PSYCHIATRIC NURSING

Psych focuses in feelings or self awareness.

Beliefs determine feelings which affects behavior (manifestation of feelings)
Sigmund Freud is the father of PSYCHOANALYSIS.
What happens to childhood will affect adulthood.
STRUCTURE OF PERSONALITY
ID

impulsive, want to, wants pleasure.

PLEASURE PRINCIPLE.
Guiding principle is PAIN AVOIDANCE.
SUPEREGO

should not
small voice of God
to stop
EGO

executive decision maker.

In touch with reality principle.
ID dominant personalities
Manic
Anti Social experienced by serial killers
Narcissistic
SUPEREGO DOMINANT PERSONALITIES
Obsessive Compulsive
Anorexia Nervosa
EGO if destroyed result in impaired reality perception.
Schizophrenia
LIBIDO

Sexual energy responsible for survival.

Oral stage

0 18 months evident.
ID is developed.
*FIXATION Person is stuck in certain developmental shape.
*REGRESSION Return to an earlier developmental stage.
EGO Developed on the 6th month.
ANAL STAGE

18 months 3 years old.

Able to control bladder, bowel.
Best time for toilet training.
SUPEREGO is developed.
TOILET TRAINING
Good Mother
Successful

Bad Mother
Dirty Clean
- disorganized - organized
- disobedient - obedient
- Anti-social - O.C
- Anal expulsive - Anal retentive

PHALLIC STAGE

3 6 years old.
Experience pleasure by manipulating genitals.
Love hate relationship.
Oedipus Complex boy loves parent of the opposite sex.
Imitates daddy called identification.
Castration fears.
Electra Complex girl loves parent of the opposite sex.
Imitates mommy called identification.
Penis envy.

*Conscious upper level of thinking.

*Preconscious tip of tongue.
*Unconscious protects us from traumatic experiences.
LATENCY STAGE

6 12 years old.
School age.
Separation anxiety.
Reading, Writing, Arithmetic.
Lasts for 6 years.
GENITAL STAGE

12 years old and above

Sexual reawakening.
Very important stage.
PHARMA NOTES:
ANTI - ANXIETY DRUGS

Valium
Librium
Ativan
Serax
Tanxene
Miltown
Equanil
Vistaril
Atarax
Ideral
Buspar
ERIC ERIKSON

There is more to life than just sex.

Psychosocial Theory of development.
You can develop a positive side or a negative side.
Developmental task begins at 0 18 months.
POSITIVE

NEGATIVE

FACTOR

0 18 mos.

Trust

Mistrust

Feeding

18 mos. 3 yrs.

Autonomy

Shame & Doubt

Toilet Training

3 yrs. 6 yrs.

Initiative

Guilt

Independence

6 yrs. 12 yrs.

Industry

Inferiority

School

12 yrs. 20 yrs.

Identity

Role Confusion

Peers

20 yrs. 25 yrs.

Intimacy

Isolation

Love

25 yrs. 45 yrs.

Generativity

Stagnation

Parenting

45 yrs. - above

Ego Integrity

Despair

Reflection

BEHAVIORAL MODELS
Ivan Pavlov

Classical Conditioning
All behaviors are learned.
BF Skinner

Behavior can be learned and unlearned.

Operant conditioning.
If given reward there is repetition.
If punished behavior becomes extinct.
LOBES OF BRAIN
1. FRONTAL LOBE
- Language
- Learning
- Personality
- Judgment
2. TEMPORAL LOBE
- Hearing
- Smell
3. PAREITAL LOBE

- Touch
- Taste
4. OCCIPITAL LOBE
- Visual
3 STEPS TO INTERACT WITH ENVIRONMENT
1. Sensory eyes, ears, tongue
2. Integration
3. Motor voluntary or involuntary
VOLUNTARY NERVOUS SYSTEM

also called as somatic

Brain
Spinal Cord
Motor Nerve
Synapse
Muscle Fiber

Motor nerve to muscle fiber you need Acethylcholine which is an On switch.

INVOLUNTARY NERVOUS SYSTEM

also called autonomic nervous system.

