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I. Basic Concepts in Psychiatric Nursing
Mental Health
Mental Ill Health
Psychiatric Nursing
-Interpersonal process whereby the professional nurse practitioner through the therapeutic use of self, assist an individual family, group or community to promote mental health, to prevent mental illness and suffering, to participate in the treatment and rehabilitation of the mentally ill and if necessary to find meaning in these experiences.
Both a Science and Art
Core of Psychiatric Nursing:
-Interpersonal process
Clientele:
-Individual, family and the community
- Both mentally healthy and mentally ill
Main Tool of the Nurse
-Therapeutic use of Self
CONCEPTS
Use of Self
Therapeutic use of self - positive use of one’s self in the process of therapy
- it requires self-awareness
Basic Principles
Basis: Joharis Window
| | Known to self | Not Known to self |
| Known to others | Public Self I | Semi-public Self II |
| Not known to others | Private self III | Areas of the Unknown IV |
Goal: To increase quadrant I, decrease quadrant II and III
Methods Used to Increase Self- Awareness
- Introspection:
-Viewing one’s self as honestly as possible
- Discussion:
- Learning about oneself through association with others
- Enlarging One’s Experience:
- Engage in a particular activity and noting one’s reaction to it.
- Role playing:
- A situation in which participants enact a role
Core Concepts on the Care of the Psychotic Patient
On Admission of the Client
- Priority
- Determine the reason why the client sought help
- Client’s rights
- Initial assessment
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Common Behavioral Signs and Symptoms
- Disturbance in perception:
Illusion -misperception of an actual external stimuli
Hallucination -false sensory perception in the absence of external stimuli
Visual -seeing
Tactile -feeling that there are some insects crawling on the skin
- Disturbances in thinking
Neologism - pathologic coining of words
Circumstantiality - over inclusion of details
Word Salad - incoherent mixture of words and phrases
Verbigeration - incoherent mixture of word or phrases
Perseveration - persistence of a response to a previous question
Echolalia - pathological repetition of words
Flight of ideas - shifting from of one topic from one subject to another in a somewhat related way
Looseness of association - shifting of a topic from one subject to another in a completely unrelated way
Clang association - the sound of the word gives direction to the flow of thought
Delusion - false belief which is inconsistent with one’s knowledge and culture
- Disturbances of affect
Inappropriate affect - disharmony between the stimuli and the emotional reaction
Blunted effect - severe reduction in emotional reaction
Flat affect - absence or near absence of emotional reaction
Apathy - dulled emotional tone
Ambivalence - presence of two opposing feelings
Depersonalization - feeling of strangeness towards one’s self
Derealization - feeling of strangeness towards the environment
- Disturbances in Motor Activity
Echopraxia - the pathological imitation of posture/action of others
Waxy flexibility – maintaining the desired position for long periods of time without discomfort
- Disturbances in memory
Confabulation - filling in of memory gaps
Amnesia - inability to recall past events
Anterograde amnesia - loss of memory of the immediate past
Retrograde amnesia - loss of memory of the distant past
Déjà vu - feeling of having been to a place which one has not yet visited
Jamais vu - feeling of having been to a place which one has visited before
Use of Appropriate Communication Techniques
Communication:
Reciprocal exchange of ideas between or among persons.
Modes of communication:
1. Verbal - written/spoken
2. Non-verbal - posture, tone of voice, facial expression
3.
Elements of Communication
Sender - originator of information
Message - information being transmitted
Receiver - recipient of information
Channel - Mode of communication
Feedback - return response
Context - the setting of communication
Criteria of successful communication
Feedback
Appropriateness
Flexibility
Efficiency
Common Problems in Communication
- Dysfunctional communication
- Double bind communication
- Denotative vs. connotative meaning
- Incongruent communication
Techniques of Communication
If your goal is:
To initiate conversation:
Giving broad opening
Giving recognition
To establish rapport and build trust:
Giving information
Use of silence
To gather information:
Focusing
Validating
Reflecting
Interpreting
Restating
To close a conversation:
Summarizing
How to Choose a Therapeutic Response in The Board Exam
Establish Nurse Patient Relationship
Nurse-Patient Relationship
Series of interaction between the nurse and the patient in which the nurse assists the patient to attain positive behavioural change.
