARDS) -use to reduce
hyperactivity, inattentiveness, impulsivity & lability of TYPES OF EATING DISORDERS
mood
1. Anorexia nervosa
C – CYLERT (pemoline) 2. Bulimia nervosa
➢ 90% of cases are women
- Last drug to be prescribed due to its ➢ 10% of cases are men
hepatotoxicity(liver damage)
DISTINGUISHING FEATURES
A – ADDERAL (amphetamine)
❖ ANOREXIA
R – RITALIN (methylphenidine) 1. Ego syntonic
D – DEXEDRINE (dextroamphetamine) 2. Early age of onset
- 12-20y/o or younger
- SE: insomnia, loss of appetite, wt loss, 3. Below normal body wt
irritability & increase self injury during 4. Do not recognize the eating behavior as a
highest dose week problem
5. Less worried
S – STATTERA (atomoxetine)
6. Starve
- Non-stimulant drug approve in 2002 7. Amenorrhea
- An antidepressant (selective ❖ BULIMIA
1. Ego dystonic
norepinephrine reuptake inhibitor)
2. Later age of onset
- SE: loss of appetite, N/V, fatigability,
abdominal distress - Usually 20y/o or older
3. Near normal or normal body wt
- OTHER DRUGS:
4. Recognize her altered eating pattern
➢TCA
5. Worried of the opinion of others
➢Alpha 2 agonist(clonidine &
6. Eat then purge
guanfacine)
7. No amenorrhea
➢Traditional antipsychotic drugs
– severe impulsiveness ANOREXIA NERVOSA
NURSING INTERVENTION - Is life-threatening eating disorder
characterized by body wt 15-85% less
- Ensure safety of client & that of other
than expected or normal body wt.
- Improved role performance
- Simplifying instructions/directions S/S:
- Structured daily routine
o Establish a daily schedule A – amenorrhea for at least 3 consecutive cycles
o Minimize changes
N – no organic factor accounts for wt loss
- Client/family education & support
O – obviously thin but feels fat
EATING DISORDERS
R – refusal to maintain body wt
- A disorder characterized by alteration in eating
pattern & disturbance in body image that E – emotional expression is restrained
X – symptoms of depression & social w/drawal are BULIMIA NERVOSA
present
- Is an eating disorder characterized by
I – intense fear of gaining wt recurrent episodes of binge eating at
least twice a week for 3mos.
A – always think of food & food related activities
S/S:
MEDICAL COMPLICATION RELATED TO WT LOSS
B – binge eating
• CARDIAC
o Hypotension U – under strict dieting or vigorous exercise
o Bradycardia
o Cardiac arrhythmias L – lack control over eating
• DERMATOLOGIC I – induced vomiting
o Dry, cracking skin
o Lanugo M – moth-eaten appearance teeth
o Acrocyanosis (blue hands & feet)
I – increase & persistent concern body
• HEMATOLOGIC
o Leukopenia A – abuse of diuretics & laxatives
o Anemia
o Thrombocytopenia TREATMENT
• METABLOIC
ANOREXIA
o Hypoglycemia
o Hypothyroidism 1. Medical mgt
▪ Intolerance to cold, body - Focuses on wt restoration, nutritional
weakness rehabilitation, rehydration & correction
• MUSCULOSKELETAL of electrolyte imbalances
o Loss of fat 2. Psychopharmacology
o Osteoporosis - Cyproheptadine(periactin)
o Pathologic fractures - Amitriptyline(elavil)
• GASTROINTESTINAL - Olanzapine(zyprexa)
o Constipation - Fluoxetine(Prozac)
o Abdominal pain 3. Psychotherapy
o Diarrhea - Family therapy
• REPRODUCTIVE - Individual therapy
o Amenorrhea
• NEUROPSYCHIATRIC BULIMIA
o Depression
1. Cognitive-behavioral therapy
o Insomnia
- Strategies designed to change the
• OTHERS
clients thinking (cognition) & action
o Electrolyte imbalances
(behavior)
o Elevated BUN
2. Psychopharmacology
o Hypertrophy of salivary gland
- TCA – desipramine (norpramin)
- Imispramine(tofranil)
- SSRI – fluoxetine(Prozac)
- Sertraline(Zoloft)
SLEEP DISORDERS
SLEEP – natural periodic suspension of consciousness
1. Restore & maintain homeostasis
2. Essential for bodys thermoregulation
3. Conservation of energy
SLEEPNESS
- The urge to fall asleep
SLEEP DEPRIVATION
- Means a person is not getting an
optimal amount of sleep every night
- Leads to chronic fatigue, memory
problems, energy deficit, mood
difficulties
- SLEEP DEBT occurs when there is
recurrent long term sleep deprivation
CAUSES OF SLEEP DEPRIVATION
1. Social problem issues
- Sleep loss diminishes safety & results in
loss of lives & property in occupations
in w/c workers are expected to work
shifts around the clock
2. Medical condition
- Sleep disturbance may be secondary to
the symptoms of disease or related to
medical condition
- Ex. Sleep apnea is related to HPN, heart
failure, diabetes, etc.
