PSYCHIATRIC AND MENTAL HEALTH NURSING PSYCHIATRIC NURSING An interpersonal process whereby the nurse assists and individual, family or community, to promote mental health, to prevent or cope with the experience of mental illness and suffering and if necessary, to find meaning in these experiences MENTAL HEALTH A state of emotional, psychological and social wellness as evidenced by satisfying interpersonal relationships, effective behavior and coping, a positive self-concept and emotional stability
POSITIVE MENTAL HEALTH (WHO) Attitude towards the individual self, Growth development and self-actualization Integrative capacity Autonomous behavior Perception of reality Mastery of ones environment
BEHAVIOR
Reflex action
Goal-directed behavior Behavior as a response to frustration
NEEDS Physiologic Safety and security Love and affection Self esteem Self actualization
MENTAL HEALTH HEALTH vs. MENTAL ILLNESS
MENTAL HEALTH Is the balance in the persons internal life and adaptation to reality
CRITERIA FOR MENTAL HEALTH: Attitude toward the individual self, selfacceptance Growth, development and self-actualization Integration capacity balance between the id, ego and superego Autonomous behavior ability to stand by the decision Environmental mastery ability to adapt and adjust to the environment environment
MENTAL ILLNESS An illness with psychologic / behavioral manifestation which may be due to a physical, psychological, social, genetic/biological or chemical imbalance
CRITERIA FOR MENTAL ILLNESS: Presence of characteristic fixation functioning Loss of existing functioning Distention of affect Presence of regressive characteristic Appearance of symptom
INITIAL EFFECTS OF MENTAL ILLNESS (BEHAVIORAL CHANGES): 1st symptom irritability and restlessness, inability to sleep, lack of appetite
TWO GENERAL TYPES OF MENTAL M ENTAL ILLNESS:
y
NEUROSIS - is a psychogenic reaction which arises because of an individual inability to cope
Personality origin: Etiology: General Behavior: Insight: Self-Management:
y
PSYCHOSIS - is a psychogenic reaction which is changed by severe personality organization
Personality Origin: Etiology:
General Behavior: Insight: Self Management:
Prognosis:
1.
intact psychological factors like conflicts inconformity with society with insight can manage self - treatment psychotherapy
absent both psychological and structural deterioration of brain cells at odds with society without insight hospitalization is needed, biologic methods like drugs and ECT deterioration is expected, bad prognosis
COMMON PSYCHOTHERAPEUTIC INTERVENTIONS
REMOTIVATION THERAPY reality orientation y 5 DIFFERENT STEPS: 1. Climate of Acceptance 2. Creating of bridge to reality prevent topic 3. Sharing the world we live in discuss 4. Appreciation of the works of the world reflect 5. Climate appreciation finish
2.
MUSIC THERAPY should be congruent to the patient y Manic fast music y Depression slow music
3. PLAY MATERIAL and it should age-appropriateness appropriate y Infant - Solitary y Toddler Parallel y Preschooler Competitive 4. GROUP THERAPY 8-10 patients, minimum of three 5.
PSYCHODRAMA patient is to play the role
6. MILIEU THERAPY scientific manipulation of the environment environment nurse acts as a facilitator
be
7.
FAMILY THERAPY indicated for abusive parents and abused children
12.
BEHAVIOR
8. PSYCHOANALYSIS exploration of the unconscious identity and defenses 9.
MODIFICATION systemic desensitization reward punishment punishment indicated for phobia
13. AVERSION THERAPY covert sensitization, overt sensitization
HYPNOTHERAPY indicated for anxiety, sexual disorder and obesity
14. TOKEN ECONOMY reward and punishment Toilet training
10. HUMOR THERAPY therapeutic laugh
15. GESTALT THERAPY forces are the here and now
11. TRANSACTIONAL ANALYSIS communication focus is effective communication
y Conscience responsible for guilt feelings; corresponds corresponds to those things parents taught were bad
PERSONALITY DEVELOPMENT /SELF AWARENESS SELF ACCEPTANCE PERSONALITY Latin word persona meaning mask Dynamic not static An integration and interaction of traits Not determined by just one trait but by a number of traits taken together Considered to be the social stimulus value of individuals Sum total of all the traits and characteristics of a person that distinguishes him from one a nother.
y
1.
PERSONALITY DEVELOPMENT/PERSONALITY THEORY: y
FREUDS PSYCHOSEXUAL THEORY 1. Oral stage 2. Anal stage 3. Phallic stage 4. Latency stage 5. Genital stage
STAGES OF DEVELOPMENT DEVELOPMENT y PSYCHOSEXUAL PSYCHOSEXUAL STAGE INFANCY birth to 12 months ORAL ORAL STAGE Satisfaction is obtained primarily through the o erogenous erogenous zone of the mouth Security is the greatest need o Narcissistic pleasure seeking is through eating o and sucking (pleasure principle) Aggressive instincts are shown by biting and o chewing Weaning is a crucial conflict in this period o FIXATION: o Arrested development in which the person retains o means of gratification characteristic of an earlier phase Develop dependent relationship in adulthood, o recreating dependency and immaturity of the oral stage Optimistic, gullible and will swallow anything o Individual uses oral approaches to hurt; biting o sarcasm Oral pleasures: eating, drinking and smoking o
THREE PARTS OF PERSONALITY y ID Consists of all our primitive, innate desires, which include bodily needs, sexual urges and aggressive impulses. Totally unconscious and drives the person toward immediate, total gratification Operates on pleasure principle (seeking of immediate gratification and avoidance of discomfort)
2. TODDLERHOOD 1 year to 3 years old ANAL
EGO
Establishes relations with environment through
conscious perception, feeling, action Controls impulses from id and demands from superego Operates on reality principle (external conditions considered and immediate gratification delayed for future gains that can be realistically achieved.
y
SUPEREGO Represents internalized moral code based on perceived social rules and norms Active and concrete in directing persons thoughts, feelings and actions
TWO SYSTEMS: y Ego ideal perfection to which person aspires; corresponds corresponds to what parents taught was good
ANAL STAGE Anus is the site of tension and sensual o gratification Excretory processes, retentive and expulsive are o experienced experienced as pleasurable The child uses these new skills to please or to o annoy parenting adults. Child exhibits motor self control and o independence independence through negativistic behavior FIXATION: o Anal retentive personality shows traits of o obstinacy, parsimony and orderliness orderliness. Anal expulsive personality shows traits of o generosity, and outgoing nature and may highly creative, expressive and a rtistically inclined.
7.
FAMILY THERAPY indicated for abusive parents and abused children
12.
BEHAVIOR
8. PSYCHOANALYSIS exploration of the unconscious identity and defenses 9.
MODIFICATION systemic desensitization reward punishment punishment indicated for phobia
13. AVERSION THERAPY covert sensitization, overt sensitization
HYPNOTHERAPY indicated for anxiety, sexual disorder and obesity
14. TOKEN ECONOMY reward and punishment Toilet training
10. HUMOR THERAPY therapeutic laugh
15. GESTALT THERAPY forces are the here and now
11. TRANSACTIONAL ANALYSIS communication focus is effective communication
y Conscience responsible for guilt feelings; corresponds corresponds to those things parents taught were bad
PERSONALITY DEVELOPMENT /SELF AWARENESS SELF ACCEPTANCE PERSONALITY Latin word persona meaning mask Dynamic not static An integration and interaction of traits Not determined by just one trait but by a number of traits taken together Considered to be the social stimulus value of individuals Sum total of all the traits and characteristics of a person that distinguishes him from one a nother.
y
1.
PERSONALITY DEVELOPMENT/PERSONALITY THEORY: y
FREUDS PSYCHOSEXUAL THEORY 1. Oral stage 2. Anal stage 3. Phallic stage 4. Latency stage 5. Genital stage
STAGES OF DEVELOPMENT DEVELOPMENT y PSYCHOSEXUAL PSYCHOSEXUAL STAGE INFANCY birth to 12 months ORAL ORAL STAGE Satisfaction is obtained primarily through the o erogenous erogenous zone of the mouth Security is the greatest need o Narcissistic pleasure seeking is through eating o and sucking (pleasure principle) Aggressive instincts are shown by biting and o chewing Weaning is a crucial conflict in this period o FIXATION: o Arrested development in which the person retains o means of gratification characteristic of an earlier phase Develop dependent relationship in adulthood, o recreating dependency and immaturity of the oral stage Optimistic, gullible and will swallow anything o Individual uses oral approaches to hurt; biting o sarcasm Oral pleasures: eating, drinking and smoking o
THREE PARTS OF PERSONALITY y ID Consists of all our primitive, innate desires, which include bodily needs, sexual urges and aggressive impulses. Totally unconscious and drives the person toward immediate, total gratification Operates on pleasure principle (seeking of immediate gratification and avoidance of discomfort)
2. TODDLERHOOD 1 year to 3 years old ANAL
EGO
Establishes relations with environment through
conscious perception, feeling, action Controls impulses from id and demands from superego Operates on reality principle (external conditions considered and immediate gratification delayed for future gains that can be realistically achieved.
y
SUPEREGO Represents internalized moral code based on perceived social rules and norms Active and concrete in directing persons thoughts, feelings and actions
TWO SYSTEMS: y Ego ideal perfection to which person aspires; corresponds corresponds to what parents taught was good
ANAL STAGE Anus is the site of tension and sensual o gratification Excretory processes, retentive and expulsive are o experienced experienced as pleasurable The child uses these new skills to please or to o annoy parenting adults. Child exhibits motor self control and o independence independence through negativistic behavior FIXATION: o Anal retentive personality shows traits of o obstinacy, parsimony and orderliness orderliness. Anal expulsive personality shows traits of o generosity, and outgoing nature and may highly creative, expressive and a rtistically inclined.
3. PRE SCHOOLER 3 years to 6 years old PHALLIC
1. INFANCY birth to 12 months TRUST vs. MISTRUST
PHALLIC STAGE TRUST Libido is centered in the genital region o Caregivers satisfaction of infants basic needs for food and sucking; warmth and LIBIDO o comfort and love and security in consistent Sexual or psychic energy arising from hidden o drives or impulses involved in conflict and sensitive manner Desire for pleasure, sexual gratification o fantasy, play activities, To develop Trust: Masturbation, o experimentation with peers and questioning of respond to the needs of an infant Somebody must respond adults about sexual topics are indicative Infant must be given a gentle, caring and loving behaviors attention Labeled phallic because the penis is presumed Care must be given by one person only o to be the object of main interest . For little girls (primary care giver). Whoever she/he is as long who are envious or to the little boy who is as they can build the trust . constantly fearing castration for unconscious Infants have to expect what will happen next . Life desires to experience sexual gratification with of an infant is a routine. mother. Major conflict is : MISTRUST o Oedipal Complex or Electra Complex o Basic needs of infants are not met or are met Child develops sexual interest toward the inadequately, infant becomes suspicious, o parent of the opposite sex fearful and mistrusting as evidenced by poor eating, sleeping and elimination 4. SCHOOL AGE 6 years to 12 years old 2. TODDLERHOOD LATENCY 1 year to 3 years old AUTONOMY vs. SHAME AND DOU BT AUTONOMY LATENCY STAGE Sexual urges are dormant until their AUTONOMY o reawakening at puberty Child develops beginning independence while During this period, libido is channeled to school, gaining control over bodily functions of o home and organizational activities, hobbies and undressing and dressing, walking, talking, relationship with peers. feeding self and toileting. Self control begins The time foe increased intellectual activity, o identification with teachers and peers To develop Autonomy: weakening of home ties Learn how to wear his/her clothes by himself Let them eat by themselves Give them something that they can manipulate 5.
ADOLESCENT 12 years to 18 years old GENITAL GENITAL STAGE Adolescent becomes sexually mature and libido o is centered again on the genital area. Person strives for independence, gains o intellectual maturity, selects a love object of the opposite sex and settles into adult roles. SOCIAL LEARNING THEORY OF PERSONALITY
SHAME / DOUBT toddlers developing independence is If discouraged by parents, child may doubt personal abilities If child is made to feel bad when attempts to be autonomous fail, child develops shame
3. PRE SCHOOLER 3 years to 6 years old INITIATIVE vs. GUILT
INITIATIVE Developed when planning and trying out new things. Child behavior is vigorous, imaginative and intrusive. Conscience and identification with same-sex parent develop
Explains personality almost entirely in terms of experience experience rather than biological factors Personality is learned just as learning to play o tennis, eat with a fork or speak a language o Values play an important role in determining behavior To develop Initiative: Let a child play with a clay, sand, mud Values and expectancies determine personality. o Explains why we are all different and when we o Let them go to the zoo. are exposed to similar environments, our ways of expressing our motives and values differ . GUILT Parental restrictiveness may prevent child from PSYCHOSOCIAL THEORY (Erik Erickson) developing developing initiative Said that the child faces a wider range of human Guilt may arise when child undertakes activities relations as he grows up and has specific in conflict with those of parents. Child must learn to initiate activities without problems to be faced with each stage infringing on right of others STAGES OF DEVELOPMENT DEVELOPMENT y PSYCHOSOCIAL CRISES o
3
Individual develops integrated sense of self
4. SCHOOL AGE 6 years to 12 years old INDUSTRY vs. INFERIORITY
INDUSTRY Child wins recognition by demonstration of skill and production of things and develops selfesteem through achievements. Child is greatly influenced by teachers and school
INFERIORITY Feelings of inferiority may occur when adults perceive childs attempt to learn how things work through manipulation to be silly or troublesome Lack of success in school, development of physical skills and making of friends also contribute to inferiority
5.
7.
