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MA. OLIVIA G.

MOLINA RN, MAN

If any of you lacks wisdom, let him ask the Lord who gives freely to his children. James 1:5

Q: It is most helpful to the nurse who is attempting to apply the principles of positive mental health to understand that: A. emotionally ill people can empathize easily with others B. psychologically healthy people function optimally in all settings C. a sense of mastery of self and environment is crucial to emotional health D. mental illness is characterized by observable signs of socially inappropriate behavior

A state of (E)emotional, (S)social and (P)psychological wellness as evidenced by: E -ffective behavior and coping, S -atisfying interpersonal relationships P -ositive self-concept and E -motional stability. (WHO)

` State

of imbalance characterized by a disturbance in a persons thoughts, feelings and behavior


CULTURALLY-SANCTIONED

COMPONENTS
ACCEPTANCE OF ONESELF & OTHERS ABILITY TO COPE WITH PROBLEMS/STR ESS RELATIONSHIPS

MENTAL HEALTH
YES

MENTAL ILLNESS
NO

YES

NO

CLOSE &LASTING

UNSTABLE & SHORTLIVED

COMPONENTS JUDGMENT ACCEPTS RESPONSIBILT Y FOR ACTIONS OPTIMISM

MENTAL HEALTH SOUND YES

MENTAL ILLNESS POOR NO

YES

NO

COMPONENTS RECOGNITION OF LIMITATIONS INDEPENDENC E PERCEPTION OF REALITY

MENTAL HEALTH YES

MENTAL ILLNESS NO

YES ABLE

NO UNABLE

COMPONENTS DEVELOPMENT OF POTENTIAL AND TALENTS PROBLEM SOLVING GRATIFICATION

MENTAL HEALTH YES

MENTAL ILLNESS NO

YES DELAYED

NO IMMEDIATE

Clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability or an important loss of freedom. (APA, 2000)

Q: Psychiatric Nursing pertains to: A. Assessment of behavior, planning and evaluation of care for individuals with mental disorders B. Promotion of optimal mental health for individual, through early diagnosis, treatment and rehabilitation C. Use of interactions between the nurse and the individual, as therapeutic D. Use of both therapeutic and non-therapeutic communication techniques in interacting with clients.

INTERPERSONAL PROCESS

Therapeutic use of self ` Promotion of mental health ` Help prevent mental illness and suffering ` Participate in the treatment and rehabilitation ` Help find meaning in these experiences
`

Id pleasure principle ego reality principle Superego moral principle

ID
M -Manic A Anti-social N Narcissistic

SUPEREG O

ID
O Obsessive-Compulsive A Anorexia Nervosa

SUPEREG O

EGO

DISTORTED

SCHIZOPHRENIA

Q: A person loses an important advertising account and gets a flat tire while driving home. That evening, the person begins to find fault with everyone. Which defense mechanism is the person using? A. displacement B. projection C. regression D. sublimation

Functions: 1. To ward off anxiety 2. To resolve a conflict 3. To protect self-esteem 4. To protect ones security

3 Ds

Common Example: A husband comes home and yells at his wife after a bad day at work Patient Example: Mrs. Faust screams at another patient after being told by her psychiatrist that she cannot have a weekend pass.

DISPLACEMENT

Feelings are transferred or redirect to other person or object that is less threatening (Negative DM; 3 entities involved)

Example: Amnesia that


prevents recall of yesterdays auto accident

DISSOCIATION

Separating and detaching a strong emotionally charged conflict from ones consciousness traumatic amnesia

Common Example: A student refuses to admit that she is flunking a course despite an F on the 1st exam. Patient Example: Mr. Davis, who is alcohol dependent, states that he can control his drinking.

DENIAL

Failure to acknowledge an unacceptable trait or situation

5Rs

Common Example: a 6-year old wets the bed at night since the birth of his baby sister Patient example: Mr. Hivey has isolated himself in his room and has lain in a fetal position since his admission

REGRESSION

Returning to an earlier developmental stage

Common Example: A student states, I got a C on the test because the teacher asked poor questions. Patient Example: Mr. Jones, a paranoid schizophrenic, states that he cannot go to work because he is afraid of his co-workers instead of admitting that he is mentally ill.

RATIONALIZATION

Self-saving with incorrect illogical explanation Look for reasoning or because

Common Example: A car accident victim is unable to remember details of the impact, but was aware at the time. Patient example: Mrs. Yong, a victim of incest, does not know why she has always hated her uncle

REPRESSION

Unconscious forgetting of an anxiety provoking situation

Common Example: An older brother who dislikes his younger brother sends him gifts for every holiday. Patient Example: Miss Marla, who unconsciously hates her mother, continuously tells staff how wonderful her mother is.

REACTION FORMATION

Opposite of intention 1 feeling (-) and 1 action (+) or 1 feeling(+) and 1 action (-)

Example: Person attends courtordered treatment for alcoholism but refuses to participate

RESISTANCE

` Overt

or covert antagonism toward remembering or processing anxiety-producing information

3 Is

Common Example: A wife states to her husband that a dented car fender is much better than a completely wrecked car and garage door. Patient Example: Mrs. Mann talks about her sons death and bout with cancer as being mercifully short without showing signs of sadness.

INTELLECTUALIZATION

Excessive use of abstract thinking; technical explanation No emotions involved or reduced

Common Example: While her mother is gone, a young girl disciplines her brother just like her mother would. Patient Example: Without realizing it, a patient talks and acts like his therapist, analyzing other patients.

INTROJECTION

Acceptance of anothers values and opinions as ones own Imitation but no admiration, like

Common Example: When a little girl dresses up like her mother to play house, she tries to talk and act like her mother. Patient example: Sheila states to the nurse, When I get out of the hospital, I want to be a nurse just like you.

IDENTIFICATION

A conscious or unconscious attempt to model oneself after a respected person Superficial, imitation with admiration, like

2 Fs

Example: Daydreaming

FANTASY

` MAGICAL

THINKING

Examples: Lack of a clear sense of identity as an adult. ` Oral fixations

FIXATION

` occurs

when a person is stuck in a certain developmental stage

2Cs

Common Example: A student awakens with a migraine the morning of a final examination and feels ill to take it. Patient example: Mr. Jenson suddenly develops impotence after his wife discovers he is having an affair with his secretary.

CONVERSION

Anxiety converted to physical symptoms Presence of physical complaints

Common Example: An academically weak high school student becomes a star in the school play. Patient Example: A schizophrenic patient who is unable to talk to other patients becomes known for his expressive poetry.

COMPENSATION

Overachievement in one area to overpower weaknesses or defective area. Can also be compensating for anothers weaknesses No relatedness on the weakness compensated with strength.

5Ss

Common Example: An adolescent arrested once for stealing later opens a business installing security systems in banks. Patient Example: A former perpetrator of incest who fears relapse initiates a local chapter of Parents United.

SUBLIMATION

Channeling instinctual drives to a more productive activity. Positive; 3 entities involved

` Example:

A student nurse decides to be a teacher because he or she is unable to master clinical competencies

SUBSTITUTION

Replaces a goal that cant be achieved for another that is more realistic. Weakness has relatedness to weakness

Example: An engagement ring symbolizes love and a commitment to another person

SYMBOLIZATION

Creates a representation to an anxiety provoking thing or concept Use of tangible things as symbols

Common Example: A student states, I cannot think about my wedding tonight. I have to study. Patient Example: Michelle states to the nurse that she is not ready to talk about her recent divorce.

SUPPRESSION

` Voluntary

or conscious exclusion from awareness, anxiety-producing feelings, ideas and situations

SPLITTING

Labile emotions; all bad all good

1U

Common Example: After spanking her son, a mother bakes his favorite cookies. Patient Example: After eating another patients cookies, Mrs. Donnelly apologizes to the patients, cleans the refrigerator, and labels everyones snack with their names.

Doing the opposite of what have done 1 (-) action, then 1 (+) action; this is constant

1P

Common Example: A teenager comes home late from a date and states that her friend did not bring her home on time. Patient Example: Katrina states that she used marijuana while her boyfriend made her smoke it.

PROJECTION

Blaming; Falsely attributing to another his/her own unacceptable feelings. 2 entities involved always; (Adam to God)

UNDOING VS. REACTION FORMATION

IDENTIFICATION VS. INTROJECTION

COMPENSATION VS. SUBSTITUTION

DISPLACEMENT VS. SUBLIMATION

REPRESSION VS. DISSOCIATION

REPRESSION VS. SUPPRESSION

RATIONALIZATION VS.
INTELLECTUALIZATIO N

FIXATION VS. REGRESSION

DEFENSE MECHANISMS COMMONLY USED IN EACH RESPECTIVE DISORDERS

Paranoid Projection

Phobia Displacement

Borderline Splitting

Amnesia Dissociation

Anorexia Suppression

Bipolar Disorder Reaction Formation

Schizophrenia Regression

Substance Abuse Denial

Depression Introjection

OC Undoing

Catatonic - Repression

DRILL EXAMPLES

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

A: SUBLIMATION

Four-year old with new baby brother starts sucking his thumb and wanting a bottle.

