ABNORMAL PSYCH

Top Rank [Refresher] LECTURE BY: Jules Joshua Arceo, RN

R

Nurse: How are you?

1 Symptomatologies in Psychiatric Care
Patient: What haffen vella? Why u crying again?
Thought Disturbances Nurse: Sino po si vella?​
Scenario 1: When asked about the details of their mother’s accident, Patient: What haffen vella? Why u crying again?
the patient explains the event in full, unnecessary, and unrelated ​ Verbigeration = stereotyped phrase repetition
detail from the moment they woke up until their mother’s accident.
with or without meaning; phrase repetition
​ Tangentiality = lacks focus and wanders off the
​ Perseveration = adherence to a single topic/idea;
topic; does not answer the question
topic repetition
​ Circumstantiality = answers in full, unnecessary
details; answers the question Patient’s SO: I missed you so much. How are you?
Patient: I, too, have craved your presence extraordinarily in the past
Scenario 2: While speaking fast, the patient states, “I am low, how weeks. It made me feel forlorn to not have your existence by my side.
low can you go? I’m going to get married. Yeah, I am going to marry ​ Stilted language = use of unnecessary choice of
Bill. I’ve got lots of bills to pay after the last spree.”
words; poetic, flowery, pompous
​ Flights of ideas = jumps from one topic to
​ Neologism = creation of new words that only the
another topic; rapid speech; there’s a connection
patient understands
​ Looseness of association = fragmented ideas with
little to no association; normal speech; no Nurse: How are you?
connection Patient: What haffen vella What haffen vella What haffen vella
What haffen vella
Thought Disturbance Definition ​ Echolalia = imitation/repetition of what the patient
Thought insertion Belief that other people are putting hears; repeats others’ words
thoughts/ideas into their heads ​ Palilalia = repetition of what the patient says;
Thought withdrawal Belief that other people are taking repeats own words in a fast manner
away the client’s thoughts
Notes:
Thought blocking Sudden/abrupt stopping of ideas
o​ Mood = internal emotion
in the middle of speaking
o​ Affect = external display of emotion
Thought Belief that other people can hear
broadcasting what the patient is thinking
Affect Definition Disorder
Disturbance
Speech Disturbances
Broad Full range —
Nurse: How are you?
Patient: I wrote the goat overload boat my float tote. Flat None Catatonia
​ Word salad = jumbled words/phrases without Restrictive Only one Paranoid
connection; words or phrases only, no rhyming, and Blunt Minimal MDD
no sentences Inappropriate Opposite to the Schizophrenia
​ Clang association = ideas are connected based on situation
rhyming; there are sentences, there is rhyming, there Labile Sudden shift of Bipolar
is no meaning emotions

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 ABNORMAL PSYCH
Top Rank [Refresher] LECTURE BY: Jules Joshua Arceo, RN

Memory Disturbances Patients who are suicidal

Memory Definition Intervention/ ●​ Suicidal ideation: thoughts about killing oneself
Disturbance Disorder -​ Active = thinks and plans to kill themselves
-​ Passive = thinks but doesn’t plan to kill
Anterograde Unable to form Reorient the patient
themselves
Amnesia new memories every day
●​ Manifestations
Retrograde Unable to recall Reminiscence therapy -​ Giving away of valuables
Amnesia past memories (using an item to -​ Cancelling appointments
from the onset of remember) -​ Apologetic
amnesia -​ Sudden cheerfulness and sudden increase
Confabulation Patient is making In Dementia in energy
up stories to fill in -​ Homicidal thoughts (killing others)
the gaps -​ Actual/Imagined loss
●​ Direct confrontation = assess if there is any plan for
suicide
2 Behavioral Nursing Management for Patients
●​ Nursing interventions
with Psychiatric Disorders
-​ Approach = authoritative = priority is
Patients who are withdrawn
safety
●​ Alone, aloof
-​ Set a safety contract = ask the patient to
●​ Priority intervention: approach the patient = safety
approach the nurse if there is suicidal
●​ If the patient rejects the presence of the nurse =
ideation
offer self and silence in a nondemanding manner
-​ Verbalize and focus on the positive sense of
●​ If the patient begins to interact with others = make
self
observations and promote verbalization; avoid
-​ Confiscate all dangerous items
giving material rewards
-​ Observation
●​ Activity characteristics = achievable and
a.​ Frequent, irregular monitoring
non-competitive = boost their self-esteem
(not predictable)
b.​ Safest: one-on-one monitoring
Patients who are depressed
(less than 1m away)
●​ If the patient rejects the presence of the nurse =
-​ Do not let the patient leave alone
offer self and silence
-​ Distract with highly structured activities
●​ Activity characteristics (as a distraction from
negative self-thoughts)
Major Depressive Disorder
-​ Simple = less effort to think/plan
●​ Risk factors
-​ Achievable = focus on self-esteem
-​ Common in women
-​ Determined/scheduled (highly-structured
-​ High risk in men as they age
activities)
-​ High risk during adolescence
●​ Psychosocial interventions
-​ Patients who have first-degree relatives who
-​ Past memories: focus on positive aspects of
have MDD
self and recall previous achievements
-​ Present problems: promote validation and
verbalization

