PSychiatric NurSing
Psychiatric Nursing
Anxiety related disorders
• Dissociative identity disorder
• Generalized anxiety disorder
• Obsessive compulsive disorder
• Panic Disorder
• Phobic disorder
• Post traumatic disorder
• Somatoform disorder
Assessment: Level of anxiety
MILD “You seem anxious.”
Enhanced learning, sit restlessly, widened perceptual field
MODERATE - Give - Anti-anxiety drugs-valium
Patient is pacing, selective inattention. …
SEVERE “I don’t know what to say or do.”
Hard to make decisions.
PANIC Suicidal.
Highest level of anxiety.
Priority: safety.
Stay with patient. Don’t touch patient.
Generalized Anxiety Disorder
Common form of anxiety disorder
• Depression
• Somatization
• Phobias
Genetics and alteration in neurotransmitters
Serotonin
Norepinephrine
Gamma – Aminobutyric acid
• It worries excessively over everything, affects every aspect of life
• GAD way of relieving anxiety
• Retreating from anxiety – situation
• Self medication with drugs or alcohol
Post – Traumatic Stress Disorder
• Develops after exposure to a clearly identifiable threat
• Acute PTSD = Occurs within 6 months
• Delayed PTSD = Occurs 6 months or more
Symptoms
• Blunted emotions
• Feelings of detachment
• Flashback
• Moral Guilt
• Numbing of responsiveness
• Survivor Guilt
• Depression
• Self destructive behaviours
• Suicidal attempts
• Substance abuse
• PTSD is common who are survivor of combat, natural disasters , sexual assault or catastrophic events
Warning:
• Clients with PTSD who use cocaine or amphetamines are more vulnerable to paranoia and psychosis than those who do not use stimulants
Dissociative Identity Disorder (DID)
( multiple personality disorder )
• Two or more identity, alters personalities that control individual behaviour
• Dissociation – act as a defense against an overwhelming sense of anxiety that is both painful and emotionally traumatic.
• Trauma: physical , emotional or sexual abuse
Time travel
Same person with different personality with each other.
• Having its own name
• Ways of behaving
• Memories
• Emotional characteristics
• Social relationship
• Unexpected travel of personality.
• Hehehe. . For some it is normal
Somatoform disorder
• Appearance of physical symptoms for which there is no apparent organic or physiologic cause.
• Seek medical attention even though he has been told that there is no evidence of physical illness:
• Conversion Disorder
• Hypochondriasis
• Pain Disorder
• Somatization Disorder
Panic Disorder
• Sudden attacks of intense fear of discomfort that peaks within 10 – 15 minutes
Assessment:
• not being able to breathe
• Feeling of heart attack
• Going crazy
What’s the problem?
• Agoraphobia
Agoraphobia
• Fear of open space
• Restrict activities outside the safety of their home
• Panic attack can be brought on by caffeine, carbon dioxide and sodium lactate
Factors affect panic disorder
• Genetic
• Environmental Factors
• Benzodiazepine receptor sites alteration
Phobic Disorders
• Expressed as intense , irrational fears of some object, situation , or activity
• The patient experience anxiety when he comes contact with the situation or feared object
What’s the problem?
• Intense fear and restlessness
Three major categories of phobic disorders
• Agoraphobia
• Social Phobia
• Specific Phobia
Therapy
• Cognitive behavior therapy
• Desensitization
Obsessive – Compulsive Disorder
• Recurrent persistent thoughts, ideas, or impulses
• Repetitive rituals in response to the obsession
• It is their defense to avoid overwhelming anxiety
What’s the problem?
• Interferes with normal activity and relationships
• Others view this as rigid, controlling and lacking spontaneity
Some evident shows:
• Genetic transmissions or alterations in serotonin regulation
Antidepressant medication:
Panic disorder
Obsessive – compulsive
Cognitive behavioral therapy and desensitization
PTSD
Phobic disorders
Important nursing interventions:
• Administering antidepressant medication
• Helping the client to become more aware of situations that increase anxiety
• Helping the client to recognize the overuse of certain defense mechanisms
• Teaching cognitive behavioral methods for reducing anxiety
Personality Disorder
• Reality based disorders
• They see nothing wrong with their behavior
• It refer to pervasive maladaptive patterns of behavior that are evident in the perceptions, communication, and thinking of an individual
Three cluster of personality disorder
Cluster A – Include Odd, eccentric Behavior
• Paranoid
• Schizoid
• Schizotypal
Cluster B – Dramatic , erratic, emotional behavior
• Histrionic
• Narcissistic
• Antisocial
• Borderline
Cluster C – anxious and fearful behavior
• Avoidant
• Dependent
• Obsessive – Compulsive
Cluster A
Paranoid Personality Disorder
• Rigid
• Suspicious
• Hypersensitive behavior
• They spend there great deal of time and energy validating their suspicions
• Do not have delusions or hallucination
What’s the problem?