A: REGRESSION

Patient criticizes the nurse after her family failed to visit.

A: DISPLACEMENT

Man who is unconsciously attracted to other women teases his wife about flirting

A: PROJECTION

Short man becomes assertively verbal and excels in business.

A: COMPENSATION

Recovering alcoholic constantly preaches about the evils of drink.

A: REACTION-FORMATION

Man reacts to news of the death of a loved one No, I dont believe you. The doctor said he was fine.

A: DENIAL

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

A: CONVERSION

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

A: UNDOING

didnt get the raise because my boss doesnt like me.

A: RATIONALIZATION

Five-year old girl dresses in her mothers shoes and dress and meets daddy at the door.

A: IDENTIFICATION

After his wifes death, husband has transient complaints of chest pain and difficulty breathing- the symptoms his wife had before she died

A: INTROJECTION

Man forgets wifes birthday after a marital fight.

A: REPRESSION

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.

A: SUPPRESSION

A man cannot accept his physician's diagnosis of cancer is correct and seeking a second opinion

A: DENIAL

Slamming a door instead of hitting as person, yelling at your spouse after an argument with your boss

A: DISPLACEMENT

Focusing on the details of a funeral as opposed to the sadness and grief

A: INTELLECTUALIZATION

Stating that you were fired because you didn't kiss up the boss, when the real reason was your poor performance

A: RATIONALIZATION

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

A: REGRESSION

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

A: REACTION-FORMATION

lifting weights to release 'pent up' energy

A: SUBLIMATION

A student is poor in academics but is a talented artist

A: COMPENSATION

A client daydreams during a serious group therapy

A: FANTASY

the pain over a parents sudden death is reduced by saying He would have not wanted to live disabled.

A: INTELLECTUALIZATION

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

A: INTROJECTION

A reviewee who fails the board exam says it is alright anyway he can take it three times

A: RATIONALIZATION

A woman rushes into marriage following a break up with her boyfriend

A: SUBSTITUTION

FG Arroyo sends GMA 33 rd roses on their 33 wedding anniversary

A: SYMBOLIZATION

ASSESSMENT
(TYPICAL SIGNS & SYMPTOMS OF PSYCHIATRIC ILLNESS)

INAPPROPRIATE AFFECT:
` Disharmony

of affect and ideation


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PLEASURABLE AFFECTS: 1. EUPHORIA heightened feeling of psychological wellbeing inappropriate to apparent events

PLEASURABLE AFFECTS: 2. ELATION-air of confidence and enjoyment associated with increased motor activity

PLEASURABLE AFFECTS: 3. EXALTATION- intense elation with feelings of grandeur

PLEASURABLE AFFECTS: 4. ECSTACY- feelings of intense rapture

UNPLEASURABLE AFFECTS 1. DEPRESSIONpsychopathological feeling of sadness

UNPLEASURABLE AFFECTS 2. GRIEF MOURNINGsadness appropriate to real loss

FLAT AFFECT showing no facial expression

RESTRICTED AFFECT displaying one type of expression usually serious

BROAD AFFECT displaying full range of emotional expressions

BLUNTED AFFECT showing little or slow-torespond facial expression

ECHOLALIA psychopathological repetition of words of one person by another

ECHOPRAXIA pathological imitation of movement of one person by another

WAXY FLEXIBILITY(Cerea Flexibility)- state in which patient maintains body position into which he is placed

CATELEPSY state of unconsciousness in which immobile position is constantly maintained

COMMAND AUTOMATISM automatic following suggestions

AUTOMATISM- automatic performance of acts representative of unconscious symbolic activity

CATAPLEXY temporary loss of muscle tone and weakness precipitated by a variety of emotions

STEREOTYPE continuous repetition of speech or physical activities

NEGATIVISMS- frequent opposition to suggestions

MANNERISMS stereotyped involuntary movements

VERBIGERATIONmeaningless repetition of speech

OVERACTIVITY

HYPERACTIVITY (Hyperkenesis)- restless, aggressive, destructive activity

TIC- spasmodic, repetitive, motor movements

SLEEPWALKING (somnambulism) motor activity during sleep

DIPSOMNIA- compulsion to drink alcohol

EGORMANIA pathological selfpreoccupation

EROTOMANIApathological preoccupation with sex

KLEPTOMANIA- compulsion to steal

MEGALOMANIApathological sense of power

MONOMANIApreoccupation with a single subject

NYMPHOMANIAexcessive need for coitus in female

SATIRIASIS- excessive need for coitus in male

TRICHOTILOMANIA compulsion to pull ones hair

RITUAL- automatic activity compulsive in nature, emotional in origin

` Goal

directed flow of ideas, symbols and associations initiated by a problem or task and leading toward a reality-oriented conclusion; when a logical sequence occurs, thinking is normal

DEREISM ` Mental activity not concordant with logic or experience

AUTISTIC THINKING ` Thinking that gratifies unfulfilled desires but has no regard for reality; term used somewhat synonymously with dereism

NEOLOGISM ` New words created by the patient for psychological reasons

WORD SALAD `Inherent mixture of words and phrases

CIRCUMSTANTIALITY ` Digression of inappropriate thoughts into ideational processes, but patient eventually gets from starting point to desired goal

TANGENTIALITY ` Inability to have goal-directed associations of thought, patient never gets from starting point to desired goal

INCOHERENCE ` Running together of thoughts with no logical connection, resulting in disorganization

PERSEVERATION ` Psychopathological repetition of the same word or idea in response to different questions

CONDENSATION `Fusion of various concepts into one

IRRELEVANT ANSWER `That is not in harmony with question asked

FLIGHT OF IDEAS ` Rapid verbalizations so that there is a shifting from one idea to another

CLANG ASSOCIATIONS ` Words similar in sound, but not in meaning all up new thoughts

BLOCKING `Interruption in train of thinking, unconscious in origin

PRESSURE OF SPEECH `Voluble of speech difficult to interrupt

MOTOR APHASIA ` Disturbance of speech due to organic brain disorder in which understanding remains but ability to speak is lost

SENSORY APHASIA ` Loss of ability to comprehend the meaning of words or use of objects

NOMINAL APHASIA `Difficulty in finding right name for an object

SYNTACTICAL APHASIA `Inability to arrange words in proper sequence

DELUSION ` False belief, not consistent with patients intelligence and cultural background, that cannot be corrected by reasoning

DELUSION OF GRANDEUR ` Exaggerated conception of ones importance DELUSION OF PERSECUTION ` False belief that one is being persecuted: often found in litigious clients DELUSION OF REFERENCE ` False belief that the behaviour others refers to oneself; derived from ideas of reference in which patient falsely feels his talked about by others

DELUSION OF SELF-ACCUSATION ` False feeling for remorse DELUSION OF CONTROL ` False feeling that one is being controlled by others DELUSION OF INFIDELITY ` False belief derived from pathological jealousy that ones lover is unfaithful

PARANOID DELUSIONS ` Oversuspiciousness leading to persecutory delusions NIHILISTIC DELUSIONS ` a false belief that everything is unreal SOMATIC DELUSIONS ` A false belief pertaining to the function of the body

TREND OR PREOCCUPATION OF THOUGHT ` Centering of thought content around a particular idea, associated with a strong affective thought

HYPOCHONDRIA ` Exaggerated concern over ones health that is not based on real organic pathology

OBSESSION ` Pathological persistence of an irresistible thought, feeling or impulse that cannot be eliminated from consciousness by logical effort

PHOBIA ` Exaggerated and invariably pathological dread of some specified type of stimulus or situation

` Awareness

of objects and relations that follows a stimulation of peripheral sense organs

DISTURBANCES ASSOCIATED WITH ORGANIC BRAIN DISEASE ` Such as agnosia, that is an inability to recognize and interpret the significance of sensory impressions

DISTURBANCES ASSOCIATED WTH HYSTERIA ` Illnesses characterized by emotional conflict, the use of the defense mechanism of conversion, and the development of physical symptoms involving the voluntary muscles or special sense organs

DISTURBANCES ASSOCIATED WTH HYSTERIA 1. HYSTERICAL ANESTHESIA ` Loss of sensory modalities resulting from emotional conflicts 2. MACROSIA ` State in which objects appear larger than they are 3. MYCROPSIA ` State in which objects appear smaller than they are

HALLUCINATIONS ` False sensory perceptions not associated with the real external stimuli

(HALLUCINATIONS)

HYPNAGOGIC HALLUCIANTIONS ` False sensory perception occurring midway between falling asleep and waking up

(HALLUCINATIONS)

AUDITORY HALLUCINATIONS `False auditory perception

(HALLUCINATIONS)

VISUAL HALLUCINATIONS `False visual perception

(HALLUCINATIONS)

GUSTATORY HALLUCINATIONS ` False perception of taste, such as unpleasant taste

(HALLUCINATIONS)

OLFACTORY HALLUCINATION `False perception of smell

(HALLUCINATIONS)

TACTILE HAPTIC HALLUCINATION ` False perception of touch, such as the feeling of worms under the skin

(HALLUCINATIONS)

