PSYCHIATRIC NURSING

WHO IS CRAZY NOW

GILBERT T. SALACUP,RN,MSN “ Sir G”

Reference BOOK

Sheila L. VidebeckAlice M. Stain

NET: www.psychcenter.com

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Psychiatric Nursing

-branch of nursing care with aim of assisting

1.Individual 2. Family 3. Community To:

P - revent mental illness

A –ttain and maintain mental health

Co – pe with mental illness

Fi – nding meaning in mental illness

experience and suffering

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Self Awareness The process of knowing ones ownR - esponses in different situations

A - ttitudes

Per - sonality,

Pre - conceptions

S - trengths,Wea - knesses,

P - rinciple,

Be - liefs, s

Fee - lings,

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Significance 1.Self awareness differs from self - understand 2.The major therapeutic tool of the n is nurse is the

use of self

Goal of Self awareness To decrease the size of blind and

private quadrants

2 Major Advantage in working toward goal

1. Increase in self – awareness and self – disclosure2. Gain more control over own behavior

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Therapeutic Nurse- 1. Pre – Interaction B-egin before the nurse first contact with the

PT S-elf awareness

Therapeutic Task of the Nurse 1.Self Exploration feelings, fears, fantasies

2. Gathering Data about Pt available information

3. Planning for the 1st interaction with the patient

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2. Orientation Stage- A - ssessment and diagnosis phase- D-evelopment of mutually acceptable

contact

Therapeutic Task of the Nurse

Rapport Trust is built by demonstrating acceptance and non-judgmental attitude.

Identify Patients Problem Mutually defined Goals with patients Formulate Nursing Diagnosis set priorities Explore the patients feelings thoughts and

actions encourage to share it with the nurse

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3. Working Phase - I - dentification and declaration of

patients problems

- R - esistance observe

Therapeutic Task of the Nurse

Explore relevant stressor Listening and Observing – tools use in this phase Realize theirs somebody appears interested to him

who is warm and accepting can relate Develop a plan of action and implement then evaluate Assess client readiness for independent functioning Assist patient change maladaptive behavior

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4. Termination Phase T - ermination has been started in initial

phase A - ssumed that Pt is already with more understanding

Therapeutic Task of the Nurse - Review progress of the therapy and

attainment of goal - Explore feelings of rejection, loss sadness,

anger - Space contacts dec. time, visits, each

contact- Established more relax environment- Privide necesarry referals

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Sigmund Freud Father of Psychoanalysis Structure of Personality (Id, Ego, Superego)

IDPLEASURABLE PRINCIPLE Dominant ID Pain Avoidance Nar -

cisistic Puro “I”/ ako Ma – nia An -

tisocial want to Eat Want to drink Want to party Want pleasure

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I

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EGO REALITY PRINCIPLE

Impaired Reality Schizophrenia

Impaired

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E

SUPER EGOCONSCIENCE PRINCIPLE

houldn't be ense the voice of God  

DOMINANT SUPER EGOObsessive – compulsiveAnorexia Nervosa

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Therapeutic Communication Effective Communication: A - daptiveN - eutral responsesA – ppropriateR - eflect, restate, rephrase verbalization of

patient

S - tate behaviors observedFo - cus on feelingsSi - mpleCo - nciseC - redibleO - pen ended questions

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Therapeutic relationship

Relationship between health care professional and client

Purpose : assisting the client to solve his problems.

Components of a Therapeutic Relationship1.TRUST2. GENUINE INTEREST - he or she should be open,

honest and display a congruent behavior3.ACCEPTANCE - Situation: A client tries to kiss the nurse.

Inappropriate response: What the hell are you doing?! I’m leaving maybe I’ll see you tomorrow.

Appropriate response: Adam, do not kiss me. We are working on your relationship with your girlfriend and that does not require you to kiss me. Now let us continue.

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4. EMPATHY It is simply being able to put oneself in the client’s

shoes. However, it does not require that the nurse should have the same or exact experiences as of the patient.

Client’s statement: “I am so sad today. I just got the news that my

father died yesterday. I should have been there, I feel so helpless.”

Nurse’s Sympathetic Response: “I know how depressing that situation is. My father

also died a month ago and until now I feel so sad every time I remember that incident. I know how bad that makes you feel.”

Nurse’s Empathetic Response: “I see you are sad. How can I help you?

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5. POSITIVE REGARD unconditional and nonjudgmental attitude

where the nurse appreciates the client.

Calling the client by name Spending time with the client Listening to the client Responding to the client openly Considering the client’s ideas and preferences

when planning care

6. SELF-AWARENESS

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THERAPEUTIC USE OF SELF Therapeutic Technique1. Offering Selfmaking self-available and showing interest and

concern.“I will walk with you”2. Active listeningpaying close attention to what the patient is saying by

observing both verbal and non-verbal cues.Maintaining eye contact and making verbal remarks to

clarify and encourage further communication.3. Exploring“Tell me more about your son”4. Giving broad openingsWhat do you want to talk about today?

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5. Silence - Planned absence of verbal remarks6. Stating the observedverbalizing what is observed in the patient to, for

validation and to encourage discussion “You sound angry”7. Encouraging comparisons

describe similarities and diff.feelings,behaviors,& events.

· “Can you tell me what makes you more comfortable, working by yourself or working as a member of a team?”

8. Identifying themesasking to identify recurring thoughts, feelings, and

behaviors.“When do you always feel the need to check the locks

and doors?”

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9. Summarizingmaking appropriate conclusions.“During this meeting, we discussed about what you

will do when you feel the urge to hurt your self again and this include…”

10. Placing the event in time or sequenceasking for relationship among events.“When do you begin to experience this ticks? Before or

after you entered grade school?”11. Voicing doubt uncertainty about the reality of statements,

perceptions and conclusions. “I find it hard to believe…”

12. Encouraging descriptions of perceptions feelings, perceptions and views of their situations“What are these voices telling you to do?”

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13. Presenting reality or confrontingstating what is real and is not without arguing “I know you hear these voices but I do not hear them”.“I am G, your nurse,and this is a hospital and not a

beach resort.14. Seeking clarificationasking patient to restate, elaborate, or give examples

of ideas or feelings to seek clarification of what is unclear.

“I am not familiar with your work, can you describe it further for me”.

15. Verbalizing the impliedrephrasing patient’s words to highlight an underlying

message to clarify statements.Patient: I wont be bothering you anymore soon.Nurse: Are you thinking of killing yourself?