- Characteristics
NPR Social Relationship
- Phases
- Pre-Interaction Phase
- begins when the nurse IS assigned/chooses a patient
- phase of NPR in which patient is excluded as an active participant
- nurse feels certain degree of anxiety
- includes all of what the nurse thinks and does before interacting with the patient
Major task of the nurse:
to develop self-awareness
Other tasks:
data gathering, planning for first interaction
- Orientation Phase
- when the nurse-patient interacts for the first time
- parameters of the relationship are laid
- nurse begins to know about the patient
Major task:
to develop a mutually acceptable contract
Other tasks:
determine why the patient sought help
establish rapport, develop trust, assessment
- Working Phase
- it is highly individualized
- more structured than the orientation phase
- the longest and most productive phase of the nurse-patient relationship
- limit setting is employed
Major task:
identification and resolution of the patient’s problems
Other tasks:
Planning and implementation
- Termination Phase
- it is a gradual weaning process
- it is a mutual agreement
- it involves feeling of anxiety, fear and loss
- it should be recognized in the orientation phase
- it should be recognized in the orientation phase
Major task:
to assist the patient to review what he has learned and transfer his learning to his relationship with others.
Other task:
Evaluation
When to terminate?
How to terminate?
Common Problems Affecting NPR
1. Transference - the development of an emotional attitude of the patient either positive or negative towards the nurse.
2. Resistance - development of ambivalent feelings towards self-exploration.
3. Counter Transference - as experienced by the nurse
Initial Interventions
Principles of Care in Psychiatric Settings
1. The nurse views the patient as a Holistic human being with interdependent and interrelated needs.
2. The nurse accepts the patient as a unique being with inherent value and worth exactly as he is.
3. The nurse should focus on the patient’s strengths and assets and not on his weakness and liabilities.
4. The nurse views the patient’s behaviour non-judgmentally, while assisting the patient to learn more adaptive ways of coping.
5. The nurse should explore the patient’s behaviour for the need it is designed to meet and message it is communicating.
6. The nurse has the potential for establishing a nurse-patient relationship with most if not all patients.
7. The quality of the nurse-patient relationship determine the degree of positive change that can occur in the patient’s behaviour.
Level of Interventions in Psychiatric Nursing
Primary – Interventions aimed at the promotion of mental health and lowering the rate of cases by altering the stressors.
Secondary – interventions that limits the severity of a disorder.
2 Components
1. Case Finding
2. Prompt treatment
Tertiary – interventions aimed at reducing the disability after a disorder.
2 Components
1. Prevention of complication
2. Active program of rehabilitation
Characteristics of a Psychiatric Nurse
1. Empathy – the ability to see beyond outward behaviour and sense accurately another person’s inner experience.
2. Genuineness/Congruence – ability to use therapeutic tools appropriately.
3. Unconditional Positive Regard – respect
Roles of the Nurse in Psychiatric Settings
1. Ward Manager
Responsibility:
2. Socializing Agent
Responsibility:
3. Counselor
Responsibility:
4. Parent Surrogate
Responsibility:
5. Patient Advocate
Responsibility:
6. Teacher
Responsibility:
7. Technician
Responsibility:
8. Therapist
Responsibility:
9. Reality Base
Responsibility:
10. Healthy Role Model
Responsibility:
Types of Interventions
7.1 Biologic
7. 1. 1 Pharmacologic
II. Basic Concepts on Psychoparmacology
Neurons:
Neurotransmitters:
Classification of Psychopharmacologic Agents
A. Major Tranquilizers/Antipsychotics:
Indication:
MOA:
Examples:
Haloperidol (Haldol)
Fluphenazine ( Prolixin
Prochlorperazine (Compazine)
Chlorpromazine (Thorazine)
Side effects:
Blurred vision, dry mouth, tachycardia, palpitation, constipation, urinary retention
Skin: Photosensitivity
BP: Orthostatic hypotension
EPS: Extra Pyramidal Symptoms
- Pseudoparkinsonism
-pill-rolling tremor, mask-like face, cog-wheel rigidity, propulsive gait
- Akathisia
-restless leg syndrome
- Dystonia
- defect in muscle tone
Adverse effect:
1. Tardive dyskinesia-lip smacking
2. Agranulocytosis
3. Hepatoxicity
Principles of Nursing Care
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B. Anti-Parkinsonian Agents:
Indication:
2 Types:
1. Dopaminergic Drugs
MOA:
Examples: Amantadine (Symmetrel)
2. Anticholinergic Drugs
MOA:
