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Psychiatric-Nursing - PSYCH LECTURE

Care of Clients with Problems in Cellular Aberrations, Acute Biologic Crisis, Emergency
and Disaster Nursing (Arellano University)

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Mental and Psychiatric Health Nursing

PSYCHIATRIC NURSING ƒ Counselor
ƒ An interpersonal process whereby a professional nurse o Cultivate the art of listening
practitioner assists the individual, the family and the o Verbalize concern
community to promote mental health, prevent mental o We do not give advice, we suggest
illness, cope with the experience of mental illness and
suffering and if necessary, find meaning in the ƒ Ward Manager
experience. o Makes sure there are adequate supplies and
that equipment are functioning
K S A o Assign responsibilities and delegate tasks
Knowledge Skills Attitude o Coordination of care
È È ƒ Researcher
Skills in Empathy ƒ Creator of a Therapeutic Environment (Milieu)
Nursing (objective, o Structuring the environment
understanding of
the patient) MILIEU THERAPY
ƒ Safety
Hopeful for the o Drugs, sharp objects
client o Anything potentially harmful is checked
ƒ Norm
ATTITUDES OF A PROFESSIONAL NURSE o Expectations, safety, acceptance, open
ƒ Accepting – taking client as is, non-judgmental environment, no impositions
ƒ Empathy – can put shoe in another person, objective ƒ Balance
understanding o Consistency vs. flexibility
ƒ Consistent – set boundaries and structure – equal to o Dependence vs. independence
trust ƒ Unit Modification
ƒ Flexible – not too consistent (rigid), able to balance ƒ Limit Setting
ƒ Hopeful on client o Setting realistic boundaries to client’s behavior
ƒ Accountable – responsible for things we do, to patient, o Implement w/o exemption
superiors, and ourselves o Give what sanctions are expected (not
threatening but informing)
ƒ Structure
ROLES OF A NURSE o Physical characteristics of the ward
ƒ Teacher o Qualifications of staff
o Relay or convey information to the client
o Must be understood GOALS OF PSYCHIATRIC NURSING
o Consider capabilities of clients to learn ƒ Promotive Primary
ƒ Preventive Primary
ƒ Socializing Agent ƒ Curative Secondary
o Initiates conversation, relates to the people in ƒ Rehabilitative Tertiary
the community, encourages client to
participate in activities LEVELS OF CARE
o One-on-one then gradually integrate into ƒ Primary
society o Promotive – healthy with no risk factors to be ill
o Withdrawn – active o Preventive – healthy but has risk factors to be
Paranoid – passive ill
Manipulative – matter-of-fact ƒ Secondary
ƒ Technician o Curative – prevent complications
o Doing skills that address the physical and o Early dx through surveillance and case finding
psychological needs of the client o Prompt tx
o Assessment, charting, technical skills o Confinement/ institutional
ƒ Parent Surrogate ƒ Tertiary
o Doing for the patient what they cannot do for o Rehabilitative – prevent relapse and disability
themselves o Optimize function
o Do not encourage dependence o Starts on admission
o Set limits

ƒ Patient Advocate THERAPEUTIC RELATIONSHIP

o Knowing their rights and fight for their rights ƒ One-on-one relationship
o Rights of Patients: ƒ Helping relationship
ƒ Right to be free from harm ƒ Clinical skills
ƒ Right to informed consent ƒ A corrective interpersonal experience
o Consent – patient
o Details - relative Therapeutic Use of Self
ƒ Right to privacy ƒ Interpersonal, communication and clinical skills
o Least intrusion ƒ Self-awareness is a must!
ƒ Right to confidentiality o Done through introspection and listening to
ƒ Right to be in a least restrictive what others say
environment o Self-understanding
o Ideal: House/ community

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Mental and Psychiatric Health Nursing

ƒ Johari’s Window
Known to you 9 Evaluation of intervention is WORKING PHASE.
Public Self Open window
and others 9 Evaluation of outcome of relationship is TERMINATION
Known to others PHASE.
Semi-public
Closed window but not known to
Self IMPASSE OR BLOCKS IN NURSE-CLIENT RELATIONSHIP
you
You know but
Private Self Hidden window ƒ
others don’t know Resistance
You and others o Avoidance of instances that are anxiety-
Inner Self Unconscious provoking
do not know
ƒ Counter-transference – feeling of nurse is transferred to o Client does not want to share, turns his back,
the client does not answer, changes topic purposely
o INTERVENTION: State observation
ƒ Transference
Comparison of the Social & Therapeutic Relationship o Shifting of feeling by the patient from
someone significant in the past to the nurse in
Social Therapeutic the present situation
Mutual approval No need for approval o Patient Æ Significant Person (Past) Æ Nurse
Mutual gratification of need Client-centered (present)
o Type of resistance
No structure Structures
o INTERVENTION: State observation
Goal is for pleasure Goal-directed
ƒ Counter Transference
o Shifting of feeling from nurse to patient
PHASES OF THE NURSE-CLIENT RELATIONSHIP
o Nurse Æ Significant Person (Past)Æ Patient
(present)
1. Pre-orientation
o INTERVENTION: Self-awareness
o Develop self-awareness
ƒ Inappropriate Boundaries
o Gather initial information about the patient
o Sharing experiences, meeting the client after
(chart, nurses, relatives)
discharge
ƒ Prepare for patient contact
o Beyond limit of boundaries
o Nurse may share as long as it helps
2. Orientation - 1st meeting with patient
ƒ Feeling of Sympathy & Encouraging Dependency
o Establish rapport, begin to build trust
o Should be empathy
o Mutually harmonious relationship
o Dependency Mgt:
o Set a contract with the client - expectations,
ƒ Assess what patient can do and
parameters, limit setting
take over as needed
o Do the initial assessment of the client
ƒ 8 Do task for patient
ƒ MSE – appearance, behavior,
ƒ 9 Let patient do task for himself
thoughts, mood & affect, social,
sensory, memory, judgment, insight)
o Formulate nursing dx and set priorities
COMMUNICATION
ƒ Defined as reciprocal exchange of messages
A ƒ May be affected by age, sex, educational attainment,
Orientation Phase
D culture and language barrier
P
I Working Phase Context (Setting)
E ƒ Dictates role
ƒ Setting where communication takes place, determines
3. Working – longest phase role and context
o Problem solving occur 9 There must be HARMONY & CONGRUENCE in context, role
o Plan related interventions and outcomes and content.
o Encourage verbalization of feelings
o Assist patient to learn more socially Channel
acceptable behavior ƒ Sight, hearing, accessories of communication
o Assist patient to learn more effective coping
patterns
o Assist the client to develop insight MODES OF COMMUNICATION:
o Evaluate problems and goals and modify ƒ Verbal – oral and written
them as necessary ƒ Non-verbal – body language
o Alternative problems
9 Only therapeutic techniques are therapeutic responses.
4. Termination 9 Not all therapeutic techniques are always therapeutic since
o Prepare from orientation phase response must be in context.
o Encourage verbalization of feelings that go
with termination
o May have feelings of sadness or anger
o Must have solidification of parting
o Summarize what he learned in the relationship
and bring it in future relationships

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Mental and Psychiatric Health Nursing

Non-verbal Aspects of Communication ƒ Exploring
ƒ Kinesics – body movement o Know more about the topic
ƒ Proxemics – physical spaces between communicators o “Tell me more about it.”
o Intimate Space (< 1 ½ ft) o Avoid “why” questions – demand explanation
ƒ May be threatening o Take note if client still want to explore the
ƒ Not done if trust is not established topic
ƒ Tell the purpose when entering o 9 “Why don’t we sit down?” – declarative
space sentence
ƒ Form of intrusion ƒ Validating
o Personal Space (1 ½ to 3 ft) o Check for mutual understanding
ƒ Comfortable for client o Check if you understand patient’s message
ƒ Should be face to face o “…. isn’t it?”
ƒ Most acceptable for patient ƒ Presenting reality
interaction o Presenting a fact as it is in external reality
o Social Space (3 to 12 ft) ƒ Supportive confrontation
ƒ Not done during therapeutic o Citing discrepancy in patient’s behavior
interaction o Alcoholic patients – primary defense: denial
ƒ Too far ƒ Giving feedback/ facilitate self-disclosure
o Public Space (12 ft or more) o Share something to the patient
ƒ No eye contact ƒ Collaborating
ƒ Not suitable for therapeutic o Work with the patient and not for the patient
interaction ƒ Focusing
ƒ Touch o Directing back to the client
o 8 Suspicious/ paranoid o Flight of ideas
o May convey emotional support – shoulder or ƒ Reflecting
forearm o Repeat what the patient said
ƒ Silence o Direct back to the client what he said
o Give client time to process information and o Patient asks a question, nurse gives back
think about what to say question
o Not all silence are therapeutic o Verbalize feeling implied - Empathy
o If too long, patient may feel uncomfortable o Encourages verbalization of feelings
ƒ Paralanguage – voice quality or how the language is o “You seem angry.”
delivered
ƒ Restating
COMMUNICATION TECHNIQUES o Repeat what the patient said
o Say it again exactly or paraphrase
Therapeutic Communication Techniques – makes patient ƒ Summarizing
comfortable to open up o Give a gist of what transpired in the
conversation
ƒ Active listening o Give sense of accomplishment to the nurse
o Listening not only w/ ears but the whole body and patient
o Establish eye contact, incline body a little bit ƒ Encouraging description of perception
forward, safe distance ƒ Encouraging evaluation
ƒ Therapeutic silence o Letting the client judge his/her experience
o Allow client to process feeling ƒ Placing events in time sequence
ƒ Offering self o “When did this happen?”
ƒ Giving recognition
o Call using name Non-therapeutic Communication Techniques
o Acknowledging accomplishment ƒ False reassurance
o Enhances client’s self-esteem o Falsely reassuring the client not to worry
o Can serve as a reward o “Don’t worry…”
ƒ Stating observation ƒ Belittling feelings
o Noting what you saw, not what you think you o Takes for granted what the patient feels
saw ƒ Approval/ Disapproval
o Keeps client aware of what is happening o Extremes are non-therapeutic
ƒ Broad opening o Approval – giving in
o Good way of starting conversation o Disapproval – may exhibit judgment
o “What do you want to talk about?” ƒ Agreeing/ Disagreeing
ƒ Accepting o Extremes are non-therapeutic
o “Uh huh”, “yes”, “I follow” o Agreeing – giving in
o May be interpreted as an agreement o Disagreeing – may exhibit judgment
ƒ General leads ƒ Giving advice
o More prompting o Telling the client what to do
o “Go on”, “and then” o Patient will feel that he does not know what is
ƒ Giving information good for him
o Giving a fact that the client needs to know ƒ Probing
ƒ Clarifying o Exploring beyond client’s willingness to explore
o Making clear what is not understood ƒ Defending
o “What do you mean?” o Taking the side of someone

