FUNDAMENTAL CONCEPTS

MENTAL HEALTH
Is a state of emotional, psychological, and social wellness evidenced by:
Satisfying interpersonal relationships
Effective behavior and coping
Positive self-concept
Emotional stability
Self-awareness
Factors Affecting Mental Health: MRS MATS
Mastering the Environment
Reality orientation
Stress Management
Maximizing Ones Potential
Autonomy and Independence
Tolerating Ones Uncertainties
Self-esteem
STRESS
is any biopsychosocial (external or internal) experiences that one views as demanding, challenging, and
threatening;
Also char as:
It is recurring.
It is normal.
It cannot be avoided.
It is caused by a stressor.
STRESSOR
is any condition, event, or agent that increases the activity of the Sympathetic NS;
Stress Adaptation Syndrome (SAS) GAS A R E
1. Stage I ALARM
Activation of the SNS (or the Fight-or-Flight Response)
Increase epinephrine, NE, and cortisol.
Client is alert with increase anxiety.
2. Stage II RESISTANCE
Hormone readjustment;
Decrease in size and activity of the adrenal cortex;
Increase use of defense mechanism;

1. Stage III EXHAUSTION
Loss of ability to stop stress;
Exaggerated defense-oriented behavior;
Disorganized thinking and personality;
May show signs of illusion, hallucination and delusions;
Client may be stuporous or violent (PANIC)
GRIEF
is a powerful emotional reaction to a separation or loss from something that is/are very valuable;
is SELF-LIMITING;
Stages of Death and Dying (Kubler-Ross) DABDA
a. Denial
b. Anger
c. Bargaining
d. Depression
e. Acceptance
DENIAL
Shes not dead! Shes still alive!
ANGER
Youre the reason shes dead!!!
BARGAINING
God, take me.. Spare her
DEPRESSION
Im not hungry, I just want to be alone.
ACCEPTANCE
At least she no longer have to suffer.
He is in the presence of our Creator.

CONCEPT OF DEATH:
TODDLER
No specific concept of death yet.
Reacts more to pain and discomfort;
Separation anxiety may be felt;
Focus is on the feelings of the parents;
PRESCHOOL
Death is like SLEEP;
Or a form of PUNISHMENT;
May use PLAY as a method of therapy;
SCHOOL AGE
Death is personified or as a final stage of life;
May fear mutilation or punishment;
Accept regressive or protest behavior from the client;
Encourage verbalization of feelings;

1. ADOLESCENT
Have MATURE understanding of death;
May show strong emotions about death (sadness, silence, anger, withdrawn)
Encourage verbalization of feelings;
Respect need for privacy and expression of grief;
2. ADULT
Death is disruption of lifestyle;
Effects of death to significant others;
3. OLDER ADULT (Elderly)
Emphasis on religious beliefs for comfort;
Time for reflection, rest or peace;
TRANSFERENCE
4. is the unconscious transfer of special feelings from a client to the nurse or therapist.
COUNTERTRANSFERENCE
Is the projection of the therapists feelings about a significant other to the patient during therapy;
CRISIS
Is an imbalance of the internal equilibrium that results from a stressor or threat to the patient;
Client is in bad situation
Problem-solving inadequate
Cannot immediately neutralize the stressor
CRISIS
Types of Crisis:
1. Maturational growth and development (identity crisis, midlife crisis)
2. Situational unexpected events (death, loss)
3. Social major disaster (landslide, typhoon)
Crisis is characterized by:
1. Self-limiting, only last for 4-6 weeks
2. Individualized - every person have their own reaction.
3. Person becomes passive and submissive.
4. Alteration in support system.
Stages of a Crisis: (DIDA)
1. Denial first reaction;
2. Increase tension the person recognizes the crisis but continues to function;
3. Disorganization the person is pre-occupied to solve the conflict and alters his ADL;
4. Attempts to reorganize by using his coping mechanism;
CRISIS INTERVENTION
Aims to restore the person to a pre-crisis state of functioning;
Focuses on resolving the immediate crisis;

DEFENSE MECHANISMS Fight for stress
DISPLACEMENT Transfer of feelings to a less
threatening object rather than the one
who provoke it
Boss shouts at you, you
shout at your subordinate
DENIAL Failure to acknowledge an
unacceptable trait or situation
Im not an alcoholic
Alcoholics
Battered wives
Anorexia nervosa
Drug dependents
DISSOCIATION Psychological flight from self
A type of amnesia
Sino ka, Sino ako?
REGRESSION Return to an earlier developmental
stage
Return to thumbsucking
REPRESSION Unconscious forgetting of an anxiety
provoking concept
Hindi komaalala
RATIONALIZATION Illogical reasoning for a socially
unacceptable trait
sayangang beer sa ref, kaya
koininum
I drink because I dont want
to waste the beer in the ref
INTELLECTUALIZATION Using only logical explanations without
feelings or an affective component.
An examinee explains how
she passed the NLE but
hardly showed any emotion
regarding the leakage.
REACTION FORMATION doing the opposite of your intention
plastic
sasabunutankita. . . ay
kuklulutinlangkita
UNDOING Doing the opposite of what you have
done due to guilt
orocan, plastic, Tupperware
ay pinatidkita,
halikapuntakitasa clinic
IDENTIFICATION Assume trait for personal, social,
occupational role
Tuladniya
PROJECTION Attributing to others ones acceptable
trait
Pasa load
hindiako alcoholic, sila
yon
INTROJECTION Assume another persons trait as your
own

ako din
Not just you, me too
SUPPRESSION Conscious forgetting of an anxiety
provoking concept
Hindi koalamyan
SUBLIMATION Placing sexual energies toward a more
productive endeavors
Angry at life, put anger in
singing
CONVERSION Repressed angers put towards
physical symptoms affecting nervous
system leading to sensory numbness
and motor paralysis
Biglangmangingig
COMPENSATION Overachievement in one area to cover
a defective part
Pilayperomagalingkumanta
SUBSTITUTION Replacing a difficult goal with a more
accessible one
Gusto ko Disneyland.
Enchanted nalang.

SELF - AWARENESS
The nurses goal is to achieve authentic, open, and personal communication;
The nurse must be able to examine personal feelings and reactions;
A good understanding and acceptance of self allow the nurse to acknowledge a patients differences and
uniqueness;
QUADRANT 1
Is the open quadrant;
known to self and others
QUADRANT 2
Is the blind quadrant;
Known only to OTHERS, unknown to self.
QUADRANT 3
Is the hidden quadrant;
Known ONLY to self
QUADRANT 4
Is the unknown quadrant;
Unknown to the self and to others
The following three principles help explain how the self functions:
A change in any one quadrant affects all other quadrants.
The smaller quadrant 1, the poorer the communication.
When quadrant 1 is larger and other quadrants are smaller, interpersonal learning is significantly
present.
STEP 1
The goal of increasing self-awareness is to enlarge the area of quadrant 1 while reducing the size of the
other three quadrants.
To increase self-knowledge, it is necessary to listen to the self;
The individual allows genuine emotions to be experienced, and identifies and accepts personal needs;
STEP 2
Reduce the size of quadrant 2 by LISTENING TO AND LEARNING FROM OTHERS;
As we relate to others, we broaden our SELF-PERCEPTIONS;
Requires active listening and openness to the feedback others provide;
STEP 3
Reduce the size of quadrant 3 by self-disclosing or revealing to others important aspects of the self;
SELF-DISCLOSURE is both a sign of personality health and a means of achieving healthy personality;
Sigmund Freud
Father of Psychoanalysis
Structure of Personality (Id, Ego, Superego)
Dominant ID
Mania
D eat Antisocial
mpulsive drink Narcissistic
want to urinate
want PLEASURE defecate

PLEASURABLE PRINCIPLE
Pain Avoidance
Its all I

DOMINANT SUPER EGO
Obsessive - compulsive
UPER EGO Anorexia Nervosa
hould not
mall voice of God
CONSCIENCE PRINCIPLE



GO
Xecutive Secretary Impaired Reality
Schizophrenia

REALITY PRINCIPLE

LIBIDO sexual energy responsible for survival
PSYCHOSEXUAL THEORY
1. ORAL STAGE
0 18 Months old
Survival
I want to eat, sleep, urinate, defecate
ID formation
Cry & Suck mouth
Child Cries

Feed the Infant Ignore the Infant

Successful Unsuccessful

Narcissistic
I
S
E
I
S
E

Defense Mechanism:
o FIXATION when a person is stuck in a certain developmental stage
o REGRESSION return to an earlier developmental stage

EGO is develop in the 6
th
month

2. ANAL STAGE
Ateen 3 years old (18 mos 3 y.o.)
Toilet training
Bowel Control 18 months.
Daytime Bladder Control 30 months.
Nocturnal Bladder Control 36 months.
Super Ego develop

Toilet Training

Good Mother Bad Mother

Successful Unsuccessful



Too Rigid Training Dirty
Disorganized
Clean Disobedient
Organized
Obedient ANTISOCIAL
(Anal Expulsive)
OBSESSIVE COMPULSSIVE
(Anal Retentive)



3. PHALLIC
3 6 y.o.
Penis/ Vagina
Parents is the significant person
Called as Preschooler
Physiologic homosexuality may also be seen in this stage.














Oedipus Complex little boy loves mommy
Electra Complex little girl loves daddy
Identification boy associates with daddy, girl assoc. with mommy
Castration fear of the little boy to daddy
Penis Envyenvy of little girl towards daddy

Dr. Karen Horney opposition to penis envy

SE


BIG
SE
Small
SE

Level of Awareness
o Conscious highest level of awareness
o Preconscious Tip of the tongue
o Unconscious deepest level of awareness

Birth Trauma First traumatic experience of child
REPRESSIONunconscious forgetting of an anxiety provoking concept
SUPRESSIONconscious forgetting of an anxiety provoking concept

4. LATENCY STAGE
6 12 years old
SCHOOlatency
Sexual energy is dormant
Reading, Riting, Rithmetic
Resolution of the oedipal complex;

SUBLIMATION placing sexual energies toward a more productive endeavors

5. GENITAL STAGE
12 y. o. above
Sexual interest emerges as the person strives to develop satisfactory relationships with potential sex
partners (intimacy)
Corresponding with genital maturation which result to sexual awakenings;
Gising Genital

PSYCHOSOCIAL MODEL
or Developmental Model;
Established by Erik Erickson from Freuds psychoanalytical model;
Spans the total life cycle from birth to death;
Each stage of development is an emotional crisis involving positive and negative experiences;
Life Stages
I. Trust vs Mistrust (0 18 months of age)
Child develops sense of trust or mistrust of others;
Shares openly and relates to others;
Interpersonal skills start to develop;
II. Autonomy vs Shame and Doubt
18 months 3 y/o;
Child learns self-control or becomes very conscious and full of doubt;
Negativistic attitude;
Exhibits motor self-control and independence thru negativism;
Parallel play is the social skill.
III. Initiative vs Guilt (3 5 y/o)
Child initiates spontaneous activities or develops fear of wrongdoing;
Shows appropriate social behaviors;
Curiosity and exploration;
Social Skill: Cooperative Play
IV. Industry vs Inferiority (6 12 y/o)
Child develops the social and physical skills necessary to negotiate and compete in life;
Acquisition of competence;
Ability to cooperate and compromise;
Identification with admired others (teachers, parents)
V. Identity vs Role Diffusion ( 12 20 y/o )
Teenager either integrates childhood experiences into a personal identity;
May develop self-doubts about sexual or occupational roles;
Establish relationship with the opposite sex;
Fidelity with friends;
Also value importance of beauty or self-image;
VI. Intimacy vs Isolation (18 25 or 30 y/o)
The person develops commitment to work and to other people;
Ability to give and receive love;
Responsible sexual behaviors;
VII. Generativityvs Stagnation (30 65 y/o)
Productive, constructive, and creative activities;
Personal and professional growth;
Parental and societal responsibilities;
Ability to care;
VIII. Integrity vs Despair (65 years old to death)
The person reviews life for meaning, fulfillment, and contributions made to the next generations;
Sense of dignity and worth;
Explores the philosophy of life;
Have period of reminiscence;
May result to regression and withdrawn;
ERIK ERIKSON
PSYCHOSOCIAL THEORY OF DEVELOPMENT
Age + - Affecting Major
Factor
0-18 mos. Trust Mistrust Feeding
18 mos. 3 y.o. Autonomy
AU nal
TO ilet training
NO favorite word
MY
Shame/ doubt Toilet Training
3 6 y.o. Initiative Guilt Independence
6 12 y.o. Industry Inferiority In da-school
12 20 y.o. Identity Role confusion Peer
20 25 y.o. Intimacy Isolation Love
25 45 y.o. Generativity Stagnation Parenting
45 y.o. and above Ego Integrity Despair Reflection

