Care of Clients with Maladaptive Patterns of Behavior, Acute

and Chronic
Psychiatric nursing o Pre-orientation Phase: self-awareness;
know patient’s information and history,
Mental Health know reason for admission
● A state of emotional, psychological and o If you think that you cannot
social wellness evidenced by satisfying handle the client you can refuse,
interpersonal relationships, effective to not experience
behavior and coping, positive self-concept countertransference and for
and emotional stability. care to be more effective
o You cannot control your
COMPONENTS OF MENTAL HEALTH emotions; you might get
● Autonomy and Independence - can work attached to the patient which
interdependently without losing autonomy would lead to ineffective care
● Maximization of One's Potential - oriented and countertransference
towards growth and self-actualization o Orientation Phase: signing of contract
● Tolerance of Life's Uncertainties - can face occurs here, setting of boundaries and
the challenges of day-to-day living with roles are also done here
hope & positive look o You also inform the patient of the
● Self-esteem - has realistic awareness of her exact time when the contract
abilities and limitations will end
● Mastery of the Environment - can deal with o Working Phase
and influence the environment o If during this phase you
● Reality Orientation - can distinguish the real experience countertransference,
world from a dream, fact from fantasy best action is to inform your
superior and you will be assessed
MENTAL ILLNESS o You are allowed to terminate the
● State of imbalance characterized by a contract here, but if other
disturbance in a person’s thoughts, feelings measures are suggested you
and behavior may follow it
o Terminal or termination phase
Criteria to Diagnose Mental Disorders o Evaluation phase
● Dissatisfactions with one's characteristics, o If plan has of management has
accomplishments, abilities been met
● Ineffective or dissatisfying relationships ● FOCUS: Patient
● Dissatisfaction with one's place in the world o Do not ignore the feelings of the
● Ineffective coping with life's events patient but the nurse should divert it
● Lack of personal growth back to the problem of the patient
o It is a policy that a nurse cannot
PSYCHIATRIC NURSING handle friends, family members, and
● Interpersonal process whereby the nurse people who have a relationship to
through the therapeutic use of self-assist an the nurse. This may also lead to
individual family, group or community to countertransference because the
promote mental health, to prevent mental nurse is already attached to the
illness and suffering, to participate in the clients
treatment and rehabilitation of the mentally o This will affect the care and
ill and if necessary, to find meaning in these judgment of the client
experiences
Foundation
● Etiology of mental disorders remain
CORE OF PSYCHIATRIC NURSING unknown
● Interpersonal relationship ● But there are some theories like biochemical
o Transference: unacceptable behavior, theories
feeling, cognition or thought of a patient
towards the nurse Central Nervous System
o Countertransference: unacceptable Cerebrum
behavior, feeling, cognition or thought
of the nurse towards the patient
 ● Frontal lobe - control organization of Sympathetic Parasympathetic
thought, body movement, memories, Increase v/s Decrease v/s
emotions and moral behavior. Decrease GI motility Increase GI motility
o Associated with schizophrenia, attention Decrease GU function
deficit/ hyperactive disorder and Increase GU function
- urinary retention
dementia Moist mouth Dry mouth
● Parietal lobe - interpret sensations of taste
and touch and assist is spatial orientation. Genetics and Hereditary
● Temporal lobes - are centers for the sense of ● Alzheimer's disease - linked with defects in
smell, hearing, memory, and expression of ● chromosomes 14 and 21
emotions. ● Schizophrenia
● Occipital lobes - assist in coordinating ● Mood disorders (depression)
language generation and visual ● Autism and AD/HD
interpretation, such as depth perception.
SIGMUND FREUD
Neurotransmitters ● Father of Psychoanalysis
● Biochemical theories say that ● “Your behavior today is directly or indirectly
neurotransmitters have an effect to the affected by your childhood days or
mental processes, behavior, cognition, and experiences.”
thoughts of a patient o Repression a defense mechanism
● Dopamine - controls complex movements, wherein there is unconscious
motivation, cognition, regulates emotional forgetting
responses ● STRUCTURE – Personality Structure
o If low, it will cause tremors
o If increased, there is a possibility to Personality Structure
have increased cognition, to the
point you are not intact with reality. ID (4-5MONTHS)
A patient may become delusional: ● Impulsive/ Instinctual drive
fixed problems in thoughts and ● I want to... PLEASURE PRINCIPLE
cognition (Schizophrenia) ● I want to... PHYSIOLOGIC NEEDS
o Do not contradict the delusion of ● I want to... PRIMARY PROCESS
your patient because it is a fixed ● All about I, me, and myself
belief and it may cause anxiety SUPEREGO
o Present reality by giving instructions ● Should not
to activities that will revert them ● Small voice of GOD
back to reality ● Set norms, standards, and values
o Do not argue but do not tolerate it, ● MORAL PRINCIPLE
just keep on mind to ignore the ● Conscience
delusion and divert the delusion to ● Contradicts ID
reality EGO
● Serotonin - regulation of emotions, controls ● Executive
food intake, sleep and wakefulness, pain ● REALITY PRINCIPLE
control, sexual behaviors ● Conscious
o Problems in this neurotransmitter may ● Competencies
be found in depression, anorexic, ● Decision Maker; Problem-Solving; Critical
bulimic patients and Creative thinking
● Acetylcholine - controls sleep and ● Balances ID and superego
wakefulness cycle (decreased in ● Once this is fully developed, you are now
Alzheimer's) intact to reality
● Histamine - controls alertness, peripheral
allergic reactions, cardiac stimulations Imbalances between Personality Elements
● GABA - modulates other neurotransmitters
o Modulates norepinephrine and
epinephrine
o When patient is having panic anxiety
there is a problem with epinephrine
● Norepinephrine / Epinephrine - causes
changes in attention, learning and memory,
mood
 ● Manic- usually seen in a bipolar patient. FIXATION
Patient experiences hyperactivity ● Occurs when a person is stuck in a certain
o Extreme exaggerated behaviors developmental stage
● Antisocial personality disorder- personality
problems in interpersonal relationships REGRESSION
● Narcissistic- there is illusion of grandiosity ● Returning to an earlier developmental stage
● Infantile behavior

ANAL STAGE
● 18 months 3 years old
● SUPEREGO develops
● Toilet training
o Good Mother - Normal
o Bad Mother
▪ Clean, organized, obedient - OC
● These are people who are strict law (anal retentive)
followers ▪ Dirty, disorganized - Anti-social (anal
● Obsessive compulsive disorder- recurring, expulsive)
unwanted thoughts, ideas or sensations that
make them feel driven to do something PHALLIC STAGE
repetitively ● Preschooler (3 6 years old)
o Those with ritualistic behaviors ● Parent
o Do not try to contradict because it o Oedipus Complex
will only increase their anxiety, ▪ Castration Fear
because that is their coping o Electra Complex
mechanism ▪ Penis Envy
o Do not abruptly stop it, but give ▪ Daughter to father
schedules for those ritualistic
behavior REPRESSION
● Obsessive compulsive personality disorder- ● UNCONSCIOUS forgetting of an anxiety
are those who are perfectionists provoking concept
o They are perfectionists because they ● 80% of rape victims go into repression
know that being unorganized is not ● There is a possibility that memories will go
acceptable to the society back once a person undergoes
● Hallucinations are sensations that seem to psychoanalysis or because of triggers

SUPRESSION
● CONSCIOUS forgetting of an anxiety
be real but is only created in the mind
provoking situation
● Hallucination vs illusion
o Both these involve the senses, it only
IDENTIFICATION
differs in cognition
● Attempts to resemble or pattern the
o Hallucination has no stimulus but can
personality of a person being admired of
sense something
o Idolizing a person and copying them
o Illusions have stimulus but is
(behaviors, attitudes, physical
interpreted wrongly
appearance)
Libido
INTROJECTION
● Sexual energy responsible for survival of
● Acceptance of another values and opinion
human beings
as one's own
● Psychosexual Theory of Freud
● Thoughts and opinions of other people are
taken as own
ORAL STAGE
● Claiming of other people’s stories
● 18 months
● Cry, suck, mouth
LATENCY STAGGE
● EGO at 6 months
● 6 to 12 years old
● Child cries - fed - successful
● School
● Child cries – ignored - unimportant -
● Reading, writing, arithmetic
narcissistic
● Ability to care about and relate to others
outside home
SUBLIMATION RATIONALIZATION VS. INTELLECTUALIZATION
● Placing sexual energies toward more
productive activities RATIONALIZATION
o Unacceptable to acceptable ● Self-saving with incorrect illogical
behaviors to the society explanation
o Diverting sexual urges to activities o Reasoning out even with the wrong
that are acceptable to the society reasons
INTELLECTUALIZATION
SUBSTITUTION ● Excessive use of abstract thinking; technical
● Replace a goal that can't be achieved for explanation
another that is more realistic. o Excessive rationalization
o Unachievable to achievable o Possibly correct but not necessary to
the current situation
GENITAL STAGE o Focusing on situations that is not
● 12 years old and above really the problem
● Developing satisfying sexual and emotional
relationships with members of the opposite DISPLACEMENT VS. PROJECTION VS. INTROJECTION
sex
● Planning life's goals DISPLACEMENT
● Feelings are transferred or redirect to
EGO DEFENSE MECHANISMS another person or object that is less
threatening
Function - To ward off anxiety ● Keyword: anger or feelings
* without defense mechanisms, anxiety might ● Anger redirection
overwhelm and paralyze us and interfere with daily
living PROJECTION
● Blaming; Falsely attributing to another
2 Features: his/her own unacceptable feelings.
1.1. they operate on an unconscious level (Except o This can be seen in paranoid
suppression) patients
2. 2. they deny, falsify or distort reality to make it less o “Takot sa sarili nilang multo”
threatening o A person unconsciously transfers
his/her own negative behavior to
REPRESSION VS. SUPPRESSION others
o The person is aware that he/she
REPRESSION possesses that behavior but
● Unconscious forgetting of an anxiety subconsciously blames others for it
provoking concept
INTROJECTION
SUPRESSION ● Acceptance of another's values and
● Conscious forgetting of an anxiety opinions as one’s own
provoking situation
SUBLIMATION VS. SUBSTITUTION
REGRESSION VS. FIXATION
SUBLIMATION
REGRESSION ● Transfer of sexual energy to a more
● Returning to an earlier developmental stage productive activity.
o Inappropriate behavior during o Unacceptable behavior to
anxiety acceptable behavior to the society
o E.g. tantrums of an adult
● Infantile behavior SUBSTITUTION
FIXATION ● Replaces a goal that can't be achieved for
● Occurs when a person is stuck in a certain another that is more realistic.
developmental stage
o A stage is not satisfied DISSOCIATION VS. ISOLATION
o Satisfaction of the stage is done by a
person e.g. smoking DISSOCIATION
o This is different from regression and ● Separating and detaching idea, situation
mannerisms from its emotional significance.
 o Detaching from the self temporarily ● Bipolar Disorder - Reaction Formation
d/t anxiety ● Borderline - Splitting
● Schizophrenia - Regression
ISOLATION ● Substance Abuse-Denial
● Individual strips emotion when talking or ● Depression - Introjection
responding about it. ● OC - Undoing
● Catatonic - Repression

EGO DEFENSE MECHANISMS ● Woman who is angry with her boss writes a
short story about a heroic woman.
Conversion
● Anxiety converted to physical symptoms ● Four-year old with new baby brother starts
o E.g. stress is converted to headache sucking his thumb and wanting a bottle.

Compensation ● Patient criticizes the nurse after her family

● Overachievement in one area to failed to visit
Overpower weaknesses or defective area.
o There should be presence of ● Man who is unconsciously attracted to other
weakness, limitation, or insecurity women teases his wife about flirting
that will be covered up by other
achievements ● Short man becomes assertively verbal and
Undoing excels in business.
● Doing the opposite of what have done
o Trying to compensate for the wrong ● Recovering alcoholic constantly preaches
a person has done about the evils of drink.
o E.g. a guy hurt a woman and then
gave her flowers after ● Man reacts to news of the death of a loved
o Restitution- you do something wrong one “No, I don't believe you. The doctor said
to a person but compensate by he was fine.”
doing good to people who are
involved to the person ● Student is unable to take a final exam
Denial because of a terrible headache.
● Failure to acknowledge an unacceptable ● After flirting with her male secretary, a
trait or situation woman brings her husband tickets to a
● Alcoholic patients commonly use this show.
defense mechanism
● “I didn't get the raise because my boss
Fantasy doesn't like me."
● Magical thinking
● Five-year old girl dresses in her mother's
Reaction Formation shoes and dress and meets daddy at the
● Opposite of intention door.

Acting out ● After his wife's death, husband has transient

● Deals with emotional conflict or stressors by complaints of chest pain and difficulty
ACTION rather than reflection or feelings breathing- the symptoms his wife had
before she died
Symbolization
● Creates a representation to an anxiety ● Man forgets wife's birthday after a marital
provoking thing or concept fight.

