Care of Clients with Maladaptive Patterns of Behavior, Acute and Chronic Psychiatric nursing

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Care of Clients with Maladaptive Patterns of Behavior, Acute and Chronic Psychiatric nursing Mental Health  A state of emotional, psychological and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self-concept and emotional stability.

COMPONENTS OF MENTAL HEALTH  Autonomy and Independence - can work interdependently without losing autonomy  Maximization of One's Potential oriented towards growth and selfactualization  Tolerance of Life's Uncertainties - can face the challenges of day-to-day living with hope & positive look  Self-esteem - has realistic awareness of her abilities and limitations  Mastery of the Environment - can deal with and influence the environment  Reality Orientation - can distinguish the real world from a dream, fact from fantasy MENTAL ILLNESS  State of imbalance characterized by a disturbance in a person’s thoughts, feelings and behavior Criteria to Diagnose Mental Disorders  Dissatisfactions with one's characteristics, accomplishments, abilities  Ineffective or dissatisfying relationships  Dissatisfaction with one's place in the world  Ineffective coping with life's events  Lack of personal growth PSYCHIATRIC NURSING  Interpersonal process whereby the nurse through the therapeutic use of self-assist an individual family, group or community to promote mental health, to prevent mental illness and suffering, to participate in the treatment and rehabilitation of the mentally ill and if necessary, to find meaning in these experiences CORE OF PSYCHIATRIC NURSING  Interpersonal relationship o Transference: unacceptable behavior, feeling, cognition or thought of a patient towards the nurse

Countertransference: unacceptable behavior, feeling, cognition or thought of the nurse towards the patient o Pre-orientation Phase: self-awareness; know patient’s information and history, know reason for admission o If you think that you cannot handle the client you can refuse, to not experience countertransference and for care to be more effective o You cannot control your emotions; you might get attached to the patient which would lead to ineffective care and countertransference o Orientation Phase: signing of contract occurs here, setting of boundaries and roles are also done here o You also inform the patient of the exact time when the contract will end o Working Phase o If during this phase you experience countertransference, best action is to inform your superior and you will be assessed o You are allowed to terminate the contract here, but if other measures are suggested you may follow it o Terminal or termination phase o Evaluation phase o If plan has of management has been met FOCUS: Patient o Do not ignore the feelings of the patient but the nurse should divert it back to the problem of the patient o It is a policy that a nurse cannot handle friends, family members, and people who have a relationship to the nurse. This may also lead to countertransference because the nurse is already attached to the clients o This will affect the care and judgment of the client o

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Foundation  Etiology of mental disorders remain unknown  But there are some theories like biochemical theories

Central Nervous System Cerebrum  Frontal lobe - control organization of thought, body movement, memories, emotions and moral behavior. o Associated with schizophrenia, attention deficit/ hyperactive disorder and dementia  Parietal lobe - interpret sensations of taste and touch and assist is spatial orientation.  Temporal lobes - are centers for the sense of smell, hearing, memory, and expression of emotions.  Occipital lobes - assist in coordinating language generation and visual interpretation, such as depth perception.

Neurotransmitters  Biochemical theories say that neurotransmitters have an effect to the mental processes, behavior, cognition, and thoughts of a patient  Dopamine - controls complex movements, motivation, cognition, regulates emotional responses o If low, it will cause tremors o If increased, there is a possibility to have increased cognition, to the point you are not intact with reality.

A patient may become delusional: fixed problems in thoughts and cognition (Schizophrenia) o Do not contradict the delusion of your patient because it is a fixed belief and it may cause anxiety o Present reality by giving instructions to activities that will revert them back to reality o Do not argue but do not tolerate it, just keep on mind to ignore the delusion and divert the delusion to reality  Serotonin - regulation of emotions, controls food intake, sleep and wakefulness, pain control, sexual behaviors o Problems in this neurotransmitter may be found in depression, anorexic, bulimic patients  Acetylcholine - controls sleep and wakefulness cycle (decreased in Alzheimer's)  Histamine - controls alertness, peripheral allergic reactions, cardiac stimulations  GABA - modulates other neurotransmitters o Modulates norepinephrine and epinephrine

When patient is having panic anxiety there is a problem with epinephrine Norepinephrine / Epinephrine - causes changes in attention, learning and memory, mood o

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Sympathetic Increase v/s Decrease GI motility Decrease GU function - urinary retention Moist mouth

Parasympathetic Decrease v/s Increase GI motility Increase GU function Dry mouth

Genetics and Hereditary  Alzheimer's disease - linked with defects in  chromosomes 14 and 21  Schizophrenia  Mood disorders (depression)  Autism and AD/HD SIGMUND FREUD  Father of Psychoanalysis  “Your behavior today is directly or indirectly affected by your childhood days or experiences.” o Repression a defense mechanism wherein there is unconscious forgetting  STRUCTURE – Personality Structure Personality Structure ID (4-5MONTHS)  Impulsive/ Instinctual drive  I want to... PLEASURE PRINCIPLE  I want to... PHYSIOLOGIC NEEDS  I want to... PRIMARY PROCESS  All about I, me, and myself SUPEREGO  Should not  Small voice of GOD  Set norms, standards, and values  MORAL PRINCIPLE  Conscience  Contradicts ID EGO  Executive  REALITY PRINCIPLE  Conscious  Competencies  Decision Maker; Problem-Solving; Critical and Creative thinking  Balances ID and superego  Once this is fully developed, you are now intact to reality

Imbalances between Personality Elements

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Psychosexual Theory of Freud

ORAL STAGE  18 months  Cry, suck, mouth  EGO at 6 months  Child cries - fed - successful  Child cries – ignored - unimportant narcissistic 

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Manic- usually seen in a bipolar patient.

Patient experiences hyperactivity o Extreme exaggerated behaviors Antisocial personality disorder- personality problems in interpersonal relationships Narcissistic- there is illusion of grandiosity

These are people who are strict law followers Obsessive compulsive disorder- recurring, unwanted thoughts, ideas or sensations that make them feel driven to do something repetitively o Those with ritualistic behaviors o Do not try to contradict because it will only increase their anxiety, because that is their coping mechanism o Do not abruptly stop it, but give schedules for those ritualistic behavior Obsessive compulsive personality disorder- are those who are perfectionists o They are perfectionists because they know that being unorganized is not acceptable to the society Hallucinations are sensations that seem to

be real but is only created in the mind Hallucination vs illusion o Both these involve the senses, it only differs in cognition o Hallucination has no stimulus but can sense something o Illusions have stimulus but is interpreted wrongly

Libido  Sexual energy responsible for survival of human beings

FIXATION  Occurs when a person is stuck in a certain developmental stage REGRESSION  Returning to an earlier developmental stage  Infantile behavior ANAL STAGE  18 months 3 years old  SUPEREGO develops  Toilet training o Good Mother - Normal o Bad Mother  Clean, organized, obedient - OC (anal retentive)  Dirty, disorganized - Anti-social (anal expulsive) PHALLIC STAGE  Preschooler (3 6 years old)  Parent o Oedipus Complex  Castration Fear o Electra Complex  Penis Envy  Daughter to father REPRESSION  UNCONSCIOUS forgetting of an anxiety provoking concept  80% of rape victims go into repression  There is a possibility that memories will go back once a person undergoes psychoanalysis or because of triggers SUPRESSION  CONSCIOUS forgetting of an anxiety provoking situation IDENTIFICATION  Attempts to resemble or pattern the personality of a person being admired of o Idolizing a person and copying them (behaviors, attitudes, physical appearance) INTROJECTION  Acceptance of another values and opinion as one's own

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Thoughts and opinions of other people are taken as own Claiming of other people’s stories

LATENCY STAGGE  6 to 12 years old  School  Reading, writing, arithmetic  Ability to care about and relate to others outside home SUBLIMATION  Placing sexual energies toward more productive activities o Unacceptable to acceptable behaviors to the society o Diverting sexual urges to activities that are acceptable to the society SUBSTITUTION  Replace a goal that can't be achieved for another that is more realistic. o Unachievable to achievable GENITAL STAGE  12 years old and above  Developing satisfying sexual and emotional relationships with members of the opposite sex  Planning life's goals EGO DEFENSE MECHANISMS Function - To ward off anxiety * without defense mechanisms, anxiety might overwhelm and paralyze us and interfere with daily living 2 Features: 1.1. they operate on an unconscious level (Except suppression) 2. 2. they deny, falsify or distort reality to make it less threatening REPRESSION VS. SUPPRESSION REPRESSION  Unconscious forgetting of an anxiety provoking concept SUPRESSION  Conscious forgetting of an anxiety provoking situation REGRESSION VS. FIXATION REGRESSION  Returning to an earlier developmental stage o Inappropriate behavior during anxiety

o E.g. tantrums of an adult  Infantile behavior FIXATION  Occurs when a person is stuck in a certain developmental stage o A stage is not satisfied o Satisfaction of the stage is done by a person e.g. smoking o This is different from regression and mannerisms RATIONALIZATION VS. INTELLECTUALIZATION RATIONALIZATION  Self-saving with incorrect illogical explanation o Reasoning out even with the wrong reasons INTELLECTUALIZATION  Excessive use of abstract thinking; technical explanation o Excessive rationalization o Possibly correct but not necessary to the current situation o Focusing on situations that is not really the problem DISPLACEMENT VS. PROJECTION VS. INTROJECTION DISPLACEMENT  Feelings are transferred or redirect to another person or object that is less threatening  Keyword: anger or feelings  Anger redirection PROJECTION  Blaming; Falsely attributing to another his/her own unacceptable feelings. o This can be seen in paranoid patients o “Takot sa sarili nilang multo” o A person unconsciously transfers his/her own negative behavior to others o The person is aware that he/she possesses that behavior but subconsciously blames others for it INTROJECTION  Acceptance of another's values and opinions as one’s own SUBLIMATION VS. SUBSTITUTION SUBLIMATION  Transfer of sexual energy to a more productive activity.

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Unacceptable behavior to acceptable behavior to the society

SUBSTITUTION  Replaces a goal that can't be achieved for another that is more realistic.

DISSOCIATION VS. ISOLATION DISSOCIATION  Separating and detaching idea, situation from its emotional significance. o Detaching from the self temporarily d/t anxiety ISOLATION  Individual strips emotion when talking or responding about it.

Symbolization  Creates a representation to an anxiety provoking thing or concept Splitting  Labile emotions; all bad - all good DEFENSE MECHANISMS COMMONLY USED IN EACH RESPECTIVE DISORDERS  Paranoid - Projection  Phobia - Displacement  Amnesia - Dissociation  Anorexia - Suppression  Bipolar Disorder - Reaction Formation  Borderline - Splitting  Schizophrenia - Regression  Substance Abuse-Denial  Depression - Introjection  OC - Undoing  Catatonic - Repression

EGO DEFENSE MECHANISMS Conversion  Anxiety converted to physical symptoms o E.g. stress is converted to headache Compensation  Overachievement in one area to Overpower weaknesses or defective area. o There should be presence of weakness, limitation, or insecurity that will be covered up by other achievements Undoing  Doing the opposite of what have done o Trying to compensate for the wrong a person has done o E.g. a guy hurt a woman and then gave her flowers after o Restitution- you do something wrong to a person but compensate by doing good to people who are involved to the person Denial  Failure to acknowledge an unacceptable trait or situation  Alcoholic patients commonly use this defense mechanism Fantasy  Magical thinking

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Woman who is angry with her boss writes a short story about a heroic woman.

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Four-year old with new baby brother starts sucking his thumb and wanting a bottle.

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Patient criticizes the nurse after her family failed to visit

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Man who is unconsciously attracted to other women teases his wife about flirting

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Short man becomes assertively verbal and excels in business.

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Recovering alcoholic constantly preaches about the evils of drink.

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Man reacts to news of the death of a loved one “No, I don't believe you. The doctor said he was fine.”

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Student is unable to take a final exam because of a terrible headache.

After flirting with her male secretary, a woman brings her husband tickets to a show.

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“I didn't get the raise because my boss doesn't like me."

