PSYCHIATRIC NURSING  First psychiatric nurse • Today, NCMH has an authorized bed

Benchmark Period in Psychiatric History  Believed the mentally sick should be at capacity of 4,200 and a daily average of
Historical Perspective of the Treatment of least as well cared for as the physically 3,400 in-patients. It sprawls on a 46.7
Mental Illness sick hectare compound with a total of 35
Pavilions/Cottages and 52 Wards.
Harriet Bailey • The NCMH is a special training and
- published the first psychiatric nursing textbook, research hospital mandated to render a
Nursing Mental Diseases in 1920 comprehensive (preventive, promotive,
curative and rehabilitative) range of
Hildegard Peplau quality mental health services nationwide.
– described the therapeutic nurse-client
relationship with its phases and tasks and wrote Standards of Mental Health Clinical Nursing
extensively about anxiety Practice
Standards of Care
The interpersonal dimension forms the
foundation of nursing practice today Standard I. Assessment
 The psychiatric-mental health nurse
June Mellow collects health data
– focuses on clients’ psychosocial needs and
strengths Standard II. Diagnosis
- argued that the nurse as the therapist is  The psychiatric-mental health nurse
Benchmark V: Decade of the Brain particularly suited to working with those with analyzes the data in determining
 The 1990s – declared the Decade of the severe mental illness in the context of daily diagnoses
Brain activities, focusing on the here and now to meet
 During this decade, a steep increase in each person’s psychosocial needs Standard III. Outcome Identification
brain research occurred that coincided  The psychiatric-mental health nurse
with an increased interest in biologic Psychiatric Nursing in the Philippines identifies expected outcomes
explanations for mental disorders • The National Center for Mental Health individualized to the client
 The Decade crystallized the fact that (NCMH) was established thru Public
some behaviors are caused by biologic Works Act 3258. Standard IV. Planning
irregularities and not willful contraries, or • It was first known as INSULAR  The psychiatric-mental health nurse
worse PSYCHOPATHIC HOSPITAL, situated develops a plan of care that prescribes
 The Decade brought back nursing into on a hilly piece of land in Barrio Mauway, interventions to attain expected outcomes
the mainstream of psychiatric care Mandaluyong, Rizal and was formally
opened on December 17, 1928. Standard V. Implementation
Psychiatric Nursing Practice • This hospital was later known as the  The psychiatric-mental health nurse
Linda Richards NATIONAL MENTAL HOSPITAL, given implements the interventions identified in
 Graduated in 1873 from New England on November 12, 1986, it was given its the plan of care
Hospital for Women and Children in present name thru Memorandum Circular
Boston No. 48 of the Office of the President. Standard Va. Counseling
 Improved nursing care in psychiatric • On January 30, 1987, NCMH was  The psychiatric-mental health nurse uses
hospitals and organized educational categorized as a Special Research counseling interventions to assist clients
programs in state mental hospitals in Training Center and hospital under in improving or regaining their previous
Illinois Department of Health. coping abilities, fostering mental health,
 and preventing mental illness and  The psychiatric-mental health nurse  Individual follows guiding values
disability evaluates the client’s progress in attaining and rules to live by
expected outcomes  Engage in independent action
Standard Vb. Milieu Therapy and thinking
 The psychiatric-mental health nurse MENTAL HEALTH  Consider the opinions and wishes
provides, structures, and maintains a • State in the relationship of the individual of others
therapeutic environment in collaboration and his environment in which the  Can work interdependently or
with the client and other health care personality structure is relatively stable, cooperatively with others without
providers and environmental stresses are within its losing his autonomy
absorptive capacity.(WHO)
Standard Vc. Self-Care Activities • A positive state in which one is • Maximizing one’s potential
 The psychiatric-mental health nurse responsible, displays self-awareness, is  Keep aiming
structures interventions around the self-directive, is worry-free and can cope  Keep going
client’s activities of daily living to foster with usual daily tension  Use talents
self-care and mental and physical well- • A state of complete physical, mental and  Continually strive to grow
being social well-being and not merely the  Self-actualization
absence of disease • Self – esteem
Standard Vd. Psychobiologic Interventions • Relative and dynamic concept. Not the  Accept strength and limitations
 The psychiatric-mental health nurse uses same to all people  Awareness of abilities and
knowledge of psychobiologic • Changes at different point in time. It is limitations
interventions and applies clinical skills to not static
restore the client‘s health and prevent • Tolerating life’s uncertainties
further disability FACTORS THAT AFFECT MENTAL HEALTH  Positive outlook in life
• Inherited characteristics – genetic make-  Face challenges life has to offer
Standard Ve. Health Teaching up  Optimism
 The psychiatric-mental health nurse, • Nurturing during childhood  Have the courage to rise after
through health teachings assists clients in • Life circumstances falling
achieving satisfying, productive, and
healthy patterns of living FACTORS INFLUENCING A PERSON’S • Mastering the environment
MENTAL HEALTH  Learn to adopt or cope and relate
Standard Vf. Case Management • Individual factors – vitality, finding  Can deal with the environment
 The psychiatric-mental health nurse meaning to life, biological make-up,  Can influence the environment
provides case management to coordinate emotional resilience, spirituality, sense of  Being competent and creative
comprehensive health services and harmony in one’s life
ensure continuity of care • Interpersonal factors – Intimacy, helping • Reality Orientation
others, effective communication,  Distinguished real world from a
Standard Vg. Health Promotion and Maintenance maintaining a balance of separateness dream
 The psychiatric-mental health nurse and connection  Distinguished facts from fantasy
employs strategies and interventions to • Social, Cultural factors – access to  Behave appropriately
promote and maintain mental health and adequate resources, sense of community,  Act accordingly
prevent mental illness intolerance of violence
• Stress management
Standard VI. Evaluation COMPONENTS OF MENTAL HEALTH  Tolerate life stresses
• Autonomy and Independence
  Experience failure without SELF-ACCEPTANCE – regards of oneself with
devastation realistic concept of strength and weakness, PERSONLITY STUCTURE
 Cope and tolerate anxiety accept others easily ID – source of all drives, instincts, reflexes, needs,
 Resolve conflicts, stress and genetic inheritance and capability to respond to
anxiety Behaviors of a self-accepting person: wishes that motive us
 Believes that crises is temporary • Perserving • Present at birth
• Trusting and accepting others • Unlearned selfish source of libidal energy
CHARACTERISTICS OF A PERSON WITH • Seeing reality • Operates on pleasure principle through
GOOD MENTAL HEALTH • Minimizing weakness the use of fantasy and images
• Have positive self-concept & relate well to • Increase strengths • Compulsive with no sense of right or
people & their environment • Learning from mistakes wrong
• Form close relationship with others • Reaching out to others • Demands immediate satisfaction
• Make decision pertaining to reality rather • Continuing growth towards self- • SIGNIFICANCE – if id is not controlled
than fantasy actualization effectively the individual function in
• Be optimistic & appreciate & enjoy life antisocial; lawless manner or ways
• be independent or autonomous in PSYCHODYNAMICS OF PERSONLITY because his primitive drives or impulses
thought and action PERSONALITY – is the sum total of or whole are freely express
• Be creative, using varying approaches as being
they perform task or solve problem – Aggregate of the physical and EGO – begins during the first 8 months of life and
• Consistent as they appreciate and mental qualities of individual as it is fairly develop when the child reaches 2 years
respect the rights of others interacts in characteristic fashion • The self or the I
• Displays willingness to listen and learn – Sum total of the person’s • Problem solver and reality tester
from others distinctive character, behavior, • Able to differentiate subjective experience,
attitude memory images and object reality
SELF - AWARENESS – The way one carries himself • Attempts to negotiate a solution with the
• Process by which the individual gains – Express through behavior outside world
recognition of his or her own feelings, – Complex, dynamic and unique • Controls and guides the action of
beliefs and attitudes individual
• The ability to recognize the nature of CONCEPT of PERSONALITY – all behavior • Part of the personality that experiences
one’s own behavior, attitude and emotion have meaning and is not determined by chance anxiety and uses defense mechanism for
• Key to self-understanding protection
• Help understand and accept the SIGMUND FREUD (1856 – 1939) • Influenced by heredity, environmental
difference of others • Believed that vast majority of mental factors and maturation
disorder were due to unresolved issues • SIGNIFICANCE – if the individual does
SELF – CONCEPT that originate in childhood not develop a strong ego to arbitrate
– part of self that lies within conscious awareness effectively between id and superego the
depends on how a person thinks he or she is LEVELS OF AWARENESS individual will surely develop
viewed by others Conscious – aware at any time intrapersonal and interpersonal conflict
Pre-conscious – can be retrieved rather easily
Good self-concept leads to self- through conscious part SUPEREGO – moral component of personality
acceptance Unconscious – repressed memories, passion, • Consists of “conscience” (“should-nots”)
unacceptable urges and ego ideal (“should”)
 • Operates both in the conscious and
unconscious but operates mostly on the
unconscious level
• Develops around 3-4 years and fairly
develop at age 10
• Formed and influence from the
internalization of what parents teach their
children regarding right or wrong through
rewards and punishments
• SIGNIFICANCE – if superego is so strong
the life of the individual is dominated by
its restriction on behavior, he or she is
likely to be unhappy, inhibited and
anxiety-guilt ridden. Individuals become
inferior if he/she cannot live up to parental
standards

ERIK ERICKSON’S DEVELOPMENTAL

THEORY JEAN PIAGET’S COGNITIVE THEORY
• Each stage of development is an • Views intellectual development as result
emotional crisis involving positive and of constant interaction between
negative experiences environmental influences and genetically
• Growth/mastery of critical task results determined attributes
from having more positive experience
than negative experience 4 STAGES OF COGNITIVE DEVELOPMENT
• Allows for corrective emotional 1. SENSORIMOTOR STAGE (0 – 2 yr)
experience beyond 5 yrs of life – Learns by exploring objects and
events and by imitating
– Infants develop SCHEMATA
FREUD’S PSYCHOSEXUAL STAGES OF (assimilation and
DEVELOPMENT accommodations incoming
information)

2. PREOPERATION STAGE (2 – 7 yr)

– Preconceptual phase (2-4 yr)
• Learns by thinking images
• Develop expressive
language and symbolic
play
– Intuitive phase (4-7)
• Egocentrism (seeing
things from own point of
view)
 SECURITY OPERATIONS – behavior is subject to reward or
3. CONCRETE OPERATIONAL STAGE (8 – a person uses to defend oneself against punishment
– 12 yr) anxiety and ensure self-esteem – changing one’s environment can
– Able to think more logically as modify behavior
concept of moral judgment, Somnolent detachment – use of sleep to avoid • maladaptive behaviors are learned
numbers, spatial relationship anxiety through classical and operant
Apathy – emotional detachment or numbing conditioning; they may continue because
4. FORMAL OPERATION STAGE (12 – Selective inattention – tuning out details they are rewarding to the individual
adulthood) associated with anxiety-producing situation • maladaptive behaviors can be change
– Develops adult logic Dissociation – prevents situation from without developing insight into the
– Able to reason, form conclusion, integrating into conscious awareness underlying concepts by altering the