• Extreme stress : transient psychotic features
• Uncontrollable Anger toward others
What’s your nursing goal?
• Safety of both health personnel and other patient
Schizoid Personality Disorder
• Shy
• Aloof
• Withdrawn Behavior
• Hermit – prefers solitary activities
• This patient are reality oriented
What’s the problem?
• The patient often fantasizes and daydream
What's your nursing goal?
• Patient’s Health ( nutrition )
Schizotypal Personality Disorder
• Found more often in relatives of those with schizophrenia
• Shy
• Aloof
• Withdrawn
• Bizaare way of thinking
What is the problem?
• They are sensitive to the reactions of and possible rejection by others
• Avoid social interaction
Cluster B
Histrionic personality disorder
• Southern belle syndrome
• Diagnosed most often in female
• Overly seductive
• Excitable
• Immature
• Emotional
What’s the problem?
• Manipulative
• Many shallow relationship that are always short lived
Narcissistic Personality disorder
“It’s all about me”
• Self absorption
• Grandiose ideas: wealth
power
intelligence
• They believe that they are superior; entitled to certain privileges and special treatment
What’s the problem?
• Cover up for deep feelings of resentment and rage
• Rationalize or blame others for their self- centered behavior
Antisocial Personality disorder
• Pattern of disregard for the rights of others
• Failure to learn from the past mistakes
• Law violation at early age of 15
Early childhood behavior:
• Animal Cruelty
• Normally Runs away from home
• Truancy
• Inflict pain to others
• Starting fire
• Obviously Intelligent
• Charming
• Ideally Smooth talking
• Abuse substances
• Law Breaking
What’s the problem?
• Take advantage of others
• Do not feel remorse for wrong doings
Defense mechanism use:
• Denial and Rationalization
Borderline Personality Disorder
• Most common treated personally disorder
• Common in female who have been victims of sexual abuse
• Difficulty identifying their feelings
Defense Mechanism:
• Splitting – inability to see self and others as having a good and bad qualities
What’s the problem?
• Feeling of abandonment and depression
What’s your nursing priority?
• Close monitoring for suicidal ideation and mutilation
• Administer antidepressant medication
• Counseling for PTSD
Cluster C
Avoidant personality disorder
• Timid
• Withdrawn
• Hypersensitive to criticism
• Socially inadequate
• Feeling of rejection
What’s the problem?
• Lack of confidence
• Helpless
Dependent Personality Disorder
• Extreme need to be taken care of by someone else
• Fear of separation
• Inferior
• Incompetent
• Involved in abusive relationship
What’s the problem?
• Fear of being left alone – Stays with a abusive relationship
What is your nursing concern?
• Safety
Obsessive – Compulsive Personality Disorder
• Perfectionist
• Overly inhibited
• Inflexible
• Preoccupied with rules
• Trivial details
• Procedures
• Cold and rigid
• No expression of tenderness or warmth
• Sets standard too high for themselves
What’s the problem?
• They are fearful of making mistake – tend to procrastinate
Managing client with
personality disorder
• Pharmacological interventions are generally not appropriate for these clients
• However if there is a coexisting diagnosis such as depression or anxiety
Your nursing Goal:
• Set Limits
• Conveying a sense of acceptance
• Maintain a professional rather friendly relationship
Psychotic Disorders
• Alterations in perceptions in reality
• Hallucinations
• Delusions
• Difficulty Organizing taughts
• Schizophrenia
• Bipolar disorder
• Dementia
• Drug intoxication
• Withdrawal
Schizophrenia
• Schizophrenia is a chronic illness, although medication improve client’s quality of life, they do not cure the disease.
• Late adolescence
• Early Adulthood
• Theories offered for the cause of schizophrenia:
• Genetics
• Environmental factors
• Biological Alterations in serotonin and dopamine
Nursing Interventions
• Provide quiet, supportive environment
• Establishing a trusting relationship
• Antipsychotic medication
• Activities of daily living
• Nutrition and hydration
Commonly ask!
• Avoid challenging activities – confusion and overwhelm the client
• Do not argue or change the delusional thinking – redirect the client to a reality based subject
• Example: Hearing Voices - acknowledge the voice – face with reality – medication
4 A’s of Schizophrenia
• Affect – flat, blunted, or inappropriate
• Autism – Preoccupation with self and retreat into fantasy
• Association – loosely joined unrelated topics
• Ambivalence – Having simultaneous opposing feelings
Subtypes of schizophrenia
• Catatonic
With stereotyped position (catatonia) with waxy flexibility, mutism, bizarre mannerism
• Disorganized
Another word is Hebephrenic. Characterized with inappropriate behavior: Silly crying, laughing, regression, transient hallucinations (Auditory).
