A - cceptance
B ehavior that is inappropriate
C - ognizence
D efence mechanism
E - xpre ssion of feelings
Therapeutic NPR
4 phases:
1. Pre Interaction
2. Orientation
3. working
4. Termination
Pre Interaction Phase
Self awareness
JOHARIS WINDOW
1. Public 2. Blind
3. Hidden 4. Closed
1 2
1 2
3 4
NURSES TASK
1. Explore own: F - _____________
F - _____________
F - _____________
Goals
6. Define goals with the pt
Working Phase
Assess Continuously
Evaluate further & explore relevant stressor
Independence
Insight developed
Overcome resistance behavior
Termination Phase
1. Establish reality of separation
2. Evaluate accomplished goals
3. Mutually explore feelings of rejection, loss, sadness & anger & other
related behaviors
4. evaluate general progress of thrx
5. maintain initially defined boundaries
6. Anticipate problems of this phase:
a.
b.
c.
Criteria for Determining Pts Readiness for
Termination
20% Experience relief from presenting problem
Therapeutic value:
Examples:
2. Broad Opening encouraging the pt to select topics for
discussion
Therapeutic value:
Examples:
3. Restating repeating the main thought the pt expressed
Therapeutic value:
Therapeutic value:
Examples:
4. Reflection directing back the pt ideas, feelings,
questions, and content
Therapeutic value:
Examples:
6. Focusing questions or statements that help the pt
expand on a topic of importance/ superficial talk
Therapeutic value:
Examples:
7. Theme identification underlying issues or problems
experienced by the pt that emerge repeatedly during the
course or NPR
Therapeutic value:
Therapeutic value:
Examples:
9. Giving Recognition greeting the pt and
acknowledgement of the effort made
Therapeutic value:
Examples:
10. Offering Self unconditional willingness to be available
Therapeutic value:
Therapeutic value:
Therapeutic value:
Therapeutic value:
Examples:
15. Voicing Doubts lets individual know that others do
not perceive in the same way.
Therapeutic value:
Examples:
DEFENSE MECHANISM
Compensation
Conversion
Denial
Displacement
Intellectualization
Projection
Rationalization
Reaction Formation
Regression
Sublimation
Suppression
Undoing
Repression
Identification
Substitution
Symbolization
Introjection
Fantasy
Isolation
Dissociation
Is a stimulus that
produces distress and
creates physical and
psychological demands on a
person, requiring coping
and adapting
Is characterized by
feelings of apprehension,
uneasiness, uncertainty, or
dread, resulting from real
or perceived threat;
is a subjective
response to stress
Communication
1. Use short, simple, clear statements
2. Avoid choices
Benzodiazepines
Non - Benzodiazepines
hlordiazepoxide(Librium)
uspirone (Buspar)
razepam (Centrax)
lonazepam (Klonopin)
xazepam (Serax)
orazepam (Ativan)
iazepam (Valium)
lonopin
prazolam (Xanax)
riazolam (Holcion)
side Effects
Fatigue rowsiness
Ataxia
taxia
Drowsiness
Depression ethargy
Mental impairment
bnormal eye movement
Slowing of reflexes
I problem
headache
Constipation
Hypotension
Incontinence
drymouth
Nursing Management
rinse mouth with water often and eat sugarless gum
Assist in ambulation
Caution against driving
Not used with minor stress
Caution in t use with glaucoma
No alcohol & other CNS depressants
A group of psyche conditions
characterized by the emotion
of intense terror
DISORDER
PANIC DISORDER
Characterized by panic attacks that occur at
unpredictable times, with intense
apprehension fear, and terror
Disrupted ADL
Assessment Nursing Action
physiologic symptoms 1. if the patient is on panic level of anxiety
of FIGHT OR FLIGHT the nurse should always:
RESPONSE
choking
remain with the client
Labored breathing Ensure privacy
Pounding Heart 2. Attend to physical symptoms
Chest Pain 3. Assist to identify precipitating factors
Nausea
Numbness Administer meds and other health
Fear of dying therapeutics
1. Teach client relaxation techniques
*deep breathing
COMMUNICATION
1. simple, calm, and reassuring voice.