ROLE CONFUSION Failure to develop sense of personal identity may lead to role confusion, which often results in feelings of inadequacy, isolation and indecisiveness
6. EARLY ADULTHOOD 18 years to 25 40 years old INTIMACY vs. ISOLATION
INTIMACY Task is to develop close and sharing relationships with others, which may include sexual partner
ISOLATION Individual unsure of self-identity will have difficulty developing intimacy Person unwilling or unable to share self will be lonely
ABRAHAM MASLOW leader in Humanistic Psychology Heavily influenced by existential philosophy Existentialists believed that each person carves out his own destiny life is what you make it . Postulated that a person is never static, he is always in the process of becoming different
Maslows humanistic conceptions of personality focused primarily on two areas. (1) Hierarchy of needs (2) Concept of self actualization
MASLOWS HIERARCHY OF NEEDS
IDENTITY MIDDLE ADULTHOOD 40 years to 65 years old GENERATIVITY VS. STAGNATION GENERATIVITY Mature adult is concerned with establishing and guiding next generation Adult looks beyond self and expresses concerns for future of world in general STAGNATION Self-absorbed adult will be preoccupied with personal well-being and material gains Pre-occupation with self leads to stagnation of life
EGO-INTEGRITY Older adult can look back with sense of satisfaction and acceptance of life and death
DESPAIR Unsuccessful resolution of this crisis may result in sense of despair in which individual views life as series of misfortunes, disappointments and failures
Major decision is to determine vocational goal
ADOLESCENT 12 years to 18 years old IDENTITY vs. ROLE CONFUSION
8. LATE ADULTHOOD 65 years old and above EGO INTEGRITY vs.. DESP AIR
Peers have major influence over behavior
HUMANISTIC THEORY Central focus is the concept of self SELF refers to the individuals own personal internal experiences and subjective evaluation This theory rejects the psychoanalysts notion of unconscious motivation as an important force in personality development . Rejects the idea that environmental forces are the major determinants of personality Believed that human beings are endowed with free will and free choice Believed that to understand ones personality, you must know how he or she perceives the world
SELF ACTUALIZATION SELF-ESTEEM
LOVE AND BELONGINGNESS
SAFETY NEEDS PHYSIOLOGICAL NEEDS
y PHYSIOLOGICAL NEEDS Include the need for oxygen, water, food, temperature control, elimination, shelter, exercise, sleep, sensory stimulation and sexual a ctivity This needs cease to exist as active means of determining behavior when satisfied, reemerging only when they are blocked or frustrated. y SAFETY NEEDS Security, consistency, stability, fairness, structure, order and limits; protection from immediate or future danger; freedom from fear, anxiety and chaos; a certain amount of routine and structured environment 4
y
y
y
y
was a German psycho-artist, who described four LOVE AND BELONGINGNESS types of techniques and their related Derived from societal factors and include a need characteristics to be cherished, a need for identification with significant others, affection from and affiliation with others, recognition and approval, Pyknic rounded full face, short neck, stocky build, short companionship and group interactions limbs, mood fluctuations and a tendency to Not synonymous with sexual needs, but sexual extroversion and manic-depression needs maybe motivated by a need for love and affection Asthenic thin and angular, introverted and a tendency to SELF ESTEEM schizophrenia Concerned with the concept of self as a worthwhile person and an awareness of Athletic individuality and uniqueness strong, solid muscular build and comparable Included are needs for self respect; respect introverted tendencies from others; sense of confidence, dignity, competence, independence, prestige, status and success; recognition from others for Dysplastic by bodily disharmony and characterized accomplishments; and desire to attain certain temperamentally introverted standards of excellence BEHAVIOR (Carl Jung) SELF ACTUALIZATION Swiss Psychoanalyst and Founder of Analytical Self fulfillment; ongoing emotional and spiritual Psychology development; ability to make decisions and be autonomous; reaching individuals potentialities; using talents; being productive and having peak CLASSIFIED PERSONALITY TYPES ACCORDING TO: y ATTITUDE TYPES experiences always becoming, it involves Extrovert Involves A tendency to direct the personality outward spontaneity rather than inward toward the self Social, a man of action, whose motives are PERSONALITY THEORY (George Kelly) conditioned by external events An individual is primarily a scientist whose life is Is negligent of ailments, not taking care of the self; an attempt to control and predict experience accommodates readily to new situations, directly An individual is motivated by the necessity of oriented by objective data knowing reality. Person classifies and categorizes perceptions, events circumstances and situations, and when Introvert Orientation inward toward the self this activity is complete experience results Preoccupied with his own thoughts Personality is the continuous construction, Avoids social contacts and tends to run away from rejection or acceptance of these personally reality significant hypothesis about oneself Conduct is governed by absolute standards and principles and lacks of flexibility and a daptability TYPE THEORIES
y
Constitutional Types theories postulate that human These subjects can profitably be classified into a smaller number of classes or types, each class or type having characteristics in common which set its members apart from other classes or types
PHYSIOLOGY OR BODY CHEMISTRY y Hippocrates laid the foundation for the doctrine of temperaments based on the humors (fluids) of the body.
GALEN (GREEK PHYSICIAN) An exact balance of these four humors resulted in a correctly constituted personality
PHYSIQUE (Body Types)
William Sheldon HUMORS bases his theory on the three layers of tissue in the TEMPERAMENTS human embryo the endoderm, mesoderm and Quick-Strong (choleric) Yellow Bile ectoderm Easily angered, quick to react Quick-weak (sanguine) Blood Endomorphy Generally warm-hearted, tends towards a roundness, heaviness and a pleasant, had a prominence of blood preponderance of visceral development Slow-strong (melancholic) Black Bile Suffers from depression and sadness Mesomorphy Phlegm tends towards stockiness and good muscular Slow-weak (phlegmatic) L istless and slow development Ectomorphy tends toward a long, stringy, skinny body Ernest Kretschmer
WAYS OF IMPROVING PERSONALITY y Self-appraisal Listing down and evaluating your physical, intellectual, social and emotional traits in terms of effectiveness, ineffectiveness or partial effectiveness 5
Effective Regulation Of Emotional Life One must develop a high degree of control over ones emotions and not allowing ones emotion to control you Negative or unpleasant emotions like fear, envy, pride should be checked or sublimated Positive emotions like joy, love, reverence, etc . should be developed
Social relations One should be capable of social intimacy forming friendships and participating in social relations that are deeper than mere acquaintances
Work One must be committed to some form of work that is satisfying as well as economically good. Keep busy and indulge in worthwhile hobbies
Love and Sex One must be able to forego personal gratification, even sexual gratification, to satisfy the loved one . Love consists or thinking more of other people rather than ones own self
Self One must have a positive regard of ones self as distinguished part of the world he lives One must have a well-developed ego identity and should know who he is, where he is going and should have an inner assurance that he will be recognized and accepted by those who count
Philosophy of Life One should live by philosophy of life that should give direction to ones actuations
SULLIVANS INTERPERSONAL THEORY 1. Infancy 2. Childhood 3. Juvenile 4. Preadolescence 5. Early adolescence 6. Late adolescence
PIAGETS COGNITVE THEORY 1. Sensorimotor 2. Preoperational 3. Concrete operational 4. Formal operations
KOHLBERGS MORAL DEVELOPMENT y pre-conventional - punishment & obedience y conventional - social system & conscience y post-conventional - universal ethical principle
ECCLECTIC APPROACH 1. Development is a continuum 2. Behavior has meaning and is not determined by chance 3. All behaviors should be goal-directed The unconscious plays an active role in 4. determining behavior 5. The early years of life are extremely important for personality development
AWARENESS Awareness is a way of focusing attention on the present, thereby strengthening the impact of life experiences . Always available and, with practice, can be used successfully to enrich life Is not only the key to self understanding, it is also the key to fullness of living y
SELF AWARENESS Involves noticing how the self feels, thinks, behaves and senses at any given time. It is only through awareness of how the self blocks messages and uses mental mechanisms that people can achieve self-understanding
First step in coping with stress. The more aware one is, the deeper one can experience feelings such as joy and pleasure
IMPROVING SELF-AWARENESS Improving self-awareness requires concentration and practice. The following suggested guidelines could be used to develop self-awareness. Awareness should never be forced; it should simply be allowed to flow. Instant results should not be expected, as growth requires time.
Periodically stop and concentrate on what your
body is feeling at the moment . At first, concentrate only on what the body senses . Later, include environmental awareness as well. Tell yourself what you are aware of .
Ask yourself, What am I aware of when I am anxious, happy, joyous, frustrated? Concentrating on the bodily sensations that accompany these feelings will make them more concrete and, therefore, manageable.
Listen to what you say and how you speak . Persons often phrase sentences to avoid
awareness, particularly awareness of responsibility. When responsibility for behavior is excluded from awareness, a person loses control over that behavior and is unable to change it .
A sentence such as It is scary is an attempt to give up ownership of an emotion . Changing the ownership from it to I helps to increase awareness that it is really I who is scared, not it that is scary. Ownership is accepted and the emotion becomes controllable.
You make me angry is another example of giving up ownership of an emotion . Changing ownership from you to I increases awareness of who is responsible for the anger. E.g. I am angry at you. When an individual accepts responsibility for her own anger, she becomes aware that no one else can cause it . Only she has control. Only she owns the emotion and only she can accept it or change it .
People often explain their own feelings by using the second or third (you or they). E.g., A person may say, You feel as if youre all alone and no one really cares. This is again giving up ownership.
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Saying, cant is another way of eliminating responsibility for an action . There are some
DISTURB ANCES OF ATTENTION The amount of effort exerted in focusing on certain portions of an experience y Distractability inability to concentrate attention y Selective Inattention blocking out of things that generate anxiety
DISTURB ANCES IN SUGGESTI BILITY
legitimate cants but the majority are really wonts . Saying I wont helps the individual become aware of the fact that she also has rights.
Clarify vague feelings of dislike by a process called exaggeration. If you do not like something and do
not really know why, you may be able to determine what it is you do not like through exaggeration. Pretend the disliked object (whether it be a dress, a classmate or a piece of furniture) is directly in front of you . Tell it how you feel as if it were really there. Each time you repeat the statement, exaggerate. Allow yourself to say whatever comes to mind. At the same time, try to concentrate on the feelings.
Another way of increasing awareness is to handle disturbing experiences of the past by bringing them into the present . Relate the experience as if it were happening in the present . At the same time, try to sense the experiences continue to disturb you and you do not know why .
y Complaint and uncritical response to an idea:
Folie a Deux (Folie a trois) communicated emotional illness between two or three persons
Hypnosis artificially induced modification of consciousness
AFFECT Visible manifestation of emotional feelings or tone
DISTURB ANCES IN AFFECT y Inappropriate Affect disharmony of affect and ideation y Pleasurable Affects y Euphoria heightened feeling of psychological well being inappropriate to a pparent event . y Elation air of confidence and enjoyment associated with increased or exaggerated motor activity; often labile and readily shifts to irritability. y Exaltation intense elation with feelings of grandeur y Ecstasy feeling of intense rapture
UNPLEASURA BLE AFFECTS y Depression psychopathologic feeling of sadness y Grief sadness appropriate to a real loss of a loved one y Despair sadness due to a loss of an object
OTHER AFFECTS y Anxiety feeling of apprehension due to unconscious conflict y Fear anxiety due to consciously recognized and realistic danger y Agitation anxiety associated with severe motor restlessness y Panic acute intense attack of a nxiety associated with personality disorganization y Free floating anxiety pervasive fear not attached to any idea y Apathy dulled emotional tone associated with detachment or indifference y Ambivalence co existence of two opposing impulses toward the same thing in the same person at the same time y Depersonalization feeling of unreality concerning one self or ones environment y Derealization distortion of apatial relationships so that environment becomes unfamiliar y Aggression forceful, goal-directed action that maybe verbal or physical and that is the motor counterpart of the affect rage, anger or hostility y Mood Swings oscillations between periods of euphoria and depression or anxiety
SELF ACCEPTANCE Self-acceptance is a regard for oneself with a realistic concept of strengths and weaknesses. y Behaviors of the self-accepting person include the following. Persevering Minimizing weaknesses Seeing reality Trusting and accepting others Continuing growth toward self-actualization and accepting ones own Recognizing behavior Reaching out to others Increasing strengths Learning from mistakes
TYPICAL SIGNS AND SYMPTOMS OF PSYCHIATRIC ILLNESS
CONSCIOUSNESS State of awareness; sensorium is intact and apprehension of external stimuli presented is unimpaired.
DISTURB ANCES IN CONSCIOUSNESS y Confusion disturbance of orientation as to time, place and person y Clouding of Consciousness Incomplete clear mindedness with disturbance in perception and attitudes. y Delirium bewildered, restless, confused, disoriented reaction associated with fear, hallucinations and illusions y Stupor lack of reaction to and awareness of surroundings y Coma profound degree of unconsciousness y Coma Vigil coma in eyes remain open y Dreamy State (Twilight) disturbed consciousness with hallucinations (visual and auditory)
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MOTOR BEHAVIOR / CONATION The capacity to initiate action or son as expressed through his behaviors
DISTURB ANCES OF CONATION y Echolalia psychopathological repeating of words of one person by another pathological imitation of y Echopraxia movements of one person by another y Cerea Flexibility (Waxy Flexibility) state in which patient maintains body position into which he is placed y Catalepsy or Catatonia immobile position is constantly and unconsciously maintained. y Command Automatism automatic following of suggestions y Automatism automatic performance of acts representative of unconscious symbolic activity y Cataplexy temporary loss of muscle tone and weakness precipitated by a variety of emotional states y Stereotype continuous repetition of speech or physical activities frequent opposition to y Negativitism suggestions stereotyped involuntary y Mannerism movements y Verbigeration meaningless repetitions of speech
leading toward a reality-oriented conclusion; when a logical sequence occurs, thinking is normal.
1. 2.
DISTURB ANCES IN THE FORM OF THINKING
Dereism mental activity not concordant with logic or experience Autistic Thinking thinking that gratifies unfulfilled desires but has no regard for reality; somewhat synonymous with deresim (dereistic thinking) y Daydreaming thinking is guided by egocentive wishes and instinctual needs.
1. 2.
