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.

PSYCHOSEXUAL STAGES OF DEVELOPMENT ACCDNG TO FREUD [O.A.P.L.G.]

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 Bad Mother

Successful
Dirty Clean
- Disorganized - organi
zed
- Disobedient - obedie
nt
- Anti-social - O.C
- Anal expulsive - Anal r
etentive
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.
PHARMACOLOGY NOTES
ANTI ANXIETY DRUGS [S.A.T.L.V.M. – E.V.A.B.I.]
Serax
Ativan
Tanxene
Librium
Valium
Miltown
Equanil
Vistaril
Atarax
Buspar
Inderal

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. PARIETAL 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
Motor nerve to muscle fiber you need ACETYLCHOLINE which is an “On switch”.
Brain
Spinal Cord
 Motor Nerve
Synapse
Muscle Fiber
INVOLUNTARY NERVOUS SYSTEM
Also called AUTONOMIC nervous system.
AUTONOMIC NERVOUS SYSTEM
SYMPATHETIC
(Awake, ADRENERGIC) PARASYMPATHETIC
(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 Acetylcholine
DRUGS WITH ANTICHOLINERGIC EFFECTS
Anti – Anxiety
Anti – Psychotic
Anti – Cholinergic
Anti – Depressants
PHARMACOLOGY NOTES
MONOAMINE OXIDASE INHIBITORS
Marplan
Nardil
Parnate
DEFENSE MECHANISMS
1. DISPLACEMENT – transfer of feelings to a less threatening object rather th
an the one who provoked it.
2. DENIAL – failure to acknowledge an unacceptable trait or situation.
3. DISSOCIATION – psychological flight from the self.
4. REGRESSION – return to an earlier development state.
5. REPRESSION – unconscious forgetting.
6. RATIONALIZATION – illogical reasoning for an unacceptable trait and situat
ion.
7. REACTION FORMATION – doing the opposite of what you have done.
8. UNDOING – doing the opposite of what you have done.
9. IDENTIFICATION – assuming trait for personal, social, occupational role.
10. PROJECTION – attribute to others one’s unacceptable trait.
11. INTROJECTION – assume another person’s trait as your own.
12. SUPPRESSION – conscious forgetting.
13. SUBLIMATION – putting destructive energies or hostile feelings towards a
more productive endeavors.
14. CONVERSION – unexpressed or repressed feelings are converted to physical
symptoms.
15. COMPENSATION – over achievement in one area to cover a defective part.
16. SUBSTITUTION – replace difficult goal with more accessible one.
PHARMACOLOGY NOTES
ANTI – PARKINSON DRUG [C.A.P.A.B.L.E.S]
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, I’m listening
7. Restating – I’m sad “You’re sad?” 1. Don’t worry be happy
2. Changing the topic/subject
3. Ignore the client
4. Value based judgment – never assume
5. Flattery
6. Advising
7. Giving Opinion
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.
Don’t 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 s
eat, easy fatigability.
PANIC ATTACKS/ DISORDER
15 – 30 minutes sympathetic nervous system escalation.
Example is AGORAPHOBIA fear of open spaces.
POST TRAUMATIC STRESS DISORDER
Victims become 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 DISORDER
No protection
Unconscious
No organic basis of being sick
DIFFERENT TYPES 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 DYSMORPHIC 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

SYMPATHETIC NERVOUS SYSTEM

GABA (Gamma Amino Butyric Acid) – stop
Epinephrine and Norepinephrine – Go
ANTI- ANXIETY MEDICATIONS
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 wee
k) 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
Maslow’s hierarchy of needs
Expressive Therapy – use of art as mode of 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
Decreased glucose
↓
Decreased judgment
↓
Increase impulsiveness
ADHD/ Hyperactivity
Need a drug that brings glucose level up.
Give RITALIN as stimulant
May result in loss of appetite
Given after meals
Given 6 hours before bedtime
EATING DISORDERS
ANOREXIA NERVOSA BULIMIA NERVOSA
Eat, eat, eat
Less 85% expected body weight
3 months Amenorrhea Eat, eat, vomit
Normal weight
Irregular menstruation
BULIMIA NERVOSA
Metabolic alkalosis (vomiting results to decreased hydrochloric acid)
Metabolic acidosis (diarrhea results to decreased 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
PHARMACOLOGY 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
EVALUATION
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
VISUAL
AUDITORY
TACTILE ABSENT
ABSENT
ABSENT
ABSENT PRESENT
PRESENT
PRESENT
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 don’t hear them”
 Diversion “Lets go to the garden”
10% of schizophrenic clients hear voices
PARKINSON’S 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 (wry-neck)
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 DRUGS

