Foundation of Psychiatric Nursing PRactice

The A to E of Psychiatric & Mental Health Nursing

A - cceptance
B ehavior that is inappropriate
C - ognizence
D efence mechanism
E - xpre ssion of feelings
 Therapeutic NPR
4 phases:
1. Pre Interaction
2. Orientation
3. working
4. Termination
 Pre Interaction Phase
Self awareness

JOHARIS WINDOW
1. Public 2. Blind

3. Hidden 4. Closed
1 2

1 2

3 4
NURSES TASK
1. Explore own: F - _____________
F - _____________
F - _____________

2. Analyze own professional strengths & limitation

3. Gather data about pt when possible
 ORIENTATION PHASE
Assessment
1. Determine why patient sought help
a. envt change
b. Nurturance
c. Control
d. Problem solving
e. Psychiatric symptoms
f. Advised to seek help

2. Explore pts thoughts, feelings & actions by _________________

Trust
3. Establish trust, acceptance, & open communication

4. Mutually formulates a contract.

a. _____________
b. _____________
c. _____________
d._____________
e._____________
f.______________
g. _____________
h. _____________
i. _____________
Nursing Dx
5. Identify pt problem

Goals
6. Define goals with the pt
 Working Phase

Assess Continuously
Evaluate further & explore relevant stressor
Independence
Insight developed
Overcome resistance behavior
 Termination Phase
1. Establish reality of separation
2. Evaluate accomplished goals
3. Mutually explore feelings of rejection, loss, sadness & anger & other
related behaviors
4. evaluate general progress of thrx
5. maintain initially defined boundaries
6. Anticipate problems of this phase:
a.
b.
c.
Criteria for Determining Pts Readiness for
Termination
20% Experience relief from presenting problem

20% Social function has improved / isolation

20% Goals are accompilshed

20% Imploys coping mechanism/ appropriate behavior

20% Ego functions has been strengtened

An impassed has been reached in the NPR because of

100%
countertranference that cannot be worked through
 Roles of the Nurse in the Therapeutic
Relationship
Stranger
Resource person
Teacher
Leader
Surrogate
Counselor
 Communication
5 elements:
1. Sender
2. Message
3. Receiver or recipient
4. Feedback
5. context
 Therapeutic Communication
Non Verbal Aspects of Communication
a. Kinetics
b. Proxemics
________ space 0 18
________ space 18 4ft
________ space 9 12ft
________ space 9 ft
c. Touch
d. silence
e. Paralangauge
Theracom Techniques
1. Listening - an active process of receiving & examining
reaction to message

Therapeutic value:

Examples:
2. Broad Opening encouraging the pt to select topics for
discussion

Therapeutic value:

Examples:
3. Restating repeating the main thought the pt expressed

Therapeutic value:

Examples: P: I am awake most of the night

N: you have difficulty sleeping
4. Clarification attempting to put into words vague ideas
or unclear thoughts of the pt.

Therapeutic value:

Examples:
4. Reflection directing back the pt ideas, feelings,
questions, and content

Therapeutic value:

Examples: P: I relied on the wrong guy

N: the wrong guy
5. Silence lack of verbal communication for therapeutic
reason:

Therapeutic value: allows time for the pt to think & gain

insight

Examples:
6. Focusing questions or statements that help the pt
expand on a topic of importance/ superficial talk

Therapeutic value:

Examples:
7. Theme identification underlying issues or problems
experienced by the pt that emerge repeatedly during the
course or NPR

Therapeutic value:

Examples: N: I have noticed that in the 5days we,ve

talkin to each other, youve been hurt by
your man in your relationship.
8. Giving information making available to the pt facts
that he needs

Therapeutic value:

Examples:
9. Giving Recognition greeting the pt and
acknowledgement of the effort made

Therapeutic value:

Examples:
10. Offering Self unconditional willingness to be available

Therapeutic value:

Examples: N: Ill stay with you for a while

N: Ill sit here with you
11. Offering General Leads encourages the individual
to continue in the direction of conversation already begun.

Therapeutic value:

Examples: N: Go on, then, next

12. Encouraging Descriptions of Perceptions &
Feeling learn how the person perceives a feeling or
interprets events

Therapeutic value:

Examples: P : they dont love me anymore

N: who are they
13. Seeking Consensual Validation process of
verifying of messages sent

Therapeutic value:

Examples: P: they dont love me anymore.

N: you say they, are they your family, or
friends?
P: Family
14. Placing Events in Sequence or Time seeing
events in perspective in relation to time and their order.

Therapeutic value: makes the conversation organized

Examples:
15. Voicing Doubts lets individual know that others do
not perceive in the same way.