COGNITIVE - BEHAVIORAL MODEL
By Piaget;
SENSORIMOTOR STAGE (birth 18 months)
The child learns by IMITATION;
Also by object permanence;
B. PREOPERATIONAL STAGE ( 2 7 years old)
Preconceptional Phase ( 2- 4 y/o)
Learns using mental images and develops symbolic language and play
(symbolism)
Intuitive Phase ( 4 7 y/o)
The child learns by separating disparate objects and events and also expands
expressive language;
Can give reason for belief and reactions but still pre-logical;
C. CONCRETE OPERATIONS (8 12 years old)
Child can systemically organize thoughts and facts about the environment;
Can apply rules to things that are seen and heard;
Child begins abstract thinking;
D. FORMAL OPERATIONS (12 adulthood)
The person can think using conceptual, abstract operations, and CAN HYPOTHESIZE and
evaluate solutions to the problems;
MASLOWS HEIRARCHY OF NEEDS
1. Physiologic Needs
o Air, food, water, shelter, rest, sleep, activity and temperature maintenance that are crucial for survival
2. Safety and Security Needs
o Safe in physical and psychological aspects
3. Love and Belonging Needs
o Giving and receiving affection, attaining a place in a group, maintaining the feeling of belonging
4. Self esteem Needs
o Self esteem feelings of independence, competence and self respect
o Esteem from others recognition, respect, appreciation
5. Self Actualization
o Ones maximum potential and realize ones abilities and qualities
BEHAVIORAL MODELS
1. Ivan Pavlov
Classical Conditioning Model
Behavior is learned and retained by positive reinforcements;
Behaviors that are inadequate or inappropriate must be replaced by more adaptive ones;
All behavior are learned
Food dog Salivation
Bell Food Dog Salivation
Bell Salivation
2. Peplau
The nurse and the client must work together to assist client grow and to resolve problems;
3. Sullivan
Behavior motivated by need to avoid anxiety and satisfy needs;
4. B.F. Skinner
Operant Conditioning
All behaviors are unlearned
Reward (+ reinforcement) and Punishment (- Reinforcement)

THERAPEUTIC COMMUNICATION
Is an interactive process that occurs between the patient and the health professional;
Focuses solely on the patients problem;
Establishment of trust is the foundation of a nurse-client relationship;
Techniques of Therapeutic Communication
C SOAP ME FEG and SURE STROL
CLARIFICATION
Encourage client to make idea more understandable;
Nurse: I dont understand what you mean. Could you explain it to me?
SILENCE
Client able to think about self or his problems;
Does not feel any pressure to speak;
Look into the eyes and listen to the client while he is talking;
OFFERING SELF
Offer to provide comfort to client by mere presence;
Ill sit with you.
Ill walk with you.
Im here for you.
ACCEPTING
by nodding and following what client says;
PRESENTING REALITY
Reports events and situations as they really are;
Client: I dont have a chance talking to my doctor.
Nurse: I saw you and your doctor talking this morning
Client: These voices are bothering. They want me to jump from the window.
Nurse: There are no other people here. OR I dont hear any voices except for ours.
MAKING OBSERVATION
Verbalize what you perceive;
I notice that you cant sit still.
I notice that something is bothering you.
EMPATHY
Showing or telling what you feel in relation to the clients suffering.
I know what you feel
I know this is hard for you.
FOCUSING
Encouraging the client to stay or focus on the topic;
You were talking about your mother.
You were saying that your..
EXPLORING
Encourage client to express feelings or ideas deeply;
Tell me more about you and your mother.
How did you respond to..
GIVING RECOGNITION
Indicate to client your awareness of him and his behaviors;
Good morning, I noticed that you combed your hair today.
I observed that youre behaving appropriately.
SUGGESTING COLLABORATION
Offer to work with client towards a specific goal;
Client: I fail at everything I try.
Nurse: May be we can figure out something together so that you can accomplish something you want to
do.
USING BROAD OPENINGS
Encourage client to introduce the topic of conversation; or to start a conversation;
Where shall we begin today?
What are you thinking about?
REFLECTING
Direct clients questions or statements back to encourage expression of ideas and feelings;
Client: Do you think I should talk to my doctor.
Nurse: What do you want to talk about?
ENCOURAGING DESCRIPTION
Ask the client to verbalize his perception;
What is happening to you right now?
What are you doing in front of the window?
SHARING PERCEPTIONS
nurse describes his or her understanding of the patients feelings and ideas;
Nurse: I noticed that you have an unresolved feelings towards your mother.
TRANSLATING INTO FEELINGS
Encourage client to verbalize feelings expressed in another way;
Client: I will never get better.
Nurse: You sound rather hopeless and helpless.
RESTATING
Repeat what client has said;
Client: I dont want to take my medicines.
Nurse: You dont want to take your medicines?
OFFERING GENERAL LEADS
Encourage client to continue discussing the topic;
And then? or Go on Im listening.
Tell me more about what you just said?
LISTENING
Blocks to Constructive Communication
These are methods of communication that obstruct the process of therapeutic conversations (Non-therapeutic)
BAD SCAR DROP
B belittling feelings
A agreeing / disagreeing
D denial
S stereotypical response
C changing topic
A approval / disapproval
R reassuring
D defending
R requesting explanation
O offering advise
P probing
Phases of Therapeutic Relationship
A. ORIENTATION
or Assessment or analysis;
The nurse establishes trust with the client;
The nurse assesses the client;
Formulation of nursing diagnosis;
Prioritization of the clients problems;
The nurse and the client establish mutually agreed goals;
Discussing the indications for termination;
B. WORKING PHASE
Pertains to planning and intervention;
the nurse plans outcomes and related interventions to assist client to meet goals;
The nurse facilitates the clients expression of problems, thoughts, and feelings;
The nurse uses problem-solving approach;
C. TERMINATION PHASE
Pertains to evaluation;
The nurse evaluates outcomes, reassess the problems, goals and interventions;
Needs close attention to avoid destroying the benefits gained from the relationship;
The nurse and client express feelings regarding the termination of the interactions;
The nurse observes the client for negative behaviors:
Regression
Anger
Inappropriate expressions (laughter)
The nurse evaluates the entire nurse-client relationship;

PSYCHOPHARMACOLOGY
ANTI-PSYCHOTIC DRUGS
Or neuroleptics or major tranquilizers;
For acute and chronic psychosis;
For bipolar I disorder, manic phase;
Paranoid disorder;
Severe nausea and vomiting*;
Severe or pathologic hiccups*;
Classification (Traditional or Typical Classification)
1. Chlorpromazine (Thorazine) - EARLIEST
2. Fluphenazine (Prolixin)
3. Thioridazine (Mellaril)
4. Trifluoperazine (Stelazine)
5. Haloperidol (Haldol)
6. Loxapine (Loxitane)
Atypical Anti-psychotics:
1. Clozapine* (Clozaril)
2. Olanzapine* (Zyprexa)
3. Risperidone* (Risperdal)
Mechanisms of Action:
Blocks dopamine receptors in the nigrostriatal system causing pseudoparkinsonism;
Inhibits dopamine receptors in the tubuloinfundibular system;
Antagonizes serotonin receptors in the cerebral cortex (Risperidone)
Typical Anti-psychotics
Decrease dopamine
Atypical Anti-psychotics
Decrease serotonin
Desired Effects of Antipsychotic Drugs:
1. CNS Effects
a. sedation
b. emotional quieting
c. slowing of psychomotor functions
2. Modification of Psychiatric Symptoms
a. Resolution of positive symptoms
Hallucinations
Illusions
Delusions
Excitement
Suspiciousness
b. Resolution of negative symptoms
Accomplished by ATYPICAL antipsychotic agents
1. Attention deficit
2. Asocial behavior
3. Blunted or flat affect
4. Communication difficulties
5. Difficulty with abstraction
SIDE EFFECTS
A. PNS Effects (anticholinergic effects)
B. PNS Effects (anti-adrenergic effects)
1. Orthostatic hypotension
2. Reflex tachycardia due to lower extremity vasodilatation;
Anti-cholinergic effects are the same irregardless of what medication.
A urinAry retention
Blurring of vision due to dilated pupils.
Constipation
Dry mouth and nasal passages
Elevated heart rate (tachycardia)
C. CNS Effects (or EPSE)
1. Akathisia
it is the most common EPSE;
inability to sit still;
px is restless, jittery or uneasy and may report a lot of nervous energy;
Tx: Anticholinergic antiparkinsondrugs (Artane, Biperiden, Cogentin)
2. Acute Dystonic Reactions (dystonia)
rigidity of the muscles of the tongue, face, neck or back;
results to abnormality in posture, gait or ocular movements;
Torticollis
Oculogyric crisis rolling of eyes backward in a fixed stare;
Laryngeal-pharyngeal dystonia
Tx: IM anticholinergic antiparkinson drug (Benztropine or Cogentin)
3. Tardive Dyskinesia (TD) potential permanent complication;
refers to abnormal voluntary skeletal muscle movements usually jerky motion;
appears after months or years of drug use but may occur sooner;
caused by dopamine hypersensitivity and cholinergic deficit;
anticholinergics may aggravate TD;
usually affects the muscles of the mouth and face:
1. Lip smacking
2. Grinding of the teeth
3. Rolling or protrusion of the tongue
4. Tics
5. Excessive facial movements
Grimacing and blinking
Chewing and lateral jaw movement
Puffing of the cheeks;
Tx:
Bromocriptine (Parlodel);
Reduction of dose;
Discontinuation of the drug;
4. Drug-induced Parkinsonism
or pseudoparkinsonism;
motor retardation (bradykinesia) and rigidity;
difficulty in initiating or carrying out motor activity;
shuffling gait;
resting tremors of the hands and feet;
hypersalivation;
Tx:
Dosage reduction
Antiparkinson drug (Akineton)
5. Neuroleptic Malignant Syndrome
is a rare but life-threatening reaction to neuroleptic drugs (1% of clients)
3-9 days after starting anti-psychotic (Haldol)
manifestations:
a. hyperthermia cardinal symptom.
b. rigidity
c. impaired consciousness
d. hypertension
e. cardiac arrhythmias
Tx: Immediate discontinuation of the drug;
Cooling blankets;
Dantrolene or Bromocriptine
6. Other Side Effects
a. Hyperglycemia
b. Jaundice
c. Blood dyscrasias or agranulocytosis (Clozapine)
d. Orthostatic hypotension (Risperidone)
e. Retinal pigmentation (Thioridazine)
f. Galactorrhea and gynecomastia (Increase secretion of prolactin)
g. Amenorrhea and impaired ejaculation
h. Sun burn

ANTI-PARKINSON DRUGS
Major cause of EPS malfunction is a DEFICIENCY in the neurotransmitter DOPAMINE (substantianigra) and a
subsequent decrease in dopamine transmission in the basal ganglia;
Mechanisms of Actions:
Increases dopamine by increasing its precursor.
Levodopa
Carbidopa-levodopa (Sinemet)
Stimulates the release of dopamine.
Amantadine (Symmetrel)
Increases the action of the dopamine receptors (Dopamine agonists)
Bromocriptine (Parlodel)
Pergolide (Permax)
Blocks the metabolism of dopamine by inhibiting MAO type b.
Selegiline (Eldepryl)
Anti-parkinsons with anti-cholinergic properties.
Benztropine (Cogentin)
Biperiden (Akineton)
Diphenhydramine (Benadryl)
Ethopropazine (Parsidol)
Procyclidine (Kemadrin)
Trihexyphenidyl (Artane)
ANTI-PARKINSON DRUGS
CAPABLES
Cogentin
Artane
Parlodel
Akineton
Benadryl
Larodopa
Eldepryl
Symmetryl

ANTIDEPRESSANTS
DEPRESSION is caused by an imbalance or decreased availability of certain neurotransmitters (deficiencies of
norepinephrine, serotonin, and possibly dopamine)
Goals in the tx of Depression:
1. Reduce or remove all signs and symptoms of depression the most important.
2. Restore occupational and psychosocial function;
3. Reduce the incident of relapse and recurrence;
A.TRICYCLIC ANTIDEPRESSANTS
Blocks reuptake of norepinephrine and serotonin;
Also increases receptor sensitivity to these neurotransmitter;
Desirable Effects:
Sedation.
Others increase psychomotor activity.
Improved appetite.
Side Effects:
Anti-cholinergic side effects
Orthostatic hypotension
Nursing Implications:
Take medications at night.
Reassure that symptoms will decrease in 2 - 4 weeks
Increase fiber and fluid diet.
Assess for adverse drug reactions.
Assess for suicide potential.
Classifications:
Tertiary Amines
Imipramine (Tofranil)
Amitriptyline (Elavil)
Clomipramine (Anafranil) used in OCD.
Secondary Amines
Amoxapine (Asendin)
Nortriptyline (Aventyl)
Desipramine (Norpramin)
Classifications
Novel Cyclic Antidepressants
Bupropion (Wellbutrin)
Trazodone (Desyrel)
Venlafaxine (Effexor)

B. SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI)
Fewer side effects that TCA;
First choice in treating depression.
MOA: inhibits reuptake of serotonin in neurons which later increases the availability of serotonin in
several neurons;
Therapeutic lag time is approximately 1 4 weeks;
Side Effects:
GIT Symptoms
Nausea
Diarrhea
Weight loss
CNS Symptoms
Headache
Dizziness
Tremors
Nervousness
Decreased libido and orgasms
Nursing Implications:
Avoid incorporating with MAOI because of the danger of serotonin syndrome (coma, hyperreflexia,
hyperthermia, death)
14 days stopping MAOI and starting SSRI:
5 weeks stopping SSRI and starting MAOI;
Avoided during the 1
st
trimester of pregnancy.
WOF: Increase activities and mood of patients because these are signs of suicidal ideations;
Classification:
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Paroxetine (Paxel)
Sertraline (Zoloft)

C. MONOAMINE OXIDASE INHIBITORS (MAOI)
Monoamine Oxidase involved in the metabolic decomposition and inactivation of amines
(norepinephrine, dopamine and serotonin);
Administered to hospitalized patients or px that can be closely monitored or supervised at home;
It takes 2 4 weeks for these drugs to take effect;
Side Effects:
CNS Hyperstimulation
Hypomania
Agitation
Insomnia
Restlessness and euphoria
Acute Anxiety Attack
Hypertensive crisis (tachycardia, palpitations, occipital headache, chest pain, elevated BP, diaphoresis,
and dilated pupils; sudden epistaxis)
Nursing Implications:
Take the medication EARLY IN THE DAY to avoid insomnia;
Caution client to avoid OTC drugs because these contain AMINES and can cause HYPERTENSIVE
CRISIS.
Cold remedies
Decongestants
Antihistamines
Sleeping aids
Stimulants
Instruct the px TO AVOID FOODS HIGH IN TYRAMINE (tyramine-restricted diet)
Foods high in TYRAMINE:
A aged cheese and avocado
B bananas, beer
C chocolate, coffee, chicken and pork liver
D dried and preserved foods (pickles)
E etc (yogurt, sausage)
F fermented foods (beer, wine)
Classifications:
Phenelzine (Nardil)
Tranylcypromine (Parnate)
Moclobemide (Manerix) atypical MAOI.