ANTICHOLINERGICS DOPAMINERGICS
(Decrease ACh) (Increase Dopam
ine)
↓
↓
Artane, Akineton P
arlodel
Benadryl L
arodopa
Cogentin E
ldepryl
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
DISORGANIZED CATATONIC PARANOID RESIDUAL UNDIFFIRENTIATED
UNCLASSIFIED
- Sad but smiles (Inappropriate affect)
- No reaction (flat affect)
- Flight of ideas (disorganized speech)
- Giggling (hebephrenic giggle)
- Combination of positive and negative signs and symptoms - Ambivalence
- Waxy flexibility
- Favorite word is “No”
- Negativism (client do not follow what you tell them to do)
Nursing management:
Meet needs - Suspicious
- Mistrust, scared, 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
- Don’t touch client
- Call for reinforcement
- One arms length away from the client. - No more positive symptoms just withdra
wn - Mixed classification, cant be classified

PHARMACOLOGY NOTES
BI-POLAR, MANIC
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 a
nxiety
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 d
efective doing)
Because there is decrease self esteem there will be increase compensation result
ing to increase interference with ADL’s and harm to others
Compensation is the culprit
Management: increase self esteem to decrease compensation and decrease interfere
nce with ADL’s and harm to others
HOW TO INCREASE SELF ESTEEM OF MANIC PATIENTS?
T - no sports (basketball, volleyball), no fine motor skills only gross motor sk
ills
A -llot energies toward more productive endeavors (sublimation)
S - escorted walk outdoors
K - punching bag (displacement)
PHARMACOLOGY 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 oth
er 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 vomi
ting
Alcoholics anonymous
Interval of 12 hours after last dose of alcohol or experience nausea and vomitin
g and hypotension
Alcoholism may result to Vitamin B1 (Thiamine) deficiency

WERNICKE’S ENCEPHALOPATHY
Problem with motor
KORSAKOFF’S 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
ALCOHOL/ DELIRIUM ALZHEIMERS
ONSET 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 A’s OF ALZHEIMERS
1. Amnesia – memory loss
2. Anomia – don’t know the name
3. Agnosia – sensory problems smell, taste, sight
4. Aphasia
EXPRESSIVE: cant say/express
Frontal lobe is affected particularly broca’s area
RECEPTIVE: cant hear
Temporal lobe is affected particularly wernicke’s area
5. Apraxia – can’t do simple things
Reminiscing Therapy – talk about past
Patients with Alzheimer’s may experience hallucinations, illusions thus becomes re
stless 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 A
ch 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 becom
es
MAOI kills MAO and increases all neurotransmitters (serotonin, epinephrine, nore
pinephrine, 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. Histrionic
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

GRIEF PROCESS [D.A.B.D.A]

1. Denial – shock/disbelief
2. Anger – question “why me?”
3. Bargaining – if, then
4. Depression – 2 weeks or more sign and symptoms becomes major clinical depr
ession
5. 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 communication
“I wont be a problem”
“This is my last day on earth”
“I’ll soon be gone”
Non-verbal communication
Giving away of valuables
Sudden change in mood

DOWNERS [A.B.O.N.-M.M.C.H.]
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 [C.H.A.R.]
Cocaine
Hallucinogens
Amphetamines
Resulting to:
Tachycardia
Awake
Tachypnea
Dry mouth
Pupils dilate
Hypertension
Seizures
Weight loss