Trihexyphenidyl (Artane)
Biperiden Hydrochloride (Akineton)
Benztropine Mesylate (Cogentin)
Diphenhydramine Hydrochloride (Benadryl)
Side effects:
Anticholinergic: blurred vision, constipation, orthostatic hypotension
Adverse effects:
Dry mouth, urinary retention, sore throat
Principles of Nursing Care
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C. Minor Tranquilizers/Anxiolytics
Indications:
MOA:
Examples:
Diazepam (Valium)
Chlordiazepoxide (Librium)
Aprazolam (Xanax)
Oxazepam (Serax)
Chlorazepate Dipotassium (Tranxene)
Side effects:
Adverse effects:
Principles of Nursing Care:
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D. Antidepressants
Common Types:
- Tricyclics
- MAO inhibitor
- Stimulants
MOA:
Examples:
Imipramine (Tofranil)
Amitriptyline (Elavil)
Tranylcypromine (Parnate)
Isocarboxazid (Marplan)
Phenelzne (Nardil)
Ritalin (Methylphenidate)
Amphetamine (Benzedrine)
Adverse effect:
Cardiac arrhythmia, hypertensive crisis, growth suppression
Side effect:
Principles of Nursing Care:
C
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Drug update: SSRI – Selective Serotonin Reuptake Inhibitor
- inhibits serotonin uptake
Example : Fluoxetine (Prozac)
Side effects : GI Discomforts
Adverse effects: Tremors, decrease in libido
E. Anti-manic agents
1. Lithium Carbonate
MOA:
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2. Carbamazepine
7. 1. 2. Somatic Therapy
Electro-convulsive Therapy
MOA:
Voltage:
Duration:
Number of treatment
Frequency:
Indicators of effectiveness:
Indications:
- Depression
- Mania
- Catatonic schizo
Contraindications: (relative) – there is no absolute contraindication to ECT
- Fever
- ICP brain tumor
- Cardiac
- TB with history of hemorrhage
- Recent fracture
- Retinal detachment
- Pregnancy
Patient Preparation:
Before the procedure:
Consent:
Physical exam:
X-ray
ECG
EEG
NPO
Restrainments:
Administration of Atropine SO4
Anectine (Succinylcholine)
Methohexital Na (Brevital)
During the procedure:
Observe the patient tonic-clonic contraction
After the procedure:
Position
Vital signs
Reorient the patient
Common complications: Memory loss, headache, fracture, apnea
7.2 Psychosocial Interventions
III. Common Psychotherapeutic Interventions
- Remotivation therapy
5 Different Steps
- Climate of acceptance
- Creating of bridge to reality
- Sharing the world we live in
- Appreciation of the works of the world
- Climate of appreciation
- Music Therapy
- Play Therapy
- Group Therapy
- Psychodrama
- Milieu Therapy
- Family Therapy
- Psychoanalysis
- Hypnotherapy
- Humor Therapy
- Transactional Analysis
- Behavior Modification
- Aversion Therapy
- Token Economy
- Gestalt Therapy
IV. Dynamics of Human Behavior
Need – is an organismic condition which requires a certain activity
Stress – pressure of varying degrees: Distress – unhealthy stress
Eustress – healthy stress
Behavior – way in which an organism responds to a stimulus
Conflict – situation that arise from the presence of two opposing drives
Types:
Approach-Approach -both of each chosen have positive attributes
Avoidance-Avoidance -negative attribute
Approach-Attribute - choice have positive and negative attributes Double approach - avoidance
V. Basic Concepts on the Client
Personality
- The integration of those systems and habits that represents an individuals characteristic adjustment to his environment
- Expressed through behaviour.
2 Characteristics of Personality
1. Distinctiveness - each individual is unique
2. Stability and consistency personality is predictable
Determinants:
1. Psychological - type of climate at home
2. Cultural - customs and traditions
3. Biological - personality is not inherited
4. Familial - parenting style
3 divisions of the mind:
1. Conscious - part of the mind that is focused on awareness
2. Subconscious - part of the mind that contains information that can be recalled at will.
3. Unconscious - largest part of the mind; contains materials and information that can never be recalled.
Structures of Personality
ID EGO SUPEREGO
Theories of Personality Development
A. Freud’s Psychosexual theory
First to identify/classify the stages of development
0-18 mos: Oral Stage
Area of Gratification:
Indicators of Fixation:
18 mos – 3 years: Anal Stage
Area of Gratification:
Indicators of Fixation:
3-6 years: Phallic Stage
Area of Gratification:
Indicators of Fixation:
6-12 years Latency: (Quiet Stage)
Area of Gratification:
Indicators of Fixation:
12 -21 years Genital Stage
Area of Gratification:
Indicators of Fixation:
B. Erikson’s Psychosocial Theory
First to include adulthood as a stage of development
0-12 mos: Trust vs. Mistrust
If the needs of the child is consistently met, trust develops.