KINESTHETIC HALLUCINATION ` False perception of movement or sensation as from an amputated limb (phantom limb)

(HALLUCINATIONS)

LILLIPUTAIN HALLUCINATION ` Perception of objects as reduced in size

ILLUSIONS `False perception of real external sensory stimuli

FACTORS HALLUCIN ILLUSION 2 ATION CONSIDE R USE OF SENSES PRESENC E OF X EXTERNAL STIMULI

DELUSION

X X

`Function

by which information stored in the brain is later recalled to consciousness

AMNESIA `Partial or total inability to recall past experiences

PARAMNESIA ` Falsification of memory by distortion of recall ` Fantasy and objective memory are confused

(PARAMNESIA)

1. FAUSE `

RENAISSANCE false recognition

(PARAMNESIA)

2. RETROSPECTIVE FALSIFICATION ` recollection of a true memory to which the patient adds false details

(PARAMNESIA)

1. `

CONFABULATION unconscious filling of gaps in memory by imagined or untrue experience that patient believes but that have no basis in fact

(PARAMNESIA)

4. DE JA VU ` Illusion of visual recognition in which a new situation is incorrectly regarded as a repetition of a previous memory

(PARAMNESIA)

5. DE JA ONTEND `Illusion of auditory recognition

(PARAMNESIA)

6. JAMAIS VU False feeling of unfamiliarity with a real situation one has experienced

HYPERMNESIA `Exaggerated degree of retention and recall situation one has experienced

` The

ability to understand, recall, mobilize and integrate constructively previous learning in meeting new situations

1. MENTAL

RETARDATION
2. DEMENTIA

NURSEPATIENT RELATIONSHIP

` Process

of understanding oneself (joharis window) ` The beginning of any relationship ` Is always the correct choice in the exam

S SOCIAL ( PURPOSE: FRIENDSHIP, SOCIALIZATION, ACCOMPLISHMENT OF TASK) I INTIMATE (PURPOSE: SHARING OF TWO HEARTS) T THERAPEUTIC (PURPOSE: PATIENT ONLY) * TO BE THERAPEUTIC, DETACH EMOTIONS

S- SIT INFRONT OF THE CLIENT O- OPEN BOY POSITIONS L- LEAN TOWARDS THE CLIENT E-EYE CONTACT R-RELATIVELY RELAX

P- POSITIVE REGARD A- ACCEPTANCE G- GENUINE INTEREST E- EMPATHY T-TRUST

PRE-INTERACTION self-awareness ORIENTATION contract setting WORKING identification of problems and exploring towards resolution. TERMINATION major task is resolve feelings of loss and evaluate progress of solutions

A.

The nurse said to the client, Do you like to discuss about your family? The nurse said to the client, What do you like to discuss?

B.

ACCEPTING BROAD OPENING CONSENSUAL VALIDATION ENCOURAGING COMPARISON ENCOURAGING DESCRIPTION OF PERCEPTIONS ENCOURAGING EXPRESSION

EXPLORING FOCUSING FORMULATING A PLAN OF ACTION GENERAL LEADS GIVING INFORMATION GIVING RECOGNITION

GIVING RECOGNITION MAKING OBSERVATIONS OFFERING SELF PLACING EVENT IN TIME AND SEQUENCE PRESENTING REALITY REFLECTING RESTATING

SEEKING INFORMATION SILENCE SUGGESTING COLLABORATION SUMMARIZING TRANSLATING INTO FEELINGS VERBALIZING THE IMPLIED VOICING DOUBT

NON-THERAPEUTIC COMMUNICATION TECHNIQUES

D-Discourages expression of feelings O-Overwhelming the patient/client R-Reassuring the client S-Sympathizing with the client A-Arguing with the client L-Limiting the ideas, opinions, of the client T-Threatening the client J-Judgmental

ADVISING AGREEING BELITTLING FEELINGS EXPRESSED CHALLENGING DEFENDING

DISAGREEING DISAPPROVING GIVING APPROVAL GIVING LITERAL RESPONSES

INDICATING THE EXISTENCE OF AN EXTERNAL SOURCE INTERPRETING INTRODUCING AN UNRELATED TOPIC MAKING STEREOTYPED COMMENTS PROBING

REASSURING REJECTING REQUESTING AN EXPLANATION TESTING USING DENIAL

DRILL QUESTIONS

Perhaps you and I can discover what causes your anxiety

What would you like to discuss?

What are you thinking about?

Has this ever happened before?

What made you say that?

Ill sit with you for a while.

Why are you reluctant to talk?

Are you sure of what you said?

Is that really what you believe?

Something seems to be bothering you. Would you like to talk about it?

What proof do you have that someone is out to harm you?

You have no reason to be afraid.

When people are under stress, they may see or hear things that others do not. Is that what just happened?

Im a nurse. Im not poisoning you. Its against the nursing code of ethics.

Im a nurse, and youre a client in the hospital. Im not going to harm you.

A client has just begun to discuss important feelings when the time of the interview is up. The next day, when the nurse meets with the client at the agreed-upon time, the initial intervention would be to say: A. Good morning! How are you today? B. Yesterday you were talking about some very important feelings. Lets continue. C. What would you like to talk about today? D. Nothing and wait for the client to open a topic.

A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, Im feeling sad. I dont want to talk now. The nurses best response would be: A. Ill help you feel better if you talk about it. B. Ill come back when you feel like talking. C. Ill stay with you a few minutes. D. Sometimes it helps to talk.

A client says to the nurse, Dr. Lim has surely botched my case. I cant believe theyd let her continue to practice. Which of the following is an appropriate response? A. Dr. Lim is a fine doctor and one worthy of respect. B. Dr. Lim has been sued before and her practice is questionable. C. You seem to have some concerns with Dr. Lim. D. Dr. Lim usually provides good care.

Earlier today you said you were concerned that your son was still upset with you. When I stopped by your room about an hour ago, you and your son seemed relaxed and smiling as you spoke to each other. How did things go between the two of you? This is an example of which therapeutic communication technique? A. Consensual validation B. Encouraging comparison C. Accepting D. General lead

Why do you always complain about the night nurse? She is a nice woman and a fine nurse and has five kids to support. Youre wrong when you say she is noisy and uncaring. The second statement reflects which nontherapeutic technique? A. Requesting an explanation B. Defending C. Disagreeing D. Advising

How does Jerry make you upset? is a non-therapeutic communication technique because it A. Gives literal response B. Indicates an external source of the emotion C. Interprets what the client is saying D. Is just another stereotyped comment

Client: I was so upset about my sister ignoring my pain when I broke my leg. Nurse: When are you going to your next diabetes education program? This is a non therapeutic response because the nurse has A. Used testing to evaluate the clients insight B. Changed the topic C. Exhibited an egocentric focus D. Advised the client what to do

Client: I had an accident. Nurse: Tell me about your accident. This is an example of which therapeutic communication technique? A. Making observations B. Offering self C. General lead D. Reflection

SELECTED PROBLEM BEHAVIORS AND INTERVENTIONS

Prevention-early recognition of increased excitement ` Avoid reinforcement ` Protect other clients ` Encourage verbal expression of feelings surrounding behaviour ` Reduce stimuli ` Set limits
`

` Acknowledge

or name feeling. ` Explore sources ` Encourage to express verbally ` Explore appropriate outlets ` Avoid arguing

` Explore

sources ` Acknowledge or name the behaviour or the feeling ` Give reassurance of safety ` Encourage appropriate expression ` Recognize that anxiety in nurse increases clients anxiety

` Relate

in a concrete manner ` Focus on immediate situation. ` Point out reality ` Clarify verbalizations that are not understood

` Accept

at stage client is in; do not push ` Give ample time for responses ` Do not reinforce dependency ` Use silence appropriately

` Recognize

means of controlling: negativism, obstruction, silence, avoidance, insults, yelling, increased chatter, crying. ` Do not impose unnecessary controls ` Allow client some control ` Develop trust

` Avoid

arguing ` Avoid arousing suspicion ` Be honest and reliable ` Be consistent ` Acknowledge clients feelings ` Point out reality; clients beliefs are not shared ` Voice doubt

Assess abilities and capabilities ` Provide only help needed ` Encourage to solve problems and make decisions ` Display attitude of firmness and confidence ` Discourage reliance beyond actual need ` Encourage successful participation
`

` Help

to recognize as manifestation of anxiety ` Encourage to give up hallucinations ` Help to relate with real persons ` Do not give attention to content unless SHE ` Present reality

` Structure

small successes. ` Give encouragement ` Exhibit expectation that client will succeed ` Encourage identification of strengths

Avoid arguing with the client ` Acknowledge and name feelings ` Explore the source of hostility with client ` Encourage to express hostility verbally, rather than resort to physical aggression ` Explore appropriate outlets for hostility (e.g. Physical activities)
`

` ` ` ` ` ` `

Spell out acceptable and unacceptable behaviour Set firm and definite limits Consistently enforce limits Avoid involvement in intellectualization i.e. Responsibility for behaviour rests with client Treat infractions with withdrawal of privileges Ensure that staff is united, firm and consistent. Maintain sense of authority