plan for the future, think abstractly Converting anxiety to anger – powerlessness is environment
and builds ideas exchanged for a temporary feeling of power • behavioral models posit that personality
associated with anger directed outward consist of learned behaviors and
personality becomes synonymous with
3 TYPES OF TENSION behavior – if behavior changes, so does
HARRY STACK SULLIVAN’S Tension of needs – stemming from the personality
INTERPERSONAL THEORY physiochemical requirement of life
Tension of anxiety – from interpersonal situation Classical conditioning (Pavlov’s theory)
PERSONALITY – behavior that can be observed Tension of need for help • classical conditioning was developed by
within interpersonal relationship Ivan Pavlov
SELF-SYSTEM – develops relatively enduring • he established that learning or
Personality development patterns for avoiding or minimizing anxiety during conditioning can occur when a stimulus is
Infancy – crying is used to establish contact with interpersonal encounters and the meeting of paired with an unconditioned response
others biologic needs – a conditioned response is pairing
Childhood – language is used to assist with – “good me” – needs are satisfied of a stimulus with a response
learning to delay the gratification of needs – “bad me” – needs are unmet and – acquisition refers to the gaining of
Juvenile period – competition, compromise and anxiety persists a learned response (once a
cooperation are tools for developing relationship – “not me” – anxiety is severe and response is learned, it continues)
with others information is not completely – Extinction is the loss of learned
Preadolescence – collaboration and the capacity integrated into the personality on response
for love assist in the development of relationship a conscious level
with same gender Operant conditioning (Skinner’s theory)
Early adolescence – with sexual desire, Behavioral Theories • developed by B. F. Skinner, operant
facilitate learning to establish relationship with Key Concepts conditioning involves the use of reinforce
members of the opposite sex • A behavioral framework is used to consequences to change the behavior
Later adolescence – interdependence develop, described a persons functioning in terms • positive reinforcement is a reward given
learns to form lasting sexual relationship of identified behaviors to help continue the behavior
– people learn to be who they are • negative reinforcement removes
ANXIETY because of environmental undesirable consequences to help
– any painful feeling or emotion arising from shaping continue the behavior
social insecurity or blocks to getting biological – behavior can be observed, • positive punishment involves the use of
needs satisfied described or recorded aversive consequences to decrease a
particular behavior
 • negative punishment involves identify maladaptive thought patterns and
withdrawing the reward to decrease a Application to nursing develop alternate ways of thinking and
particular behavior • In the behavioral framework, the nurse behaving.
assesses both adaptive and maladaptive – This is often used in depression
Behavioral treatments behaviors. that stems from the individual’s
• behavioral modification involves the use • The nurse and the client collaborate to negative self concept, or
of various learned techniques to change identify behaviors that require change. exaggerated prolonged guilt, that
maladaptive behavior, it is commonly • As a member of the treatment team, the result in automatic thoughts of
used with clients who have anxiety nurse uses various behavioral self deprecation.
disorders, substance abuse problems or modification techniques to help the client. – The goal of the therapy is to
other specific behavioral problems diminish depressive symptoms by
• modeling refers to new behaviors that Cognitive Framework helping the client challenge and
are learned by imitating the behavior of Key concepts invalidate distorted thoughts
another person • the cognitive framework focuses on through series of mental
• operant conditioning involves the use of distorted or negative thought patterns exercises and replace them with
tokens for desirable behavior that lead to maladaptive or symptomatic appropriate, realistic thoughts.
• systemic desensitization involves feelings and behaviors • In Rational-Emotive therapy developed
gradually confronting a stimulus that – distorted thinking leads to and by Albert Ellis, helps the client examine
evokes intense anxiety, it is useful in perpetuates maladaptive own irrational thoughts and behavior
treating phobias behaviors through verbal discussion followed by
– the therapist initially teaches the – certain thought patterns can be activities that allows the individuals to
client how to relax and begins a identified as misperceptions challenge the faulty beliefs by directly
stimulus that causes mild anxiety confronting the feared situation. This is
– the client learns to invoke the useful in mild to moderate anxiety states
relaxation response when • In Gestalt therapy, based on the
confronted with a stimulus collective efforts of Fritz Perls and Paul
– the process continues until an Goodman, the therapist promotes the
intensely anxiety provoking client’s self awareness and increased self
stimulus no longer causes the responsibility for meeting needs.
client to feel anxious • In Beck’s Cognitive therapy, developed
• aversive therapy operates on the by Aaron Beck, the therapist teaches the
principle that unpleasant consequences client to identify and correct dysfunctional
result from undesirable behavior, it may thoughts about the self, world and the
be used in treatment of paraphilias • patterns of thinking leads to and future
• biofeedback involves training techniques perpetuates maladaptive behaviors
used to control physiologic responses • the amount of perceived control over a Cognitive techniques may be used:
such as stress response and its situation affects how an individual – Cognitive restructuring – change
physiologic manifestations responds to stressors and problems of maladaptive beliefs through
• relaxation techniques are training positive self statements and
techniques used to counteract anxiety Treatments refusing irrational beliefs
symptoms • Cognitive therapy, a form of therapy – Thought stopping – constantly
• assertiveness training incorporates developed by Aaron Beck, encompasses say “STOP” to maladaptive
techniques to overcome passivity or various treatment methods in which the thoughts
aggression in interpersonal situation therapist and client work closely to
 – Psychotherapy fosters the Treatments
process of learning to be fully • Diagnostic work ups include detailed
one’s own self history and lab test as well as careful
– The therapist is genuine and observation of current behavior
without façade when relating to • Pharmacotherapy is a common treatment
the client including g nurse patient interaction and
– The client’s behavior changes milieu management.
toward positive functioning when
the therapist conveys acceptance, Eclectic Theory
respect and genuine empathy for Eclectic
the client • varied; made up of parts from various
Humanistic Framework • Existential therapy – a form of talk sources
therapy that focuses on life issues of • choosing what is best or preferred from a
• Key Concepts
– Humanistic framework focuses on freedom, helplessness, loss, isolation, variety of sources or styles
the “here and now” – current aloneness, anxiety and death; through
psychotherapy, the client discovers his Schizophrenia
behaviors, issues and problems –
as well as spiritual values and own meaning of existence. Possible causes:
meanings. 1. Genetic
– human nature is viewed as MASLOW’S HIERARCHY OF NEEDS 2. Organic
positive and growth oriented, and • Human motivation as a hierarchy of 3. Biomedical theories
dynamic process or needs that are critical 4. Psychological theories – increased
existence involves search for
meaning and authenticity for the development of all humans incidence among the lower socio-
– Abraham Maslow’s theory of • Focused on human needs fulfilment, economic groups
which is categorized into 6 incremental 5. Unknown
human motivation theory
describes human needs that are stages.
Mood Disorders
organized according to levels in
which individuals move on to Predisposing factors:
1. Medical – Biological Theories
higher needs as lower, more
a. Genetic – higher incidence among
basic needs are met
– failure to develop one’s potential individuals with relatives with the disorder
leads to poor coping b. Biochemical – electrolyte imbalances,
error in metabolism results in
– lack of self awareness and unmet
needs interfere with feelings of transposition of Sodium and Potassium
within a neuron, low levels of NE,
security as well as with
relationships dopamine and serotonin
– fundamental human anxiety is
Dynamics of Behaviour
fear of death which leads to
existential anxiety Biomedical Framework 1. Behavior refers to the way in which an
Key Concepts organism responds to a stimulus
Treatments • Physiologic, social and environmental – All behaviors are meaningful and
• Client centered therapy, developed by factors can predispose to mental illness. purposeful
Carl Rogers is based on the belief that • Mental illness can be classified as in the
mental illness results from an individuals multi axial DSM IV-TR Varieties of behavior
failure to develop fully as human being.
A. Reflex action – automatic response to a demands on a person that requires coping and • Chronic anxiety
stimulus (blinking reflex, gag reflex) adapting – the person has lived with the
B. Goal oriented behavior – presence of two stress for a long time
factors: CHARACTERISTICS OF STRESS
 Presence of need within the individual • It is recurring PRECIPITATING FACTORS OF ANXIETY
 Presence of goal outside the individual which • It is normal • Threats to biological integrity – refers
is capable of producing a change in his • It cannot be avoided to the distortion in homeostasis ----
internal condition and thus satisfying the • It is brought about by stressors temperature control
need (e.g.. Hunger, anxiety) • Threat to self-esteem – threat towards
STRESSOR – any condition, agent, situation, maintaining established views of self,
– Need – an organismic condition feeling, thought or behavior which demands an values and patterns of behavior he uses
which exist within an individual increase in any activity within the ANS & CNS to resists changes in self review
and which demands certain – Sense of isolation (alienation)
activity. It is a requirement for ANXIETY – a response to internal conflict – Sense of insecurity (threat to
survival. - feeling of uncertainty; uneasiness, identity)
apprehension or tension that a person – Sense of helplessness
Sources of Need experiences in response to an unknown
 Those which arise as a direct result of object or situation
metabolic process (hunger and thirst)
 Those that results from a change in the Anxiety is describe as:
person’s relationship with his external • Subjective experience
environment (drop in room temperature) • Emotional pain BEHAVIOR RESPONSE TO ANXIETY
 Symbolic behavior – talking, reading • Apprehension, fearfulness or a sense of • Anger
and thinking powerlessness • Crying
• Warning signs of perceived danger or • Withdrawal
CONFLICT threat • Forgetfulness
• The result o f the presence of two • Emotional response that triggers behavior • Quarrelling
opposing or incompatible drives wherein • Alerting and individual to prepare for self- • Complaining
the person is required to make a choice defense • Defensive behavior
between the possible responses • Occurring in degrees
• Contagious LEVELS OF ANXIETY
DYNAMICS OF CONFLICT • Part of a process, not an isolated
phenomenon
Conflict → ↑ anxiety → feeling of hopelessness,
helplessness CATEGORIES OF STRESS
and isolation → ↑ perceived conflict increases → • Normal anxiety
↑ anxiety – healthy life force
– Motivates people to make &
survive change
– Proportionate to actual events
STRESS and ANXIETY • Acute anxiety
– Precipitated by an imminent loss
STRESS – a stimulus or situation that produces or change that threatens an
distress and create physical and psychological individual’s sense of security
 • Evaluate effective past useful coping
mechanism MOST HEALTH DEFENSES
• Assist in developing alternative solution to Altruism – emotional conflicts and stressors are
a problem dealt with by meeting the needs of others
• Provide outlets from working off excess
energy Sublimation – unconscious process of
• Use non-verbal language to demonstrate substituting constructive and socially acceptable
interests activity for strong impulses that are not
acceptable in the original form.