1-3 years: Autonomy vs. Shame and Doubt
If toilet training is not hurried, autonomy develops.
3-6 years: Initiative vs. Guilt
If the child’s sexual curiosity is handled without anxiety, initiative develops.
6-12 years: Industry vs. Inferiority
If the child’s efforts at learning is supported, industry develops.
12-18 years: Identity vs. Role Diffusion
If the adolescent’s vocational decision is supported, identity develops.
18-25 years: Intimacy vs. Isolation
If the adolescent’s decisions regarding love relationship is supported, intimacy develops.
25-65 years: Generativity vs. Stagnation
If an individual enjoys support from the family, generativity develops.
65 onward: Integrity vs. Despair
If the person has a satisfying past recollection, integrity develops.
C. Piaget’s Cognitive Theory of Development.
First to Focus on Cognitive Development
0-2 years: Sensory Motor Stage
Development proceeds from reflex activity to sensory motor learning
Child learns that he is separate from the environment
Child learns the concept of object permanence
2-7 years: Pre-operational Stage
2-4 yrs: pre-conceptual development proceeds from sensory motor learning to pre-logical thought.
The child learns language and symbols.
4-7 yrs: intuitive thought: The child is able to think in terms of class.
The child is able to determine that individuals have roles.
7-12 years: Concrete Operational Stage
Development proceeds from pre-logical concrete thought.
12 years to adulthood: Formal Operational Stage
The child is able to think abstractly, able to apply the scientific method.
VI Crisis and Crisis Intervention
Crisis – situation that occurs when an individual’s habitual coping ability becomes ineffective to meet the demands of a situation.
Characteristics:
Types of Crisis:
1. Maturational/developmental crisis - expected, predictable and internally motivated.
Example: growth
2. Situational/accidental - unexpected, unpredictable and externally motivated.
Example: car accident
3. Social crisis - due to acts of nature
Example: earthquake
Crisis intervention
A way of entering into the life situation of an individual, family, group, or community to help them mobilize their resources and to decrease the effect of a crisis inducing stress.
Phases of Crisis
Denial – initial reaction
Increased tension – the person recognizes the presences of a crisis and continues to do activities of daily living.
Disorganization – the person is preoccupied with the crisis and is unable to ADL.
Attempts to reorganize – individual mobilizes previous coping mechanism.
Some Conditions Requiring Crisis Intervention
- Rape
Some Facts of Rape:
Ruthless
Abusive
Personal
Experience
Essential Elements Necessary to Define an Act of Rape
- Use of threat/force
- Lack of consent of the victim
- Actual penetration of the penis into the vagina
Different Kinds of Rape
Power
Anger
Sadistic
Principles of Nursing Care:
Rape Trauma Syndrome (RTS)
1. acute phase
2. denial
3. heightened anxiety
4. stage of reorganization
Battered Wife Syndrome (BWS)
Characteristics of Abusive Husband:
1. They usually come from violent families
2. They are immature, dependent and non-assertive
3. They have strong feelings of inadequacy
Phases
1. Tension building phase
2. Acute battering incident
3. Aftermath/honeymoon stage
Principles of Nursing Care:
Child Abuse
Abuse - is what happens when an adult takes advantage of his authority over a child.
Violence - refers to the use of force.
Neglect - lack of provision of those things which are necessary for the child’s growth and development.