` Do

not interrupt repetitive act, it could lead to panic ` Set limits on repetitive behaviour ` Engage in alternative activities with client ` Provide physical protection from repetitive acts

Understand unconscious motivation of the behaviour and differentiate it from malingering ` Understand and alleviate primary symptoms ` Encourage client to explore the motivation of the behaviour ` Explore alternatives to the primary symptom for handling anxiety
`

` Do

not focus on physical symptoms ` Give appropriate information regarding somatic complaints ` Point out reality i.e. Correct misinformation

` Suggest

solitary activities for

client ` Put client in charge of things, not people ` Give client activities at which client can succeed

ANXIETY & ANXIETY DISORDERS

Alarm Reaction Stage - stress stimulates the body to send messages from the hypothalamus to the glands and other organs to prepare for potential defense needs. Resistance Stage rerouting or shunting of blood to vital organ system readying the body to FIGHT, FLIGHT or even FREEZE behaviors. The Exhaustion Stage occurs when the person has responded negatively to anxiety and stress; body stores are depleted or the emotional components are not resolved.
`

Vague uneasy feeling of discomfort or dread accompanied by an autonomic response wherein the source often nonspecific or unknown to the individual. x A subjective feeling of vague apprehension due to real or perceived threat; x Is a NORMAL response to stress felt preceding new experiences; A feeling of apprehension caused by anticipation of danger; An alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat.

` `

` Reality
real threat;

Anxiety Anxiety

- from external

` Neurotic

fear that instinct will cause one to do something that will cause punishment; guilt from wrongdoing against the conscience;

` Moral

Anxiety

Mild Anxiety
  

associated with the tension of everyday life; the individual is alert and attentive (SNS is stimulated) perceptual field is increased; with mild muscle tension;

NO INTENSE FEELING BECAUSE SELF-CONCEPT NOT THREATENED

Interventions: - Discuss source of anxiety. - Problem solving to neutralize anxiety. - Teach the client to accept anxiety as normal.

Moderate Anxiety


the focus is on immediate concerns; narrows the perceptual field; selective inattentiveness occurs; learning and problem-solving still take place; self-concept may be threatened (may have discomfort and irritability) may show moderate muscle tension with increase vitals, mydriasis, and sweating; Interventions:  Decrease anxiety by ventilation of feelings, crying, or exercise.

Severe Anxiety
    

a feeling that something bad is about to happen; With significant reduction in perceptual field; All behavior is directed at relieving the anxiety; learning and problem-solving are not possible; HEARING IS NOT POSSIBLE;

May show:  Hyperventilation  Severe muscle tension  Rapid pacing or walking  Shouting and trembling
Interventions:  GOAL: TO DECREASE ANXIETY THRU SUPPORTIVE AND PROTECTIVE MEANS.  Stay with the client.  Use kind, firm, and simple directions.  IM anxiolytics as ordered.

Panic Level of Anxiety




associated with dread and terror and a sense of impending doom;

  

the personality of the individual is disorganized; the individual is unable to communicate or function effectively; may experience loss of rational thoughts with distorted perception (hallucination or illusion)

May have:  Fight or flight  Freeze  Helplessness  Out of control (jump from windows)  Rage, anger, and terror Interventions:  DECREASE ANXIETY AND KEEP CLIENT SAFE;  Guide firmly or physically take control.  IM anxiolytics as ordered.  Restraints if needed (FOR SAFETY)

Panic Disorder is characterized by recurrent, unexpected panic attacks that caused constant concern. Panic attack is the sudden onset of intense apprehension, fearfulness, or terror associated with feelings of impending doom. Specific Phobia is characterized by significant anxiety provoked by a specific feared object or situation, which often lead to avoidance behavior. Social Phobia is characterized by anxiety provoked by certain types of social or performance situations, which often lead to avoidance behavior. Obsessive-Compulsive Disorder involves obsessions (thoughts, impulses or image) that cause marked anxiety and/or compulsions (repetitive behaviors or mental acts) that attempts to neutralize anxiety. Generalized Anxiety Disorder is characterized by at least 6 months of persistent and excessive worry and anxiety. Acute Distress Disorder is the development of anxiety, dissociative, and other symptoms within 1 month of exposure to an extremely traumatic stressor; it lasts 2 days to 4 weeks. Posttraumatic Stress Disorder is characterized by the re-experiencing of an extremely traumatic event, avoidance of stimuli associated with the event, numbing of responsiveness, and persistent increased arousal; it begins within 3 months to years after the event and may last a few months or years.

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

Promoting safety and comfort. Using therapeutic communication. Managing Anxiety. Providing client and family education. Pharmacologic if medically advised. Psychological Management if advised.

Also called as mood disorders, are pervasive alterations in emotions that are manifested by depression, mania, or both. Interferes with a persons life, plaguing him or her with drastic and long-term sadness, agitation, or elation accompanied by selfdoubt, guilt, and anger alter life activities especially those that self-esteem, occupation, and relationships.

` `

Mood Spectrum Mood Spectrum is the wide range representation of the different state of feelings and emotions
E U T H Y M I A

ANERGIA/DYS PHORIA

MANIA/EUPHORIA

Major Depressive Disorder depressive episodes lasts


at least 2 weeks, during which the person experiences a depressed mood or loss of pleasure in nearly all activities.
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There must also be four of the following symptoms; changes in appetite or weight sleep psychomotor activity decreased energy feelings of worthlessness or guilt difficulty decisions thinking or concentrating or making

recurrent thoughts of death or suicidal ideation, plans or attempts.

Continuation
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Dysthemic disorder is characterized by at least 2 years of


depressed mood for more days than not with some additional less severe symptoms that do not meet the criteria for a major depressive episode.

Cyclothemic disorder is characterized by 2 years of


numerous periods of both hypomanic symptoms that do not meet the criteria for bipolar disorder.

Substance Induced Mood Disorder is characterized by a


prominent and persistent disturbance in mood that is judged to be a direct physiological consequence of ingested substance such as alcohol, drugs or toxins.

Mood Disorder Due to a General Medical Condition is


characterized by a prominent and persistent disturbance in mood that is judged to be a direct consequence of a medical condition such as degenerative neurologic condition, CVD, metabolic or endocrine conditions, autoimmune and others.

Continuation
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Seasonal Affective Disorder (SAD) is of two subtypes winter


depression SAD and spring-onset SAD.

Post-Partum Blues is a frequent normal experience after


delivery of a baby characterized by labile mood and affect, sadness, insomnia and anxiety that begins approximately 1 day after delivery, usually peaks in 3-7 days , and disappears rapidly without medical treatment.

Post-Partum Depression meets all the criteria for a major


depressive episode with onset within 4 weeks of delivery.

Post-Partum Psychosis is characterized by a psychotic


episode developing within 3 weeks of delivery beginning with fatigue, sadness, poor memory, and confusion and progressing to delusions, hallucinations, poor insight and judgment, and loss of contact with reality.

1. 2. 3.

Provide a safe environment. Physical safety is a priority. Continually assess the clients potential for suicide. Observe the client closely (medication, change of behavior, mood) Reorient the client to person, place, and time as necessary. Spend time with the client. Initially and when possible, assign same staff members to manage. When approaching the client, use a moderate, level tone of voice.

4. 5. 6.

7.

8. Use silence and active listening when interacting with client. 9. During admission and early residency, use simple, direct sentences. Avoid complex sentences and directions. 10. Allow client to cry and verbalize but dont encourage to go into catharsis. 11. Minimize interaction/interruptions during clients verbalization. 12. Interact with the client on topics comfortable for him or her to discuss. Avoid too much proving. 13. Teach the client about the problem-solving process. 14. Provide positive feedback at each step of the process when progressing

Personality

Is defined as an ingrained, enduring pattern of behaving and relating to self, others, and the environment; includes perceptions, attitudes, and emotions.

Are diagnosed when personality traits become inflexible and maladaptive and significantly interfere with how a person functions in society or cause the person emotional distress.
Diagnosis is made when the person exhibits enduring behavioral patterns that deviate from cultural expectations in two or more of the following areas: ways of perceiving & interpreting self, other people, & events. Range, intensity, lability, and appropriateness of emotional response. Interpersonal functioning. Ability to control impulses or express behavior at the appropriate time/place.

Cluster A: Individual whose behavior appears odd or eccentric and includes paranoid, schizoid, and schizotypal personality disorders. Cluster B: Includes people appear dramatic, emotional, or erratic and includes antisocial, borderline, histrionic, and narcissistic personality disorder. Cluster C: Includes people who appear anxious or fearful and includes avoidant, dependent, and obsessivecompulsive personality disorder.

Personality Disorder

Symptoms
Mistrust and suspicions of others; guarded, restricted affect.

Nursing Intervention
Serious, straightforward approach; teach client to validate ideas before taking action; involve client in treatment planning.

Paranoid

Schizoid

Detached from social relationships; restricted affect; involved with things more than people

Improve clients functioning in the community; assist client to find case manager.

Antisocial

Disregard for rights of others, rules, and laws.

Limit-setting; confrontation; teach client to solve problems effectively and manage emotions of anger or frustration.