SSRI TCA MAOI


Antidepressant

Anticholinergic Side Effects
(Syphathetic)

Male Erectile Dysfunction

ANTI-MANIC DRUGS (Mood Stabilizers)
LITHIUM
Is used for manic phase of manic-depressive illness and refractory depression;
The exact action of lithium is UNKNOWN;
Substitute for Na in neurons altering the release and attachment of certain neurotransmitters in most
neurons;
Increases the reuptake of NE and serotonin;
Lithium has a lag time of 7 10 days;
Lithium is well absorbed from the GIT (via ORAL route)
The typical dose for acute mania is 600 mg TID which produces a therapeutic blood dose of 0.6 1.2 mEq/L;
Blood levels over 1.5 mEq/L can be toxic;
Nursing Implications:
WOF signs of early Li toxicity:
Vomiting earliest;
Diarrhea and Drowsiness
Muscular weakness
Lack of coordination
Polyuria
Client may have mild exercise or activities.
Advise px not to drive during Li therapy;
Advise px to practice balanced diet and salt intake;
Increase Salt intake = decrease blood Li
Decrease salt intake = increase blood Li
For Li determination, blood must be drawn at least 8-12 hrs after the last dose and performed in the
morning (every 3 4 months of Li intake)
Take Li with meals to avoid nausea and vomiting;
Increase fluid intake (2500-3000 ml) per day to reduce thirst and maintain normal fluid balance;

PHARMA MOMENT
LITHIUM

L evel 0.6 1.2 mEq/L ausea, vomiting, diarrhea
Increase urination Lithium Toxicity
Tremors, fine hand a+
Hydration 3 L/day
Increase
KidneyUudiarhea
Mouth, dry

CARBAMAZEPINE (Tegretol)
Used for px who do not respond to Li or for px Li is contraindicated;
Used in px with bipolar disorders and for px with seizure disorders;
Thought to inhibit the small abnormal activity in the brain;
Side Effects:
Nausea and vomiting
Anorexia
Sedation and drowsiness
Agranulocytosis

VALPROIC ACID (Depakene)
Is an anticonvulsant with antimanic property;
Effective in px with bipolar disorders;
Rapid acting and with less effect on cognition;
Side Effects:
Transient hair loss
Weight gain
Tremors
GI Upset
Thrombocytopenia

ANTIANXIETY DRUGS
Are also known as anxiolytics;
Classified into:
a. Benzodiazepines
b. Sedative-Hypnotics
Benzodiazepines
are the major class of anxiolytics or minor tranquilizers;
Are used in px:
a. chronic anxiety
b. acute anxiety or persons in crises
c. presurgery
d. panic attacks
e. insomnia
f. alcohol withdrawal syndrome
g. bipolar disorders with Li therapy
h. seizures
Types of Benzodiaze PAM PAM
1. Diazepam (Valium)
2. Lorazepam (Ativan)
3. Clonazepam (Klonopin)
4. Oxazepam (Serax) for elderly.
5. Alprazolam (Xanax)
6. Chlordiazepoxide (Librium)
7. Clorazepate (Tranxene)
8. Buspirone (BuSpar)
Adverse Drug Reactions:
1. CNS Depression
a. Drowsiness
b. Fatigue
c. Decreased coordination
d. Mental impairment
e. Slow reflexes
f. Confusion
g. Respiratory depression***

1. Anticholinergic side effects

3. Problems of dependence, withdrawal, and tolerance;
a. Dependence or addiction the person must take the drug to feel normal;
b. Withdrawal physical signs and symptoms that occur when the addictive substance is reduced or withheld;
c. Tolerance the need to increase the amount of a substance to achieve the same effects;
Nursing Interventions:
Advise the px to avoid taking alcohol and other CNS depressants with the drug.
WOF of overdose ( somnolence, confusion, coma, decreased reflexes, and hypotension)
Advise the px to avoid driving;
Monitor VS especially breathing;
Sedative-Hypnotics
Are also used in the treatment of anxiety, insomnia, and prevention of alcohol withdrawal syndrome;
Barbiturates:
Phenobarbital
Secobarbital
Pentobarbital
Antihistamines:
Diphenhydramine


THERAPEUTIC LAG TIME
Anti-psychotics
TCA 2 4 weeks
MAOI
SSRI 1 4 weeks
Lithium 7 10 days
Clomipramine 2-3 months




ELECTROCONVULSIVE THERAPY
An electrical current (70-150 v) passes thru electrodes applied to the patients temple to induce a generalized
tonic-clonic seizure (or Grand Mal) and unconsciousness;
Is use when other traditional therapies failed;
Length of application: 0.5 - 2 secs;
Length of seizure: 30 - 60 secs;
The cumulative effect of ECT is approx220 - 250 secs.
Used to treat patients with depression, bipolar disorders, manic, and psychotic symptoms;
The exact action of ECT remains unknown;
Nursing Interventions:
Obtain an informed consent from the patient, family, or legal representative of the patient;
Teach the family and the patient about the treatment and what to expect like:
Short-term memory loss resolve after 4-8 weeks;
Disorientation
Confusion
Respiratory depression
NPO post-midnight to prevent aspiration and vomiting; at least 8 hrs.
Remove all prostheses including hairpins and dentures;
Administer all preop meds as indicated like:
AtSO
4
to decrease oral and nasal secretions*;
Succinylcholine muscle relaxant;
Short-acting barbiturates*
Does not affect seizure threshold
Ex. Methohexital
Vital signs must be monitored before and after the procedures;
Tongue guard is inserted to prevent tongue injury during seizure;
Monitor heart rate and rhythm, blood pressure, and EEG;

Antidepressant no effect ECT





ELECROCONVULSIVE THERAPY
Pre
o Informed consent
o NPO 6 8 hours prior
Meds
o Atropine dry mouth
o Barbituate Sedative
o Succinylcholine muscle relaxant, prevent seizure
Post
o Side-lying lateral
o S/E
headache, dizziness,
TEMPORARY MEMORY LOSS distinct sign
70 110 volts
20 30 seconds
hour asleep post

NEUROSIS
is a maladaptive emotional state due to unresolved emotional conflict;
I. OVERVIEW
ANXIETY is a subjective feeling of vague apprehension due to real or perceived threat;
is a NORMAL response to stress;
Or may precede new experiences;
II. ETIOLOGY
1. Biological Theory
a. **GABA decrease;
b. Norepinephrine increase;
c. Serotonin increase;
d. Dopamine increase;
2. Psychodynamic Theory
Due to unresolved developmental conflicts;
1. Interpersonal Theory (by Sullivan)
When expectations, approval, or needs are not met.
2. Behavioral Theory
Anxiety is a learned response to combat stress;
Kind of Anxiety (Freud)
1. Reality Anxiety - from external real threat;
2. Neurotic Anxiety - fear that instinct will cause one to do something that will cause punishment;
3. Moral Anxiety - guilt from a wrongdoing against the conscience;


Levels of Anxiety:
1. Mild Anxiety
associated with the tension of everyday life;
the individual is alert and attentive (SNS is stimulated)
perceptual field is increased;
NO INTENSE FEELING BECAUSE SELF-CONCEPT NOT THREATENED
With mild muscle tension;
Interventions:
- Discuss source of anxiety.
- Problem solving to neutralize anxiety.
- Teach the client to accept anxiety as normal.

1. Moderate Anxiety
the focus is on immediate concerns;
narrows the perceptual field;
selective inattentiveness occurs;
learning and problem-solving still take place;
self-concept may be threatened (may have discomfort and irritability)
may show moderate muscle tension with increase vitals, mydriasis, and sweating;
Interventions:
Decrease anxiety by ventilation of feelings, crying, or exercise.
2. Severe Anxiety
a feeling that something bad is about to happen;
With significant reduction in perceptual field;
All behavior is directed at relieving the anxiety;
learning and problem-solving are not possible;
May show:
Hyperventilation
Severe muscle tension
Rapid pacing or walking
Shouting and trembling
Interventions:
Stay with the client.
Decrease anxiety and pressure.
Use kind, firm, and simple directions.
IM anxiolytics as ordered.

3. Panic Level of Anxiety
associated with dread and terror and a sense of impending doom;
the personality of the individual is disorganized;
the individual is unable to communicate or function effectively;
may experience loss of rational thoughts with distorted perception;


May have:
Fight or flight
Freeze
Helplessness
Out of control (jump from windows)
Rage, anger, and terror
Interventions:
Guide firmly or physically take control.
IM anxiolytics as ordered.
Restraints if needed (FOR SAFETY)

ANXIETY Anticholinergic side effect
Constipation
Urinary Retention Within 1 week
Dry Mouth Rebound
Blurred Vision phenomenon
Seizure
Abrupt

Anti-Anxiety Dependence
Withdrawal
Drowsy
No Alcohol
No Coffee
Develop Orthostatic
Hypotension
Prevetion of O.H.
1. Sit Down
2. Dangle feet Gradually
3. Stand Up Gradually Tapered Dose
RELAXED


ANXIETY
Vague sense of impending doom





Mild Moderate Severe Panic
+1 +2 +3 +4
Widened acing ont know what uicide
Perceptual to say/do afetyDont touch client
Field RN Meds IRECTIVE Respi Alkalosis
Restless Bown Bag
Enhanced Learning
Capacity
You Seem Restless




III. COPING WITH ANXIETY
Coping Mechanisms
any effort that will decrease the stress response;
either a constructive or destructive mechanisms;
they can be task-oriented to solve the problem;
or defense-oriented to protect the pxs feelings;
Type of Coping:
1. Adaptive coping for mild anxiety;
2. Pallative coping for moderate anxiety;
3. Maladaptive coping for severe anxiety;
4. Dysfunctional coping for panic level of anxiety;
Type of Coping:
1. Adaptive solve the problem.
Ex. If you have an exam you study or review. You PASSED with flying colors.
2. Pallative temporarily decrease the anxiety but does not solve the problem (allows the client to
return to problem solving)
Ex. If you have an exam. Go to the gym first then review. Youll PASS.
3. Maladaptive unsuccessful to decrease anxiety without attempting to solve the problem.
Ex. You have an exam Watch movies with friends first then cramming for
review. Result of exam FAILED!!!
4. Dysfunctional not successful in reducing the anxiety or solving the problem; minimal
functioning becomes difficult;
Ex. You have an exam drinking spree with buddies.. When you wake up
UMAGA NA. Result of exam . Asaka pa. Eh di bagsak!!!
Common Nursing Diagnosis:
Ineffective individual coping***
Anxiety
Impaired adjustment
Risk for injury
Risk for violence, self-directed or directed at others
Fear
Important Nursing Interventions:
C calm environment
A ask client to identify cause/s.
L let client describe feelings.
M monitor for suicide ideation.
E expression of feelings.
R release tension and energy (art therapy)















6 years old Anxiety SOMATOFORM
>no pretension
Assignments/ I am sick > no organic
Homeworks basis
MALINGERING > unconscious
No Assignments/ pretending to be sick
Homeworks (Conscious) PSYCHOSOMATIC
> Real pains/ illness
You Think Absent > Real symptoms
Teacher may > 4 major types
get angry * Hypertension
* Migraine
Escape from Mama Care * Stress Ulcer
Teacher * Asthma
PRIMARY GAIN Attention
(Behavior anxiety) SECONDARY GAIN

ANXIETY RELATED DISORDERS
GENERAL ANXIETY DISORDER (GAD)
Characterized by diffused, persistent, or unrealistic worry that rarely occurs by itself;
Increase amount of inner energy consumed on controlling anxious feelings;
Have used alcohol or other drugs to the point of dependence to control anxiety;
Person may experience physical symptoms:
Dyspnea
Palpitations
Chest pain
Gastric distress - diarrhea
Tremors
Insomnia
Restlessness
Tx:
Anxiolytics
Psychotherapy