• Paranoid
Presenting sign is SUSPICIOUSNESS,
ideas of persecution and delusions
• Residual
No longer exhibits overt symptoms, no more delusions but still has negative
• Undifferentiated
Symptoms of more than one type of schizophrenia
Medications:
New Medication
Atypical antipsychotics
Risperidone – given in small doses
Fewer side effects
Manage negative symptoms of schizophrenia
Old medication
Antipsychotic
Chloropromazine-
Many side effects
may experience extra pyramidal effect
Exam Alert!
Neuroleptic malignant syndrome
• Symptoms: hyperthermia
( 107 degree Fahrenheit )
Antidote:
Antiparkinsonian drug
Bipolar Disorders
Acute mania
• Profound changes in mood
• Elevated
• Expansive
• Irritable
Additional Symptoms:
• Delusion of granduer
• Flights of ideas
• Increase motor activity
• Increase risk taking and promiscuity
• Use of profanity
• Uncontrolled spending
• Failing to sleep or eat for a long periods of time
• When limitations are placed on the client’s behavior, he typically reacts with sarcasm and belligerence.
What’s your nursing intervention?
• Quiet
• Nonstimulating environment
• Protecting from physical exhaustion
• Nutrition: High calorie, high protein finger foods and snacks that can be eaten while moving about
What to give?
• Mood stabilizers
• Valproic Acid
• Carbamezipine
• Lithium
Watch out for Lithium Toxicity
• This is not a drug, mineral that stabilizes the mood of the client
• Start of lithium – drawn twice weekly
• 2-3 months during long term therapy
Normal Therapeutic Level
0.5 – 1.5 meq/ L
• Symptoms: muscle weakness, confusion, ataxia , seizures, cardio pulmonary change, organ failure.
• What’s the only fluid to give?
Plain NSS
Major Depression
• Depressed mood lasting at least two weeks.
• Eating disorder : Anorexia
• Patient Feeling of worthlessness
• Recurrent thoughts of death and suicide
• Early assessment: Diminished ability to concentrate
• Sleep disturbance
What’s the problem?
• Suicidal Ideation and suicidal plan
• Improving – Greater risk
What to give?
• Ordered Medication: Anti –depressants: Selective serotonin reuptake inhibitor
Monoamine oxidase inhibitor
Tricyclic antidepressant
What’s your nursing intervention?
• Nursing Intervention
Harmful object should be removed
Constant observation
provide safe environment
physiologic needs
Assists in ECT
Substance Abuse
• Excessive use of drugs that is different from societal norm
• Illegal - Heroin
• Legal – Alcohol or prescription drugs
What’s the history of the patient
• Absenteesim
• Decline in school or work performance
• Frequent accidents
• Increase isolation
• Slurred speech
• Tremors
What is the primary substance abuse?
Alcohol
Alcoholism
• Alcohol withdrawal
• 6- 8 hours after the last drink
• Or when the amount consumed is less than usual
• Four stages of alcohol withdrawal
• Stage 1 : 6- 8 hours after last use – anxiety, anorexia, tremors, nausea and vomiting, depression, headache, icrease blood pressure
• Stage 2 : 8- 12 hours after last use – confusion hallucinations hyperactivity and gross tremor
• Stage 3 : 12 – 48 hours after last use – severe anxiety, increased BP , profuse sweating, severe hallucination and grandmal seizure
• Stage 4 : 3- 5 day after last use – delirium tremens including confusion, insomnia, agitation , hallucinations and uncontrolled tachycardia. Death- cardiac complicationw4w
Types of Crisis
1. Maturation Crisis
- Adolescence (identity crisis)
- Mid-life crisis;
- Pregnancy
- Parenthood
2. Situational crisis
- Most common: Death of a loved one
Important Diagnosis
NSG DX: Ineffective Individual Coping/ Denial
- Abortion Murder,, rape and fire
3. Adventitious Crisis
Calamity, disaster
ex. World War I & II, epidemic, tsunami
In a DISASTER 1st assess/survey the scene 7.
Stages of psychosocial Development
AGE Psychosocial
Infancy (0- 18 months ) Trust vs. Mistrust
Toddler (18mos. – 3 years) Autonomy vs. Shame and doubt
Preshool Age ( 3 – 6 yrs ) Initiative vs. Guilt
School Age ( 6 – 12 yrs ) Industry vs Inferiority
Adolescence ( 12 – 20 yrs ) Identity vs. Role confusion
Early Adulthood ( 20 – 35 yrs) Intimacy vs. Isolation
Middle Adulthood (35 – 65 yrs ) Generativity vs stagnation
Later Years/ Old age ( 65 yrs ) Integrity vs Despair
SIGMUND FREUD
Psychosexual Theory
▪ Infancy : Oral Phase; Id
▪ Toddler : Anal Phase; Ego
▪ Preschooler: Phallic Phase; Superego (Conscience)
Electra complex: Attachment of the girl to her father and jealousy toward the mother
Oedipal Complex: Attachment of the son to his mother and jealousy toward the father.
