Psychiatric Nursing Reviewer
Psychiatric Nursing Reviewer
Psychiatric Nursing Reviewer
PSYCHIATRIC NURSING
Introduction
Mental hygiene
measures to promote mental health , prevent mental illness and suffering and
facilitate rehabilitation
It requires self-awareness
Illusion
misinterpretation of an actual external stimuli
Hallucinations
false sensory perception in the absence of external stimuli
Word salad incoherent mixture of words and phrases with no logical sequence
Flight of ideas- shifting of one topic from one subject to another in a somewhat
related way
Magical thinking primitive thought process thoughts alone can change events
Disturbances of affect
Inappropriate disharmony between the stimuli and the emotional reaction
Blunted affect severe reduction in emotional reaction
Flat affect absence or near absence of emotional reaction
Apathy dulled emotional tone
Depersonalization feeling of strangeness from ones self
Derealization feeling of strangeness towards environment
Agnosia lack of sensory stimuli integration
Disturbances in motor activity
Echopraxia imitation of posture of others
Waxy flexibility maintaining position for a long period of time
Ataxia loss of balance
Akathesia extreme restlessness
Dystonia- uncoordinated spastic movements of the body
Tardive dyskinesia involuntary twitching or muscle movements
Apraxia involuntary unpurposeful movements
Disturbances in memory
Confabulation filling of memory gaps
Dj vu something unfamiliar seems familiar
Jamais vu- something familiar seems unfamiliar
Amnesia memory loss (inability to recall past events)
Retrograde-distant past
Anterograde immediate past
Anomia lack of memory of items
Personality
totality of emotional and behavioral traits that characterize the person in day to
day living under ordinary conditions; it is relatively stable and predictable.
FORMATION OF PERSONALITY
TEMPERAMENT
mostly unalterable
our nature.
CHARACTER
the outcome of the process of socialization, the acts and imprints of our
environment and nurture on our psyche during the formative years (0-6 years and in
adolescence).
6-12 years latency (quiet stage) sexual energy diverted to play. Institution of
superego: control of instinctual impulses
Sexual maturation
0-12mos
1-3y
3-6
6-12
12-18
18-25
25-60
60 and above
TRUST vs. MISTRUST
AUTONOMY vs. SHAME & DOUBT
INDUSTRY vs. INFERIORITY
INITIATIVE vs. GUILT
IDENTITY vs. IDENTITY CONFUSION
INTIMACY vs. ISOLATION
EGO INTEGRITY vs. STAGNATION
GENERATIVITY vs. DESPAIR
INFANCY
CONSISTENT MATERNAL CHILD INTERACTION TRUST
INNER FEELING OF SELF WORTH
HOPE
TODDLER
ALLOW EXPLORATION
PROVIDE FOR SAFETY
NO, NO NEGATIVISM
OFFER CHOICES / REVERSE PSYCHOLOGY
TOILET TRAINING 18 MOS.-BOWEL
DAYTIME BLADDER: 2 yo
NIGHTIME BLADDER: 3 yo
REWARD W/ PRAISE AND AFFECTION
INDEPENDENCE
PRE-SCHOOL
PROVIDE PLAY MATERIALS
SATISFY CURIOSITY
TEACH AND REINFORCE(HYGIENE,SOCIAL BEHAVIOR)
SIBLING RIVALRY
WILLPOWER
SCHOOL AGE
HOW TO DO THINGS WELL-SUPPORT EFFORTS
CHUMS AND HOBBIES
NEEDS TO EXCEL/ACCOMPLISH
NEED FOR PRIVACY AND PEER INTERACTION
COMPETENCE
ADOLESCENCE
MAKE DECISION,EMANCIPATION FROM PARENTS
BODY IMAGE CHANGES
NEED TO CONFORM BUT KEEP INDIVIDUALITY
SELF - AWARENESS
YOUNG ADULT
RESPONSIBILITY
ACHIEVEMENT OF INDEPENDENCE
MIDDLE ADULTHOOD
SUPPORT-PERIOD OF ROLE TRANSITIONS
MIDLIFE CRISIS
ALTRUISM
LATE ADULTHOOD
SELF ACCEPTANCE
SELF WORTH
WISDOM
Jean Piagets
COGNITIVE THEORY
0-2 SENSORIMOTOR
REFLEXES
SELF-CENTERED,EGOCENTRIC
ANIMISTIC THINKING
Adolescence
Sexual social roles
Relationships
Independence and ideology
Early adulthood
Career
Selecting a mate
Finding Civic or social responsibility
Middle age
