Psychiatric Nursing PDF

PSYCHIATRIC NURSING THEORIES OF PERSONALITY DEVELOPMENT Interpersonal process whereby the professional nurse practitioner through the...

PSYCHIATRIC NURSING THEORIES OF PERSONALITY DEVELOPMENT Interpersonal process whereby the professional nurse practitioner through the FREUD’S PSYCHOSEXUAL ERIKSON’S PSYCHOSOCIAL therapeutic use of self assists clients to Libido is the driving force of human Social factors Promote health behavior Prevent mental illness and suffering Participate in the treatment and rehabilitation of the mentally ill 0-18 MONTHS [ ORAL ] 0-12 MONTHS [ TRUST | MISTRUST ] Find meaning in these experiences (joyce travelbee) Gratification: things in mouth Consistent maternal care = trust Virtue: Hope MENTAL HEALTH WHO 2020 18m - 3y [ ANAL ] 1y - 3y [ AUTONOMY | SHAME AND DOUBT State of well-being in which an individual realizes his or her own abilities, can cope Gratification: Control of elimination ] with the normal stresses of life, can work productively, and is able to make a Autonomy: toilet needs met consistently; contribution to his or her community. Will Good: balanced reward / discipline Opposite: mental disorder (becomes a disorder when it affects daily living) Bad: No balance, disorganized PERSONALITY 3y - 5y [ PHALLIC / OEDIPAL ] 3y - 6y [ INITIATIVE | GUILT ] A result of a person's genetic constitution, psychological development and culture. It Genital is the focus of interest, Initiative: efforts and learning supported can be changed and modified at any point. stimulation and excitement Start activities, best time to learn language Curiosity of opposite sex, / talent Emergence of personality occurs around 2 years of age, parent-child relationship is masturbation, penis envy Virtue: Purpose significant. Resolution of oedipal complex through role identification with 1. Conscience - judge of what is right or wrong parent of same sex 2. Ego Ideal - provides rewards 5y - 13y [ LATENT ] 6y - 12y [ INDUSTRY | INFERIORITY ] THREE PERSONALITY COMPONENTS BY FREUD Sublimation (sexual energy diverted Industry: learns to make things through to play) working with others ID (devil) EGO (reality based) SUPEREGO (angel) Resolution of oedipal stage Virtue: Competence Formation of superego At birth 1 to3 years old, maintains 3 to 6 years old sanity 12y - 21y [ GENITAL ] 12y - 18y [ IDENTITY | ROLE CONFUSION ] ↑ Sexual activity Identity: vocational choices supported Pleasure Principle Partly unconscious and Conscience Strengthened Sexual Identity Virtue: Fidelity Unconscious conscious Unconscious Orgasm: sexual release, relieves ↓ Sense of right and Reality Principle Morality anxiety; however if it becomes wrong Integrator of personality answer for anxiety = multiple sexual Internal / Innate D Balancer disorder (masochism, saddhism) Desires Enables adaptive behavior 18y - 25y [ INTIMACY | ISOLATION ] Intimacy: satisfying relationships Bipolar manic Imbalance between Id and Paranoid, OCD, Virtue: Love masturbates superego = shattered ego = Anorexia Nervosa Antisocial mental disorder  FOUR PHASES OF NURSE-CLIENT RELATIONSHIP 25y - 65y [ GENERATIVITY | STAGNATION ] PHASE DESCRIPTION TASKS Interested in guiding next generation Virtue: Care PRE-INTERACT Before first contact Explore ideas, biases, values that ION may impinge ↑ 65y [ INTEGRITY | DESPAIR ] Identify client’s strengths and Evaluates life and acknowledges wisdom needs developed through experience Develop self-awareness to Reflection on legacy prevent countertransference ORIENTATION Acceptance, trust and Develop mutually acceptable NOTES: INTRODUCTOR boundaries established contract 1. Regression Y INITIATION Clarify expectations return to an earlier developmental stage Nurse meets and ends Termination should be 2. Oral Fixation: fixated when client identifies communicated needs to put something into mouth to relieve anxiety / stress problems Help identify problem (paulit ulit) (smokers) 3. Avoidant Personality disorders Trust and Rapport more complex inferiority complex Reflect on words of patients 4. Transference Use contract, boundaries and schedules Patient to nurse Strength and weaknesses 5. Countertransference Therapeutic environment Nurse to patient; Form of displacement 6. Resistance WORKING Achieve goals, share facts Identify and resolve problems Ambivalent attitude toward self-exploration IDENTIFICATIO and feelings Encourage independence = Frequent tardiness in scheduled activities N Examine feelings and recovery = readiness for EXPLOITATION responses = better coping termination skills Overcome resistance SELF-AWARENESS Planning and The process by which the nurse gains recognition of own feelings, beliefs and intervention Self concept of the patient increases attitudes. Organize support system Most difficult and Lead to plan of action SIGNIFICANCE longest phase Verbalization of feelings 1. Differs from self-understanding; in SA, does not require knowledge of why Encourage independence one believes and feels as one does Realistic goal setting 2. Major tool of psychiatric nurse is the therapeutic use of self (peplau) 3. Nurse must learn to accept these differences among people and view each TERMINATION Begins when problems are Evaluate progress and client as a worthwhile person regardless of the client’s opinions and lifestyle. resolved and ends when achievement of goals relationship is ended Encourage client to express GOAL feelings about termination 1. Decrease the size of blind and private quadrants, enlarging the size of the Assist client to review learnings open quadrant and transfer relationship with 2. Know one so that one’s values, attitudes and beliefs are not projected to the others client, interfering with nursing care  4. TOUCH Reinforce and reward change and strength of patient Encourage expression of feelings about termination of the Shows attempt to connect or relate relationship Offer therapeutic touch (Back rub massage) Summarize and evaluate the progress ○ TOUCH: anorexic patient, grieving mother Terminate the relationship without giving promises ○ NO TOUCH: manic patient, paranoid 