PERSONALITY

aggregate of physical and mental qualities of the individual as he/she interacts with the environment. LEVELS OF CONSCIOUSNESS 1. Conscious past experiences easily recalled and is aware of the here and now. Conscious part of the mind that functions when the person is awake Enables person to be aware of himself, thoughts, feelings, perception, and what is going on in the environment. 2. Preconscious / Subconscious Situated between the conscious and unconscious portion of the psyche. Contains some partly remembered, partly forgotten experiences which can be usually recalled spontaneously and voluntarily. 3. Unconscious storehouse of all memories and responses experienced by the individual during the entire life. Cannot be deliberately brought back to awareness. Largest portion of the psyche contains memories of ones past life, particularly unpleasant and emotionally painful experiences stored away from the conscious awareness and difficult to recall except under certain cisrcumstances. Examples of unconscious activity Everyday slips of the tongue and pen which are elicited without apparent conscious control Forgetting well-known names, telephone numbers, appointments, to mail letters which is often motivated by opposing wishes and thoughts. People who are accident prone or who habitually drop or break articles are said to be behaving under the influence of the unconscious mind. Behind every dreams there are unconscious thoughts and desires. Sometimes the dream can produce a satisfying effect upon the dreamer which cannot be achieved during conscious awareness because of drives and impulses. The relaxation occurring with sleep permits some unconscious thoughts, ideas and wishes to be expressed. In jumbled mixed events that occur during a dream is thought to be under the influence of unconscious mind which cannot accept pure expression of some unconscious thoughts, feelings and impulses.

STRUCTURES OF PERSONALITY 1. Id source of instinctive energy, impulses and drives; based on the pleasurable principle. 1

 Untamed, uncultured, primitive drives and impulses of the individual Assumed to comprise the entire psychic apparatus of after birth of an individual Reflects the persons innate and basic desires such as pleasure seeking, aggression, sexual impulses; it desires immediate gratification; unthinking behavior and has no regard for rules or social convention. 2. Ego conscious self which in contact with reality and tempers the primitive drives of Id; based on reality principle moderator of the struggle between the Id and Superego. Balancing or the mediating force of the Id and Superego 3. Superego - critical censoring portion of ones personality referred to as conscience (checks the expression of socially unacceptable Id drives and impulses) - part of the persons nature that reflects moral and ethical concepts, values, and parental expectations. THEORIES OF PERSONALITY DEVELOPMENT 1. Sigmund Freud Psychosexual Theory the libidinal energy and its relationship to the development of personality. 2. Erick Erikson Eight Stages of Human Developmental Tasks stages of personality development include entire life span and identified by age-apecific achievements. Harry Stack Sullivan Interpersonal Theory the relationship between infant and mother as the fundamental to personality development Jean Piaget Cognitive Theory stages of cognitive development according to specific age leve Adolf Meyer Psychobiologic Theory Carl Jung Analytical Theory STAGES OF PERSONALITY DEVELOPMENT

EGO DEFENSE MECHANISM

1. REPRESSION Unpleasant, unacceptable thoughts, desires and impulses are stored in the unconscious mind but not admitted in the conscious awareness but not forgotten. Selective forgetting, selective remembering 2

During nurse-patient interactions, patient often unconsciously avoid discussing those repressed anxiety, producing experiences which are emotionally difficult to verbalize.

2. SUPPRESSION voluntary exclusion from consciousness anxiety producing ideas, feelings and situations. Id rather not talk about it, Dont talk about that, I dont feel like talking 3. REGRESSION return to methods of adjustment that proved to be successful at an earlier stage of life when an individual escapes the frustration and anxiety of conflict. A person who becomes ill in the face of a disappointment which brought about attention sympathy as child. 4. UNDOING engaging in thoughts and action to cancel out threatening thoughts and actions occurred in the past. Feelings of guilt and anxiety are relieved for the moment as the patient symbolically reversely enacts or undoes the steps of the painful experience. Reversing the action helps the patient to make amends and atonement for some past actions. Example: when we are trying to re-establish rapport with person/s whom we have broken good relationship. 5. REACTION FORMATION unconsciously reverses unacceptable feelings and behaves in exact opposite manner. 6. DISPLACEMENT emotionally-charged situations or object are shifted to a relatively safe substitute situation or object. A student may not show expressly his resentment to his professor but later displaces her original feelings to dogs, cats, horses, etc. 7. SUBSTITUTION substituting one thing to another that is less gratifying. It is acceptance of something else in place of a desired object or need which cannot be obtained. The substitute is easier to obtain, socially acceptable and helps to achieve at least partial gratification. A rejected suitor accepting affection of another loved one. 3