INTERVENTIONS FOR SEVERE TO PANIC
LEVELS OF ANXIETY Humor – deals with emotional conflict or stress
• Maintain a calm manner by emphasizing the amusing or ironic aspects of
• Always remain with the client the conflict or stressor.
• Minimize environmental stimuli
• Use clear and simple statements and Suppression – conscious denial of a disturbing
repetition situation or feeling
• Use a low pitched voice; speak slowly
• Reinforce reality INTERMEDIATE DEFENSES
• Listen for themes in communication Repression – exclusion of unpleasant or
• Attend physical and safety needs when unwanted experiences, emotions, or ideas from
necessary conscious awareness
• Set physical limit. Speak in a firm, Displacement – transfer of emotion associated
authoritative voice. with a particular person, object, or situation to
• Provide opportunities for exercises another person, object, or situation that is non-
• Physical needs must be met to prevent threatening
exhaustion
• Assess need for medication or seclusion Reaction formation – unacceptable feelings or
behaviors are kept out of awareness by
DEFENSE MECHANISM developing the opposite behavior or emotion
• Protects people from painful awareness
of feelings and memories that can Somatization – transforming anxiety on an
provoke anxiety unconscious level into a physical symptoms that
has no organic cause
5 IMPORTANT PROPERTIES OF DEFENSE
MECHANISM Undoing – consciously doing something to
1. Defenses are major means of managing counteract or make up for a transgression or
INTERVENTIONS FOR MILD TO MODERATE conflict and affect wrongdoing
LEVELS OF ANXIETY 2. Defenses are relatively unconsciousness
• Help client to focus and sole problems 3. Defenses are discrete from one another Rationalization – justifying illogical or
with the use of communication techniques 4. Although defenses are often the hallmark unreasonable ideas, actions, or feelings by
• Help client identify anxiety of major psychiatric syndrome, they are developing acceptable explanation that satisfy
• Provide a calm presence reversible the teller as well as the listener
• Recognize the anxious person’s distress 5. Defenses are adaptive as well as
• Be willing to listen pathological
Intellectualization – consciously or goal-oriented oriented
unconsciously using only logical explanation Denial – escaping unpleasant realities by behavior & inhibition
without one’s feelings or an affective component ignoring their existence - Seat of
Personality
Compensation – consciously covering up for a Regression – unconscious return to an earlier ◦ Basal ganglia – regulation of
weakness by overemphasizing or making up a and more comfortable developmental level movements
desirable trait ◦ Limbic system
 Amygdala and
IMMATURE DEFENSES hippocampus – emotions,
Passive aggression – deals with emotional ORGANIZATION OF THE NERVOUS SYSTEM learning, memory and
conflict or stressors by indirectly and BRAINSTEM – regulates the internal organs and basic drives
unassertively expressing aggression towards responsible for vital functions such as regulation
another of blood gases and the maintenance of BP NEUROTRANSMITTERS AND RECEPTORS
 Conduction along a neuron involves the
Acting-out behavior – deals with emotional Hypothalamus – hunger, thirst and sex. inward movement of sodium ions (Na)
conflict or stressors by actions rather than - thought & emotions followed by the outward movement of
reflections or feelings potassium ions (K). When the current
RAS – allows human to sleep and carry out reaches the end of the cell, a
Dissociation – unconscious separation of painful conscious mental activity neurotransmitter is released. The
feelings and emotion from an unacceptable idea, transmitter crosses the synapse and
situation or object Limbic system – crucial role in emotional status attaches to a receptor on the postsynaptic
and psychological function (norepinephrine, cell. The attachment of transmitter to
Identification – conscious or unconscious serotonin, dopamine receptor either stimulates or inhibits the
attempt to model oneself after a respected postsynaptic cell
person CEREBELLUM  the destruction of the action of the
 Coordinated muscle energy & activity enzyme acetylcholinesterase on the
Introjection – unconsciously incorporating  Maintenance of equilibrium neurotransmitter acetylcholine.
values & attitudes of others as if they were your  Coordinates contraction Acetylcholinesterase is present at the
own postsynaptic membrane and destroys
CEREBRUM – responsible for mental acetylcholine shortly after it attaches to
Devaluation – emotional conflict or stressors are activities and a conscious sense of being. nicotinic or muscarinic receptors on the
dealt with by attributing negative qualities to self Also responsible for language and the ability postsynaptic cell.
or others to communicate
A full explanation of the various ways in
Idealization – attributing exaggerated positive Cerebral cortex – responsible for conscious which psychotropic drugs alter neuronal
qualities others sensation and the activity requires a brief review of the
initiation of movement manner in which neurotransmitters are
Splitting – the inability to integrate the positive ◦ Parietal cortex – touch destroyed after attaching to the receptors.
and negative qualities of oneself or others into a ◦ Temporal – sound To avoid continuous and prolonged action
cohesive image. ◦ Occipital – vision on the post- synaptic cell, the
◦ Frontal – initiation of skeletal neurotransmitter is released shortly after
Projection – person unconsciously rejects muscle contraction attaching to the postsynaptic receptor.
emotionally unacceptable personal features and  Prefrontal cortex - Once released, the transmitter is
attributes to other people, objects or situation. responsible for thoughts, destroyed in one of two ways.
 One way is the immediate inactivation  When you do not know
of the transmitter at the postsynaptic what to say, “SAY
membrane. NOTHING”
 When in doubt, focus on
 After interacting with the postsynaptic feelings
receptor, the transmitter is released and  Avoid advice
taken back into the presynaptic cell, the  Avoid relying on questions
cell from which it was released. This  Pay attention to non-
process, referred to as the reuptake of verbal cues
neurotransmitter. Once inside the  Keep focus on the client
presynaptic cell, the transmitter is either
recycled or inactivated by an enzyme  Dynamics of therapeutic
within the cell. The monoamine communication
transmitters norepinephrine, dopamine, ◦ Interpretation of communication
and serotonin are all inactivated in this ◦ Themes in patients
manner by the enzyme monoamine communication
oxidase.  Content themes
 Mood themes
A second method of neurotransmitter  Interaction themes
inactivation is a little more complex. ◦ Environmental consideration
is a common target for drug action. ◦ Physical consideration
◦ Kinesis consideration
NEUROTRANSMITTERS AND RECEPTORS
 Effective tools in communicating
◦ The use of silence - a specific
channel for transmitting and
receiving messages
Therapeutic Communication ◦ Active listening
 Clinical Interview - “The client leads”  Observing the client’s
How to begin non-verbal behaviors
◦ Setting – private, safe  Listening to and
◦ Seating – assume the same understanding the person
height, avoid face to face, avoid in the context of the social
sitting without ready access to a setting of his/her life
door, avoid a desk barrier  Listening for ‘false notes”
◦ Introduction – name, school,  Providing the client with
purpose, time limit feedback information
◦ How to start – use open-ended about himself/herself of
question which the client might not
◦ Guidelines: be aware
 Speak briefly ◦ Clarifying techniques
 Paraphrasing
 Restating
 Reflecting
  Exploring as monitoring their own nonverbal  Suspending value judgment
response  Recognize their presence
THERAPEUTIC RELATIONSHIP 2. Helps strengthens the client’s ability  Identify how or where you learned these
 Therapeutic relationship is consistently to solve personal problems response to client’s behavior
focused on the client’s problem & 3. The nurse communicates that the  Construct alternative ways to view the client’s
needs client is not alone, rather, the nurse is thinking and behavior
working along with the client  Helping client develop resources –
Factors that enhances growth in others  Clarifying techniques consistently encourage client to use their
1. Genuineness – self-awareness of one’s 1. Helps both participants identify major resources helps minimize the client’s feeling
feelings differences in their frame of of helplessness & dependency & also
2. Empathy – one understands the ideas references, giving them the validates their potential for change
expressed opportunity to correct misconception
before these cause any serious Establishing boundaries
5 concepts of empathy misunderstanding.  Transference – the process whereby a
◦ Human trait person unconsciously & inappropriately
◦ Professional state  Degree of openness displaces onto individuals in his/her
◦ communication process 1. Open-ended questions current life those patterns of behavior &
◦ caring process 2. Close-ended question emotional reaction that originated in
◦ special relationship 3. Indirect or implied question relationship to significant figures in
childhood
3. Positive regard – ability to view another Interference with therapeutic communication
person as being worthy of caring about & 1. Nurse’s fear and feelings  Countertransference - the tendency of
as someone who has strength &  Avoid personalizing what the the nurse to displace onto the client
achievement potential patients say or do feelings related to people in the nurse’s
◦ Attitudes - the nurse takes the  Ask question in a kind and past
client & the relationship seriously matter-of-fact manner, by
◦ Actions – conveying empathy, and by  Common countertransference reaction
reiterating a desire to help 1. Boredom (indifference)
Attending - foundation of interviewing 2. Nurse’s lack of knowledge and 2. Rescue
- an intensity of presence or being insecurity 3. Overinvolvement
with the client  Patients are usually more 4. Overidentification misuse of
accepting when the nurse is honesty
Non-verbal behaviors the reflect degree of honest about not knowing an 5. Anger
attending answer and expresses a 6. Helplessness or hopelessness
1. Nurse’s posture willingness to find answers
2. Nurse’s degree of eye contact 3. Ineffective responses STAGES OF NURSE – PATIENT
3. Nurse’s body language  Nurses must avoid premature RELATIONSHIP
conclusions 1. PREORIENTATION PHASE
Therapeutic techniques  Do not be preoccupied with ◦ Goal: to establish a client
Therapeutic communication skills what to say next, rather, listen database & assess own feelings
 Use of silence to patient or they might be regarding the client
 Active listening listening to
1. nurse carefully note what the client is 2. ORIENTATION PHASE
saying verbally & nonverbally, as well THERAPEUTIC RELATIONSHIP
 ◦ Goal: develop mutual trust, ◦ Development of more adaptive  Manipulation
establish role of the nurse as behavior ◦ Provide limit setting
significant other to the client ◦ Accomplishment of the client’s ◦ Help client express their needs
◦ Client recognizes needs & seek goals directly to others
help ◦ Impasses in therapy that the
◦ Trustworthiness is built when the nurse is unable to resolve  Crying
nurse is honest regarding ◦ Unless a form of manipulation,
intention, is consistent, and keeps Interaction with client behaviors allow client to cry
promises  Violent behavior ◦ Provide privacy
◦ Assess the degree of patient’s ◦ Stay out of striking distance ◦ Be quiet and unobtrusive
awareness of problems & the ◦ Avoid touching clients without
ability & motivation to change approval  Sexual innuendos or inappropriate
◦ Talk about feelings directly then ◦ Change topic temporarily touch
focus on coping more effectively ◦ Suggest time out with patient ◦ Remind client these actions are
with them ◦ Avoid being alone with patient inappropriate
◦ Provide structure by limit setting ◦ Leave temporarily if patient is
agitated  Denial & lack of cooperation
3. WORKING PHASE ◦ Call for staff assistance ◦ Reality testing & supportive
◦ Goal: identify & address client’s confrontation with denial
problem  Hallucinations
◦ Reality testing helps patient see ◦ Comment on behavior  Depressed affect, apathy, &
reality more clearly & objectively ◦ Provide reality but acknowledge psychomotor retardation
compared with the past behavior ◦ Patience, frequent contact, and
◦ Limit setting – intervention ◦ Assess the hallucination based on empathy
designed to prevent clients from content of the messages ◦ Encourage hygiene, proper
harming themselves or others ◦ Do not focus on hallucination nutrition and gradual increase in
◦ Nurse’s awareness of personal once content is known activities
feelings & reaction to the client is ◦ Ignore the hallucination ◦ Postponed major decisions until
vital for effective interaction with emotions have subsided
the client  Delusions
◦ Clarify the meaning of the  Suspiciousness
4. TERMINATION PHASE delusions then ignore ◦ Communicate clearly, simply, and
◦ Goal: assist client to review what congruently.
