Psychiatric Nursing Notes• Psych focuses in feelings or self awareness.• Beliefs determine feelings which affects behavior (manifestation of feelings)• Sigmund Freud is the father of PSYCHOANALYSIS.• What happens to childhood will affect adulthood.

STRUCTURE OF PERSONALITY

ID

• impulsive, want to, wants pleasure.• PLEASURE PRINCIPLE.• Guiding principle is PAIN AVOIDANCE.

SUPEREGO• should not• small voice of God• to stop

EGO• executive decision maker.• In touch with reality principle.

ID DOMINANT PERSONALITIESManicAnti – Social – experienced by serial killersNarcissistic

SUPEREGO DOMINANT PERSONALITIES Obsessive CompulsiveAnorexia Nervosa

EGO – if destroyed result in impaired reality perception.Schizophrenia

LIBIDO• Sexual energy responsible for survival.

Oral Stage• 0 – 18 months evident.• ID is developed.

*FIXATION – Person is stuck in certain developmental shape.*REGRESSION – Return to an earlier developmental stage.EGO – Developed on the 6th month.

Anal Stage• 18 months – 3 years old.

1

• Able to control bladder, bowel.• Best time for toilet training.• SUPEREGO is developed.

TOILET TRAINING

Good Mother------------------------ Bad MotherSuccessful -----------------Dirty ---------------------- Clean-------------------------disorganized --------------- organized------------------------- disobedient ---------------- obedient------------------------- Anti-social ------------------- O.C----------------------- Anal expulsive ----------- Anal retentive

PHALLIC STAGE• 3 – 6 years old.• Experience pleasure by manipulating genitals.• Love – hate relationship.• Oedipus Complex boy loves parent of the opposite sex.• Imitates daddy called identification.• Castration fears.• Electra Complex girl loves parent of the opposite sex.• Imitates mommy called identification.• Penis envy.*Conscious – upper level of thinking.*Preconscious – tip of tongue.*Unconscious – protects us from traumatic experiences.

LATENCY STAGE• 6 – 12 years old.• School age.• Separation anxiety.• Reading, Writing, Arithmetic.• Lasts for 6 years.

GENITAL STAGE• 12 years old and above• Sexual reawakening.• Very important stage.

2

PHARMA NOTES:ANTI - ANXIETY DRUGS• Valium• Librium• Ativan• Serax• Tanxene• Miltown• Equanil• Vistaril• Atarax• Ideral• Buspar

ERIC ERIKSON• There is more to life than just sex.• Psychosocial Theory of development.• You can develop a positive side or a negative side.• Developmental task begins at 0 – 18 months.

-------------------- POSITIVE ------NEGATIVE -------- FACTOR0 – 18 mos. ----------Trust ------------ Mistrust ------------ Feeding18 mos. – 3 yrs. ----Autonomy -------Shame & Doubt ---- Toilet Training3 yrs. – 6 yrs. -------Initiative ---------- Guilt --------------Independence6 yrs. – 12 yrs. -----Industry ---------Inferiority ------------ School12 yrs. – 20 yrs. ----Identity ---------Role Confusion --------- Peers20 yrs. – 25 yrs. ----Intimacy -----------Isolation --------------Love25 yrs. – 45 yrs. ---Generativity --------Stagnation -----------Parenting45 yrs. - above ----Ego Integrity --------- Despair ------------Reflection

LOBES OF BRAIN

1. FRONTAL LOBE- Language- Learning- Personality- Judgment

2. TEMPORAL LOBE- Hearing- Smell

3. PAREITAL LOBE- Touch- Taste

4. OCCIPITAL LOBE- Visual

3

3 STEPS TO INTERACT WITH ENVIRONMENT1. Sensory – eyes, ears, tongue2. Integration3. Motor – voluntary or involuntary

VOLUNTARY NERVOUS SYSTEM• also called as somaticBrainSpinal CordMotor NerveSynapseMuscle Fiber• Motor nerve to muscle fiber you need Acethylcholine which is an “On switch”.

INVOLUNTARY NERVOUS SYSTEM• also called autonomic nervous system.