Splitting ● Businessman who is preparing to make an

● Labile emotions; all bad - all good important speech that day is told by his wife
that morning that she wants a divorce.
DEFENSE MECHANISMS COMMONLY USED IN EACH Although visibly upset, he puts this incident
RESPECTIVE DISORDERS aside until after his speech, when he can
● Paranoid - Projection give the matter his total concentration.
● Phobia - Displacement
● Amnesia - Dissociation
● Anorexia - Suppression
● A man cannot accept his physician's things) to reduce anxiety, explain
diagnosis of cancer is correct and seeking a that you understand how the
second opinion patients feel but don’t forget to
present the reality to the patient
● slamming a door instead of hitting as o Divert the attention to a realistic
person, yelling at your spouse after an environment
argument with your boss ● General leads
o Broad opening statements, leave
● focusing on the details of a funeral as
the direction of the conversation to
opposed to the sadness and grief
the patient
● stating that you were fired because you o Used when patients have difficulty in
didn't kiss up the boss, when the real reason expressing or verbalizing thoughts
was your poor performance and feelings
o Schizophrenic patients are
● having a bias against a particular race or disorganized, general leads may be
culture and then embracing that race or helpful
culture to the extreme o May also be used in geriatric
patients
● sitting in a corner and crying after hearing ● Silence
bad news; throwing a temper tantrum when o If you remain silent when a patient is
you don’t get your way talking it indicates that you are
listening
● forgetting sexual abuse from your childhood o A sign of respect to the person
due to the trauma and anxiety
speaking
o Best therapeutic communication
● lifting weights to release 'pent up' energy
used for paranoid patients, to be
able to establish trust
o May help develop rapport
Therapeutic Communication
● Non-verbal cues are more accurate than
verbal cues
o Reaction formation may be seen in
these situations Therapeutic communication
● Therapeutic communication is important
● Continuous, dynamic process of SENDING
because it can affect the progress of the
and RECEIVING MESSAGES by various verbal
patient
or non- verbal means (words, signals, signs,
● Always assert and affirm authority
symbols) utilized in a goal- directed
o The healthcare provider should be
professional framework.
followed and not the patient
● Offering self
● For paranoid patients, always position in
o Offering safety, service, comfort
front of the patient but should have a space
o “I’ll sit beside you”
in between
o “Do you need help?”
o Because standing on the sides may
o You want to tell the patient that you
pose as a threat to the patient
want to provide care
o Being too close or too far may also
o Very helpful for depressed patients,
present as a threat to the patient
this shows that people care for them
o Paranoid patients are hypervigilant
o E.g. Ursula, age 25, is found on the
● Reality orientation
floor of the bathroom in the day
o Alcoholic patients who are already
treatment cleaning with moderate
in withdrawal may experience
lacerations to both wrists.
formication
Surrounded by broken glass, she sits
o Sensation that resembles that of
staring blank at her bleeding wrist
small insects crawling on (or under)
while staff members call for an
the skin when there is nothing there.
ambulance. The best way the nurse
o Acknowledge what the patient feels
should do is to approach Ursula
(because they are not inventing
 slowly while speaking in the calm ● Contract – 2 famous psychiatric contracts:
voice, calling her name and telling
her that the nurse is here to help her. o 1. No suicide contract 🡪 Major
This approach provides reassurance depression = emergency
for a patient in distress o TWO definitions of no suicide
3 LEVELS OF PSYCHIATRIC NURSING (Levels of contract:
Health) o 24 hours monitoring
Primary o Verbalization to the nurse of all
● Objective: PROMOTION & PREVENTION suicide ideas
● Client and Family Teaching (Health ● Diet contract 🡪 Eating disorder
Teaching)
● No existing illness yet ● The start of termination phase: “Good
morning, full name, RN, shift, session, date
Secondary start & end.”
● Screening, Diagnosis, and Immediate
Treatment
● Screening Working phase
o Denver Development Screening Test
● Promote acceptance of each other
(DDST) #1 test for PDD
o Accept client as having value and
Tertiary
worth as a unique individual.
● Rehabilitation o Stage of resistance
● Counter transference phase
● Most difficult phase
● NCP is on going
● Identification of the problem/exploration
● The #1 Psychiatric Core Value is Consistency
🡪 For manipulative patients
Four phases of nurse- client relationship (NCR) ● Be consistent to patient with: BAAAM COPS

Pre-interaction/Pre-orientation (For the Nurse) B orderline C onduct d/o

● Stage of Self-Awareness 🡪 To prevent A ntisocial O ral/eating disorder

Counter Transference A lzheimer’s P aranoid
● #1 CORE VALUE OF Psychiatric Nursing
AIM: PLAN THE RELATIONSHIP A utistic S uicidal
● Upon admission, discharge instruction plan
● Use therapeutic and problem- solving
should already be formulated techniques
o You already know the chief o Maintain professional, therapeutic
complaint (existing problems) relationship
o To not neglect other problems that o Keep interaction reality- oriented- here
will come out during the working and now
phase o Provide active listening and reflection of
feelings
Orientation (initiation) o Use non- verbal communication to
support client
● Assessment of problems, needs, o Recognize blocks to communication
expectations of clients and work to remove them
● Identify anxiety level of self and client ● FOCUS on client’s:
● Set goals of relationship. o Confronting and working through
● Define responsibilities of nurse and client. identified problems
Stage of testing. o Problems- solving skills
● Establish boundaries of relationship. Stress o Increasing independence
confidentiality. o Help client develop alternative,
adaptive coping mechanisms
 o Personal biases (manifestation by ● Subconscious- information or memory where
counter-transference & vice versa) are you need to exert effort in order to
seen during working phase remember
o the Preconscious; composed of
material that has been deliberately
Termination pushed out of conscious level; helps
repress unpleasant thoughts or
● Plan for termination of relationship early the feelings and can examine or censor
relationship certain desires or thinking; can be
● Stage of Separation Anxiety 🡪 Signs & recalled with some effort
symptoms: Regression: Temper tantrums, ● Unconscious- memories or information that
thumb sucking, apathy, fetal position when are already repressed
crying o Composed of the LARGEST BODY OF
● Phase of prognosis 🡪 Evaluation MATERIAL- the thoughts, memories
● Maintain boundaries and feelings that are repressed and
● Anticipate problems of termination: not available to the conscious mind,
o Increased dependency on the nurse not logical and governed by
o Recall of previous negative PLEASURE PRINCIPLE – and since it is
experience- rejection, depression, usually painful and unacceptable to
abandonment, etc. the individual, it cannot be
o Regressive behaviors deliberately brought back into
o Emphasize to the patient that a awareness unless in disguised or
discharge instruction has been distorted form (dreams)
made which would help his/ her o Information cannot be totally
progression remembered
o Discharge plan is discussed in this o Largest storage among the three
phase
● Discuss client’s feelings and objectives
achieved

Levels of awareness
Additional notes

● Exploration is a sign of suicide

o They are giving their belongings to
other people
● If a patient has suicidal ideations, do you
confront or ask that patient?
o Yes, because it is considered to be
therapeutic
o A no suicide attempt contract will be
given, because once a suicide
happen the hospital and staff will be
held liable
o When you ask the patient if he/she
will perform suicide the patient will
know that the nurse is
knowledgeable leading to delay in
the plan, do this until serotonin levels
go back to normal and depression
● Conscious- you can immediately answer or will be solved
remember because this is still in your o Confrontation is therapeutic to
memory
suicidal patients. You can ask when,
o Composed of past experiences,
where, and how can be asked but
logical and governed by REALITY
never why
PRINCIPLE; are remembered and
easily recalled or available to the ● Asking questions starting with why is never
individual therapeutic
o Because why is an open-ended
question, leading the patient to
 rethink of the thoughts and feelings o A person with flat affect has no or
that drove them to do suicide nearly no emotional expression. He
or she may not react at all to
Mental status examination circumstances that usually evoke
● A systematic assessment that checks if a strong emotions in others. A person
person is mentally sound or not with blunted affect, on the other
o Assessment in terms of their mental hand, has a significantly reduced
health intensity in emotional expression
o No tools are available for this exam o Inappropriate vs labile affect
o Not used to create a diagnosis but o Inappropriate affect is an affect that
only to assess is incongruent with the
o Only used to add confirmation to a situation or with the content of a
specific mental disorder patient's ideas or speech. Labile
● Clinical eye may be used in this assessment affect that characterized by rapid
● Histrionic personality disorder changes in emotion unrelated to
o Characterized by a pattern of external events or stimuli
excessive attention-seeking ▪ Inappropriate affect is
behaviors, usually beginning in early somehow similar to the
childhood, including inappropriate reaction formation
seduction and an excessive desire o Restricted affect is a term used to
for approval. describe a mild constriction in a
● Hygiene should be assessed client's physical affect: range and/or
● Eye contact intensity of emotion or display of
o Does the person engage in eye feelings
contact? ▪ The person does not want to
o But always take into consideration of really show his/her feelings
the norms and practices about eye ● Speech
contact of the patient o There are certain forms or types of
● Attitude speech that manifests in mental
o Mannerisms (can usually be seen in disorders
Tourette’s and autism) o Bipolar patients manifest flight of
o It is important to detect mannerisms ideas when speaking (flight of ideas
because this may be a sign of where one sentence has little
neurologic dysfunction connection to the second
o Alcohol and drug use may induce statement) d/t hyperactive thinking
mannerisms because these o Schizophrenia not intact with reality
damages the CNS when speaking (delusional)
● Appearance ▪ Loses association in spoken
o Check the way a person dresses, is it statements
appropriate for the time and ▪ Word salad (speaking of
occasion? words not related to one
o Can be observed in narcissists and another)
people with illusion of grandeur o Neologisms can also be observed in
● Speech schizophrenic patients
o Depressed patients can only answer ▪ Coining or use of new words
close-ended questions ▪ Invented words that is only
o They cannot explain d/t decreased known by the patient
levels of serotonin ▪ When talking to the patient,
o Volume of the voice may also be an clarify what these words are
indicator depending on the client to the client
● Mood and affect o Echolalia, echopraxia, and palilalia
o Affect can be seen in the client’s ▪ Echolalia is the repetition of
facial expression words spoken by others,
o Affect is the experience of feeling whereas palilalia is the
an emotion while mood is a state automatic repetition of one's
of emotion own words
o Affect is usually short-lived ▪ Echopraxia (also known as
while mood can last for hours or days echokinesis) is the involuntary
o Blunted vs. flat affect repetition or imitation of
another person's actions.
 ▪ Can be seen in autism ● Best therapy for major depression (last
patients resort)
o Clanging- rhyming of words or ● Invasive
phrases also observed in ● Induction of 70-150 volts of electricity
schizophrenic patients] in).5-2secs. Then, it is followed by a
o Blocking grand-mal seizure lasting 30-60 secs.
▪ People with o Prone to aspiration that is why
thought blocking often atropine sulfate is given to decrease
interrupt themselves abruptly secretions and prevent aspiration
mid-sentence. o Should be in supine during ECT, then
▪ Can be observed in after place in a side-lying position to
schizophrenic-paranoid type allow drainage of secretions
▪ This occurs d/t hallucinations ● 6-12 treatments, “every other day”
of the patient ● Before ECT
● Thought o Should be on NPO
o Thought insertion can be seen in o Food is introduced when gag reflex
schizophrenia is back
▪ Experiencing one's ● Before ECT a major depressed client
own thoughts as someone undergoes the ff meds:
else's ● Phenobarbitals are given as anticonvulsants
o Thought withdrawal and may also decrease heart rate of
▪ Delusion that thoughts have patients
been taken out of the ● SSRi (Selective Serotonin Reuptake
patient's mind Inhibitor inhibitor) –2 weeks
o Disturbed sensory perception and ● Antidepressants 🡪 TCA 2nd Generation
altered thought process may be a o 2-4 weeks
nursing diagnosis ● MAOIs – are taken for 2 weeks
o Agnosia- loss of the ability to
recognize objects, faces, voices, or Side Effects
places ● After ECT, reorient the patient because
o Apraxia- inability to perform learned antegrade amnesia is expected after
(familiar) movements on command therapy
▪ Inability to use objects o Temporary RECENT Memory Loss
properly ANTEROGRADE amnesia
o Aphasia- impairment of language, o Intervention: Re-orient client to 3
affecting the production or spheres
comprehension of speech and the o Reintroducing yourself, therapy,
ability to read or write where patient is, time and date,
secure the safety of a patient as well
Therapy for mental disorders o confusion/disorientation (usually 24
hours)
Electroconvulsive therapy o Headache 🡪 ↑02 demand, ↑cerebral
● ECT is passing of an electric current through hypoxia
electrodes applied to one or both temples o Muscle spasm
to artificially induce a grand mal seizure for o Wt. gain (stimulate thalamic/limbic 🡪
the safe and effective treatment of appetite)
depression.
● ECT’s mechanism of action is unclear at Contraindications
present ● PPPP– Post MI, Post CVA, pacemaker,
● For depressed patients pregnant women
● Last resort for a depressed patient who can ● People with cardiovascular problems
no longer wait for the effect of an ● Neurologic problem 🡪 Alzheimer’s,
antidepressant medications or is no longer degenerative disorder
responsive to medications ● Brain tumor, weakness of lumbosacral spine

