Mental Health

WHO definition: state of complete physical, mental, and social wellness, not merely absence of disease or infirmity
State of emotional, psychological, and social wellness evidenced by:
– satisfying interpersonal relationships
– effective behavior and coping
– a positive self-concept
– emotional stability
Mental Illness
 Historically viewed as possession by demons, punishment for religious or social transgressions, weakness of will or spirit, and
violation of social norms
 Today seen as a medical problem, although some stigma from previous beliefs remains
 Mental disorder is “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that
is associated with distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important
loss of freedom” (American Psychological Association [APA])

Components of Mental Health

• Autonomy and Independence-can work interdependently without losing autonomy

• Maximization of One’s Potential-oriented towards growth and self-actualization
• Tolerance of Life’s Uncertainties-can face the challenges of day-to-day living with hope & positive look
• Self-esteem-has realistic awareness of one’s abilities and limitations
• Mastery of the Environment-can deal with and influence the environment
• Reality Orientation-can distinguish the real world from a dream, fact from fantasy

Mental Illness
State of imbalance characterized by a disturbance in a person’s thoughts, feelings and behavior (psychological, neurobiological and genetic
factors.)

Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision

The DSM-IV-TR is a taxonomy published by APA and is used by all mental health professionals. It describes all mental disorders according to
specific diagnostic criteria.

The DSM-IV-TR is based on a multiaxial classification system

Used to provide standard nomeclature of mental disorders ,define characterisitcs of mental disorders and assist in identifying underlying causes
of mental disorders

Axis I: all major psychiatric disorders except mental retardation and personality disorders

• Ex.Depression,Schizophrenia,anxiety and substance abuse disorder

Axis II: mental retardation, personality disorders, maladaptive personality features, and defense mechanisms

Axis III: current medical conditions

Axis IV –reporting psychosocial and environmental problems that may affect the diagnosis, treatment and prognosis of mental disorder

Axis V - presents global assessment of functioning (GAF) which rates the person’s

Overall psychological functioning on a scale of 0 – 100.

DSM-IV-TR Categories

 Cluster A - people whose behavior is odd or eccentric (paranoid, schizoid, schizotypal)

 Cluster B - people who appear dramatic, emotional, or erratic (antisocial, borderline, histrionic, narcissistic)

 Cluster C - people who are anxious or fearful (avoidant, dependent, obsessive-compulsive)

 Disorders being considered for inclusion are depressive and passive-aggressive

Personality Disorders
 Personality - an ingrained, enduring pattern of behaving and relating to self, others, and the environment; behaviors and
characteristics are consistent across a broad range of situations and do not change easily
 Personality disorders - when personality traits become inflexible and maladaptive and significantly interfere with how a person
functions in society or cause the person emotional distress; usually not diagnosed until adulthood; maladaptive behavior can be
traced to early childhood or adolescence

Cluster A Personality Disorders

Clinical Picture Nursing Interventions
Paranoid Mistrust and suspiciousness, aloof and withdrawn, guarded or Approach in a formal, business-like manner, keep
personality hypervigilant, restricted affect, use the defense mechanism of commitments, be straightforward, involve them
disorder projection in formulating their care plans, help them learn
to validate ideas before taking action

Schizoid Detached from social relationships, restricted affect, aloof and
personality indifferent, no leisure or pleasurable activities, do not report feeling
disorder distressed about lack of emotion, intellectual and accomplished with
solitary interests, indifferent to praise or criticism, dissociate from or no
bodily or sensory pleasures
Improve functioning in the community, make
referrals to social services, provide care that
accommodates the desire for solitude

Schizotypal Acute discomfort in relationships, cognitive or perceptual distortions, Promote self-care, social skills, and improved
personality eccentric behavior, bizarre speech, affect flat and sometimes functioning in the community
disorder inappropriate

Cluster B Personality Disorders

Clinical Picture Nursing Interventions
Antisocial Pervasive pattern of disregard for and violation of rights of  Forming therapeutic relationship
Personality others, deceit and manipulation o Limit setting
Disorder o Confrontation
 Promoting responsible behavior
 Helping client solve problems and control emotions
 Enhancing roleperformance
Borderline Pervasive pattern of unstable interpersonal relationships, self-  Long-term therapy to resolve family dysfunction
Personality image, affect, and marked impulsivity and abuse
Disorder  Hospitalization when client is exhibiting self-harm
behaviors or having intense symptoms
 Brief hospitalizations to stabilize condition

Histrionic Excessive emotionality and attention seeking;colorful and Give feedback about social interactions; teach social
Personality theatrical speech;overly concerned with impressing others; skills through role playing
Disorder emotionally expressive, gregarious, and effusive; emotions are
insincere and shallow; self-absorbed; uncomfortable when they
are not the center of attention and go to great lengths to gain
that status

Narcissistic Grandiose; lack of empathy; need for admiration; arrogant or Use self-awareness skills to avoid anger and frustration;
Personality haughty attitude; disparage, belittle, or discount the feelings of use matter-of-fact manner; set limits on rude or verbally
Disorder others; view their problems as the fault of others; hypersensitive abusive behavior
to criticism and need constant attention and admiration

Cluster C Personality Disorders

Clinical Picture Nursing Interventions
Avoidant Social inhibitions; feelings of inadequacy; hypersensitivity to Explore positive self-aspects and reasons for self-criticism;
personality negative evaluation; avoid situations or relationships that practice self-affirmations and positive self-talk; cognitive
disorder may result in rejection, criticism, shame, or disapproval; restructuring techniques, such as reframing and
strongly desire closeness and intimacy but fear possible decatastrophizing; teach social skills
rejection and humiliation

Dependent Submissive and clinging behavior; excessive need to be taken Help identify strengths and needs; use cognitive
Personality care of; pessimistic and self-critical; other people hurt their restructuring; assist in daily functioning; teach problem
Disorder feelings easily; report feeling unhappy or depressed; solving and decision making; refrain from giving advice
difficulty making decisions; seek advice and repeated
reassurances

Obsessive- Preoccupation with orderliness, perfectionism, and control; Help accept or tolerate less-than-perfect work; use
Compulsive formal and serious demeanor; constricted emotions; cognitive restructuring techniques; encourage to take
Personality stubborn; preoccupied with details, rules, lists, and risks; practice negotiation
Disorder schedules; believe they are right; problems with judgment Related Disorders:
and decision making  Depressive personality disorder
 Passive-aggressive personality disorder

Depressive Sad, gloomy, or dejected affect; persistent unhappiness,
Personality cheerlessness, and hopelessness; inability to experience joy
Disorder or pleasure in any activity; cannot relax; do not display a
sense of humor; brood and worry over all aspects of daily
life; thinking is negative and pessimistic
Assess risk for self-harm; encourage to become involved
in activities; give factual feedback; use cognitive
restructuring techniques; teach effective social skills

Passive- Negative attitudes; resent, oppose, and resist demands Help examine the relationship between feelings and
Aggressive expected by others; express resistance through subsequent actions; teach appropriate ways to express
Personality procrastination, forgetfulness, stubbornness, and intentional feelings directly
Disorder inefficiency

PSYCHIATRIC NURSING

• Interpersonal process whereby the nurse through the therapeutic use of self assist an individual family, group or community to
promote mental health, to prevent mental illness and suffering, to participate in the treatment and rehabilitation of the mentally ill
and if necessary to find meaning in these experiences
• It is a social 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 its art.

PSYCHIATRIC MENTAL HEALTH NURSING

It is organized around eight human response processes: activity, cognition, ecological, emotional, interpersonal, perception, physiologic and
valuation

Central Nervous System

Cerebrum
• Frontal lobe – control organization of thought, body movement, memories, emotions and moral behavior.
• Parietal lobe – interpret sensations of taste and touch and assist is spatial orientation.
Temporal lobe – are centers for the sense of smell, hearing, memory, and expression of emotions.
Occipital lobe – assist in coordinating language generation and visual interpretation, such as depth perception.

Neurotransmitters
• Dopamine-controls complex movements, motivation, cognition, regulates emotional responses
• Serotonin-regulation of emotions, controls food intake, sleep and wakefulness, pain control, sexual behaviors
• Acetylcholine- controls sleep and wakefulness cycle (decreased in Alzheimer’s)
• Histamine-controls alertness,peripheral allergic reactions, cardiac stimulations
• GABA-modulates other neurotransmitters
• Norepinephrine / Epinephrine-causes changes in attention, learning and memory, mood

Autonomic Nervous System

Sympathetic (alert) Parasympathetic (relax)
• “ Fight or flight “ • Maintains normal body functioning
• Increases HR, RR and BP • Normalizes HR, RR and BP
• Decreases peristalsis • Increases peristalsis
• Secretes epinephrine and norepinephrine • Secretes acetylcholine
• Dilates pulmonary bronchioles • Constricts pulmonary bronchioles
• Dilates pupils (mydriasis) • Constrict pupils (myotic)
• Vasoconstriction • Vasodilation
• Anticholinergic • cholnergic

TYPES OF MEMORY

Conscious – highest level of awareness

Pre-conscious – thoughts not currently in persons awareness but she can recall recall them with some effort.
Unconscious –thoughts and feelings that motivate a person even though he is totally unaware of it. forgotten
• Repression – Unconscious forgetting
• Suppression – conscious forgetting
Subconscious –those in preconscious or unconscious level of awareness

Sigmund Freud
• Father of Psychoanalysis

Structure of personality

ID (4-5MONTHS)

• Impulsive / Instinctual drive

• I want to… PLEASURE PRINCIPLE
• I want to… PHYSIOLOGIC NEEDS
• I want to… PRIMARY PROCESS

SUPEREGO

• Should not
• Small voice of GOD
• Set norms, standards and values
• MORAL PRINCIPLE
• Conscience
• Direct opposition to the ID
EGO

• Executive
• REALITY PRINCIPLE
 • Conscious
• Competencies
• Decision Maker; Problem-Solving; Critical and Creative thinking
• Balancing force between ID and superego

Theories of Personality Development

ERIK ERIKSON’S PYSCHOSICIAL THEORY OF DEVELOPMENT

AGE + - FACTORS
0-18 months Trust Mistrust Feeding

18-3 Autonomy Shame and Doubt Toilet Training

3-6 Initiative Guilt Independence

6-12 Industry Inferiority School

12-20 Identity Role confusion Peers

20-40 Intimacy Isolation Love

40-60 Generativity Stagnation Parenting

60-above Ego Reality Despair Reflection

SIGMUND FREUD PSYCHOSEXUAL THEORY

AGE STAGES PLEASURE SOURCE CONFLICT

0-18 Oral Mouth:Sucking,Biting, Fixation- strong attachment to a person or thing

Swallowing Regression- return to an earlier stage of development

18-3 Anal Eliminating and retaining feces Anal retentive - obsession with cleanliness, perfection, and control
Anal expulsive - messy and disorganized

