PSYCHIATRIC NURSING
Course Outline:
I.
II.
III.
IV.
V.
Psychiatric Medications
I.
STAGE
0 -18 mos
INFANT
18 mos -3 yrs
Developmental Tasks
TODDLER
3-5 years
PRE-SCHOOL/
EARLY
CHILDHOOD
6-12 years
SHOOL AGE
Industry vs Inferiority
Involvement in competitive
activities like academic/ school
competencies and games
13-18 years
ADOLESCENCE
Identity vs Confusion
Establishment of friends,
Belongingness to peers
19-25 years
YOUNG
ADULTHOOD
26-45 years
MIDDLE
ADULTHOOD
Generativity vs.
Stagnation
LATE
ADULTHOOD
Id
Needs
Implication
46- death
Sexual development
200
ANAL 18 months to 3
years
Toilet training
sense of control (autonomy)
PHALLIC 3 to 6 years
old
LATENT 6 to 12 years
old
GENITAL 12 years to
18 years old
Physiologic Needs needs such as air, food, water, shelter, rest, sleep, sex,
activity and temperature maintenance are crucial for survival
II. Safety and Security Needs the need for safety has both physical and physiologic
aspects
III. Love and Belonging Needs the third level of needs includes giving and receiving
affection, attaining a place in a group and maintaining the
feeling of belonging
IV. Self-Esteem Needs the individual needs both self-esteem and esteem from
others
V. Self-Actualization when the need for self-esteem is satisfied, the individual strives for selfactualization, the innate need to develop ones maximum potential and
realize ones abilities and qualities
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Conversion
Denial
Displacement
Dissociation
Fixation
Identification
Introjection
Projection
Rationalization
Reaction formation
Regression
Repression
Sublimation
Substitution
Suppression
Undoing
202
Therapeutic communication
Family Therapy
Behavior Modification
Crisis Intervention
Milieu Therapy
Expressive Therapy
Group Therapy
Self-Help Groups
1. Therapeutic Communication
THERAPEUTIC
NON-THERAPEUTIC
3. Silence
Reconditioning
maladaptive behavior
Desensitization
-frequent exposure to undesirable stimulus to make
individual get used
to it and decrease anxiety despite of exposure. Ex. treatment to phobias
Punishment
Reinforcement
3. Milieu Therapy
An environment that is organized to assist patients to control behavior and give opportunity to
utilize psychosocial skills in coping with self, others and environment.
4. Group Therapy
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Accdg. to Nudelman: Group therapy is an identifiable group of at least three people who share
common goal.
5. Family Therapy
- Treating family members in a modified group therapy.
- Establishes open communication an healthy interactions within the family.
6. Crisis Intervention
- An attempt to resolve an immediate crisis when a persons life goals are obstructed and
usual problem-solving methods fails.
Four Methods:
a. Assessment
b. Planning therapeutic interventions
c. Implementing Techniques of intervention and Resolution of the Crisis
d. Anticipatory Planning
7. Expressive Therapy
- Additional therapeutic modalities used to aid in assessment where expression of feelings can be
relayed through dancing, singing, drawing, etc.
IV.
MALADAPTIVE PATTERNS OF
BEHAVIOR
ANXIETY
A Feeling of uncertainty, uneasiness, apprehension or tension that a person experiences in
response to an unknowm object or situation.
Levels of
Anxiety
Description
Nursing Interventions
MILD
Listen to patient
Remain calm
Moderate
Listen to patient
Remain calm
Reassurance and support
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.
Generalized anxiety disorder
-A condition of recurrent and persistent urge to repeat an act purposefully to prevent some future event or
situation.
Examples: Rituals, Frequent rearranging, washing of hands, opening / closing, rigidity
Defense Mechanisms present: Displacement, undoing, reaction formation
Nursing Interventions:
a.
b.
c.
d.
PHOBIA
-
Types of Phobia:
1.
or situation
2.
exposure
3.
fear of being alone in the crowd where there is no escape
Examples of phobias:
Acrophobia- fear of heights
Androphobia fear of men
Astraphobia fear of storms, thunder, lightning
Ceraunophobia fear of thunder
Claustrophobia- fear of enclosed places
Hematophobia- fear of blood
Nursing Intervention:
a.
b.
c.
