PSYCHIATRIC NURSING

Mental Health
v It is a state of emotional, psychological, and social wellness evidenced by satisfying personal
relationships, effective behavior and coping, apositiveself-conceptand emotional stability

Mental Disorder
v A clinically significant behavioral or psychological syndrome or pattern that occurs in an
individual and is associated with present distress or disability or with significantly increased risk
of suffering, death, pain, disability or an important loss of freedom (APA, 2000)

Components of Mental Health

v Autonomy and Independence
v Maximizing one's potential
v Tolerating Life's Uncertainties
v Self-esteem
v Mastering Orientation
v Reality Orientation
v Stress Management

HISTORICAL PERSPECTIVES OF THE TX OF MENTAL ILLNESS

Ancient Times
v A belief that any sickness indicates displeasure of the gods and punishment for sins and wrongdoing
v Peoplewithmentaldisordersareeither viewed as divine or demonic
v Divine = worshipped and adored
v Demonic = punished and burned
v Aristotledeveloped atheoryaboutthe amounts of blood, water and yellow and black bile in the body
v Thesefoursubstancescorrespondwith happiness, calmness, anger, and sadness.
v Any imbalance from the four substances will cause mental disorders
v Treatment: bloodletting, starving and purging

Early Christian Times

v Primitive and superstitious beliefs
v All diseases were blamed to demons.
v Mentally ill personswere viewed as possessed
v Treatment: performance of exorcisms to rid evil spirits
v If thatfails = incarceration in dungeons, flogging and starving

Renaissance
v People with mental illness were distinguished from criminals
v Ifharmless = allowed to wanderthe countryside
v Harmful (dangerouslunatics) = thrownin prison, chained and starved
v Hospital of [Link] of Bethlehem = first hospital for insane
v Inmates were viewed as animals
v Also during this period, mentally ill people were viewed as evil and possessed.
v Treatment = witchhunts were conducted; offenders were burned

Period of Enlightenment
v Philippe Pinel and William Tuke
• Formulated the concept of asylum (safe refuge)
v Dorothea Dix advocated adequate shelter, nutritious food and warm clothing to those who are
mentally ill.

EmilKraepelin =classifiesmentaldisorders according to their symptoms.

Eugene Bleuler = coined the term schizophrenia.

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v Main tool used by the nurse in Psychiatric Nursing.
v Nurses use themselves as a therapeutic tool to establish therapeutic relationship with the client
v Introduced by Hildegard Peplau (1952)
v According to him, nurses must have a clear understanding of themselves to promote client's growth.
v Therapeutic use of self requires self-awareness

SELF-AWARENESS
v It is the processby which the nurse gains recognition of his or her own feelings, beliefs, and attitudes.
Goal: To know oneself so that one's values,attitudes, and beliefs are not projected to the client,
interfering with nursing care.
Onetoolthat is useful in learning about oneself is Johari's Window

Four Quadrants of Johari's Window

QUADRANT I  Arena/Open/ Public Self
 Qualities known to oneself and others
QUADRANT II  Blind/Unaware Self
 Qualities known only to others, not to self
QUADRANT III  Façade/ Hidden/ Private Self
 Qualities known only to oneself
QUADRANT IV  Unknown
 An empty quadrant to symboliz equalities as yet undiscoveredby oneself
or others

v Role Play
v Introspection
v Discussion
v Enlarging one's experience
THERAPEUTIC COMMUNICATIONUTIC COMMUNICATION
v It is an interpersonal interaction between the nurse and client during which the nurse focuses on
the client's specific needs to promote effective exchange of information
Goals
• Establish a therapeutic nurse—client relationship.
• Identify the most important client concern at that moment (the client-centered goal).
• Assess the client's perception of the problem as it unfolded.
• Facilitate the client's expression of emotions.
• Teach the client and family necessary self-care skills.
• Recognize the client's needs.
• Implement interventions designed to address the client's needs.
• Guide the client toward identifying a plan of action to a satisfying and socially acceptable resolution

TheraCom Techniques: Examples: Rationale:

Accepting "Yes";"I follow what you said"; An accepting response
- Indicating reception Nodding indicates the nurse has
heard and followed the
train of thought. It does not
indicate agreement but is
non-judgmental.

Broad Openings "Is there something you'dlike to Broad opening makes

- Allowing client to take the talk about?";'Where would you explicit that the client has
initiative in introducing the topic. like me to begin?" the leadin the
interaction;may stimulate
him or her to take the
initiative.

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Consensual Validation "Tell me whether my For verbal communication to be
-Searching for mutual understanding of it agrees with meaningful, it is essential that
understanding, for accord in the yours."; "Are you using this word the words being used should
meaning of the words. to convey that?" have the same meaning for all
participants.

Encouraging Comparison 'Was it something like?"; "Have For verbal communication to be

-Helping the client to understand you had similar experiences?" meaningful, it is essential that
by looking at similarities and the words being used should
differences. have the same
meaning for all participants.

Encouraging Description of "Tell me when you feel anxious"; To understand the client. the
Perceptions "What is happening?"; "What nurse must see things from his or
-Asking client to verbalize what does the voice seem to be her perspective; may relieve the
he or she perceives. saying?" tension the client is feeling and
he or she might be less likely to
take action on ideas that are
harmful or frightening

Encouraging Expression Whatare your feelings in regard Encourages the client to make
- Asking client to appraise the to?" his or her own appraisal rather
quality of his or her experience. than accepting the opinion of
others.

Exploring "Tell me more about that."; This can help them examine the
- Delving further into a subject or 'Would you describe it more issue more fully; If the client
idea. fully'?"; 'What kind of work?" expresses an unwillingness to
explore a subject, however, the
nurse must respect his or her
wishes.
Focusing "This point seems looking at This encourages the client to
- Concentrating on a single point. more closely.";"Of all the concentrate his or her energies on
concerns you have mentioned, a single point, which may prevent a
Which is most multitude of factors or problems
troublesome?" from overwhelming the client;
useful technique when a client
jumps from one topic to
another.

Formulating a Plan of Action What could you do to let your It may be helpful for the client to
- Asking the client to consider anger out harmlessly?"; "Next plan in advance what he or she
kinds of behavior likely to be time this comes up, what might might do in future similar
appropriate in future situations. you do to situations; making definite plans
handle it?" increases the likelihood that the
client will cope more effectively in
a similar situation

General Leads "Goon.";"And then?";"Tell me This indicates that the nurse is

- Giving encouragement to about it." listening and following what the
continue. client is saying without taking away
the initiative for the interaction;
encourage the client to continue if
he or she is hesitant or
uncomfortable about the topic.

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Giving Information "My name is...";"Visiting hours Informing the client of facts
-Making available the facts that are. . ."; "My purpose in being increases his or her knowledge
the client needs.. here is..." about a topic or lets the client
know what to expect; builds trust
with the client.

Giving Recognition Good morning, Mr.S..."; Greeting the client by name,

- Acknowledging, indicating "You've finished your list of indicating awareness of change, or
awareness. things to do."' "I noticed that noting efforts the client has made
you've combed your hair." all show that the nurse recognizes
the client as a person, as an
individual.

Making Observations "You appear tense."; "Areyou Sometimes clients cannot

- Verbalizing what the nurse uncomfortable when . . ?"; "I verbalize or make themselves
perceives. notice that you are biting your understood.

Offering Self "I will sit with you a while."; "I The nurse can offer his or her
- Making oneself available. will stay here with you."; "I am presence, interest, and desire to
interested in what you think." understand; It is important that
this offer is unconditional, that is,
the client does not have to
respond verbally to get the
nurse's attention

Placing event in Time Sequence 'What seemed to lead up to?"; This helps both the nurse and client
- Clarifying the relationship of Was this before or after?"; 'to see them in perspective;The
events in time. 'When did this happen?" client may gain insight into cause-
andeffect behavior and
consequences, or perhaps some
things are not related. The nurse
may gain information about
recurrent patterns or themes in the
client behavior relationship

Presenting Reality I see no one else in the room."; When it is obvious that a client is
-Offering for consideration that "That sound was a car back misinterpreting reality, the nurse
which is real. firing."; "Your mother is not can indicate what is real.
here.I am a
nurse."

Reflecting Client: "Do you think I should tell This encourages the client to
- Directing client actions, the doctor?" recognize and accept his or her
thoughts, and feelings back to Nurse: "Do you think you own feelings.
the client. should?"
Client: "My brother spends all my
money and then has the nerve to
ask for more."
Nurse: "This causes you to feel
angry'?"
Restating Client: "I can't sleep. I stay awake Restatement lets the client know
- Repeating the main idea all night." Nurse: "You have that heor she communicated the
expressed. difficulty sleeping." idea effectively; encourages the
Client: "I am really mad. I am really client to continue
upset." Nurse: "You're really mad
and upset."

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Seeking Information "I am not sure that I follow."; This can help the nurse to avoid
-Seeking to make clear that "Have I heard you correctly?' making assumptions that
which is not meaningful or that understanding has occurred
which is vague. when it has not; helps the client
to articulate thoughts,
feelings,and ideas more clearly.

Silence Nurse says nothing but continues This often encourages the client
-Absence of verbal to maintain eye contact and to verbalize provided that it is
communication,which provides conveys interest interested and expectant; gives
time for the client to put the client time to organize
thoughts or feelings in thoughts, direct the topic of
towords,regain interaction, or focus on issues
composure, or continue talking. that are most important.

Suggesting Collaboration "Perhaps you and I can discuss The nurseseeks to offer a
- Offering to share, to strive, to and discover the triggers for your relationship in which the client
work with the client for his or her anxiety."; "Let's go to your room can identify problems in living
benefit and I will with others, grow emotionally,
help you find what you are and improve the ability to form
looking for." satisfactory relationships.

Summarizing "Have I got this straight?"; This brings out the important
-Organizing and summing up that "You've said that. ."; "During the points of the discussion and to
which has gone before past hour, you and I have increase the awareness and
discussed.." understanding of both
participants;omits the
irrelevantand organizes the
pertinent aspects of the
interaction.

Translating Into Feelings Client: "I am dead." The nurse must concentrateon
-Seeking to verbalize client's Nurse: "Are you suggesting that what the client might be feeling
feelings that he or she expresses you feel lifeless?" to express himself or herself this
only indirectly Client: "I am way out in the way
ocean."
Nurse:"You seem to feel lonely
or deserted."

Verbalizing the Implied Client:"I can't talk to you or This tends to make the
-Voicing what the client has [Link] is a waste of time." discussion less obscure.
hintedator suggested. Nurse: "Do you feel that no one
understands?"

Voicing Doubt "Isn't that unusual?"; "Really?"; This permits the client to become
-Expressing uncertainty about "That is hard to believe." aware that others do not
the reality of the client's necessarily perceive events in
perceptions. the same way or
draw the same conclusions.

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NON THERAPEUTIC COMMUNICATIONS:
Advising Examples: "I think you advising should."; 'Why don't you?"
- telling the client what to do Rationale: This implies that client what to do only the nurse knows what is
best for the client.

Agreeing Examples: "That is right.” "I agree."

- indicates accord with the Rationale: This indicates the agreeing
client

Belittling feelings expressed Example:

- misjudging the degree of Client: “I have to live for…I wish I was dead”
the client’s Nurse: “Everybody gets down in the dumps” or “I have felt the way myself.”
discomfort Rationale: When the nurse tries to equate in the intense and overwhelming
feelings the client has expressed to “everybody” or to the nurse’s own
feelings, the nurse implies that the discomfort is temporary, mild self-limiting,
or not very important

Challenging Example: ”But how can you be the president of the United State?” “if you
– demanding proof from the are dead, why is your heart beating
client Rationale: Often the nurse believe that if he or she can challenge the client
to prove unrealistic idea, the client will realize there is no “proof” and then
will recognize reality. Actually challenging causes the client to defend the
delusions or misconception

Defending Example:” the hospital has a fine reputation”; “ I am sure your doctors has
- attempting to protect your best interest in mind.”
someone or something from Rationale: this implies that he or she no right to express impression,
the verbal attack opinion or feeling

Disagreeing Example: ”that is wrong”; ”I definitely disagree with…”;”do not believe on

- opposing the client’s idea that…”
Rationale: this implies the client is “ wrong”; consequently the client feels
defensive about his or her point of view or ideas

Giving approval/ Agreeing Examples: "That is good."; "I am glad that."