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Mental and Psychiatric Health Nursing

o Behavior is learned, unlearned and modified
ƒ Requesting explanation ƒ Learned – acquisition
o “Why?” ƒ Unlearned – extinction of behavior
o Reason o Behavior Æ pleasant Æ repeated Æ learned
ƒ Changing the topic behavior
o 9 Patient does not want to talk about a ƒ Pleasant – reward/ reinforcement –
certain topic strengthens behavior
ƒ Pleasant behavior Æ learned
Eliminate answer choices like: behavior
1. Authoritarian answers o Behavior + reward (positive reinforcer)=
o “I want you to help me ambulate your behavior change
daughter.” o Check what behavior is rewardable
2. Close-ended Questions o Learning the behavior is acquiring the
o “Do you discuss your problems with behavior
someone?” o Aversion therapy – behavior is followed by
3. Why questions something unpleasant to decrease behavior
o “Why do you feel this way?” o Systematic desensitization
4. Don’t worry statements o Stress reduction techniques
o “Don’t worry, the doctor will do everything.”
5. Nurse-focused answers V. Psychodynamic/ Developmental/ Psychoanalytic
o “I know from experience…” Model
o Freud/ Erikson
Remember! o How past affects the present
ƒ Base your answer on a sound principle not on what o Past affects how a person relates to others
sounds good
ƒ Assess what the client knows first o Mental Activity
ƒ Focus on the theme of the client’s verbalization ƒ Conscious - awareness
ƒ Choose an answer that demonstrates the nurse ƒ Subconscious – partly remembered,
empathizing with the patient partly forgotten
ƒ Focus on reality; Don’t argue, don’t disagree ƒ Residual – painful memories
ƒ Choose an answer that allows and encourages
verbalization o 3 Structures of Psyche
ƒ Understanding patient’s condition is the basis of the ƒ Id
best therapeutic response o Pleasure principle
ƒ Do not pass the buck. Nurse attempts to critically think o Does not tolerate what is
for the answer painful
ƒ Look for the answer that personalizes the information o Infant
ƒ All components of the answer must be correct o Strong Id – Manic

THEORETICAL MODELS OF PATIENT CARE ƒ Ego

ƒ Explain phenomenon of mental illness o Reality principle –
responsible for coping
I. Biologic Model * o Fulcrum/ balance between
Schizophrenia id & superego
o Biological/ medical explanation o Has defensive function
o Genetic predisposition o Coping mechanism to
o Chemical imbalance return to homeostasis
o Structural brain changes - enlargement o May come in the form of
o Biochemical treatment problem solving (most
adaptive coping way)
II. Cognitive Model *
Depression ƒ Superego
o Thoughts affect behavior and feelings o Conscience
o Irrational thoughts = irrational behavior o Starts to develop: 1 ½ to 3
o (+) Thoughts (+) Behavior y/o
o (-) Thoughts (-) Behavior o No, limits
o Cognitive therapy/ reconstructing o Weak superego - antisocial
o Challenge (-) thoughts o Very strong superego –
III. Social Model depression
o Environment affects behavior
o Milieu Therapy VI. Interpersonal
o Considers totality of environment/ o Sullivan
behavior ƒ Significant other plays a big role in
development
IV. Behavioral Model - Freud ƒ Anxiety: disapproval of significant
o Learning theories others
o A - Antecedent o Communicable
B - Behavior o People affect people
C - Consequent

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Mental and Psychiatric Health Nursing

VII. Existential/ Humanistic o No organic reason
o No regard for the past, only present o Stammering, diarrhea
o Only here and now 15. Symbolization
o Humanistic: Maslow’s Hierarchy of Needs – o Attributing a meaning to an object to
needs NOW represent the unacceptable
o Contradicting with Psychodynamic Model 16. Substitution
o Taking a more attainable goal because the
DEFENSE MECHANISM original goal was unattainable
ƒ Relieve tension but does not solve problem 17. Sublimation
ƒ Patterns of adaptation o Rechanneling socially unacceptable drives or
ƒ Sparing manner impulse into something that is socially
ƒ Threat Æ ego will make a way to handle Æ defense acceptable
mechanism (problem solving) 18. Rationalization
ƒ Maladaptive or excessive use – unhealthy o Using a reason which is not a real reason to
justify
1. Suppression 19. Denial
o Conscious forgetting o Refusal to acknowledge a painful reality as if
2. Repression reality is not there
o Unconscious forgetting
o Common in anxiety disorders CRISIS AND CRISIS INTERVENTION
Crisis
3. Dissociation ƒ State of disequilibrium resulting from a stressful event or
o Form of repression a perceived threat where the individual’s usual coping
o Forgets concepts about self & identity mechanisms become ineffective in dealing with it
o Forgetting personal details ƒ Highly individualized
4. Isolation ƒ Immediate problem
o Behavior: does not want to mingle
o Separation of the feeling from the thought of Types:
the event ƒ Developmental
5. Regression o Transitions in life/ maturational crisis
o Manifest behavior expected of an earlier o Expected - anticipatory guidance
stage of dev’t ƒ Situational
o Goes back to earlier stage o External events that are threatening w/c a
6. Fixation person finds difficult to handle
o Unable to outgrow behavior expected of an o External stressful events
earlier stage of dev’t o Events that suddenly happen
o Carries over o Loss of loved one/ separation
7. Identification ƒ Adventitious (Situational Crisis)
o Imitates a behavior of a significant person o Traumatic, extraordinary
o Integrates characteristics o Calamities, rape, violence
8. Introjection
o Imitates a behavior of a significant person Balancing Factors – determines whether a person will go to crisis
o Incorporates characteristics or not
o Becomes the person the admire ƒ Individual’s perception of the event
o Used by suicidal people ƒ Situational support
ƒ Internalized anger ƒ Coping mechanisms
9. Displacement
o Transfer of feeling to a less threatening object Event

10. Projection
o Throwing of/or attributing someone one’s own Perception of
characteristics – what one cannot accept as Event
his
o Blaming
o Used by suspicious people Not a stressor Stressor
ƒ Delusion of persecution
11. Undoing
o Repairing or negating something Coping,
o Negating the guilt in compulsion Resources,
o Reverse enactment Support
12. Reaction formation
o Showing the exact opposite of one’s wishes or
Effective, Ineffective,
desires Adequate Inadequate
13. Compensation
o Exaggerating a trait to cover for one’s
inadequacy
14. Conversion Crisis
o Expressing one’s feelings/ conflicts through the
body

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Mental and Psychiatric Health Nursing

Characteristics of Crisis State o What does the situation mean
ƒ Highly individualized 3. Assist the client in managing feelings
ƒ Self-limiting – 4 to 6 wks o Helpless, powerless
o Short-term management 4. Explore with the client the resources available
o Ç stressor – crisis o Assess what coping mechanisms were already
o End varies used
5. Assist the client in action planning
ƒ Rarely affects the individual without also affecting the
significant others Techniques of Crisis Intervention
ƒ The person is amenable to suggestions – problem ƒ Abreaction – discuss feelings
solving ƒ Clarification
ƒ Has a growth potential: return to pre-crisis state, to a ƒ Suggestion
more distressing situation, or to develop a higher level ƒ Manipulation
of functioning ƒ Reinforcement of behavior
ƒ Support of defenses
ƒ Raising self-esteem
Stress
ƒ Exploration of solution

RAPE AND SEXUAL ASSAULT

Equilibrium Rape
ƒ A sexual act with penile penetration or a penetration
with a blunt object
Ineffective coping ƒ W/o consent - È 18 y/o, mentally challenged
mechanisms ƒ Against the will
ƒ Not because of sexual gratification but because of
feeling of inadequacy
Disequilibrium
Sexual Assault
ƒ Any other form of forced sexual contact
CRISIS ƒ Does not qualify as rape)

9 If child consents, it is still considered as rape - minor

9 If with impaired judgment, it is rape
Ç Stressor Crisis
Truths about Rape
ƒ It is an act of violence
o Anger rape
Attempt at
reorganization o Destructive way of expressing anger
ƒ It is an act of dominance and power
o Power rape/ sadistic rape
Trial & Error ƒ There are more females who are raped than males
(Crisis Intervention) ƒ There are more acquaintance rape done
o Date rape
o Familiar but not personally connected
o Liquid ecstasy
Effective coping Ineffective coping
Stages of Recovery from Trauma:
ƒ Acute Phase (Disorganization)
Resolution Mentally ill o Rape trauma symptoms
o Client may be brought to the hospital
o Injuries/ documentation of rape for legal
charges
Return to state
before crisis ƒ Outward Adjustment (Recoil)
o 2 weeks after
9 NURSE ADOPTS A COUNSELLING ROLE o Composed state, no longer crying, calm on
o Active and directive the outside but in distress inside
o No advice o Should not be interpreted as not needing
9 Any victim of abuse is on a crisis state emotional support
9 Patient must have a correct perception of situation o May believe that she does not need support
o Shock, disbelief, denial, silent reaction
Steps in Crisis Intervention: o Trying to be in control
1. Assess the situation – ask person to help in identifying o Must undergo debriefing
problem ƒ Resolution (Reorganization)
o Physical implication o May sustain reaction or period of growth
o Suicidal tendencies o May cause sexual dysfunctions
o Physical integrity o Successful or unsuccessful
2. Assist the client to develop cognitive awareness of the ƒ Rape Trauma Syndrome
event o Sustained maladaptive response to rape