DISTURB ANCES ASSOCIATION
IN
THE
STRUCTURE
OF
Neologism new words created or invented by the patient for psychological reasons Word Salad incoherent mixture of words and phrases
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Circumstantiality excessive associated ideas come to consciousness because selective suppression is reduced every detail about the topic discussed but patient eventually gets from starting point to desired goal.
y
Tangentiality inability to have goal-directed associations of thought; patient never gets from starting point to desired goal
OVERACTIVITY y Hyperactivity restless, aggressive, destructive activity, maybe purposeful but simple and nony productive y Tic spasmodic, repetitive motor movements y Sleepwalking (Somnambulism) motor y activity during sleep y Compulsion uncontrollable impulse to perform an act repetitively
Incoherence running together of thoughts with no logical connection, resulting in disorganization Perserveration involuntary repetition of the answer to a previous question when answering a new question; can also be as endless repetition of activity; patient is unable to shift from one task to a nother. Condensation fusion of various concepts into one
y OBSESSIVE IN ACTION y Dipsomania compulsion to drink alcohol y Irrelevant Answer answer that is not in harmony y Egomania pathological self pre occupation with question asked y Erotomania pathological pre occupation with sex DISTURB ANCES IN SPEED OF ASSOCIATIONS y Kleptomania compulsion to steal y Megalomania pathological sense of power 1. Flight of ideas rapid, continuous verbalization so y Monomania pre occupation with a single that there is a shifting from one idea to another subject 2. Clang Associations words similar in sound but not y Nymphomania excessive need for coitus in in meaning call up new thoughts female y Satiriasis excessive need for coitus in male y Blocking interruption in train of thinking; y Trichotilomania compulsion to pull ones hair unconscious in origin y Ritual automatic activity, compulsive in nature y Pressure of Speech voluble speech, difficult to understand EMOTIONAL IN ORIGIN y Volubility (Logorrhea) copious, coherent, logical y Hypoactivity decrease activity or retardation, speech as in psychomotor retardation, allowing of y Looseness of Association frequent speech psychological and physical functioning characteristic in which the point of the clients y Mimicry simple, imitative motion activity of conversation shifts abruptly without any apparent childhood connection y Violence acting out of destructive aggression by assaulting persons or objects in the DISTURB ANCES IN TYPE OF ASSOCIATION environment y Suicide destructive aggression turned inward; 1. Motor Aphasia disturbance of speech due to taking ones own life . organic brain disorder in which understanding remains but ability to speak is lost . THINKING 2. Sensory Aphasia loss of ability to comprehend the meaning of words or use of objects y Goal directed flow of ideas, symbols and associations initiated by a problem or task and 8
Nominal Aphasia difficulty in finding right name 2. for an object 4. Synctactial Aphasia inability to arrange words in proper sequence
3.
Disturbances associated with HYSTERIA Illnesses characterized by emotional conflict, the use
of defense mechanism of conversion and the development of physical symptoms involving the voluntary muscles or special sense organs
DISTURB ANCES IN CONTENT OF THOUGHT a. Hysterial Anesthesia loss of sensory modalities resulting from emotional conflicts b. Macropsia state in which objects appear larger than they are c. Micropsia state in which objects appear smaller than they are
Delusion false belief, not consistent with patients intelligence and cultural background that cannot be corrected by reasoning or logic. y Delusion of Grandeur exaggerated conception of ones importance y Delusion of Persecution false belief that one is 2. Hallucinations false sensory perceptions not being persecuted; often found in litigious clients associated with the real external stimuli y Delusion of Reference / Ideas of Reference false belief that the behavior others portray refer y Hypnagogic Hallucination false sensory or relate directly to the client . perception occurring midway between falling y Delusion of Influence / Ideas of Influence asleep and being awake distorted thoughts about an event that occurred y Auditory Hallucination false auditory because of the clients influence perception y Delusion of Self Accusation False feeling of y Visual Hallucination false visual perception remorse y Gustatory Hallucination false perception of y Delusion of Control false feeling that one is taste being controlled by others y Olfactory Hallucination false perception of y Delusion of Infidelity false belief derived from smell pathological jealousy that ones lover is unfaithful Tactile Haptic Hallucination false perception y y Paranoid Delusion over suspiciousness of touch, such as the feeling of worms under the leading to persecutory delusions skin y Kinesthetic Hallucination false perception of 2. Trend or Preoccupation of Thought centering of movement of sensation, as from an amputated thought content around a particular idea, associated limb (phantom limb) with a strong affective tone 3. Hypochondria exaggerated concern over ones y Lilliputian Hallucination perception of objects health that is not based on real organic pathology as reduced in size 4. Obsession pathological persistence of an irresistible thought, feeling or impulse that cannot be eliminated from consciousness by logical effort; closely related ILLUSION to compulsion wrong perception of real external sensory stimuli 1.
Phobia exaggerated and invariably pathological dread of some specific type of stimulus or situation y y y y y y y y y y y y y y y
1.
Acrophobia dread of high places Agoraphobia dread of open spaces Astraphobia dread of storms, thunder, lightning Algophobia dread of pain Claustrophobia dread of closed spaces Hematophobia dread of blood Monophobia dread of being alone dread of germs and Mysophobia contaminations Nyctophobia dread of darkness Ochlophobia dread of crowds Pathophobia dread of diseases Pyrophobia dread of fire Xenophobia dread of strangers Zoophobia dread of animals or a particular animal Treskardekephobia dread of number 13
PERCEPTION Awareness of objects and relations that follows stimulation of peripheral sense organs Disturbances associated with organic brain disease y Agnosia inability to recognize and interpret the significance of sensory impressions
MEMORY Function by which information stored in the brain is later recalled to consciousness
DISTURB ANCE IN MEMORY y y
y
y y y
y
y
y y
Amnesia partial or total inability to recall past experiences Anterograde Amnesia one that extends forward to cover a period following the apparent regaining of environmental contact Retrograde Amnesia loss of memory extending back over a period prior to the time when the onset occurred; recovery is chronological those memories nearest the injury being the last to return Paramnesia falsification of memory by distortion of recall Fausse Reconnaisance false recognition Retrospective Falsification recollection of a true memory to which the patient adds false details Confabulation unconscious filling of gaps in memory by imagined or untrue experiences that patient believes but that have no basis in fact . De Ja Vu illusion of visual recognition in which a new situation is incorrectly regarded as a repetition of a previous memory Jamais Vu false feeling of unfamiliarity with a real situation one has experienced Hypermnesia exaggerated degree of retention and recall 9
INTELLIGENCE The ability to understand, recall, mobilize and integrate constructively previous learning in meeting new situations DISTURB ANCES IN INTELLIGENCE y
R D
ecent infection (Measles) nvironmental factors hyroid deficiency lcoholic mother H incompatibility amage to brain from various cause
A
IDS
R E T
A
oxemia nherited factor piate intoxication eurological / neurodevelopmental impairment
Mental Retardation organically caused by lack T of intelligence to such a degree that there is I interference with social and vocational O N performance
Categories of Mental Retardation according to WHO
y
Normal Intelligence Quotient (IQ) : above
MILD Borderline MODERATE Educable SEVERE Trainable PROFOUND Custodial Care
81
DIAGNOSIS:
Impaired
intellectual
functioning
and
60 to 80
subnormal
/
y y y
40 to 60
imbecile
/
20 to 40
moron
/
20 and below
idiot
/
MENTAL RETARDATION Mild - IQ level 50-55 to approximately 70 Moderate - IQ level 35-40 to 50-55 Severe - IQ level 20-25 to 35-40 Profound - IQ below 20 or 25
NURSING
PRINCIPLES OF NURSING CARE: Repetition they dont learn in single session Role modeling they learn by examples Restructuring the environment
FOCUS OF EDUCATION: Reading, Writing and Basic Arithmetic
AUTISTIC DISORDER delayed socialization and communication stereotypical behaviors peculiar preoccupations early age of onset (before 30 months) II. PERVASIVE DEVELOPMENTAL DISORDER
AUTISTIC DISORDER
Etiology
Chromosomal abnormalities
Infantile Autism Treatable but not curable More common among boys
genetic factors prenatal factors prenatal substance exposure complications of pregnancy perinatal factors acquired childhood disorders Disorders Usually First Diagnosed During Infancy, Childhood or Adolescence MENTAL HEALTH AND REHABILITATION
Usually diagnosed at age 2 y/o MAIN PROBLEM: Interpersonal functioning Most acceptable cause: Biological factors brain anoxia, intake of drugs Most commonly manifests itself in infancy but may begin as late as 36 months of age. The autistic person is markedly dysfunctional in most realms of human functioning. The aspects of impaired functioning are as follows:
MENTAL RETARDATION: Interpersonal relations a. lack of awareness of the presence of other people; lack of awareness of others emotions or their need for privacy b. no comfort-seeking when distressed mental c. limited or no imitation, social play or capacity to form peer friendships 1.
IQ less than 70 Not a form of mental illness
y
MAIN PROBLEM:
y
functioning AGE OF ONSET:
Inadequate
18 years old
CAUSES:
familial or genetic damage to the embryos developing nervous system while in the uterus injuries from the stress of birth anoxia which occur prenatally, perinatally or postnatally childhood diseases with high fever and toxicity accidents and falls M E N
T
A L
aternal infection exact gestational age is not reached utritional deficiency oxoplasmosis noxia ead poisoning
2. Verbal and non-verbal communication abnormal eye-to-eye contact abnormal speech patterns abnormal conversational ability 3. Activity level and interests a. repetitive body movements b. preoccupation with objects c. very low range of interests adherence to nonfunctional routines or rituals SIGNS AND SYMPTOMS:
resist normal teaching method silly laughing or giggling echolalia acts as deaf 10
no fear of danger insensitive to pain crying tantrums loves to spin objects resists change in the routine not cuddly sustained odd play difficulty interacting with others no eye contact wants block not ball points to anything attachment to inanimate objects
Characterized by writing skills that are significantly
below the expected level for a persons age, intellectual capacity and education as measured by a standardized test . Components include Poor spelling Errors in grammar and punctuations Poor handwriting TERMS USED:
MANAGEMENT OF PRIORITY PROBLEMS:
Spelling disorder Spelling dyslexia
Tantrums involves headbanging (place a helmet on the
ETIOLOGY:
head) Routines provides consistency Communication all vowels
DIAGNOSIS:
NURSING
Unknown History of childs early poor
motor behavior Below normal in intelligent test and above normal in verbal subtest
CARE:
CLINICAL FEATURES: 24-hour monitoring Assistance with normal ADLs depending on the level of impairment Child markedly impaired performance Ensure safety of the environment coordination NURSING
DIAGNOSIS:
Potential for injury
in
motor
TREATMENT:
III. LEARNING DISORDERS
Perceptual motor training Neurophysiological
These disorders include educational areas in which
children may have problems:
1.
MATHEMATICS DISORDER
3. READING DISORDER
Impairment in 4 group of skill Linguistic
techniques of exercise for motor dysfunctions Modified physical education
Characterized By:
Skill
those related to understanding mathematical terms and converting written problems into mathematical symbols Perceptual Skills the ability to recognize and understand symbols and to clusters of numbers Mathematical Skills basic addition, subtraction, multiplication and division and following sequences of basic operations Attentional Skills copying figures correctly and observing operational symbols c orrectly
Impaired ability to recognize words Slow inaccurate reading Poor comprehension ETIOLOGY: Theories / Studies Dyslexia and birth during winter months
Abnormal symmetries in the temporal or parietal lobes of persons with reading disorders Association to nutritional deficiency EPIDIMIOLOGY: 6% of school age children who are not Association to psychiatric disorders cause and effect MR DIAGNOSTIC CRITERIA: ETIOLOGY:
Multifactoral Reading achievement is substantially below the expected
Maturational Cognitive Emotional Socio-economic DIAGNOSIS:
History
arithmetic subjects Standardized arithmetic test
of
difficulties
chronological age, measured intelligence and ageappropriate education It interferes with academic achievement or activities of daily living If a sensory deficit is present, the reading difficulties are with in excess of those usually associated with it . CLINIC AL FEATURES;
CLINICAL FEATURES:
Poor performance in handling Omissions, additions and distortions of words basic number concepts such as counting and adding even Errors in oral reading one digit . Speed is slow with minimal comprehension Can copy but poor spellers TREATMENT: Remedial education TREATMENT: 2. DISORDER OF WRITTEN EXPRESSION Remedial Education 11
Psychotherapy
Includes many disorders in which developmentally
expected speech sounds for the patients and intelligence are incorrect or delayed. Errors in sound production Substitution of one sound for another Omission of such sounds as fi nal consonants
IV. COMMUNICATION DISORDERS EXPRESSIVE LANGUAGE DISORDER This category includes the criterion of lack of correlation
between a standardized test of expressive language and the persons nonverbal IQ, determined by an individually administered test . The expressive language score is substantially lower than the IQ score. In addition, the disturbance significantly interferes with academic achievement or ADLs.
Unknown but can be related to: ETIOLOGY: Perinatal problems Hearing impairment Structural abnormalities
ETIOLOGY:
A. Disturbances in the normal fluency and time patterning of speech (inappropriate for the individual age) characterized by frequent occurrences of one or more of the following :
Not known
DIAGNOSIS: Presence of makedly below-age-level verbal or
sign language, accompanied by a standardized expressive verbal tests.
low
score
DIAGNOSTIC CRITERIA:
on
CLINICAL FEATURES: 18 months child fail to echo even single sounds like mama Age 4 can speak short phrases but forget old words as they learn new ones
COMPLICATIONS: Emotional problems of poor self-image, frustration and depression . In contrast to patient with pervasive
Sound and syllable repetition Sound prolongation Interjections Broken words
Audible or silent blocking (filled or unfilled pauses in speech) Circumlocutions (words substitution to avoid problematic words) Words produced with an excess of physical tension Monosyllabic whole-word repetitions B. The disturbance in fluency interferes with academic or
occupational achievement or with social communication
disorders. C. If a speech-motor or sensory deficit is present, the TREATMENT:
Language Therapy
speech difficulties are in excess of those usually associated with those problems.
