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BASIC CONCEPTS IN PSYCHIATRIC NURSING

MENTAL HEALTH
Balance in a persons internal life and adaptation to reality.
A state of well being in which a person is able to realize his
potentials.
Characteristics :
attitude of self-acceptance
growth, development and self-actualization
integrative capacity
autonomous behavior
perception of reality
environmental mastery

MENTAL ILLNESS
A state of imbalance characterized by a disturbance
in a persons thoughts, feelings and behavior.
Poverty abd abuses are major factors which increases
the risk of mental illness in the home.
PSYCHIATRIC NURSING
Interpersonal process whereby the professional nurse
practitioner through the 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.
It is both Science and an Art.
Science in Psychiatric Nursing.
the use of different theories in the practice of nursing,
serves as the science of psychiatric nursing.

Art in Psychiatric Nursing.


The therapeutic use of self is considered as the art of
psychiatric nursing.
Core of Psychiatric Nursing.
The interpersonal process, that is, the human to human
relationship, is the core of psychiatric nursing.
Clientele in Psychiatric Nursing.
The individual, family, and the community, both mentally
healthy and mentally ill.
Mental Hygiene.
It is the science that deals with measures to promote
mental health, prevent mental illness and suffering and
facilitate rehabilitation.

THERAPEUTIC USE OF SELF


- THERAPEUTIC USE OF SELF SERVES AS THE NURSES MAIN
TOOL.

CORE CONCEPT

- It is the positive use of ones self in the process of therapy.


- It requires self-awareness.

BASIS OF THERAPEUTIC USE OF SELF


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

Area of the unknown


IV

Psychiatry
field of medicine: a medical specialty concerned
with the diagnosis and treatment of disorders
that have primarily mental or behavioral
symptoms and with the care of people having
such disorder.
Psychiatric Nursing
Is an interpersonal process that promotes and
maintains behavior that contributes to integrated
functioning. It is a specialized area of nursing
practice employing theories of human behavior
as its science and purposeful use of self as it art.
Is the specialty of nursing that cares for people of
all ages with mental illness or mental distress
such as psychosis,depression

What is the science in psychiatric nursing?


The use of different theories in the practice of
nursing, serves as the science of psychiatric
nursing.
What is the art in psychiatric nursing?
The therapeutic use of self is considered as
the art of psychiatric nursing
What is the core of psychiatric nursing?
The interpersonal process, that is, the human
to human relationship, is the core of
psychiatric nursing

Who are the clients of the nurse in


psychiatric settings?
The individuals, family, and the community,
both mentally healthy and mentally ill, are
considered as the clientele in psychiatric
nursing.

The aims and functions are:

Determine etiology or cause:


ascertains the cause of a patients
disorder

Diagnosis: ascertain the nature of a


patients illness; study the origin,
development, and symptoms of the
disorder through various methods and
techniques

Prognosis: determine the cause and


probable outcome of the patients disorder;
estimate how long the treatment take and
whether the patient will recover completely,
partially, or not at all.

Treatment or Psychotherapy: medication,


electroshock and surgery, the procedure is
referred to as treatment; psychoanalysis,
interview analysis, hypnoanalysis, and
reeducation, the procedure is referred to as
psychotherapy.

Principles of Care in Psychiatric Settings

The nurse views the patient as a Holistic human


being with interdependent and interrelated needs
The nurse accepts the patient as a unique human
being with inherent value and worth exactly as he
is
The nurse should focus on the patients strengths
and assets and not on his weakness and liabilities
The nurse views the patients behavior nonjudgmentally, while assisting the patient to learn
more adaptive ways of coping

The nurse should explore the patients


behavior for the need it is designed to meet
and the message it is communicating

The nurse has the potential for establishing a


nurse-patient relationship with most if not all
patients.

The quality of the nurse-patient relationship


determines the degree of change that can
occur in the patients behavior

DEFENSE MECHANISM
DEFENSE
MECHANISM

COMMON
EXAMPLE

PATIENT
EXAMPLE

REPRESSION
- Unconscious
and involuntary
forgetting of
painful ideas,
events and
conflicts.

A car accident
victim is unable
to remember
the details of
the impact, but
was aware of
the time.

Mrs. Jose, a
victim of incest,
does not know
why she has
always hated
her uncle.

SUPPRESSION
voluntary
exclusion from
awareness,
anxiety-producing
feelings, ideas,
and situations.

A student
states, I
cannot think
about my
wedding
tonight. I have
to study.

Michelle tells
the nurse that
she is not
ready to talk
about her
recent
separation.

DENIAL
unconscious
refusal to admit
an unacceptable
idea or behavior.

A student
refuses to
admit that she
is flunking a
course despite
a 65 on the
midterm
exam.