Schizotypal

Acute discomfort in relationships; cognitive or perceptual distortions; eccentric behavior.

Develop self-care skills; improve community functioning; social skills training.

Personality Disorder

Symptoms
Preoccupation with orderliness, perfection, and control

Nursing Intervention
Encourage negotiation with others; assist client to make timely decisions and complete work

Obsessive-compulsive

Depressive

Pattern of depressive cognitions and behaviors in a variety of contexts.

Assess self-harm risk; provide factual feedback; promote selfesteem; increase involvement in activities.

Passive-Aggressive

Pattern of negative attitudes and passive resistance to demands for adequate performance in social and occupational situations.

Help client to identify feelings and express them directly; assist client to examine own feelings and behavior realistically.

Personality Disorder

Symptoms
Unstable relationships, self-image, and affect; impulsivity; selfmutilation

Nursing Intervention
Promote safety; help client to cope and control emotions; cognitive restructuring techniques; structure time; teach social skills.

Borderline

Narcissistic

Grandiose; lack of empathy; need for admiration

Matter-of-fact approach; gain cooperation with needed treatment; teach client any needed self-care skills.

Avoidant

Social inhibitions; feelings of inadequacy; hypersensitive to negative evaluation.

Support and reassurance; cognitive restructuring techniques; promote self-esteem.

Dependent

Submissive and clinging behavior; excessive need to be taken care of

Foster clients self-reliance and autonomy; teach problem solving and decision-making skills; cognitive restructuring techniques.

1.

Encourage the client to identify the actions that precipitated hospitalization. Give positive feedback for honesty. The client may try to act as though he or she is sick or helpless or use other techniques to avoid responsibility. Identify behaviors that are unacceptable. Develop specific consequences for the identified unacceptable behaviors. Avoid any discussion or debate about why the rules or requirements exit. State the requirements or rules in a matter-of-fact manner.

2.

3. 4.

5.

6. Inform the client of unacceptable behaviors and the resulting consequences in advance of their occurrence. 7. Communicate and document in the clients care plan all behaviors and consequences in specific terms for all staff members. 8. Avoid discussing another staff members actions or statements with the client until the other staff member is present. 9. Be consistent and firm with the care plan. 10. Avoid trying to coax or convince the client to do the right thing. 11. Point out the clients responsibility for his or her behavior in a nonjudgemental manner.

12. Provide immediate positive feedback or reward for acceptable behavior. 13. Encourage the client to identify sources of frustration, how he or she dealt with it previously, and any unpleasant consequences that resulted. 14. Explore alternative, socially and legally acceptable methods of dealing with identified frustrations. 15. Include exploration and information on job seeking, work attendance, debt paying, court appearances, and so forth when working with the client in anticipation of discharge.

Causes distorted and bizarre thoughts, perceptions, emotions, movements, and behavior. It cant be defined as a single illness rather a disease process or SYNDROME. Usually diagnosed in late adolescence or early adulthood and rarely manifest in childhood. The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women. The prevalence is about 1% of the total population.

Morel described schizophrenia before as dementia praecox (precocious senility); Bleuler later coined the term schizophrenia which means split mind (not split personality); 95% of clients with schizophrenia have a lifetime disease; It is the most common thought disorder;

` Positive
` ` ` ` ` ` ` `

or Hard Symptoms

Ambivalence

Holding seemingly contradictory beliefs or feelings about the same person, event, or situation.

Associative Looseness fragmented or poorly related thoughts and ideas. Delusions fixed false beliefs that have no basis in reality.
observing.

Echopraxia

imitation of movements/gestures of another person whom the client is continuous flow of verbalization in which the person jumps rapidly

from one topic to another.

Flight of Ideas

Hallucinations false sensory perception. Ideas of Reference


for the person. false impressions that external events have special meaning

Perseveration persistent adherence to a single idea or topic.

Negative or Soft Symptoms

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Alogia tendency to speak very little or to convey little substance of meaning. Anhedonia feeling no joy or pleasure from life or any activities or relationships. Apathy feelings of indifference toward people, activities, and events. Blunted affect restricted range of emotional feeling, tone or mood. Catatonia
psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless,as if in a trance.

Flat affect absence of any facial expression that would indicate emotions or mood. Lack of Volition
tasks. absence of will, ambition, or drive to take action or accomplish

`
`

Schizophrenia, Paranoid Type

Characterized by persecutory or grandiose delusions, hallucinations, and, occasionally, excessive religiosity or hostile and aggressive behavior.
`

Schizophrenia, Disorganized Type

Characterized by grossly inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behavior.
`

Schizophrenia, Catatonic Type

Characterized by marked psychomotor disturbance, either motionless or excessive motor activity. Motor immobility may be manifested by catalepsy or stupor. Other features include extreme negativism, mutism, peculiarities of voluntary movement, echolalia, and echopraxia.

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Schizophrenia, Undifferentiated Type

Characterized by mixed schizophrenic symptoms (of other types) along with disturbances of thought, affect, behavior.
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Schizophrenia, Residual Type

Characterized by at least one previous, though not a current episode; social withdrawal, flat affect; and looseness of associations.
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Schizophreniform Disorder

The client exhibits the symptoms of schizophrenia but for less than 6 months necessary to meet the diagnostic criteria for schizophrenia. Social or occupational functioning may or may not be impaire.

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Schizoaffective Disorder

The client exhibits the symptoms of psychosis and, at te same time, all the features of a mood disorder, either depression or mania.
`

Delusional Disorder

The client has one or more nonbizarre delusions that is the focus of the delusion is believable. Psychosocial functioning is not markedly impaired, and behavior is not obviously odd or bizarre.
`

Brief Psychotic Disorder

The client experiences the sudden onset of a least one psychotic symptom, such as delusions, hallucinations, or disorganized speech or behavior, which lasts from 1 day to 1 month. ` Shared Psychotic Disorder Two people share a similar delusion.

1.

Be sincere and honest when communicating with the client. Avoid vague or evasive remarks. Be consistent in setting expectations, enforcing rules and so forth. Do not make promises that cant be kept. Encourage the client to verbalize but not to pry or crossexamine for information. Explain procedures plainly and simply. Give positive feedback for signs of improvement. Do not argue but discuss inappropriate behavior. Engage client in one-to-one activities then progess from there.

2.

3. 4.

5. 6. 7. 8.

9. Show empathy regarding clients feelings. 10. Do not be judgemental or to belittle or joke about the clients belief. 11. Never convey to the client that you accept the delusions as reality. 12. Directly interject doubt regarding delusions as soon as the client seems ready to accept this. Again, do not argue. 13. Attempt to discuss the delusional thoughts as a problem in the clients life.

` Eating

can be viewed on a continuum with clients with anorexia eating too little or starving themselves, clients with bulimia eating chaotically, and clients with obesity eating too much.

Disorders

General Classifications of Eating Disorder:


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Anorexia Nervosa - diet, exercise, fasting Bulimia Nervosa binge eating/purging

Anorexia Nervosa is a life-threatening eating disorder characterized by the clients refusal or inability to maintain a minimally normal body weight, intense fear of gaining weight or becoming fat.
`

Symptoms are as follows: Fear of gaining weight Amenorrhea Food preoccupation Inflexible thinking Cold intolerance Emaciation Elevated BUN w/ electrolyte anemia Elevated liver function studies

* Body image misperception * Depressive symptoms * Feelings of ineffectiveness * Complaints of bowel problem * Lethargy * Hypotension imbalances, leukopenia, mild

Bulimia Nervosa is an eating disorder characterized by recurrent episodes of binge eating followed by inappropriate compensatory behaviors to avoid weight gain such as purging, fasting, laxatives, diuretics, enemas, or excessive exercising.
`

Symptoms are as follows: Fear of gaining weight Self evaluation overly influenced by body shape & weight. Depressive and anxiety symptoms Loss of dental enamel, chipped ragged, or moth-eaten Menstrual irregularities; dependence on laxatives Metabolic alkalosis (vomiting); metabolic acidosis (diarrhea) Elevated serum amylase levels w/ electrolyte imbalances Binge eating w/ purging

Body System Musculoskeletal

Symptoms Loss of muscle mass, loss of fat, osteoporosis, and pathologic fracture. Hypothyroidism, hypoglycemia, and decreased insulin sensitivity. Bradycardia, hypotension, loss of cardiac muscle, small heart, arrhythmias, sudden death. Delayed gastric emptying, bloating, constipation, abdominal pain, gas, diarrhea. Dry, cracking skin due to dehydration, edema, and acrocynosis Leukopenia, anemia, thrombocytopenia, hypercholesterolemia, hypercarotenemia. Amenorrhea and low levels of FSH, LH

Metabolic

Cardiac

Gastrointestinal

Dermatologic

Hematologic

Reproductive

Body System Metabolic

Symptoms Electrolyte abnormalities, particularly hypokalemia, hypochloremic alkalosis, hypomagnesemia, and elevated BUN. Salivary gland and pancreas inflammation and enlargement with an increase in serum amylase, esophageal and gastric erosion or rupture, dysfunctional bowel, and superior mesenteric artery syndrome. Erosion of dental enamel (perimyolysis), particularly front teeth Seizures (related to large fluid shifts and electrolyte disturbance), mild neuropathies, fatigue, weakness, and mild organic mental symptoms.