MIXED RECEPTIVE EXPRESSIVE LANGUAGE DISORDER PHASE 1: This category includes the criterion that the score
received on a standardized test of receptive language does not correlate with standardized, individually administered IQ tests. The deficit also interferes years significantly with academic achievement or A DLs. - chronic ETIOLOGY: Not known DIAGNOSIS: Presence of a markedly below-age-appropriate level of
- occurs preschool period
- episodic PHASE 2:
-
elementary
school
PHASE 3:
- 8 yrs old and above - comes and goes largely in response to specific situations PHASE 4:
- late adolescence and
comprehension of verbal sign language with intact age- adulthood appropriate nonverbal intellectual capacity. Language difficulties by standardized receptive language TREATMENT: test The absence of pervasive developmental disorders Distraction Suggestion confirms the diagnosis. Relaxation CLINICAL FEATURES: 4. STUTTERING Significant impairment in both language comprehension and language expression This category includes the criterion that speech patterning is inappropriate for the persons age and is TREATMENT: characterized by frequent repetitions, sound prolongations, broken words, or words produced with an excess of tension. The disturbance interferes with Speech and language therapy Psychotherapy academic achievement or ADLs. 3. PHONOLOGICAL DISORDERS
V. MOTOR SKILLS DISORDER
The criterion that determines this category is a consistent The disorder in this category is DEVELOPMENTAL failure to use developmentally expected speech sounds. COORDINATION DISORDER. In this condition, the person
is significantly unable to perform academic functions or ADLs requiring motor coordination at level similar to 12
other children or adults of the same age. This condition is not caused by a physical disorder, such as cerebral palsy, hemiplegia or muscular dystrophy ETIOLOGY:
Unknown
DRUG OF CHOICE: Methylphenidate (Ritalin)
to increase attention span given after meals / 6 hours before bedtime growth suppression
DIAGNOSIS:
SIDE EFF ECTS:
history of childs early poor motor behavior below-normal in intelligent test and above-normal in verbal subtest .
2. CONDUCT DISORDER
CLINICAL FEATURES:
childs markedly coordination
impaired
performance
in
motor
insomnia and growth retardation
A child with this disorder shows a repeated, persistent pattern of behavior that demonstrates little recognition or consideration of other peoples basic rights or that violates social norms expected of a child of his or her age. The diagnostic criteria for conduct disorder require that at least three of the following symptoms be present
TREATMENT: Perceptual motor training Neurophysiological
techniques of exercise for motr dysfunctions Modified physical education ATTENTION DEFICIT AND DISRUPTIVE BEHAVIOR DIS ORDERS VI.
Often bullies, threatens or intimidates others Often initiates physical fights Has used weapon in more than one fight Has been physically cruel to a nimals or people Has stolen with confrontation of a victim Has forced someone into sexual activity Has deliberately destroyed others property Has deliberately set fires Has broken into someone else house, building or
ATTENTION DEFICIT / HYPERACTIVITY DISORDER car Has stolen items or forged without confrontation (ADD) The child with this disorder displays a majority of the of a victim following behaviors: Has run away from house at least twice Often stays out all night despite parental MAIN PROBLEM: Inattention, Hyperactivity and prohibitions Impulsivity Is frequently truant
CAUSES:
ETIOLOGY:
Neurologic
Parental factor faulty child rearing practices
impairment Prenatal trauma Early malnutrition Frontal lobe hypoperfusion Use of drug SIGN AND SYMPTOMS:
- chaotic home conditions Sociocultural factors socioeconomic deprived children Psychological factors brought up in chaotic and negligent condition Neurobiological factors decreases noradrenergic functioning Child abuse and maltreatment
D E
ifficulty remaining sitted easily stimulated by extraneous stimuli TREATMENT:
F
idgetting nterrupt / intrudes on others hild exhibits hyperactivity ndulges in destructive behavior alks excessively
I C I T
Biopsychosocial factors
Environmental structure with consistent rules Individual psychotherapy Medication
3. OPPOSITIONAL DEFIANT DISORDER
Distractability Difficulty waiting turn, following instructions, sustaining
This is a disturbance that has been present for at least 6 months. The symptoms should be present more
attention, remaining task-focused and playing quietly Blurting out answers prematurely Inattention Excessively losing things Engaging in dangerous activities
frequently than they are in other children of the sa me age. The disturbance in behavior significantly impairs functioning in school, At home and social settings . The symptoms include:
These behaviors begin to manifest themselves before age
7, and they are not related to a pervasive personality disorder NURSING
DIAGNOSIS:
Potential for injury
PRINCIPLE OF NURSING CARE: Nutrition and safety foods on the run (eg sandwich)
Frequent episodes of loss of temper Arguing with adults Defying or refusing adults requests or rules Deliberately annoying others Blaming others for own mistakes Becoming easily aggravated Becoming resentful or angry Swearing Being spiteful or vindictive 13
VII . FEEDING
AND EATING DISORDERS NURSING
CARE OF CLIENTS WITH EATING DISORDERS
PIC A Supportive nursing attitudes and behaviors, including an
An eating disorder seen most frequently in toddlers between 12 and 24 months of age. The youngster persistently eats non-nutritive substances such as paint, sand, plaster and so on. It usually disappears spontaneously .
emphatic approach that avoids nurses disbelief or displeasure regarding the appearance or behavior of the client Observe for signs of suicidal risk Encourage discussion of the clients feelings
RUMINATION DISORDER
5. BULIMIA NERVOSA
Condition in which an infant, usually between 3 and
12
months of age, repeatedly regurgitates partially digested food without nausea or other GI illness. In order to meet the criteria for this diagnosis, the condition must follow a period of normal functioning and occur for 1 month. The infant experience weight loss or fails to gain weight at a normal rate for his age . FEEDING DISORDER OF INFANCY OR EARLY CHILDHOOD
Occurs predominantly in adolescent females. The person indulges in eating binges of high calorie food. She is aware of the abnormal eating patterns. The binge eating may be pleasurable, but it is followed by a depressed mood. The binge-eating episode ends abruptly with abdominal pain, self-induced vomiting or sleep. The young woman repeatedly attempts to reduce weight by self-induced vomiting, laxatives or diuretics or severely restricted diets. She is fearful that she will not be able to stop eating voluntarily.
Category for eating disorder that do not meet the criteria for the above disorders. E.g. If a child experiences severe
inge eating B emotional trauma that involves some aspect of eating . U nder strict dieting Such as being unreasonably disciplined for not L acks control of binge eating completely eating all the food on the plate, he may nduced vomiting I demonstrate some aberration of normal eating behavior inimum of 2 binge eating M at the time or during a later stage of development episode a week for 3 months ncrease / persistent concern of I 4. ANOREXIA NERVOSA body size / shape A buse of diuretics and laxatives A condition seen primarily in females between 12 and 18 years of age. The young woman develops a strong fear of becoming obese, that she limits food intake and does not VIII. TIC DISORDERS decrease as weight loss occurs The disorders included in this category all include an abnormality of gross motor movement MOST COMMON CAUSE: called tics. A tic is a rapid, involuntary movement of a Psychological Factors: related group of muscles or the involuntary production of - Individual factors (conflict about words or noises. growing up) - Parental factors (domineering parents) A. TOURETTES DISORDER - Sociocultural Occurs before the age of 18 and usually MAIN SIGN: Fear of gaining weight has a chronic lifelong course. The person experiences multiple vocal and motor (body) tics in many muscle A menorrhea groups . The condition must be present over 1 year in N o organic factor account for order to be diagnosed as Tourettes disorder. weight loss O bviously thin but feels fat ETIOLOGY: R efusal to maintain normal body weight Genetic pigastric discomfort is common E Neurochemical and neuroantomical factors X symptom (peculiar symptom 0 Dopamine system involvement loves to hide foods ntense fear of gaining weight I TREATMENT: Pharmacologic Agents A lways thinking of foods Dopamine Antagonist Haloperidol .25 and .5 mg. Body image disturbance NURSING DIAGNOSES: esteem B. CHRONIC MOTOR OR VOCAL DISORDER Self disturbance Ineffective Includes the presence of either motor or individual coping vocal tics, but not both, in someone under the age 18. They occur very frequently for a period of over a year . PRINCIPLES OF NURSING CARE: There is no other neurologic c ondition causing the tics Monitor patients weight Stay with the patient 30 minutes 1 hour after meals Public place Encourage oral hygiene Behavior modification
IX. ELIMINATION DISORDERS
A. ENCOPRESIS
14
A disorder in which a child over 4 years of age passes feces voluntarily or involuntarily in socially acceptable places at least once a month.
Individual psychotherapy
B. ENURESIS
PHARMACOTHERAPY:
Family education Family Therapy Tryclic
and
Tetracyclic
-
antidepressants A condition in which a child at least 5 years voids into clothing or bed during the daytime or nighttime. The child B. SELECTIVE MUTISM has at least two events per week for at least three consecutive months. A condition in which a person has the ability to speak a nd understand language but consistently fails to talk in one X. OTHER DISORDERS OF INFANCY AND CHILDHOOD or more major social situations A. SEPARATION ANXIETY DISORDER
ETIOLOGY: History
The youngster experiences anxiety at or near panic level when separated from a major attachment figure. The
reaction exceeds what would be expected of a child of his age. The child demonstrates clinging behavior. Physical signs of anxiety appear i.e. stomachaches, nausea, vomiting, diarrhea, headaches, dizziness and palpitations. Their separation form significant others may cause morbid fears about death or accidents that might happen to themselves of their parents. ETIOLOGY: Psychosocial factors Learning factors
Genetic factors DIAGNOSTIC DIS ORDER:
CRITERIA
FOR SEPARATION
of delayed onset of speech abnormalities that may be contributory.
or
speech
DIAGNOSTIC CRITERIA FOR SELECTIVE MUTISM Consistent failure to speak in specific social situations
despite speaking in other situations The disturbance interferes with educational or occupational achievement or with social communication The duration of the disturbance is at least 1 month (not limited to the first month of school) The failure to speak is not due to a lack of knowledge of, or comfort with the spoken language required in the social situation. The disturbance is not better accounted for by a communication disorder (eg stuttering) and does not occur exclusively during the course of a pervasive ANXIETY developmental disorder, schizophrenia, or other psychotic disorder.
A. Developmentally inappropriate and excessive anxiety TREATMENT: concerning separation from home or from those to whom the individual is attached, as evidenced by three (or Multimodal Approach more) of the following: Individual Behavioral Recurrent excessive distress when separation from whom Family interventions or major attachment figures occurs or i s anticipated Individual Psychotherapy Persistent and excessive worry about losing, or about possible harm befalling, major attachment figures C. REACTIVE ATTACHMENT DISORDER OF Persistent and excessive worry that an untoward event INFANCY OR EARLY CHILDHOOD will lead to separation from a major attachment figure Persistent reluctance or refusal to go to school or This condition affects the childs ability to bond with or elsewhere because of fear of separation attach to others in a trusting manner. The child either is Persistently and excessively fearful or reluctant to be aloof and uninterested in social relations or is alone or without major attachment figures at home or inappropriately familiar with unknown people . without significant adults in other settings Persistent reluctance or refusal to go to sleep without ETIOLOGY: grossly pathogenic care of the infant being near a major attachment figure to sleep away from DIAGNOSIS AND CLINICAL FEATURES: home Repeated nightmares involving the theme of separation Repeated complaints of physical symptoms (such as Non-organic failure to thrive headaches, stomachaches, nausea or vomiting) when Infants look sad, unhappy, joyless and miserable separation from major attachment figures occurs or is Infants appear frightened and watchful, with a radarlike anticipated gaze B. The duration of the disturbances is at least 4 weeks CRITERIA: C. The onset is before age 18 D. The disturbance causes clinically significant distress or A. Markedly
disturbed and developmentally impairment in social, academic or other important areas inappropriate social relatedness in most contexts, of functioning beginning before age 5 years as evidenced by either (1) or E. The disturbance does not occur exclusively during the (2): course of pervasive developmental disorder, schizophrenia or other psychotic disorder and in, Persistent failure to initiate or respond in a adolescents and adults, is not better accounted for by developmentally appropriate fashion to most social panic disorder with agoraphobia. interactions as manifested by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses. TREATMENT: Multimodal Treatment Approach 15
Diffuse attachments as manifested by indiscriminate
sociability with marked inability to exhibit appropriate selective attachments
DISORDER ATTENTION-DEFICIT /HYPERACTIVITY (ADHD) B. The disturbance in criterion A is not accounted for Inattention solely by developmental delay (as in mental retardation) Hyperactivity-impulsivity and does not meet a criteria for a pervasive Mixed developmental disorder the onset is not later than 7 years of age treatment is through C. Pathogenic care as evidenced by at least one of the psychostimulants, Methylphenidate (Ritalin), Pemoline following: (Cylert) Persistent disregard of the childs basic emotional needs the Feingold diet for comfort, stimulation and affection OTHER CHILDHOOD DISORDERS Persistent disregard of the childs basic physical needs Repeated changes of primary caregiver that prevent Pervasive developmental disorders Disruptive disorders formation of stable attachments Learning disorders D. There is a presumption that the care in criterion C is Communication disorders Tic disorders ; Tourettes Syndrome responsible for the disturbed behavior in A. Elimination disorders TREATMENT: The Nurses Role in Childhood Mental Disorders Psychosocial support services Help the parents accept a diagnosis and plan a realistic approach to the situation Hiring a homemaker Adequate housing help shape family members and other peoples attitudes Improve financial status towards them and accept them help in activities of daily living Psychotherapeutic interventions standards of acceptable behavior within the ability of the Individual psychotherapy child should be provided he should be taught to seek help when in difficulty to Psychotropic medications Family or marital therapy resist frustration and achieve emotional control create a therapeutic environment Educational counseling services Close monitoring of emotional and physical well-being VICTIMS OF ABUSE AND VIOLENCE Crime D. STEREOTYPIC MOVEMENT DISORDER Phases Of Recovery From Trauma Impact phase Involves repetitive intentional behaviors such as head Recoil Phase banging, body weaving, self-biting and hand shaking or Reorganization waving. The activity either causes or risks physical injury or interferes with ADLs. Rape and sexual assault ETIOLOGY:
RAPE TRAUMA SYNDROME Sleep disturbances, nightmares
Associated with normal development Maternal neglect or abuse Associated with dopamine activity.