PANIC DISORDER
The cause is usually cannot be identified;
sudden onset, with feelings of intense apprehension, and dread;
May be severe, recurrent, or intermittent lasting 5 30 minutes;
Fear of losing control about themselves, going crazy, heart attack, or dying;
Client may also experience physical symptoms similar to GAD;
Treatment:
a. Relaxation techniques
b. Cognitive Behavioral Therapy
c. Benzodiazepines Alprazolam (Xanax)
d. *** Antidepressants Sertraline; Paroxetine;

OBSESSIVE-COMPULSIVE DISORDER
Characterized by episodes of obsession (unwanted, repetitive thought) and compulsion ( unwanted,
repetitive action) that influence a persons life;
Char by irrational, repetitive, ritualistic behaviors that the px uses in attempt to control the anxiety
resulting from obsessions;
Affects the ADL of the client;
Anxiety occurs if O-C are resisted, and from being powerless to stop obsession.
Compulsive behaviors are related to decrease or neutralize anxiety;
Treatment:
a. Behavioral techniques
Desensitization
Graded response
Modeling of desired behaviors
Cognitive therapy - to stop altered thought.
b. Antidepressants ***Clomipramine (Anafranil); SSRIs.
c. Anxiolytics

PHOBIA
An irrational fear of an object or situation that persists even though the px may recognize it as
unreasonable;
Associated with panic-level of anxiety if the object, situation, or activity cannot be avoided;
Client will do anything just to avoid the phobic object regardless of the consequences;




Types of Phobia:
a. Agoraphobia
fear of being alone in open or public places where escape might be difficult or impossible;
Client may not leave home;

a. Social Phobia
fear of situations in which one might be embarrassed or criticized, and the fear of making
fool of oneself;
includes the fear of eating in public places, public speaking, or performing in public
places;
b. Specific Phobia
a fear of a single object, activity, or situation such as snakes, closed spaces, and flying;
Arachnophobia
Aerophobia
Acrophobia
Aviophobia
Claustrophobia
Treatment:
a. Behavioral techniques
***desensitization therapy of choice.
b. Benzodiazepine Therapy

POSTTRAUMATIC STRESS DISORDER
(PTSD)
Grieving-like behaviors that result from a major and severe trauma like rape, assault, accident, fire, war,
or natural disaster;
Usually occurs AFTER a major traumatic events (usually after ONE month)
Acute Stress Disorder anxiety during or immediate after a traumatic event (within 4 weeks or 1 month)
May show physical manifestations:
a. Flashbacks
b. Insomnia and nightmares
c. Eating problems
d. Depression and isolation
e. Hypervigilance and guilt about surviving the event;
Types of PTSD:
a. Acute less than 3 months after the event;
b. Chronic 3 months or more after the event;
c. Delayed at least 6 months after the event;
Treatments:
a. Psychotherapy
b. Pharmacotherapy
1. Benzodiazepines
2. Antidepressants SSRI.
Nursing Interventions:
P provide safe environment for the client.
T try to recall the traumatic event.
S suicide precaution.
D dont leave client alone.

DISSOCIATIVE DISORDERS
Is characterized by splitting off or removal from conscious awareness of some information, feeling, or
mental function;
Also associated with traumatic events and severe anxiety;
Types of Dissociative Disorders:
a. Dissociative Identity Disorder
or multiple personality;
existence of two or more fully developed distinct and unique personalities within the person;
the personalities may take full control of the person one at a time;

the personalities may or may not be aware of each other;
the person is unable to recall important information;
char by sudden transition from one personality to the other RELATED TO STRESS;
dissociation is used as a method of distancing and defending self from anxiety and traumatic events;
Clients with depersonalization disorder (like DID) are not admitted unless they are suicidal;
GOAL: Integrate the personalities or memories so that they can coexist with the original personality.
Psychotherapy
Hypnosis
Amobarbital sodium.
b. Dissociative Amnesia
inability to recall important personal information because it is anxiety provoking;
memory impairment may be partial or complete;
amnesia may be anterograde (recent information) or retrograde (past information);
c. Dissociative (Psychogenic) Fugue
Sudden travel away from home and assumes a new personality with inability to recall the past;
This may occur suddenly for several hours or days;
Follows severe psychosocial stress (marital quarrels, personal rejections, or natural disaster)
It allows escape or flightfrom an intolerable situations.
When the fugue state stops or lost .. the client returns home UNABLE to recall the fugue state.


Tx:
Psychotherapy
Anxiolytics
SSRI
Depersonalization Disorder
An altered self-perception in which ones own reality is temporarily lost or changed;
Feeling of self- detachment;
The client may experience feelings of detachment but intact reality testing;
To protect the client from an overwhelming stress;
Tx: SSRI (Fluoxetine)

SOMATOFORM DISORDERS
Complains of physical symptoms or illness for which no organic or physiologic cause can be identified;
Evidence is present or presumption exists that the physical symptoms are connected to psychological factors or
conflicts;
With prolonged periods of diagnostic work ups with negative physical findings;
The nurse or health team must never assume that patients are not sick.

SOMATOFORM DISORDERS

SOMATOFORM


Nervous System Illusion of structural defect
CONVERSION DISORDER BODY DYSMHORPIC DISORDER
La Belle Indifference
emotionaldisattachment
from disability
Minor Discomfort
Interpreted as major illness
HYPOCHONDRIASIS
Maliitnabutas, pinalalaki
Favorite Past Time: Doctor Hopping
Nursing Focus: Feelings
PSYCHOSOMATIC DISORDERS
Anxiety

SNS PNS

BP Vasoconstriction Bronchoconstriction

Hypertension Cerebral Artery Left Gastric Artery Asthma

Migraine Stress Ulcer

BODY DYSMORPHIC DISORDER
Preoccupation with an imaginary defect in ones physical appearance even though the person appears
normal to others;
Complaints of facial or body deformities;
Client may have slight physical deformity but the reaction or preoccupation is out of proportion to the
degree of deformity;
Usually encountered during adolescence;
Tendency to seek unnecessary surgery to correct the imaginary defect or minor flaws;
May manifest with social impairment and altered work performance resulting from the clients desire to
hide the imaginary defect;

CONVERSION DISORDER
Alteration or loss of functioning of a body part that is not related to any physical abnormalities (eg.
Paralysis, blindness)
Most symptoms are unconscious;

HYPOCHONDRIASIS
Morbid preoccupation with fear or belief that one has a serious disease based on personal interpretation
of physical health;
Paralysis
Anosmia
Blindness
Aphonia
Seizures
Anesthesia or paresthesia
No physical evidence of serious disease;
Char by unwavering conviction of his/her illness;
May show LA BELLE INDIFFERENCE.
- Lack of concern regarding the severity of the above symptoms;
- The client explains a severe disease calmly

PAIN DISORDER
Preoccupation with pain with no diagnostic findings as to the cause or intensity of pain;
Pain that doesnt follow anatomical nervous system distribution;
Have long history of several consultations with numerous doctors, use of drugs, or alcohol abuse;
There is clear connection between a psychological stressor and onset of symptoms;
With marked impairment in lifestyle and ADL;

SOMATIZATION DISORDER
These individuals verbalize recurrent, frequent, and multiple somatic complaints for several years without
physiologic cause;
Begins before age 30;
Clients usually see several physicians thru the years and even have exploratory and unnecessary
surgeries;
May also have social and occupational impairments;
These pxs may have anxiety or depression;
Or sleep disturbances, nervousness and experience suicidal ideation because of hopelessness about
getting better;
Common symptoms:
Nausea and vomiting
Dizziness
Shortness of breath
Dysmenorrhea
Chest pain
Other Types of Somatoform Disorders:
1. MALINGERING
Intentional production of false or grossly exaggerated physical or psychological symptoms to get
external compensation (leave, evading prosecution, compensation)
May have no real symptoms or over exaggerated minor symptoms.
2. FACTITIOUS DISORDER
aka Munchausens syndrome;
When physical or psychological symptoms are intentionally produced or feigned TO GAIN
ATTENTION;
they may inflict injury to themselves to receive attention;
Munchausens by proxy person inflicts injury or illness on SOMEONE else to gain attention or to
be a hero;

MOOD DISORDERS
Associated with severe and painful sadness or abnormal elation;
Changes a persons behavior, cognition, motivation, and emotions;
Most common psychiatric diagnosis???
Also known as AFFECTIVE DISORDERS;
Two Diagnostic Categories:
1. Major Depressive Disorder (MDD)
A person experiences one or more episodes of depression with no manic or hypomanic
manifestations;
Twice as many women than men;
Onset is usually early - mid 20s;
2. Bipolar Disorders
A person experiences major depression with one or more manic or hypomanic episodes;
Female and male ratio is the same;
Onset is usually late 20s;
MAJOR DEPRESSION

Etiologies:
a. Biochemical Theory
Altered or deficient levels of norepinephrine and serotonin are most often related to depression
(Dopamine, Acetylcholine and GABA)
Alterations in the functions of the hypothalamic-pituitary-adrenal system may cause depression;
Alterations in the circadian rhythm (wake-sleep cycle) will cause problem with sleep patterns,
arousal, activity, and hormonal secretions;
b. Psychodynamic or Psychoanalytical Theory
Depression occurs as a result of a persons ego loss in relationship to early life occurrences;
Aggressive behavior inappropriately directed at self;
Cognitive Theory
Depression results when a person perceives all stressful situations as being negative;
Interpersonal Theory
Stated that persons difficulties, coping with individuals, life events, and life changes can be stressful and
may lead to depression;
Behavioral Theory
Depression develops when one feels helpless and unworthy.
Sociological Theory
Stated that depression is caused by abnormal medical, social learning, stress, and response mechanism
by an individual;
Criteria for Major Depressive Disorder:
1. **Depressed mood.
2. **Anhedonia inability to experience or even imagine any pleasant emotion;
3. Sleep disturbances insomnia or hypersomnia;
4. Possible weight loss or weight gain.
5. Fatigue or energy loss.
6. Reduced recognition and concentration;
7. Psychomotor agitation increase or decrease activities;
8. Feelings of worthlessness or guilt;
9. Recurrent death or suicidal thoughts;
10. Symptoms must persists for a minimum of 2 weeks.
A person must have at least 5/9, one of which is a depressed mood and/or anhedonia.
Other symptoms of depression:
1. Apathy and sadness
2. Hopelessness and helplessness
3. Unworthiness and guilt
4. Anger
5. Decreased libido
6. Private verbal berating of self
7. Sudden crying without a cause
8. Dependency and Passiveness


Nursing Diagnosis for MDD and Bipolars:
1. Ineffective individual coping
2. Hopelessness
3. Potential for injury
4. Potential for violence
5. Powerlessness
6. Altered nutrition
7. Sleep pattern disturbances
8. Impaired verbal communication
Management:
A. Nurse Interventions
D drugs
E expression of feelings
P patient involvement in physical activities
R reinforce decision making
E nEvEr reinforce hallucination or delusions
S suicide precaution
S safe environment
B. Pharmacotherapy
1. SSRI Fluoxetine (Prozac)
2. TCA Imipramine (Tofranil)
3. MAOI Phenelzine (Nardil)

BIPOLAR DISORDERS
Approximately 2 million people yearly suffer from bipolar disorders;
Bipolar I disorders appear equally common among men and women;
In men, the first episode is usually of manic manifestations;
In women, it is depressive symptoms that come first before the manic signs;
Characterized by episodes of mania and depression with periods of normal mood and activity in between;
Also known as manic-depressive disorder;
Clinical Manifestations of Mania:
Denial**, distractibility, and delusions
Resistance to treatment**
Hyperactivity**
Anorexia**
Pleasurable activity involvement
Irritability and insomnia
Elevated mood
Flight of ideas
Loud and rapid speech
Anger with labile mood
Grandiosity or inflated self-esteem






Types of Bipolar Disorders:
1. Bipolar I Disorder
Has major depression and mania;
Bipolar II Disorder
The person has major depression and hypomanic rather than mania;
Hypomanic Episode
Is almost similar to mania but with less severe level of impairment;
Not severe enough to cause major problems in school, work, or home;
Manic episodes only last at least 4 days in duration and does not warrant hospitalization;
A. Nursing Management
M - Maintain a safe environment.
Monitor sleeping pattern.
A - Always limit group activities.
N - Never reinforce altered perceptions and delusions.
I - Institute motor programs (running, walking)
A - Avoid stimulants. Provide finger foods.