3-6 Phallic Genitals Oedipus Complex - male children develop a sexual attraction to their
mother
Electra Complex - female children develop a sexual attraction to their
father
6-12 Latency Same sex friendships Sublimation- place sexual energies to productive endeavors
12-above Genital Sexual desires

Jean Piaget Cognitive Theory of Development

AGE STAGE
0 to 18 SENSORIMOTOR STAGE development proceeds from reflex activity to representation and sensorimotor solutions to
months problems

2 to 7 years PRE-OPERATIONAL  development proceeds from sensorimotor representation to prelogical thought and
STAGE solutions to problems
 can use these representational skills only to view the world from their own perspective.
 Understand the meaning of symbolic gestures
7 to 12 years CONCRETE OPERATIONAL  development proceeds from prelogical thought to logical solutions to concrete problems
 understand concrete problems
 cannot yet contemplate or solve abstract problems

12 and above FORMAL OPERATIONAL  development proceeds from logical solutions to concrete problems to logical solutions to
all classes of problems
 cannot yet contemplate or solve abstract problems
 can also reason theoretically

Harry Stack Sullivan Interpersonal Theory

AGE STAGE
0 to 18 months Infancy anxiety develops as a result of unmet needs by the mother (bodily needs); needs met, the child has
sense of well-being

18 months to 6 Childhood  anxiety as a result of lack of praise/acceptance from parents

years  gratification leads to positive self-esteem
 moderate anxiety leads to uncertainty and insecurity; - severe anxiety results in self-defeating
patterns of behavior

6 to 9 years Juvenile  severe anxiety may result in a need to control or restrictive, prejudicial attitudes
 learns to negotiate own needs

9 to 12 years Pre-  capacity to attachment, love and collaboration emerges or fails to develop
adolescence  move to genuine intimacy with friend of the same sex

12 to adulthood Adolescence  if self-system is intact, areas of concern expand to include values, career decisions and social
concerns
 lust is added to interpersonal equation
 need for special sharing relationship shifts to opposite sex
 new opportunities for social experimentation lead to consolidation or self-ridicule

Hildegard Peplau Nurse Patient Relationship

PHASES
PRE-  Begins when the nurse is assigned/chooses a patient
INTERACTION  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 is: Self-awareness
ORIENTATION  When the nurse and patient interacts for the first time
 Nurse begins to know the patient
Major task of the nurse: develop a mutually acceptable contract
WORKING  It is highly individualized
 More structured than the orientation phase
 The longest and most productive phase of the nurse-patient relationship
 Limit setting is employed
Major task of the nurse: identification and resolution of the patient’s problem
TERMINATION  Gradual weaning process
 There is a mutual agreement
 It involves feeling of anxiety,fear of loss
 It should be recognized in the orientation phase
Major task of the nurse: to assist the patient to review what he has learned and transfer his learning to his relationship
with others.
 KOHLBERG’S DEV OF MORAL REASONING
STAGES LEVEL I LEVEL II LEVEL
(Preconventional Level) (Conventional Level) III
(Post Conventional Level)
Stage 1  Punishment and Obedience
Orientation
“I must follow the rules otherwise I will be
punished”

Stage 2  Instrumental Relativist Orientation

“ I must follow the rules for the reward and
favor it gives”

Stage 3  Good- Boy-Nice Girl Orientation

“ I must follow the rules so I will be
accepted”

Stage 4  Society- Maintaining Orientation

“ I must follow rules so there is order
in the society”

Stage 5  Social Contract Reorientation

“ I must follow rules as there are
reasonable laws for it.”

Stage 6  Universal Ethical Principle

Orientation
“ I must follow rules because my
conscience tells me.”

DEFENSE MECHANISMS COMMONLY USED IN EACH RESPECTIVE DISORDERS

 Paranoid – Projection
 Phobia – Displacement
 Amnesia – Dissociation
 Anorexia – Suppresion
 Bipolar Disorder – Reaction Formation
 Borderline – Splitting
 Schizophrenia – Regression
 Substance Abuse – Denial
 Depression – Introjection
 OC – Undoing
 Catatonic – Repression

DEFENSE MECHANISM
Denial - refusal to acknowledge painful realities, thoughts, or feelings.

Ex. “I am not” an alcoholic!

Displacement - unconscious shift of emotions, affect, or desires from the original object to a more acceptable or immediate substitute.

Projection - Blaming; Falsely attributing to another his/her own unacceptable feelings.

Ex. A reviewee blames the review center for his failure in the board exams
Undoing - an attempt to erase an act, thought, feeling or desire

Ex. After flirting with her male secretary, a woman brings her husband tickets to a show.

Compensation - the counterbalancing of any defect.

Ex. A student is poor in academics but is a talented artist

Symbolization - one idea or object comes to represent another because of similarity or association between them.

Substitution - an unattainable or unacceptable goal, emotion, or object is replaced by one that is attainable or acceptable.

Ex. A little girl spanks her doll like her mother does to her

Introjection - standards and values of other persons or groups are unconsciously and symbolically taken within oneself.

Ex. “Not just you.. Me, too”

Repression - painful or unacceptable ideas, memories, or feelings are removed from conscious awareness or recall.(unconscious forgetting)

Ex. Man forgets wife’s birthday after a marital fight.

Supression - Conscious exclusion of unacceptable desires, thoughts, or memories from the mind.

Ex. Businessman who is preparing to make an important speech that day is told by his wife that morning that she wants a divorce. Although
visibly upset, he puts this incident aside until after his speech, when he can give the matter his total concentration.

Reaction Formation - adopts conscious attitudes, interests, or feelings that are the opposites of their unconscious feelings, impulses, or
wishes.(Plastic)

Ex. having a bias against a particular race or culture and then embracing that race or culture to the extreme

Regression - a return to earlier, usually childish or infantile, patterns of thought or behavior.

Ex. sitting in a corner and crying after hearing bad news; throwing a temper tantrum when you don't get your way

Dissociation - detachment of painful emotional conflicts from consciousness

Ex. forgetting sexual abuse from your childhood due to the trauma and anxiety

Conversion - emotional problems are converted into symptoms

Ex. Student is unable to take a final exam because of a terrible headache.

Fantasy- Magical thinking

Identification - a person patterns his or her personality on that of another person, assuming the person's qualities, characteristics, and actions.

Ex. Five-year old girl dresses in her mother’s shoes and dress and meets daddy at the door.

Intellectualization - reasoning is used as a means of blocking a confrontation with an unconscious conflict and the emotional stress associated
with it.

Rationalization - uses “because” justifying ideas, actions, or feelings with seemingly acceptable reasons or explanations.

Ex. I did not get a high grade because I forgot to study.

Sublimation - unacceptable instinctual drives and wishes are modified into more personally and socially acceptable channels.

Ex. Woman who is angry with her boss writes a short story about a heroic woman.
THERAPEUTIC COMMUNICATION

ORIENTATION

 Broad Opening
 Recognition
 Giving information
 Silence
 Offering Self – “Do you want me to sit beside you?”

WORKING

 Focusing – “Let us discuss this topic more.”

 Exploring – “Tell me more about it.”
 Encourage Evaluation – “IS this what you want?”
 Reflecting – same idea
 Restating – same statement
 Verbalizing Implied – “Are you going to kill yourself?”
 Seeking Clarification – “May you please repeat that statement”
 General lead – “Please continue.”; “And then?”
 Limit setting – “Stop.”
 Interpreting – “Maybe that thing is very significant to you.”

TERMINATION

 Summarizing – “Let us now sum up. You have stated earlier…etc.”

 “Do you have any questions?”
 “Our next therapy…”
 Look for changes in behavior
 Resistance is a common problem

Therapeutic Communication Techniques

Therapeutic Communication Techniques

Techniques Example
Accepting Indicating reception ”Yes”
“I follow what you said”
Nodding..

Broad Openings Allowing the client to take the initiative in “is there something you’d like to talk about?”
introducing the topic “Where would you like to begin?”

Consensual Validation Searching for mutual understanding, for “Tell me whether my understanding of it agrees with yours”
accord in the meaning of the words “Are you using this word to convey that . .?”
Encouraging Comparison Asking that similarities and differences be “was it something like..?”
noted
“Have you had similar experiences?”

Encouraging Description Asking the client to verbalize what he or ”Tell me when you feel anxious”
of Perceptions perceives “What is happening?”
“What does the voice seem to be saying?”

Encouraging Expression Asking client to appraise the quality of his “what are your feelings in regard to..?”
or her experience “Does this contribute to your distress?”

Exploring Delving further into a subject or idea “Tell me more about that.”

“Would you describe it more fully?”

“What kind of work?”

Focusing Concentrating on a single point “This point seems worth looking at more closely”

“Of all the concerns you’ve mentioned, which is most troublesome?”

Formulating a Plan of Asking the client to consider kinds of “What could you do to let your anger out harmlessly?”
Action behavior likely to be appropriate in future
situations “Next time this comes up, what might you do to handle it?”

General Leads Giving encouragement to continue “Go on”

“And then?”
“Tell me about it”

Giving Information Making available the facts that the client “My name is…”
needs “Visiting hours are…”
“My purpose in being here is… “

Giving Recognition Acknowledging, indicating awareness “Good morning, Mr. S…”

“You’ve finished your list of things to do.”
“I noticed that you’ve combed your hair”

Making Observations Verbalizing what the nurse perceives “You appear tense..”
“I notice that your biting your lips”

Offering Self Making oneself available “I’ll sit with you awhile”
“I’ll stay here with you”
“I’m interested in what you think”

Placing Event in Time or Clarifying the relationship of events in “what seemed to lead up to…?
Sequence time “Was this before or after?”

Presenting Reality Offering for consideration that which is “I see no one else in the room.”
real “Your mother is not here; I am a nurse.”
Reflecting Directing client actions, thoughts, and Client: “Do you think I should tell the doctor…? Nurse: “Do you think
feelings back to client you should?”

Restating Repeating the main idea expressed Client: I can’t sleep. I stay awake all night.”
Nurse:You have difficulty sleeping.”
Client:”I’m really mad, and upset”
Nurse: You’re really mad and upset.”

Seeking Information Seeking to make clear that which is not “I’m not sure that I follow.”
meaningful or that which is vague “Have I heard you correctly?”

Silence Absence of verbal communication, which Nurses says nothing but continues to maintain eye contact and
provides time for for the client to put conveys interest.
thoughts or feelings into words, regain
 composure, or continue talking

Suggesting Collaboration Offering to share , to strive, to work with Perhaps you and I can discuss and discover the triggers for your
the client for his or her benefit anxiety

Summarizing Organizing and summing up that which “Have I got this straight?”
has gone before

Translating into Feelings seeking to verbalize client’s feelings that Client: “I’m dead”
he or she expresses only indirectly Nurse: “Are you suggesting that you feel lifeless?”