was learned and to transfer  Conflicting values ◦ Clarify misinterpretation
learning interaction with others ◦ Help client examine the effects or ◦ Provide simple rationale or
◦ Attempt to make termination outcomes of their beliefs on their explanations for rules, activities,
official and state feelings about lives, relationship, and happiness occurrences, noises and requests
the relationship
◦ Reasons for terminating the  Severe anxiety & incoherent speech  Hyperactivity
nurse-client relationship ◦ Spend frequent, brief time with ◦ Patient should be in a quiet area,
◦ Symptom relief patients, offer support, and build with minimal auditory & visual
◦ Improved social functioning trust stimulation
◦ Greater sense of identity
 ◦ Remain calm, speak slowly and ◦ Physical protection – safety from 2. Activities needs to be selected for
softly & respect patient’s personal physical harm specific psychosocial reason to
space ◦ Psychological safety – nurse’s achieve specific effects
◦ Give direction in a kind, simple active intervention to prohibit 3. Nonverbal means of expression
but firm manner verbal abuse, ridicule or as an additional behavioral outlet
harassment of patient add a new dimension to treatment
 Transference & countertransference 4. Sublimation of sexual drives is
◦ Nurses must be open and clear 2. Structure – the physical environment possible through activities
◦ State action that they cannot rules & daily schedules of treatment 5. Indication for activity therapy:
meet patient’s need activities clients with low self-esteem who
◦ Limit setting ◦ Patient education lead by the are socially unresponsive
nurse
Milieu Management ◦ Opportunities for recreation Goals
 Consists of treatment by means of control 6. Encourage socialization in
modification of the client’s environment to 3. Norms – specific expectations of community & social activities
promote positive experiences behavior that permeates the treatment 7. Provide pleasurable activities
 Purpose: helps patient recover from environment 8. Help client release tension and
psychiatric & mental health problem ◦ Promotes safety & trust express feelings
◦ To create an environment that is 9. Teach new skills, help client find
Characteristics of milieu therapy more predictable & applicable to new hobbies
 Friendly, warm, trusting, secure, all who share the environment 10. Offer graded series of experience,
supportive, comforting atmosphere from passive spectator role &
throughout the unit 4. Limit settings – should be set on acting- vicarious experiences to more
 An optimistic attitude about prognosis of out behavior direct and active experience
illness ◦ Reinforces the norms of making 11. Free and/or strengthen physical &
rules & expectations clear & creative abilities
 Attention to comfort, food, and daily living
encourage the milieu therapy 12. Increase self-esteem
needs; help with resolving difficulties
related to tasks of daily living concept---responsibility to self
ANXIETY DISORDERS
 Opportunity for client to take responsibility
5. Balance – the process of gradually  Group of conditions in which the affected
for themselves and for the welfare of the
allowing independent behavior in a person experiences persistent anxiety
unit in gradual steps
dependent situation that the person cannot dismiss and that
 Maximum individualization in dealing with interferes with daily activities
clients  Etiology:
 Opportunity to live through & test out Activity therapy
 Consists of a variety of recreational and 1. Neurobiological – hereditary,
situations in a realistic way brain chemistry, developmental
 Opportunity to discuss interpersonal vocational activities (recreational therapy,
occupational therapy, music, art, and factors, disruption of the
relationship in the unit among clients and amygdala
between clients and staff dance therapy) designed to test 7
examine social skills & serve as adjunct 2. Psychological - low self-esteem,
 Program carefully selected resocialization shy or timid in childhood, critical
activities to prevent regression therapies
parents, discomfort with
Concept and principles aggression, abuse, violence,
Elements of milieu therapy poverty
1. Safety 1. Socialization counters the
regressive aspect of illness
A. GENERAL ANXIETY DISORDER  Sign/symptoms: palpitations, chest pain, Compulsion – repetitive stereotyped behavior
 Characterized by excessive chronic dyspnea, nausea, feelings of choking, that are performed in a particular manner in
anxiety or worry & might concern chills & hot flashes response to an obsession
everyday events - Performed to prevent discomfort & to bind
 Individuals have no control over anxiety & 2. Panic disorder without agoraphobia or neutralized anxiety
worrying becomes habitual  Agoraphobia - intense, excessive - It interferes with normal routines,
anxiety or fear about being in places or occupational & social functioning
Characteristics: restlessness. Fatigue, poor situations from which escape might be - Interferes with patient’s interpersonal
concentration, irritability, muscle tension, sleep difficult or embarrassing or in which help relationship
disturbance, physical symptoms (dry mouth, might not be available if panic attack
upset stomach) occurs Etiology: genetic, increase brain activity in the
 Feared places are avoided e.g.. Outside, frontal lobe & basal ganglia, serotonin
Psychotropic mgt: alone @ home, travelling in car, bus or dysregulation
1. NPR – reduce level of anxiety plane, being on a bridge, riding in a
Goal: assist patient with developing adaptive, elevator Psychotherapeutic mgt.:
coping responses 1. NPR:
 Promote trust Etiology: hereditary, trauma, life stress or trauma,  Accept rituals permissively
 Convey empathy disruption in the amygdala  Avoid criticism or punishment, making
demands, showing impatient – positive
Psychopharmacology Psychotherapeutic mgt: feedback
◦ Antidepressants: SSRI. SSNRI 1. NPR:  Allow extra time for slowness & client’s
◦ Benzodiazepine – short-acting  Reduce immediate anxiety – stay action
physically close to patient, use simple  Help client verbalize feelings, solve
sentences, firm voice, remove to smaller problem & make decisions
Milieu mgt: quiet room to minimize stimuli  Protect from rejection by others & self-
 Recreational activities  Patient education inflected harm
 Relaxation exercises, meditation &  Cognitive restructuring
biofeedback Psychopharmacology:
 CBT Psychopharmacology:  Antidepressant:
 Therapeutic touch & acupressure  SSRI o Clomipromine (anafranil)
 Benzodiazepine (clonazepam, lorazepam)  SSRI – fluoxetine (Prozac), setraline
B. PANIC DISORDERS – recurrent panic attack – immediate effect (Zoloft), fluovoxamine (Luvox) &
& are worried about having more attacks paroxetine (Plaxil)
 Panic attacks – sudden, intense fear or Milieu mgt.: gross motor activities – diffuse
discomfort and peaks at 10 minutes energy Milieu mgt.:
 Feelings of impending doom  Relaxation exercises & stress mgt.
