Nursing Study: Psych Lec

Mental Health- is a state of emotional, psychological and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self-concept, and emotional stability

Components:-autonomy and independence

-maximization of one’s potential

- tolerance of life’s uncertainties

- self-esteem

-mastery of the environment

- reality orientation

-stress management

Mental Hygiene – science which deals with measures employed to promote mental health, to reduce the incidence of mental illness through prevention and early treatment and ensure effective management and rehabilitation

Mental Disorder- as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present illness

Psychiatric Nursing- concerned with the promotion of mental health, prevention of mental disorders, and the nursing care of the patients during mental illness and rehabilitation

THE JOHARI WINDOW” ( JOSEPH LUFT/HARRY INGHAM,1963)

A model for SELF-AWARENESS”

I    KNOWN TO SELF             AREA OF OPEN ACTIVITY             SOCIAL CONVERSATION             KNOWN TO –public self, area Which includes the behavior,feelings and Thoughts to the individual and those around Him, this is the self that is presented to and observed by others, the part of the self that engages in daily Conversation

II      NOT KNOWN TO SELF                RISK AREA                CRACKS IN THE MASK          UNDETECTED BY WEARER – the semi-public self, this is the blind area because it includes those things about the self which others may know but the individual doesn’t know, it is an aspect of the self about which person may get honest, genuine uncensored feedback from others that brings it more into the person’s awareness

III      NOT KNOWN TO OTHERS                  PRIVATE AREA                  BEHIND THE SOCIAL MASK –the private self, this is the hidden quadrant and it represents the knowledge one has about oneself that is not known to others, it includes personal secrets, and private feelings of the individual not revealed to others

IV      AREA OF THE UNKNOWN                   UNCONSCIOUS,UNSHOWN –this contains Aspects of the self that are unconscious and unknown both to the individual and to others, this may be brought into awareness through free association, hypnosis or dream analysis with guidance

GLOSSARY

1. Abreaction – ventilation of feelings that takes place when the patient verbally recounts emotionally charged areas
2. Aberration – a deviation from what is natural or normal
3. Affect – a subjective feeling state
4. Aggression – a feeling or action that is hostile or self-assertive
5. Ambivalence – coexisting but contrasting, feeling tones
6. Analictic depression – a deprivational reaction in infants separated from their mothers in the second half of their first years of life
7. Apathy – absence of interest or emotion in a situation which would ordinarily arouse response
8. Autism – subjective thinking with much introspection, resulting in phantasy, delusions and hallucinations
9. Blocking – a sudden stopping in the stream of thought
10. Blunting – dullness of emotional response
11. Cathexis – Freud’s term for the attachment of psychic energy to an object or mental construct
12. Compulsion – an uncontrollable urge to think or act against one’s better judgment
13. Confabulation – the filling in of memory gaps with made –up episodes
14. Conflict – a painful state resulting from existence of opposing desires, emotions or goals

      15. counter-transference – an emotional response of the nurse that is generated by the qualities of the patient    

      and is inappropriate to the content and context of the therapeutic relationship

      16. Dementia – a deterioration of intellectual capacities

     17. Depersonalization – loss of feeling of personal identity with one’s self

     18. Dipsomania – a periodic overwhelming desire for alcoholic drinks

     19. Dissociation – the detachment of certain aspects or activities of the personality from the control of the

     individual

     20. Diurnal mood variation- changes in mood that are related to the time of the day

21. Double bind – simultaneous communication of conflicting messages in the context of a situation that does not allow escape

22. Echolalia – the pathological repetition of phrases or words of another person

23. Echopraxia – the repetition or imitation of movements the subject is observing

24. Ego – the conscious self which deals with reality

25. Egocentric – self-centered

26. Empathy – the capacity of feeling in communion with others

27. Encopresis – the involuntary passage of feces

28. Euphoria- an exaggerated sense of well-being

29. Flight of ideas – a rapid succession of ideas in which the goal idea is not reached

30. Free association – a psychoanalytical therapeutic that requires the patient to repeat all his thoughts without censorship, drifting naturally from one thought to another

31. Kleptomania – an uncontrollable impulse to steal petty and often useless articles

32. La belle indifference-term used to describe the patient’s lack of concern or anxiety regarding his physical illness

33. Mutism – inability to speak

34. Narcissism – unconscious self love

35. Necrophile – sexually aroused by thought of death or having sex with dead person

36. Neologism – literally new words

37. Nihilistic – the delusion of nonexistence of self, the environment or the world

38. Psyche – the mind

39. Remission – temporary period of relief from the symptoms of an illness

40. Soma – the body

41. stereotype- aimless, repetition of verbal, intellectual, emotional or motor activities

42. Synergistic – a reaction between 2 or more substances when introduced into the body they enhance the physiological effects of each other

43. Ventilation – free verbal expression of feelings, worries, tensions and problems

44. Verbigeration – meaningless repetition of incoherent words or sentences

45. Waxy flexibility – a condition found in catatonic schizophrenia in which the extremities have a wax-like rigidity and will remain for long periods in any placed position no matter how uncomfortable

46. word-salad – a mixture of words and phrases which are incomprehensible and incoherent

Neurotransmitter- are the chemical substances manufactured in the neurons that aid in the transmission of information throughout the body, these neurotransmitter are necessary in just the right proportions to relay messages across the synapses

DOPAMINE – located primarily in the brain stem, has been found to be involved in the control of complex movements, motivation, cognition, and regulation of emotional responses.