Therapeutic value:

Examples:
DEFENSE MECHANISM
 Compensation

Conversion

Denial

Displacement

Intellectualization
 Projection

Rationalization

Reaction Formation

Regression

Sublimation
Suppression

Undoing

Repression

Identification

Substitution
Symbolization

Introjection

Fantasy

Isolation

Dissociation
 Is a stimulus that
produces distress and
creates physical and
psychological demands on a
person, requiring coping
and adapting
 Is characterized by
feelings of apprehension,
uneasiness, uncertainty, or
dread, resulting from real
or perceived threat;
is a subjective
response to stress

Mother of all Anxiety Disorder

Physical s/sx of Anxiety Psychic/ Behavioral
Headache Irritability
BP ____ Complaining
HR ____ Arguing
Palpitation Quarrelsome
Dryness of the mouth Crying
Diaphoresis/ cold and clammy Withrawal
skin Inattention
Pallor forgetfulness
Tremors
Diarrhea
N/V
Urinary frequency
 Levels of Anxiety
alertnass, ehnaced learning
The most desired level of anxiety
Mild
Tension of day to day living
Senses are alert
focus on central concern
Moderate Narrowed perception or selective inattention
can easily assist back on mild level of anxiety

inability to focus or problem solve

Severe CNS stimulation
Focus on specific detail

complete inability to focus

panic Physiological symptoms of fight & flight response
Perceptual field is completely disrupted
Nursing Action
1. Remain with the client at all times. ( Severe and Panic)
2. Move client to a quiet area
3. Encourage relaxation technique
4. Encourage expression of feelings

Communication
1. Use short, simple, clear statements
2. Avoid choices
 Benzodiazepines
Non - Benzodiazepines
hlordiazepoxide(Librium)
uspirone (Buspar)
razepam (Centrax)
lonazepam (Klonopin)
xazepam (Serax)
orazepam (Ativan)
iazepam (Valium)
lonopin
prazolam (Xanax)
riazolam (Holcion)
 side Effects
Fatigue rowsiness
Ataxia
taxia
Drowsiness
Depression ethargy
Mental impairment
bnormal eye movement
Slowing of reflexes
I problem
headache
Constipation
Hypotension
Incontinence
drymouth
Nursing Management
rinse mouth with water often and eat sugarless gum
Assist in ambulation
Caution against driving
Not used with minor stress
Caution in t use with glaucoma
No alcohol & other CNS depressants
 A group of psyche conditions
characterized by the emotion
of intense terror

DISORDER
 PANIC DISORDER
Characterized by panic attacks that occur at
unpredictable times, with intense
apprehension fear, and terror
Disrupted ADL
Assessment Nursing Action
physiologic symptoms 1. if the patient is on panic level of anxiety
of FIGHT OR FLIGHT the nurse should always:
RESPONSE
choking
remain with the client
Labored breathing Ensure privacy
Pounding Heart 2. Attend to physical symptoms
Chest Pain 3. Assist to identify precipitating factors
Nausea
Numbness Administer meds and other health
Fear of dying therapeutics
1. Teach client relaxation techniques
*deep breathing
COMMUNICATION
1. simple, calm, and reassuring voice.
2. The nurse can walk with the client who feels unable to sit and talk
3. avoid use of ______
4. use an ____________ questions/ communication technique once
anxiety diminishes

it seems you anxiety is subsiding. Is that correct?

can you share with me what it was like a few minutes ago?
fear resulting conscious aavoidance of the feared
object, activity, or situation resulting to disruption of
ADL
Characteristic of Phobic Disorder
Irrational fear of an objet, person, or situationl; the fear is
accompanied by persistent avoidnace of the object, person or
situation.
The indiv. Recognize the fear as irrational and inappropriate
but feels owerless to control it
Simple Phobia is the fear of specific things
Social Phobia is the fear of potentially embarassing social
situation.
Assessment Data
Associated with Panic Level of Anxiety if feared object is confronted

Nursing Action
1. Stay with the client when the anxiety is high
2. D o not force the client to have ________________________
3. provide (+) reinforcement for adoptive behavior/desired behavior/
coping/ appropriate

Other Health Therapeutics

Systematic desensitization

Communication
Allow the client to verbalize feelings about feared object or situation
OBSESSIVE COMPULSIVE DISORDER
Obsession recurrent & intrusive thought,
feeling, idea or sensation
Compulsion conscius standardized, recurrent
thought or behavior such as counting, checking
or avoiding

Assessment Data
tensed
May be immobilized
Dificulty concentrating
Aware that the behavior is
inappropriate BUT
CANNOT CONTROL
sleeping problem
poor hygiene
Nursing Action
Ensure basic needs
Allow the client to _______________
Implement schedule that will distract the
client from inappropriate behavior
Other Health Therapeutics
exposure and response prevention
Anxiolytic meds
teach relaxation technique
Communication
Encourage the client to talk about feelings
Recognza and reinforce (+) non ritualistic
behavior.
 Causes:
1. Combat experience
Experienced an emotional stress that 2. Natural
was f a traumatic magnitude for almost catastrophies
anyone 3. Assault
4. Rape
5. Serious accident
Characteristic of PTSD
can be acute of delayed response; can also become chronic
Symptoms include an exaggerated startle response sleep d/s,
guilt (survivors guilt) nightmares and flashbacks, anger with
numbing of other emotions
Affected indiv often use dugs, alcohol, or both to self
medicate for distressful symptoms
Nursing Action
1. be non judgmental and
supportive
2. Assure client that his/her
feelings and behavior are
normal rxns
3. Facilitate a progressive review
of the trauma experience
4. Make the pt feel that he/she is
a survivor rather than a victim
Administer meds & other
therapeutics
1. Anxiolytics
2. Antidepressants
3. Relaxation Techniques
4. Inform clt that HYPNOTHRX or
SYSTEMATIC DESENSITIZATION may
be used as a form of treatment
Communication
1. Encourage the clt to express his/her
feelings
2. Systematic desensitization with
flooding
3. Imagery
 GAD