Mr. David, who


is alcohol
dependent,
states that he
can control his
drinking.

RATIONALIZATION
attempts to make or
prove that ones feelings
or behaviors are
acceptable.

A student
states, I got a
70 on the test
because the
questions are
confusing.

Mr. Honorio, a
paranoid
schizo, states
that he cannot
go to work
because he is
afraid of his
co-workers.

INTELLECTUALIZATION
using only logical
explanations without
feelings or an affective
component.

An older adult
is asked to
share her
feelings on
death. She
reviews all the
stages of DD.

Mrs. Mana
talks about her
sons death
and bout with
cancer without
showing any
signs of
sadness.

IDENTIFICATION
a conscious or
unconscious
attempt to model
oneself after a
respected person.

When a little girl


dresses up like her
mother to play
house, she tries to
talk and act like
her mother.

Shiela tells the


nurse, When I
get out of the
hospital, I want to
be a nurse just
like you.

COMPENSATION
covering up for
a weakness by
overemphasizing
or making a
desirable trait.

An academically
weak HS student
becomes a star in
the school play.

A schizo patient
who is unable to
talk to other
patients becomes
known for his
expressive poetry.

INTROJECTION
unconsciously
incorporating
wishes, values,
and attitudes of
others as if they
were your own.

While her
mother is
gone, a young
girl disciplines
her brother
just like her
mother.

Without
realizing it, a
patient talks
and acts like his
therapist,
analyzing other
patients.

PROJECTION blaming
someone else
for ones
difficulties or
placing ones
unethical
desires on
someone else.

A teenager
comes home
late from a
date and
states that her
friends did not
bring her
home on time.

Kathy states
that she used
marijuana while
on pass
because her
boyfriend made
her smoke it.

REACTION
FORMATION - a
conscious
covering
behavior that is
the exact
opposite of an
unconscious
feelings.

An older
brother who
dislikes his
younger
brother sends
him gifts for
every holiday.

Maria, who
unconsciously
hates her
mother,
continuously
tells staff how
wonderful her
mother is.

SUBLIMATION
channeling
instinctual
drives into
acceptable
activities.

An adolescent
arrested once
for stealing
later opens
business
installing
security

A former victim
of violence
joins the VACC
and
encourages
others to do
the same.

DISPLACEMEN
T discharging
pent-up feelings
to a less
threatening
object.
Redirecting
emotions or
impulses to
others

A husband
comes home
and yells at
his wife after a
bad day at
work.

Mrs. Fa screams
at another
patient after
being told by
her psychiatrist
that she cannot
have a weekend
pass.

CONVERSION
the unconscious
expression of
intrapsychic
conflict
symbolically

A student
awakens with
a migraine the
morning of a
final exam and
feels to ill to

Mr. Jeff
suddenly
develops
impotence after
his wife
discovers he is

UNDOING /
RESTITUTION
doing
something to
counteract or
make up for a
transgression or
wrongdoing.

After the mother


spanking her
son, she makes
his sons favorite
spaghetti.

After eating another


patients cookies,
Mrs. Dina apologizes
to the patient, cleans
the ref, and labels
everyones snack
with their names.

REGRESSION
return to an
earlier and
more
comfortable
developmental
level.

A 6-y/o wets the


bed at night
since the birth of
his baby sister.

Mr. Hugo has isolated


himself in his room
and has lain a fetal
position since his
admission.

FANTASY - A person
uses non-rational
mental activity to
escape from daily
pressures and
responsibilities.

SYMBOLIZATION
representing an idea
of object by a
substitute object of
sign.

A housewife
faced with a sink
full of dirty
dishes dreams
she has a live-in
maid.

A schizo pt
escapes the
real world by
hallucinations.

CORE CONCEPTS ON THE CARE OF


PSYCHOTIC PATIENT .
COMMON BEHAVIORAL SIGNS AND SYMPTOMS

1. Disturbances in perception:
Illusion misperception of an actual external stimuli.
Hallucination false sensory perception in the absence of external
stimuli.

2. Disturbances in thinking:
Neologism pathological coining of new words.
Circumstantiality over inclusion of details.
Word salad incoherent mixture of words and phrases.

Echolalia pathological repetition of words of others.


Flight of ideas shifting of one topic form 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 words gives direction to the flow
of thought.
Delusion false belief which is inconsistent with ones knowledge and
culture and cannot be corrected by reasons.
3. Disturbances of affect.
Inappropriate affect disharmony between the stimuli and the
emotional reaction.
Flat affect absence or near absence of emotional reaction.
Apathy dulled emotional tone.
Blunted affect severe reduction in emotional reaction.
Ambivalence presence of two opposing feelings.
Depersonalization feeling of strangeness towards ones self
Derealization feeling of strangeness towards the environment

4. 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.
5. Disturbances in memory.
Confabulation filling in memory gap.
Amnesia inability to recall past events.
Anterograde amnesia loss memory of the immediate past.
Retrograde amnesia loss of memory of the distant past.
Dj vu feeling of having been to place which one has not yet
visited.
Jamais vu feeling of not having been to a place which one has
visited.