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Five-year old girl dresses in her mother's shoes and dress and meets daddy at the door.

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After his wife's death, husband has transient complaints of chest pain and difficulty breathing- the symptoms his wife had before she died

Reaction Formation  Opposite of intention Acting out  Deals with emotional conflict or stressors

by ACTION rather than reflection or feelings

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Man forgets wife's birthday after a marital fight.

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Businessman who is preparing to make an important speech that day is told by his wife that morning that she wants a divorce. Although visibly upset, he puts this incident aside until after his speech, when he can give the matter his total concentration.

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A man cannot accept his physician's diagnosis of cancer is correct and seeking a second opinion

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slamming a door instead of hitting as person, yelling at your spouse after an argument with your boss

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focusing on the details of a funeral as opposed to the sadness and grief

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stating that you were fired because you didn't kiss up the boss, when the real reason was your poor performance

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having a bias against a particular race or culture and then embracing that race or culture to the extreme

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sitting in a corner and crying after hearing bad news; throwing a temper tantrum when you don’t get your way

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forgetting sexual abuse from your childhood due to the trauma and anxiety

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lifting weights to release 'pent up' energy

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Therapeutic Communication 

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Non-verbal cues are more accurate than verbal cues o Reaction formation may be seen in these situations Therapeutic communication is important because it can affect the progress of the patient Always assert and affirm authority o The healthcare provider should be followed and not the patient For paranoid patients, always position in front of the patient but should have a space in between o Because standing on the sides may pose as a threat to the patient o Being too close or too far may also present as a threat to the patient o Paranoid patients are hypervigilant

Reality orientation o Alcoholic patients who are already in withdrawal may experience formication o Sensation that resembles that of small insects crawling on (or under) the skin when there is nothing there. o Acknowledge what the patient feels (because they are not inventing things) to reduce anxiety, explain that you understand how the patients feel but don’t forget to present the reality to the patient o Divert the attention to a realistic environment General leads o Broad opening statements, leave the direction of the conversation to the patient o Used when patients have difficulty in expressing or verbalizing thoughts and feelings o Schizophrenic patients are disorganized, general leads may be helpful o May also be used in geriatric patients Silence o If you remain silent when a patient is talking it indicates that you are listening o A sign of respect to the person speaking o Best therapeutic communication used for paranoid patients, to be able to establish trust o May help develop rapport

Therapeutic communication 

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Continuous, dynamic process of SENDING and RECEIVING MESSAGES by various verbal or non- verbal means (words, signals, signs, symbols) utilized in a goaldirected professional framework.

Offering self o Offering safety, service, comfort o “I’ll sit beside you” o “Do you need help?” o You want to tell the patient that you want to provide care

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Very helpful for depressed patients, this shows that people care for them E.g. Ursula, age 25, is found on the floor of the bathroom in the day treatment cleaning with moderate lacerations to both wrists.

Surrounded by broken glass, she sits staring blank at her bleeding wrist while staff members call for an ambulance. The best way the nurse should do is to approach Ursula slowly while speaking in the calm voice, calling her name and telling her that the nurse is here to help her. This approach provides reassurance for a patient in distress

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To not neglect other problems that will come out during the working phase

Orientation (initiation)      

Assessment of problems, needs, expectations of clients Identify anxiety level of self and client Set goals of relationship.

Define responsibilities of nurse and client.

Stage of testing.

Establish boundaries of relationship. Stress confidentiality.

Contract – 2 famous psychiatric contracts: o

1. No suicide contract  Major depression = emergency

3 LEVELS OF PSYCHIATRIC NURSING (Levels of Health)

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TWO definitions of no suicide contract:

Primary

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24 hours monitoring

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Verbalization to the nurse of all suicide ideas

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Objective: PROMOTION & PREVENTION Client and Family Teaching (Health Teaching) No existing illness yet

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Screening, Diagnosis, and Immediate Treatment Screening o Denver Development Screening Test (DDST) #1 test for PDD

Tertiary 

Diet contract  Eating disorder

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The start of termination phase: “Good morning, full name, RN, shift, session, date start & end.”

Working phase 

Promote acceptance of each other

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Accept client as having value and worth as a unique individual. o Stage of resistance Counter transference phase Most difficult phase NCP is on going Identification of the problem/exploration The #1 Psychiatric Core Value is Consistency  For manipulative patients Be consistent to patient with: BAAAM COPS o

Rehabilitation

Four phases of nurse- client relationship (NCR) Pre-interaction/Pre-orientation (For the Nurse) 

Stage of Self-Awareness  To prevent Counter Transference

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#1 CORE VALUE OF Psychiatric Nursing AIM: PLAN THE RELATIONSHIP Upon admission, discharge instruction plan should already be formulated o You already know the chief complaint (existing problems)

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B orderline

C onduct d/o

A ntisocial

O ral/eating disorder

A lzheimer’s

P aranoid

A utistic

S uicidal

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Use therapeutic and problem- solving techniques o Maintain professional, therapeutic relationship

Keep interaction reality- oriented- here and now o Provide active listening and reflection of feelings o Use non- verbal communication to support client o Recognize blocks to communication and work to remove them FOCUS on client’s: o Confronting and working through identified problems o Problems- solving skills o Increasing independence o Help client develop alternative, adaptive coping mechanisms o Personal biases (manifestation by counter-transference & vice versa) are seen during working phase o

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 Termination  

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Plan for termination of relationship early the relationship Stage of Separation Anxiety  Signs & symptoms: Regression: Temper tantrums, thumb sucking, apathy, fetal position when crying Phase of prognosis  Evaluation Maintain boundaries Anticipate problems of termination: o Increased dependency on the nurse o Recall of previous negative experience- rejection, depression, abandonment, etc. o Regressive behaviors o Emphasize to the patient that a discharge instruction has been made which would help his/ her progression o Discharge plan is discussed in this phase Discuss client’s feelings and objectives achieved

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Levels of awareness

Conscious- you can immediately answer or remember because this is still in your memory o Composed of past experiences, logical and governed by REALITY PRINCIPLE; are remembered and easily recalled or available to the individual Subconscious- information or memory where you need to exert effort in order to remember o the Preconscious; composed of material that has been deliberately pushed out of conscious level; helps repress unpleasant thoughts or feelings and can examine or censor certain desires or thinking; can be recalled with some effort Unconscious- memories or information that are already repressed o Composed of the LARGEST BODY OF MATERIAL- the thoughts, memories and feelings that are repressed and not available to the conscious mind, not logical and governed by PLEASURE PRINCIPLE – and since it is usually painful and unacceptable to the individual, it cannot be deliberately brought back into awareness unless in disguised or distorted form (dreams) o Information cannot be totally remembered o Largest storage among the three

Additional notes 

Exploration is a sign of suicide

They are giving their belongings to other people If a patient has suicidal ideations, do you confront or ask that patient? o Yes, because it is considered to be therapeutic o A no suicide attempt contract will be given, because once a suicide happen the hospital and staff will be held liable o When you ask the patient if he/she will perform suicide the patient will know that the nurse is knowledgeable leading to delay in the plan, do this until serotonin levels go back to normal and depression will be solved o Confrontation is therapeutic to suicidal patients. You can ask when, where, and how can be asked but never why Asking questions starting with why is never therapeutic o Because why is an open-ended question, leading the patient to rethink of the thoughts and feelings that drove them to do suicide o

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Mental status examination  A systematic assessment that checks if a person is mentally sound or not o Assessment in terms of their mental health o No tools are available for this exam o Not used to create a diagnosis but only to assess o Only used to add confirmation to a specific mental disorder  Clinical eye may be used in this assessment  Histrionic personality disorder o Characterized by a pattern of excessive attention-seeking behaviors, usually beginning in early childhood, including inappropriate seduction and an excessive desire for approval.  Hygiene should be assessed  Eye contact o Does the person engage in eye contact? o But always take into consideration of the norms and practices about eye contact of the patient  Attitude o Mannerisms (can usually be seen in Tourette’s and autism)

It is important to detect mannerisms because this may be a sign of neurologic dysfunction o Alcohol and drug use may induce mannerisms because these damages the CNS Appearance o Check the way a person dresses, is it appropriate for the time and occasion? o Can be observed in narcissists and people with illusion of grandeur Speech o Depressed patients can only answer close-ended questions o They cannot explain d/t decreased levels of serotonin o Volume of the voice may also be an indicator depending on the client Mood and affect o Affect can be seen in the client’s facial expression o Affect is the experience of feeling an emotion while mood is a state of emotion o Affect is usually short-lived while mood can last for hours or days o Blunted vs. flat affect o A person with flat affect has no or nearly no emotional expression.

He or she may not react at all to circumstances that usually evoke strong emotions in others. A person with blunted affect, on the other hand, has a significantly reduced intensity in emotional expression o Inappropriate vs labile affect o Inappropriate affect is an affect that is incongruent with the situation or with the content of a patient's ideas or speech. Labile affect that characterized by rapid changes in emotion unrelated to external events or stimuli  Inappropriate affect is somehow similar to the reaction formation o Restricted affect is a term used to describe a mild constriction in a client's physical affect: range and/or intensity of emotion or display of feelings  The person does not want to really show his/her feelings Speech o

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There are certain forms or types of speech that manifests in mental disorders o Bipolar patients manifest flight of ideas when speaking (flight of ideas where one sentence has little connection to the second statement) d/t hyperactive thinking o Schizophrenia not intact with reality when speaking (delusional)  Loses association in spoken statements  Word salad (speaking of words not related to one another) o Neologisms can also be observed in schizophrenic patients  Coining or use of new words  Invented words that is only known by the patient  When talking to the patient, clarify what these words are to the client o Echolalia, echopraxia, and palilalia  Echolalia is the repetition of words spoken by others, whereas palilalia is the automatic repetition of one's own words  Echopraxia (also known as echokinesis) is the involuntary repetition or imitation of another person's actions.  Can be seen in autism patients o Clanging- rhyming of words or phrases also observed in schizophrenic patients] o Blocking  People with thought blocking often interrupt themselves abruptly mid-sentence.  Can be observed in schizophrenic-paranoid type  This occurs d/t hallucinations of the patient Thought o Thought insertion can be seen in schizophrenia  Experiencing one's own thoughts as someone else's o Thought withdrawal  Delusion that thoughts have been taken out of the patient's mind o

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Disturbed sensory perception and altered thought process may be a nursing diagnosis Agnosia- loss of the ability to recognize objects, faces, voices, or places Apraxia- inability to perform learned (familiar) movements on command  Inability to use objects properly Aphasia- impairment of language, affecting the production or comprehension of speech and the ability to read or write

Therapy for mental disorders Electroconvulsive therapy  ECT is passing of an electric current through electrodes applied to one or both temples to artificially induce a grand mal seizure for the safe and effective treatment of depression.  ECT’s mechanism of action is unclear at present  For depressed patients  Last resort for a depressed patient who can no longer wait for the effect of an antidepressant medications or is no longer responsive to medications Advantages  Quicker effects than antidepressants; Safer for elderly; 80 % improvement rate of major depressive episode with vegetative aspects  Best therapy for major depression (last resort)  Invasive  Induction of 70-150 volts of electricity in).5-2secs. Then, it is followed by a grand-mal seizure lasting 30-60 secs. o Prone to aspiration that is why atropine sulfate is given to decrease secretions and prevent aspiration o Should be in supine during ECT, then after place in a side-lying position to allow drainage of secretions  6-12 treatments, “every other day”  Before ECT o Should be on NPO o Food is introduced when gag reflex is back  Before ECT a major depressed client undergoes the ff meds:

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Phenobarbitals are given as anticonvulsants and may also decrease heart rate of patients SSRi (Selective Serotonin Reuptake Inhibitor inhibitor) –2 weeks Antidepressants  TCA 2nd Generation o 2-4 weeks MAOIs – are taken for 2 weeks

Side Effects  After ECT, reorient the patient because antegrade amnesia is expected after therapy o Temporary RECENT Memory Loss ANTEROGRADE amnesia o Intervention: Re-orient client to 3 spheres o Reintroducing yourself, therapy, where patient is, time and date, secure the safety of a patient as well o confusion/disorientation (usually 24 hours) o Headache  ↑02 demand, ↑cerebral hypoxia o Muscle spasm o Wt. gain (stimulate thalamic/limbic  appetite) Contraindications  PPPP– Post MI, Post CVA, pacemaker, pregnant women  People with cardiovascular problems  Neurologic problem  Alzheimer’s, degenerative disorder  Brain tumor, weakness of lumbosacral spine Legal/Pre-Nursing Responsibilities Preparation: Similar to preparing a client for surgery  Informed Consent – if client is coherent, if not a guardian may sign the consent forms.  No metallic objects o Metals can interfere with electrical transmissions  No nail polish to check peripheral circulation  No contact lenses it may adhere to the cornea  Let the patient void first  Wash & dry hair  6. Give following medications BEFORE ECT:  Atropine sulfate – anticholinergic  PRIMARY purpose – to dry secretions and prevent aspiration  SECONDARY purpose – to prevent bradycardia (vagolytic)

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Phenobarbital (Luminal), Methohexital (barbiturate Na)- minor tranquilizer also an anticonvulsant Succinylcholine (Anectine) – muscle relaxant o Given because ECT can cause muscle spasm Priority vs. to focus ABC; check RR 12 less; LOC Before ECT  supine position; after ECT  side-lying Have patient VOID before giving ECT

Nursing Diagnosis  Risk for Airway Obstruction/aspiration  Risk for Injury  Impaired/Altered Cognition/LOC Nursing Intervention  5 S in Seizure  Safety (#1 objective)  Side-lying (#1 Position)  Side rails up  Stimulus ↓ (no noise & bright lights)  Support the head with a pillow AFTER the seizure  FIRST & TOP priority: Ensure a patent airway. Side-lying after removal of airway.