Excessive anxeity and worry about a number of events or

activities that are usually:
a. past? C. future?
b. Present?
Characteristics:
Restlessness
Feeling keyed up or on the edge
Easily fatigued
Dificulty concentrating
Irritability
Muscle tension
Sleep disturbances
Nursing Action
Stay with the client and provide support
Keep demands on the client to a minimun
Limit envt stimuli
Encourage physical activity to release energy
Administer prescribed anxiolytics in a timely manner
Assist the client in performing relaxation technique
 Are characterized by complaints of physical
symptoms that cannot be explained by known
physical mechanism
 Characterized by many somatic
symptoms that cannot be
explained adequately on the basis
of physical & laboratory exams
Multple physical complain from
multiple organ system

SOMATIZATION D/O
 Diagnostic Criteria:
_____ Pseudoneurological Symptoms
_____ GIT Symptoms
_____ Pain Symptoms
_____ Sexual Sypmtoms
Characterized by the presence
of ONE OR MORE
NEUROLOGICAL SYMPTOMS
that cant be explained by any
neurological or medical
disorder
 Diagnostic Criteria:
Motor Symptom or Deficit
Sensory Symptom or Deficit
Convulsion or Seizure
Mixed Presentation
 Normal body
sensations are
thought to be
symptoms of a
serious illness
 Diagnostic Criteria
Preoccupation with a Serious Illness
Not helpful by Reassurance
Poor Insight
6 mos
Body Dysmorphic Disorder
dysmorphophobia
Char by preoccupation with
an imagined defect in
appearance that causes
clinically significant distress
or impairment in important
areas of functioning
Pain Disorder
Primary symptom of
pain
Unrelieved by
analgesics
Chronic pain in one
or anatomical sites
 Management
The mainstay of tx is a long term relationship with a specific
health care provider to prevent the client from seeking multiple
providers with multiple recommendations for testing, dx and
medications.
avoid meds that are characterized by tolerance and
depandence
ENCOURAGE PYSCHOTHRX
FAMILY EDUCATION
ENCOURAGE THE CLIENT TO PARTICIPATE IN COMMUNITY
BASED SELF HELP GROUPS
 Nursing Action
1. Provide health teaching on:
as established health routine that includes improved health behaviors
Adequate nutritional intake and balance between rest and activity

2. Expression of emotional feelings by keeping a journal

3. Limit time spent on physical symptoms:

Dont let open up on physical symptoms experienced by the pts
Just let the pt talk about it, but avoid follow-ups
Have another topic

4. Limit primary and secondary gain

5. Report and assess new physical complaints, because
organic disease is also a possibility for this client
6. Decreased reinforcement of secondary gains for physical
symptoms.
i. Recognize that the person will experience worsening of
symptoms when under stress
ii. Expect person to function despite physical symptoms; doing
things for them and making decisions will increase dependent
behavior.
iii. a matter of fact attitude is helpful to decrease emphasis
on dramatic symptoms
iv. Expression of concern should be directed toward real life
problems rather than bodily symptoms
v. Encourage family member to remain with one healthcare
provider on long term basis
vi. Family thrx can be helpful to clarify roles, communication and
expectations.
7. Avoid fostering dependency. Encourage dependent behavior
8. Maintain therapeutic focus on feelings, emotional responses,
and relationship problems rather than on somatic symptoms.
9. Set limits on manipulative behaviors in a matter of fact matter.
10. Help the client identify and use positive means to meet
emotional needs
11. Encourage maintenance of long term relationship with
primary health provider.
12. Teach and encourage use of stress reducing measures
13. Help identify relationship of stressful life events and somatic
complaints
For Conversion d/o
Treat physical symptoms matter of factly
provide diversional activities
Reduce pressure on client
Provide recreational and social activity
Control environment
For Hypochondriasis:
use friendly, supportive approach but not to focus on physical
symptoms.
Provide diversional activities to build self esteem
Provide for clients physical needs
Accept clients and understand that complaints are not
conscious
For Somatization d/o:
Focus on anxiety reduction not on symptom
Minimize secondary gains
Rule out organic basis for current complaints
Be aware of own response (irritation, impatience) to
client
For Body Dysmorphic d/o:
establish a trusting relationship
Accept symptom are real to the patient
Attempt to limit defenses until the individual is ready to give
them up
help individual develop better ways of handling anxiety
producing situations through problem solving
A client with somatization disorder has been
attending group thrx. Which of the folllowing
statements indicates that the thrx is having a
positive outcome for this client.
a. I feel better physically just from getting a chance to
talk
b. I havent said much, but I get a lot from listening to
others
c. I shouldnt complain much; my problems arent as bad
as others
d. the other people in this group have emotional
problems
COMMUNICATION
The challenge is for the nurse to validate the
clients feelings while encouraging him or her to
particiapte in activities
EXERCISE
Nurse: lets take a walk outside fro some fresh air
Client: I wish I could. But I feel so terrrible, I just cant do it
Nurse: I know this is difficult, but some exercise is essential. It
will be a short walk