2. The nurse can walk with the client who feels unable to sit and talk
3. avoid use of ______
4. use an ____________ questions/ communication technique once
anxiety diminishes
Nursing Action
1. Stay with the client when the anxiety is high
2. D o not force the client to have ________________________
3. provide (+) reinforcement for adoptive behavior/desired behavior/
coping/ appropriate
Communication
Allow the client to verbalize feelings about feared object or situation
OBSESSIVE COMPULSIVE DISORDER
Obsession recurrent & intrusive thought,
feeling, idea or sensation
Compulsion conscius standardized, recurrent
thought or behavior such as counting, checking
or avoiding
Nursing Action
Assessment Data Ensure basic needs
tensed Allow the client to _______________
May be immobilized Implement schedule that will distract the
Dificulty concentrating client from inappropriate behavior
Aware that the behavior is
inappropriate BUT
CANNOT CONTROL
Other Health Therapeutics
exposure and response prevention
sleeping problem
Anxiolytic meds
poor hygiene
teach relaxation technique
Communication
Encourage the client to talk about feelings
Recognza and reinforce (+) non ritualistic
behavior.
Causes:
1. Combat experience
Experienced an emotional stress that 2. Natural
was f a traumatic magnitude for almost catastrophies
anyone 3. Assault
4. Rape
5. Serious accident
Characteristic of PTSD
can be acute of delayed response; can also become chronic
Symptoms include an exaggerated startle response sleep d/s,
guilt (survivors guilt) nightmares and flashbacks, anger with
numbing of other emotions
Affected indiv often use dugs, alcohol, or both to self
medicate for distressful symptoms
Nursing Action Administer meds & other
1. be non judgmental and
therapeutics
supportive 1. Anxiolytics
2. Antidepressants
2. Assure client that his/her
feelings and behavior are 3. Relaxation Techniques
normal rxns 4. Inform clt that HYPNOTHRX or
SYSTEMATIC DESENSITIZATION may
3. Facilitate a progressive review be used as a form of treatment
of the trauma experience
4. Make the pt feel that he/she is Communication
a survivor rather than a victim 1. Encourage the clt to express his/her
feelings
2. Systematic desensitization with
flooding
3. Imagery
GAD
SOMATIZATION D/O
Diagnostic Criteria:
_____ Pseudoneurological Symptoms
_____ GIT Symptoms
_____ Pain Symptoms
_____ Sexual Sypmtoms
Characterized by the presence
of ONE OR MORE
NEUROLOGICAL SYMPTOMS
that cant be explained by any
neurological or medical
disorder
Diagnostic Criteria:
Motor Symptom or Deficit
Sensory Symptom or Deficit
Convulsion or Seizure
Mixed Presentation
Normal body
sensations are
thought to be
symptoms of a
serious illness
Diagnostic Criteria
Preoccupation with a Serious Illness
Not helpful by Reassurance
Poor Insight
6 mos
Body Dysmorphic Disorder
dysmorphophobia
Char by preoccupation with
an imagined defect in
appearance that causes
clinically significant distress
or impairment in important
areas of functioning
Pain Disorder
Primary symptom of
pain
Unrelieved by
analgesics
Chronic pain in one
or anatomical sites
Management
The mainstay of tx is a long term relationship with a specific
health care provider to prevent the client from seeking multiple
providers with multiple recommendations for testing, dx and
medications.
avoid meds that are characterized by tolerance and
depandence
ENCOURAGE PYSCHOTHRX
FAMILY EDUCATION
ENCOURAGE THE CLIENT TO PARTICIPATE IN COMMUNITY
BASED SELF HELP GROUPS
Nursing Action
1. Provide health teaching on:
as established health routine that includes improved health behaviors
Adequate nutritional intake and balance between rest and activity
NUTRITION
Client: I just cant eat anything. I have no appetite.
Nurse: I know you dont feel well, but it is important to begin
eating
Client: I promise Ill eat just as soon as Im hungry
Nurse: actually if you begin to eat a few bites, youll begin to
feel better, and your appetite may improve.