CORE CONCEPTS ON THERAPEUTIC


COMMUNICATION.

Communication refers to the reciprocal exchange of ideas between


or among persons.
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 techniques in communication


To initiate conversation:
- Giving broad openiong: giving the patient an opportunity
to set the direction of the conversation.
Example: Is there anything that you want to talk about?
- Giving recognition: focusing on the positive aspects of
the patients personality.
Example: I noticed that you combed your hair today.
To establish rapport and build trust
- Giving information: responding with the needed facts.
- Use of silence: refraining from sppech to give the
patient a time to sort out thoughts and feelings.

To gather information
- Focusing: assisting a patient to explore a specific topic.
Example: Patient: I cant decide about
Nurse: Lets talk about that. Perhaps if we talk about it, it
will help you to decide.
- Validating: confirming ones observation.
Example: Are you saying that
- Relflecting: directing back ideas, feelings and content.
Example: You feel tense when you fight.
- Restating: repeating what the patient had said.
- Summarizing: developing a concise resume of what has transpired

Proxemics: is the study of distance zones


between people during communication.

Intimate zone (0 to 18 inches between people):


This amount of space 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 to 36 inches): this distance


is comfortable between family and friends who
are talking.

Social zone (4 to 12 feet) : This


distance is acceptable for
communication in social, work, and
business setting.

Public zone (12 to 25 feet): This is an


acceptable distance between a speaker
and an audience, small groups, and
other informal functions.

Touching

a client may be
comforting and
supportive if it is
permitted and
welcome; nurse must
evaluate whether the
client perceives touch
as positive or
threatening and
unwanted and should
never assume that
touching a client is
acceptable

Five Types of Touch

Functional-professional touch is used in


examination or procedures such as when
the nurse touches a client to assess skin
turgor or a masseuse performs a massage.

Social-polite touch is used in greeting,


such as a handshake and the air kisses
some women use to greet acquaitances, or
when a gentle hand guides someone in the
correct direction.

Friendship-warmth touch involves a hug in


greeting, an arm thrown around the
shoulder of a good friend, or the back
slapping some men use to greet friends and
relatives

Love-intimacy touch involves tight hugs


and kisses between lovers or close relatives

Sexual-arousal touch is used by lovers

NURSE PATIENT RELATIONSHIP

- Series of interaction between the nurse and


patient in which the nurse assist the patient to
attain positive behavioral change.

CHARACTERISTICS

It is goal directed, focused on the needs of the


patient, planned, time limited and professional.

BASIC ELEMENTS

Trust
Rapport
Unconditional positive regard
Setting limits
Therapeutic communication

PHASES
A. PRE-INTERACTION PHASE

Begins when the nurse is assigned to a


patient.
Phase of NPR in which the 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: develop self
awareness
Data gathering, planning for first
interaction

B. ORIENTATION PHASE
Begins when the nurse and the patients
interacts for the first time
Parameters of the relationship are laid
Nurse begins to know about the patient
Major task of the nurse: develop a mutually
acceptable contract
Determine why the patient sought help
Establish rapport, develop trust, assessment

C. WORKING PHASE

It is highly individualized

More structured than the orientation phase

The longest and most productive phase of the NPR

Limit setting is employed

Major task: Identification and resolution of the


patients problems

Planning and implementation

D. TERMINATION PHASE
It is a gradual weaning process
It is a mutual agreement
It involves feelings of anxiety
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
Evaluation

When to Terminate?

When goals have been accomplished


When the patient is emotionally
stable
When the patient exhibits greater
independence
When the patient able to cope with
anxiety separation, fear and loss

How to Terminate?

Gradually decreased interaction


time
Focus on future oriented topics
Encourage expression of feelings
Make the necessary referral

COMMON PROBLEMS AFFECTING


COMMUNICATION
Transference the development of an emotional
attitude of the patient either positive or negative
towards the nurse
Resistance development of ambivalent feeling
towards self- exploration
Counter transference transference as
experienced by the nurse

PRINCIPLES OF CARE IN PSYCHIATRIC


SETTINGS

The nurse views the patient as a Holistic


human being with interdependent and
interrelated needs
The nurse accepts the patient as a unique
human being with inherent value and worth
exactly as he is.
The nurse should focus on the patients
behavior non-judgmentally, while assisting
the patient to learn more adaptive ways of
coping

The nurse should explore the patients


behavior for the need it is designed to meet
and the message it is communicating

The nurse has the potential for establishing


a nurse-patient relationship with most if not
all patients

The quality of the nurse-patient


relationship determines the degree of
change that can occur in the patients
behavior.