Legal/Pre-Nursing Responsibilities
Advantages Preparation: Similar to preparing a client for surgery
● Quicker effects than antidepressants; Safer ● Informed Consent – if client is coherent, if
for elderly; 80 % improvement rate of major not a guardian may sign the consent forms.
depressive episode with vegetative aspects ● No metallic objects
 o Metals can interfere with electrical ● REINFORCER: A reward positively or
transmissions negatively influences and strengthens
● No nail polish to check peripheral circulation desirable behaviors.
● No contact lenses it may adhere to the ● POSITIVE REINFORCER: A desirable reward
cornea produced by specific behavior (TV time
● Let the patient void first after doing homework)
● Wash & dry hair ● NEGATIVE REINFORCER: A negative
● 6. Give following medications BEFORE ECT: consequence of a behavior (Spanking child
● Atropine sulfate – anticholinergic for wetting the floor)
● PRIMARY purpose – to dry secretions and
prevent aspiration
● SECONDARY purpose – to prevent Classical conditioning
bradycardia (vagolytic) ● (pairing of two stimuli in order to gain a new
● Phenobarbital (Luminal), Methohexital learning behavior – by Ivan Pavlov)
(barbiturate Na)- minor tranquilizer also an ● Acquisition (newly acquired behavior or the
anticonvulsant by-product of classical conditioning)
● Succinylcholine (Anectine) – muscle ● Extinction
relaxant ● Reward and punishment in order to change
o Given because ECT can cause the behavior of the patient
muscle spasm ● How frequent do we need to do this?
● Priority vs. to focus ABC; check RR 12 less; o Behavior changes quicker if rewards
LOC are not given frequently, because
● Before ECT 🡪 supine position; after ECT 🡪 once reward is gone attitude may
side-lying come back
● Have patient VOID before giving ECT o Should have a gap in between
before you give another reward
Nursing Diagnosis o This is to train them to maintain the
● Risk for Airway Obstruction/aspiration good behavior and not wait for the
● Risk for Injury rewards
● Impaired/Altered Cognition/LOC ● If with bad behavior, punishment should be
provided right away
Nursing Intervention o Because there is a tendency that
● 5 S in Seizure they will not believe that the
● Safety (#1 objective) punishment is not true
● Side-lying (#1 Position) ● Provides a stimulus to encourage good
● Side rails up behavior
● Stimulus ↓ (no noise & bright lights) ● Appropriate therapy for phobias is
● Support the head with a pillow AFTER the systematic desensitization
seizure o A gradual exposure of the person to
● FIRST & TOP priority: Ensure a patent airway. feared objects
Side-lying after removal of airway. Observe o E.g. fear of snakes, first show it from
for respiratory problems afar or a stuffed toy, then progress
● Remain with client until alert. VS q 5 min until until patient can touch the snake
stable. o Reinforce to the patient that not all
● REORIENT: Time, place (unit), person (nurse); snakes are venomous
Reassure regarding confusion and memory ● If systematic desensitization is not effective,
loss. Same RN before & after. flooding may be done
o This is the abrupt exposure to feared
Behavior therapy objects until the patient becomes
tolerant with it
TERMINOLOGIES
● STIMULUS: Any event affecting an individual OPERANT CONDITIONING
● PROBLEM BEHAVIOR: Deficient, excessive, Burrhus Skinner
condemned, unwanted behavior ● used in Behavior Modification
● OPERANT BEHAVIOR: Activities that are
strongly influenced by events that follow 1. Positive reinforcement (Reward Orientation)
them. o Token Economy – use tokens as a source
● TARGET BEHAVIOR: Activities that the nurse of reward.
wants to develop or accelerate in the client. o Used in eating disorders and depression
 o Token economy is also effective for 1. Economical: Less staff used.
toddlers 2. Increased feelings of closeness > Reduction
2. Negative Reinforcement (Punishment on feelings of being alone.
Orientation) 3. With feedback group >
o Aversion Therapy/Aversion Technique o Corrects distortions of problems
o Builds self- image and self- confidence
BEHAVIORAL TREATMENTS o Increases reality- testing opportunities
1. Desensitization – gradual exposure to the o Gives info on how one’s personality and
feared object behavior appear to others
o #1 treatment for phobia 4. With opportunities for practicing alternative
2. Flooding/Implosive Therapy – sudden behaviors and methods of coping with
exposure feelings
3. Relaxation Technique – light stroking = labor 5. Provides attention to reality and provides
o Purse Lip Breathing Exercise = development of insight into one’s problems
COPD/CAL (Chronic Airflow Limitation) by expressing own experiences and listening
4. Biofeedback – mind over matter. Ex. HPN > to others in groups
↓BP, palpitations, headache
5. Guided Imagery (Child) & Visualization
(Adult

Group therapy PRINCIPLES OF GROUP THERAPY

1. Verbalization: Members express feelings and
● Psychotherapeutic processes that occur in group reinforces appropriate
formally organized groups designed to communication.
change maladaptive or undesirable Desired outcome of group therapy includes
behavior. verbalization of feelings rather than acting
● Knowledge of therapeutic modalities them out
enhances the performance of nursing 2. Activity: Provides stimuli to verbalization and
interventions during therapy. 8-10 patients expression of feelings.
are the optimal number of patients in a 3. Support: Members gain support from one
group. another through interaction, sharing and
● There should be 8-10 members only communication.
● Maximum of 10, no longer therapeutic if too 4. Change: Members have opportunity to try
many out new and desirable behaviors in group,
● All members should have or experience the supportive setting to effect change.
same problem
● Done during rehabilitation in order to gain PHASES OF GROUP THERAPY
other coping mechanisms of other patients 1. Initial Phase
who have overcome the problems ● Formation of group
● Setting and clarification of goals and
TYPES OF GROUPS expectations
1. Structured ● Initial meeting, acquaintance and
o Goals: Pre-determined interaction
o Format: Clear and specific
o Factual material: Presented 2. Working Phase
o Leader: Retains control ● Confrontation between members→
2. Unstructured Cohesiveness
o Goals: Not pre-determined. ● Identification of problems→ Problem- solving
Responsibility for goal is shared by group processes
and leader ● In a group therapy when one client says to
o Format: Discussion flows according to another, “Maybe you’re taking on someone
group members’ concern else’s problems.” this shows that they are in
o Materials and topics are not the working phase
pre-elected.
o Leader: Nondirective 3. Termination Phase
o Emphasis: More on FEELINGS rather than ● Evaluation of goals attainment
facts ● Support for leave- taking
● In group therapy if a client says, “Leave me
ADVANTAGE OF GROUP THERAPHY alone & get away from me.”, best action of
the RN is to maintain distance from the pt.
 ● Behavior indicating that goal is met after o If it resolves then recurs, its fine so
socialization in a group therapy includes long as it resolves
participation of each group member telling
the leader about specific problems

Milieu therapy

● Milieu therapy or environmental therapy

o If a patient is having a religious
delusion remove images of saints, or
smokes, because it only adds to the
delusion of the patient
o This does not bring the patient back
to reality
● Therapeutic milieu is an environment that is
structured and maintained as an ideal,
dynamic settings in which to work, with
client
Stages of grief
● For hyperactive patients do not place them
in areas with a lot of activities
o Place them in safe environments
● Any activity that is to be done should be
supervised by the nurse

Crisis

● Expected especially when a person is

growing up (developmental crisis)
o E.g. a girl undergoing puberty had
her first menstruation has increased
anxiety because this is her first time
o This cannot be avoided
● Midlife crisis where a person experiences
ttransition of identity and self-confidence
that can occur in middle-aged individuals,
typically 45 to 65 years old ● Denial – The first reaction is denial. In this
● When a person gets married, a person may stage, individuals believe the diagnosis is
also undergo crisis because there will be a somehow mistaken, and cling to a false,
huge adjustment preferable reality.
● Situational crisis involves an unexpected o Present the reality to the client
event that is usually beyond the individual's ● Anger – When the individual recognizes that
control. Examples of situational denial cannot continue, they become
crises include natural disasters, loss of a job, frustrated, especially at proximate
assault, and the sudden death of a loved individuals. Certain psychological responses
one. of a person undergoing this phase would
● Adventitious crisis where natural resources be: "Why me? It's not fair!"; "How can this
are involved happen to me?"; "Who is to blame?"; "Why
o Called events of disaster. They are would this happen?".
rare, unexpected happenings that ● Bargaining – The third stage involves the
are not part of everyday life and hope that the individual can avoid a cause
may result from: Natural disasters, of grief. Usually, the negotiation for an
such as floods, fires, and extended life is made in exchange for a
earthquakes reformed lifestyle. People facing less serious
● You are considered healthy is you are able trauma can bargain or seek compromise.
to cope up with the crisis in 4-6 weeks Examples include the terminally ill person
o It should lessen in 4-6 weeks, but if it who "negotiates with God" to attend a
increases you need to seek daughter's wedding, an attempt to bargain
professional help for more time to live in exchange for a
 reformed lifestyle or a phrase such as "If I o Mentioning one word then
could trade their life for mine". connecting it to another
● Depression – "I'm so sad, why bother with o Ex. Sir Gan—gun, I want to kill
anything?"; "I'm going to die soon, so what's somebody
the point?"; "I miss my loved one; why go ● Looseness of association- sentences are not
on?" connected with one another
During the fourth stage, the individual o Common in schizophrenic patients
despairs at the recognition of their mortality. o Because they are not intact with
In this state, the individual may become reality
silent, refuse visitors and spend much of the ● Clanging- rhyming words
time mournful and sullen. ● Neologism- making of words
● Acceptance – "It's going to be okay."; "I ● Projection is used by paranoid patients
can't fight it; I may as well prepare for it." ● Conversion- anxiety converted to physical
In this last stage, individuals embrace symptoms
mortality or inevitable future, or that of a ● Compensation- weakness covered by
loved one, or another tragic event. People greatness
dying may precede the survivors in this ● Orient the patient to location, time, place,
state, which typically comes with a calm, and person
retrospective view for the individual, and a ● Narcissistic patient- always remind them of
stable condition of emotions. the roles and the patient should be the one
● It is important for nurses to guide patients following the nurse
not to stay too long in denial stage o Reinforce to the patient that all the
● Nurse should guide the patient through the activities to be done is for her/his
stages good
o Always set the boundaries
o Confrontation can be done since
there is a contract
Additional notes

