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PSYCHIATRIC NURSING
Psychiatric Nursing
Anxiety related disorders
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Dissociative identity disorder
Generalized anxiety disorder
Obsessive compulsive disorder
Panic Disorder
Phobic disorder
Post traumatic disorder
Somatoform disorder
Assessment: Level of anxiety
MILD
MODERATE
SEVERE
PANIC
“You seem anxious.”
Enhanced learning, sit restlessly, widened
perceptual field
- Give - Anti-anxiety drugs-valium
Patient is pacing, selective inattention.
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“I don’t know what to say or do.”
Hard to make decisions.
Suicidal.
Highest level of anxiety.
Priority: safety.
Stay with patient. Don’t touch patient.
Post – Traumatic Stress Disorder
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Symptoms
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Warning:
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Common form of anxiety disorder
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Depression
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Somatization
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Phobias
Genetics and alteration in neurotransmitters
Serotonin
Norepinephrine
Gamma – Aminobutyric acid
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It worries excessively over everything, affects every aspect of
life
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GAD way of relieving anxiety
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Retreating from anxiety – situation
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Self medication with drugs or alcohol
Blunted emotions
Feelings of detachment
Flashback
Moral Guilt
Numbing of responsiveness
Survivor Guilt
Depression
Self destructive behaviours
Suicidal attempts
Substance abuse
PTSD is common who are survivor of combat, natural disasters ,
sexual assault or catastrophic events
Clients with PTSD who use cocaine or amphetamines are more
vulnerable to paranoia and psychosis than those who do not use
stimulants
Dissociative Identity Disorder (DID)
( multiple personality disorder )
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Generalized Anxiety Disorder
Develops after exposure to a clearly identifiable threat
Acute PTSD = Occurs within 6 months
Delayed PTSD = Occurs 6 months or more
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Two or more identity, alters personalities that control individual
behaviour
Dissociation – act as a defense against an overwhelming sense
of anxiety that is both painful and emotionally traumatic.
Trauma: physical , emotional or sexual abuse
Time travel
Same person with different personality with each other.
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Having its own name
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Ways of behaving
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Memories
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Emotional characteristics
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Social relationship
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Unexpected travel of personality.
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Hehehe. . For some it is normal
Somatoform disorder
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Appearance of physical symptoms for which there is no
apparent organic or physiologic cause.
Seek medical attention even though he has been told that there is
no evidence of physical illness:
Conversion Disorder
Hypochondriasis
Pain Disorder
Somatization Disorder
Panic Disorder
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Sudden attacks of intense fear of discomfort that peaks within
10 – 15 minutes
Assessment:
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not being able to breathe
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Feeling of heart attack
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Going crazy
What’s the problem?
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Agoraphobia
Agoraphobia
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Fear of open space
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Restrict activities outside the safety of their home
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Panic attack can be brought on by caffeine, carbon dioxide and
sodium lactate
Factors affect panic disorder
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Genetic
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Environmental Factors
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Benzodiazepine receptor sites alteration
Phobic Disorders
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Expressed as intense , irrational fears of some object, situation ,
or activity
The patient experience anxiety when he comes contact with the
situation or feared object
What’s the problem?
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Intense fear and restlessness
Three major categories of phobic disorders
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Agoraphobia
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Social Phobia
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Specific Phobia
Therapy
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Cognitive behavior therapy
Desensitization
Obsessive – Compulsive Disorder
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Recurrent persistent thoughts, ideas, or impulses
Repetitive rituals in response to the obsession
It is their defense to avoid overwhelming anxiety
What’s the problem?
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Interferes with normal activity and relationships
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Others view this as rigid, controlling and lacking spontaneity
Some evident shows:
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Genetic transmissions or alterations in serotonin regulation
Antidepressant medication:
Panic disorder
Obsessive – compulsive
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Cognitive behavioral therapy and
desensitization
PTSD
Phobic disorders
Important nursing interventions:
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Administering antidepressant medication
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Helping the client to become more aware of situations that
increase anxiety
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Helping the client to recognize the overuse of certain defense
mechanisms
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Teaching cognitive behavioral methods for reducing anxiety
Personality Disorder
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Reality based disorders
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They see nothing wrong with their behavior
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It refer to pervasive maladaptive patterns of behavior that are
evident in the perceptions, communication, and thinking of an
individual
Three cluster of personality disorder
Cluster A – Include Odd, eccentric Behavior
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Paranoid
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Schizoid
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Schizotypal
Cluster B – Dramatic , erratic, emotional behavior
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Histrionic
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Narcissistic
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Antisocial
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Borderline
Cluster C – anxious and fearful behavior
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Avoidant
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Dependent
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Obsessive – Compulsive
Cluster A
Paranoid Personality Disorder
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Rigid
Suspicious
Hypersensitive behavior
They spend there great deal of time and energy validating their
suspicions
Do not have delusions or hallucination
What’s the problem?