5. SILENCE Encourages verbalization of feelings COMMUNICATION Exchange of information between 2 or more person ESSENTIALS FOR A THERAPEUTIC COMMUNICATION Genuineness SENDER > MESSAGE > RECEIVER > FEEDBACK (most important) Respect (encoder) (decoder) Empathy (putting self into somebody else’s shoe, understand how they feel) Attentive Listening (providing feedback) ELEMENTS OF NON-VERBAL COMMUNICATION Trust 1. KINETICS Body language, movement Facial expressions, poise, posture, gait, movements, etc Reflects mood THERAPEUTIC COMMUNICATION CLARIFYING 2. PROXEMICS Asking the client what their statements meant, showing them that you don’t Space/ distance between sender and receiver understand them “I’m not sure I understand what you are trying to say” A. INTIMATE DISTANCE Neologism up to 18 inches Enema, BP checking, catheterization EXPLORING Maintain professionalism; giving privacy / consent Want the client to give you more information about the topic “Tell me more” B. PERSONAL SPACE “Would you describe your responsibilities” 18 inches to 4ft. Patient interviews, health teaching GIVING BROAD OPENINGS OR ASKING OPEN ENDED QUESTIONS Give the client general lead of the conversation C. SOCIAL SPACE Open ka sa kahit anong gustong pag usapan ng patient 9 to 12 ft “Is there something you’d like to do” Lectures and group therapies ACCEPTING D. PUBLIC SPACE Accept the client’s concerns and hindi mo sya minamaliit Beyond 12 ft Public speaking, seminar, general audience ACKNOWLEDGING OR GIVING RECOGNITION ○ Know your audiences “I notice that you’ve your bed” 3. PARALANGUAGE Bawal mag praise ng patient gagu, irecognize mo lang! ○ This will encourage repetition of good behavior Vocal cues, Message delivery How message is delivered / pronounced, voice quality ASKING DIRECT QUESTIONS SUPPORTIVE CONFRONTATION “Are you going to kill yourself?” - mATIK!!! Acknowledge client’s feelings Close-ended questions are not always wrong ○ Magic sarap ng theracomm For suicidal, “I know it isn’t easy, but you can do it” Alzheimer’s It would be difficult at first, but you’ll get through it” ○ Ex.: “Do you want pokpok? (answerable by yes or no) NON-THERAPEUTIC COMMUNICATION TECHNIQUES OFFERING SELF FALSE REASSURANCES “I’ll sit with you in a while” Invalidates the patient “Don't worry everything will be alright” PRESENTING REALITY “I see no one else in the room” JUDGING Delusions: false beliefs - do not present reality! “It’s your own mistake” ○ Instead, voice doubts: “I find it hard to believe” “Is there something wrong?” MATIK WRONG INFORMING DEFENDING Health teaching using layman’s terms “All doctors here are simply great” “I’ll be your nurse for today, from 7:00 until 3:00 this afternoon” BELITTLING MAKING OBSERVATIONS “Don’t be concerned, everyone feels like that.” Notice negative Gives them hint to explain themselves Seems like asking why without asking why DONT’S: “You appear tense” 1. Why questions 2. Do not lecture the patient REFLECTING ○ Teaching what is right or wrong Reflect feelings, ideas and thoughts 3. Do not give advice Client: I do not want those medicines! /pout 4. Avoid Agreeing / Disagreeing Nurse: You are unhappy of taking the medication 5. Do not moralize ○ Ito yung tama sa mata ng Diyos RESTATING 6. Do not ignore the patient 7. Do not blame the patient Literal na cinopy paste mo lang sinabi ng patient 8. Avoid passing the buck Will hint the client na kulang yung information na sinabi nya ○ Do not refer Client: i can’t sleep, I stay awake all night ○ Ikaw dapat ang magrereply as a nurse if hindi nag ccause ng sakit Nurse: You can’t sleep at night? (restate) ○ If life-threatening: refer to physician ○ “I will ask your physician to talk with you about this” SUMMARIZING During the past hour, we talked about your plans for the future, they include… MENTAL HEALTH DISORDERS Tell the client all the things you’ve talked about General Criteria Shows the patient na interested kang kausapin sya 1. Disturbance in normal mental function (organic/functional) 2. Discomfort with thoughts, feelings, behavior USING SILENCE 3. Dissatisfaction with characteristics and interpersonal relationships 4. Discontentment with abilities and accomplishments  5. Disorganized coping or ineffective adaptation MANAGEMENT Directives; direct questions ANXIETY DISORDERS ○ Paternalism; do not ask the patient what they want Fear of the unknown to do, decide for them A normal response to stress IM meds anxiolytics (faster route) A subjectively experience that includes feelings of apprehension, uneasiness, Safety uncertainty or dead Panic (+4) Hallucination, Harming others, Chest pain, Syncope, Parang GENERALIZED ANXIETY DISORDER (GAD) phobia (avoidance and displacement) Anxiety of day to day activities Restlessness MANAGEMENT Fatigue No touch, stay with the client Excessive anxiety and worry Safe environment Increased muscle aches or soreness ○ palabasin other patients, sara pinto / Impaired concentration bintana, keep harmful objects Irritability No IM meds Difficulty sleeping Pwedeng mag restrain but last option to LEVELS OF ANXIETY [ HILDEGARD PEPLAU ] CHRONIC FATIGUE SYNDROME Mild (+1) Good type of anxiety, No management A chronic illness characterized by severe fatigue for 6 months or longer usually following flu-like symptoms with at least 4 of the following criteria required for Widened Perceptual Field diagnosis Increased senses Restless (Stationary) 1. Sore throat Enhanced Learning Capacity 2. Substantial impairment in short-term memory or concentration 3. Tender lymph nodes Moderate (+2) Pacing back and forth (safety problem) 4. Muscle pain Nausea 5. Multiple joint pain with redness or swelling Anorexia 6. Headaches of a new type, pattern or severity Vomiting 7. Unrefreshing sleep Diarrhea and Increased Urination 8. Post-exertional malaise lasting more than 24 hours Abdominal Butterflies PSYCHOTROPIC MEDICATIONS MANAGEMENT ANXIOLYTICS Safety Oral Meds Does not cure; manages the symptoms only by potentiating GABA and depressing the ○ Anxiolytics CNS ○ Para hindi na mag progress yung anxiety into Minor tranquilizers with sedation, also