- Sanctioning the client's Rationale: Saying what the client thinks or feels if "good" implies that the
behavior or ideas opposite is "bad"; tends to limit the client's freedom to think, speak, or act
in a certain way; can lead to the client's acting in a particular way just to
please the nurse

Giving literal responses Example:

- Responding to a figurative Client:"They are looking in my head with a television camera." Nurse: "Try
comment as though it were a not to watch television." or 'What channel?"
statement of fact. Rationale: Often the client is at a loss to describe his or her feelings, so such
comments are the best he or she can do; usually it is helpful for the nurse to
focus on the client's feelings in response to such statements

Indicatingthe existence of an Examples:'What makes you say that?"; 'What made you do that?";
external “Who told you that you were a prophet?"
source Rationale: The nurse can ask, “What happened?" Or “What events led you
-Attributingthe source of to draw such a conclusion?";But to question “What made you think that?"
thoughts, feelings, and implies that the client was made or compelled to think in a certain way.
behavior to others or to
outside influences.

Interpreting Examples: “Whatyoureally meanis...";"Unconsciously you are saying ..."

- Asking to make conscious Rationale: Client's thoughts and feelings are his or her own,

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that which is unconscious not tobe interpretedby the nurse or for hidden meaning.
Introducing an unrelates Example:
topic Client: “I would like to die”
–change the subject Nurse: “ did you have visitors last night?”
Rationale: the nurse takes the initiative for the interaction away from the
client

Making stereotype Example: “Now tell me about this problem. You know I have to find out”;”
comments tell your psychiatric history”.
- offering meaningless clichés Rationale: Tend to make the client feel used or invaded; clients have the
or tripe comments right not to talk about issues or concerns if they choose.

Reassuring Example: “I would not worry about that”;” everything would be alright”;
- indicates that there is no you are coming along just fine.”
reason for anxiety or other Rationale: This is completely devalues the client’s feelings
feelings of discomfort

Rejecting Example: “ Let us not discuss…:”;”I do not want to hear about…”

- refusing to consider or Rationale: Nurse closes it off exploring; in turn, the client will feel
showing contempt for the personally rejected along with his or her ideas
client’s idea or behavior

Requesting an explanation Example:“why do you think that?; “ why do you feel that way?’’
- asking the client to provide Rationale: using “ why” question is intimidating
reasons for thoughts,
feelings, behaviors, events

Testing Example: “ do you know what kind of hospital this is”; “do you still have the
– appraising the client’s idea that…?’’
degree of insight. Rationale: This is forces the client to try to recognize his or her problems.

Using Denial Example: Client: "I am nothing.

-Refusing to admit that Nurse:"Of courseyou are something. Everybody is something."
problem exists. Client: "I am dead."
Nurse: "Do not be silly."
Rationale:denies the client's feelings or the seriousness of the situation by
dismissing his or her comments without attempting to discover the feelings or
meaning behind them

DISTURBANCES IN THOUGHT PROCESS AND CONTENT:

Circumstantial Thinking Example:
-a client gives out excessive Nurse: "How have you been A client sleeping lately?"
unnecessary details, but eventually Client: "Oh, I goto bed,so I can get plenty of rest. I like to listen to musicor
gets to the point. read books before bed. Right now I am reading a good mystery. Maybe I
will
write a mystery someday. But is it isn’t helping reading, reading I mean. I
have
been getting only 2 or 3 hours of sleep at night.”

Tangential Thinking Example:

-a client gives out excessive Nurse: "How have you been A client sleeping lately?"
unnecessary Client: "Oh, I goto bed,so Ican get plenty of rest. I like to listen to musicor
details and never gets to the point. read books before bed. Right now I am reading a good mystery. Maybe I
will
write a mystery someday. But sometimes I also like drama or non-fiction.”

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Word salad Example: “ corn, potatoes, jump up, play games, grass, cupboard.”
- It is a combination of jumbled
words and phrase that are
disconnected or incoherent and
make no sense to the
listener

Verbigeration Example: “I want to go home, go home, go home.”

-stereotyped repetition of wordsor Example: “I want to go home, go home, go home.”
phase that may or not have
meaning to the listener.

Perseveration Example:
-Persistent adherence to a single Nurse: "How have you been sleeping lately?"
idea or topic and verbal repetition Client:"Ithinkpeoplehave been following me."
of a sentence, phrase, or word, Nurse: 'Where do you live?"
even when another person Client:"At my place people have been following
attempts to change the topic. Nurse: 'What do you like to do in your free time?"
Client: "Nothing because people are following me."

Echolalia Example:
- Client's imitation or repetition of Nurse: Can you tell me how you’re feeling?
what the nurse says. Client: Can you tell me how you’re feeling,

Flight of Ideas Example: 'The sun is

Excessive amount andrate of [Link] is my sun? I love Lucy. Let us play ball."
speech composed of fragmented
or unrelated ideas

Looseness of Association Example:

- Disorganized thinking that jumps Nurse: "Do you have enough money to buy that candy bar?"
from one idea to another with little Client: "I have a real yen for chocolate. The Japanese have all the yen and
or no evident relation between the have taken all of our money and mark edit. You know,you have to be
thoughts careful of the Marxists because they are friends with the Swiss and they
have all the cheese and all the watches and that means they have taken all
the time. The worst thing about Swiss cheese is all the holes. People have
to be careful about falling into holes."
Delusion The client may claimtobe engaged to a famous movie star or related to
-False belief which is inconsistent some public figure such as claiming to be the daughter of the President of
with one's knowledge and culture the Philippines

Hallucination The client may claim to be speaking with an imaginary person commanding
- False sensory perceptions, or him to do something bad to another person.
perceptual experiences that do not
really exist.

Neologisms Example:
-Words invented by the client "I'm afraid of grittiz. If there are any grittiz here, I will have to leave. Are
you a grittiz?

Inappropriate Affect
v Disharmony between the stimulus and the emotional reaction.

Blunted Affect
v Severe reduction in emotional reaction.

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Flat Affect
v Absence or near absence of emotional/facial reaction that would indicate emotions or mood

Apathy
v Feelings of indifference toward people, activities, and events

Ambivalence
v Holding seemingly contradictory beliefs or feelings about the same person, event or
situation. Presence of two opposing feelings.

Depersonalization
v Clients feel detached from their behavior
v Feelings of strangeness towards oneself
v Although client can state his name correctly, he feels as if his body belongs to someone
else, or that his spirit is detached from is body.

Derealization
v Feeling of strangeness towards the environment
v Environmental objects become smaller larger, or seem unfamiliar.
v Individual feels that the outside world has changed.
v Everything may seem gray and dull

DISTURBANCES IN MOTOR ACTIVITY

Echopraxia
v The pathological imitation of posture or action of others
v Imitation of the movements and gestures of another person whom the client is observing

Waxy Flexibility
v Maintaining the desires position for long periods of time without discomfort
even when it is awkward or uncomfortable

DISTURBANCES IN MEMORY
Confabulation
v Filling a memory gap with detailed fantasy believed by the teller
v Purpose of confabulation: Maintainself-esteem
Example:
Nurse: "Do you know Gemma? (referring to one the residents at the patient's home)
Patient: "Yes, I know her. I used to play cards war her husband."Actually, Gemma's husband was
dead for many years and the patient had never met him.

Amnesia
v Inability to recall past events

BASIC ELEMENTS OF THE NURSE-PATIENT RELATIONSHIP

T — rust
R — apport
U — nconditional positive regard
S — etting limits
T — herapeutic communication

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CHARACTERISTICS OF THE NURSE-PATIENT RELATIONSHIP
v Goal — directed
v Focused on the needs of the patient Planned
v Time-limited
v Professional

PHASES OF THE NURSE-PATIENT RELATIONSHIP

Pre-orientation Phase
v Begins when the nurse is assigned to a nurse
v Major task: Develop self-awareness
v Tasks include data gathering, planning for the first interaction

Orientation Phase
v Begins when the nurse and client meet
v Ends when the client begins to identify problems to examine.
v Tasks: establishing rapport, developing trust, assessment, establishing roles, purpose of the meeting,
parameters of
subsequent
v Major Task: develop a mutually acceptable contract

Working Phase
v Longest and most productive phase of the nurse-patient relationship
v Limit-setting is employed
v Divided in two sub-phases
• Problem identification
ü Client identifies the issues or concerns causing problems
• Exploitation
ü Nurse guides the client to examine feelings and responses and to develop better coping skills
and a more positive self-image
• Transference
v Client unconsciously transfers his feelings to the nurse.
• Countertransference
v Therapist displaces on to the client attitudes or feelings from his /her past
• Resistance
v Development of ambivalent feelings toward self-exploration
• Termination Phase
v Also termed Resolution phase
v Begins when problems are resolved
v Ends when the relationship is ended.
v It involves feelings of anxiety, fear and loss.

PSYCHOTROPIC DRUG CATEGORIES

ANTI-PSYCHOTICS
v Also known as Neuroleptics
v Used to treat symptoms of psychosis.
v Primary treatment for schizophrenia
Used in psychotic depression, acute mania and drug-induced psychosis

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Side Effects
1. Extrapyramidal Symptoms (EPS)
v Major side effects of antipsychotic agents
v Includes acutedystonia, PseudoParkinsonism, akathisia, tardive dyskinesia
v EPS happen when there is blockade of dopamine (D2) receptors in the midbrainregion of
the brain stem.

Treatment for EPS

GENERIC NAME DRUG CLASS
(TRADE)
Amantadine (Symmetrel) Dopaminergic Agonist
Benztropine (Cogentin) Anticholinergic
Biperiden (Akineton) Anticholinergic
Diazepam (Valium) Benzodiazepine
Diphenhydramine (Benadryl) Antihistamine
Procyclidine (Kemadrin) Anticholinergic
Propranolol (Inderal) Beta-blocker
Trihexyphenidyl (Artane) Anticholinergic
Acute Dystonia
• Torticollis
• Opisthotonus
• Oculogyric crisis
• Acute muscular rigidity and cramping
• Stiff or thick tongue
• Difficulty swallowing
• Laryngospasm
• Respiratory difficulties

Treatment
• Intramuscular Benztropine mesylate (Cogentin)
• IM or IV Diphenhydramine (Benadryl)

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PseudoParkinsonism
• Stiff, stooped posture
• Mask-like facies
• Decreased arm swing
• Shuffling, festinating gait
• Cogwheel rigidity
• Drooling
• Coarse pill-rolling movements of the thumbs and fingers while at rest.

Treatment
• Changing antipsychotic medication that has lower incidence of EPS
• Adding an anti-cholinergic agent or
Amantadine.

Akathisia
• Inability to sit still
• Restless/anxious
• Rigid posture or gait
• Lack of spontaneous gestures

Treatment
• Change of antipsychotic medication
• Addition of an oral agent (Beta-blocker,
Anticholinergic, Benzodiazepine)

Tardive Dyskinesia
• Vermiform (Worm-like) tongue movements
• Sucking, smacking movements of the lips
• Involuntary movements of the body
• Permanent, irreversible
• Appears after at least 8 months of antipsychotic therapy

Treatment
• Valbenazine
• Deutetrabenazine
• Progression can be arrested by decreasing the antipsychotic medication

2. Neuroleptic Malignant Syndrome

v Potentially fatal, idiosyncratic reaction to an antipsychotic
v Rigidity
v High fever
v Autonomic instability (unstable blood pressure, diaphoresis, pallor, delirium)
v May fluctuate from agitation to stupor
v Increasedrisk for: dehydration and poor nutrition

Treatment
• Immediate discontinuance of all antipsychotic medications
• Treatment of dehydration and
hyperthermia

3. Anticholinergic Side Effects

v Often occurs with the use of antipsychotics
v Side effects usually decrease within 3 to 4 weeks but do not entirely remit

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MANIFESTATIONS
 Orthostatic hypotension
 Dry mouth
 Constipation
 Urinary hesitance or retention
 Blurry vision
 Dry eyes
 Photophobia
 Nasal congestion
 Decreased memory

Nursing Interventions
• Stool softeners
• Calorie-free beverages
• Adequate fluid intake
• Inclusion of grains and fruits in the diet

NURSING ALERT
Droperidol, Thioridazine, Mesoridazine
- These drugs may lengthen the QT interval to potentially life-threatening cardiac dysrhythmia or cardiac
arrest

NURSING RESPONSIBILITIES: ANTI-PSYCHOTIC DRUGS

Dry mouth • Drink sugar-free fluids
• Sugar-free hard candy
Constipation • Increase OFI
• Eat bulk-forming food
• Exercise

• Stool softeners but laxatives

Photosensitivity • Use sunscreen
• Avoidlongperiods time in the sun
•Wear protective covering
Orthostatic
Hypotension • Rising slowly from sitting or lying postings
Drowsiness •Avoid driving a car or performing other dangerous activities
Dizziness • Wait to walk until any dizziness has subsided
Medication • If you forget a dose of antipsychoticmedication, take it if the dose is
Compliance only 3 to 4
hours late. If the missed dose is more than 4 hours late or the next
dose is due,
omit the forgotten dose
• If you have difficult remembering your medication, use a chart to
record doses
when taken, or use a pill box labelled with dosage times and/or
days of the week
to help you remember when to take medication.