Physical abuse - abuse in the form of inflicting pain
Emotional abuse - insult and undermining one’s confidence
Sexual abuse - abuse in the form of unwanted sexual contact
Characteristic of Abusive Parents
- they come from violent families
- they were also abused by their parents
- they have inadequate parenting skills
- they are socially isolated because they don’t trust anyone
- they are emotionally immature
- they have negative attitude towards the management of the abused
Indicators of Child Abuse
Principles of Nursing Care:
Where to report:
Whom to report:
Priority:
Anxiety:
Causes of Anxiety
2 classification factors
- Predisposing factor
Factors that make you at risk
- Precipitating factor
Factors that cause direct effect
Psychoanalytic theory
Anxiety is caused by a conflict between the Id and the Superego
Interpersonal Theory
Cause of anxiety is fear of interpersonal rejection
Behavioral Theory
Anxiety is a product of frustration
Learning Theory
Exposure to early life fearful experiences causes anxiety
Conflict theory
Presence of opposing drives
Biologic Theory
Anxiety may accompany physical ailments/diseases
Family Studies
Anxiety can run in families
Precipitating factors
Threat to one’s biological integrity
e. g. surgery
Threat to one’s self system
e. g. insult
Signs and Symptoms of Anxiety
| Signs and Symptoms | Mild | Moderate | Severe | Panic |
| Physical | PR, RR, Pupillary dilatation, sweating | nausea, anorexia, vomiting, diarrhea, constipation, restlessness | S/Sx becomes the focus of attention | S/Sx of exhaustion are ignored |
| Cognitive | Attentive and alert | narrowed perceptual field and selective inattention | perceptual field is greatly narrowed; focus of attention is trivial events | personality disorganized |
| Emotional | Minimal use of defenses | use of any defense mechanism available | defense mechanisms operate to prevent panic, amnesia, and dissociation | defense mechanisms fail |
Nursing Diagnosis
Principles of Nursing Care:
BE C-ALM
A-DMINISTER MEDICATIONS
L-ISTEN
M-INIMIZE ENVIRONMENTAL STIMULI
Defense Mechanisms:
Unconscious, specific intrapsychic adaptive efforts which are employed by the individual to resolve emotional conflict and to cope with anxiety
Characteristics:
It is automatic
It is not the defense mechanism that is pathological but it is the frequent use of it
Used by both mentally healthy and mentally ill individuals
Types:
Compensation - an attempt to overcome a real or imagined shortcoming
Conversion - emotional problems are converted to physical symptoms
Denial - failure to acknowledge an intolerable thought, feeling, experience or reality
Displacement - the redirection of feelings to a less threatening object
Dissociation - detachment of certain activities from normal consciousness which then function alone
Fantasy - conscious distortion of unconscious feelings or wishes
Fixation - arrest of maturation at certain stages of development
Isolation - cutting of or blunting of an unacceptable aspect of a total experience
Introjection - symbolic assimilation or taking into one’s self a love/hatred object
Identification - conscious patterning of one’s self from another person
Intellectualization - over use of intellectual concepts by an individual to avoid expression of feelings
Projection - attributing to other’s one’s unconscious wishes/fears
Reaction formation - expression of feelings that is the direct opposite of one’s real feelings
Rationalization - justifying one’s actions which are based on other motives
Regression - returning to an earlier level of development in the face of stress
Repression - unconscious forgetting
Suppression - conscious forgetting
Substituting - replacing the desired unattainable goal with one that is attainable
Sublimation - the channelling of unacceptable instinctual drive with one that is acceptable
Symbolization - less threatening object is used to represent another
Undoing - an attempt to erase an act, thought, feeling or desire
Anxiety Disorders
Panic Attacks
Intervention:
Agoraphobia
Intervention:
Social Phobia
Intervention:
Simple Phobia
Intervention:
Obsessive-compulsive behaviour
Intervention:
General Anxiety Disorder
Intervention:
Post-traumatic Stress Disorder
Intervention:
Nursing Diagnosis
Drug of Choice:
VII. Personality Disorders
Etiological Factors
- Genetic Factors
- Temperamental Factors
- Biological Factors
- Psychoanalytic Factors
Types:
Hypochondriacal
Anti-social - habitually breaks the law; with low self-esteem; lacks sense of guilt.
