ANTHONY E. ESTOLAS, RN
– A state of emotional, psychological and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self-concept and emotional stability.(Videbeck) – Lifelong process of successful adaptation to a changing internal and external environments.
– A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress, increased risk of suffering, death, disability and loss of freedom. (Videbeck) – Loss of ability to respond to environment in ways that are in accord with oneself and society.
• • • • •
Accepts himself Perceives reality Mastery of self and environment Autonomy Unifying, integrated outlook in life
Theoretical Foundations • Mental health-Psychiatric treatment integrates concepts and strategies from theories. • Theoretical Models are used as guides for treatments • These theories attempt to explain human behavior, health and mental illness
Theoretical Foundations • Theoretical frameworks – allow the systematic organization of knowledge – guide data collection – provide explanations for assessed behaviors – guide care plan development – provides rationales for interventions and – determine evaluation criteria – Guide research by providing assumptions to be tested.
Theoretical Foundations PsychosexualPsychoanalytical Theory Psychosocial Theory
Sigmund FREUD
Cognitive Theory
Jean PIAGET
Interpersonal Theory
Harry Stack Sullivan
Moral Theory
KOHLBERG
Spiritual Theory
FOWLER
Erik ERIKSON
Theoretical Foundations Behavioral Theories
Pavlov and Skinner
Humanistic Theories
Maslow and Carl Rogers
Psychobiology theory
Neuroanatomy and physiology
Theories of Personality development • • • • • •
Freud’s Psychoanalytic theory Erikson’s Psychosocial theory Sullivan’s interpersonal theory Piaget’s Cognitive theory Fowler’s Spiritual theory Kohlberg’s Moral theory
Psychosexual/Psychoanalytical • This theory supports the notion that EVERY human behavior is caused and can be explained • Freud believes that “repressed” sexual urges, desires, impulses or drives motivated much human behavior
Psychosexual/Psychoanalytical Components of Personality 1. ID- part of a person that reflects BASIC or innate DESIRES, INSTINCT and SURVIVAL impulses 2. EGO- represents the REALITY aspect 3. SUPER-EGO- part that reflects MORALITY and ethical concepts, and values
Psychosexual/Psychoanalytical Personality Stages and Functional Awareness 1. Conscious – perceptions, thoughts and emotion that exist in the person’s awareness 2. Pre-conscious/Subconscious- Thoughts and emotions not currently in awareness but can be recalled with effort 3. Unconscious- thoughts, drives and emotions totally a person is Unaware
Psychosexual/Psychoanalytical According to this theory, much of our behavior is motivated by our SUBCONSCIOUS thoughts or feelings
Psychosexual/Psychoanalytical Five Stages of psychosexual development 1. Oral 2. Anal 3. Phallic or Oedipal 4. Latency 5. Genital
Psychosexual/Psychoanalytical Phase
Age
Focus
Oral
0-18 months Site of gratification: Mouth
Anal
1 ½ - 3 years Site of gratification: Anus
Phallic
3- 5 years
Site of gratification: Genitals
Latency 6- 12 years
Site of gratification: (School Activities)
Genital
Site of gratification: Genitals
12 & above
Psychosexual/Psychoanalytical Phase
Age
Focus
Oral
0-18 months Major task: Weaning
Anal
1 ½ - 3 years Major task: Toilet training
Phallic
3- 5 years
Major task: Oedipal & Electra complex
Latency 6- 12 years
Major task : School activities
Genital
Major task: Sexual intimacy
12 & above
Psychosexual model (Freud) 1. Oral a. 0-18 months b. Pleasure and gratification through mouth c. Behaviors: dependency, eating, crying, biting d. Distinguishes between self and mother e. Develops body image, aggressive drives
Psychosexual model (Freud) 2. Anal a. 18 months - 3 years b. Pleasure through elimination or retention of feces c. Behaviors: control of holding on or letting go d. Develops concept of power, punishment, ambivalence, concern with cleanliness or being dirty.
Psychosexual model (Freud) 3. Phallic/Oedipal a. 3 - 6 years b. Pleasure through genitals c. Behaviors: touching of genitals, erotic attachment to parent of opposite sex d. Develops fear of punishment by parent of same sex, guilt, sexual identity
Psychosexual model (Freud) 4. Latency a. 6 - 12 years b. Energy used to gain new skills in social relationships and knowledge c. Behaviors: sense of industry and mastery d. Learns control over aggressive, destructive impulses e Acquires friends
Psychosexual model (Freud) 5. Genital a. 12 - 20 years b. Sexual pleasure through genitals c. Behaviors: becomes independent of parents, responsible for self d. Develops sexual identity, ability to love and work
Psychosexual/Psychoanalytical Transference and Counter-transference • TRANSFERENCE is the clients feeling toward nurse arising from unconscious experiences with early significant others • COUNTER TRANSFERENCE is the nurse’s feelings toward the patient arising also form previous experiences
Psychosexual/Psychoanalytical The Freudian View of Mental Illness • All behavior has meaning • Mental illness and manifestations are caused by unconscious INTERNAL conflict arising from unresolved issues in early childhood • Ego defenses are utilized to relieve inner tension
Psychosocial Theory • Theory that focuses on developmental task, focuses on EGO as this develops from social interaction • The developmental tasks are sequential and depend on prior successful mastery • An individual who fails to “master” the task at appropriate age may return to work on mastery
Psychosocial Theory Use of the theory in Nursing • Assessment can be done focusing on the psychosocial development at specific age • Appropriate interventions can be selected based on task • Nurses can promote healthy behaviors and encourages hope that re-learning is possible
Erikson’s Psychosocial theory • • • • • • • •
Trust versus mistrust Autonomy versus shame and doubt Initiative versus guilt Industry versus inferiority Identity versus role confusion Intimacy versus isolation Generativity versus stagnation Ego integrity versus despair
Psychosocial Model (Erikson) 1. Trust vs mistrust a. 0 - 18 months b. Learn to trust others and self vs withdrawal, estrangement
2. Autonomy vs shame and doubt a. 18 months - 3 years b. Learn self-control and the degree to which one has control over the environment vs compulsive compliance or defiance
Psychosocial Model (Erikson) 3. Initiative vs guilt a. 3 - 5 years b. Learn to influence environment, evaluate own behavior vs fear of doing wrong, lack of selfconfidence, over restricting actions
4. Industry vs inferiority a. 6 - 12 years b. Creative; develop sense of competency vs sense of inadequacy
Psychosocial Model (Erikson) 5. Identity vs role confusion a. 12 - 20 years b. Develop sense of self; preparation, planning for adult roles vs doubts relating to sexual identity, occupational career
6. Intimacy vs isolation a. 18 - 25 years b. Develop intimate relationship with another; commitment to career vs avoidance of choices in relationships, work, or life-style
Psychosocial Model (Erikson) 7. Generativity vs stagnation a. 21 - 45 years b. Productive; use of energies to guide next generation vs lack of interests, concern with own needs
8. Integrity vs despair a. 45 years to end of life b. Relationships extended, belief that own life has been worthwhile vs lack of meaning of one’s life, fear of death