used for patients with insomnia severe Downer: ↓ HR, BP, RR, anxiety Problem Solving BENZODIAZEPINES Severe (+3) Increased RR, HR, BP, Dyspnea, Confusion, Alogia Short acting, quick onset 1. Valium (diazepam) 2. Xanax (Alprazolam)  3. Klonopin (Clonazepam) INTERVENTIONS 4. Serax (Oxazepam) GOAL: To help patient return to pre-crisis level 5. Ativan (Lorazepam) FOCUS: Gestalt Therapy (here and now) NURSING EDUCATION APPROACH Avoid downers like alcohol to prevent respiratory depression DIRECTIVE - promote problem solving Antidote: Flumazenil (rumazicon) SUPPORTIVE - Encourage expression of feelings PRECAUTIONS PHOBIA Bed Rest at bed time before meals Fear of the known; An illogical, intense and persistent fear of a specific object or Avoid driving / heavy machinery social situation Avoid stimulants (caffeine, cigarettes) as effect will be neutralized or Symptoms of a phobia are generally similar signs and symptoms to a panic attack decreased (with avoidance and displacement) Monitor kidney and liver (toxic) 20mmHg (systolic) drop = withhold drug and notify physician 1. Acrophobia 9. Nyctophobia Contraindicated in acute narrow-angle glaucoma 2. Agoraphobia 10. Pyrophobia Taper gradually over 2 to 6 weeks 3. Astrophobia 11. Social phobia 4. Claustrophobia 12. Xenophobia WITHDRAWAL SYMPTOMS 5. Hematophobia 13. Zoophobia Restlessness, Irritability, Insomnia, Hand Tremors, Abdominal or muscle cramps, 6. Hydrophobia 14. Arachnophobia Sweating, Vomiting, Seizures 7. Monophobia 15. Ophidiophobia 8. Mysophobia CRISIS DefMech: Displacement, Avoidance, Repression A temporary emotional disturbance that occurs when there is lack of support and coping mechanisms are ineffective resulting in disequilibrium. MANAGEMENT (let the client think and talk about the feared object) Decision making and problem solving is inadequate 1. Cognitive Behavioral therapy Self limiting: usually lasts for 4-6 weeks 2. Flooding 3. Systematic Desensitization TYPES OF CRISIS 1. Maturational / Developmental STRESS DISORDERS Expected or predictable; relates to developmental stages and associated role Fear of the traumatic past changes (marriage, birth of child, retirement) 1. PTSD - symptoms persist for over 1 month 2. ASD - within the 1st month after a traumatic event 2. Situational / Accidental SIGNS AND SYMPTOMS Unanticipated events; normal crisis na hindi expected; associated with a life Same with panic and severe anxiety event that upsets an individual’s psychological equilibrium (loss or change in job, Increased HR, RR, BP, Dyspnea [ severe ] death of loved one, divorce, severe illness, abortion) Hallucination + Harming others [ panic ] Guilt and angers of the past 3. Adventitious / Social Self blames Relates to a crisis of disaster or an event that is not part of everyday life and ○ Give assurance: it is not your fault is unplanned and accidental; Something abnormal because it is related to disaster; ○ Address guilt and anger these are the situations na hindi normal mangyare (crime of violence, natural or Insomnia national disaster) Appetite loss Nightmares ○ Asleep  Flashbacks GUIDED IMAGERY A mind-body intervention where clients concentrate on ○ Awake Only done by mental images to help reduce stress, anxiety and improve ○ Hallucinations psychiatrist concentration. Violence Relaxing technique to guided scenarios MANAGEMENT GROUP THERAPY 3 to 5 members (open forum) 1. Safety GOAL: To reduce isolation and communicate acceptance 2. Provide Reassurance 3. Psychotherapy THERAPEUTIC Set up an environment that is therapeutic for the patient; 4. Pharmacologic MILIEU provides a safe and secure environment for clients that are SSRI in therapy Anxiolytics SUICIDAL PATIENT PSYCHOTHERAPY / TALK THERAPY Place in semi-private room para may watcher / other Can help eliminate or control troubling symptoms patients; wag sa private, near nurses’ station DEFUSING Providing stress and stress management technique AUTISTIC PATIENT Deep breathing techniques, coughing exercises, Private, away from the nurses’ station. listening to relaxing music Teach “self-defuse” [ bago mag defuse yung bomba ] GESTALT THERAPY Encouraging to develop a sense of awareness of feelings and behaviors and their effects upon their environment in DEBRIEFING Talk to the client regarding emotional reaction or feeling the present time instead of the incident itself EXPOSURE Confronting trauma associated thoughts rather than THERAPY avoiding PERSONALITY DISORDERS Expose the patient sa kinakatakutan then let them verbalize a way of thinking, feeling, and acting that goes against what people in the culture feelings expect, causes distress or makes it hard to function, and lasts for a long time. They are unaware na ayaw sila ng tao (yung way of thinking, way of feeling is against the ADAPTIVE Empty chair technique [ Kakausapin yung empty chair; while society) CLOSURE THERAPY iniimagine nakaupo doon yung taong gusto mong makusap (especially sa taong wala kang closure) ] CLUSTER A: ODD & ECCENTRIC CATHARSIS Releasing repressed emotions thru art and music PARANOID Very controlling of their environment HORTICULTURAL Use of plants to improve mobility, balance, endurance, PERSONALITY Gets easily triggered and angered THERAPY socialization and memory skills DISORDER Projection RE-MOTIVATION Simple group therapy that focuses on client’s abilities Suspicious, Intense and controlling, Lonely, Over jealous, Sensitive THERAPY enabling them to think about reality r/t themselves SCHIZOID Avoid people because they do not like people COGNITIVE It helps clients reframe their thought processes in order to PERSONALITY Madaling ma turn off sa ibang tao BEHAVIORAL slowly cope with stress and anxiety DISORDER Socially detached THERAPY Change of mindset to change the behavior  No bestfriend, Avoids people (attached to pets and computers), “I Wife battered syndrome, Indecisive and good follower, Fears don’t like people”, Loner, Stand on separation, Enabler and codependent SCHIZOTYPAL Tell horror and magical stories OBSESSIVE Unaware, may progress to panic attack and harm others; PERSONALITY Have superstitious