B. Pharmacotherapy
Lithium carbonate
WOF signs of lithium toxicity.
Carbamazepine
Valproic acid
Antianxiety drugs.
**Antipsychotics for psychotic episodes during the manic phase of Bipolar I.
PERSONALITY DISORDERS
These are groups of psychiatric disorders that affects behavioral responses of an individual;
Persons with this type of disorders are incapable of functioning effectively in the society;
Patients are unaware of the adverse impacts of their behaviors;
DSM-IV CLASSIFICATION
Cluster A Odd/ Eccentric
Aloof and emotionally distant from others;
Behaviors are considered strange;
2. Paranoid Personality Disorder
3. Schizoid Personality Disorder
4. Schizotypal Personality Disorder
Cluster B Dramatic / Erratic
The individual is egocentric or self-centered;
Little ability to understand anothers perspective;

1. Borderline Personality Disorder
2. Histrionic Personality Disorder
3. Antisocial Personality Disorder
4. Narcissistic Personality Disorder
Cluster C Anxious / Fearful
Appears overly anxious about various social and personal issues;
Unusually concerned with the rules, procedures, and acceptance by others;
2. Dependent Personality Disorder
3. Avoidant Personality Disorder
4. Obsessive-Compulsive Personality Disorder
CLUSTER A PERSONALITY DISORDERS
A. Paranoid Personality Disorder
Individual is very secretive, suspicious, and dont trust others;
Conviction that other people are out to do me in
Also very aloof, cold, and overly serious affect;
Uses projection;
Schizoid Personality Disorder
Steadfast determination to remain distant and aloof;
Preferred solitary activities;
Lack of desire to develop social contacts (answer using words or phrases)
Fearful of intimate relationships;
Tend to fantasize or daydream;

C. Schizotypal Personality Disorder
Usually expressed unusual ideas and magical thinking;
Inability to form and maintain age-appropriate relationships;
May have transient psychotic symptoms but not sufficient to be diagnosed as schizophrenia;
Ex. People with ESP; can see and talk with dead people (Sixth Sense)
CLUSTER B PERSONALITY DISORDERS
A. Antisocial Personality Disorder
More common in males;
Char by constant antisocial behaviors (robbery, theft, alcoholism, vandalism, etc.)
Sustained history of irresponsibility, self-centeredness, and impulsiveness;
Lack of remorse for ones destructive actions;
Very manipulative and exploits others;
Manifests with anger that results in hostile outburst;
Potential for violence;
Commonly uses rationalization;
Tx: Group Psychotherapy
Borderline Personality Disorder
The px may be impulsive with splitting tendency and suicidal;
With outburst of intense anger and rage;
Emotionally labile and with unstable personality;
Tendency for self-mutilation;
Also are manipulative;
Most commonly treated;
Histrionic Personality Disorder
Melodramatic, colorful, highly energetic, and seductive;
Tendency to have shallow relationships;
Self-centered character;
Wants to be the center of attention;
Tendency to make many demands on others for reassurance;
Narcissistic Personality Disorder
More common in males;
Inflated sense of self-importance;
Feeling of entitlement for recognition;
Feelings of worthlessness if not praised and admired by others;
With labile affect;
Tx: Group Psychotherapy
CLUSTER C PERSONALITY DISORDERS
B. Dependent Personality Disorder
Relies on others to assume large areas of responsibilities for his life;
Excessive need to be taken care of;
Unassertive and passive;
Fear of shame and criticism;
Inability to take risks or to initiate anything;
May show signs of depression and anxiety;
B. Avoidant Personality Disorder
Avoidance of any situation that could result in criticisms and shame;
Px feels discomfort in social gatherings;
Px may be shy and fearful (of rejection or disapproval)
Afraid to enter into a relationship unless he/she feels secured and accepted;
C. Obsessive-Compulsive Personality Disorder
Preoccupation with orders, rules and regulations;
Usually perfectionist and meticulous;
Too busy working to have social life;
Has difficulty in making decisions;
Uses reaction formation, undoing, and displacement;
SCHIZOPRENIA
Morel described schizophrenia before as dementia praecox (precocious senility);
Bleuler later coined the term schizophrenia which means split mind (not split personality);
95% of clients with schizophrenia have a lifetime disease;
It is the most common thought disorder;
SUICIDE is the most common cause of premature death of these clients;
Usually appears in late adolescent or early adulthood;
Affects men and women almost equally;
II. Theoretical Perspective
A. Biological Theories
1. Biochemical Theory (Dopaminergic Hypotheses)
Excessive dopaminergic activity in cortical areas causes acute positive symptoms of
schizophrenia (HIDES)
2. Neurostructural Theory
Patients with schizophrenia have four structural changes in the brain:
a. Cerebral ventricular enlargement.
b. Cerebral atrophy
c. Hypoplasia of the medial limbic structures.
d. Decreased cerebral blood flow specially in the prefrontal cortex.
3. Genetic Theory
Higher incidence of schizophrenia in patients with a diagnosed psychotic relative;
Monozygotic twins have a higher incident rate compared to ordinary individuals;
Identical twins have 50% risk;
Fraternal twins have 15% risk;
4. Perinatal Risk Factors
Prenatal exposure to influenza
Minor malformations developing during early gestation
Complications of pregnancy particularly during labor and delivery;
B. Developmental Theory
The first stage (trust vs mistrust) is very important in the development of interpersonal
relationship.
A child deprived of nurturing, loving environment, neglected or rejected, is very vulnerable to
mental disturbances;
Therapeutic intervention focuses on the reestablishment of trust thru consistent, anxiety-free
relationship;

III. DSM-IV Criteria in the Diagnosis of Schizophrenia
A. Characteristic symptoms:
Two (or more) of the following, each present for a significant portion of time during a 1-month
period (or less if successfully treated):
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g., frequent derailment or incoherence)
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (anergia, alogia)
B. Social / Occupational Dysfunction:
Manifestations of psychosis will significantly affect the level of functioning of the client.
C. Duration
Signs of the disturbance persist for at least 6 months.

D. Schizoaffective and Mood Disorder Exclusion:
The manifestations of psychosis are NOT secondary to other mental illness.
E. Substance / General medical condition exclusion:
The manifestations of psychosis are NOT secondary to substance abuse (shabu use) or medical
illness (delirium, typhoid psychosis)
BLEULERS Four As
1. Affective Disturbance
Inappropriate affective response does not match the circumstances;
Blunted the response to certain circumstances is weakly appropriate;
Flat inability to generate any affective response;
Labile emotional tone changes quickly;
2. Autism preoccupation with the self with little concern for external reality;
3. Associative looseness the stringing together of unrelated topics with VAGUE connections;
4. Ambivalence simultaneous opposite feelings;
Positive vs Negative Symptoms of Schizophrenia
1. Positive Symptoms (type I)
believed to be caused by an increase in the amount of dopamine;
Symptoms are additional of abnormal cognition and perception;
Targeted by typical anti-psychotics (Haldol, Thorazine)
Examples of Positive Symptoms:
Hallucinations and hostility
Illusions and ideas of reference
Delusions
Excitement
Suspiciousness
Bizarre behavior
Agitation or tension
Grandiosity
HIDES BAG
2. Negative Symptoms (type II)
Symptoms are essentially an absence or diminution of what should be ( lack of affect, lack of
energy)
May be related to:
decrease amount of dopamine
cerebral atrophy
decreased cerebral blood flow
increase serotonin;
Targeted by ATYPICAL anti-psychotics (Clozapine, Olanzapine)
Examples of Negative Symptoms:
Alogia poverty of content; lack of meaning or substance in what he say;
Anhedonia
Asocial behavior
Attention deficit
Avolition lack of motivation;
Blunted affect
Communication difficulties (echolalia, neologism, word salad, etc)
Difficulty with abstraction;
Objective vs Subjective Behavioral Manifestations:
A. Objective Signs
1. Alterations in personal relationships.
Poor attention span.
Poor self care or grooming.
Poor social communication.
2. Alterations of activity.
Psychomotor agitation
Echopraxia
Catatonic rigidity
Stereotype behaviors
Subjective Signs:
Autism and Ambivalence
Blocking
Clanging association and concrete thinking
Delusions
Retardation slow mental activity.
Flight of ideas, mutism, and word salad.
neoloGism invented words.
Hallucination
Illusions and ideas of reference
Delusions fixed, false beliefs;
1. Somatic delusions
2. Delusion of grandiosity
3. Delusion of religion
4. Delusion of nehilism (dead)
5. Delusion of reference other people is talking about you.
6. Delusion of influence or control
7. Delusion of persecution
8. Paranoid delusions
Subtypes of Schizophrenia (DSM-IV)
1. Paranoid
extreme suspiciousness
persecutory delusions
auditory hallucinations
Uses PROJECTION.
ND: Potential for violence, directed to others or self.



2. Catatonic
Increased purposeless motor activities
Stuporous or waxy flexibility
Rigid posturing behavior
Mutism and negativism
Peculiar movements
Echolalia or echopraxia
Uses REPRESSION.
ND: Impaired motor activities.
3. Disorganized / Hebephrenic
With child-like behaviors
Incoherent speech
Disorganized behavior
Unsystematized delusions
Inappropriate or flat affect
Abnormal social behavior
uses REGRESSION.
4. Undifferentiated
Grossly disorganized and incoherent behavior
Severe hallucinations
Prominent delusions
Severely impaired level of functioning.
Or if the clients manifestations will not fall under the three categories.
5. Residual
Absence of psychotic symptoms although the px had previous schizophrenia;
Functional level moderately impaired and the client cant keep a permanent job;
Treatment:
1. Psychosocial Therapy
Initially focuses on the patients physical safety;
Helping px to become stronger than their symptoms
Support the patient by abandoning maladaptive behaviors for more acceptable ones;
Design a treatment plan to raise the patients functional level and to educate the family on how to
respond appropriately to the patients behavior;
2. Pharmacotherapy
Use of phenothiazines (Thorazine) and other neuroleptics;
Adjunctive drugs such as antiparkinsons, anticholinergics, propranolol, and diphenhydramine may
be used to control adverse drug reactions;
3. Combination Therapy
Psychotherapy and pharmacotherapy;
To build a stable psychological foundation and helping the patient accept responsibility for self
care, develop social relationships, and vocational satisfaction;
Nursing Diagnosis:
1. Altered thought process***
2. Sensory/perception alteration***
3. Potential for violence, directed to self or others;
4. Ineffective individual coping
5. Personal identity disturbance
6. Impaired verbal communication
7. Self-care deficit
8. Impaired social interaction
9. Nursing Interventions:
10. Safety
Remove any unsafe objects from the patients environment;
2. Environment
Keep the px oriented to reality and 3 spheres;
Minimize environmental stimuli;
Communicate in clear, direct, and concise manner;
3. Self-esteem
Assist the px with grooming if needed;
Allow the px to make decisions when appropriate;
Acknowledge the pxs abilities and skills, and use them to reinforce teaching;
4. Social activities
Give positive reinforcement when the px voluntarily interacts with others;
Encourage the px to participate in group activities;
5. Ego development
Validate the patients perceptions that are accurate and correct all misperceptions;
6. Homeostasis
Monitor the patients vital signs;
Provide period for adequate sleep and diet;
Control hyperactive psychomotor activity;
WOF: adverse drug reactions (EPSE)
7. Correct delusions
Establish and maintain reality for the client.
Teach the client to practice positive thinking and IGNORING delusions.
8. Correct hallucinations and illusions
Help maintain reality.
Engage px in reality-based activities such as card playing or occupational therapy.
SCHIZOPHRENIA
Ego disintegration
Impaired reality perception
Genetic vulnerability
Stress Diathesis Model
o Too much stress in the reality will lead client to escape it and go to the fantasy world
Biological Theory
o Dopamine level is High
The exact cause is unknown


ffect appropriate, inappropriate, flat, blunt (incomplete emotion)
mbivalence torn between 2 opposing forces
utism
ssociative Looseness

Symptoms
Negative Positive
Hypoactive Hyperactive
Withdrawn Sociable
Apathy Flight of Ideas
Talkative

Assess : Content of Thought
NxDx : Disturbed thought process
Planning/ Implementation:
Present reality
Provide safety
Evaluation : Improve thought process


Assess : Hallucination/ Illusions
NxDx : Disturbed sensory perception
Planning/ Implementation:
Present reality
Provide safety
Evaluation : Improve sensory perception
Assess : Suspicious
NxDx : Risk for other directive behavior
Planning/ Implementation:
Present reality
Provide safety
Evaluation : Eliminate/ minimize risk for other-directed violence
Assess : Suicidal
NxDx : Risk for self directive behavior
Planning/ Implementation:
Present reality
Provide safety
Evaluation : Eliminate/ minimize risk for self-directed violence

Flight or Looseness

I am going to the mall. I am going to the mall.
Where is the light? The mall is big.
Go here. Big is the tree.
Mineral Water. The tree is tall.