AUTONOMIC NERVOUS SYSTEM-----------------------SYMPATHETIC ------------PARASYMPATHETIC-------------------(Awake, ADRINERGIC) --------(Relax, CHOLINERGIC)Heart Rate ------------ Increase -------------------- DecreaseRespiratory Rate ------ Increase -------------------- DecreaseGI ---------------------Decrease ------Increase (Moist mouth, Diarrhea)GU -------------------- Decrease ---- Increase (Urinary Frequency)Neurotransmitter---- Epinephrine, Norepinephrine ----Acethylcholine

DRUGS WITH ANTICHOLINERGIC EFFECTS• Anti – Anxiety• Anti – Psychotic• Anti – Cholinergic• Anti – Depressants

PHARMA NOTES:

MONOAMINE OXIDASE INHIBITORS (MAOI DRUGS)• Marplan• Nardil• Parnate

DEFENSE MECHANISMS1. Displacement – transfer of feelings to a less threatening object rather than the one who provoked it.2. Denial – failure to acknowledge an unacceptable trait or situation.3. DISOCIATION – psychological flight from the self.4. REGRESSION – return to an earlier development state.5. repression – unconscious forgetting.

4

6. RATIONALIZATION – illogical reasoning for an unacceptable trait and situation.7. REACTION FORMATION – doing the opposite of what you have done.8. UNDOING – doing the opposite of what you have done.9. IDENTIFICATION – assuming trait for personal, social, occupational role.10. PROJECTION – attribute to others one’s unacceptable trait.11. INTROJECTION – assume another person’s trait as your own.12. SUPPRESSION – conscious forgetting.13. SUBLIMATION – putting destructive energies or hostile feelings towards a more productive endeavors.14. CONVERSION – unexpressed or repressed feelings are converted to physical symptoms.15. COMPENSATION – over achievement in one area to cover a defective part.16. SUBSTITUTION – replace difficult goal with more accessible one.

PHARMA NOTES:

ANTI – PARKINSON DRUG - CAPABLES• Cogentin• Artane• Parlodel• Akineton• Benadryl• Larodopa• Eldepryl• Symmetrel

AUTONOMIC NERVOUS SYSTEM----------------- SYMPATHETIC -------- PARASYMPATHETICPupils ----------------Dilate ----------------ConstrictBlood Vessels --------Constrict ------------- DilateBlood Pressure --------Increase ------------ Decrease

THERAPEUTIC COMMUNICATION TECHNIQUES

THERAPEUTIC1. Offer Self2. Silence – provide time to think3. Making observation – what you see you say4. Active Listening – nodding, eye contact5. Broad Opening – how are you today?6. General Leads – Go on, I’m listening7. Restating – I’m sad “You’re sad?” 1. Don’t worry be happy2. Changing the topic/subject3. Ignore the client4. Value based judgment – never assume5. Flattery6. Advising7. Giving Opinion

5

NONTHERAPEUTIC

1. Don’t worry be happy2. Changing the topic/subject3. Ignore the client4. Value based judgment – never assume5. Flattery6. Advising7. Giving Opinion

FEAR – protects us from something bad.

ANXIETY• Vague sense of impending doom.• Triggers the sympathetic nervous system.• Assess level of anxiety of client.

TYPES OF ANXIETYMILD ANXIETY• + 1 level of anxiety.• Widened perceptual field.• Restless (say you seem restless).• Enhanced learning capacity.

MODERATE ANXIETY• + 2 level of anxiety.• Client pace.• Give PRN meds.

SEVERE ANXIETY• + 3 level of anxiety.• Don’t know what to do/say.• Directive orders (please sit down).

PANIC• + 4 level of anxiety.• May commit suicide.• Promote safety.• Never touch patient.• Hyperventilation (Respiratory Alkalosis)• Breathe into paper bag.

NURSING DIAGNOSIS:• ineffective individual coping.• Powerlessness.• Impaired skin integrity

PLANNING/IMPLEMENTATION:• decrease level of anxiety.

6

• Decrease environmental stimuli.• Relaxation techniques.

EVALUATION• effective individual coping.

GENERALIZED ANXIETY DISORDER• 6 month excessive worrying.• Restless, difficulty concentration, sleep disorders, palpitations, edge of the seat, easy fatigability.