Verbalizing the Implied Voicing what the client has hinted at or Client: I cant’ talk to you or anyone. It’s a waste of time.”
suggested Nurse: “Do you feel that no one understands”

Voicing Doubt Expressing uncertainty about the reality of “Isn’t that unusual?”
the client’s perceptions “Really?”
“That’s hard to believe.”

NONTHERAPEUTIC COMUNICATION TECHNIQUES

TECHNIQUES DEFINITION EXAMPLES
Advising telling the client what to do “I think you should….”

Agreeing Indicating accord with the client “that’s right.” “I agree”

Belittling Feelings expressed Misjudging the degree of the client’s comfort Client: “I have nothing to live for..I wish I
was dead”
Nurse: “Everybody gets down in the dumps.”

Challenging Demanding proof from the client “But how can you be President of the
Company?”

Defending Attempting to protect someone or something from “This hospital has a fine reputation.”
verbal attack

Disagreeing Opposing the client’s ideas “That’s wrong”

Disapproving Denouncing the client’s behavior or ideas “That’s bad”
“I’d rather you wouldn’t”

Giving approval Sanctioning the client’s behavior or ideas “ That’s good.” “I’m glad that..”

Giving Literal Responses Responding to a figurative comment as though it were Client: “They’re looking in my head with
a statement of fact television camera.”
Nurse: “Try not to watch television.”
Indicating the existence of an “What makes you say that?”
external source
Interpreting Asking to make conscious that which is unconscious “What you really mean is..”

Introducing an unrelated topic Changing the subject Client: “I’d like to die.”
Nurse: “did you have visitors last night?”

Making stereotyped comments Offering meaningless cliches or trite comments “Keep your chin up.”
“Just have a positive outlook.”

Probing Persistent questioning of the client “Now tell me about this problem. I need to
know.”

Reassuring Indicating there is no reason for anxiety “Everything will be alright.”

Rejecting Refusing to consider or showing contempt for the “Let’s not discuss..”
client’s behavior, ideas
Requesting an explanation Asking the client to provide reasons for thoughts, ‘Why do you think that?”
feelings, behaviors, events
Testing Appraising the client’s degree of insight “Do you know what kind of hospital this is?”

Using Denial Refusing to admit that a problem exists Client: “I am nothing.”

Nurse: “Of course, you’re something.”

ROLES OF THE PSYCHIATRIC NURSE

COUNSELOR-listens to the patient’s verbalizations

PARENT SURROGATE- assists the patients in the performance of activities of daily living

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 patient’s needs, problems and concerns through varied therapeutic means

SOCIALIZING AGENT- assists the patient to feel comfortable with others

WARD MANAGER- creates a therapeutic environment

BEHAVIORAL SIGNS AND SYMPTOMS

Assessment

ALWAYS SEND MAIL THRU POST OFFICE

• A-Affect/Appearance
• S-Speech
• M-Motor Behavior/Mood/Memory
• T-Thought Process
• P-Perception
• O-Orientation

Distubances in Perception

Illusion – misinterpretation of an actual external stimuli

Hallucinations – false sensory perception in the absence of external stimuli

• Auditory-Ex. “I keep hearing my mother’s voice telling me I am bad. She died a year ago.”
• Tactile-Ex. A paranoid man feels electrical impulses “ from outer space” entering his body and controlling his mind.
• Visual –Ex. During alcohol withdrawal he kept shouting, “I see snakes on the walls!”

Distubances in Thinking

Flight of Ideas – shifting of one topic from one subject to another in a somewhat related way

Ex. “Say babe, how’s it going…going to my sister’s to get some money…money, honey, you got any bread…bread and butter, staff of life, ain’t
life grand?”

Looseness of Association – incoherent, illogical flow of thought

Ex. “Can’t go to the zoo, no money, Oh…I have a hat, these members make no sense, man…What’s the problem?”
Delusion – belief held with strong conviction despite superior evidence to the contrary

Delusions of Grandeur - a delusion that you are much greater and more powerful and influential than you really are

Ex. A newly admitted patient told the nurse that she was muse of the United Nations and that she is the most beautiful among
women.

Persecutory – A fixed, false, and inflexible belief that others are engaging in a plot or plan to harm an individual

Ex. An intern believes that the chief of staff is plotting to kill him to prevent the intern from becoming powerful

Ideas of Reference - involve the belief that casual events, people's remarks, etc. are referring to oneself when, in fact, they are not.

Ex.”The nurses are talking about me”

Somatic – body reacting in a particular way

Magical Thinking – primitive thought process thoughts alone can change events

Autistic Thinking – regressive thought process – subjective interpretations not validated with objective reality

Nihillistism – false sense of being worthless

Abolition – lack of ability to exercise willpower, indecision in performing voluntary acts

Disturbances in Speech

Clang Association – sound of word gives direction to the flow of thought

Ex. “Good luck, buck, chuck, duck”

Neologism- invented words that people do not understand

Ex. “I am afraid to go to the hospital because the “norks” are looking for me there.”

Word Salad- incoherent mixture of words and phrases with no logical sequence

Ex.“I am fine…apple pie…no sale…furniture store…take it slow…cellar door”

Circumstantiality- over inclusion of inaapropriate thoughts and details

Ex. N: Where are you going for the weekend Harry?

P: Well, I first thought of going to my mother’s but that was before I remembered that she was going to my sister’s. My sister is having a
picnic. She always has picnics at the beach. But I don’t like the beach that she goes to so I decided to some place else…I finally decided to stay
home.

Verbigeration- meaningless repitition of words and phrases

Perseveration- persistence of a response to a previous question

Ex. N: How are you doing Harry?

P: Fine nurse, just fine.

N: Did you go for a walk?

P: Fine nurse, just fine.

Echolalia- repitition of words of others

Ex. The nurse said to the client, “Tell me your name.” The client responded, “Tell me your name, Tell me your name.”
Aphasia- speech difficulty and disturbance

Alogia-lack of speech

Disturbances of Affect

Inappropriate- disharmony between the stimuli and the emotional reaction

Blunted Affect- marked reduction in the range and intensity of emotional expression

Flat Affect- absence or near absence of emotional reaction

Apathy-dulled emotional tone

Depersonalization-feeling of strangeness from one’s self

Derealization-feeling of strangeness towards environment

Agnosia- inability to recognize the import of sensory impressions

Disturbances in Motor Activity

Echopraxia- imitation of posture of others

Ex. Everytime the nurse would move or gesture with her hands, the client would copy her gestures

Waxy Flexibility-maintaining position for a long period of time

Ex. The nurse lifted the client’s arm to check the pulse, and the client left his arm extended in the same position

Ataxia-loss of balance

Akathesia-extreme restlessness

Ex. The client’s leg kept jiggling up and down when he talked to the nurse. When his feet were still, his arm would jiggle constantly during the
interview

Dystonia-uncoordinated spastic movements of the body

Tardive Dyskenisia-involuntary twitching or muscle movements

Apraxia- involuntary unpurposeful movements

Disturbances in Memory

Confabulation- filling of memory gaps, inventing stories to increase self esteem

Ex.The nurse asked Harry who spent the weekend at home, what he did that weekend. “Well, I just came back from California after signing a
contract with MGM for a film on the life of Roosevelt. We have the most marvelous tour at the studio…went to lunch with the director.

Deja vu- experience of feeling sure that one has witnessed or experienced a new situation previously, 2nd time-like feeling

Jamais vu- not having been to the place on has been before

Amnesia-memory loss, inability to recall past events

Retrograde-distant past
Anterograde-immediate past
Anomia- inability to name objects or persons

Agraphia- partial or total loss of the ability to express ones thoughts coherently in writing

Agnosia-loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective

LOSS AND GRIEVING

GRIEF- refers to the subjective emotions and affect that are a normal response to the experience of loss

ANTICIPATORY GRIEVING- when people facing an imminent loss begin to grapple with the very real possibility of the loss or death in the near
future

DISENFRANCHISED GRIEF-grief over a loss that is not or cannot be acknowledged openly, mourned publicly or supported socially

COMPLICATED GRIEVING-when a person is void of emotion, grieves for prolonged periods, has expressions of grief that seem disproportionate
to the event

LOSS

 Physiologic Loss
 Safe and Security Loss
 Love and Belongingness Loss
 Self-Esteem Loss
 Self-actualization Loss

GRIEVING PROCESS

KUBLER-ROSS’s

 Denial
 Anger
 Bargaining
 Depression
 Acceptance
 Dysfunctional grieving – grieving which extends from 4 to 6 weeks leading to CRISIS

CRISIS AND ITS MANAGEMENT

CRISIS- situation that occurs when an individual’s habitual coping ability becomes ineffective to merit demands of a situation

TYPES OF CRISES:

MATURATIONAL / DEVELOPMENTAL
Normal expected crisis that runs through age
SITUATIONAL
Unexpected and sudden event in life
ADVENTITIOUS
Calamities, war

PHASES OF A CRISIS
• Pre-crisis: State of equilibrium
• Initial Impact (may last a few hours to a few days): High level of stress, helplessness, inability to function socially
• Crisis (may last a brief or prolonged period of time): Inability to cope, projection, denial, rationalization
• Resolution: attempts to use problem-solving skills
• Post crisis: may have OLOF or may have symptoms of neurosis, psychosis
CRISIS MANAGEMENT

• Role of the nurse is to return the client to its pre-crisis state by assisting and guiding them until they achieved their OLOF.
• Goal: to enable patient to attain an OLOF
• Nurse’s Primary Role: Active and Directive

Steps in Crisis Intervention

• Identify the degree of disruption the client is experiencing
• Assess the client’s perception of the event
• Formulate nursing diagnoses
• Involve the patient and family if applicable with planning
• Implement interventions- new and old coping mechanisms
• Evaluate-reassessment, reinforcement

TYPES OF THERAPIES

Remotivation Therapy- treatment modality that promotes expression of feelings through interaction facilitated by discussion of neutral topics
Music Therapy- involves use of music to facilitate expression of feelings, facilitate relaxation and outlet of tension
 Play Therapy- enables patient-to-experience intense emotion to a safe environment with the use of play
 Children express themselves more easily in play, revealing as reflection of child’s situation in the family
Group Therapy- Number of people coming together, sharing a common goal, interest or concern, staying together and developing relationships

Milleu Therapy-

 Total environment has an effect on the individual’s behavior

 Increase patients awareness of feelings, increase sense:responsibility and help return to community

Family Therapy- Client: Whole family

Concepts

 The family is the most fundamental unit of the society.

