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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