-          generally excitatory and is synthesized from tyrosine, a dietary amino acid

-          implicated in schizophrenia and parkinson’s disease

-          antipsychotic meds work by blocking dopamine receptors and reducing dopamine activity

SEROTONIN- found in the brain, derived from tryptophan, a dietary amino acid

-          the function is mostly inhibitory, and is involved in the control of food intake, sleep and wakefulness, temperature regulation, pain control, sexual behavior, and regulation of emotions

-          plays an important role in anxiety and mood disorders and schizophrenia

-          it has been found to contribute to the delusions, hallucinations and withdrawn behavior seen in schizophrenia

-          depressants block serotonin reuptake, thus leaving it available for longer in the synapse, which results in improved mood

Norepinephrine/epinephrine – located in the brain stem, plays an important role in changes in attention, learning and memory, sleep and wakefulness and mood regulation.

                -excess is implicated in anxiety disorders, deficits may contribute to memory loss, social withdrawal and depression

                - antidepressant block norepenephrine

                - controls fight or flight response

Histamine – allergic responses, controls gastric secretions, cardiac stimulation, and alertness

-          psychotropic drug blosks histamine, resulting in weight gain, sedation and hypotension

ACETYLCHOLINE- found in the brain, spinal cord and peripheral nervous system particularly the neuromuscular of skeletal muscle

-          excitatory or inhibitory, synthesized from dietary choline found in meat and vegetables and has been found to affect the sleep / wake  and to signals muscles to become active cycle

-          Alzheimer’s  and MG– decreased acetylcholine

GLUTAMATE –excitatory, high levels can be neurotoxic

-          Huntington’s and alzhemer’s

GABA- gamma aminobutyric acid- inhibitory

-          benzodiazepines- increase function, and to treat anxiety and induce sleep

Causes of mental disorders:

1. Predisposing factors- inheritance, age, sex, environment, occupation, previous attack

2. Precipitating factors- exciting cause of psychiatric disorders

                - sudden death of love ones, personal failures, divorce, financial losses

3. Physical precipitating factors- infections, fever, exhaustion, intoxicants, organic conditions, trauma

4. Psychic precipitating causes – rejection, disappointments, deprivation, marital difficulties, failures, inferiorities

HISTORY OF PSYCHIATRY AND PSYCHITARIC NURSING             

I. Primitive people –

                - believed that mentally ill patients were possessed by demons as punishment for sins committed

                - brutal measures were used like starving and beating, abandoned to the forest to be devoured by wild animals, some were buried at the stake

II. Ancient People ( 2600-600 BC )

-          believed in demonical theory which gave rise to a group of healers ( a mixture of priest, physicians, psychologist and magicians)

-          later, herbs, vegetables and ointments were used in the treatment of the mentally ill patient

III. Pre- Christian Development ( 580-510 BC )

                1. Pythagoras – a Greek philosopher, the first to regard the brain as the central organ of intellectual activity and mental disorders as an illness of the organ

                2. Hippocrates – classified mental illness as phrenic, mania and melancholia

                3. Plato- ( 427-347 BC ) – expressed the psychosomatic viewpoint that body and mind were inseparable, that mental illness could cause both by the body and moral disturbance

                4. Aristotle – ( 384—322 BC ) pupil of Plato, believed that the brain and nervous system were associated with intellect but not with sensation

                5. Herophilus –( 335-280 BC ) – first systematic anatomist and dissected human being described the meninges and brain circulation

IV. Early Christian Period

                1. Galen – ( 130-200 AD ) – familiar with many mental disorders and advocated the importance of taking family history, described the brain to be center of intelligence, feelings and memory

                2. Soranus ( 98-138 AD)

V. The middle ages

                - mentally ill patients were treated best by the Moslems

                - mentally ill patients in Europe were being sent to churches and monasteries to be exorcised

                - from year 1000 to 1300, Arabian physicians were interested with mentally ill patients but their contributions to psychiatry were very few

VI. The Renaissance – 1300-1500

-          several mental hospitals were made through psychiatry and medicine did not progress very much

VII. The Reformation – 1500-1600

-          men think of scientific inclination

-          ignorance, fear and superstition that surrounded mental illness were discarded

VIII. Post-reformation period

-          persecution o witches

-          almshouses, workhouses and jails provided the only available means of detention

IX. 18^th century

-          In 1752, Hospital of Persia was built

-          Dr. Benjamin Rush- father of American psychiatry

-          Ist mental Hospital – established in Williamsburg-1773

Roles of a Psychiatric Nurse

1. As a technician- giving baths, serving food, assisting or administering medications and treatment

                - most important responsibility of the nurse in this role is the accurate and perspective observation and recording of the patient’s behavior

2. As a mother- ADL

3. As a teacher – example setting, orienting, teaching, helping

4. As a counselor- helping patient to remember and to understand fully what is happening to him

5. As a social agent – social activity serves as energy and anxiety releasing outlets

6. As a ward manager –

Phases of the Relationship

1. Preinteraction phase- tasks: self exploration of feelings and fears, gathering data, info, planning for the first interaction

2.     Orientation of introductory phase- task: det why patient sought help, establish trust, mutually formulate a contract, explore pt’s thoughts, feelings and actions, identify pt’s problem, define goals

3.     Working phase- tasks: explore relevant stressors, remove patient’s development of insight and use of constructive coping mechanisms, overcome resistant behaviors, problem solving

4.     Termination phase- tasks: establishing reality of the situation, review, mutually explore feelings of rejection, loss, sadness and anger and related behaviors

                                                                                                                                                                Personality development next…..

THERAPEUTIC COMMUNICATION

ACCEPTING- Yes, I follow what you said, nodding

BROAD OPENINGS-Is there something you’d like to talk about?

CONSENSUAL VALIDATION- Tell me whether my understanding of it agrees with yours.

ENCOURAGING COMPARISON- Was it something like……

ENCOURAGING DESCRIPTION OF PERCEPTION-Tell me when you feel anxious. What is happening?

ENCOURAGING EXPRESSION- What are your feelings in regard to…….