Gastrointestinal

Dental Neuropsychiatric

Establishing nutritional eating patterns

Sit with the client during meals and snacks. Offer liquid protein supplement if unable to complete meal. Adhere to treatment program guidelines on nutrition Weigh client daily in uniform clothing. Be alert for attempts to hide or discard food or inflate weight.

Helping the client identify emotions and develop non-food-related coping strategies

Ask

the client to identify feelings. using a journal.

Self-monitoring Relaxation

techniques.

Distraction. Assist

client to change stereotypical belief.

Helping client deal with body image issues

Recognize benefits of a more near-normal weight. Assist to view self in ways not related to body image. Identify personal strengths, interest, talents.
`

Providing client and family education

Nutrition Emotional Support System General health issues possible professional help and assistance Emergency conditions.

` Somatoform

can be characterized as the presence of physical symptoms that suggest a medical condition without a demostrable organic basis to account fully for them. Somatization is defined as the transference of mental experience and states into bodily symptoms.

Disorder

General Classifications of Somatoform Disorder:


` ` `

Somatization Disorder Pain Disorder

Conversion Disorder Hypocondriasis

Body Dysmorphic Disorder

Somatization Disorder is characterized by multiple physical symptoms. It begins by 30 y/o, extends over several years, and includes a combination of pain and gastrointestinal, sexual, and psuedoneurologic symptoms. Conversion Disorder, sometimes called conversion reaction, involves unexplained usually sudden deficits in sensory or motor function (eg. Blindness, paralysis). These deficits suggest a neurologic disorder but are associated with psychological factors.

Pain Disorder has the primary physical symptom of pain, which generally is unrelieved by analgesics and greatly affected by psychological factors in terms of onset, severity, exacerbation, and maintenance. Hypochondriasis is preoccupation with the fear that one has a serious disease (disease conviction) or will get a serious disease (disease phobia). It is thought that clients with thisdisorder misinterpret bodily sensations or function. Body Dysmorphic Disorder is preoccupation with the imagined or exaggerated defect in physical appearance. Self being too unatttractive.

Pain Symptoms complains of headache and other forms of body pain. Gastrointestinal Symptoms nausea, bloating, vomiting, diarrhea. Sexual Symptoms sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding. Pseudoneurologic Symptoms conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump on the throat, double vision, deafness, blindness, seizures; dissociative symptoms like amnesia, fainting Malingering is a the intentional production of false or grossly exaggerated physical or psychological symptoms.

Munchausens By Proxy occurs when a person inflicts illness or injury on someone else to gain the attention of emergency medical personnel or to be a hero for saving the victim. Internalization happens when people keeps stress, anxiety, or frustration inside rather than expressing them outwardly. Primary gains are the direct external benefits that being sick provides such as relief of anxiety, conflict, or distress. Secondary gains are the internal or personal benefits received form others because one is sick such as attention from family members and comfort measures (eg. Being brought of tea, receiving a back rub). Factitious Disorder (Munchausens Syndrome) occurs when a person intentionally produces or feigns physical or psychological symptoms solely to gain attention.

Health Teachings

Establish a daily routine. Promote adequate nutrition and sleep.


`

Expression of Emotional Feelings

Recognize relationship between stress/coping and physical symptoms. Keep a journal. Limit time spent on physical complaints (primary & secondary gains).

Coping Strategies

Emotion-focused coping strategies such as relaxation techniques, deep breathing, guided imagery, and distraction. Problem-focused coping strategies such problem-solving strategies and role-playing. as

Emotion-focused Coping Strategies help client to relax and reduce feelings of stress. Problem-focused Coping Strategies help client to resolve or change clients behavior or manage lifes stressors.

is a disruption or impairment in higher-level functions of the brain bearing a devastating effects on the ability of the a person to function in daily life. Cognition is the brains ability to process, retain, and use information (reasoning, judgment,perception,attention, comprehension, and memory).
`

General Classifications of Cognitive Disorder: Delirium Disorder Amnestic Disorder Dementia

Amnestic Disorder is characterized by a disturbance in memory that results directly from the physiologic effects of a general medical condition or the persisting effects of a substance such as alcohol or other drugs. Etiology: Physiologic (CVA, head injury, etc) Substance-induced (carbon monoxide, alcholism) Deficiency (Vitamin B12 deficiency)

` ` ` `

Dementia is a mental disorder that involves multiple cognitive deficits, primarily memory impairment and at least one of the following cognitive disturbances.
Symptoms:

` `

Aphasia-deterioration of language function (echolalia & palilalia). Apraxia-impaired ability to execute motor function despite intact motor abilities. Agnosia-inability to recognize or name objects despite intact sensory abilities. Disturbance in Executive Functioning-inability to think abstractly and to plan, initiate, sequence, and complex behavior.

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Progressive Stages: Mild forgetfulness is the hallmark of beginning. Moderate confusion is apparent along with progressive memory loss. Severe personality ad emotional changes occur. Pathologic Etiology: ` Alzheimers Disease Vascular Dementia ` Picks Disease Creutzfeldt-Jakob Disease ` HIV/AIDS Parkinsons Disease ` Huntingtons Disease Head Trauma

Promoting Safety from Injury Promote adequate sleep, nutrition, hygiene Structure environment and routine Provide emotional support Promote interaction and involvement Psychotherapy = Reminiscence Therapy family and client to lament and re-live past experiences.

Promoting Safety from Injury Promote adequate sleep, nutrition, hygiene Structure environment and routine Provide emotional support Promote interaction and involvement Psychotherapy = Reminiscence Therapy family and client to lament and re-live past experiences.

Psychiatric disorders are not diagnosed as easily in children as they are in adults. Children usually lack the abstract cognitive skills and verbal skills to describe what is happening. Because of they constantly are changing and developing, children have no sense of a stable, normal self to allow them to discriminate unusual or unwanted symptoms from normal feelings and sensations.

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General Classifications: Learning Disorders Motor Skills Disorder Pervasive Dev. Dis ADD Beh. Disorder Tic Disorder Disorder Elimination

Mental Retardation Communication Dis Feeding/Eating Dis

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Other Disorders of Infancy, Childhood, and Adolescence

Mental Retardation essential feature is below average intellectual functioning (IQ less than 70) accompanied by significant limitations in areas of adaptive functioning such as communication, selfcare, home living, social or interpersonal skills, self direction, academic skills, health and safety.
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Degrees of Retardation

Mild Retardation: IQ 50-70 Moderate Retardation: IQ 35-50

x Severe Retardation: IQ 20-35 x Profound Retardation: IQ less than 20

Learning Disorder is diagnosed when a childs achievement in reading, mathematics, or written expression is below that expected for age, formal education, and intelligence. Low self-esteem and poor social skills are common. Assistance with academic achievements are given through special education classes.
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General Types Of Learning Disorder


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Reading Learning Disorder

Mathematics Learning Disorder Disorder of Written Expression

Motor Skills Disorder also known as Developmental Coordination Disorder is an impairment of coordination severe enough to interfere with academic achievement or activities of daily living. It often coexists with communication disorder. Adaptive Physical Education Program Sensory Integration Programs Most cases, the symptoms persist until adulthood and its disease course is so invariable but generally degenerative.

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Communication Disorder is diagnosed when a communication deficit is severe enough to hinder development, academic achievement, or ADLs including socialization.
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General Types Of Communication Disorder

Expressive Language Disorder involves an impaired ability to communicate through verbal and sign language. Mixed Receptive-Expressive Language Disorder includes the problems of expressive language along with difficulty understanding (receiving) and determining the meaning and how is the proper response (expressing). Phonologic Disorder involves problems with articulation (forming sounds that are part of speech and speaking process). Ex. Stuttering

Pervasive Developmental Disorder are characterized by pervasive and usually severe impairment of reciprocal social interaction skills, communication deviance, and restricted stereotypical behavior patterns.
`

General Types

Autistic Disorder lack spontaneous enjoyment, have apparently no moods or emotional affect, cant engage in play, little intelligence, most common in boys. Retts Disorder characterized by the development of multiple deficits after a period of normal functioning. Rare and exclusively in girls, and persists throughout life. Aspergers Disorder characterized of same symptoms to autism but w/o language or cognitive delays.