Magical Thinking
Believes to have a magical power
I can turn you into a frog
Echolalia I repeat what you say Parrots
Echopraxia I repeat what you do
Word Salad words, no rhyme
Clang Association words with rhyme : Dunk, plank, sunk
Neologism creation of new words Plinking, hustash
Clarification done in case of neologism
Delusion:
Persecutory NBI is out to get me/ someone will harm the client
Religious I am Jesus Christ
Grandeur I am the queen of the world.
Ideas of reference Nurses are talking about me.
Concrete Associationpilosopo what will you wear? clothes
Thought Blocking

Halucinations Illusion
Stimulus Absent Present
Visual X
Auditory X
Tactile X

In case of hallucinations do:

Hallucinations
Acknowledgment
I know you the voices are real to you


Reality orientation
But I dont hear them
Diversion
Lets go to the garden

But if nothing in the preceeding intervention are seen
Assess what the voices are saying











SCHIZOPRENIA











OTHER PSYCHOTIC DISORDERS
A. Schizoaffective Disorder
Is a psychosis characterized by both affective and schizophrenic symptoms with substantial loss of
occupational and social functioning;
Schizophrenic symptoms are dominant but are accompanied by major depressive or manic symptoms;
Delusional Disorder
Manifest symptoms similar to schizophrenia but with substantial differences exists:
1. DELUSIONS have basis in reality.
Disorganized

Sad but smiles
o Inappropriate affect
No reaction
o Flat affect
Flight of ideas
o HEBEPHRENIC
Giggling
Positive and Negative
S/Sx
Catatonic
Ambivalence
Waxy Flexibility
o Iniwanna posture,
ganun forever
No favorite word
Negativism
Paranoid
Suspicious
Tendency to be
violent
MistrustScared
Withdrawn
Nrsg. Int:
Develop trust
1 to 1
short
interaction
frequent visit
foods in
sealed
container
meds
wrapped
for violent pt.
Doors open
Near the door
Dont touch
the pt.
Eye contact
1 arms length
away
call
reinforcement

Residual

No more positive s/sx,
just withdrawn
classified
differentiated

Mixed classification
Cant be classified
1
st
paranoid, then
disorganized then
catatonic, etcetc
2. Have not met the criteria of schizophrenia.
3. Behavior is relatively normal other than their delusions.
4. Duration of symptoms is brief.
5. Symptoms may be due to substance or general medical conditions.
Tx: Anti-psychotics
C. Brief Psychotic Disorder
Psychotic disturbances that last less than 1 month and are not related to other mental disorders, general
medical conditions, or substance abuse;
Tx: Anti-psychotics
Schizophreniform Disorder
Shows symptoms of typical schizophrenia and last at least 1 month but no longer than 6 months;
Tx: Anti-psychotics
COGNITIVE DISORDERS
Cognitive abilities are processes that allow the person to make sense of experience and to interact
productively with the environment;
1. Judgment
2. Attention
3. Perception
4. Orientation
5. Reasoning
6. Memory
Char by deficit in memory or cognition that significantly changes a persons level of functioning;
Also known as Organic Brain Disorders;
DELIRIUM (acute brain syndrome)
Deficiency in the capacity to maintain attention;
With rapid onset and brief duration;
Char by acute loss of conscious awareness;
May lasts for hours or weeks and resolves in a few days (reversible);




Causes:
1. Physical abuse
2. Infection - sepsis
3. Endocrine problems thyrotoxicosis
4. Trauma massive blood loss;
5. Abuse of substance
Signs and Symptoms:
1. Prodromal signs
Restlessness
Anxiety
Sleep disturbance
Irritability
2. **Cloudy consciousness cardinal sign.
3. Apathy
4. Impaired cognition and memory defects
5. Disturbances in perception
6. Disorganized thought process
Nursing Diagnosis:
1. **Risk for injury related to cognitive and psychomotor deficit.
2. Self-care deficit related to inability to carry out ADL.
Nursing Interventions:
**Follow treatment plan to relieve cause of delirium.
1. Reality orientation
a. Call the px by name and keep a clock and calendar in plain view.
b. Use very simple words and short sentences.
c. Provide a safe and quiet environment;
3. Monitor vital signs.
4. Set limitations on inappropriate and harmful behaviors.
5. Provide adequate nutritional and fluid intake if tolerated;
DEMENTIA (chronic brain syndrome)
Char by memory impairment and insidious loss of intellectual ability;
May be due to destruction of neurons in the brain;
Etiology usually due to other NEUROLOGIC diseases:
1. Parkinsons Disease
2. Picks disease
3. Huntingtons chorea
4. Wernicke-Korsakoffs Syndrome
5. Alzheimers Disease ****
DSM-IV Criteria for Dementia
1. Memory impairment (amnesia)
2. At least one of the ff cognitive disturbances:
a. Aphasia language disturbance
b. Apraxia inability to carry out motor activities despite intact motor
function;
c. Agnosia failure to recognize or identify objects despite intact sensory function;
d. Disturbance in executive functioning (abstracting, planning, organizing)
3. Significant impairment in social or occupational functioning after the onset of illness.

ALZHEIMERS DISEASE
Is the most common type of dementia;
Exact cause is UNKNOWN;
Is a degenerative brain disease causing dementia that is progressive and most of the time irreversible;
Usually begins after age 60 but early signs can be observed at age 40;
Death may occur within five years after diagnosis (pneumonia or from other infections)
More common in males;
Char by microscopic brain changes:
1. Senile plaques**
2. Degeneration of neurons or neurofibrillary tangles **
3. Cerebral atrophy **
4. Reduced level of acetylcholine:**
Loss of neurons in the basal ganglia
Increase action of acetylcholinesterase enzyme;
As of Alzheimers Disease:
aging
amnesia
agnosia
aphasia
apraxia
aluminum deposition
amyloid deposition
antibodies abnormalities
acetylcholine abnormality
abnormality in chromosome 21

Clinical Manifestations of AD:
- Memory loss (amnesia) and mood swings
- Intolerance for activity
- Depression
- Anger
- Helplessness and hopelessness
- Incontinence and abnormal reflexes
- Lack of self-care and home care
- Altered sleep and arousal patterns
- Numerous behavioral symptoms (hallucinations, delusions, dysphoria, apathy, agnosia,
apraxia, aphasia)
Nursing Diagnosis:
- **High risk for injury
- Altered thought process
- Anxiety
Nursing Interventions:
1. Ensure safety:
- removing toys and other dangerous objects in the vicinity;
- rearranging furniture and use of pads;
2. Support and meet the clients basic needs (food, shelter, clothing)
3. Encourage activities of daily living.
4. Provide sensory stimulation (reading, music)
5. Encourage life review or reminisce.
6. Use clear, short and concise communication.
Pharmacotherapy:
- Antipsychotics for psychotic symptoms;
- Antidepressants SSRIs; Nortriptyline and Desipramine;
- Antianxiety used for agitation, anxiety, and sleep disturbances;
Buspirone
Lorazepam
Oxazepam
2. Metabolic enhancers / Vasodilators - treat cognitive impairment;
Hydergine
3. Nootropic agents used to enhance neuronal metabolic activity;
Nootrophil
4. Donepezil (Aricept) and Tacrine (Cognex)
acetylcholinesterase inhibitors;
TO INCREASE ACH LEVEL;
Aricept given once daily with low incidence of hepatotoxicity;

SUBSTANCE ABUSE
Causes maladaptive behaviors secondary to mood-altering substances;
UPPERS Stimulation of SNS
DOWNERS Depression of SNS
Substance abuse is a widespread concern with broad social ramifications and personal consequences;
May lead to addiction;
Most commonly abused substances:
1. Alcohol
2. Opiates
3. Narcotics
4. Hallucinogens
5. Stimulants
6. Inhalants
ALCOHOL - is considered as the leading abused substance;
CIGARETTE is the most commonly abused substance by psychiatric patients;
ALCOHOL ABUSE
Alcohol is a CNS depressant that is rapidly absorbed into the bloodstream;
Alcoholism is considered to be present when there is 0.1% or 10mL for every 1000mL of blood;
Levels:
.1 - .2% - slow coordination, slurred speech
.2 - .3% - tremors, irritability, violence
.3% and above - unconsciousness
Effects of Alcohol Intake:
1. Aggression
2. Blackouts
3. Coordination problem
4. Difficulty walking (unsteady gait)
5. Experience slurred speech
6. F - polyuria
7. Gone are inhibitions
8. Hanepmakapag-relax
9. Impaired attention, concentration, memory and judgment;



An overdose or excessive alcohol intake in short period of time can result to (ABCD):
Altered level of consciousness
Breathing is depressed and vomiting
Coma
Death

Wernicke - Korsakoffs Syndrome
Char by amnesia, clouding of consciousness, confabulation (falsification of memory) and peripheral
neuropathy;
Results from inadequate amounts of THIAMINE (B1) and NIACIN, and the neurotoxic nature of
alcohol;
Tx: Vitamin B1 or B-complex replacement;
Common Behavioral Problems:
Denial
Dependency
Demanding
Destructive
Domineering
Treatment:
Symptoms of withdrawal usually begin 4 12 hours (6-8 hrs) after cessation or marked reduction of alcohol
intake;
May lasts up to 5 days;
ALCOHOL WITHDRAWAL SYNDROME
Stage I
6-8 hrs after last intake.
Anxiety and anorexia
Insomnia and tremors
N/V and hyperactivity
Increase pulse and BP
Depression
Stage 2
8-12 hrs after lasts intake.
Confusion
Gross tremors
Nervousness
Disorientation
Auditory and visual hallucinations
Illusions
Nightmares
Stage 3
12-48 hrs after last intake.
Severe hallucinations
Seizures (Dilantin)
Stage 4
3 5 days after last ingestion.
Confusion and delirium.
Clouding of consciousness.
Disorientation.
Visual and tactile hallucinations.
Fever and increase BP.
Tremors and tachycardia.
Medical emergency.
Alcohol withdrawal can be life-threatening, so detoxification needs to be accomplish under medical supervision;
Safe withdrawal is usually accomplished by benzodiazepines:
Lorazepam (Ativan) drug of choice;
Diazepam (Valium)
Disulfiram (Antabuse)
Inhibits the breakdown of acetaldehydes by an enzyme (aldehyde dehydrogenase)Alcohol (Ethanol)
Acetaldehyde + H
2
Acetic acid
CO
2
+ H
2
O (for excretion)
The person who drinks alcohol while taking disulfiram will become ill: (DISULFIRAM OR ANTABUSE
REACTION)
1. Sweating
2. Flushing of the neck and face
3. Tachycardia and palpitations
4. Hypotension
5. Throbbing headache
6. Nausea and vomiting
7. Dyspnea
8. Tremors
9. Weakness
Disulfiram may also cause arrhythmias, MI, cardiac failure, seizures, coma, and death;
The unpleasant effects to alcohol is intended to help stop alcohol drinking;
Once disulfiram is started, the px must not take alcohol because of the danger of these adverse effects;

ALCOHOLISM
Etiology:
Intergenerational Transmission
From one generation to another generation

Alcohol

Blackout awake but unaware

Confabulation inventing stories to self-esteem

Denial I am not an alcoholic

Dependence I cant live without it

Enabling significant other tolerates abusers
Another term CO DEPENDENCY

TOLERANCE Substance to achieve a previous effect

DETOXIFICATION
Withdrawal with MD supervision
Check Alcohol, Mouthwash, Elixer

void alcohol
version therapy
lcoholics Anonymous self help group
ntabuse DISULFIRAM Never drink alcohol
12 hour interval/ 12 h last alcohol intake
B1 Vitamin Deficiency or else: nausea, vomiting and hypotension
Wernickes Encephalopathy motor
Complications
Korsakoffs Psychosis memory
Delirium Tremens 24 72 h after last dose of alcohol
untreated withdrawal syndrome
ormocation bugs crawling under the skin
amily Therapy mother, father, brother


FETAL ALCOHOL SYNDROME (FAS)
Is the result of alcohols inhibiting effects on fetal development during the first trimester of pregnancy;
Pregnant women who drink alcohol run the risk of seriously harming their unborn child;
Characteristics:
1. Microcephaly
2. Severe mental retardation
3. Stillborn
SEDATIVES, HYPNOTICS, and ANXIOLYTICS
These are CNS depressants;
Intoxication symptoms: (SIC LULI)
1. Slurred speech and stupor
2. Impaired verbal communication
3. Coma
4. Lack of coordination
5. Unsteady gait
6. Labile mood
7. Impaired attention or memory
8. Benzodiazepines when taken orally are rarely fatal (ONLY causes lethargy and confusion)
Barbiturates (Parenteral or oral) can be lethal when taken in overdose (2 10 g can be fatal)
1. Coma
2. Respiratory arrest
3. Cardiac failure
4. Death
Withdrawal Symptoms:
1. Usually occurs 6 8 hrs after cessation of some benzodiazepines;
2. Manifested by:
1. Autonomic hyperactivity
a. Increase PR
b. Increase BP
c. Increase RR
d. Increase in temperature
2. Hand tremors
3. Anxiety
4. Nausea
5. Insomnia
6. Psychomotor agitation
Detoxification from sedatives, hypnotics, and anxiolytics often manage by TAPERING the amount
of drugs the client receives over a period of days or weeks;
Barbiturates can cause fetal abnormalities because these can cross the placental barrier;
- Infants born to mothers who take barbiturates during the last trimester of pregnancy can experience withdrawal
symptoms postpartum;
OPIOIDS
Are popular drugs because these desensitize the person to both physiologic and psychological pain and induce a
sense of euphoria and well-being;
Examples:
1. Morphine*
2. Opium*
3. Meperidine (Demerol)*
4. Codeine
5. Hydrocodone
6. Methadone drug of choice during detoxification.
7. Heroin*
OPIOID INTOXICATION happen after the initial euphoric feeling:
1. Pinpoint pupils*
2. Apathy
3. Respiratory depression
4. Uncoordinated movements
5. Lethargy and listlessness
6. Attention and memory impairment
7. Slurred speech
8. NALOXONE (opioid antagonist) - is the treatment of choice for toxicity; NOT FOR
DETOXIFICATION;
9. It reverses all the signs of opioid toxicity by blocking the neuroreceptors affected by opioids;
10. Immediately improves pxs respiration and consciousness;
Withdrawal develops when (1) drug intake ceases or is (2) markedly decreased, or it can also be (3) precipitated
by the administration of naloxone:
1. Craving
2. Restlessness and rhinorrhea
3. Anxiety with aching backs and legs
4. Nausea and vomiting
5. Dysphoria and diarrhea
6. Sweating
7. Fever
8. Insomnia
9. Lacrimation
CRANDS FIL
Heroin Withdrawal: STRICY
Sneezing
Tears
Restlessness
Irritability
Coryza
Yawning
Methadone - is used to replace opioid during detoxification to reduce signs and symptoms of withdrawal;
STIMULANTS (Amphetamines, Cocaine, Ecstasy )
Also known as uppers;
These drugs excite the CNS;
The effects of these drugs, even though they are different, are the virtually same;
These drugs have limited clinical indications and a high potential for abuse;
Amphetamines are commonly used before to lose weight (ex. IONAMINE)
Cocaine and ecstasy have NO clinical use and is highly addictive;
Commonly used as a recreational drug because of intense and immediate feeling of euphoria;
Intoxication from stimulants develops rapidly:
1. Super active
2. Talkative
3. Impaired judgment
4. Mabilispumayat (weight loss)
5. Unhappiness or anger
6. Loss of appetite (anorexia)
7. Anxiety
8. The presence of hallucinations and illusions
9. Euphoria
Physiologic effects:
a. Tachycardia
b. Elevated BP
c. Dilated pupils
d. Diaphoresis with chills
e. Nausea
f. Chest pain and Confusion
g. Cardiac arrhythmias
Cocaine users may also report bugs crawling beneath the skin (FORMICATION) and foul smells;
Nasal septum perforation is associated with chronic snorting cocaine and is due to extreme
vasoconstriction which impedes blood supply to the nasal septum causing necrosis;
Cocaine or Stimulant Withdrawal:
Occurs within a few hours to several days;
Manifestations: ( D MANIPIS)
a. Depressive symptoms
b. Marked dysphoria feeling of unhappiness and anger;
c. Agitation
d. Nightmares
e. Increase appetite
f. Psychosis
g. Increase suicidal ideations
h. Sleeping disturbances
CANNABIS (Marijuana)
From Cannabis sativa, a hemp plant for making ropes and cloth;
contain DELTA-9 TETRAHYDROCANNABINOL (THC) - the active substance;
Marijuana upper leaves, flowering tops, and stems of the plant;
Hashish is the dried resinous exudates from the leaves of the female plant;
Cannabis most of the time is smoked like cigarettes but it can be eaten (brownies)
Therapeutic use of cannabis:
1. Lowers IOP
2. ** Relieves nausea and vomiting associated with cancer chemotherapy (dronabinol, nabilone)
3. Anorexia and weight loss of AIDS
Cannabis Intoxications:
1. Begins to act less than 1 minute after inhalation;
2. Peak levels occur in 20 30 minutes and lasts at least 2 - 3 hours;
3. Symptoms of Cannabis Intoxication:
4. Tachycardia
5. Hypotension
6. Eye redness
7. Psychotic symptoms (hallucinations)
8. Abnormal motor coordination
9. Short-term memory loss
10. Inappropriate laughter (laughing trip)
11. Social withdrawal
12. Increase appetite (food trip)
13. Disorientation, delirium, and dysphoria
Treatment is usually symptomatic and overdose does not occur ( because easily excreted )
Withdrawal symptoms are usually not present when sudden cessation is performed;