Observe for respiratory problems  Remain with client until alert. VS q 5 min until stable.  REORIENT: Time, place (unit), person (nurse); Reassure regarding confusion and memory loss. Same RN before & after.

Behavior therapy TERMINOLOGIES  STIMULUS: Any event affecting an individual  PROBLEM BEHAVIOR: Deficient, excessive, condemned, unwanted behavior  OPERANT BEHAVIOR: Activities that are strongly influenced by events that follow them.  TARGET BEHAVIOR: Activities that the nurse wants to develop or accelerate in the client.  REINFORCER: A reward positively or negatively influences and strengthens desirable behaviors.  POSITIVE REINFORCER: A desirable reward produced by specific behavior (TV time after doing homework)  NEGATIVE REINFORCER: A negative consequence of a behavior (Spanking child for wetting the floor) Classical conditioning

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(pairing of two stimuli in order to gain a new learning behavior – by Ivan Pavlov)

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Acquisition (newly acquired behavior or the by-product of classical conditioning) Extinction Reward and punishment in order to change the behavior of the patient How frequent do we need to do this? o Behavior changes quicker if rewards are not given frequently, because once reward is gone attitude may come back o Should have a gap in between before you give another reward o This is to train them to maintain the good behavior and not wait for the rewards If with bad behavior, punishment should be provided right away o Because there is a tendency that they will not believe that the punishment is not true Provides a stimulus to encourage good behavior Appropriate therapy for phobias is systematic desensitization o A gradual exposure of the person to feared objects o E.g. fear of snakes, first show it from afar or a stuffed toy, then progress until patient can touch the snake o Reinforce to the patient that not all snakes are venomous If systematic desensitization is not effective, flooding may be done o This is the abrupt exposure to feared objects until the patient becomes tolerant with it

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OPERANT CONDITIONING Burrhus Skinner  used in Behavior Modification 1. Positive reinforcement (Reward Orientation) o Token Economy – use tokens as a source of reward. o Used in eating disorders and depression o Token economy is also effective for toddlers 2. Negative Reinforcement (Punishment Orientation) o Aversion Therapy/Aversion Technique BEHAVIORAL TREATMENTS 1. Desensitization – gradual exposure to the feared object

o #1 treatment for phobia 2. Flooding/Implosive Therapy – sudden exposure 3. Relaxation Technique – light stroking = labor o Purse Lip Breathing Exercise = COPD/CAL (Chronic Airflow Limitation) 4. Biofeedback – mind over matter. Ex. HPN > ↓BP, palpitations, headache 5. Guided Imagery (Child) & Visualization (Adult Group therapy 

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Psychotherapeutic processes that occur in formally organized groups designed to change maladaptive or undesirable behavior.

Knowledge of therapeutic modalities enhances the performance of nursing interventions during therapy. 8-10 patients are the optimal number of patients in a group.

There should be 8-10 members only Maximum of 10, no longer therapeutic if too many All members should have or experience the same problem Done during rehabilitation in order to gain other coping mechanisms of other patients who have overcome the problems

TYPES OF GROUPS 1. Structured o Goals: Pre-determined o Format: Clear and specific o Factual material: Presented o Leader: Retains control 2. Unstructured o Goals: Not pre-determined.

Responsibility for goal is shared by group and leader o Format: Discussion flows according to group members’ concern o Materials and topics are not preelected. o Leader: Nondirective o Emphasis: More on FEELINGS rather than facts ADVANTAGE OF GROUP THERAPHY 1. Economical: Less staff used.

2. Increased feelings of closeness > Reduction on feelings of being alone.

3. With feedback group > o Corrects distortions of problems o Builds self- image and self- confidence o Increases reality- testing opportunities o Gives info on how one’s personality and behavior appear to others

4. With opportunities for practicing alternative behaviors and methods of coping with feelings 5. Provides attention to reality and provides development of insight into one’s problems by expressing own experiences and listening to others in groups

PRINCIPLES OF GROUP THERAPY 1. Verbalization: Members express feelings and group reinforces appropriate communication.

Desired outcome of group therapy includes verbalization of feelings rather than acting them out 2. Activity: Provides stimuli to verbalization and expression of feelings.

3. Support: Members gain support from one another through interaction, sharing and communication.

4. Change: Members have opportunity to try out new and desirable behaviors in group, supportive setting to effect change.

PHASES OF GROUP THERAPY 1. Initial Phase  Formation of group  Setting and clarification of goals and expectations  Initial meeting, acquaintance and interaction 2. Working Phase  Confrontation between members→ Cohesiveness  Identification of problems→ Problemsolving processes  In a group therapy when one client says to another, “Maybe you’re taking on someone else’s problems.” this shows that they are in the working phase 3. Termination Phase  Evaluation of goals attainment  Support for leave- taking  In group therapy if a client says, “Leave me alone & get away from me.”, best action of the RN is to maintain distance from the pt.  Behavior indicating that goal is met after socialization in a group therapy includes participation of each group member telling the leader about specific problems Milieu therapy 

Milieu therapy or environmental therapy

If a patient is having a religious delusion remove images of saints, or smokes, because it only adds to the delusion of the patient o This does not bring the patient back to reality Therapeutic milieu is an environment that is structured and maintained as an ideal, dynamic settings in which to work, with client For hyperactive patients do not place them in areas with a lot of activities o Place them in safe environments Any activity that is to be done should be supervised by the nurse o

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Crisis 

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Expected especially when a person is growing up (developmental crisis) o E.g. a girl undergoing puberty had her first menstruation has increased anxiety because this is her first time o This cannot be avoided Midlife crisis where a person experiences ttransition of identity and self-confidence that can occur in middle-aged individuals, typically 45 to 65 years old When a person gets married, a person may also undergo crisis because there will be a huge adjustment Situational crisis involves an unexpected event that is usually beyond the individual's control. Examples of situational crises include natural disasters, loss of a job, assault, and the sudden death of a loved one.

Adventitious crisis where natural resources are involved o Called events of disaster. They are rare, unexpected happenings that are not part of everyday life and may result from: Natural disasters, such as floods, fires, and earthquakes You are considered healthy is you are able to cope up with the crisis in 4-6 weeks o It should lessen in 4-6 weeks, but if it increases you need to seek professional help o If it resolves then recurs, its fine so long as it resolves

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Stages of grief  

become silent, refuse visitors and spend much of the time mournful and sullen.

Acceptance – "It's going to be okay."; "I can't fight it; I may as well prepare for it."

In this last stage, individuals embrace mortality or inevitable future, or that of a loved one, or another tragic event. People dying may precede the survivors in this state, which typically comes with a calm, retrospective view for the individual, and a stable condition of emotions.

It is important for nurses to guide patients not to stay too long in denial stage Nurse should guide the patient through the stages

Additional notes 

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Denial – The first reaction is denial. In this stage, individuals believe the diagnosis is somehow mistaken, and cling to a false, preferable reality. o Present the reality to the client Anger – When the individual recognizes that denial cannot continue, they become frustrated, especially at proximate individuals. Certain psychological responses of a person undergoing this phase would be: "Why me? It's not fair!"; "How can this happen to me?"; "Who is to blame?"; "Why would this happen?".

Bargaining – The third stage involves the hope that the individual can avoid a cause of grief. Usually, the negotiation for an extended life is made in exchange for a reformed lifestyle. People facing less serious trauma can bargain or seek compromise. Examples include the terminally ill person who "negotiates with God" to attend a daughter's wedding, an attempt to bargain for more time to live in exchange for a reformed lifestyle or a phrase such as "If I could trade their life for mine".

Depression – "I'm so sad, why bother with anything?"; "I'm going to die soon, so what's the point?"; "I miss my loved one; why go on?"

During the fourth stage, the individual despairs at the recognition of their mortality. In this state, the individual may

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Voluntary admission- patient wants to seek mental help so he/she surrendered self to the facility o Contract may be ended by the patient o He/ she may request to be discharged o False imprisonment, assault, battery may be charged if the nurse does not allow the client to be discharged and was restrained Involuntary- those who were escorted to the facility because they are still in denial of their condition o Patients in this type of admission cannot request to be discharged o Contact the legal guardian who brought the client there Safety and security must always be prioritized when a patient is in jeopardy o E.g. a patient is having seizures and the IV lines are dislodged, ensure the safety of the client first side rails up!

How do you consider an alcoholic patient already okay?

Delusion of grandeur- fixed false belief of being high or important Flight of ideas are somewhat related to one another o Very common in bipolar disorders o Mentioning one word then connecting it to another o Ex. Sir Gan—gun, I want to kill somebody Looseness of association- sentences are not connected with one another o Common in schizophrenic patients o Because they are not intact with reality Clanging- rhyming words

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Neologism- making of words Projection is used by paranoid patients Conversion- anxiety converted to physical symptoms Compensation- weakness covered by greatness Orient the patient to location, time, place, and person Narcissistic patient- always remind them of the roles and the patient should be the one following the nurse o Reinforce to the patient that all the activities to be done is for her/his good o Always set the boundaries o Confrontation can be done since there is a contract

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MIDTERMS Anxiety 

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DEFINITION: Effective subjective response to an imagined or real internal or external threat.

Perceived SUBJECTIVELY by the conscious mind is as a painful, diffuse apprehension or vague uneasiness, but the causative conflict or threats is not in the conscious mind or awareness.

Low / mild level of anxiety is healthy and helps in individual growth and development.