NUTRITION
Client: I just cant eat anything. I have no appetite.
Nurse: I know you dont feel well, but it is important to begin
eating
Client: I promise Ill eat just as soon as Im hungry
Nurse: actually if you begin to eat a few bites, youll begin to
feel better, and your appetite may improve.
The nursing assistant tells the nurse that the
client is not in the dining room for lunch. The
nurse should direct the nursing assistant to do
which of the following?
a. Take the client a lunch tray and let him eat in his room
b. Tell the client hell need to wait until supper
c. Invite the client to lunch and accompany him to the dining
area
d. Inform the client that he has 10 ins to get to the dining area
Teach coping Mechanisms
a. Relaxation techniques
b. Deep breathing
c. Guided imagery
Factitious
Disorder
 Munchausens by Proxy
A person inflicts illness or injury
on someone else to gain the
attention of emergency
medical personnel or to be a
hero for saving the victim
 Malingering
The intentional production of
false or grossly exaggerated
physical or physical symptoms
Dissociative
Disorders
 Dissociative Amnesia
Is sudden inability to recall
important personal info
because of physical or
psychological trauma
Predisposing factors include an
intolerable life situation,
unacceptability of certain
impulses or acts and a threat
of physical injury or death
Types:
1. Circumscribed or localized
2. Selective
3. Generalized
4. Continuous
 Dissociative Fugue
Is a sudden, unexpected
flight from home with
inability to recall events
from ones past.
It is rare occurrence that
may be seen during times
of extreme stress such as
war, severe conflict and
natural disasters, and may
last days or months.
 Depersonalization Disorder
Is the feeling detached
from, and as if one is an
outside observer of, ones
thoughts or body
Includes being in a
dreamlike state out of the
body, mechanical or
bizarre in appearance
 Dissociative Identity Disorder
Presence of two or
more distinct
personalities within a
single person
 Management
Dissociative d/o tend to be difficult to
diagnose
An individual with this d/o often has had
multipe pyschiatric dx; tx is often lengthly
 Nursing Action
Discuss self harm thoughts
Help client develop plan for going to a safe place when having
destructive thoughts or impulses.
Help client view him/herself as a survivor rather than as a
victim
Encourage clients to write a journal to get in touch with their
feelings
Encourage the ct to disclose and discuss her feelings in
relation to painful memories becoming conscious
Accurately record information on various personalities as a art
of an interdisciplinary team approach
Administer Medications and other health
therapeutics
Treated symptomatically with:
i. Anti anxiety Agents
ii. Antidepressants
iii. Deep breathing Exercise
iv. Relaxation Techniques
v. Distraction Techniques
COMMUNICATION
1. Validating and Presenting Reality
i. I know this is frightening, but you are safe now.
ii. what are you feeling?
iii. Are you hearing something?
iv. Can you see and the room were in?
v. Do you feel your feet on the floor?
vi. Do you feel your arm on the chair?
vii. Do you feel the watch on your wrist?
2. Grounding Technique

Hello Nicole, Im here with you. My name is Celeste.

Im the nurse working with you today. Today is
Wednesday. March 16, 2017. Youre here in the
Hospital. Can you open your eyes and look at me?
Nicole, my name is Celeste
 Eating
Disorder
 Refusal to eat
14 18 yo
(-) self view
Ego syntonic
Wt <85% of IBW
Ameorrhrea for 3 consecutive
cycles
Fear of growing up
Unusual ritualistic behavior

2 TYPES
1. Restricting type
2. Binge eating / purging type
 Late onset: 18 19yo
Repeated episodes of binged
eating
Teds to be OCD
Ego dystonic (feards of inability
to stop eating voluntarily)
Experinces depression
Normal to neart normal body
weight

Bulimia Nervosa
2 types:
1.Purging type
2. Nonpurging Tupe
 Etiology:
5HT, altered neurotransmitter
( - ) perception of self
Separation individual conflicts
Fx who values perfection and the child cant attain standard
Overinvlved families
Form of rebelion
Influenced by peer group
Avoids food to gain attention
Insecurities of physical appearance
Starvation is used as self punishment
 Females who fears adult feminity when growing up
Fears of becoming like her mother
To suppress feelings of emotional emptiness
Wants to be unique
Common in females
Have genetic tendencies
Mortality rate is 10 14%
Risk for suicide is increased
 DIFFERENTIATION OF BULIMIA AND ANOREXIA

ANOREXIA BULIMIA

ONSET: 14 18YO 18 19 YO

UNDERWIGHT Near normal

Ego sytonic Ego dystonis

Bradycardia, hypoTN, hypoK, hypoCa, Bradycardia, hypoTN, hypoK, hypoNa,

DHN DHN
Amenorrhea Irregular menses
Lanugo, dry cracked skin, Hoarseness, dental caries, enlarged
hypothermia, hairloss parotid gland
Hypoglycemia, constipation hypoCa, constipation, esophagitis
 Management:
Priority is to maintain clt safety & stabilize physiologic
problems (DHN, F & E imbalances, arrythmia00
Refeeding to restore wt
Behavioral contract (no purging)
Psychotherapy
Cognitive Behavioral approach
FX Thrx
Meds: TCAs SSRI
 Wt gain of 2-3lbs weekly
emphasis on specific good or bad foods
Weight the clt 2x a week (not to often)
Accompany clt to the bathroom for at least 1-2 hrs after meals
Stay with the client during meals; focus on the client not on
the food
Set limits on time alloted for eating
Monitor VS
 Other eating d/o
Binge eating syndrome
Night eating syndrome
Nocturnal sleep related eating disorder
Pica - geophagia, coprophagia, urophagia
Orthortexia
Rumination d/o
Feeding d/o
 Various enduring,
inflexible maladaptive
behavior that impair
functioning
Exaggerated behavior

Personality
Disorders
 Characteristics:
1. Still in touch with reality
2. Stress exacerbates PD
3. Recognizable by adolescence or earlier &
continue throughout adult life
4. Have troubles with working & loving
 Cluster A
Known as odd / Eccentric weird PD
- Trust issues

Schizoid Personality
Paranoid Personality
Schizotypal Personality
 They demonstrate
lack in personal and
social relationship
detached fro others
and withdraws from
interactions.