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Extreme stress : transient psychotic features
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Uncontrollable Anger toward others
What’s your nursing goal?
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Safety of both health personnel and other patient
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PSYCHIATRIC NURSING
Schizoid Personality Disorder
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Shy
Aloof
Withdrawn Behavior
Hermit – prefers solitary activities
This patient are reality oriented
What’s the problem?
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The patient often fantasizes and daydream
What's your nursing goal?
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Patient’s Health ( nutrition )
Schizotypal Personality Disorder
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Found more often in relatives of those with schizophrenia
Shy
Aloof
Withdrawn
Bizaare way of thinking
What is the problem?
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They are sensitive to the reactions of and possible rejection by
others
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Avoid social interaction
Cluster B
Histrionic personality disorder
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Southern belle syndrome
Diagnosed most often in female
Overly seductive
Excitable
Immature
Emotional
What’s the problem?
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Manipulative
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Many shallow relationship that are always short lived
Narcissistic Personality disorder
“It’s all about me”
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Self absorption
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Grandiose ideas: wealth
power
intelligence
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They believe that they are superior; entitled to certain privileges
and special treatment
What’s the problem?
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Cover up for deep feelings of resentment and rage
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Rationalize or blame others for their self- centered behavior
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Antisocial Personality disorder
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Pattern of disregard for the rights of others
Failure to learn from the past mistakes
Law violation at early age of 15
Early childhood behavior:
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Animal Cruelty
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Normally Runs away from home
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Truancy
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Inflict pain to others
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Starting fire
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Obviously Intelligent
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Charming
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Ideally Smooth talking
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Abuse substances
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Law Breaking
What’s the problem?
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Take advantage of others
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Do not feel remorse for wrong doings
Defense mechanism use:
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Denial and Rationalization
Borderline Personality Disorder
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Most common treated personally disorder
Common in female who have been victims of sexual abuse
Difficulty identifying their feelings
Defense Mechanism:
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Splitting – inability to see self and others as having a good and
bad qualities
What’s the problem?
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Feeling of abandonment and depression
What’s your nursing priority?
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Close monitoring for suicidal ideation and mutilation
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Administer antidepressant medication
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Counseling for PTSD
Cluster C
Avoidant personality disorder
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Dependent Personality Disorder
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Extreme need to be taken care of by someone else
Fear of separation
Inferior
Incompetent
Involved in abusive relationship
What’s the problem?
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Fear of being left alone – Stays with a abusive relationship
What is your nursing concern?
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Safety
Obsessive – Compulsive Personality
Disorder
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Perfectionist
Overly inhibited
Inflexible
Preoccupied with rules
Trivial details
Procedures
Cold and rigid
No expression of tenderness or warmth
Sets standard too high for themselves
What’s the problem?
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They are fearful of making mistake – tend to procrastinate
Managing client with
personality disorder
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Pharmacological interventions are generally not appropriate for
these clients
However if there is a coexisting diagnosis such as depression or
anxiety
Psychotic Disorders
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Alterations in perceptions in reality
Hallucinations
Delusions
Difficulty Organizing taughts
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Schizophrenia
Bipolar disorder
Dementia
Drug intoxication
Withdrawal
Schizophrenia
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Schizophrenia is a chronic illness, although medication improve
client’s quality of life, they do not cure the disease.
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Late adolescence
Early Adulthood
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Theories offered for the cause of schizophrenia:
Genetics
Environmental factors
Biological Alterations in serotonin and dopamine
Nursing Interventions
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Commonly ask!
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Your nursing Goal:
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Set Limits
Conveying a sense of acceptance
Maintain a professional rather
friendly relationship
Timid
Withdrawn
Hypersensitive to criticism
Socially inadequate
Feeling of rejection
Provide quiet, supportive environment
Establishing a trusting relationship
Antipsychotic medication
Activities of daily living
Nutrition and hydration
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Avoid challenging activities – confusion and overwhelm the
client
Do not argue or change the delusional thinking – redirect the
client to a reality based subject
Example: Hearing Voices - acknowledge the voice – face with
reality – medication
4 A’s of Schizophrenia
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Affect – flat, blunted, or inappropriate
Autism – Preoccupation with self and retreat into fantasy
Association – loosely joined unrelated topics
Ambivalence – Having simultaneous opposing feelings
What’s the problem?
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Lack of confidence
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Helpless
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PSYCHIATRIC NURSING
Subtypes of schizophrenia
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Catatonic
With stereotyped position (catatonia) with waxy
flexibility, mutism, bizarre mannerism
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Disorganized
Another word is Hebephrenic. Characterized with
inappropriate behavior: Silly crying, laughing,
regression, transient hallucinations (Auditory).
