PSYCHIATRIC NURSING
Psych focuses in feelings or self-awareness.
Beliefs determine feelings which affects behavior (manifestation of feelings)
Sigmund Freud is the father of PSYCHOANALYSIS of PSYCHOANALYSIS
What happens to childhood will affect adulthood
STRUCTURE OF PERSONALITY ID
Impulsive, “want to”, wants pleasure.
PLEASURE PRINCIPLE
Guiding principle is PAIN AVOIDANCE
SUPEREGO
Should not
Small voice of God
To stop
EGO
Executive decision maker.
In touch with REALITY principle. principle .
ID DOMINANT PERSONALITIES Manic Anti - Social experienced by serial killers Narcissistic
SUPEREGO DOMINANT PERSONALITIES Obsessive Compulsive Anorexia Nervosa
EGO – if destroyed result in impaired reality perception. Schizophrenia
LIBIDO
Sexual energy responsible for survival.
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PSYCHOSEXUAL STAGES OF DEVELOPMENT ACCDNG TO FREUD [O.A.P.L.G.] ORAL STAGE
0 – 18 months evident.
ID is developed.
*FIXATION – Person is stuck in certain developmental shape. *REGRESSION – Return to an earlier developmental stage. *EGO – Developed on the 6 th month. month.
ANAL STAGE
18 months – 3 years old.
Able to control bladder, bowel.
Best time for toilet training.
SUPEREGO is developed.
TOILET TRAINING
Good Mother
Bad Mother
Successful Dirty
Clean
- Disorganized
- organized
- Disobedient
- obedient
- Anti-social
- O.C
- Anal ex expulsive
- Anal re retentive
PHALLIC STA STAGE GE
3 – 6 years old.
Experience pleasure by manipulating genitals.
Love – hate relationship.
Oedipus Complex boy loves parent of the opposite sex.
Imitates daddy called IDENTIFICATION.
Castration fears.
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*Conscious – *Conscious – upper level of thinking. *Preconscious – tip of tongue. *Unconscious – *Unconscious – protects us from traumatic experiences.
LATENCY STAGE
6 – 12 years old.
School age.
Separation anxiety.
Reading, Writing, Arithmetic.
Lasts for 6 years.
GENITAL STAGE
12 years old and above
Sexual reawakening.
Very important stage.
PHARMACOLOGY NOTES ANTI ANXIETY DRUGS
[S.A.T.L.V.M. – E.V.A.B.I.]
Serax
Equanil
Ativan
Vistaril
Tanxene
Atarax
Librium
Buspar
Valium
Inderal
Miltown
ERIC ERIKSON
There is more to life than just sex.
Psychosocial Theory of development.
You can develop a positive side or a negative side.
Developmental task begins at 0 – 18 months.
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POSITIVE 0 – 18 mos. 18 mos. – 3 yrs. 3 yrs. – 6 yrs. 6 yrs. – 12 yrs. 12 yrs. – 20 yrs. 20 yrs. – 25 yrs. 25 yrs. – 45 yrs. 45 yrs. - above
Trust Autonomy Initiative Industry Identity Intimacy Generativity Ego Integrity
NEGATIVE Mistrust Shame & Doubt Guilt Inferiority Role Confusion Isolation Stagnation Despair
FACTOR Feeding Toilet Training Independence School Peers Love Parenting Reflection
BEHAVIORAL BEHA VIORAL MODELS MOD ELS Ivan Pavlov
Classical Conditioning
All behaviors are learned.
BF Skinner
Behavior can be learned and unlearned.
Operant conditioning.
If given reward there is repetition.
If punished behavior becomes extinct.
LOBES OF BRAIN 1. FRONTAL LOBE
3. PARIETAL LOBE
Language
Touch
Learning
Taste
Personality
Judgment
2. TEMPORAL LOBE
Hearing
Smell
3 STEPS TO INTERACT WITH ENVIRONMENT 1. Sensory – eyes, ears, tongue 2. Integration 3. Motor – voluntary or involuntary
4. OCCIPITAL LOBE
Visual
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Spinal Cord
Motor Nerve
Synapse
Muscle Fiber
INVOLUNTARY INVOLUNTAR Y NERVOUS SYSTEM
Also called AUTONOMIC nervous system.