So long as you are still oriented to time, space, and situation the anxiety you are feeling is still normal o Up to moderate level of anxiety may still be considered normal There are internal and external threats o Internal- formed in the mind o External- due to your situation or environment

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 MAJOR ASSESSMENT CRITERION FOR MEASURING DEGREE OF ANXIETY: 

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Mild: The perceptual field is wide allowing the client to focus realistically on what is happening to him. Alert senses, increased attentiveness, and increased motivation. o Expected incoming threats o Can still focus on other things Moderate: Another word is selective inattention. The perceptual field narrows and the client is able to partially focus on what is happening if directed to do so and can verbalize feelings of anxiety

Cannot focus anymore on other things

Severe: The perceptual field is significantly reduced and the client may not be able to focus on what is happening to him and may not be able to recognize or verbalize anxiety. All senses affected; decreased perceptual field; drained energy; Learning and problem-solving not possible. Start of sympathetic symptoms: tachycardia, palpitations, hyperventilation (brown paper bag to prevent Respiratory Alkalosis) and cold clammy skin. o Patient is already disorganized Panic: The perceptual field is severely reduced and the client experiences feelings of panic and dread. Client overwhelmed and helpless; personality may disintegrate → hallucinations and delusions. Pathological conditions requiring immediate intervention. Client may harm self or others. o A patient stating, “Sometimes I feel like I’m going crazy & losing control over myself,” is showing symptoms of panic attack Perceptual field and anxiety are inversely proportional o Sensorium or senses are involved o As anxiety increases sensorium decreases o When a patient is anxious, he/she can only see what is in front and can only hear loud noises Talk to the patient in a short and direct manner, use close-ended questions Always place yourself in front of the patient Identify the stimulus that causes anxiety and remove it Do not leave the patient alone during anxiety attack o Safety is always priority Still give space and do not touch the patient unless he/she permits you to do so

POTENTIAL NURSING DIAGNOSES  Ineffective Individual Coping  Anxiety NURSING INTERVENTION IMPLEMENTATON:  Identify anxious behavior and anxiety levels and institute measures to decrease anxiety at a level where learning can occur.  Provide appropriate environment where environmental stress & stimulation are low (First nursing action):

Structured, NON-STIMULATING, uncluttered o SAFE from physical exhaustion and harm.

STAY. Do not leave client alone. Recognize if additional help is needed. Provide physical care if necessary.

Establish PERSON-TO-PERSON relationship and maintain an accepting attitude: o ACCEPT client. Show willingness to LISTEN. o Encourage, allow EXPRESSION OF FEELINGS at client’s OWN PACE avoid forcing verbalization.

Administer medication as directed and needed. The pharmacologic therapy of choice is ANXIOLYTIC-reduces anxiety so client can participate in psychotherapy.

Assist to cope with anxiety more effectively. Assist to recognize individual strengths realistically Encourage measures to reduce anxiety: activities: relaxation techniques, exercises (DANCING, WALKING, JOGGING), hobbies, talking with support groups, desensitization treatment program Provide individual or group therapy to identify anxiety and new ways of dealing with it and develop more effective coping interpersonal skills.

If patient can be redirected back to the topic after he gets anxious while the RN gives discharge teaching, it is an indication that discharge teaching can be resumed. o

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TYPES OF ANXIETY DISORDER 

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Phobia o Fear of heights- acrophobia o Fear of fire- pyrophobia o Fear of doctor- iatrophobia o Fear of microorganismsgermaphobia o Fear of death- thanatophobia o Fear of animals- zoophobia Obsessive Compulsive Post-Traumatic Stress Disorder (PTSD) Generalized Anxiety Disorder (GAD) Panic Disorder

PHOBIA AND PANIC DISORDER  Extreme anxiety and apprehension experienced by an individual when confronted with feared object/ situation; commonly begins in early twenty’s (young adult) as a result of childhood environmental factors characterized by ORDER & RIGIDITY; use compensatory mechanism of the psychoneurotic pattern

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of behavior and development of symptoms permits some measure of social adjustment.

PRECIPITATING FACTOR: Pressures of decision-making regarding life-style in early adult period

TYPES OF PHOBIA 

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Agoraphobia: Fear of being alone, fear of open spaces or PUBLIC places where help would not be immediately available (trains, tunnels, crowds, buses) A client with agoraphobia who is already able to go outside the house indicates a positive response to therapy.

Expected outcome for agoraphobia includes going out to see the mailbox Social phobia: Fear of public speaking or situations in which public scrutiny may occur Simple phobia: Fear of specific objects, animals or situations

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Recognize the client’s feelings about phobic object/ situation o Specific precipitants are present with phobia Avoid confrontation and humiliation; Provide constant support (Stay with client during an attack) if exposure to phobic object or situation cannot be avoided Do not focus on getting patient to stop being afraid Provide relaxation techniques Implement behavioral therapy: SYSTEMIC DESENSITIZATION (the #1 treatment for PHOBIA). Administer antidepressants as ordered

OBSESSIVE-COMPULSIVE DISORDER 

A psychiatric disorder characterized by persistent, recurring anxiety-provoking thoughts and repetitive acts; Unconscious control of anxiety by the use of rituals and thoughts o OBSESSION: Persistent, repetitive, uncontrollable thoughts  These are thoughts that are recurring in the mind  Thoughts that keeps a patient preoccupied, thus, affects ADLs o COMPULSION: Repetitive, uncontrollable acts of irrational behavior that serve NO rational purpose → rigidity, rituals, inflexibility; the development of

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rituals permits some measure of social adjustment  Things that the patient unconsciously does to decrease the level of anxiety because of the obsession  Helps in decreasing the anxiety felt by the patient ASSESSMENT FINDINGS: Ritualistic, rigid, inflexible; with difficulty making decisions and demonstrates striving at perfection; use verbal and intellectual defenses Acknowledge positive reinforcement

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Provide for physical safety (1st); meet physical needs Accept, allow ritualistic activity; DO NOT INTERFERE with it; (The best time to interfere with ritual is after client has completed it.) Accept behavior but set limits on length and frequency of the ritual. Offer alternative activities; support attempts to reduce dependency on the ritual; guide decisions o Just set a time when to perform the ritualistic behavior (time management) o Do not stop, because it will increase anxiety Provide structured environment, minimize choices Provide socialization, group therapy Administer CLOMIPRAMINE (ANAFRANIL) as ordered o A Tricyclic antidepressant used in phobias, anxiety and obsessivecompulsive disorder; SIDE-EFFECTS/ ADVERSE REACTIONS: Tachycardia, cardiac arrest, dizziness, tremors, seizures, CONTRAINDICATIONS: Pregnancy, hypersensitivity; Interactions/Incompatibilities: Hypertensive crisis, convulsions, with MAOIs

POST-TRAUMATIC STRESS SYNDROME 

A disorder following exposure to extreme traumatic event (wars, rape, natural catastrophes) causing intense fear, recurring distressing recollections and nightmares o Retained in the patient’s mind o They are detached because they do not know who to trust anymore.

They think that people who surround them are going to do something bad

ASSESSMENT: 2 Cardinal Sign: FLASHBACK & NIGHTMARES. Images, thoughts, feelings → intense fear and horror, sleep disturbances. o Depression, or irritability or outburst of anger o Exaggerated startle response; Poor impulsive control o Avoidance; Inability to maintain intimacy; Hypervigilance o The two cardinal signs should be present in order to diagnose PTSD  PRIORITY NURSING DIGNOSIS o Altered Sleeping Patterns o Altered Skin Integrity o Ineffective Individual Coping NURSING INTERVENTATION o Encourage VERBALIZATION about painful experience. Show empathy; be nonjudgmental; Help feel safe. o To prevent level of anxiety o Rational emotive-therapy; Allow to grieve o Help client identify, label and express feelings safely o If they have difficulty in sharing the experience their level of anxiety may increase  Enhance support systems: Self-help groups, family psychoeducation, and socialization. o In a rape victim, a statement like, “If I should not have worn that red panty, it won’t happen to me”, shows denial o Statement of a rape patient who is beginning to resolve trauma includes, “I’m able to tell my friends about being raped.” o An RN needs further teaching about caring for a post-traumatic client when she keeps on asking the client to describe the trauma that caused patient’s distress after recovering from a PTSD SOMATOFORM DISORDERS  Body Dysmorphic Disorder  Somatization  Conversion Disorders  Hypochondriasis  Psychogenic Pain  This are all caused by anxiety 

BODY DYSMORPHIC DISORDER  Preoccupation with an imagined defect in his or her appearance  A perceived distortion to the physical body  This is not made up by the client but this is what he/she sees SOMATIZATION  A client expresses emotional turmoil or conflict through a physical system, usually with a loss or alteration of physical functioning

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Involves a person having a significant focus on physical symptoms, such as pain, weakness or shortness of breath, that results in major distress and/or problems functioning. The individual has excessive thoughts, feelings and behaviors relating to the physical symptoms When validated by laboratories it is not confirmed to be true

CONVERSION DISORDERS  A psychological condition in which an anxiety-provoking impulse is converted unconsciously into functional symptoms  Anxiety is converted to physical symptoms  Patients with this disorder do not fake the physical signs and symptoms  Physical symptoms can be confirmed through diagnostic tests  Does not do hospital-hopping because the doctor will validate that the symptoms are real HYPOCHONDRIASIS  Presentation of unrealistic or exaggerated physical complaints  When a patient complains of backache and thoughts of it as bone cancer DISSOCIATIVE DISORDERS  Dissociative amnesia  Dissociative fugue  Depersonalization  Dissociative Identity Disorder/Multiple Identity Disorder  These disorders are still because of anxiety DISSOCIATIVE AMNESIA  Characterized by the inability to recall an extensive amount if important personal information because of physical or psychological trauma  Once the patient has recovered from the crisis, the memory of the patient will return DISSOCIATIVE FUGUE  The person suddenly and unexpectedly leaves home or work and is unable to recall the past  If the patient moves from one country to another the patient will not be able to recall the previous life and the previous country he has been in  Characterized by reversible amnesia for personal identity, including the memories, personality, and other identifying characteristics of individuality. The state can last days, months or longer.

DEPERSONALIZATION  Person experiences a strange alteration in the perception or experience of the self, often associated with a sense of unreality  Depersonalization/derealization disorder is a type of dissociative disorder that consists of persistent or recurrent feelings of being detached (dissociated) from one’s body or mental processes, usually with a feeling of being an outside observer of one’s life (depersonalization), or of being detached from one's surroundings (derealization).  This is not fixed, only temporary. The patient can still go back to reality MULTIPLE PERSONALITY DISORDER  A person is dominated by at least one of two or more definitive personalities at one time  Maintenance of at least two distinct and relatively enduring personality states.

The disorder is accompanied by memory gaps beyond what would be explained by ordinary forgetfulness.  The person won’t know about the different personalities unless they are already being treated  Once they verbalize and is conscious of the multiple personalities it is a sign of progress or recovery *Hindi to kasama sa lecture pa po hehe ERIK ERICKSON PSYCHOSOCIAL THEORY OF DEVELOPMENT 1.18 mos. TRUST VS. MISTRUST  attachment to mother which lays foundations for later trust in others  conflict: general difficulties relating to others. suspicion, fear of the future 18 mos-3 yrs AUTONOMY VS. SHAME/DOUBT  Gaining some basic control of self and environment  Conflict: independence-fear conflict, severe feelings of self-doubt 3 yrs-6 yrs INITIATIVE VS. GUILT  becoming purposeful and directive  conflict: aggression-fear conflict, sense of inadequacy and guilt 6 

yrs-12 yrs INDUSTRY VS. INFERIORITY Developing social, physical and school skills, competence

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Conflict: sense of inferiority, difficulty learning and working

12 yrs-20 yrs IDENTITY VS. ROLE DIFFUSION  Making transition from childhood to adulthood, developing a sense of identity  Conflict: confusion of who one is, identity submerged in relationships or group memberships 21 yrs -35 yrs INTIMACY VS. ISOLATION  establishing intimate bonds of love and friendship  conflict: emotional isolation 35 yrs-55 yrs GENERATIVITY VS. STAGNATION  fulfilling life's goals that involve family, career and society, developing concerns that embrace future generations  conflict: self-absorption. Inability to grow as a person 55 yrs-above INTEGRITY VS. DESPAIR  looking back into one’s life and accepting its meaning  conflict: dissatisfaction with life, denial of or despair over prospect of death JEAN PIAGET COGNITIVE THEORY OF DEVELOPMENT ASSIMILATION  people transform incoming information so that it fits within their existing schemes or thought patterns ACCOMMODATION  people adapt their schemes to include incoming information PIAGET’S COGNITIVE THEORY SENSORIMOTOR STAGE  development proceeds from reflex activity to representation and sensorimotor solutions to problems  0 to 18 months PRE-OPERATIONAL STAGE  development proceeds from sensorimotor representation to prelogical thought and. solutions to problems can use these representational skills only to view the world from their own perspective.  Understand the meaning of symbolic gestures  2 to 7 years