Interpersonal theory • This concept focuses on interaction between an individual and his environment • Personality is shaped through “interaction” with significant others • We internalize approval or disapproval form our parents
Interpersonal theory Personality has three SELF-SYSTEM 1. “Good Me” develops in response to behaviors receiving approval by parents/SO 2. “Bad Me” develops in response to behaviors receiving disapproval by parents/SO 3. “Not Me” develops in response to behaviors generating extreme anxiety in parents/SO and this is denied as part of oneself
Interpersonal theory Mental Health is Viewed as: 1. Related to conflict or problematic interpersonal relationships 2. Past relationships, inappropriate communication and current relationship crisis are etiologic factors of mental illness
Interpersonal theory Treatment of Mental illness: • Focuses on anxiety and its causes • Therapeutic relationship with client that is active and participative • Feelings and emotions are verbalized by the clients to modify problematic relationships
Interpersonal theory Usefulness in Nursing • Nurse and client can participate in and contribute to the relationship that is therapeutic • This relationship can be used as a corrective interpersonal experience • Anxiety management
Interpersonal Model (Sullivan) 1. Infancy a. 0 - 18 months b. Others will satisfy needs
2. Childhood a. 18 months - 6 years b. Learn to delay need gratification
3. Juvenile a. 6 - 9 years b. Learn to relate to peers
Interpersonal Model (Sullivan) 4. Preadolescence a. 9—12 years b. Learn to relate to friends of same sex
5. Early adolescence a. 12—14 years b. Learn independence and how to relate to opposite sex
6. Late adolescence a. 14—21 years b. Develop intimate relationship with person of opposite sex
Cognitive Theory • This theory focuses on the inborn development of thinking ability from infancy to adulthood • A person is born with a tendency to organize and to adapt to their environment • Mental illness is not directly discussed
Cognitive Theory Usefulness of Cognitive theory in Nursing 1. This provides an understanding how an individual think and communicate. Nurse can provide intervention accordingly 2. Nursing interventions should be congruent to the age-specific cognitive level 3. Teaching strategies are modified according to cognitive process
Piaget • Sensori-motor (birth to 2 ) • Pre-operational (2-7) – Preoperational preconceptual (2-4) – Preoperational intuitive (4-7)
• Concrete operational (7-12) • Formal operational (12 to adulthood)
Cognitive Theory (Piaget) A. 0 - 2 years: sensorimotor -reflexes, repetition of acts B. 2 - 4 years: preoperational/preconceptual -no cause and effect reasoning; egocentrism; use of symbols; magical thinking C. 4 - 7 years: intuitive/preoperational -beginning of causation
Cognitive Theory (Piaget) D. 7 - 11 years: concrete operations - uses memory to learn - aware of reversibility E. 11 - 15 years: formal operations -reality, abstract thought -can deal with the past, present and future
Behavioral Theory • This concept describes a person’s function in terms of identified BEHAVIORS • People learn to be who they are • Behavior can be observed, described and recorded • Behavior is subject to reward or punishment • Behavior can be modified by changing environment
Behavioral Theory • The Classical Conditioning by Pavlov – Learning can occur when a stimulus is paired with an unconditioned response – Conditioned responses happens when stimulus is present – Acquisition – gain of learned response – Extinction – loss of learned response
Behavioral Theory • The Operant Conditioning by Skinner – Rewards and punishments are utilized – Positive reinforcement- rewards – Negative reinforcement– Positive punishment – Negative punishment- withdrawing reward
Behavioral Theory Mental Illness is viewed as: • Mal-adaptive BEHAVIORS are learned through classical and operant conditioning • Mal-adaptive behaviors can be changed by altering environment
Behavioral Theory Application to Nursing 1. The nurse assess both adaptive and ,aladaptive behaviors 2. The nurse and client collaborate in identifying behaviors that need to change 3. Behavioral modification techniques are utilized by the nurse in the treatment of mental illness
Humanistic theory • Human nature is positive and growth centered and existence involves search for meaning and truth • Maslow’s theory of Needs are organized in a hierarchy
Humanistic theory Mental illness in this framework 1. The failure to develop one’s FULL potential leads to poor coping 2. Lack of self awareness and unmet needs interfere with feelings of security 3. Fundamental human anxiety is fear of death which leads to existential anxiety
Humanistic theory Application of the theory to Nursing 1. NCR is based on positive regard, respect and empathy 2. Nurses assess the spiritual aspects of the client including religion, love and relationships 3. Through reflective listening and emphatic responses, the nurse helps the client gain self-understanding
KOHLBERG’S STAGES OF MORAL DEVELOPMENT
PRECONVENTIONAL LEVEL • Stage 1 Age 2-3 • Description: – Punishment or obedience (heteronomous morality) – A child does the right things because a parent tells him or her to avoid punishment
PRECONVENTIONAL LEVEL • Stage 2 Age : 4-7 • Description: – Individualism – Child carries out actions to satisfy own needs rather than society’s. The child does something for another if that person does something for him in return
CONVENTIONAL LEVEL level 2 • Stage 3 Age : 7-10 • Description: – Orientation to interpersonal relations of mutuality – A child follows rules because of a need to be a good person in own eyes and in the eyes of others
CONVENTIONAL LEVEL level 2 • Stage 4 Age : 10-12 • Description: – Maintenance of social order, fixed rules and authority – Child follows rules of authority figures as well as parents to keep the system working
POSTCONVENTIONAL LEVEL level 3 • Stage 5 Age :older than 12 • Description: – social contract, utilitarian law making perspective – child follows standards of society for the good of all people
POSTCONVENTIONAL LEVEL level 3 • Stage 6 Age :older than 12 • Descriptions: – universal ethical principle orientation – child follows internalized standards of conduct
• • • • • •
Establish rapport Obtain understanding of problem Assess for risk factors & psychological functioning Identify nursing diagnosis & goals Perform mental status examination Identify behaviors/beliefs/areas to be modified to effect positive change • Formulate a plan of care
PSYCHOSOCIAL ASSESSMENT • • • • • • • • •
Previous Hospitalizations Educational Background Occupational Background Social Patterns Sexual Patterns Interest and Abilities Substance Use and abuse Coping Abilities Spiritual Assessment
MENTAL STATUS EXAMINATION • • • • • • • •
Personal Information Appearance Behavior Speech Affect and Mood Thought Process Perceptual Disturbances Cognition
• Test to Assess Cognitive Function • Interpretation Any score over 24 (out of 30) is effectively normal. The normal value is also corrected for degree of schooling and age. Low to very low scores correlate closely with the presence of dementia, although other mental disorders can also result in abnormal findings of the MMSE testing. The presence of physical problems can also interfere with the interpretation. For example a patient that is physically unable to hear or read the instructions properly, or has a motor deficit that affects his writing and drawing skills.