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16. Reflectingthrowing back the patient’s statement in a form of

questionPatient: I think I should leave now.Nurse: Do you think you should leave now?17. Restatingrepeating the exact words of patients Patient: I can’t sleep. I stay awake all night.Nurse: You can’t sleep at night?18. General leadsusing neutral expressions to encourage patients to

continue talking.“Go on…”“You were saying…”

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19. Asking questionusing open-ended questions to achieve relevance

and depth in discussion.“How did you feel when the doctor told you that you

are ready for discharge soon?”20. Empathy 21. Focusingpursuing a topic until its meaning or importance is

clear.“Let us talk more about your best friend in college”“You were saying…”22. Interpreting - providing a view of the

meaning or importance of something.Patient: I always take this towel wherever I go.Nurse: That towel must always be with you.

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23. Encouraging evaluationasking for patients views of the meaning or importance

of something.“What do you think led the court to commit you here?”“Can you tell me the reasons you don’t want to be

discharged?24. Suggesting collaborationoffering to help patients solve problems.“Perhaps you can discuss this with your children so

they will know how you feel and what you want”.25. Encouraging goal settingasking patient to decide on the type of change needed.“What do you think about the things you have to

change in your self?”

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26. Encouraging formulation of a plan of action

probing for step by step actions that will be needed.

“If you decide to leave home when your husband beat you again what will you do next?”

27. Encouraging decisionsasking patients to make a choice among options.“Given all these choices, what would you prefer to

do.28. Encouraging consideration of optionsasking patients to consider the pros and cons of

possible options.“Have you thought of the possible effects of your

decision to you and your family?”

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29. Giving information - providing information will help patients make better choices.

“Nobody deserves to be beaten and there are people who can help and places to go when you do not feel safe at home anymore”.

30. Limit settingdiscouraging nonproductive feelings and behaviors,

and encouraging productive ones.“Please stop now. If you don’t, I will ask you to leave

the group and go to your room.31. Supportive confrontationacknowledging the difficulty in changing, but pushing

for action.“I understand. You feel rejected when your children

sent you here but if you look at this way…”

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32. Role playing - both the nurse and patient play particular role.

“I’ll play your mother, tell me exactly what would you say when we meet on Sunday”.

33. Rehearsingasking the patient for a verbal description of what

will be said or done in a particular situation.“Supposing you meet these people again, how would

you respond to them when they ask you to join them for a drink?”.

34. Feedbackpointing out specific behaviors and giving

impressions of reactions.“I see you combed your hair today”.

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35. Encouraging evaluationasking patients to evaluate their actions and

their outcomes.“What did you feel after participating in the

group therapy?”.

36. Reinforcementgiving feedback on positive behaviors.

“Everyone was able to give their options when we talked one by one and each of waited patiently for our turn to speak”.

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Non-therapeutic TechniqueAvoid pitfalls:

1. Giving advise2. Talking about your self3. Telling client is wrong4. Entering into hallucinations and delusions of client5. False reassurance6. Cliché7. Giving approval8. Asking WHY?9. Changing subject10.Defending doctors and other health team members.

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Non-therapeutic Technique1. Overloadingtalking rapidly, changing subjects too often, and asking

for more information than can be absorbed at one time.

“What’s your name? I see you like sports. Where do you live?”

2. Value Judgmentsgiving one’s own opinion, evaluating, moralizing or

implying one’s values by using words such as “nice”, “bad”, “right”, “wrong”, “should” and “ought”.

“You shouldn’t do that, its wrong”.3. Incongruencesending verbal and non-verbal messages that contradict

one another.The nurse tells the patient “I’d like to spend time with

you” and then walks away.

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4. Under loadingremaining silent and unresponsive, not picking up cues,

and failing to give feedback.The patient ask the nurse, simply walks away.5. False reassurance/ agreementUsing cliché to reassure client. “It’s going to be alright”.6. InvalidationIgnoring or denying another’s presence, thought’s or feelings.

Client: How are you?Nurse responds: I can’t talk now. I’m too busy.7. Focusing on selfresponding in a way that focuses attention to the nurse

instead of the client.“This sunshine is good for my roses. I have beautiful

rose garden”.

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8. Changing the subjectintroducing new topic inappropriately,The client is crying, when the nurse asks “How many

children do you have?”9. Giving advice giving opinions or making decisions for the client, “If I were you… Or it would be better if you do it this

way…”10. Internal validationmaking an assumption about the meaning of

someone else’s behavior that is not validated by the other person (jumping into conclusion).

The nurse sees a suicidal clients smiling and tells another nurse the patient is in good mood.

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Other ineffective behaviors and responses:1. Defending – Your doctor is very good.

2. Requesting an explanation – Why did you do that?

3. Reflecting – You are not suppose to talk like that!

4. Literal responses – If you feel empty then you should eat more.

5. Looking too busy.

6. Appearing uncomfortable in silence.

7. Being opinionated.

8. Avoiding sensitive topics

9. Arguing and telling the client is wrong

10. Having a closed posture - crossing arms on chest

11. Making false promises I’ll make sure to call you when you get home.

12. Ignoring the patient – I can’t talk to you right now

13. Making sarcastic remarks

14. Laughing nervously

15. Showing disapproval – You should not do those things

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DEFENSE MECHANISMS

DISPLACEMENT Transfer of feelings to a less threatening object rather than the one who provoke it

Boss shouts at you, you shout at your subordinate

A patient yells at a nurse after becoming angry at his mother for not calling him.

DENIAL Failure to acknowledge an unacceptable trait or situation

“I’m not an alcoholic” A woman newly

diagnosed with end-stage-cancer says, “I’ll be okay, it’s not a big deal”.

DISSOCIATION Psychological flight from self A type of amnesia

“Sino ka, Sino ako?”

Acting Out Acting out refers to repeating certain actions to ward off anxiety without weighing the possible consequences of those action.

Example: A husband gets angry with his wife and starts staying at work later.

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INTROJECTION Assume another person’s trait as

your own “ako din” Not just you, me

too

SUPPRESSION Conscious forgetting of an anxiety

provoking concept Hindi ko alam yan

SUBLIMATION Placing sexual energies toward a

more productive endeavours may channel

his sex drive into his sports or hobbies.

CONVERSION Repressed angers put towards

physical symptoms affecting nervous system leading to sensory numbness and motor paralysis

Biglang mangingig

COMPENSATION Overachievement in one area

to cover a defective part Pilay pero magaling

kumanta

SUBSTITUTION Replacing a difficult goal with a

more accessible one Gusto ko .

Enchanted nalang.

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UNDOING Doing the opposite of what you have done due to guilt

plastic

“ay pinatid kita, halika punta kita sa clinic

A patient who says something bad about a friend may try to undo the harm by saying nice things about her or by being nice to her and apologizing.

IDENTIFICATION Assume trait for personal, social, occupational role

Tulad nya An adolescent girl

begins to dress and act like her favorite pop star.

