PSYCHIATRIC NURSING Overview: A. Psychiatric Nursing Mental health Primary purpose is to promote mental health Not curable, only to reduce the symptoms B. Main Tool : IPR (Interpersonal Relationship) Client, individual, family, environment Nurse: self- awareness to minimize weakness, maximize strength C. Focus of Psyche : Human Behavior - Leads to identification of feelings - Responses to the environment, changes are meaningful D. Tool Used By The Nurse : Therapeutic use of self acquired thru self-awareness E. Levels Of Prevention: 3 Levels Of Prevention : 1.) Primary Promote mental health (Healthy) Remove factors before they can cause illness Ex. Stress reduction Health Teachings/Community Teachings/Community Demographics Support System Accident Prevention 2.) Secondary Lessen the duration of mental illness (ill) Ex. Suicide Prevention Crisis Intervention/ Treatment & Diagnosis Providing Psychotherapy & Milieu Therapy 3.) Tertiary Function to become independent Ex. Rehabilitation Centers/ Al anon Created by Niňa E. Tubio 1
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PSYCHIATRIC NURSING
Overview:
A. Psychiatric Nursing
Mental health Primary purpose is to promote mental health Not curable, only to reduce the symptoms
Ex. Rehabilitation Centers/ Al anonRelapse Avoidance
F. Stages Of Interaction
1st Stage: OrientationAssessment 2nd Stage: WorkingEstablishment of Trust Problem Solving Tell Patient of Termination Discussion 3rd Stage: Termination Set contract Patient is mostly cooperative SummarizeEvaluation Say Goodbye Patient is resistant Grief-Anger (Focus of RN)
Pt. violent/suicidalI. MENTAL HEALTH ----- A state of mind
6 Concepts In Mental Health:
Created by Niňa E. Tubio 1
1. Self-Awareness
2. Self-Actualization –Self-fulfillment or self-realization
If there’s Weakened EGO Impaired Reality Perception Characteristic of: SCHIZOPHRENIA
B. THE THEORY OF LIBIDO
LIBIDO - Sexual energy for survival Man’s sexual desires & urges Personal-----libidal striving w/c focuses on gratification
C. THE THEORY OF DREAMS Resides in the unconscious
D. THE THEORY ON LEVELS OF AWARENESS
3 Levels of Awareness:> Highest level of Awareness> Contains all experiences that can be recalled voluntarily
> “Tip Of The Tongue”; Deja Vu> Experiences that partly forgotten & partly remembered
> Forgotten> Experiences that cannot be recalled Ex. Dreams, accidents, anxieties & phobias> Where traumatic experiences are stored (Repression)
Ex. Birth Trauma (the cause of 1st anxiety)
*The ID, Ego & Superego -----all resides in the unconscious & operates on different levels of the mindExcept the ego when dealing with reality----resides on the ---conscious
E. THE PSYCHOSEXUAL THEORY
STAGES OF PSYCHOSEXUAL DEVELOPMENT
1. ORAL STAGE 0 – 18 months
“ Survival” All ID Cry, suck mouth Biting, Thumb sucking & Nail biting-----------------all normal in infancy Dependent, Helpless----------------needs to develop sense of trust, sense of security
After 6 months, EGO develops------Development of Self-Concept
Maternal Deprivation results if there’s no feeding, not given milk/water, not kept warm
Residuals Developed : 3 Maladaptive Behavior:
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ID SUPEREGO
CONSCIOUS
PRE-CONSCIOUS(Sub-conscious)
UNCONSCIOUS
Repression – Unconscious forgetting of an anxiety-provoking event
Suppression – Conscious forgetting of an anxiety-provoking event (voluntary)
Focus on Elimination -----Bowel -------the 1st to developed -----Bladder (Bedwetting) Toilet training Temper Tantrums---Normal---Ignore as long as no harm is present: If (+) harm---set limits SUPEREGO is being formed(begins)---------------Mother as the superego
Sense of Autonomy Develops------manifested through
Focus: Genitals------Penis only Development of Gender Identity Sense of Being Masculine/Feminine Sense of Initiative Genital Exhibitionism/Masturbation Imaginative With a friend Explorative “Why” Residuals Developed: Sexual Deviation Sibling Rivalry is normal