AUTONOMIC NERVOUS SYSTEM SYMPATHETIC (Awake, ADRENERGIC) Heart Rate Increase Respiratory Rate Increase GI Decrea Decrease se (Dry (Dry mouth, mouth, Cons Constip tipati ation) on) GU Decrease (Urinary Retention) Neurotransmitter Epinephrine, Norepinephrine
PARASYMPATHETIC (Relax, CHOLINERGIC) Decrease Decrease Increa Increase se (Mois (Moistt mouth, mouth, Diarr Diarrhea hea)) Increase (Urinary Frequency) Acetylcholine
DRUGS WITH ANTICHOLINERGIC EFFECTS
Anti – Anxiety
Anti – Psychotic
Anti – Cholinergic
Anti – Depressants
PHARMACOLOGY NOTES MONOAMINE OXIDASE INHIBITORS
Marplan
Nardil
Parnate
DEFENSE MECHANISMS 1.
DISPLACEMENT – transfer of feelings to a less threatening object rather than the one who provoked it.
2.
DENIAL – failure to acknowledge an unacceptable trait or situation.
3.
DISSOCIATION – psychological flight from the self.
4.
REGRESSION – return to an earlier development state.
5.
REPRESSION
unconscious forgetting.
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10.
PROJECTION – attribute to others one’s unacceptable trait.
11.
INTROJECTION – assume another person’s trait as your own.
12.
SUPPRESSION – conscious forgetting.
13.
SUBLIMATION – putting destructive energies or hostile feelings towards a more productive endeavors.
14.
CONVERSION – unexpressed or repressed feelings are converted to physical symptoms.
15.
COMPENSATION – over achievement in one area to cover a defective part.
16.
SUBSTITUTION – replace difficult goal with more accessible one.
PHARMACOLOGY NOTES ANTI – PARKINSON DRUG [C.A.P.A.B.L.E.S]
Cogentin
Artane
Parlodel
Akineton
Benadryl
Larodopa
Eldepryl
Symmetrel
AUTONOMIC NERVOUS SYSTEM Pupils Blood Vessels Blood Pressure
SYMPATHETIC Dilate Constrict Increase
PARASYMPATHETIC Constrict Dilate Decrease
THERAPEUTIC COMMUNICATION TECHNIQUES 1.
THERAPEUTIC Offer Se Self
NONTHERAPEUTIC 1. Don’ Don’tt wor worry ry be happ happy y
2. Silen Silence ce – provi provide de time time to to thin think k
2. Chan Changi ging ng the the topic topic/s /sub ubje ject ct
3. Maki aking obse observ rvat atiion – what what you see
3. Igno Ignore re the the cli clien entt
you say
4. Value alue based based judg judgmen mentt – never never assu assume me
4. Activ Active e Liste Listenin ning g – noddin nodding, g, eye eye contac contactt
5.
Flattery
5. Broad Broad Openin Opening g – how how are you today? today?
6.
Advising
6. Gener General al Leads Leads – Go on, I’m listen listening ing
7.
Giving ving Opini pinion on
7. Restat Restating ing – I’m I’m sad sad “You’ “You’re re sad? sad?”” FEAR – protects us from something bad.
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TYPES OF ANXIETY MILD ANXIETY
+ 1 level of anxiety.
Widened perceptual field.
Restless (say you seem restless).
Enhanced learning capacity. capacity.
MODERATE ANXIETY
+ 2 level of anxiety.
Client pace.
Give PRN meds.
SEVERE ANXIETY
+ 3 level of anxiety.
Don’t know what to do/say.
Directive orders (please sit down).
PANIC
+ 4 level of anxiety.
May commit suicide.
Promote safety.
Never touch patient.
Hyperventilation (Respiratory Alkalosis)
Breathe into paper bag.
NURSING DIAGNOSIS
PLANNING/IMPLEMENTATION
Ineffective individual coping.
Decrease level of anxiety.
Powerlessness.
Decrease environmental stimuli.
Impaired skin integrity
Relaxation techniques
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POST TRAUMATIC STRESS DISORDER
Victims become survivors and experience flashbacks or nightmares.
MALINGERING
Pretending to be sick (conscious).
Primary Gain anxiety decreases, able to escape source of anxiety.