PROJECTION Attributing to others one’s acceptable trait

Pasa load

“hindi ako alcoholic, sila yon”

RATIONALIZATION Illogical reasoning for a socially unacceptable trait

“sayang ang beer sa ref, kaya ko ininum”

I drink because I don’t want to waste the beer in the ref

An individual states that she didn’t win the race because she hadn’t gotten a good night’s sleep

REACTION FORMATION doing the opposite of your intention

Plastic

sasabunutan kita. . . ay kuklulutin lang kita

Love turns to hate and hate into love.

REGRESSION Return to an earlier developmental stage

Return to thumbsucking

REPRESSION Unconscious forgetting of an anxiety provoking concept

Hindi ko maalala A woman who was

sexually abused as a young child can’t remember the abuse but experiences uneasy feelings when she goes near the place where the abuse occurred.

ANXIETY

ANXIETY Definition:Subjective, individual experience

characterized by a feeling of apprehension, uneasiness, uncertainty, or dread.

Occurs as result of threats may be - Actual or imagined, - misperceived or misinterpreted, - threat to identity or self-esteem.It often precedes new experiences.

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Types of Anxiety:Normal

A healthy type of anxiety that mobilizes a person to action.

AcutePrecipitated by imminent loss or

change that threatens the sense of security.

ChronicAnxiety that the individual has lived

with for a long time.

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Levels of Anxiety: 1.Mild/ Alertness Level (+1)- Normal Type of Anxiety

P -erceptual field increasedA - lertR - estlessI - ncreases learning

Nursing Interventions:- Recognize the anxiety by statements such as “I notice you being restless today”.-Explore causes of anxiety and ways to solve

problems “Let’s discuss ways to…”

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2. Moderate/ Apprehension Level (+2)

The response of the body to immediate danger and focus is directed to immediate concerns.

S - elective inattentiveness occurs

I - ncreased tension optimal time for learning

N - arrows the perceptual field

U - ses palliative coping mechanisms.

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Nursing Interventions:1. Provide outlets for anxiety such as crying or

talking.2. Tell client “It’s all right to cry”.3. Encourage in motor activity to reduce tension.4. Make client be aware of his behavior and feelings

by statements such as “ I know you feel scare…”5. Encourage client to move from affecting (feeling)

to cognitive mode (thinking).6. Refocus attention7. Encourage the client to talk about feelings and

concerns.8. Help the client identify thoughts and feelings that

occurred prior to the onset of anxiety.9. Provide anti-anxiety oral medications.PRN Meds

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3. Severe/ Free-floating Level (+3)Creates a feeling that something bad is about to happen, or feeling of an impending doom.

D - ilated pupils, fixed visionF - ight and flight response sets inA - ll behaviors are directed at alternative the anxiety

N - arrow perceptual field occurs.T - he person uses maladaptive coping mechanisms.I - ndividual needs direction to focus Don’t know what to do Don’t know what to say

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Nursing Interventions:1.Do not focus on coping mechanisms2.Stay calm and stay with the client3.Give short and explicit direction4.Provide IM anti anxiety medications.5.Modify the environment byS- etting limits or seclusion, I -nteraction limit with others, R - educe environmental stimuli to

calm client.

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4. Panic Level (+4)I- f prolonged, panic can lead to exhaustion and death

S - uicide

P-ersonality and behavior is disorganized

I - nability to concentrate

T-he person uses dysfunctional coping mechanisms.F- eelings of helplessness and terror U - nable to communicate or function effectivelyL - essens perception of the environment to protectNursing Interventions:Safety Guide patient step by step to actionRestrain if necessary.

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ANTI-ANXIETY drugsBenzodiazepines - Zolam – Zepam1. F - lurazepam(dalamne) 7. T - riazolam(Halcion)

2. O - xazepam(Serax) 8. A - lpraZolam (Xanax)

3. L - orazepam(Antivan) 9.Chlo -rdiazepoxide(librium)

4. D - iazepam(Valium) 10.Chlo - razepate(Tranxene)

5. C - lonazepam(Klonopin)

6. T - emazepam(Restoril)

Non Benzodiazepines:

Buspirone (Buspar)

Meprobamate ( Miltown, Equanil)

Assess: Level of Anxiety

Nx Dx: Ineffective Individual Coping Powerlessness Impaired Skin Integrity

Planning/ Implementation: level of anxiety environmental StimuliRelaxation Technique

Evaluation : Effective individual coping

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GENERALIZED ANXIETY DISORDER - 6months excessive worrying

- Might be mild, moderate and severe anxiety

S/SxS - leep DisordersP - alpitationsE - dge of the seatE - asy fatigabilityR - estlessD - ifficulty of concentration

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PANIC DISORDER - recurring severe panic attacks

15 – 30 Minutes escalation of Somatic NS

Phobia

Phóbos, meaning "fear" or "morbid fear"Types of Phobias1. Agoraphobia - fear of open space/ public places2. Social Phobia - Also called Social Anxiety Disorder

fear of public /presence of others.

3. Specific Phobia - Also called Simple PhobiaA persistent fear of a specific object or situation, other

than of two phobias mentioned above.

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Risk FactorsLearning theory phobias are learned and become conditioned

responsesCognitive theory

anxiety-inducing self-instructions of faulty cognitions.

Life experiences Certain life experiences, such as traumatic events

Signs and SymptomsW - ithdrawalH - igh levels of anxietyI - nappropriate behavior used to avoid the feared

situation, object or activityD - ysfunctional social interactions and relationshipsE - nability to function and meet self-care needs

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Nursing DiagnosesAnxietyPowerlessIneffective individual copingImpaired verbal communicationAltered thought processesSelf-esteem disturbanceImpaired social interactionRisk for injuryTherapeutic Nursing Management Systematic desensitization

This process of gradual exposure to phobic object or situation

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POST TRAUMATIC STRESS DISORDER

S - oldier T - raumaE – arthquakeW – ar VICTIMS Survivors

A - ccident R - ape FlashbackD – isaster Nightmares

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SOMATOFORM - no pretension, suggest medical diseases -no organic basis to support the illness.

Types of Disorder1. Somatization disorder - chronic syndrome is

characterized by multiple somatic symptoms that cannot be explained medically.

The physical symptoms are associated with psychological stress.

2. CONVERSION DISORDERNervous SystemLa Belle Indifference emotional disattachment from disability

Sleep disorder This is characterized by difficulty initiating or

maintaining sleep.Hypersomnia - or excessive sleepiness,

Narcolepsy - is a chronic sleep disorder, or dyssomnia, --- excessive sleepiness and sleep attacks at inappropriate times, such as while at work

Parasomnias - involve abnormal and unnatural movements, behaviors, emotions, perceptions,

- dreams that occur while falling asleep- sleeping, between sleep stages, - during arousal from sleep.

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Hypochondriasis This is a person’s unwanted fear or belief that

he or she has a serious disease without significant pathology.