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 NURSING ALERT
Clozapine
ü May cause agranulocytosis
ü Clients should have a baseline WBC count anddifferential before initiation of treatment
ü WBC count everyweek throughout treatment and for 4 weeks after discontinuation of
clozapine

ANTI-DEPRESSANT DRUGS
v Primarily used in the treatment of:
• Major depressive illness
• Anxiety disorders
• Depressedphaseofbipolar disorder
• and psychotic depression

TYPES OF ANTIDEPRESSANT DRUGS

1. Selective Serotonin Reuptake Inhibitors (SSRI)
2. Tricyclic Antidepressant (TCA)
3. Monoamine Oxidase Inhibitors (MAOI)

Tricyclic Antidepressant Drugs (TCA)

• First choice of drugs to treat depression
• Available since 1950's

Nursing Alert
• Potentially lethal if taken in an overdose.
• Depressed or impulsive clients who are taking these drugs need to have prescriptions and refills in
limited amounts to decrease the risk.

Imipramine (Tofranil) Side Effects

Desipramine (Norpramin) • Dry mouth
Amitriptyline (Elavil) • Constipation
Nortriptyline(Pamelor) • Urinary retention
Doxepin (Sinequan) • Dry nasal passages
Trimipramine (Surmontil) • Blurred vision
Protriptyline (Vivactil) • Orthostatic hypotension
Maprotiline (ludiomil) • Sedation
Mirtazapine (remeron) • Weight gain
Amoxapine (ascendin) • Tachycardia
Clomipramine (anafranil) • Sexual dysfunction
• Agitation
• delirium

Selective Serotonin Reuptake Inhibitor (SSRI)

• Replacedthe tricyclic drugs as the first choice in treating depression because they equalin efficacy and
produce fewer side effects
• Effective in the treatment of obsessive-compulsive disorder
• Safest drug to give during panic attack

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 SSRI DRUGS Side Effects
Fluoxetine (Prozac) • Agitation
Fluvoxamine (Luvox) • Akathisia
Paroxetine (Paxil) •Nausea
Sertraline (Zoloft) •Insomnia
Citalopram (Celexa) • Sexual dysfunction
Escitalopram (Lexapro) • Weight gain (less)
• Sedation
•Sweating
•Headaches

Monoamine Oxidase Inhibitors

• With low incidence of sedation
• Can cause hypertensive crisis
• This drugshould not be givenwith other MAOIs, tricyclic antidepressants, Meperidine (Demerol), CNS
depressants

MAOI DRUGS Side Effects

Phenelzine (Nardil) • Daytime sedation
Tranylcypromine (Parnate) • Insomnia
lsocarboxazid (Marplan) • Weight gain
• Dry mouth
• Orthostatic hypotension
• Sexual dysfunction

Nursing Interventions
• Avoid tyramine foods
• No mature or aged cheeses or dishes made with cheese, such as lasagna, pizza (exceptcottage cheese.
cream
cheese, ricotta cheese, and processed cheese slices)
• No aged meats such as pepperoni, salami, mortadella, summer sausage, beef logs, and similar products.
• No Italian broad beans (fava) pods or banana [Link] pulp and all other fruits and vegetables are
permitted
• Avoid all tap beers and microbrewery [Link] no more than two cans or bottles of beer (including
nonalcoholic beer) or 4 ounces of wine per day

Side Effect of the other Antidepressant

Sedation Nefazodone
Trazodone
Mirtazapine
Headache Nefazodone
Trazodone
Dry mouth & nausea Nefazodone

Loss of appetite Bupropion venlafaxine

Nausea
Agitation
Insomnia
Dizziness Venlafaxine
Sweating
Sedation
priapism Trazodone

15
Nursing Alert
v Bupropion
• Can cause seizures at rate 4 times that of other antidepressants

NURSING RESPONSIBILITIES

Mood-stabilizing Drugs
v Used to treat bipolar disorder
v Functions to:
• Stabilize client's mood
• Preventing or minimizing the highs and lows that characterize bipolar illness
• Treat acute episodes of mania

Lithium is the most established mood stabilizer; this normalizes the reuptake of serotonin,
NE, acetylcholine & dopamine.
- Other drugs that are effective in stabilizing the mood:
• Carbamazepine (Tegretol)
• Valproic acid (Depakote, Depakene)
• Gabapentin (Neurontin)
• Lamotrigine (Lamictal)

Lithium
- Available in tablets, capsules, liquid sustained-released form.
- No parenteral forms
- Normal level: 0.5 — 1.5 mEq/L
- Therapeutic level: 0.6 – 1.2 mEq/L
- Common side effects:
• Mild nausea/diarrhea
• Anorexia
• Fine hand tremor
• Polydipsia
• Polyuria
• Metallic taste in the mouth
• Fatigue
• Lethargy
TOXIC EFFECTS
• Severe diarrhea
• Severe vomiting
• Muscle weakness
• Lack of coordination
If left untreated, symptoms mayworsen and can lead to
renal failure, coma and death Lithium levels exceed 3.0
mEq/L = Dialysis

16
NURSING ALERT
Valproic acid can cause hepatic failurein fatality
Carbamazepine can cause aplastic anemia and agranulocytosis
Lamotrigine can cause Steven-Johnsons Syndrome

MOOD STABILIZING DRUGS: NURSE RESPONSIBILITIES

• Have serum levels monitored periodically
• Take the medication with food to minimize nausea
• For the fine hand tremors ask the physician to prescribe a beta-blocker such as
propranolol (Inderal)
• To helpminimize weight gain,get a balance diet and get regular exercise. Expect some
weight gain.
• Normal sodium intake (2-3days)
• Minimize side effects of sedation and drowsiness from anticonvulsant medications
by taking larger dosesat bedtimeand smaller doses during the day
• If you are takinglithium, keep water intake in a normal rangeand avoid heavy
sweating, because this increases serum lithium levels rapidly

ANTI-ANXIETY DRUGS (ANXIOLYTICS)

v Used to treat:
• Anxiety disorders
• Insomnia
• OCD
• Depression
• Post-traumatic stress disorder
• Alcohol withdrawal

 ANTI-ANXIETY DRUGS
Alprazolam (Xanax)
Chlordiazepoxide (Librium)
Clonazepam (Klonopin)
Diazepam (Valium)
Flurazepam (Dalmane)
Lorazepam (Ativan)
Oxazepam (Serax)
Temazepam (Restoril)
Triazolam (Halcion)
Buspirone (BuSpar)

v Benzodiazepines have proved to be most effective in relieving anxiety

ANTI-ANXIETY DRUGS: NURSING RESPONSIBILITIES

v It is important for clients to know that antianxiety agents are aimed at relieving
symptoms, such as anxiety or insomnia; it does not treat the underlying problems that
cause the anxiety.
v Benzodiazepines strongly potentiate the effects of alcohol
v One drink may have the effect of three drinks (alcohol)
v Avoid driving (drowsiness)
v Benzodiazepine withdrawal can be fatal: once a course of therapy has been started,
benzodiazepines should never be discontinued abruptly without the supervision of the
physician.
v Take anxiolytic drugs only as prescribed.

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Stimulants
• First used to treat psychiatric disorders
• Before, they were used to treat depression
• At present,they are used for attention deficit/hyperactivity disorder in adolescents and children
DRUGS SIDE EFFECTS
Methylphenidate (Ritalin) • Anorexia • Dizziness
Dextroamphetamine (Dexedrine) • Weight loss • Dry mouth
Pemoline (Cylert) • Nausea • Blurred vision
• Irritability • Palpitations

NURSING ALERT
Pemoline
• Can cause life-threatening liver failure
• May require liver transplantation in 4 weeks from the onset of symptoms

STIMULANT: NURSING RESPONSIBILITIES

v Never leave the supply of medication in a place the child can reach
v Nausea & vomiting: Take medication at meal time.
v Growth suppression: Monitor thechild's weight and height
v Try a dosage schedule that provides a dose of medication before beginning routine tasks of
concentration such as nightly homework.
v Dry mouth: Calorie-free beverages or sugar-free candy
v Caffeine-free beverages; avoid chocolate & excessive sugar.
v Medications should be given in a manner that is not intrusive,nor should it draw undue
attention to the child.

Disulfiram (Antabuse)
• Sensitizingagent that causes anadverse reaction when mixed with alcohol in the body.
• Usefulfor persons who are motivated to abstain from drinking and who are not impulsive.
• Symptoms begin to appear after five to ten minutes and may last from 30 minutes to 2 hours
ü Facial and body flushing
ü Throbbing headache
ü Sweating
ü Dry mouth
ü Nausea
ü Vomiting
ü Dizziness
ü Weakness
• In severe cases, there may be chest pain,dyspnea, severe hypotension, confusion and even
death

Other side effects:

• Fatigue
• Drowsiness
• Halitosis
• Tremor
• Impotence

Nursing Responsibilities
Common products that may contain alcohol:
• Shaving cream
• Aftershave lotion
• Cologne

18
• Deodorant
• OTC drugs (cough preparations)
• Client must read the products carefully and select items that are alcohol-free

ELECTROCONVULSIVE THERAPY
Functions:
• Treat depression in select groups such as clients who do not respond to antidepressants
• Indicated to clients who are actively suicidal while waiting weeks for full effects of
antidepressant medication

Preparation:
• NPO after midnight
• Void prior to the procedure
• I.V should be started for the administration of the medication

Procedure
• Client receives short acting anesthetic so she is not awake during the
procedure
• Receives muscle relaxant to reduce outward signs of seizure
• The brain is monitored with EEG while the electrical stimulation is
delivered
• Following ECT the client may be mildly confused, disoriented and may
have short term memory impairment.

Voltage of electrical current administered to the 70-50 volts

client

Length of electrical shock applied to the patient 0.5 to 2.0 seconds

Usual number of treatments needed to produce a 6 -12 treatments(up to 15)

therapeutic effect

Frequency of treatments There should be an interval of 48 hours for each

treatment
Indication of effectiveness of ECT The occurrence of generalized tonic-clonic seizure

Indication for ECT -Depression

-Mania
-Catatonic
-Schizophrenia

Very High Risks

• Increased intracranial pressure
• Recent Fracture
• Cardiac Condition
• Retinal detachment
• Pregnancy

Need for consent prior to ECT

Yes, consent is needed
Atropine sulfate To decrease secretions

19
 Succinylcholine (Anectine) Topromote muscle relaxation
Methohexital Sodium(Brevital) Serve as an anesthetic agent

Common complications of ECT

• Loss of memory
• Headache
• Apnea
• Fracture
• Respiratory depression

Nursing Responsibilities After ECT

• The nurse or anesthesiologist mechanically ventilates the patient with 100%
oxygen until the patient can breathe unassisted.
• The nurse monitors for respiratory problems.
• ECTcausesconfusionand disorientation; thus, it is important to help with reorientation
(time, place, person) as the patient emerges from this unconscious state.
• Nurse might need to administer a benzodiazepine, as needed.
• Observation is necessary until the patient is oriented and steady, particularly when the
patient first attempts to stand.
• All aspects of the treatment should be carefully documented for the patient's record.

PERSONALITY STRUCTURE
v Freud conceptualized personality structure as having three components

ID
 Seeks instant gratification; causes impulsive, unthinking behavior; and has no
regard for rules or social convention

SUPER EGO
- Values, and parental and social expectations, therefore, it is in direct opposition to the id.