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 ABNORMAL PSYCH
Top Rank [Refresher] LECTURE BY: Jules Joshua Arceo, RN

●​ Types -​ Promote sleep hygiene

-​ Exogenous = loss, self-depreciation -​ Promote ADL participation
(criticizes themselves), self-reproach
(blaming themselves) Bipolar Disorder
-​ Endogenous (biopsychosocial origin) = Bipolar 1 Bipolar 2
decrease in serotonin and norepinephrine
Hyperactive Hyperactive
levels
With delusions Without delusions
●​ Symptoms
Depressed feeling Depressed feeling
-​ Mood: continuous and persistent
May be suicidal May be suicidal
depressed mood
●​ Criteria
-​ Activities: anhedonia (lack of pleasure or
-​ Flights of ideas
joy)
-​ Grandiose
-​ Weight: gain or loss
-​ Distracted
-​ Sleep: insomnia or hypersomnia
-​ Engage in risky activities
-​ Fatigue: anergia
●​ Length = at least 1 week
-​ Hallmark signs: hopeless/helpless/
●​ Neurotransmitters = high serotonin and
worthless
norepinephrine
●​ Length of symptoms = more than 2 weeks
●​ Effect of life = impaired functioning/cannot do
The Anger Cycle
ADLs
Phase Patient Manifestations
Patients who are manic Triggering Non-compliance + visible signs
●​ When the manic phase is triggered, bring the of anger
patient to a non-stimulating, quiet, safe, and private Escalation Verbal aggression = swearing,
room = low stimulus yelling, threats
●​ In cases of inappropriate behavior Crisis Physical aggression/harm to self,
-​ Do not ignore or argue with the patient others, or property
-​ Provide limit setting Recovery Fatigue, drowsy (relaxation)
a.​ Point out unacceptable behavior
Postcrisis Remorse: apologetic, crying,
b.​ Inform of the acceptable behavior
shameful
c.​ Identify with the client the
consequences of repeated
unacceptable behavior (the patient Patients who are angry/aggressive
should know what the result is) ●​ [Triggering Phase] If the patient seems angry or
●​ Food characteristics = finger foods that are high in shows signs of anger, approach the patient calmly
calories -​ Promote verbalization
●​ Activity interventions = gross motor activities (big -​ Validate the feelings
movement) = should also be non-competitive and -​ Redirect feelings towards physical activities
solitary (alone) = gross motor = should also be
●​ Self-care activities non-competitive and solitary
-​ Remove dangerous objects -​ If the patient does not want to talk, offer
self and silence

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 ABNORMAL PSYCH
Top Rank [Refresher] LECTURE BY: Jules Joshua Arceo, RN