loss of appetite fear, anxieties, phobias and suspicions decreased activities and motivation disturbance in relationships DIAGNOSTIC CRITERIA: self-blame, guilt and shame lowered self-esteem, worthlessness 1. Repetitive, seemingly driven and nonfunctional motor somatic symptoms Nursing Interventions : behavior Behavior markedly interferes with normal activities or Reaffirm that they are worthwhile persons with dignity results in self-inflicted bodily injury that requires medical and rights, who id not cause and deserve the ra pe treatment convey to them that their anger is natural If Mental retardation is present, the stereotypic or self- move at the victims pace and be supportive injurious behavior is so of sufficient severity to become a always give rationales and descriptions for any focus of treatment procedures The behavior is not better a ccounted for by compulsion, a protect the patients rights tic, a stereotypy that is a part of a pervasive developmental disorder, or hair pulling CARE OF THE CAREGIVER The behavior is not due to the direct physiological of a Caregivers substance or a general medical condition Role Strain constant fatigue unrelieved by rest The behavior persists for 4 weeks or longer. use of alcohol/ other substances TREATMENT: social isolation inattention to personal needs Provide a well balanced psychosocial environment Psychotherapy Nursing Interventions : Psychopharmacology Refer caregivers to knowledgeable health professional who can provide information, support and assistance provide outlets for dealing with caregivers feelings 16
help them seek and accept assistance from other people provide or agency and not wait until they are exhausted
a ubiquitous emotional state that is experienced when the self-identity or essential values are threatened but has no specific object . The feeling state is characterized by a subjective sense of dread, apprehension, threat, failure, helplessness or impending disaster; by a sense of losing control, becoming disoriented, or committing a destructive act; or by a fear of sudden death.
Is
In contrast, fear is a feeling of apprehension or
disaster in response to a specific object .
Well and ill people experience both feelings
y
Normal Anxiety The degree of arousal appropriate to a situation, as validated bu others familiar with the situation
y
State Anxiety Refers to the temporary state the person is in when the anxiety episode occurs and sympathetic arousal results.
y
Trait Anxiety Refers to habitual or chronic anxiety or arousal Prone to attacks of acute, severe anxiety
y
Psychic Anxiety Refers to an emotional state and includes muscular tension and worry
y
Somatic Anxiety Refers to use of somatic or physical complaints to discharge feelings and mental distress
y
Morbid Anxiety anxiety or panic that is Severe incapacitating, causing the person to be unable to function effectively
Anxiety is a word that has many meanings: y Affect - vague, uncomfortable feeling
for
a
personal
y Etiology cause of behavior: for example, overeating or withdrawal y Motivator drive or reason for behavior: for example, anxious or eager to participate in an activity y Personality state or response specific response to specific situational stimuli : for example, a job or school y Personality trait inherent and habitual mode of responding y Emotional disorder free floating, nonsituational, generalized, and nonspecific distress, diagnosed as anxiety disorders, anxiety neurosis or anxiety reaction
DEMENTIA organic loss of mental functions causing progressive loss of cognitive and other higher intellectual functions; slow and insidious onset
ANXIETY A feeling of severe discomfort or dread that arises from within the individual in response to a threat, which is less visible and definable than fear, which has a visible object or trigger.
support
MANIFESTATIONS OF ANXIETY y Physiologic y Psychological y Intellectual/ Cognitive LEVELS OF ANXIETY y Mild (+1) Attentive, alert, perceptive to variety of stimuli y
Moderate (+2) Impatient, Irritable, forgetful, demanding, crying, angry
y
Severe (+3) Alarm stage changes intensify and stage of resistance may progress to stage of exhaustion Sense of helplessness Mood changes Disorientation, confusion, hallucination and delusions may be present
y
Panic (+4) Behavior focused on finding relief : may scream, cry, pray, trash limbs, run, hit others, hurt self Often easily distracted, cannot attend or concentrate No learning, problem solving, decision making or realistic judgements
COPING RESPONSES/COPING MECHANISMS DEFENSE MECHANISMS y
1.
2. 3. 4. 5. 6. 7. 8.
9. 10.
SPECIFIC DEFENSE MECHANISMS 11. Conversion 12. Substitution 13. Sublimation 14. Displacement 15. Reaction formation 16. Undoing 17. Projection 18. Regression 19. Fixation 20. Fantasy
Repression Suppression Denial Rationalization Intellectualization Isolation Symbolization Compensation Identification Introjection
DEFENSE MECHANISMS Defense Mechanisms are unconscious and automatic mental maneuvers that decrease the unpleasant feelings and anxiety. They 17
function to protect the ego from overwhelming anxiety. Mostly, they operate on an unconscious level and occur in everyday life. Its formation begins in infancy .
Everyone uses defense mechanisms at one or
another. When overused, ineffective or ego defeating.
they
y
become
y COMPENSATION Making up for a perceived deficiency by strongly emphasizing a feature that he regards as an asset .
y
A businessman perceives his small stature negatively. He tries to overcome this by being aggressive, forceful and controlling in business dealings.
y DENIAL of disagreeable realities by Avoidance ignoring or refusing to recognize them, probably simplest and most primitive of all defense mechanisms.
y
y
y
A woman who was diagnosed to have breast cancer tells her husband that no one has discussed the laboratory results with her.
DISPLACEMENT Shift of emotion from a person or object to another usually neutral or less dangerous person or object . A boy who has just been punished by his mother for drawing on his bedroom walls shouts at his younger brother. IDENTIFICATION Trying to become like someone admired by taking on thoughts, mannerisms or tastes of that individual.
y
y
y
Sally has her styled like similarity to her young English teacher whom she admires.
INTELLECTUALIZATION Excessive reasoning or logic is used to avoid experiencing disturbing feelings.
A woman avoids dealing with her anxiety in shopping malls by explaining that she is saving the frivolous waste of time and money by not going into them.
y
y
INTROJECTION Intense type of identification in which a person incorporates qualities or values of another person or group into his own ego structure. It is one of the earliest mechanisms of the child; important information of conscience. Eight-year-old Jimmy tells his 3-year old sister, Dont scribble in your book of nursery rhymes . Just look at the pretty pictures thus expressing his parents values to his little sister.
ISOLATION Splitting off of emotional components of a thought which maybe temporary or long term.
PROJECTION Attributing ones thoughts or impulses to another person A young woman who denies she has sexual feelings about a co -worker accuses him without basis of being a flirt and says he is trying to seduce her. RATIONALIZATION Offering a socially acceptable or apparently, logical explanation to justify or make acceptable otherwise unacceptable impulses, feelings, behaviors and motives . John fails an examination and complains that the lectures were not well organized or clearly presented. REACTION FORMATION Development of conscious attitudes and behavior patterns that are opposite to what one really feels or would like to do. A married woman who feels attracted to one of her husbands friends treats him rudely
REGRESSION Retreat in face of stress to behavior characteristics of any earlier level of development . Four-year-old Nicole, who has been toilet-trained for over a year, begins to wet her pants again when her new baby brother is brought home from the hospital. REPRESSION Involuntary exclusion of a painful or conflictual thought, impulse or memory from awareness. Mr. R does not recall hitting his wife when she was
pregnant y
A second year medical student dissects a cadaver for her anatomy course without being disturbed by thoughts of death.
SUBLIMATION Acceptance of a socially approved substitute goal for a drive whose normal channel of expression is blocked. Ed has an impulsive and physically aggressive nature. He tries out for the football team and
becomes a star tackle. y
y
SUPPRESSION counterpart of repression, Conscious intentional exclusion of material from consciousness. A young man at work finds he is thinking so much about his date that evening that it is interfering with his work . He decides to put out his mind until he leaves the office for the day. UNDOING Act or communication that partially negates a previous one. 18
NON-THERAPEUTIC COMMUNICATION TECHNIQUES y Giving advice y Rejection y Directly agreeing or disagreeing with the client y Directly expressing either approval or disapproval y Belittling the clients feelings y Giving false reassurance y Requesting or even demanding an explanation y Defending y Stereotypical responses y Changing the topic
THEORETICAL FRAMEWORK OF CARE Medical-Biological Model Psychoanalytical Model Interpersonal Model Behavioral-Cognitive Model Social Model
Larry makes a passionate declaration of love to Sue
on a date. On their next meeting, he treats her formally and distant . CRISIS Maturational/ Developmental Crisis Situational Crisis/Crisis Intervention
COPING WITH LOSS, GRIEVING AND DEATH y Developmental Concept of Death Stages of Grieving (Kubler-Ross) 1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance THERAPEUTIC USE OF THE SELF y Self-Awareness 1. Introspection 2. Discussion 3. Self-disclosure
THERAPEUTIC NURSE-CLIENT RELATIONSHIP y Nurse-Client Relationship
Phases of the Nurse-Client Relationship 1. Initial or Orientation Phase 2. Working Phase 3. Termination or Resolution
THERAPEUTIC COMMUNICATION y Modes of Communication 1. Verbal 2. Non-verbal 3. Meta-communication
THERAPEUTIC COMMUNICATION y GENERAL GUIDELINES: y Here and now rather than the past y what rather than why y orientation and presentation of reality y description rather than judging with actual client behaviors and nursing observations rather than giving inferences y maintenance of biologic integrity y nursing interventions rather than roles designated to other health team members y sharing information and exploring alternatives rather than giving actual solutions
THERAPEUTIC COMMUNICATION TECHNIQUES y Giving Information y Giving Broad Openings y Reflecting y General Leads y Verbalizing observations y Clarifying y Validating y Paraphrasing y Summarizing y Requesting descriptions/comparisons y Suggesting collaboration y Offering Self y Presenting Reality y Silence
PSYCHOPHARMACOLOGY y PRINCIPLES OF PSYCHOPHARMACOLOGY A medication is selected based on the clients target symptoms many psychotropic drugs must be given in adequate dosages for a period of time before their full effect is realized the dosage of medication is often adjusted to the lowest dose effective for clients elderly persons require lower dosages of medication to produce therapeutic effects and it may take longer for a drug to achieve its full therapeutic effect psychotropic drugs are often decreased gradually rather than abruptly discontinued care is essential to ensure follow-up compliance with the medication regimen, to make needed adjustments in dose and manage side effects
ANTI-PSYCHOTICS PHENOTHIAZINES like chlorpromazine(thorazine), thioridazine(mellaril), fluphenazine(prolixin), trifluoperazine(stelazine), perphenazine (trilafon) haloperidol (serenace), loxapine
clozapine(Clozaril),risperidone(Risperdal), olanzapine(Zyprexa),quetiapine(Seroquel), sertindole( Serlect), ziprasidone(Zeldox)
SIDE EFFECTS : 1. Extrapyramidal Symptoms ( EPS) y acute dystonia y pseudoparkinsonism y akathisia 2. Neuroleptic Malignant Syndrome (NMS) 3. Tardive Dyskinesia 4. Anticholinergic effects 5. Endocrine changes 6. Agranulocytosis
ANTIPARKINSON DRUGS Dopaminergic drugs include : carbidopa-levodopa (Sinemet), Amantadine (Symmetrel), bromocriptine (Parlodel), pergolide (permax), selegiline(Eldepryl)
ANTICHOLINERGICS USED ARE : 19
benztropine (Cogentin), biperiden (Akineton), Trihexyphenidyl (Artane), diphenhydramine (Benadryl)
ANTI-DEPRESSANTS 1. Tricyclic antidepresants (TCAs) includes: (Tofranil), Amitriptyline imipramine (Elavil), desipramine(Norpramin), Bupropion amoxapine (Asendin), (Wellbutrin), (Sinequan), Doxepin Nefazodone(Serzone), Trazodone (Desyrel), trimipramine (Surmontil), Venlafaxine (Effexor)
be manifested by cognitive impairment or may be the cause of a decline in mental status. Can be identified by feelings of sadness, hopelessness and worthlessness and a decreased interest in activities.
TYPES OF DEPRESSION y Mild depression Lasts less than 2 weeks Feeling sad Alterations in sleep pattern Disinterest Substance abuse y
2. Monoamine oxidase inhibitors (MAOIs) Isocarboxacid (Marplan), Phenelzine( Nardil), tranylcypromine(parnate) moclobemide M ( anerix)
Moderate depression Persist overtime Sense of change Low sel-esteem Intense anxiety and anger Diurnal variation
3.