EGO
 Balancing or mediating force between the id and the [Link] ego represents mature and
adaptive behavior
that allows a person to function successfully in the world

EGO DEFENSE MECHANISM

RATIONALIZATION Examples: Student blames failure on teacher being
Excusing own behaviorto avoid responsibility, mean; Man says he beats his wife because she does
conflict, anxiety, or loss of self-respect not listen to him

REACTION FORMATION Examples:Woman who never wanted to have

Acting the opposite of what one thinks are feels children becomes a super-mom;Person who
despises the boss tells everyone what a great boss
she is
REGRESSION Examples: Five-year-old asks fora bottle when
Moving back to previous developmental stage in new baby brother is being fed; Man pouts like a
order to feel safe or have needs met four-year-old if he is not the center of his
girlfriend's attention.

REPRESSION Examples: Woman has no memoryof themugging

 Excluding emotionally painful or anxiety- she suffered yesterday; Woman has no
provoking thoughts and feelings memorybefore age 7 when she was removed from
 Unconscious forgetting abusive parents

20
SUPRESSION Examples: Woman has tried to forget her
 Excluding emotionally painful or anxiety- memoryof the financial problems she had in the
provoking thoughts and feelings past.
 Conscious forgetting

DISPLACEMENT v Examples: A person who

Ventilation of intense feelings toward persons less is mad at the boss yells at his
threatening than the one who aroused those or her spouse
feelings.
COMPENSATION Examples: Napoleon complex: Diminutive man
- Over achievement in one area to offset real or becoming an emperor; Nurse with low self-esteem
perceived deficiencies in another area works double shifts so
her supervisor will like her

CONVERSION Example: A teenager forbidden to see x-rated

- Expression of an emotional conflict through the movies is tempted to do so by friends and develops
development of a physical symptom usually blindness, and the
sensorimotor in nature. teenager is unconcerned about the loss of sight

DENIAL Examples: Diabetic eating chocolate candy;

- Failure to acknowledge an unbearable condition; spending money freely when broke; Waiting 3 days
failure to admit the reality of a situation, or how to seek help for severe
one enables the abdominal pain
problem to continue

DIVISIONS OF THE MIND OR LEVELS OF

AWARENESS
- Freud believed that the human personality
functions at three levels of awareness: Conscious;
Preconscious;
Unconscious

Conscious
- Perceptions,thoughts,and emotions that existin
the person's awareness such as being aware of
happy feelings or
thinking about a loved one
- Part of the mind focused on awareness

Preconscious Example: An adult remembering what he or she

- Not currently in the person's awareness, but he or did, thought, or felt as a child.
she can recall them with some effort.
- Part of the mind that contains information that
can be recalled at wil

Unconsciousness
v Realm of thoughts and feelings that motivate a
person, even though he or she is totally unaware of
them.
v This realm includes most defense mechanisms
and some instinctual drives or motivations.
v It is the largest part of the mind; contains
materials and information that can never be
recalled

21
COMMON PSYCHOTHERAPEUTIC INTERVENTIONS
1. Remotivation Therapy
v Promotes expression of feelings through interactions facilitated by discussion of neutral topics
v Reality orientation for rehabilitative patients only and not for activetly psychotic patients
2. Music Therapy
v Use of music to facilitate relaxation, expression of feelings and outlet of tension
3. Play Therapy
v Enables the patient to experience intense emotion ina safe environment with the use of play
Example:For victims of child abuse, give dolls.
4. Group Therapy
v Therapeutic interactions of three or more patients with a therapist to relieve emotional difficulties,
increase self
esteem, develop insight and improve behavior in relation with others
v Minimum number of members in a group is 3, while the ideal number is 8 —10

Types of Group
v Therapeutic Group
• To gain insight into their problems (i.e. Alcoholic Anonymous)
v Socialization Group
• To enhance interaction among patients
v Life Review / Reminiscing Group
• To lessen isolation

5. Milieu Therapy
v Treatment by means ofcontrolled modification of the patients' environment to facilitate positive
behavioral change
v Nurse identifies what each patient needs from the therapeutic milieu, while keeping in mind the needs of
the larger patient group
6. Family Therapy
v Focuses on the total family as an interactional system
v Best suited for families where there is domestic violence
7. Psychoanalysis
v Focuses on the exploration of the unconscious, to facilitate identification of the patient's defenses
v Behavioral disorders are related to unresolved anxiety-provoking childhood experiences that are
repressed into the unconscious
v Goal is to bring repressed experiences into conscious awareness and to learn healthier means of coping
with anxiety.
v Utilizes dream analysis and free association (verbalization of thoughts without censorship)
8. Hypnotherapy
v Involves various methods and techniques to induce a transtate where the patient becomes submissive to
instructions
9. Humor Therapy
v Use of humor to facilitate expression of feelings and to enhance interaction
v Therapeutic laughing lessens the high levels of tension that often as company discussions of serious
matters.
10. Behavior Modification
v Application of learning principles in order to change maladaptive behavior
v It attempts to streng then a desired behavior or response by reinforcement, either positive or negative

Positive reinforcement

22
• If the desired behavior is assertiveness, whenever the client uses assertiveness skills in a communication
group, the group leader provides positive reinforcement by giving the client attention and positive
feedback.
• For example, a teacher praises her student for getting high grades, so that the student will be motivated
to get high grades again the next time.

Negative reinforcement
• Involves removing a stimulus immediately after a behavior occurs so that the behavior is more likely to
occur again.
• For example, if a client becomes anxious when waiting to talk in a group, he may volunteer to speak first
to avoid the anxiety

CRISIS AND CRISIS INTERVENTION

v Turning point in an individual's life that produces an overwhelming emotional response
Characteristics of a Crisis State
• Highly individualized
• Lasts for 4 — 6 weeks
• Person affected becomes passive and submissive
• Affects a person's support system

Types of Crisis
v Maturational or Developmental Crisis
• Expected, predictable and internally motivated events in the normal course of life such as:
ü Leaving home for the first time; Getting married
ü Having a baby; Beginning a career
ü Growth; Parenthood
v Situational or Accidental Crisis
• Unanticipated or sudden, unexpected, Unpredictable and externally motivated events that threaten the
individual's integrity such as:
ü Death of a loved one
ü Loss of a job
ü Physical and emotional illness in the individual family or member; Car accident
v Social or Adventitious Crisis
• Includes natural disasters and acts 0 nature like:
• Floods Earthquakes Hurricanes
• War, Terrorist attacks; Riots
• Violent crimes such as rape or murder

Phases of a Crisis
1. Denial - Initial reaction
2. Increased Tension
• Person recognizes the presence of a crisis and continues to do activities of daily living
3. Disorganization
• Person is pre-occupied with the crisis and is unable to do activities of daily living
4. Attempts to Reorganize
• Individual mobilizes previous coping mechanisms

CRISIS INTERVENTION
v A way of entering into the life situation of an individual, family, group, or community to help them
mobilize their resources and to decrease the effect of a crisis inducing stress
Goal: To enable the patient to attain an optimum level of functioning

Types of Crisis Intervention

v Authoritative Crisis Intervention

23
• Designed to assess the person's health status and promote problem- solving such as:
ü Offeringthe person new information, knowledge or meaning
ü Raising the person's self- awareness by providing feedback about behavior
ü Directing the person's behavior by offering suggestions or courses of action
v Facilitative Crisis Intervention
• Aim at dealing with the person's needs for empathetic understanding such as:
ü Encouraging the person to identify and discuss feelings
ü Serving as a sounding board for the person
ü Affirming the person's self-worth

Primary Role of the Nurse in Crisis

• Active and directive, the nurse has to assist the patient

RAPE
v It is a crime of violence and humiliation of the victim expressed through sexual means
v It is the penetration of an act of sexual intercourse with a female against her will and without her
consent,
whether her will is overcome by force, fear of force, drugs, or intoxicants
v It is also considered rape if the woman is incapable of exercising irrational judgment because of mental
deficiency or when she is below the age of consent.
v According to Republic Act 8353, it refers to the insertion of the penis into the mouth. vagina, anus of a
victim
v It is generally considered as an act of hostility, anger or violence

POWER RAPE
v The intent of the rapist is not to injure the victim but to command and master another person sexually
v The rapist has an insecure self-image and feelings of incompetence and inadequacy,
v The rape is the vehicle for expressing power and potency.
v This is done to prove one's masculinity

SADISTIC RAPE
v Involves brutality
v The use of bondage and torture is not an expression of anger but necessary for the rapist's sexual
excitement
v The assault is often eroticized and is sexually stimulating
v This is done to express erotic feelings

RAPE TRAUMA SYNDROME

v Group of signs and symptoms experienced by a victim in reaction to a rape

Phases of the Rape Trauma Syndrome

v Acute Phase - shock, numbness and disbelief
v Denial Phase - victim's refusal to talk about the event
v Heightened Anxiety- fear, tension, and nightmares
v Stage of Reorganization - victim's life normalizes

Nursing Care for Rape Victims

v In the emergency setting, provide immediate emotional support
v The nurse should allow the woman to proceed at her own pace and not rush her through any interview
or examination
v Give as much control back to the victim as possible by allowing her to make decisions, when possible,
about whom to call, what to do next, what she would like done, etc.
v It is the victim's decision about whether or not to file charges and testify against the perpetrator and the
victim must
sign consent forms before any photographs of hair and nail samples are taken for future evidence

24
v The priority in the care of a rape victim is the preservation of evidence
v Prophylactic treatment for STDs is offered
v Prophylaxis can be offered to prevent pregnancy
• In some areas, HIV testing is strongly encourage
• Referrals to rape crisis centers are encourage

AUTISM SPECTRUM DISORDER

v Disorder characterized by impairment in communication skills, or the presence of stereotyped behavior,
interests and activities with associated impairment in social interactions
v More prevalent in boys than girls
v Identified no later than 3 years of age.
v It is treatable but not curable
v Does have a genetic link
Main Problem: Impaired Interpersonal Functioning
Manifestations
• Display little eye contact
• Few facial expressions towards others
• They do not use gestures to communicate
• Do not relate to peers and parents
• Lack spontaneous enjoyment
• No moods or emotional affect
• Little intelligible speech
• Stereotyped motor behaviors (hand-flapping body twisting, head-banging)
• Acts as deaf
• No fear of danger
Common Problems and Appropriate Management
v Drug
• Low-dose Antipsychotic
v Tantrums
• Involves head-banging
• Provide safety
• Helmet
• Padded walls
• Monitor behavior (1:1)
v Communication
• All vowels
• Use of short sentences when talking to the child
v Nutrition: Less Than Body Requirements
• Provide well-balanced diet
• Small frequent feedings
v Routines
• Provide consistency
v Love & Belongingness
• Family Therapy
v Priority Nursing Diagnosis
• Risk for Injury
ATTENTION-DEFICIT HYPERACTIVITY DISORDER
v Characterized by inattentiveness, overactivity, and impulsiveness.
v Common in boys
v Identified and diagnosed when the child begins preschool or school (before the age of 7)

Common Etiological Factors

• UNKNOWN

25
• Neurologic impairment
• Early malnutrition
• Frontal lobe hypoperfusion
• Use of drugs and exposure to alcohol and tobacco during pregnancy

Risk Factors
• Family history of ADHD
• Male relatives with antisocial personality disorder
• Lower socioeconomic status
• Gender (Male)
• Marital or Family Discord

Clinical Manifestations
INATTENTIVE BEHAVIORS
Misses details
Makes careless mistakes
Has difficulty sustaining attention
Doesn't seem to listen
Dos not follow-through on chores
Has difficulty with organization
Avoids tasks requiring mental effort
Often loses necessary things

HYPERACTIVE BEHAVIOR
Fidgets
Often leaves seat (during a meal)
Runs or climbs excessively
Can’t play quietly
Is always on the go; driven
Talks excessively
Blurts out answers
Interrupts
Can’t wait for turn
Is intrusive with siblings/playmates

TX
DRUGS NURSING CONSIDERATION
Methylphenidate (Ritalin) • Monitor for appetite suppression and growth
delays
• Give regular tablet after meals
• Alert client that full drug effect takes 2 days

Dextroamphetamine (Dexedrine) • Monitor for insomnia

• Give last dose early afternoon
• Full drug effect takes 2 days

Pemoline (Cylert) • Monitor for elevated liver function

• Drug may take 2weeks for full effect
Nursing Interventions for ADHD
1. Ensuring the child’s safety and that of others.
• Stop unsafe behavior
• Provide close supervision
• Give clear direction about acceptable and unacceptable behavior
2. Improved role performance
• Give positive feedback for meeting expectations