Achieving Civic or social responsibility
Adjusting to changes
Satisfactory career performance
Adjusting to aging parents
Adjusting to parental roles
Old age
Adjusting to changes
Establishing satisfactory living arrangements and affiliations
Kohlbergs
MORAL DEVELOPMENT/ THINKING/ JUDGEMENT
PRE-CONVENTIONAL (0-6)
PUNISHMENT AND OBEDIENCE
OBEDIENCE TO RULES TO AVOID PUNISHMENT
CONVENTIONAL ( 6-12 )
STEPS :
climate of acceptance
creating bridge to reality
sharing the world we live in
appreciation of works of the world
climate of appreciation
MUSIC THERAPY
Involves use of music to facilitate expression of feelings, relaxation and outlet of
tension
PLAY THERAPY
enables patient to experience intense emotion in a safe environment with the use
of play
provide toys and materials facilitate interaction observe and help child resolve
problems through play
Group therapy
IDEAL 8 10 MEMBERS
MILIEU THERAPY
Increase patients
Awareness of feelings
points out function of the sick member for the rest of the family
PSYCHOANALYTIC
Various methods and techniques to induce a trance state where patient becomes
submissive to instructions
BEHAVIOR MODIFICATION
DESENSITIZATION
Slow adjustment or exposure to feared objects (phobias)
Periodic exposure until undesirable behavior disappears or lessens
OPERANT CONDITIONING
AVERSION THERAPY
An example of behavior modification
Painful stimulus is introduced to bring about an avoidance of another stimulus
End view: behavioral change
OTHER THERAPIES
HUMOR THERAPY
To facilitate expression and enhance interaction
ACTIVITY THERAPY
Group interaction while working on a task together
BIOLOGICAL/ MEDICAL THEORY
EMOTIONAL PROBLEM IS AN ILLNESS
cause may be inherited or chemical in origin
ELECTROCONVULSIVE THERAPY
6 to 12 treatments
intervals of 48 hours
common complications:
loss of memory
headache
apnea
fracture
respiratory depression
Psychopharmacologic Therapy
Benzodiazepines
Indications
Anxiety
Sedation/sleep
Muscle spasm
Seizure disorder
Alcohol withdrawal syndromes
Generic
Alprazolam
Chlordiazepoxide
Clorazepate
Diazepam
Lorazepam
Oxazepam
Busipirone
Anti-anxiety drugs
Trade name
Xanax
Librium
Tranxene
Valium
Ativan
Serax
BuSpar
Side effects
Drowsiness/ sedation
Ataxia
Feelings of detachment
Increase irritability and hostility
Anterograde amnesia
Increased appetite & weight gain
Nausea
Headache, confusion
Anti-depressants
Indications
Depression
Bipolar depression
Panic disorder
Bulimia
Obsessive-compulsive d/o
Possibly
Conduct d/o
Tricyclic (TCA)
Generic
Trade name
Amitriptyline
Elavil
Imipramine
Tofranil
Trimipramine
Surmontil
Nortriptyline
Pamelor
Trazodone
Desyrel
Bupropion
Wellbutrin
Side effects
Orthostatic hypertension
Anticholinergic effect
Neurologic effects
Generic
Isocarboxazid
Phenelzine
Tranylcypromine
Constipation
Delay ejaculation or orgasm
Muscle twitching
Drowsiness
Dry mouth
Dietary restrictions
Cheese, esp. aged and matured
Fermented or aged protein
Drowsiness
Dizziness
Sweating
Mood stabilizing drugs
Indications
Acute mania
Bipolar prophylaxis
Possibly
Bulimia
Alcohol abuse
Aggressive behavior
schizoaffective
Mode of action
Effects intracellularly
Trade names
Eskalith
Lithotabs
Lithane
Lithonate
Prelithium workup
Early
Anorexia
Metallic taste
Fatigue
Lethargy
Late
Weight gain
acne
Contraindications
Brain damage/ CV disease
Epilepsy
Elderly/ debilitated
Thyroid and renal disease
Severe dehydration
Pregnancy (1st trimester)
Toxic
Nursing considerations
Lithium levels should be checked q 2-3 mos
Serum drawn in the AM, 12H after last dose
Common causes of inc. levels
Dec. Na intake
Diuretic therapy
Dec. renal functioning
F&E loss
Medical illness
Overdose
NSAIDS