Minor Discomfort Interpreted as major illness

Body dysmorphic disorders The client is preoccupied with an image defect in appearance

when there is no abnormality. Illusion of structural defect Client obsesses about imaged bodily defects (facial flaws,

heavy buttocks or thighs)

Pain disorder The pain is unrelated to a medical disease. The individual experiences severe pain that is in

disproportion to the originating source.

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Risk FactorsGender: FemaleAge: Children and older adults

Nursing DiagnosesImpaired adjustmentChronic painSleep pattern disturbance

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PSYCHOSOMATIC 1. to a physical disorder that is caused by or notably

influenced by emotional factors. 2. pertaining to or involving both the mind and the

body.

4 major types H - ypertension A - sthma M - igraine

S - tress Ulcer

- Real pains/ illness- Real symptoms

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Obsessive Compulsive Disorder (OCD)persistent thought and urges to perform repeated

acts or rituals releasing tension Obsession

recurrent and persistent thoughts, impulses, images that are intrusive, disturbing, inappropriate, and

usually triggered by anxiety.Compulsion

Repetitive behaviors or mental acts that a person feels driven to perform, specifically defined routine.

 

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Thinking (Belief) Mind-setWindows open Anxiety

Akyat bahay gang magnanakaw

 

Obsession (thought/thinking ) anxiety(thought)

Compulsion (Action) Anxiety Check the house

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Specific Biological Factor OCD is linked to a deficiency in serotonin. Abnormalities in frontal lobes and basal ganglia

Signs and SymptomsRuminations – forced preoccupation with thoughts about a

particular topic, associated with brooding and inconclusive speculation.

Cognitive rituals – mental acts the client feels compelled to complete.

Compulsive motor rituals – elaborate rituals of everyday functioning such as grooming, dressing, eating,

Other symptoms – chronic anxiety, low self-esteem, difficulty expressing positive feelings and depressed mood.

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4 Defense Mechanism by OCD

R - epresionI - solationR - eaction formationU - ndoing

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Nursing Interventions Provide time to perform the rituals Limit, but do not interrupt, the compulsive acts. Teach to use alternate methods to decrease

anxiety. Client’s behavior maybe frustrating to staff and

family. Power struggles often result. Consistency to the approach to care is critical.

Assess the client’s needs carefully. Provide an environment that has structure and

predictability as a strategy to decrease anxiety. Risk associated with the use of alcohol and drug

abuse.

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N

defined as the totality of a person’s unique biopsychosocial and spiritual traits that consistently influence behavior.

1. Interpersonal relations that ranges from distant to overprotective.

2. Suspiciousness3. Social anxiety4. Failure to conform to social

norms.5. Self-destructive behaviors6. Manipulation and splitting.

PERSONALITY DISORDERS

Cluster A:Personality Disorders(The Eccentric and Mad group)

Paranoid – Moto wag magtiwala Sa iba

overly suspicious and mistrustful behaviorNX. Management Psychotheraputic task on dealing trust Issues Low dose Phenothiazine

SCHIZOID – Moto little emotionN - ever had a best friendB - elieves he can stand on his ownI - don’t want peopleC - ares more about computers and petsA - void groups and social activities no enjoymentNX management Gradual involvement Milleu and group therapy Focus on building trust

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N,

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N

Schizotypal Personality Disorder- pervasive pattern of social and interpersonal deficits, with

cognitive and perceptual distortions and behavioral eccentricities.

Clinical Manifestations: R - estricted range of emotions O - dd appearance (stained or dirty clothes, unkempt and disheveled)

L - oose, bizarre or vague speech E - xpresses ideas of suspicions regarding the motives of others

E - xperiences anxiety with people W - ander aimlessly I - deas or reference and magical thinking is noted

Nx Management Low dose of neuroleptic Involved activity with others

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N

Cluster B: Personality Disorders ( The Erratic and Bad group) 

ANTI - SOCIAL M - otto I break the law A - s a child,: steal, lie, always get reprimanded G - ood talker, charmer, witty manipulator  A - dult – grand robbery, illegal activitist against

the law, drug addiction, drives fast, unsafe sex, thrill seeker

Nx Management Firm Limit Setting Confront behaviors consistently Enforce consequences Group therapy

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N

BORDERLINE PERSONALITY DISORDER

- Most common personality disorder found in clinical settings.

- Marked impulsivity. - It is more common in females than

in males. - Self-mutilation injuries such

as cutting or burning Moto my life is an empty glassNx Management Promote safety Help client to cope and control

emotions Teach social skills , Set limits Behavioral contracts decrease

mutilation Empathy and group therapy

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MS

NNarcissistic I love myself Moto I am famous

Insensitive, arrogant, use rationalization I am the best lack of empathy. Ambitious and confident

Nx management Teach client that mistake are acceptable Focus on here and now Teach client imperfection do not decrease worth

Histrionic Excessive emotionality and attention-seeking behaviors excited, dramatic but manipulative Center of attention Highly suggestible and will agree with almost

anyone to gain attention Uses colorful speech, Tends to overdress Concerned with impressing others

Motto Ako ang bidaNx management Facilitate expression + reinforcement for unselfish behavior

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N

Cluster C: Personality Disorders ( The anxious and Sad group)

AVOIDANT = No people No trouble I avoid people, I fear criticism Have talent but no confidence

3 Pattern Social uneasiness and reticence Very Low self-esteem Hypersensitivity to negative reaction

Nx Management Promote Self Esteem Gradually confront fears Increase exposure to small groups

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N

Dependent Moto I can’t live without you self esteem , Pessimistic Poor decision making skills Uncomfortable and helpless when alone Has difficulty initiating  or completing simple daily

tasks on their own

Nx management Teach problem solving and decision making skills NPR Goal increase assertiveness

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N,

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N

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NObsessive – Compulsive

I am Perfect, moto I am organized Perfectionist Provide time to do rituals Precise and detail-orientedNx Management Explore the feelings Teach patient mistakes are acceptable

Other related disorder Depressive – Moto I think I'm gonno die again

Pattern of depressive cognition and behavior in variety of context

Occurs equally in men and woman Same behavior characteristic in major depression but

less severe . Recurrent thought of death Total disinterest in all activity Inability to express joy Self Criticism

Nx Management Assess self harm risk, provide safety Promote self esteem Increase involvement in activity

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N

Passive Aggressive Moto Oh yes Oh your not Always say yes but resistance is hidden 1-3% IN GEN, POP. 2-8% IN CLINICALSET UP May appear cooperative even ingratiating Blame others for misfortune

Nursing management Teach relaxation techniques Assertiveness Teach expressing the feelings directly

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N,

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N

SchizophreniaS - tress – Diathesis Model

Too much stress in the reality will lead client to escape it and go to the fantasy world

I - mpaired reality perception

G - enetic vulnerability

E - go disintegration

B - iological TheoryDopamine level is High

A - exact cause is unknown

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N

Extremely complex mental disorder Recent research reveals that schizophrenia may be

a result of faulty neuronal development in the fetal brain, which develops into full-blown illness in late adolescence or early adulthood.