26
• Provide a quiet place free of distractions for ask completion.
3. Simplifying instructions/ directions
• Get the child’s full attention
• Break complex tasks into small step
• Allows break
4. Structured daily routine
• Establish a daily schedule
• Minimize changes
5. Nutrition
• Provide finger foods
6. Client/Family education and support
• Listen to parent’s feelings and frustration

MENTAL RETARDATION
v Below-average intellectual functioning
v IQ less than 70
v Significant limitations in areas of adaptive functioning
Causes
• Hereditary (Tay-Sachs Disease; Trisomy 21)
• Pregnancy/Perinatal problems (fetal malnutrition)
• Medical conditions of infancy

Levels of Mental Retardation IQ What can be done

Mild 55–69 Educable
Moderate 40–54 Trainable
Severe 25–39 Need Close Supervision
profound < 25 Custodial Care
v Educable
• Patient can be thought how to read and write.
v Trainable
• Vocational skills (cooking, sewing, etc.)
v Close Supervision
• Activities of daily living (brushing, wearing clothes)
v Custodial Care
• Client is totally dependent

Nursing Care
• Repetition
• Role modelling
• Restructuring the environment
Focus of Education for Mentally Retarded Patient
• Reading
• Writing
• Basic Arithmetic
ANXIETY
v Stage of uneasiness or discomfort experienced to varying degrees frequently coupled with doubts, fears,
and obsessions.
v Feeling of terror or dread; the most uncomfortable feeling a person can experience
Positive states of heightened awareness and sharpened senses,
allowing the person to learn new behaviors and solve problems,
MILD ANXIETY
The person can take in all available stimuli (enlarged perceptual

27
 field)

Decreased perceptual field (focus on immediate task only)

MODERATE ANXIETY The person can learn new behavior or solve problems only with
assistance

Feelings of dread or terror

The person cannot be redirected into a task; he or she focuses only

on scattered details and has physiological symptoms of
SEVERE ANXIETY tachycardia, diaphoresis, and chest pain.

People with severe anxiety often go to emergency

departments, believing they are having a heart attack.

Loss of rational thoughts, delusion, hallucinations, and complete

physical immobility and muteness
PANIC ANXIETY
The person may bolt and run aimlessly, often exposing himself or
herself to injury

PRIORITY NURSING DIAGNOSES FOR ANXIETY

v Ineffective individual coping
v Anxiety

PRINCIPLES OF NURSING CARE IN ANXIETY

v Calm
v Administer medications
v Listen to the patient’s concern
v Minimized environment stimuli

ANXIETY DISORDER
v Emotional illness characterized by fear, automatic nervous system symptoms and avoidance behavior
v Diagnosed when anxiety no longer functions as a signal of danger or a motivation for needed change but
become chronic and permeates major portions of the person’s life, resulting in maladaptive behaviors and
emotional instability

Symptoms of Anxiety Disorder

• Agoraphobia
• Anxiety about or avoidance of places or situation from which escape might be difficult or help might be
unavailable
Symptoms:
ü Avoids being outside alone or at home alone
ü Avoids travelling in vehicles; impaired ability to work
ü Difficulty meeting daily responsibilities (e.g., grocery shopping, going to appointments)
• Panic Disorder
• It is characterized by recurrent, unexpected panic attacks that cause constant concern.
• Panic attack
• It is the sudden onset of intense apprehension, fearfulness, or terror associated with feelings of
impending doom
Symptoms: A discrete episode of panic lasting 15 to 30 minutes with four or more of the following:
• Palpitations • Nausea
• Sweating • Derealisation/depersonalization

28
 • Trembling or shaking • Dear of dying or going crazy
• Shortness of breath • Paresthesias
• Choking • Chills or hot flashes
• Chest pain or discomfort

Social Phobia
• It is characterized by anxiety provoked by certain types of social or performance situations, which of
leads to avoidance behavior

Symptoms
• Fear of embarrassment or inability to perform
• Avoidance or dreaded endurance of behavior or situation
• Belief that others are judging him or her negatively
• Significant distress or impairment in relationship, work, or social life
• Anxiety can be severe or panic level.

Management
• Anti-anxiety medicatio
• Social skills training

GENERAL ANXITY DISORDER

• It is characterized by at least 6 month of persistent and excessive worry and anxiety

Symptoms
• Apprehensive expectation more days than not for 6 months or more about several events or activities
• Incontrollable worrying
• Significant distress or impaired social or occupational functioning
• Three of the following symptoms:
ü Restlessness
ü Easily fatigued
ü Difficulty concentrating of mind going blank
ü Irritability
ü Muscle tension
ü Sleep disturbance
Management
• Buspirone (Buspar) and SSRI antidepressants

ACUTE STRESS DISORDER

• It is the development of anxiety, dissociative, and other symptoms within 1 month of exposure to an
extremely traumatic stressor; it last 2 days to 4 weeks

Symptoms
• Exposure to traumatic events causing intense fear, helplessness, or horror, marked anxiety symptoms or
increased arousal;
• Significant distress or impaired functioning
• Persistent re-experiencing of the event
• Three of the following symptoms:
ü Sense of emotional numbing or detachment
ü Feeling dazed
ü Derealisation
ü Depersonalization
ü Dissociative amnesia (inability to recall important aspect of the event

POST-TRAUMATIC STRESS DISORDER

29
• It is characterized by the re-experiencing of an extremely traumatic events, avoidance of stimuli
associated with the event, numbing of responsiveness, and persistent increased arousal

Symptoms
• Flashbacks and nightmares
• Exposure to traumatic events involving intense fear, helplessness or horror;
• Avoidance of memory-provoking stimuli and numbing of general responsiveness
• Increased arousal (sleep disturbance, irritability or angry outbursts, difficulty concentrating,
hypervigilance, exaggerated startle response)
• Significant distress or impairment

Management
• Anti-anxiety Medication Diazepam ( Valium)
ü Oxazepam (Serax)
ü Chlordiazepoxide (Librium)
ü Clorazepate dipotassium
ü Alprazolam (Xanax)
• Anti-depressant Medications
• Group Therapy

When to Administer Anxiolytic Drug

• Best taken before meals, food in the stomach delays absorption
Side Effects of Anxiolytic Drugs
• Drowsiness; Sedation; Poor coordination; Impaired memory and clouded sensorium
Client Teaching on Anxiolytic Drugs
• Intake of alcohol and caffeine-containing foods alter the effect of the drugs.
• It potentiates the effect of the alcohol
• Administer separately, it is incompatible with any drugs.
Priority Nursing Diagnosis for Anxiety Disorder
• Ineffective Individual Coping

Treatment
Cognitive Behavioral Techniques
v Positive Reframing
• Turning negative message into positive messages
• Instead of thinking , “My heart is pounding. I think I am going to die” the client thinks, “I can stand this.
This just an anxiety. It will go away”.

v Decatastrophizing
• Involves the therapist’s use of the questions to more realistic appraise the situation
• The therapist may ask: ‘What is the worst thing that could happen? Is that likely? Could you survive that?
Is that as bad as you imagine?”
v Thought-stopping
• The client uses thought stopping and distraction techniques to jolt himself from focusing on the negative
thoughts
• Techniques that can break the cycle of negative thoughts includes:
ü Splashing the face with water
ü Snapping a rubber band worn on the wrist

v Assertiveness Training
• Helps the person take more control of the situation
• Techniques help the person negotiate interpersonal situation and foster self-assurance
• They involve using “I” statement to identify feelings and to communicate concerns or the needs of others
Example: “I feel angry when you turn your back while I’m talking”, ‘I want to have five minutes of your time
for an uninterrupted conversation about something important

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SPECIFIC PHOBIA
v Characterized by significant anxiety provoked by a specific feared object or situation which leads to
avoidance behavior.
Symptoms
• Marked anxiety response to the object or situation
• Avoidance or suffered endurance of object or situation
• Significant distress or impairment of daily routing, occupation or social functioning
• Adolescent and adults recognize their fear as excessive or unreasonable

Management
• Anti-anxiety Medications
• Systematic Desensitization
ü The therapist progressive exposes the client to threatening object in a safe setting until the client’s
anxiety decreases.

PERSONALITY
v Defined as an ingrained, enduring pattern of behaving and relating to self, other, and the environment;
personality includes perception, attitudes, and emotions.

Categories of Personality Disorders

1. Cluster A
• Odd and eccentric behavior
• Includes paranoid, schizoid, and schizotypal personality
2. Cluster B
• Includes people appear dramatic, emotional, or erratic
• Includes antisocial, borderline , histrionic, and narcissistic personality disorder
3. Cluster C
• Includes people who appear anxious or fearful
• Includes avoidant, dependent, and obsessive –compulsive personality disorder

CLUSTER A
Paranoid Personality Disorder
Symptoms / Characteristics
• Mistrust and suspicion of others
• Uses the defense mechanism of projection, which is blaming other people, institutions or events for their
own difficulties
Nursing Interventions
• Approach these clients in a formal, business –like manner and refrain from chi-chat and jokes (serious
and straight forward approach)
• Involve the client in treatment planning
• Teach client to validate ideas before taking action.
Schizoid Personality Disorder
Symptoms / Characteristics
• Detached from social relationships
• Restricted affect and little, if any emotion; aloof and indifferent, appearing emotionally cold, uncaring, or
unfeeling
• Report no leisure or pleasurable activities because they rarely experience enjoyment
• Involve themselves more with things than people
Nursing Interventions
• Focus in improved functioning of the client in the community
• Assist the client to find a case manager one who helps the client to obtain services and health care,
manage finances, etc.

Schizotypal Personality Disorder

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Symptoms / Characteristics
• Has social and interpersonal deficits marked by acute discomfort with andreduced capacity for close
relationships
• Clothes are ill fitting, do not match, and may be strained or dirty
• Cognitive distortions include ideas of reference, magical thinking that he has special powers, unfounded
beliefs

Nursing Interventions
• Development of self-care skills
• Nurse encourage clientto establish a daiy routine for hygiene and grooming
• Improve community functioning and provide social skills training

CLUSTER B
Antisocial Personality Disorder
Symptoms / Characteristics
• Violation of the right of others
• Lying
• Rationalization of own behavior
• Thrill-seeking behaviors
• Poor work history;
• Consistent irresponsibility
Nursing Interventions
• Promote responsible behavior
• Limit setting
• Consistent adherence to rules and treatment plan\the nurse should not become angry or respond to the
client harshly or punitively
• Confrontation – technique designed to manage manipulative or deceptive behavior.
Example:
Nurse: “You’ve said you’re interested in learning to manage angry outbursts, but you’ve missed the last
three group
meetings.”
Client: “Well, I can tell no one in the group likes me. Why should I bather?”
Nurse: “The group meetings are designed to help you and the others, but you can’t work on issues if you
are not there.”

Borderline Personality Disorder

Symptoms / Characteristics
• Fear of abandonment, real or perceived
• Unstable and intense relationship
• Recurrent self-mutilating behavior or suicidal threats or gestures
• Transient psychotic symptoms such as hallucinations, demanding self-harm
Nursing Interventions
• Promote client’s safety
• Helping clients to cope and control emotions
• Cognitive restructuring techniques
• Structure the time
• Teach social skills

Histrionic Personal Disorder

Symptoms / Characteristics
• With a pervasive pattern of excessive emotionality and attention-seeking
• Clients are overly concerned with impressing others with their appearance
• Dress and flirtatious behavior are not limited to social situations or relationships but also occur in
occupation and professional settings
Nursing Interventions

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• It would be more acceptable to stand at least 2 feet away from them and to shake hands,
• Teaching social skills and role-playing those skills in a safe, non-threatening environment can help clients
to gain confidence in their ability to interact socially
• Provide factual feedback about behavior.