AUTONOMIC NERVOUS SYSTEM
SYMPATHETIC

PARASYMPATHETIC

(Awake, ADRINERGIC)

(Relax, CHOLINERGIC)

Heart Rate

Increase

Decrease

Respiratory Rate

Increase

Decrease

GI

Decrease (Dry mouth, Constipation)

Increase (Moist mouth, Diarrhea)

GU

Decrease (Urinary Retention)

Increase (Urinary Frequency)

Neurotransmitter

Epinephrine, Norepinephrine

Acethylcholine

DRUGS WITH ANTICHOLINERGIC EFFECTS

Anti Anxiety
Anti Psychotic
Anti Cholinergic
Anti Depressants
PHARMA NOTES:
MONOAMINE OXIDASE INHIBITORS

Marplan
Nardil
Parnate
DEFENSE MECHANISMS

1. Displacement transfer of feelings to a less threatening object rather than the one who
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.

provoked it.
Denial failure to acknowledge an unacceptable trait or situation.
DISOCIATION psychological flight from the self.
REGRESSION return to an earlier development state.
repression unconscious forgetting.
RATIONALIZATION illogical reasoning for an unacceptable trait and situation.
REACTION FORMATION doing the opposite of what you have done.
UNDOING doing the opposite of what you have done.
IDENTIFICATION assuming trait for personal, social, occupational role.
projection attribute to others ones unacceptable trait.
introjection assume another persons trait as your own.
suppression conscious forgetting.
sublimation putting destructive energies or hostile feelings towards a more productive
endeavors.
conversion unexpressed or repressed feelings are converted to physical symptoms.
compensation over achievement in one area to cover a defective part.
substitution replace difficult goal with more accessible one.

PHARMA NOTES:
ANTI PARKINSON DRUG

Cogentin

Artane
Parlodel
Akineton
Benadryl
Larodopa
Eldepryl
Symmetrel
AUTONOMIC NERVOUS SYSTEM
SYMPATHETIC

PARASYMPATHETIC

Pupils

Dilate

Constrict

Blood Vessels

Constrict

Dilate

Blood Pressure

Increase

Decrease

THERAPEUTIC COMMUNICATION TECHNIQUES

THERAPEUTIC

NONTHERAPEUTIC

1. Offer Self
2. Silence provide time to think
3. Making observation what you see you
say
4. Active Listening nodding, eye contact
5. Broad Opening how are you today?
6. General Leads Go on, Im listening

1.
2.
3.
4.
5.
6.

Dont worry be happy

Changing the topic/subject
Ignore the client
Value based judgment never assume
Flattery
Advising

7. Giving Opinion
7. Restating Im sad Youre sad?
FEAR protects us from something bad.
ANXIETY

Vague sense of impending doom.

Triggers the sympathetic nervous system.
Assess level of anxiety of client.
TYPES OF ANXIETY
MILD ANXIETY

+ 1 level of anxiety.
Widened perceptual field.
Restless (say you seem restless).

Enhanced learning capacity.

MODERATE ANXIETY

+ 2 level of anxiety.
Client pace.
Give PRN meds.
SEVERE ANXIETY

+ 3 level of anxiety.
Dont know what to do/say.
Directive orders (please sit down).
PANIC

+ 4 level of anxiety.
May commit suicide.
Promote safety.
Never touch patient.
Hyperventilation (Respiratory Alkalosis)
Breathe into paper bag.
NURSING DIAGNOSIS:

ineffective individual coping.

Powerlessness.
Impaired skin integrity
PLANNING/IMPLEMENTATION:

decrease level of anxiety.

Decrease environmental stimuli.
Relaxation techniques.
EVALUATION

effective individual coping.

GENERALIZED ANXIETY DISORDER

6 month excessive worrying.

Restless, difficulty concentration, sleep disorders, palpitations, edge of the seat, easy
fatigability.

PANIC ATTACKS/DISORDER

15 30 minutes sympathetic nervous system escalation.

Example is AGORAPHOBIA fear of open spaces.
POST TRAUMATIC STRESS DISORDER

victims becomes survivors and experience flashbacks or nightmares.