LEVELS OF INTERVENTIONS IN PSYCHIATRIC


NURSING
Primary interventions aimed at the promotion of mental
health and lowering the rate of cases by altering the
stressors
Examples: Health education
Information dissemination
Counseling
Secondary Intervention that limit the severity of a
disorder
Two components
1. Case finding
2. Prompt treatment
Examples: Crisis intervention
Administration of medications

Tertiary interventions aimed at reducing the disability after a disorder


Two components
1. Prevention of complication
2. Active program of rehabilitation
Examples: Alcoholic anonymous
Occupational therapy
CHARACTERISTICS OF A PSYCHIATRIC NURSE
Empathy the ability to see beyond outward behavior and sense
accurately another persons inner experiencing
Genuineness/Congruence ability to use therapeutic tools
appropriately
Unconditional positive regard RESPECT
ROLES OF THE NURSE IN PSYCHIATRIC SETTINGS
Ward manager creates a therapeutic environment
Socializing agent assists the patient to feel comfortable with others
Counselor listens to the patients verbalizations
Parent surrogate assists the patient in the performance of activities
of daily lining

Patient advocate enables the patient and his relatives to know their
rights and responsibilities
Teacher assists the patient to learn more adaptive ways of coping
Technician facilitates the performance of nursing procedures
Therapist explores the patients needs, problems and concerns
through varied therapeutic means
Reality base enables the patient to distinguish objective reality and
subjective reality
Healthy role model acts as a symbol of health by serving as an
example of healthful livings

PSYCHOPHARMACOLOGY

BASIC CONCEPTS ON
PSYCHOPHARMACOLOGY

C heck why the medication is given and


know the classification of the drug.

H ow will you know if the medication is


effective.

E xactly what time should the medication be


given.

C lient teaching tips. What would you tell


your patient to expect.

K eys to giving it safely.

Psychopharmacolgic agents
A. Major tranquilizers/antipsychotic/neuroleptics
Common indication : Schizophrenia
Examples:
Haloperidol (Haldol)
Prochlorperazine (Compazine)
Fluphenazine (Prolixin)
Chlorpromazine (Thorazine)
Clozapine (Clozaril)
Olanzapine (Zyprexa)

ANTIPSYCHOTIC/
NEUROLEPTIC DRUGS

dopamine receptor blockers


typical or atypical

Typical causes several adverse


effects associated with Dopamine-2
receptor blockage

ANTIPSYCHOTIC/
NEUROLEPTIC
DRUGS
Typical

EPS (Extrapyramidal Side-effects) common

Pseudoparkinsonism muscle tremors,


cogwheel rigidity, shuffling gait, slow
movements
Dystonia spasms of tongue, neck, back and
legs, abnormal eye movements, drooling
Akathisia continuous restlessness, foot tapping
Tardive dyskinesia lip smacking, tongue
darting, chewing movts, slow arm and leg
movts

ANTIPSYCHOTIC/
NEUROLEPTIC
DRUGS
Typical

EPS (Extrapyramidal Side-effects) common

Pseudoparkinsonism muscle tremors,


cogwheel rigidity, shuffling gait, slow
movements
Dystonia spasms of tongue, neck, back and
legs, abnormal eye movements, drooling
Akathisia continuous restlessness, foot tapping
Tardive dyskinesia lip smacking, tongue
darting, chewing movts, slow arm and leg
movts

ANTIPSYCHOTIC/
NEUROLEPTIC DRUGS

Typical
Chlorpromazine (Thorazine),
Fluphenazine (Prolixin),
Haloperidol (Haldol),
Thioridazine (Mellaril) =>
classified as Phenothiazines

ANTIPSYCHOTIC/
NEUROLEPTIC DRUGS

Atypical blocks both Dopamine and


Serotonin receptors => less neurologic
effects and depression
blocks more of D1 and D4 receptors =
less EPS
Diabetes Mellitus can develop from
using these drugs
Clozapine (Clozaril), Olanzapine
(Zyprexa), Risperidone (Risperdal),
Ziprasidone (Geodon)

ANTIPSYCHOTIC/
NEUROLEPTIC DRUGS

Antipsychotics in General
Indications: psychosis (Bipolar,
Schizophrenia, Autism)
Contraindications: hypotension, CAD,
glaucoma, PUD, urinary, intestinal
obstruction

ANTIPSYCHOTIC/
NEUROLEPTIC DRUGS

Side effects: Sedation, weakness, tremor,


drowsiness,
CV: hypotension, arrhythmias, CHF
anticholinergic effects (dry mouth, nasal
congestion, flushing, constipation,
urinary retention, photophobia, blurred
vision
! pink to reddish-brown urine: no
clinical significance (common in
phenothiazines)