EXPLORING- Tell me more about that.

FOCUSING- This point seems worth looking at more closely

FORMULATING A PLAN OF ACTION- What could you do to let your anger out harmlessly

GENERAL LEADS- Go on, And then….

GIVING INFORMATION –My name is……

GIVING RECOGNITION- Good morning , Ms. Santos.

MAKING OBSERVATION- You appear tense today.

OFFERING SELF- I’ll sit with you awhile.

PRESENTING REALITY- I see no one else in the room.

REFLECTING- Client: Do you think, I should tell to the doctor……?

                                Nurse: Do you think you should?

RESTATING- Client: I can’t sleep, I stay awake all night.

                                                Nurse: You have difficulty sleeping?

ASKING INFORMATION- I’m not sure that I follow….

SILENCE

SUGGESTING COLLABORATION- Perhaps you and I can discuss and discover things that triggers for your anxiety

SUMMARIZING- Have I got it straight, you said that…….

VERBALIZING THE IMPLIED – Client: I can’t talk to you or anyone.

                                              Nurse: Do you think no one understand you?

TRANSLATING INTO FEELINGS- Client: I’m dead

                                                 Nurse: Are you suggesting that you feel lifeless?

VOICING DOUBT- Isn’t that unusual, Really?

NON THERAPEUTIC COMMUNICATION

AGREEING – That’s right.

ADVISING- I think you should….

BELITTLING FEELINGS- Client: I have nothing to live for…

  Nurse: Everybody gets down in the dumps….

CHALLENGING- But how can you be the president?

DEFENDING – This hospitals has a fine reputation.

DISARREING- That’s wrong

DISAPPROVING- That’s bad

GIVING LITERAL EXISTENCE OF AN EXTERNAL SOURCE- What makes you say that…

INTERPRETING- What you really mean is….

INTRODUCING AN UNRELATED TOPIC

MAKING STEREOTYPED COMMENTS-It’s for your own good.

PROBING, PERSISTENT QUESTIONING- Now tell me about this problem

REASSURING- Don’t worry

REJECTING- Let’s not discuss

REQUESTING AN EXPLANATION

TESTING- Do you know what kind of hospital this is?

USING DENIAL-Client: I’m nothing

   Nurse: Of course you’re something, everybody’s something.

DEFENSE MECHANISMS

DENIAL- failure to acknowledge an intolerable thoughts, feelings, experience, reality

DISPLACEMENT-redirection of feelings to subject that is acceptable or less threatening ( scapegoating- a device of disguising unpleasant realities to which we cannot admit)

PROJECTION- attribution to others of one’s thoughts, feelings, qualities, unconscious blaming of unacceptable inclinations or thoughts of an external object ( disown things in ourselves and to project it to others, by attributing them to someone else)

INTROJECTION- characteristics of another incorporated into self, accepting as one’s own ( hero worship- we attribute to ourselves the good qualities of others

UNDOING- an attempt to erase an unacceptable act or thought, is acting in a way to relieve the guilt or unacceptable thought y reparation

COMPENSATION- an attempt to overcome a real or imagined shortcomings ( vicarious compensation- handicapped excels in another)

SYMBOLIZATION- a less threatening object or idea is used to represent another

SUBSTITUTION- replacing desired, impractical or unobtainable object with one that is attainable

SUBLIMATION- substituting a socially acceptable activity for an impulse that is unacceptable, is the displacement of energy associated with primitive drives into more acceptable outlets

REPRESSION- unacceptable thought kept from awareness, involuntary, automatic banishment of unacceptable ideas or impulse into the unconscious

SUPPRESSION- conscious exclusion of unacceptable thoughts and feelings from conscious awareness

Conversion – a mechanism by which an individual converts an emotional problem into a physical symptom or outlet which provides a release for the tension and associated with the conflict

REACTION FORMATION- acting the opposite of what one thinks or feels, causes person to act exactly the opposite to the way they feel

REGRESSION- moving back to a previous developmental stage

FIXATION- immobilization of a portion of the personality

IDEALIZATION- glorifying another’s characteristics

IDENTIFICATION- incorporating certain attributes of another into one’s thoughts and behavior, is the attempt to manage anxiety by imitating the behaviors of someone feared or respected

RATIONALIZATION- attempts to justify.

Intellectualization- the overuse of intellectual concepts and words to avoid affective experience or expressions of feelings

Isolation- the separation of unacceptable impulse, act or idea from its memory origin, thereby removing the motional charge associated with the original memory.

Dissociation- the detachment of certain personal activities from normal consciousness which then functional alone/sleepwalking, amnesia, fugue,twilight states

Phantasy/ Fantasy- use of imagination or daydreaming

Splitting – viewing self, others or situations as all good or bad

Intellectualization – overdose of intellectual concepts and words to avoid effective experience or expression of feelings

PSYCHONEUROTIS DISORDERS- are maladaptive emotional states, resulting from unresolved conscious conflicts

General Characteristics:

1. anxiety- the person attempts to control anxiety by using various coping mechanisms

2. reality is not grossly distorted and personality not grossly organized

3. the relationship between the subjective symptoms and underlying conflicts is not recognized by the neurotic

NEUROSIS	PSYCHOSIS
Does not usually require hospitalization	Requires hospitalization
The condition is considered minor reaction to stress	A major reaction to stress
There is no vague interference with reality testing, ego remains sound	Reality testing is greatly impaired
Neurotic feels his suffering and wants to get well	Does not recognize he is ill
Neurotic does not deny reality, merely ignores it	Conation is greatly disturbed
Conation-impulse toward action-is slightly disturbed	Psychotic denies reality and substitutes something else
Neurotic explains symptoms for secondary gain	No secondary gain derived by the patient
Neurotic patient’s desires and motives are never externalized/ no delusion	Desires and motives are often projected
Patient’s personality usually remains socially organized	Distortion of personality is great and social functioning is greatly disturbed

Incidence:

1. very high, late adolescence, mid 30’s

2. more in women than in men

3. common in higher-income group

ANXIETY –theories: Freud- viewed anxiety as due to the conflict bet the id and the superego-the ego serves as the battleground as it tries to mediate the demands of these 2 clashing elements-

Sullivan believed that through the close emotional bond between the mother and the infant, anxiety is first conveyed by the mother to the infant,who respond as if he and his mothering person were one unit.