Development of Complexes----child attachment to opposite sex
Both complexes resolved thru
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NarcissisticStems from being deprived & neglected as a child
Regression Going to an earlier developmental stage
Good mother Bad mother
DirtyDisorganizedDisobedient
SE SE
SE
Oedipus Complex(boy loves mommy)
Identification(boy imitates daddy)
Boys-“Castration fears”
Electra Complex(girl loves daddy)
Identification(girl imitates mommy)
Girls-“Penis Envy”
Fixation Stopping in a certain stage of Development
R
Identification To parent of the same sex(Role Identification)
4. LATENCY STAGE 6 to 12 years old (School Age) (“Log tu” tulog ang libido)
Focus: School & Peer The Homosexual Stage-----------Identify with the same sex------Best friend Areas on school & social competition--------------form the sense of group success Sense of Industry Fear: School Phobia-------------Separation-Anxiety
EADING W ITING
A ITHMETIC
Residuals Developed: School Dropout
5. GENITAL STAGE 12 years and above (Gising na ulit ang sexual energy)
Focus: Genitals Emergence of LUST ENITAL The Heterosexual Stage ISING Sense of Identity AMBIVALENCE: Child Adult
Struggle for independence from parents Problems: Conflicts & Frustrations dominates
Residuals Developed: Drug Addiction, Promiscuity, Alcoholism2. ERIK ERICKSON------- Psychosocial Theory Of Development
Considered the “Social Factors” Man as a Social Being Person play different roles & as we play them, we achieve something
PSYCHOSOCIAL STAGES OF DEVELOPMENT
Stage Freud (+) (-) Factor Significant Person
0-18 months(Infancy)
Oral Trust( Friendly/ Affectionate)
(Self-Confidence)
Mistrust(Withdrawn/Suspicious)
Feeding Mother
18 months – 3 years
(Toddler)
Anal Autonomy (Self-Determination)
(Independence)
Shame & Doubt (Overtly Compliant)
Toilet Training“No,No”
“My”
Parents
3 – 6 years(Pre-Schooler)
Phallic Initiative(Responsible)
(Role Identification)Initiate the 1st step
Guilt(Denial, Restrictions)
Anger To Self
Independence“Teach The
Child”
Family
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Sublimation – placing sexual energies (feelings) toward more productive endeavors
G
6-12 years(School)
Latent Industry(Competition) (Cooperative)
“Sx of High Self-Esteem”
Inferiority(Social Loner)
(School Drop-out)
School“Who Am I” based on
beliefs, selects & become who you are along w/ your peers
TeacherPeer
12 – 20 years(Adolescence)
Genital Identity(Self-Actualized)(Self-Direction)
Role Confusion(Identity Crisis)
Peers(Major factor in
the dev’t of beliefs
Opposite Sex
20-25 years(Young Adult)
Intimacy(Commitment)
Isolation(Relationships/Jobs on
Temporary Basis)
Love Husband/WifeChildren
25-45 years(Middle Adult)
Generativity(Productivity)
“Sharing”
Stagnation(Selfish, Self-Centered)
“No Learning”
Parenting“Sharing beliefs w/ children”
ChildrenGrandchildren
45 & Above(Late Adult)
Ego Integrity(Worthiness)
(Completeness)
Despair(Hopeless, Unworthy)
(Fear of Death)
Reflection Husband/WifeBest friend
Paranoia = Stems from the development of mistrust
Exercise: Newly admitted Patient:----Develop 1st ----Trust ----Develop/teach autonomy since pts. Are dependent with self-care deficit
3. JEAN PIAGET-------Theory Of Cognitive Development
Four Stages Of Cognitive Development
1st Stage : Sensorimotor 0- 2 years old Preverbal Recognizing environment by the use of senses (baby can see,perceive,hear)
Adapt through the use of reflexes & motor skill Concept of Object Permanence
----even if they cannot see the object, they still believed its existence
2nd Stage : Pre-Operational 2- 7 years old Egocentric----does not feel what adults feel Animistic Thinking -------cartoons are powerful Imitates other people Pre-Conceptual 2-4 y/o -----Use of language to talk Intuitive Stage 4 -7 y/o-----Unidimentional classification/characteristics
(Child can fix toys according to size, color, height---1 at a time only