MALINGERING

pretending to be sick (conscious).

Primary Gain anxiety decreases, able to escape source of anxiety.
Secondary Gain able to get attention.
SOMATOFORM

no protection
unconscious
no organic basis of being sick
DIFFERENT TYPE OF SOMATOFORM
1. Conversion Disorder

cannot speak, see, hear.

Nervous system affected.

2. La Belle Indifference

do not care what happens to them.

HYPOCHONDRIASIS

has minor discomfort and interprets it as major illness.

Focus on clients feelings.
BODY DISMORPHIC DISORDER

Illusion of structural defect.

Favorite past time is doctor hopping.
Focus on clients feelings.
PSYCHOSOMATIC

Real pains/illness
Real symptoms because of anxiety
PSYCHOSOMATIC
Increase Anxiety
SNS
Increase BP & HR
Hypertension
Fat Deposits
Atherosclerosis
Calcium
Arteriosclerosis
Decrease Oxygen
Angina Pectoris
MI
Necrosis
CHF
Coma
PHOBIA

Irrational fear
Etiology: Knowledge of certain object
Bad experience
Immediate nursing objective: Removal of stimulus will remove anxiety
Systemic Desensitization gradually expose client to stimuli/feared object
Employ relaxation techniques
SNS

GABA (Gamma Amino Butyric Acid) stop

Epinephrine and Norepinephrine Go

ANTI-ANXIETY

Increase GABA and client becomes drowsy (no alcohol and coffee)
May develop orthostatic hypotension
Let patient sit then dangle feet and then stand
Develop anti cholinergic effects
If abruptly withdrawn to anti anxiety it may result to rebound phenomenon (1 week) may
lead to seizures
Do it in gradual and in tapered dose
Anti anxiety leads to dependence
AUTISM

Unresponsive and does not want to be touched

Autistic Savant: high intelligence and has a ratio of 1:100
Assessment
Appearance flat affect and loves constancy and ritualistic
Behavior withdrawn
Communication echolalia
NURSING DIANOSIS

Impaired verbal communication

Impaired social interaction
Self mutilation
Risk for injury
PLANNING/IMPLEMENTATION

Maslows hierarchy of needs

Expressive Therapy use of art as mode if communication
EVALUATION

Enhanced communication
Improved social interaction
Safety
ATTENTION DEFICIT HYPERACTIVITY DISORDER

7 years and below onset

Duration: 6 months and above
Settings: house and school

Assessment
Appearance: dirty, clumsy, hyperactive, impatient, easily distracted and has no focus
Behavior
Communication: talkative
NURSING DIAGNOSIS

Risk for injury

Impaired social interaction
PLANNING/IMPLEMENTATION

Structure: place to play, sleep, eat and study

Schedule: there is always a time for everything that you do
Set limits
Safety
EVALUATION

Minimize risk for injury

Improved social interaction
FRONTAL LOBE OF ADHD
Decrease glucose
Decrease judgment
Increase impulsiveness
ADHD
Hyperactivity

Need a drug that brings glucose level up.

Give Ritalin a stimulant
May result in loss of appetite
Given after meals
Given 6 hours before bedtime
EATING DISORDERS
ANOREXIA NERVOSA

BULIMIA NERVOSA

- Eat, eat, eat

- Eat, eat, vomit

- Less 85% expected body weight

- Normal weight

- 3 months amenorrhea

- Irregular menstruation

BULIMIA NERVOSA

Metabolic alkalosis (vomiting results to decrease hydrochloric acid)

Metabolic acidosis (diarrhea results to decrease bicarbonate)
Dental caries
Wound in knuckles
MANAGEMENT

Fluid and electrolyte imbalance

Meal contract
Weight gain for client
After eating stay with client for 1 hour and accompany when going to the comfort room
PHARMA NOTES:
ANTI PSYCHOTIC DRUG

Stelazine
Serentil
Thorazine
Trilafon
Clozaril
Mellaril
Haldol
Prolixin
SCHIZOPHRENIA