Dependent - incessant demands for attention from others
Schizoid – withdrawn, last to catch up in fashion, introvert, aloof
Shizotypal – bizarre behaviour, silly laughter
Borderline - fears separation; impulsive; unstable but intense relationships
Histrionic – overly concerned with physical appearance, attention seeking behaviour
Extrovert
Avoidant – fears rejection
Paranoid – extreme mistrust and suspiciousness
Passive-Aggressive – loves to procrastinate, expresses anger through passivity
Emphatic Narcissistic – (self-love), believe that they are special and they demand special attention
Obsessive-Compulsive – repetitive thoughts and action, perfectionist, inflexible, rigid
Nursing diagnoses;
- Ineffective individual coping
- Self- esteem disturbance
Principles of Nursing Care
- consistency
- limit setting
VIII Autism
Treatable but not curable
More common among boys
Usually diagnosed at age 2
Main Problem: Interpersonal functioning
Most Acceptable Cause:
Biological factors – brain anoxia, intake of drugs
Signs and symptoms
- resist normal teaching method
- silly laughing or giggling
- echolalia
- acts as if deaf
- no fear of danger
- insensitive to pain
- crying tantrums
- loves to spin objects
- resists change in the routine
- not cuddly
- sustained odd play
- difficulty interacting with others
- no eye contact
- wants blocks not ball
- points to anything
- attachment to inanimate objects
Management of priority problems
Tantrum - involves headbanging = place a helmet on the head
Communication – all vowels = use build up and break down
Routines – consistency
Nursing diagnosis:
Potential for injury
IX. Mental Retardation
IQ less than 70
Not a mental illness
Main problem: Inadequate mental functioning
Age of Onset: 18 years old
Causes:
Maternal infection
Exact gestational age is not reached (premature)
Birth injuries
Nutritional deficiency
Toxoplasmosis
Anoxia
Lead poisoning
Recent infection – measles
Environmental factors
Thyroid deficiency
Alcoholic Mother
RH Incompatibility
Damage to brain from various causes
AIDS
Toxemia
Inherited factor
Opiate intoxication
Neurological/neurodevelopment impairment
Levels of Mental Retardation
1. Mild/Moron IQ: 50/55-70 Educable
2. Moderate/Imbecile IQ: 35/40 -50/55 Trainable
3. Severe/Idiot IQ: 20/25 -35/40 Needs close supervision
4. Profound Below 20-25 Needs custodial care
Nursing diagnosis:
Principles of Nursing Care:
- Repetition
- Role Modeling
- Restructuring
Focus of Education:
Reading, writing, basic arithmetic
X. Attention Deficit Hyperactivity Disorder
Common in boys
Usually diagnosed before age 7
Main problem: Inattention, hyperactivity, and impulsivity
Causes:
Neurologic impairment
Pre-natal trauma
Early malnutrition
Frontal lobe-hypoperfusion
Use of drug by mother
Signs and symptoms:
Difficulty remaining seated
Easily distracted by extraneous stimuli
Fidgeting
Interrupts/intrudes on others
Child exhibits hyperactivity
Indulges in destructive behaviour
Talks excessively
Nursing diagnosis: Potential for injury
Principles of Nursing Care:
Nutrition:
Safety:
Drug of Choice: Methylphenidate (Ritalin)
XI. Eating Disorders
Common among females (adolescents)
Most common cause:
Psychological factors
Individual factors (conflict about growing up)
Parental factors (domineering parents)
Socio-cultural factors
Anorexia
Main sign: fear of gaining weight
Amenorrhea
No organic factor accounts for weight loss
Obviously thin but feels fat
Refusal to maintain normal body weight
Epigastric discomfort
X symptoms (peculiar symptoms)
Intense fear of gaining weight
Always thinking of food
Bulimia
Binge eating
Under strict dieting or vigorous exercise
Lacks control over eating binges
Induced vomiting
Minimum of 2 binge eating episode a week for 2 months
Increased/persistent concern of body size/shape
Abuse of diuretics and laxatives
Nursing diagnosis: Body image disturbance/self-esteem disturbance
Ineffective individual coping
Principles of Nursing Care:
- Monitor patient’s weight
- Oral hygiene
- Stay with the patient during mealtime and within 2 hours after meals
- encourage the patient to remain in a public place after meals
- behaviour modification
XII. Sexual Disorders
Cause: Psychological factors, unresolved oedipal complex
Paraphilia – a term which generally refers to abnormal sexual behaviour
Types: Sexual Stimulus
Exhibitionism - publicly showing the genitals
Fetishism - from inanimate objects
Anilingus - tongue brushing the anus
Cunnilingus - tongue brushing the vulva
Fellatio - inserting the penis into the mouth
Partialism - inserting the penis into the other parts of the body
Pedophilia - sexual intercourse with a child
Urophilia - urinating on the partner
Coprophilia - smearing feces on the partner
Masochism - sexual gratification from experiencing pain
Sadism - inflicting pain
Telephone scatologia - sex on phone
Voyeurism - sexual gratification by seeing others in the nude
Frotteurism - rubbing the genitalia to the body parts
Transvestism - using the apparel of the opposite sex
Nursing diagnosis: Altered sexual functioning
Principles of Nursing Care:
- Limit setting
- Behavior Modification
XIII. Schizophrenia
“
Not a single disease but a combination of disorders
Main Problem:
Signs and Symptoms:
1. Associative looseness
2. Autism
3. Apathy
4. Ambivalence
5. Auditory Hallucination
Most acceptable theory on the cause of Schizophrenia, Biologic Theory
Signs and Symptoms
Social isolation
Catatonic behaviour
Hallucination
Incoherent/marked looseness of association
Zero/lack of interest, energy, and initiative
Obvious failure to attain expected levels of development
Peculiar behaviour
Hygiene and grooming are impaired
Recurrent illusions and unusual perceptual experiences
Exacerbation and remissions are common
No organic factor accounts for signs or symptoms
Inability to return to baseline functioning after each relapse
Affect is inappropriate
Different Types
| | Catatonic | Disorganized | Paranoid |
| Onset | Acute | Insidious | Abrupt |
| Distinguishing feature | Abnormal motor behavior | Bizarre behavior | Suspiciousness and ideas of reference |
| Defense mechanism | Repression | Regression | Projection |
| Nursing diagnosis | Impaired motor activity | Impaired social functioning | Potential for injury directed at others |
| Priority nursing care | Circulation Nutrition | Assistance with ADL | Nutrition and Safety |
| Prognosis | Good | Poor | Good |
Other types: Undifferentiated
Residual – with minimal symptoms
Criteria for Prognosis
| Favorable Prognosis | Unfavorable Prognosis |
| 1. Good socialization 2. Late/acute onset 3. Adequate support system 4. Family history of mood disorder |
|
XIV. Mood Disorders
Predisposing Factors:
Genetic: If one parent ahs bipolar disorder, 25 percent chance of transmission to the child.