Rumination Suicidal thoughts
ANTIMANIC standard drug of choice is Lithium Carbonate (Quilonium, Eskalith)
Selective serotonin reuptake inhibitors (SSRIs)Includes: Sertraline Paroxetine(Seroxat,Paxil), (Zoloft), Fluvoxamine(Luvox), Fluoxetine (Prozac) y
Valproic acid (Depakote) or carbamazepine (Tegretol)
ANTIANXIETY AGENTS Clonazepam( Klonopin), diazepam(Valium), Lorazepam(Ativan), Triazolam(Halcion), chlordiazepoxide(Librium) clorazepate(Tranxene)
ELECTROCONVULSIVE THERAPY Induction of grand mal seizures through the application of electrical current to the brain to effect behavioral changes the side effects are confusion and temporary memory loss
PSYCHOTHERAPY y BEHAVIORAL MODIFICATION systematic desensitization; ignoring the behavior; time out; token economy; aversion
PSYCHOLOGICAL TESTING Diagnostic Statistical Manual Fourth Edition (DSM IV)
y
MOOD DISORDERS DEPRESSION A functional disorder of mood that is not linked to with aging. The depression maybe precipitated by losses related to aging. Can
MANIFESTATIONS: depressed mood anhedonia appetite disturbance with significant change in weight psychomotor disturbance sleep disturbance fatigue or energy loss (anergia) feelings of worthlessness or excessive or inappropriate guilt diminished concentration and indecisiveness recurrent thoughts of death and suicidal thoughts ETIOLOGY: biological theories of depression psychological theories
NURSING INTERVENTIONS: offer sincere concern and empathy bolster self-esteem involve patients in activities in which they can experience success recognize dependence respond to anger therapeutically spend time with withdrawn patients never reinforce delusions or hallucinations
BIPOLAR
MILIEU THERAPY y EVALUATING MENTAL FUNCTIONING Psychiatric History MENTAL STATUS EXAMINATION ABCs of assessment (appearance, behavior, communication pattern)
Severe depression Intense Guilt and worthlessness Flat affect Decreased speech Self destructive thoughts Poor concentration Delusions and hallucinations
Anorexia Somatic complaints Increase abuse of substance
y
DISORDERS (MANIC-DEPRESSIVE) MANIC EPISODES Inflated self-esteem or grandiosity decreased need for sleep very talkative (pressured speech) flight of ideas or subjective feeling that thoughts are racing reduced ability to filter out external stimuli ; easily distractible 20
increased number of activities with increased energy and psychomotor agitation
ETIOLOGY: Psychodynamic theories Biological theories
NURSING INTERVENTIONS: Provide for patients physical safety and safety of those around him use short simple sentences to communicate provide the client with a list of daily activities ensure that nutritional and fluid balance meals are met channel clients need for movement into socially acceptable motor activities
SPECIFIC PROBLEMS: Altered thought process Risk for self harm Activity intolerance Altered nutrition Sleep pattern disturbance Maladaptive Behaviors MALADAPTIVE BEHAVIOR Inability to act or react to a particular condition or situation in an appropriate manner Very complex Can develop at any time from infancy through old age Stress and problems in any area can contribute to maladaptive behavior Reaction of an individual to stress y
y
Anxiety attacks may be brought on by even mild stress, or they may occur for no apparent reason The person cannot relax Becomes restless and irritable and continually over-reacts to stressful situations. May experience loss of appetite, heart palpitations, and increased respirations If anxiety is severe or prolonged, symptoms intensify and the person may need to be hospitalized Anxiety attacks may be caused by repressed feelings of anger and frustration
SYMPTOMS: Nausea Anorexia Dry mouth Diarrhea Tachycardia Difficulty in swallowing Nervous stomach SUBTYPES: PHOBIC DISORDER
PHOBIA Abnormal excessive fear of a specific situation or object PHOBIA Androphobia Cynophobia Gamophobia Hodophobia Kainophobia Kakorrhaphiophobia Laliophobia Necrophobia Olfactophobia Ophidiophobia Pharmacophobia Phasmophobia Ponophobia Traumatophobia Vaccinophobia
NORMAL Has social, clinical, moral and statistical aspect Includes a wide range of acceptable behaviors Concerned with actions that fit the social rules
FEAR OF man dogs marriage travel change failure speaking death odor snakes medicine ghosts work injury vaccination
y ABNORMAL To many people, weird or bizarre
PSYCHOLOGICAL DISORDERS Emotional disturbances characterized by maladaptive behavior aimed at avoiding anxiety Formerly classified as PSYCHONEUROSES OR NEUROSES Represents a poor adaptation to stress, there is a crippling of personality growth May occur at any time during the life c ycle A person with psychological disorder has contact with his environment Has the same view of reality as does the normal person However, lacks awareness and so lacks control over his behavior A N X I E T Y D I S O R D E R Characterized by anxiety that is proportionate to the stresses of daily living May occur periodically or it may be constant
OBSESSIVE COMPULSIVE DISORDER Often caused by repressed thoughts and feelings An attempt to relieve anxiety and is another example of converting anxiety into other symptoms
OBSESSION Persistent, recurring thought or feeling that is overpowering
COMPULSION Irresistible urge to engage in a behavior Maybe in the form of frequent handwashing or shoplifting The behavior is engaged in because it lowers anxiety, when anxiety level builds up, the obsessive-compulsive act is performed again. This process is cyclic and may occupy the persons entire life 21
SOMATOFORM DISORDERS y MAJOR CHARACTERISTICS: Patients have physical symptoms for which there is no known organic cause or physiologic mechanism Symptoms are very real to the patient; serve to prevent or relieve anxiety. Patients are not in control of their symptoms which are unconscious and involuntary Patients repeatedly seek medical diagnosis and treatment, even though they have been told that there is no known physiological or organic evidence to explain their symptoms or disability Persons with somatoform disorders often appear to be needy and dependent on others Defense mechanisms used: repression, denial displacement CLASSIFICATION: 1. SOMATIZATION DISORDER SOMATIZATION DISORDER Is the expression of an emotional turmoil or conflict through a physical symptom with a loss or alteration of physical functioning which is not under voluntary control and is not otherwise explained by a known physical disorder Refers to the persisting abnormal autonomic discharge caused by anxiety that is experienced as a physical symptom CHARACTERISTICS: Usually begins before the age of 30; characterized by multiple somatic complaints involving various body systems . Patients see many physicians through the years and may even have exploratory and unnecessary surgical procedures (+) Impairment of social and occupational functioning Complaints or impairment are in excess of what is expected Symptoms / complaints tend to be vague and reported in exaggerated or histrionic manner Patients maybe anxious or depressed, feel nervous, have sleep disturbances and experience suicidal ideation because they experience hopelessness about ever getting better 4 pain symptoms in 4 different bodily sites (e.g. head, chest, pain during coitus or urination) 2 GI symptoms occur other than pain (nausea, diarrhea, intolerance to different foods) 1 sexual or reproductive symptom other than pain (erectile or ejaculatory problem, irregular menses, excessive menstrual bleeding) Other pseudoneurological symptom or deficit that suggest a neurological disorder (blindness, deafness, paralysis, seizures, difficulty in swallowing or breathing and dissociative symptom such as amnesia)
y CHARACTERISTICS: Preoccupation with pain for at least 6 months is the sole symptom Pain in one or more areas of the body that is severe enough to seek treatment causes impairment in functioning or significant distress Location or complaint of pain does not change, unlike the complaints voiced in somatization disorder there is a physiological Sometimes disorder but the amount of pain or impairment is greatly exaggerated or out of proportion Doctor shoppers; may use analgesics excessively without experiencing any relief from their pain
3.
HYPOCHONDRIASIS (HYPOCHONDRIAC NEUROSIS) y HYPOCHONDRIASIS Is the expression of excessive anxiety about physical concerns and fears of deteriorating health As feelings of isolation, loneliness, and lack of gratification with other people increase, the hypochondriachal person begins to turn all of his / her energy inward . The person regresses to an early narcissistic level of development
4.
CONVERION DISORDER (HYSTERICAL NEUROSIS, CONVERSION TYPE) y CONVERSION Defined as the unconscious process through which anxiety is converted or transmuted into a physical, physiological or psychological symptoms
CHARACTERISTICS: Conversion symptoms are expressed through motor and sensory symptoms and relate to increased stress, repressed or disowned ideas and feelings and maladaptive coping methods In conversion, the person invests a large amount of energy and interest in the illness so that the illness is the main preoccupation. The person becomes the illness The client will complain to you bitterly about the symptoms.
Commonly encountered manifestations are
dyskinesias, ataxia, contractures, paralysis, blindness, deafness, numbness, tingling, itching and vomiting
The client will be invested in or preoccupied
with the symptoms, spending time and effort to describe complain, and go over in detail every change in symptoms. Yet the significance that the illness plays in the persons life is of no great concerns
2.
MANAGEMENT: No definite therapy Pay attention to the prevention of unnecessary treatment and diagnostic procedures
LA BELLE INDIFFERENCE: the significance implications or incapacity of the symptoms is not given the importance if would be ordinarily
PAIN DISORDER PAIN DISORDER 22
5.
suicidal attempt
EXAMPLE: The blind person is not concerned about blindness when he or she is describing the loss of sight
Somatization NURSING DIAGNOSIS: through conversive symptoms related to chronic anxiety and unresolved conflicts
GOAL: Expresses anxiety and conflicts verbally rather than physically
INTERVENTION: Help the person see the significance and connection between needs and conflicts and the symptoms in terms of his/her life
completed suicide
ETIOLOGY: Psychodynamic theories Sociological theories Biological theory
CLUES: Giving away personal, special, and prized possessions canceling social engagements making out or changing a will taking out or changing insurance policies sudden calmness or improvement in a depressed client
BODY
DYSMORPHIC DISORDER (DYSMORPHOPHO BIA OBSESSION DELA HONTU DE CORPS)
Nursing Interventions: Avoid reinforcing the symptoms increase self esteem by involving clients in activities in which they can be successful encourage to identify and explore feelings
NURSING INTERVENTION: Evaluate patients for suicidal risks evaluate the patients access to a means of suicide develop a formal no suicide contract with patients support patients reason to live
MANAGEMENT: Suicide precautions Develop a contract Encourage verbalization of feelings
FACTITIOUS DISORDER A person uses physical or mental symptoms to receive treatment and become a patient Putting blood in a stool sample Putting oral thermometer in hot water
MALINGERING If there is a recognizable motive and the behavior is evident of a voluntary act
CHARACTERISTICS: Orderliness, stinginess, obstinacy miserly, very reliable, Egocentric, conscientious in performing petty duties, irascible, distrustful This characteristics are similar to those of the obsessive compulsive personality with one major difference, the hypochondriac has an unusual concern about body image and size
NURSING DIAGNOSIS: Somatization through hypochondriasis related to chronic anxiety and inability to cope with life situations and others
GOAL: Demonstrate less concern with body functions and symptoms and direct attention to other people and events
INTERVENTION: 1. Listen to the persons complaints 2. Listen to the life story 3. Try to develop a relationship
SUICIDAL CLIENTS y SUICIDAL BEHAVIOR Clients characteristically have feelings of worthlessness, guilt, and hopelessness that are so overwhelming that they feel unable to go on with life and unfit to live.
SUICIDE y Levels Of Suicidal Behavior Suicidal gestures suicidal ideations suicidal threats
ASSESSMENT: look for the plan client history of attempts Psychosocial
SCHIZOPHRENIA BEHAVIOR)
FOUR AS OF SCHIZOPHRENIA 1. Affective disturbances 2. Autism 3. Associative looseness 4. Ambivalence
(WITHDRAWN
CRITERIA OF SCHIZOPHRENIA At least two characteristic symptoms Delusions Hallucinations disorganized speech disorganized or catatonic grossly behavior negative symptoms social and occupational dysfunction and deterioration continuous sign of the disturbance for at least 6 months schizoaffective and mood disorders are not present and is not responsible for symptoms not caused by substance abuse or a general medical condition
OTHER PSYCHOTIC DISORDERS: Schizophreniform Brief Psychotic disorder Schizoaffective disorder
SUBTYPES: y Paranoid Schizophrenia 23
y y y y
Disorganized Schizophrenia Catatonic schizophrenia
Undifferentiated schizophrenia Residual schizophrenia
ETIOLOGY: Biological theories Developmental theories Family theories Vulnerability-Stress Model
y
NURSING INTERVENTIONS: do not reinforce delusions nor hallucinations orient the patients to time and place if indicated do not touch the patients without warning them avoid whispering or laughing when patients are unable to heal all of a conversation reinforce positive behaviors do not embarrass patients
ANXIETY DISORDERS creates a significant impairment in socio occupational functioning y P rimary gain y S econdary gain
NURSING INTERVENTIONS: y To Reduce Anxiety: provide a calm and quiet environment ask patients to identify what and how they feel help patients identify possible causes of their feelings listen carefully for patients expressions of helplessness and hopelessness plan and involve patients in activities such as walking or playing recreational games
y
GENERALIZED ANXIETY DISORDER y Panic Disorders y Obsessive-Compulsive disorder y Phobic disorders y Acute Stress disorder y Post Traumatic Stress disorder
y
For Obsessive-Compulsive: provide patients with time to perform their rituals ; never take away the ritual assist patient in connecting behaviors and feelings structure simple activities, games or tasks for patients and reinforce positive non recognize ritualistic behaviors For ASD and PTSD: acknowledge any unfairness or injustice related to trauma assure them that their feelings and reactions are typical reactions to serious trauma help establish connections between trauma and feelings, behaviors a nd problems encourage safe verbalizations of feelings especially anger adaptive coping strategies, encourage exercise, relaxation techniques and sleeppromoting strategies facilitate progressive review of the trauma and its consequences
encourage the patients to establish or reestablish relationships
DISSOCIATIVE DISORDERS y Dissociative amnesia y Dissociative fugue y Dissociative Identity disorder y Depersonalization ROLES OF A NURSE : Uncovering and linking feelings with conflicts and managing feelings are important aspects of recovery of these patients assist patients in establishing supportive relationships because social interaction reduces the tendency for dissociation AGGRESSIVE BEHAVIORS y Anger y Hostility y Physical aggression y Passive-aggressive ETIOLOGY: Biologic theories Psychosocial theories y
PHASES OF THE AGGRESSIVE CYCLE 1. Triggering phase 2. Escalation phase 3. Crisis phase 4. Recovery phase 5. Post crisis phase
NURSING INTERVENTIONS: nurse should approach the client in a non threatening way provide directions for the client in calm firm voice advice the client to take time-out for cooling show of force planned team approach is best restraints may be used or applied if needed encourage the client to explore alternatives to aggressive behaviors encourage continued verbalizations of feelings
PERSONALITY DISORDERS y COMMON CHARACTERISTICS: These clients are often in conflict with their families and even society as a whole A particular personality trait or behavioral pattern is used almost exclusively The behavior is usually troubling to others Extremely difficult to change It is difficult to form and maintain satisfying interpersonal relationships
CLUSTERS OF PERSONALITY DISORDER
A Paranoid personality disorder Schizoid personality disorder Schizotypal personality disorder
B Borderline personality disorder 24
Antisocial personality disorder Histrionic personality disorder Narcissistic personality disorder
C Obsessive-compulsive personality disorder Avoidant personality disorder Dependent personality disorder
Nursing Interventions : Encourage the clients to express both negative and positive feelings increase the clients ego strength through positive reinforcement and feedback help the client expand his repertoire of coping behaviors Implement strategies for reducing anxieties set firm, rational limits making sure that the client is aware of expectations encourage client to identify the effects of his/her behaviors on others assist clients in becoming assertive rather than passive or aggressive
SUBSTANCE ABUSE
y
y
y
y
SUBSTANCE ABUSE Excessive or unhealthy use of harmful substances such as alcohol, tobacco or drugs, or use of products such as food, that becomes unhealthy when excessive amounts are ingested.