PANIC ATTACKS/DISORDER• 15 – 30 minutes sympathetic nervous system escalation.• Example is AGORAPHOBIA fear of open spaces.

POST TRAUMATIC STRESS DISORDER• victims becomes survivors and experience flashbacks or nightmares.

MALINGERING• pretending to be sick (conscious).• Primary Gain anxiety decreases, able to escape source of anxiety.• Secondary Gain able to get attention.

SOMATOFORM• no protection• unconscious• no organic basis of being sick

DIFFERENT TYPE OF SOMATOFORM1. Conversion Disorder• cannot speak, see, hear.• Nervous system affected.2. La Belle Indifference• do not care what happens to them.

HYPOCHONDRIASIS• has minor discomfort and interprets it as major illness.• Focus on clients feelings.

BODY DISMORPHIC DISORDER• Illusion of structural defect.• Favorite past time is doctor hopping.• Focus on clients feelings.

PSYCHOSOMATIC• Real pains/illness• Real symptoms because of anxiety

PSYCHOSOMATICIncrease Anxiety

7

SNSIncrease BP & HRHypertensionFat DepositsAtherosclerosisCalciumArteriosclerosisDecrease OxygenAngina PectorisMINecrosisCHFComa

PHOBIA• Irrational fear• Etiology: Knowledge of certain object• Bad experience• Immediate nursing objective: Removal of stimulus will remove anxiety• Systemic Desensitization gradually expose client to stimuli/feared object• Employ relaxation techniquesSNS• GABA (Gamma Amino Butyric Acid) – stop• Epinephrine and Norepinephrine – Go

ANTI-ANXIETY• Increase GABA and client becomes drowsy (no alcohol and coffee)• May develop orthostatic hypotension• Let patient sit then dangle feet and then stand• Develop anti cholinergic effects• If abruptly withdrawn to anti anxiety it may result to rebound phenomenon (1 week) may lead to seizures• Do it in gradual and in tapered dose• Anti anxiety leads to dependence

AUTISM• Unresponsive and does not want to be touched• Autistic Savant: high intelligence and has a ratio of 1:100• Assessment• Appearance – flat affect and loves constancy and ritualistic• Behavior – withdrawn• Communication – echolalia

NURSING DIANOSIS• Impaired verbal communication• Impaired social interaction• Self mutilation• Risk for injury

PLANNING/IMPLEMENTATION

8

• Maslow’s hierarchy of needs• Expressive Therapy – use of art as mode if communication

EVALUATION• Enhanced communication• Improved social interaction• Safety

ATTENTION DEFICIT HYPERACTIVITY DISORDER• 7 years and below onset• Duration: 6 months and above• Settings: house and school• Assessment• Appearance: dirty, clumsy, hyperactive, impatient, easily distracted and has no focus• Behavior• Communication: talkative

NURSING DIAGNOSIS• Risk for injury• Impaired social interaction

PLANNING/IMPLEMENTATION• Structure: place to play, sleep, eat and study• Schedule: there is always a time for everything that you do• Set limits• Safety

EVALUATION• Minimize risk for injury• Improved social interaction

FRONTAL LOBE OF ADHDDecrease glucoseDecrease judgmentIncrease impulsivenessADHDHyperactivity• Need a drug that brings glucose level up.• Give Ritalin a stimulant• May result in loss of appetite• Given after meals• Given 6 hours before bedtime

EATING DISORDERS

ANOREXIA NERVOSA ---------------BULIMIA NERVOSA- Eat, eat, eat --------------------------- Eat, eat, vomit- Less 85% expected body weight ------- Normal weight

9

- 3 months amenorrhea --------------- Irregular menstruation

BULIMIA NERVOSA• Metabolic alkalosis (vomiting results to decrease hydrochloric acid)• Metabolic acidosis (diarrhea results to decrease bicarbonate)• Dental caries• Wound in knuckles

MANAGEMENT• Fluid and electrolyte imbalance• Meal contract• Weight gain for client• After eating stay with client for 1 hour and accompany when going to the comfort room