Schizoid
Characteristics:
1. Detachment from social relationships and a restricted range
of expressions of emotion in interpersonal settings
2. Introverted since childhood
3. Avoids close relationship with fx and others hermit
4. Choose solitary act; has little interest in sexual experiences
5. Does not take pleasure in activities
6. Flat affect
7. May function well in vocations in w/c one generally works
alone
 May have behavior similar
to schizophrenia, however,
psychotic episodes are
infrequent; may be
acutely uncomfortable in
relationship

Schizotypal
 Characteristics
1. Ideas of references
2. Odd beliefs or magical thinking
3. Unusual perceptual experiences
4. Odd thinking and speech
5. Suspiciousness or paranoid ideation
6. Inappropriate or constricted affect
7. Appears strange or odd
8. Lack o close friends or confidants
9. Excessive social anxiety
 They demonstrate a
pattern of distrust and
suspiciousness; the
individual interprets other
peoples motives as
threatening

Paranoid
 Characteristics
1. Suspects attempts to harm or trick him
2. Questions loyalty of others
3. Display pathologic jealousy
4. Observe environment for sign of threat, display
secretiveness
5. Becomes hypersensitive or display excessive feelings of self
importance
6. May appear to be unemotional, lack of sense of humour and
ability to relax
7. Interpersonal relationships are poor especially when relating
to authority figures
 Nursing Actions
Adopt, objective, matter of fact manner when interacting with
clt, and maintain clear, consistent verbal and non verbal
communication
Provide daily structure of ADL
Maintain focus on reality and reality based topics
Help clt identify feelings that are impaired
Assist with problem solving for life issues identified as source
of stress.
Gradually involve clt in group situations, providing support
when necessary, and provide positive feedback for socially
appropriate behavior.
Impaired social interaction rel/t: extreme fear
of abandonment
1. Develop consistent relationship
2. Encourage patient to examine behavior and
discuss feelings and experience about self
related to others
3. Give positive reinforcement for successful
interaction with oters
4. Rotate staff who work with the patient
 Cluster B
Aka dramatic, emotional, erratic PD
Has self esteem difficulty
Has self esteem due to originally self esteem

orderline
ntisocial
arcisistic
istrionic
 Characterized by
impulsive, unpredictable
and unstable moods;
disturbed relationships
with others; intolerance to
being alone
A chronic sense of
boredom
Borderline
 Characteristics
1. Frantic efforts to avoid real or imagined abandonment
2. Unstable yet intense relationship
3. Identity disturbance
4. Impulsivity of at east two ( spending, sex, substance, abuse,
reckless, driving, binge eating)
5. Tends to have self detrimental behavior
6. Affective instability
7. Chronic feelings of emptiness
8. Difficulty controlling anger
9. Transient paranoid ideation
 Have a pattern of
disregard for and
violation of the rights of
others
Has good verbal skills,
ozzy charisma

Antisocial
 Characteristics
1. Common in men aging 18 40yo
2. Exhibits behaviour that is hostile to the well being of society,
and therefore found in the prison system
3. Unable to follow rules, is grossly selfish and irresponsible;
generally manipulated in relationship with others to fulfil
needs.
4. Uses rationalization to justify actions
5. Lack of remorse or indifference to persons
6. Expectation of immediate gratification
7. Repeated lying
8. Reckless behavior that disregards the safety of others.
9. Cessation of criminal activities tend to occur around age 40
 Me, myself and I
Characterized by excessive
emotionality and
attention seeking
behaviors that are
dramatic and ego syntric
Social climer

Narcissistic
 Characteristics
1. Has grandiose sense of importance
2. Is preoccupied with fantasies of unlimited success, power,
brilliance beauty or ideal love
3. Believes that he or she is special
4. Requires excessive admiration has a sense of entitlement
5. Is interpersonally exploitative
6. Lacks empathy
7. Is often envious of others or believes that the others are
envious of him or her.
8. shows arrogant, haughty behavior or attitude
 Cock teaser/brick teaser
Char by excessive
emotionality and
attention seeking
behavior that are
dramatic and egocentric

Histrionic
 Characteristics
1. Is uncomfortable in situations in which he or she is not the
COA
2. Inappropriate sexually seductive or provocative behavior
3. Rapid shifting of emotion\uses physical appearance to draw
attention to self
4. Speech is excessively impressionistic and lacking in detain
5. Shows self dramatization
6. Suggestible
7. May seem warm or genuine
8. May be creative and imaginative
9. Labile emotions
10. Feelings of dependence and helplessness exist
 Nursing Actions
Prevent self harm by observing the clt frequently and
developing a no harm contract
Give immediate feedback, when confronting inappropriate or
manipulative behavior.
Act as a role model for inappropriate expression of feelings
and negative emotions
Work with the tx team in maintaining consistent feedback for
ctl, reinforcing specific tx objectives and avoiding
manipulation of staff by client
Avoid rejecting the client
 Set limits: reinforce of manipulative behavior or disregard for
rights of others
Give positive feedback for goal achievement and independent
behavior
Self- esteem disturbance r/t: lack of possitive feedback.
Absent, erratic, inconsistent
parental discipline