Nature of Psychiatric Nursing The DSM(DIAGNOSTIC STATISTICAL MANUAL)-TR (TEXT REVISION) IV- APA (AMERICAN PSYCHIATRIC ASSOCIATION) – – –
A taxonomy that describes all mental disorders, outlining specific diagnostic criteria for each based on clinical experience and research. Clinicians utilize this to diagnose psychiatric disorders. Purpose of DSM-TR: 1. Standard nomenclature/ classification 2. Defining characteristics 3. Underlying cause of disorders
Nature of Psychiatric Nursing The DSM-TR IV : Multi Axis Classification AXIS I- Major Psychiatric Disorders AXIS II- Mental Retardation and Personality Disorders AXIS III- Current Medical Condition AXIS IV- Psychosocial and Environmental Problems AXIS V- Global Assessment of Function
Nature of Psychiatric Nursing Historical People Worth Mentioning 1. Aristotle- the Humors 2. Freud- -Psychosexual theory 3. Kraeplin- symptomatic classification of mental disorders. 4. Bleuler- coined “schizophrenia”
Nature of Psychiatric Nursing Psychiatric Nursing in the Philippines • GO and NGOs • Mental health programs
Nature of Psychiatric Nursing Psychiatric Nursing in the Philippines Mental Health State of well being, where a person can realize his potential. Mental Ill Health Disturbance of thought, feelings and behavior. Mental Disorder Medically diagnosable illness. Mental Hygiene Science which deals with measures employed to promote mental health.
Nature of Psychiatric Nursing Scope of Nursing Practice • •
Individual, family and community Healthy and ill person
Nature of Psychiatric Nursing Self Awareness • The process by which the nurse gains recognition of his/her own feelings, beliefs and attitudes. (Videbeck) • Initial nursing activity to do before practicing psychiatric nursing.
Nature of Psychiatric Nursing Self Awareness • This is accomplish through reflection, spending time deliberately focusing on how one feels and what one values or believes.
Mental Health Concepts • Assessment (psychosocial processes ) – Appearance , behavior or mood – Speech , thought content and thought process – Sensorium – Insight and judgment – Family relationships and work habits – Level of growth and development
Common Behavioral Signs and Symptoms 1) Disturbances in perception Illusion •
Misinterpretation of an actual external stimuli.
Hallucinations •
False sensory perception in the absence of external stimuli.
2)
•
• •
• •
• • •
Disturbances in thinking and speech Neologism Coining of words that people do not understand.
Circumstantiality Over inclusion of inappropriate thoughts and details.
Word salad Incoherent mixture of words and phrases with no logical sequence.
Verbigeration Meaningless repetition of words and phrases.
Perseveration Persistence of a response to a previous question.
Echolalia Pathological repetition of words of others.
Aphasia Speech difficulty and disturbance Expressive , receptive or global
Magical thinking • Primitive thought process thoughts alone can change events.
Autistic thinking • Regressive thought process Subjective interpretations not validated with objective reality.
Flight of ideas • Shifting of one topic from one subject to another in a somewhat related way.
Looseness of association • Incoherent ,illogical flow of thoughts(unrelated way).
Clang association • Sound of word gives direction to the flow of thought.
Delusion • Persistent false belief,rigidly held. • • • •
Delusions of grandeur- special /important in a way Persecutory-threatened Ideas of reference-situation/events involve them Somatic- body reacting in a particular way
3) Disturbances of affect Inappropriate •
Disharmony between the stimuli and the emotional reaction.
Blunted affect •
Severe reduction in emotional reaction.
Flat affect •
Absence or near absence of emotional reaction.
Apathy •
Dulled emotional tone.
Depersonalization •
Feeling of strangeness from one’s self.
Derealization •
Feeling of strangeness towards environment.
Agnosia •
Lack of sensory stimuli integration.
4) Disturbances in motor activity Echopraxia •
Imitation of posture of others.
Waxy flexibility •
Maintaining position for a long period of time.
Ataxia •
Loss of balance.
Akathesia •
Extreme restlessness.
Dystonia •
Uncoordinated spastic movements of the body.
Tardive dyskenisia •
Involuntary twitching or muscle movements.
Apraxia •
Involuntary unpurposeful movements.
5) Disturbances in memory Confabulation •
Filling of memory gaps
Déjà vu •
2nd time-like feeling
Jamais vu •
Not having been to the place one has been before.
Amnesia •
Memory loss (inability to recall past events) Retrograde-distant past Anterograde – immediate past Anomia – lack of memory of items
Therapeutic Relationships • This is a nurse-client interaction that is directed toward enhancing the client’s wellbeing (Isaacs) • A relationship established between a health care professional and a client for the purpose of assisting the client to solve his problems
Therapeutic Relationships • The nurse- patient relationship is characterized by a helping process – The nurse and client work together for his benefit – The nurse uses herself therapeutically and this is achieved by self-awareness
Therapeutic Relationships • The nurse- patient relationship – Respect the client and vale as individual – Holistic care – Maintain appropriate limits – Covey empathy not sympathy – Maintain honest and therapeutic communication – Encourage expression of feelings
Therapeutic Relationships ELEMENTS OF THE THERAPEUTIC RELATIONSHIP • Contract • Boundaries • Confidentiality • Therapeutic Behaviors
Therapeutic Relationships ELEMENTS OF THE THERAPEUTIC RELATIONSHIP Therapeutic Behaviors 1. Genuineness = sincerity and honesty 2. Concreteness= ability to identify client’s feelings 3. Respect= shown through consideration of patient as unique being 4. Self- exploration and self disclosure
Therapeutic Relationships PHASES OF THE THERAPEUTIC RELATIONSHIP 1. Pre-Interaction- Pre-orientation 2. Orientation- Interaction 3. Working 4. Termination
Therapeutic Relationships Phase
Nursing Activities
Pre-interaction
Nurse obtains data from secondary sources
Interaction- Orientation
Nurse establishes trust, assess client, establishes mutual agreement
Working
Nurse assists the client to meet goals and resolve problems
Termination
Nurse and client express feelings about termination, observes regressive behaviors and evaluates NCR
Orientation • Establishment of goals, rules, boundaries etc.. • Rapport is built • Identify expectations • Trust is gained • Assessment is done • Goals are defined • Contract is made
Working/Exploration/Identification • Problems are identified • Solutions are explored, applied and evaluated • Nurse assists the client to develop coping skills, positive self concept and independence • Promote insight and the use of adaptive coping mechanisms
Termination/Resolution • Nurse terminates the relationship based on mutually agreed goals when these are already achieved • Focus of this stage is growth that has occurred • Client may become anxious and reacts • Nurses must help patient resolve the anxiety and ends the relationship professionally
Therapeutic Communication • Therapeutic communication – Dynamic process of exchanging information – Composed of verbal and non-verbal techniques that the nurse uses to focus on the client’s needs
Therapeutic Relationships Therapeutic communication : ELEMENTS 1. Sender- the source of message 2. Message- the information transmitted 3. Receiver- recipient of message 4. Feedback- receiver’s response to the message
Therapeutic Relationships NON VERBAL COMMUNICATION 1. Proxemics- the physical space between the sender and receiver 2. Kinetics- the body movements such as gestures, facial expressions and mannerisms 3. Touch- intimate physical contact
Therapeutic Relationships NON VERBAL COMMUNICATION 4. Silence 5. Paralanguage- voice quality (tone, inflection) or how a message is delivered
Therapeutic Relationships VERBAL COMMUNICATION • Use of therapeutic communication techniques • Effective communication should be therapeutic, appropriate, simple, adaptive, concise and credible
Therapeutic Communication Open ended questions Focus on FEEELINGS State behaviors observed Reflect, restate, rephrase Neutral responses
Therapeutic Communication Offering self
I am here to help you
Active listening
Eye to eye contact
Exploring
Tell me more about…,.