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Mental and Psychiatric Health Nursing

o Referred for proper management ƒ Sexual Abuse
o Sexual act w/ child
Rights of a Rape Victim o Playing w/ child’s genitalia
ƒ Right to gentle treatment o Not in menarche but underwear has blood
ƒ Right for informed consent – examinations stains, genital pain, dysuria, genital discharge,
ƒ Right to refuse a lot of knowledge about sex
ƒ Right to confidentiality
ƒ Right to privacy Roles of the Nurse
o All legal evidences must be kept intact ƒ Primary consideration is the protection of the child.
ƒ 8 wash, douche, change clothes, Report any suspected case of child abuse.
bathe
ƒ Clothes, underwear 1. The physical needs of the injured/ neglected child must
ƒ Proper documentation be met before attempts are made to alter the family
ƒ Right to progress according to readiness pattern of functioning
ƒ Right for legal assistance 2. Manage the psychological effects of abuse – PLAY
THERAPY for children who lack language facility to
Psychotherapeutic Management of Victims of Rape express self
ƒ Needs continual empathy, support, and opportunity to o Family dolls, puppets
process the event and intense feelings o Drawing
ƒ Keep evidences 3. Manage the abuser/ abusive family
o Avoid cleansing herself o Develop awareness of abusive behavior
ƒ Emphasize that it is not her doing o Learn effective way of coping
o Help overcome feeling of guilt
ƒ Provide nursing care supportively at the individual’s SPOUSE/ PARTNER ABUSE - È self-esteem, inadequacy
pace Characteristic Battered Wife Response to Abuse:
ƒ Stabilize physical aspect first ƒ Believes abuser will reform
ƒ Consider the rights of the rape victim ƒ Fears leaving due to threat from abuser
ƒ Learned helplessness
CHILD ABUSE ƒ Isolates self from other relationships
ƒ Maltreatment of a child which ranges from violent ƒ Feels inadequate, accepts self blame
physical attacks to passive neglect ƒ Both are dependent to each other
ƒ Maltreatment may be physical or emotional o Husband – inadequate
ƒ Dynamics underlying child abuse: o Wife – believes she deserves it
o Individual factors – way of coping
o Societal factors – powerless and subordinates, 9 Only way to stop this is to leave the partner; empower the
females woman through crisis intervention, give card of crisis center
o Familial factors – multigenerational problem to call for help
(established using genogram) 9 Ensure safe place for victim and children
ƒ Abused, abuser and crisis
Cycle of Abuse
Assessment: ƒ Tension – minor injurious acts, call for help
Physical and Behavioral Indicators ƒ Serious battery stage – husband relieved
ƒ RA 7610 – Anti-Child Abuse Law - report suspected ƒ Honeymoon stage – husband promises not to hurt wife
cases of child abuse anymore

ƒ Physical Abuse (Battered Child) - Commission

o Injuries - welts, multicolored bruises (diff stages Serious
of healing – repeated abuse), bald area on Tension
build up
battery
head, burns (cigarette burns – hidden areas), stage

fractures, dislocations
o Behavior: doesn’t want to go home, fear of
abuser
ƒ Abuser gives explanations not Honeymoon
consistent w/ child’s injuries stage
ƒ Aggressive, withdrawn, apathetic,
scared of parent, prefers to overstay 9 The best time to call for help is when it is just starting
in school 9 Must have action plan when abuse starts
ƒ Physical Neglect – Omission (needs are not provided) o Ask direct question
o Malnourished – may engage in child labor 9 Interview – done in the comfort room
ƒ Begs for food 9 The abuser must also be treated
o No adequate clothing – unkempt/ dirty
o No adequate medical attention Nursing Diagnosis – Physical first before psychological
o No place to stay - may be street children ƒ Impaired tissue integrity
o Assumes adult responsibility ƒ Pain
ƒ Emotional Abuse ƒ Risk for injury
o Berated, humiliated ƒ Altered nutrition
o Delays in physical dev’t, failure to thrive ƒ Sleep pattern disturbance
o Anxiety through thumb sucking, nail biting, ƒ Fear
enuresis ƒ Self-esteem disturbance

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Mental and Psychiatric Health Nursing

ƒ Risk for violence o Heightened sexuality and increases feeling of
ƒ Ineffective individual/ family coping closeness and empathy, “club drug”

9 Symptomatic management
SUBSTANCE USE DISORDER 9 May be diagnosed w/ urine test – w/in 1 to 2 days to trace
ƒ Socially maladaptive behavior characterized by abuse substances
of substance or the regular use of such substance 9 Urine should not be diluted
impairs the functioning of individual
CNS Depressants
9 Substance Abuse vs. Substance dependence ƒ Alcohol
9 Physical dependence vs. Psychological dependence o Most commonly abused substance
9 Substance intoxication vs. Substance withdrawal o Oldest anti-anxiety
ƒ Sedative/ Hypnotics
Definitions: o Valium – same effect as alcohol
ƒ Substance Abuse o Dangerous to mix alcohol and sedative
o Using a drug in a way that is inconsistent with o If taken therapeutically, no alcohol
medical and social norms and despite
negative consequences ƒ Narcotics - Opioids
ƒ Substance Dependence – more serious problem o Papaver somniferum – derivatives of opiates
o Tolerance – takes higher dose of substance to o Opium, heroine, codeine (cough syrup),
bring about the same effect morphine (Demerol)
o Withdrawal symptoms – substance-specific o Can only bought w/ prescription
manifestations that occur upon reduction/ o Euphoria, sleepy, È VS, È RR
cessation of substance o Heroin - most common
ƒ Intoxication – occurs when ƒ Tell-tale Sign: Pinpoint pupil non-
substance is within the body - effects reactive to light
on CNS ƒ Severe CNS depression – Narcan
o Unsuccessful attempts to give up the (Naloxone)
substance ƒ Can be passed through the
o More time to get, more time to take the placenta – shrill cry of neonates
substance ƒ Taken via IV push or main line – w/
ƒ Physical Dependence – with withdrawal symptoms needle marks
ƒ Psychological Dependence ƒ Risk for blood-borne infections
o Takes the substance to avoid undesirable o Effects of Heroin:
effects of withdrawal ƒ Euphoria w/ sleepiness
o Stimulants – physical and psychological o Relieve physical and
o Depressants - physical emotional pain
ƒ Morphine
CNS Stimulants o Potent respiratory
ƒ Amphetamines depressant
o Methamphetamine HCl – Shabu o RR < 12 – overdose
o Dextrin, Ritalin, Benzedrine o Antidote: Narcan – narcotic
ƒ Ritalin - ADHD agonist
ƒ Pupils constriction
o Brings about euphoria – exaggerated form of ƒ È VS
well-being o Withdrawal from Heroine
o Pupils dilate ƒ Early – can be likened to beginning
o Cannot sleep, no appetite respiratory infection
o Does not get tired o Runny nose
o Dependent: remain energetic, wants to be o Teary eyes
slim o Sneezing
o Abdominal cramps
ƒ Cocaine o Muscle cramps
o Not used for therapeutic use ƒ Inhalants
o Almost the same effect as amphetamines o Gasoline, glue, solvents, thinner, nail polish
ƒ More potent that amphetamines remover, spray paint, rugby (used by street
o Euphoria, Ç VS, bronchodilation, energetic boys)
o Taken through snorting or sniffing o Headache, È LOC, dizziness, lack of
coordination, mirthfulness, mouth ulcers,
ƒ Ecstasy slurred speech, unsteady gait, tremors, muscle
o Rush then crash if next dose is not taken weakness, blurred vision, GI upset, nausea
o Takes next dose even if the first one does not and vomiting
lose its effect yet o Rugby - È hunger
ƒ If they fail, they feel painful o DEATH – severe CNS depression
depression - Crash
o Fatigability, painful depression w/c may cause 9 Must only take for 2 weeks to avoid addiction
them to commit suicide
o Methylenedioxymethamphetamine (MDMA) Hallucinogens
o Snorting, sniffing Æ red nose w/ lesion ƒ Mind altering drugs/ psychomimetics

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ƒ Distortion in time and space ƒ Breath analyzer level
ƒ Colorful surroundings: psychedelic
ƒ Synethesia – “blending of senses”, see odor, frightening BAL BEHAVIORS
hallucination (bad trip) 0.05 % ¾ Loss of inhibition
ƒ Effect of substance can last Up to 0.1 % ¾ Anxiety relief, euphoria, loud speech
0.10 to 0.15 ¾ Slurred speech, motor incoordination,
ƒ Mescaline % moodiness (LEGAL INTOXICATION)
0.2 – 0.3 % ¾ Irritability, black out (memory impairment/
ƒ Cannabinols does not remember what happened),
o Least potent tremor, ataxia, stupor
o Marijuana, hemp grass 0.3 % and ¾ Unconsciousness
o Dried leaves and dried into rolls – tyonke, up
dyutsa – euphoria/floating, tachycardia, dry
mouth, increase in appetite, hallucinations, Alcohol Metabolism – 10 mL in 90 mins
RED EYES or conjunctival irritation, loss of Complications of Alcohol Use
motivation, change in decision ƒ GI – stomach absorbs alcohol – does not need to
making/judgement, may lead to sterility due reach intestines
to È testosterone. o Malnutrition – early satiety
o Dagta of cannabis – hashish; increase in o Inflammation – esophagitis
appetite with preference for sweets – hash ƒ CNS – due to deficiency in Vitamin B
brownies/ space cakes/ space brownies o Neuritis – tingling sensation
o Wernicke’s - Korsakoff’s syndrome
ƒ PCP – Phencyclidine/ Ketamine ƒ Reproductive System
o Veterinary anesthesia o Impotence - È Testosterone
o Heightened sexuality and closeness ƒ CV
o Distortion in memory, dissociation, near death o Cardiomyopathy, CHF
experience ƒ Fetal Alcohol Syndrome
o K-hole experience – do not remember
anything that happened Nursing Diagnosis r/t Chemical Dependence
ƒ Ineffective denial
ƒ LSD ƒ Ineffective individual coping
o Bloodshot eyes – conjunctival irritation ƒ Altered family process
o Family can contribute to drinking behaviors
ALCOHOLISM o Enabling behavior – kunsintidor
ƒ Commonly abused substance o Codependency – behaviors of relatives of
ƒ Etiology: alcoholics; adjust to the alcoholic
o Biologic – genetics ƒ Anxiety – before and during withdrawal
ƒ Altered sensory perception
o Psychodynamic o Hallucination – withdrawal
ƒ Lack of adaptive coping ƒ Altered thought processes
o Denial ƒ Impaired verbal communication – slurring
o Projection ƒ Sleep pattern disturbance
o Rationalization ƒ Altered nutrition
ƒ Fixated in oral stage o Vitamin B supplement
o Inconsistency, poor role ƒ Self-esteem disturbance
modeling, lack of nurturing, ƒ Alteration in social interaction
lack of adaptive coping ƒ Risk for violence
ƒ Id – strong
ƒ Ego – weak (alcohol as coping) PSYCHODYNAMICS OF SUBSTANCE DEPENDENCE

o Personality Profile – weak ego, dependent, Unresolved Needs of Early Attachments

manipulative Ç Id È Ego
¾ Strong oral ¾ Uses denial (should be
o Behavioral
tendencies confronted), rationalization
ƒ Learned behavior
¾ Demanding/ (do not allow to explain
manipulative inappropriate behavior) and
o Social - Peer pressure
projection (blaming others
ƒ Group therapy – mgt is better in
for behavior)
groups
* Learn to delay ¾ Accept the person, not the
o Give up a drinking friend
gratification behavior – “tough love”
o Relapse – go back to
¾ Uses escape behavior
alcohol-drinking friends
provided by alcohol
¾ Inferior feeling