8. SUBLIMATION rechanneling socially unacceptable urges into socially acceptable manner. Example: Strong sexual desires is sublimated into creative arts such as writing, sculpture, design. 9. COMPENSATION exaggerating a trait to mask up feelings of inadequacy and inferiority. Is used when a person attempts to overcome some inability and inferiority. Helps to maintain ones self respect and raise self-esteem. Example: Short person may talk loudly to gain acceptance, an unattractive person may dress like a fashion model to attract admiration. 10. IDENTIFICATION integrating attributes of an admired persons to compensate perceived inadequacy. Unconscious imitation of mannerisms, behavior, feelings in accordance with those considered as heroes and heroines. 11. INTROJECTION complete acceptance of anothers opinions as ones own. For instance feeling of persecution might be introjected by the growing child who listens to discussion filled with ideas of persecution. In later life, he might use such ideas to explain a failure 12. CONVERSION expressing unconscious emotional conflicts into physical symptoms. Converts emotional problem to physical symptoms Example: a person who lacks self-confidence to assume the executive responsibilities will develop symptoms of an illness which could prevent his acceptance of a promotion 13. PROJECTION attributing to others unacceptable feelings and behavior in oneself. Blaming or scapegoat mechanism. Individual may blame others for their failure. An alcoholic husband blaming the wife for the breakdown of marriage. 14. SYMBOLIZATION attributes meaning to represent an unacceptable idea or object. An idea, feeling, quality or object is represented by a meaningful sign. Repetitive hand washing may represent guilt; assuming a fetal position is a symbol of longing to return to dependency fetal period.

15. DENIAL blocking from conscious mind threatening object or event and refusal to recognize its existence. 4

An act to evade or escape the unpleasant reality of living by ignoring or refusing to acknowledge their existence An aging sick lady: Wala akong sakit,

16. RATIONALIZATION attempts to explain behavior by logical reasoning, makes acceptable excuses for behavior and feelings. Person states reasons which favor approval of his behavior by others. Helps to save face from embarrassment 17. FANTASY obtaining satisfaction by conscious distortion and unconscious needs or wishes. Daydreaming or imagination is a common behavior especially during adolescence When fantasy replaces reality in the life of an individual, it is pathological behavior. 18. ISOLATION separating thoughts and feelings connected with an event to prevent undue anxiety. Person consciously protects himself by avoiding situations or separates disturbing ideas from their affects

TREATMENT MODALITIES
A. ELECTROCONVULSIVE THERAPY (ECT) 1. Definition: a. induction of a brief tonic-clonic (grand-mal) seizure by passing an electric current through the brain. b. ECT is not a permanent cure. c. At risk clients includes those with recent myocardial infarctions, CVA, or clients with intracranial mass lesion. 2. Advantages: a. Works quietly than antidepressants b. Major depressive episodes with improvement rate at 80% 3. Administration: a. Medications Atropine- reduces secretions by blocking vagal stimulation Muscle relaxant (succinylcholine) General anesthesia with short acting barbiturates b. Side effects: - Temporary memory loss, headache, confusion. 4. Nursing Considerations: a. Prior to procedure NPO after midnight Explain the procedure to the client Check for the dentures b. Following the procedures 5

Remain with the client until alert Monitoring of vital signs Reorientation to the unit Giving reassurance regarding memory loss

5. Uses: a. Clients with major depressive and bipolar disorders, especially when psychotic symptoms are present such as delusions of guilt, somatic delusions and delusions of infidelity. b. Clients who have depression with marked pychomotor retardation and stupor. c. Manic clients whose conditions are resistant to Lithium and antipsychotic medications and client who rapid cyclers ( mood swings that are close together). d. Client with schizphrenia (especially catatonia), those with schizoaffective syndromes and psychotic clients. 6. Indications for use a. When antidepressant medications have no effect. b. When there is a need for a rapid definitive response, such as when a client is suicidal or homicidal. c. The client is in extreme agitation or stupor. d. The client has a history of poor medication, history of good ECT response. e. The client prefers it. Implementations Preprocedure: 1. Explain the procedure to the client. 2. Obtain informed consent. 3. NPO after midnight or at least 4 hours prior to treatment. 4. The client is requested to avoid. 5. Hairpins, contact lenses, and dentures are removed. Implementations during the Procedure 1. VS is monitored throughout the procedure. 2. Medications administered may include a short-acting anesthetic such as thiopental and a muscle relaxant. 3. 100% oxygen by mask via positive pressure is administered throughout the procedure. 4. An airway or bite block is placed to prevent biting of tongue. 5. Electrical stimulus is administered and the seizure should last 30-60 seconds. Implementations Postprocedure 1. Once the client is awake, talk to the client and take vital signs. 2. The client may be confused; provide frequent orientation (brief, distinct and simple). 6

3. The client returns to the nursing unit when a 90% 02 saturation is maintained, vital signs are stable and mental status is satisfactory. 4. Assess gag reflex prior to giving fluids, foods or medications.