Secondary Gain able to get attention.
SOMATOFORM SOMAT OFORM DISORDER
No protection
Unconscious
No organic basis of being sick
DIFFERENT TYPES OF SOMAT SOMATOFORM OFORM 1. Co Conv nver ersi sion on Di Diso sord rder er
Cannot speak, see, hear.
Nervous system affected.
2. La Be Bell lle e Ind Indif iffe fere renc nce e
Do not care what happens to them.
HYPOCHONDRIASIS
has minor discomfort and interprets it as major illness.
Focus on clients feelings.
BODY DYSMORPHIC DISORDER
Illusion of structural defect.
Favorite past time is doctor hopping.
Focus on clients feelings.
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Increase BP & HR
↓ Hypertension
↓ Fat Deposits
↓ Atherosclerosis
↓ Calcium
↓ Arteriosclerosis
↓ Decrease Oxygen
↓ Angina Pectoris
↓ MI
↓ Necrosis
↓ CHF
↓ Coma
PHOBIA
Irrational fear
Etiology: Knowledge of certain object
Bad experience
Immediate nursing objective: Removal of stimulus will remove anxiety
Systemic Desensitization gradually expose client to stimuli/feared object
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ANTI- ANXIETY MEDICA MEDIC ATIONS
Increase GABA and client becomes drowsy (no alcohol and coffee)
May develop orthostatic hypotension
Let patient sit then dangle feet and then stand
Develop anti cholinergic effects
If abruptly withdrawn to anti anxiety it may result to rebound phenomenon (1 week) may lead to seizures
Do it in gradual and in tapered dose
Anti anxiety leads to dependence
AUTISM
Unresponsive and does not want to be touched
AUTISTIC SAVANT: SAVANT : high intelligence and has a ratio of 1:100
Assessment
Appearance – flat affect and loves constancy and ritualistic
Behavior – withdrawn
Communication – echolalia
NURSING DIANOSIS
Impaired verbal communication
Impaired social interaction
Self mutilation
Risk for injury
PLANNING/IMPLEMENTATION
Maslow’s hierarchy of needs
Expressive Therapy – use of art as mode of communication
EVALUATION
Enhanced communication
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NURSING DIAGNOSIS
Risk for injury
Impaired social interaction
PLANNING/IMPLEMENTATION
Structure: Structure : place to play, sleep, eat and study
Schedule: Schedule : there is always a time for everything that you do
Set limits
Safety
EVALUATION
Minimize risk for injury
Improved social interaction FRONTAL LOBE OF ADHD Decreased glucose
↓ Decreased judgment
↓ Increase impulsiveness ADHD/ Hyperactivity
Need a drug that brings glucose level up.
Give RITALIN as stimulant
May result in loss of appetite
Given after meals
Given 6 hours before bedtime EATING EATING DISORDERS DISORD ERS
ANOREXIA NERVOSA Eat, eat, eat
BULIMIA NERVOSA Eat, eat, vomit
Less 85% expected body weight
Normal weight
3 months Amenorrhea
Irregular menstruation
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ANTI – PSYCHOTIC DRUG
Stelazine
Serentil
Thorazine
Trilafon
Clozaril
Mellaril
Haldol
Prolixin
SCHIZOPHRENIA
Ego disintegration
Impaired reality perception
Genetic vulnerability
Stress – Diathesis Model
Biological theory – increase dopamine level
Exact cause unknown
ASSESSMENT
Affect: Appropriate, Appropriate, Inappropriate, Flat, Blunt (incomplete)
Ambivalence: pulled into 2 opposing forces
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Improved thought process
II. ASSESS
Hallucinations/ Illusions
NURSING DIAGNOSIS
Disturbed sensory perception
PLANNING/IMPLEMENTATION
Present reality
Safety
EVALUATION
Improved sensory perception
III. ASSESS
Suspicious
NURSING DIAGNOSIS
Risk for other directed violence
PLANNING/IMPLEMENTATION
Present reality
Safety
EVALUATION
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FLIGHT OF IDEAS
Jumping from on topic to another
AMBIVALENCE
Pulled between 2 strong opposing forces
MAGICAL THINKING
acting like magician
ECHOLALIA
Client repeats what you say
ECHOPRAXIA
Client repeats what you do