9 In psych, do not manage diagnosis, manage behavior

9 Set limits, no bargaining, maintain consistency
9 Patient must know that there is a connection between
Blood Alcohol Concentrations/ Levels (BAC/ BAL) to Behavioral
anxiety and maladaptive behavior
Manifestations of Intoxication

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Management of Alcoholism o Antianxiety meds
ƒ Short-term – Detoxification ƒ Seizure
o Process of safely withdrawing from the o Anticonvulsants
substance o Dilantin
o Best done in a controlled environment - o MgSO4 – enhance absorption of Vit D
Institution ƒ AntiHTN
o Search things and confiscate anything that ƒ Bloodshot eyes – no management
has alcohol
o Disulfiram Therapy Long term - Rehabilitation – foundation is abstinence
ƒ Remain sober
ƒ Long-term
o Rehabilitation Goals:
o Foundation is abstinence ƒ To give up alcohol
o Disulfiram or Antabuse Therapy
Detoxification ƒ If drank alcohol Æ Disulfiram
ƒ Assessment reaction: HA, n/v, hypoBP, DOB,
ƒ Withdrawal Symptoms retching
o Earliest: Tremors o Meds are for safe withdrawal and to prevent
relapse
ƒ Stage 1 – 6 to 8 hours after last drink
o Tremors, headache, n/v, anxiety, sweating ƒ Live a positive lifestyle; use other coping strategies
ƒ Stage 2 – 8 to 12 hours o Things you do everyday in life
o Stage 1 + anorexia and insomnia o Group therapy – Alcoholics anonymous group
o May start hallucinations o Group - collection of people working together
ƒ Intensifying anxiety = È perception working towards a common goal
ƒ NOT managed with antipsychotics o 8-10 persons
ƒ Given anxiolytics o Brings interpersonal learning; more input and
ƒ Side effect: È seizure threshold – feedback
more prone to seizure o Instilling of hope and universality
o Perception: o Altruism – feeling of helping others
o Cohesiveness and unity is important; must give
up denial
9 Metabolism of alcohol lasts for 1.5 hours and gives off
acetaldehyde – acetaldehyde dehydrogenase – gives off
acetic acid

Therapeutic Goal: Abstinence from the substance

ƒ Stage 3 – 2 to 3 days later Nursing Interventions:

o Stage 2 + seizure ƒ Providing for physical and nutritional needs
o Cannot be managed at home ƒ Confrontation
o Risk for aspiration ƒ Tough love – accept person
ƒ Group work – alcoholics anonymous; leader is a
ƒ Stage 4 – 2 to 5 days after delirium tremens reformed alcoholic
o CNS Depressants ƒ Education
ƒ Intoxication – depressant
ƒ Withdrawal – stimulant
o CNS Stimulant ANXIETY AND RELATED DISORDERS
ƒ Intoxication – stimulant ƒ Anxiety – a subjective feeling of apprehension, dread,
ƒ Withdrawal - Depressant or impending doom
o Delirium tremens – excitability, agitated, ƒ Fear – an objective threat
disoriented and confused, Ç VS, seizures, red
eyes Characteristics of Anxiety
ƒ Most extreme withdrawal symptom ƒ Subjective feeling
ƒ Universally seen as unpleasant – move people to do
Goal and Priority Management of Withdrawal Patients something
ƒ Ensure physiologic integrity and safety of patient ƒ Both a stressor and adaptation
o Quiet, non-stimulating environment ƒ A form of energy
ƒ Cluster care ƒ Occurs in degree
o VS q hour or 2 hours o Mild, moderate, severe, panic
o Safety – put up side rails Manifestations:
ƒ Restraints (last resort) ƒ Mild (+1)
o Offer emotional support o No management, helpful anxiety
o Reorient patient ƒ Moderate (+2)
o Well-lighted room o Low pitched voice, less confidence, things are
ƒ Illusion – misinterpretation of external stimuli getting out of control
ƒ Hallucination – false perception o Selective inattention – chooses non-anxiety
o Present reality provoking events
o Offer to stay

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o Allow client to pace, encourage verbalization ƒ Repression
and identify stressor first, state observation, ƒ Isolation
assistance in problem solving ƒ Undoing - repetitive doing w/c
o No need for medications negates anxiety
ƒ Severe (+3) ƒ Reaction formation
o Fight or flight response, continuous and rapid
speech, feeling of dread, ineffective o Intervention:
reasoning and problem solving, disorientation, ƒ Allow the client to engage in the
limited perception compulsion but set time limits
o Use concise and brief statements ƒ Modification of schedule
o IM medications ƒ Instead of compulsion, distract with
repetitive relaxing activities
ƒ Panic (+4) o Music therapy
o Disorganized in all areas, harmful, hysterical, ƒ Must jive with the interest of
incoherent, suicide attempts, intelligible, personExpress feelings
overwhelmed, hallucinations (ANXIETY), ƒ Do not recognized maladaptive
palpitation, profuse sweating behavior since client already is
o Provide controlled environment aware but cannot control it
o Stay in a small room to prevent feeling o Do not say “paulit ulit mo
overwhelmed naman ginagawa yan”
o Parenteral anti-anxiety meds ƒ Thought stopping – stop by using a
o Breath into brown bag repetitive activity
o Rubber band
Types of Anxiety-Related Disorders
Anxiety Disorders (Neurosis) 2. Phobic Disorder
ƒ È GABA – inhibitory neurotransmitter o Irrational fear of something outside the body
ƒ Etiology: o Defense Mechanisms:
o Interpersonal theory ƒ Displacement - transfer conflict to a
o Psychodynamic (Freud) – anxiety is caused by situation outside
conflict of id and ego, or sexual/oedipal ƒ Repression
conflicts that is repressed ƒ Symbolization
o Hyperactivity of autonomic nervous system o Phobia may just be a symbol of conflict
Unacceptable feeling, ƒ Agoraphobia – fear of open space
desire, or wish ƒ Claustrophobia – fear of closed
spaces
ƒ Social phobia – fear of being in a
Repression (unconscious situation where one can be
forgetting) embarrassed or be humiliated
o Avoidance to prevent experiencing distressing
Stimulus related to situation
unacceptable o May have phobia but does not have function
impairment
o Intervention:
Consciousness ƒ Safety – priority concern
o Example: avoidance may
cause the client to jump off
Anxiety and unpleasant a building to avoid the
feeling phobia
ƒ Positive reinforcement (Behaviorist
approach)
Behaviors to negate ƒ Systematic desensitization
anxiety
ƒ Flooding – implosive therapy –
bombardment of stimulus
Disorder
3. Generalized Anxiety Disorder (GAD)
o Continuous anxiety for 6 months
1. Obsessive Compulsive Disorder o Diffuse and free-floating (not attached to a
o Obsessions – irrational repetitive thoughts that specific thing)
a person cannot control
o Compulsions – irrational repetitive actions that 4. Panic Disorder
a person cannot control o Sudden onset
o Obsessions & compulsions control the person o Short duration (5 mins -1 hour)
o Anxiety causes repetitive thought which o Recurrent
translates into an uncontrollable behavior o High intensity
(compulsion Æ negating anxiety, ineffective
coping) 5. Post-traumatic Stress Disorder
o Obsession is related to compulsion o Stress after a traumatic event
o Defense Mechanisms: o Maintains life of being a victim, controlled by
the event

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o Disasters, calamities, violence, war hygiene, sugarless
o Should last 1 month gum/ sour candy
o Manifestations: ƒ Constipation -
ƒ Flashback (re-experiences the laxative
event) ƒ Urinary retention –
ƒ Emotional numbness (avoidance) palpate bladder,
ƒ Cannot sleep or eat stimulate
ƒ Muscle tension, cannot concentrate, ƒ Blurring of vision –
guilt feelings, irritability safety – adequate
o Interventions: lighting
ƒ Establish trusting relationship ƒ Nausea – give w/
ƒ Talk about the situation vividly until meals
person is able to tell the story without o Orthostatic Hypotension
feeling upset ƒ Check BP first
(lying then sitting)
ƒ Grounding ƒ Decrease of > 20
o Can you feel you hand? mmHg
o Can you feel your feet on ƒ Rise slowly from
the ground? bed
ƒ Dizziness, pallor,
Nursing Management: nausea, tachyPR
ƒ Minimize the client’s anxiety and provide for the safety ƒ Adverse Effects:
of the client o Dependence
o Assess the level of anxiety ƒ Do not take
o Maintain a calm non-threatening environment longer than 2-3
o Reassure the client of his safety conveyed wks
through your physical presence ƒ Withdrawal should
o Administer tranquilizers as ordered be done
ƒ Initially, allow plenty of time for rituals, then gradually gradually
begin limit setting o Paradoxi
o Set time for compulsions & activity c
o Allow pt to do compulsions if attack occurs excitem
during activities ent
ƒ Encourage verbalization o Anti-depressants
ƒ Encourage client to talk about traumatic experience ƒ Anafranil (Clomipramine HCl)
under non-threatening condition (debriefing) ƒ Prozac (Fluoxetine HCl)
o Intense but progressive
ƒ Assist in developing more effective coping ƒ Psychotherapy
ƒ When level of anxiety has been reduced, explore w/ o Dream analysis
the client or teach client signs & symptoms of o Hypnosis
escalating anxiety & ways to interrupt its progression ƒ Milieu Therapy
(Stress mgt techniques) o Non-stimulating, calm environment
ƒ For the client w/ phobia, desensitize or involve the
client rather than allowing avoidance ƒ Behavior Modification
o Gradually expose client to feared object o Recognition of coping