B. PSYCHOTHERAPY 1. Definition a. goal oriented, corrective emotional experience with a therapist in order to effect behavioral change, including increased well-being b. Use of group techniques to modify feelings, attitudes and behaviors in clients. 2. Focus a. The basic concept involves understanding. b. The focus in on the interaction to the client, the purpose of the interaction, identification of the roles of the therapist and the client, and the use of primarily verbal means of communication. c. Non-verbal techniques include silence, body language, facial expressions and respect for personal space. 3. Levels of Psychotherapy a. Supportive helps the individual cope with his problems and include such techniques as diagnosis, advice, education, guidance, counseling and assurance. Allows the client to express feelings, explore alternatives and make decisions in a safe, caring environment. There is no plan to introduce new methods of coping instead the therapist reinforces the clients existing coping mechanisms. b. Reeducative therapy involves learning new ways to introduce new perceiving and behaving. The client enters into a new contract that specifies desired changes of behavior. Reeducative therapy includes short-term psychotherapy, reality therapy, cognitive restructuring and behavior modification. c. Reconstructive therapy it may involve 2 to 5 years of therapy or more and focuses on all aspects of the clients life. Emotional and cognitive restructuring of self takes place Positive outcomes include greater understanding of self and others, more emotional freedom and the development of potential abilities. 4. Length of Treatment a. Long Term 7

b. Short Term

C. CRISIS INTERVENTION 1. Definition: a time-limited (4-6 weeks) directive approach to help cope a crisis Crisis: a temporary state of severe emotional disorganization resulting from failure of coping mechanism and/or lack of support. 2. Phases of a Crisis a. Phase 1: External Precipitating Factors b. Phase 2: Perception of Threat Increase in anxiety Client may resolve or cope crisis Phase 3 Failure of coping Increasing disorganization Physical symptoms emerge Phase 4 Mobilization of internal and external resources Resolution related to precrisis functioning include functioning at a higher level, at the same level or at a lower level 3. Crisis Intervention a. Treatment is immediate, supportive and directly to the immediate crisis b. Goal-directed intervention c. Feelings of the client are acknowledged. d. Provides opportunities for expansion and validation of feelings. e. Connections are made between the meaning of the event and the crisis. f. Explores alternative coping mechanisms and tries new behaviors. D. BEHAVIOR MODIFICATION 1. Definition a. process for dealing with undesirable behavior by systematically changing its consequences. b. The belief is that behaviors are learned. c. Maladaptive behavior is a way of dealing with stress and the therapy is an approach to bringing about a change in the behavior. 2. Techniques: a. Systematic desensitization The reduction of intense reactions to a stimulus by repeated exposure to the stimulus in a weaker and milder form. b. Aversion therapy Negative reinforcement is a technique to change behavior 8

c. Operant conditioning use rewards to reinforce positive behaviors 3. Process: a. Determine the unacceptable behavior b. Replacing unacceptable with more adaptive behavior c. Apply learning principles d. Present positive reinforcement when desired behavior occurs e. Consistently reward desired behavior f. Consistently respond to unacceptable with negative reinforcement E. MILIEU THERAPY 1. Definition: Purposeful use of all interactions to assist client in developing interpersonal and social skills in a conducive physical and emotional environment 2. Characteristics a. Physical needs are met b. Decision making is clearly defined c. Provides testing ground for the establishment of new patterns of behavior d. Client is respected with needs, rights, opinions and protected from injury 3. Aspects of Therapy a. Emphasis is on social and group interaction b. The goal is to provide a climate in which clients gain awareness of their feelings and thoughts c. Maintenance of open communication through a meeting d. Awareness of roles, limitations, responsibilities and authority e. Availability of information 4. Activities a. Occupational therapy increase living skills and self-esteem b. Activity therapy increase social interaction and skill c. Play therapy choices of colors, toys and interaction with toys is revealing as reflection of childs situation in the family d. Recreational therapy e. Music therapy F. GROUP THERAPY 1. Definition: psychotherapeutic processes in formally organized groups to effect improvement in behavior through interactions 2. Types of groups: a. Structured groups has predetermined goals b. Unstructured discussion flows according to the members 3. Phases of group therapy a. Group orientation and development of identity b. Group interaction and observation of dynamics c. Resolution of dynamics and production of insights 4. Forms of therapy a. Psychodrama allows individuals to role play problems by altering various roles 9