CONCRETE OPERATIONAL  development proceeds from prelogical thought to logical solutions to concrete problems  understand concrete problems  cannot yet contemplate or solve abstract problems  7 to 12 years FORMAL OPERATIONAL  development proceeds from logical solutions to concrete problems to logical solutions to all  classes of problems  cannot yet contemplate or solve abstract problems  can also reason theoretically  12 and above HARRY STACK SULLIVAN INTERPERSONAL THEORY SULLIVAN'S INTERPERSONAL THEORY INFANCY  anxiety develops as a result of unmet needs by the mother (bodily needs); needs met, the child has sense of well-being  0 to 18 months CHILDHOOD  anxiety as a result of lack of praise/acceptance from parents  gratification leads to positive self-esteem  moderate anxiety leads to uncertainty and insecurity  severe anxiety results in self-defeating patterns of behavior  18 months to 6 years JUVENILE  severe anxiety may result in a need to control or restrictive, prejudicial attitudes learns to negotiate own needs  6 to 9 years PRE-ADOLESCENCE  capacity to attachment, love and collaboration emerges or fails to develop  move to genuine intimacy with friend of the same sex  9 to 12 years ADOLESCENCE  if self-system is intact, areas of concern expand to include values, career decisions and social concerns  lust is added to interpersonal equation  need for special sharing relationship shifts to opposite sex

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new opportunities for social experimentation lead to consolidation or self-ridicule 12 to adulthood

HILDEGARD PEPLAU NURSE PATIENT RELATIONSHIP PEPLAU'S NPR PRE-INTERACTION  Major task of nurse- to develop selfawareness ORIENTATION  Major task of the nurse: to develop a mutual acceptable contract WORKING  Major task: identification and resolution of patient's problem TERMINATION  Major task: to assist the patient to review what he has learned and transfer his learning to his relationship with others THERAPEUTIC COMMUNICATIONS ORIENTATION  Broad Opening  Recognition  Giving information  Silence  Offering Self - "Do you want me to sit beside you?”

WORKING  Focusing - "Let us discuss this topic more”  Exploring - "Tell me more about it.”  Encourage Evaluation - "IS this what you want?”  Reflecting - same idea  Restating - same statement  Verbalizing Implied - "Are you going to kill yourself?"  Seeking Clarification – “May you please repeat that statement”  General lead - "Please continue.”; “And then?”  Limit setting - "Stop"  Interpreting - "Maybe that thing is very significant to you.”

TERMINATION  Summarizing – “Let us now sum up. You have stated earlier... etc.”  “Do you have any questions?”

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“Our next therapy...”

Look for changes in behavior Resistance is a common problem

THERAPEUTIC COMMUNICATION TECHNIQUES  

Accepting-indicating reception E.g., “Yes" “I follow what you said” Nodding

BROAD OPENINGS  Allowing the client to take the initiative in introducing the topic  e.g., "is there something you'd like to talk about?”

“Where would you like to begin?”

CONSENSUAL VALIDATION  Searching for mutual understanding, for accord in the meaning of the words  e.g., "Tell me whether my understanding of it agrees with yours” “Are you using this word to convey that…?”

ENCOURAGING COMPARISON  Asking that similarities and differences be noted  e.g., "was it something like...?

“Have you had similar experiences?”

ENCOURAGING DESCRIPTION OF PERCEPTIONS  Asking the client to verbalize what he or perceives  E.g., “Tell me when you feel anxious” “What is happening?”

“What does the voice seem to be saying?”

ENCOURAGING EXPRESSION  Asking client to appraise the quality of his or her experience  e.g., “what are your feelings in regard to...?”

“Does this contribute to your distress?”

EXPLORING  Delving further into a subject or idea  e.g., "Tell me more about that.”

“Would you describe it more fully?”

“What kind of work?”

FOCUSING  Concentrating on a single point  e.g., "This point seems worth looking at more closely"

“Of all the concerns you've mentioned, which is most troublesome?”

FORMULATING A PLAN OF ACTION  Asking the client to consider kinds of behavior likely to be appropriate in future situations  e.g., "What could you do to let your anger out harmlessly?"

“Next time this comes up, what might you do to handle it?"

GENERAL LEADS  Giving encouragement to continue  e.g., "Go on” “And then?"

"Tell me about it” GIVING INFORMATION  Making available the facts that the client needs  E.g., “My name is…”

“Visiting hours are…”

“My purpose in being here is…”

GIVING RECOGNITION  Acknowledging, indicating awareness  E.g., “Good morning, Mrs. S…” “You’ve finished your list of things to do.”

“I noticed that you’ve combed your hair” MAKING OBSERVATIONS  Verbalizing what the nurse perceives  E.g., “You appear tense…”

“I notice that you’re biting your lips” OFFERING SELF  Making oneself available  E.g., “I’ll sit with you awhile.”

“I’ll stay here with you” “I’m interested in what you think PLACING EVENT IN TIME OR SEQUENCE  Clarifying the relationship of events in time  E.g., “What seemed to lead up to…?”

“Was this before or after?”

PRESENTING REALITY  Offering for consideration that which is real  E.g., “I see no one else in the room” “Your mother is not here; I am a nurse” REFLECTING

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Directing client actions, thought, and feeling back to the client E.g., Client: “Do you think I should tell the doctor…?

Nurse: “Do you think you should?”

RESTATING  Repeating the main idea expressed  E.g., Client: “I can’t sleep. I stay awake all night” Nurse: “You have difficulty sleeping” Client: “I’m really mad, and upset” Nurse: “You’re really mad and upset” SEEKING INFORMATION  Seeking to make clear that which is not meaningful or that which is vague  “I’m not sure that I follow” “Have I heard you correctly?”

SILENCE  Absence of verbal communication, which provides time for the client to put thought or feelings into words, regain composure, or continue talking  E.g., nurses say nothing but continues to maintain eye contact and conveys interest SUGGESTING COLLABORATION  Offering to share, to strive, to work with the client for his or her benefit  E.g., “perhaps you and I can discuss and discover the triggers for your anxiety” SUMMARIZING  Organizing and summing up that which has gone before  E.g., “Have I got this straight?”

TRANSLATING INTO FEELINGS  Seeking to verbalize client’s feelings that he or she expresses only indirectly  E.g., Client: “I’m dead” Nurse: “Are you suggesting that you feel lifeless?”

VERBALIZING THE IMPLIED  Voicing what the client has hinted at or suggested  E.g., Client: “I can’t talk to you or anyone.

It’s a waste of time.”

Nurse: “Do you feel that no one understands” VOICING DOUBT  Expressing uncertainty about the reality of the client’s perceptions  “isn’t that unusual?”

“really?” “that’s hard to believe” NONTHERAPEUTIC COMMUNICATION TECHNIQUES  Advising – telling the client what to do Agreeing – indicating accord with the client  E.g., “I think you should…”

“That’s right” AGREEING  Indicating accord with the client  “that’s eight.” “I agree” BELITTLING FEELINGS EXPRESSED  Misjudging the degree of the client’s comfort  Client: “I have nothing to live for… I wish I was dead” Nurse: “Everybody gets down in the dumps” CHALLENGING  Demanding proof from the client  “But how can you be president of the Philippines?”

DEFENDING  Attempting to protect someone or something from verbal attack  “this hospital has a fine reputation” DISAGREEING  Opposing the client’s ideas  E.g., “that’s wrong” DISAPPROVING  Denouncing the client’s behavior or ideas  “that’s bad” “I’d rather you wouldn’t” GIVING APPROVAL  Sanctioning the client’s behavior or ideas  “that’s good.” “I’m glad that…”

GIVING LITERAL RESPONSES  Responding to a figurative comment as though it were a statement of fact  Client: “They’re looking in my head with television camera” Nurse: “Try not to watch television” INDICATING EXISTENXE OF AN EXTERNAL SOURCE  “What makes you say that?”

INTERPRETING  Asking to make the conscious that which is unconscious  “what you really mean is…”

INTRODUCING AN UNRELATED TOPIC  Changing the subject  Client: “I’d like to die.”

Nurse: “did you have visitors last night?”

MAKING STEREOTYPED COMMENTS  Offering meaningless cliché or trite comments  “keep your chin up” “just have a positive outlook” PROBING  Persistent questioning of the client  “now tell me about this problem. I need to know” REASSURING  Indicating there is no reason for anxiety  “everything will be alright” REJECTING  Refusing to consider or showing contempt for the client’s behavior, ideas  “let’s not discuss…”

REQUESTING AN EXPLANATION  Asking the client to provide reasons for thoughts, feelings, behaviors, events  “why do you think that?”

TESTING  Appraising the client’s degree of insight  “do you know what kind of hospital this is?”

USING DENIAL  Refusing to admit that a problem exists  Client: “I am nothing” Nurse: “Of course, you’re something” NON-THERAPEUTIC COMMUNICATIONS  Overloading – “blah, blah, blah”  Underloading – ignoring  Value Judgement – use of adjectives  False Reassurance – “Don’t worry, you will be fine later”  Focusing on Self – “I gave you meds so you are now feeling good”  Incongruence  Internal Validation – biased judgement  Giving Advice – “If I were you, I’ll…”  Changing Subject LOSS AND GREIVING GRIEF – refers to the subjective emotions and affect that are a normal response to the experience of loss

ANTICIPATORY GRIEVING – when people facing an imminent loss begin to grapple with the very real possibility of the loss or death in the near future DISENFRANCHISED GRIEVING - grief over a loss that is not or cannot be acknowledged openly, mourned publicly or supported socially COMPLICATED GRIEVING – when a person is void of emotion, grieves for prolonged periods, has expressions of grief that seem disproportionate to the event LOSS     

Physiologic loss Safe and security loss Love and belongingness loss Self-esteem loss Self-actualization loss

GRIEVING PROCESS  Denial  Anger  Bargaining  Depression  Acceptance 

Dysfunctional Grieving – grieving which extends from 4 to 6 weeks leading to CRISIS

INTERVENTIONS  Explore client’s perceptions and meaning of the loss  Allow adaptive denial  Assist client to reach out for and accept support  Encourage client to examine patterns of coping in past and present situation of loss  Encourage client to care for themselves  Offer client food without pressure to eat  Use effective communication CRISIS AND ITS MANAGEMENT CRISIS  Situation that occurs when an individual’s habitual coping ability becomes ineffective to merit demands of a situation TYPES OF CRISES  MATURATIONAL/DEVELOPMENTAL: normal expected crisis that runs through age  SITUATIONAL: an expected and sudden event in life  ADVENTITIOUS: calamities, war CHARACTERISTICS OF A CRISIS STATE  Highly individualized  Lasts for 4-6 weeks

  

Self-limiting Person affected becomes passive and submissive Affects a person’s support system