Broad Openings
What do you want to talk about You seemed depressed
Making observation
Therapeutic Communication Summarizing
A few minutes ago, we were talking about.. Then…
Voicing doubt
I find it hard to believe
Encouraging description of perception
What are these voices telling you
Presenting reality
The sound is produced by the car No one is in the room I am not sure of what you mean
Seeking clarification
Therapeutic Communication Verbalizing the implied
Are you saying you want to kill yourself ?
Reflecting
Do you think you should?
Restating
P: I cant sleep at night N: You cant sleep at night ?
General leads
GO on… then…. Hmm….you were saying….
Focusing
Lets talk more about what you think of your problems
Non-therapeutic communication • These are blocks to communication • Usually, these are the common pitfalls of communicating non-therapeutically: – Giving advise – Talking about self – Telling client is wrong – False reassurance – Cliché’ – Asking ‘Why’
Non-therapeutic communication Making judgment
You are wrong
False reassurance
It’s going to be alright
Invalidation
I cannot talk now, I’m busy
Focusing on self
I am the best nurse to care for you
Changing the subject
P: I’m afraid of the surgery N: Ho many children do you have
Giving advice
If I were you, I will
Non-therapeutic communication Agreeing
Yes I think you are right
Disapproving
I don’t want you to do that
Defending
This hospital is the best
Requesting explanation
“why”
Cliché
There is the sun after the rain
Belittling feelings
P: I’m so depressed today N: everyone feels sad at times
Proxemics INTIMATE=
Distances Touching to 1 ½ ft
PERSONAL=
1 ½ to 4 ft
SOCIAL=
4 to 12 ft
PUBLIC=
12 to 15 ft
Psychiatric Nursing Process • Applies to all clients • Utilizes unique process for psychological assessment • Similar to other types of nursing process approaches
Psychiatric Nursing Process • Nursing ASSESSMENT Nursing History Physical Examination including the Neurological examination Laboratory Examination
Psychiatric Nursing Process • Nursing ASSESSMENT – Refers to the scientific process of identifying a patient’s psychosocial problems, strengths an concerns – Interview is done to acquires broad information about a client
Psychiatric Nursing Process • MENTAL STATUS ASSESSMENT – Level of consciousness – General appearance – Behavior – Speech – Mood and affect – Judgment – Memory – insight
Psychiatric Nursing Process • MENTAL STATUS ASSESSMENT – Observation of mood and affect – Assessment of thought, sensorium and intelligence – Speech and content – Assess developmental status and family-culturalspiritual background
Psychiatric Nursing Process • MENTAL STATUS ASSESSMENT – Emotional status – Cognitive assessment – Socio-cultural assessment
Psychiatric Nursing Process • Physical Examination – Observation for key signs
• Diagnostic Tests – CT, MRI, PET, EEG – Laboratory tests= CBC, Electrolytes, Drug levels
Psychiatric Nursing Process – Other diagnostic tests • • • • •
Beck depression inventory Minnesota multiphasic personality inventory Draw-a person test Sentence completion test Thematic aperception test
Psychiatric Nursing Process • Nursing Diagnoses – Anxiety – Ineffective coping- individual, family – Fatigue – Fear – Sleep pattern disturbance – Altered thought process – Etcetera
Psychiatric Nursing Process • Nursing Objectives • Short term goals are set for immediate problems, feasible and within client's capabilities • Long term goals are related to discharge planning and prevention of recurrence of symptoms
Psychiatric Nursing Process • Nursing Objectives: The client will: – Participate in treatment program – Becomes oriented to three spheres and exhibit reality-based behaviors – Recognize reasons for behavior – Maintain self-care activities
Psychiatric Nursing Process • Nursing Interventions – Use of therapeutic communication – Therapeutic Groups – Psychotherapy: Family, Milieu, Behavioral modification, Crisis intervention, Psychopharmacology – Electroconvulsive therapy
Psychiatric Nursing Process • Nursing Evaluation – Determine if goals are met by collecting data and comparing them to baseline – Clients’ behavior should demonstrate optimal orientation to reality and interaction with others appropriately
Treatment Modalities 1. 2. 3. 4. 5. 6. 7.
Therapeutic Environment- Milieu Therapeutic Groups Crisis intervention Family therapy Behavioral modification Cognitive therapy Psychotherapy
Therapeutic environment • Research has documented that the environment in which the mentally ill person is treated is a major factor in enhancing or impeding the therapeutic effects of other treatment modalities
Therapeutic environment Characteristics of a Therapeutic environment 1. The clients’ physical needs are met 2. The client is respected 3. Decision making authority is clearly defined 4. Client is protected from injury (self and others)
Therapeutic environment Characteristics of a Therapeutic environment 5. Clients are allowed freedom of choice commensurate to his ability to decide 6. Nursing Personnel remain constant and assignments are stable 7. Emphasis is placed on social interaction between clients and staff
Therapeutic Modalities Milieu therapy – Total environment has an effect on the person’s behavior- physical, emotional, relationships
Purposes of therapy 1. Improve client’s behavior 2. Involve client in decision making 3. Increase autonomy and communication 4. Set structure of unit and behavioral limits
Therapeutic Modalities Milieu therapy • The surrounding is made positive to effect behavioral changes in the prescribed directions • Goals of milieu therapy: to help patient develop sense of self-esteem, personal growth, improve ability to relate to others and return to the community better prepared
Therapeutic modalities Milieu therapy – The nurse involves the client in decision making – The nurse promotes the involvement of staff in care – Social skills are developed and sense of community is fostered
Therapeutic Groups – A treatment approach in which the entire milieu is used as treatment – This includes the physical environment and the others clients
Therapeutic Groups Group Therapy – Involves meaningful interaction between members of a group as they relate their personal experiences to each other – The main objective is for each group member to examine his own behavior and relationship. The group can influence to change his behavior and relationships
Therapeutic Groups • Groups of clients meet with one or more therapists to work together to solve client problems
Therapeutic Groups • Purposes – To increase self-awareness – To improve interpersonal relationships – To make changes in behavior – To enhancing group teaching and learning
Therapeutic Groups • Structure of the Therapeutic Group – One leader chosen by the group – Members – Size is usually 10 – Physical arrangement – Time and place of meeting
Therapeutic Groups Phases of group development 1. Beginning phase – Info given, anxiety heightened
2. Middle phase – Confrontation, cohesiveness, trust and selfreliance
3. Termination phase – Goals of the group are achieved – Individuals leave the group when work is done
Therapeutic modalities CRISIS • A disturbance caused by a precipitating event such as perceived loss, a threat of loss or a challenge that is perceived as a threat to self.