Aggression turned inward theory: overdeveloped superego
Object loss theory: loss of parent before age 11
Personality Organization Theory: Obsessive-Compulsive theory, Oral dependent, hysterical personalities have higher predisposition to mood disorders.
Cognitive Theory: Mood disorder results from (-) view of self, (-) view of future, (-) interpretation of experience
Learned Helplessness Theory: Mood disorder is caused by a belief that one has no control over his environment
Psychoanalytic Theory: Mania is a defense against an underlying depression
Depression due to rigid SE
Biologic Factor: Mania is cause by increased norepinephrine while depression is cause by low norepinephrine
Precipitating Factors
1. Loss of a loved one
2. Major life events
3. Roles strain
4. Decreased coping resources
5. physiological changes
Types of Mood Disorders
- Depression
- Major Depression-severe, lasts for at least 2 weeks
- Dysthymic Depression-less severe (2 years)
- DNOS – lasts for 2 days – 2 weeks
- Bipolar Disorders
- Manic-severe, lasts for at least 1 week
- Hypomanic-lasts for at least 4 days
- Bipolar I – with history of mania
Bipolar II – with no history of mania
- Cyclothymic – numerous episodes of hypomania and depressed mood that lasts for at least 2 years
Signs and symptoms:
Mania Depression
Appearance Colorful Sad
Behavior Highly driven, hyperactive Passivity/Psychomotor
retardation
Communication Talkative (Flight of ideas) Monotonous
Nursing Diagnosis Risk for injury Risk for injury to self
directed at others
Nursing Care Lithium ECT
Milieu Therapy Non-stimulating Stimulating
Activity Quiet Type Monotonous activity
Avoid competitive e. g. counting
Attitude therapy Matter of Fact Kind firmness
(attitude of casualness)
Suicide
Ultimate form of self-destruction
“cry for help”
Major intervention: Prevention
Listen
Risk Factors
Sex (more female attempts at suicide but more males commit suicide)
Unsuccessful previous attempt
Identification with a family member who committed suicide
Chronic
Illness (e.g. Cancer)
Depression/Dependent personality
Age (18-25 and 40)/Alcoholism
Lethality of previous attempt/Losses
Nursing Diagnosis: Risk for self-directed injury
Nursing Care:
- One-on-one monitoring
- Frequent unscheduled rounds
- Avoid use of metals and glass utensils
- Monitor for the signs of impending suicide (e.g. giving away of prized possession)
XV. Conditions Common in the Elderly
Delirium Dementia
Disorientation Loss/impairment of memory
Acute Chronic
Involves young and old Exclusive in the elderly
Clouded sensorium Clear sensorium
Reversible Irreversible
Good prognosis Poor prognosis
Alzheimer’s disease: Irreversible
Main pathology: presence of senile plaques-destroys neurons (decreased acethylcholline)
Signs and symptoms:
Aphasia-inability to talk
Agnosia- inability to recognize object
Apraxia-inability to perform ADL
Amnesia/Memory Loss/Mnemonic disturbance
3 phases
- Forgetfulness Phase-difficulty of remembering appointments
- Advance Phase-difficulty of remembering past events but not recent events
- Terminal Phase-death occurs in 1 year
Nursing Diagnosis: Altered thought processes
Nursing Care:
- Calendar
- Clock (frequent orientation)
- Color
- Consistency (one nurse to lessen confusion)
XVI. Substance Abuse and Substance Dependence
Substance Abuse: use of a substance for other than its legitimate medical purpose
Substance Dependence: physiological and psychological dependence of the body on a substance as evidenced by tolerance and withdrawal
Tolerance: need for an increasing amount of the substance to produce its desired effect or it refers to the declining effect of the drug.