Will- believed that a person with low self-esteem or has a poor opinion of himself, has a high predisposition to anxiety and is easily threatened.Learning theories believe that individual   who have been exposed in early life to intense fears are more likely to demonstrate a high preposition top anxiety in later life
                -is the result of emotional conflict, fear is the result of discrete physical or psychological entity, the source of fear is identifiable, anxiety is not, anxiety is vague whereas fear is definite, anxiety is related to anticipated event, fear is related to present

Major precipitating factors: threat to biological integrity ( unmet bodily needs,threat to the self-esteem)

Levels of anxiety

1. mild-high degree of alertness, mild uneasiness, sleepless, irritable, hypersensitive to noise, can solve problems, G.I butterflies

2. moderate- skin cold and clammy, poor comprehension, diaphoresis, headache, dry mouth, higher pitch of voice, frequent urination, muscle tension

3. severe- hallucination, delusion, can not complete a task, can not solve problem, severe headache, trembling, vertigo, chest pain, crying

4. panic- inability to see and hear, inability to function, possibly suicidal, perceptual field focus to self, hallucinations

ANXIETY DISORDERS

1. Phobia-chromo, alluro ( cats),bacillo ( germs), myso ( dirt), acro( height), agora( open), claustro( close),.                                   

                -avoid confrontation

                -do not focus on getting patient to stop being afraid

                -systematic desensitization

                -relaxation technique

                -antidepressant meds.

2. Obsessive-compulsive disorders

Obsession-repetitive, uncontrollable thoughts

Compulsion- repetitive, uncontrollable acts

                -accepts ritualistic behavior

                -structure environment

                -provide for physical needs

                -offer alternative activities

                -guide decisions, minimize choices

                -encourage socialization

                -group therapy

                -drug-Anafranil (chlomipramine)

3. Conversion hysteria- physical symptoms with no organic basis

                -diagnostic evaluation

                -discuss feelings rather than symptoms

                -promote therapeutic relationship

                -avoid secondary gain                                               

4.DISSOCIATIVE DISORDERS

•      Sudden change in the patient’s consciousness, identity or motor behavior

•      Loss of memory or knowledge of identity or how the individual came to be in that particular area

Types

1. dissociative identity disorder – client displays two or more distinct identities or personalities that recurrently take control of his behavior

2. depersonalization disorder- client has persistent or recurrent feeling of being detached from his mental processes or body

3. dissociative amnesia – the client cannot remember important personal information usually of a traumatic or stressful nature

4. dissociative fugue – client has episodes of suddenly leaving the home or place of work without explanation, traveling to another city, and being unable to remember his past identity.

GENERAL CARE; develop trust, encourage verbal expressions of painful experiences, anxieties, explore methods of coping, provide non-demanding simple routines, stress reduction, group, individual therapy

SOMATOFORM DISORDERS

1. Somatization disorders- characterized by multiple physical symptoms, it begins with 30 years of age, includes of combination of pain and gastrointestinal

2. Conversion disorder- sometimes called as conversion reaction ,involves unexplained usually sudden deficits in sensory or motor function ( blindness, paralysis)

3. Hypochondriasis- preoccupation with the fear that one has a serious disease , duration is 6 months

4. Pain disorder- primary symptom of pain, which generally unrelieved by analgesics, more than 6 months

Care:-offer explanation and support during diagnostic tests

                   -spend time with clients at times other than when summons nurse to    offer physical complaints, shift focus from somatic complaints to feelings  or to neutral topics, assess secondary gains , use of matter of fact approach

5. Body dysmorphic disorder- preoccupation with an imagined or exaggerated defect in physical appearance

SITUATIONAL CRISES

GRIEVING PATIENT

Stages of grief- shock and disbelief, awareness of the pain of loss, restitution

*acute grief period- 4-8 weeks

*usual resolution within 1 year

*long term resolution over time

Nursing intervention

                -focus on here and now

                -provide support to family when loved ones dies

                -provide family privacy

                -encourage verbalization of feelings

                -facilitate expression of anger

                -emphasize strengths

                -increase ability to cope

                -support adjustment to illness, loss of body part

DYING PATIENT

Stages of dying- denial, anger, bargaining, depression, acceptance

Nursing Intervention:

-keep communication open

-allow expression of feelings

-focus on here and now

-let patient know that he is not alone

-provide comforting environment

-be attentive to the need of privacy

-provide comforting care

-give sense of control and dignity

-respect patient’s wishes

RAPE TRAUMA

Stages of crisis- acute reaction lasts  3-4 weeks, reorganization is long term

*Common responses to rape

-self-blame, embarrassment, phobias, fear of violence, anxiety, trauma, wish to escape, move or relocate, psychosomatic disturbances

Nursing Intervention:

-focus on here and now

-write out treatments and appointments for clients

-record all information in chart

-give clients referrals for legal assistance, support psychotherapy, and rape crisis center

-follow up regularity until client is improved

POST-TRAUMATIC STRESS SYNDROME-exposure to traumatic event( war, combat, fire, earthquake, tsunami, murder, etc.)

duration is at least 1 month, but syndrome can emerge months to years

                -recurrent recollections of distressing events( images, thoughts, feelings) nightmares, panic attack, memory impairment