Therapeutic modalities CRISIS Can be classified as to maturational crisis, situational crisis or adventitious crisis – Maturational= role changes – Situational= loss of job, death – Adventitious= fires, earthquakes and floods – In a crisis, the person’s usual methods of coping are INEFFECTIVE, resulting in increasingly greater levels of anxiety.
Therapeutic Modalities • Characteristics of Crisis: – It is sudden – It is short term may last for 4-6 weeks – Individualized – The person becomes dependent and overwhelmed
Therapeutic Modalities Factors that can produce crisis • 1. Hazardous EVENTS • 2. Threat to the individual’s equilibrium • 3. Inadequate coping skills
Therapeutic Modalities • There are four PHASES of Crisis (DIDA) – Denial – Increased Tension- when the person knows the existence of crisis and still continues ADL – Disorganization= pre-occupied and unable to perform function – Attempts to Reorganize= by mobilizing previous coping mechanisms
Therapeutic Modalities CRISIS INTERVENTION – A technique of helping the person go through the crisis – To mobilize his resources – To help him deal with the here and now – A five step problem solving technique designed to promote a more adaptive outcome including improved abilities to cope with future crises
Therapeutic modalities Goal of Crisis intervention: help the patient go back to his state of optimum level of functioning – IDENTIFY the problem- A solution is not possible unless the problem be identified. – LIST alternatives- all possible solutions to the problem need to be listed. – CHOOSE from among the alternatives- each options is carefully considered, and the alternative chosen is usually highly individualized, based on priorities and values of the person – IMPLEMENT the plan- the alternative is put into action. The nurse may need to support and encourage patient to take action – EVALUATE the outcome- the effectiveness of the plan is evaluated.
Therapeutic modalities Family therapy • An approach in which the therapist focuses on the behavior of the entire family as a system instead of focusing on the pathology of one member
Therapeutic modalities Family therapy – –
Focuses on the client as a ‘family” Involvement of family members
Purposes of family therapy 1. Improve relationships among family members 2. Promote family functions 3. Resolve family problems 4. Help family find ways to cope with problems
Therapeutic modalities Family therapy • Problems are identified by each family members and each discusses his/her involvement in the problem • Members discuss how problems affect them and they explore how to solve them
Therapeutic Modalities Family therapy • The nurse functions to assess the family interactions, makes observations and encourages expression of feelings • Helping the family resolve the problem is the goal
Therapeutic Modalities Behavioral Modification – Therapy to change the unacceptable behavior to acceptable – The nurse determines the unacceptable behaviors and she identifies adaptive behaviors – Punishment is given to unacceptable behavior – Reward is given to acceptable behavior
Therapeutic Modalities Behavioral Modification • Other Behavioral therapies 1. Self-control therapy 2. Aversion therapy 3. Desensitization 4. Modeling 5. Operant conditioning
Therapeutic Modalities Cognitive therapy • An active, directive, time-limited approach • Therapeutic techniques are used to identify reality testing • The nurse helps the patient think and act more realistically and adaptively about his problems
Therapeutic Modalities Play therapy – Therapy with children in which they are helped to express themselves or their behavior through play
Therapeutic Modality: Psychotherapy • A method of treating mental illness in which verbal and expressive techniques are used to help the person resolve inner conflict and modify behaviors
Therapeutic Modality: Psychotherapy 1. 2. 3. 4. 5. 6.
Psychoanalysis Client centered therapy Rational emotive therapy Gestalt therapy Reality therapy Transactional analysis
Therapeutic Modality: Psychotherapy 1. Psychoanalysis – THE therapist obtains information about the past and present experiences that have repressed in the person’s subconscious mind – By learning the source of the problem, the problems can be brought to the conscious where the therapist helps the individual dealt with them
Therapeutic Modality: Psychotherapy 2. Client Centered therapy – The therapist work with one client – Accepting, non-judgmental environment aimed at reducing the anxiety and reducing negative defenses – The patient is encouraged to express his feelings and increase self-awareness – When the person is aware of what he feels, he can work on improving behavior
Therapeutic Modality: Psychotherapy 3. Rational-Emotive therapy – This is based in the assumption that a person’s behavior is due to his own thinking – Problems arise as the person believes about eh events – The therapy aims to change the person’s belief system
Therapeutic Modality: Psychotherapy 4. Gestalt Therapy – The mind receives experiences as a whole – When the experience is complete, the problem will arise – The goal of the therapy is to help patients complete the experience through awareness
Therapeutic Modality: Psychotherapy 5. Transactional Analysis – A group therapy method – Helps people “analyze” their transaction or interaction with others and guides them to the conclusion: I’m OK you are OK
Responses to Illness • • • •
Stress Anxiety Crisis Anger and hostility
Psychosexual/Psychoanalytical Ego Defense Mechanisms
Unconscious Ego Defense Mechanism • These are PSYCHOLOGIC adaptive mechanisms • Mental mechanisms that develop as the personality attempts to DEFEND itself, establishes compromises among conflicting impulses and allays inner tensions.
Unconscious Ego defense mechanism • The unconscious mind working to protect the person from anxiety. • Releases tension .
Ego Defense Mechanisms • Compensation
• Denial
• Covering up weaknesses by emphasizing a more desirable trait. • Attempt to ignore unacceptable realities by refusing to acknowledge them.
Ego Defense Mechanisms • Displacement
• Discharging emotional reactions from one object to a LESS threatening object/person.
• Identification
• Imitation of someone feared or respected.
Ego Defense Mechanisms • Intellectualization
• Use of rational explanations that remove from the event any personal significance and feelings.
• Introjection
• Acceptance of other’s norms as oneself.