The nursing assistant tells the nurse that the
client is not in the dining room for lunch. The
nurse should direct the nursing assistant to do
which of the following?
a. Take the client a lunch tray and let him eat in his room
b. Tell the client hell need to wait until supper
c. Invite the client to lunch and accompany him to the dining
area
d. Inform the client that he has 10 ins to get to the dining area
Teach coping Mechanisms
a. Relaxation techniques
b. Deep breathing
c. Guided imagery
Factitious
Disorder
Munchausens by Proxy
A person inflicts illness or injury
on someone else to gain the
attention of emergency
medical personnel or to be a
hero for saving the victim
Malingering
The intentional production of
false or grossly exaggerated
physical or physical symptoms
Dissociative
Disorders
Dissociative Amnesia
Is sudden inability to recall
important personal info
because of physical or
psychological trauma
Predisposing factors include an
intolerable life situation,
unacceptability of certain
impulses or acts and a threat
of physical injury or death
Types:
1. Circumscribed or localized
2. Selective
3. Generalized
4. Continuous
Dissociative Fugue
Is a sudden, unexpected
flight from home with
inability to recall events
from ones past.
It is rare occurrence that
may be seen during times
of extreme stress such as
war, severe conflict and
natural disasters, and may
last days or months.
Depersonalization Disorder
Is the feeling detached
from, and as if one is an
outside observer of, ones
thoughts or body
Includes being in a
dreamlike state out of the
body, mechanical or
bizarre in appearance
Dissociative Identity Disorder
Presence of two or
more distinct
personalities within a
single person
Management
Dissociative d/o tend to be difficult to
diagnose
An individual with this d/o often has had
multipe pyschiatric dx; tx is often lengthly
Nursing Action
Discuss self harm thoughts
Help client develop plan for going to a safe place when having
destructive thoughts or impulses.
Help client view him/herself as a survivor rather than as a
victim
Encourage clients to write a journal to get in touch with their
feelings
Encourage the ct to disclose and discuss her feelings in
relation to painful memories becoming conscious
Accurately record information on various personalities as a art
of an interdisciplinary team approach
Administer Medications and other health
therapeutics
Treated symptomatically with:
i. Anti anxiety Agents
ii. Antidepressants
iii. Deep breathing Exercise
iv. Relaxation Techniques
v. Distraction Techniques
COMMUNICATION
1. Validating and Presenting Reality
i. I know this is frightening, but you are safe now.
ii. what are you feeling?
iii. Are you hearing something?
iv. Can you see and the room were in?
v. Do you feel your feet on the floor?
vi. Do you feel your arm on the chair?
vii. Do you feel the watch on your wrist?
2. Grounding Technique
2 TYPES
1. Restricting type
2. Binge eating / purging type
Late onset: 18 19yo
Repeated episodes of binged
eating
Teds to be OCD
Ego dystonic (feards of inability
to stop eating voluntarily)
Experinces depression
Normal to neart normal body
weight
Bulimia Nervosa
2 types:
1.Purging type
2. Nonpurging Tupe
Etiology:
5HT, altered neurotransmitter
( - ) perception of self
Separation individual conflicts
Fx who values perfection and the child cant attain standard
Overinvlved families
Form of rebelion
Influenced by peer group
Avoids food to gain attention
Insecurities of physical appearance
Starvation is used as self punishment
Females who fears adult feminity when growing up
Fears of becoming like her mother
To suppress feelings of emotional emptiness
Wants to be unique
Common in females
Have genetic tendencies
Mortality rate is 10 14%
Risk for suicide is increased
DIFFERENTIATION OF BULIMIA AND ANOREXIA
ANOREXIA BULIMIA
ONSET: 14 18YO 18 19 YO
Personality
Disorders
Characteristics:
1. Still in touch with reality
2. Stress exacerbates PD
3. Recognizable by adolescence or earlier &
continue throughout adult life
4. Have troubles with working & loving
Cluster A
Known as odd / Eccentric weird PD
- Trust issues
Schizoid Personality
Paranoid Personality
Schizotypal Personality
They demonstrate
lack in personal and
social relationship
detached fro others
and withdraws from
interactions.