● Voluntary admission- patient wants to seek

mental help so he/she surrendered self to
the facility MIDTERMS
o Contract may be ended by the
Anxiety
patient
o He/ she may request to be ● DEFINITION: Effective subjective response to
discharged an imagined or real internal or external
o False imprisonment, assault, battery threat.
may be charged if the nurse does ● Perceived SUBJECTIVELY by the conscious
not allow the client to be discharged mind is as a painful, diffuse apprehension or
and was restrained vague uneasiness, but the causative conflict
● Involuntary- those who were escorted to the or threats is not in the conscious mind or
facility because they are still in denial of awareness.
their condition ● Low / mild level of anxiety is healthy and
o Patients in this type of admission helps in individual growth and
cannot request to be discharged development.
o Contact the legal guardian who ● So long as you are still oriented to time,
brought the client there space, and situation the anxiety you are
● Safety and security must always be feeling is still normal
prioritized when a patient is in jeopardy o Up to moderate level of anxiety may
o E.g. a patient is having seizures and still be considered normal
the IV lines are dislodged, ensure the ● There are internal and external threats
safety of the client first side rails up! o Internal- formed in the mind
● How do you consider an alcoholic patient o External- due to your situation or
already okay? environment
● Delusion of grandeur- fixed false belief of
being high or important MAJOR ASSESSMENT CRITERION FOR MEASURING
● Flight of ideas are somewhat related to one DEGREE OF ANXIETY:
another
● Mild: The perceptual field is wide allowing
o Very common in bipolar disorders
the client to focus realistically on what is
 happening to him. Alert senses, increased ● Identify anxious behavior and anxiety levels
attentiveness, and increased motivation. and institute measures to decrease anxiety
o Expected incoming threats at a level where learning can occur.
o Can still focus on other things ● Provide appropriate environment where
● Moderate: Another word is selective environmental stress & stimulation are low
inattention. The perceptual field narrows (First nursing action):
and the client is able to partially focus on o Structured, NON-STIMULATING,
what is happening if directed to do so and uncluttered
can verbalize feelings of anxiety o SAFE from physical exhaustion and
o Cannot focus anymore on other harm.
things ● STAY. Do not leave client alone. Recognize if
● Severe: The perceptual field is significantly additional help is needed. Provide physical
reduced and the client may not be able to care if necessary.
focus on what is happening to him and may ● Establish PERSON-TO-PERSON relationship
not be able to recognize or verbalize and maintain an accepting attitude:
anxiety. All senses affected; decreased o ACCEPT client. Show willingness to
perceptual field; drained energy; Learning LISTEN.
and problem-solving not possible. Start of o Encourage, allow EXPRESSION OF
FEELINGS at client’s OWN PACE
sympathetic symptoms: tachycardia,
avoid forcing verbalization.
palpitations, hyperventilation (brown paper
● Administer medication as directed and
bag to prevent Respiratory Alkalosis) and
needed. The pharmacologic therapy of
cold clammy skin. choice is ANXIOLYTIC-reduces anxiety so
o Patient is already disorganized client can participate in psychotherapy.
● Panic: The perceptual field is severely ● Assist to cope with anxiety more effectively.
reduced and the client experiences feelings Assist to recognize individual strengths
of panic and dread. Client overwhelmed realistically
and helpless; personality may disintegrate → ● Encourage measures to reduce anxiety:
hallucinations and delusions. Pathological activities: relaxation techniques, exercises
conditions requiring immediate intervention. (DANCING, WALKING, JOGGING), hobbies,
Client may harm self or others. talking with support groups, desensitization
o A patient stating, “Sometimes I feel treatment program
like I’m going crazy & losing control ● Provide individual or group therapy to
over myself,” is showing symptoms of identify anxiety and new ways of dealing
panic attack with it and develop more effective coping
● Perceptual field and anxiety are inversely interpersonal skills.
proportional ● If patient can be redirected back to the
o Sensorium or senses are involved topic after he gets anxious while the RN
o As anxiety increases sensorium gives discharge teaching, it is an indication
decreases that discharge teaching can be resumed.
o When a patient is anxious, he/she
can only see what is in front and can
only hear loud noises TYPES OF ANXIETY DISORDER
● Talk to the patient in a short and direct
manner, use close-ended questions ● Phobia
● Always place yourself in front of the patient o Fear of heights- acrophobia
● Identify the stimulus that causes anxiety and o Fear of fire- pyrophobia
remove it o Fear of doctor- iatrophobia
● Do not leave the patient alone during o Fear of microorganisms-
anxiety attack germaphobia
o Safety is always priority o Fear of death- thanatophobia
● Still give space and do not touch the o Fear of animals- zoophobia
patient unless he/she permits you to do so ● Obsessive Compulsive
● Post-Traumatic Stress Disorder (PTSD)
POTENTIAL NURSING DIAGNOSES ● Generalized Anxiety Disorder (GAD)
● Ineffective Individual Coping ● Panic Disorder
● Anxiety
PHOBIA AND PANIC DISORDER
NURSING INTERVENTION IMPLEMENTATON: ● Extreme anxiety and apprehension
experienced by an individual when
 confronted with feared object/ situation; o COMPULSION: Repetitive,
commonly begins in early twenty’s (young uncontrollable acts of irrational
adult) as a result of childhood behavior that serve NO rational
environmental factors characterized by purpose → rigidity, rituals, inflexibility;
ORDER & RIGIDITY; use compensatory the development of rituals permits
mechanism of the psychoneurotic pattern some measure of social adjustment
of behavior and development of symptoms ▪ Things that the patient
permits some measure of social adjustment. unconsciously does to
● PRECIPITATING FACTOR: Pressures of decrease the level of anxiety
decision-making regarding life-style in early because of the obsession
adult period ▪ Helps in decreasing the
anxiety felt by the patient
TYPES OF PHOBIA ● ASSESSMENT FINDINGS: Ritualistic, rigid,
inflexible; with difficulty making decisions
● Agoraphobia: Fear of being alone, fear of and demonstrates striving at perfection; use
open spaces or PUBLIC places where help verbal and intellectual defenses
would not be immediately available (trains, ● Acknowledge positive reinforcement
tunnels, crowds, buses)
● A client with agoraphobia who is already NURSING IMPLEMENTATION
able to go outside the house indicates a
positive response to therapy. ● Provide for physical safety (1st); meet
● Expected outcome for agoraphobia physical needs
includes going out to see the mailbox ● Accept, allow ritualistic activity; DO NOT
● Social phobia: Fear of public speaking or INTERFERE with it; (The best time to interfere
situations in which public scrutiny may occur with ritual is after client has completed it.)
● Simple phobia: Fear of specific objects, Accept behavior but set limits on length and
animals or situations frequency of the ritual. Offer alternative
activities; support attempts to reduce
NURSING IMPLEMENTATION dependency on the ritual; guide decisions
o Just set a time when to perform the
● Recognize the client’s feelings about ritualistic behavior (time
phobic object/ situation management)
o Specific precipitants are present with o Do not stop, because it will increase
phobia anxiety
● Avoid confrontation and humiliation; ● Provide structured environment, minimize
Provide constant support (Stay with client choices
during an attack) if exposure to phobic ● Provide socialization, group therapy
object or situation cannot be avoided ● Administer CLOMIPRAMINE (ANAFRANIL) as
● Do not focus on getting patient to stop ordered
being afraid o A Tricyclic antidepressant used in
● Provide relaxation techniques phobias, anxiety and
● Implement behavioral therapy: SYSTEMIC obsessive-compulsive disorder;
DESENSITIZATION (the #1 treatment for SIDE-EFFECTS/ ADVERSE REACTIONS:
PHOBIA). Administer antidepressants as Tachycardia, cardiac arrest, dizziness,
ordered tremors, seizures, CONTRAINDICATIONS:
Pregnancy, hypersensitivity;
OBSESSIVE-COMPULSIVE DISORDER Interactions/Incompatibilities:
Hypertensive crisis, convulsions, with
● A psychiatric disorder characterized by MAOIs
persistent, recurring anxiety-provoking
thoughts and repetitive acts; Unconscious
control of anxiety by the use of rituals and POST-TRAUMATIC STRESS SYNDROME
thoughts ● A disorder following exposure to extreme
o OBSESSION: Persistent, repetitive, traumatic event (wars, rape, natural
uncontrollable thoughts catastrophes) causing intense fear,
▪ These are thoughts that are recurring distressing recollections and
recurring in the mind nightmares
▪ Thoughts that keeps a o Retained in the patient’s mind
patient preoccupied, thus, o They are detached because they do
affects ADLs not know who to trust anymore. They
 think that people who surround them with a loss or alteration of physical
are going to do something bad functioning
● ASSESSMENT: 2 Cardinal Sign: FLASHBACK & ● Involves a person having a significant focus
NIGHTMARES. Images, thoughts, feelings → on physical symptoms, such as pain,
intense fear and horror, sleep disturbances. weakness or shortness of breath, that results
o Depression, or irritability or outburst of in major distress and/or problems
anger functioning. The individual has excessive
o Exaggerated startle response; Poor thoughts, feelings and behaviors relating to
impulsive control the physical symptoms
o Avoidance; Inability to maintain ● When validated by laboratories it is not
intimacy; Hypervigilance confirmed to be true
o The two cardinal signs should be present
in order to diagnose PTSD CONVERSION DISORDERS
● PRIORITY NURSING DIGNOSIS ● A psychological condition in which an
o Altered Sleeping Patterns anxiety-provoking impulse is converted
o Altered Skin Integrity unconsciously into functional symptoms
o Ineffective Individual Coping ● Anxiety is converted to physical symptoms
NURSING INTERVENTATION ● Patients with this disorder do not fake the
o Encourage VERBALIZATION about painful physical signs and symptoms
experience. Show empathy; be ● Physical symptoms can be confirmed
non-judgmental; Help feel safe. through diagnostic tests
o To prevent level of anxiety ● Does not do hospital-hopping because the
o Rational emotive-therapy; Allow to grieve doctor will validate that the symptoms are
o Help client identify, label and express real
feelings safely
o If they have difficulty in sharing the HYPOCHONDRIASIS
experience their level of anxiety may ● Presentation of unrealistic or exaggerated
increase physical complaints
● Enhance support systems: Self-help groups, ● When a patient complains of backache
family psychoeducation, and socialization. and thoughts of it as bone cancer
o In a rape victim, a statement like, “If I should
not have worn that red panty, it won’t DISSOCIATIVE DISORDERS
happen to me”, shows denial ● Dissociative amnesia
o Statement of a rape patient who is ● Dissociative fugue
beginning to resolve trauma includes, “I’m ● Depersonalization
able to tell my friends about being raped.” ● Dissociative Identity Disorder/Multiple
o An RN needs further teaching about caring Identity Disorder
for a post-traumatic client when she keeps ● These disorders are still because of anxiety
on asking the client to describe the trauma
that caused patient’s distress after DISSOCIATIVE AMNESIA
recovering from a PTSD ● Characterized by the inability to recall an
SOMATOFORM DISORDERS extensive amount if important personal
● Body Dysmorphic Disorder information because of physical or
● Somatization psychological trauma
● Conversion Disorders ● Once the patient has recovered from the
● Hypochondriasis crisis, the memory of the patient will return
● Psychogenic Pain
● This are all caused by anxiety DISSOCIATIVE FUGUE
● The person suddenly and unexpectedly
BODY DYSMORPHIC DISORDER leaves home or work and is unable to recall
● Preoccupation with an imagined defect in the past
his or her appearance ● If the patient moves from one country to
● A perceived distortion to the physical body another the patient will not be able to recall
● This is not made up by the client but this is the previous life and the previous country he
what he/she sees has been in
● Characterized by reversible amnesia for
SOMATIZATION personal identity, including the memories,
● A client expresses emotional turmoil or personality, and other identifying
conflict through a physical system, usually characteristics of individuality. The state can
last days, months or longer.
 THE FOUR A’s of SCHIZOPHRENIA
DEPERSONALIZATION ACCORDING TO BLEULER
● Person experiences a strange alteration in ASSOCIATIONS, LOOSE: Jumping to
the perception or experience of the self, different topics WITHOUT association or
often associated with a sense of unreality relevance
● Depersonalization/derealization disorder is a AMBIVALENCE (Two opposing
type of dissociative disorder that consists of A thoughts/feelings toward others at the
persistent or recurrent feelings of being same time)
detached (dissociated) from one’s body or AUTISM (withdrawal from environment and
mental processes, usually with a feeling of others) → magical thinking, neologism,
being an outside observer of one’s life aloofness, echolalia)
(depersonalization), or of being detached AFFECT, FLAT (Inappropriate or no display
from one's surroundings (derealization). of feelings)
● This is not fixed, only temporary. The patient ***should be assessed to diagnose schizophrenia
can still go back to reality
***symptoms should be present for at least 6 months
to confirm schizophrenia
MULTIPLE PERSONALITY DISORDER
***At least 2 positive symptoms and 1 negative
● A person is dominated by at least one of
two or more definitive personalities at one symptoms\
time
● Maintenance of at least two distinct and THEORIES
relatively enduring personality states. 1) Increased dopamine –coming from the
The disorder is accompanied by memory substancia nigra
gaps beyond what would be explained by 2) Genetics
ordinary forgetfulness. └ 65% chances- if two parents are
● The person won’t know about the different diagnosed with schizophrenia
personalities unless they are already being
└ 32.5% chances- if 1 parent is diagnosed
treated
with schizophrenia
● Once they verbalize and is conscious of the
multiple personalities it is a sign of progress 3) Drug addicts and alcoholics: High probability for
or recovery schizophrenia due to increase Delusions &
hallucination
Psychotic Disorders 4) Pregnant woman who is a smoker may increase
risk for development of schizophrenia of her
SCHIZOPHRENIA baby
→ Severe impairment of mental & social
functioning with grossly impaired reality testing, CLINICAL MANIFESTATIONS OF SCHIZOPHRENIA
sensory perception and with deterioration & ✔ Characterized by both (-) & (+) symptoms &
regression of psychosocial functioning. social / occupational dysfunction for at least SIX
→ Schizo = Split (6) months.
→ Phrenia = Mind ✔ Patient with 5 admissions in 2 yrs is considered a
→ Dopamine is increased chronic schizophrenia
└ Dopamine is responsible in cognitive ✔ (+) POSITIVE SIGNS OF SCHIZOPHRENIA: Due to
function EXCESS DOPAMINE
└ Increased levels will lead to delusions and HILDDA PI
hallucinations o Hallucination
→ #1 HALLUCINATION of Schizophrenia is Auditory. o Illusion
→ Irreversible disease o Looseness of Association
└ It can be managed but not treated o Delusion of Grandeur
└ Intake of antipsychotics drugs is lifetime o Disorientation
└ If intake of medications are stopped, o Agitation
schizophrenia manifestations will return o Paranoia
again o Insomnia
→ Ego is damaged because ego is what keeps ✔ (-) NEGATIVE SIGNS OF SCHIZOPHRENIA: Due to
the patient intact in the reality LACK OF DOPAMINE
POOR A’s
o Poor judgment
 o Poor insight → Developmental Stage FIXATION: ORAL
o Poor self care PHASE (TRUST vs. MISTRUST)
o Alogia [lack of speech caused by a → Defense Mechanism: Projection
disruption in the thought process] → Nursing Care:
o Anhedonia [absence of sexual urges] 1. Consistency to build trust
2. Food: PACKED OR SEALED foods
NURSING DIAGNOSIS FOR NEGATIVE SYMPTOMS OF except canned goods: No metal
SCHIZOPHRENIA: 3. Social Isolation – no group session
1. Alteration in Thought Process when schizophrenic
2. Alteration in Content of Thought 4. At least 4 feet away and in front of
the patient when communicating
✔ OTHER POSITIVE SYMPTOMS: 5. Never touch the patient
All this signs & symptoms can also be seen in → Eg. Paranoid who is suspicious saying, “This
SAM (Schizophrenia, Alzheimer’s & Manic)
place is meant for bugs & prison,” In order to
1. Neologism (creating NEW WORDS) vs. Word
encourage trust, the patient should be
Salad (incoherent mixture of words)
involved in the plan of care.
2. Verbigeration (meaningless repetition of
→ Eg. How will you feed a malnourished
action words and phrases
paranoid schizophrenic patient? Involve
Perseveration
patient in all interventions so that they will
e.g. 1st stimulus → correct response
see that everything is prepared safely with
2nd & following stimulus → still
no harm
responding to
the 1st stimuli
3. Circumstantiality (beating around the bush; 2. CATATONIC
answers but delayed) vs. Tangentiality (did → With stereotyped position (catatonia) with
not answer the stimulus/ question) waxy flexibility, mutism,
→ Usually found in disorganized type of → #1 Cardinal Sign of Catatonia – waxy
schizophrenia flexibility
4. Clang association (use of rhymes in → Most dangerous/serious type of
sentences/words connected) vs. schizophrenia– may die from dehydration
Echolalia/Parroting & → Catatonic stupor – markedly slowed
Echopraxia-involuntary imitation of movement.
movements made by another. o Waxy Flexibility
└ decreased response to stimuli and
5 TYPES OF SCHIZOPHRENIA a tendency to remain in an
1. PARANOID immobile posture
→ Presenting sign is SUSPICIOUSNESS, ideas of └ lack of movement for a prolonged
persecution and delusions period of time
└ sees environment as hostile and └ occurs because the patient is
threatening regressive
→ most difficult to handle because they are o mutism
usually uncooperative → Catatonic hyperactivity or excitability
→ REMEMBER the 4 P’s: → Nursing Responsibility: prevent injury
o Projection (#1 defense mechanism)
attributing one’s own unacceptable 3. DISORGANIZED/ HEBEPHRENIC
feelings & thoughts to others → Characterized with inappropriate behavior:
o Proxemics (4 feet away from the o Silly crying
patient) o Laughing
o P Friendliness (#1 attitude therapy: No o Regression
touching, no whispering & laughing) o Confusion
o Delusion of Persecution (#1 delusion of o disorganized thoughts
Paranoid Schizophrenia) – thinking of o transient hallucinations (Auditory)
being attacked by someone else → Common in women
 → All behaviors are similar with toddlers since
they are anal fixated. *Hindi to kasama sa lecture pa po hehe
→ Developmental Stage FIXATION: Anal ERIK ERICKSON
Fixation PSYCHOSOCIAL THEORY OF DEVELOPMENT
→ #1 Defense Mechanism: Regression &
0-18 mos. TRUST VS. MISTRUST
Fixation ● attachment to mother which lays
foundations for later trust in others
4. UNDIFFERENTIATED/ MIXED ● conflict: general difficulties relating to
→ Symptoms of more than one type of others. suspicion, fear of the future
schizophrenia has delusions & disorganized
behavior
→ The #1 drug of choice is Fluphenazine 18 mos-3 yrs AUTONOMY VS. SHAME/DOUBT
● Gaining some basic control of self and
(Prolixin decanoate)
environment
● Conflict: independence-fear conflict, severe
5. RESIDUAL feelings of self-doubt
→ No longer exhibits overt symptoms, no more
delusions but the signs and symptoms may 3 yrs-6 yrs INITIATIVE VS. GUILT
comeback due to non-compliance with ● becoming purposeful and directive
drug intake ● conflict: aggression-fear conflict, sense of
→ No more PO drugs, IV drugs are now given inadequacy and guilt
→ Nursing care: consistency
→ Give antipsychotic –hallucination / delusion
6 yrs-12 yrs INDUSTRY VS. INFERIORITY
→ Undifferentiated type chronic schizophrenia ● Developing social, physical and school skills,
must be referred to a program promoting competence
social skills due to functional loss deficit ● Conflict: sense of inferiority, difficulty
learning and working
PRINCIPLES OF CARE FOR SCHIPHRENIA
1. Maintenance of safety: 12 yrs-20 yrs IDENTITY VS. ROLE DIFFUSION
→ Protect from altered thought processes. ● Making transition from childhood to
→ Respond to feelings, and not to delusions adulthood, developing a sense of identity
● Conflict: confusion of who one is, identity
→ Do not argue
submerged in relationships or group
→ Validate reality memberships
→ Remove from areas of tension
→ Eg. Appropriate action of RN to a 21 yrs -35 yrs INTIMACY VS. ISOLATION
Schizophrenic who yells loudly, talks to wall ● establishing intimate bonds of love and
and saying “Don’t talk to me, bastard.” friendship
includes walking towards the pt & ask him ● conflict: emotional isolation
who he is talking to.
2. Meeting of physical needs
35 yrs-55 yrs GENERATIVITY VS. STAGNATION
→ May have to be fed / bathe initially ● fulfilling life's goals that involve family, career
3. Establishment and maintenance of therapeutic and society, developing concerns that
relationship embrace future generations
→ Engage in individual therapy ● conflict: self-absorption. Inability to grow as
→ Promote trust a person
→ Encourage expression by verbalizing the
observed 55 yrs-above INTEGRITY VS. DESPAIR
● looking back into one’s life and accepting
→ Offer presence-Tolerate long silences
its meaning
4. Implementation of appropriate family, group, ● conflict: dissatisfaction with life, denial of or
social or diversional therapies despair over prospect of death
→ Patients with schizophrenia need activities
that do not require interaction, so solitary JEAN PIAGET
activities are preferred over team activities. COGNITIVE THEORY OF DEVELOPMENT