helps in lessening emotional trauma by reenacting situations and opportunity to freely express feelings the audiences experiences the feelings and identifies with the action on the stage. b. Transactional analysis the three ego states of the individual, the parent, the child and the adult are examined. The goal is individual in the group will communicate from the proper ego states for the situation and the responses of others, thereby lessening conflict and promoting mature relationships. c. Gestalt therapy emphasis is the here and now emphasizes self-expression, self-exploration, and self-awareness in the present. The client and the therapist focus on everyday problems and try to solve them.

G. FAMILY THERAPY 1. Definition: a form of therapy base on the premise that it is the total family rather than the identified client that is dysfunctional. 2. Goal: to reestablish rational communication between family members a. family can reassess and recognize alliance b. family can resolve to accept differences between 3. Process: a. Problems are identified by each member b. Members discuss their involvement in problems c. Members discuss how problems affect them d. Members explore ways each of them can help resolve problems 4. Differences between family therapy and group therapy a. In family therapy participants enter therapy with a long-standing system of roles and interactions which must the therapist must learn. b. In group therapy relationship between participants begins with the first session; no history of a relationship.

PSYCHOPHARMACOLOGY

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THERAPEUTIC COMMUNICATION
is an interpersonal interaction between the nurse and client during which the nurse focuses on the clients needs to promote an effective exchange of information all nurses need skills in skills in therapeutic communication to effectively apply the nursing process and to meet standards of care for their clients. Establishing a therapeutic communication is one of the most responsibilities of the nurse when working with the client It can help nurses to accomplish many goals: It enables the nurse form a working relationship with both patient Identify the most important client concern at that moment Facilitate the clients expression of emotion Teach the client and family necessary self-care skills. Implement interventions designed to address the clients needs PRIVACY AND RESPECTING BOUNDARIES > people from some culture (Hispanic, Asian, Middle East, etc.) are more comfortable with less than 4-12 feet distance between while talking; nurses from European-Americans and African-Americans may feel uncomfortable if clients stands close when talking. Intimate Zone (0-18 inches between people) is comfortable for parents with young children, people who mutually desire personal contact, or people whispering. Invasion of this intimate zone by anyone else is threatening and produces anxiety. Personal Zone (18-36 inches): This distance is comfortable between family and friends who are talking. Social Zone (4-12 feet). This distance is acceptable for communication in social, work and business settings Public Zone (12-25 feet). This is an acceptable distance between a speaker and an audience. Both the client and the nurse can feel threatened if one invades others personal and intimate zone. If the nurse must invade the clients intimate or personal zone, he/she must ask permission
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 The therapeutic communication is comfortable when the nurse and

client are 3-6 feet apart. TOUCH can be comforting and supportive when it is welcome and permitted; though it is an invasion of personal and intimate space. Functional professional touch. Used in physical examinations or procedures Social-polite touch. Used in greeting, such as handshake, air kisses, etc. Friendship-warmth touch . A hug for greeting, arm thrown around the shoulder of a good friend, back slapping Love- intimacy touch . Tight hugs and kisses between lovers and close relatives Sexual-arousal touch. Used by lovers. when a staff member is going to touch a client for purposes of nursing care, he/she must verbally prepare the client before starting the procedure. USING THERAPEUTIC COMMUNICATION TECHNIQUES REFLECTING encourages client to recognize and accept own feelings communicates to the patient that the nurse has heard and understand what the patient is trying to communicate, and that the client has the right to have opinions, make decisions, and think independently. When reflecting feelings, the nurse focuses on the feelings and not the content of what is said. Client: Do you think I should tell the doctor? Nurse: Do you thinks you should? Client: My brother spends all my money and then has nerve to ask for more. Nurse: This causes you feel angry? RESTATING The nurse repeats what the client has said in approximately or nearly the same words the client has used. Restatement lets the client know that he or she communicated the idea effectively; this encourages the client to continue.
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 If the client has been misunderstood, he/she can clarify the information. Client: I cant sleep. I stay awake all night. Nurse: You have difficulty sleeping. Client: Im really mad, Im really upset. Nurse: Youre really mad and upset. CLARIFICATION nurse should seek information throughout the interaction with clients; this can avoid making assumptions it helps the client to articulate thoughts, feelings and ideas more clearly. Nurse: Im not sure that I follow Have I heard you correctly? EXPLORING delving further into a subject or idea. When clients deal with topics superficially, exploring can help the nurse examine the issue more fully. If the client expresses unwillingness, the nurse must respect the decision. Nurse: Tell me more about that Would you describe it more fully GIVING INFORMATION making the facts available to the client informing the client of facts increases knowledge about t a topic and lets the client know what to expect also builds trust with the client Nurse: My name is Visiting hours are This medication is for PRESENTING REALITY offering for consideration that which is real When it is obvious that the client is misinterpreting reality, the nurse can indicate what is real; the nurse does this by calmly expressing the nurses perception of the facts not by arguing with the client or belittling the experience.
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Nurse:

