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Think Link PSYCHIATRIC NURSING Psychiatric Nursing Anxiety related disorders • • • • • • • 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. … “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 • • • Symptoms • • • • • • • • • • • Warning: • Common form of anxiety disorder • Depression • Somatization • Phobias Genetics and alteration in neurotransmitters Serotonin Norepinephrine Gamma – Aminobutyric acid • It worries excessively over everything, affects every aspect of life • GAD way of relieving anxiety • Retreating from anxiety – situation • 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 ) • • Generalized Anxiety Disorder Develops after exposure to a clearly identifiable threat Acute PTSD = Occurs within 6 months Delayed PTSD = Occurs 6 months or more • 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. • Having its own name • Ways of behaving • Memories • Emotional characteristics • Social relationship • Unexpected travel of personality. • Hehehe. . For some it is normal Somatoform disorder • • • • • • 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 • Sudden attacks of intense fear of discomfort that peaks within 10 – 15 minutes Assessment: • not being able to breathe • Feeling of heart attack • Going crazy What’s the problem? • Agoraphobia Agoraphobia • Fear of open space • Restrict activities outside the safety of their home • Panic attack can be brought on by caffeine, carbon dioxide and sodium lactate Factors affect panic disorder • Genetic • Environmental Factors • Benzodiazepine receptor sites alteration Phobic Disorders • • 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? • Intense fear and restlessness Three major categories of phobic disorders • Agoraphobia • Social Phobia • Specific Phobia Therapy • • Cognitive behavior therapy Desensitization Obsessive – Compulsive Disorder • • • 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? • Interferes with normal activity and relationships • Others view this as rigid, controlling and lacking spontaneity Some evident shows: • Genetic transmissions or alterations in serotonin regulation Antidepressant medication: Panic disorder Obsessive – compulsive Think Link: My Self Review Guide For Nurses www.thinklink.weebly.com Cognitive behavioral therapy and desensitization PTSD Phobic disorders Important nursing interventions: • Administering antidepressant medication • Helping the client to become more aware of situations that increase anxiety • Helping the client to recognize the overuse of certain defense mechanisms • Teaching cognitive behavioral methods for reducing anxiety Personality Disorder • Reality based disorders • They see nothing wrong with their behavior • 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 • Paranoid • Schizoid • Schizotypal Cluster B – Dramatic , erratic, emotional behavior • Histrionic • Narcissistic • Antisocial • Borderline Cluster C – anxious and fearful behavior • Avoidant • Dependent • Obsessive – Compulsive Cluster A Paranoid Personality Disorder • • • • • 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? • Extreme stress : transient psychotic features • Uncontrollable Anger toward others What’s your nursing goal? • Safety of both health personnel and other patient 1 Think Link PSYCHIATRIC NURSING Schizoid Personality Disorder • • • • • Shy Aloof Withdrawn Behavior Hermit – prefers solitary activities This patient are reality oriented What’s the problem? • The patient often fantasizes and daydream What's your nursing goal? • Patient’s Health ( nutrition ) Schizotypal Personality Disorder • • • • • Found more often in relatives of those with schizophrenia Shy Aloof Withdrawn Bizaare way of thinking What is the problem? • They are sensitive to the reactions of and possible rejection by others • Avoid social interaction Cluster B Histrionic personality disorder • • • • • • Southern belle syndrome Diagnosed most often in female Overly seductive Excitable Immature Emotional What’s the problem? • Manipulative • Many shallow relationship that are always short lived Narcissistic Personality disorder “It’s all about me” • Self absorption • Grandiose ideas: wealth power intelligence • They believe that they are superior; entitled to certain privileges and special treatment What’s the problem? • Cover up for deep feelings of resentment and rage • Rationalize or blame others for their self- centered behavior Think Link: My Self Review Guide For Nurses Antisocial Personality disorder • • • 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: • Animal Cruelty • Normally Runs away from home • Truancy • Inflict pain to others • Starting fire • Obviously Intelligent • Charming • Ideally Smooth talking • Abuse substances • Law Breaking What’s the problem? • Take advantage of others • Do not feel remorse for wrong doings Defense mechanism use: • Denial and Rationalization Borderline Personality Disorder • • • Most common treated personally disorder Common