C. OBSESSIVE – COMPULSIVE DISORDER  Recreational or social skills
Types of panic disorder Obsession – persistent thoughts, impulses,  CBT, problem-solving & communication
1. Panic disorder with agoraphobia images or desires that maybe trivial or morbid or assertive training groups
 Feelings of terror that function is - Recognize thoughts are irrational &
suspended, perceptual field is severely senseless D. PHOBIC DISORDERS
limited & misinterpretation of reality - Intense, irrational, persistent fear responses to
 Personality disorganization an external object activity or situation
Phobia – response to experience anxiety & is
characterized by a persistent fear of specific E. ACUTE STRESS DISORDER & POST 4. Other symptoms
places or things TRAUMATIC STRESS DISORDERS  Anxiety or panic attack
- Develop after exposure to a clearly identifiable  PTSD – grief, depression, suicidal
3 types of phobias traumatic event that threatens the self, others, ideation or attempts, impulsive self-
1. Agoraphobia with history of resources, and/or sense of control or hope destructive behavior, anxiety-relate
panic disorders – fear of being disorders & substance abuse
in public or open spaces places or ACUTE STRESS SYNDROME – symptoms
situations in which escape might occur within 1 month of extreme stressor; Psychotherapeutic mgt: prevent or minimize
be difficult or help might not be includes dissociative symptoms the symptoms
available (depersonalization, emotional detachment., 1. NPR: develop trust
2. Social phobia – fear of being dazed appearance, amnesia)  Nurse needs to be non-judgmental
humiliated, scrutinized, or honest, emphatic, and supportive
embarrassed in public POST STRESS DISORDER – severe traumatic  Teach dynamics of ASD & PTSD
3. Specific phobia – fear of a event that is not an ordinary occurrence e.g..  Exposure therapy & systematic
specific object or situation that is Rape, fire, flood, earthquake, tornado, bombing, desensitization
not either of the above plane crash, war, torture, kidnapping  Expressive therapy (art, music, poetry) –
facilitate externalizing painful emotions
Etiology: environment, genetic predisposition Diagnostic criteria that are difficult to verbalize
1. Dissociative symptoms & numbing  Crisis counselling –
Psychotherapeutic mgt.:  Amnesia, depersonalization, derealization
1. NPR: & awareness of surrounding, numbing, Psychopharmacology
 Accept patient & their fears with a non- detachment or lack of emotional response  Benzodiazepine (clonazepam,
critical attitude  Numbing of responses or reduced lorazepam) – to reduce level of anxiety
 Provide & involve patient in activities that involvement with the external world and fear. Help with sleep disturbance
do not increase anxiety but increase  Persistent avoidance of situation,  Clonidine & propanolol – diminish the
involvement, rather that promote activities and people, thoughts and peripheral autonomic response
avoidance feelings associated with fear, anxiety & nightmare
 Help client with physical safety and  Denial, repression & suspension  Lithium carbonate – prescribed to
comfort  Feel detached or estrange from family & patients experiencing explosive outburst
 Help patient recognize that their behavior friends → withdrawal → depression  SSRI (paroxetine, setraline, fluoxetine)
is a method of avoiding anxiety  Lost interest in activities, hopelessness – decrease repetitive behaviors,
 Change in sleep pattern disturbing images & somatic states
Psychopharmacology:  Impulsive behavior, sudden life change  TCA – depression, adehonia & sleep
SSRI – to reduce anxiety & depression & block
disturbances
panic attacks, if present 2. Reexperiencing the trauma & intrusive  Antipsychotic (respirodone) –
memories – hallucinations (PTSD) psychotic thinking
Milieu mgt:
 Assertive training & goal-setting groups 3. Arousal symptoms Milieu mgt:
 Social skills group to help redevelop  ↑ arousal, anxiety, restlessness, irritability,  Social activities
social skills and decrease avoidance disturbance in sleep, memory impairment  Recreational & exercise program
 Behavior therapy – systemic or concentration  Group therapy
desensitization, flooding, exposure, and  PTSD – outburst of anger, rage, survivor
self-exposure guilt
F. SOMATOFORM DISORDERS ◦Alteration in voluntary or motor  Do not push awareness of or insight into
- Characterized by the presence of physiologic sensory functioning that suggest conflicts or problems
complaints or symptoms, which are not under neurological or medical condition
voluntary control & no demonstrable organic ◦ Not due to malingering or Psychopharmacology: SSRI – to treat anxiety
finding and physiologic bases factitious disorder and not and depression
culturally sanctioned
Types of somatoform disorders ◦ Cannot be explained by gen. Milieu mgt:
1. Somatization disorder medical condition or effects of a  Relaxation exercises meditation and CBT
◦ Conversion of mental states or substance  Family therapy
experiences into bodily symptoms 5. Body dysmorphic disorder
associated with anxiety ◦ Individual is preoccupied with an G. DISSOCIATIVE DISORDER
◦ Recurrent, frequent & multiple imagined defect in appearance – disturbances in the normally well-integrated
somatic complaints for several which are usually facial flaws. continuum of consciousness, memory, identity,
years without physiologic cause ◦ Dermatologist & plastic surgeon is and perception
◦ Client’s constantly seek medical often consulted
attention, undergo numerous ◦ May also exhibit obsessive  Dissociation – the removal from
tests; at risk for unnecessary compulsive traits & depressive conscious awareness of painful feelings,
surgery or drug abuse syndrome memories, thoughts, or aspects of identity
2. Pain disorder ◦ Controls relationship through ◦ Unconscious defense mechanism
◦ Associated with psychological physical complaints that protects an individual from
factors like severe pain in one or the emotional pain of experiences
more of anatomical sites that Causes: or conflicts that have been
causes significant distress or 1. Inability of the CNS to regulate & interpret repressed
impairment in functioning sensory input or to decrease  Defense mechanism: repression
◦ Pain is exaggerated or out of communication between right & left
proportion hemisphere Causes:
◦ Causes significant impairment in 2. Hx of physical & sexual abuse witnessing  Inability to recall important personal
occupational or social functioning violent acts in childhood, poor nurturing information usually of a traumatic or
or causes marked distress from family, lack of job, and social skills stressful nature
◦ Symptoms not intentionally 3. Need to be sick to relieve oneself of  The disorder is often associated with
produced or feigned obligations & to gain attention exposure to traumatic event common
3. Hypochrondiasis 4. Dissociation during disaster and wartime
◦ Worried & belief that they have  Sexual abuse during childhood
serious disorders base on the Psychotherapeutic mgt.  Psychopathology: an escape mechanism
misinterpretation of bodily signs & 1. NPR: from memory of painful experiences or
sensation for at least 6 months  Use matter-of-fact caring approach devoid of emotional satisfaction. There is
◦ Preoccupation persists despite  Encourage patient to verbalize & describe little or no participation of the conscious
appropriate medical tests & feeling personality so the person is unable to
reassurances  Use positive reinforcement & set limits recall
◦ Causes significant impairment in  Be consistent
occupational or social functioning  Use diversion by including patient Types of dissociative disorders
or causes marked distress patients in milieu activities and 1. Dissociative amnesia
4. Conversion disorder recreational games ◦ Sudden inability recall important
information of one or more
 episodes not associated with  Confirm identity of client and orientation  Impairment in social
organic disorders usually of a to time & place interaction
traumatic or stressful nature  Encourage client to do things for self and  Markedly restricted,
 Localized amnesia make decision about routine tasks stereotypical patterns of
 Selective amnesia behavior, interest and
 General amnesia Milieu mgt: activities
 Individual therapy  Childhood & Adolescent psychiatric
2. Dissocialise fugue – sudden,  Task-oriented group disorders
unexpected travel away from home or  OT and art therapy a. Asperger’s disorders – a severe
some other location with the assumption  Cognitive therapy developmental disorder
of a new identity or a confusion about  Self-help groups characterized by major difficulties
one’s identity in social interaction & restricts &
◦ Fugue states is characterized Childhood & Adolescent psychiatric unusual interest & behavior
amnesia; consequently, patients disorders  Use monotone speech
do not remember what happened.  Risk factors: and rigid language
 They cannot understand
◦ Genetic factor
3. Depersonalization disorder – involves jokes and are taken
◦ Social & environment – severe
an altered sense of self, so that the advantage easily
marital discord, low
individual feel unreal or strange or believe  Inability to show empathy
socioeconomic status, large
that danger is not happening to then or to to others but want to meet
family & overcrowding, parental
someone else people & make friends
criminality maternal psychiatric
◦ Reality testing remains intact  Have an obsession with
disorder, traumatic life event,
facts about circumscribed
sexual/physical abuse
4. Dissociative identity disorder – and odd topics
◦ Psychosocial factor – b. Attention deficit/hyperactivity disorder
existence of 2 or more identities or
◦ Biochemical factors – alterations – characterized by inattention,
personalities that take control of the
of neurotransmitters (decrease in impulsiveness, and overactivity in school
person’s behavior with its own patterns of
norephhinephrine & serotonin 9before 7 years old)
relating, perceiving, and thinking
◦ Temperament – a style of ◦ Causes:
◦ The person or host us unaware of
behavior a child habitually uses to  Environmental exposure –
the other personalities, but the
cope with the demands & perinatal insults, head
other alters might be aware of
expectations of the environment injury, psychosocial
each other to varying degrees
 Types of childhood mental disorders adversity, lead poisoning,
◦ Defense mechanism: repression
1. Pervasive development disorders and diet
a. Autistic disorder  Genetic and hereditary
Psychotherapeutic mgt.
b. Characterized by impairment in factors
1. NPR:
social interaction, communication  Dysfunction in the frontal
 Establish trust & support, provide caring and restricted repertoire of activity
and empathy lobe
& interest ◦ Characteristics of ADHD
 Assist in gathering data about feelings, c. Usually first observed before 3
conflicts, or situations that patient  Inattention
years of age  Difficulty paying
experienced d. Sign & symptoms
 Ensure client safety attention in tasks
 Impairment in or play
 Provide nondemanding, simple routine communication &
imaginative activity
  Does not seem to  Risk for injury and a tendency to blame others
listen, follow  Impaired social interaction for quarrels or accidents
through or finish  Ineffective individual  Recurrent pattern of
tasks  Risk for violence for self- negativistic, disobedient,
 Does not pay directed or directed to hostile , defiant behavior
attention to details others towards authority figures
& makes careless ◦ Nursing intervention with serious violation of
mistakes  Establish trust basic rights of others
 Is easily distracted,  Talk to client about safe &  Exhibit persistent testing
lose things, & is unsafe behavior – use of limits, an unwillingness
forgetful in daily clear, honest to give in or negotiate,
activities straightforward and a refusal to accept
 Childhood & Adolescent psychiatric communication blame for misdeeds
disorders  Assess the frequency &  Behavior do not violate
 Hyperactivity severity of accidents the rights of others
 Fidgets, is unable  Provide supervision for ◦ Conduct disorder –
to sit still or stay potentially dangerous characterized by persistent
seated in school  Assist the client, parent or pattern of behavior in which the
or at other times caregivers to make the rights of others & age-appropriate
 Runs & climbs distinction between societal norms or rules are
excessively in accidental & purposeful violated.