Narcissistic Personality Disorder

Symptoms / Characteristics
• Has a pervasive pattern of grandiosity, need for admiration, and lack of empathy for others
Nursing Intervention
• Provide matter-of-fact approach
• The nurse must not internalize such criticism or take it personally
• She sets limits to rude or verbally abusive behavior and explains his or her expectations from the clients.
• Teach client any needed self-care skills

CLUSTER C
Avoidant Personality Disorder
Symptoms / Characteristics
• Pervasive pattern of social discomfort and silence, low self- esteem and hypersensitivity to negative
evaluation
• They fear rejection, criticism, shame or disapproval
• They remain aloof in their relationship and feel inferior to others
Nursing Interventions
• Require much support and reassurance from the nurse
• The nurse can help them to explore positive self-aspects, positive responses from other, and possible
reasons for self-criticism

Dependent Personality Disorder

Symptoms / Characteristics
• Pervasive and excessive need to be taken care of which leads to submissive and clinging behavior and
fears of separation
Nursing Interventions
• Foster client’s self-reliance and autonomy
• Teach problem-solving and decision-making skills
• Cognitive-restructuring techniques

Obsessive – Compulsive Personality Disorder

v Involves obsessions (thoughts, impulses or image) that cause marked anxiety and/or compulsions
(repetitive behaviors or mental acts) that attempt to neutralize anxiety
Symptoms / Characteristics
• Preoccupation with orderliness, perfectionism and control

OBSESSIONS COMPULSION
Fear of Dirt and Games Excessive Hand Washing
Repeated Checking of Door and
Fear of Burglary or Robbery window locks

Nursing Interventions
• Encourage negotiation with others
• Assist clients to make timely decisions and complete work
• Cognitive restructuring techniques
NG DISORDERS
ANOREXIA NERVOSA
v Life-threatening eating disorder characterized by:

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• Client’s refuse or inability to maintain a minimally normal body weight
• Intense fear of gaining weight or becoming fat
• Significant disturbed perception of the shape or size of the body
• Refusal to acknowledge the seriousness of the problem
• Body weight that is 85% less than expected for their age and height

Clinical Manifestations
• Fear of gaining weight • Complaints of constipation & abdominal pain
• Body image disturbance • Cold intolerance
• Amenorrhea • Lethargy
• Depressed mood • Emaciation
• Social withdrawal • Dec BP, Dec Temperature, Dec PR
• Insomnia • Hypertrophy of salivary glands
• Feelings of ineffectiveness • Elevated BUN
• Limited spontaneity • Leukopenia & mild anemia
• Elevated liver function studies

Sub types:
v Binge eating
• Consuming large amount of food in a discrete period of usually 2 hours or less
v Purging
• Compensatory behavior designed to eliminate food by means of self-induced vomiting or misuse of
laxatives, enemas and diuretics
Note: Some clients with anorexia do not binge but engage in purging behavior after ingesting small
amounts of food

Treatment
v Focus on:
• Weight restoration
• Nutritional rehabilitation
• Rehydration
• Correction of electrolyte imbalance
v Drugs
• Amitriptyline (Elavil) & Cyproheptadine (Periactin) for weight gain
• Olanzapine (Zyprexa) = promotes weight gain and produces antipsychotic effect
v Individual therapy

BULIMIA NERVOSA
v Eating disorder characterized by recurrent episode (at least twice a week for 3 months) of binge eating
followed by inappropriate compensatory behaviors to avoid weight gain such as purging, use of laxatives,
diuretics, enemas, and fasting.
v Weight usually in normal range, although some clients are overweight or underweight.
v Low-self-esteem
Clinical Manifestations
• Recurrent episodes of binge eating and purging • Menstrual irregularities
• Selection of low-calorie foods • Dependence in laxatives
• Depressive and anxiety symptoms • Esophageal tears
• Substance use (alcohol and stimulants) • Metabolic alkalosis (vomiting)

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• Loss of dental enamel • Metabolic acidosis (diarrhea)
• Chipped ragged or moth-eaten appearance to • Mildly elevated serum amylase levels
teeth
• Increased dental carries

Common Nursing Diagnoses related to Eating Disorders

• Body Image Disturbance
• Self –esteem Disturbance
• Ineffective Individual Coping
Nursing Interventions
• Promote improved nutrition
• Assume a calm, matter-of-fact attitude and positive expectation of the client
• Behavior modification therapy
• Promote effective individual coping with anxiety
• Improved fluid volume
• Drugs: desipramine (Norpramin), Imipramine (Tofranil), Amitriptyline (Elavil), Nortriptyline (Pamelor),
Phenelzine (Nardil)AL DISORDERS

Paraphilias
v Group of psychosexual disorders characterized by unconventional sexual behaviors
v Abnormal expressions of sexuality

Non-Coercive Paraphilias
v Fetishism
• Sexual arousal elicited by inanimate objects (shoes, leather and rubber) or specific body parts (feet, hair)
v Autoerotic Asphyxia
• Constriction of the neck to enhance masturbation experience
• Often leads to accidental death
v Sexual Masochism
• Erotic interest in receiving psychological or physical pain, real or fantasized
v Transvestitism
• Erotic interest is achieved by using the apparel of the opposite sex

Coercive Paraphilias
v Exhibitionism
• International exposure of the genitals to a stranger
• May be accompanied by arousal and masturbation either during or after the exposure
v Voyeurism
• Secret observation of an unsuspecting person (usually a woman) engaged in a private act (e.g.
undressing, having sex, etc.)
• Voyeur often masturbates during or after the viewing
v Frotteurism
• Intense sexual arousal elicited by rubbing the genitals a non-consenting person
v Pedophilia
• Sexual interest in a child
v Urophilia
• Urinating on the sexual partner
v Coprophilia
• Smearing feces on the partner
v Sadism
• Erotic interest in inflicting physical pain

Nursing Interventions
• Diversional activities

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• Limit-setting
• Behavior modification

SCHIZOPHRENIA
v Coined by Bleuler to describe a lack of integration of the patient’s functions
v Distorted and bizarre thoughts perceptions, emotions, movements and behavior
v Disturbance in thought process and perception for at least 6 months.
v Usually diagnosed in late adolescence and early adulthood
v Main Problem: Altered thought Process

Two major categories

v Positive/Hard symptoms
v Negative/soft Symptom

POSITIVE/HARD SYMPTOMS NEGATIVE/SOFT SYMPTOMS

Hallucination Alogia
Delusions Anhedonia
Ambivalence Apathy
Associative Looseness Blunted affect
Echopraxia Catatonia
Flight of ideas Flat affect
Ideas of reference Lack of volition (Avolition)
Perseveration

General Manifestations
1. Perceptual changes
v Perceptions may either be heightened or blunted
v May occur in all senses or in just one or two.
v Hallucinations (hallmark of Schizophrenia)
v May be visual, olfactory, gustatory, tactile or auditory

2. Disturbances in Thought
v Clang associations
• Ideas that are related to one another based on sound or rhyming rather than meaning.
Example: “I will take a pill if I go up to the hill but not if my name is Jill, I don’t want to kill.”
v Delusions
• Disturbances in the content rather than the form of thought.

Types
• Persecutory/Paranoid Delusions
ü Involve the client’s belief that “other” are planning to harm the client or are spying, following, ridiculing
or belittling the client in some way.
Example: The client may think that food has been poisoned or that rooms are bugged with listening
devices.
• Grandiose Delusions
ü Characterized by the client’s claim to association with famous people or celebrities, or the client’s belief
that he or she is famous or capable of great feats.
• Religious Delusions
ü Often center around the second coming of Christ or another significant religious figure or prophet.
Example: client claims to be the Messiah or some prophet sent from God; believes that God communicates
directly to him
or her, or that he or she has a “special” religious mission in life or special religious powers.
• Somatic Delusion
ü Generally vague and unrealistic beliefs about the client’s health or bodily functions.

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Examples: A male client may say that he is pregnant, or a client may report decaying intestines or worms in
the brain.
• Referential delusion / Ideas of Reference
ü Involve the client’s belief that television broadcasts, music, or newspaper articles have special meaning
for him or her.
Examples: The client may report that the president was speaking directly to him on a news broadcast or
that special
messages are sent through newspaper articles.

3. Changes in Communication
[Link] Communication
B. Tangential Communication
[Link] Disorganization
ü Responses are inappropriate to the situation
D. Thought Blocking
ü Stopping abruptly in the middle of a sentence or train of thoughts
ü Sometimes unable to continue the idea
E. Alogia
ü Poverty of content describes the lack f any real meaning are substance in what the client says
Example:
Nurse: ”How have you been sleeping lately?”
Client: “Well, I guess, I do not know... it’s hard to tell.”
v Thought Broadcasting
• A delusion belief that other can hear or know what the client is thinking
v Thought Insertion
• A delusional belief that others are taking the client’s thoughts away and the client is powerless to stop it.
v Neologisms
v Echolalia
v World salad

Treated for schizophrenia

v Antipsychotic ( Atypical & typical)
• Best taken after meals
Nursing Intervention
• Provide adequate communication
• Promote compliance with medical regime
• Assist with grooming and hygiene
• Promote organized behavior
• Promote social interaction and activity
• Social skills training
• Promote reality-based perceptions as hallucinations and illusions often frighten clients

MOOD / AFFECTIVE DISORDERS

v Pervasive alterations in emotions that are manifested by depression, mania or both.

Common Etiological Theories of Mood Disorders

v Genetic Theory
• If one parent has a bipolar these is 25% chance of transmission to the child
v Aggression Turned Inward Theory
• Overdeveloped superego leads to depression
v Object Loss Theory
• Loss of parent before age 11 increases the risk of depression
v Personality Organization Theory

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 • Obsessive-compulsive, oral-dependent, hysterical personalities have higher redisposition
to moon disorders
v Cognitive Theory
• mood disorder result from:
ü Negative views of the self and future
ü Negative interpretation of experiences
v Learned Helplessness Theory
• Mood disorder is caused by a belief that one has no control over his environment.
v Biologic factors
• Mania is related to increased levels of norepinephrine while depression is related to low
norepinephrine levels.
Precipitating Factor
• Major life events
• Decrease coping resources
• drastic Physiological changes
• Loss of a loved one

Categories of Mood Disorder

1. Major depressive Disorder
v Last at least 2 weeks
v Person experience a depressed mood or loss of pleasure in nearly all activities
v Four of the following symptoms are present:
• Changes in appetite or weight
• Changes in sleep or psychomotor activities
• Decreased energy
• Feelings of worthlessness or guilt
• Difficult thinking, concentrating or making decisions
• Suicidal ideation, plans or attempts
v Symptoms must be present every day for 2 weeks
2. Bipolar Disorder
v It is diagnosed when a Person's mood cycles between extremes of mania and depression

3. Mania
• It is a distinct period during which mood is abnormally and persistently elevated expansive or irritable
• Period lasts for 1 week
• At least 3 of the following symptoms accompany the manic episode:
ü Inflated self-esteem 'grandiosity
ü Decreased need for sleep Pressured speech
ü Flight of ideas
ü Distractibility
ü Psychomotor agitation Hallucinations

Hypomania
• Period of abnormally and persistently elevated expansive or irritable mood tasting 4 days and
including three or four of additional symptoms
• Difference: Hypomanic episodes do not impairthe person's ability to function and there
are no psychotic features (hallucinations & delusions)
• Less severe than mania

Mixed episode
• Also termed as rapid-cycling
• Diagnosed when the person
• experiences both mania and depression nearly every day for at least 1 week.

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 •With history of mania
Bipolar I Disorder •One or more manic or mixed episodes usually accompanied by major
depressive episode
•No history of mania
Bipolar II Disorder •One or more major depressive episode accompanied by at least one hypomanic
episode

ü Other disorders that are classified as mood disorders but lacks symptoms that required
for a bipolar or depressive disorder:
v Dysthymic Disorder
• Less severethan major depression
• Characterized by at least 2 years of depressed mood for more days than with
some additional less severe symptoms that do not meet the criteria for a
major depressive episode
v Cyclothymic Disorder
v Characterized by 2 years of numerous periods of both hypomanic symptoms that
do not meet the criteria of bipolar disorder

3. Substance-Induced Mood Disorder

v Characterized by a prominent and persistent disturbance in mood that is judged
to be a direct physiological consequence of ingested substances such as alcohol
and other drugs, or toxins

Other Disorders that involve changes in mood include the following:

v Seasonal Affective Disorder (SAD)
Winter-Depression
• Fall-onset SAD
• People experience increased sleep
• Appetiteand carbohydratecravings
• Weight gain
• Interpersonal conflict beginning in the late autumn and a bating in spring and summer

Spring-onset
• Less common
• Insomnia, weight loss, and poor appétit
Lasts from late spring or early summer until early fall.

v Postpartum Blues
• Frequent normal experienceafter delivery of a baby
• Characterized by labile mood and affect, sadness. insomnia and anxiety.
• Peak in 3 to 7 days
• Disappear rapidlywithnomedical
Treatment
v Postpartum Depression
• Meets allthecriteria for a depressive episode with onset with. weeks of delivery
v Postpartum psychosis
• Psychotic episode developing within 3 weeks of delivery.