 Adaptive or maladaptive patterns of behavior are learned from the family
 Dysfunction in the family = dysfunction in the individual

Purpose
 Improve relationships among family members
 Promote family function
 Resolve family problems

OTHER TYPES OF THERAPIES

SUPPORT GROUPS
– For those with AIDS, Mother-Against-Drug Dependence
SELF-HELP GROUPS
– Alcoholic Anonymous

BEHAVIORAL THERAPIES
Pavlov’s Classical Conditioning - All behavior are learned
B.F. Skinner’s Operational Conditioning -Reinforcements
Behavioral Modification – Substance Abuse
Token Economy – Anorexia / Schizo
Systematic Desensitization – Phobia

ATTITUDE THERAPY
Paranoid – Passive Friendliness
Withdrawn – Active Friendliness
Depressed / Anorexia – Kind Firmness
Manipulative – Matter of Fact
Assaultive – No Demand
Anti-social – Firm, consistent
PSYCHOSOMATIC THERAPY
Electroconvulsive Therapy-
• Effective in most affective disorders
• The induction of a grandmal seizure in the brain.
• Abnormal firing of neurons in the brain causes an increase in neurotransmitters
• Number of Treatments: 6-12 ,3 times a week, about .5-2seconds
• Unilateral or bitemporal

ANXIETY

Peplau’s Levels of Anxiety

Mild
 Associated with the tension of day-today living
 Perceptual field increased
 More alert than usual
 Adaptive
Moderate
 Narrowed perception
 Difficulty focusing
 Selective inattention
 Mild somatic complaints: stomachache and butterflies in the stomach
Severe
 Very narrowed perception
 Unable to focus on problem solving
 Increased physical discomfort
 All behavior is aimed at relieving anxiety
 Direction is needed to focus attention
Panic
 Awe, dread and terror
 Unable to see the whole situation or reality
 Distortion of perception
 Disorganization of the personality
 A frightening and paralyzing experience

Antipsychotic Drugs
Sub Classification: Mechanism of Action: Side Effects:
Phenothiazines • Increase v/s
Chlorpromazine(Thorazine) Antagonizes dopamine in the CNS and also • Constipation / dry mouth
Fluphenazine(Prolixin) blocks Cholinergic, Histaminic, Serotogenic, • Postural hypotension
Perphenazine(Trilafon) Adrenergic • Photophobia / photosensitivity
Prochlorperazine(Compazine) neurotransmitters(anticholinergic, • Drowsiness
Thioridazine(Mellaril) antihistaminic, anti-emetic) blocks activity of • Agranulocytosis
Triflouperazine(Stelazine) the CNS receptors and sympathetic nervous • Extrapyramidal symptoms
system – Parkinson’s syndrome
Non-Phenothiazines – Akathisia
Clozapine – Akinesia
Haloperidol – Dystonia – oculogyric crisis,
Olanzapine torticollosis, opistothonus
Risperidone – Tardive dyskinesia
Thioxanthenes – Neuroleptic Malignant
Thiothixene(Navane) Syndrome

Nursing Care Guidelines:

 Avoid sunlight
 Report sorethroat,fever,muscular
rigidity
 Rduced psychomotor agitation and
insomnia-1week
 Reduction of hallucinations,delusions,
and thought disorder takes 6-8 weeks
 for full therapeutic effect
 Monitor Potassium level, BP,
Temperature

Antidepressant Drugs

SSRI Antidepressant Drugs Action: Side Effects:

Fluoxetine (Prozac) Inhibits reuptake and destruction of  Anxiety
Paroxetine (Paxil) serotonin to prolong its action  Agitation
Sertraline (Zoloft)  Akathisia
Citalopram (Celexa)  Nausea
Escitalopram (Lexapro)  Insomnia
 Sexual dysfunction (anorgasmia/impotence)

Nursing Care Guidelines:

 2-3 weeks initial effect
 3-4 weeks full therapeutic effect
TCA Antidepressant Drugs Action: Side Effects:
Imipramine (Tofranil), Prolongs the action of norepinephrine  Anticholinergic (blurred vision, urinary retention, dry
Desipramine (Norpramin), Dopamine Serotonin by blocking the mouth, constipation)
Amitriptyline (Elavil), reuptake of this neurotransmitters  Orthostatic hypotension
Doxepin (Sinequan),  Sedation
Clomipramine (Anafranil)  Weight gain
 Tachycardia
 Sexual dysfunction
 Patient Teaching
 Taking in the evening
 Using caution when driving

Nursing Care Guidelines:

 2-3 weeks initial effect
 3-6 weeks full therapeutic effect
 Emphasize compliance avoid citrus fruits as it decrease
the absorption
 Monitor BP, HR and ECG
MAOI Antidepressant Drugs Action: Side Effects:
Phenelzine (Nardil) blocks the metabolic destruction of  Sedation
Tranylcypromine (Parnate) neurotransmitters by the enzyme  Insomnia
Isocarboxazid (Marplan) monoamine oxidase  Weight gain
 Dry mouth
 Orthostatic hypotension
 Sexual dysfunction
 Hypertensive crisis with excessive tyramine or
sympathomimetic drugs

Nursing Care Guidelines:

 2-3 weeks initial effect
 3-4 weeks full therapeutic effect
 Avoid foods rich in
tyramine(processed,preserved,fermented) because it
will lead to hypertensive crisis
 Monitor BP and food items
CNS Stimulant Drugs Action: Side Effects:
Methylphenidate (Ritalin) Increases levels of neurotransmitters in the  Anorexia
Pemoline (Cylert), brain thereby increasing and decreasing  Weight loss
Dextroamphetamine hyperactivity  Nausea
 Irritability
 Patient Teaching
 Avoiding caffeine, sugar, and chocolate
 Taking after meals
 Long-term use can cause dependency
 Nursing Care Guidelines:
Give in AM, not beyond 2PM 6 hours before bedtime

Anti-Manic Drugs(Mood Stabilizing Drugs)

lithium; anticonvulsant medications
LithiumCarbonate(Eskalith,Lithane,Quilinium) Uses: Side Effects (Lithium)
Carbamazepine (Tegretol) Bipolar disorder  Nausea
Valproic acid (Depakote) Action:  Diarrhea
Lamotrigine (Lamictal) Exact mechanism is unknown, alters the  Anorexia
Gabapentin (Neurontin) level of norepinephrine and other  Fine hand tremor
neurotransmitters  Polydipsia
 Polyuria
 Fatigue
 Weight gain
 Acne

Nursing Care Guidelines:

• Initial Effect: 10-14 days
• Full Therapeutic Effect: 3-4 weeks
• Take after meals with food or milk
• Discontinue drug, if toxicity occurs—
diarrhea, vomiting, ataxia,
tremor, drowsiness, lack of
coordination or muscular
weakness.Antidote for toxicity Mannitol
or Acetazolamide
• Avoid caffeine,diuretics,and activities
that increase perspiration
• Monitor serum level at least once a
month
o Maintenance dose:0.6-1.2 meq/L
o Acute Level: 1.5meq/L
o Level for the elderly: .4-1.0meq/L

ANTIANXIETY DRUGS
Classification: Side Effects
Uses:  Tolerance and dependence
Benzodiazipines- Anxiety disorders, insomnia, OCD,  Drowsiness
Alprazolam(Xanqax) depression, PTSD, alcohol withdrawal  Sedation
Chlordiazepoxide(Librium)  Poor concentration
Chlorazepate(Tranxene) Action:  Impaired memory
Diazepam(Valium) Moderate the actions of GABA  Clouded sensorium
Lorazepam(Ativan)  Patient Teaching
 Using caution during driving due to
Azaspirones-Buspirone(Buspar) slower reflexes and response time
 Never discontinuing abruptly as
Nonbenzodiazepines- withdrawal can be
Hydroxyzine(Vistaril)
 fatal
Meprobamate(Equanil)
 Avoiding alcohol

Nursing Care Guidelines

 Use only in a short time (1-2 weeks)
 Tolerance (after 7 days) and
dependence (after 1 month)
 Liver function test
 Monitor for side effects.
 Avoid machines, activities needing
concentration
  Z tract if given parenterally
 Avoid mixing with alcohol, antacids
 Don’t stop abruptly but gradually for 2-
6 weeks
 Avoid caffeine

CATEGORIES OF ANXIETY DISORDERS

• Basic Anxiety Disorders

• Somatoform Disorders
• Dissociative Disorders

Basic Anxiety Disorders

• Generalized Anxiety Disorder
• Post Traumatic Stress Disorders
• Phobia
• Obsessive Compulsive

Generalized Anxiety Disorder

• Excessive worry and anxiety for days but not more than 6 months
• Difficulty in controlling the worry
• Anxiety and worry are evident by 3 or more of the following :
– Restlessness
– Fatigue and irritability
– Decreased ability to concentrate
– Muscle tension
– Disturbed sleep
• Anxiety or worry causes significant impairment in interpersonal relationship or activities of daily living

Post Traumatic Stress Disorders

• Disturbing pattern of behavior occurring after a traumatic event that is outside the range of usual experience.
• Characteristics
– Persistent re-experiencing of the trauma through recurrent intrusive recollections of the event, through dreams or
flashbacks
– Persistent avoidance of the stimuli
– Feeling of detachment of estrangement from others
– Chemical abuse to relieve anxiety

Phobias
• Persistent, irrational fear of a specific object, activity or situation that leads to a desire for avoidance or actual avoidance of the
object of fear
• Specific Phobia
– Experience of high level of anxiety or fear provided by a specific object or situation
– Treatment: Systematic Desensitization
• Defense mechanisms
– Repression and displacement

Major Types of Phobias

• Agoraphobia
– Fear of being alone in open or public spaces
• Social Phobia
– Fear of situations where one might be seen and embarrassed or criticized
• Specific Phobias
– Fear of a single object, situation or activity that cannot be avoided
• Clausrophobia – close place
• Agoraphobia- open place
• Acrophobia –high place
• Aelophobia –cats
• Cynophobia –dog
Obsessive Compulsive Disorder
Obsessions
 Preoccupation with persistent intrusive thoughts, impulses or images
Compulsions
 Repetitive behaviors or mental acts that the person feelds driven to perform in order t reduce distress or prevent a dreaded event or
situation
Cues:
• Ritualistic behavior
• Constant doubting if he/she has performed the activity

Care Strategies

• Be nonjudgmental and honest; offer empathy and support

• Help patient to recognize the connections between the trauma experience and their current feelings, behaviors and problems.
• Encourage verbalizations of feelings, especially anger.
• Encourage adaptive coping strategies and techniques
• Encourage patients to establish or reestablish relationships
• Explore shattered assumptions. “I’m a good person. This is a safe world”.
• Promote discussion of possible meaning of the events.