ASSIMILATION
 ● people transform incoming information so ● moderate anxiety leads to uncertainty and
that it fits within their existing schemes or insecurity
thought patterns ● severe anxiety results in self-defeating
patterns of behavior
ACCOMMODATION ● 18 months to 6 years
● people adapt their schemes to include
incoming information JUVENILE
● severe anxiety may result in a need to
PIAGET’S COGNITIVE THEORY control or restrictive, prejudicial attitudes
learns to negotiate own needs
SENSORIMOTOR STAGE ● 6 to 9 years
● development proceeds from reflex activity
to representation and sensorimotor solutions PRE-ADOLESCENCE
to problems ● capacity to attachment, love and
● 0 to 18 months collaboration emerges or fails to develop
● move to genuine intimacy with friend of the
PRE-OPERATIONAL STAGE same sex
● development proceeds from sensorimotor ● 9 to 12 years
representation to prelogical thought and.
solutions to problems can use these ADOLESCENCE
representational skills only to view the world ● if self-system is intact, areas of concern
from their own perspective. expand to include values, career decisions
● Understand the meaning of symbolic and social concerns
gestures ● lust is added to interpersonal equation
● 2 to 7 years ● need for special sharing relationship shifts to
opposite sex
CONCRETE OPERATIONAL ● new opportunities for social experimentation
● development proceeds from prelogical lead to consolidation or self-ridicule
thought to logical solutions to concrete ● 12 to adulthood
problems
● understand concrete problems
● cannot yet contemplate or solve abstract
problems
● 7 to 12 years HILDEGARD PEPLAU
NURSE PATIENT RELATIONSHIP
FORMAL OPERATIONAL
● development proceeds from logical PEPLAU'S NPR
solutions to concrete problems to logical
solutions to all PRE-INTERACTION
● classes of problems ● Major task of nurse- to develop
● cannot yet contemplate or solve abstract self-awareness
problems
● can also reason theoretically ORIENTATION
● 12 and above ● Major task of the nurse: to develop a mutual
acceptable contract
HARRY STACK SULLIVAN
INTERPERSONAL THEORY WORKING
● Major task: identification and resolution of
SULLIVAN'S INTERPERSONAL THEORY patient's problem

INFANCY TERMINATION
● anxiety develops as a result of unmet needs ● Major task: to assist the patient to review
by the mother (bodily needs); needs met, what he has learned and transfer his
the child has sense of well-being learning to his relationship with others
● 0 to 18 months
THERAPEUTIC COMMUNICATIONS
CHILDHOOD
● anxiety as a result of lack of ORIENTATION
praise/acceptance from parents ● Broad Opening
● gratification leads to positive self-esteem ● Recognition
 ● Giving information ● Asking the client to verbalize what he or
● Silence perceives
● Offering Self - "Do you want me to sit beside ● E.g., “Tell me when you feel anxious”
you?” “What is happening?”
“What does the voice seem to be
WORKING saying?”
● Focusing - "Let us discuss this topic more”
● Exploring - "Tell me more about it.” ENCOURAGING EXPRESSION
● Encourage Evaluation - "IS this what you ● Asking client to appraise the quality of his or
want?” her experience
● Reflecting - same idea ● e.g., “what are your feelings in regard to...?”
● Restating - same statement “Does this contribute to your
● Verbalizing Implied - "Are you going to kill distress?”
yourself?"
● Seeking Clarification – “May you please EXPLORING
repeat that statement” ● Delving further into a subject or idea
● General lead - "Please continue.”; “And ● e.g., "Tell me more about that.”
then?” “Would you describe it more fully?”
● Limit setting - "Stop" “What kind of work?”
● Interpreting - "Maybe that thing is very
significant to you.” FOCUSING
● Concentrating on a single point
TERMINATION ● e.g., "This point seems worth looking at more
● Summarizing – “Let us now sum up. You closely"
have stated earlier... etc.” “Of all the concerns you've
● “Do you have any questions?” mentioned, which is most
● “Our next therapy...” troublesome?”
● Look for changes in behavior
● Resistance is a common problem FORMULATING A PLAN OF ACTION
● Asking the client to consider kinds of
THERAPEUTIC COMMUNICATION TECHNIQUES behavior likely to be appropriate in future
situations
● Accepting-indicating reception ● e.g., "What could you do to let your anger
● E.g., “Yes" out harmlessly?"
“I follow what you said” “Next time this comes up, what
Nodding might you do to handle it?"

BROAD OPENINGS GENERAL LEADS

● Allowing the client to take the initiative in ● Giving encouragement to continue
introducing the topic ● e.g., "Go on”
● e.g., "is there something you'd like to talk “And then?"
about?” "Tell me about it”
“Where would you like to begin?”
GIVING INFORMATION
CONSENSUAL VALIDATION ● Making available the facts that the client
● Searching for mutual understanding, for needs
accord in the meaning of the words ● E.g., “My name is…”
● e.g., "Tell me whether my understanding of it “Visiting hours are…”
agrees with yours” “My purpose in being here is…”
“Are you using this word to convey
that…?” GIVING RECOGNITION
● Acknowledging, indicating awareness
ENCOURAGING COMPARISON ● E.g., “Good morning, Mrs. S…”
● Asking that similarities and differences be “You’ve finished your list of things to
noted do.”
● e.g., "was it something like...? “I noticed that you’ve combed your
“Have you had similar experiences?” hair”

ENCOURAGING DESCRIPTION OF PERCEPTIONS MAKING OBSERVATIONS

● Verbalizing what the nurse perceives
 ● E.g., “You appear tense…” ● E.g., “Have I got this straight?”
“I notice that you’re biting your lips”
TRANSLATING INTO FEELINGS
OFFERING SELF ● Seeking to verbalize client’s feelings that he
● Making oneself available or she expresses only indirectly
● E.g., “I’ll sit with you awhile.” ● E.g., Client: “I’m dead”
“I’ll stay here with you” Nurse: “Are you suggesting that you
“I’m interested in what you think feel lifeless?”

PLACING EVENT IN TIME OR SEQUENCE VERBALIZING THE IMPLIED

● Clarifying the relationship of events in time ● Voicing what the client has hinted at or
● E.g., “What seemed to lead up to…?” suggested
“Was this before or after?” ● E.g., Client: “I can’t talk to you or anyone.
It’s a waste of time.”
PRESENTING REALITY Nurse: “Do you feel that no one
● Offering for consideration that which is real understands”
● E.g., “I see no one else in the room”
“Your mother is not here; I am a VOICING DOUBT
nurse” ● Expressing uncertainty about the reality of
the client’s perceptions
● “isn’t that unusual?”
REFLECTING “really?”
● Directing client actions, thought, and feeling “that’s hard to believe”
back to the client
● E.g., Client: “Do you think I should tell the NONTHERAPEUTIC COMMUNICATION TECHNIQUES
doctor…? ● Advising – telling the client what to do
Nurse: “Do you think you should?” Agreeing – indicating accord with the client
● E.g., “I think you should…”
RESTATING “That’s right”
● Repeating the main idea expressed
● E.g., Client: “I can’t sleep. I stay awake all AGREEING
night” ● Indicating accord with the client
Nurse: “You have difficulty sleeping” ● “that’s eight.” “I agree”
Client: “I’m really mad, and upset”
Nurse: “You’re really mad and BELITTLING FEELINGS EXPRESSED
upset” ● Misjudging the degree of the client’s
comfort
SEEKING INFORMATION ● Client: “I have nothing to live for… I wish I
● Seeking to make clear that which is not was dead”
meaningful or that which is vague Nurse: “Everybody gets down in the dumps”
● “I’m not sure that I follow”
“Have I heard you correctly?” CHALLENGING
● Demanding proof from the client
SILENCE ● “But how can you be president of the
● Absence of verbal communication, which Philippines?”
provides time for the client to put thought
or feelings into words, regain composure, DEFENDING
or continue talking ● Attempting to protect someone or
● E.g., nurses say nothing but continues to something from verbal attack
maintain eye contact and conveys interest ● “this hospital has a fine reputation”

SUGGESTING COLLABORATION DISAGREEING

● Offering to share, to strive, to work with the ● Opposing the client’s ideas
client for his or her benefit ● E.g., “that’s wrong”
● E.g., “perhaps you and I can discuss and
discover the triggers for your anxiety” DISAPPROVING
● Denouncing the client’s behavior or ideas
SUMMARIZING ● “that’s bad”
● Organizing and summing up that which has “I’d rather you wouldn’t”
gone before
GIVING APPROVAL ● Underloading – ignoring
● Sanctioning the client’s behavior or ideas ● Value Judgement – use of adjectives
● “that’s good.” “I’m glad that…” ● False Reassurance – “Don’t worry, you will
be fine later”
GIVING LITERAL RESPONSES ● Focusing on Self – “I gave you meds so you
● Responding to a figurative comment as are now feeling good”
though it were a statement of fact ● Incongruence
● Client: “They’re looking in my head with ● Internal Validation – biased judgement
television camera” ● Giving Advice – “If I were you, I’ll…”
Nurse: “Try not to watch television” ● Changing Subject

INDICATING EXISTENXE OF AN EXTERNAL SOURCE LOSS AND GREIVING

● “What makes you say that?”
GRIEF – refers to the subjective emotions and affect
INTERPRETING that are a normal response to the experience of loss
● Asking to make the conscious that which is
unconscious ANTICIPATORY GRIEVING – when people facing an
● “what you really mean is…” imminent loss begin to grapple with the very real
possibility of the loss or death in the near future
INTRODUCING AN UNRELATED TOPIC
● Changing the subject DISENFRANCHISED GRIEVING - grief over a loss that
● Client: “I’d like to die.” is not or cannot be acknowledged openly,
Nurse: “did you have visitors last night?” mourned publicly or supported socially

MAKING STEREOTYPED COMMENTS COMPLICATED GRIEVING – when a person is void of

● Offering meaningless cliché or trite emotion, grieves for prolonged periods, has
comments expressions of grief that seem disproportionate to
● “keep your chin up” the event
“just have a positive outlook”
LOSS
PROBING ● Physiologic loss
● Persistent questioning of the client ● Safe and security loss
● “now tell me about this problem. I need to ● Love and belongingness loss
know” ● Self-esteem loss
● Self-actualization loss
REASSURING
● Indicating there is no reason for anxiety GRIEVING PROCESS
● “everything will be alright” ● Denial
● Anger
REJECTING ● Bargaining
● Refusing to consider or showing contempt ● Depression
for the client’s behavior, ideas ● Acceptance
● “let’s not discuss…”
● Dysfunctional Grieving – grieving which
REQUESTING AN EXPLANATION extends from 4 to 6 weeks leading to CRISIS
● Asking the client to provide reasons for
thoughts, feelings, behaviors, events INTERVENTIONS
● “why do you think that?” ● Explore client’s perceptions and meaning of
the loss
TESTING ● Allow adaptive denial
● Appraising the client’s degree of insight ● Assist client to reach out for and accept
● “do you know what kind of hospital this is?” support
● Encourage client to examine patterns of
USING DENIAL coping in past and present situation of loss
● Refusing to admit that a problem exists
● Encourage client to care for themselves
● Client: “I am nothing”
● Offer client food without pressure to eat
Nurse: “Of course, you’re something”
● Use effective communication
NON-THERAPEUTIC COMMUNICATIONS CRISIS AND ITS MANAGEMENT
● Overloading – “blah, blah, blah”
 ● Change is achieved by the exploration of
CRISIS feelings, attitudes, thinking behavior and
● Situation that occurs when an individual’s conflict
habitual coping ability becomes ineffective
to merit demands of a situation SEVEN SUBTYPES