I see no one else in the room. Your mother is not here. Im a nurse.

ENCOURAGING DESCRIPTION OF PERCEPTION asking the client to verbalize what or she perceives may relieve the client of any tension Nurse: What does the voice seem to be saying. Tell me what makes you feel anxious. What is happening? ACCEPTING indicates reception and that the nurse has heard and followed the train of thought it does not imply agreement but non-judgmental facial expression, tone of voice, must also convey acceptance Nurse: Yes, I understand. I follow what you said. Nodding USING SILENCE Allows the client time to think and reflect; conveys acceptance Allows the client to take lead in the conversation. Remember that non-verbal communication is the most accurate reflection of attitude.

TEST TAKING STRATEGIES

A. Be empathetic and reflect the patients feelings. Empathy is the ability to perceive when another person experiences using that persons frame of reference. I can see that you are frightened about being here. You seem very upset.
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B. Give the correct information - Offering information encourages further communication from the client You are experiencing acute alcohol withdrawal; you see and feel things that arent real. There are many reasons for memory loss; tell me more about what you have noticed. C. Eliminate the incorrect responses 1. Nurse focused answers: Eliminate all choices if the focus of comment is on the nurse Be careful because these answers may sound very empathetic. The focus should always on the patient. That happened to me once I know from experience that this is hard for you 2. Dont worry remarks - Eliminate choices that offer false reassurance. It only discourages communication. It is going to be OK Dont worry. Your doctors will do everything necessary for your care. 3. Lets explore question - Avoid being a junior psychiatrist - It is not the nurses role to delve into the reasons why the patient is feeling in a particular way. - Let the patient verbalize the fact the he/she is sad, angry, fearful, or overwhelmed. Lets talk about why you didnt take your medications. Tell me why you really injured yourself. 4. Authoritarian Answers - The nurse is telling the patient what to do without regard to the feelings or desires.
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- Insisting that client follow what you command immediately. 5. Why questions Any response puts the patient on the defensive and is not therapeutic and therefore incorrect. These questions seek reasons and justification. Why questions imply disapproval of the patient who may become defensive. Can come in many forms and need not always begin with a why. - What makes you feel that - Why do you feel this way? 6. Closed ended- questions Questions that can be answered by yes or no. Closed-ended questions discourages the client from sharing thoughts and feelings. - Are you feeling guilty about what happened? - How many children do you have?

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Therapeutic Techniques Listening Being Silent Respecting the Client Providing Recognition and Acknowledgment Providing Feedback Offering to assist Focusing and Refocusing Clarifying and Validating Reflecting Making Observations Giving informations Presenting reality Summarizing Using open-ended questions Providing non-verbal encouragement Maintaning neutral responses Encouraging formulation of plan of action
Blocks

Giving advice Changing the subject Giving approval or disapproval Challenging the client Making stereotypical comments Making value judgments Placing the clients feelings on hold Asking the client why Being defensive

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SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)

inhibit serotonin reuptake Citalopram (Celexa) Fluoxetine (Prozac) Fluuvoxamine (Luvox) Paroxetine hydrochloride (Paxil) Sertraline hydrochloride (Zoloft)

Adverse Effects:
Nausea and diarrhea Dry mouth Sweating, hand tremor CNS stimulation (anxiety, agitation, akathisia, insomnia) Sexual dysfunction (diminished sexual drive, erection, ejaculation) Weight gain

Nursing Implementation
1. Monitor weight 2. Initiate safety precautions, particularly if dizziness occurs 3. Instruct the client to take a single dose in the morning to prevent insomnia 4. Administer with snack or with meals to reduce the risk of dizziness and lightheadedness 5. For the client on long term therapy, monitor liver and renal function test 6. Instruct the client to avoid alcohol 7. If the client forgets a dose, he/she can take it up within 8 hours of missed dose.