PHARMA NOTES:ANTI – PSYCHOTIC DRUG• Stelazine• Serentil• Thorazine• Trilafon• Clozaril• Mellaril• Haldol• Prolixin

SCHIZOPHRENIA• Ego disintegration• Impaired reality perception• Genetic vulnerability• Stress – Diathesis Model• Biological theory – increase dopamine level• Exact cause unknown

ASSESSMENT• Affect: Appropriate, Inappropriate, Flat, Blunt (incomplete)• Ambivalence: pulled into 2 opposing forcesAutism• Looseness, no idea, not related to one another

ASSESSMENTNEGATIVE ------------------------POSITIVEHypoactive ------------------------ HyperactiveWithdrawn ------------------------- SociableThought Blocking ------------------Flight of ideasApathy

I. ASSESS• Content of thought

10

NURSING DIAGNOSIS • Disturbed thought processPLANNING/IMPLEMENTATION• Present reality• Provide safetyEVALUATION• Improved thought process

II. ASSESS• Hallucinations/Illusions

NURSING DIAGNOSIS• Disturbed sensory perceptionPLANNING/IMPLEMENTATION• Present reality• SafetyEVALUATION• Improved sensory perception

III. ASSESS• Suspicious

NURSING DIAGNOSIS• Risk for other directed violencePLANNING/IMPLEMENTATION• Present reality• SafetyEVALUATION• Eliminate/minimize risk for other directed violence

IV. ASSESS• Suicidal

NURSING DIAGNOSIS• Risk for self directed violencePLANNING/IMPLEMENTATION• Present reality• SafetyEVALUATION• Eliminate/minimize risk for self directed violence

LOOSENESS OF ASSOCIATION• There is connection with statements

FLIGHT OF IDEAS• Jumping from on topic to another

AMBIVALENCE• Pulled between 2 strong opposing forces

11

MAGICAL THINKING• acting like magician

ECHOLALIA• Client repeats what you say

ECHOPRAXIA• Client repeats what you do

WORD SALAD• Just words no rhyme

CLANG ASSOCIATION• Words that rhyme

NEOLOGISM• Formation of new words (needs clarification)

DELUSION: PERSECUTORY• “The NBI is out to get me”

DELUSION: RELIGIOUS• “I am Jesus Christ the savior”

DELUSION: GRANDEUR• “ I am the queen of the world”

DELUSION: IDEAS OF REFERENCE• “The nurses are talking about me”

CONCRETE ASSOCIATION• Also known as “pilosopo”

THOUGHT BLOCKING• Unable to think

-----------------------HALLUCINATIONS------ ILLUSIONSSTIMULUS ------------ ABSENT------------ PRESENTVISUAL ----------------ABSENT------------ PRESENTAUDITORY ----------- ABSENT------------ PRESENT TACTILE ABSENT --- ABSENT------------ PRESENT

• Present reality to clients experiencing hallucinations• Technique in handling clients with hallucinations• Hallucinations• Acknowledgement “I know the voices are real to you”• Reality orientation “I know the voices are real but I don’t hear them”• Diversion “Lets go to the garden”• 10% of schizophrenic clients hear voices

12

PARKINSON’S DISEASE• If acethylcholine (on switch) is increased there is excessive movement resulting to decrease in dopamine (off switch)

ANTI-PSYCHOTICDecrease dopamine levelParkinson like effectExtra pyramidal side effectWith akathesiaRestless, inability to rest

AKINESIA• Muscle rigidity

DYSTONIA• Torticollis (wryneck)

OCULOGYRIC CRISIS• Fixed stare

OPISTHOTONUS• Arched back• Lips – smacking• Tongue – protruding• Cheeks – puffing• The 3 are irreversible and called tardive dyskinesia• Neuroleptic malignant syndrome – hyperthermia

ANTI – PARKINSONAnticholinergics Dopaminergics(Decrease Ach) (Increase Dopa)Artane, Akineton ParlodelBenadryl LarodopaCogentin EldeprylSymmetrel

OTHER SIDE EFFECTS OF DECREASE DOPAMINE• Photosensitivity• Agranulocytosis – decrease WBC• Clients prone to infection due to decrease WBC• First sign for infection is sore throat