ANTIPSYCHOTIC/
NEUROLEPTIC DRUGS

Adverse: EPS, Neuroleptic


Malignant Syndrome (NMS),
myelosuppression
Drug interactions: beta-blockers,
anticholinergics additive effect

ANTICHOLINERGICS
oppose the effects of acetylcholine in the
substantia nigra and corpus striatum
Synthetic drugs (greater affinity to CNS than
other Anti-Chs)
General side effects: slowed GI motility, dry
mouth, constipation, urinary retention, blurred
vision, dilated pupils, disorientation, decreased
sweating
Benztropine (Cogentin), Biperiden
(Akineton), Diphenhydramine (Benadryl)
Used as adjunct to levodopa in managing
parkinsonism

ANTICHOLINERGICS
Contraindications: allergy, glaucoma,
GI obstruction, prostatic hypertrophy,
Myasthenia Gravis
Drug interactions: TCA,
Phenothiazines => increased
toxicity, paralytic ileus

DOPAMINERGICS

Increase the effects of dopamine at


receptor sites
More effective than anticholinergics

DOPAMINERGICS

Levodopa mainstay treatment for


parkinsonism

a dopamine precursor; crosses the BBB


and is converted to dopamine
given in combination with carbidopa
(Sinemet)
carbidopa inhibits the enzyme
dopamine decarboxylase in the
periphery, allowing more dopamine to
reach CNS

DOPAMINERGICS

Other dopaminergics: Amantadine


(Symmetrel), Bromocriptine
(Parlodel), Pergolide (Permax)

DOPAMINERGICS
Contraindications: glaucoma, skin
lesions (levodopa may cause melanoma)
SIDE EFFECTS: ataxia, hand tremors,
weakness, agitation, anxiety, anorexia,
nausea, dry mouth, flushing, urinary
retention
Drug interactions: MAOI potentiating
effects, increased risk of hypertensive
crisis; VITAMIN B6 decreased efficacy

DOPAMINERGICS
Nursing Considerations
Give drug with meals
Promote safety (due to CNS side effects)
Advise client not to eat foods rich in
Vitamin B6 (tuna, pork, dried beans, liver)
Monitor hepatic, renal, and hematological
tests
Allow patient to void prior to
administering the drug

ANTICHOLINERGICS
Nursing Considerations
Decrease/discontinue drug if there is
severe dryness of mouth
Establish safety precautions
Give drug with meals

Neuroleptic Malignant
Syndrome
life- threatening neurological disorder most

often caused by an adverse reaction to


neuroleptic or antipsychotic drugs
Signs/Symptoms
muscle cramps, muscle tremors

The muscular symptoms are most likely caused


by the blockade of D2 which cause problems in
the basal ganglia motor loop of the brain

unstable blood pressure and fever


agitation, delirium and coma
Leukocytosis and increased CPK

ANTIPSYCHOTIC/
NEUROLEPTIC
DRUGS
Nursing Considerations

Keep patient in recumbent position until 30


minutes after parenteral administration of drug
Gradual dose reduction, do not withdraw
abruptly
Protective positioning of legs
Promote safety and comfort measures (Side
rails, voiding before administration of drug,
candies for dry mouth)
Monitor VS, particularly temperature, BP, and
HR

C Antipsychotic
H Decreased delusions, hallucinations, and
looseness of association
E Best taken after meals
C Report sorethroat and avoid exposure to
sunlight. Report elevated temp. and muscle
rigidity, it indicate Neurologic Malignant
Syndrome.
K check the BP, the drug causes hypotension.
Observe for EPS, check the CBC, drygs cause
leukopenia

B. Anti-parkinsonian drugs
Indication: EPS (Extrapyramidal Syndrome)
Two Types:
1. DOPAMINERGIC DRUGS
Examples:
Amantadine (Symmetrel)
Levodopa
Levodopa-Carbidopa (Sinemet)
2. ANTICHOLINERGIC DRUGS
Examples:
Trihexylphenidyl (Artane)
Biperiden Hydrochloride (Akineton)
Benztropine Mesylate (Cogentin)
Diphenhydramine Hydrochloride (Benadryl)

C Antiparkinsonian drug

H Muscles become less stiff; decreased


pill-rolling tremors

E Best taken after meals

C Avoid driving, the drug causes blurred


vision

K Check the BP, the drug may cause


hypotension

C. Minor Tranquilizers/Anxiolytics
Common indication: Anxiety disorders
Examples: Diazepam (Valium)
Oxazepam (Serax)
Chlodiazepoxide (Librium)
Chlorazepate Dipotassium (Tranxene)
Alprazolam (Xanax)
C Antianxiety; given as muscle relaxant to patients in
traction
H Decreased anxiety, adequate sleep
E Best taken before meals, food in the stomach delays
absorption
C Avoid driving, intake of alcohol and caffeine
containing foods,
since it alters the effect of drug
K Administer it separately, it is incompatible with any
drug