beliefs COMPULSIVE cannot perform ADLs, cannot stop rituals because it will lead DISORDER PERSONALITY to panic attack Alone, Has special powers, Withdrawn, Often tells horror/magical DISORDER stories, Overly detached OBSESSIVE COMPULSIVE DISORDER CLUSTER B: DRAMATIC & UNPREDICTABLE Obsessions and Compulsions are ways of reducing or eliminating anxiety DefMech: Undoing, Repression, Displacement NARCISSISTIC Needs admiration d/t ↑ self esteem (maintains) OBSESSIONS = excessive thoughts and impulses / intrusive thoughts PERSONALITY Needs admiration, Arrogant and grandiose, Really believe they are COMPULSIONS = repetitive “ritualistic behaviors” DISORDER perfect, Constant need of praise, Superiority complex TYPES: Wants attention because of positive things 1. OCD 2. Body Dysmorphic Syndrome HISTRIONIC Overacting with low self esteems which rises when needs are 3. Hoarding disorder PERSONALITY gratified 4. Trichotillomania (hair pulling) DISORDER Attention seeker and seductive, Gratification needed, Hysterical 5. Excoriation (skin-picking) and dramatic, Hyperemission MANAGEMENT: Wants attention regardless of the reason 1. Divert/redirect the ritual to a productive activity Direct to positive ritual BORDERLINE Has abandonment issues 2. Initially, allow patient to continue the rituals PERSONALITY Manipulative and gaslighter (uses suicide and extortion) Kailangan nya tapusin yung rituals DISORDER “You are the best nurse in here, the others are rude” 3. Engage patient in social activities 4. Set limits to patient’s ritual, but do not stop / interrupt a ritual ANTISOCIAL Strong personality kaya gusto sila ng mga dependent Decrease the ritual time PERSONALITY Dependent + antisocial = sexual disorder 5. Pharmacologic: SSRIs DISORDER Good talker and charming, Manipulative, Aggressive (sexually), Impulsive, Law breakers DISSOCIATIVE DISORDERS DISSOCIATIVE IDENTITY DISORDER Unaware that has different identities as a result of defense mechanism CLUSTER C: ANXIOUS AND FEARFUL Occurs when 2 or more identities (alters) rotate control over the client’s behavior > AVOIDANT Shy and has inferiority complex, sensitive to criticisms Sira ang ego dahil sa sexually traumatic event > Host creates alter personalities na PERSONALITY Prone to abuse hindi magkakakilala DISORDER Avoidant, timid, Inferiority complex, Sensitive to rejection TYPES DEPENDENT Scared of being left which results to loss of functioning PERSONALITY Needs comfort person; starts with being indecisive 1. Dissociative Amnesia DISORDER Abused by society due to their weak personality Cannot recall personal info / purchases 2. Dissociative Fugue 4. Attend to physical complaints Patient has assumptions of a new identity in a new environment 5. Consistent caregiver must be provided 6. Encourage verbalization of feeling 3. Depersonalization Disorder Temporary loss or change of self-perception; An altered self-perception in TREATMENT which one’s own reality is temporarily lost or change 1. Antidepressants: SSRI 2. Chronic Pain Therapy (Avoid opiates / narcotic analgesics) MANAGEMENT 3. Cognitive Behavioral Therapy 1. Stay with patient, Maintain safe environment 2. Gather data about the current patient 3. Do not present all data, avoid flooding 4. Explore stressors EATING DISORDERS 5. Ask the patient to relate the event Uncertain self identification and grossly disturbed eating habits 6. Look for effective coping 7. No Pharmacologic Intervention; Anxiolytics for symptom management only COMPULSIVE OVEREATING Binge like overeating without purging; eating relieves tension but does not produce SOMATIC SYSTEM DISORDERS pleasure; Aware that eating patterns are abnormal and feels depressed after eating; (Psycho + Soma) = mind over body repeatedly tries to diet but without success, helpless and hopeless abt weight a psychological disorder where clients have unexplained physical symptoms like abdominal pain, weakness, chest pain, SOB and others. It has no medical cause and PICA EATING everything is psychological thus, all lab results are normal but symptoms are real Eating inedible food over 1 month (subjective) ANOREXIA NERVOSA SOMATOFORM DISORDERS Preoccupied with foods that prevent weight gain and has a phobia against food that Imagined, exists in the mind but symptoms are manifested produce weight gain 1. Conversion Onset: 10-30 y/o, Common in females (expected to be sexy), self-esteem problem Imagined disability or loss of function of an organ (la belle indifference - Cause of Death: starvation, suicide, electrolyte imbalance, cardiomyopathy patient is unconcerned with the symptoms/unfocused) Fears obesity, has appetite, problem in hypothalamus (thirst and hunger) = 2. Hypochondriasis altered perception Preoccupied with serious illness often resulting in Doctor Shopping Refuses to eat 3. Body Dysmorphic Disorder Loves talking about foods and calories Organ defect without loss of function Slow suicide WITH PHYSICAL SYMPTOMS BUT NO ORGANIC CAUSE ASSESSMENT 1. Malingering 1. Refuses to eat or drink Faking an illness 2. Excessive exercise 2. Factitious 3. Perfectionist Cause illness to self 4. Underweight or 15% or less than IBW 3. Factitious Disease by Proxy 5. Signs of Malnutrition Munchausen’s Syndrome; cause illness to others Bony prominence Amenorrhea for 3 periods MANAGEMENT Dry Hair 1. Rule out any possible organic of physiologic cause Lanugo 2. Real for the patient Imbalance of fluids and Electrolytes = hypokalemia 3. Recognize manipulation Poor Skin Turgor  6. Ensure safety NEUROTRANSMITTERS DOPAMINE/ EPINEPHRINE / NOREPINEPHRINE INTERVENTIONS Excitatory 1. Stay with client during meals and promote family therapy (kasi family Elevation of mood members yung bully usually) ↑ levels of these will result schizophrenia BULIMIA NERVOSA Binge eating followed by self-induced vomiting (purging) SEROTONIN Most clients remain within normal weight range but think that their lives are Excitatory or inhibitory dominated by eating-related conflict Pag nagstay sa synapses, it is excitatory Pag naka pasok na sa cells, it is inhibitory ASSESSMENT 1. Hoarseness of Voice SSRIs