TYPES OF SCHIZOPHRENIA

DISORGANIZED SCHIZOPHRENIA- Sad but smiles (inappropriate affect)- No reaction (flat affect)- Flight of ideas (disorganized speech)- Giggling (hebephrenic giggle)

13

- Combination of positive and negative signs and symptoms

CATATONIC SCHIZOPHRENIA- Ambivalence- Waxy flexibility- Favorite word is “No”- Negativism (client do not follow what you tell them to do)Nursing management: meet needs

PARANOID SCHIZOPHRENIA- Suspicious- Mistrust, scared, withdrawnNursing management:- Gain trust by 1 to 1 short interaction but frequent- Foods should be in a sealed container- Medications should be in tamper resistant foil.Violent:- Keep door open- Position near door- Don’t touch client- Call for reinforcement- One arms length away from the client.

PARANOID SCHIZOPHRENIA- No more positive symptoms just withdrawn

UNDIFFIRENTIATED SCHIZOPHRENIA- Mixed classification, cant be classified

PHAMRA NOTES:

BI-POLAR, MANIC• Lithium: undergo first kidney test and check for blood levels• Level: .6 – 1.2 meq/L• Increase urination• Tremors, fine hand• Hydration of 3L/day• Increase• Uu (diarrhea)• Mouth dry

Signs of Lithium toxicity• Nausea, vomiting, diarrhea• Increase sodium* Wait for 2 – 4 weeks before lithium therapy takes effects

BIPOLAR DISORDER/MANIC PROFILE• 20 years old• Female

14

• Stress• Obese

ASSESSMENT• Decrease appetite (give finger foods)• Decrease sleep (place in a private room)• Hyperactive• Increase sexual activity – only means of addressing anxiety so decrease level of anxiety• Risk for injury/other directed violence• Impaired social interaction (care giver role: strain and stay with client)• Self esteem decrease (to cover up their sadness there is compensation to cover defective doing)• Because there is decrease self esteem there will be increase compensation resulting to increase interference with ADL’s and harm to others• Compensation is the culprit• Management: increase self esteem to decrease compensation and decrease interference with ADL’s and harm to others

HOW TO INCREASE SELF ESTEEM OF MANIC PATIENTST- no sports (basketball, volleyball), no fine motor skills only gross motor skillsA lot energies toward more productive endeavors (sublimation)S - escorted walk outdoorsK – punching bag (displacement)

PHARMA NOTES:

ANTI – DEPRESSANTS• Asendin• Norpralamin• Tofranil• Sinequan• Anafranil• Aventyl• Vivactil• Elavil• Prozac• Paxil• Zoloft

ALCOHOL LEADS TO:• Blackout: awake but unaware• Confabulation: inventing stories to increase self esteem• Denial: “I am not an alcoholic”• Dependence: cant leave with out leading to enabling where in the significant other tolerates the abuser co dependence is another term• Tolerance: gradual increase in amount of stimuli to experience the same euphoria

15

MANAGEMENT• Detoxification: withdrawal with medical doctor supervision• Avoid alcohol therapy• Aversion therapy a more technical term for avoid alcohol therapy• Antabuse: Disulfiram makes the client never drink alcohol because it causes vomiting• Alcoholics anonymous• Interval of 12 hours after last dose of alcohol or experience nausea and vomiting and hypotension• Alcoholism may result to Vitamin B1 (Thiamine) deficiency

WERNICKE’S ENCEPHALOPATHY• Problem with motor

KORSAKOFF’S PSYCHOSIS• Problem with memory• 24 – 72 hours after last dose of alcohol expect:• Delirium Tremens: sympathetic nervous system• Prevent hallucinations/Illusions by placing client in a well lit room• Formication: feeling of bugs crawling under the skin

ALZHEIMERS DISEASE• Axon (away) and Dendrites (toward) nerve• Neurofibrillary tangles• Neurotic plaques

--------------------------ALCOHOL --- ALZHEIMERSONSET -------------------- Abrupt -------- GradualLEVEL OF CONSCIOUSNESS -- Fluctuating ----UnaffectedDURATION ----------- Hours to days --- ProgressiveMEMORY -------------- Short term ---Short and long term