Somatoform Disorders
• Body Dysmorphic Disorder
• Somatization
• Conversion Disorders
• Hypochondriasis
• Psychogenic pain

Body Dysmorphic Disorder

• Preoccupation with an imagined defect in his or her appearance

• Ex. Michele, a young, attractive woman, is preoccupied that her nose is too long and “ugly”. She is preoccupied and quite distressed
over her perception. Two plastic surgeons she consulted are hesitant to reshape her nose but have not altered her thinking that her
nose makes her ugly.
Somatization

• A client expresses emotional turmoil or conflict through a physical system, usually with a loss or alteration of physical functioning
• Hx of pain in at least 4 sites
• Hx of at least 2 GIT symptoms other than pain
• Hx of at least one sexual/reproductive symptom
• Hx of at least one neurologic disorder
• Ex. Deanna, 27, presents at the doctor’s office with excessive heavy menstruation. She tells the nurse that recently she experienced
pain “first in my back and then going to every part of my body.”She states that she is often bothered with constipation and frequent
vomiting when she “eats the wrong food.” She states she had been “unwell” and had suffered from seizures and still experiences it
occasionally. The nurse becomes confused, not knowing what symptoms she wants the doctor to evaluate. Deanna tells the nurse
she lives at home with her parents because her poor health makes it hard for her to hold a job

Conversion Disorders

• A psychological condition in which an anxiety-provoking impulse is converted unconsciously into functional symptoms
• Development of a symptom suggesting neurologic disorder(blindness, deafness etc.) or involuntary motor function(paralysis,
seizures)
• Ex. Jan, a 28 year old former secretary, awakes one morning to find that she has a tingling in both hands and cannot move her
fingers. Two days earlier, her husband had told her that he wanted a separation and that she would have to go back to work to
support herself.

Hypochondriasis

• Presentation of unrealistic or exaggerated physical complaints

• Ex. Garry, 52, lost his wife to colon cancer 5 months ago, which he “took very well”. Recently he consulted the physician with the
same complaint. He believes that he has liver cancer, despite repeated and extensive diagnostic tests, which are all negative. He has
ceased seeing his friends, has dropped his hobbies and spends much of his time checking his sclera and “resting his liver”.
Nursing Diagnosis

• Ineffective Individual Coping

• Self-Care Deficit
• Diversional Activity Deficit

Nursing Interventions

• Offer explanations and support during diagnostic testing-reduces anxiety while ruling out organic illness
• After physical complaints have been investigated, avoid further reinforcement-directs focus away from physical symptoms
• Spend time with client at all times other than when client summons nurse to offer physical complaint-rewards non-illness related
behaviors and encourages repetition of desired behavior
• Observe and record frequency and intensity of somatic symptoms-establishes a baseline and later evaluation of effectiveness of
interventions
• Do not imply that symptoms are not real-psychogenic symptoms are real to the client even though causation is not organic
• Shift focus from somatic complaints to feelings or to neutral topics-conveys interest in client as a person rather than in client’s
symptoms
• Assess secondary gains that “physical illness” provides for client-nurse can work with the client to meet these needs in healthier
ways and thus minimize secondary gains
• Use matter-of-fact approach to clients exhibiting resistance or covert anger-avoids power struggles, demonstrates acceptance of
anger and permits discussion of angry feelings
• Set limits on manipulative behavior that violates rights of others-protects other clients and significant others
• Help client look at result of manipulative behavior on others-encourages insight and can help improve intrafamily relationships
• Show concern for client while avoiding fostering dependency needs-shows respect for client’s feelings while minimizing secondary
gains
• Reinforce client’s strengths and problem-solving abilities-contributes to positive self-esteem

Dissiociative Disorders

• Dissociative amnesia
• Dissociative fugue
• Depersonalization
• Dissociative Identity Disorder / Multiple Identity Disorder

Dissociative amnesia

• Characterized by the inability to recall an extensive amount of important personal information because of physical or psychological
trauma
• Ex. A young woman was partly dressed and poorly nourished when found by a police road patrol. She had no knowledge of who she
was. Her parents identified her when she appeared on a morning news television program. Hospital examination revealed the
probability of recent rape. She was able to remember going to a party off-campus but had no recall of the party or the events after.

Dissociative fugue
• The person suddenly and unexpectedly leaves home or work and is unable to recall the past

Depersonalization

• Person experiences a strange alteration in the perception or experience of the self, often associated with a sense of unreality
• Ex. Mrs. Chin Sue became highly distressed when she perceived changes in her appearance when she looked in a mirror. She thought
her image looked wary and indistinct. Soon after, she described feeling as though she was floating in a fog with her feet not actually
touching the ground. During therapy, it was learned that Mrs. Chin Sue’s son had revealed to her his HIV positive status

Dissociative Identity Disorder / Multiple Identity Disorder

• A person is dominated by at least one of two or more definitive personalities at one time
• Ex. Gertrude, a passive, conservative woman alternated personalities with Diana, who was sexy and flirtatious. During therapy,
Gertrude and Diana revealed themselves as other distinct personalities.
PSYCHOSOMATIC DISORDER
- hormonal and bodily changes
- Increase anxiety may result to asthma, stress ulcers or migraine

Schizophrenia
• A major form of psychotic disorder that affects a person’s thinking, language, emotions, social behavior and ability to perceive reality
• At least 2 of 5 types of positive and negative symptoms
• Characteristic Symptoms
• Social or occupational dysfunction
– Self care
• Duration
– Continuous for at least 6 months

Signs and Symptoms

Positive Symptoms- symptoms that normal people don’t exhibit

• Hallucinations –false sensory perception/experiences that does not exist in reality
• Delusions –persecutory or grandiose or ideas of preference.),
• Ambivalence-holding seemingly contradictory beliefs o feelings about the same person
• Associative looseness-fragmented or poorly related thoughts and ideas
• Perseveration-persistent adherence to a single idea or topic.(verbal repitition of a sentence, word or phrase;resisting attempts to
change the topic

Negative Symptoms- absence of those that normal people exhibit

• Affective flattening-absence of facial expression
• Anhedonia –feeling no joy or pleasure from life or any activities or relationships
• Attention impairment
• Apathy-feeling of indifference towards people,activities and events
• Anergia
• Avolution-decreased motivation

Types of Schizophrenia
Types and Manifestations CATATONIC DISORGANIZED PARANOID
Distinguishing Features Abnormal motor behavior-waxy Bizaare behavior Suspiciousness and ideas of
flexibility,echopraxia reference
Defense Mechanism Regression Regression Projection
Nursing Diagnosis Impaired motor activity Impaired Social Functioning Potential for injury directed
at others
Priority Nursing Care Circulation and nutrition Assistance with ADL Nutrition and Safety
Other types:undifferentiated-mixture of all types
Residual- with minimal symptoms

Manifestations:
S-social isolation
C-catatonic behavior
H-hallucinations
I-Incoherence
Z-zero/lack of interest and initiative
O-obvious failure in development
P-peculiar behavior
H-hygiene and grooming impaired
R-recurrent illusions
E-exacerbations and remissions
N-no organic factor account S/S
I-inability to return to functioning
A-affect is inappropriate
Bipolar Disorder
• Also called affective disorders, are pervasive alterations in emotions that are manifested by depression, mania or both
• Interferes with a person’s life
• With accompanying self-doubt, guilt and anger which alter life activities

Mania-a distinct period during which mood is abnormally and persistently elevated, expansive or irritable lasting 1 week with at least 3
additional symptoms(can be inflated self-esteem, pressured speech, decreased need for sleep, flight of ideas, distractibility, psychomotor
agitation); impairs the person’s ability to function.

Hypomania-a period of abnormally and persistently elevated, expansive or irritable mood lasting 4 days and including 3 or 4 additional
symptoms (above); does not impair the person’s ability to function and there are no psychotic features

Euthymic mood-average affect and activity

Anergia-lack of energy
Anhedonia-lack of interest on previously enjoyed activities

Primary Mood Disorders:

Major depressive disorder

• Bipolar disorder
Bipolar I disorder-one or more manic or mixed episodes usually accompanied by major depressive episodes
Bipolar II disorder-one or more major depressive episode accompanied by at least one hypomanic episode

PREDISPOSING FACTORS

I. Biologic theories

• -first degree relatives (3%-8%)

• -identical twins (2-4x higher risk than fraternal twins)

II. Neurochemical theories

• deficits of serotonin occur in people with depression

• norepinephrine maybe deficit in depression and increased in mania
• Kindling-process by which seizure activity in a specific area of the brain is initially stimulated by reaching a threshold of the
cumulative effects of stress. Low amounts of electric impulses or chemicals such as cocaine that sensitize nerve cells or pathways.
These highly sensitized nerve cells respond by no longer needing the stimulus to induce seizure activity, which now occurs
spontaneously.

III. Psychodynamic theories

1. Freud-looked at the self-depreciation of people with depression and attributed that self approach to anger turned inward related
to either a real or perceived loss.
2. Bibring-believed that one’s ego(self) aspired to be ideal that is good and loving, superior or strong. Depression results when in
reality these ideals all the time
3. Jacobson- compared the state of depression to a situation in which the ego is a powerless, helpless child victimized by the
superego much like a powerful and sadistic mother who takes delight in torturing the child.
4.Meyer-viewed depression as a reaction to a distressing life experience such as an event with psychic casuality
5.Horney-believed that children raised by rejecting or unloving parents were prone to feelings of insecurity and loneliness, making
them susceptible to depression and helplessness
6.Beck-saw depression as resulting from specific cognitive distortions in susceptible people. Early experiences shaped distorted ways
of thinking.

Major Depressive Disorder

• At least 5 of the following symptoms present during the 2 week period

• IN – Interest is lacking in most everything. They may feel lethargic. Libido may be decreased and they are commonly apathetic. They
may experience despair and become apathetic.
• S -Sleep is hard to come by. They often have several hours of sleep and then awaken with inability of going back to sleep. Real rest is
often hopeless which may add to the depression. Some people may want to sleep all the time. They are so depressed, they do not
want to go out of bed.
 • A - Appetite is very often depressed. Food doesn’t look good or taste good.
• D –Depressed people can be very tearful. They no longer smile and have a “flat effect” or no expression on their face.
• C – Concentration is often lacking. They may not be able to do their jobs or maintain their relationships due to the depression.
• A – Activity is decreased. They may become “couch potatoes” and refuse to participate in routine activities. Exercise may be an
activity that they can no longer perform.
• G – Guilt may bring a negative view of self, world or future.
• E –energy level is decreased. They may have a poverty of ideas and turn their aggressive feelings inward.
• S – suicide precautions are mandatory. Maintaining a safe environment and negotiating a contract with them may be life saving.