Due to pricking of throat leading to regurgitation of HCl acid Inhibits serotonin na pumasok sa cells 2. Enlarged Parotid Glands Antidepressants will maintain serotonin sa synapses For saliva reproduction 3. Russell’s Sign GABA (GAMMA-AMINOBUTYRIC ACID) Calluses on knuckles due to frequent exposure to the teeth when purging It is the balancer; it balances the other neurotransmitters 4. Toothache Balances the chemical environment of the brain Dental caries and Halitosis due to Hydrochloric acid 5. Metabolic acidosis and alkalosis Neurons and muscles ay walang physical contact, they communicate through Use of laxatives / enema: acidosis (bicarbonate in the intestines are excreted wireless transmissions = neurotransmitters kasi hyperactive yung GI) Synapses = space Purging: alkalosis (kasi lumalabas yung hydrochloric acid) NEURODEVELOPMENTAL DISORDERS INTERVENTIONS AUTISM SPECTRUM DISORDER 1. Encourage expression of feelings (disorder is triggered by depression) 2. Always use the same scale developmental disorder that impairs a child’s ability to communicate and interact; 3. To promote the feelings of control cause is unknown 4. Include dietician or psychiatrist 5. No signs of Malnutrition SIGNS AND SYMPTOMS 6. Goal Does not Maintain eye contact Does not unteract with gestures Stay with the client 1 to 2 hours after meals and assess for purging Like being cuddled & plays alone Restrict or limit bathroom privileges (risk for purging) Delay in language development Echolalia and Rituals (OC) MEDICATIONS (for anorexia nervosa and bulimia nervosa) Respond to questions 1. TCA (tofranil, elavil) 2. SSRI (prozac, zoloft) ROUTINES AND CONSISTENCY Safety Side effects of antidepressants: Structure (Provide place to study, eat, play, bath and etc) 1. Weight gain for anorexia nervosa ○ Gustong gusto nila kasi OC sila 2. Decreased purging episodes for bulimia nervosa Schedule ○ Time for everything Set limits Prevent overstimulation  ○ Limit number of visitors and choices A child who has started taking amphetamine will manifest stunted growth ○ Admit in private room away from the nurse’s station 2. Nursing Interventions MANAGEMENT Monitor BP, height and weight trends with physician 1. Nursing Interventions Give finger foods with complete nutrition (cheeseburger, siopao) Give a written schedule of daily activities Promote safety Aggressive behavior: distract the child & ask them to blow up a balloon Limit caffeine-containing foods ○ Do not restrain or time-out ○ DOC: haloperidol (haldol) - major tranquilizer 3. Antidote: Alprazolam Provide helmet if child throws self into head banging and tantrums Provide consistent and firm limit setting for behavior PSYCHOTIC DISORDERS Increased risk for injury, assess safety SCHIZOPHRENIA 2. Communication A long-term mental disorder involving a deteriorating breakdown in the relation Simple language with Eye contact (before speaking) between thought, emotion, and behavior; has shattered ego Child repeats back what was said Earlier onset = worse prognosis Offer praise upon task completion 3. Management CAUSES Expressive therapy drawing, music 1. Genetic Enhanced communication and Improved social interaction 2. Neuroanatomic / Neurochemical Safety Decreased brain tissue / CSF Elevated dopamine ATTENTION DEFICIT HYPERACTIVITY DISORDER 3. Immunovirologic Bagsak ang dopamine at norepinephrine = low attention span Meningitis / Encephalitis Depressed Frontal lobe function which is responsible for attention and concentration 4. Substance Abuse SYMPTOMS Impulsiveness “excessive talking” Hyperactivity “restless” Inattention “reduced ability to focus” SIGNS AND SYMPTOMS Low self esteem and impaired social skills 1. Positive / Hard Symptoms Clear, visibly displayed, active, kapansin-pansin PHARMACOLOGIC MANAGEMENT Ambivalence, associative looseness, delusions, echopraxia, flight of ideas, Methylphenidate (ritalin) hallucinations, ideas of reference, perseveration ○ Marang and durian is like ritalin Amphetamine mixture 2. Negative Symptoms Dextroamphetamine Non-active / not visibly displayed, absent Stimulants Alogia, anhedonia, apathy, blunted affect, catatonia, flat affect, lack of Side effect of ADHD med: insomnia and loss of appetite volition Indication: ADHD and narcolepsy (affected brain ability to control sleep-wake cycles) PSYCHOMOTOR DISTURBANCES Posturing / movement disorders MANAGEMENT Posturing 1. ADHD medications (ritalin, dexedrine, pemoline) ○ behavior intended to impress or mislead Give once a day after meals (to prevent loss of appetite) Apraxia (no movement) Do not give at bedtime because it is a stimulate and may cause insomnia Automatism (repeated purposeless behavior / movement) ○ Give 6 hours prior bedtime if twice a day ○ Shaking of legs, tapping pens, twisting locks of hair  Waxy flexibility (maintains awkward posture) 9. STILTED LANGUAGE ○ Para syang wax na pwedeng imold - nagsstay sa ganung position Use of flowery words (Adjectives, unnecessary) Echopraxia (repeats someone else’s action) Rigidity (stiffness or inflexibility 10. PERSEVERATION Adherence to a single topic; Pilit mo topic mo kahit palit palitan na MOOD / AFFECT DISORDERS Apathy (lack of interest or emotions) 11. ILLUSION Blunt affect (decreased ability to express emotion) Walang stimulus; False perception of actual external stimuli Ambivalence (opposing emotions) ○ Occurs before euphoria 12. HALLUCINATION Flat speech (don’t express outwardly vocally) False sensory perception in the absence of external stimuli Inappropriate affect (incompatible emotional response) Melancholia (deep sadness) Alexithymia (inability to recognize or describe own emotions) SENSE SUBSTANCE Labile (changeable mood) Euphoria (extreme happiness) Visual Psychedelics Marijuana users DISORGANIZED SPEECH AND THOUGHT Tactile Formication Alcohol Withdrawal 1. LOOSE ASSOCIATIONS Feeling of bugs crawling on skin Rapid shift of thought with no logical connection; Walang connect yung mga topic Olfactory Phantosmia PTSD 2. FLIGHT OF IDEAS Tanda / naaamoy yung Rapid shift of thought with logical connection; May connect ang mga topic scent