ANTIDEPRESSANTS:

MONOAMINE OXIDASE
INHIBITORS (MAOIS)

Requires a specific diet regimen to prevent


toxicity (no tyramine in the diet)
Isocarboxazid (Marplan), Phenelzine
(Nardil), Tranylcypromine (Parnate)
Action: irreversibly inhibit MAO, an enzyme
that breaks down NE and dopamine =>
accumulation of NE and Dopamine in the
synaptic cleft => increased stimulation of
postsynaptic receptors => relief of
depression

MONOAMINE OXIDASE
INHIBITORS (MAOIS)
Indications: depression that is unresponsive to
other antidepressants
Side effects: dizziness, vertigo, HA,
overactivity, tremors, weakness, drowsiness,
fatigue, sweating, orthostatic
hypotension, dry mouth, diarrhea, edema
Adverse: HYPERTENSIVE CRISIS
Drug interactions: other anti-depressants hypertensive crisis, coma, convulsions
(TCA); sympathomimetics additive effect

MONOAMINE OXIDASE
INHIBITORS (MAOIS)

TYRAMINE RICH FOODS:


hypertensive crisis

Aged cheeses, beans, red wine,


smoked meats, liver HIGH
amounts of tyramine
Chocolates, cheeses, raisins, soy
products, yogurt, grapes
Moderate amounts of tyramine

MONOAMINE OXIDASE
INHIBITORS (MAOIS)
Nursing Considerations
Onset of therapeutic effect is within 2-4
weeks of treatment
Monitor BP closely, including other signs
of HTN such as severe headache
Have Phentolamine or other adrenergic
blocker on standby
Teach client about foods that are rich in
tyramine

D. Tricyclic Antidepressants
Examples: Imipramine Hydrochloride (Tofranil)
Amitriptyline (Elavil)
C Tricyclic anti-depressantprevents
H Increased appetite; adequate sleep
E Best given after meals
C Therapeutic effects may become evident only after 2
3 weeks of intake
K Check BP, it causes hypotension, Check the heart rate,
it causes
cardiac arrythmias

E. Antidepressant MAO inhibitors


Examples: Tranylcypromine (Parnate)
Phenelzine (Nadril)
Isocarboxazid (Marplan)
C Antidepressant MAO inhibitors
H Increased appetite; adequate sleep
E Best taken after meals
C Report headache; it indicates hypertensive crisis, avoid
tyramine
containing foods like:
Avocado
Banana
Cheddar and aged cheese
Soy sauce and preserved foods
It takes 2 3 weeks before initial therapeutic effects become
noticeable
K Monitor BP, There shoulb be at least a two week interval
when
shifting from one antidepressant to another

ANTIDEPRESSANTS:

TRICYCLIC
ANTIDEPRESSANTS

Reduce reuptake of Norepinephrine into


nerves => accumulation of NE in the
synaptic cleft => increased stimulation
of postsynaptic receptors
Clinical response: 2-4 weeks of
treatment
Imipramine (Tofranil), Amitriptyline
(Elavil), Clomipramine (Anafranil),
Nortriptyline (Pamelor)

ANTIDEPRESSANTS:

TRICYCLIC ANTIDEPRESSANTS
Indications: anxiety, sleep disturbances,
Indications: anxiety, sleep disturbances,
enuresis
Contraindications: allergy, MI, concurrent MAOI
use
Side effects: Sedation, fatigue, hallucinations,
disorientation, visual disturbances, weakness,
weight loss,

ANTICHOLINERGIC effects: dry mouth,


constipation, n/v, increased salivation, cramps,
diarrhea
CV: Orthostatic hypotension, hypertension, MI,
angina

ANTIDEPRESSANTS:

TRICYCLIC ANTIDEPRESSANTS

Drug interactions: SSRIs increased


TCA levels; Anticoagulants
increased bleeding; MAOI
hypertensive crisis

ANTIDEPRESSANTS:

TRICYCLIC ANTIDEPRESSANTS

Nursing Considerations
Ideally given at bedtime
Limit access to suicidal patients =>
risk for overdose
Provide comfort measures

SELECTIVE SEROTONIN
REUPTAKE INHIBITORS (SSRIS)

Newest group of antidepressants


Specifically block serotonin, with no
known effect on NE
Less side effects than other classes
Fluoxetine (Prozac), Paroxetine
(Paxil), Setraline (Zoloft), Citalopram
(Celexa), Escitalopram (Lexapro)
4 weeks of treatment before therapeutic
effects can be seen