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TRICYCLIC ANTIDEPRESSANTS (TCAs)

blocks reuptake of serotonin and norepinephrine at the presynaptic neuron and blocks cholinergic neurons may reduce seizure threshold may reduce effectiveness of antihypertensive agents concurrent use with alcohol or antihistamines cans cause CNS depression concurrent use with MAOIs can cause hypertensive crisis

Amitriptylline (Elavil) Amoxapine (Asendin) Bupropion (Wellbutrin) Clomipramine (Anafranil) Desipramine hydrochloride (Norpramin) Doxepin hydrochloride (Sinequan) Fluoxetine hydrochloride (Prozac) Imipramine hydrochloride (Tofranil) Maprotiline (Ludiomil) Mirtazapine (Remeron) Nefazodone (Serzone) Nortriptylline hydrochloride (Aventyl) Protriptylline hydrochloride (Vivactil) Trazodone (Desyrel) Trimipramine maleate (Surmontil)

Adverse Effects:
Dry mouth, constipation, Difficulty voiding Dry nasal passages Urinary retention Dilated pupils and blurred vision Photosensitivity Cardiovascular disturbances Tachycardia, dysrhythmias Orthostatic hypotension Sedation Weight gain Anxiety, restlessness, irritability 19

 confusion Decreased libido, ejaculatory and erectile dysfunction

Nursing Implementation
1. Instruct the client that the medication may take several weeks to produce the desired effect (2-4 weeks after the first dose) 2. Monitor pattern of daily bowel activity 3. Administer with milk or food if G.I. distress occurs 4. Administer the entire daily oral dose at one time, preferably at bedtime. 5. Assess for urinary retention 6. Instruct the client to change position slowly to avoid hypotensive effect 7. For the client on long-term therapy, monitor liver and renal function test 8. Instruct the client to avoid alcohol and nonprescription medications to prevent adverse medication interaction 9. Instruct the client to avoid driving and other activities requiring alertness 10. When the medication is discontinued, it should be tapered gradually 11. If the client forgets a dose, he/she should take it within 3 hours of missed dose or omit the dose for that day.

MONOAMINE OXIDASE INHIBITORS (MAOIs)

inhibit MAO enzyme present in the brain, blood platelets, liver, spleen, kidneys concurrent use with amphetamines, antidepressants, dopamine, epinephrine, guanethidine, levodopa, methyldopa, nasal decongestants, reserpine, tyraminecontaining foods may cause hypertensive crisis concurrent use with narcotic analgesics may cause hyper/hypotension, coma or seizures Isocarboxacid (Marpil) Phenelzine (Nardil) Tranylcypromine sulfate (Parnate)

Adverse Effects:
Orthostatic hypotension Restlessness Insomnia, daytime sedation Weight gain 20

Dizziness Weakness, lethargy GI upset Dry mouth Peripheral edema CNS stimulation including anxiety, agitations and mania Delay in ejaculation Hypertensive Crisis hypertension, occipital headache radiating frontally, neck stiffness, sweating, fever and chills, clammy skin, dilated pupils, chest pain, palpitations, tachycardia, bradycardia antidote: Phentolamine 5 10 mg IV

Nursing Implementation
1. Monitor BP frequently for hypertension/hypertensive crisis 2. If palpitations or frequent headaches occur, discontinue the medication and notify the physician 3. Administer with food if GI distress occurs 4. Instruct the client that the medication effect may be noted during the first week of therapy, but maximum benefit may take up to 3 weeks 5. Instruct the client to report headache, neck stiffness immediately 6. Instruct the client to change position slowly to prevent orthostatic hypotension 7. Instruct the client to avoid caffeine or OTC medications such as weight reducing pills or cold remedies 8. Avoid administering the medication in the evening because insomnia may result 9. MAOIs should be tapered and discontinued 7-14 days before surgery 10. When the medication is discontinued it should be discontinued gradually 11. Instruct the client to avoid foods that contain tyramine

Tyramine-containing Foods Cheese especially aged, except cottage cheese Sour cream Pickled herring Avocado Banana Papaya Broad beans Figs Overripe fruit Brewers yeast Meat extracts and tenderizers Yogurt Sausage, bologna, pepperoni, salami Soy sauce Raisins Red Wine, beer Beef or chicken liver Caffeine as coffee, team chocolate