PHASES OF A CRISIS  PRE-CRISIS: state if equilibrium  INITIAL IMPACT (may last a few hours to a few days): high level of stress, helplessness, inability to function socially  CRISIS (may last a brief or prolonged period of time): inability to cope, projection, denial, rationalization  RESOLUTION: attempts to use problemsolving skills  POST CRISIS: may have OLOF or may have symptoms of neurosis, psychosis CRISIS MANAGEMENT  Role of the nurse is to return the client to its pre-crisis state by assisting and guiding them until they achieved their OLOF  Goal: to enable patient to attain an OLOF  Nurse’s Primary Role: active and directive STEPS IN CRISIS INTERVENTION  Identify the degree of disruption the client is experiencing  Assess the client’s perception of event  Formulate nursing diagnoses  Involve the patient and family if applicable with planning  Implement interventions – new and old coping mechanisms  Evaluate – reassessment, reinforcement TYPES OF THERAPIES TREATMENT MODALITIES INDIVIDUAL PSYCHOTHERPAY  One to one relationship between therapist and client  For dissociative, anorexia, paranoid, narcissistic  Change is achieved by the exploration of feelings, attitudes, thinking behavior and conflict SEVEN SUBTYPES CLASSICAL PSYCHOANALYSIS  Based on Freud’s theory  To uncover unconscious feelings and thoughts that interfere with the client’s living a fuller life  Free association – client is encouraged to say anything that comes to mind, without censoring thoughts or feelings  Dream analysis  Working through (transference) – process of repeated interpretation to the person of

his or her unconscious processes has the effect of bringing about change PSYCHOANALYTICAL PSYCHOTHERAPY  Uses dream analysis, transference and free association  Therapist is much more involved and interacts with the client more freely  Done through intimate professional relationship between the nurse/therapist and the client over a period of time (introductory, working and termination phase) SHORT TERM DYNAMIC PSYCHOTHERAPY  Indication – persons with specific symptom or interpersonal problem that he/she wants to work on  Therapist directs the content  Use of transference and dream analysis  Weekly sessions (total number – 12 to 30)  Successful for highly motivated individuals who have insight and with positive relationship with the therapist TRANSACTIONAL ANALYSIS  Eric Berne  Each person has three ego states and change from one to another frequently  Parent – concepts of standards of behavior and how things should be done. o E.g., go and take out the garbage  Adult – rational thinking and data analyzing part of the personality. o E.g., would you please take out the garbage  Child – feelings associated with persons, things or incidents represent the needgratifying aspects of the personality o E.g., is this why you married me? To be your garbage man?  For group, family and individual  Client to identify ego states for each given situation  Rewarding of positive or negative behaviors with strokes  Client work through these behaviors COGNITIVE PSYCHOTHERAPY  Restructuring or changing ways in which people think about themselves  Thought stopping  Positive self-talk  DE catastrophizing  Therapists help patients identify these thoughts BEHAVIORAL THERAPY  Changes in maladapted behavior can occur without insight into the underlying cause

   

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Based on learning theory Modeling Operant conditioning Self-control therapy – combination of cognitive and behavioral approaches “talking to self” Systemic desensitization Aversion therapy

GESTALT THERAPY  Emphasis on the “here and now”  Only present behavior can be changed, not history  Uncover repressed feelings and needs  Techniques: have a person behave the opposite of the way he/she feels, presuming that a person can then come in contact with a submerged part of the self; in dreams, person is asked to play roles of persons in the dream to get in touch with different repressed feelings MILIEU THERAPY  Total environment has an effect on the individual’s behavior  Components o Physical environment o Interpersonal relationships o Atmosphere of safety, caring, and mutual respect o For alcoholics PROGRAMS FOR MILIEU SHOULD HAVE:  An emphasis on group and social interaction  No rules and expectations mediated by peer pressure  A view of patients’ roles as responsible human beings  An emphasis on patients’ rights for involvement in setting goals  Freedom of movement and informality relationships with staff  Emphasis on interdisciplinary participation  Goal-oriented, clear communication GROUP THERAPY  Number of people coming together, sharing a common goal, interest or concern, staying together and developing relationships  For PTSD and alcoholics  Phases o Orientation o Working o Termination CHARACTERISTICS OF GROUP THERAPY  Universality → “you are not alone”  Instilling hope and inspiration

  

Developing social skills by interacting with one another Feeling of acceptance and belonging Altruism → “giving of one’s self

FAMILY THERAPY  Psychoanalytically oriented group therapy  Psychodrama  Family therapy ASSUMPTION OF FAMILY THERAPY  Client: whole family  Concepts: o The family is the most fundamental unit of the society o Adaptive or maladaptive patterns of behavior are learned from the family o Dysfunction in the family = dysfunction in the individual  Purpose o Improve relationships among family members o Promote family function o Resolve family problems OTHER TYPES OF THERAPIES SUPPORT GROUPS  For those with AIDS, Mother-Against-Drug Dependence SELF-HELP GROUPS  Alcoholic Anonymous RULES FOR PSYCHOTHERAPEUTIC MANAGEMENT  Provide support, treat patients with respect and dignity  Do not place patients in situations wherein they will feel inadequate or embarrassed  Treat patients as individuals  Provide reality testing  Handle hostility therapeutically  Provide psychopharmacologic treatment BEHAVIORAL THERAPIES TREATMENT MODALITIES     

Pavlov’s Classical Conditioning: All behaviors are learned B.F. Skinner’s Operational Conditioning: Reinforcements Behavioral Conditioning: substance abuse Token Economy: anorexia/schizo Systematic Desensitization: phobia

ATTITUDE THERAPY TREATMENT MODALITIES 1. Paranoid – passive friendliness

2.

3.

4.

5.

6.

Withdrawn – active friendliness Depressed/Anorexia – kind firmness Manipulative – matter of fact Assaultive – no demand Anti-social – firm, consistent

PSYCHOSOMATIC THERAPY TREATMENT MODALITIES ELECTROCONVULSIVE THERAPY  Effective in most affective disorders  The induction of a grandmal seizure in the brain  Abnormal firing of neurons in the brain causes an increase in neurotransmitters  Number of Treatments: 6-12, 3 times a week, about .5-2 seconds  Unilateral or bitemporal Indications:  Patients who require rapid response  Patients who cannot tolerate pharmacotherapy or cannot be exposed to pharmacotherapy  Patients who are depressed but have not responded to multiple and adequate trials of medication Preparations for ECT:  Pretreatment evaluation and clearance  Consent  NPO from midnight until after the treatment  Atropine Sulfate – to decrease secretions Succinylcholine (Anectine) – to promote muscle relaxation Methohexital Sodium (Brevital)- anesthetic  Empty bladder  Remove jewelry, hairpins, dentures and other accessories  Check vital signs Care after ECT:  O2 therapy of 100% until patient can breathe unassisted  Monitor for respiratory problems, gag reflex  Reorient patient  Observe until stable  Careful documentation  Male erectile dysfunction OTHER THERAPIES  Neurosurgery ANXIETY PEPLAU’S LEVEL OF ANXIETY MILD  Associated with the tension of day to day living

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Perceptual field increased More alert than usual Adaptive

MODERATE  Narrowed perception  Difficulty focusing  Selective inattention  Mild somatic complaints: stomachache and butterflies in the stomach INTERVENTIONS FOR MILD TO MODERATE ANXIETY  Assist the client in identifying anxiety  Anticipate anxiety provoking situations  Use nonverbal language to demonstrate interest  Encourage the client to talk about his or her feelings  Avoid closing off avenues of communication (refraining from offering advice or changing the topic)  Encourage problem-solving  Explore past and present coping behaviors  Provide outlets for working off excess energy LEVELS OF ANXIETY SEVERE  Very narrowed perception  Unable to focus on problem solving  Increased physical discomfort  All behavior is aimed at relieving anxiety  Direction is needed to focus attention PANIC  Awe, dread and terror  Unable to see the whole situation or reality  Distortion of perception  Disorganization of the personality  A frightening and paralyzing experience INTERVENTIONS FOR SEVERE AND PANIC LEVELS OF ANXIETY  Maintain a calm manner  Remain with the person  Minimize environmental stimuli  Reinforce reality  Listen for themes in communication  Attend to physical safety and medical needs first  Physical limits may need to be set  Provide opportunities for exercising  Assess the person’s need for mediation or seclusion ANTI-ANXIETY DRUGS

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Valium Librium Ativan Serax Tranxene Miltown Equanil Vistaril Atarax Inderal Xanax Buspar

ANTI-ANXIETY DRUGS  Used only in a short time (1-2 weeks)  Tolerance (after 7 days) and dependence (after 1 month)  Liver function test  Monitor side effects  Avoid machines, activities needing concentration  Z tract if given parenterally  Avoid mixing with alcohol, antihistamines, antipsychotics  Don’t stop abruptly but gradually for 2-6 weeks  Avoid caffeine CATEGORIES OF ANXIETY DISORDERS  Basic Anxiety Disorders  Somatoform Disorders  Dissociative Disorders BASIC ANXIETY DISORDERS  Generalized Anxiety Disorder  Panic  Phobia  PTSD  Obsessive Compulsive GENERALIZED ANXIETY DISORDER  Excessive worry and anxiety for days but not more than 6 months  Difficulty in controlling the worry  Anxiety and worry are evident by 3 or more of the following: o Restlessness, keyed up o Fatigue and irritability o Decreased ability to concentrate o Muscle tension o Disturbed sleep  Anxiety or worry causes significant impairment in interpersonal relationship or activities of daily living POST TRAUMATIC STRESS DISORDER  Disturbing pattern of behavior occurring after a traumatic event that is outside the range of usual experience Characteristics

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Persistent re-experiencing of the trauma through recurrent intrusive recollections of the event, through dreams or flashbacks Persistent avoidance of the stimuli Feeling of detachment of estrangement from others Chemical abuse to relieve anxiety

PHOBIAS Definition  Persistent, irrational fear of a specific object, activity or situation that leads to a desire for avoidance of the object of fear Specific Phobia  Experience of high level of anxiety or fear provided by a specific object or situation Treatment  Systematic Desensitization Defense Mechanisms  Repression and displacement MAJOR TYPES OF PHOBIAS AGORAPHOBIA  Comes from the Greek word “agora”  Meaning “market place”  Fear of being alone in open or public spaces SOCIAL PHOBIA  Fear of situations where one might be seen and embarrassed or criticized SPECIFIC PHOBIAS  Fear of a single object, situation or activity that cannot be avoided

or cleaning

Need for order Germs or dirt

Symmetr y

sins.” Thought appeared after sexual encounter with a married man “Everything must be in place” “Everything is contaminated”

“Secretaries who practice neatness never gets fired”

repeatedly washes hands

Arranges and rearranges items Avoids touching all objects.

Scrubs hands if she is forced to touch any object Secretary lines up objects in rows on her desk, then realigns them repeatedly during the day

CARE STRATEGIES  Be nonjudgmental and honest; offer empathy and support  Help patient to recognize the connections between the trauma experience and their current feelings, behaviors and problems  Encourage verbalizations of feelings, especially anger  Encourage adaptive coping strategies and techniques  Encourage patients to establish or reestablish relationships  Explore shattered assumptions. “I’m a good person. This is a safe world”  Promote discussion of possible meaning of events

OBSESSIVE COMPULSIVE DISORDERS OBSESSIONS  Preoccupation with persistent intrusive thoughts, impulses or images COMPULSIONS  Repetitive behaviors or mental acts that the person feels driven to perform in order to reduce distress or prevent a dreaded event or situation CUES:  Ritualistic behavior  Constant doubting if he/she has performed the activity EXAMPL ES Washing

OBSESSIONS “Wash away my

COMPULSION S Young woman

PSYCHOSOMATIC DISORDER  True/unconscious because of hormonal and bodily changes  Increase anxiety may result to asthma, stress ulcers or migraine SCHIZOPHRENIA  A major form of psychotic disorder that affects a person’s thinking, language, emotions, social behavior and ability to perceive reality  At least 2 of 5 types of positive and negative symptoms  Characteristic Symptoms  Social or occupational dysfunction o IPR o Self-care  Duration

o

Continuous for at least 6 months

POSITIVE AND NEGATIVE SYMPTOMS POSITIVE SYMPTOMS  Hallucinations  Delusions  Illusions  Abnormal thought patterns or perceptions  Bizarre behavior NEGATIVE SYMPTOMS  Affective flattening  Anhedonia  Attention impairment  Asocial behavior  Anergia  Autism  Avolition DELUSIONS  Persecutory  Religious  Grandeur  Ideas of Reference DISTURBED THOUGHT PROCESS  Looseness of association  Flight of ideas  Ambivalence  Magical thinking  Echolalia/Echopraxia  Word salad  Neologism  Thought blocking  Concrete association

BLEULER’S FOUR A’s OF SCHIZOPHRENIA  Affective disturbances  Autism  Associative looseness  Ambivalence  Other A’s o Attention deficits o Disturbances of activities SCHIZOPHRENIA  Brief Psychotic Disorder – may be seen when a person exhibits clinical symptoms of illogical thinking, incoherent speech, delusions, or disorganized behavior after psychological trauma  Induced Psychotic Disorder – develops in a second person as a result of a close relationship with a person who has psychosis  Delusional Psychotic Disorder  Schizoaffective Disorder – characterized by depression or elation as



the psychosis symptoms of schizophrenia and MDD Schizophreniform – when a person exhibits features of schizophrenia for more than one week but less than 6 months