Paranoid
Presenting sign is SUSPICIOUSNESS,
ideas of persecution and delusions
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Residual
No longer exhibits overt symptoms, no more
delusions but still has negative
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Undifferentiated
Symptoms of more than one type of schizophrenia
Medications:
New Medication
Atypical antipsychotics
Risperidone – given in small doses
Fewer side effects
Manage negative symptoms of schizophrenia
Old medication
Antipsychotic
ChloropromazineMany side effects
may experience extra pyramidal effect
Bipolar Disorders
Major Depression
Acute mania
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Profound changes in mood
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Elevated
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Expansive
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Irritable
Additional Symptoms:
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Delusion of granduer
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Flights of ideas
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Increase motor activity
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Increase risk taking and promiscuity
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Use of profanity
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Uncontrolled spending
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Failing to sleep or eat for a long periods of time
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When limitations are placed on the client’s behavior, he
typically reacts with sarcasm and belligerence.
What’s your nursing intervention?
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Quiet
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Nonstimulating environment
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Protecting from physical exhaustion
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Nutrition: High calorie, high protein finger foods and snacks
that can be eaten while moving about
What to give?
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Mood stabilizers
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Valproic Acid
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Carbamezipine
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Lithium
This is not a drug, mineral that stabilizes the mood of the client
Start of lithium – drawn twice weekly
2-3 months during long term therapy
Normal Therapeutic Level
0.5 – 1.5 meq/ L
Exam Alert!
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Symptoms: muscle weakness, confusion, ataxia , seizures,
cardio pulmonary change, organ failure.
Neuroleptic malignant syndrome
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What’s the only fluid to give?
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Symptoms: hyperthermia
( 107 degree Fahrenheit )
Antidote:
Antiparkinsonian drug
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Depressed mood lasting at least two weeks.
Eating disorder : Anorexia
Patient Feeling of worthlessness
Recurrent thoughts of death and suicide
Early assessment: Diminished ability to concentrate
Sleep disturbance
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What’s the problem?
Suicidal Ideation and suicidal plan
Improving – Greater risk
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What to give?
Ordered Medication: Anti –depressants:
serotonin reuptake inhibitor
Monoamine oxidase inhibitor
Tricyclic antidepressant
Plain NSS
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Selective
What’s your nursing intervention?
Nursing Intervention
Harmful object should be removed
Constant observation
provide safe environment
physiologic needs
Assists in ECT
Excessive use of drugs that is different from societal norm
Illegal - Heroin
Legal – Alcohol or prescription drugs
What’s the history of the patient
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Absenteesim
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Decline in school or work performance
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Frequent accidents
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Increase isolation
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Slurred speech
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Tremors
What is the primary substance abuse?
Alcohol
Alcoholism
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Alcohol withdrawal
6- 8 hours after the last drink
Or when the amount consumed is less than usual
Four stages of alcohol withdrawal
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Stage 1 : 6- 8 hours after last use – anxiety, anorexia, tremors,
nausea and vomiting, depression, headache, icrease blood
pressure
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Stage 2 : 8- 12 hours after last use – confusion hallucinations
hyperactivity and gross tremor
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Stage 3 : 12 – 48 hours after last use – severe anxiety, increased
BP , profuse sweating, severe hallucination and grandmal
seizure
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Stage 4 : 3- 5 day after last use – delirium tremens including
confusion, insomnia, agitation , hallucinations and uncontrolled
tachycardia. Death- cardiac complicationw4w
Types of Crisis
Substance Abuse
Watch out for Lithium Toxicity
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1. Maturation Crisis
- Adolescence (identity crisis)
- Mid-life crisis;
- Pregnancy
- Parenthood
2. Situational crisis
- Most common: Death of a loved one
Important Diagnosis
NSG DX: Ineffective Individual Coping/ Denial
- Abortion Murder,, rape and fire
3. Adventitious Crisis
Calamity, disaster
ex. World War I & II, epidemic, tsunami
In a DISASTER 1st assess/survey the scene
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Stages of psychosocial Development
AGE
Psychosocial
Infancy
(0- 18 months )
Trust vs. Mistrust
Toddler
(18mos. – 3 years)
Autonomy vs. Shame and doubt
Preshool Age ( 3 – 6 yrs )
Initiative vs. Guilt
School Age ( 6 – 12 yrs )
Industry vs Inferiority
Adolescence ( 12 – 20 yrs )
Identity vs. Role confusion
Early Adulthood ( 20 – 35 yrs)
Intimacy vs. Isolation
Middle Adulthood (35 – 65 yrs )
Generativity vs stagnation
Later Years/ Old age ( 65 yrs )
Integrity vs Despair
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PSYCHIATRIC NURSING
SIGMUND FREUD
Psychosexual Theory
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Infancy
: Oral Phase; Id
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Toddler
: Anal Phase; Ego
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Preschooler: Phallic Phase; Superego (Conscience)
Electra complex: Attachment of the girl to her
father and jealousy toward the mother
Oedipal Complex: Attachment of the son to his
mother and jealousy toward the father.