Ego disintegration
Impaired reality perception
Genetic vulnerability
Stress Diathesis Model
Biological theory increase dopamine level
Exact cause unknown
ASSESSMENT

Affect: Appropriate, Inappropriate, Flat, Blunt (incomplete)

Ambivalence: pulled into 2 opposing forces

Autism

Looseness, no idea, not related to one another

ASSESSMENT
NEGATIVE

POSITIVE

Hypoactive

Hyperactive

Withdrawn

Sociable

Thought Blocking

Flight of ideas

Apathy
I. ASSESS

Content of thought
NURSING DIAGNOSIS

Disturbed thought process

PLANNING/IMPLEMENTATION

Present reality
Provide safety
EVLUATION

Improved thought process

II. ASSESS

Hallucinations/Illusions
NURSING DIAGNOSIS

Disturbed sensory perception

PLANNING/IMPLEMENTATION

Present reality
Safety
EVALUATION

Improved sensory perception

III. ASSESS

Suspicious
NURSING DIAGNOSIS

Risk for other directed violence

PLANNING/IMPLEMENTATION

Present reality
Safety
EVALUATION

Eliminate/minimize risk for other directed violence

IV. ASSESS

Suicidal
NURSING DIAGNOSIS

Risk for self directed violence

PLANNING/IMPLEMENTATION

Present reality
Safety
EVALUATION

Eliminate/minimize risk for self directed violence

LOOSENESS OF ASSOCIATION

There is connection with statements

FLIGHT OF IDEAS

Jumping from on topic to another

AMBIVALENCE

Pulled between 2 strong opposing forces

MAGICAL THINKING

acting like magician

ECHOLALIA

Client repeats what you say

ECHOPRAXIA

Client repeats what you do

WORD SALAD

Just words no rhyme

CLANG ASSOCIATION

Words that rhyme

NEOLOGISM

Formation of new words (needs clarification)

DELUSION: PERSECUTORY

The NBI is out to get me

DELUSION: RELIGIOUS

I am Jesus Christ the savior

DELUSION: GRANDEUR

I am the queen of the world

DELUSION: IDEAS OF REFERENCE

The nurses are talking about me

CONCRETE ASSOCIATION

Also known as pilosopo

THOUGHT BLOCKING

Unable to think
HALLUCINATIONS

ILLUSIONS

STIMULUS

ABSENT

PRESENT

VISUAL

ABSENT

PRESENT

AUDITORY

ABSENT

PRESENT

TACTILE

ABSENT

PRESENT

Present reality to clients experiencing hallucinations

Technique in handling clients with hallucinations
Hallucinations
Acknowledgement I know the voices are real to you
Reality orientation I know the voices are real but I dont hear them
Diversion Lets go to the garden
10% of schizophrenic clients hear voices
PARKINSONS DISEASE

If acethylcholine (on switch) is increased there is excessive movement resulting to

decrease in dopamine (off switch)
ANTI-PSYCHOTIC
Decrease dopamine level
Parkinson like effect
Extra pyramidal side effect
With akathesia
Restless, inability to rest
AKINESIA

Muscle rigidity
DYSTONIA

Torticollis (wryneck)
OCULOGYRIC CRISIS

Fixed stare
OPISTHOTONUS

Arched back
Lips smacking
Tongue protruding
Cheeks puffing
The 3 are irreversible and called tardive dyskinesia
Neuroleptic malignant syndrome hyperthermia
ANTI PARKINSON
Anticholinergics

Dopaminergics

(Decrease Ach)

(Increase Dopa)

Artane, Akineton

Parlodel

Benadryl

Larodopa

Cogentin

Eldepryl
Symmetrel

OTHER SIDE EFFECTS OF DECREASE DOPAMINE

Photosensitivity
Agranulocytosis decrease WBC
Clients prone to infection due to decrease WBC
First sign for infection is sore throat
TYPES OF SCHIZOPHRENIA
TYPES