HALLUCINOGENS
Also referred to as psychotomimetics or psychedelics;
Are substances that distort the users perception of reality and produce symptoms similar to psychosis;
Used to treat chronic alcoholism and reduction of cancer pain and PLP;
Two basic groups:
1. Natural
a. Mescaline peyote from cactus;
b. Psilocybin psilocin from mushrooms;
c. Cannabis
Synthetic
a. LSD lysergic acid diethylamide
b. STP dimethoxy-4-methylamphetamine
c. Pencyclidine (PCP) most potent;
d. DMT dimethyltryptamine
e. MDA - methylenedioxyamphetamine
f. Hallucinogen intoxication is marked by a variety of maladaptive behavioral or
psychological changes:
2. Hallucinations
3. Anxiety
4. Paranoid ideation
5. Depression and dangerous behaviors
6. Ideas of reference
7. Toxic reactions to hallucinogens (except PCP) are primarily psychological and overdose usually
will not occur;
Psychotic reactions are best managed by:
1. Isolation from external stimuli.
2. Using physical restraints if necessary for the CLIENTS SAFETY.
INHALANTS
Are diverse groups of drugs that are inhaled for their effects:
1. Anesthetics
2. Nitrates
3. Organic solvents
a. Gasoline
b. Glue
c. Paint thinner
d. Spray paint
e. Inhalants can cause significant brain damage, PNS damage, and liver disease;
Inhalants may cause acute toxicity:
1. Respiratory depression
2. Anoxia
3. Vagal stimulation
4. Arrhythmias
5. Death ( due to bronchospasm, cardiac arrest, suffocation, or aspiration)
6. Treatment consist of supporting respiratory and cardiac functions until the substance is removed
from the body;
There are no withdrawal or detoxification procedures for inhalants;
EFFECTS OF SUBSTANCE ABUSE
1. Decrease number of social friends.
2. Reduction of leisure activities.
3. Erosion of spiritual values and moral standards.
4. Abnormal physical functions.
5. Mounting family tension and mental deterioration.
6. Sexual and occupational problems.

EATING DISORDERS
ANOREXIA NERVOSA
is a disorder characterized by compulsive resistance to eat and maintain body weight;
Common in adolescent and young adult 12 18 years of age;
With a mortality rate of 15 20%;
Majority of cases are females;
Clients usually die of severe malnutrition;
Most of them are experiencing DENIAL (unconscious refusal to admit their disease)
May be triggered by:
adolescent crisis
unconscious fear of growing up
excessive concern and fear of obesity
elevated feelings for self-control
Manifestations of Anorexia Nervosa:
Hypothermia, and hypotension
Anemia with bradycardia/tachycardia.
Nutritional deficiency (malnutrition)
Obvious weight loss ( 15% or more of original body weight ) ***
Resistance to eat (fear of eating)
Electrolyte imbalance (hypoK and hypoNa)
Keep high performance in school and sports
Social withdrawal with poor individual coping
Increase in size of salivary gland (hypertrophy)
Amenorrhea (absence of at least 3 consecutive menstrual cycle)
Nursing Diagnosis:
Altered nutrition: less than body requirements
Disturbed body image
Ineffective individual coping
Ineffective family coping
Fluid and Electrolyte imbalance
BULIMIA
A syndrome char by recurrent binge eating with lack of control and followed by purging (vomiting, use of
laxatives or diuretics, or vigorous exercise)
May also manifest with pica (or eating non-nutritious foods such as plaster, paint, clay, or sand)
Common among adolescent and young adults 17-23 years old;
More common among women;
Tend to be episodic with remissions and relapse;
Most clients know their illness;
Is predispose to have depression;
May have discord with family relationship;
There is a profound history of obesity in the family;
Manifestations:
1. Body and weight conscious.
2. Unusual, extroverted, and impulsive individuals.
3. Lability in weight (due to binge-eating and long hours of fasting)
4. Induced purging after binge-eating.
5. Multiple dental staining
6. I - Electrolyte imbalance (hyponatremia, hypokalemia, and hypochlorinemia)
7. Engages in vigorous exercises.
8. Signs of depression.
Nursing Diagnosis:
1. Altered nutrition: less than body requirements
2. Ineffective family coping
3. Ineffective individual coping
4. Personal identity disturbance
Nursing Interventions for Eating Disorders:
1. Weigh client daily.
2. Encourage verbalization of feelings.
3. Increase self-esteem.
4. Go observe for signs of purging and depression.
5. Help clients reestablish proper eating behavior.
6. Monitor caloric intake.
7. Electrolyte monitoring regularly.

EATING DISORDERS

18 mos. 3 y.o. 6 y.o.class valedictorian/ model student

Toilet Training social inactive/ no BF

Clean weighing
Obedient
Organized

Thought Feeling Behavior
I Am Fat Self Esteem Diet, Diet, Diet
Anorexia Nervosa Eating Disorders Bulimia
Diet, diet, diet Eating Pattern Eat, eat, vomit
<85% of expected body Weight Normal weight
3 mos. ammenorhea Menstruation Irregular menstruation
Karen Carpenter Dao Ming Xi
Da Ming Sugat/ suka
Vomiting
Dental caries
Wounded knuckles
Metabolic alkalosis
Metabolic acidosis

Vomiting

Fluid Volume Deficit ARRHYTHMIA (fatal complication)

Diarrhea


Interventions
Restore fluid and electrolyte balance
Collaborative regarding menu contract
Target weight gain
After meals: stay 30 mins 1 hour

SEXUAL DISORDERS
These are disorders that are related to human sexuality due to psycho-physiological causes;
Types:
1. Alteration in gender identity
2. Alteration in sexual orientation
3. Alteration in sexual behavior
4. Alteration in sexual functioning
5. Painful sexual disorders
ALTERATION IN GENDER IDENTITY
1. Transsexualism
Persistent discomfort about ones sex assignment;
Caused by confused learning about gender roles;
Feeling of being trapped in the wrong body;
With intense feeling or preoccupation about transsexual surgery;
2. Gender Identity Disorder of Childhood
Persistent and intense distress at ones sexual identity;
Client insists that he/she is an opposite sex;
Assertion that he/she will grow up to have transsexual surgery;
3. Nontranssexual Cross Gender Disorder
Persistent discomfort about ones sex but with no preoccupation with getting rid of the genitalia;
ALTERATION IN SEXUAL ORIENTATION
1. Ego-Dystonic Homosexuality
Weak heterosexual arousal with desire to have heterosexual relationship;
Client experience inappropriate homosexual arousal pattern;
ALTERATION IN SEXUAL BEHAVIOR
1. Sexual Acting Out
With disturbed conduct or poor impulse control;
Have extramarital affairs and promiscuous individuals;
With high sexual drive;
Presence of inadequate coping and interpersonal skills;
2. Paraphilia
Sexual urges or fantasies that are directed toward nonhuman objects, pain to self, partner, or
children, or other non-consenting individuals;
This may be asymptomatic;
Behavior often followed by guilt, shame, low self-esteem, or anxiety;
Not due to other mental disorder;
ALTERATION IN SEXUAL FUNCTIONING
1. Sexual Dysfunction individual is unsatisfied in his sexual function;
2. Hypoactive sexual desire absence of sexual fantasies and desires;
3. Sexual aversion avoidance of genital sexual contact with a partner;
4. Sexual arousal disorder
Failure to attain and maintain erection in males;
Lack of lubrication in females;
Persistent or recurrent lack of subjective sense of sexual excitement and pleasure;
PAINFUL SEXUAL DISORDERS
1. Vaginismus an involuntary vaginal spasm at penetration;
Protection against anticipated pain associated with sexual trauma, intense guilt, or high
religion offense;
2. Dyspareunia painful sexual intercourse;


NURSING DIAGNOSIS
1. Altered sexuality patterns
2. Ineffective individual coping
3. Altered family process
4. Anxiety
5. Potential for violence: self-induced or to others.
NURSING INTERVENTIONS:
1. Sexuality belief and values discussion.
2. Encourage to discuss feelings of guilt, remorse, anger, and loneliness.
3. X explain to the client the institution of suicidal precaution.

OVERVIEW OF SUICIDE
SUICIDE

Verbal Non Verbal
I wont be a problem anymore
This is my last day on earth
Ill soon be gone
Take this ring, its yours (giving of valuable)
Sudden change in mood

Who will commit Suicide?
Sex Male (more successful)/ female (hesitant)
Age 15 24 y/o or above 45
Depression
Patient with previous attempt
ETOH ethanol - alcoholics
Rirrational
Social support lacking
Organized plan greater risk
No family
Sickness, terminal

SUICIDE TRIAD
Loss of spouse
Loss of job
Aloneness

Is Patient is SUICIDAL; nurse should: DIE
Direct question Are you going to commit suicide?
Irregular interval of visit to pt. room
Early AM and period of endorsement the time pts commit suicide

Best approach for suicidal pt. :Direct approach
Nursing Management: Close surveillance

Hospital area majority sucide will happens at:
weekends 1- 3 am Sunday
Weekend less staff personnel
Early AM everyone is asleep

Give simple task. Dont give complex may cause depression ex. Jigsaw
Water plants
Wash the dishes except sharps

is the 9
th
leading cause of death in the US;
Among the three leading causes of death for those aged 15-34 years old;
Females are higher to COMMIT suicide;
Men are 4x higher to COMPLETE SUICIDE than females;

SUICIDE
Or self-inflicted death;
outcome of a persons inability to deal with catastrophic stress (depression)
Suicide most often is the result of depression, diagnosed or not;
Suicide may occur in children, adolescent, or adult populations;
Suicidal ideation includes a persons thoughts regarding suicide;
Suicidal gestures non-lethal self-injury acts like:
1. Cutting of skin areas
2. Burning of skin
3. Ingestion of poisonous substances or drugs
Suicidal gestures may be considered as ATTENTION-SEEKING measures and MAY NOT
LEAD to serious attempts or completion;
Suicidal threats are persons verbal statements that may declare their intent to commit suicide;
Threats OFTEN PRECEDE an actual suicide attempt;
Suicide attempt is the actual implementation of a self-injurious act with the purpose of ending a
persons life;
The death by suicide of a psychiatric client is of particular importance to the nurse because of opportunities for
assessment and interventions;
(HIGH) Risk Factors for Completed Suicide:
1. Caucasian and Native Americans
2. Living alone single, divorced, widow/er
3. Age 40-60 and older
4. Male sex
5. Prior suicide attempts 50-85%
6. Substance use (alcoholism, drugs)
7. Hopelessness and helplessness
8. Unemployed or financial problems
9. General medical illness terminal cancer
10. Severe anhedonia

Assessment of Suicidal Patients:
It is important for the nurse to be able to assess the suicidal potential of mentally ill clients
because of higher risk in committing suicide;
Plan
The more developed the plan, the greater risk of suicide;
Impulsive suicide attempts can also result in death but generally are less often lethal
because of lack of planning;
2. Method
Some methods of suicide are more lethal than others;
One important factor in determining the lethality of a method is the time between initiation and the
delivery of the lethal impact of the method;
Ex. GSW is more lethal than drowning or suffocation;
Types of Methods:
1. Gunshot
2. Jumping from high places
3. Hanging
4. Drowning
5. Carbon monoxide poisoning
6. Overdose with certain drugs (alcohol, barbiturates, and other CNS depressants,
ASA, valium)
7. Wrist cutting
8. Ingestion of poisonous substances
3. Rescue
A person who deliberately attempts to deceive would-be rescuers has a high lethal potential;
The more detailed the plan, the more lethal and accessible the method;
The more effort to block rescuers, the greater the chance for a successful suicide;
Nursing Diagnosis:
Ineffective individual coping
Potential for violence: self-directed
Fear
Anxiety
Nursing Interventions:
Assess and evaluate client for suicidal risk to develop a reasonable plan of care.
Suspect suicidal ideation in most depressed clients.
Inquire directly about the frequency and content of suicidal ideations.
The nurse will not provoke suicide.
The nurse will convey concern, worth of the client, and a sense of understanding.
To plan nursing care.
Evaluate clients access to a means of suicide to block the access.
Develop a formal no suicide contract with the client.
Advise the client to discontinue drugs and/or alcohol intake.