Nursing considerations
Diet: adequate Na+ and fluid
3g NaCl/ day
6-8 glasses of H2O
No caffeine
Side effects
Nausea
Hepatoxicity
Neurotoxicity
Hematological toxicity
Pancreatitis
Prep: tab, cap, sprinkles
MOA: inc. levels of GABA; inhibits the kindling process or snoball-like effect
seen in mania & seizures
Nursing considerations
Toxic effects
Severe diarrhea, vomiting, drowsiness, mm. weakness, lack of coordination
Renal failure, coma, death
Anti-psychotic drugs
Indications
Psychotic symptoms of schizophrenia, acute mania and depression
Gilles de Tourette disorder
Treatment-resistant bipolar disorder
Huntingtons disease and other movement disorder
Possibly
Paranoid
Childhood psychoses
General considerations
Avoided in pregnancy
TYPICAL: High Potency
Fluphenazine (Prolixin)
Haloperidol (Haldol)
Thiothexene (Navane)
Trifluoperazine (Stelazine)
Moderate Potency
Loxapine (Loxitane)
Molindone (Moban)
Perphenazine (Trilafon)
Low Potency
Chlopromazine (Thorazine)
Chlorprothixene (Taractan)
Mesoridazine (Serentil)
Thioridazine (Mellaril)
ATYPICAL
Clozapine (Clozaril)
Resperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Sertindole (Serlect)
Ziprasidone (Zeldox)
Contraindications
CNS depression: brain damage, excess alcohol/ narcotics
Parkinsons disease
Allergy
Blood dyscrasias
Acute narrow angle glaucoma
BPH
Side effects
Hypotension
Sedation
Dermal and ocular syndrome
Neuroleptic malignant syndrome
Anticholinergic syndrome
Movement syndrome (Extrapyramidal Syndrome)
Atropine psychosis
Agranulocytosis
Seizures
Neuroleptic Malignant Syndrome
A potentially fatal, idiosyncratic reaction to an antipsychotic drug
10-20% mortality rate
Sx:
rigidity,
high fever,
autonomic instability (BP, diaphoresis, pallor, delirium, elev. CPK), confused or
mute, fluctuate from agitation to stupor
Risk: high dose of high-potency drugs; dehydration, poor nx, concurrent med
illness
Movement Syndromes
Akathisia
Dystonia
Tardive dyskinesia
Bradykinesia
Parkinsonism
Other s/e
Agranulocytosis (Clozapine)
Occurs 3-8 wks after
Medical emergency
s/s: fever, malaise, sore throat, leukopenia
TTT: d/c, reverse iso, antibiotics
Seizures (Clozapine)
Occurs in 5% of patients; TTT: D/c drug
Anticholinergics
Benztropine (Cogentin)
Trihexyphenidyl (Artane)
Biperiden (Akineton)
Procyclidine (Kemadrin)
ANTIPARKINSONIAN MEDICATIONS
COMMON DRUGS:
Trihexyphenidyl (Artane)
benztropine (Cogentin)
Biperiden (Cogentin)
Selegiline (Eldepryl)
Pergolide (Permax)
ANTIHISTAMINE
Diphenhydramine HCl (BENADRYL)
PANIC DISORDERS
SPECIFIC PHOBIA
SOCIAL PHOBIA
OCD
PTSD
ACUTE STRESS DISORDER
Sweating
Trembling or shaking
Feeling of choking
Recurrent and persistent thoughts, impulses, or images are experienced during the
disturbance as intrusive and inappropriate
Person has experienced, witnessed or been confronted with an event that involved
actual or threatened death or serious injury, or a threat to physical integrity
Meets the criteria for exposure to a traumatic event and person experiences 3 of
the ff sx:
sense of detachment,
derealization,
depersonalization,
dissociated amnesia
Excessive anxiety or worry, occurring in more days than not for at least 6 mos,
about a number of events or activities
BIPOLAR D/O
BIPOLAR I: current or past experience of manic episode, lasting at least a week,
that is severe enough to cause extreme impairment in social or occupational functioning.
MANIA: hyperactivity
MIXED
@ least 5 sx of same 2- wk period with one being either depressed mood or loss
of interest or pleasure.
CYCLOTHYMIC D/O
DYSTHYMIC D/O
Depression that comes with shortened daylight in fall and winter that disappears
during spring and summer.