in female who have been victims of sexual abuse Difficulty identifying their feelings Defense Mechanism: • Splitting – inability to see self and others as having a good and bad qualities What’s the problem? • Feeling of abandonment and depression What’s your nursing priority? • Close monitoring for suicidal ideation and mutilation • Administer antidepressant medication • Counseling for PTSD Cluster C Avoidant personality disorder • • • • • Dependent Personality Disorder • • • • • Extreme need to be taken care of by someone else Fear of separation Inferior Incompetent Involved in abusive relationship What’s the problem? • Fear of being left alone – Stays with a abusive relationship What is your nursing concern? • Safety Obsessive – Compulsive Personality Disorder • • • • • • • • • 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? • They are fearful of making mistake – tend to procrastinate Managing client with personality disorder • • Pharmacological interventions are generally not appropriate for these clients However if there is a coexisting diagnosis such as depression or anxiety Psychotic Disorders • • • • Alterations in perceptions in reality Hallucinations Delusions Difficulty Organizing taughts • • • • • Schizophrenia Bipolar disorder Dementia Drug intoxication Withdrawal Schizophrenia • Schizophrenia is a chronic illness, although medication improve client’s quality of life, they do not cure the disease. • • Late adolescence Early Adulthood • • • • Theories offered for the cause of schizophrenia: Genetics Environmental factors Biological Alterations in serotonin and dopamine Nursing Interventions • • • • • Commonly ask! • • Your nursing Goal: • • • 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 • 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 • • • • 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? • Lack of confidence • Helpless www.thinklink.weebly.com 2 Think Link PSYCHIATRIC NURSING Subtypes of schizophrenia • Catatonic With stereotyped position (catatonia) with waxy flexibility, mutism, bizarre mannerism • • 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 • Residual No longer exhibits overt symptoms, no more delusions but still has negative • 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 • Profound changes in mood • Elevated • Expansive • Irritable Additional Symptoms: • Delusion of granduer • Flights of ideas • Increase motor activity • Increase risk taking and promiscuity • Use of profanity • Uncontrolled spending • Failing to sleep or eat for a long periods of time • When limitations are placed on the client’s behavior, he typically reacts with sarcasm and belligerence. What’s your nursing intervention? • Quiet • Nonstimulating environment • Protecting from physical exhaustion • Nutrition: High calorie, high protein finger foods and snacks that can be eaten while moving about What to give? • Mood stabilizers • Valproic Acid • Carbamezipine • 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! • Symptoms: muscle weakness, confusion, ataxia , seizures, cardio pulmonary change, organ failure. Neuroleptic malignant syndrome • What’s the only fluid to give? • Symptoms: hyperthermia ( 107 degree Fahrenheit ) Antidote: Antiparkinsonian drug Think Link: My Self Review Guide For Nurses 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 • • What’s the problem? Suicidal Ideation and suicidal plan Improving – Greater risk • • What to give? Ordered Medication: Anti –depressants: serotonin reuptake inhibitor Monoamine oxidase inhibitor Tricyclic antidepressant Plain NSS • • • 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 • Absenteesim • Decline in school or work performance • Frequent accidents • Increase isolation • Slurred speech • Tremors What is the primary substance abuse? Alcohol Alcoholism • • • • Alcohol withdrawal 6- 8 hours after the last drink Or when the amount consumed is less than usual Four stages of alcohol withdrawal • Stage 1 : 6- 8 hours after last use – anxiety, anorexia, tremors, nausea and vomiting, depression, headache, icrease blood pressure www.thinklink.weebly.com Stage 2 : 8- 12 hours after last use – confusion hallucinations hyperactivity and gross tremor • Stage 3 : 12 – 48 hours after last use – severe anxiety, increased BP , profuse sweating, severe hallucination and grandmal seizure • 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 • • • • • • • • • • 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 7. 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 3 Think Link PSYCHIATRIC NURSING SIGMUND FREUD Psychosexual Theory Infancy : Oral Phase; Id Toddler : Anal Phase; Ego 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. 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 • • • • • • • • 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 Think Link: My Self Review Guide For Nurses 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 www.thinklink.weebly.com 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) 4