SELECTIVE SEROTONIN
REUPTAKE INHIBITORS (SSRIS)

Indications: OCDs, panic attacks,


bulimia, PTSD, social anxiety disorders
Side effects: HA, nervousness,
insomnia, SEXUAL DYSFUNCTION, n/v,
diarrhea, dry mouth, weight loss, fever
Drug interactions: MAOIs, TCAs =>
increased therapeutic and toxic effects

SELECTIVE SEROTONIN
REUPTAKE INHIBITORS (SSRIS)
Nursing Considerations
establish suicide precautions
offer support if patients experience
sexual dysfunction

F. Anti Manic agent


Lithium Carbonate
C Anti- Manic
H Decreased hyperactivity
E Best taken after meals
C Increase fluid intake (3L / day) and sodium intake (3
gm / day). Avoid activities that increase perspiration
K It takes 10 14 days before therapeutic effect
becomes evident
Antipsychotic is administered during the first two
weeks to manage the acute symptoms of mania until
lithium takes effect.
Monitor serum level, normal is 0.5- 1.5meq/L,
NAUSEA, ANOREXIA, VOMITING, DIARRHEA,
AND

ANTIMANIC DRUGS

Lithium as the mainstay treatment


Very toxic, can cause severe CNS,
renal and pulmonary problems
Therapeutic lithium level: 0.6-1.2
mEq/L
Other antimanic drugs: Lamotrigine
(Lamictal), Quetiapine (Seroquel)

ANTIMANIC DRUGS
Action of Lithium: alters sodium
transport in nerve and muscle cells;
inhibits NE and Dopamine release =>
modulates the responsiveness of
hyperactive neurons
Contraindications: renal or cardiac
disease, history of leukemia, sodium
depletion, dehydration and diuretics use
! Lithium depletes sodium reabsorption =
severe hyponatremia

ANTIMANIC DRUGS
ADVERSE EFFECTS:
Mild toxicity CNS symptoms such as lethargy,
slurred speech, muscle weakness and fine tremor,
POLYURIA, beginning of gastric toxicity (NAUSEA,
VOMITING, DIARRHEA) => lithium levels < 1.5
mEqs/L

Moderate toxicity Same as above + ECG changes,


hypotension => lithium levels 1.5 2.5 mEqs/L

Severe toxicity Multiorgan failure, death =>


lithium levels above 2.5 mEqs/L

ANTIMANIC DRUGS

Drug interactions: HALDOL


aggravated side effects, including
encephalopathic syndrome
(weakness, lethargy, tremors, etc);
THIAZIDES increased lithium
toxicity; ANTACIDS Decreased
lithium efficacy

ELECTRO-CONVULSIVE THERAPY
Mechanism of action: Unclear at present.
Voltage applied to the patient: 70 150 volts
Duration of application: 0.5 2 seconds
Usual number of treatments to produce
therapeutic effect: 6 12 treatments
Frequency of treatments: An interval of 48 hours for each treatment.
Indications of effectiveness: Generalized tonic-clonic seizure
Indication for ECT: Depression, Mania, Catatonic Schizophrenia
Contraindication to ECT: Fever, Increased ICP, Cardiac problems,
TB with history of hemorrhage, Recent fracture, Retinal detachment,
Pregnancy.
Consent needed prior to ECT: YES
Medication prior to ECT
Atropine Sulfate to decrease secretions
Anectine (Succinylcholine) to promote muscle relaxation
Methohexital Sodium (Brevital) serve as an anesthetic agent
COMMON COMPLICATION: Loss of memory, Headache, Apnea,
Fracture, Respiratory depression.

ANTIMANIC DRUGS
Nursing Considerations
Give with meals
Maintain adequate salt and fluid
intake
Provide safety measures

COMMON PSYCHOTHERAPEUTIC
INTERVENTIONS

MUSIC THERAPY involves the use of


music to facilitate relaxation, expression
of feelings and outlet of tension.

PLAY THERAPY treatment modality


which enables the patient to experience
intense emotion in a safe environment
with the use of play.

GROUP THERAPY treatment modality

involving therapeutic interactions of three or more


patients with a therapist to relieve emotional
difficulties, increase self-esteem, develop insight
and improve behavior in relation with others. The
minimum number of members in a group therapy
is 3, while the ideal number is 8 10.
MILIEU THERAPY consists of treatment by
means of controlled modification of the patients
environment to facilitate positive behavioral
change.

FAMILY THERAPY a method of psychotherapy which


focuses on the total family as an interactional
system.

PSYCHOANALYSIS a method of psychotherapy


which focuses on the exploration of the unconscious,
to facilitate identification of the patients defenses.