TYPES OF CRISES CLASSICAL PSYCHOANALYSIS

● MATURATIONAL/DEVELOPMENTAL: normal ● Based on Freud’s theory
expected crisis that runs through age ● To uncover unconscious feelings and
● SITUATIONAL: an expected and sudden thoughts that interfere with the client’s living
event in life a fuller life
● ADVENTITIOUS: calamities, war ● Free association – client is encouraged to
say anything that comes to mind, without
CHARACTERISTICS OF A CRISIS STATE censoring thoughts or feelings
● Highly individualized ● Dream analysis
● Lasts for 4-6 weeks ● Working through (transference) – process of
● Self-limiting repeated interpretation to the person of his
● Person affected becomes passive and or her unconscious processes has the effect
submissive of bringing about change
● Affects a person’s support system
PSYCHOANALYTICAL PSYCHOTHERAPY
PHASES OF A CRISIS ● Uses dream analysis, transference and free
● PRE-CRISIS: state if equilibrium association
● INITIAL IMPACT (may last a few hours to a ● Therapist is much more involved and
few days): high level of stress, helplessness, interacts with the client more freely
inability to function socially ● Done through intimate professional
● CRISIS (may last a brief or prolonged period relationship between the nurse/therapist
of time): inability to cope, projection, denial, and the client over a period of time
rationalization (introductory, working and termination
● RESOLUTION: attempts to use phase)
problem-solving skills
● POST CRISIS: may have OLOF or may have SHORT TERM DYNAMIC PSYCHOTHERAPY
symptoms of neurosis, psychosis ● Indication – persons with specific symptom
or interpersonal problem that he/she wants
CRISIS MANAGEMENT to work on
● Role of the nurse is to return the client to its ● Therapist directs the content
pre-crisis state by assisting and guiding them ● Use of transference and dream analysis
until they achieved their OLOF ● Weekly sessions (total number – 12 to 30)
● Goal: to enable patient to attain an OLOF ● Successful for highly motivated individuals
● Nurse’s Primary Role: active and directive who have insight and with positive
relationship with the therapist
STEPS IN CRISIS INTERVENTION
● Identify the degree of disruption the client is TRANSACTIONAL ANALYSIS
experiencing ● Eric Berne
● Assess the client’s perception of event ● Each person has three ego states and
● Formulate nursing diagnoses change from one to another frequently
● Involve the patient and family if applicable ● Parent – concepts of standards of behavior
with planning and how things should be done.
● Implement interventions – new and old o E.g., go and take out the garbage
coping mechanisms ● Adult – rational thinking and data analyzing
● Evaluate – reassessment, reinforcement part of the personality.
o E.g., would you please take out the
TYPES OF THERAPIES garbage
TREATMENT MODALITIES ● Child – feelings associated with persons,
things or incidents represent the
INDIVIDUAL PSYCHOTHERPAY need-gratifying aspects of the personality
● One to one relationship between therapist o E.g., is this why you married me? To be
and client your garbage man?
● For dissociative, anorexia, paranoid, ● For group, family and individual
narcissistic
 ● Client to identify ego states for each given ● Freedom of movement and informality
situation relationships with staff
● Rewarding of positive or negative behaviors ● Emphasis on interdisciplinary participation
with strokes ● Goal-oriented, clear communication
● Client work through these behaviors
GROUP THERAPY
COGNITIVE PSYCHOTHERAPY ● Number of people coming together, sharing
● Restructuring or changing ways in which a common goal, interest or concern, staying
people think about themselves together and developing relationships
● Thought stopping ● For PTSD and alcoholics
● Positive self-talk ● Phases
● DE catastrophizing o Orientation
● Therapists help patients identify these o Working
thoughts o Termination

BEHAVIORAL THERAPY CHARACTERISTICS OF GROUP THERAPY

● Changes in maladapted behavior can ● Universality → “you are not alone”
occur without insight into the underlying ● Instilling hope and inspiration
cause ● Developing social skills by interacting with
● Based on learning theory one another
● Modeling ● Feeling of acceptance and belonging
● Operant conditioning ● Altruism → “giving of one’s self
● Self-control therapy – combination of
cognitive and behavioral approaches FAMILY THERAPY
“talking to self” ● Psychoanalytically oriented group therapy
● Systemic desensitization ● Psychodrama
● Aversion therapy ● Family therapy

GESTALT THERAPY ASSUMPTION OF FAMILY THERAPY

● Emphasis on the “here and now” ● Client: whole family
● Only present behavior can be changed, not ● Concepts:
history o The family is the most fundamental unit
● Uncover repressed feelings and needs of the society
● Techniques: have a person behave the o Adaptive or maladaptive patterns of
opposite of the way he/she feels, presuming behavior are learned from the family
that a person can then come in contact o Dysfunction in the family = dysfunction in
with a submerged part of the self; in dreams, the individual
person is asked to play roles of persons in ● Purpose
the dream to get in touch with different o Improve relationships among family
repressed feelings members
o Promote family function
MILIEU THERAPY o Resolve family problems
● Total environment has an effect on the
individual’s behavior OTHER TYPES OF THERAPIES
● Components
o Physical environment SUPPORT GROUPS
o Interpersonal relationships ● For those with AIDS, Mother-Against-Drug
o Atmosphere of safety, caring, and Dependence
mutual respect
o For alcoholics SELF-HELP GROUPS
● Alcoholic Anonymous
PROGRAMS FOR MILIEU SHOULD HAVE:
● An emphasis on group and social RULES FOR PSYCHOTHERAPEUTIC MANAGEMENT
interaction ● Provide support, treat patients with respect
● No rules and expectations mediated by and dignity
peer pressure ● Do not place patients in situations wherein
● A view of patients’ roles as responsible they will feel inadequate or embarrassed
human beings ● Treat patients as individuals
● An emphasis on patients’ rights for ● Provide reality testing
involvement in setting goals ● Handle hostility therapeutically
 ● Provide psychopharmacologic treatment ● O2 therapy of 100% until patient can
breathe unassisted
BEHAVIORAL THERAPIES ● Monitor for respiratory problems, gag reflex
TREATMENT MODALITIES ● Reorient patient
● Observe until stable
● Pavlov’s Classical Conditioning: All ● Careful documentation
behaviors are learned ● Male erectile dysfunction
● B.F. Skinner’s Operational Conditioning:
Reinforcements OTHER THERAPIES
● Behavioral Conditioning: substance abuse ● Neurosurgery
● Token Economy: anorexia/schizo
● Systematic Desensitization: phobia ANXIETY

ATTITUDE THERAPY PEPLAU’S LEVEL OF ANXIETY

TREATMENT MODALITIES
MILD
1. Paranoid – passive friendliness ● Associated with the tension of day to day
2. Withdrawn – active friendliness living
3. Depressed/Anorexia – kind firmness ● Perceptual field increased
4. Manipulative – matter of fact ● More alert than usual
5. Assaultive – no demand ● Adaptive
6. Anti-social – firm, consistent

PSYCHOSOMATIC THERAPY
TREATMENT MODALITIES
MODERATE
ELECTROCONVULSIVE THERAPY ● Narrowed perception
● Effective in most affective disorders ● Difficulty focusing
● The induction of a grandmal seizure in the ● Selective inattention
brain ● Mild somatic complaints: stomachache and
● Abnormal firing of neurons in the brain butterflies in the stomach
causes an increase in neurotransmitters
● Number of Treatments: 6-12, 3 times a week, INTERVENTIONS FOR MILD TO MODERATE ANXIETY
about .5-2 seconds ● Assist the client in identifying anxiety
● Unilateral or bitemporal ● Anticipate anxiety provoking situations
● Use nonverbal language to demonstrate
Indications: interest
● Patients who require rapid response ● Encourage the client to talk about his or her
● Patients who cannot tolerate feelings
pharmacotherapy or cannot be exposed to ● Avoid closing off avenues of
pharmacotherapy communication (refraining from offering
● Patients who are depressed but have not advice or changing the topic)
responded to multiple and adequate trials ● Encourage problem-solving
of medication ● Explore past and present coping behaviors
● Provide outlets for working off excess energy
Preparations for ECT:
● Pretreatment evaluation and clearance LEVELS OF ANXIETY
● Consent
● NPO from midnight until after the treatment SEVERE
● Atropine Sulfate – to decrease secretions ● Very narrowed perception
Succinylcholine (Anectine) – to promote ● Unable to focus on problem solving
muscle relaxation ● Increased physical discomfort
Methohexital Sodium (Brevital)- anesthetic ● All behavior is aimed at relieving anxiety
● Empty bladder ● Direction is needed to focus attention
● Remove jewelry, hairpins, dentures and
other accessories PANIC
● Check vital signs ● Awe, dread and terror
● Unable to see the whole situation or reality
Care after ECT: ● Distortion of perception
● Disorganization of the personality
 ● A frightening and paralyzing experience ● Difficulty in controlling the worry
● Anxiety and worry are evident by 3 or more
INTERVENTIONS FOR SEVERE AND PANIC LEVELS OF of the following:
ANXIETY o Restlessness, keyed up
● Maintain a calm manner o Fatigue and irritability
● Remain with the person o Decreased ability to concentrate
● Minimize environmental stimuli o Muscle tension
● Reinforce reality o Disturbed sleep
● Listen for themes in communication ● Anxiety or worry causes significant
● Attend to physical safety and medical impairment in interpersonal relationship or
needs first activities of daily living
● Physical limits may need to be set
● Provide opportunities for exercising POST TRAUMATIC STRESS DISORDER
● Assess the person’s need for mediation or ● Disturbing pattern of behavior occurring
seclusion after a traumatic event that is outside the
range of usual experience
ANTI-ANXIETY DRUGS
● Valium Characteristics
● Librium ● Persistent re-experiencing of the trauma
● Ativan through recurrent intrusive recollections of
● Serax the event, through dreams or flashbacks
● Tranxene ● Persistent avoidance of the stimuli
● Miltown ● Feeling of detachment of estrangement
● Equanil from others
● Vistaril ● Chemical abuse to relieve anxiety
● Atarax
● Inderal PHOBIAS
● Xanax
● Buspar Definition
● Persistent, irrational fear of a specific object,
ANTI-ANXIETY DRUGS activity or situation that leads to a desire for
● Used only in a short time (1-2 weeks) avoidance of the object of fear
● Tolerance (after 7 days) and dependence
(after 1 month) Specific Phobia
● Liver function test ● Experience of high level of anxiety or fear
● Monitor side effects provided by a specific object or situation
● Avoid machines, activities needing
concentration Treatment
● Z tract if given parenterally ● Systematic Desensitization
● Avoid mixing with alcohol, antihistamines,
antipsychotics Defense Mechanisms
● Don’t stop abruptly but gradually for 2-6 ● Repression and displacement
weeks
● Avoid caffeine MAJOR TYPES OF PHOBIAS

CATEGORIES OF ANXIETY DISORDERS AGORAPHOBIA

● Basic Anxiety Disorders ● Comes from the Greek word “agora”
● Somatoform Disorders ● Meaning “market place”
● Dissociative Disorders ● Fear of being alone in open or public
spaces
BASIC ANXIETY DISORDERS
● Generalized Anxiety Disorder SOCIAL PHOBIA
● Panic ● Fear of situations where one might be seen
● Phobia and embarrassed or criticized
● PTSD
● Obsessive Compulsive SPECIFIC PHOBIAS
● Fear of a single object, situation or activity
GENERALIZED ANXIETY DISORDER that cannot be avoided
● Excessive worry and anxiety for days but not
more than 6 months OBSESSIVE COMPULSIVE DISORDERS
OBSESSIONS PSYCHOSOMATIC DISORDER
● Preoccupation with persistent intrusive ● True/unconscious because of hormonal and
thoughts, impulses or images bodily changes
● Increase anxiety may result to asthma, stress
COMPULSIONS ulcers or migraine
● Repetitive behaviors or mental acts that the
person feels driven to perform in order to SCHIZOPHRENIA
reduce distress or prevent a dreaded event ● A major form of psychotic disorder that
or situation affects a person’s thinking, language,
emotions, social behavior and ability to
CUES: perceive reality
● Ritualistic behavior ● At least 2 of 5 types of positive and negative
● Constant doubting if he/she has performed symptoms
the activity ● Characteristic Symptoms
● Social or occupational dysfunction
EXAMPLES OBSESSIONS COMPULSIONS o IPR
Washing “Wash away my Young woman o Self-care
or sins.” Thought repeatedly ● Duration
cleaning appeared after washes hands o Continuous for at least 6 months
sexual encounter
with a married POSITIVE AND NEGATIVE SYMPTOMS
man
Need for “Everything must Arranges and POSITIVE SYMPTOMS
order be in place” rearranges items ● Hallucinations
Germs or “Everything is Avoids touching ● Delusions
dirt contaminated” all objects. ● Illusions
Scrubs hands if ● Abnormal thought patterns or perceptions
she is forced to ● Bizarre behavior
touch any
object NEGATIVE SYMPTOMS
Symmetry “Secretaries who Secretary lines ● Affective flattening
practice up objects in ● Anhedonia
neatness never rows on her ● Attention impairment
gets fired” desk, then ● Asocial behavior
realigns them ● Anergia
repeatedly ● Autism
during the day ● Avolition