Dealing with Inappropriate Behaviors
AGGRESSIVE BEHAVIOR
Encourage the client to talk out instead of acting out feelings of frustration
Maintain safety
Use calm approach and communicate with a calm, clear tone of voice (be
assertive not aggressive
Set clear, consistent, realistic, and enforceable limits and communicate expected
behaviors
Biochemical factors
Serotonin imbalance
Weak ego
Catatonic type
Disorganized type
Paranoid type
where delusions and hallucinations are present but thought disorder, disorganized
behavior, and affective flattening are absent
Residual type
Undifferentiated type
psychotic symptoms are present but the criteria for paranoid, disorganized, or
catatonic types has not been met
Symptoms
According to Bleuler: 4 As
Affect is inappropriate
Associative looseness
Autistic thinking
Ambivalence
Symptoms
Positive symptoms
delusions, auditory hallucinations and thought disorder and are typically regarded
as manifestations of psychosis.
Negative symptoms
E.G. flat, blunted or constricted affect and emotion, poverty of speech and lack of
motivation.
Symptoms
Social isolation
Catatonic behavior
Hallucinations
Peculiar behavior
Affect is inappropriate
Nsg Dx: Abnormal thought process
CONFABULATION
LOOSENESS OF ASSOCIATION
NEOLOGISM
WORD SALAD
Interventions
Set limits
Maintain safety
Be neutral
Environment
Provide safe environment
Limit stimuli
Psychological Ttt
Behavior therapy
Social skills training
Self-monitoring
Social ttt
Milieu therapy
Family therapy
Group therapy (long-term ttt)
Related psychotic disorders
SCHIZOAFFECTIVE DISORDER schiz + mood disorder (mania/ depression)
Signs
Lack of remorse or indifference to persons hurt
Immediate gratification
Failure to accept social norms
Impulsivity
Consistent irresponsibility
Aggressive behavior
Reckless behavior that disregards the safety of others
BORDERLINE
Signs
instability
Impulsivity: unpredictable gambling, shoplifting, sex & substance abuse
hypersensitivity, self-destructive, profound mood shifts
unstable & intense relations
Disturbance in self concept
Common in women
HISTRIONIC
Pattern of theatrical or overtly dramatic behavior
Signs
NARCISSISTIC
Exaggerated or grandiose sense of self-importance
Develop early in childhood
Preoccupied with fantasies of unlimited success, power and beauty
Signs
arrogance, need for admiration,
lack of empathy,
seductive, socially exploitative, manipulative
Occurs more in men
AVOIDANT
DEPENDENT
Lacks confidence and unable to function in an independent role
Allows other persons to be responsible of their lives
Most frequent personality disorder in the mental health clinic
submissive behavior, low self-esteem, inadequate, helpless
OBSESSIVE-COMPULSIVE
Preoccupied with rules & regulations, overly concerned about trivial detail,
excessively devoted to their work
Depression is common
Encourage the client to discuss feelings rather than act them out
Inform the client that harm to self, others, and property is unacceptable
Infidelity
PARAPHILIAS
SEXUAL SADISM: the recurrent urge or behavior involving acts in which the
pain or humiliation of the victim is sexually exciting.
SOMATOFORM D/O
La belle indifference
PAIN D/O: pain in 1 or more anatomical sites severe enough to warrant clinical
attention and causes clinically significant distress or impairment in fxning.
Interventions
Explore with the client the needs being met by the physical symptoms
Convey understanding that the physical symptoms are real to the client
next
EATING DISORDER BEHAVIORS
Slightly younger
More introverted
Hunger denied
Sexually inactive
Frequent
Less wt loss
Slightly older
More extroverted
Hunger experienced
Amenorrhea
time.
COGNITIVE DISTORTIONS: (+) or (-) distortions of reality that might include
errors of logic, mistakes in reasoning, or individualized view of the world that do not
reflect reality.
See dementia
DEMENTIA
Types:
VASCULAR or MULTI-INFARCT
PARKINSONIAN DEMENTIA
Reversible Causes:
Subdural hematoma
Tumor (meningioma)
Cerebral vasculitis
Hydrocephalus
Disturbing behaviors
Aggressive psychomotor
Nonaggressive psychomotor
Verbally aggressive
Passive
Illusions, hallucinations
Poor judgment
next
Disorganized, rich in content, delusional, paranoid
No change in perception
Poor judgment
No insight
Consistently poor & progressively worsens in MSE
ALZHEIMERS DEMENTIA
Most common type of dementia
Stages:
Symptoms
AGNOSIA: Difficulty recognizing well-known objects
APHASIA: Difficulty in finding the right word
COMMUNICATION D/O
EXPRESSIVE LANGUAGE
MIXED RECEPTIVE/EXPRESSIVE
PHONOLOGICAL
STUTTERING
SELECTIVE MUTISM
COMMUNICATION D/O NOS
ANXIETY D/O
D/O OF RELATIONSHIP
SEPARATION ANXIETY
The following ranges, based on the Wechsler Adult Intelligence Scale (WAIS), are
in standard use today:
Class
IQ
Terms
Profound
Below 20
Idiot
Severe
2034
Imbecile
Moderate
3549
Moron
Mild
5069
Borderline
7079
RETTS D/O
Development is normal until 6-18 months, when language and motor milestones
regress,
Common in females
CHILDHOOD DISINTEGRATIVE D/O or HELLERS SYNDROME
CDD has some similarity to autism, but an apparent period of fairly normal
development is often noted before a regression in skills or a series of regressions in skills.