DEVELOPMENTAL DISORDERS
A. MENTAL RETARDATION
Or Cognitive Developmental Delay;
Is defined by IQ BELOW 70 before 18 y/o that is accompanied by impairments in performing age-
expected activities in daily living;
3% of the US population are considered MR;
Most mentally retarded are in the MILD range;
The causes of MR:
1. Specific
Downs syndrome most common.
Fragile X syndrome
Phenylketonuria
2. Multifactorial causes
Congenital anomalies
Perinatal trauma
Postnatal trauma
Postnatal infections
DSM-IV Classification of Mental Retardation


LEVELS OF MENTAL RETARDATION
Profound
o < 20
o thinks like an infants
o cant be trained
o stay with the patient
Severe
o 20 35
Moderate
o 35 50
o can be train
o mental age is 2 7 y/o
o pre-operational stage
Mild
o 50 70
o mental age is 7 12
o educable
o can go to school
Borderline
o 70 - 90
Normal
o 90 100

MILD MR capable of EDUCATION;
- Mental age of 8 12 years old;
- Can learn to read, write, achieve vocational skills, and function in the society;

MODERATE MR the client is TRAINABLE;
- Mental age of 3 7 years old;
- Can learn the activities of daily living;
- Can be trained to work;
SEVERE MR the client is barely trainable;
- Mental age 0 -2 years old;
- Totally dependent and in need of custodial care;
- May say few words;
- With uncoordinated motor movements;
PROFOUND MR mental age of young infant;
- Requires full-time care;
- No academic skills;
- No fine or gross motor skills;
B. DOWN SYNDROME (TRISOMY 21)
Is the most common identifiable cause of MR;
Down syndrome is one of the most widely known syndromes associated with MR;
Clinical Manifestations:
1. Characteristic facial anomalies and others.
a. Brachycephaly
b. Epicanthal folds
c. Flat nasal bridge
d. Low-set ears
e. Oblique palpebral fissures
f. Protruding tongue
g. Simean crease of palms
2. Congenital heart defects VSD, TOF, PDA
3. Mental retardation
4. Hypotonia
5. Growth retardation
C. Fragile X Syndrome
2
nd
most common identifiable cause of MR;
Most common inherited cause;
Dx made during mid-childhood;
Clinical Manifestations:
ero 2 y/o
ensorimotor
evere

Modera e
hirtyfive 50 rainable
wo 7 y/o
1. Mild to moderate MR
2. Elongated face, prominent ears, macrocephaly, high-arched palate;
3. Macroorchidism at puberty
4. Autism
5. Attention deficit, hyperactive
6. Self-mutilating or self-injurious behaviors;
D. Turners Syndrome
rare genetic disorder found among females;
There is an absence of a normal 2
nd
sex chromosomes;
Genetic analysis reveals a 45,X chromosome constitution;
Clinical Manifestations:
1. The most prevalent:
a. Short stature, webbed neck, low posterior hairline, edema of the hand and feet;
b. Broad chest with inverted or underdeveloped nipples;
c. Immature reproductive organs, primary amenorrhea
AUTISTIC DISORDER
Char by detachment from reality when self-preoccupation and self-involvement are predominant;
Strong genetic contributions but the exact cause remains UNKNOWN;
Others suggest:
o increase level of serotonin
o abnormal serotonin receptors;
Most are mentally retardate;
Onset is usually at 30 months of age;
AUTISM
Autistic Savant autistic with a special talent
Assess
Appearance flat affect, consistent movement
Behavior repetitive, ritualistic
Communication echolalia, incomprehensible
NxDx
Impaired verbal communication
Impaired social interaction
Self mutilation
Risk for injury
Planning/ Implementation
Maslows hierarchy of needs
Constancy, promote safety
Evaluation
Expressive therapy drawing, muscicetc
Enhanced communication
Improved social interaction
Safety

Clinical Manifestations:
o Profoundly disturbed social relatedness;
o Constant delay in the developmental profile;
o Aloof and indifferent to others;
o Prefers inanimate objects than human contacts;
o Temper tantrums
o Language is delayed and deviant:
Abnormal intonation
Pronoun reversals
Echolalia
o Stereotypical behaviors
Rocking
Hand flapping
Extraordinary insistence on sameness
Preoccupation with peculiar interests (fans, aircons)
Nursing Interventions:
o Maintain a consistent and familiar environment.
o Set consistent and firm limits for behaviors.
o Encourage verbalization of feelings and concerns.
o Prevents destructive behaviors.
o Provide routine for ADLs.
Pharmacologic Tx:
o Haloperidol (Haldol) - to decrease or relieve:
Temper tantrums
Aggressiveness
Self-injury
Hyperactivity
Stereotypical behaviors
o Naltrexone
o Clomipramine
o Clonidine
o Stimulants
DISRUPTIVE BEHAVIOR DISORDERS
ATTENTION-DEFICIT HYPERACTIVITY
DISORDER
Is char by inattention, impulsiveness, and overactivity;
Is a relatively common among SCHOOL-AGED CHILDREN (2-11%);
The exact etiology is STILL UNKNOWN;
Experts suggest that dysfunction of the frontal lobe;
May occur together with learning disabilities;
Possible Etiologies:
1. Environmental exposures
a. Perinatal insults
b. Head injury
c. Psychosocial adversity
d. Lead poisoning
2. Food additives and history of allergies.
3. Genetic predisposition especially among identical and fraternal twins.
ATTENTION DEFICIT HYPERACTIVE DISORDER
Onset : 7 y.o. and below
Duration : 6 months and above
Settings : 2 House and school
Id Dominant : Mom or RN will act as superego

ADHD Glucose Frontal Lobe impaired judgement ADHD S/Sx
Ritalin Frontal Lobe Judgement ADHD S/Sx
(stimulant)
Assess
Appearance dirty
Behavior clumsy, impatient, easily distracted, hyperactive
Communication talkative, blurts out in class


NxDx
Risk for injury
Impaired social interaction
Planning/ Implementation
tructure separate room for eating, playing, sleeping and etc
chedule time for everything
et limits
afety
Evaluation
Minimize Risk for Injury
Improved social interaction
Safety

Residual ADHD grows up not antisocial

Meds: Ritalin, dexedrin, pemoline, adderal
Best time to give: once a day: AFTER MEALS: prevent lost of appetite
Dont give at bedtime STIMULANT causes insomnia
Give 6 hours prior bedtime if bid

MAIN PROBLEMS OF ADHD:***
I Inattention
H Hyperactivity
I Impulsivity
NURSING DIAGNOSIS:
Risk for injury.***
Management:
1. Multidisciplinary approach (environmental and behavioral) is the treatment of choice.
2. Pharmacotherapy
CNS STIMULANTS work for 70-75% of ADHD (only for children older than 7 years old)
Effective in decreasing motor activities and increasing attention span and
concentration;
*** Methylphenidate (Ritalin) most common;
Dextroamphetamine (Dexadrin)
Pemoline (Cylert)
Clonidine (Catapres)
TCAs (Imipramine, desipramine, nortriptyline)
TIC DISORDERS
Term used to describe several disorders that are characterized by motor and/or vocal tics;
TIC is a sudden, rapid, recurrent, non-rhythmic, stereotyped motor movement or vocalization;
Tics can be suppressed for a period of time but not indefinitely;
Tics are exacerbated by stress and diminished during sleep and when the person is
engaged in an absorbing activity;
Motor Tics typically rapid, jerky movements of the eyes, face, neck, and shoulders;
Vocal Tics most common are throat clearing, grunting, or other repetitive noises;
Echolalia
Palilalia
Coprolalia
TOURETTES SYNDROME is a chronic idiopathic movement disorder that is char by the presence of
multiple motor and vocal tics for more than 1 year;
May experience all types of tics in his lifetime;
Will lead to significant impairment on social, academic, or occupational functioning;
May feel ashamed and self-conscious;
Rare and more common among BOYS than girls;
Onset usually by age 7 years;
Dx: Haloperidol (Haldol)
ABUSE
Wrongful use and maltreatment of another person (spouse, partner, child, or elderly)
May lead to:
Physical injuries
Psychological injuries
Victims of abuse may also show:
Upset
Numb
Agitation
Withdrawn low self-esteem
Aloof
Domestic violence goes undisclosed for months or years (due to FEAR OF THE ABUSER)
Char of a Violent Family:
1. Social Isolation
Do not invite others into their home or tells others what is going on;
Threat from the abuser;
2. Abuse of Power and Control
Abuser is almost always in a position of power and control over the victim;
Physical, economic, or social power;
3. Alcohol and Drug Abuse
Abuser commonly uses alcohol or drugs;
Alcoholism is also present in 50% of abused women;
Alcohol and drugs are also associated with date rape;
4. Intergenerational transmission process
Family violence is a learned response;
1/3 of abusive men grew from a violent family or with history of abuse;
SPOUSE OR PARTNER ABUSE
Is the maltreatment or misuse of one person by another in the context of an intimate relationship;
90 95% of domestic violence victims are WOMEN;
Pregnancy increases violence in a relationship;
This can be:
1. Psychological or emotional abuse
Name-calling
Belittling
Shouting
Destroying properties
Threats
Refusing to speak to the victim
2. Physical Abuse
Shoving
Pushing
Battering
Choking
Fractures
Homicide
3. Sexual Abuse
During sex;
Biting nipples
Pulling hair
Slapping
Hitting
Rape
Char of an Abuser:
1. inAdequacy
2. Isip Bata (immature)
3. pUr problem-solving skills
4. low Self-esteem
5. jEalous and possessive
6. act is Rewarding
Why women stay with their abusive husbands?
1. DEPENDENCY - is the most common reason.
2. Cycle of Violence
CYCLE OF VIOLENCE
Violent behavior
1. Violent Behavior
Explodes in violent / abusive attack;
2. Period of Remorse
Or Honeymoon Period
Regret and apology
Im sorry. It will never happen again. Promise
Buys gifts, flowers, jewelries, etc.
Wife believes her husband.
May start from weeks to months. Then becomes frequent.
3. Tension Building Stage
Arguments again ensue;
Silence
No complaints
Assess for signs of abuse
CHILD ABUSE
or child maltreatment;
Intentional injury to a child;
May include:
Physical abuse and injuries
Neglect or failure to prevent harm
Failure to provide care
Abandonment
Sexual assault
Torture
Types of Child Abuse:
Physical
Emotional
Neglect
Sexual
Physical Abuse
Usually due to corporal punishment;
Hitting and Burning
Biting and Cutting
Poking
Twisting limbs
Scalding with hot water
Evidence of old injuries (healed fx) and multiple bruises of various stages.
Stop crying
Diumebskananaman...
Emotional Abuse
Verbal assaults
Constant family violence
Withholding affection and love
Neglect
Is the most common type of maltreatment;
Refused or delay to seek medical help.
Abandonment
Inadequate supervision
Disregard for safety
Spousal abuse in childs presence
Failure to enroll to school
Sexual Abuse
75% of cases involve father-daughter incest;
Rape
Sodomy
Molestation
Exploitation of minors
Char of Parents (in Child Abuse)
Lack of parenting skills
Lack of understanding in childrens needs
Lack of money
Lack of education
With history of child abuse
Warning Signs of Abused Children:
A Absence of trauma but with serious injuries (fracture, burns, lacerations)
B Bruised, red, swollen, teared genitalia (vagina and anal)
U Unusual injuries for age and development (Femoral fx in a 2 month old)
S Switching and inconsistencies in childs history.
E Evidence of old injuries.***
D Delay in seeking treatment for severe injury.
Nursing Interventions:
Ensure the childs safety and well-being.
Thorough psychiatric evaluation.
Establish trust to help child deal with trauma of abuse.
Use play therapy to express his feelings.
Refer to social works.