Treatment Modalities Critical incident – a situation or event that causes distressing,

ƒ Pharmacotherapy dramatic or profound change or disruption in physical or
o Anti-anxiety psychological functioning
ƒ Anxiety Æ ÇÈ GABA Æ anxiolytics
Æ Ç GABA Critical Incident Stress Debriefing (CISD) Protocol Key Points
1. Assess the impact of the critical incident on support
personnel and survivors
ƒ Examples: 2. Identify immediate issues surrounding problems
o Valium (Diazepam) involving safety & security
o Librium (Chlordiazepoxide) 3. Use defusing for the ventilation of thoughts, emotions,
o Midazolam (Dormicum) and experiences associated w/ the event
o Xanax (Alprazolam) 4. Predicts events and reactions to come in the aftermath
ƒ Side Effects: of the event so survivor can prepare and plan
o CNS Depressants 5. Conduct a systematic review of the critical incident.
ƒ 8 CNS Look for maladaptive responses to the trauma
depressants & 6. Bring closure to the incident and ground to resources to
stimulants start rebuilding process
ƒ Do not allow 7. Re-entry (recovery) into the community/ workplace
activities requiring
alertness
o Cholinergic Effects
ƒ Dry mouth - Ç OFI, DYNAMICS OF SOMATOFORM DISORDERS
adequate oral ƒ Not medically ill

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ƒ Primary gain Somatoform Disorder VS Malingering
o Direct advantage for being sick ƒ Malingering
o Decrease anxiety (within) o Planned
ƒ Secondary gain o FAKE, deliberate
o Other advantages from the environment o Conscious simulation of illness in order to get a
o Ex: attention from members, benefits –deliberate gain
o DO NOT GRATIFY SECONDARY GAIN
Nursing Diagnosis
Assessment ƒ Altered role performance
ƒ Physical manifestations vary depending upon the type ƒ Disturbed body image
of somatoform disorder
Goals on Intervention
Somatization Disorder ƒ To make the client as functional as his condition will
ƒ Varied physical complaints allow to improve the quality of life
ƒ (-) in dx exams o Needs are being attended but do not
encourage dependence
Somatoform Pain Disorder o Do not out rightly do things for the patient
ƒ Pain is the only manifestation ƒ To relieve the symptoms
ƒ Do not push awareness of an insight into conflict/
Hypochondriasis problems
ƒ Morbid preoccupation ƒ To encourage expression of emotional feeling
ƒ Doctor shopping o Not physical complaints
o Neutral topics
Conversion Disorder ƒ To assist in learning more effective coping strategies
ƒ Alteration/ loss in motor and sensory function w/c ƒ Psychotherapy
symbolizes the conflict ƒ Anti-anxiety and anti-depressants
o Paralysis after fight with mother (motor) ƒ Other tx modalities
o Blindness after witnessing crime (sensory) o Stress management techniques
o Meditation and yoga
ƒ La belle indifference
o “A beautiful indifference” PSYCHOPHYSIOLOGIC DISORDERS
o Not concerned w/ loss of function Psychological Factors Affecting Medical Condition
o Physical manifestations absorbed by the body ƒ Given medical treatment but not transferred to a
o Absorb anxiety psychiatric unit
o Ex: witness of crime ƒ If underlying cause is not treated, physiologic
manifestations may be present
Body Dysmorphic Disorder
ƒ Body part is removed already Dissociative Disorders
ƒ Defect in body w/c results in cosmetic surgery ƒ Unconscious forgetting
ƒ Dissociative Amnesia – forgets identity
ƒ Dissociative Fugue – forgets identity, travels to another
Common Characteristics of the Physical Symptoms place and assumes new identity
ƒ Real (not fake) to the patient even if not supported by ƒ Dissociative Identity Disorder – multiple personality;
diagnostic results shifts from one to another; not aware of the other
o Matter-of-fact attitude personalities; WEAK EGO since person is not unified;
o Do not disagree w/ the presence of high incidence in abused and one of the personalities is
manifestation the abuser
o Accept that manifestations are real even if ƒ Depersonalization Disorder – dream-like state, trance-
diagnosis tests are (-) so that we do not like state; reintegrate the self; comorbidity in
become the source of anxiety schizophrenia
o Pay attention to the person but not on his o Establish what the client knows
body o Keep the patient safe
o Do not allow person to engage on his body o Psychoanalysis
pain (when in conversation)
ƒ Occur unconsciously (not DELIBERATE) PSYCHOTIC DISORDERS
o 8 Blame or scold patient with symptoms Psychosis
ƒ No underlying structural or organic basis ƒ Inability to distinguish from reality and what exists in the
o Use of anti-anxiety meds only mind
o Analgesics – pain; partial relief – dependent
ƒ Anti-anxiety and antidepressant medications Schizophrenia
ƒ Placebo – may be dependent ƒ Thought disorder
ƒ Stress reduction techniques ƒ Characterized by an disintegration from what the client
o Guided imagery thinks, feels or does
o Breathing exercises ƒ Used to be called “split personality”
o Progressive muscle spasm – relaxation of ƒ Social withdrawal
specific group of muscles to help relieve ƒ Deterioration in function
tension
ƒ With 1° and 2° gain – do not gratify Etiology
ƒ Biological

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o Family history ƒ Heightened
o Ç Dopamine – disturbed information anxiety Æ
processing ability of thinking violence
ƒ Excitatory neurotransmitter o Ensure safety of pt and
ƒ Structural other people
ƒ Psychodynamic ƒ Delusion of Reference
o Dysfunctional family relationships o False beliefs that
o Lack of loving and nurturing family conversations are about
o Inconsistency causes tension him
ƒ Mother is overprotective and over o Talk loud enough so that
loving while father is cold patient would hear what
o High expressed emotion type of family, low you are talking about
socioeconomic group – Stress Vulnerability ƒ Delusion of Control
Theory o External force is controlling
him
Assessment ƒ Religious Delusion
ƒ Manifestations: Bleuler’s 4 A’s ƒ Somatic Delusion
o Affect o Body is changing in some
ƒ Apathy (flat affect), inappropriate way
ƒ External manifestation of an emotion o Decayed or removed
ƒ Evaluated in intensity ƒ Nihilistic Delusion
ƒ Incongruence o False belief that a body or
its part does not exist
o Ambivalence
anymore
o Associative looseness
ƒ Inability to connect one’s thoughts ƒ Hallucinations - Distortion in thought process
ƒ Fragmented, illogical, incoherent o Alteration/ distortion in sensory perception
o Autism o Visual, auditory – common in schizophrenia
ƒ Self-absorption o Gustatory, tactile
ƒ Does not pay attention to other
stimulus ƒ Disorganized Speech
o * Auditory hallucinations o Neologism – coining of new words; meaning is
ƒ False sensory perception subjective
ƒ Talks by himself o Clang Association – rhyming words are put
ƒ Dangerous if command together
hallucinations ƒ Boom, broom, groom
o Word Salad – jumbled words put together
DSM V Diagnostic Criteria o Perseveration – persistent use of a single
ƒ At least 2 of the following, each present for a significant response to varied stimuli
period of time during a 1-month period o Verbigeration – repeating words over and
ƒ Continuous signs for at least 6 months over before they hear it
o Echolalia – repeating heard words

Positive Symptoms: ƒ Grossly Disorganized Behavior

ƒ Delusions – false fixed belief o Rigid behavior
o Alteration in thought process o Very regressed behavior - unkempt
o Types of Delusions based on Content
ƒ Delusion of Grandeur ƒ Catatonic Behavior
o False belief that one is o Motor manifestations due to mental illness
exulted o Catatonic negativism
o Has a lot of inadequacies o Bizarre/ rigid posture
o Accept belief but do not o Refuse to talk – mutism
reinforce o Immobile
o Present reality
o Enhance sense of Negative Symptoms:
importance ƒ Alogia – poverty of speech
ƒ Delusion of Persecution ƒ Anhedonia – inability to experience pleasure
o Believes that he will be ƒ Avolition – no drive/ motivation; regression
killed/ harmed ƒ Anergia – no energy
o Paranoid ƒ Asocial – few friends, difficulty establishing relationship
o Insecure/ tensed person ƒ Inattention – inability to sustain attention
o Encourage client to
verbalize feeling to diffuse Brief Psychotic Disorder – 2 of the following but less than 1 month
tension
o Potential problem: Violence Shizophreniform – 2 of the following more than 1 month but less
o Observe for client’s than 6 months
behavior
Types of Schizophrenia
ƒ Paranoid Schizophrenia