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 • Begins with fatigue, sadness, emotional lability, poor memory, and confusion sod
progressing to delusions & hallucinations.

GRAPHIC REPRESENTATION OF CYCLES OF BIPOLAR DISORDER

TREATMENT
v Lithium carbonate
• Can stabilized bipolar disorder by reducing the degree and frequency of cycling or eliminating
manic episode
• Mechanism of action is unknown
• Works in the synapses to hasten destruction of catecholamines, inhibit neurotransmitter
releases & decrease the sensitive of postsynaptic receptors
• Crosses the blood-brain barrier and placenta
• Not used during pregnancy

LITHIUM THERAPHY: NURSING RESPONSIBLITY

Medication
Administration Best taken after meals
Normal level 0.5- 1.5 mEq/L
Toxicity Report: Severe nausea, vomiting diarrhea, muscle weakness & tremors
Management: Administration of Mannitol
Therapeutic Effects Take 10 -14 days before therapeutic effect becomes evident
Fluids Adequate amount of fluid (2-3 L/day)
Sodium Salt intake (2-3 L/day)
Monitor daily weights and the balance between intake and output and checking
Weight for
dependent edema
If there is too much water, lithium is diluted and the lithium level will be too low
Other Information to be
therapeutic
Drinking too little amount of water or losing fluid through excessive sweating,
vomiting or
diarrhe will increase the lithium level, which may result in toxicity

Nursing Intervention
• provide for client's physical safety and safety of those around the client
• Assess client for suicidal Ideation. plans or thoughts of hurting others

40
 • Clients in the manic phase have little insight into their anger and agitation and how their
behaviors affect others
• Set limits on clients behavior when needed and remind client to respect distances between
self and others
• Clarity the meaning of client's communication
• Frequently provide finger foods that are high in calories and protein
• Promoterestandsleepby decreasing environmental stimulation
• Establishing bedtime routine
• Nurse should handle behavior in a matter-ot tact approach and non-judgmental manner
• It is Important to treat clients with dignity ,us, s respect despite their Inappropriate behavior

Treatment Modalities for Depression

• Electroconvulsive Therapy
• psychopharmacology
ü Tricyclic Antidepressant
ü MAOI
ü SSRI

SOMATOFORM DISORDER
v Description: it can be characterized as the presence of physical symptoms that suggest a medical
condition without a demonstrable organic basis to account fully for them:
v Three Central Features:
• Physical complaints suggest major medical illness but have no demonstrable organic basis
• Psychological factor and conflicts seems important in initiating, exacerbating, and maintaining the
symptoms.
• Symptoms or magnified health concerns are not under the client’s conscious control.
v Somatoform disorder:
Ø Somatoform disorder- Characterized by multiple physical symptoms. It begins by 30 years of age,
extends over several years, and includes a combination of pain and gastrointestinal, sexual, and pseudo-
neurologic symptoms.

SYMPTOMS OF SOMATIZATION DISORDER

Pain symptoms: complaints of headaches; pain in the abdomen, head, Joints, back, chest,
rectum, pain during urination, menstruation, or sexual intercourse

Gastrointestinal symptoms: nausea, bloating, vomiting (other than during pregnancy), diarrhea, or
Intolerance of several foods

Sexual symptoms: sexual Indifference, erectile or ejaculatory dysfunction, irregular menses,

excessive menstrual bleeding, vomiting through-out pregnancy

Pseudo-neurologic symptoms: conversion symptoms such as Impaired coordination or balance,

paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention,
hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures;
dissociative symptoms such as amnesia; or loss of consciousness other than fainting

• Conversiondisorders-sometimes called conversion reaction,involves unexplained, usually sudden

deficits insensory or motor function (e.g., blindness, paralysis)
ü These deficits suggest a neurologic disorder but are associated with psychological factors.
ü La belle in difference, a seeming lack of concernor distress, is a key feature.

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• Pain disorder- has the primary physical symptom of pain,which generally is unrelieved by
analgesics and greatly affected by psychological factors interms of onset,severity,
exacerbation and maintenance.

• Hypochondriasis
ü Disease conviction- is preoccupation with the fear that one has a serious disease
ü Disease phobia- one will get a serious disease
ü It is thought that clients with this disorder misinterpret bodily sensations or functions.

• Body dysmorphic disorder

ü It is preoccupation with an imagined or exaggerated defect in physical appearance such as
thinking one's nose is too large or teeth are crooked and unattractive.

v Other Related Disorders

• Malingering
ü it is the intentional production of false or grossly exaggerated physical or psychological
symptoms
ü it is motivatedby incentives suchasavoiding work, evading criminal
prosecution, obtaining financial compensation, or obtaining drugs.
ü People who malinger can stop the physical symptoms as soon as they have gained what
they wanted
• Factitious disorder occurs when a person intentionally produces or feigns physical or
psychological symptoms solely to gain attentions.
ü Munchausen’s syndrome- people with factitious disorder may even inflict injury to
themselves to receive attention
ü Munchausen's by proxy- Occurs when a person inflicts illness or injury on
someone else to gain the attention of emergency medical personnel or to be a
"hero" for saving the victim.

v Psychosocial Theories
• Internalization- people with somatoform disorders keep stress, anxiety,
frustration inside rather than expressing them outwardly.
• Somatization-clients express these internalized feelings and stress through physical symptoms
• Both internalization and somatization are unconscious defense mechanisms.
• Primary gains are the direct external benefits that being sick provides such as relief of
anxiety, conflict, or distress.
• Secondary gains are the internal or personal benefits received from others because
\ one is sick such as attention from family members

v Biologic Theories
• Clients cannot sort relevant from irrelevant stimuli and respond equally to both types.
• They may experience a normal body sensation such as peristalsis and attach a pathologic than
a normal meaning to it
• Awareness of physical symptoms and exaggerates response to bodily sensations.
• This amplified sensory awareness causes the person toexperience somatic sensations as
more intense, noxious, and disturbing

v Management:
• Treatment focuses on managing symptoms and improving quality of life.
• The health care provider must show empathy and sensitivity to the clients physical complaints
• A trusting relationship will help to ensure that clients stay with and receive care from
one provider instead of "doctor shopping.'
• The nurse should never try to confront the client about the origin of these symptoms until
the client has learned other coping strategies.

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 • Selective serotonin re-uptake inhibitors are used most commonly for the accompanying
depression
ü Fluoxetine (Prozac)
ü Sertraline (Zoloft)
ü Paroxetine (Paxil)
Pain
• Pain management such as visual imaging and relaxation.
• Services such as physical therapy to maintain and build muscle tone help to improve functional
abilities.
• Providers should avoid prescribing and administering narcotic analgesics to these clients
because of the risk of dependence or abuse
• Clients can use non-steroidal anti-inflammatoryagents to help reduce pain.
Involvement in therapy groups is beneficial for some people with somatoform
disorders

Health teaching:
• Establish a daily routine.
• Promote adequate nutrition and sleep.
• Expression of emotional feelings
• Recognize relationship between stress/coping and physical symptoms.
• Keep journal
• Limit time spent on physical complaints
• Limit primary and secondary gains.
• Coping strategies
• Emotion-focused coping strategies such as relaxation techniques, deep breathing, guided
imagery, and distraction
• Problem-focused coping strategies such as problem-solving strategies and role playing

v Two categories of coping strategies:

• Emotion-focused coping strategies,which help clients relax and reduce feeling of stress
ü Progressive relaxation
ü Deep breathing
ü Guided imagery
ü Distractions
v Problem-focused coping strategies: which help to resolve or change a client’s behavior and
situation or manage life stressor
ü Problem-solving method
ü Applying the process to identified problems
ü Role-playing interactions with others.

Substance Abuse
v Terminologies:
• Intoxication- use of a substance that results In maladaptive behavior
• Withdrawal syndrome- refers to the negativepsychological and physical reactions that
occur when use of a substance abuse ceases or dramatically decreases
• Detoxification- the process of safely withdrawing from a substance
• Substance abuse- defined as using a drug in a way that is inconsistent with
medical or social norms and despite negative consequences. Itdenotes problems in
social, vocational, or legal areas of the person's life.
• Substance dependence- includes problems associated with addiction such as
tolerance, withdrawal and unsuccessful attempts to stop using the substance.

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 • Black-out- a episode during which the
person continues to function but has no consciousawarenessof his or her behavior
• Tolerance- the patient needs more of the substance (alcohol) to produce same effect.
• Tolerance break- after continued heavy drinking, the person experiences intoxication in a
very small amount of the substance (alcohol).
• Spontaneous remission- also known as natural recovery. Some people with alcohol
problems can modify or quit drinking on theirownwithouta treatment program

v Biological factors
• Generic/ hereditary- children of alcoholic parents are at higher risk for developing
alcoholism and drug dependence than are children of non-alcoholicparents.
• Distribution of the substance throughout the brain alter the balance of
neurotransmitter that modulate pleasure, pain, and reward responses

v Psychologic factors
• Inconsistency in the parent’s behavior, poor role modelling, and lack of nurturing pave
the way for the child to adopt a similar style of maladaptive coping, stormy
relationship, and substance abuse.

v Social and environmental factors

• Cultural factors, social attitudes, peer behaviors, laws, cost, and availability all influence
initial and continued use of substance.
ALCOHOLISM
v Intoxication:
• Clinical manifestations
ü Slurred speech
ü Unsteady gait
ü Lack of coordination
ü impaired memory. and judgment
ü Aggressive or display inappropriate sexual behavior
ü Blackout
• Treatment:
ü Gastric lavage
ü Dialysis
ü Support of respiratory and cardiovascular functioning in an intensive care unit.
ü The administration of central nervous system stimulants is contraindicated
ü Withdrawal and Detoxification
• Symptoms of withdrawal usually begin 4
to 12 hours after cessation or marked reduction of alcohol intake
• Withdrawal may take 1 to 2 weeks.
Clinical manifestations:
ü Coarse hand tremors
ü Sweating
ü Elevated pulse and blood pressure
ü Insomnia
ü Anxiety
ü Nausea or vomiting
ü Transient hallucinations, seizures, or delirium— delirium tremens (DTs).
Treatment:
ü Administration of benzodiazepines such as:
Ø Lorazepam (Ativan),
Ø Chlordiazepoxide (Librium)
Ø Diazepam (Valium).

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 • Detoxification:
ü Disulfiram- Antabuse

PHYSIOLOGIC EFFECTS OF LONG-TERM ALCOHOL USE

• Cardiac myopathy
• Wernicke's encephalopathy
• Korsakoff's psychosis
• Pancreatitis
• Esophagitis
• Hepatitis
• Cirrhosis
• Leukopenia
• Thrombocytopenia
• Ascites

Sedatives, Hypnotics And Anxiolytics

v This class of drugs includes all central nervous system depressants:
• Barbiturates
• Nonbarbiturate
• Hypnotics
• Anxiolytics

v Intoxication:
• Clinical manifestations:
ü Slurred speech
ü Lack of coordination
ü unsteady gait
ü Labile mood
ü Impaired attention or memory
ü Stupor and coma

v Benzodiazepines
ü rarely fatal
ü lethargic and confused
v Barbiturates
ü Can be lethal
ü Coma
ü Respiratory arrest
ü Cardiac failure
ü Death

v Treatment:
ü Benzodiazepines:
Ø Gastric lavage
Ø Ingestion of activated
Ø charcoal
Ø Saline cathartic
Ø Dialysis.

ü Barbiturates:
Ø Intensive care unit
Ø Lavage or dialysis

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 Ø Support respiratory and cardiovascular function

v Withdrawal and Detoxification

• The onset of withdrawal symptoms depends on the half-life of the drug
• Clinical manifestations:
ü Autonomic hyperactivity (Increased pulse, blood pressure, respirations and temperature)
ü Hand tremors
ü Insomnia
ü Anxiety
ü Nausea
ü Psychomotor agitation
ü Seizures
ü Hallucinations

v Detoxification:
• Managed medically by tapering the amount of the drug the client receives over a period of
days or weeks,
• Tapering, or administering decreasing doses of a medication, is essential with
barbiturates to prevent coma and death that willoccur if the drug is stopped abruptly.