3. Tx issues (drug & chemical substances)
- Alcohol
- Antidepressants
- Barbiturates
- Caffeine
- Diuretics
- Narcotics
- SSRI
- Steroids
- Amphetamines
- Aspirin
- Benzodiazepines
- Cocaine
- Lithium
- Nicotine
- Phenothiazine
4. Psychiatric disorder
- Sleep disturbance is a part of the
psychiatric disorders.
- Ex. Major depressant, anxiety, manic
disorders
- Prolonged period of sleep deprivation
are linked to hallucinations & delusions
STAGES OF SLEEP
- Sleep last anywhere between 90-110 minutes.
(SLEEP ARCHITECTURE)
• A. NON-RAPID EYE MOVEMENT(NREM)
o Occurs about 90mins after falling asleep
o 1. Stage 1 & 2
▪ First & lightest phase sleep
▪ Person is easily aroused
o 2. Stage 3 & 4
▪ Deepest state or slow energy
because metabolism & body
temp decreases during this
stage
▪ Comprises 10-23% of sleep
POLYSOMNOGRAPHY – measure the physiologic
changes of sleep-wake cycle
• B. RAPID MOVEMENT (REM)
o Eyes dart back & forth
o The HR, BP &RR are variable & may
increase
o Muscles are mostly paralyzed (Atonia)
o Vivid dreams occur
PRIMARY SLEEP DISORDERS
1. DYSSOMNIAS
- Involves problems in initiating or maintaining
sleep
- Main symptoms are disturbance in the amount,
quality, or timing of sleep
2. PARASOMNIAS
- Characterized by unusual or undesirable
behaviors that intrude into sleep or occur at the
threshold between waking & sleeping
TYPES OF DYSSOMNIAS
• PRIMARY INSOMIA
o Refers to difficulty falling asleep,
trouble maintaining sleep, or waking up
too early for at least 1 month
o Co-morbid w/ medical conditions such
as arthritis, GIT disordedrs, parkinsons
disease, etc.
NURSING INTERVENTION
• Promote sleep hygiene strategies
• 1. SET A REGUGLAR TIME FOR SLEEPING HOUR
o Go to sleep at the same time each night
& awaken at the same hour each
morning
o Provide a non-interrupted sleep during
the night
o Limit daytime sleep by providing activity
that promote wakefulness
o Provide for naps during the day, if
indicated to meet sleep requirements
• PROVIDE COMFORT
o Sleep in loose, comfortable clothing
o Sleep in a comfortable bed
o Take a warm bath before going to bed
o Relaxation techniques: avoid taking
worries to bed
o Exercise daily
• PROVIDE A CONDUCTIVE ENVIRONMENT
o Provide calm, quiet environment
o Provide dim lights as desired
o Maintain a comfortable temperature
• INSTRUCT PT WHAT TO AVOID
o Avoid caffeine during the day because
the stimulating effects of caffeine can
linger for as long as 12hrs
o Avoid heavy meals before bedtime
o Avoid alcohol before bedtime.
• PROVIDE HEALTH EDUCATION
o Importance of adequate sleep specially
during illness, psychosocial stresses,
pregnancy, etc.
o Instruct pt & significant others about
factors that contribute to sleep pattern
disturbance
▪ Ex: psychological, physiological,
lifestyle factors, frequent work
shift changes
▪ Excessive long work hrs
o Provide pamphlet w/ information about
sleep enhancement techniques
• TREATMENT
o BENZODIAZEPINE
▪ Triazolam (halcion)
▪ Estazolam (ProSom)
▪ Flurazepam (dalmane)
▪ Temazepam (Restoril)
▪ Quazepam (doral)
o NON-BENZODIAZEPINE
▪ Zolpidem (ambien)
▪ Zaleplon (sonata)
▪ Eszopiclone (Lunesta)
o Absorbed rapidly & reduced sleep latency
(time measured from bedtime to the
beginning of sleep)
• 2. PRIMARY HYPERSOMIA
o Excessive sleepiness for at least 1 month
occurring almost everyday as evidenced by
either prolong sleep episodes or delaying &
causes significant distress or impairment of
functioning
o Occurs less frequently than insomnia but is
not rare.