inappropriate incident  Predisposing factors:
situations ◦ Childhood & Adolescent ADHD, oppositional child
 Has difficulty psychiatric disorders behaviors, parental
playing quietly in  Give instruction slowly rejection, inconsistent
leisure activities using simply giving parenting with harsh
 Acts as if “driven instruction discipline, early
by a motor”,  Ask client to repeat institutional living,
constantly on the exercise or instruction frequent shifting of
go before beginning a task parental figures, large
 Talks excessively  Administer stimulant in family size, absence of
 Impulsivity the morning to maximize father or alcoholic father,
 Blurts out answer effectiveness for daytime antisocial & drug-
before question activity dependent family
has been  Help parents decrease members, & association
completed their feelings of guilt & with a delinquent group
 Has difficulty blame  Examples of behaviors:
waiting for own  Maintain a safe physically aggressive,
turn environment at home & in have poor peer
 Interrupts, school relationships & shows
intrudes in others’ ◦ Oppositional defiant disorder – little concern for others &
conversation & enduring pattern of disobedience, lack of guilt or remorse
games argumentative, explosive angry  Childhood & Adolescent psychiatric
◦ Nursing Dx outburst, low frustration tolerance, disorders
c. Anxiety disorders  Protect the child from ◦ Accomplishes goals
1. Separation anxiety disorders – panic levels of anxiety by ◦ Defines & expresses spirituality
excessively anxious when acting as parental  Personality disorder – “enduring pattern
separated from or anticipating a surrogate of inner experience & behavior that
separation from their home or  Accept regression but deviates markedly from the expectation of
parental figures giving emotional support the individual’s culture, is pervasive &
2. Most children will express worry to help child progress inflexible, has an onset in adolescence or
about harm or permanent loss of again early adulthood, is stable over time, &
the mother or major attachment  Increase child’s self- lead to distress or impairment “ (APA,
figure esteem & feelings of 2000)
3. Characteristics: competence in the ability  Etiology of PD
 Excessive distress when to perform , achieve, ◦ Theorist – PD is related to
separated from or influence the future unsuccessful mastery of task in
anticipating separation  Help child accept and early stages of development that
from home or parental work through traumatic can lead to anxiety
figure events or losses ◦ Behaviorist – Developmentalist –
 Excessive worries that 5. Psychopharmacology: believe that PD originates in early
one will be lost or antihistamines, anxiolytics and childhood experiences (negative
kidnapped or that parental antidepressants experiences)
figures will be harmed 6. Cognitive therapy, behavior ◦ Genetic cmponents
 Fear of being home alone modification ◦ Stressful environment
or in situation without  PERSONALITY DISORDERS  PERSONALITY DISORDERS
other significant adults  Personality – sum total of the person’s  CRITERIA FOR A PERSONALITY
 Refusal to sleep unless distinctive character, behavior, attitudes, DISORDER
near a parental figure & the way one carries himself , the way one 1. CLUSTER A DISORDERS (ODD,
refusal to sleep away from communicate ECCENTRIC)
home ◦ An enduring pattern of behavior a. Paranoid personality disorder
 Refusal to attend school that is considered to be both  These individuals interpret
or other activities without conscious and unconscious and other people's motives as
a parental figure reflects a means of adapting to a threatening resulting in an
 Physical symptoms as a particular environment & it cultural, increase in anxiety & the
response to anxiety ethnic and community standards need for vigilance
4. Nursing interventions: (Carson)  Characterized by distrust
 Assess the quality of the ◦ Healthy personality: & suspiciousness toward
relationship between child ◦ Sees his or her own strengths others, based on the
& parents or caregivers weaknesses belief (unsupported by
for evidence of anxiety, ◦ Identifies his or her own evidence) that others
conflicts or difficulty of fit boundaries want to exploit, harm, or
between child’s and ◦ Recognizes interaction & deceive the person &
parent’s temperament thoughts that lead to strong often act in defense of a
 assess the child’s emotions such as joy or anger fragile self-concept
previous & current ability ◦ Interacts with others without  They demonstrate
to separate from parents expecting them to meet all needs jealousy, controlling
or caregivers ◦ Seeks a balance of work & play
 behaviors, and indifference to praise or communicating
unwillingness to forgive criticism from others and perceiving
 Common in men than  Can be a precursor to 4. Has eccentric
women schizophrenia or delusion appearance and
 Irritable and stubborn – disorder shows evidence of
prejudice  Defense mechanism: magical thinking
 With ideas of reference INTELLECTUALIZATION or perceptual
 Blunted affect , humorless  DSM IV criteria distortion that are
and serious 1. Lacks desire for not clear
 Fear in confiding in others close relationship delusions or
 Hold grudges towards or friends hallucination
others 2. Choose to be 5. Sensitive to
 Easily get angry if they alone behavior of other
are threatened 3. Lack sexual people especially
 Emotionally cold in experience rejection & anger
appearance but are 4. Avoid activities 6. Speech may be
acceptable of close 5. Appears cold and difficult to follow –
relationship to few detached the individual
b. Nursing guidelines  Nursing guideline: develops a
c. – may carry or conceal weapons 1. Avoid being too personalized style
 PERSONALITY DISORDERS “nice” or “friendly” with vague
b. Schizoid personality disorder 2. Do not try to association
 Individuals with this increase 7. Socially inept
disorder lacks personal & socialization  Nursing guideline
social relationship. They  PERSONALITY DISORDERS 1. Offer support like
are detached from others b. Schizotypal personality kindness
& withdraws from disorder 2. Be calm, non-
interaction –  Individuals with this threatening in all
hypersensitive disorder may have or approaches
 Introverted since behavior similar to those 3. Respect client’s
childhood, rarely have of someone with need for social
close friends schizophrenia, however isolation – cannot
 Use autistic thinking, psychotic episode are tolerate group
daydreaming are more infrequent & less severe therapy
gratifying  Characteristics: 4. Speak in a gentle
 They respond with short 1. Ideas of reference manner to
answers to questions & 2. With magical encourage to get
do not initiate thinking/odd involve in group
spontaneous conversation beliefs leading to activities
 They are reality-oriented interpersonal 5. Be aware of
but maintain fair contact difficulties client’s
with others 3. Problems in suspiciousness &
 They function in a solitary thinking, employ
occupation but shows
 appropriate 3. Aggressive Characterized
 by
intervention behavior impulsiveness,
6. Assist & teach the 4. Lack of guilt or unpredictable, unstable
client about social remorse moods
skills & 5. Irresponsible in  Desperately seek
appropriate work & with relationship to avoid
behavior to finances feeling abandoned
improve his 6. Impulsiveness  Chronic sense of
interpersonal 7. Recklessness boredom
relationship  Etiology: genetics,  Overspending,
 PERSONALITY DISORDERS environment, family promiscuity, overeating
2. CLUSTER B CRITERIA (DRAMATIC, environment (unstable  Problems with identity &
EMOTIONAL, ERRATIC) parent – child self-image
a. Antisocial personality disorder realationship  history of substance
 Has consistent disregard  PERSONALITY DISORDERS abuse & multiple or
for others with exploitation  Nursing guidelines dramatic suicidal gesture,
& repeated unlawful 1. Prevent or reduce risk of suicide and
actions. untoward effects mutilation
 Unable to postpone of manipulation  Manipulative and
gratification, selfish and (flattery, dependent
irresponsible seductiveness,  Emotional lability
 Generally manipulative, instilling guilt) by  Defense mechanism:
does not feel guilty, setting limits projection
sorrow & not loyal 2. Encourage client  Etiology:
 Charming, intellectual and to verbalize  Inadequate regulation of
smooth talkers feeling serotonin & dopamine &
 They repeatedly neglect 3. Be firm, steadfast other transmitters
responsibilities, tell lies and consistent in  Parents may cling to the
and perform destructive or dealing with child and prevent
illegal acts, without patient’s behavior autonomy, individual or
developing any insight and reinforcing parent withdraws support
into predictable rules & policies & attention making the
consequences 4. Help client be child confuse
 Hostile, unable to follow aware of the  PERSONALITY DISORDERS
rules consequences of  Pharmacologic mgt:
 Diagnose before age 15 their behavior  Neuroleptic drugs (3-12
as conduct disorder 5. Explain & point wks)
 Criteria for Antisocial out the effects of  Lithium
PD their behavior  Valporic acid
1. Violate rights of towards others  Carbamazepine
others 6. Avoid moralizing  Benzodiazepine
2. Engage in illegal c. Borderline personality  Nursing guidelines
activities disorders  Set realistic goals, use
clear action word
 Be aware of manipulative Individual with this fears of separation” (APA,
behaviors disorder are characterized 2000)
 Provide clear & consistent by excessive emotional  Extreme dependency in a
boundaries & limits attention seeking behavior close relationship, with an
 Use clear 7 and are dramatic and urgent search to find a
straightforward ego-centric replacement when one
communication  Seductive, flamboyant relationship ends - they
 Avoid rejecting or and shallow – use speech are afraid to be alone
rescuing to impress others  They want others to make
 Assess for suicidal & self-  Needs to be the center of decision for them – they
mutilating behavior attention need direction and
c. Narcissistic personal disorder  Impulsive and reassurance
 Individuals with this melodramatic  They feel the need to be
disorder display  Demands “the best of rewarded if they do good
grandiosity about his everything” and can be deeds for others
performance and very critical  To avoid conflict they
achievement  Related factors: mother- become passive, conceal
 Arrogant, extrovert child relationship sexual feelings and anger
 Believe to be special with  Nursing guidelines:  Nursing guidelines:
need to be admired  Understand seductive  Increase
 Feel intense shame & fear behavior as a response to responsibility for
that if they are “bad”, they distress self in daily livings
will be abandoned  Keep communication &  Be assertive
 Afraid of their own interaction professional,  Encourage client
mistakes, as well as the despite temptation to to verbalize
mistakes of others. collude with the client in a feeling
 Defense mechanism: flirtatious & misleading  Be aware of
rationalization manner countertranferenc
 PERSONALITY DISORDERS  Encourage & model the e
 Nursing guidelines: use of concrete & b. Avoidant personality disorder
 Supportive confrontation descriptive rather that  These clients are timid,
 Remain neutral; avoid vague & impressionistic socially uncomfortable,
engaging in power language with self care and