Attention Deficit and Disruptive Behavior Disorder is characterized by inattentiveness, overactivity, and impulsiveness. (Attention Deficit Hyperactivity Disorder)
Inattentive Behaviors
Misses details Makes careless mistakes Difficulty sustaining attention Doesnt seem to listen Doesnt follow assigned tasks Difficulty with organization Avoids task requiring efforts Often looses things Easily distracted Forgetful of activities

Hyperactive/Impulsive Behaviors
Fidgets Often leaves seat Runs and climbs excessively Cant play quietly Talks excessively Blurts out answers Interrupts Cant wait for turn Intrusive with siblings/classmates

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` ` ` ` ` ` ` ` ` `

Interventions for ADHD

Ensuring the childs safety and others Stop unsafe behavior Provide close supervision Give clear directions wit little compromises. Improve role performance Give positive feedback for meeting expectations Manage the environment Client and Family Education and Support Listen and encourage verbalization of both Simplify activities and direction

Feeding and Eating Disorders are persistent natured disorders and are not explained by underlying medical conditions. Most conditions affect early year of life specifically infants and early childhood.
`

General Types

Pica is persistent ingestion of nonnutritive substances such as hair, cloth, leaves, sand, etc and common seen in mental retardation. Rumination Disorder is the repeated regurgitation and rechewing of food. The regurgitation does not involve nausea or vomiting. Feeding Disorder is characterized by persistent failure to eat adequately or to refuse eating which results in significant weight loss or failure to gain weight.

Elimination Disorder
`

General Types

Encopresis is the repeated passage of feces into inappropriate places, such as clothing or the floor, by a child who is at least 4 years of age either chronologically or developmentally. Involuntary encopresis is usually is usually associated with mental or psychological issues that medicine cant seem to explain. Intentional encopresis is often associated with oppositional defiant disorder or conduct disorder. Enuresis is the repeated voiding of urine during the day or at night into clothing or bed by a child at least 5 years of age either chronologically or developmentally.

Is defined as using drug in a way that is inconsistent with medical or social norms and despite negative consequences. It denotes problems in social, vocational, or legal areas of the persons life. Substance Dependence also includes problems associated with addiction such as tolerance, withdrawal, and unsuccessful attempts to stop using the substance.

INTOXICATION is use of a substance that results in maladaptive behavior. WITHDRAWAL SYNDROME refers to the negative psychological and physical reactions that occur when use of a substance ceases or dramatically decreases. DETOXIFICATION is the process of safely withdrawing from a substance which have been used for some long time already.

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Alcohol Caffeine Cocaine Inhalants Opioids Sedatives

Amphetamines Cannabis Hallucinogens Nicotine Phencyclidine Hypnotics/Anxiolytics

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Alcohol is a central nervous system depressant that is absorbed rapidly into the bloodstream. Initially the effects are: - relaxation and loss of inhibitions - slurred speech - unsteady gait - lack of coordination - impaired attention, concentration, memory and judgment - blackout.

Alcohol withdrawal is usually accomplished with the administration of pharmacological interventions of benzopdiazepines such as lorazepam (Ativan) and diazepam (Valium). Methodology used = Fixed-schedule Dosing

` `

Symptom-triggered Dosing

Sedatives, Hypnotics, and Anxiolytics are all considered as CNS depressants with benzodiazepines and barbiturates as the most frequently abused drugs in this category. Intoxication symptoms include the following: - slurred speech - impaired attention - lack of coordination -memorylapses - unsteady gait -stupor or coma - labile mood

Stimulants are drugs that stimulate or excite the CNS. The DSM IV-TR categorizes amphetamines, cocaine and other CNS stimulants as having same intoxication and withdrawal symptoms. Methamphetamine is particularly dangerous as it is highly addictive and causes psychotic behavior. Marked DYSPHORIA (unhappiness, restlessness, malaise) is the primary withdrawal symptom and is accompanied by fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor retardation or agitation. Psychotic symptoms also can include suicidal ideation due to severe depressive experience.

` ` ` ` ` `

Cannabis sativa is a hemp plant that became wellknown for its psychoactive resins the contains more than 60 substances called cannabinoids, particularly delta-9-tetrahydrocannabinol (THC) responsible for the psychoactive side-effects. Effects includes : - lowered inhibitions - relaxation - euphoria - increased appetite - impaired motor coordination - inappropriate laughter - impaired judgment - memory and perception loss and distortion

` ` ` ` `

Hallucinogens are substances that distort the users perception of reality and produce symptoms similar to psychosis (visual hallucination and depersonalization). Examples LSD (lysergic acid diethylamide), Ecstacy, even PCP (phencyclidine) an anesthetic. Effects includes : - increased vital signs - dilated pupils - hyperreflexia - paranoid ideation - ideas of reference -depression, anxiety - sweating, blurred vision - tremor - unpredictable behavior (belligerence, aggression)

` ` ` ` `

Inhalants are substances including anesthetics, nitrates, and organic solvents (aliphatics & aromatic hydrocarbons) which are all inhaled for their effects. Effects includes : - dizziness, nystagmus - slurred speech - unsteady gait - muscle weakness - aggressive behavior - tremor, apathy unpredictable behavior (belligerence, aggression) Acute toxicity causes anoxia, respiratory depression, vagal stimulation and dysrhythmias, bronchospasm, and cardiac arrest.

1. 2.

Encourage open expression of feelings. Validate the clients frustration or anger in dealing with dual problems. Maintain frequent contact with the client even if it is only brief telephone calls. Give positive feedback for abstinence on a day-by-day basis. If drinking or substance use occurs, discuss the events that led to the incident with the client in a nonjudgmental manner. Discuss ways to avoid similar circumstances in the future. Assess the amount of unstructured time with which the client must cope.

3.

4.

5.

6. 7.

8. Assist the client to plan weekly or even daily schedules of purposeful activities: errands, appointments, taking walks, and so forth. 9. Writing the schedule on a calendar may be beneficial. 10. Recording a journal of activities, feelings and thoughts may be helpful to the client. 11. Teach clients social skills. 12. Give positive support to the client for appropriate use of social skills.

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ANTIPSYCHOTIC DRUGS ANTIDEPRESSANT DRUGS MOOD STABILIZER DRUGS ANXIOLYTIC DRUGS STIMULANT DRUGS

Also know as NEUROLECTICS. Used to treat symptoms of Psychosis (delusions & hallucinations). Indications: Schizophrenia, Schizoaffective Disorder, Manic phase of Bipolar Disorder, Psychotic Depression, Drug-induced Psychosis, short-term use in Borderline Personality Disorder. Mechanism of Action: The major action of all neuroleptics in the nervous system to block receptors for the neurotransmitter DOPAMINE. Side Effects: Extrapyramidal Symptoms (EPS) is

` `

Acute Dystonia acute muscular rigidity and cramping, still or thick tongue with difficulty of swallowing, in severe cases: laryngospasm and respiratory distress. Pseudoparkinsonism also known as drug-induced parkinsonism (stiff and stooped posture, mask-like faces, cogwheel rigidity, drooling, tremor, bradycardia. x Akathesia intense need to move about, client appears restless and anxious, rigid posture, lacks spontaneous gestures.

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Other Side Effects: Neuroleptic Malignant Syndrome a potentially fatal idiosyncratic reaction to an antipsychotic drug although with very low incidence rate. Major symptoms include rigidity, high fever, unstable BP, diaphoresis, pallor, delirium and elevated CPK. Tardive Dyskinesia a syndrome of permanent and involuntary movement. Commonly is caused by the long term use of conventional antipsychotic drugs. Symptoms include involuntary movement of the tongue, facial and neck muscles, upper and lower extremities, protruding and lip-smacking, excessive and unnecessary facial movements. x Anticholinergic Side-effects Includes orthostatic hypotension, dry mouth, constipation, urinary hesitance or retention, blurred near vision, dry eyes, photophobia, nasal congestion, and decreased memory. x CLOZAPINE may cause agranulocytosis, potentially life threatening. Must have baseline WBC count, weekly monitoring and evaluation. x DROPERIDOL, THIORIDAZINE, MESORIDAZINE may lengthen QT interval, potentially life threatening causing cardiac dysrhythmias or even cardiac arrest.

Generic Name
Conventional
Chlorpromazine (Thorazine) Trifluoperazine Fluphenazine Thioridazine Mesoridazine Thiothixene Haloperidol (Haldol) Loxapine

Sedation

Hypotension

EPS

Antichol

++++ ++ + ++++ ++++ + +++

+++ +++++ + +++ ++ + +

++ + ++++ + + ++++ ++++

+++ + +++ ++ + +

Atypical
Clozapine Risperidone Olanzapine Quetiapine Ziprasidone ++++ +++ ++++ ++ ++ ++ +++ ++++ ++ + + + ++ + ++ + +

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Management of some unpleasant side effects: Drinking sugar-free and chewing sugar-free hard candy. Stool softeners is allowed but should avoid laxatives. Sunscreens for photosensitivity. Avoid activities like driving due to unexpected drowsiness.

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Indications: Used to treat symptoms and in the treatment of Major Depressive Illnesses, Anxiety Disorders, Depressed Phase of Bipolar Disorder and Psychotic Depression. Mechanism of Action: The major action somehow is in the interaction of the drug with two neurotransmitters, Norepinephrine and Serotonin, that regulate mood, arousal, attention, sensory processing, and appetite. Four Categories: Tricyclic and the Related Cyclic Antidepressants Selective Serotonin Reuptake Inhibitors Monoamine Oxidase Inhibitors x Atypical and other Antidepressants

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Generic Name
SSRI
Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Citalopram (Celexa)

Side Effects
Anxiety, agitation, akathesia, nausea, insomnia, sexual dysfunction, diminished sexual drive or difficulty achieving erection or orgasm...