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o Delusions and hallucination ƒ Talk to client in case client will open
o Even without paranoia first
ƒ Disorganized Schizophrenia ƒ Avoid touching paranoid patients
o Disorganized speech and behavior ƒ Gradual integration to a group
o Grossly disorganized or catatonic ƒ Show that you are genuinely
o Most regressed concerned
ƒ Catatonic Schizophrenia ƒ Be honest and consistent
o Only motor manifestations present ƒ Use therapeutic communication
o Most acute o For concrete thinking
o Can have: ƒ Simple
ƒ Hyperactivity (stimulus from inside); ƒ Be specific
manic (stimulus outside) o For incoherence
ƒ Catatonic posturing ƒ Clarify
ƒ Waxy Flexibility – assumes and ƒ “I do not follow what you are
maintains a position that is imposed saying…”
by another person o For mutism
ƒ Stupor – immobile, does not open ƒ Talk to client but do not expect to
mouth and eyes, looks unconscious respond
but is aware of surroundings ƒ Give client time to talk
ƒ Catatonic Negativism – does ƒ Neutral topics, open-ended
opposite of what he is supposed to questions
do; do not use reverse psychology ƒ Therapeutic silence in between
ƒ Catatonic Rigidity – assumes a stiff ƒ Do not reinforce delusions and hallucinations
posture o Do not argue about delusions
ƒ Undifferentiated Schizophrenia – combination of o Do not reinforce hallucinations
symptoms, cannot be classified o If a patient is acting odd and the nurse
ƒ Residual Schizophrenia – only negative symptoms suspects he or she is hallucinating, the patient
should be asked about it then present reality
Common Nursing Diagnosis o Help patients to identify the stressors that
ƒ Risk for violence self-directed might precipitate hallucinations or delusion
ƒ Potential/ risk for other directed violence o Focus on real people and real events
ƒ Altered thought process o If happened earlier, stress the connection
o No abstract thinking – literal way of between stressor and anxiety
interpreting o Do not explore the false content, explore the
ƒ Altered sensory perception feeling
ƒ Personal identity disturbance ƒ Physiologic and self-care considerations
o Distinguish self from non-self o Circulation
ƒ Impaired verbal communication o Nutrition – NO NGT – attack
ƒ Social isolation o Hygiene
ƒ Self-care deficit: nutrition, grooming o Paranoid
ƒ Altered nutrition: less than body requirements r/t ƒ Sealed food – packed containers
suspiciousness ƒ Same kind of food to other patients
ƒ Ineffective coping ƒ Do not taste the food
ƒ Let him observe preparation
Nursing Intervention ƒ Deal with socially inappropriate behavior
ƒ Promote safety of client and others
o Verbalization Pharmacologic Management/ Therapeutic Milieu
o Time-out Antipsychotics/ Neuroleptics/ Major Tranquilizers
ƒ NO isolation room ƒ Blocks dopamine receptors at the post-synaptic area
ƒ Least restrictive environment to decrease availability of dopamine
o Medications ƒ Delusions and hallucinations would decrease then
ƒ Haldol (Anti-psychotic) + Benadryl disappear
(Sedative) ƒ Mouth checking
o Restraints ƒ Not meant to cure – alleviate symptoms
ƒ With doctor’s order ƒ Check for adherence
ƒ Last resort ƒ Maintenance meds:
ƒ Document step by step o Phenothiazines:
ƒ Firm but not tight ƒ Thorazine (Chlorpromazine) 
ƒ Check circulation – nail beds, PR ƒ Compazine (Prochlorperazine)
ƒ Check q 15 mins ƒ Mellaril (Thioridazine)
ƒ Remove restraints one at a time for ƒ Prolixin (Fluphenazine)
15 mins q 2° ƒ Modecate (Fluphenazine
ƒ Establish a therapeutic relationship Decanoate)
o Withdrawn patient o Long acting injection –
ƒ Active friendliness once q3 wks
o Suspicious patient ƒ Nozinan (Levomepromazine)
ƒ Gain client’s trust ƒ Stelazine (Trifluoperazine)
ƒ Passive friendliness ƒ Trilafon (Perphenazine)

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o Butyrophenones Rehabilitation:
ƒ Haldol (Haloperidol) ƒ Compliance to tx
ƒ Serenace (Haloperidol) ƒ Independence in activities of daily living
o Atypical Antipsychotics ƒ Social skills
ƒ Risperdal (Risperidone) o Help client to mingle starting on one-on-one
ƒ Clozaril (Clozapine) ƒ Dealing with future hallucinations
o Blood dyscrasia - CBC o Keep patient busy
ƒ Zeldox (Ziprasidone) o Deep thought will become voice
ƒ Seroquel (Quetiapine Fumarate) o Thought stopping
ƒ Zyprexa (Olanzapine) o Teach to recognize hallucination
ƒ Abilify (Aripiprazole) o Ignore hallucinations
ƒ Develop more effective coping patterns
ƒ Hallucinations must decrease o Role playing Æ test behavior

Side Effects: GRIEVING PROCESS

ƒ CNS depression ƒ Normal reaction to real or anticipated loss
ƒ Anticholinergic effects
ƒ Orthostatic effects Phases of the Grieving Process
ƒ GI upset – with meals ƒ E Kübler-Ross – 6 months
ƒ Photosensitivity – long sleeves, sunblock, umbrella, o Denial
sunglasses, walk on shady parts o Anger
ƒ Endo changes – gynecomastia, amenorrhea o Bargaining
ƒ Weight gain o Depression
ƒ Extrapyramidal Symptoms (EPS) o Acceptance
o Akathesia ƒ Engel
ƒ Fidgety, restlessness Shock and disbelief Æ Awareness of the pain Æ
ƒ Allow to pace Acceptance
o Akinesia
ƒ Weakness, muscle fatigue Duration: 6 months to 1 ½ year or 2 years for older people
o Dystonia
ƒ Eyes roll up with a fixed stare Assessment: 3 Major Areas to Assess
(oculogyric crisis) ƒ Adequate perception regarding the loss
ƒ Tongue protrusion ƒ Adequate support while grieving for the loss
ƒ Opisthotonos ƒ Adequate coping behavior during the process
ƒ Torticollis – neck torsion
o Pseudoparkinsonism Interventions:
ƒ Pill-rolling tremors ƒ Allow adaptive denial
ƒ Mask-like facies ƒ Explore the client’s perception and meaning of the loss
ƒ Muscle rigidity ƒ Encourage to reach out for and accept support
ƒ Shuffling gait ƒ Encourage the client to examine coping patterns in the
past and present situation of loss
Anti-EPS Drugs ƒ Encourage patient to care for self
ƒ Akineton (Biperiden)
ƒ Artane (Trihexyphenidyl) MAJOR DEPRESSIVE DISORDER
ƒ Symmetrel (Amantadine) ƒ Pathologic grieving
ƒ Cogentin (Benztropine)
ƒ Benadryl (Diphenhydramine) – anti-cholinergic effect Etiology:
ƒ Cognitive
Adverse Effects: o Pessimistic – negative concept
ƒ Decrease in seizure threshold o Best managed with cognitive therapy
ƒ Tardive Dyskinesia ƒ Biologic
o Delayed o Genetic predisposition
o Noted in patients who take the meds for a o È Norepinephrine, Serotonin
long time o Ç MAO – destroys neurotransmitters
o Vermicular movement of tongue ƒ Psychodynamic
Lip smacking o Unresolved conflict
Cheek puffing o Debilitating life experience – distant past,
ƒ Blood dyscrasia – spontaneous gum bleeding early life trauma
o CBC – leukopenia, agranulocytosis o Reaction to life events
o Low grade fever
ƒ Mouth sores 9 Highest risk for suicide
ƒ Sore throat o Low esteem
ƒ Neuromalignant syndrome (NMS) o Worthless
o Hyperthermia (39 to 41° C), bleeding, muscle o Problem with expressing sadness
stiffness, profuse sweating
o MOST FATAL - Depleted dopamine 9 Major Depressive Disorder vs. Dysthymia (less intense
o Given dopamine agonist but more chronic – 2 years)
o Stupor Æ Coma Æ DEATH
9 Exogenous vs. Endogenous Factors

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o Exogenous - outside factors ƒ Provide for the client’s safety
ƒ Psychotherapeutic approaches o Cues and Clues of Suicide
o Endogenous - inside factors ƒ Talks about it directly or indirectly –
ƒ Biologic – amenable to ask directly
antidepressants ƒ Gives away his valuables
ƒ Change in behavior – more willing to
mingle w/ others
Loss ƒ Starvation
ƒ Possession of things that are
potentially harmful
Helplessness/ abandonment ƒ Suicidal note
o Age/ Gender
ƒ Ç Adolescents, elderly
Hostility ƒ Ç Females – attempt
ƒ Ç Males – successful
o Marital Status
Guilty and worthlessness
ƒ Single
(low esteem) - Ç SE
ƒ Widow
ƒ Widower
Internalized Hostility o Attempt to evade rescue
o Recent loss then another loss
o Previous attempt and plan increases the risk
Depression
o Suicide Lethality Assessment Criteria
ƒ Plan
ƒ Means
Introjection of hostility
o È Lethality – wrist, overdose
of pills, starvation
o Ç Lethality – jugular vein,
Self-mutilation (Suicide) strangulation, sedative +
alcohol, gun shot, jumping,
drowning, drinking poison,
Assessment: At least 5 of the criteria for a minimum of 2 weeks
MVA
ƒ Sadness
ƒ Do not make the means available
ƒ Loss of interest
ƒ Must be confined
ƒ Worthlessness/ excessive or inappropriate guilt
ƒ No suicide contract
ƒ Psychomotor disturbance
ƒ Confiscate potentially harmful
ƒ Diminished ability to concentrate or indecisiveness
objects
ƒ Somatic manifestations
o Close observation
o Appetite disturbance
ƒ Low lethality - q 15 mins
o Sleep disturbance – does not deserve to sleep
ƒ High lethality – constant, someone
ƒ Initial insomnia – unable to sleep
should always be w/ patient
ƒ Remedial insomnia – easily awakens
ƒ Irregular intervals
ƒ Terminal insomnia – wakes up in wee
ƒ Room – close to nurses’ station
hours of morning and unable to
ƒ Establish a therapeutic relationship with the client and
sleep
verbalize concerns
o Fatigue or loss of energy
o Accept patient
ƒ Recurrent thoughts of death
o Spend time w/ patient
o Respond to anger therapeutically
Atypical depression – reverse of somatic manifestations
o Kind firmness
ƒ Encourage to perform something
9 Suicide is highest when depression starts to abate.
ƒ Engage in repetitive, monotonous,
non-gratifying activity to stimulate
Nursing Diagnosis Commonly Established for a Depressed Person
expression of anger
ƒ Altered nutrition more/ less than body requirements
ƒ Sleep pattern disturbance
ƒ Focus on the client’s strength
ƒ Anxiety
o Should not remain alone
ƒ Ineffective individual coping
o Walk and pace w/ client
ƒ Hopelessness – no solution
o Music therapy
ƒ Powerlessness – no energy
o Gradual introduction to group therapy
ƒ Self-care deficit
o Recognize accomplishments
ƒ Low esteem
o Avoid embarrassing experiences for client
ƒ Social isolation
ƒ Altered role performance
ƒ Create a scheduled and structured but non-
ƒ Constipation
demanding env’t
ƒ Risk/ potential for violence directed to self – suicidal
ƒ Promote independence by encouraging pt to perform
ADL’s
o Small frequent feeding
Interventions