struggle or becoming  Teach and role-model withdrawn
defensive in response to assertiveness  Social inhibition and
the client’s disparaging  PERSONALITY DISORDERS avoidance of all situation
remarks 3. CLUSTER C DISORDERS (ANXIOUS, that require interpersonal
 Convey unussuming self- FEARFUL) contact
confidence a. Dependent personality disorder  Hyeprsensitive to criticism
 Point out reality  “pervasive & excessive  Uncertain and lacks
 Tell client no one is need to be taken care of confidence and afraid to
perfect that leads to submissive ask question or speak in
c. Histrionic personality disorder and clinging behavior & public
 Nursing guidelines
  Be friendly, gentle,  Guard against g. Feelings of worthlessness
reassuring engaging in power or inappropriate guilt (may
approach struggle with client be delusional)
 Help client to  Confront client’s h. Recurrent thoughts of
confront fears procastination and death or suicidal ideation
gradually intellectualization i. Decrease concentration
 Support & direct  MOOD or indecisiveness
client in DISORDERS  MOOD DISORDERS
accomplishing  Mood – a person’s state of mind exhibited ◦ Characteristics
short-term goals through feeding & emotions (APA, 2001) a. Disregards grooming,
 Relaxation  Mood disorders – extreme change in cleanliness & personal
techniques mood that presents problems in daily appearance
 PERSONALITY functioning b. Stooped posture &
DISORDERS - alteration in effect or mood that occurs dejected facial expression
c. Obsessive-compulsive when an individual experience exaggerated c. Dishevelled, downcast,
personality disorder feeling for a prolong period of time that is lacking eye contact &
 Perfectionist and inflexible psychologically, physically & socially tearful
 Overly strict & often set unacceptable d. Agitated
standards for themselves  Causes: ◦ Specifiers:
that are too high ◦ Genetics a. Atypical depression –
 Preoccupied with details, ◦ Biochemistry occurs in younger
rules, trivial and ◦ Personality population
procedures ◦ Environment  Increase appetite
 Difficult to express  Types of depression: or wt. gain,
emotions or warmth 1. MAJOR DEPRESSIVE DISORDER hypersomnia,
 They try to control partner (MDD) leaden paralysis &
in a relationship ◦ Characterized by 1 or more major extreme sensitivity
 Serious, affect is depressive episodes, which are to interpersonal
constricted and would defined as at least 2 weeks by rejection
speak in monotone voice depressive mood or less of b. Melancholic depression
 Defense mechanism: interest accompanied by at least – older adults
intellectualization, 4 additional symptoms of  Anhedonia &
rationalization, reaction- depression inability to be
formation ◦ Signs/behavior cheered up
 Etiology: early parent- a. Depressed mood most of  Depression worse
child relationship the day in AM
 Nursing guidelines: b. Anhedonia  Early AM
 Help client make c. Significant weight loss or awakening
decision gain (5% wt. in month)  Psychomotor
encourage follow- d. Insomia or hypersomia (2 retardation or
through behaviors hrs in 1 month) agitation
 Encourage leisure e. Increase or decrease  Significant
activities motor activities anorexia or wt
f. anergia loss
 Excessive or  Do not argue ◦ Behavior – always on the go,
inappropriate guilt  Divert patient’s increase sexual drive
c. Catatonic features – attention 2. Acute manic episodes
psychomotor attraction b. Bolster self-esteem ◦ Intensified symptoms
including immobility, c. Be amphatic ◦ Mood disturbance & lability
excessive motor activities, d. Point out or reward small ◦ Enthusiastic & intrusive
mutism, echolalia or visible accomplishment ◦ Hyperactivity
echopraxia, inappropriate e. Do not embarrass patient ◦ Flight of ideas
posturing f. Never reinforce ◦ Distractibility
 negativism hallucination, delusions or
◦ Distortion of self-esteem
d. Postpartum depression irrational beliefs
3. Delirium – state of extreme excitement
– mood disturbance that g. Encourage verbal
◦ Disorientation, incoherence
occurs during the first 30 expressions of anger
days post partum h. Provide non-threatening ◦ Visual or olfactory hallucination
e. Psychotic depression – one-to-one relationship ◦ Exhaustion, dehydration, injury
delusions & i. Guide patient to even death
hallucination appropriate decisions by  MANIC DISORDERS
 Delusion of guilt, using problem solving  Basic syndromes of bipolar disorders
delusions of  MOOD DISORDERS a. Manic episodes – elevated, expansive or
deserved 2. DYSTHMIC DISORDER irritable mood
punishment,  Patient is depressive mood for at b. Hypomanic episodes – less, severe
somatic delusions, least 2 years level of impairment
nihilistic delusion,  With poor appetite or over-eating c. Depressive episodes – hypersomia,
& delusion of  Insomia or hypersomia hyperphagia, wt. gain, leaden paralysis,
poverty  Low energy or fatigue little energy
f. Seasonal affective  Low self-esteem d. BIPOLAR DISORDER
disorder (SAD) – occur in  Poor concentration or difficulty ◦ Bipolar I disorder – experiences
conjunction with a making decisions swings between manic episodes
seasonal change  Feelings of hopelessness and major depression
 MOOD DISORDERS  Difference between MDD & DD ◦ Bipolar II disorder – characterized
◦ Psychopharmacological mgt. (duration & severity) by 1 or more depressive episodes
a. SSRIs  Patient may engage in activities accompanied by at least one
b. Tricyclics to generate excitement hypomanic episodes
c. Antidepressant  may turn to substance abuse or ◦ Cyclothymic disorders – a swing
d. MAOIs food between a hypomanic and
◦ Nursing guidelines:  Patients do not readily recognize depressive symptoms
a. Establish trust their symptoms as abnormal ◦ Behavior of bipolar disorder
 Nonjudgmental &  MANIC DISORDERS  Objective behavior
friendly approach  STAGES OF MANIA  Disturbance of
 Use silence & stay 1. Mild elation or hypomaniac (4 days) speech, social,
with patient ◦ Affect – feeling of happiness, interpersonal &
 Avoid challenging confidence occupational
or testing the ◦ Thought – flight of ideas, inflated relationship,
client self-esteem
 activity &  Safety ◦ Osteopenis or osteoporosis
appearance  Consistency among staff ◦ Cardiac arrythmias
 Speech – rapid,  Reduction of ◦ Bizaare behavior regarding fool &
pressured, loud, environmental stimuli eating
easily distracted  Dealing with patient who ◦ Feel abandoned or inadequate
 Altered social, are escalating ◦ Depression, irritability, social
interpersonal &  Reinforcement of withdrawal, lessened sex drive &
occupational appropriate hygiene & obsession symptoms
relationship dress  EATING DISORDERS
 Subjective behavior  Nutrition & sleep issues ◦ Etiology
 Alteration of affect  EATING DISORDERS  Biologic factors – increase
– euphoric,  ANOREXIA NERVOSA serotonin
grandiosity, labile ◦ Limit their intake or refuse to eat  A culture of thinness,
 Alteration of but do not lose their appetite relational orientation of
perception – ◦ Perfectionist & introvert with self- women
delusion & esteem & peer relationship  Genetic component
hallucination problems  Family environment
 MANIC DISORDERS ◦ Clinical manifestation/behaviors  Odd eating habits &
◦ Nursing responsibilities Restricters Vomiters-purgers emphasis on appearance
 Use matter of fact tone ◦ Normal or slightly ↑  Rejection of food & wt.
 Clear, concise direction & Induction of vomiting 7 loss as a positive
comments – remarks excessive use of laxative or reinforcement
should be simple & brief diuretics  Childhood sexual abuse
 Limit – setting ◦ Avoids people  Regression to a
 Reinforcement of reality denies concern prepubertal state
 Respond to legitimate ◦ Competitive, compulsive,  Fear of being out of
complaints obsessive dental problems control
 Redirect patient into more ◦ Rigid excersie program  Defense mechanism:
healthy activities uncontrollably eat large REACTION FORMATION
 Provide for can be eaten amounts of food  BULIMIA NERVOSA
easily ◦ Hyperactive ◦ Intermittent binge period and
 Assess amount of sleep & substance abuse periods of restrictive eating
rest family ◦ Loss of control over eating
 Provide quiet place to conflict ◦ Anxious & feeling of weakness –
sleep
◦ Amenorrhea before eating while binging
 Structure activities during
◦ Hypotension, bradycardia, ◦ Angry & agitated or depressed
the day
hyponatremia ◦ Mood disorders
 Do not drink caffeine at
bedtime ◦ Dry skin with lanugo ◦ Substance sbuse
◦ Psychopharmacology ◦ Delayed gastric emptying ◦ Self-induce vomiting
 Lithium – ◦ Slow peristalsis----constipation  EATING DISORDERS
 Anticonvulsant & atypical ◦ Dehaydration ◦ Clinical manifestation/behavior
antipsychotics ◦ Refeeding syndrome  Secretive about behavior
◦ Milieu mgt. ◦ Pitting edema  Binge eating
 F/E abnormalities  Collaborate with patient 6. Birth & pregnancy complication, viral infxn,
Use of laxatives  Teach patient about poor nutrition or starvation, exposure to
Use of ipecac syrup disorders toxin
Menstrual irregularities  Determine patient’s 7. Stress – development/family
Dental carries weight with their back on 8. Weak ego
Russel’s sign the scale 9. Vitamin deficiency – vitamins B1, B6, B12,
Loss of control over  Initiate behavioral vit. C
eating modification  SCHIZOPHRENIA
 Anxious & feeling  Express emotions  Precipitating factors
weakness assertively 1. Emotional - marital problem
 Angry & agitated or  Help patient identify & 2. Somatic – pregnancy, physical illness
depressed express bodily sensation 3. May be none
 Mod disorders  identify non-weight  4 A’s (Eugene Bleuler)
 Substance abuse related interest Affect – outward manifestation of a person’s
 Self – induce vomiting ◦ Psychopharmacology feelings & emotion – flat, blunted, inappropriate
◦ Etiology  Anxiolytics bizarre affect
 Low serotonin activity  Atypical antipsychotics Associative looseness – haphazard & confused
 Inherited  Antidepressants - SSRI thinking manifested in jumbled & illogical speech
 Cycles of low self-esteem,  SCHIZOPHRENIA & reasoning
extreme concerns about  Schizophrenia – mental disorder Autism – thinking that is not bound to reality but
body shape & wt., strict characterized by disturdance in thought & reflects the private perceptual world of the
dieting, binge eating & sensory perception & deterioration in individual – delusions, hallucination, neologism
compensatory behavior psychosocial functioning Ambivalence – simultaneously holding 2
 Ambivalence  Psychotic – delusions, any prominent opposing emotions, attitudes, ideas, or wishes
 Feel unworthy of nurturing hallucinations, disorganized speech or towards the same person situation or object
 EATING DISORDERS disorganized catatonic behavior (APA,  Phases of schizophrenia
◦ Psychotherapeutic mgt 2000) 1. Acute phase – period of florid positive
 Medical stabilization  Comorbidity symptoms as well as negative symptoms
 Wt. restoration – 1. Substance abuse 2. Maintenance phase – period when acute
 Help patient reestablish 2. Depressive symptoms symptoms decrease in severity
appropriate eating 3. Anxiety disorders 3. Stabilization phase – patient is might
behavior  Theory still experience hallucination & delusions
 Elevate self-esteem 1. Dopamine hypothesis but not as severe nor as disabling as they
 Medical treatment – IV 2. Alternative biochemical hypothesis – were during the acute phase