characterized by late onset (>3 years of age) of devtal delays in language, social
function and motor skills; skills apparently attained are lost
ASPERGERS D/O
characterized by the presence of multiple physical (motor) tics and at least one
vocal (phonic) tic; these tics characteristically wax and wane
haloperidol (Haldol)
pimozide (Orap)
ADHD
Inattention:
Failure to pay close attention to details or making careless mistakes when doing
schoolwork or other activities
Avoiding tasks that require a high amount of mental effort and organization, such
as school projects
Excessive distractibility
Forgetfulness
Easily frustrated
Easily distracted
Hyperactivity-impulsive behaviour
Excessive speech
Feingold diet which involves removing salicylates, artificial colors and flavors,
and certain synthetic preservatives from children's diets.
CONDUCT D/O
repetitive and persistent pattern of behavior in which the basic rights of others or
major age-appropriate societal norms or rules are violated,
DESTRUCTION OF PROPERTY
DECEITFULNESS OR THEFT
Signs
Losing temper
Blaming others
Easily annoyed
Angry and resentful
Spiteful or even revengeful
next
SUBSTANCE ABUSE
Terms:
TOLERANCE: the declining effect of the same drug dose when it is taken
repeatedly over time
WITHDRAWAL
Anorexia
Anxiety
Easily startled
Hyperalertness
HPN
Insomnia
Irritability
Jerky movt
Tachycardia
tremors
WITHDRAWAL DELIRIUM
Agitation
Anorexia
Anxiety
Delirium
Diaphoresis
Disorientation with fluctuating levels of consciousness
Fever (100 to 103 F)
Hallucinations and delusions
Insomnia
Tachycardia and HPN
Disulfiram (Antabuse) therapy
Nursing care
Assess v/s
Maintain orientation
Ensure safety
Use restraints
Administer medications
Phases
Loving phase: batterer is remorseful and assures spouse that he will not harm her
again. This leads to reconciliation.
Myths
They believe that if they try not to antagonize with their husband, he will change.
Efforts to coerce the wife out of the victim role can be fruitful.
Facts
Women stay in relationships with men who batter because they feel guilty or
responsible of the husbands behavior
Wife develops little sense of self-worth, immobilized and unable to remove self
from the relationship.
PHYSICAL BATTERING
EMOTIONAL
SEXUAL
NEGLECT
ELDERLY ABUSE
A variety of behaviors that threaten the health, comfort, and possibly the lives of
the elderly, including physical and emotional neglect, emotional abuse, violation of
personal rights, financial abuse, and direct physical abuse.
Components
Incest: refers to the relationship between the victim and abuser blood relative or
step parent role
Interventions
next
COMPLETED SUICIDE
Self-inflicted death
LEVELS OF SUICIDE
Ideation: thought
Completed
CHEMICAL RESTRAINT
GUIDELINES
All hospital staff who have direct contact with the px should have ongoing
education and training in the proper use of seclusion and restraints and other alternatives
Physician or licensed practitioner should evaluate need within 1 hour after the
initiation of this intervention.
Max of 4 hours for adults, 2 hours for ages 9-17, and 1 hour for children under 9
yrs
Orders may be renewed for 24 hrs before another face to face evaluation
For both restrained and secluded: constant monitoring face to face or by both
audio and video equipment.
SECLUSION
RESTRAINTS
Privacy is important
Review with px the behavior that precipitated the intervention & pxs capacity to
exercise control over behavior
DEBRIEFING: reviewing the facts related to an event & processing the response
to them; can be used after any stressful event
next
THERAPEUTIC IMPASSES
oneself
TRANSFERENCE
COUNTERTRANSFERENCE
Created by the nurses specific emotional response to the qualities of the patient;
inappropriate in the context, content and intensity of emotion; nurses identify the px with
individuals from their past, and personal needs
love or caring
Disgust or hostility
Eg.
Difficulty empathizing
Attempts to help the px with matters not related to the identified nursing problems