3rd Stage : Concrete Operational 7 – 12 years old Logical Concept of Cause & Effect
4th Stage : Formal Operation 12 years old & above Idealistic Abstract Thinking
4. ABRAHAM MASLOW’S HIERARCHY OF NEEDS
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> Continuous Improvement of Self> Low self- esteem: Give Task
5. OTTO RANK------Theory Of Birth Trauma Birth Trauma---------Manifested Through----------Separation Anxiety Birth Trauma --------the 1st cause of Anxiety
6. CARL JUNG------Theory Of Libido
Theory Of Libido-------derived from an energy level
7. ADOLF MEYER--------Psychobiology Theory Concept of the mind & body as one entity
8. ALFRED ADLER------Individual Psychology Unique Man born with a weakness but overcomes it through
Compensation Inferiority Vs. Superiority Concept
9. HARRY STACK SULLIVAN-----Theory Of Interpersonal Relationships
Theory of Interpersonal Relationships
Mother & Child developed IPR during infancy------if lacking------anxiety
Anti-Cholinergic/ Anti-Parasympathetic Effect is sympathetic
Sympathetic Drug Classifications:
A- anxiety P- psychotic
ANTI C-cholinergic D- depressants
V. DEFENSE MECHANISMS
Mental mechanisms Coping Mechanisms from stress Patterns of adjustment Affects/Interferes with ADL--------harm to self or others Operates on the unconscious level
Processes on the Ego---------to reduce anxiety--------maintain self-esteem
Displacement Transfer of feelings to less threatening object/person rather than the one who provoked it
UnacceptableEx. “ Boss shouts at you, you shout to your subordinate”
Denial Failure to acknowledge an unacceptable trait or situation or realityEx. “I am not an alcoholic”
Regression Returning to an earlier developmental stage (earlier pattern of behavior)Ex. Acting like a child
Repression Unconscious forgetting of anxiety provoking concept (Selective forgetting)
Rationalization Illogical reasoning for a socially unacceptable trait (Giving rational reasons) Uses “because” Most common defense mechanism used
Ex. “I drink the beer in the ref rather than waste it”
Reaction-Formation Doing opposite of the intention (Hypocrites)
Undoing Doing opposite of what you have done (Action & then amends)Ex. Show true feeling then feels guilty after doing it
Identification Assuming trait, persona, social & occupational role (Models a certain behavior)
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Unconsciously imitating another person
Projection Attribute to others one’s unacceptable trait (Scapegoat Mechanism)Ex. “Not me but them”
Introjection Assume another’s trait as your own (Taken into oneself)Ex. “Not only you, Me too”
Suppression Conscious forgetting of an anxiety-provoking concept (Voluntary forgetting) Intentional forgetting to an unpleasant experienceEx. “I don’t want to talk about it”
Sublimation Excessive energies put towards more productive endeavors Redirect feelings (anger) to a socially acceptable behavior
Substitution Replacing a difficult goal with an accessible oneConversion Repression. Anger repressed & converted to physical symptoms
Ex. numbness & motor paralysis Solve conflicts by manifesting physical symptoms
Compensation Overachieving in one area to cover defective part or weakness To overcome inferiority & excel in other aspect of personality
Fantasy Use of imagination/daydreaming
Isolation Separating your feelings from the situation
Fixation Arrest of maturation/Persistence of one stage of development
Symbolism Give meaning to objects
Dissociation Psychological flight from selfEx. Amnesia, Rape or traumatic experiences Unconscious separation of certain parts or functions of personality
Alteration in--------MemoryIdentityConsciousness
To reduce/avoid anxietyCategories:
1. Psychogenic Amnesia------loss of memory
2. Fugue --New identity in a new place
3. Multiple Personality Dissociative identity disorder 2 or more personalities
4. Depersonalization Unreality to oneself With altered sense of self