1. Ensure that goals are realistic

2. Set limits on manipulative behavior
3. All staff must be consistent and follow through with
consequences in a matter of fact manner
4. Provide positive feedback for non manipulative behavior
5. Offer recognition and praise for accomplishment
 Cluster C
Aka ANXIOUS, FEARFUL PD
ependent

bsessive - Compulsive
assive - Aggressive
voidant
 Characterized by
submissive and clinging
behavior associated
with excessive need to
be cared for by others
The most frequently
seen personality d/o in
mental health units
Dependent
 Characteristics
1. has low self esteem
2. Has difficulty making everyday decision
3. Needs other to assume responsibility for the most areas in
life
4. Difficulty expressing disagreement
5. Has difficulty initiating projects
6. Feels uncomfortable or helpless when alone
7. Urgently seeks another relationship when a close
relationship ends
8. Unrealistic preoccupied with fears of being left to take care
of self
 Characterized by
preoccupation with
orderliness,
perfectionism and the
need to be in control of
situations, objects and
people.

Obsessive
Compulsive
 Characteristics
1. men are frequently affected than women
2. Is excessively devoted to work & productivity
3. Inflexible
4. Is unable to discard worn out or worthless objects even
when they have no sentimental value
5. Preoccupied with details
6. Leisure activities and friendships are excluded because of the
clts excessive devotion to work and productivity
7. Shows rigidity & stubborness
 characterized by being
helpless and indecisive
Resist demands for
adequate performance
in job and relationship

Passive
Aggressive
 Characteristics
1. expresses anger in passive, convert behavior
2. Anger can be seen through:
a. Resistances
b. Procrastination
c. Dawdling
d. forgetfulness
e. Inefficiency
 Nursing Actions
Establish a caring, consistent therapeutic relationship and
clear expectations for responsible behavior
Expect the client to make decisions, and teach the client how
to be assertive
Encourage the client to identify positive self attributes
Provide positive feedbacks when the client interacts in social
situations in appropriate manner.
Teach client to use stress management and relaxation
techniques to cope with anxiety.
Self esteem disturbance r/t lack of positive
feedback
1. Ensure that goals are realistic.
2. Provide positive feedback for indepandent interaction
3. Assist patient identify positive aspects of self
4. Offer recognition and praise for accomplishment
5. Encourage expressions of feelings of anger and inadequacy
6. Role model positive aspect of life.
Are characterize by
disturbances in feelings,
thinking and behavior;
may occur form severe
depression to severe
mania (hyperactivity).
 Concepts of Mood and Affect
Mood refers to persons pervasive and
enduring emotional state
Affect outward expression of mood
Blunted affect
Broad affect
Flat affect
Inappropriate affect
Restricted affect
Labile
 Anergia

Euthymic mood

Depression

Mania

Hypomania

Unipolar depression

Bipolar
 Types of Mood Disorders
Major Depressive disorder
Dysthymia
Bipolar d/0
Bipolar I
Bipolar II
Cyclothymia
 Causes:
Neurochemical theory or Biogenic amines
theory 5HT and NE is
- NE in mania
Genetics 2 -10x chances of having depression
Psycholoanalytical theory those with
unsatisfactory early mother infant relationship
Cognitive theory being depressed is only on the mind
Self perception of inadequacy
 Learning Theory numerous failure in life

object loss theory (most accepted) depression

is brought by actual / imagined loss f an actual imagined love,
property, status
 Characterized by at
least 2 weeks of
continuous depressed
mood or loss of interest
in pleasure and
activities with at least of
the ff symptoms:
Major Depressive
disorder
Anger directed to self
Symptoms:
1. or in appetite
2. or in sleep
3. Psychomotor agitation or retardation
4. Fatigue and loss of energy
5. ability to think and concentrate
6. Recurrent thought of suicide
Feature:
i. Melancholic Features
ii. Atypical Feature
iii. Psychotic feature
iv. Postpartum onset
v. Seasonal affective d/o
 Characterized by chronically
depressed mood occurring most
of the day, for more than days
than not, for at least 1- 2 yr
period
Does not affect social or
occupational functioning
At least 2 or more of the other
symptoms of depression must be
present.
Dysthymia
 At least 3-4 manic episode
Combination of opposite
feelings

Bipolar disorder 2 types:

Bipolar I
Bipolar II
 Characterized by 1 or more
manic or mixed episodes usually
accompanied by a major
depressive episode

Depression + manic episodes

Bipolar I d/o
Symptoms of Manic Episodes:
1. Inflated self esteem or grandiosity
2. need for sleep
3. or pressured speech
4. FOI
5. Distractibility
6. involvement in goal directed activities
7. Excessive involvement in pleasurable activities that has high
potential for painful consequences)
 Characterized by 1 or more
depressive episodes
accompanied by at least 1
hypomanic episode

Major Depression + hypomanic

episodes

Bipolar II d/o
 Characterized by at least 2 years
of several period of hypomanic
symptoms