                -hyper vigilance and exaggerated startle response

Nursing Intervention:

                -encourage client to talk painful stored memories (flooding technique) remain nonjudgmental, allow client to grieve over losses

                -help client label his feelings and find ways to escape them safely

                -stress management

                -recognize anger as normal feeling, teach time out or other ways

                -move away from object of anger

                -cognitive restructuring

                -develop regular schedule of physical activities of the client

                -use empowering strategies

                -regular bedtime

                -refer to self help group

                -educate the client regarding the recovery process

                -drug- anti depressant

DISORDERS OF PERCEPTION

1. Illusions- stimulus in the environment is misperceived, maybe visual, auditory.

Nursing Intervention:

                -show/explain stimulus to client to promote reality testing

2. Delusion – fixed, false belief that client has power, wealth, status, or is famous person. (persecutory, grandiose, religious, somatic)

Intervention:

                -avoid arguing

                -determine client’s need

                -reduce anxiety

                -accept client’s need for delusion

                -present reality, after therapeutic relationship has been established

3. Hallucination-sensory perceptions that have no stimulus in environment. (auditory/command, visual, olfactory, smells –odors), tactile sensations), gustatory-taste-sense lingering in the mouth) cenesthetic-fells bodily functions that are undetectable),Kinesthetic-motionless but reports sensation of bodily movement)

Intervention:

                -encourage client to describe hallucination

                -accept that this is a real experience for the client

                -present reality

4. Ideas of reference – belief that events or behaviors of others relate to self

PERSONALITY DISORDERS- character disorders

1. Paranoid personality disorder-a pervasive pattern of distrust and  suspiciousness

                -hypersensitive, serious, cold,blunted affect, humorless

                -came from parents with irrational outburst of anger, increase incidence with delusional disorders

                -uses projection, externalizes own feelings by projecting own desires and traits to others, holds grudges

Intervention:

                -establish trust

                -be honest and non-intrusive

                -structured social situations

2. SCHIZOID PERSONALITY DISORDER-pervasive pattern of detachment from social relationship and a restricted range of expression of emotions in interpersonal settings. THE LONER

                -shy ,introvert, rarely has close friends, little verbal interaction, cold and detached

                -came from home environment that do not have enough nurturing

     -daydreaming may be more gratifying than real life

Intervention:

                -establish trust

3. SCHIZOTYPAL PERSONALITY

•      BY ACUTE DISCOMFORT WITH AND REDUCED CAPACITY FOR CLOSE RELATIONSHIP AS WELL AS BY COGNITIVE OR PERSONAL DISTORTIONS OF BEHAVIOR.BELIEVES IN FAIRIES

-genetic component, problems in thinking, perceiving, communicating

-sensitive to rejection and anger, suspicious of others, blunted and inappropriate affect

-drug-neuroleptics

-care-same as paranoid

4. ANTI-SOCIAL PERSONALITY DISORDER-sociopathic personality disturbance

characterized by deceit, manipulations, revenge and harm to others with and absence of guilt or anxiety. THE SEMI-CRIMINAL

-father is alcoholic or also an antisocial, lack of consistent person to give emotional loving support as a child.

- Defective ego-poorly developed conscience

-more common in males: childhood= truancy, run-away, enuresis-adolescence=truancy petty thefts, conflict with authority

-disregard the rights others, lying, cheating, stealing,  intellectual, appears charming and intellectual, lack of guilt, immature and irresponsible especially in finances.

-rationalizes and denies own behavior

•      Care:

-firm limit setting

-confronts behaviors consistently

-enforce consequences

-group therapy

5. BORDERLINE PERSONALITY DISORDER

Characterized by pervasive pattern of unstable interpersonal relationship, self image and affect, and marked impulsivity

-SELF-MUTILATION BEHAVIOR,THE SOAP OPERA TYPE OF LOVE LIFE

-Abnormal in serotonin level

-Suicidal behaviors ,manipulative, depression, intense anger, seeks brief and intense relationship, temper tantrums, physical fights

-75%-women-sexually abused

•      Care:

-use empathy

-consistent limit-setting

-enforce unit rules

-group therapy, journal writing

-help person identify and verbalize feelings and control negative behavior

-behavioral contracts

6. NARCISSISTIC PERSONALITY DISORDER

A pervasive pattern of grandiosity, and need of admiration, lack of empathy

-NARCISSUS,SELF-ABSORBED,SUPERIORITY COMPLEX

-Lack of clear parental appreciations of the child’s efforts or accomplishment leads to continuous attention seeking

-Arrogant, sense of entitlement, use others to meet their own needs, display grandiosity, expects special treatment,

-Lacks ability to feel or demonstrate empathy

•      Care:

-mirror what persons sounds like, especially contradictions

-supportive confrontation to increase sense of responsibility

-limit-setting and consistency

-teach that mistakes are acceptable, imperfection do not decreases worth

7. HISTRIONIC PERSONALITY

- pervasive pattern of excessive emotionality and attention seeking.