Diagnosed in late adolescence or early adulthood.

Peak incidence of onset MEN - 15 to 25 years of age WOMEN - 25 to 35 years of age Rarely In childhood.

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N

Negative or Soft symptoms 

Positive or Hard symptoms 

Flat affect Delusion

Lack of volition Hallucinations,

Social withdrawal or discomfort

Grossly disorganized thinking, speech, and behavior

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N,

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N

1. Assess : Content of ThoughtNx Dx : Disturbed thought processPlanning/ Implementation:Present realityProvide safetyEvaluation : Improve thought process 2. Assess : Hallucination/ IllusionsNx Dx : Disturbed sensory perceptionPlanning/ Implementation:Present realityProvide safetyEvaluation : Improve sensory perception

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N

3. Assess : SuspiciousNx Dx : Risk for other directive behaviorPlanning/ Implementation:Present realityProvide safetyEvaluation : Eliminate/ minimize risk for other-

directed violence4. Assess : SuicidalNx Dx : Risk for self directive behaviorPlanning/ Implementation:Present realityProvide safetyEvaluation : Eliminate/ minimize risk for self-

directed violence

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N,

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N

Flight or Looseness 

I am super star I am super star. Gulay is malungay? Super star is Nora Were are you. Nora is a gay I love beer. Gay is man 

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N

4 A’s ffect appropriate, inappropriate,

flat, blunt (incomplete emotion) mbivalence torn between 2

opposing forces

utism ssociative Looseness

 

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N

Magical Thinking - Believes to have a magical power

Echolalia I repeat what you say Parrots

Echopraxia I repeat what you do

Word Salad words, no rhyme

Clang Association words with rhyme : Doom, Kaboom, Bromm

Neologism creation of new words olasta, labidada

Clarification done in case of neologism

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N

Delusion: fixed falls belief with no basis in realityPersecutory FBI will get me/ someone will

harm the Patient Religious I am Jesus, allah, budahGrandeur I am the king of the world.Ideas of reference MD are talking about me.

Concrete Association pilosopo “ what will u use in txting your calculator?”

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Hallucinations IllusionStimulus Absent PresentVisual X Auditory X Tactile X

Hallucinations Management: H - allucinationsA – cknowledgment - I know the voices are real to

youR - eality orientation - But I don’t hear themD - iversion - Lets walk 

Take note But if nothing in the preceding intervention are seen= Assess what the voices are saying

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N

TYPES OF SCHIZOPHRENIA1. Paranoid - Suspicious Ideas of reference Tendency to be violent - Defense

mechanism MistrustScaredWithdrawn Projection

Nrsg. Int:Build up trust: 1 to 1 short interaction frequent visit foods in sealed container meds wrapped

For violent pt.- Doors open - Near the door - Don’t touch the pt.- Eye contact - 1 arms length away -call reinforcement 

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N

Catatonic – abnormal motor behaviorOnset - Acute DFM - RepressionNo – favorite word

I - niwan na posture, ganun foreverW - axy FlexibilityA - mbivalenceN - egativism

Treatment ECT Benzodiazepines (such as diazepam or lorazepam)

for catatonic schizophrenia.

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N,

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N

Unclassified / undifferentiated Mixed Manifestation Can’t be classified 1st paranoid, then disorganized then catatonic, etc

etc

DFM – Regression

ResidualRecovering/ decrease S/S

No more positive s/sx, just withdrawn

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N

Disorganized/HEBEPHRENIC Bizarre behavior

DFM- Regression and Fantasy Sad but smiles Inappropriate affect No reaction Flat affect Flight of ideas Giggling Positive and Negative S/Sx

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N,

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N

High Dopamine= Schizophrenia

Dopamine Acetylcholine

Antipsychotics = Dopamine goes down

If Acetylcholine Dopamine

Extra pyramidal Side EffectsAKATHISIA AKINESIARestless, inability to sit Muscle rigidityMakati siya, ahh kati siya Ahh kiniss siya

GIL

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N,

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N

DYSTONIA3 features

TORTICOLLIS Wry neckOCULOGYRIC CRISIS Fixed stareOPISTHOTUNOS Arched back

TARDIVE DYSKINESIA Irreversible side effects of antipsychoticsLip smackingTongue protrudingCheeks puffing

NEUROLEPTIC MALIGNANT SYNDROMEHyperthermia among client taking antipsychoticHyperthermia with muscle rigidity

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N,

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N

Other Side Effects Photosensitivity

SunscreenWide brimmed hat

AgranulocytosisReport immediately Sore throat

1st sign to appear 

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N

ANTIPSYCHOTIC AGENT–major tranc/nueroleptics Sub classification:

 Phenothiazines: Non Phenothiazines: Thorazine – Tora Tora Haldol – Ha Idol Prolixin – Pro ang lixi n Navane – Sundalo pangdagat

Mellaril – Mella nmaril Tegretol – Hayop yan Tegre tol

Serentil – on seren til mawalaTrilafon - Trila in Fonila

Stelazine - Nanood si stela Zine

AtypicalClozaril – close sa reel! yehSeroquel – Sero kal talagaInvega – in vega n natin mga sisterIsigaw ntin ang - Geodon 

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N,

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N

ANTI PARKINSON'S –management anti psychotic induce EPS

A tivan(lorazepam) - Ati - van

D iazepam(valium)- ang tunog nyan Dia - zepammmmm

I nderal(propanolol) – Inde – Ral ral rallK emadrin(procyclidine)- Keme – Drin drin drin

A- akineton (biperiden)- ay nako mga baliw akin ne to

B- benadryl(diphenhydramine)- ben that’s a dryl

L- larodopa(Levodopa)- mmm Laro kc kau ng laro! D pa

E- Eldepryl (Selegilene)- ang sbi bi ni elde p reel kc kau akin n nga ung

S- symmetrel-(amantadine)- Sym Motor ko hmm bulol symmetrel

C- cogentin(Benztropine)-Sakay nlang kau sa coge tin

A- artane(trihexyphenidyl)- ang a artane kc nila

P- parlodel(Bromocriptine)- Para Lodel at nkarating na silang lhat end

Increase protein and give B6

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N,

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N

Mood DisorderDisturbance in mood ( Affect) that is either depression or elation

(mania = persistent hyperactive)

Bipolar - Mania more commonResults from disturbances in the areas of the brain that regulate mood

It involves periods of excitability (mania) alternating with periods of depression

Men and women equally Usually appears between ages 15 – 25Cause Unknown Stressful life Obese

It occurs more often in relatives of people with bipolar disorder

Ref. Videbeck Page 317

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N

Risk factors Biochemical imbalances Family genetics – one parent, child has 25% risk; two parents, 50-75%

risk.