Ego Defense Mechanisms • Minimization
• Projection
• Not acknowledging the significance of one’s behavior
• Blame is attached to others or to environment for unacceptable thoughts, mistakes, etc
Ego Defense Mechanisms • Rationalization
• Reaction Formation
• JUSTIFICATION of certain BEHAVIORS by faulty logic/reasons
• Acting OPPOSITELY to the way they feel
Ego Defense Mechanisms • Regression
• Repression
• Resorting to an earlier, more comfortable level of functioning that is less demanding • Unconscious mechanism of keeping threatening desires or thoughts from becoming CONSCIOUS
Ego Defense Mechanisms • Sublimation
• Substitution
• Re-channeling of aggressive energies into socially acceptable activities
• Replacement of a highly valued object by a LESS valuable or acceptable and available object
Ego Defense Mechanisms • Undoing
• Actions or words designed to cancel some disapproved thoughts, impulses , or acts in which the person relieves GUILT by making reparation
Disturbances in 2 or more of the following: • Cognition (thinking about self, people, & events). • Affectivity (range, intensity, lability, & appropriateness of emotional response) • Interpersonal functioning • Impulse control 192
Type
Characteristics
Paranoid
Suspicious & mistrust
Schizoid
Hermitlike lifestyle, aloneness
Schizotypal
Similar to but less severe than those of schizophrenia 193
• Suspicious of others • Doubt trustworthiness or loyalty of friends & others. • Fear of confiding in others. • Suspicious, without justification, of spouse’s or sexual partner’s fidelity. • Interpret remarks as demeaning or threatening. • Hold grudges toward others. • Become angry & threatening when they perceive they are attacked by others. 194
• • • • • • •
Lacks desire for close relationships or friends Chooses solitary activities; a lifelong loner Little interest in sexual experiences Avoids activities Appears cold & detached Lacks close friends Appears indifference to praise or criticism 196
• Ideas of reference • Magical thinking or odd beliefs • Unusual perceptual experience, including bodily illusion • Odd thinking & vague, stereotypical, over elaborate speech • Suspicious • Blunted or inappropriate affect • Odd or eccentric appearance or behavior • Few close relationships • Excessive social anxiety 197
Type
Characteristics
Antisocial
Disregard of others’ rights without guilt Borderline Problems with self-identity, IPRs, mood shifts, & self-destructiveness. Narcissistic Over-evaluation of self, arrogance, & indifference to the criticism of others Histrionic Dramatic behaviors, attention seeking, & superficiality 198
• • • • • • • •
Deceitfulness as seen in lying or conning others Engages in illegal activities Aggressive behavior; violence Lack of guilt or remorse Irresponsible in work & with finances Impulsiveness Reckless disregard of safety for self or others Insensitivity 201
• Before age 15, these behaviors are diagnosed as conduct disorder. • DUI, substance abuse, domestic violence ie; child abuse, wife abuse. -> meet clients at court/prison • History is more important than mental status assessment. • Seems no conscience, irresponsible, immature & dependent. • Nursing care- set firm limits & be consistent in confronting behaviors & enforcing unit rules.
• Frantic avoidance of abandonment; real or imagined • Unstable & intense IPR; Identity disturbances • Impulsivity; Affective instability • Recurrent suicidal behavior or self-mutilating behavior – to express feelings of anger/frustration • Rapid mood shifts • Chronic feelings of emptiness • Transient dissociative & paranoid symptoms
203
• Uncertain about his self-image, career goals, personal values, & sexual orientation • Unhealthy R & in short-term intimate R • For client’s impulsivity – Nurse’s self awareness and set limit are important. • Pt alternates between overidealization & devaluation of individuals ie falls in love with the perfect person and shortly can find no redeeming quality in the formerly idealized person. • Manipulation & dependency commonly occur. Pt has great difficulty in being alone & therefore seeks intense but brief relationships • tend to view themselves as victims and assume little responsibility for their problems
• Grandiose self-importance • Fantasies of unlimited power, success, or brilliance • Believes he/she is special or unique; Needs to be admired • Sense of entitlement (i.e., deserves to be favored or given special treatment) • Takes advantage of others for own benefit • Lacks empathy • Envious of others or others are envious of him/her • Arrogant or naughty
205
• Family may complained “The pt never really seemed to see me as a person with my own thoughts and problems.”
• • • • • • • •
Needs to be center of attention Displays sexually seductive or provocative behaviors Shallow, rapidly shifting emotions Uses physical appearance to draw attention Uses speech to impress others but is lacking in depth Dramatic expression of emotion Easily influenced by others Exaggerates degree of intimacy with others 207
Type
Characteristics
Dependent
Submissiveness, helplessness, fear of responsibility, & reliance on others for decision making. Timidity, social withdrawal behavior, & hypersensitivity to criticism.
Avoidant
Obsessivecompulsive
Indecisiveness, perfectionism, inflexibility, & difficulty expressing feelings. 208
• Unable to make daily decisions without much advice & reassurance. • Needs others to be responsible for important areas of life. • Seldom disagrees with others because of fear of loss of support or approval. • Problem with initiating projects or doing things on own because of little self-confidence. • Performs unpleasant tasks to obtain support from others. • Anxious or helpless when alone because of fear of being unable to care for self. • Urgently seeks another relationship for support & care after a close R ends. • Preoccupied with fear of being alone to care for self. 209
• Avoids occupations involving interpersonal contact because of fears of disapproval or rejection. • Uninvolved with others unless certain of being liked. • Fears intimate Rs due to fear of shame or ridicule. • Preoccupied with being criticized or rejected in social situations. • Inhibited & feels inadequate in new interpersonal situations. • Believes self to be socially inept, unappealing, or inferior to others. • Very reluctant to take risks or engage in new activities due to possibility of being embarrassed. 211
AVOIDANT • A pervasive pattern of social interaction, feeling of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in variety of context.
• Preoccupied with details, rules, lists, organization. • Perfectionism that interferes with task completion. • Too busy working to have friends or leisure activities. • Over conscientious & inflexible. • Unable to discard worthless or worn-out objects. • Others must do things his/her way in work or task related activity. • Reluctant to spend and hoards money. • Rigid and stubborn. 214
• • • • • • •
Anxiety High risk for self-mutilation Hopelessness Impaired communication Ineffective individual coping Self-esteem disturbance Social isolation 216
Nursing Care • Nurse-Patient relationship – trust, empathy, authenticity • Focus on specific behaviors, distress to self or others or both & awareness of dysfunctional & self-defeating patterns • Case management – stress reduction & crisis intervention • Assertive training; Social skill training • Psychobiological therapy (with caution) • Milieu therapy – setting limits 217
Conclusion • Personality traits -> individualization • Disorder = rigid, dysfunctional, distress • Distress come from others’ reaction to or behaviors toward that person -> evoke interpersonal conflict • Usually have more than one DSM diagnosis • Long-term hospitalization is unnecessary • Limit setting – multidisciplinary work • Px - have a fairly good prognosis only with therapy 218
Substance-Related Disorders Personal and societal toll Terminology & criteria for diagnoses Care plan and interventions
225
Introduction • Epidemiology - # 1 health problem in the US -> effects on cost, quality of life, society • Types - Alcohol, tobacco, other drugs ie opium, heroin, codeine, synthetic narcotics. • Cigarettes and alcohol – gateway drugs • History – medical use, social use, illegal use • Central nervous system (CNS) was affected • Substance dependency – Client experiences tolerance and withdrawal symptoms 226
Substance • Prescribed medications – Ritalin – OxyContin
• Over-the-counter cough, cold, sleep, and diet medication. • Narcotics – – – –
Heroin Morphine Demerol Methadone.