●​ [Escalation Phase] Yelling, swearing, and ●​ [Recovery Phase] If the patient can talk,
threatening to harm is NOT acceptable formulate a plan
-​ Provide limit setting -​ Explore other options the patient can do if
-​ Approach in a calm, matter-of-fact manner they are angry
-​ Bring to a quiet, safe, and private room -​ Options: talk to the nurse if they feel angry
●​ Priority is safety again
-​ Remind the patient that they can still ●​ If the patient is too tired, let them sleep or rest
control self ●​ To family, other patients, SO, fellow staff = assess
-​ Offer chemical restraints (anxiolytics) for injuries
●​ If uncooperative, show-of-force = call 4-6 staff ●​ To fellow staff = do a debriefing to verbalize our
●​ [Assault Cycle Phase] Notes on crisis = imminent feelings
or actual physical harm ●​ [Post-crisis Phase] Removal of restraints
-​ Seclude or physically restrain the patient ●​ Formulate a plan of action = talk to RN if angry
-​ Goal: restorative, not punitive ●​ To other patients/SO/family, they may feel
-​ The patient loses the right to refuse apologetic or shameful
treatment -​ Assist the patient in expressing apologies
●​ Seclusion -​ Reintegrate into the social environment
-​ Consent will be obtained through their -​ To RN, be a mediator
significant other
-​ Room: lockable and observable from the Patients with delusions
outside ●​ False and fixed belief
-​ Monitoring: one-on-one for 1 hour ●​ Types
●​ Restraints -​ Grandiose = superiority or invulnerability
-​ The doctor’s order is obtained within 1 -​ Persecutory = someone is planning to
hour after seclusion harm them
-​ Consent will be obtained through their -​ Somatic = abnormal body function
significant other -​ Nihilistic = abnormal body shape/figure
-​ Needs 4 to 6 staff = 4 limbs, 1 head, 1 torso -​ Erotomatic = someone is in love with them
-​ Anchor on the stable part of the bed (bed -​ Ideas of reference = general events (war)
frame) are about them
-​ Continuous monitoring -​ Religious = second coming of a religious
-​ Monitor skin and circulation figure (only appears in psychosis)
-​ Duration -​ Sexual = sexual behavior is exposed to
a.​ Adults: max 4 hours others
b.​ Children: max 2 hours ●​ Intervention
c.​ Children below 9: less than 1 hour -​ Clarify and assess the feelings behind
-​ Removal -​ Acknowledge and validate the feelings
a.​ One at a time every 10 minutes behind
b.​ Right arm → Left leg → Left arm -​ Do not challenge or ask for proof
→ Right leg -​ Do not argue with them
-​ Do not reinforce the patient

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 ABNORMAL PSYCH
Top Rank [Refresher] LECTURE BY: Jules Joshua Arceo, RN

-​ Voice doubt = present reality -​ Engage the patient in reality-based

-​ Engage in reality-based activities as a activities
distraction -​ Reintegrate the patient into the social
environment (promote social interactions)
Patients with hallucinations ●​ Other interventions
●​ Illusions: misperceptions based on reality (with -​ For auditory hallucinations, it is effective
stimuli) to ask the patient to talk back to the voices
-​ To address illusions, clarify reality -​ Hallucinations and anxiety = the more
●​ Hallucinations: misperception NOT based on they are anxious, the more they will have
reality (without a stimulus) hallucinations
●​ Types a.​ Identify or reduce anxiety triggers
-​ Auditory b.​ Use relaxation techniques
a.​ Most common in psychosis
b.​ Command: most dangerous Schizophrenia
-​ Visual ●​ Former term: Dementia Praecox
a.​ Sight ●​ Risk factors
b.​ The second most common -​ Genetics
-​ Tactile a.​ 1 parent = 15% chance
a.​ Touch b.​ 2 parents = 35% chance
b.​ Common in alcohol withdrawal -​ Socioeconomic: the lower their status is
-​ Olfactory the more prone they are to schizophrenia
a.​ Smell -​ During pregnancy: influenza, tobacco,
b.​ Common in seizure aura (before) alcohol, and low nutrition
-​ Gustatory ●​ Biological basis
a.​ Taste -​ Neuroanatomical manifestation
b.​ Common in seizure aura (before) a.​ Decreased CSF
-​ Cenesthetic b.​ Decreased brain tissue
a.​ Feeling undetectable body -​ Neurotransmitters
movements a.​ Increased dopamine
-​ Kinesthetic b.​ Increased serotonin
a.​ Feeling motion or movements, ●​ Criteria
despite being motionless -​ 2 or more hard or soft symptoms
-​ Synesthesia -​ For 6 months or more
a.​ Sensory mixing (tastes colors, sees -​ Hard: positive symptoms
sounds) a.​ Ambivalence = contradictory
●​ Interventions beliefs or feelings about
-​ Hallucinations must be recognized something
-​ Assess the hallucinations b.​ Echopraxia = imitation of others’
-​ Reality presentation movements
-​ Divert the attention to the environment