Withdrawal: syndrome or a group of symptoms experienced by the patient when the amount of the substance is reduced or when the intake is stopped.
Alcoholism
Definition:
WHO- alcoholism is a chronic disease or a disorder characterized by excessive alcohol intake and interference in the individual’s health, interpersonal relationship and economic functioning.
Alcoholism – considered to be present when there is 1% or 10 ml for every 1000 ml of blood.
What happens at level:
.1-.2% (low coordination)
.2-.3% (presence of ataxia, tremors, irritability, stupor)
.3 and above (unconsciousness)
Theories of Causation
- Psychoanalytic Theories
- Learning Theories
- Biological Theories
- Socio-Cultural Theories
Progression of Alcoholism
- Pre-alcoholic Phase – starts with social drinking tolerance begins to develop
- Prodromal Phase – Alcohol becomes a need, blackout’s occur; denial begins to develop
- Crucial Phase – cardinal symptoms of alcoholism develops (loss of control over drinking)
- Chronic Phase – the person becomes intoxicated all day
Outcome:
Brain Damage
Alcoholic Hallucinosis
Death
Common Behavioral problems of the Alcoholic Patient
Denial Dependency Demanding Destructive Domineering
Common Withdrawal Signs and Symptoms
Hallucinations
Increased vital signs
Tremors
Sweating and Seizure
Criteria D. Tremens Korsakoff Psychosis Wernickes P.
Cause Faculty metabolism Thiamine & Niacin Thiamine
of alcohol deficiency deficiency
Onset Acute Chronic Chronic
Essential Delirium Memory disturbances
feature
Other S/Sx Vital Signs Retrograde A Confusion
Visual and tactile Anterograde A Opthalmoplegia
Coarse tremors Confabulation Ataxia
Korsakoff’s P. Thiamine def.
Long terms of care
Community resources
Other coping means aside from denial
Personal responsibility for not drinking
Isolation
Nutrition Vitamin B & C, CHO diet
Group therapy
Nursing diagnosis: Ineffective individual coping
Principles of Nursing Care:
- Well-lighted room
- DAT
- Monitor vital signs
- Administration of glucose
- Vitamins
Drug of choice: Disulfiram (Anti-abuse) – delays the metabolism of alcohol
Avoid:
Mouth wash
Over the counter cold remedies
Food sauces made up of wine
Fruit flavoured extracts
Aftershave lotion
Vinegar
Skin products
Commonly Abused Substances
Substance Physical signs Withdrawal Effect
a. Stimulants
Amphetamine (shabu) Weight loss, hyperactivity depression
Euphoria
Cocaine perforated nasal septum psychomotor agitation
b. Narcotics
Heroin pinpoint pupils, drowsiness piloerection & runny nose
c. Hallucinogens
LSD dilated pupils & hallucinations none
Nursing Diagnosis:
Ineffective individual coping
Nursing interventions for substance abusers:
Behavior Modification (Firmness-matter of fact)
Detoxification
Antihypertensive; anti-anxiety- administered to patients who are abusing stimulants
Anti-anxiety; anti-depressants- administered to patients who are abusing depressants
Anti-anxiety (Librium), disulfiram (anti-abuse);- administered to patients who are abusing alcohol
XVII. Concept of Loss
Grief/Grieving-George Engel
- Shock, Numbness, Disbelief- Searching behaviour
- Yearning and Protest – anger towards God
- Anguish, Disorganization, and Despair – reality of the loss is accepted
- Identification stage- a family member imitates some characteristics of the dead person.
- Reorganization/restitution- life normalizes
Death/Dying: Elizabeth Kubler-Ross
Stages:
Denial – “No, Not me!”
Anger - “Why me?”
Bargaining- “If only…”
Depression – silence
Acceptance – “Yes, it’s me.”
Nursing Diagnosis: Ineffective individual coping
Nursing Care:
- Be physically present
- Be non-judgmental
- Encourage verbalization of feelings
- Allow the patient to cry
- Recognize your own thoughts about death and dying
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