ng rapist 3. NEOLOGISMS Gustatory Dysgeusia Seizure Making up imaginary words may nalalasahan na wala sa pagkain 4. CLANG ASSOCIATIONS Listing rhyming words together that make no sense Auditory (commands) most dangerous 5. WORD SALAD Synesthesia mixing of senses Mixing words together that have no meaning except to the client; Walang nabubuong sentence, pinagsasama lang yung words MANAGEMENT 1. Hallucination must be recognized 6. CONCRETE THINKING Feelings and hallucinations must be recognized / acknowledged Taking a statement literally Hallucination recognition + Reality presentation COMBO ○ “It must be frightening that you’re hearing voices” 7. ECHOLALIA ○ “But I dont hear any voices” – Present reality Repetition of words they hear from someone else 2. Assess the content 8. VERBIGERATION Ask for safety baka may harm / commands Repeating phrases that does not make sense anymore “What are the voices telling you?” 3. Reality presentation “But I don’t hear any voices”  4. Divert the attention DELUSION OF Naka connect lahat ng nagyayari sa mundo sakanya “Let’s walk to the park” REFERENCE “This song has a secret message just for me” 5. Engage in reality-based activity Lagay mo sa kwarto na kayong dalawa lang “Where do you think the voices are coming from?” MANAGEMENT 6. Reintegrate with the milieu 1. Clarification of the meaning Milieu: environment 2. Acknowledge the feelings Example: remove radio / people from surrounding “You seem upset” 7. Talk back to the voices 3. Voice Doubt Labanan nya ang boses / command “I find it hard to believe” 4. Engage in reality-based activities 13. DELUSION False belief that is inconsistent with one’s knowledge and culture CLASSIFICATIONS OF SCHIZOPHRENIA 1. DISORGANIZED / HEBEPHRENIC DELUSION OF Naka connect lahat ng nagyayari sa mundo sakanya Taong grasa REFERENCE “This song has a secret message just for me” FEATURES DELUSIONS OF Paniniwala na may mga taong nag ccontrol sakanya - at ayaw Characterized with inappropriate behavior CONTROL nyang mag pa control Silly crying, laughing, regression, transient hallucinations (auditory) “I do not go online, that ‘s how the NBI controls you” Problem: Defense Mechanism: Regression DELUSIONS OF Belief that one is powerful / important ○ Nagging toddler na habang buhay, hindi makaligo mag isa GRANDEUR “I have a very important meeting with the President today” Anal Fixation Social Withdrawal PERSECUTORY Paranoid; “The hospital food is trying to poison me” MANAGEMENT Assist in ADLs RELIGIOUS often centers on the second coming of Christ or another DELUSIONS significant religious figure or a prophet. 2. PARANOID Presenting signs of SUSPICIOUSNESS, ideas of persecution and delusion. CAPGRAS’ Thinks that someone (usually a family member) has been + Paranoid schizoprenia = nag ppsychosis (hallu, illu, delu) SYNDROME replaced by an identical impostor. MANIFESTATIONS DORIAN GRAY thinks others are ageing while the client appears to remain the 4P’s same age. Projection (#1 Defense mechanism) ○ Blaming others of own characteristics JEALOUS unfaithfulness of a spouse or a lover; May story at timeline pa Proxemics (6-7ft away from the patient) DELUSIONS ○ Do not intrude their intimate or personal space Passive Friendliness SOMATIC involves bodily functions or sensations; A false belief that ○ #1 attitude therapy: no touching, no whispering and laughing DELUSIONS there is a physical ailment ○ Do not smile, giggling, whispering in front of the client Persecutory Delusion EROTOMANIC Thinks someone / loved object (usually married, of a higher ○ #1 delusion of paranoid schizophrenia DELUSIONS socio-economic status, or otherwise unattainable) is in love with them NURSING DIAGNOSIS 5. RESIDUAL 1. Alteration in nutrition: Less than body requirement Puro negative symptoms Goal: meet the patient’s daily nutritional requirements No longer exhibits overt symptoms No more delusions but still has negative symptoms NURSING INTERVENTIONS 1. Do not force patient to eat foods that he refuses 2. You may do any of the following 6. UNDIFFERENTIATED OR MIXED Allow client to buy foods Symptoms of more than one type of schizophrenia ○ The only person they trust is themselves The #1 drug of choice is FLUPHENAZINE (Prolixin Decanoate) Allow client to prepare his own food ○ Allow them to cook ANTIPSYCHOTICS Offer packaged foods except canned foods ○ Sealed container, may wrapper Neuroleptics ○ Wag ulam na galing sa delata, BAWAL kasi risk for injury / violence Treat psychosis Dysgeusia : may ibang nalalasahan ○ Schizophrenia ○ Schizoaffective NOTES: ○ Manic phase of bipolar disorder + Wag mo titikman pag sinabi ng patient na tikman mo, kasi you’re Lowers dopamine level submitting to the patient’s delusions. + Do not force, you need to gain their trust! TYPICAL ANTIPSYCHOTICS ATYPICAL ANTIPSYCHOTICS 2. Non-compliance with therapy Chlorpromazine (Thorazine) Aripiprazole (Abilify) [ New Explain to the client the reason administering the drug Gen ] Administer drugs in the same form always Fluphenazine Decanoate Clozapine (Clozaril) ○ Sya mag oopen ng meds (Prolixin Decanoate) Risperidone (Risperdal) Do not hide tablets Haloperidol (Haldol) Olanzapine (Zyprexa) Do not hide in food Thioridazine (Mellaril) Quetiapine (Seroquel) Ziprasidone (Geodon) 3. CATATONIC May movement disorder, Increased dopamine First generation drugs Second generation drugs / Conventional New generation FEATURES Unconventional Psychomotor disturbances ○ Waxy flexibility (cerea flexibilitas) rigidity, posturing, -azine, -dol - pine, - done negativism, mutism USAGE Defense Mechanism Autism and Mutism Positive symptoms Negative symptoms 4. SCHIZOAFFECTIVE RISK Schizophrenia + mood disorders (depression) Increased risk for EPS Decreased risk for EPS  MANIFESTATIONS Cheaper Expensive 1. Hyperthermia (crisis) Positive for Agranulocytosis Hindi bababa after antipyretics (decreased WBC) = increased risk for infection 2. Hypertension (crisis) Fever, sore throat for all age Hindi bumaba after medications groups Altered level of 3. Muscle Spasms consciousness in elderly (confusion / agitation) NURSING ACTION