DRUG USE Ingesting in any manner a chemical substance that has an effect on the body. This definition applies to all drugs taken legally and illegally, both for medical and non-medical usage.
y
DRUG ABUSE Persistent or sporadic excessive drug use inconsistent with or unrelated to acceptable medical practice. This definition includes all drug intakes that is not prescribed for medical use or is not within the generally accepted context of taking nonprescription medications for a specific health problem, such as a headache or . gastrointestinal upset
y
TOLERANCE The declining effect of the same drug dose when it is taken repeatedly overtime
REASONS: Relieving tension Helping unwind Drowning sorrow Making one feel free Coping with stress Helping one be sociable
y
EFFECTS OF ALCOHOL CNS Depressant Immediate effects due to action on brain (acute intoxication) Causes slurred speech, incoordination and memory Chronic uses causes multisystem dysfunction
y
WITHDRAWAL SYMPTOMS RELATED TO CNS EXCITATION Early Phase 6-12 hours after last drink agitation, tremors, tachycardia, Anxiety, hypertension, diaphoresis, nausea and vomiting
SUBSTANCE Refers to alcohol, drugs and food that are ingested for reasons unrelated to health
y
CHEMICAL DEPENDENCE A state of psychic and or physical dependence on a substance following its administration on a periodic or continuing basis
6. ALCOHOLISM Any use of alcoholic beverage that causes damage to the individual, society or both Illness characterized by significant impairment that is directly associated with persistent and excessive use of alcohol
TERMINOLOGY: y
HABITUATION A psychological dependence on the use of a drug
Delirium Tremens Increased temperature, diaphoresis, hypertension and tachycardia, seizures, perceptual disturbances such as illusions and hallucinations Fetal Alcohol Syndrome an C occur in infants born to alcoholic mothers Causes intellectual deficits, physical abnormalities Requires infant withdrawal from a lcohol
STAGES OF ALCOHOLISM
I. PREALCOHOLIC Occasional drinking Constant relief drinking Increase in alcoholic tolerance II. PRODROMAL Onset of memory blackouts
y
ADDICTION Physical dependence on a substance causing an altered physiological state because of repeated use of a substance The drug must be continued to avoid physical symptoms of withdrawal, which vary from moderate, such as muscular pain or increased perspiration, to life threatening, such as convulsions
Secretive drinking Preoccupation with alcohol
Gulping first drink Inability to discuss problems Increase memory blackouts III. CRUCIAL Loss of control Rationalization of drinking behavior 25
Failure in efforts to control drinking Grandiose and aggressive behavior Trouble with family and employer Self-pity Loss of outside interest Unreasonable treatment Neglect of food Tremors Morning drinking IV. CHRONIC
Encourage
increase fluids and adequate nutrition Decrease environmental stimuli during initial withdrawal period
Keep
Stay with patient and keep in touch with reality
Maintain seizure precaution as indicated by
the room lighted to lessen the fear and facilitate observation
individual client response Prolonged intoxication Physical and moral deterioration
Maintain
Teach the client and significant others about
Impaired drinking Indefinable anxieties
Obsession with drinking Constant alibis given
AN ALCOHOLIC TYPICALLY PORTRAYS THE FOLLOWING CHARACTERISTICS
Angry overdependency Inability to express emotions adequately High anxiety in interpersonal relationships Emotional immaturity Ambivalence toward authority Low frustration tolerance Grandiosity Low self-esteem Feelings of isolation Perfectionism and compulsiveness
COMMON BEHAVIORAL PROBLEMS OF THE ALCOHOLIC PATIENT Denial Dependency Demanding Destructive Domineering ALCOHOL WITHDRAWAL SYNDROME
y TREMULOUSNESS Most common manifestation of alcohol withdrawal. Tremors, also known as shakes or the jitters occur
within the first 24 to 48 hours and can range from mild to severe
acceptance
avoiding
substance abuse
Biopsychosocial symptoms and consequence
y y y
of abuse Progressive course of dependence Phenomenon of relapse Effects of chronic abuse
Encourage the client to use self-help groups
such as AA Assist the client to identify strengths and utilize these by abstinence
y
y y HALLUCINOSIS Refers to symptoms of disordered perception and hallucinations that occur in about one-fourth of those suffering withdrawal from alcohol
attitude judgmental behavior
A MULTI ALCOHOLISM
APPROACH
IN
TREATING
Alcoholic anonymous An organization run by former alcoholics whose personal experiences with alcohol enable them to understand the alcoholic problem Goal: to abstain from drinking one day at a time Al-Anon (family groups) and Alateen (teenagers) focus on effects of alcoholism on family and children. These self-help groups meet regularly The personal contact with relatives of alcoholic is therapeutic and provides emotional support RATIONAL EMOTIVE THERAPY Goal: to help alcoholic learn to tolerate stressors that come with living and use coping mechanism that are less defeating
TRANSACTIONAL ANALYSIS Goal: to help alcoholic stop playing games and to rewrite his life script . Patient is then able to cope with his problems more directly y
y CONVULSIVE SEIZURES May occur within 7 to 48 hours or longer after alcohol intake is markedly lowered or discontinued y DELIRIUM TREMENS Characterized by profound confusion, delusions, vivid
hallucinations, tremors, agitation, sleeplessness, dilated pupils, hypertension, fever, tachycardia and profuse perspiration
y
y y WERNICKE-KORSAKOFF SYNDROME Nutritional disease of the nervous system found in alcoholics, caused primarily by the deficiency of thiamine and niacin as a result of alcohol intake
NURSING CARE
PSYCHOANALYSIS Goal: to gain insight into behavior through talking GROUP THERAPY Goal: to examine each member his impact on others through increased understanding of his own behavior and relationship
ANTABUSE An optional drug therapy that reinforces abstinence
Monitor vital signs, daily weight and I and O 26
MEDICATIONS:
y Antabuse (Disulfiram) Interferes with the metabolism of alcohol a nd produce toxic reaction when combined with it .
y
Intervention :
Kept in quiet environment and not touched
Watch out for violent reaction Anticipate that judgment is impaired due to delusional state No injection of drugs should be attempted
y Tranquilizers To facilitate psychotherapy and lessen the anxiety y ANXIOLITICS Given over 5-7 days in gradually decreasing doses Chordiazepoxide (Librium) and Oxazepam (Serax)
4. LSD y Intervention: Provision of quiet environment and calm reassurance The patient needs to be talked down Talking down to complete the trip
TREATMENT FACILITIES
Detoxification Centers Half-way house Hot meal programs
TREATMENT APPROACHES
y
Group Therapies Methadone maintenance program Narcotic Anonymous Self-help program Psychotherapy
DRUG ABUSE / DEPENDENCE
y
NURSING CARE
y
ASSESSMENT 1.
Vital signs
particularly respiratory function Level of consciousness (Orientation and alertness) Reaction to pupil to light Patent airway Signs of withdrawal Nutritional needs Fluid intake Urinary output PLAN AND INTERVENTION The nurse should familiarize herself with the
streetnames of psychoactive drugs Ability to feel confident and comfortable with the drug dependent person Personal attitudes and value system Develops sensitivity to the feelings and reactions of others Understanding of the influences that led to the problem Skill in assessing the mood and attitude of the patient is necessary drug addict is very persuasive and tends to be manipulative The nurse needs to deal with addicts in straightforward, honest manner The nurse must watch for and report the danger signals of drug abuse NURSING INTERVENTION
1. HEROIN muscle flaccidity, respiratory depression and coma y Intervention : Assess for needle marks and constricted pupil Maintenance of patent airway Mouth-to-mouth resuscitation or mechanical ventilator 2. B ARBITURATES y Intervention: abrupt withdrawal is dangerous and fatal 3. AMPHETAMINES irritable, hyperactive and suspicious
2.
SUBSTANCE RELATED DISORDERS y Substance Dependence Tolerance Withdrawal
y y y
Pattern of Pathologic Use Impairment in socio-occupational functioning Etiology: Psychoanalytic/Psychodynamic Sociological Biochemical
Common Drugs of Abuse y Sedatives/depressants benzodiazepines and barbiturates y Psychostimulants amphetamines, cocaine, and metamphetamine HCl y Cannabinoids Cannabis sativa (marijuana, hashish) is the common drug y Inhalants ether, cleaning fluids, adhesives/ gasoline/ kerosene, and aerosols are
glue
vapors
y psychedelics/ hallucinogens phencyclidine (PCP, angel dust) and Lysergic Acid Diethylamide (LSD)
y
Opiates Opium and Heroin
y
Nursing Interventions:
Encourage
participation
in
a
treatment
program support the client through the detoxification or withdrawal detoxification may take 2-3 weeks and should take place in an in-patient setting paced gradual withdrawal is best phenothiazines maybe used as ordered remain with highly anxious or panicky clients and provide reassurance monitor vital signs, nutrition and hydration status of clients 27
Assist clients to identify life stresses and conflicts and encourage exploration of alternative coping strategies assist the client to identify social support network provide health teachings to clients
monitor nutritional and electrolyte status
BULIMIA NERVOSA
recurrent episodes of binge eating and a sense of lack of control over eating recurrent compensatory behaviors at least 2x a week for the past 3 months self-evaluation is unduly influenced by body weight and shape disturbance does not occur exclusively during episodes of anorexia
y
y y y y y y y y
SEXUAL DISORDERS Sexual dysfunctions
the sexual response cycle Sexual desire disorders hypoactive sexual aversion disorder Sexual arousal disorder Orgasmic disorder premature ejaculation anorgasmia Sexual pain disorders Dyspareunia vaginismus
y y
y y
PARAPHILIAS (SEXUAL PERVERSI ONS) * bestiality Exhibitionism
y
frotteurism pedophilia scatologia incest sexual masochism sexual sadism fetishism voyeurism
* necrophilia * telephonic
* * * *
coprophilia pyromania nymphomania satyriasis
y y y
GENDER IDENTITY DISORDER Homosexuality Bisexuality Transexualism (gender dysphoric disorder)
EATING DISORDERS
y
Anorexia Nervosa refusal to maintain body weight at a normal BMI or it is less than 85% of the DBW intense fear of gaining weight or becoming fat disturbance in the way in which ones body weight or shape is experienced self evaluation is based on body weight but is always in denial amenorrhea (at least 3 consecutive cycles)
y y y y y y y y y
y y
y y y
y y y y y y
Types Restricting type binge eating/ purging type Etiology Biological Socio-cultural Psychological Physiologic Symptoms Hypothermia Edema Bradycardia Hypersensitivity Hypotension lanugo Nursing Interventions: Monitor caloric intake watch out for signs of purging weigh daily monitor activities plan for a realistic and healthy diet
Types: Purging Non-purging Nursing Interventions: For Binge Eating create an atmosphere of trust identify feelings associated binging/purging behavior improve self-esteem teach about eating disorders explore interpersonal relationships SLEEP DISORDERS Dysomnias primary insomnia (Initial, middle terminal) primary hypersomnia Parasomnias sleep terrors nightmares somnambulism breathing related sleep disorders sleep-wake cycle disorder
with
and
Nursing Interventions: physical and psychosocial assessment coordinate sleep studies attend to activities of daily living monitor nutritional pattern and activity level establish environment conducive to sleep teach relaxation techniques record sleep patterns
MENTAL ILLNESS IN THE ELDERLY
y
Barriers to the Care of the Elderly
Etiology: Biological Psychological
o o
y y y y y
Ageism Attitudes
Psychiatric Disorders In The Elderly Depression Bipolar disorders Psychotic disorders Anxiety disorders Substance Abuse Nursing Interventions: Assess and meet physical needs maximize independence promote sense of control provide consistency encourage open awareness increase self-esteem acknowledge individual feelings appreciate individuals uniqueness 28
reinforce genuine hopes consider family and caregivers
y
COGNITIVE DISORDERS
y y
y
DELIRIUM
Nursing Interventions: Determine the degree of cognitive impairment create a structured and safe environment institute measures to help patient relax and fall asleep keep the room lit to allay fears and prevent visual hallucinations monitor effects of medications
y y y y y y
y y y
DEMENTIA Multiple Cognitive Deficits Amnesia Aphasia Apraxia Agnosia Disturbance in executive functioning ALZHEIMERS DISEASE Stage I Early stage Stage II Middle stage Stage III Terminal stage
Anti cholinesterase agents (Cognex), donazepil (Aricept) antipsychotic agents benzodiazepines
-
tacrine
Nursing Interventions: Remove any hazardous items or potential obstacles from the patients environment to provide and maintain safety monitor food and fluid intake provide verbal and non-verbal communication that is consistent and structured state expectations simply a nd completely Increase social interaction to provide stimulus for the patients encourage the use of community resources promote physical activity and sensory stimulation
VASCULAR DEMENTIA y MENTAL DISEASES IN CHILDREN o risk factors for childhood psychiatric disorders are genetic and biological factors adverse environmental influences family and socio-cultural factors stress experiences Resilience
Drug therapy
Therapeutic Communication
COMMUNICATION The means by which people make their needs known The way they obtain understanding, reinforcement and assistance from others. SOCIAL CONVERSATION usually superficial and meets the needs of both parties. Its goal is usually enjoyment. THERAPEUTIC COMMUNICATION - less superficial, it is effective and purposeful. Its main goal is to develop or maintain a healthy personality. Done by relieving stress and assisting the patient in developing better coping mechanisms. PRINCIPLES OF THERAPEUTIC COMMUNICATION: Keep your voice calm. Do not ignore the patient by talking as if he was not there. Reassure the patient that you will help him regain control and will not let him hurt himself or others. Stress that you know patient can maintain control of himself if he chooses Never offer the patient something you cannot deliver 29
Do not threaten the patient Avoid lengthy negotiation Offer simple and brief choices GOALS OF THERAPEUTIC COMMUNICATION: Obtain useful information Show caring Help the patient understand himself Relieve stress Provide information Teach problem-solving skills Encourage acceptance of responsibility Encourage activities of daily living CHARACTERISTICS OF A THERAPEUTIC RELATIONSHIP
LISTENING Perceiving the patients message in the cognitive and affective domains WARMTH Feeling of cordiality and affection GENUINENESS Being oneself and not acting out a role; being open and truthful ATTENTIVENESS Demonstrating a concentration of time and / or attention on the patient EMPATHY Understanding the patients feelings; viewing the world as the patient does. POSITIVE REAGARD Accepting the patient as he is. THERAPEUTIC TECHNIQUES
EXAMPLES
Using Silence
Uh humm Nodding
2. Accepting
Yes
3. Giving Recognition
Good Morning, Mrs. X I noticed that you combed your hair
4. Offering Self
Ill sit with you a while Ill stay here with you Im interested in your comfort
5.