Nursing Concerns
*administer in AM if nervous or PM if drowsy. *Monitor for hyponatremia *adequate fluid. *report sexual difficulties if any. *administer with food *check orthostatic blood pressure. *administer in AM if nervous or PM if drowsy. *Monitor for hyponatremia *adequate fluid. *report sexual difficulties if any. *administer with food *check orthostatic blood pressure.

Cyclic
Amitriptyline (Elavil) Amoxapine (Asendin) Doxepin (Sinequan) Imipramine (Tofranil) Desipramine

Sedation, Orthostatic Hypotension Anticholinergic Symptoms Potentially lethal on OVERDOSE.

Generic Name
Atypical
Venlafaxine (Effexor) Bupropion (Wellbutrin) Nefazodone (Serzone) Mirtazipine (Remeron)

Side Effects
Increased blood pressure & pulse, nausea, vomitting, headache, dizziness, dry mouth, sweating, agitation, weight gain, sexual dysfunction.

Nursing Concerns
*administer in AM if nervous or PM if drowsy. *Monitor for hyponatremia *adequate fluid. *report sexual difficulties if any. *administer with food *check orthostatic blood pressure.

MAOI
Isocarboxazid (Marplan) Phenelzine (Nardil) Tranylcypromine

Daytime sedation, insomnia, weight gain, dry mouth, sexual dysfunction, Hypertensive Crisis (due to Tyramine-containing food; very lethal),

Assist client to rise slowly. Administer in AM Administer with food. Ensure adequate fluids. Health teachings in medication.

NEFAZODONE may cause lethal condition of Liver Damage which may lead to failure. x BUPROPION can cause Seizures and not highly recommended to patients of opiates, cocaine or stimulant addiction; diabetes or if taking insulin drugs. x TRAZODONE may cause Priapism (sustained and painful erection) and must be stopped immediately that may lead to impotence. x PAROXETINE most often causes SEDATION compared with others.

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Additional Health Teachings and Interventions SSRIs should be taken in the morning unless sedation is a problem. Cyclics are generally taken at night time in a single daily dose. Must adhere to dietary restriction and be given list of foods to avoid.

Indications: Used to treat Bipolar Disorder by stabilizing the clients mood, preventing or minimizing the highs and lows of the condition, and treating acute episodes of mania. Included are as following: Lithium and Anticonvulsants. Mechanism of Action: Lithium: normalizes the reuptake of some neurotransmitters such as serotonin, norepinephrine, acetylcholine and dopamine. Also reduces release of norepinephrine through competition with calcium. Anticonvulsants: (Carbamazepine, Valproic Acid, Gabapentin, Lamotrigine etc.)not yet so clear but close to have known to increase levels of inhibitory neurotransmitter GABA and the KINDLING PROCESS. (snowball-like process of increasing the threshold to prevent minor occurrences of minor mood fluctuations.

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Available in tablets, capsules, liquid and a sustained-released form; no parenteral form. Usual dosage ranges from 900 to 3,600 mg daily in divided dose. Monitoring of serum lithium levels is a MUST to assess response to drug & regulation. 1.0 mEq/L is said to be the THERAPEUTIC level. 0.5 mEq/L or less is said to be RARELY THERAPUTIC. 1.5 mEq/L or more is considered TOXIC. Monitoring of serum lithium levels is to be done every 2 or 3 days while therapeutic level is being determined and then weekly then after. If the condition as stabilizes, the level may be checked once a month or less frequently. Side Effects: Mild nausea or diarrhea, anorexia, fine hand tremor, polydipsia, polyurea, a metallic taste in the mouth and fatigue or lethargy. Toxic signs for lithium overdose may lead to real failure, coma and death.

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Generic Name
Carbamazepine

Side Effects
Dizziness, hypotension, ataxia, sedation, blurred vision, rashes

Nursing Concerns
Assist client to rise slowly. Monitor gait and assists as necessary. Report rashes to physician. Provide rest periods. Assist client during movement especially during ambulation. Give with food. Report rashes to physician. Monitor gait and movements. Assist client as necessary. Provide rest period. Establish balance nutrition. Provide rest periods. Assist client during movement especially during ambulation. Give with food.

Oxcarbazepine

Dizziness, hypotension, ataxia, sedation, blurred vision, rashes, tremor, rashes, confusion Dyspnea, nystagmus, vomiting, weight gain, hair loss, ataxia, menstrual changes, dyspepsia. Hypotension, headache, fatigue, nausea, vomiting, nystagmus, coordination, sedation.

Divalproex

Gabapentin

Taking this medication with meals will minimize nausea. Side effects like dizziness, lethargy must be noted and patients prevented from driving. Side effects like dizziness, lethargy must be noted and patients prevented from driving. Pretreatment hematologic baseline data must be obtained. Liver function test at regular intervals for medication usage at long term prescription.

VALPROIC ACID and DERIVATIVES may cause Hepatic failure resulting in fatality. Can produce Teratogenic effects (6 months) such as neural tube defects (eg. Spina bifida). x CARBAMAZEPINE can cause Aplastic Anemia and Agranulocytosis. x LAMOTRIGINE may cause serious rashes requiring hospitalization including StevensJohnson Syndrome and rarely, life-threatening toxic epidermal necrolysis. Incidence rate is higher to patients 16 years old and below.

Also know as ANTIANXIETY AGENTS. Benzodiazepines have proved to be most effective in relieving anxiety and are the drugs most frequently prescribed. These drugs can also be prescribed for their anticonvulsant and muscle relaxant effects. Non-benzodiazepines less frequently prescribed and is so on case to case basis or as a professional choice of doctors. Indications: Anxiety and Anxiety Disorders, Depression, PTSD, and Alcohol withdrawal. Insomnia, OCD,

Mechanism of Action: Benzodiazepines mediate the actions of the amino acid GABA, the major inhibitory neurotransmitter in the brain. While Buspirone is believed to exert its anxiolytic effect by acting as a partial agonist at serotonin receptors which decreases serotonin turnover.

Side Effects: Psychological Benzodiazepine. Additional Health Teachings:

Dependence

to

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Clients need to know that antianxiety agents are aimed at relieving symptoms but not the underlying problems that cause the anxiety. Benzodiazepines strongly potentiate the effects of alcohol. Clients must be reminded of the decreased response time, slower reflexes, and sedative effects. No driving. Benzodiazepine withdrawal can be fatal. No abrupt stopping after long term use without the supervision of the physician.

2. 3.

4.

Generic Name Benzodiazepines


Diazepam (Valium) Chlorazepate Alprazolam Clonazepam

Speed of Effect Ranges from very fast to intermediate effect

Side Effects Dizziness, clumsiness, sedation, headache, fatique, sexual dysfunction, blurred vision, dry throat, high potential for abuse and dependence.

Nursing Concerns *avoid other CNS depressants. *avoid caffeine & alcohol *drink adequate fluids. *rise/move slowly.

Non-Benzodiazepines Ranges from rapid to very slow effect Buspirone


Meprobamate (equinil)

Dizziness, restlessness, agitation, drowsiness, weakness, vomiting, paradoxical excitement (euphoria).

*take with food. *rise/move slowly. *report persistent & recurring side effects.

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As the term implies, it has pronounced effects of CNS stimulation. No caffeine, sugar, and chocolate. Indications: In the past, they were used to treat Depression and Obesity. Now, ADHD in children and adolescents, Residual Attention Deficit Disorder in adults, and Narcolepsy. Mechanism of Action: Amphetamines and Methylphenidate act by causing release of the neurotransmitters (norepinephrine, dopamine, and serotonin) from presynaptic nerve terminals as opposed to having direct agonist effects on the postsynaptic receptors. Side Effects: Most common: Anorexia, weight loss, nausea, and irritability. Less common: Dizziness, dry mouth, blurred vision and palpitations.

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Highly addictive. Taking after meals minimizes anorexia and nausea. Avoid caffeine, sugar and chocolate.
AMPHETAMINES may result to abuse. Long term use may cause to drug dependence. x METHYLPHENIDATE can cause tolerance and psychic dependence. marked

x PEMOLINE may cause life-threatening liver failure, which can result in death or require liver transplantation. Would require additional regulation permit and consent from government regulating body.

A sensitizing agent that causes an adverse reaction when mixed with alcohol in the body. The agent is used only as DETERRENT to drinking alcohol in persons receiving treatment program for Alcoholism. 5-10 minutes after alcohol ingestion with result to the following symptoms: - facial and body flushing - dry mouth, nausea, vomiting - dizziness and weakness - In severe cases, chest pain, dyspnea, severe hypotension, confusion and even death. Other side effects would include halitosis, tremor and impotence Can interfere with other drugs like Phenytoin, Isoniazid, Warfarin, Barbiturates, Benzo.

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A turning point in an individuals life that produces an overwhelming emotional response. Stressors or challenges that they can not effectively manage through use of their customary coping skills. Maturational or Developmental Crises Situational Crises The individuals perception of the event. Availability of emotional support. Availability of adequate coping mechanisms.

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