Schizoid
Characteristics:
1. Detachment from social relationships and a restricted range
of expressions of emotion in interpersonal settings
2. Introverted since childhood
3. Avoids close relationship with fx and others hermit
4. Choose solitary act; has little interest in sexual experiences
5. Does not take pleasure in activities
6. Flat affect
7. May function well in vocations in w/c one generally works
alone
May have behavior similar
to schizophrenia, however,
psychotic episodes are
infrequent; may be
acutely uncomfortable in
relationship
Schizotypal
Characteristics
1. Ideas of references
2. Odd beliefs or magical thinking
3. Unusual perceptual experiences
4. Odd thinking and speech
5. Suspiciousness or paranoid ideation
6. Inappropriate or constricted affect
7. Appears strange or odd
8. Lack o close friends or confidants
9. Excessive social anxiety
They demonstrate a
pattern of distrust and
suspiciousness; the
individual interprets other
peoples motives as
threatening
Paranoid
Characteristics
1. Suspects attempts to harm or trick him
2. Questions loyalty of others
3. Display pathologic jealousy
4. Observe environment for sign of threat, display
secretiveness
5. Becomes hypersensitive or display excessive feelings of self
importance
6. May appear to be unemotional, lack of sense of humour and
ability to relax
7. Interpersonal relationships are poor especially when relating
to authority figures
Nursing Actions
Adopt, objective, matter of fact manner when interacting with
clt, and maintain clear, consistent verbal and non verbal
communication
Provide daily structure of ADL
Maintain focus on reality and reality based topics
Help clt identify feelings that are impaired
Assist with problem solving for life issues identified as source
of stress.
Gradually involve clt in group situations, providing support
when necessary, and provide positive feedback for socially
appropriate behavior.
Impaired social interaction rel/t: extreme fear
of abandonment
1. Develop consistent relationship
2. Encourage patient to examine behavior and
discuss feelings and experience about self
related to others
3. Give positive reinforcement for successful
interaction with oters
4. Rotate staff who work with the patient
Cluster B
Aka dramatic, emotional, erratic PD
Has self esteem difficulty
Has self esteem due to originally self esteem
orderline
ntisocial
arcisistic
istrionic
Characterized by
impulsive, unpredictable
and unstable moods;
disturbed relationships
with others; intolerance to
being alone
A chronic sense of
boredom
Borderline
Characteristics
1. Frantic efforts to avoid real or imagined abandonment
2. Unstable yet intense relationship
3. Identity disturbance
4. Impulsivity of at east two ( spending, sex, substance, abuse,
reckless, driving, binge eating)
5. Tends to have self detrimental behavior
6. Affective instability
7. Chronic feelings of emptiness
8. Difficulty controlling anger
9. Transient paranoid ideation
Have a pattern of
disregard for and
violation of the rights of
others
Has good verbal skills,
ozzy charisma
Antisocial
Characteristics
1. Common in men aging 18 40yo
2. Exhibits behaviour that is hostile to the well being of society,
and therefore found in the prison system
3. Unable to follow rules, is grossly selfish and irresponsible;
generally manipulated in relationship with others to fulfil
needs.
4. Uses rationalization to justify actions
5. Lack of remorse or indifference to persons
6. Expectation of immediate gratification
7. Repeated lying
8. Reckless behavior that disregards the safety of others.
9. Cessation of criminal activities tend to occur around age 40
Me, myself and I
Characterized by excessive
emotionality and
attention seeking
behaviors that are
dramatic and ego syntric
Social climer
Narcissistic
Characteristics
1. Has grandiose sense of importance
2. Is preoccupied with fantasies of unlimited success, power,
brilliance beauty or ideal love
3. Believes that he or she is special
4. Requires excessive admiration has a sense of entitlement
5. Is interpersonally exploitative
6. Lacks empathy
7. Is often envious of others or believes that the others are
envious of him or her.