Mania Vs Depression

Mania Depression
Appearance Colorful, flamboyant Sad and gray
Behavior Psychomotor agitation Psychomotor retardation
Communication Pressured speech Monotonous speech
Stuttering
Cluttering
Nursing Diagnosis Risk for Injury(others) Risk for injury(self)suicidal precaution
Nursing Priority Safety and Nutrition Safety and Nutrition
Nutrition Finger foods and high in calorie Increased in nutrients
Treatment Lithium;ECT TCA;SSRi’s;MAIOS;ECT
Milleu Non-stimulating environment Stimulating
Appropriate Activity Quite type;non-competitive Monotonous;non-competitive
Attitude Therapy Matter of Fact Kind Firmness;Active Friendliness

Suicide
The intentional act of killing oneself

Suicidal Ideation- means thinking about oneself

A. Passive suicidal ideation-when a person thinks about wanting to die or wishes he/she were dead but has no plans to cause his/her
death (e.g. reckless driving, heavy smoking, overeating, self-mutilation, drug abuse)

B. Active suicidal ideation-when a person thinks about and seeks to commit suicide.

SAD PERSON’S SCALE

• S-Sex Men kill themselves 3x more than women though women make attempts 3x more often than men
• A-Age High risks groups:19 years or younger; 45 years or older, especially the elderly 65 and above
• D-Depression Studies report that 35-79% of those who attempt suicide manifested a depressive syndrome
• P-Previous Attempts Of those who commit suicide, 65-70% have made previous attempts
• E-ETOH Alcohol is associated with up to 65% of successful suicides
• R-Rational Thinking Loss People with functional or organic psychoses are more apt to commit suicide than those in the general
population
• S-Social Supports Lacking A suicidal person often lacks significant others, meaningful employment and religious supports
• O-Organized Plan The presence of a specific plan for suicide signifies a person at high risk
• N-No Spouse repeated studies indicate that persons who are widowed, separated, divorced or single at greater risk than those who
are married
• S-Sickness Chronic, debilitating and severe illness is a risk factor

Theories of SUICIDE

Psychodynamic theories
• describe suicide as a wish to be at peace with the internalized significant person
• Wish to be reunited with a deceased loved object
• Suicide is an attempt to escape from an intolerable situation or intolerable state of mind
Sociological Theories
• Durkheim-pioneer of sociological research in the study of suicide
3 Principal types:
1. Egotistic suicide-occurs when a person is insufficiently integrated into society
2. Anomic suicide-occurs when a person is isolated from others through abrupt changes in social norms/status
3. Altruistic suicide- occurs as a response to societal demands (deaths of Buddhist monks who set themselves on fire to protest the
Vietnam war)

Precipitating factors

Social isolation-have difficulty forming and maintaining relationships

Severe life’s events-divorce, death, sickness, legal problems, interpersonal discord
Sensitivity to Loss-may react tragically to separation or loss of a loved one (had insecure or unreliable childhood experiences)

Suicide Precautions

• Execute a “no suicide contract”. The client will inform the nurse when he/she has suicidal ideations
• Ask direct questions. Find out if the person has specific plan for suicide. Determine what method.
• Be alert for cries for suicide
• Provide a safe environment and protect client from self
• Encourage to ventilate feelings and thoughts
• Give emotional support
• Make the patient realize that the tendency to commit suicide is due to the disturbance in the brain chemistry and is treatable-once
they know that an episode of suicidal thinking will pass, they will likely not act on the impulse
• Provide structured schedule and involve in activities with others to increase self-worth and divert attention
• On discharge: help patient create “plan for Life”(list of warning signs of suicidal ideation and actions to take)
• Always remember:
A. That a suicidal person want to die only during the period of suicidal crisis-during this time the person is ambivalent about
living and dying
B. Suicidal people gives warning
C. Persons recovering from depression are high risk for 9-15 months after recovery
D. Suicidal people are extremely unhappy but not always mentally ill

Personality behaviors

PERSONALITY DISORDERS
Paranoid A pervasive pattern of distrust and Intervention:
suspiciousness of others such that their centered on building trust
motives are interpreted as malevolent
 Suspicious (e.g. others are
exploiting or deceiving him)
 Doubt trustworthiness of others
 Fear of confiding in others
 Fear personal information will be
used against him
 Interpret remarks as demeaning
or threatening
 Hold grudges toward others
 Becomes angry and threatening
when they perceive to be attacked
by others

Schizoid A pervasive pattern of detachment from Interventions:

social relationships and a restricted range of
expression of emotions in interpersonal building trust followed by identification and
settings appropriate verbal expression
 Lacks desire for close relationships
or friends including family
 Chooses to be alone
 Lack of sexual experiences
 Avoids activities
 Appears cold and detached
Schizotypal A pervasive pattern of social and Interventions:
interpersonal deficits marked by acute
 discomfort with and reduced capacity for
close relationships as well as by cognitive or
perceptual distortions and eccentricities of
behavior
 Ideas of reference
 Magical thinking or odd beliefs
 Unusual perceptual experiences,
including bodily illusions
 Peculiar thinking
 Vague, stereotypical, over
elaborate speech
 Suspiciousness
 Blunted or inappropriate affect
 Eccentric appearance or behavior
 Few close relationships
 Uncomfortable in social situations
Anti-social Characterized by deceit, manipulation,
revenge and harm to others with an absence
of guilt or anxiety
 Violates rights of others
 Engages in illegal activities
 Aggressive behavior
 Lack of guilt or remorse
 Irresponsible in work and with
finances
 Impulsiveness
 Recklessness
 Manipulative
Borderline Characterized by pervasive pattern of
unstable interpersonal relationships; self-
image and affect; and marked impulsivity
Frantic avoidance of abandonment; real or
imagined
 Unstable and intense
interpersonal relationships
 Identity disturbances
 Impulsivity
 Self-mutilating behavior
 Rapid mood shifts
 Chronic feelings of emptiness
 Problems with anger
 Transient dissociative and
paranoid symptoms
Narcissistic  Grandiose self importance
 Fantasies of unlimited power,
success or brilliance
 Believes he or she is special
 Needs to be admired
 Sense of entitlement
 Takes advantage of others for own
benefit
 Lacks empathy
 Envious of others or others are
envious of him
 Arrogant
Histrionic A pervasive pattern of excessive emotionality
and attentive seeking
 Overly dramatic
 Draws attention to self
Improving Interpersonal relationships, social
skills, and appropriate behaviors
Interventions:
 Consistency
 Kind firmness in confronting
behaviors and enforcing rules and
policies
 Limit setting
 Decrease impulsivity
 Enhance role performance
 Effective use of confrontation
Interventions:
 Use of empathy.
 Recognize the reality of the
patient’s pain.
 Offer support
 Empower and work with the
patient to understand control and
change dysfunctional behaviors.
 Provide safe environment
 Teach social skills
 Make a list of solitary activities to
combat boredom
 Diary keeping
 Cognitive restructuring
 Suicide precaution
Interventions
 Supportive confrontation on what
the patient says and what exists.
 Limit setting and consistency to
decrease manipulation and
entitlement behaviors.
 Remain neutral, avoid power
struggles, or becoming defensive.
Interventions:
Positive reinforcement in the form of
attention, recognition or praise are given for
  Extroverted and thrives on being unselfish or other-centered behaviors
the center of attraction
 Uses somatic complaints to avoid
responsibility and support
dependency
 Dissociation

Dependent A pervasive and excessive need to be taken Interventions:

care of that leads to submissive and clinging
behavior and fears of separation increase responsibility for self in day to day
 Needs others to be responsible for living; assertiveness training
important areas of life.
 Problems with initiating with
projects or doing things on his
own because of little self
confidence
 Performs unpleasant tasks to
obtain support from others
 Urgently seeks another
relationship for support and care
after a close relationship ends
 Preoccupied with fear of being
alone to care for self

Avoidant A pervasive pattern of social inhibition,

feelings of inadequacy and hypersensitivity to
negative evaluation
 Avoids occupations involving
interpersonal contact due to fears
of disapproval or rejection
 Preoccupied with being criticized
or rejected in social situations
 Inhibited and feels inadequate in
new interpersonal situations
 Very reluctant to take risks or
engage in new activities due to
the possibility of being
embarrassed

Obsessive Compulsive A pervasive pattern of preoccupation with

orderliness, perfectionism and mental and
interpersonal control at the expense of
flexibility, openness and efficiency
 Preoccupied with details, lists,
rules, organization
 Perfectionist
 Too busy working to have friends
or leisure activities
 Unable to discard worthless or
worn-out objects
 Reluctant to spend and hoards
money
 Rigid and stubborn

DELIRIUM & DEMENTIA

Delirium
• Characterized by disturbance of consciousness and a change in cognition such as impaired attention span and disturbances in
consciousness that develop over a short period of time.
– Always secondary to another condition (medical condition or substance abuse)
– Frequent among the elderly and young febrile children
– Fluctuations of consciousness and inoculation throughout the day
 • Classified as mild to severe.
• Sundowning

Dementia
• Characterized by multiple cognitive deficits that include impairment of memory which develops slowly
– 80-90% irreversible
– Reversible due to pathologic process
– Most common: Alzheimer’s Dementia

4 Symptoms of Dementia
• Loss of memory
• Deterioration of language function
• Loss of ability of think abstractly, plan, initiate, sequence, monitor or stop complex behavior
• Loss of ability to perform ADLs

Stages of Dementia

Stage 1 Mild (Forgetfulness)

• Losses in short term memory
• Memory aids compensate
• Aware of the problem, disturbed
• Not diagnosable at this time

Stage 2 Moderate (Confusion)

• Progressive memory loss
• ST memory loss interferes with ADLs
• Withdrawn, Denial, Fear of Losing their minds
• Depression, Confabulation
• Problems increase when stressed
• Needs home care or in-home assitance

Stage 3 Moderate to Severe (Ambulatory Dementia)

• Loss of reasoning ability, planning and verbal communication
• Frustrated, withdrawn, self-absorbed
• Depression decreases
• Reduced stress threshold
• Institutional care required

Stage 4 Late (EndStage)

• Family recognition disappears
• Doesn’t recognize self
• Nonambulatory
• Little purposeful activity
• Often mute, may scream spontaneously
• Forgets most ADLs
• Problems associated with immobility
• Institutional care required
• Return of primitive reflexes

LATER CHANGES IN DEMENTIA

• Aphasia – speech
• Apraxia – purposeful activity
• Agnosia – sensory stimuli
• Anomia – memory of items
• Amnesia – loss of memory

CHEMICAL DEPENDENCE
Alcohol Abuse
Substance Abuse
Substance Dependence
maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by three or more of the following,
occurring at any time in the same 12 month period
• Tolerance
• Withdrawal
• Substance is often taken in larger amounts or over a longer period than intended
• Persistent desire or unsuccessful effort to cut down
• Time is spent in activities necessary to obtain the substance, use the substance or recover from its effects
• Important social, occupational or recreational activities are given up or reduced because of substance use.