• 3. NARCOLEPSY
o Overwhelming urge to sleep occurring anytime
of the day w/ 2-6 sleep attacks a day frequently
report dreaming.
o Attacks are usually short, lasting 5-20 mins, but
may last up to an hour if sleep is not
interrupted
o A chronic disorder that usually begins between
the ages of 15-35 yrs
o Has no cure & remains stable over the lifetime
o Treatment is designed to control symptoms &
depends on clinical presentation
• GROUP OF SYMPTOMS OF NARCOLEPSY
• Daytime sleepiness
• Cataplexy
o Brief episodes of sudden bilateral loss of
muscle tone precipitated by intense
emotions
 • Hypnagogic hallucinations
o Dream like hallucination while falling
asleep such as seeing images, hearing
sounds, smelling, etc.
• Sleep paralysis
o Inability to move or speak when falling
asleep or waking up.
o Episodes are usually brief, lasting only
few seconds to minutes, & usually
terminate spontaneously or when
someone touches the individual
• Treatment:
o CNS stimulant: Ritalin
(methylphenidate, modafinil, &
pemoline)
o TCA – suppress REM sleep
o Gamma – hydroxybutyrate decrease
cataplexy attack
• 4. BREATHING RELATED SLEEP DISORDER
o A. OBSTRUCTIVE SLEEP APNEA
SYNDROME
o Report of apparent apneic episodes w/c
last from 10 secs to several mins,
causes restless sleep & abrupt
awakening w/ feeling of chocking or
falling out of bed
▪ Report of loud snoring
• TREATMENT:
o UVULOPALATOPHARYNGOPLASTTY
▪ Removal of redundant soft
plate tissue, the uvula, &
tonsillar pillars
o CONTINUOUS POSITIVE AIRWAY
PRESSURE
▪ Wearing a nose mask that is
connected by a long tube to an
air compressor
DYSSOMNIA NOT OTHERWISE SPECIFIED
• MENTRUAL-ASSOCIATED SYNDROME
o Characterized by marked hypersomnia,
a change in behaviors, & voracious
eating before or during menstruation
• KLEINE-LEVIN SYNDROME
o Rare condition characterized by
recurrent periods of prolonged sleep
(lasting from 1 or several wks) w/
intervening periods of normal sleep &
alert waking
o “sleeping beauty” disorder
• SLEEP DRUNKENNES
o A rare & abnormal form of awakening
in w/c the state that often leads to
social inconvenience & sometimes to
criminal acts
TYPES OF PARASOMNIAS
• NIGHTMARE DISORDERS
o Repeated occurrence of frightening
dreams that fully awaken an individual
o For some people this is a lifetime
condition, for others it occurs at time of
stress & illness.
• SLEEP TERROR DISORDERS
o Also called “night terror” or “pavor
nocturnus” in children & often in boys
o May last 1-10mins
o Characterized by scream or cries & is
accompanied by intense anxiety (panic)
• SLEEPWALKING DISORDERS
o Characterized by repeated episodes of
rising form the bed during sleep &
moving about
o Amnesia for the episode on awakening
w/c results to confusion &
disorientation
PARASOMNIAS NOT OTHERWISE SPECIFIED
• SLEEPTALKING
o Common in children & adults
• SLEEP-RELATED BRUXISM
o Tooth grinding that occurs throughout
the night
• SLEEP RELATED HEAD BANGING
o Sleep behavior consisting of rhythmic
to-and-fro head rocking occurring just
before or during sleep
• REM SLEEP BEHAVIOR DISORDEER
o The client may act out his dreams &
poses significant risk to the client as
well as to clients bed partner
 o Characterized by atonia during REM
sleep & followed by the emergence of
violent complex behaviors.
o Chronic progressive condition found
mostly in men
• TREATMENT FOR PARASOMNIAS
o Reduction of stress
o Measures to protect the pt
o Use dental-bite plate for sleep-realted
bruxism
o Psychopharmacology
▪ Klonopin (clonazepam)
▪ Tegretol (carbamazepine)