▪ Schooler : Latency phase Strict Superego
▪ Adolescent : Genital phase
Therapeutic responses
Offering of self – safety, service, comfort
“I am here. I will sit here beside you.
I will lead you to the group therapy session.”
Reflection: (mirror of feelings)
“It must be difficult for you.”
“You seem angry. You seem concerned.”
Elaboration/Exploration
“Tell me more about your feelings”
Clarification
“What do you mean by…”
“I could not follow you.”
Reality Orientation/Reality Testing
Client: “Help! Help! There are rats on my back!”
Nurse: “I don’t see rats but for you that are real.”
What is your Nursing Diagnosis?
Altered Sensory Perception
Delusion; Hallucination, Illusion
Validation – interpret
Client: “I see a dead people.”
Nurse: “You’re frightened.”
Open-ended question / broad openings
“How are you?”
“How’s your day?”
“What are your favorite things?”
Non- Therapeutic Responses
• WHY?
• Being defensive
• Changing subject
• Giving advice or approval
• Providing false reassurance
• Making Judgment
• Don’t Worry
• I am
What defense mechanism are they using?
Sexually Abused:
Repression
Involuntary recall or unpleasant thoughts
Moderate Anxiety:
Suppression
Voluntary Forgetfulness
Somatoform:
Conversion
Transferring of mental conflict or anxiety into physical symptoms
Multiple Personality:
Dissociation
Detaching of strong emotionally charged conflict from one’s consciousness
Phobia:
Symbolization
Object, idea, or act represents another through some common aspect
Preschooler:
Identification
Imitator, similar to role playing
Depression:
Introjection
Attributing to oneself the good qualities of another. Incorporate feelings
Anti – social
Alcoholics
Rationalization
Is justifying one’s actions which are based on other motives.
Paranoid
Projection
Person rejects unwanted characteristics of self and assigns them to others.
Obsessive Compulsive
Undoing
Negation of previous consciously intolerable action or experience to reduce or alleviate feelings of guilt.
Borderline
Drug Addicts
Alcoholic
Splitting
Viewing people as all good, and others as all bad
Passive Aggressive personality disorder
Reaction – Formation
OVERCOMPENSATION. Conscious intent often altruistic. Procrastinate
Molested Child
Acting out
Unconscious wish turned into reality
Alcoholics
PTSD
Incurable illness
Denial
Blocking the awareness of reality.
Schizoid
Fantasy
Imagined events or mental images. Wishful thinking; Temporary flight from reality to ↓ anxiety
Others ---
Intellectualization
The act of transferring emotional concerns into the intellectual sphere
Fixation
Permanent or persistence into later life of interests and behavior patterns appropriate to an early age.
Regression
A temporary retreat to past levels of behavior that reduce anxiety, allow one to feel more comfortable.
Compensation
The act of making up for a real or imagined deficiency with a specific behavior. Conscious or unconscious.
Sublimation
Rechanneling of consciously intolerable or socially unacceptable behavior
Anti-anxiety Drugs
Valium ( Diazepam)
Miltown (Meprobamate)
Librium (Chlordiazepoxide)
Equanil (Meprobamate)
Ativan (Lorazepan)
Vistaril (Hydroxyzine pamoate)
Serax (Oxazepan)
Atarax (Hydroxyzine hydrochloride)
Tranxene (Chlorazapate)
Buspar (Buspirone)
Monoamine Oxide Inhibitors
Marplan
Nardil
Parnate
Antiparkinsonian Drugs
Artane
Akineton
benadryl
Cogentin
Eldepryl
Larodopa
Symmetrel
Antipsychotic Drugs
Haldol (Haloperidol)
Trifalon (Perphenazine)
Prolixin (Fluphenazine
Stelazine (Triflourperazine)
Clozaril (Clozapine)
Serentil (Mesoridazine)
Mellaril (Thioridazine HCl)
Thorazine (Chlorpromazine)
Anti depressant drugs
Elavil (Amitriptyline)
Prozac (Fluoxetine)
Paxil (Paroxetin)
Zoloft (Sertraline)
Luvox (Fluvoxamine Maleate)
Asendin (Maprotiline)
Norpram (Desipramine)
Tofranil (Imipramine)
Sinequan (Doxepin)
Anafranil (Clomipramine)
Aventyl (Nortriptyline)
Vivactile (Protriptyline Hydrochloride)
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