STIMULANTS (AMPHETAMINE, COCAINE AND OTHERS)

• Stimulants are drugs that stimulate or excite the central nervous system.
• Amphetamines ("uppers") were popular in the past;they were used by people who wanted to lose
weight or to stay awake
• Cocaineanillegal drug with virtually no clinical use in medicine, is highly addictive and a
popular recreational drug because of the intense and immediate feeling of euphoria it
produces.
• Methamphetamine is particularly dangerous. It is highly addictive and causes psychotic
behavior. Brain damage related to its use is frequent, primarily as a result of the substances
used to make it.
• Intoxication and overdosage
Clinical Manifestation
ü High or euphoric feeling
ü Hyperactivity
ü Hypervigilance
ü Talkativeness
ü Anxiety
ü Grandiosity
ü Hallucinations
ü Stereotypic or repetitive behavior
ü Anger
ü Fighting
ü Impaired judgment
ü Tachycardia
ü Anorexia/ Loss of appetite
ü Elevated blood pressure
ü Dilated pupils, perspiration or chills, nausea, chest pain, confusion, and cardiac
dysrhythmias.
ü Overdoses of stimulants can result in seizures and coma ; deaths

v Treatment with Chlorpromazine (Thorazine), an antipsychotic,controlshallucinations, lowers

blood pressure, and relieves nausea

v Withdrawal and Detoxification

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 • Withdrawal from stimulants occurs within a few hours to several days after cessation of the
drug and is not life threatening.
• Marked dysphoria is the primary symptom andisaccompaniedby fatigue, vivid and unpleasant
dreams, insomniaor hypersomnia, increased appetite, and psychomotor retardation or
agitation
• Marked withdrawal symptoms are referred to as "crashing symptoms;"
• The person may experience depressive symptoms including suicidal ideation for several days.
• Stimulant withdrawal is not treated Pharmacologically.

Cannabis (Marijuana)
v Cannabis sativa is the hemp plant that is widely cultivated for its fiber used to make rope and cloth
and for oil from its seeds.
v Marijuanarefers tothe upper leaves, floweringtops,and stems of the plant; hashish is the dried
resinous exudate from the leaves of the female plant.
v Cannabis is most often smoked in cigarettes (“joints”), but it can be eaten.

v Effects:
• Cannabis begins to act less than 1 minute after inhalation.
• Peak effects usually occur 20 to 30
minutes and last at least 2 to 3 hours
Clinical Manifestations:
ü Impaired motor coordination
ü Inappropriate laughter
ü Impaired judgement and short-term memory
ü Distortion of time and perception.
ü Anxiety
ü Dysphoria
ü Social withdrawal
ü Increased appetite
ü Conjunctive injection (bloodshot eyes)
ü Dry mouth
ü Hypotension
ü Delirium
ü Cannabis-induced psychotic disorder

v Withdrawal and Detoxification

• No clinically significant withdrawal syndrome is identified
• Cannabis does not cause intoxication.

Opioids
v Populardrugsofabusebecausethey desensitize the user to both physiologic and psychological pain
and induce a sense of euphoria and well being
v Opioids:
• Morphine
• Meperidine (Demerol)
• Codeine
• Hydromorphone
• Oxycodone
• Methadone
• Oxymorphone
• Hydrocodone
• Propoxyphene
• Heroin
• Normethadon

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Intoxication
• Clinical manifestation
ü Euphoric feeling
ü Apathy
ü Lethargy
ü Listlessness
ü Impaired judgement
ü Psychomotor retardation or agitation
ü Constricted pupils
ü Drowsiness
ü Slurred speech
ü Impaired attention and memory
ü Coma
ü Respiratory depression
ü Papillary constriction
ü Unconsciousness
ü Death
• Treatment
ü Administration of Naloxone (Narcan)
Ø An opioid antagonist
Ø Is the treatment of choice because it reverses all signs of opioid intoxication.
Ø Naloxone is given every few hours until
the opioid level drops to nontoxic v
Withdrawal and Intoxication
• Clinical Manifestations:
ü Anxiety
ü Restlessness
ü Aching back and leg
ü Cravings for more opioids
ü Nausea
ü Vomiting
ü Dysphoria
ü Lacrimation
ü Rhinorrhea
ü Sweating
ü Diarrhea
ü Yawning
ü Fever
ü Insomnia

• Treatment:
ü Do not require pharmacologic intervention to support life or bodily functions.
ü Methadonecanbeusedasa replacement for the opioid

Hallucinogens
Substances that distort the user's perception of reality and produce symptoms similar to psychosis
including hallucinations (usually visual) and depersonalization

v Examples of hallucinogens:
• Mescaline
• Psilocybin
• Lysergic acid

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 • Lysergic acid Diethylamide (LSD)
- "Designer drugs" such as Ecstasy.
• Phencyclidine (PCP)

v Intoxication and Overdose

• Clinical Manifestations
ü Anxiety
ü Depression
ü Paranoid ideation
ü Ideas of reference
ü Fear of losing one's mind
ü Potentially dangerous behavior such as jumping out a window in the belief that one can fly.
ü Sweating
ü Tachycardia
ü Palpitations
ü Blurred vision
ü Tremors
ü Lack of coordination
ü Belligerence
ü Aggression
ü Impulsivity
ü Unpredictable behavior

• Treatment:
ü These drugs are not a direct cause of death although fatalities have occurred from related
accidents, aggression and suicide
ü Treatment is supportive.
ü Psychotic reactions are managed best byisolationfrom external stimuli
ü Physical restraints
ü Cooling devices such as a hyperthermia blanket are used and mechanical ventilation is used to
support respirations

v Withdrawal and Detoxification

ü No withdrawal syndrome has been identified for hallucinogens,although some people have
reported a craving for the drug.
ü Hallucinogens can produce flashbacks, which are transientrecurrencesof perceptual disturbances

Inhalants
v Diverse group of drugs including anesthetics, nitrates, and organic solvents that are inhaled for their
effects.
v Inhalants can cause significant brain damage, peripheral nervous system damage, and liver disease.
v Inhalants:
• Gasoline
• Glue
• Paint thinner
• Spray paint
• Cleaners
• Correction fluid
• Spray can propellants
• Esters
• Ketones
• Glycols
v Intoxication
• Clinical manifestations:

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 ü Dizziness
ü Nystagmus,
ü Lack of coordination
ü Slurred speech
ü Unsteady gait,
ü Tremors
ü Muscle weakness
ü Blurred vision
ü Stupor and coma can occur
ü Belligerence
ü Aggression
ü Apathy
ü Impaired judgment
ü Inability to function
Acute toxicity:
ü Anoxia
ü Respiratory depression
ü Vagal stimulation
ü Dysrhythmias
ü Death- bronchospasm,cardiac arrest, suffocation, aspiration of the compound or vomitus

• Treatment
ü Supporting respiratory and cardiac functioning until the substance is removed from the body
ü There are no antidotes or specific medications to treat inhalants toxicity.

v Withdrawal and detoxification

• There are no withdrawal symptoms or detoxification procedures foe inhalants
• Persistent dementia
• Inhalant-including disorders- psychosis, anxiety, or mood disorder

MANAGEMENT
v Alcoholics Anonymous (AA)
• Founded in the 1930’s by alcoholics
• Self-help group developed the 12 step program model for recovery which is based on the philosophy that
total abstinence is essential and that alcoholics need help and support of others to maintain sobriety.

v AA meetings
• "Closed" - only those who are pursuing recovery can attend
• "Open"- anyone can attend
ü Narcotics Anonymous
ü Al-Anon-Asupport group for spouses, partners, and friends of alcoholics
ü AlaTeen- A group for children of parents with substance problems.
v Nursing Alert:
• Alcohol
ü VitaminB1 (thiamine) often is prescribed to prevent or to treat Wernicke's syndrome and Korsakoff's
syndrome,which are neurologic conditions thatcan result from heavy alcohol use.
ü Cyanocobalamin (Vitamin B12) and folic acid often are prescribed for client with nutritional deficiencies.
ü Disulfiram (Antabuse) may be prescribed to help to deter clients from drinking.
Ø If aclient taking disulfiram drinks alcohol, a severe adverse reaction occurs:
o Flushing
o Throbbing headache
o Sweating
o Nausea and vomiting
o Severe hypotension
o Confusion

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o Coma
o Death

• Opiates
ü Methadone
 A potent syntheticopiate is used as a substitute for heroin in some maintenance programs
 Meets the physical need for opiates but does not produce cravings for more

ü Levomethadyl
 Is a narcotic analgesic whose only purpose is the treatment of opiate dependence

ü Naltrexone (ReVia)
 It is an opioid antagonist often used to treat overdose.
 It blocks the effects of any opioids that might be ingested
 Negating the effects of using more opioids used in the same manner as methadone.

ü Clonidine (Catapres)
Ø is analpha-2-adrenergic agonist used to treat hypertension.
 It is given to clients with opiate dependence to suppress some effects of withdrawal or
abstinence
 It is most effective against nausea, vomiting, and diarrhea but produces modest
relief from muscle aches, anxiety, and restlessness

ü Ondansetron (Zofran)
 A 5-HT3 antagonist that blocks the vagal stimulation effects of serotonin inthe small
intestine
 It is used as an antiemetic

NURSING INTERVENTIONS FOR CLIENTS WITH SUBSTANCE ABUSE

• Health teaching for the client and family

• Dispel myths surrounding substance abuse
• Decrease codependent behaviors among family members
• Make appropriate referrals for family members
• Promote coping skills
• Role-play potentially difficult situations
• Focus on the here-and-now with clients
• Set realistic goals such as staying sober today

DISSOCIATIVE DISORDERS
 Dissociation-is a subconscious defense mechanism that helps a person protect is or her
emotional self from recognizing the full effects of some horrific or traumatic event by
allowing the mind to forget or remove itself from the painful situation or memory.
 Dissociative disorders-essential feature of a disruptionintheusually integrated
functions of consciousness, memory,identity or environmental perception

TYPES OF DISSOCIATIVE DISORDER

v Dissociative amnesia
• The client cannot remember important personal information usually of a traumatic or stressful
nature.

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v Dissociative fugue
• The client has episodes of suddenly leaving the home or place of work without any
explanation, traveling to another city,and being unable to remember his or her past or
identity. He or she may assume a new identity

v Dissociative identity disorder

• Formerly multiple personality disorder
• The client displays two or more distinct identities or personality states that recurrently
take control of his or her behavior.
• This is accompanied by the inability to
recall important personal information.
• Depersonalization disorder
• The client has a persistent or recurrent feeling of being detached from his or her mental
processes or body.
• Thisis accompanied by intact reality testing
• The clientis not psychotic or out of touch with reality.

ASSESSMENT FINDINGS
v General Appearance and Motor Behavior
• Appears hyperalert and reacts to even small environmental noises with a startle response.
• He or she may be very uncomfortable if the nurse is too close physically
• The client may appearanxious or agitated and may have difficulty sitting still
• Pace or move around the room.
• Curl up with arms around knees

v Mood and Affect

• Look frightened or scared, or agitated
• May cry, scream, or attempt to hide

v Thought process
• Self-destructive thoughts and impulses
• Intermittent suicidal ideation

v Sensorium and Intellectual Process

• Memory gaps-periodsfor which they have no clear memories

v Self-concept
• Clients will have low self-esteem. They may believe they are bad people who somehow
deserve or provoke the abuse.

v Roles and Relationships

• Close relationships are difficult or impossible
• Ability to trust others is severely compromised.

v Physiologic signs
• Difficulty sleeping because of nightmares or anxiety over anticipating nightmares
• Overeating or lack of appetite
• Clients use alcohol or other drugs to attempt to sleep or to blot out intrusive thoughts or
memories

MANAGEMENT
v Pharmacologic management:

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 • Paroxetine (Paxil)
• Sertraline (Zoloft)

v Psychotherapy:
• Group or individual therapy
• Cognitive behavioral therapy
• Focuses on re-association or putting the consciousness back together

v Nursing Management:
• Assess the client's potential for self harm or suicide
• Help the client learn to go to a safe place during destructive thoughts and impulses so
that he or she can calm down and wait until they pass
• Grounding techniques remind the client that he or she is in the present, as an adult and is safe.
• Getting the client to standand walk around helps to dispel the dissociative or flashback
experience
• The nurse encourages the client to write down feelings throughout the day at specified intervals
• Deep breathing and relaxation
• Focus on sensory information or stimuli in the environment
• Engage in positive distractions
ü Physical exercise
ü Listening to music
ü Talking to others,
ü Engaging in a hobby or activity
ü Often it is useful to view the client as a survivor of trauma or abuse rather than a victim

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