Discontinue the medication Supportive management EXTRAPYRAMIDAL SYNDROME “PAA” – result of overdose MANAGEMENT + Temporary kasi naoverdose lang yung patient Baclofen (muscle relaxant), antipyretics 1. Pseudoparkinsonism ○ False parkinsonism PREVENTION ○ Temporary, pero same signs and symptoms Hydrate the patient Shuffling gait Pill rolling TARDIVE DYSKINESIA Mask like face 2. Acute Dystonia Not deadly, not temporary, but lifetime ○ Facial grimace ○ Dysphagia MANIFESTATIONS ○ Opisthotonus (arching of the back) 1. Tongue Protrusion 3. Akathisia 2. Teeth Grinding ○ Restless, agitated 3. Lip Smacking NURSING ACTION DO NOT STOP, REPORT / NOTIFY NURSING ACTION ○ Stop = withdrawal Notify the physician MANAGEMENT MANAGEMENT Decrease the dose and shift to another generation Valbenazine (Ingrezza) ○ Decreases tongue protrusion and lip smacking NEUROLEPTIC MALIGNANT SYNDROME PREVENTION This is deadly Due to severe adverse reactions, the body cannot accommodate the Start with the lowest dose antipsychotics, hindi nya kaya OTHER SYMPTOMS DENIAL Failure to acknowledge an unacceptable 1. Constipation trait or situation increase fluid and fiber in diet #1 defense mechanism of alcoholics kasi it 2. Agranulocytosis is an unacceptable act Monitor WBC, report signs of infection ○ Defends their ego 3. Tooth Decay Sugarless hard candy or gum DISSOCIATION Psychological flight from self 4. Dry Mouth A type of amnesia Sugarless hard candy or gum Defends self from real self and past 5. Orthostatic hypotension Change position gradually REGRESSION Return to an earlier developmental stage 6. Galactorrhea Example: Excessive milk production, use cotton bra + Nail biting (oral regression) 7. Photosensitivity Avoid direct sunlight, use umbrella / hot and wear sunglasses REPRESSION Unconscious forgetting of an anxiety Apply 25 spf lotion provoking concept 8. Arrhythmias For painful / traumatic past Report abnormal heart rate immediately Nangyayare sa mga may DID 9. Weight Gain Example: Lessen intake of sugary foods and beverages + Walang maalala si sir archie sa childhood Decrease calorie in diet nya (kasi nilalatigo sya dati) 10. Sedation + Walang maalala yung kaklase ni sir kevin Avoid driving / operating machineries after the hold up situation PRECAUTIONS SUPPRESSION Conscious forgetting of an anxiety Best taken after meals, Avoid administering in the evening because provoking concept insomnia may result Sinsadyang kalimutan Monitor BP frequently for hypertension / hypertensive crisis SUBLIMATION Placing sexual energies towards a more productive endeavors DEFENSE MECHANISM by Sigmund Freud Turning negative into positive To protect ego and decrease anxiety Example: Undefended ego = increased anxiety, anger + Lumaki sa hirap si Pacquiao; Sumali ng boxing para yumaman DISPLACEMENT Transfer of feelings to a less threatening object rather than the one who provoke it RATIONALIZATION Illogical reasoning / making up excuses to Usually anger justify self / for socially unacceptable trait Example: Also for alcoholics + Pinalo ka ng mama mo, Binalibag mo yung Example: pinto kasi galit ka sa nanay mo + Bat 13 score lang? mA LAHAT KAMI BAGSAK !  REACTION Doing the opposite of your intention yung partner mo FORMATION Plastic + Bumagsak sa boards tas sabi “si sir archie Iba ang sinasabi sa nararamdaman kasi di magaling magturo” Common in bipolar disorder (shows other people they are happy, but in reality, dying CONVERSION Repressed angers put towards physical inside) symptoms affecting nervous system leading to sensory numbness and motor Example: paralysis + Crush nya kaya lagi nyang binubully Example: UNDOING Doing the opposite of what you have done + Parang hihimatayin before thesis defense due to guilt Hugas kamay to relieve guilt feelings COMPENSATION Overachievement in one area to cover a defective part Example: + Binugbog mo tas dinala mo sa clinic Example: + Husband buys gift for wife after cheating + Hindi napapansin sa trabaho, ang ginawa nya ay nag 24 hours shift IDENTIFICATION Assume trait for personal, social, occupational role INTELLECTUALIZATI Acknowledging the facts but not the Conscious copying ON emotions ○ Because you are not satisfied sa Reasoning in a detailed manner with sariling ego references Certain features lang yung nakuha, sadya Example: + Talking without emotions Example: + Ginaya mo si robin padilla kasi binubully SUBSTITUTION Replacing a difficult goal with a more ka na accessible one From unavailable = available INTROJECTION Assume another person’s trait as your own Unconscious copying Example: Blaming self + Instead na nag doctor, nag nurse nalang Exact replica ng tao (nawala na yung kasi 4 year course lang personality mo) Opposite of identification SPLITTING Seeing someone as either good or bad, idealised or devalued PROJECTION Attributing to others one’s acceptable trait Sa mga borderline personality disorder Blaming others Example: Example: + Client: “nurse you are so good to me, while + Cheater ka; then sinisisi mong cheater most of the nurses here are rude to me”  IDEALIZATION The action of regarding or representing SYMPTOMS something as perfect or better than in reality Diagnosis: 5 or more symptoms Andami ng redflags pero inaaccept mopa 1. Depressed mood (hopeless, empty) din kase mahal mo 2. Anhedonia (loss of joy/ interest in life) 3. Weight loss (anorexia) or Wt. Gain Example: 4. Psychomotor retardation or Agitation + Prostitute jowa mo; pero pinagtatanggol 5. Insomnia or hypersomnia (sleeping too much) mong ikaw lang jowa nya 6. Fatigue (Anergia) 7. Feelings of worthlessness or Guilt 8. Difficulty in concentration MOOD DISORDERS 9. Suicidal thoughts (Recurrent) Hindi maregulate ng maayos yung mood DEPRESSED CLIENT Hypomania Kind firmness Nagkakaroon ng hyperactivity, restlessness, increased sex drive, Silence euphoria Offering self Motivate - remind the client of time when she or he felt better and Mania was successful Upgraded version ng hypomania Engage in social activities Hypomania promax + hallu + illu + delu MANAGEMENT FOR DEPRESSED CLIENT Hypo Depression DIET Excessive loneliness 1. Small frequent meals Anergia, hopelessness, worthless feelings 2. High calorie foods and fluids 3. Stay with client during meals Major depression 4. Weekly weighing Upgraded 5. Continuous one-to-one observation Hypodepression promax + suicidal thoughts and attempts 6. Semi-private room Near nurses’ station Dysthymia 7. Remove harmful objects from the room 2-3 years Belt, IV tubings 8. Supervise during meals DEPRESSION 9. Reassess: changes Major Depressive Disorder (MDD) also called clinical depression is when a client experiences a severe depressed mood, loss of ANTIDEPRESSANTS - 4 RULES enjoyment in life, low energy & few other critical signs and 1. Increased risk of suicide symptoms. Priority management Everything is low & slow, it is thought to be from low levels of Magkakagana na to commit suicide neurotransmitters within the brain. 