DISORGANIZED

CATATONIC

PARANOID

RESIDUAL

UNDIFFIRENTIATED
UNCLASSIFIED

- Sad but smiles

- Ambivalence
(inappropriate affect)
- Waxy flexibility
- No reaction (flat
- Favorite word is
affect)
No
- Flight of ideas
- Negativism (client
(disorganized
do not follow what
speech)
you tell them to do)
- Giggling
(hebephrenic giggle) Nursing
management:
- Combination of
meet needs
positive and negative
signs and symptoms

- Suspicious

- No more
positive
- Mistrust, scared, symptoms
withdrawn
just
withdrawn
Nursing
management:
- Gain trust by 1 to
1 short interaction
but frequent
- Foods should be
in a sealed
container
- Medications
should be in
tamper resistant
foil.
Violent:
- Keep door open
- Position near
door
- Dont touch client
- Call for
reinforcement
- One arms length
away from the
client.

PHAMRA NOTES:
BI-POLAR, MANIC

- Mixed classification,
cant be classified

Lithium: undergo first kidney test and check for blood levels
Level: .6 1.2 meq/L
Increase urination
Tremors, fine hand
Hydration of 3L/day
Increase
Uu (diarrhea)
Mouth dry
Signs of Lithium toxicity

Nausea, vomiting, diarrhea

Increase sodium
* Wait for 2 4 weeks before lithium therapy takes effects
BIPOLAR DISORDER/MANIC PROFILE

20 years old
Female
Stress
Obese
ASSESSMENT

Decrease appetite (give finger foods)

Decrease sleep (place in a private room)
Hyperactive
Increase sexual activity only means of addressing anxiety so decrease level of anxiety
Risk for injury/other directed violence
Impaired social interaction (care giver role: strain and stay with client)
Self esteem decrease (to cover up their sadness there is compensation to cover

defective doing)
Because there is decrease self esteem there will be increase compensation resulting

to increase interference with ADLs and harm to others

Compensation is the culprit
Management: increase self esteem to decrease compensation and decrease
interference with ADLs and harm to others
HOW TO INCREASE SELF ESTEEM OF MANIC PATIENTS
T- no sports (basketball, volleyball), no fine motor skills only gross motor skills
A lot energies toward more productive endeavors (sublimation)

S - escorted walk outdoors

K punching bag (displacement)
PHARMA NOTES:
ANTI DEPRESSANTS

Asendin
Norpralamin
Tofranil
Sinequan
Anafranil
Aventyl
Vivactil
Elavil
Prozac
Paxil
Zoloft
ALCOHOL LEADS TO:

Blackout: awake but unaware

Confabulation: inventing stories to increase self esteem
Denial: I am not an alcoholic
Dependence: cant leave with out leading to enabling where in the significant other
tolerates the abuser co dependence is another term
Tolerance: gradual increase in amount of stimuli to experience the same euphoria
MANAGEMENT

Detoxification: withdrawal with medical doctor supervision

Avoid alcohol therapy
Aversion therapy a more technical term for avoid alcohol therapy
Antabuse: Disulfiram makes the client never drink alcohol because it causes vomiting
Alcoholics anonymous
Interval of 12 hours after last dose of alcohol or experience nausea and vomiting and
hypotension
Alcoholism may result to Vitamin B1 (Thiamine) deficiency
WERNICKES ENCEPHALOPATHY

Problem with motor

KORSAKOFFS PSYCHOSIS

Problem with memory

24 72 hours after last dose of alcohol expect:
Delirium Tremens: sympathetic nervous system
Prevent hallucinations/Illusions by placing client in a well lit room
Formication: feeling of bugs crawling under the skin
ALZHEIMERS DISEASE

Axon (away) and Dendrites (toward) nerve

Neurofibrillary tangles
Neurotic plaques

ONSET

ALCOHOL

ALZHEIMERS

Abrupt

Gradual

LEVEL OF CONSCIOUSNESS Fluctuating

Unaffected

DURATION

Hours to days

Progressive

MEMORY

Short term memory loss

Short term and long term (orient

patient)