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 ABNORMAL PSYCH
Top Rank [Refresher] LECTURE BY: Jules Joshua Arceo, RN

c.​ Bizarre behavior = outlandish d.​ Schizo affective disorder =

appearance, unusual or psychotic disorder + mood
inappropriate social behavior disorder
d.​ Looseness of association ●​ Initial early sign: loss of will to live
e.​ Delusions ●​ Other signs: self-neglect
f.​ Flight of ideas
g.​ Hallucinations Anxiety
h.​ Ideas of reference ●​ Mild

⭐️
i.​ Perseveration -​ Wide perception, increased focus, and
caused by an increase in dopamine levels attention
-​ Soft: negative symptoms -​ Restless
a.​ Alogia = decreased speech or -​ GI butterflies
mutism -​ Insomnia
b.​ Anhedonia = lack of pleasure or -​ Priority is health teaching
joy from activities -​ Promote verbalization and validation
c.​ Apathy = indifference to others ●​ Moderate
d.​ Asociality = no social -​ Narrowed perception, focused on one task
relationships -​ Restless, has muscle tension
e.​ Catatonia = psychologically -​ GI upset
induced immobility -​ Tachycardia
f.​ Avolition = loss of will or -​ Diaphoresis
motivation to live -​ Insomnia
g.​ Inattention -​ Priority is refocusing on other tasks

⭐️
h.​ Blunt/Flat Affect -​ Slow, simple, and easy to understand
caused by an increase in serotonin levels sentences
●​ Types -​ Oral Anxiolytics
-​ Outdated ●​ Severe
a.​ Catatonic = immobile -​ Scattered perception
b.​ Paranoid = high suspicion, has -​ Restless, headache
persecutory delusions -​ Vomiting
c.​ Disorganized = has thought and -​ Palpitations or chest pain
speech disturbances -​ Pallor
-​ Updated -​ Insomnia
a.​ Brief psychotic symptoms = -​ Priority is physical signs and symptoms
psychotic symptoms for less than (vomiting, headache)
1 month -​ Remain with the patient
b.​ Schizophreniform = 1 month to -​ Voice should be calm and soothing
less than 6 months -​ IM Anxiolytics
c.​ Shared psychotic (folle a deux) = ●​ Panic
the close relationship of the -​ Distorted perception, has delusions and
patient developed a psychosis hallucinations

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 ABNORMAL PSYCH
Top Rank [Refresher] LECTURE BY: Jules Joshua Arceo, RN

-​ Risk to harm a.​ If child abuse, report to Bantay

-​ Vomiting Bata
-​ Palpitations or chest pain b.​ If elder abuse, report to the
-​ Pallor Protective Committee for Senior
-​ Insomnia Citizens
-​ Priority is safety -​ The nurse needs to be certain of the abuse
-​ Stay with the patient first before reporting
-​ Bring the patient to a quiet, safe, and -​ DSWD is in charge of instances of abuse
non-stimulating room -​ During assessment, ensure privacy and
-​ If there is physical harm, restrain/seclude confidentiality
-​ Develop a safety plan of escape
Patients who are abused a.​ Provide information regarding
●​ Abuse = non-accidental infliction of physical harm hotlines or the VAWC committee
●​ Emotional = shaming, bullying, and manipulation -​ Report the patient to crisis intervention
●​ Neglect = non-accidental omission of physical or therapy
emotional care -​ If sexual abuse
●​ Sexual abuse = non-consensual infliction of sexual a.​ Assess the patient first
acts b.​ Offer fresh clothing or a shower
●​ Financial = withholding or misuse of money,
property, and assets
●​ Shaken baby syndrome = violent shaking of an
infant = intracranial bleeding
●​ People most at risk are females, children, older
adults, dependent patients, and LGBTQ
●​ Warning signs of abused/neglected children
-​ Serious injury with no obvious signs and
symptoms of trauma
-​ There is a significant injury, but there is a
delay in seeking treatment
-​ Inconsistencies between
a.​ Adult’s claimed history
b.​ Injury characteristics and the
adult’s history
-​ With regards to age, there are unusual
injuries
-​ Swollen genitals or frequent UTIs
-​ Old injuries with varying stages of healing
●​ Interventions
-​ Priority is physical trauma
-​ Legal obligation: RN should report
suspected and actual cases of abuse

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