Behavior modifications
Relaxation
Desensitization
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d.
e.
Expression of feelings
Anti-depressant
DEPRESSION
Denial getting away from reality, This cant be happening, this cant be real
Anger blaming. Why me?
Bargaining closing a deal to the cheapest possible price, If only I will
Depression silence
Acceptance client acts according to situation. Patient prepares living will.
Suicide cues:
I wont be a problem any longer
Remember me when Im gone
This is my last day
This is my wedding ring give it to my son
there is a sudden change in mood
Intervention:
direct question Are you going to commit suicide?
irregular interval of visit to patients room
early in the morning and during endorsement period time the patient commits suicide
give simple task, do not give complex ones
Risk factors:
sex male (more successful) female (hesitant)
age 15 to 25 years old or above 45
depression
patient with previous attempts will try again
alcoholics
irrational
lacks social support
organized plan greater risk
no family
with terminal sickness
SCHIZOPRENIA
- A serious psychiatric disorder characterized by impaired communication with loss of contact to reality
4 As of Schizoprenia (Bleuler)
1. Autism - retreat from reality
2. Affect
- inappropriate, flat or blunt ed emotional response
3. Ambivalence contradictory or opposing emotions, attitudes, ideas or desires
4. Associative Disturbance unable to think logically, shifts from one subject to another
Other manifestations besides 4 As
1.
2.
3.
4.
Delusions
Illusions
Hallucinations
Loss of ego
Types of Schizoprenia
206
1. Disorganized
Incoherent; thought
disturbance;
2. Catatonic
Psychomotor
symptoms
3. Paranoid
Suspiciousness
a.
Hallucinations persecutory or
grandeur
b.
Delusions
c.
Angry, Suspicious, mistrust of
others,
overly religious
4. Undifferentiated
Mixture of behaviors
5. Residual
State of partial
remission
207
AUTISM
- echolalias, poor eye contact, cant express verbally
Manifestations:
appearance neat, obsessive compulsive, wants constancy
behavior ritualistic behavior, flat affect, repetitive
communication difficulty communicating
Nursing Intervention:
constancy
promote safety
expressive therapy uses art, poetry, decreasing risk for injury, improve social interaction, be
able to express feelings.
ATTENTION DEFICIT HYPERACTIVITY DISORDER
- can progress to conduct disorder to anti-social behavior
short attention span
impulsive ; shifts from one activity to the other
Destructive and hyperactive: unable to sit still, keeps on running and climbing
May occur at age 3 and lasts for at least 6 months but often diagnosed upon entrance to school
Id dominant: mother or the nurse will act as superego
Manifestations:
appearance dirty
behavior clumsy, impatient, easily distracted
talkative
Nursing Intervention:
safety
provide place to study, eat play, bath
schedule time for all activities
set limits
ANOREXIA NERVOSA
-
diet, underweight <85% of expected fat, 3 months amenorrhea, failure to recognize problem
Most common in women (90-95%), usually
teenagers
Starvation- an attention-getting device; a psychotic disorder, early manifestation of schizophrenia.
Contributing Factors:
1.
2.
3.
resulting to feeling
of dependency & helplessness
Disturbed self-image
Parent-child conflicts
Past and present experiences
Skeletal-like appearance
Presence of lanugo
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irregularity
Constipation
Hypothermia
obese
Distorted body image as
continues to
see self as fat
Loss of appetite
Total lack of concern about
symptoms
BULEMIA NERVOSA
-Binge eating and purging , normal weight, irregular menstruation, dental carries, diarrhea, knows the
problem but ashamed and embarrassed.