Substance Abuse
A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following
within a 12 month period.
• Recurrent substance use resulting in failure to fulfill major role obligations at work, school or home
• Used in dangerous situations
• Substance related-legal problems
• Continued substance use despite having persistent or recurring problems caused or exacerbated by the effects of the substance

Alcohol Abuse
• Alcohol is a legal substance
• A central nervous system depressant
• A disease that can be arrested but not cured.
• Used with other substance

Alcohol equivalents
• One drink= 1 oz 86 proof “hard liquor”= 5 oz glass of table wine= 12oz can/bottle of beer

ALCOHOLISM
• Intergenerational Transmission
• Awake but unaware
• Blackout
• Confabulation
• Denial, dependence
• Enabling, co-dependence
• Tolerance increases
• Detoxification - doctor
• Avoid alcohol during therapy
• Aversion therapy
• Antabuse – disulfiram
• Belongings – check for alcohol, mouthwash, elixir etc.
• B1 deficiency
• Complication
• Wernicke’s Encephalopathy (Motor)
• Korsakoff’s Psychosis (Mind)
• Delirium Tremens
• Formication

Principles of Nursing Care

• Provide a well-lighted room
• DAT; Vitamin B1; Glucose
• Monitor v/s
• Long term therapy
– Support system –
• Alcoholic Anonymous
• Alanon
• Alateen
• Family therapy
• Provide safety: alcohol free environment
• Increase self-esteem
• Resocialization
Stages of Alcohol Withdrawal

• I 8 hours after the last drink

– Mild tremors, tachycardia, increased BP, diaphoresis, nervousness
• 2 8-12 hours after the last drink
– Gross tremors, hyperactivity, profound confusion, loss of appetite, insomnia, weakness disorientation, illusions,
hallucinations and delusions
• 3 12-48 hours after the last drink
– * severe hallucinations, grand mal seizures
• 4 3-4 days after the last drink
– Delirium tremens, confusion, agitation, hallucinations, insomnia and tachycardia

CODEPENDENCY
• An over responsible behavior-doing for others what they just as well do to themselves
• Women or wives of alcoholics
• Codependent individuals find themselves:
1. Attempting to control someone else’s drinking
2. Spending inordinate time thinking about the alcoholic person
3. Covering up the person’s drinking or lying
4. Feeling responsible for the person’s alcohol use
5. Feeling guilty for the alcoholic’s behavior
6. Avoiding family and social events because of concerns or shame about the alcoholic’s behavior
7. Allowing moods to be influence by the alcoholic
8. Assuming the alcoholic’s duties and responsibilities
9. Often bailing the alcoholic out of financial or legal problems

UPPERS AND DOWNERS

UPPER
Cocaine
Hallucinogens
Amphetamines

DOWNERS
Marijuana
Alcohol
Barbiturates
Narcotics
Heroin
Codeine
Morphine

Intervention:
• Behavioral Modification
• Detoxification
• Family Marital Therapy
• Self Help Groups
• Medication

Cardinal signs
• Narcotics: pupillary constriction, decreased BP
• Stimulants: pupillary dilation, increased BP, paranoia
• Hallucinogen : Bloodshot eyes, dry mouth, cravings for junk foods
• Sedatives: tremors, sedation

SEXUAL AND GENDER IDENTITY DISORDERS

Paraphilias
Data Base

A.Etiologic factors

1. Sexual urges or fantasies that are directed toward nonhuman objects, infliction of pain to self, partner, children, or other nonconsenting
individuals for at least 6 months’ duration
2.Diagnosis is made when the individual has acted on urges or is extremely distressed by the urges
3. Sexual arousal accompanies paraphiliac fantasies or stimuli
4. Person may or may not be able to function sexually without the paraphiliac fantasy or stimuli
5. May be symptomatic of other personality or psychiatric disorders
6. May occur as a behavior aberration or a disordered personality
7. Onset of fantasies and related behaviors may begin in childhood or early adolescence and becomes more defined in adulthood

B. Types and Behavioral/Clinical Findings

1. Fetishism: substitution of an inanimate object for the genitals

2. Transvestic fetishisms: wearing clothes of the opposite sex to achieve sexual pleasure
3. Exhibitionism: sexual pleasure obtained by exposing the genitals
4. Pedophilia: attraction to children as sex objects
5. Voyeurism: sexual gratification obtained by watching the sexual play of others
6. Sadism: sexual gratification obtained from cruelty to others used as substitute for or an accompaniment to the sex act
7. Masochism: sexual gratification obtained from self-suffering; used as a substitute for or an accompaniment to the sex act
8. Frotteurism: sexual pleasure obtained by touching or rubbing against a nonconsenting person usually occurs in crowds or on public
transportation
9. Necrophilia: sexual gratification obtained from sexual relations with a corpse
10. Telephone Scatologia: sexual gratification from or during lewdness on the telephone

C. Therapeutic Interventions

1. Rather unsuccessful with these individuals unless they really want to change
2. If change is desired, psychotherapy may be effective treatment models
a. Cognitive therapy
b. Behavioral therapy

NURSING CARE OF CLIENTS WITH PARAPHILIAS

A. Assessment

1. History of sexual behavior

2. Presence of other psychosocial difficulties
3. Level of Anxiety regarding sexual behavior
4. Pending criminal charges
5. Why client is seeking treatment at this time
6. Potential for violence toward others or self
B. Analysis/Nursing Diagnoses

1. Anxiety related to threat to security, fear of discovery, and conflict between sexual desires and societal norms
2. Disturbed body image related to feelings about size and functioning of genitalia and ineffective past sexual functioning
3. Ineffective coping related to inability to meet basic sexual need and sexual role expectations and poor self-esteem
4. Risk for infection related to frequent changes in sexual partners and sadistic or masochistic acts
5. Risk for injury related to retaliation for sexual behavior or sadistic or masochistic acts
6. Ineffective sexuality patterns related to an inability to achieve sexual satisfaction without the use of paraphiliac behaviors
7. Risk for violence: directed toward others or self, related to choice of sex objects or obtaining sexual gratification by inflicting or
receiving physical abuse

C. Planning/Implementation

See Fundamental Principles When Caring for Clients with Sexual and Gender Identity Disorders

D. Evaluation/Outcomes

1. Ceases socially unacceptable behavior

2. Seeks and continues long-term therapy
 3. Limits paraphiliac behavior to consenting adults
4. Utilizes safer sex techniques

Sexual Dysfunction
Data Base

A.Etiologic factors
1. Inhibition or interference with the desire, excitement, orgasm or resolution phases of the sexual response cycle
2. Dysfunction is psychogenic, but it may begin with a physiologic basis
3. Dysfunction can be lifelong or acquired
4. Dysfunction can be generalized or situational

B. Types and Behavioral/Clinical Findings

1. Sexual desire disorders: deficient, absent, or extreme aversion to and avoidance of sexual activity
2. Sexual arousal disorders: partial or complete failure to achieve a physiologic (subjective) response to sexual activity
3. Orgasm disorders: delay in or absence of orgasm or premature ejaculation
4. Sexual pain disorders: recurrent or persistent genital pain before, during, or after sexual activity

C. Therapeutic interventions
1. Treatment of underlying physiologic cause if present
2. Sexual counseling for client and partner

Nursing Care of Clients with a Sexual Dysfunction

A. Assessment
1. Feelings about inability to function sexually
2. Expectations regarding sexual ability
3. Effect of sexual dysfunction on relationship with significant other

B. Analysis/Nursing Diagnoses
1. Anxiety related to threat to security and fear of discovery
2. Disturbed body image related to feelings about size and functioning of genitalia and ineffective past sexual functioning
3. Ineffective coping related to inability to meet basic sexual needs and sexual role expectations and poor self-esteem
4. Sexual dysfunction related to lack of sex education, lack of communication with partner regarding individual responses, ineffective
sexual techniques, physical (illness, injury, surgery, medication) or substance abuse (addiction) contributing to sexual dysfunction,
feelings of vulnerability, value conflict, and actual or perceived sexual limitations

C. Planning/Implementation
1. See Fundamental Principles When Caring for Clients with Sexual and Gender Identity Disorders
2. Recognize that the problem is real to the client regardless of age
3. Recognize that the desire to function sexually does not diminish with age

D. Evaluation/Outcome
1. Reports an increased satisfaction in sexual functioning
2. Reports sexual ability approaches sexual expectations

Intervention
• Psychotherapy
• Individual therapy
• Group Psychotherapy
• Social skills training
• Treatment of co-morbid physical and psychiatric features
• Hormonal treatments
• Medications
• Anti-androgen drugs (Medroxyprogesterone acetate and Cyproterone acetate)

AUTISM & ADHD

Autism
• Living in their own world
• Appearance – flat (consistent)
 • Behavior – ritualistic, repetitive
• Communication – echolalia, incomprehensible

Nursing Diagnosis:
• Impaired Verbal Communication
• Impaired Social Interaction
• Self Mutilation
• Risk for Injury

Attention Deficit/Hyperactive Disorder(ADHD)

• 7 years old and above

• Duration: 6 months and above
• Requires 2 settings: home and school
• Appearance: Dirty child
• Behavior: Clumsy, hyperactive, impatient
• Communication: talkative, bursts out
• Structure
• Setting limits
• Schedule
• Safety

Mental Retardation

• Subnormal general intellectual functioning which originates during the developmental period and is associated with impairment of
either learning and social adjustment or maturation or both.