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ANTIMANIC MEDICATIONS
Lithium carbonate (Eskalith, Lithane, Lithobid) Lithium citrate (Cibalith-Si) affects cellular transport mechanism and alter both the presynaptic and postsynaptic events affecting serotonin, thus enhancing serotonin function normalizes the reuptake of NE, serotonin, acetylcholine, dopamine; also reduces release of NE concurrent use with diuretics, fluoxetine, methyldopa, or NSAIDs increases renal reabsorption and/or excretion, either of which increases the risk of toxicity Acetazolamide, aminophylline, phenothiazines, or sodium bicarbonate may increase renal excretion Dosages generally range from 900-3,600 mg Therapeutic serum level: 0.6 to 1.2mEq/L Decrease sodium intake, fluid, electrolyte loss due to severe sweating, DHN, diuretic therapy, illness may cause increase in lithium level Serum levels should be checked every 1-2 months or whenever behavioral changes suggest altered serum level Blood samples should be checked in the morning, 12 hours after the last dose was taken

Adverse Effects:
Polyuria Polydipsia Metallic taste Dry mouth Weight gain, acne Abdominal bloating Nausea, soft stools, diarrhea Fine hand tremors Inability to concentrate Muscle weakness Lethargy, Headache Hair loss

Nursing Implementations
1. Administer with food to minimize GI irritation 2. Instruct the client to maintain a fluid intake of 6-8 glasses or water a day 3. Instruct the client to avoid excessive amounts of coffee, tea, or cola, which have a diuretic effect 4. Instruct the client to maintain adequate salt intake 5. Do not administer diuretics while client is taking Lithium 6. Instruct the client to avoid alcohol 22

7. Instruct the client to avoid OTC medications 8. Instruct the client that he/she may take a missed dose within 2 hours of the scheduled time; otherwise the client should skip the missed dose and take the next dose at the scheduled time. 9. Instructing the client not to adjust the dosage without consulting the physician, because lithium should be tapered off and not discontinued abruptly 10. Instruct the client that the therapeutic response will be noted in 1-3 weeks. 11. Monitor ECG, renal function and thyroid tests.

Lithium toxicity
symptoms occur when serum level is 1.5 to 2.0 mEq/L

Assessment
1. Mild 1.5 mEq/L apathy, lethargy, diminished concentration, mild ataxia, coarse hand tremors, slight muscle weakness 2. Moderate 1.5 to 2.5 mEq/L nausea/vomiting, severe diarrhea, moderate ataxia and incoordination, slurred speech, tinnitus, blurred vision, muscle twitching, irregular tremor 3. Severe 2.5 mEq/L nystagmus, muscle fasciculation, hyperreflexia, visual or tactile hallucinations, oliguria/anuria, impaired LOC, seizure, coma

Nursing Implementation
1. 2. 3. 4. Hold Lithium and notify physician Monitor cardiac status Prepare to obtain Lithium level; electrolyte, BUN, creatinine, CBC Monitor for suicidal tendencies and institute suicide precautions

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ANXIOLYTIC MEDICATIONS
depress the CNS, increasing the effects of gamma-aminobutyric acid (GABA), which produces relaxation and may depress the limbic system Benzodiazepines have anxiety-reducing (anxiolytic), sedative hypnotic, muscle relaxing and anticonvulsant actions. Benzodiazepines Alprazolam (Xanax) Chlordiazepoxide (Librium) Clonazepam (Klonopin) Clorazepate (Tranxene) Diazepam (Valium) Estazolam (ProSom) Flurazepam (Dalmane) Halazepam (Paxipam) Lorazepam (Ativan) Oxazepam (Serax) Prazepam (Centrax) Quazepam (Doral) Temazepam (Restoril) Triazolam (Halcion)

Adverse Effects:
Daytime sedation Dizziness, poor coordination, impaired memory, clouded sensorium Blurred or double vision Tremor Amnesia Slurred speech Urinary incontinence Constipation Paradoxical CNS stimulation Physical dependence except Buspirone (BuSpar)

Acute Benzodiazepine Toxicity somnolence confusion diminished reflexes and coma 24

 antidote: Flumazenil (Romazicon) a benzodiazepine antagonist, administered IV, will reverse intoxicaton in 5 minutes the client being treated for an ovedose may experience agitation, restlessness, discomfort and anxiety.