-THE CLOWN

-Frequent problem in child parent relationship leads to decrease self-esteem, dramatic behavior use to gain attention secondary to low self-esteem and belief

-Thrives on being the center of attention, silly, colorful, hurried, restless, overreacts, somatic complaints, seductive

-Easily influenced by others

•      Care:

-positive reinforcement for unselfish or other-centered behaviors

-help clarify feelings

-facilitate appropriate expressions

8. DEPENDENT PERSONALITY

-A pervasive and excessive need to be taken cared of,that leads to submissive and clinging behavior and fears separation

-FOREVER FOLLOWER

-Anxious and helpless when alone

-Lacks self-confidence

•      Care:

-emphasize decision making to increase self responsibility

-teach assertiveness

-assist to clarify feelings, needs and desires

9. AVOIDANT PERSONALITY

A pervasive pattern of social inhibition, feeling of inadequacy, and hypersensitive to negative evaluation

-THE OLD MAID

-Fixation at the stage where shyness or fear of strangers is common

-Timid, lacks self-confidence, hypersensitive to criticism

-Fears intimate relationship due to fear of ridicule

-Unappealing or inferior

•      Care:

-gradually confronts fear

-discuss feelings before and after accomplishing a goal

-teach assertiveness

-increase exposure to small groups

10. OBSESSIVE-COMPULSIVE PERSONALITY

-A pervasive pattern of preoccupation with orderliness, perfection and mental and interpersonal control at the expense of flexibility, openness and efficiency

-THE PERFECTIONIST

-Stagnation of the anal stage, controlling parents

-Sets personal standards for self and others, preoccupied with rules, lists, organization, overconscieintiousness, inflexible

•      Care:

-explore feelings

-help with decision-making

-teach mistakes are acceptable

-confronts procrastination and intellectualization

11. Sexual deviations- any aberrant sexual behavior which is preferred to, or takes the place of, normal heterosexual behavior

-early stages of psychosexual development, intense attachment to their mothers

- homosexuality, pedophilia, pederasty, sodomy, bestiality, fellatio, cunnilingus,exhibitionism,voyeurism, sadism, masochism, fetishism, transvestism, trans-sexualism,incest,pyromania

BIPOLAR DISORDER

-involves extreme mood swings from episodes of mania to depression (manic-depressive)

-Heightened, grandiose, agitated mood

-Flight of ideas, inappropriate dress, excessive make-up and jewelry

-Uses sarcastic, profane and abusive language, talks excessively, jokes, dances, sings, hyperactive

-Can’t stop moving to eat, easily stimulated by environment, no appetite, hypersexual, sexually indiscreet, insomia

-Elation or grandiosity –defense to underlying depression or feeling of low self-esteem

•      Care:

-simplify the environment and decrease environmental stimuli

-limit people, anticipate situations that will provoke or over stimulate client

-Distract and redirect energy

-assign one staff to provide control, set limit, refuse unreasonable demands, explain restrictions on behavior

-do not encourage client when telling jokes or performing, avoid laughing

-guard vigilantly against suicide, remain non-judgmental

-avoid long, complicated discussions, avoid giving advices when solicited, use short sentences

-meet physical needs, give high calorie finger foods and drinks to be carried while moving

-encourage rest, sedate PRN

-help decrease denial and increase client’s awareness of feelings

-help client acknowledge the need for help when denying

-have patient verbalize needs directly

-drug- lithium

SCHIZOPHRENIA

-          split mind- lack of integration of patient’s function

-          cause is unknown

•      Causes distorted and bizarre thoughts, perceptions, emotions, movements, and behavior.

•      Characterized by disorganized thinking, delusion, hallucination, depersonalization, impaired reality testing

•      Incidence-15-25/25-35 years old, genetic, organic, psychological

•      Interpersonal theorists suggested that schizophrenia resulted from dysfunctional relationships in early life and adolescence

•      4 A’s-autism, association (disorganized) ambivalence (can’t choose between conflicting emotions), affect (flat, blunted)

•      Withdrawal from relationship, neologism ( rhyming that others can’t understand), magical thinking, suspiciousness, short attention span, hallucination,regression

•      TYPES

1. disorganized-silly laughing and regression, transient hallucination

2. catatonic – sudden onset of mutism, bizarre mannerisms, stereotyped

position and waxy flexibility, catalepsy( pathologic limb rigidity)

3. paranoid- suspicion and ideas of persecution and delusion

4. undifferentiated-more than one symptom

5. residual – no longer present overt symptoms, recovered to return to the community, still manifest recognizable, residual disturbances of thinking, feeling and behavior

Implementation:

1. Maintain patient safety- decreased sensory stimuli, remove from the areas of tension, validate reality, do not argue, with patient
2. Protect from erratic and inappropriate behavior- communicate in calm, authoritative tone, address client by name, observe for s/s of escalating behavior
3. Meet physical needs of severely depressed type/catatonic- ask pt to pick up fork, if unable to make decision, then feeding is necessary, when ready encourage patient to eat in the dining room with others
4. Establish a therapeutic relationship-be consistent and reliable in keeping all scheduled appointments, avoid direct questions, accept client’s indifference, discuss all staff changes, tolerate silences, encourage client’s affect by verbalizing what you observe
5. Engage in family therapy
6. Engage in socialization or activity group therapy
7. Provide simple activities- finger painting, clay,avoid competitive situations
8. DOC – Prolixin( Fluphenazine decanoate )- oily, IM or SQ Q 2 weeks

DEPRESSION

Response to real or imagined loss

Anger and aggression toward self results from feelings of guilt about negative or ambivalent feelings

Low self-esteem, feelings of helplessness, hopelessness, obsessive thoughts and fears

Unkempt, depressed appearance, multiple physical complaints, prone to injury, accidents and infections, loss of appetite, no sexual desire, insomia, constipation

Decreased attention span, slowed speech, impaired reality testing, withdrawn

Care:

-       Be alert for signs of self destructive behavior, report all changes to the team

-       Meet physical needs, companionship during mealtime, frequent feedings, favorite food

-       Promote rest, medicate PRN, stay with client if necessary

-       Avoid pep talks, no promises, keep encouragement

-       Avoid presenting choices, be brief and simple, avoid long explanations, brief orientation, simple language, written schedules