• Inhalants • Hallucinogen
– Marijuana, LSD, PCP…
• Stimulants
– Cocaine – Amphetamines
227
Other Substance & Trends • Club drugs ie MDMA (ecstasy), GHB, Rohypnol, ketamine, methamphetamine, LSD
• • • • •
CNS depressants ie. Valium, phenobarbital Steroids 1960 – hallucinogens, amphetamines 1970 – heroin, marijuana, sedatives 1980 – cocaine – injection, smoking 228
Terminology • Dependence – physical & psychological
• Codependence – an emotional, psychological and behavioral pattern of coping that an individual develops as a result of prolonged exposure to a dysfunctional pattern of behavior within the family. – The individual experiences difficulty with identity development and set in functional boundaries which lead to taking care of others rather than self. 229
• Tolerance
– May be influenced by the enzyme ie French
• Cross-tolerance
– A condition in which tolerance to one drug often results in a tolerance to chemically similar drugs.
• Withdrawal
– Abstinence syndrome. – Physical signs and symptoms that occur when the addictive substance is reduced or withheld .
• Dual diagnosis • CAGE – cutdown, annoy, guilty, eye opener • Blackout – The person appears to function normally while drinking but later is unable to remember what occurred. – It may last a few hours or several hours.
• Withdrawal from Cocaine -> anxiety and depression • hallucinogens do not produce physical dependence, so there are no withdrawal symptoms
A Continuum of Substance Use Nonuse
Social use
Dependence
Addiction
• Social • Recreational • Medical
•Physical •Tolerance •Withdrawal •Psychological •Compulsive use •Craving
• Loss of control of ingestion • Using despite related problems • Tendency to relapse
232
Etiology • Biological theories – Genetic predisposition
• Psychological theories – Psychoanalytic theories – Interpersonal theories
• Family theories – Family system theory
• Learning theories – Positive effect of mood alternations – Media reinforcement – Peer pressures
• Psychosocial and behavioral factors increase the client’s vulnerability to drug or alcohol abuse. 233
Age & Substance Use Grade 8th Grade 12th Grade College Substance 1993 1993 2001 Alcohol 70 % 80 % ->92%(2001) 90% Cigarettes
44 %
63 %
Marijuana
10 %
37 %
Cocaine
2 %
8 % 234
Perinatal Concerns • 25-30% of women expose their children to nicotine in utero • 3 out of every 5 women of childbearing age drink alcohol • 10% of women of childrearing age use an illicit drug • Substances = teratogens -> malformations in the fetus, intrauterine growth retardation, subtle mental and behavioral deficits. 235
Fetal Alcohol Syndrome (FAS) • Low birth weight • Certain facial characteristics ie. microcephaly, microthalmia, short palpebral fissures, poorly developed philtrum, thin upper lip, short nose, small chin, flattening of the maxillary area • Neurological abnormalities ie developmental and/or intellectual delays; it is a preventable cause of mental retardation • Fetal Alcohol Effect (FAE)- Less severe cases 236
Other problems of FAS & FAE • Other organs – heart, hearing, visual, dental, genital anomalies • Hyperactivity, poor coordination, short attention spans, dependency, social withdrawal, impulsivity… • Co-morbidity • Depression, anger, suicidal ideation, antisocial behaviors • Preventable health problem for children 237
Adolescent Substance Abuse • • • • • •
Health & social problem School drop-out Victim of abuse – child/parental, sexual Experienced trouble with law Suicide attempts Feelings of inferiority, history of mental problems 238
Signs of Adolescent Drug Use • • • • • • • •
Sudden behavioral changes Sweating, especially at night Needle marks Inebriation (intoxicated, drunk) Change in nutritional intake Nasal congestion Rhinorrhea with cocaine use School problems 239
Warning Ss of Teen Sub. Abuse Physical
Fatigue, health complaints, red/glazed eyes, lasting cough Emotional Personality, mood change, irritability, irresponsible behavior, depression… Family Arguments, breaking rules, withdrawing School Decreased interest, neg. attitude, drop in grades, absences, truancy Social Problems with law, changes to less problems conventional styles in dress and music 240
Prevention of Adolescent substance Use • • • • • • •
Positive role modeling Reinforce positive behaviors Support – cope with social pressure Establish normative expectations Help to anticipate pressures Involve in life skills training programs Open communication 241
Alcohol Abuse • Body damage - brain cell -> neurological S/S Liver, G-I, muscle, heart, sexual function …
• Blackouts – • Wernicke’s syndrome - intact intellectual function but poor memory, ataxia, confusion, vit B deficiency • Korsakoff’s syndrome – disorientation
• Alcohol withdrawal syndrome (AWS) • Alcohol withdrawal delirium - Delirium tremens (DT) – confusion, disorientation, hallucination, tachycardia, tremor, …
242
Wernicke’s Encephalopathy • Clouding of consciousness with an abrupt onset of confusion and mental status changes along with drowsiness. • Ocular motor abnormalities. • Ataxia of gait from weakness in limbs or coordination of muscles or poor balance
243
Korsakoff Syndrome • Difficulty in acquiring new information or learning new skills • Lack of insight into their deficit • Amnesia • Impaired short term memory • Tendency for confabulation • Apathy • Inattention • Impaired fine motor skills • Impaired sense of smell • Talkative an repetitive behaviors
244
Treatment of WKS • IV or IM thiamine • Medications – Cholinersterase inhibitors – Atypical antipsychotics – SSRI • Alcohol cessation • Dietary consumption 245
Clinical Description • • • • • • •
Denial Dependence – compulsive use Abuse – dysfunction in work, … Intoxication Withdrawal Delirium Psychotic disorders 246
• Denial – N’s role - to question why they feel threatened to help them to gain insight. • Dependence – use of the drug is no longer under control, & continue to use despite adverse effects. • Abuse- recurrent use -> failure to manage work, school, or home roles, hazardous situation • Withdrawal – physiological, behavioral , cognitive, and affective symptoms that occur after reduction or discontinuance of a drug that has been used heavily over a long period of time. • Alcohol Withdrawal – tremulousness, nervousness, anxiety, anorexia, nausea, vomiting, insomnia, sleep disturbances, rapid pulse, high bp, profuse perspiration, diarrhea, fever, unsteady gait, difficulty concentrating, craving