Giving broad openings
6. Offering general leads And then Tell me about it 7.
Placing events in time or in sequence When did this happen?
Is there something youd like to talk about? What are you thinking about? Where would you like to begin? Go on
What seemed to lead up to? Was this before or after?
8. Making observation You appear tense Are you comfortable when you 9. Encouraging description Tell me when you fell anxious of perceptions What is happening? What does the voice seems to be saying? 10. Encouraging comparisonWas this something like? Have you had similar experiences? 11. Restating P: I cant sleep. I stayed awake the whole night N: You have difficulty in sleeping? P: The fellow that is my mate died at war and is pending yet to marry N: You were going to marry him, but he died during the war? 30
12. Reflecting
P: Do you think I should tell the doctor? N: Do you think you should?
13. Focusing P: My brother spends all my money and then the nerve to ask for more. N: This causes you to feel angry? 14. Exploring
Tell me more about it Would you describe it more fully?
What kind of work? 15. Giving Information My name is Visiting hours are My purpose of being here is Im taking you to the 16. Seeking Clarification 17. Presenting reality I see no one in this room That sound is a car backfiring Your mother is not here. Im a nurse 18. Voicing doubt
Isnt that unusual? Really? Thats hard to believe
19. Seeking consensual validation
Tell me whether my understanding of it agrees with yours
20. Verbalizing the implied
P: Its a waste of time N: It is your feeling that no one understand P: My wife pushes me around just like my mother and sister did N: It is your impression that women are dominating? 21. Encouraging evaluation
What are you feeling with regards to Does this contribute to your discomfort?
22. Attempting to translate P: Im dead into feelings N: Are you suggesting that you feel lifeless? P: I was out in the ocean N: You must be lonely or you seem to feel deserted 23. Suggesting collaboration
Perhaps you and I can discuss and discover what produces your anxiety.
24. Summarizing
Have I got this straight? Youve said that During the past hours, you and I have discussed 25. Encouraging formulation What could you do to let your anger out of a plan of action harmlessly? Next time this come up, what might you do to handle it? NON
- THERAPEUTIC TECHNIQUES Reassuring Youre coming along fine Giving Approval Im glad that you Rejecting I dont want to hear that Agreeing I agree! Disapproving Id rather You shouldnt Disagreeing I definitely disagree with I dont believe that Advising Why dont you Probing Tell me your life history
EXAMPLES
Dont worry about it, everything will be alright Thats good Lets not discuss Thats right! Thats bad
Its wrong
I think you should Now, tell me about
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Generic name
Trade name
Range of daily Oral dosage (mg)
Comments
PHENOTHIAZINE DERIVATIVES: ALIPHATIC SUBGROUP 200-1000 Chloropromazine Thorazine PHENTOTHIAZINE DERIVATIVES: PIPERIDINE SUBGROUP Thioridazine Mellaril 200-800 Piperacetazine Quide 20-160 Mesoridazine Serentil 100-400 Schizophrenia,
Organic mental disorders, and alcolohisms are odften treated with srentil PHENOTHIAZINE DERIVATIVES: PIPERAZINE SUBGROUP Prolixin Prolixin decanoate often Fluphenazine 2.5-40
Given intramuscularly, initially at 12.5-25 mg and repeated every 2-4 weeks for maintenance Perphenazine Trilafon 8-64 Trifluoperazine Stelazine 15-20 BUTYROPHENONE DERI VATIVES 32
Haloperidol
Haldol
1-100
Optimum dosage highly
Variable
THIOXANTHENE DERIVATIVES Chlorprothixene Taractan
75-600 Specific for moderate to severe agitation, anxiety, and tension related to schizophrenia 20-30 Thiothixene Navane DIHYDROINDOLONE DERIVATIVES Molidone Schizophrenia
Moban
40-225
DIBENZOXAPEPINE DERI VATIVES Loxapine succinate Loxitane
Specific for use in
20-250
Table 15-3 Side Effects of antipsychotic drugs Side effects Dry mouth, blurred vision,
Comments These effects result from the drugs interference with acetylcholine. The first three should be treated symptomatically and client reassured. In
constipation, urinary hesitance, paralytic ileus instances of urinary hesitance and paralytic ileus medication should be withheld until medical evaluation is obtained.
Drug used with great caution if cardiovascular Orthostatic hypotension disease is present and with the elderly. Individual should be warned about possible occurrences and taught to rise slowly and dangle legs before standing. Photosentisivity
Protect client from ultraviolet light . Use sunscreen. Occurs most frequently with chlorpromazine. Examine skin frequently. Endocrine changes Weight gain, edema, lactation, and menstrual irregularities. Treat symptomatically. Reassure client . Extrapyramidal reactions
Dose and duration related. Managed by adjusting
dose of drug or adding antiparkinsonism drug. Pseudoparkinsonism
Typical shuffling gait, masklike facies, tremor,
muscular rigidity, slowing of movements, and other symptoms mimicking those seen in Parkinsons disease. Continuous restlessness, fidgeting, and pacing occur Akathisia, dystonia Spasm of neck muscles, extensor rigidity of back muscles, carpopedal spasm, eyes rolled back, swallowing difficulties occur. There is acute onset, but condition is reversible with appropriate medication . Reassurance should be provided until symptoms subside. Lethargy, feelings of fatigue and muscle weakness. Akinesia Must be differentiated form withdrawal.
Table 15-4 Possible adverse effects of antipsychotic drugs
Adverse effects
Comments
Skin reactions
Urticarial, maculopapolar, edematous, or petechial responses may occur 1 to 5 weeks after initiation of treatment . Withhold drug until after medical evaluation. Jaundice Develops in about 4 % of the clients and is a dangerous complication; drug should be discontinued. Agranulocycotisis and leukopenia Chlorpromazine depresses production of leukocyte. Initial symptoms of sore throat, high temperature, and lesions in mouth indicate that drug should be stopped immediately. Outcome may be lethal, but this is rare. Corneal and lenticular changes and pigmentary Ocular changes ` retinopathy may occur with high dosages over long periods of time. Periodic ocular examinations are recommended. Convulsions Antipsychotic agents lower seizure threshold, 33
making seizure-prone persons more likely to have seizures. Persons with a history seizures or organic associated with seizures require an increased dosage of anticonvulsant medication if a ntipsychotic are used. Tardive dyskinesia Insidious onset of fine vermicular movements of tongue occur, which is reversible if drug is discontinued at this time. Can progress to rhythmical involuntary movements of the tongue, face, mouth, or jaw with protrusion of tongue, puffing of cheeks, and chewing movements . No known treatment; often irreversible . Prevention is imperative. Female over 50 years on prolonged doses are particularly at risk . Do no withhold drug until after medical evaluation symptoms will increase. HISTORY, TRENDS AND STANDARDS / STRESS AND MENTAL HEALTH / ANXIETY MENTAL HEALTH AND REHABILITATION HISTORY, TRENDS AND STANDARDS CONCEPTS OF MENTAL ILLNESS
TIME PERI OD
CONCEPTS OF MENTAL ILLNESS
PRIMITIVE TIMES
- Evil spirits possessed the body and must be driven from the body.
ANCIENT CIVILIZATION
- Thought to be natural phenomenon; humanistic approach
MIDDLE AGES
- Superstition, witchcraft and torture
RENAISSANCE
- Decline in belief of possession by evil spirits - Mental problems irreversible - Scientific inquiry; humanism
EIGHTEENTH CENTURY
- Reform movement; chains removed - Need for medical care recognized - First mentally ill patient treated in hospital
NINETEENTH CENTURY
- Research began - Legislation concerning mental health enacted - Hospitals for mentally ill established with long term custodial care - First psychiatric training school in United States established
TWENTIETH CENTURY
- Start of mental health movement - Large state hospitals built - Psychoanalysis - More legislation concerning mental health enacted - Community health care centers established - Holistic concept of care and short-term care introduced - Goal to return patient to society - Human services programs established - Focus on prevention
CURRENT TRENDS - In the early 1970s, care of the mentally ill shifted from hospital to the community. Community mental health services included: Foster Homes Crisis centers Hotlines Counseling centers Therapeutic communities Halfway houses Day care centers Services offered by comprehensive community mental health centers: Inpatient services Diagnosis Pre and Post hospitalization Professional and Paraprofessional Training
Partial Hospitalization Emergency Services Rehabilitation Services Research and Evaluation Emergency Services Education and Consultation STANDARDS OF CARE
Nurses responsibilities are determined by legislation, agency policy, and standards set by the profession. Legislation is enacted to provide safe practitioners Standards focus on practice and fulfill the professions obligation to provide a means of determining the quality of nursing which the patient receives, whether such services are provided by the professional nurse, the practical nurse, or the nursing assistant . The nurse, working in a mental health care setting, is responsible for providing high quality care as identified 34
by the standards of psychiatric nursing within the nurses legal role. The American Nurses Associations booklet S tandards of P sychiatric Mental Health Nursing P ractices lists fourteen standards of psychiatric mental health nursing practice. STANDARD I : Data are collected through pertinent clinical observations based on knowledge of the arts and sciences, with particular emphasis upon psychosocial and biophysical sciences STANDARD II : Clients are involved in the assessment, planning, implementation, and evaluation of their nursing care program to the fullest extent of their capabilities STANDARD III : The problem solving approach is utilized in developing nursing care plans STANDARD IV : Individuals, families, and community groups are assisted to achieve satisfying and productive patterns of living through health teaching STANDARD V : The activities of daily living are utilized in a goal directed way in work with clients STANDARD VI : Knowledge of somatic therapies and related clinical skills are utilized in working with clients STANDARD VII : The environment is structured to establish and maintain a therapeutic milieu STANDARD VIII : Nursing participates with interdisciplinary teams in assessing, planning, implementing and evaluating programs and other mental health a ctivities STANDARD IX : Psychotherapeutic interventions are used to assist clients to achieve their maximum development STANDARD X : The practice of individual, group or family psychotherapy requires appropriate preparation and recognition of accountability for the practice STANDARD XI : Nursing participates with other members of the community in planning and implementing mental health services that include the broad continuum of promotion of mental health, prevention of mental illness, treatment and rehabilitation
STANDARD XIV : Contributions to nursing and the mental health field are made through innovations in theory and practice and participation in research. LEGAL RIGHTS OF PATIENTS Patients have the right to refuse treatment Patients must be provided with information which will
enable him to make a valid decision concerning any proposed treatment Patients have a right to humane treatment Patients have the right to be treated a s individuals STRESS AND MENTAL HEALTH STRESS THEORY According to Hans Selye, STRESS is a nonspecific response to any demand made on the body. Demands may range from a disappointment to a severe illness. Some stress is necessary, but too much stress may send the body into a state of exhaustion. Coping with stress requires a great deal of energy; the supply of this energy is limited. A persons response to stress is only one theory used to explain mental illness. However, it provides a useful framework for the study and practice of mental health nursing. PHYSIOLOGICAL EFFECTS OF STRESS
ADAPTIVE ENERGY Was coined by Selye to indicate a force that the individual uses to adapt to stress STRESSORS
The demands which cause chemical and structural changes that are manifestations of the bodys attempt to maintain homeostasis GENERAL ADAPTATION SYNDROME (GAS) CRISIS OR ALARM STAGE
An instantaneous, short-term, life preserving and total sympathetic nervous system response that occurs when the person consciously or unconsciously perceives a stressor and feels helpless, insecure or biologically uncomfortable. Fight or flight reaction The body mobilizes its forces to handle the stressors. The sympathetic nervous system is stimulated STAGE OF RESISTANCE Bodys
STANDARD XII : Learning experiences are provided for other nursing care personnel through leadership, supervision, and teaching STANDARD XIII : Responsibility is assumed for continuing educational and professional development and contributes are made to the professional growth of others
way of adapting through an adrenocortical response to the disequilibrium caused by the stressors of life STAGE OF EXHAUSTION
Occurs when the person is unable to continue to ada pt to internal and external environmental demands or when adaptive mechanisms are inadequate
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