5 over 9 symptoms = Major depressive Disorder  2. Slow onset and slow taper off SSRI It will take at least 2 to 4 weeks to see the onset Serotonin syndrome / sexual dysfunction Do not stop abruptly Side effects but suicide risk Taper off 2 to 4 weeks para hindi mag withdrawal Rigid muscles and restless 1 to 4 weeks only [ onset and taper off ] 3. Never mix Serotonin Syndrome TRICYCLIC ANTIDEPRESSANT ○ Serotonin, Dopamine, and Norepinephrine ay Action: Prevents the reuptake of norepinephrine and serotonin bumagsak, antidepressants ay pinapataas ito increasing these neurotransmitters in the body ○ Pag napasobra sa antidepressants = SS (lahat Two- four weeks onset and taper off increased = seizures = death) Check for the higher incidence of side effects (anticholinergic - 5 ↑ RR, HR, Temp, Anxiety, tremors cant’s!) Assess for suicide 4. All antidepressants drugs Decrease BP EXAMPLES Cause weight changes Imipramine (Tofranil) ○ Short term: weight loss Doxepin (Sinequan) ○ Long term: weight gain Amitriptyline (Elavil) Noticeable kasi antidepressant is long term Aendin Anafranil ➔ Primarily used in the treatment of major depressive illness, anxiety Norpralamin disorders, the depressed phase of bipolar disorder, and psychotic Aventyl depression. Vivactil 3 MAJOR GROUPS AND COMMON EXAMPLES: MONOAMINE OXIDASE INHIBITORS Mother MAOI: PaMaNa (Parnate, Marplan, Nardil) ↑ availability of norepinephrine, serotonin, and dopamine in the TCA: ToSiEl (Tofranil, Sinequan, Elavil) brain SSRI: CeProZo (Celexa, Prozac, Zoloft) Most powerful SELECTIVE SEROTONIN REUPTAKE INHIBITOR EXAMPLES Action: prevent of serotonin increasing the availability of serotonin Phenelzine (Nardil) in the body Tranylcypromine (Parnate) Serotonin lang mag iincrease dito Isocarboxazid (Marplan) Safest drug EFFECTS EXAMPLES MASSIVE HTN CRISIS RISK Fluoxetine (Prozac) Avoid tyramine Sertraline (Zoloft) ○ Will activate catecholamines = increased BP and will not go Citalopram (Celexa) down (crisis) kahit bigyan ng meds AVOID Involuntary: from the next of kin / next immediate 1. Alcohol family member that can decide for the patient 2. Chocolates ○ Has serotonin 3. NPO 6-8 hours prior to procedure 3. Cheese (aged) ○ To prevent aspiration 4. Avocado 5. Soy Sauce 4. Medications 6. Processed and Preserved foods ○ Atropine will cause dry mouth, oral secretion to prevent aspiration OTC DRUGS = HTN CRISIS ○ Barbiturate to sedate kasi masakit yung Calcium ○ Succinylcholine - muscle relaxant, prevent seizure Antacids Acetaminophen POST PROCEDURE NSAIDS Side- lying – lateral ○ To prevent aspiration OTHER ANTIDEPRESSANTS Most common: confusion / short term memory loss Serotonin Syndrome ○ Reorient the patient INCREASED SUICIDE RISK 5 S IN SEIZURE Priority safety 1. Safety: Need to relax the patient at iwasan ang seizure (#1 objective) ELECTROCONVULSIVE THERAPY 2. Side lying an effective treatment for depression that consists of inducing a (#1 position) grand mal (tonic-clonic) seizure by passing an electrical current 3. Side rails up through electrodes attached to the temples. 4. Stimulus ↓ (no noise and bright light) Electrical charges will neutralize and balance the chemical charges of 5. Support the head with a pillow the brain (neurotransmitters) After the seizure ECT kasi hindi na gumagana yung drugs For treatment resistant disorders POINTS TO REMEMBER NURSING RESPONSIBILITIES ELECTRIC CURRENT 70 to 150 volts PRE PROCEDURE 1. X-ray DURATION OF 0.5 to 2 seconds ○ The most common complication of ECT is fracture ADMINISTRATION 2. Informed consent FREQUENCY OF 2 to 3 treatments weekly ○ Obtained by the Physician TREATMENT ○ Witnessed by the nurse ○ Either voluntary or involuntary TOTAL NUMBER OF 6 to 12 ECT therapy Voluntary: from the patient TREATMENTS  ○ So ask direct question about their suicide plan SIDE EFFECT: SEIZURE Lasts 30 seconds to 1 minute or slightly (TONIC-CLONIC) longer ➔ Best approach for suicidal pt.: Direct approach ◆ Monitor client 24/7 SUICIDE ➔ Nursing Management: Close surveillance VERBAL NON-VERBAL NURSING INTERVENTION 1. Assess directly and monitor for signs/ plans ASK DIRECT QUESTION: “Are you going to die” “Are you going to kill Suicidal clues yourself?” Non-verbal and verbal cues “I won’t be a problem “Take this ring, it’s yours” ○ Nagbago bigla ang mood anymore” (giving of valuable) “This is my last day on earth” Sudden change in mood 2. Safety, security and supervision I’ll soon be gone ○ From Suicide contract ○ Di sya pwedeng mag suicide ○ Everytime magka suicidal thoughts, kailangan sabihin RISK FACTORS sa nurse 1. Sex: Male ○ Windows must be lockable from the outside ○ Hindi marunong mag express kaya mas success ○ Bawal sharp objects ○ Because of lethality of equipment used ○ Babae, more on attempts because of hesitancy 3. Provide family therapy/ support group and counselling 2. Unsuccessful previous attempt HOSPITAL AREA MAJORITY SUICIDE WILL HAPPENDS AT: ○ Will reattempt Weekends 1 to 3 AM Sunday 3. Identification with someone who committed suicide Less staff personanel ○ Risk increases if you have friend / relative na nag suicide Early AM: everyone is asleep During endorsement: commonly kasi 1 hour yung endorsement ng 4. Chronic illness mga nurse ○ Mawawalan ng pag asa Irregular / Unpredict