WORD SALAD
Just words no rhyme
CLANG ASSOCIA ASSOCI ATION
Words that rhyme
NEOLOGISM
Formation of new words (needs clarification)
DELUSION: PERSECUTORY
“The NBI is out to get me”
DELUSION: RELIGIOUS
“I am Jesus Christ the savior”
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Reality orientation “I know the voices are real but I don’t hear them”
Diversion “Lets go to the garden”
10% of schizophrenic clients hear voices
PARKINSON’S DISEASE
If acethylcholine (on switch) is increased there is excessive movement resulting to decrease in dopamine (off switch) ANTI-PSYCHOTIC
↓ Decrease dopamine level
↓ Parkinson like effect
↓ Extra pyramidal side effect
↓ With akathesia
↓ Restless, inability to rest AKINESIA
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↓
↓
Artane, Akineton
Parlodel
Benadryl
Larodopa
Cogentin
Eldepryl Symmetrel
OTHER SIDE EFFECTS OF DECREASE DOPAMINE
Photosensitivity
AGRANULOCYTOSIS – decrease WBC
Clients prone to infection due to decrease WBC
First sign for infection is sore throat
TYPES OF SCHIZOPHRENIA DISORGANIZED
CATATONIC
- Sad but smiles (Inappropriate affect) - No reaction (flat affect) - Flight of ideas (disorganized speech) - Giggling (hebephrenic giggle) - Combination of positive and negative
- Ambivalence - Waxy flexibility - Favorite word is “No” - Negativism (client do not follow what you tell them to do) Nursing management: Meet needs
PARANOID
RESIDUAL
- Suspicious - No more - Mistrust, positive scared, symptoms withdrawn just Nursing withdrawn management: - Gain TRUST by 1 to 1 short interaction but frequent
UNDIFFIRENTIATED UNCLASSIFIED - Mixed classification, cant be classified
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Tremors, fine hand
Hydration of 3L/day
Increase
Uu (diarrhea)
Mouth dry
Signs of Lithium toxicity
Nausea, vomiting, diarrhea
Increase sodium
**** WAIT FOR 2 – 4 WEEKS BEFORE LITHIUM THERAPY TAKES EFFECTS BIPOLAR DISORDER/ MANIC PROFILE
20 years old
Female
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Vivactil
Paxil
Elavil
Zoloft
Prozac
ALCOHOL LEADS TO:
Blackout: awake but unaware
Confabulation: inventing stories to increase self esteem
Denial: “I am not an alcoholic”
Dependence: cant leave with out leading to enabling where in the significant other tolerates the abuser co abuser co dependence is another term
Tolerance: gradual increase in amount of stimuli to experience the same euphoria
MANAGEMENT
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ONSET LEVEL OF CONSCIOUSNESS DURATION MEMORY
Abrupt Fluctuating Hours to days Short term memory loss
Gradual Unaffected Progressive Short term and long term (orient patient)
5 A’s A’s OF ALZHEIMERS 1. Amnesia – memory loss 2. Anomia – don’t know the name 3. Agnosia – sensory problems smell, taste, sight 4. Aphasia
EXPRESSIVE: cant say/express
Frontal lobe is affected particularly broca’s area
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ASENDIN, NORPRALAMIN, TOFRANIL, SINEQUAN, ANAFRANIL, AVENTYL, VIVACTIL, ELAVIL
MONO AMINE OXIDASE INHIBITORS
MAO kills serotonin
Increased MAO results to decreased serotonin the more depressed the client becomes
MAOI kills MAO and increases all neurotransmitters (serotonin, epinephrine, norepinephrine, dopamine but client becomes prone to hypertensive crisis
Avoid tyramine rich foods
Avocado, Alcohol
Beer
Chocolates, Cheese (aged)
Fermented foods
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“I love myself”
They get jealous even with achievement of family members
8. Obsessive – Compulsive “I am so organized”
9. Paranoid
Suspicious
May lead to domestic violence
ANTI – DEPRESSANT SIDE EFFECTS
MALE – Erectile dysfunction, prone to impotence
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DOWNERS [A.B.O.N.-M.M.C.H.] Alcohol
Marijuana
Barbiturate
Morphine
Opiates
Codeine
Narcotics
Heroine