Causes:
1. congenital numerical deficiency or abnormal arrangement of brain cells
2. birth injuries due to pelvic disproportions, premature births or forceps delivery
3. infectious diseases e.g. german measles of the mother during the first 3 months of pregnancy
4. infectious diseases during childhood e.g. meningitis or encephalitis
5. endocrine deficiencies such as thyroid deficiency, known to be the cause of cretinism
6. exposure to environmental deprivation, with poor housing and economic and social conditions
7. familial or hereditary causes
8. inborn errors of metabolism e.g. inability to metabolize proteins, carbohydrates or fats
9. genetic defects e.g. abnormalities in the genes and chromosomes

Physical Appearance

• small head; almond-shaped, downward slanted eyes; thick lips.short fat hands with usually one palmar line (simian crease); yellow
complexion
• tongue is flabby with deep groves and fissures
• friendly and love to imitate others
• acute leukemia is more prevalent in them
• usually mouth breathers and prone to respiratory infections
• many die at an early age
• Temper tantrums

Classification of Mental Retardation according to IQ

CATEGORY IQ

Borderline 68-85

Mild 52-67

Moderate 36-51

Severe 20-35

Profound Under 20
Mild (Educable/Moron)
• Can develop social communication skills; minimal retardation in sensorimotor areas; often not distinguished from normal until late
age (0-5 years)
• Can learn academic skills up to approximately 6th grade until late teens. Can be guided toward social conformity, ‘educable’ (6-20
years)
• Can usually achieve social and vocational skills adequate to minimum self-support but may need guidance and assistance when
under unusual social or economic stress(21-adult

Moderate (Trainable/Imbecile)
• Can talk or learn to communicate; poor social awareness; fair motor development, profits from training in self-help; can be managed
with moderate supervision (0-5)
• Can profit from training in social and occupational skills; unlikely to progress beyond second grade in academic subjects; may learn
to travel alone in familiar places (6-20)
• May achieve self-maintenance in unskilled or semi-skilled work under sheltered conditions; needs supervision and guidance when
under mild social or economic stress (21-adult)

Severe(Imbecile)
• Poor motor development; speech is minimal; generally unable to profit from training in self-help; little or no communication skills (0-
5)
• Can talk or learn to communicate; can be trained in elemental health habits, profits from systematic habit training (6-20)
• May contribute partially to self maintenance under complete supervision; can develop self-protection skills to a minimal useful level
in a controlled environment (21-adult)

Profound (Idiot)
• Gross retardation; minimal capacity for functioning in sensorimotor areas;needs nursing care (0-5)
• Some motor development present; may respond to minimal or limited training in self-help (6-20)
• Some motor and speech development; may achieve very limited self-care; needs nursing care (21-adult)

Nursing Care

• Help parents accept diagnosis of mental retardation

• Consider the developmental/functional age, not the chronological age
• Teach parents/caregivers that they should:
– Protect the child from danger
– Make the child as independent as his condition will permit
– Teach the child to refrain from holding their mouths open as this gives them a dull appearance
– Select attractive, well-fitting clothing, hairstyle and good hygiene practices
• Teach parents/caregivers that they should:
– Eliminate the child’s undesirable social traits, e.g. touching their noses and ears, scratching
– Teach the child only one thing at a time
– Demonstrate what they teach as much as possible
– Use pictures for these are valuable teaching aids
– Start teaching the child simple things, gradually progressing to complex learning experiences
– Remember that repetition and patience are necessary virtues
– Refrain from scolding because it blocks learning
– Recognize that temper tantrum as a child’s attempt to meet some underlying emotional needs

Eating Disorders
Anorexia Nervosa
Bulimia Nervosa

Anorexia Nervosa
Symptoms:
• Refusal to maintain body weight over a minimum normal weight for age and height
• Intense fear of gaining weight or becoming fat, even though underweight
• Disturbance in the way in which one’s bodyweight, shape or size is experienced
• In females, absence of menses of at least 3 consecutive cycles
• Inability or refusal to acknowledge the seriousness of the problem
• Onset: 12-15, 17-21 years of age
Etiology
• Cultural pressure
• Serotonin imbalance controls appetite and the satiety control center
• Family Patterns
– Perfectionist
– Does not permit verbalization of feelings
– Marital problems

Clinical Presentation Part 1

• Terrified of gaining weight

• Pre-occupied with thoughts of food
• See themselves as fat even when emaciated
• Peculiar handling of food
– Cutting food into small bits
– Pushing pieces of food around the table
• May develop rigorous exercise program
• Self-induced vomiting, laxatives and diuretics
• Cognition so disturbed that they judge their self-worth by their weight.

Clinical Presentation Part 2

• Low weight • Low T3 and T4

• Amennorrhea • Hypotension
• Yellow skin • Bradycardia
• Cold extremities • Hypokalemia
• Peripheral edema • Anemia
• Muscle weakening • Pancytopenia
• Constipation • Decreased bone density

Signs related to Purging Behaviors

• Gastrointestinal
– Parotid gland tenderness, Pancreatitis, esophageal and gastric erosion or rupture
• Metabolic
– Electrolyte abnormalities hypokalemia
• Dental
– Erosion of dental enamel of the front teeth

Objectives

• Increasing body weight to at least90% of average weight for age and height
• Reestablishing good eating behavior
• Increasing self esteem

Nursing Interventions:

• Monitor daily caloric intake, activity level, weight and electrolyte status.
• Establish nutritional eating patterns
– Sit with client during meals
– Offer liquid protein supplement if unable to complete a meal
– Observe signs of purging 1-2 hours after meals
• Provide accurate information on nutrition and discuss realistic and healthy diet
• Help the client identify emotions and develop non-food related strategies.
– Convey warmth and sincerity
– Ask the client to identify feelings
– Assist the client to change stereotypical beliefs
• Assist in identifying at least three positive characteristics
• Teach patient about their illness
• Behavior modification : reward increase in weight with meaningful privileges
• Identify patient’s non weight related interests to reduce anxiety and refocus attention.
Bulimia Nervosa

Symptoms:
• Recurrent episodes of binge eating
• Feeling of lack of control over eating behaviors during the eating binges
• Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self induced vomiting
• Binge eating and inappropriate eating behaviors
• Persistent over concern with body shape and weight

Clinical Presentation

• Binge and Purging behaviors

• Have depressive signs and symptoms
• Disturbed home life
• Major concerns
– Interpersonal relationships
– Self-concept
– Impulsive behaviors
• Chemical dependence is also common
• Normal to slightly low weight
• Dental carries
• Parotid swelling
• Gastric swelling and rupture
• Callusses or scars on the hand
• Peripheral edema
• Hypokalemia, Hyponatremia

ANOREXIA BULIMIA
Etiology Psychological (Freudian); Socio-cultural; Familial, internal
gender
Behavior Diet, diet, diet…die Diet, diet, diet…vomit
Fear of weight gain; preoccupation with food Binge eating; purging; still on diet
(knowledgeable in nutrition)
Communication Denial Verbalization of body dysmorphic image
Nursing Diagnosis Nutrition Imbalance nutrition more than or less than
Body Image disturbance
Nursing Priority Nutrition, promote self-esteem Nutrition; promote self-esteem
Treatment / Therapy CBT; weight gain; behavioral modification / CBT; weight gain; behavioral modification /
Kind Firmness Kind Firmness
Environment Stay with the client one hour after eating; Stay with the client one hour after eating;
Don’t allow client to go to toilet at once Don’t allow client to go to toilet at once

Management:

• Trust
• Help patient identify feelings associated with binge-purge behaviors
• Accept patient as worthwhile human beings because they are often ashamed of their behavior
• Encourage patient to discuss positive qualities about themselves
• Teach about bulimia nervosa
• Encourage to explore interpersonal relationships
• Encourage patients to adhere to meal and snack schedules
• Encourage the patient to approach the staff if she feels like binging or purging
• Encourage to attend group sessions
• Encourage family therapy
• Encourage participation in art, recreation and occupational therapy
• Encourage the patient to describe their body image at different ages of their lives.
VIOLENCE & ABUSE

Battered Wife Syndrome

• Often done by the husband to his wife

• Abusive husband believes that he owns his wife (as one of his possessions) and starts to be violent and abusive when the wife shows
signs of being independent (like having her own job)

Profile of the Abuser

• Inadequate
• With low self-esteem
• Poor problem-solving and social skills
• Immature
• Needy
• Unreasonably jealous
• Possessive
• He longs for power and a sense of control, which he is able to have when he bullies and punishes the family physically

Profile of the Abused

• Dependent
• Low self-esteem
• Perceives herself as unable to function away from her husband
• Equates success with her blind loyalty to her husband
• Fear of being killed by the abuser if they try to escape

Nursing Intervention
• Assessment for physical injuries immediately after the episode of violence
• Provision of temporary shelter
• Individual psychotherapy or counseling, group therapy, or support and self-help groups help the women to deal with the trauma and
help them to build new relationships that are healthier

Rape

• A crime of violence expressed through sexual means (Videbeck)

• The female victim is forced into a sexual intercourse, against her will, whether the force was done under the influence of drugs,
threat to one’s life, or use of intoxicants
• Age range: 15 months -82 years
• Peak age: 16-24 years old

Underreported because:
• Guilt and shame
• Fear of further injury
• A false belief that she has no recourse in the legal system

Nursing Intervention

• Give immediate support to the victims and allow expression of fear and rage
• The client should be allowed to proceed at her own pace and not be rushed in the interview or examination
• Give as much control to the client as possible, ask permission before doing any procedures or taking any samples for evidence
• Give prophylactic treatment for STDs such as Chlamydia, gonorrhea, or both
• Pregnancy and HIV testing is also done
• Prophylactic treatment with ethinyl estradiol and norgestrel could be offered
• Therapy is supportive and focused on restoring the patient’s sense of control, relieving feelings of helplessness, dependency,
trauma and obsession that follow rape up to the level of regaining trust, strengthening support system, restoring daily functions and
dealing with guilt, shame, and anger

Types of Child Abuse

• Physical abuse
• Sexual Abuse
• Neglect
• Psychological Abuse
Physical Abuse
• Involves the performance of a severe corporal punishment of hitting or beating child victims
• These acts include biting, burning, cutting, poking, twisting limbs, or scalding with hot water
• Signs and symptoms:
– Untreated fractures
– bruises of various ages
– injuries not explained adequately by caregivers

Nursing Intervention
• Report all cases of child abuse to the AUTHORITY.
• Assess the child both physically and psychologically
• Perform a thorough physical and psychiatric exam
• Interview the abused child with the following in mind: developmental level, psychological readiness (allow the child to disclose at
his/her own pace and not coercing the client)
• Interview the parents and note the ff: discrepancy between their narration and the actual evidences gathered, inconsistency in their
stories, delay in their consultation
• Treat the presenting injuries and do the necessary tests and screening for STD.
• Ensure the child’s safety from any immediate threat, may arrange for the placement in a temporary shelter
• Long-term, the child may need to undergo play therapy
The parent abusers may also need to undergo psychiatric treatment, parenting classes or treatment for substance abuse
• The whole family may need to undergo family therapy
• Referral to the Social Service to investigate the home and the set-up in the family and to determine and make the needed
arrangements in case when the abused child needs to be put in a permanent foster care to ensure safety

Sexual Abuse

• Involves sexual acts committed by an adult towards an individual below 18 years of age
• This may involve incest, rape, sodomy, exposure, rubbing or fondling of the victim’s genitals
• This also includes sexual exploitation of involving minors in acts of pornography or in doing obscene acts

Neglect

Intentional or ignorant withholding of physical, emotional, or educational needs for the improvement of the child’s well-being
May be in the form of:
• refusal or delay in seeking medical treatment
• abandonment
• inadequate supervision
• recklessness with the child’s safety
• spouse abuse in the child’s presence,
• failure to enroll the child in school

Psychological Abuse
Abuse which adversely affects the child’s emotional make-up
These may include:
• verbal abuse
• blaming
• screaming
• name-calling
• constant family
• arguments resulting to fighting and yelling
• withholding of affection and experiences that promote love, security, and self-worth

Prepared By: Diane Cruz RN