Dysthymia + hypomania

Cyclothymia
 Safe and Quality Nursing Care
Assessment Data:

1. Affect
2. Thoughts
3. Physical Activities
4. Verbalization
5. Socialization
 Suicidal Behavior
A direct purposeful attempt to end ones own life
At risk indiv:
A plan
Hx of attempt
Medical Illness
Depressed indiv is about to commit suicide
when:
giving away personal possessions of
extraordinary importance.
Ties up loose ends
Shows dramatic or drastic behavioral changes
Manifest verbal / written cues
 Meds: Antidepressants
moods elevators
Pyschic energizers
 TCAs Side Effects:
Orthostatic hypotn
Anticholinergic effects
dry mouth
1st choice Constipation
Tachycardia
Neurologic effect
Doxepine (SINEQUAN) sedation
Ataxia
Imipramine (TOFRANIL) Tremors
Psychomotor slowing

Elvil (AMITRYPTYLINE)
fatigue
V Libido & sexual
Performance
 MAOIs
Side Effects:
Orthostatic hypotn
Anticholinergic effects
dry mouth
Constipation
Tachycardia
Neurologic effect
Parnate (tranylcipromine) sedation
Ataxia

Nardil (phenelzine) Tremors

Psychomotor slowing
fatigue
MAl Hypertensive Crisis
Delayed ejaculation/
orgasm
Avoid tyramine rich foods
Principle of MAOI and TCA Adm:
1. TCA given 1st
2. dont use together with alcohol
3. Expect a lag
4. Gap bet meds
5. Surgery d/c 10 days before
 SSRIs
Side Effects:
Drymouth
Dizziness
Drowsiness
Diarrhea/ N & V
Paxil (paroxetine) Insomnia
Impotence male sexual

Luvox (flovoxamine) dysfunction

5ht syndrome - temp

Prozac (fluoxetine)
E.C.T
Aka electroshock therapy
FOR HIGH RISK SUICIDAL &
ANTIDEPRESSANTS ARE NOT
AVAILABLE OR HAS NO EFFECT YET
 IMMEDIATELY AFTER ECT
Secure consent
Take vs
70 150 volts
For 0.5 to 2 sec E equipment at bedside
6-12 tx 02 tank
Electrodes placed on temporal Suction machine
area Cardiac monitor
At least 48hrs interval each tx Rescitating machine
Done 2-3x/wk E cart
Induces tonic clonic sz
Prepare like clt will have major Pre ECT meds
surgery Atropine SO4
Succinylcholine
Shortacting barbiturates
 Nursing Action
High Risk for Self Directed Violence r/t
suicide

1. Ask the pt directly

have you thought about killing yourself?
2. Create a safe envt
3. Encourage verbalization of feelings
4. Spend time with the patient
A nurse is planning care for a client who
attempted suicide and who is being admitted to
the nursing unit. Which of the following priority
nursing interventions will the nurse include in
the plan of care?
a. Check the whereabouts of the client q15mins
b. Suicide precautions with 30 mins check
c. One on one suicide precautions
d. Ask the client to report suicidal thoughts
 Self esteem disturbance
Nursing Care:
1. Be accepting of pt and his negativism
2. Spend time with the pt
3. Help pt recognize strenghts and accomplishments
4. Encourage participation in group activities
5. Encourage self - care
The depressed client verbalizes feelings of low
self esteem and self worth typified by
statements such as Im such a failure. I cant do
anything right. The best nursing response
would be to:
a. Tell the client that is not true, that we all have a
purpose in life.
b. Identify recent behavior or accomplishment that
demonstrates clients skills.
c. Reassure the client that you know how the client is
feeling and that things will get better.
d. Remain with the client and sit in silence; this will
encourage the client to verbalize feelings.
 Altered nutrition, less than body
requirement
Nursing Care
1. In collaboration w/ dietician, det no. of calories
required.
2. Ensure that diet includes foods high in fiber.
3. Weigh the pt daily
4. Small frequent feedings
5. Give vit & mineral supplements
6. Stay w/ the pt during meals
A client is admitted to the hospital with dx of
Major Depression, severe, single episode. The
nurse assesses the clt and identifies a nsg dx of
Nutrition: Less than Body Requirements. The
appropriate nsg intervention r/t this dx is:
a. weight the clt 3x/per wk before breakfast
b. Explain to the clt the importance of good nutritional
value
c. Schedule brief nsg interactions w/ the clt during
several meals in w/c small portions are offered
d. Report the nutritional concern to the psychiatrist
and obtain a nutritional consultation as ASAP
 Communication to depressed patient
To increase self esteem
1. Convey genuine interest and caring

my name is Joshua. Im your nurse today. Im going to sit wit you for
a few minutes. If you need anything, or if you would like to talk,
please tell me.

after time has elapsed, the nurse would say the following:

Im going now. I will be back in an hour to see you again.

To promote self Care
1. ask client perform global task
Ruby, its time to get dressed.

2. if cannot respond, break task into smaller segments.

Here are your gray slacks. Put them on.