SUBTYPES: Paranoid – most common form if the illness Suspicious  Promote trust  Short interaction but frequent  Food in containers (sealed)  Prepare food in front of them  Let them see preparation of drugs Violent  Keep door open  Position near door and with distance of 1 arm length (patient-nurse)  Don’t touch  Maintain eye contact Disorganized – absence of systematized delusions; presence of incoherence and inappropriate affect  Inappropriate, flat affect  Hebephrenic, flight of ideas Catatonic  Risk for suicide  Catatonic stupor, rigidity  Waxy flexibility Undifferentiated  Unclassified Residual  No more positive symptoms but withdrawn NURSING PROCESS  Disturbed thought process  Disturbed sensory process  Risk for self-directed violence  Risk for other directed violence  

Present safety Present reality

ANTI-PSYCHOTIC  Tara, look natin sina Stella, Mel, at Thor na nag mo-moulin rogue… sssh, alam niyo ba na ang trio na yan na akala mo may halo ay mga closet queens pala…, namen”  Taractan, Loxitane, Stelazine, Mellaril, Thorazine, Molindone, Seroquel, Serlect, Trilafon, Haloperidol, Clozapine, Navane  

Stelazine Serentil

      

Thorazine Trilafon Clorazil Millaril Haldol Risperidol Prolixin

ANTI-PSYCHOTIC DRUGS Watch for side-effects  Increase v/s  Constipation/dry mouth  Postural hypotension  Photophobia/photosensitivity  Drowsiness  Agranulocytosis  Extrapyramidal symptoms o Parkinson’s syndrome o Akathisia o Akinesia o Dystonia – oculogyric crisis, torticollis, opisthotonos o Tardive dyskinesia o NMS UNDESIRABLE EFFECTS  S-edation/sunlight sensitivity/sleepiness  T-ardive dyskinesia  A-nticholinergic/agranulocytosis/akathisia  N-euroleptic malignant syndrome  C-ardiac effects (orthostatic hypotension)  E-xtrapyramidal (dystonia) PARKINSONISM  Motor retardation or akinesia characterized by mask-like appearance, rigidity, tremors, “pill-rolling”, salivation  Generally occurs after 1st week of treatment or before second month  Administer anticholinergic agent, antiParkinson medication (Akineton) AKATHISIA  Constant state of movement, characterized by restlessness, difficulty sitting still, or strong urges to move about  Generally occurs two weeks after treatment begins  Rule out anxiety or agitation before administration of an anticholinergic agent ACUTE DYSTONIC REACTIONS  Irregular, involuntary spastic muscle movement, wryneck or torticollis , facial grimacing, abnormal eye movements, backward rolling of eyes on the sockets  May occur anytime from a few minutes to several hours after a first dose of antipsychotic drug  Administer anticholinergic agent, have respiratory support equipment available

TARDIVE DYSKINESIA  Most frequent serious side effect resulting from termination of the drug, during reduction in dosage, or after long term high dose therapy a  Characterized by involuntary rhythmic, stereotyped movements, tongue protrusion, cheek puffing, involuntary movements of extremities and trunk  Occurs in approximately 2—25% of patients taking antipsychotics for over two years  No treatment except discontinuation of the antipsychotic agent

NEUROLEPTIC MALIGNANT SYNDROME  A potentially fatal syndrome  May occur anytime during therapy  Seen during the initiation of therapy, change of therapy, after a dosage increase or when a combination of meds is used  Early sign: rigidity or mental status changes  Catatonia, tachycardia, tachypnea, labile blood pressure, dysphagia, diaphoresis, incontinence, rigidity, myoclonus, tremors, low grade fevers  Discontinue antipsychotic agent. Have cardiopulmonary support available; administer skeletal muscle relaxant (e.g., dantrolene) or central acting dopamine agonist (.e.g., bromocriptine) NOTES ON SCHIZOPHRENIA  Distorted EGO  Disturbed thought process  Disorganized personality  Dopamine – increase  Autism  Ambivalence  Associative looseness  Affect – flat  Stimulation  Structure  Socialization  Support MANIFESTATIONS S – social isolation C – catatonic behavior H – hallucinations I – incoherence Z – zero/lack of interest and initiative O – obvious failure in development P – peculiar behavior H – hygiene and grooming impaired R – recurrent illusions E – exacerbations and remissions

N – no organic factor account S/S I – inability to return to functioning A – affect is inappropriate ANTI-PARKINSONIAN DRUGS DOPAMINERGIC DRUGS  To live (Levodopa), you need a car (Carbidopa) and a man (Amantadine) not your brother (Bromocriptine) per (Pergolide) se (Selegiline) ANTI-CHOLINERGIC  BACPAK (Benadryl, Artane, Cogentin, Parsidol, Akineton, Kemadrin) OTHER TREATMENTS  Psychotherapy – individual, group, behavioral, supportive or family therapy may be used depending on the clinical symptoms  Milieu therapy – a structured environment to minimize environmental and physical stress and to meet the individual needs of the patients until they are able to assume responsibility for themselves CONCEPTS AND PRINCIPLES OF HALLUCINATION  Possible to replace hallucination with satisfying interactions  Can re-learn to focus attention on real things and people  Hallucinations originate during extreme emotional stress when the patient is unable to cope  Hallucinations are very real to the patient  Patient will react as the situation is perceived  Concrete experiences, not argument on confrontation will correct sensory distortion  Hallucinations are a substitute for human relations BIPOLAR DISORDER MOOD DISORDER/AFFECTIVE DISORDER  A distinct period of abnormally and persistently elevated expansive or irritable mood lasting at least 1 week  3 or more of the following o Psychomotor overexcitability or excitement o Insomnia with fatigued o Euphoria or elated mood o Distractibility o Pressured speech o Flight of ideas o Manipulative or demanding behavior o Destructive or combative behavior o Delusions of grandeur  Risk

o o o o

Female 20 years old and above Stressful life Obese

o

Care giver role strain

MANIA VS DEPRESSION MANIA APPEARANCE BEHAVIOR COMMUNICATI ON

Nx NURSING PRIORITY NUTRITION TREATMENT MILIEU APPROPRIATE ACTIVITY ATTITUDE THERAPY

Colorful, flamboyant Psychomoto r agitation Pressured speech Stuttering Cluttering Risk for Injury (others) Safety and nutrition Finger foods and high in calories Lithium; ECT Nonstimulating environment Quiet type; noncompetitive Matter of fact

DEPRESSIO N Sad and gray Psychomotor retardation Monotonous speech Risk for Injury (self) Suicidal precaution Safety and nutrition Increased in nutrients TCA; SSRI; MAOOI’s; ECT Stimulating Monotonous; noncompetitive Kind firmness; active friendliness

LITHIUM  Level of lithium (0.5 to 1.5 meq/L)  Increase urination (polyuria)  Tremors – fine hand  Hydration  Increase peristalsis  U2 – 4 weeks effective  Increased bowel movements  Mouth is dry o Assess function of kidney o Toxicity: nausea and vomiting, diarrhea PHARMACOLOGY MOMENTS

ANTIDEPRESSANTS ANTIDEPRESSANTS  Asendin  Norpramin  Tofranil  Sinequan  Anafranil  Aventil  Vivactil  Elavil  Prozac  Luvox  Paxil  Zoloft SSRI      TCA    

Selective Serotonin Reuptake Inhibitor Safest Side effects are low 1 to 4 weeks Prozac, Paxil, Zoloft, Luvox Tricyclic Antidepressants 2 to 4 weeks Anticholinergic Amitriptyline, Nortiptyline, Doxepin Trimipramine, Amoxapine, Anafranil, Venlafaxine

MAOI’s  Increases all neurotransmitters  2 to 6 weeks  Hypertensive crisis  Don’t take: o Avocado o Aged cheese o Beer/B6 (tyramine) o Chocolate o Fermented foods o Soy sauce o Pickles and preserved foods A. TCA “knock! Knock! Who’s there? SEVANA to gagah!”

-------- (Sinequam, Elavil, Vivactil, Ascendin, Norpramin, Aventyl, Tofranil) B. SSRI Ngongo: “Paxil ka! Paxil ka! Prozoleta ka lang, kala ko luv mo ko! (Praxil, Prozac, Zoloft, Luvox) C. MAO “naman, parnate ko pa” (Nardil, Manerix, Parnate) SUICIDE  The intentional act of killing oneself

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Suicidal Ideation – means thinking about oneself Passive suicidal ideation – when a person thinks about wanting to die or wishes he/she were dead but has no plans to cause his/her death (e.g., reckless driving, heavy smoking, overeating, selfmutilation, drug abuse) Active suicidal ideation – when a person thinks about and seeks to commit suicide

SAD PERSON’S SCALE  S-Sex. Mean kill themselves 3x more than women though women make attempts 3x more often than men  A-Age. High risk groups: 19 years or younger; 45 years or older, especially the elderly 65 and above  D-Depression. Studies report that 3579% of those who attempt suicide manifested a depressive syndrome  P-Previous Attempts. Of those who commit suicide, 65-70% have made previous attempts  E-ETOH. Alcohol is associated with up to 65% of successful suicides  R-Rational Thinking Loss. People with functional or organic psychoses are more apt to commit suicide than those in the general population  S-Social Support Lacking. A suicidal person often lacks significant others, meaningful employment and religious supports  O-Organized Plan. The presence of a specific plan for suicide signifies a person at high risk  N-No Spouse. Repeated studies indicate that persons who are widowed, separated, divorced or single at greater risk than those who are married  S-Sickness. Chronic, debilitating and severe illness is a risk factor SCORING  0-2 home with follow up care  3-4 close follow up and possible hospitalization  5-6 strongly consider hospitalization  7-10 hospitalize SITUATION:  Charles Brown, age 52 lost his wife in a car accident few months ago. Since that time, he has been severely depressed and has taken to drinking to numb the pain  How many points according to the SAD PERSONS SCALE?

work out.”; “I won’t be a problem much longer.”; “How can I give my body to medical science?”

THEORIES OF SUICIDE PSYCHODYNAMIC THEORIES  Describe suicide as a wish to be at peace with the internalized significant person  Wish to be reunited with a deceased loved object  Suicide is an attempt to escape from an intolerable situation or intolerable state of mind SOCIOLOGICAL THEORIES  Durkheim – pioneer of sociological research in the study of suicide  3 Principal Types:  Egoistic suicide – occurs when a person is insufficiently integrated into society  Anomic suicide – occurs when a person is isolated from others through abrupt changes in social norms/status  Altruistic suicide – occurs as a response to societal demands (deaths of Buddhist monks who set themselves on fire to protest the Vietnam war) BIOCHEMICAL  Low serotonin levels PRECIPITATING FACTORS  Social Isolation – have difficulty forming and maintaining relationships Norman Cousins Story: A woman who committed suicide had written in her diary every day during the week before her death “Nobody called today. Nobody called today. Nobody called today. Nobody called today. Nobody called today…” 



Severe life’s events – divorce, death, sickness, legal problems, interpersonal discord Sensitivity to Loss – may react tragically to separation or loss of a loved one (had insecure or unreliable childhood experiences)

ASSESSING VERBAL AND NONVERBAL CLUES VERBAL CLUES:  Overt Statements: “I can’t take it anymore!”; “Life isn’t worth living anymore.”; “I wish I were dead.”; “Everyone will be better off if I am dead.”  Covert Statements: “It’s ok now, soon everything will be fine”; “Things will never