CARE STRATEGIES DELUSIONS

● Be nonjudgmental and honest; offer ● Persecutory
empathy and support ● Religious
● Help patient to recognize the connections ● Grandeur
between the trauma experience and their ● Ideas of Reference
current feelings, behaviors and problems
● Encourage verbalizations of feelings, DISTURBED THOUGHT PROCESS
especially anger ● Looseness of association
● Encourage adaptive coping strategies and ● Flight of ideas
techniques ● Ambivalence
● Encourage patients to establish or ● Magical thinking
reestablish relationships ● Echolalia/Echopraxia
● Explore shattered assumptions. “I’m a good ● Word salad
person. This is a safe world” ● Neologism
● Promote discussion of possible meaning of ● Thought blocking
events ● Concrete association

BLEULER’S FOUR A’s OF SCHIZOPHRENIA

● Affective disturbances
 ● Autism ● Disturbed sensory process
● Associative looseness ● Risk for self-directed violence
● Ambivalence ● Risk for other directed violence
● Other A’s
o Attention deficits ● Present safety
o Disturbances of activities ● Present reality

SCHIZOPHRENIA ANTI-PSYCHOTIC
● Brief Psychotic Disorder – may be seen when ● Tara, look natin sina Stella, Mel, at Thor na
a person exhibits clinical symptoms of nag mo-moulin rogue… sssh, alam niyo ba
illogical thinking, incoherent speech, na ang trio na yan na akala mo may halo
delusions, or disorganized behavior after ay mga closet queens pala…, namen”
psychological trauma ● Taractan, Loxitane, Stelazine, Mellaril,
● Induced Psychotic Disorder – develops in a Thorazine, Molindone, Seroquel, Serlect,
second person as a result of a close Trilafon, Haloperidol, Clozapine, Navane
relationship with a person who has psychosis
● Delusional Psychotic Disorder ● Stelazine
● Schizoaffective Disorder – characterized by ● Serentil
depression or elation as the psychosis ● Thorazine
symptoms of schizophrenia and MDD ● Trilafon
● Schizophreniform – when a person exhibits ● Clorazil
features of schizophrenia for more than one ● Millaril
week but less than 6 months ● Haldol
● Risperidol
SUBTYPES: ● Prolixin

Paranoid – most common form if the illness ANTI-PSYCHOTIC DRUGS

Suspicious Watch for side-effects
● Promote trust ● Increase v/s
● Short interaction but frequent ● Constipation/dry mouth
● Food in containers (sealed) ● Postural hypotension
● Prepare food in front of them ● Photophobia/photosensitivity
● Let them see preparation of drugs ● Drowsiness
● Agranulocytosis
Violent ● Extrapyramidal symptoms
● Keep door open o Parkinson’s syndrome
● Position near door and with distance of 1 o Akathisia
arm length (patient-nurse) o Akinesia
● Don’t touch o Dystonia – oculogyric crisis, torticollis,
● Maintain eye contact opisthotonos
o Tardive dyskinesia
Disorganized – absence of systematized delusions; o NMS
presence of incoherence and inappropriate affect
● Inappropriate, flat affect UNDESIRABLE EFFECTS
● Hebephrenic, flight of ideas ● S-edation/sunlight sensitivity/sleepiness
● T-ardive dyskinesia
Catatonic ● A-nticholinergic/agranulocytosis/akathisia
● Risk for suicide ● N-euroleptic malignant syndrome
● Catatonic stupor, rigidity ● C-ardiac effects (orthostatic hypotension)
● Waxy flexibility ● E-xtrapyramidal (dystonia)

PARKINSONISM
Undifferentiated ● Motor retardation or akinesia characterized
● Unclassified by mask-like appearance, rigidity, tremors,
“pill-rolling”, salivation
Residual ● Generally occurs after 1st week of treatment
● No more positive symptoms but withdrawn or before second month
● Administer anticholinergic agent,
NURSING PROCESS anti-Parkinson medication (Akineton)
● Disturbed thought process
AKATHISIA ● Associative looseness
● Constant state of movement, characterized ● Affect – flat
by restlessness, difficulty sitting still, or strong ● Stimulation
urges to move about ● Structure
● Generally occurs two weeks after treatment ● Socialization
begins ● Support
● Rule out anxiety or agitation before
administration of an anticholinergic agent MANIFESTATIONS
S – social isolation
ACUTE DYSTONIC REACTIONS C – catatonic behavior
● Irregular, involuntary spastic muscle H – hallucinations
movement, wryneck or torticollis , facial I – incoherence
grimacing, abnormal eye movements, Z – zero/lack of interest and initiative
backward rolling of eyes on the sockets O – obvious failure in development
● May occur anytime from a few minutes to P – peculiar behavior
several hours after a first dose of H – hygiene and grooming impaired
antipsychotic drug R – recurrent illusions
● Administer anticholinergic agent, have E – exacerbations and remissions
respiratory support equipment available N – no organic factor account S/S
I – inability to return to functioning
TARDIVE DYSKINESIA A – affect is inappropriate
● Most frequent serious side effect resulting
from termination of the drug, during ANTI-PARKINSONIAN DRUGS
reduction in dosage, or after long term high
dose therapy a DOPAMINERGIC DRUGS
● Characterized by involuntary rhythmic, ● To live (Levodopa), you need a car
stereotyped movements, tongue protrusion, (Carbidopa) and a man (Amantadine) not
cheek puffing, involuntary movements of your brother (Bromocriptine) per (Pergolide)
extremities and trunk se (Selegiline)
● Occurs in approximately 2—25% of patients
taking antipsychotics for over two years ANTI-CHOLINERGIC
● No treatment except discontinuation of the ● BACPAK (Benadryl, Artane, Cogentin,
antipsychotic agent Parsidol, Akineton, Kemadrin)
OTHER TREATMENTS
● Psychotherapy – individual, group,
behavioral, supportive or family therapy
NEUROLEPTIC MALIGNANT SYNDROME may be used depending on the clinical
● A potentially fatal syndrome symptoms
● May occur anytime during therapy ● Milieu therapy – a structured environment to
● Seen during the initiation of therapy, minimize environmental and physical stress
change of therapy, after a dosage increase and to meet the individual needs of the
or when a combination of meds is used patients until they are able to assume
● Early sign: rigidity or mental status changes responsibility for themselves
● Catatonia, tachycardia, tachypnea, labile
blood pressure, dysphagia, diaphoresis, CONCEPTS AND PRINCIPLES OF HALLUCINATION
incontinence, rigidity, myoclonus, tremors, ● Possible to replace hallucination with
low grade fevers satisfying interactions
● Discontinue antipsychotic agent. Have ● Can re-learn to focus attention on real
cardiopulmonary support available; things and people
administer skeletal muscle relaxant (e.g., ● Hallucinations originate during extreme
dantrolene) or central acting dopamine emotional stress when the patient is unable
agonist (.e.g., bromocriptine) to cope
● Hallucinations are very real to the patient
NOTES ON SCHIZOPHRENIA ● Patient will react as the situation is
● Distorted EGO perceived
● Disturbed thought process ● Concrete experiences, not argument on
● Disorganized personality confrontation will correct sensory distortion
● Dopamine – increase ● Hallucinations are a substitute for human
● Autism relations
● Ambivalence
BIPOLAR DISORDER Matter of Kind firmness;
MOOD DISORDER/AFFECTIVE DISORDER ATTITUDE THERAPY fact active
● A distinct period of abnormally and friendliness
persistently elevated expansive or irritable
mood lasting at least 1 week LITHIUM
● 3 or more of the following ● Level of lithium (0.5 to 1.5 meq/L)
o Psychomotor overexcitability or ● Increase urination (polyuria)
excitement ● Tremors – fine hand
o Insomnia with fatigued ● Hydration
o Euphoria or elated mood ● Increase peristalsis
o Distractibility ● U2 – 4 weeks effective
o Pressured speech ● Increased bowel movements
o Flight of ideas ● Mouth is dry
o Manipulative or demanding behavior o Assess function of kidney
o Destructive or combative behavior o Toxicity: nausea and vomiting, diarrhea
o Delusions of grandeur
● Risk PHARMACOLOGY MOMENTS
o Female ANTIDEPRESSANTS
o 20 years old and above
o Stressful life ANTIDEPRESSANTS
o Obese ● Asendin
● Norpramin
o Care giver role strain ● Tofranil
● Sinequan
● Anafranil
● Aventil
● Vivactil
● Elavil
● Prozac
MANIA VS DEPRESSION ● Luvox
MANIA DEPRESSION ● Paxil
Colorful, Sad and gray ● Zoloft
APPEARANCE
flamboyant
Psychomotor Psychomotor SSRI
BEHAVIOR
agitation retardation ● Selective Serotonin Reuptake Inhibitor
Pressured Monotonous ● Safest
speech speech ● Side effects are low
COMMUNICATION 1 to 4 weeks
Stuttering ●
Cluttering ● Prozac, Paxil, Zoloft, Luvox
Risk for Injury Risk for Injury
(others) (self) TCA
Nx ● Tricyclic Antidepressants
Suicidal
precaution ● 2 to 4 weeks
Safety and Safety and ● Anticholinergic
NURSING PRIORITY ● Amitriptyline, Nortiptyline, Doxepin
nutrition nutrition
Finger foods Increased in Trimipramine, Amoxapine, Anafranil,
NUTRITION and high in nutrients Venlafaxine
calories
Lithium; ECT TCA; SSRI; MAOI’s
TREATMENT MAOOI’s; ● Increases all neurotransmitters
ECT ● 2 to 6 weeks
● Hypertensive crisis
Non-stimulati Stimulating
● Don’t take:
MILIEU ng
o Avocado
environment
o Aged cheese
Quiet type; Monotonous;
APPROPRIATE o Beer/B6 (tyramine)
non-competi non-competi
ACTIVITY o Chocolate
tive tive
o Fermented foods
o Soy sauce
 o Pickles and preserved foods ● 0-2 home with follow up care
● 3-4 close follow up and possible
A. TCA hospitalization
“knock! Knock! Who’s there? SEVANA to gagah!” ● 5-6 strongly consider hospitalization
-------- (Sinequam, Elavil, Vivactil, Ascendin, ● 7-10 hospitalize
Norpramin, Aventyl, Tofranil)
SITUATION:
B. SSRI ● Charles Brown, age 52 lost his wife in a car
Ngongo: “Paxil ka! Paxil ka! Prozoleta ka lang, kala accident few months ago. Since that time,
ko luv mo ko! (Praxil, Prozac, Zoloft, Luvox) he has been severely depressed and has
taken to drinking to numb the pain
C. MAO ● How many points according to the SAD
“naman, parnate ko pa” (Nardil, Manerix, Parnate) PERSONS SCALE?

SUICIDE
● The intentional act of killing oneself
Suicidal Ideation – means thinking about
oneself
● Passive suicidal ideation – when a person
thinks about wanting to die or wishes he/she THEORIES OF SUICIDE
were dead but has no plans to cause
his/her death (e.g., reckless driving, heavy PSYCHODYNAMIC THEORIES
smoking, overeating, self-mutilation, drug ● Describe suicide as a wish to be at peace
abuse) with the internalized significant person
● Active suicidal ideation – when a person ● Wish to be reunited with a deceased loved
thinks about and seeks to commit suicide object
● Suicide is an attempt to escape from an
SAD PERSON’S SCALE intolerable situation or intolerable state of
● S-Sex. Mean kill themselves 3x more than mind
women though women make attempts 3x
more often than men SOCIOLOGICAL THEORIES
● A-Age. High risk groups: 19 years or younger; ● Durkheim – pioneer of sociological research
45 years or older, especially the elderly 65 in the study of suicide
and above ● 3 Principal Types:
● D-Depression. Studies report that 35-79% of ● Egoistic suicide – occurs when a person is
those who attempt suicide manifested a insufficiently integrated into society
depressive syndrome ● Anomic suicide – occurs when a person is
● P-Previous Attempts. Of those who commit isolated from others through abrupt
suicide, 65-70% have made previous changes in social norms/status
attempts ● Altruistic suicide – occurs as a response to
● E-ETOH. Alcohol is associated with up to 65% societal demands (deaths of Buddhist
of successful suicides monks who set themselves on fire to protest
● R-Rational Thinking Loss. People with the Vietnam war)
functional or organic psychoses are more
apt to commit suicide than those in the BIOCHEMICAL
general population ● Low serotonin levels
● S-Social Support Lacking. A suicidal person
often lacks significant others, meaningful PRECIPITATING FACTORS
employment and religious supports ● Social Isolation – have difficulty forming and
● O-Organized Plan. The presence of a maintaining relationships
specific plan for suicide signifies a person at
high risk Norman Cousins Story:
● N-No Spouse. Repeated studies indicate A woman who committed suicide had
that persons who are widowed, separated, written in her diary every day during the
divorced or single at greater risk than those week before her death “Nobody called
who are married today. Nobody called today. Nobody
● S-Sickness. Chronic, debilitating and severe called today. Nobody called today.
illness is a risk factor Nobody called today…”