lines & feeding tubes structural cerebral abnormalities, reduced Common symptoms of schizophrenia
◦ Nursing guidelines gray matter, increase ventricular brain 1. Delusions – false fixed beliefs that cannot
 Convey warmth & ratio be corrected by reasoning
sincerity 3. Genetics 2. Hallucinations – sensory perception for
 Listen emphatically 4. Autoimmune which no external stimulus exist
 Be honest 5. Double bind communication – 2 3. Illusions – misinterpretation of
 Set appropriate messages that contradict each other are environmental stimuli
behavioral limit sent causing the child to be confused on 4. Depersonalization – feeling of the
 Assist patient in what action to engage in which individual that the self has been changed
identifying their qualities immobilize the child & results to anxiety or altered
 5. Affective flattening – absence of hostility, ideas of reference, illusions, ◦ Objective Sx
emotional response insomia  Less concerned with their
6. ambivalences Type II schizophrenia appearance
 SCHIZOPHRENIA  Slow onset of negative symptoms aused  Introspection & apathy
 Common delusions in schizophrenia by viral infxn & abnormalities in  Anergia
1. Delusions of reference – everything that cholecystokinin  Inadequate interpersonal
is occurring in the environment has  Sx: dimunition or loss og normal function, communication
significance to oneself anergia, anhedonia, alogia, avolition,  Hostility
2. Delusion of persecution – false belief that blunted affect or affective flattening,  Withdrawal
one is being singles out for harm by attention deficits, poor eye contact,  Psychomotor agitation or
others – someone is platting against asocial behavior, difficulty in abstract inactive or catatonic
him/her thinking ◦ Subjective Sx
3. Somatic delusion – appearance or  SCHIZOPHRENIA  Hallucnation
functioning of one’s body is altered  SCHIZOPHRENIA SUBTYPES  Illusion
4. Grandiose delusion – false belief that one 1. PARANOID TYPE  Paranoid thinking
is a very powerful & important person ◦ Experience persecutory or  Thoiught disorder
5. Nihilistic delusion – “I am dead” grandiose delusion & auditory  Delusions
6. Delusions of influence – one is controlled hallucination  Confusion, incoherent
by others or outside force 2. CATATONIC TYPE – psychomotor speech, clouding, & a
Jealousy – false belief that one’s mate in disturbances sense of going crazy
unfaithful; may have so-called proof ◦ Motoric immobility, waxy flexibility  Inappropriate, flattened,
 Symptoms of loose association or stupor blunted, or labile affect
1. Neologism ◦ Excitement (excessive motor  SCHIZOPHRENIA
2. Echolalia activity)  Psychopharmacology
3. Word salad ◦ Extreme negativism or mutism ---- ◦ Stabilize acute symptoms
4. Clang association withdrawal ◦ Maintain therapeutic plasma
 SCHIZOPHRENIA ◦ Peculiar movements levels
 3 broad clinical symptoms ◦ Echolalia or echopraxia ◦ Typical antipsycotics
1. Positive symptoms 3. DISORGANIZED TYPE – most severe  Haloperidol (Haldol)
◦ Reflects the presence of overt prognosis, disintegration of personality &  Chlorpromazine
psychotic or distorted behavior is withdrawn, disorganized speech, (Thorazine)
2. Negative symptoms – reflect a disorganized behavior, flat or  Thiothixene (Navane)
dimunition or loss of normal function inappropriate affect ◦ Atypical antipsychotics
3. Disorganized symptoms – presence of 4. UNDIFFERENTIATED TYPE –  Clozapine (Clozaril)
confused thinking, incoherent or characterized by atypical symptoms that  Respirodone (Respiradol)
disorganized speech & disorganized do not meet the criteria for other subtypes  Olanzopine (Zyprexa)
behavior ◦ Characteristics symptoms  Milieu mgt.
 2 diagnostic categories ◦ Prognosis is favorable ◦ For disruptive patients:
Type I schizophrenia 5. RESIDUAL TYPE  Set limits
 Onset of positive symptoms is generally  Frequently observe
◦ Continuing evidence of negative
acute escalating patients to
symptoms without characteristic
 Sx: delusions, excitement, feelings of intervene
symptoms of schizophrenia
persecution, grandiosity, hallucination,
 SCHIZOPHRENIA
 Assessment
 Modify the environment to  Do not place patient in ◦ Do not reinforce hallucinations or
minimize objects that can group activities that would delusions
be used as weapons frustrate them, damage ◦ Do not touch patient without
 Be careful in stating what self-esteem, or over-tax warning
the staff will do if a patient their abilities ◦ Reinforce positive behaviors
acts out  Provide opportunities for ◦ Avoid competitive activities
 When using restraints, purposeful psychomotor ◦ Do not embarrass patient
provide for safety by activity ◦ Allow & encourage verbalization
evaluating the patient’s ◦ SCHIZOPHRENIA of feelings
status of hydration, ◦ For patient with hallucinations:  SCHIZOPHRENIA – LIKE DISORDERS
nutrition, elimination, &  Attempt to provide 1. Schizoaffective disorders
circulation distracting activities ◦ Uninterruptive period of illness
 SCHIZOPHRENIA  Discourage situation in during which at some point the
◦ For withdrawn patients: which patient talk to patient experiences a MDD,
 Arrange non-threatening others about their manic or mixed episodes along
activities that involve disordered perception with the negative symptoms of
these patient in doing  Monitor television schizophrenia
something selection ◦ In the absence of prominent
 Arrange furniture in a  Monitor for command mood symptoms, patient exhibits
semicircle or around a hallucination that might delusion or hallucination
table increase the potential for 2. Schizophreniform disorder
 Help client to participate patient to become ◦ Patient exhibits features of
in decision making dangerous schizopohrenia for more than 1
 Reinforce appropriate  Have staff members month but fewer that 6 months
grooming & hygiene available in the dayroom
◦ No impaired social or
 Provide psychosocial so that patient can talk to
occupational function
rehabilitation real people about real
3. Brief psychotic disorder
◦ For suspicious patients: people or real events
◦ Onset of at least 1 or more
 Be matter-of-fact ◦ For disorganized patients:
positive symptoms of psychosis
 Staff members should not  Remove disorganized
laugh or whisper around ◦ Occur at least 1 day to less that
patient to a less
patients unless patient an month then full recovery
stimulating environment
can hear what is being 4. Psychotic disorder due to a general
 Provide a calm
said medical condition
environment
 Do not touch suspicious  Provide safe & relatively ◦ Presence of prominent
patients without warning simple activities for these hallucination or delusion
 Be consistent in activities patients determined as resulting from the
 Maintain eye contact  Nursing guidelines direct physiologic effect of a
◦ For patient with impaired specific medical condition
◦ Build a therapeutic alliance
communication:  CRISIS
with patient
 Be patient & do not  It is an overwhelming reaction to a
◦ Be calm
pressure patient to make threatening situation in which an
◦ Accept patient individual’s usual problem-solving skills
sense ◦ Keep promises
◦ Be honest
 and coping responses are inadequate for These crisis can affect individuals, professional such as
maintaining psychological equilibrium communities and even nation hospital personnel, police
 General Consideration Sequence of Crisis Development and firemen, who have
1. Crisis occurs in all individuals at one time 1. Pre-Crisis period – individual has been involved in a crisis
or another emotional equilibrium situation.
2. Crisis is not necessarily pathological, it 2. Crisis period – individual has the 2. Role of the Nurse
can provide stimulus for growth & subjective experience of being upset,  Nurse provides direct services to people
learning failure of usual coping mechanism, in crisis and serve as members of crisis
3. Crisis is time limited and is usually symptoms are expereinced intervention teams
resolve one way or another in a brief 3. Post-Crisis period – resolution of crisis ◦ In acute and chronic hospital
period (4-6 weeks) Symptoms common in individual setting assist individuals and
a. Successful crisis resolution experiencing crisis families responding to the crisis of
occurs when functioning is  Physical symptoms – somatic serious illness, hospitalization and
restored or enhanced through complaints death
new learning  Cognitive symptoms – confusion, ◦ In community setting provide
b. Unsuccessful crisis resolution is difficulty concentrating, racing thoughts, assistance to individuals and
when functioning is not restored inability to make decisions families in developmental and
to pre-crisis level, and the  Behavioral symptoms – disorganization, situational crisis
individual experiences decreased impulsive, angry outburst, withdrawal ◦ Nurses working with a particular
level of functioning from social interaction group of client should anticipate
4. Individual’s perception of the problem  Emotional symptoms – anxiety, anger, situations in which crisis may
determine the crisis. Each individual has guilt, sadness, depression, paranoia, occurs. They also collaborate
unique response to the problem suspicion, helplessness, powerlessness with other health team members
5. Balancing factors are important in  CRISIS to help an individual resolve crisis
predicting outcomes for the individual Management of Crisis: Crisis Intervention  CRISIS
responding to a crisis 1. Assistance Principles of crisis intervention
a. Perception of precipitating event ◦ Assistance for an individual  the goal of crisis intervention is to return
is realistic rather than destored affected by a crisis the individual to pre-crisis level of
b. Situational supports (ex. Family, ◦ Assistance for groups or functioning
friends) communities affected by crisis  Emphasis is on strengthening and
c. Coping mechanism that alleviate  Mobile crisis team – supporting healthy aspects of individual’s
anxiety interdisciplinary teams functioning
 CRISIS provide services to groups  A problem-solving approach is use in a
Type of Crisis of communities affected systematic manner
 Developmental crisis - occurs from by crisis ◦ Assessing the individual’s
transition from one stage of maturation to  Disaster response team – perception to problem assessing
another in the life cycle teams have an organized strengths and weaknesses of the
 Situational crisis – occurs to a sudden, plan to provide help to individual and family support
unexpected event in an individual life. large segments of the system
These events is all about experiences of population affected by ◦ Planning specific outcomes or
loss. natural disaster goals based on priorities
 Adventitious crisis – occurs in response  Critical incident stress ◦ Providing direct intervention
to severe trauma or natural disaster. debriefing – assistance is ◦ Evaluation outcome and results of
directed at groups of intervention
  Use the framework of Maslow’s hierarchy
of needs to determine the priorities for
intervention
◦ Physical resources – necessary
for survival
◦ Social resources – necessary for
regaining sense of belonging
◦ Psychological resources –
necessary for regaining self-
esteem
Role of crisis intervention worker includes:
 Establishes rapport and communities
hope and optimism
 Assumes an active, directive role if
necessary
 Make suggestions and offer alternatives