5 A’s OF ALZHEIMERS1. Amnesia – memory loss2. Anomia – don’t know the name3. Agnosia – sensory problems smell, taste, sight4. Aphasia- expressive: cant say/express- frontal lobe is affected particularly broca’s area- receptive: cant hear- temporal lobe is affected particularly wernicke’s area5. Apraxia – cant do simple things* Reminiscing Therapy – talk about past• Patients with alzheimer’s may experience hallucinations, illusions thus becomes restless and may wander• As sun goes down client becomes restless, agitated, disoriented called sundowning• Drug of choice is Cognex and Aricept a cholinesterase inhibitor that increases Ach causing delay in disease progression

16

SEROTONIN• Responsible for happiness• Decrease serotonin clients becomes sad give anti-depressants

SELECTIVE SEROTONIN REUPTAKE INHIBITORSafest drugSide effects lowRI to 4 weeks- Increases serotonin and affects only serotonin- Prozac, Paxil, Zoloft

TRICYCLIC ANTI DEPRESSANTTwo – four weeksCA- Has higher incidence of side effects- Also increases norepinephrine- Asendin, Norpralamin, Tofranil, Sinequan, Anafranil, Aventyl, Vivactil, Elavil

MONO AMINE OXIDASE INHIBITORS• MAO kills serotonin• Increased MAO results to decreased serotonin the more depressed the client becomes• MAOI kills MAO and increases all neurotransmitters (serotonin, epinephrine, norepinephrine, dopamine but client becomes prone to hypertensive crisis• Avoid tyramine rich foods• Avocado, Alcohol• Beer• Chocolates, Cheese (aged)• Fermented foods• Pickles• Preserved foods• Soy sauce• There is increase incidence of side effects after 2 – 6 weeks• Marplan, Nardil, Parnate

PERSONALITY DISORDERS1. Schizophrenia- They avoid people because there is no enjoyment2. Avoidant- They avoid people because they are afraid of criticisms- They have talent but has no confidence3. Anti-Social- Constantly breaks law- Project charm- They are witty and articulate- Manipulative

17

4. Borderline - They perceive life as an empty glass- They like splitting friends- Sudden change in mood “labile affect”- Prone to suicide5. Dependent- “Cant live if living is without you”6. Histrioinic- Constantly wants to be the center of attention- Excited, dramatic, manipulative7. Narcissistic- “I love myself”- They get jealous even with achievement of family members8. Obsessive – Compulsive- “I am so organized”9. Paranoid - Suspicious- May lead to domestic violence

ANTI – DEPRESSANT SIDE EFFECTS:Male – erectile dysfunction, prone to impotence

GRIEF PROCESS1. Denial – shock/disbelief2. Anger – question “why me?”3. Bargaining – if, then4. Depression – 2 weeks or more sign and symptoms becomes major clinical depression5. Acceptance – client acts according to situation

ASSESSMENT• Decrease self actualization• Decrease self esteem• Withdrawn: stay with client• Suicidal: risk for self directed violence• Increase/decrease eat, increase/decrease sleep, hypoactive, decrease sexual urge• Be sensitive to clients needs

FOR SUICIDAL OBSERVE FORVerbal• “I wont be a problem”• “This is my last day on earth”• “I’ll soon be gone”Non verbal• Giving away of valuables• Sudden change in mood

18

WHEN THE CLIENT IS SUICIDAL WHAT WILL THE NURSE DODirect: “Do you plan to commit suicide?”Irregular/interval visitsEndorsement period, early morning clients are most likely to commit suicide

DOWNERSAlcoholBarbiturateOpiatesNarcoticsMarijuanaMorphineCodeineHeroine

Resulting to:• Bradycardia• Bradypnea• Moist mouth• Pupils constrict• Constipation• Urinary retention• Hypotension• Coma• Weight gain• Narcotics overdose: give narcotic antagonist (Narcan, Naloxone hydrochloride)

UPPERSCocaineHallucinogensAmphetaminesResulting to:• Tachycardia• Awake• Tachypnea• Dry mouth• Pupils dilate• Hypertension• Seizures• Weight loss

19