SCORING
 ● Severe life’s events – divorce, death, ● Provide structured schedule and involve in
sickness, legal problems, interpersonal activities with others to increase self-worth
discord and divert attention
● Sensitivity to Loss – may react tragically to ● On discharge: help patient create “plan for
separation or loss of a loved one (had Life” (list of warning signs of suicidal ideation
insecure or unreliable childhood and actions to take)
experiences) Always remember:
● That a suicidal person wants to crisis – during
ASSESSING VERBAL AND NONVERBAL CLUES this time the person is ambivalent about
living and dying
VERBAL CLUES: ● Suicidal person gives warning
● Overt Statements: “I can’t take it anymore!”; ● Persons recovering from depression are high
“Life isn’t worth living anymore.”; “I wish I risk for 9-15 months after recovery
were dead.”; “Everyone will be better off if I ● Suicidal people are extremely unhappy but
am dead.” not always mentally ill
● Covert Statements: “It’s ok now, soon
everything will be fine”; “Things will never PERSONALITY BEHAVIORS
work out.”; “I won’t be a problem much
longer.”; “How can I give my body to PERSONALITY PROBLEMS
medical science?” ● Schizoid
● Dependent
NONVERBAL CLUES ● Antisocial
● Behavioral Clues: sudden behavioral ● Avoidant
changes especially when depression is lifting ● Histrionic
and when the person has more energy ● Borderline
available to carry out the plan
● Signs: giving away prized possessions, writing PARANOID PERSONALITY DISORDER
farewell notes, making out a will and putting ● A pervasive pattern of distrust and
personal affairs in order suspiciousness of others such that their
● Somatic Clues: physiological complaints motives are interpreted as malevolent
can mask psychological pain and o Suspicious (e.g., others are exploiting or
internalized stress deceiving him)
● Headaches, muscle aches, trouble sleeping, o Doubt trustworthiness of others
irregular bowel habits, unusual appetite or o Fear of confiding in others
weight loss o Fear personal information will be used
● Emotional Clues: social withdrawal, feelings against him
of hopelessness and helplessness, confusion, o Interpret remarks as demeaning or
irritability, and complaints of exhaustions threatening
o Hold grudges toward others
SUICIDE PRECAUTIONS o Becomes angry and threatening when
● Execute a “no suicide contract.” The client they perceive to be attacked by ithers
will inform the nurse when he/she has ● Intervention: centered on building trust
suicidal ideations
● Ask direct questions. Find out if the person SCHIZOID PERSONALITY DISORDER
has specific plan for suicide. Determine ● A pervasive pattern of detachment from
what method social relationships and a restricted range of
● Be alert for cries for suicide expression of emotions in interpersonal
● Provide a safe environment and protect settings
client from self o Lacks desire for close relationships or
● Encourage to ventilate feelings and friends including family
thoughts o Chooses to be alone
● Give emotional support o Lack of sexual experiences
● Make the patient realize that the tendency o Avoids activities
to commit suicide is due to the disturbance o Appears cold and detached
in the brain chemistry and is treatable – ● Interventions: building trust followed by
once they know that an episode of suicidal identification and appropriate verbal
thinking will pass, they will likely not act on expression
the impulse
SCHIZOTYPAL PERSONALITY DISORDER
 ● A pervasive pattern of social and ● Priority nursing diagnosis: high risk for injury
interpersonal deficits marked by acute directed to self-related to self-mutilation
discomfort with and reduced capacity for behaviors
close relationships as well as by cognitive or ● Coping mechanisms used: splitting
perceptual distortions and eccentricities of o Classifying people as either “good” or
behavior “bad”
o Ideas of reference
o Magical thinking or odd beliefs INTERVENTIONS
o Unusual perceptual experiences, ● Use of empathy
including bodily illusions ● Recognize the reality of the patient’s pain
o Peculiar thinking ● Offer support
o Vague, stereotypical, overelaborate ● Empower and work with the patient to
speech understand control and change
o Eccentric appearance or behavior dysfunctional behaviors
o Few close relationships ● Provide safe environment
o Uncomfortable in social situations ● Teach social skills
● Interventions: improving interpersonal ● Make a list of solitary activities to combat
relationships, social skills, and appropriate boredom
behaviors
NARCISSISTIC PERSONALITY DISORDER
ANTI-SOCIAL PERSONALITY DISORDER ● Grandiose self-importance
● Characterized by deceit, manipulation, ● Fantasies of unlimited power, success or
revenge and harm to others with an brilliance
absence of guilt or anxiety ● Believes he or she is special
o Violates rights of others ● Needs to be admired
o Engages in illegal activities ● Sense of entitlement
o Aggressive behavior ● Takes advantage of others for own benefit
o Lack of guilt or remorse ● Lacks empathy
o Irresponsible in work and with finances ● Envious of others or others are envious of him
o Impulsiveness ● Arrogant
o Recklessness ● Interventions:
o Manipulative o Supportive confrontation on what the
● Interventions: patient says and what exists
o Consistency o Limit setting and consistency to
o Kind firmness in confronting behaviors decrease manipulation and entitlement
and enforcing rules and policies behaviors
o Limit setting o Remain neutral, avoid power struggles,
o Decrease impulsivity or becoming defensive
o Enhance role performance
o Effective use of confrontation HISTRIONIC PERSONALITY DISORDER
● A pervasive pattern of excessive
BORDERLINE PERSONALITY DISORDER emotionality and attentive seeking
● Characterized by pervasive pattern of o Overly dramatic
unstable interpersonal relationships; o Draws attention to self
self-image and affect; and marked o Extroverted and thrives on being the
impulsivity center of attraction
o Frantic avoidance of abandonment; o Uses somatic complaints to avid
real or imagines responsibility and support dependency
o Unstable and intense interpersonal o Dissociation
relationships ● Interventions: provide reinforcement in the
o Identity disturbances form of attention, recognition or praise
o Impulsivity given for unselfish or other centered
o Self-mutilating behavior behaviors
o Rapid mood shifts
o Chronic feelings of emptiness DEPENDENT PERSONALITY DISORDER
o Problems with anger ● A pervasive and excessive need to be
o Transient dissociative and paranoid taken care of that leads to submissive and
symptoms clinging behavior and fears of separation
o Needs others to be responsible for
OTHER IMPORTANT INFORMATION important areas of life
 o Problems with initiating with projects or o 80-90% irreversible
doing things on his own because of little o Reversible due to pathologic process
self confidence o Most common: Alzheimer’s Dementia
o Performs unpleasant tasks to obtain ● 4 Symptoms of Dementia
support from others o Loss of memory
o Urgently seeks another relationship for o Deterioration of language function
support and care after a close o Loss of ability to think abstractly, plan,
relationship ends initiate, sequence, monitor or stop
o Preoccupied with fear of being alone to complex behavior
care for self o Loss of ability to perform ADLs
● Interventions: increase responsibility for self in
day to day living; assertiveness training STAGES OF DEMENTIA

AVOIDANT PERSONALITY DISORDER STAGE 1 MILD (FORGETFULNESS)

● A pervasive pattern of social inhibition, ● Losses in short term memory
feelings of inadequacy and hypersensitivity ● Memory aids compensate
to negative evaluation ● Aware of the problem, disturbed
o Avoids occupations involving ● Not diagnosable at this time
interpersonal contact due to fears of
disapproval or rejection STAGE 2 MODERATE (CONFUSION)
o Preoccupied with being criticized or ● Progressive memory loss
rejected in social situations ● ST memory loss interferes with ADLs
o Very reluctant to take risks or engage in ● Withdrawn, denial, fear of losing their minds
new activities due to the possibility of ● Depression, confabulation
being embarrassed ● Problems increase when stressed
● Needs home care on in-home assistance
OBSESSIVE COMPULSIVE PERSONALITY DISORDER
● A pervasive pattern of preoccupation with STAGE 3 MODERATE TO SEVERE (AMBULATORY
orderliness, perfectionism and mental and DEMENTIA)
interpersonal control at the expense of ● Loss of reasoning ability, planning and
flexibility, openness and efficiency verbal communication
o Preoccupied with details, lists, rules, ● Frustrated, withdrawn, self-absorbed
organization ● Depression decreases
o Perfectionist ● Reduced stress threshold
o Too busy working to have friends or ● Institutional care required
leisure activities
o Unable to discard worthless or worn-out STAGE 4 LATE (END STAGE)
objects ● Family recognition disappears
o Reluctant to spend and hoards money ● Doesn’t recognize self
o Rigid and stubborn ● Nonambulatory
● Little purposeful activity
DELIRIUM ● Often mute, may scream spontaneously
● Characterized by disturbance of ● Forgets most ADLs
consciousness and a change in cognition ● Problems associated with immobility
such as impaired attention span and ● Institutional care required
disturbances in consciousness that develop ● Return of primitive reflexes
over a short period of time DELIRIUM VS DEMENTIA
o Always secondary to another condition DELIRIUM DEMENTIA
(medical condition or substance abuse) ONSET Usually sudden Usually gradual
o Frequent among the elderly and young Usually brief Usually long-term
febrile children with return to and progressive,
o Fluctuations of consciousness and COURSE
usual level of occasionally maybe
inoculation throughout the day functioning arrested or reversed
● Classified as mild to severe AGE Any Elderly
● Sundowning GROUP

DEMENTIA SEXUAL DISORDERS

● Characterized by multiple cognitive deficits ● Homosexuality
that include impairment of memory which ● Heterosexuality
develops slowly
 ● Bisexuality
● Masochism NX: Impaired verbal communication
● Sadism Impaired social interaction
● Frotteurism Self-mutilation
● Pedophilia Risk for injury
● Necrophilia
● Voyeurism ADHD
● Transvestism ● Attention-deficit/hyperactive disorder
● Transsexualism ● 7 years old and above
● Duration: 6 months and above
ALCOHOL ● Requires 2 settings: home and school

ALCOHOLISM ● Appearance: dirty child

● Intergenerational Transmission ● Behavior: clumsy, hyperactive, impatient
● Awake but unconscious ● Communication: talkative, bursts out
● Blackout
● Confabulation ● Structure
● Denial, dependence ● Setting limits
● Enabling, co-dependence ● Schedule
● Tolerance increases ● Safety

● Detoxification – doctor EATING DISORDERS

● Anorexia Nervosa
STAGES OF ALCOHOL WITHDRAWAL ● Bulimia Nervosa
● Pica
1 → 8 hours after the last drink ● Compulsive Eating Behavior
● Mild tremors, tachycardia, increased BP,
diaphoresis, nervousness ANOREXIA NERVOSA

2 → 8-12 hours after the last drink Symptoms:

● Gross tremors, hyperactivity, profound ● Refusal to maintain body weight over a
confusion, loss of appetite, insomnia, minimum normal weight for age and height
weakness, disorientation, illusions, ● Intense fear of gaining weight or becoming
hallucinations and delusions fat, even though underweight
● Disturbance in the way in which one’s
3 → 12-48 hours after the last drink bodyweight, shape or size is experienced
● Severe hallucinations, grand mal seizures ● In females, absence of menses of at least 3
consecutive cycles
4 → 3-4 days after the last drink ● Inability or refusal to acknowledge the
● Delirium tremens, confusion, agitation, seriousness of the problem
hallucinations, insomnia and tachycardia ● Onset: 12-15; 17-21 years of age
ALCOHOLISM
● Avoid alcohol during therapy Etiology
● Aversion therapy ● Cultural pressure
● Antabuse – disulfiram ● Serotonin imbalance → controls appetite
● Belongings – check for alcohol, mouthwash, and the satiety control center
elixir, etc. ● Family patterns
● B1 deficiency o Perfectionist
● Complication o Does not permit verbalization of feelings
o Wernicke’s Encephalopathy (Motor) o Marital problems
o Korsakoff’s Psychosis (Mind)
● Delirium Tremens Clinical Presentation
● Fornication ● Low weight
● Amenorrhea
AUTISM ● Yellow skin
● Living in their own world ● Cold extremities
● Appearance – flat (consistent) ● Peripheral edema
● Behavior – ritualistic, repetitive ● Muscle weakening
● Communication – echolalia, ● Constipation
incomprehensible ● Low T3 and T4
 ● Hypotension ● Recurrent inappropriate compensatory
● Bradycardia behavior in order to prevent weight gain,
● Hypokalemia such as self-induced vomiting
● Anemia ● Binge eating and inappropriate eating
● Pancytopenia behaviors
● Decreased bone density ● Persistent over concern with body shape
and weight
SIGNS RELATED TO PURGING BEHAVIORS
Clinical Presentation
Gastrointestinal ● Binge and purging behaviors
● Parotid gland tenderness, pancreatitis, ● Have depressive signs and symptoms
esophageal and gastric erosion or rupture ● Disturbed home life
● Major concerns
Metabolic o Interpersonal relationships
● Electrolyte abnormalities → hypokalemia o Self-concept
o Impulsive behaviors
Dental ● Chemical dependence is also common
● Erosion of dental enamel of the front teeth ● Normal to slightly low
● Dental carries
OBJECTIVES OF CARE ● Parotid swelling
● Increasing body weight to at least 90% of ● Gastric swelling and rupture
average weight for age and height ● Calluses or scars on the hand
● Reestablishing good eating behavior ● Peripheral edema
● Increasing self-esteem ● Hypokalemia, hyponatremia

Management:
NURSING INTERVENTIONS ● Trust
● Monitor daily caloric intake, activity level, ● Help patient identify feelings associated
weight and electrolyte status with binge-purge behaviors
● Establish nutritional eating patterns ● Accept patient as a worthwhile human
o Sit with client during meals being because they are often ashamed of
o Offer liquid protein supplement if unable their behavior
to complete a meal ● Encourage patient to discuss positive
o Observe signs of purging 1-2 hours after qualities about themselves
meals ● Teach about bulimia nervosa
● Provide accurate information on nutrition ● Encourage to explore interpersonal
and discuss realistic and healthy diet relationships
● Help the client identify emotions and ● Encourage patients to adhere to meal and
develop non-food related strategies snack schedules
o Convey warmth and sincerity ● Encourage the patent to approach the
o Ask the client to identify feelings staff if they feel like binging or purging
o Assist the client to change stereotypical ● Encourage to attend group sessions
beliefs ● Encourage family therapy
● Assist in identifying at least three positive ● Encourage participation in art, recreation
characteristics and occupational therapy
● Teach patient about their illness ● Encourage the patient to describe their
● Behavior modification: reward increase in body image at different ages of their lives
weight with meaningful privileges
● Identify patient’s non weight related
interests to reduce anxiety and refocus
attention

BULIMIA NERVOSA

Symptoms
● Recurrent episodes of binge eating
● Feeling of lack of control over eating
behaviors during the eating binges