Environmental factors-such as stress, losses, poverty, social isolation.

Psychological influences–inadequate coping, denial of disordered behavior

Specific Biological Factors Possible excess of norepinephrine, serotonin, and

dopamine. Increased intracellular sodium and calcium Neurotransmitters supersensitive to transmission of

impulses

Defective feedback mechanism in limbic system.

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N

1. BIPOLAR MIXED – PERIODS OF MANIA, NORMAL, DEPRESION, NORMAL, MANIA2. BIPOLAR TYPE I – MANIC EPISODES AT LEAST 1 DEPRESSIVE EPISODE3. BIPOLAR TYPE II – RECURRENT DEPRESSIVE EPISODE AT LEAST 1 HYPOMANIC EPISODE

Self Actualization =Task

Self Esteem = Nursing Role Restrain

Impaired social interaction = safety

Risk for injury/ other directed violence= safety

Eating Sleep Hyperactive Sexfinger food Private room Anxiety

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N

SE Compensation interfere ADLs, harm othersSE Compensation interfere ADLs, harm othersTASK increases client’s self esteem Escorted walk outdoors Punching bagNo group games compitition will increase anxiety

3 or more signs confirms disorderS - leeplessnessP- ressured speechE - xaggerated SEE - xtraneous stimuli (easily distracted)D - istractibilityG - randioseF - light of ideas

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N

Therapeutic Nursing Management Environment Psychological treatment

Individual Psychotherapy – may be used to identify stressors and pattern of behavior.

Group therapy – establishes a supportive environment and redirect inappropriate behavior.

Family therapy – verbalizes family frustration and establishes a treatment plan for outpatient use.

Somatic and Psychopharmacologic treatmentselectroconvulsive therapy Psychopharmacology

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N

DEPRESSION Serotonin if unresponsive to drugs, ECT

Kubbler-Ross Stages of Dying / Grief ProcessDenial “No not me”, “Its not true”, “Its not impossible”Anger why me, why now, What did I do to deserve

this?”Bargaining “If I live until Christmas or until my child’s graduation ( So many if’s), I will do

this…”Depression “Yes, I’m dying”Acceptance “Yes, I am ready”

Self Actualization Self Esteem = Task

Withdrawn = stayRisk for self directed violence

  Eating Sleep Hypoactive Sex

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N

Major Depressive Disorder2 or more weeks of sad mood

9 Symptoms S –leep disturbance (insomia/hypersomia)O – Vert Suicidal Ideation (Recurrent thoughts of

deaths)M – emory Disturbance (Indecisiveness)E – nergy loss or Fatigue

A – gitation psychomotor L – ost of interest/ PleasureO – bvious Wt Significance N – ihilism – feeling of worthlessnessE – motional blanting and sad effect – depress mood5/9 symptoms present 2 or more weeks 1 of which is depressed

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N

Risk Factors Biological factors – brainchemicals Family genetics – parent with depression, child 10-13% risk of

depression.

Gender – higher rate for women Age – often less than 40 when begins Marital status – more frequently single, widowed Season of year – Seasonal Affective Disorder (SAD)

occurs when client experiences recurrent depression that occurs annually at the same time.

Psychological influences – low self-esteem, unresolved grief.

Environmental factors – lack of social support, stressful life events.

Medical co-morbidity – clients with chronic or terminal illness, postpartum, and current substance abuse are especially prone to becoming depresses.

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Therapeutic Nursing Management Safe environment Psychological treatment

Individual psychotherapy – long –term therapeutic approach or short term solution-oriented, may focus on in-depth exploration, specific stress situations, or problem solving.

Behavioral therapy – modifying behavior to assist in reducing depressive symptoms and increasing coping skills.

Behavioral contacts – focus on specific client problems and need to help the client resolve them.

Social treatment Milieu therapy – day to day living experiences in a therapeutic

environment Family therapy – aimed at assisting the family cope with the client’s

illness and supporting the client in therapeutic ways.

Group therapy – focuses on assisting clients with interpersonal communication, coping, and problem-solving skills.

Psychopharmacologic and Somatic treatments Administer antidepressant medications Continued assessment interms of agitation and suicidal ideation. Electroconvulsive therapy

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Nursing Interventions1.Priority for care is always the client’s

safety.2. Use of behavioral contacts. “no self-harm” or no suicidal ideation or

plan.

3. Assess regularly for suicidal ideation or plan.4. Observe client for distorted, negative thinking.5. Assist client to learn and use problem solving and stress management

skills.

6. Avoid doing too much for the client, as this will only increase client’s dependence and decrease self-esteem.

7.Explore meaningful losses in the client’s life.

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N

ANTIDEPRESSANTSS - inequan – Watch tau ng Sine Quan A - nafranil – Ana Franil PalaV - ivactil – Bi back tau agad after nuod ngE - lavil – Ela evil

P - rozac – Pero sak a naA - ventyl – Aveeen Til Midnight tayoN - orpramin – Nor T - ofranil – Tofra an kita

P - axil – Taksil kaA - sendin – asan n din kau Z - oloft – yan mag Solo ka 

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N

1st Line of Drug Prescribed afest

ELECTIVE Prozac(Fluxetine)

ide effects low EROTONIN Paxil (Paroxetine)

EUPTAKE Zoloft(Sertraline)

note: No suicidal or

to 4 weeks Homicidal NHIBITOR take in am to avoid

insomnia

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N

Two – 4 wks Sendin (Amoxapine)

Tri

orpramine (Desipramine)

CYCLIC ofranil (Imipramine)

inequan (Doxepine)

NTIDEPRESSANT Lavil

amelor Higher incidence of Side effects Serotonin/ Epi affectedNeuro and hepatotoxisity,Cardiac Arrytmias

Suicide Precausion 10 -15 days precausion

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N,

MS

N

ONO arplan (isocarboxazid)

ardil ( Phenelzine) Mine arnate

(Tranylcypromine)

Xidase

Nhibitor All neurotransmitter affected Highest Side effectsAvoid tyramine rich food may lead to HYPERTENSIVE CRISES  

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N

TYRAMINE RICH FOODS vocado ged Cheese  eer   hocolate

  ermented Foods  ickles

reserved Foods  oy Sauce

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N,

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N

LITHIUML evel 0.5 – 1 mEq/LI ncrease urinationT remors, fine hand H ydration 3 L/dayI ncrease Na+Uu diarhea M outh, dry

Maintenace level 0.5 – 1 mEq/L Treatment level – 0.8 – 1.5 mEq/L

Toxic level – 1.5 aboveLithium Toxicity Nausea, vomiting, diarrhea

GIL

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N,

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N

ELECROCONVULSIVE THERAPY

Nowadays, ECT is not only used for major depression,

but also for the treatment of: mania (in bipolar disorder) Catatonia (motion less or excessive motion) quick relief for self-destructive behavior

ECT only be indicated for the treatment of severely depressed clients that needs fast relief

Can pregnant women undergo ECT?