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Schooler
: Latency phase Strict Superego
Adolescent : Genital phase
Therapeutic responses
Offering of self – safety, service, comfort
“I am here. I will sit here beside you.
I will lead you to the group therapy session.”
Reflection: (mirror of feelings)
“It must be difficult for you.”
“You seem angry. You seem concerned.”
Elaboration/Exploration
“Tell me more about your feelings”
Non- Therapeutic Responses
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WHY?
Being defensive
Changing subject
Giving advice or approval
Providing false reassurance
Making Judgment
Don’t Worry
I am
What defense mechanism are they using?
Sexually Abused:
Repression
Involuntary recall or unpleasant thoughts
Moderate Anxiety:
Suppression
Voluntary Forgetfulness
Somatoform:
Conversion
Transferring of mental conflict or anxiety into physical
symptoms
Multiple Personality:
Dissociation
Detaching of strong emotionally charged conflict from one’s
consciousness
Phobia:
Symbolization
Object, idea, or act represents another through some common
aspect
Clarification
“What do you mean by…”
“I could not follow you.”
Molested Child
Acting out
Unconscious wish turned into reality
Alcoholics
PTSD
Incurable illness
Denial
Blocking the awareness of reality.
Anti – social
Alcoholics
Rationalization
Is justifying one’s actions which are based on other motives.
Paranoid
Anti-anxiety Drugs
Valium
Miltown
Librium
Equanil
Ativan
Vistaril
Serax
Atarax
Tranxene
Buspar
( Diazepam)
(Meprobamate)
(Chlordiazepoxide)
(Meprobamate)
(Lorazepan)
(Hydroxyzine pamoate)
(Oxazepan)
(Hydroxyzine hydrochloride)
(Chlorazapate)
(Buspirone)
Monoamine Oxide Inhibitors
Marplan
Nardil
Parnate
Antiparkinsonian Drugs
Artane
Akineton
benadryl
Cogentin
Eldepryl
Larodopa
Symmetrel
Schizoid
Fantasy
Imagined events or mental images. Wishful thinking;
Temporary flight from reality to ↓ anxiety
Others --Intellectualization
The act of transferring emotional concerns into the intellectual
sphere
Permanent or persistence into later life of interests and behavior
patterns appropriate to an early age.
Regression
Introjection
Attributing to oneself the good qualities of another. Incorporate
feelings
What is your Nursing Diagnosis?
Altered Sensory Perception
Delusion; Hallucination, Illusion
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Passive Aggressive personality disorder
Reaction – Formation
OVERCOMPENSATION. Conscious intent often altruistic.
Procrastinate
Identification
Imitator, similar to role playing
Depression:
Open-ended question / broad openings
“How are you?”
“How’s your day?”
“What are your favorite things?”
Borderline
Drug Addicts
Alcoholic
Splitting
Viewing people as all good, and others as all bad
Fixation
Preschooler:
Reality Orientation/Reality Testing
Client: “Help! Help! There are rats on my back!”
Nurse: “I don’t see rats but for you that are real.”
Validation – interpret
Client: “I see a dead people.”
Nurse: “You’re frightened.”
Undoing
Negation of previous consciously intolerable action or
experience to reduce or alleviate feelings of guilt.
A temporary retreat to past levels of behavior that reduce
anxiety, allow one to feel more comfortable.
Compensation
The act of making up for a real or imagined deficiency with a
specific behavior. Conscious or unconscious.
Sublimation
Rechanneling of consciously intolerable or socially
unacceptable behavior
Projection
Person rejects unwanted characteristics of self and assigns them
to others.
Obsessive Compulsive
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Antipsychotic Drugs
Haldol
Trifalon
Prolixin
Stelazine
Clozaril
Serentil
Mellaril
Thorazine
(Haloperidol)
(Perphenazine)
(Fluphenazine
(Triflourperazine)
(Clozapine)
(Mesoridazine)
(Thioridazine HCl)
(Chlorpromazine)
Anti depressant drugs
Elavil
Prozac
Paxil
Zoloft
Luvox
Asendin
Norpram
Tofranil
Sinequan
Anafranil
Aventyl
Vivactile
(Amitriptyline)
(Fluoxetine)
(Paroxetin)
(Sertraline)
(Fluvoxamine Maleate)
(Maprotiline)
(Desipramine)
(Imipramine)
(Doxepin)
(Clomipramine)
(Nortriptyline)
(Protriptyline Hydrochloride)
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