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Chapter 35 Care of the Patient with a Psychiatric Disorder - Organic Mental Disorders - Thought Process Disorders - Major Mood Disorders: Depression and Bipolar Disorder - Anxiety Disorders Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 1 Care of the Patient with a Psychiatric Disorder • The nurse should have basic understanding of the classifications of human responses and treatments for mental illness. • It is important for nurses to be able to interact therapeutically with both the physical and emotional aspects of patient care. Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 2 Care of the Patient with a Psychiatric Disorder • Neurosis Ineffective coping with stress that causes mild interpersonal disorganization Remains oriented to reality but may have some degree of distortion of reality manifested by a strong emotional response to the trigger event • Psychosis Out of touch with reality and severe personality deterioration, impaired perception and judgment, hallucinations, and delusions Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 3 Organic Mental Disorders • Identifiable brain disease or dysfunction is bases for behavior • Cognitive or intellectual abilities are affected • Effects could be mild lapses in memory to severe behavioral changes • Predominant characteristic is disorientation Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 4 Organic Mental Disorders • Delirium A rapid change in consciousness that occurs over a short time Associated with • Reduced awareness and attention to surroundings, disorganized thinking, sensory misinterpretation, and irrelevant speech • Sleep patterns are disturbed Causes • Physical illness Fever, heart failure, pneumonia, azotemia, or malnutrition • Drug intoxication • Anesthesia Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 5 Organic Mental Disorders • Delirium (continued) Symptoms • Reduced awareness and attention to surroundings, disorganized thinking, sensory misinterpretation, and irrelevant speech • Disturbed sleep patterns • Nocturnal delirium or Sundowning syndrome: increased disorientation and agitation during the evening and nighttime Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 6 Organic Mental Disorders • Delirium (continued) Treatment • Homeostatic imbalance i.e. hypoxemia, electrolyte imbalance, or malnutrition o Focused on problem causing the imbalance • Chemical agents or drugs Chemicals or drugs should be withdrawn or the dosage should be reduced Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 7 Organic Mental Disorders • Dementia Altered mental state secondary to cerebral disease A slow and progressive loss of brain function that is often irreversible Causes • Cerebral disease Alzheimer’s (most common type) Vascular dementia Symptoms • • • • Impaired memory and judgment Personality changes Decreased cognitive function Impaired orientation Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 8 Organic Mental Disorders • Dementia (continued) Treatment • Medications Agitation: lorazepam, Haldol Dementia: Cognex, Aricept • Nutrition Finger foods; frequent feedings • Safety Removing burner controls at night Double-locking all doors and windows Constant supervision Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 9 Organic Mental Disorders • Dementia and Delirium Nursing interventions • Reality orientation techniques Clock and calendar Curtains open and lights on during the day Calm supportive approach • Decreased sensory stimuli No crowds One instruction at a time; keep it simple Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10 Organic Mental Disorders • Dementia and Delirium (continued) Nursing Interventions • Provide for safety Bed in low position Side rails up Rails in hallways Chair and bed alarms Call light and personal articles in reach Sufficient night light Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11 Organic Mental Disorders • Dementia and Delirium (continued) Nursing interventions • Adequate nutrition Reduce dining distractions: TV. Encourage snacks: finger foods. Monitor weight. • Self-care support Assist with ADLs as needed. Encourage mobility and other activities that use large muscle groups. Daily routine should be the same time each day. Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12 Thought Process Disorders • Schizophrenia Bizarre, non-reality–based thinking Characterized by • Gross distortion of reality, disturbance of language and communication, withdrawal from social interaction, and disorganization and fragmentation of thought, perception, and emotional reaction Strikes young adulthood, both sexes equally and about 1% of population will experience it in their lifetime Chronic disorder with residual disability in functioning Aggravated by stresses in life Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13 Thought Process Disorders • Schizophrenia – cont’d Causes • Brain tissue changes Ventricles of the brain larger than normal o Left larger than right ventricle Cerebral cortex smaller that normal o Accounts for disorganized thinking, hallucinations and delusions • Excessive dopamine (neurotransmitter) • Pupils differ in size and blinking rate may be faster or slower than normal • Clumsiness and difficulty distinguishing right and left sides of body are attributed to enlarge ventricle of the brain Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14 Thought Process Disorders • Schizophrenia – cont’d Symptoms are individualized but include • Hallucination; disordered thinking • Apathy and social withdrawal • Flat affect; delusions Behaviors • Positive or excessive and negative or absent Prognosis with positive behavior pattern is good Fewer structural changes in brain and better response to drug therapy Positive behavior pattern o Delusions, hallucinations, disordered thinking Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15 Thought Process Disorders • Schizophrenia – cont’d Delusion • False, fixed belief that cannot be corrected by feedback and is not accepted as true by others in culture • Starts with false premise, believing it to be true • Logically fits this false premise into his or her interpretation of reality • Due to strong logic supporting false premise, it is difficult for the individual to accept what is really true • Types of delusion: see box 35-1, pg 1145 grandeur, ideas of reference, persecution, somatic delusions, thought broadcasting, thought insertion, thought withdrawal Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16 Thought Process Disorders • Schizophrenia – cont’d Hallucination • Sensory experience without a stimulus trigger • Auditory is the most experienced type • Visual, olfactory, and tactile can also occur Disordered thinking • Individual cannot interpret information being received in brain • Exhibited by loose association in speech • Conversation does not flow logically • Concreteness, a sign of disordered thinking i.e. picture is being taken and schizophrenic person is told to “watch the birdie” that person will look up into the tree for bird instead of smiling Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17 Thought Process Disorders • Schizophrenia – cont’d Negative behaviors • Apathy (avolition), social withdrawal, alogia, blunted emotional response, anhedonia Apathy • lack of energy, a contentment to just sit and do nothing • unkempt appearance is a reflection of apathy Social withdrawal • Attempt to reduce stimulus to brain • Person is frightened or overwhelmed by experience of trying to communicate with someone and find it easier to withdraw from event Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 18 Thought Process Disorders • Schizophrenia – cont’d Alogia • Reduced content of speech • Part of overload of information that occurs in conversation and schizophrenics need time to sort out messaged received Flat affect and Anhedonia • Lack of expressed feelings • Flat affect is lack of nonverbal expression of emotions • Anhedonia is inability to experience happiness or joy Bizarre posturing or behaviors such as laughing when given news about a death in family Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19 Thought Process Disorders • Schizophrenia – cont’d Five Subtypes • Disorganized Flat or inappropriate affect, incoherence; prognosis is poor • Paranoid Delusions, auditory hallucinations; prognosis is good with treatment • Catatonic Features stupor, negativism, rigidity, excitement, posturing; prognosis is fair Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20 Thought Process Disorders • Schizophrenia – cont’d Five Subtypes – cont’d • Undifferentiated Delusions, hallucinations, incoherence, gross disorganization (does not fit categories of other types); prognosis is fair • Residual Demonstrates typical signs and symptoms associated with schizophrenia without displaying evidence of gross disorganization, incoherence, delusions, and hallucinations; prognosis is poor Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 21 Thought Process Disorders • Schizophrenia – cont’d Four stages marked by acute episodes of psychosis alternating with periods of relatively normal functions • • • • Prodromal phase Prepsychotic pahse Acute phase Residual phase Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 22 Thought Process Disorders • Schizophrenia – cont’d Four stages • Prodromal phase Begins in adolescence and begins with lack of energy or motivation and withdrawal Symptoms o Affect becomes blunted; beliefs and ideas become odd; person develop excessive interest in philosophy or religion; self-care and personal hygiene are ignored; presence of emotional lability; speech is difficult to follow; complain about multiple physical problems o Magical thinking or believing one’s thoughts control events Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 