3. If cannot put on slacks.

let me help you with your slacks, Ruby.
To encourage describe feeling
Nurse: How are you feeling today?
Client: I feel so awful . . . Terrible.
Nurse: Tell me more. What is that like for you?
Client: I dont feel like myself. I dont know what to do
nurse: That must be frightening
The nurse observes that a client with depression sat at a table
with two other clients during lunch. The best feedback the nurse
could give the client is:
a. Do you feel better after talking wit others during lunch?
b. Im so happy to see you interacting with other client.
c. I see you were sitting with others today
d. you must feel much better than you were a few days ago.
Anger directed
towards the envt

Types:
1. Mild elation
2. Acute Manic Episode
 Aka hypomania

Characterized by:
Feeling of happiness
Rapid assoc of ideas
motor activity
sexual drives
Mild Elation Superficial relationship
 Requires institutionalization

Characterized by:
Mood disturbance
Motor restlessness
Indulgence in sexual &
recreational activities
Poor money mngt
Poor sleep
Acute Manic Tendency to argue
Episode Flight of ideas
Delusion of granduer
Bizarre habits of grooming
Poor hygiene
 Nursing Action
1. Potential for injury r/t: EXTREME
HYPERACTIVITY
Reduce environmental stimuli
Assign to quiet unit
Limit group activities
Remove hazardous objects & substances
from pts environment
Provide physical activities as a substitute for
purposeless hyperactivity
The client with mania is skipping up and down the
hallway practically running into other clients. Which of
the following activities should the nurse expect to
include in the clients plan of care?
a. Leading a group activity
b. Watching television
c. Reading the newspaper
d. Cleaning the dayroom tables
2. Potential for violence Self Directed or directed at
others related to:
* erratic excitement
* rage rxn

a. Observe pt behavior frequently

b. Respond matter of fact to verbal hostility
c. Have sufficient staff available
d. Administer tranquilizing meds. As ordered.
e. Use mechanical restrains if necessary
 What is the indication of mechanical restraints?
a. Verbal aggressiveness
b. Physical aggressiveness

How long is the life span of a restraint order?

 Meds: MOOD
Nursing Implications
STABILIZERS Drowsiness, dizziness,
headache
LITHIUM Dry mouth
CARBONATE GI upset
300mg/tab/cap hypoTN, pulse
irregularities, arrythmias
Polyuria DHN
Patient and FX education:
1. Take meds a.d
2. Do not skimp on dietary Na intake.
3. Drink 10 13 glass of water /day
4. Avoid excessive use of beverages containing caffeine
5. Notify physicians if vomiting or diarrhea occur
6. Carry alert card always
7. Avoid indulging with crash/ fad diet
 Points to remember LiCO3
1. LiCO3 is started with 300mg/cap/tab TID x 7days

1. Blood level is checked 12hrs after the last dose. Then:

a. q wk for the 1st month
b. q 3 6 months

3.Therapeutic level:
Adult: 0.6 1.4/1.5 mEq/L
Elderly: 0.6 0.8 mEq/L

For maintenace: 0.6 1.2mEq/L

 Adverse Rxn
Lithium Toxicity Lithium Intoxication:
Prodrome: >2.0mEq/L >2.0mEq/L

1. Fever
1. Anorexia
2. UO
2. N/V
3. BP
3. Diarrhea
4. Irregular pulse
4. Coarse hand tremor
5. ECG change
5. Lethargy
6. Impaired consciousness
6. Tinnitus
7. SZ
7. Vertigo
8. Coma
8. drowsiness
9. death
3. Altered Nutrition: body requirements r/t:
inability to sit long enough to eat meals, lack of
appetite
1. Provide w/ high CHON, high calorie, nutritious
foods and drinks.

select foods that can be given during manic phase:

Spaghetti french fries cheese sticks
Carrot sticks potato chips hamburger
vegestable sandwhich milkshake

2. Pace & walk w/ pt. As finger foods are taken

4. Impaired Social Interaction r/t:
delusion of grandeur
Delusion of persecution
Low self esteem
Inability to delay gratification

1. Recognize the purpose these behavior serve

for the pt
2. set Limits on manipulative behavior
3. dont argue, bargain or reason.
4. Provide (+) reinforcement for non
manipulative behavior
The nurse overhears a client with acute manic who is in euphoric
and flirtatious attempting to be sexually inappropriate with other
clients by talking about sexual exploit to a group of clients seated
at a table. Which of the following should the nurse do next?

a. Continue walking down the hall, ignoring the conversation

b. Speak with the client later in private while saying nothing at
this time.
c. Tell the client, others may not want to hear about sex, and
invite him to walk along with you
d. Inform the client that if he continues to talk about sex, no
one will want to be around him.
5. Sleep Pattern Disturbance r/t: agitation

a. Assess pts activity

b. Provide structured schedule of activities that includes
established times for nap or rest
c. Provide nsg measures that promote sleep
d. Prohibit intake of caffeinated drinks
e. Administer medications and other health therapeutics
 COMMUNICATION
SETTING LIMITS

Lex, you are too close to my face. Please stand 2 ft

back

it is unacceptable to hug other clients. You may talk to

others, but do not touch them

Please speak more slowly. I am having trouble

following you
During morning community meeting, a client with bipolar,
manic phase, interrupts others to the point where no one
can finish their statements. Which of the following
responses by the nurse is most appropriate?
a. please stop interrupting others. You can speaks when
its your turn.
b. stop talking. Its time for you to leave the meeting.
c. if you cant control yourself, well have to take action.
d. please behave like an adult. Your behavior is childish.