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Pharmacotherapy - Antidepressants o Examples:
ƒ Tricyclic Antidepressants (TCA’s) ƒ Effexor (Venlafaxine HCl)
o Oldest ƒ Remeron (Mirtazapine)
o Blocks reuptake of NE and S ƒ Lexapro (Escitalopram Oxalate)
o 2 to 3 wks before effect
ELECTROCONVULSIVE THERAPY
o Examples: ƒ Somatic therapy due to neurochemical and
ƒ Tofranil (Imipramine) neurophysiologic effects
ƒ Elavil (Amitriptyline) ƒ 70 to 150 volts
ƒ Norpramin (Desipramine HCl) ƒ 8 all depressed
ƒ Aventyl (Nortriptyline)
ƒ Doxepin
ƒ Anafranil (Clomipramine HCl) Indications:
ƒ Surmontil (Trimipramine) ƒ Severely depressed not responding to use of
o Side Effects: antidepressants
ƒ Anticholinergic – same as ƒ Acutely suicidal and cannot wait for 2-4 wks
antipsychotics ƒ Mental illness like schizophrenia and mania w/c does
ƒ CNS depression not respond to meds
ƒ 8 EPS
9 Reuptake Contraindications:
o Going back of neurotransmitters to ƒ With pacemaker
presynaptic cell ƒ Organic mental disorder – tumor, aneurysm - EEG
o Trapped in the synapse ƒ Cardiac conditions – HTN - ECG
ƒ Active bleeding tendencies – CBC – blood dyscrasias
ƒ Respiratory conditions
ƒ Fracture
ƒ Pregnancy
Nursing Responsibilities:
ƒ Consent – responsible family member
ƒ NPO: 6 to 8 hrs
ƒ Shampoo: okay but should be dried well
ƒ NO shaving
ƒ Remove dentures
ƒ Wear loose clothing – hospital gown
ƒ Check VS – baseline
ƒ Monoamine Oxidase Inhibitors (MAOIs) o 8 ECT - Ç BP
o May have food-drug interactions ƒ Void before procedure
o Avoid Tyramine-rich foods (vasopressor) Æ
HTN crisis Types:
ƒ MAO is needed to metabolize ƒ Modified - with pre-meds
tyramine o IV Pentothal (Thiopental Na) – short-acting
ƒ Fresh – low in tyramine except sedative
banana, avocado, chicken, meat o Atropine sulfate – dry secretions, prevent
liver, fish bradyPR
ƒ Processed, brewed or preserved o Anectine (Succinylcholine) – muscle relaxant,
foods become tyramine rich – aged can cause respitory arrest
cheese, mozzarella, sardines, dried ƒ Unmodified – no pre-meds
and smoked fish, bagoong, coffee,
wine, chocolate Doctor: applies electrodes to patient
ƒ Raisins (fresh grapes - 8 tyramine
rich) Tonic-Clonic Seizure
ƒ Cream cheese - 8 tyramine rich ƒ Remove electrodes
ƒ Effective: Seizure for 30 to 60 secs
o Examples: ƒ After seizure:
ƒ Parnate (Tranylcypromine) o Turn to sides
ƒ Nardil (Phenelzine) o Suction if needed
ƒ Marplan (Isocarboxazid) o Check VS
ƒ Respiratory arrest – Anectine
ƒ Specific Serotonin Reuptake Inhibitors (SSRIs) ƒ Deep sleep for a while
o Lesser side effects ƒ Wake up: Disoriented – reorient client
o Watch out for tachycardia, hypomanic ƒ May eat as long as gag reflex has returned
episode
o Examples:
ƒ Prozac (Fluoxetine)
ƒ Zoloft (Sertraline HCl)
ƒ Paxil (Paroxetine HCl)
ƒ Luvox (Fluvoxamine)

ƒ Atypical Antidepressants BIPOLAR MOOD DISORDER

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ƒ Etiology: o Do not stay at elevated space - eye to eye
o Biologic level
ƒ Genetic o Eye contact but do not stare
ƒ Ç NE, S o Escalating phase – set limits
ƒ Ç Intracellular Na ƒ Restraints are applied firmly but not too tightly
o Psychodynamics o Tied on the side of the bed not on side rails
ƒ Mania is a defense against o Change client position accordingly
depression ƒ Place client in a room that is away from the nurse’s
ƒ Denies underlying depression station
ƒ Formation reaction o Single room
ƒ Constant struggle between id and o Simple and pastel in color
superego ƒ Ensure that nutritional and fluid balance needs are met
ƒ Mania – externalized hostility o Ç OFI – offer every hour or two
Depression – internalized hostility o Ç Calories Ç protein – finger foods
ƒ Mania – Ç Id ƒ Use short, simple sentences to communicate
Depression – Ç Superego ƒ Set limits and be consistent – matter-of-fact attitude
ƒ Confront the behavior, not the patient
ƒ Channel excessive energy into socially acceptable
motor activities
o Clean, sweep the floor, distribute linens
ƒ Provide solitary activity but something that would not
require concentration

Pharmacotherapy
ƒ Anticonvulsants
o Tegretol (Carbamazepine) – blood dyscrasia
Assessment: o Epival (Divalproex Na) – Valproic Acid
ƒ Elevated, expansive mood of at least 1 week and any 3 o Depakote (Divalproex Na)
of the following:
o Pleasurable activities ƒ Antimanic - Ç NE and S
ƒ Loud colors, activities o Lithium Carbonate – oral only
ƒ Heavy make-up ƒ Blocks release and fastens reuptake
o Increase in goal-directed activities of NE and S
o Psychomotor disturbance ƒ Fastens excretion of Na
o Delusion of grandeur – manic = low esteem ƒ Transposition of IC Na
o Pressure of speech/ loquacious speech o Where lithium is, Na will go
ƒ Pressure of speech o Lithium will find NA and
o Fast, rapid spitfire removes Na intracellularly
o Cannot understand o Na – EC/ IT/ IV
ƒ Loquacious speech o Secreted in the
o Very productive speech renal tubules
o Distractibility ƒ Thin line between therapeutic and
o Flight of ideas/ racing thoughts toxic level
o Somatic manifestations ƒ Toxic to renal tubules – MD orders
o Sarcastic, manipulative, demanding BUN and Crea before lithium is given
ƒ Hides weakness the through ƒ Therapeutic Serum Level: 0.6 to 1.2
weakness of others mEq/ L
o Up to 1.5 mEq/ L –
Nursing Diagnosis Commonly Identified Safeguard Level
ƒ Risk for violence – safety first o > 1.5 mEq/L – TOXICITY
ƒ Risk for injury – safety first ƒ Serum lithium exam: Blood test
ƒ Altered nutrition: less than body requirement ƒ Does not cure – stabilizes the mood
ƒ Ineffective individual coping ƒ Continue even if not hyper/ manic
ƒ Self-care deficit anymore
ƒ Self-esteem disturbance
ƒ Impaired social interaction
ƒ Ineffective role performance Side Effects of Lithium Adverse Effect of Lithium
Fine tremors Gross tremors
Interventions: Polyuria Oliguria
ƒ Provide for client’s physical safety and safety of those Polydipsia (3L fluids/ day) Vomiting (earliest
around him/her (PRIORITY than physiologic) Nausea manifestation of toxicity)/
o Ç Environmental stimuli Ç Hyper Metallic taste diarrhea
o Provide quiet, non-stimulating environment Motor incoordination
o Low pitched voice, non-confrontational, arms Confusion
on side, palms out Ataxia
o Do not cross arms
o Do not place hands at the back or inside the
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o The other 3A’s – apraxia, agnosia, aphasia
ƒ NO antidote for lithium - dialysis ƒ Expressive aphasia
o Stopped if toxicity occurs ƒ Perceptive aphasia
o Diuretic – excrete ƒ Global aphasia
o Na – facilitate excretion o Needs assistance and supervision with ADL’s
ƒ Diuretics are contraindicated while o Direct the client step-by-step
taking lithium – polyuria o Approach in full view
ƒ Diet: regular Na diet o Use vivid colors
o È Na – reabsorption of Na and lithium - o Reorient every interaction you have
toxicity o Environment – same, consistent
ƒ If lithium reaches 3 mEq/ L – HD to remove lithium o Sleep-wake cycle disturbance
ƒ Insomnia – known cause first
COGNITIVE DISORDERS ƒ Environmental modifications
ƒ Used to be called Organic Mental Disorders
ƒ Disorders that affect consciousness, memory, ƒ Severe (5 to 10 years)
orientation, attention, perception and language o Personality with emotional changes
disturbance o Deterioration in all areas of function
o Requires 24° supervision, close supervision or
Delirium: Acute confusional state both
ƒ Causes: o Irritable and combative
o Physical illness ƒ Give time
ƒ CHF, uremia, pneumonia, metabolic ƒ Distract when angry
d/os, CVA, DHN, infx, etc
o Prescription Drugs: Nursing Diagnosis
ƒ Polypharmacy w/ drugs and ƒ Risk for injury
anticholinergic effects ƒ Altered thought process (memory, confusion,
Dementia: Progressive cognitive deterioration deterioration)
ƒ Causes: ƒ Impaired communication
o Reversible conditions like: ƒ Impaired socialization
ƒ Encephalopathy ƒ Altered role performance
ƒ Infxs like syphilis ƒ Self-care deficit
ƒ Toxic conditions due to substances ƒ Sleep pattern disturbance
like alcohol, metal ƒ Low esteem
ƒ Caregiver role strain
Dementia of the Alzheimer’s Type
ƒ Etiology: Unknown but with various theories like Interventions:
o Genetics ƒ Goal: Promote optimum function and have patience
o Toxin o Promote client’s safety and protection from
o Infection injury
o Cholinergic deficit – acetylcholine ƒ Non-slippery floor
ƒ May use cholinesterase blockers ƒ Test temperature
o Structural o Structure environment and routine
ƒ Neurofibrillary tangles ƒ 8 Rearrange room
ƒ Neuritis/ senile block ƒ Client does not want change
ƒ Acetylcholinesterase ƒ Consistent, highly structured
ƒ Downhill trend o Promote adequate sleep, proper nutrition,
hygiene and activity
Stages: ƒ Time away – if insists, leave for a
ƒ Mild (2 to 3 yrs) while and return after 15 mins
o Forgetfulness is the hallmark ƒ Can do what he can do/ able to do
o 4 A’s ƒ Warm milk, warm bath, quiet
ƒ Amnesia – short term/ recent first environment
o Promote interaction & involvement
ƒ Aphasia – loss of expressive ability
ƒ Reminiscing activities
ƒ Apraxia – loss of purposeful bodily o Early stage
mov’t ƒ Gardening
ƒ Agnosia – loss of ability to recognize ƒ Interactive activities
o Word and name-finding difficulties o Provide emotional support, acceptance,
o Problem in decision making, judgment and increase worth by letting them perform what
reasoning they know
o Repetitive questioning ƒ Allow verbalization of feelings
o Difficulty performing usual activities o Do not come from the side, approach from
o Not too deteriorated yet the front
o Goal: ensure optimum activities, place wall o Reorient patient
clock and calendar inside room o Family/ caregiver support