23 Thought Process Disorders • Schizophrenia – cont’d Four stages • Prepsychotic phase Quiet and passive behavior Prefers to be alone Hallucinations and delusions Odd, suspicious, or eccentric behavior patterns • Acute phase Disturbances of thought, perception, emotion and behavior Individual loses contact with reality and is unable to function in most basic way Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 24 Thought Process Disorders • Schizophrenia – cont’d Four stages • Residual phase Symptoms similar that in prodromal phase Follows acute phase Following residual is remission period wherein person is able to experience symptoms relief and manage basic activities in life Prognosis to recovery is fair to poor Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 25 Thought Process Disorders • Schizophrenia (continued) Treatment • Psychotherapies Allow patient for self-expression • Antipsychotic drug therapy To control symptoms • Therapeutic relationship Maintained for years to provide continuity for individual who suffers a lifelong illness Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 26 Major Mood Disorders: Depression and Bipolar Disorder • Mood Disorders Also known as affective disorders Psychotic disorders characterized by • Severe and inappropriate emotional responses • Prolonged and persistent disturbances of mood and related thought distortions • Other symptoms associated with either depressed or manic states Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 27 Major Mood Disorders: Depression and Bipolar Disorder • Mood Disorders Cause • Hereditary factors Account for about 60-80% • Biologic May be inherited or environmental factors such as prolonged stress or brain trauma. o Depression: insufficiency of norepinephrine and serotonin o Mania: excess norepinephrine Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 28 Major Mood Disorders: Depression and Bipolar Disorder • Mood Disorders (continued) Symptoms: Depression • Mood disturbance characterized by exaggerated feelings of sadness, despair, lowered self-esteem, loss of interest, and pessimistic thoughts Neglect of appearance, difficulty concentrating, complaints of physical problems, disturbed sleeping or eating patterns, loss of self-esteem, feelings of helplessness, hopelessness, extreme anxiety or panic Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 29 Major Mood Disorders: Depression and Bipolar Disorder • Mood Disorders (continued) Symptoms: Depression • Unipolor Major depression (severe depressive episodes lasting more than 2 years) • Disthymic disorder Daily moderate depression lasting more than 2 years Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 30 Major Mood Disorders: Depression and Bipolar Disorder • Mood Disorders (continued) Mania • Persistent abnormal overactivity and an euphoric state • Hypomanic When manic symptoms are not severe • Bipolor Manic-depressive • Cyclothymic Involves repeated mood swings of hypomania and depression Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 31 Major Mood Disorders: Depression and Bipolar Disorder • Mood Disorders (continued) Treatment • Antidepressants Prozac (flouxetine);Desyrel (trazodone); Elavil (amitriptyline); Effexor (venlafaxine) • Lithium Used to treat bipolar disorders Must be monitored closely • Electroconvulsive therapy (ECT) May be used when drug therapy is ineffective • Psychotherapy Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 32 Anxiety Disorders • Anxiety is a normal response to stress or a threat. • Anxiety is a state of feeling of apprehension, uneasiness, agitation, uncertainty, and fear resulting from the anticipation of some threat or danger. • Signal anxiety A learned response to an event such as test taking • Free-floating anxiety Feelings of dread that cannot be identified • Anxiety trait A learned aspect of personality; anxious reactions to relatively nonstressful events Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 33 Anxiety Disorders • Generalized anxiety disorders are characterized by a high degree of anxiety and/or avoidance behavior. Panic: acute, intense, and overwhelming anxiety Agoraphobia: high anxiety brought on by possible situation such as people, places, or events Obsessive-compulsive disorder: recurrent, intrusive, and senseless thoughts and behaviors that are performed in response to the obsessive thoughts Post-traumatic stress disorder (PTSD): response to an intense traumatic experience that is beyond normal experience Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 34 Anxiety Disorders • Treatment Panic Disorders • Educate on the nature of the disorder. • Assist to develop better coping mechanisms. Block attacks pharmaceutically. Post-traumatic Stress Disorder • Antidepressant or antiseizure medications • Cognitive therapy or behavioral therapy • Debriefing right after the event Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 35