Nursing Implementation
1. Monitor for responses such as agitation, trembling, and tension 2. Monitoring for autonomic responses such as cold, clammy hands and sweating 3. Monitoring for paradoxical CNS stimulation during early therapy, particularly in elderly or debilitated individuals 4. Monitor for visual disturbances; it can worsen glaucoma 5. Monitor liver, renal function test and blood count 6. Initiate safety precaution especially elderly client due to risk of falling 7. Instruct the client that drowsiness usually disappears during continued therapy 8. Instruct the client to avoid tasks that require alertness until the response to the medication is established 9. Instruct the client to avoid alcohol 10. Instruct the client not to withdraw the medication abruptly; the dosage should be tapered gradually over 2 to 6 weeks.

ANTI-INSOMNIA AND ANXIOLYTIC

enhances the inhibitory effect of GABA used for short term treatment of insomnia or for sedation to relieve anxiety, tension and apprehension. Barbiturates and Sedative-Hypnotic Anxiolytics BARBITURATES Amobarbital (Amytal) Aprobarbital (Alurate) Butabarbital (Butisol) Pentobarbital (Nembutal) Phenobarbital (Luminal) Secobarbital (Seconal) SEDATIVE-HYPNOTIC ANXIOLYTICS Buspirone (BuSpar) Chloral Hydrate (Noctec) Ethychlorvynol (Placidyl) Hydroxyzine hydrochloride (Atarax) Meprobamate (Equanil) Zolpidem tartrate (Ambien) 25

Adverse Effects:
Confusion Irritability Alllergic reactions Agranulocytosis Thrombocytopenic purpura Megaloblastic anemia

Overdosage: tachycardia hypotension cold and clammy skin dilated pupils weak and rapid pulse signs of shock depressed respirations absent reflexes coma and death may result from respiratory and cardiovascular collapse Withdrawal - begin within 24 hours after the medication is discontinued in an individual with severe drug dependence - gradual withdrawal is used to detoxify a dependent person anxiety insomnia nightmares daytime insomnia tremors delirium seizures

Nursing Implementation
1. Medication should be used with caution in the client who has suicidal tendencies or has a history of drug addiction 2. Maintain safety; supervise ambulation; use side rails at night 3. Instruct the client to avoid driving or operating hazardous equipments if drowsiness, dizziness or unsteadiness occurs 4. Instruct the client to avoid alcohol 5. For insomnia, instruct the client to take the medication 30 minutes before bedtime 6. Instruct the client not to discontinue the medication abruptly 26

7. Instruct the client to take Chloral Hydrate with food to improve taste and prevent gastric irritation

ANTIPSYCHOTIC MEDICATIONS
blocks dopamine receptor in the brain reducing psychotic symptoms; also blocks CTZ in the brain producing an antiemetic effect Phenothiazines may lower seizure threshold Antipsychotic should not be given with other antispychotic or antidepressant medications

CONVENTIONAL ANTIPSYCHOTICS Phenothiazines Chlorpromazines (Thorazine) Perphenazine (Trilafon) Fluphenazine (Prolifin) Thioridazine (Mellaril) Trifluoperazine (Stelazine) Thiothixene (Navane) Butyrophenones Haloperidol (Haldol) Droperidol (Inapsine) ATYPICAL ANTIPSYCHOTICS Clozapine (Clozaril) Risperidone (Risperdol) Olanzapine (Zyprexa) Quetiapine (Seroquel) NEW GENERATION ANTIPSYCHOTIC Aripiprazole (Abilify)

Adverse Effects
dry mouth tachycardia urinary retention constipation hypotension drowsiness 27

blood dyscrasias pruritus photosensitivity EPS

Nursing Implementation
1. 2. 3. 4. 5. Monitor VS Note that liquid concentrate has faster absorption rate Avoid direct contact with liquid concentrate to prevent dermatitis Protect the liquid concentrate from light Inform the client that a full therapeutic effect may not be evident for 3 to 6 weeks following initiation of therapy; however observable therapeutic response may be observed after 7 to 10 days 6. Inform the client that phenothiazines may cause pinkish to red-brown urine color 7. Instruct the client to use sunscreen, hats and protective clothing when outdoors 8. Instruct the client to avoid alcohol or other CNS depressants 9. Instruct the client to report sore throat, fever and malaise, jaundice, RUQ pain 10. When discontinued, it should be withdrawn gradually to avoid sudden recurrence of psychotic symptoms 11. Administer medications for extrapyramidal symptoms

DRUGS USED TO TREAT EPS Amantadine (Symmetrel) Benztropine (Cogentin) Biperiden (Akineton) Diazepam (Valium) Diphenhydramine (Benadryl) Lorazepam (Ativan) Propranolol (Inderal) Trihexyphenidyl (Artane)

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