PICA eating non-nutritive foods like ice, starch
Priority:
fluid volume balance
weight gain monitor weight, eating pattern, stay 1 hour after eating, accompany in toilet
Complications:
1. Chronic inflammation of the lining of the esophagus
2. Rupture of the esophagus
3. Dilatation of the esophagus
4. Rupture of the stomach
5. Electrolyte imbalance or abnormalities, leading to arrhythmias of the heart and metabollic
alkalosis
6. Heart problems, irreversible Cong. Heart failure
7. Chronic enlargement of the parotid gland
8. Dehydration
9. Irritable bowel syndrome or abnormal dilatation of the colon
10. Rectal prolapse or abcess
11. Rupture of the diaphragm
12. Dental erosion
13. Chronic edema
14. Fungal infections of the vagina or rectum
Nursing intervention for ANOREXIA NERVOSA AND BULEMIA
1. Establish nutrition pattern
2. Setting limits
3. State that three meals a day is necessary to maintain a healthy body
4. Allow some control in decision making
5. Teach stress management, journal keeping
6. Monitor eating pattern and weight
7. Anti-depressant
BIPOLAR DISORDER
- Depression and Mania
- 2 poles, happy (more dominant) and sad, affects more female than male >20 years of age,
stress and obese
Depression a mood state characterized by a feeling of sadness, dejection, despair,
discouragement or hopelessness
Mania
6.
Flight of ideas
7.
Manipulative or
demanding behavior
8.
Destructive / Combative
9.
Delusions of grandeur
10. Impaired judgment
209
Schizoid doesnt care about people, believes that he can stand on his own, never had a
best friend, avoid groups and activities no enjoyment
2.
Avoidant avoid group fear criticism, have talent but with no confidence
3.
Anti-social law breaker, do not follow rules from childhood until adulthood
4.
5.
6.
7.
8.
9.
ALCOHOL ABUSE
- socializing, escape from problem, peer pressure
Manifestations of Individual under Abuse of alcohol:
1. Chronic absenteeism from work
2. Repeated job-related accidents
3. Overuse of rationalization, or excuses for drinking
4. Disruption of home, marital and family relationships
5. Frequent job changes
6. Poor job performance
7. Deterioration of health
Intervention:
1. Gradually avoid alcohol
2. Aversion therapy
3. Anti-abuse (DISULFIRAM)
4. May refer to group therapy
Complications:
1. Wernickes motor side effects
210
2.
3.
SUBSTANCE ABUSE
check effect
signs of widrawal
2.
If patients take a downer, all vital signs are down. If he stops taking it (during
withdrawal), patient will experience the opposite effect of a downer. All of the
patients vital signs will shoot up just the same with uppers (e.g., patient had
cocaine intoxication, patient will manifest hyperactivity, tachypnea, seizure.
During withdrawal, patient will manifest bradypnea or coma).
CHILD ABUSE
211
Denial of pregnancy
Depression during pregnancy
Unwanted child
Fear of delivery
Lack of support form husband or family
Undue concern about the unborn childs sex and how
Fear that the child will be one of too many children
Resentment towards the child
Inability to tolerate the childs crying, viewing child as being too demanding
Physical
Multiple injuries in various stages
of healing
Unexplained bruises, fractures,
lacerations
Behavioral
Fear of strangers
Labile behavior
Rigid, distant
Fatigue
Withdrawal
Engaged in substance abuse
Emotional Maltreatment
Decreased self-esteem,
hypochondriasis
Developmental lag
Sleep disorders, behavioral
problems
Sexual Abuse
Venereal disease
Pregnancy
1.
2.
3.
4.
5.
6.
7.
Anti-cholinergic/Anti-parasympathetic
mono amine oxidase inhibitors
marplan
nardil
parnate
Anti-parkinson drugs
cogentin
artane
parlodel
akineton
benadryl
larodopa
eldepryl
symmetrel
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Alcoholics
disulfiram
anti depressants
Electro-convulsive therapy (ECT)
-if the medication the patient was taking did not take effect ECT is administered.
Pre-ECT:
sign informed consent
NPO 6 hours
give atropine sulfate
give barbiturate
succinylcholine chloride to relax muscles
Post-ECT
side lying lateral
side effects: headache, dizziness, temporary, memory loss (distinct symptoms)
PSYCHIATRIC MEDICATIONS
Anti-mania
Anti-depressant
MAO Inhibitors Isocarboxacid, Phenelzine
Drug:
LITHIUM
Tricyclic Anti-depressant Imipramine,
Amitryptilne
Tetracyclic Anti-depressant
- Maprotiline
Drug Interaction
Side Effects
Initial Dosage:
Fine tremor, nausea, drowsiness,
lethargy, polyuria, thirst, fatigue,
weight gain
Toxic Level:
Vomiting, diarrhea, lethargy,
muscle twitching, ataxia, slurred
speech, coma, seizure
Nursing Intervention
213
Mind-Setting
214