-       Provide consistent daily care, avoid task at which the client will fail

-       Sit with client during long quiet times, touch to promote acceptance

-       Introduce to others when ready

-       Group, individual, family therapy

-       Imply confidence in client’s capabilities, give assistance when needed

-    Drug- anti-depressant

suicide

BEHAVIORAL CUES FOR IMPENDING SUICIDE
1-any sudden changes in patient’s behavior
2-becomes energetic after period of severe depression
3-improved mood 10-14 days after taking antidepressant
4-gives away valuable possessions or pets
5-finalizes business or personal affairs
6-withdraws from social activities and plans
7-appears emotionally upset
8-presence of weapons, razors, etc
9-has death plans
10-leaves a note
11-makes direct or indirect statements
 

CARE:

-be alert for signs of destructive behavior, remove all potentially dangerous items

-one to one relationship, stay with the client

-discuss all behavior with health team, note for clues as cry for help, increase energy

-intervene quickly and calmly during actual destructiveness, stay with client

-avoid judgmental remarks or interpretations

-no suicide, no harm, no self injury contract

Groups at increased Risk for Suicide

1. adolescents/ young adults- 15-24
2. Elderly
3. Terminally ill
4. Persons who have experienced loss/stress
5. Survivors of persons who have committed suicide
6. Individuals with bipolar disorders
7. Depressed persons/ when depression begins to lift
8. Substance abusers
9. Persons who have attempted suicide previously
10. More women attempt suicide, more men complete suicide

assist with electroconvulsive therapy

NURSING CONSIDERATION FOR ECT

1 -prepare patient by explaining procedure and telling him about temporary memory loss and confusion

2-informed consent, physical exam, labwork

3 -NPO after MN

4 -have patient void before the ECT

5-remove dentures, jewelries, glasses

6 -usually a muscle relaxants and short acting anesthesia and barbiturates are given

7 -give atropine  30 min before treatment

8 -oxygen on hand

9 -after procedure, take vital signs, orient patient

10 -observe patient’s reaction and stay with him

11 -observe for sudden improvement and indications of suicidal threats after ECT

CHRONIC CNS DISORDERS ASSO.WITH ALCOHOLISM

1. Alcoholic chronic brain syndrome (DEMENTIA)- is a mental disorder that involves multiple cognitive deficits, primarily memory impairment

                - 3 A’ s : aphasia- deterioration in language, apraxia – impaired ability to execute motor functions, agnosis- inability to recognize or name objects, and disturbed executive functioning- plan , think etc

                - mild, moderate and severe type

-fatique, anxiety, personality changes, depression, confusion,loss of memory of recent events

-can progress to dependent, bedridden state

2. Wernicke’s Syndrome

-       confusion, diplopia, nystagmus, ataxia, disorientation, apathy

3. Korsakoff’s Psychosis

-memory disturbance with confabulation, loss of memory of recent event, learning problem, possible problem with taste, smell, loss of reality testing

Care:

-balanced diet

-avoidance of alcohol

-IV or IM thiamine

SUBSTANCE USE DISORDERS

ABUSE- continued use despite problems

DEPENDENCE- need for large amount, unsuccessful attempts to decrease discontinue use, withdrawal symptoms, inability to function as usual in work, social activities

ADDICTION- compulsive use of a substance

Phases of alcohol addiction

-       Prealcoholic- drink almost everyday, increase amount of alcohol ingested

-       Addiction: - blackouts, secret drinking ,large amount

-       Dependence:- physical cravings, makes up reason for drinking, reduced nutrition, aggressive behavior

-       Chronic:- long periods of intoxication, impaired thinking, less alcohol produces sedation tremors

CARE:

-       Assess drug use pattern: identity ,recent use, frequency

-       Support client during acute phase of detoxification or withdrawal

                -stay with client, manifestations are temporary

                -monitor V/S, LOC

                -institute suicidal precautions

                -administer drugs as ordered

                -if hallucinating, reinforce reality, speak in calm voice

                -confront’s denial

               

DRUG ABUSE TERMS

1. ACE – a marijuana cigarette
2. ACID – LSD – lysergic acid diethylamide
3. ACID head – a user of acid
4. Angel dust – PCP- phencyclidine- finely powdered hashish
5. Artillery – equipment used for injecting and dissolving a powdered drug or a solution of drugs
6. Barrels – LSD tablets
7. Bed bugs – fellow addicts
8. Big C – coccaine
9. Bid D – LSD
10. Blow Charlie- Snow Sniff coccaine
11. Blue – blue leaves, LSD
12. Blue angels, blue clouds- amytal/ amobarbital Na
13. Busted – arrested for possession of drugs
14. C, coke, gold dust, girl, snow – coccaine
15. Cabbage head-

EATING DISORDERS

1. Anorexia Nervosa

-most common in females 12-18 years old

-characterized by fear of obesity, dramatic weight loss, distorted body image

-amenorrhea, anemia, excessive exercise, electrolyte imbalance

2. Bulimia

-characterized by all of the characteristics of anorexia and binge eating

-may be of normal weight or overweight

Care:

-monitor clinical status, hydration and electrolytes

-behavior modification

-family therapy

-support efforts to take responsibility for self

-explore issues regarding sexuality

-drug- antidepressant

-nutritional assessment

-weigh patient 3x a week, at the same time

-sets limit on time allotted for eating

-stay with the client during meals, accompany client to bathroom

-record amount eaten

ABUSE

1. Child Abuse

-inconsistency of type/location of injury with the history of the incident

-severe CNS or abdominal injuries, obvious disturbance in parent/child interaction

-sexual abuse-genital laceration, STD’s, emotionally neglect, failure to thrive

2. Elder Abuse

-battering, fractures, bruises, over/undermedicated, absence of needed dentures

-physical evidence of sexual abuse, urine burns, pressure sores

3. Domestic Violence

-frequent visits to physician’s office for unexplained trauma

Care

-provide for physical needs first, safety

-mandatory reporting of identified/suspected cases to appropriate agency

-nonjudgmental treatment of parents, encourage expression of feelings

-provide role model and encourage parents to involved in acre

-teach growth and development concepts

-provide emotional support for child, play therapy initiate protective placement or appropriate referrals