Alcohol-related Disorders Alcohol intoxication • Slurred speech • Incoordination • Unsteady gait • Nystagmus • Attention/ memory impairment • Stupor or coma
Alcohol withdrawal Substance induced delirium • Nausea/vomiting • Impaired • Anxiety consciousness • Hallucination • Cognitive change • Sweating (memory, • Psychomotor disorientation, agitation hallucination) • Grand mal seizure • Short period of • Hand tremor time/fluctuates • Evidence of sub. abuse 248
Alcohol • Detoxification – 3Ss–Secure environment –Sedation –Supplements
249
CNS Depressant - Narcotics • Opioids – endorphin agonist, euphoria • Increasing pain threshold, reducing anxiety and fear • Decreased pulmonary ventilation/esp. elders • Respiratory depression in neonates/preg • Withdrawal is rarely fatal, but painful – ie yawning, tearing, rhinorrhea, sweating, flushing, tachycardia, tremor, restlessness, irritability, muscle spasm, fever, nausea, diarrhea, vomiting, repetitive sneezing, abdominal cramps, backache 250
CNS depressant - Barbiturates • Medical – relieve anxiety, produce sleep, anesthesia, epilepsy, soften withdrawal from heroin • Narrow therapeutic index • Classification- ultrashort (30’-3h), short (3-4h), intermediate (6-8h), long (10-12h) • Intoxication: unsteady gait, slurred speech, sustained nystagmus, confusion, irritability, insomnia • Tolerance
251
• Narrow therapeutic index- lethal dose being only slightly higher than the therapeutic dose • Barbiturates with short to intermediate duration have the highest abuse potential i.e. amobarbital( Amytal), pentobarbital (Nembutal), and seconbarbital (Seconal).
Stimulant - Cocaine • Medical – relief for altitude sickness, anesthetics, • Block norepinephrine & dopamine reuptake • CNS & PNS effects – euphoria, alertness, anorexia, sexual stimulation • Derivatives: crack, rock • Physical dependence is less severe • Psychological dependence is intense • Highs (+ reinforcement) & lows ( - reinforcement) • Cocaine-induced depression, suicide • Death – caused by meta. & resp. acidosis, and hyperthermia, prolonged seizure, tachyarrhythmias
253
Stimulant - Amphetamine • Speed, ice, crank, poor person’s cocaine • Medical – ADD, narcolepsy, obesity • CNS effects – wakefulness, alertness, heightened concentration, energy, euphoria, insomnia, amnesia, restlessness, agitation, • PNS effects- palpitations, tachycardia, hypertension • Amphetamine-induced psychosis • Facilitate excretion by acidification of urine
254
Hallucinogen • Natural & synthetic • Heighten awareness of reality or cause a terrifying psychosis-like reaction, distortions in body image, sense of depersonalization, loss of the sense of reality, panic, anxiety, confusion, paranoid reaction • Altered perception -> unable to perform simple tasks or lead to violent behaviors
255
Dual Diagnosis • Comorbidity – 2 or more disorders in the same person • Dual diagnosis- 2 initial unrelated disorders that interact and cause increased manifestations of the other disorder • Personality disorders – higher incidence – 47% of antisocial; 2/3 of borderline; 4.5-15% above the norm in Schizophrenia 256
Etiology of Dual Diagnosis • Substance use -> calmer, feel better, less anxious, decrease the intensity of hallucinations. • Compare with using antipsychotics – less uncomfortable side effects • Increase social acceptance, feeling of autonomy or power -> self-esteem
257
Tx for Dual Dx • Multifaceted & multidisciplinary – case management, ind/gr therapy, skill training, vocational counseling, … • N-Pt Relationship – knowledgeable, skilled, nonjudgmental, empathic • Monitoring – S/s of withdrawal • Milieu therapy – set limits • Psychopharmacology - compliance 258
Impaired Professionals • Incidence: 5% - chemical abuser • 8-10% (or higher) -chemically dependent • Common profile – – – – –
Family hx of sub abuse, depression, sexual abuse Academically and professionally successful Divorced Received professional treatment for sub abuse Regularly attends recovery self-help groups
• Report to supervisor immediately 259
Common Nursing Diagnoses • Anxiety • Ineffective individual coping/ self-care • Altered health maintenance/ nutrition/ sensory-perception/ family process, • Risk for injury/infection • Impaired communication/ social interaction • Violence, potential for 260
Substance Abuse Problems Needing Collaboration • 53% of drug abusers have at least 1 serious psychiatric problem
• 37% of alcohol abusers have at least 1 serious psychiatric problem
261
Pharmacological Treatment • Alcoholism – Naltrexone (Trexan, ReVia) – – Disulfiram (Antabuse) – • Opiod addict – Methadone (Dolophine) – L-alpha Acetylmethadol (LAAM) – Naltrexone (Trexan, ReVia) – Clonidine 262
Pharmacological Treatment (II) • Stimulant dependence – – Dopaminergic drugs ie. Amantadine (Symmetrel), bromocriptine (Parlodel) – Anticonvulsants ie carbamazepine (Tegretol) – TCA ie desipramine (Norpramine)
• Hallucinogen dependence – – Diazepam (Valium)
263
Supplementary Treatment • Sedatives – Benzodiazepine ie Librium, Valium – Phenobarbital
• • • • •
Thiamine (Vit B1) Folic Acid Magnesium sulfate Anticonvulsant Multivitamins
264
N-Pt Relationship • • • •
Trust - communication Support – minimizes anxiety Consistency – objective & nonjudgmental Continually assess – Presence of predictable defense style – Psychophysiological responses
• Referral – local resources/ community agencies 265
Milieu Therapy • Drug-free – safety, structure, norms, limit setting • Motivation – Dependency vs. face the consequences • 3Cs – Family members – did not cause the disease, – cannot control it, – cannot cure it • Belongingness – significant relationship, social skills, 266
Interdisciplinary Interventions • • • • • •
Breaking through defenses - denial Understanding and accepting the disorder Identification with peers Development of hope Re-socialization Developing self-esteem and self-worth
267
DELIRIUM • Delirium is a serious and often undetected neuropsychiatric syndrome. • Failure to identify delirium can lead to longer hospital stays and increased morbidity and mortality.
Other Terms Applied to Delirium • • • • • •
Acute Brain Syndrome Acute Confusional State Metabolic Encephalopathy Toxic Psychosis Acute Brain Failure Altered Mental Status