5 As OF ALZHEIMERS
1. Amnesia memory loss
2. Anomia dont know the name
3. Agnosia sensory problems smell, taste, sight
4. Aphasia
- expressive: cant say/express
- frontal lobe is affected particularly brocas area
- receptive: cant hear
- temporal lobe is affected particularly wernickes area
5. Apraxia cant do simple things
* Reminiscing Therapy talk about past

Patients with alzheimers may experience hallucinations, illusions thus becomes restless
and may wander

As sun goes down client becomes restless, agitated, disoriented called sundowning
Drug of choice is Cognex and Aricept a cholinesterase inhibitor that increases Ach
causing delay in disease progression
SEROTONIN

Responsible for happiness

Decrease serotonin clients becomes sad give anti-depressants
SELECTIVE SEROTONIN REUPTAKE INHIBITOR
Safest drug
Side effects low
R
I to 4 weeks
- Increases serotonin and affects only serotonin
- Prozac, Paxil, Zoloft
TRICYCLIC ANTI DEPRESSANT
Two four weeks
C
A
- Has higher incidence of side effects
- Also increases norepinephrine
- Asendin, Norpralamin, Tofranil, Sinequan, Anafranil, Aventyl, Vivactil, Elavil
MONO AMINE OXIDASE INHIBITORS

MAO kills serotonin

Increased MAO results to decreased serotonin the more depressed the client becomes
MAOI kills MAO and increases all neurotransmitters (serotonin, epinephrine,
norepinephrine, dopamine but client becomes prone to hypertensive crisis
Avoid tyramine rich foods
Avocado, Alcohol

Beer
Chocolates, Cheese (aged)
Fermented foods
Pickles
Preserved foods
Soy sauce
There is increase incidence of side effects after 2 6 weeks
Marplan, Nardil, Parnate
PERSONALITY DISORDERS
1. Schizophrenia
- They avoid people because there is no enjoyment
2. Avoidant
- They avoid people because they are afraid of criticisms
- They have talent but has no confidence
3. Anti-Social
- Constantly breaks law
- Project charm
- They are witty and articulate
- Manipulative
4. Borderline
- They perceive life as an empty glass
- They like splitting friends
- Sudden change in mood labile affect
- Prone to suicide
5. Dependent
- Cant live if living is without you

6. Histrioinic
- Constantly wants to be the center of attention
- Excited, dramatic, manipulative
7. Narcissistic
- I love myself
- They get jealous even with achievement of family members
8. Obsessive Compulsive
- I am so organized
9. Paranoid
- Suspicious
- May lead to domestic violence
ANTI DEPRESSANT SIDE EFFECTS:
Male erectile dysfunction, prone to impotence
GRIEF PROCESS

1.
2.
3.
4.
5.

Denial shock/disbelief
Anger question why me?
Bargaining if, then
Depression 2 weeks or more sign and symptoms becomes major clinical depression
Acceptance client acts according to situation

ASSESSMENT

Decrease self actualization

Decrease self esteem
Withdrawn: stay with client
Suicidal: risk for self directed violence
Increase/decrease eat, increase/decrease sleep, hypoactive, decrease sexual urge
Be sensitive to clients needs
FOR SUICIDAL OBSERVE FOR

Verbal

I wont be a problem
This is my last day on earth
Ill soon be gone
Non verbal

Giving away of valuables

Sudden change in mood
WHEN THE CLIENT IS SUICIDAL WHAT WILL THE NURSE DO
Direct: Do you plan to commit suicide?
Irregular/interval visits
Endorsement period, early morning clients are most likely to commit suicide
DOWNERS
Alcohol
Barbiturate
Opiates
Narcotics
Marijuana
Morphine
Codeine
Heroine
Resulting to:

Bradycardia
Bradypnea
Moist mouth
Pupils constrict
Constipation
Urinary retention

Hypotension
Coma
Weight gain
Narcotics overdose: give narcotic antagonist (Narcan, Naloxone hydrochloride)
UPPERS
Cocaine
Hallucinogens
Amphetamines
Resulting to:

Tachycardia
Awake
Tachypnea
Dry mouth
Pupils dilate
Hypertension
Seizures
Weight loss