8. shows arrogant, haughty behavior or attitude
Cock teaser/brick teaser
Char by excessive
emotionality and
attention seeking
behavior that are
dramatic and egocentric
Histrionic
Characteristics
1. Is uncomfortable in situations in which he or she is not the
COA
2. Inappropriate sexually seductive or provocative behavior
3. Rapid shifting of emotion\uses physical appearance to draw
attention to self
4. Speech is excessively impressionistic and lacking in detain
5. Shows self dramatization
6. Suggestible
7. May seem warm or genuine
8. May be creative and imaginative
9. Labile emotions
10. Feelings of dependence and helplessness exist
Nursing Actions
Prevent self harm by observing the clt frequently and
developing a no harm contract
Give immediate feedback, when confronting inappropriate or
manipulative behavior.
Act as a role model for inappropriate expression of feelings
and negative emotions
Work with the tx team in maintaining consistent feedback for
ctl, reinforcing specific tx objectives and avoiding
manipulation of staff by client
Avoid rejecting the client
Set limits: reinforce of manipulative behavior or disregard for
rights of others
Give positive feedback for goal achievement and independent
behavior
Self- esteem disturbance r/t: lack of possitive feedback.
Absent, erratic, inconsistent
parental discipline
bsessive - Compulsive
assive - Aggressive
voidant
Characterized by
submissive and clinging
behavior associated
with excessive need to
be cared for by others
The most frequently
seen personality d/o in
mental health units
Dependent
Characteristics
1. has low self esteem
2. Has difficulty making everyday decision
3. Needs other to assume responsibility for the most areas in
life
4. Difficulty expressing disagreement
5. Has difficulty initiating projects
6. Feels uncomfortable or helpless when alone
7. Urgently seeks another relationship when a close
relationship ends
8. Unrealistic preoccupied with fears of being left to take care
of self
Characterized by
preoccupation with
orderliness,
perfectionism and the
need to be in control of
situations, objects and
people.
Obsessive
Compulsive
Characteristics
1. men are frequently affected than women
2. Is excessively devoted to work & productivity
3. Inflexible
4. Is unable to discard worn out or worthless objects even
when they have no sentimental value
5. Preoccupied with details
6. Leisure activities and friendships are excluded because of the
clts excessive devotion to work and productivity
7. Shows rigidity & stubborness
characterized by being
helpless and indecisive
Resist demands for
adequate performance
in job and relationship
Passive
Aggressive
Characteristics
1. expresses anger in passive, convert behavior
2. Anger can be seen through:
a. Resistances
b. Procrastination
c. Dawdling
d. forgetfulness
e. Inefficiency
Nursing Actions
Establish a caring, consistent therapeutic relationship and
clear expectations for responsible behavior
Expect the client to make decisions, and teach the client how
to be assertive
Encourage the client to identify positive self attributes
Provide positive feedbacks when the client interacts in social
situations in appropriate manner.
Teach client to use stress management and relaxation
techniques to cope with anxiety.
Self esteem disturbance r/t lack of positive
feedback
1. Ensure that goals are realistic.
2. Provide positive feedback for indepandent interaction
3. Assist patient identify positive aspects of self
4. Offer recognition and praise for accomplishment
5. Encourage expressions of feelings of anger and inadequacy
6. Role model positive aspect of life.
Are characterize by
disturbances in feelings,
thinking and behavior;
may occur form severe
depression to severe
mania (hyperactivity).
Concepts of Mood and Affect
Mood refers to persons pervasive and
enduring emotional state
Affect outward expression of mood
Blunted affect
Broad affect
Flat affect
Inappropriate affect
Restricted affect
Labile
Anergia
Euthymic mood
Depression
Mania
Hypomania
Unipolar depression
Bipolar
Types of Mood Disorders
Major Depressive disorder
Dysthymia
Bipolar d/0
Bipolar I
Bipolar II
Cyclothymia
Causes:
Neurochemical theory or Biogenic amines
theory 5HT and NE is
- NE in mania
Genetics 2 -10x chances of having depression
Psycholoanalytical theory those with
unsatisfactory early mother infant relationship
Cognitive theory being depressed is only on the mind
Self perception of inadequacy
Learning Theory numerous failure in life
Bipolar I d/o
Symptoms of Manic Episodes:
1. Inflated self esteem or grandiosity
2. need for sleep
3. or pressured speech
4. FOI
5. Distractibility
6. involvement in goal directed activities
7. Excessive involvement in pleasurable activities that has high
potential for painful consequences)
Characterized by 1 or more
depressive episodes
accompanied by at least 1
hypomanic episode
Bipolar II d/o
Characterized by at least 2 years
of several period of hypomanic
symptoms
Dysthymia + hypomania
Cyclothymia
Safe and Quality Nursing Care
Assessment Data:
1. Affect
2. Thoughts
3. Physical Activities
4. Verbalization
5. Socialization
Suicidal Behavior
A direct purposeful attempt to end ones own life
At risk indiv:
A plan
Hx of attempt
Medical Illness
Depressed indiv is about to commit suicide
when:
giving away personal possessions of
extraordinary importance.