-documentation

ANTIDEPRESSANT MEDICATIONS

1. MONOAMINE OXIDASE INHIBITORS ( Isocarboxazid/Marplan, Tranylcypromine/Parnate, Phenelzine Sulfate/Nardil)

Precaution: if foods with Tyramine ingested, life threatening-can have hypertensive crisis ( headache, sweating, palpitations, stiff neck), foods high in Tyramine- aged meats,pepperoni, salami, summer sausage, beef logs, lasagna, tap beers

                -potentially fatal drug interactions-no CNS depressants, Demerol, antihypertensive and general anesthetics(sweating, fever, agitation, rigidity, coma death)

                -potentially lethal in overdose-potential risk, suicide

Side effects:daytime sedation,weight gain,dry mouth, anorexia, constipation, drowsiness, insomia, orthostatic hypotension.

Implications

-assist client to rise slowly from sitting position

-administer in the morning

-administer with food

-ensure adequate fluids

-avoid foods with Tyramine

-takes 3-4 weeks to work

-avoid tricyclics until 3 weeks after stopping MAO

-monitor vital signs

-sunblock

2. TRICYCLICS –Amitiplyline hydrochloride/Elavil, Imipramine/Tofranil, Norpramin, Desipramine hydrochloride.

Side effects: dry mouth, diaphoresis, postural hypotension, nausea, vomiting, constipation,  increased appetite, sedation, drowsiness, blurred vision

Care:

-watch out for suicidal attempt

-monitor V/S

-sunblock

-increase fluid intake

-take dose at bedtime

-use sugarless candy or gum

-delay of 2-6 weeks before noticeable effects

-monitor for cardiac dysfunction

3. SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SSRI ( Fluoxetine/Prozac, Paroxetine/Paxil, Sertraline hydrochloride/Zoloft

Side effects: palpitations,N/V, increased or decrease appetite, nervousness, urinary retention, insomia, sexual dysfunction, dry mouth, headache, akathisia

Care:

-take in the morning

-take at least 4 weeks to work

-Can potentiates effects of digoxin, Coumadin, and Valium

-used for anorexia, not suicidal

-sugar free beverages or candy

-administer with food

-monitor for hyponatremia

ANTIPSYCHOTIC DRUGS-( neuroleptics )-blocks dopamine

chlorpromazine/Thorazine, Fluphenazine/Prolixin, Haloperidol/Haldol, Trifluoperazine/Stelazine, Thioridazine/Mellaril, Olanzapine/ Zyprexa, Clozapine/Clozaril

-EPS effects=1. muscle spasms (dystonia-abnormalmuscle tone- / torticollis, oculogyric crisis/eye, protrusion of the tongue. 2. pseudoparkinsonisms/shuffling gait, masklike face, drooling, akinesia, 3. akathisia/restless  motor movement, pacing, inability to remain still.

-Tardive Dyskinesia-abnormal voluntary movements, lip smacking, tongue protrusion, chewing, blinking

-seizures, neuroleptic malignant syndrome ( fatal- high fever muscle rigidity), agranulocytosis

-anticholinergic symptoms-dry mouth, blurred vision, constipation, urinary retention,photophobia

Care:

-if with NMS ( neuroleptic malignant syndrome-idiosyncratic reaction)- rigidity, high fever, unstable BP, diaphoresis,pallor, stop the medication, administer drugs as ordered, ( Cogentine, Artane,Valium, Ativan)

-increase fluid intake

-caution about sun exposure

-ice chips

-rise slowly

-do not mix with beverages that contain caffeine or apple juice

-       May cause false positive pregnancy test

-       Monitor bowel function

-       Monitor vital signs, watch out infection

-       Change positions slowly, weekly blood monitoring

NOOD STABILIZING DRUGS- lITHIUM, Carbamazine/Tegretol, Valproic acid/Depakote/Depakene, Clonazepam
Litium-competes with Na+ and K+ transport in nerve and muscle cells

SIDE EFFECTS: Lithium-dizziness, headache, impaired vision, fine hand tremors, reversible leukocytosis

                -Carbamazine- dizziness, vertigo, ataxia, aplastic anemia, agranulocytosis

                - Depakote- sedation, pancreatitis, indigestion, trombocytopenia, toxic hepatitis

CARE:

                -Blood levels monitoring

                - take with meals

                -therapeutic effects-1-2 weeks

                -TEACH –TOXIC SIGNS-VOMITING, DIARRHEA, MUSCULAR WEAKNESS, ATAXIA

                -check serum levels 2-3 times weekly(start) monthly ( maintenace)

                -adequate fluid intake

Depakote- liver function test, platelet

Tegretol- BUN, liver function test, urinalysis

ANTIANXIETY AGENTS- Librium, Tranxene, Valium,Ativan,Serax, BuSpar, Vistaril ( Benzodiazepine)

vomiting

CARE:

                -CNS depressant

                -long duration

                -renal and hepatic function

                -withdraw drug gradually( over 2 weeks)

                - give with meals

                -monitor therapeutic level

                - avoid alcohol

TREATMENT MODALITIES FOR MENTAL ILLNESS

1.Biological-causemaybeinheritedorchemicalinorigin-tx. Medications,ECT

2. Psychoanalytical (individual) –therapists helps the patient to become aware of unconscious thought and feelings

3. Milleu therapy –clients plan social and group interactions

4. Group therapy –members learn new ways to cope with stress and develop insights

5. Family Therapy-

6. Activity therapy –

7. Play therapy- help the child resolve problems

8.Behavioral –desensitization, operant conditioning

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