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N

Contraindications and precautions recent myocardial infraction stroke sever hypertension presence of intracerebral mass Mechanism of action The therapy induces a therapeutic tonic seizure (a seizure where the person loses consciousness and

has convulsions) which lasts for about 15 seconds.

It is believed that the shock intensifies brain chemistry to correct the chemical imbalance in depression

(decrease serotonin and norepinephrine).

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N

Frequency of treatment 6-15 treatments are scheduled three times a

week. 6 treatments are needed to observe a sustained

improvement of depressive symptoms. Maximum effect or benefit is achieved in 12 to 15

treatments. 70 – 150 volts .5-2 seconds Duration 6-15 treatments 48hrs interval

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Nursing Interventions Before ECT1. Informed consent should be signed.

2. NPO post midnight.

3. Remove fingernail polish.

4. IV line initiation.

1. Atropine dry mouth

2. Barbituate short-acting anesthetic.

3. Succinylcholine muscle relaxant, prevent seizure

5. Let the client void before the procedure.

During ECT1. Place electrodes on the client’s head on one side (unilateral)

or both (bilateral).

2. Brain monitoring through electroencephalogram (EEG).

3. Oxygen administration with an Ambu-bag.

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N

After ECT1. When the client is awake, reorient the client.2. Obtain vital signs.3. Assess client for the return of gag reflex.4. Allow the client to eat (with a positive gag reflex).

Side-lying – lateralS/E

headache, dizziness, TEMPORARY MEMORY LOSS distinct sign

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N

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SN

SuicideDefinitionSelf imposed death stemming from depression

Verbal Non Verbal

I wont be a problem anymore

This is my last day on earth

I’ll soon be gone

Take this ring, its yours (giving of valuable)

Sudden change in mood

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Who will commit Suicide?S - ex – Male (more successful)/ female (hesitant)A ge – 15 –24 y/o or above 45D epression

P atient with previous attemptE ethanol - alcoholicsR irrationalS ocial support lackingO rganized plan greater riskN o familyS ickness, terminal 

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SUICIDE TRIAD1. Loss of spouse2. Loss of job3. Aloneness

Nursing Intervention 1.D irect question – “Are you going to commit

suicide?”2. I rregular interval of visit to pt. room3.E arly AM and period of endorsement – the time

pt’s commit suicide

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Best approach for suicidal pt. : Direct approachNursing Management: Close surveillance

Hospital quarter common suicide will come about

weekends - 1- 3 am Sunday - few staff personnelEarly AM - every one is asleep 

Simple task Water plants Wash the dishes except sharps

Don’t give complex - may cause depression ex. Puzzle

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N

Cyclothymic disorderMilder symptoms of both mania

and depressions often separated by long periods of normal moods

Dysthymic DisorderLong standing symptoms of depression

alternating with short periods of normal moods clients can maintain normal roles and jobs

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N

EATING DISORDERS

  Bulimia Nervosa The Diet-Binge-Purge Disorder”.

 dieting, binging and purging through vomiting

Rapid eating for about two hours (over 8000 calories in 2 hours and 50,000 in 1 day)

Methods of controlling weight (diet pills, excessive exercise, enemas, diuretics, laxatives),

Weight normal or fluctuations are due to alternating fasting and binging

Ages 15-24 years. Bulimic often belong to a family and society that

place great value on external appearance. self hatred low self-esteem, symptoms of depression, fear of losing control, suicide tendencies. Perfectionist, achievers scholastically and

professionally. They hide their disorder because of fear of

rejection. Person is aware that the behavior is abnormal, b. After the episode she becomes guilty and

depressed

GIL

BER

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P R

N,

MS

N

GIL

BER

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LA

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N,

MS

N

Nursing Diagnosis1. Alterations in health maintenance.2. Altered nutrition: Less than body requirements.3. Altered nutrition: More than body requirements4. Anxiety5. Body image disturbance6. Ineffective family coping; compromised7. Ineffective individual coping8. Self-esteem disturbance

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During interview Nursing Interventions to gain trust and acceptance of nurses. Create an

atmosphere of trust. Develop strength to cope with problems.

Encourage patient to discuss positive qualities about themselves to increase self-esteem.

Help patient identify feelings and situations associated with or that triggers binge eating.Encourage making a journal of incident and

feelings before-during and after a binge episode.Make a contract with the patient to approach the

nurse when they feel the urge to binge Encourage adhering to meal and snack schedule of

hospital. Cognitive behavioral therapy is the ideal therapy

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N

ANOREXIA NERVOSAStarvation and

Emaciation is a disorder with an insidious

onset that often affects adolescent girls.

upper middle class families. youngest child is affected.

uses denial 10-20 % of anorexics die and

half of these deaths are due to suicide.

Nursing Interventions Cognitive and Behavioral therapy to positive and negative

reinforcement: focus is on client’s responsibility to gain weight.

Privileges are gained with weight gain. Privileges are lost with weight loss.

Increase self-esteem Teach about the disorder. Monitor weight three times a week but weigh with the patient facing

away from the weighing scale As soon as the ideal weight is gained, allow patient to regulate his or

her own progression and program. High protein and high carbohydrate diet, serve foods the patient

prefer in small frequent feedings. NGT if the patient refuses to eat. Setting limits to avoid manipulative behavior:

Restrict use of bathroom for 2 hour after eating. Accompany to the bathroom to ensure that they will not self induce

vomiting. Stay with client during meals. Do not accept excuses to leave eating area.

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N

Anorexia Nervosa

Eating Disorders

Bulimia

Diet, diet, diet Eating Pattern Eat, eat, vomit

<85% of expected body

Weight Normal weight

3 mos. amenorrhea

Menstruation Irregular menstruation

Karen Carpenter Dao Ming SuDa Ming Sugat/ suka

VomitingDental caries

Wounded knucklesMetabolic alkalosisMetabolic acidosis

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

Paraphilias Paraphilias are complex psychiatric disorders that

are manifested as unusual sexual behavior.

Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR) defined it as a “recurrent, intensely sexually arousing fantasies, sexual urges, or behaviors generally involving:

S = uffering or humiliation of oneself or partner I = nanimate objects (non-human objects) N = onconsenting person C = hildren

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

Eight specific disorders of paraphilia Exhibitionism – Exposing one’s genitals to strangers

or masturbating in public areas.

Fetishism – (Pa suot) inanimate objects to achieve orgasm women’s undergarments (brassiere, lingerie, and panty), shoes and other apparels.