Ties up loose ends
Shows dramatic or drastic behavioral changes
Manifest verbal / written cues
Meds: Antidepressants
moods elevators
Pyschic energizers
TCAs Side Effects:
Orthostatic hypotn
Anticholinergic effects
dry mouth
1st choice Constipation
Tachycardia
Neurologic effect
Doxepine (SINEQUAN) sedation
Ataxia
Imipramine (TOFRANIL) Tremors
Psychomotor slowing
Elvil (AMITRYPTYLINE)
fatigue
V Libido & sexual
Performance
MAOIs
Side Effects:
Orthostatic hypotn
Anticholinergic effects
dry mouth
Constipation
Tachycardia
Neurologic effect
Parnate (tranylcipromine) sedation
Ataxia
Prozac (fluoxetine)
E.C.T
Aka electroshock therapy
FOR HIGH RISK SUICIDAL &
ANTIDEPRESSANTS ARE NOT
AVAILABLE OR HAS NO EFFECT YET
IMMEDIATELY AFTER ECT
Secure consent
Take vs
70 150 volts
For 0.5 to 2 sec E equipment at bedside
6-12 tx 02 tank
Electrodes placed on temporal Suction machine
area Cardiac monitor
At least 48hrs interval each tx Rescitating machine
Done 2-3x/wk E cart
Induces tonic clonic sz
Prepare like clt will have major Pre ECT meds
surgery Atropine SO4
Succinylcholine
Shortacting barbiturates
Nursing Action
High Risk for Self Directed Violence r/t
suicide
my name is Joshua. Im your nurse today. Im going to sit wit you for
a few minutes. If you need anything, or if you would like to talk,
please tell me.
after time has elapsed, the nurse would say the following:
Types:
1. Mild elation
2. Acute Manic Episode
Aka hypomania
Characterized by:
Feeling of happiness
Rapid assoc of ideas
motor activity
sexual drives
Mild Elation Superficial relationship
Requires institutionalization
Characterized by:
Mood disturbance
Motor restlessness
Indulgence in sexual &
recreational activities
Poor money mngt
Poor sleep
Acute Manic Tendency to argue
Episode Flight of ideas
Delusion of granduer
Bizarre habits of grooming
Poor hygiene
Nursing Action
1. Potential for injury r/t: EXTREME
HYPERACTIVITY
Reduce environmental stimuli
Assign to quiet unit
Limit group activities
Remove hazardous objects & substances
from pts environment
Provide physical activities as a substitute for
purposeless hyperactivity
The client with mania is skipping up and down the
hallway practically running into other clients. Which of
the following activities should the nurse expect to
include in the clients plan of care?
a. Leading a group activity
b. Watching television
c. Reading the newspaper
d. Cleaning the dayroom tables
2. Potential for violence Self Directed or directed at
others related to:
* erratic excitement
* rage rxn
3.Therapeutic level:
Adult: 0.6 1.4/1.5 mEq/L
Elderly: 0.6 0.8 mEq/L
1. Fever
1. Anorexia
2. UO
2. N/V
3. BP
3. Diarrhea
4. Irregular pulse
4. Coarse hand tremor
5. ECG change
5. Lethargy
6. Impaired consciousness
6. Tinnitus
7. SZ
7. Vertigo
8. Coma
8. drowsiness
9. death
3. Altered Nutrition: body requirements r/t:
inability to sit long enough to eat meals, lack of
appetite
1. Provide w/ high CHON, high calorie, nutritious
foods and drinks.