HYPNOTHERAPY a therapeutic modality which


involves various methods and techniques to includes
a trance state where the patient becomes
submissive to instructions.

HUMOR THERAPY involves the use of humor to


facilitate expression of feelings and to enhance
interaction.

BEHAVIOR

MODIFICATION a therapeutic intervention


involving the application of learning principles in order to
change maladaptive behavior.
TOKEN-ECONOMY an example of behavior
modification technique which utilizes the principle of
rewarding desired behavior to facilitate change.
DESENSITIZATION periodic exposure of the individual
to a feared object, until the undesirable behavior
disappears or is lessened.
COGNITIVE THERAPY short term structured therapy
between the patient and the therapist oriented towards
present problems and solutions. The main focus of
cognitive therapy is depressive disorders

BATTERED WIFE SYNDROME (BWS)


Cycle of domestic violence characterized by wife beating by the
husband, humiliation and other forms of aggression.
The most common trait of abusive men is low self-esteem.
The most common trait of the abused women is dependence.
CHARACTERISTICS OF ABUSIVE HUSBANDS
They usually come from violent family.
They are immature, dependent and non-assertive.
They have a strong feeling of inadequacy.
PHASES OF BWS
Tension building phase
involves minor battering incidents
Acute battering incident
more serious form of battering
Aftermath/honeymoon stage
the husband becomes loving and
gives the wife hope
PRIORITY CARE OF THE BATTERED WIFE
Provision of shelter

CHILD ABUSE
Abuse is what happens when an older adult takes advantage of his
authority over a younger child.
VIOLENCE
Refers to the use of force.
NEGLECT
Lack of provision of those things which are necessary for the childs
growth and development
2 COMPONENTS
1. Child abandonment
2. Child neglect
PHYSICAL ABUSE
Abuse in the form of inflicting pain
EMOTIONAL ABUSE
Abuse in the form of insults and undermining ones confidence.
SEXUAL ABUSE
Abuse in the form of unwanted sexual contact

CHARACTERISTICS OF ABUSIVE PARENTS


They come from violent family
They were also abused by their parents
They have inadequate parenting skills
They are socially isolated because they dont trust anyone.
They are emotionally immature
They have negative attitude towards the management of the abused
INDICATORS OF CHILD ABUSE
S erious injuries in various stages of healing
H ealthy hair in various length
A pathy, No reaction
D epression
E xcessive knowledge of sex
S elf esteem is low
PRIORITY IN CHILD ABUSE
R.A. 7610, the anti child abuse law requires reporting of suspected
cases to authorities.
Report cases to the barangay officers, DSWD personnel, police
within 48 hours.

ANXIETY

Vague sense of impending doom


subjective emotional response to stress.
ETIOLOGY
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 two opposing drives, causes anxiety.
BIOLOGIC THEORY
Anxiety may accompany physical and physiological ailments.
FAMILY STUDIES
Anxiety can run in families.

DELIRIUM AND DEMENTIA

DELIRIUM

Disorientation

Acute
Involves young and old
Clouded sensorium
Reversible
Good prognosis

DEMENTIA
Loss/impiarment of
memory
Chronic
Exclusive in the elderly
Clear sensorium
Irreversible
Poor prognosis

Alzheimers Disease
a type of dementia that frequently affects the elderly.
Main Pathology

presence of senile plaques that destroys neurons leading to decreased


acetylcholine.

Common signs and sypmtoms


Aphasia inability to talk
Agnosia inability to recognize objects
Apraxia inability to perform ADL
Amnesia / Memory loss / Mnemonic disturbance

3 Phases

Forgetfulness phase difficulty of remembering appoinments


Advance phase difficulty of remembering past events but not recent events
Terminal phase death occurs in 1 year.

Priority Nursing Diagnosis


Altered thought processes

Primary need of the patient


Reorientation

ALCOHOLISM
WHO defines alcoholism as a chronic disease or a disorder characterized
by excessive intake and interference in the individuals health, interpersonal
relationship and economic functioning.
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)

Etiological theories

Psychoanalytic theory
- due to fixation in the oral stage
Learning theory
- due to a learned behavior
Biological theory
- due to inherited traits
Socio-cultural theory
- due to effects of mass media.

Phases of progression of alcoholism

Pre-alcoholic phase starts with social drinking


Prodromal phase alcohol becomes a need; blackouts 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.

Outcomes of alcoholism
Brain damage
Alcoholic hallucinosis
Death

Common behavioral problems


Denial
Dependency
Demanding
Destructive
Domineering

Withdrawl signs and symptoms


Halucinations, visual and tactile
Increased vital signs
Tremors
Sweating and Seizure

Common defense mechanism


Denial
Rationalization
Isolation
Projection

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