ƒ Moderate (3 to 4 years)
o Confusion and disorientation
o Wandering and sleep disturbance

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o Increase self- esteem
EATING DISORDERS ƒ Identify good points
Anorexia Nervosa ƒ Give recognition when she gains
ƒ Does not eat weight
ƒ Self-imposed starvation o Assist in expression of feelings
ƒ Journaling
Etiology:
ƒ Biologic factors: Other Treatment Modalities
o Genetic predisposition ƒ Behavior modification
o Dysfunction of the hypothalamus ƒ Pharmacotherapy w/ antidepressant
o È Serotonin o Elavil (Amitriptyline), Prozac (Fluoxetine HCl)
ƒ Developmental factors: ƒ Family therapy
o Overprotective/ domineering enmeshed ƒ Psychotherapy – should have ff-up
family o Discharge if patient has gained almost 90% of
ƒ È Control and helplessness IBW
o Disturbed body image
o Conflicts about growing up – doesn’t like to Bulimia Nervosa
be a grown up ƒ Characterized by binge eating
o Sees herself as fat o Taking in a lot of food over a short period of
o Preoccupied with losing weight and is afraid time
of gaining weight
ƒ Social factor: Assessment:
o “Thin is in” ƒ Recurrent episodes of binge-eating
ƒ A feeling of lack of control over eating behaviors
Assessment: ƒ Inappropriate compensatory behavior to lose weight
ƒ Refusal to maintain body wt at or above minimum (the use of ipecac syrup to induce vomiting)
normal weight ƒ Self-evaluation overly influenced by body shape and
ƒ Must lose 15 to 25% below normal weight weight
ƒ Intense fear of gaining wt ƒ Love-hate relationship
ƒ È VS ƒ Normal/ a little above/ below the normal weight
ƒ Absence of at least 3 consecutive menstrual cycles
ƒ Lanugo – endo changes 9 Focus on feelings not on behaviors
ƒ Hypoglycemia, fluid and electrolyte imbalance
ƒ Compulsive people, good girl in the family, achievers Nursing Interventions:
ƒ Set limit to binge-eaters – adhere to meal schedule
Management: ƒ Assist in identifying feelings associated with binge/
ƒ Goal: Gradual steady weight gain of 1-2 lbs/wk purge and facilitate expression of feelings/ alternative
ways
ƒ 3 Major Objectives: ƒ Improve self-esteem
o To re-establish appropriate eating behavior
ƒ Re-feeding Program Other tx modalities:
o Desired weight gain – 1 to 2 ƒ Use of antidepressants
lbs/ wk ƒ Cognitive behavior therapy
o 500 – 1000 kcal/day in
divided amount PERSONALITY DISORDERS
o Small, frequent feeding ƒ Personality - Subtotal of physical and mental
o Monitoring the client’s characteristics of a person
weight before breakfast ƒ Developmental disorder – disorder developed before
after voiding, same clothes 18 y/o
and weighing scale ƒ Rigid/ inflexible traits Æ impaired function
ƒ Behavior Modifications Contract ƒ A lifelong pattern, fixated in a certain stage
o For active participation of ƒ They are not aware that something is wrong with them
patient, set limits and – poor insight
conditions ƒ They get admitted in the ward because of other
o Agree that all food will be conditions
eaten for a specified time
o Include patient in tx Excessive/ Rigid/ Inflexible Æ impairs function/ lifestyle
planning, do not force like
parents Cluster A – Odd and Eccentric
o Expected wt gain ƒ Paranoid
o Encourage participation o Does not rely on other people
ƒ Sit w/ client during meals o Questions loyalty of associates
o Observe how much was o Suspicious
eaten and remind contract ƒ Schizoid
o Stay in public place o Very shy, timid
o Stay for at least 1 hour after o Few set of friends
ƒ DO NOT GIVE LAXATIVE. May disturb o Prefers to be alone
the already disturbed GI, verify with ƒ Schizotypal
doctor, give stool softener o Shy and timid

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o Wants to be alone o If talks – echolalia
o W/ magical thoughts – believes in superstition o Does not establish eye contact
ƒ Disturbed personal identity
o Uses third person
Cluster B – Dramatic/ Emotional/ Erratic ƒ Engages in repetitive activities
ƒ Weak superego ƒ Head banging, sometimes ignores nutrition
ƒ 8 Limits o Self-absorbed

ƒ Antisocial Characteristics of a Nurse:

o Weak superego (conscience) ƒ Accepting
o Violate norms and rights of person ƒ Reality-based
o Bad record ƒ Safe
o Does not feel guilty ƒ Consistent
o Manipulative
o Acts out feelings Interventions:
ƒ Borderline ƒ Goal: Optimize function
o Females
o Dependent child Æ Good ƒ Accepting
Independent adult Æ Bad o Eye contact
o Categorized either good or bad only o Spend time with child
o “Splitting” – defense mechanism ƒ Reality-based
o Difficult to establish relationship o Impaired personal identity
o Tendency for self-harm o Reinforcing identity
o Impulsive ƒ Safe
o Strong need for dependence o Self-harm
o Fears abandonment – gives all o Pad side of bed
o Clings to people o Helmet
ƒ Histrionic ƒ Consistent
o Hysterical, dramatic, seductive o Same environment
o Describes things in a beautiful way
o Likes to be the center of attention Antipsychotic Drugs - Haldol
o Female
ƒ Narcissistic Care of a Child with Attention Deficit (Hyperactivity) Disorder
o Exaggerated sense of self (ADHD)
o Wants to be praised/ admired by people ƒ Genetic
ƒ Biochemical – too much stimulant
Cluster C - Anxious/ Fearful ƒ Min brain d/o
ƒ Does not want rejection ƒ Psychosocial factors
ƒ Does not want to be criticized o Stress/ disequilibrium in the family
ƒ Avoidant ƒ Get attention of child before giving instructions
o Likes to have a relationship but scared of ƒ Child knows that the other children does not like him
rejection because of his hyperactivity
ƒ Dependent o È self-esteem
o Depends on other people for decisions
o Low self-esteem Manifestations:
ƒ Obsessive-Compulsive ƒ Impulsivity Æ AD
o Rigid personality ƒ Inattention/ distractibility Æ AD
o Clean, meticulous, organized, willing to work ƒ Hyperactivity Æ ADHD
hard
Management:
9 No specific drug but symptomatic tx ƒ Set Limits
o Does not benefit in a lenient upbringing
SELECTED CHILDHOOD DISORDERS o Should not be scolded and point out what is
Autistic Disorder socially unacceptable
ƒ Self-absorbed o Quiet, non-stimulating environment
ƒ Does not pay attention to others o Classroom – front
ƒ Enhance self-worth
ƒ Etiology: o Behave – award
o Genetic o Give recognition to good points
o Biochemical - PKU ƒ Short term activities
ƒ Remove the child from the upsetting situation (time out)
Impairments of a Child w/ Autism ƒ Set time frame
ƒ Impairment in social interaction
o Prefer to be with inanimate objects
o Things that spin Drugs: Stimulants
o Security object ƒ Improve attention span
ƒ Impairment in verbal communication ƒ Enhance concentration
o Does not know how to communicate w/ ƒ Ritalin (Methylphenidate HCl) – paradoxic effect, help
others client focus

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ƒ Side Effects: Interventions:
o Insomnia – give at daytime: AM til noon ƒ Goal: Optimize function
o È Appetite – give after meals ƒ Planning must not be on chronological age but on
o Tics - report developmental age
ƒ Teach from simple to complicated
MENTAL RETARDATION o Use visual aids
ƒ Developmental disorder of sub-average intellectual ƒ Be patient - repetition
capacity ƒ Do not be overprotective
ƒ Ave IQ: 90 – 110 o Protect from possible injury
ƒ Difficulty in ADLS ƒ Protect from teasing of others/ help them become
ƒ È Adaptive ability more acceptable to others
o Help them smell good
Etiology: o Teach social phrases
ƒ Pre-natal ƒ Support – parents
o Chromosomal aberration – 21 chromosomes ƒ Parents must not reject their child
o German measles – 1st trimester SEPARATION ANXIETY DISORDER
o Malnourished mother ƒ Excessive anxiety when being separated from a parent
o PKU ƒ School phobia – not because of school, but fear of
o Cardiac condition of mother resulting to È separation
oxygenation ƒ Teach how to become independent
o FAS
o Maternal malnutrition SEXUAL DISORDERS
ƒ Perinatal
o Cerebral anoxia
o Traumatic delivery
ƒ Forcep/ vacuum
o Abruptio
o Multiple births
o Placenta previa
ƒ Postnatal
o Infection – meninges/ brain
o Head injury
o Malnutrition
o Lead intoxication
o Poor parenting
ƒ È Environmental stimulation

Developmental Age/ Mental Age

ƒ Highest capability that a child can reach regardless of
the chronological age

Classification:
Description Mental
Degree Range
Age
Profound < 20 IQ
ƒ Abilities of 3 y/o
20 – 40
Severe ƒ Contribute to self- 0-3
IQ
care
ƒ Self-care
ƒ Until grade 2 only
ƒ Trainable:
unskilled and
40 – 55
Moderate skilled work 3-8
IQ
ƒ May need
support even in
just minimal
stressor
ƒ Until grade 6
ƒ Educable:
Vocational
55 – 70
Mild
IQ
ƒ 8 Professional 8 - 12
ƒ Cannot move
around
neighborhood
70 to 85
Borderline ƒ Slow learning
IQ

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