NONVERBAL CLUES  Behavioral Clues: sudden behavioral changes especially when depression is lifting and when the person has more energy available to carry out the plan  Signs: giving away prized possessions, writing farewell notes, making out a will and putting personal affairs in order  Somatic Clues: physiological complaints can mask psychological pain and internalized stress  Headaches, muscle aches, trouble sleeping, irregular bowel habits, unusual appetite or weight loss  Emotional Clues: social withdrawal, feelings of hopelessness and helplessness, confusion, irritability, and complaints of exhaustions SUICIDE PRECAUTIONS  Execute a “no suicide contract.” The client will inform the nurse when he/she has suicidal ideations  Ask direct questions. Find out if the person has specific plan for suicide. Determine what method  Be alert for cries for suicide  Provide a safe environment and protect client from self  Encourage to ventilate feelings and thoughts  Give emotional support  Make the patient realize that the tendency to commit suicide is due to the disturbance in the brain chemistry and is treatable – once they know that an episode of suicidal thinking will pass, they will likely not act on the impulse  Provide structured schedule and involve in activities with others to increase self-worth and divert attention  On discharge: help patient create “plan for Life” (list of warning signs of suicidal ideation and actions to take) Always remember:  That a suicidal person wants to crisis – during this time the person is ambivalent about living and dying  Suicidal person gives warning  Persons recovering from depression are high risk for 9-15 months after recovery  Suicidal people are extremely unhappy but not always mentally ill PERSONALITY BEHAVIORS PERSONALITY PROBLEMS

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Schizoid Dependent Antisocial Avoidant Histrionic Borderline

PARANOID PERSONALITY DISORDER  A pervasive pattern of distrust and suspiciousness of others such that their motives are interpreted as malevolent o Suspicious (e.g., others are exploiting or deceiving him) o Doubt trustworthiness of others o Fear of confiding in others o Fear personal information will be used against him o Interpret remarks as demeaning or threatening o Hold grudges toward others o Becomes angry and threatening when they perceive to be attacked by ithers  Intervention: centered on building trust SCHIZOID PERSONALITY DISORDER  A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings o Lacks desire for close relationships or friends including family o Chooses to be alone o Lack of sexual experiences o Avoids activities o Appears cold and detached  Interventions: building trust followed by identification and appropriate verbal expression SCHIZOTYPAL PERSONALITY DISORDER  A pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior o Ideas of reference o Magical thinking or odd beliefs o Unusual perceptual experiences, including bodily illusions o Peculiar thinking o Vague, stereotypical, overelaborate speech o Eccentric appearance or behavior o Few close relationships o Uncomfortable in social situations  Interventions: improving interpersonal relationships, social skills, and appropriate behaviors

ANTI-SOCIAL PERSONALITY DISORDER  Characterized by deceit, manipulation, revenge and harm to others with an absence of guilt or anxiety o Violates rights of others o Engages in illegal activities o Aggressive behavior o Lack of guilt or remorse o Irresponsible in work and with finances o Impulsiveness o Recklessness o Manipulative  Interventions: o Consistency o Kind firmness in confronting behaviors and enforcing rules and policies o Limit setting o Decrease impulsivity o Enhance role performance o Effective use of confrontation BORDERLINE PERSONALITY DISORDER  Characterized by pervasive pattern of unstable interpersonal relationships; selfimage and affect; and marked impulsivity o Frantic avoidance of abandonment; real or imagines o Unstable and intense interpersonal relationships o Identity disturbances o Impulsivity o Self-mutilating behavior o Rapid mood shifts o Chronic feelings of emptiness o Problems with anger o Transient dissociative and paranoid symptoms OTHER IMPORTANT INFORMATION  Priority nursing diagnosis: high risk for injury directed to self-related to selfmutilation behaviors  Coping mechanisms used: splitting o Classifying people as either “good” or “bad” INTERVENTIONS  Use of empathy  Recognize the reality of the patient’s pain  Offer support  Empower and work with the patient to understand control and change dysfunctional behaviors  Provide safe environment  Teach social skills  Make a list of solitary activities to combat boredom NARCISSISTIC PERSONALITY DISORDER  Grandiose self-importance

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Fantasies of unlimited power, success or brilliance Believes he or she is special Needs to be admired Sense of entitlement Takes advantage of others for own benefit Lacks empathy Envious of others or others are envious of him Arrogant Interventions: o Supportive confrontation on what the patient says and what exists o Limit setting and consistency to decrease manipulation and entitlement behaviors o Remain neutral, avoid power struggles, or becoming defensive

HISTRIONIC PERSONALITY DISORDER  A pervasive pattern of excessive emotionality and attentive seeking o Overly dramatic o Draws attention to self o Extroverted and thrives on being the center of attraction o Uses somatic complaints to avid responsibility and support dependency o Dissociation  Interventions: provide reinforcement in the form of attention, recognition or praise given for unselfish or other centered behaviors DEPENDENT PERSONALITY DISORDER  A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation o Needs others to be responsible for important areas of life o Problems with initiating with projects or doing things on his own because of little self confidence o Performs unpleasant tasks to obtain support from others o Urgently seeks another relationship for support and care after a close relationship ends o Preoccupied with fear of being alone to care for self  Interventions: increase responsibility for self in day to day living; assertiveness training AVOIDANT PERSONALITY DISORDER  A pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation o Avoids occupations involving interpersonal contact due to fears of disapproval or rejection

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Preoccupied with being criticized or rejected in social situations Very reluctant to take risks or engage in new activities due to the possibility of being embarrassed

OBSESSIVE COMPULSIVE PERSONALITY DISORDER  A pervasive pattern of preoccupation with orderliness, perfectionism and mental and interpersonal control at the expense of flexibility, openness and efficiency o Preoccupied with details, lists, rules, organization o Perfectionist o Too busy working to have friends or leisure activities o Unable to discard worthless or wornout objects o Reluctant to spend and hoards money o Rigid and stubborn DELIRIUM  Characterized by disturbance of consciousness and a change in cognition such as impaired attention span and disturbances in consciousness that develop over a short period of time o Always secondary to another condition (medical condition or substance abuse) o Frequent among the elderly and young febrile children o Fluctuations of consciousness and inoculation throughout the day  Classified as mild to severe  Sundowning DEMENTIA  Characterized by multiple cognitive deficits that include impairment of memory which develops slowly o 80-90% irreversible o Reversible due to pathologic process o Most common: Alzheimer’s Dementia  4 Symptoms of Dementia o Loss of memory o Deterioration of language function o Loss of ability to think abstractly, plan, initiate, sequence, monitor or stop complex behavior o Loss of ability to perform ADLs STAGES OF DEMENTIA STAGE 1 MILD (FORGETFULNESS)  Losses in short term memory  Memory aids compensate  Aware of the problem, disturbed  Not diagnosable at this time

STAGE 2 MODERATE (CONFUSION)  Progressive memory loss  ST memory loss interferes with ADLs  Withdrawn, denial, fear of losing their minds  Depression, confabulation  Problems increase when stressed  Needs home care on in-home assistance STAGE 3 MODERATE TO SEVERE (AMBULATORY DEMENTIA)  Loss of reasoning ability, planning and verbal communication  Frustrated, withdrawn, self-absorbed  Depression decreases  Reduced stress threshold  Institutional care required STAGE 4 LATE (END STAGE)  Family recognition disappears  Doesn’t recognize self  Nonambulatory  Little purposeful activity  Often mute, may scream spontaneously  Forgets most ADLs  Problems associated with immobility  Institutional care required  Return of primitive reflexes DELIRIUM VS DEMENTIA DELIRIUM DEMENTIA ONSET Usually sudden Usually gradual Usually brief Usually long-term with return to and progressive, COURS usual level of occasionally maybe E functioning arrested or reversed AGE Any Elderly GROUP SEXUAL DISORDERS  Homosexuality  Heterosexuality  Bisexuality  Masochism  Sadism  Frotteurism  Pedophilia  Necrophilia  Voyeurism  Transvestism  Transsexualism

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Tolerance increases

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Detoxification – doctor

STAGES OF ALCOHOL WITHDRAWAL 1 → 8 hours after the last drink  Mild tremors, tachycardia, increased BP, diaphoresis, nervousness 2 → 8-12 hours after the last drink  Gross tremors, hyperactivity, profound confusion, loss of appetite, insomnia, weakness, disorientation, illusions, hallucinations and delusions 3 → 12-48 hours after the last drink  Severe hallucinations, grand mal seizures 4 → 3-4 days after the last drink  Delirium tremens, confusion, agitation, hallucinations, insomnia and tachycardia ALCOHOLISM  Avoid alcohol during therapy  Aversion therapy  Antabuse – disulfiram  Belongings – check for alcohol, mouthwash, elixir, etc.  B1 deficiency  Complication o Wernicke’s Encephalopathy (Motor) o Korsakoff’s Psychosis (Mind)  Delirium Tremens  Fornication AUTISM  Living in their own world  Appearance – flat (consistent)  Behavior – ritualistic, repetitive  Communication – echolalia, incomprehensible NX: Impaired verbal communication Impaired social interaction Self-mutilation Risk for injury ADHD  Attention-deficit/hyperactive disorder  7 years old and above  Duration: 6 months and above  Requires 2 settings: home and school

ALCOHOL ALCOHOLISM  Intergenerational Transmission  Awake but unconscious  Blackout  Confabulation  Denial, dependence  Enabling, co-dependence

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Appearance: dirty child Behavior: clumsy, hyperactive, impatient Communication: talkative, bursts out

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Structure Setting limits Schedule Safety

EATING DISORDERS  Anorexia Nervosa  Bulimia Nervosa  Pica  Compulsive Eating Behavior ANOREXIA NERVOSA Symptoms:  Refusal to maintain body weight over a minimum normal weight for age and height  Intense fear of gaining weight or becoming fat, even though underweight  Disturbance in the way in which one’s bodyweight, shape or size is experienced  In females, absence of menses of at least 3 consecutive cycles  Inability or refusal to acknowledge the seriousness of the problem  Onset: 12-15; 17-21 years of age Etiology  Cultural pressure  Serotonin imbalance → controls appetite and the satiety control center  Family patterns o Perfectionist o Does not permit verbalization of feelings o Marital problems Clinical Presentation  Low weight  Amenorrhea  Yellow skin  Cold extremities  Peripheral edema  Muscle weakening  Constipation  Low T3 and T4  Hypotension  Bradycardia  Hypokalemia  Anemia  Pancytopenia  Decreased bone density SIGNS RELATED TO PURGING BEHAVIORS Gastrointestinal  Parotid gland tenderness, pancreatitis, esophageal and gastric erosion or rupture Metabolic  Electrolyte abnormalities → hypokalemia Dental  Erosion of dental enamel of the front teeth

OBJECTIVES OF CARE  Increasing body weight to at least 90% of average weight for age and height  Reestablishing good eating behavior  Increasing self-esteem NURSING INTERVENTIONS  Monitor daily caloric intake, activity level, weight and electrolyte status  Establish nutritional eating patterns o Sit with client during meals o Offer liquid protein supplement if unable to complete a meal o Observe signs of purging 1-2 hours after meals  Provide accurate information on nutrition and discuss realistic and healthy diet  Help the client identify emotions and develop non-food related strategies o Convey warmth and sincerity o Ask the client to identify feelings o Assist the client to change stereotypical beliefs  Assist in identifying at least three positive characteristics  Teach patient about their illness  Behavior modification: reward increase in weight with meaningful privileges  Identify patient’s non weight related interests to reduce anxiety and refocus attention BULIMIA NERVOSA Symptoms  Recurrent episodes of binge eating  Feeling of lack of control over eating behaviors during the eating binges  Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting  Binge eating and inappropriate eating behaviors  Persistent over concern with body shape and weight Clinical Presentation  Binge and purging behaviors  Have depressive signs and symptoms  Disturbed home life  Major concerns o Interpersonal relationships o Self-concept o Impulsive behaviors  Chemical dependence is also common  Normal to slightly low  Dental carries  Parotid swelling  Gastric swelling and rupture  Calluses or scars on the hand

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Peripheral edema Hypokalemia, hyponatremia

Management:  Trust  Help patient identify feelings associated with binge-purge behaviors  Accept patient as a worthwhile human being because they are often ashamed of their behavior  Encourage patient to discuss positive qualities about themselves  Teach about bulimia nervosa  Encourage to explore interpersonal relationships  Encourage patients to adhere to meal and snack schedules  Encourage the patent to approach the staff if they feel like binging or purging  Encourage to attend group sessions  Encourage family therapy  Encourage participation in art, recreation and occupational therapy  Encourage the patient to describe their body image at different ages of their lives