Frotteurism – (Pa Touch) urges of touching or

rubbing against a non consenting.

Pedophilia – a sexual activity done with a child 13 years younger is a characteristic of this disorder. at least 16 years old or at least 5 years older than the victim.

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

Sexual masochism – (Saktan mo ako) the intense and persistent sexual urge involving acts of suffering (beaten or bound) and being humiliated.

Sexual sadism – (Sasaktan kita) sexual urge involving acts in which the pain, suffering or humiliation of a partner is arousing a person.

Transvestic fetishism – sexual fantasies, urge and behaviors involving cross-dressing by a heterosexual male.

Voyeurism – sexual arousal by observing an unsuspecting person who is naked, in the process of undressing or engaging in sexual activity.

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

SUBSTANCE ABUSE

ALCOHOLISM - state of alcohol addictionEtiology:Intergenerational TransmissionFrom one generation to another generationAlcohol Blackout awake but unaware Confabulation inventing stories to self-esteem Denial “I am not an alcoholic”Dependence “I can’t live without it”

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

Enabling significant other tolerates abusersAnother term CO – DEPENDENCY

 TOLERANCE Substance to achieve a previous

effect DETOXIFICATION Withdrawal with MD supervision Safe withdrawal is accomplished through the

administration of benzodiazepines such as Chlordiaxepoxide (Librium), Lorazepam (Ativan) or Diazepam (Valium) to suppress the withdrawal symptoms

Check Alcohol, Mouthwash, Elixir

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

  void alcohol version therapy lcoholics Anonymous self help group ntabuse DISULFIRAM Never drink alcohol

12 hour interval/ 12 h last alcohol intakeB1 Vitamin Deficiency or else: nausea, vomiting and hypotension

Wernicke’s Encephalopathy motorComplications

Korsakoff’s Psychosis memoryDelirium Tremens 24 – 72 h after last dose of alcohol untreated withdrawal syndrome ormocation bugs crawling under the skin amily Therapy mother, father, brother 

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

SUBSTANCE ABUSEDowners - B - arbituates MorphineO - piates Codeine NARCAN

antidoteN - arcotics HeroineA – lcohol

Uppers (Hac - S) Hallucinogens Amphetamines Cocaines

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

LEVELS OF MENTAL RETARDATIONProfound Less 20 IQ thinks like an infants can’t be trained Some speech

Severe - 20 – 35 IQ May learn Talk and communicate Perform simple task elementary hygiene

Moderate - 35 – 50 IQ can be train mental age is 2 – 7 y/o pre-operational stage

P 434 videbeck

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

4. Mild50 – 70meantal age is 7 – 12educablecan go to school

5. Borderline70 - 90

6. Normal90 – 100

Mental Retardation IQ Less than 70 Onset before 18 yrs/old Not often detected until school age Impaired learning and social adjustment

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

Nursing Intervention Role Modeling Repetition Remorivation Provide sensory stimulationAUTISM/Kanner Syndrome/ Pervasive devt. Dis. With a special talent /Head banging and head

rocking Diagnose at 2 Y.O. Appears at 3 y.o. 4x more common in male than in femaleAssessAppearance - flat affect, consistent movementBehavior - repetitive, ritualisticCommunication - echolalia, incomprehensible

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

Nursing diagnosis S -elf mutilation I - mpaired verbal communication R -isk for injury I - mpaired social interactionNursing Intervention Priority Safety,security supervision Counseling Education Expressive therapy - drawing, muscic etc Improved social interactionMeds:Anti Psychotics: Haldol,risperidone=tempertantrums

Naltrexone(revia)Anafranil,Clonidine(catapres)= hyperactivity

 

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

ATTENTION DEFICIT HYPERACTIVE DISORDER Onset : before 7 y.o. Episode : 6 months and above Settings : 2 House and school Id Dominant : Mom or RN will act as superegoAssessC - ommunication - talkative, blurts out in classR - estlessI - mpulsiveD - ecrease attention spanE - asy distractibility

Nursing DiagnosisRisk for injury Impaired social interaction 

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

Nursing Intervention Priority safety and Nutrition Structure separate room for eating, playing, sleeping

and etc Schedule - time for everything Slimits Ignore Temper tantrums Finger foordsMeds: for 6 Y.O. Ritalin,, pemoline, adderal 3 Y.O and Above dexedrinBest time to give: once a day: AFTER MEALS: prevent lost of appetiteDon’t give at bedtime STIMULANT causes

insomnia Give 6 hours prior bedtime if bid

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

ALZHEIMER NOMIA don’t know name of objects GNOSIA problem with senses PHASIA can’t say it PRAXIA can’t do it

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

Domestic ViolenceCHILD ABUSE Burns, bruise, bone fracturesExcessive Knowledge of sex/Violence

DepressionApathy no reactionsBantay Bata 163Don’t bathe the child, don’t brush teet. Body of evidence will be lost

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

TypesViolence- implies only the use of physical forceNeglect – Child abandonment, insufficient Childs

needs for survival

Physical Abuse – abuse in the form of inflicting pain Emotional abuse – form of insults mind gameSexual abuse- unwanted sexual contact

Nursing management Safe , secutiy, supervision Proper reporting of child abuse – w/ in 48hrs Brgy captain, DSWD, Police Play therapy

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

RapeCrime lack of consent, treat, force and sexual penetration

Sexual assault - Forcible sexual acts lack of consent, against his or her will

3 essential elements of rape Vaginal penetration Use of force , intimidation, treat Lack of consent

Rape trauma syndrome Immediate acute phase

Displays 2 type of emotion (disorganization)

Controlled

Expressed

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

Long term process (reorganization) 3-4wks Flash backs in dreams and night mares Development of phobia Self guilt

Crisis InterventionCrisis is a situation or period in an

individual’s life that produces an overwhelming emotional response.

stressor that he or she cannot effectively manage by using his or her usual coping skills.

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

Type of Crisis Maturational crisis – also called developmental

crisis. These are predictable events in a person’s life which includes getting married, having a baby and leaving home for the first time.

Situational crises – unexpected or sudden events that imperils ones integrity. Included in this type of crisis are: loss of a job, death of a loved one or relative and physical and emotional illness of a family member or an individual.

Adventitious crisis – also called social crisis. Included in this category are: natural disasters like floods, earthquakes or hurricanes, war, terrorist attacks, riots and violent crimes such as rape and murder.

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N

Guide for an effective crisis intervention:

Assist the person to view the event or issue in a different perspective.

Assist the individual to use the existing support systems. It is vital to help the person find new sources of support that can help in decreasing the feelings of being alone or overwhelmed.

Assist the individual in learning new methods of coping that will help resolve the current crisis and give him or her new coping skills to be used in the future when dealing with another overwhelming situation.

GIL

BER

T T. S

ALA

CU

P R

N,

MS

N