5. Dissociation not otherwise classified Sleep talking----somniloquism Sleepwalking---somnambulism Amok aggression
VI. CONCEPT OF NEUROSES & PSYCHOSES
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Neuroses Psychoses
1. Maladaptive emotional state 1. Disturbance of the mind2. Reality is present 2. No reality3. Ego in the conscious 3. Ego in the unconscious4. Behavior is socially acceptable 4. Behavior is appropriate
PLANNING/ IMPLEMENTATION: ↓ level of anxiety↓ level of environmental stimuli
Relaxation techniques (Psychophysiology)
EVALUATION: Effective individual copingB. DISORDERS ASSOCIATED WITH ANXIETY
1.) GENERALIZED ANXIETY DISORDER
6 months excessive worrying Restless Concentration difficulty Sleep problems Palpitations Feeling of being at the edge of seat Easy fatigability Patient knows what the problem is
2.) PANIC DISORDER
15-30 minutes escalation of the SNS Sudden: Happens w/o warning With or W/O agoraphobia
2 Types:Agoraphobia - Fear of open spaces > Outstanding Sign of Panic DisorderSocial Phobia - Fear of public
3.) POST TRAUMATIC STRESS DISORDER (PTSD)
Trauma Disasters Rape War (not forever) Others
4.) MALINGERING - Pretending to be sick (Conscious) - No organic basis - Intentional
*Primary gain – the result you get when you manifest certain behavior that ↓ anxiety (Ex. Escape from Teacher)
*Secondary gain = ↑ Attention ( Ex. from mother)
Physiology:
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Victims Survivors
Flashbacks : > 1 monthNightmares
ANXIETY
“I am sick”
Malingering(Pretending)
Somatoform(Unconscious)
Psychosomatic Disorders(Real pain/ real Sx, ) illness
5.) SOMATOFORM DISORDERS
Unconscious Not pretending but no organic basis Major
Sign:
Affects the 3 system
6.) PSYCHOSOMATIC DISORDERS
Psycho physiologic Real illness, real Sx & pain with organic basis
Physiology:
Decreased O2 supply----cells die
7.) OBSESSIVE-COMPULSIVE DISORDER (OCD)
Physiology:
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SOMATOFORM(unconscious)
Nervous SystemCONVERSION
La belle difference(Emotional detachment)
Loss of Sensory/Motor FxS &Sx real
HYPOCHONDRIASISMinor discomfort interpreted
as major illness
BODY DYSMORPHIC DISORDER
Illusion of structural defectsS &Sx not real
DOCTOR HOPPINGFavorite pastime of people suffering from this disorder
↑ ANXIETY
SNS PNS
↑BPHypertension
Vasoconstriction Bronchoconstriction
Cerebral ArteryMigraine
Left Gastric Artery
Breakdown of mucosal lining-----ulceration
Asthma
Stress ulcer
NURSING FOCUS: Client’s Feelings (↓anxiety leads to ↓symptoms)
Beliefs/Thoughts reflect into feelings
Factors: If disturbed thoughts Anxiety
Obsession (Persistent Thoughts) Anxiety (Root of Anxiety)
Do something to relieve anxietyAction : Compulsion
Persistent Behavior & Action
↓ anxiety
Reasons when compulsion becomes negative:1. Interferes with ADLs2. Harms self & others
8.) PHOBIA Irrational fear
Etiology: Prior knowledge Ex. Tire will cause burningExperience Ex. Trauma in past related to feared object
Intervention: REMOVE stimulus (object of fear) to ↓ anxiety (Immediate intervention)
1. BINGE EATING DISORDER - Recurrent episodes of binge eating- No regular use of appropriate compensatory behaviors
2. NIGHT EATING SYNDROME (NES)- Characterized by morning anorexia- Evening hyperphagia (Consuming 50% of daily calories after last evening meal)- Nightime awakenings (at least once a night)
3. COMORBID PSYCHIATRIC DISORDERS COMMON IN CLIENTS WITH EATING DISORDER
X. PERSONALITY DISORDERS
Cluster A
SCHIZOID Avoids people, Do not care about people & believes he can stand on his ownDetachment from social relationships Avoids activities & group more concerned with thingsNo enjoyment: Limited range of emotional expression in interpersonal settings
PARANOID Suspicious
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NURSING CONSIDERATIONSBulimic induces vomiting & tends to abuse laxatives
Assess for:Dental caries
Wounded knucklesVomiting - Risk for metabolic alkalosisDiarrhea – risk for metabolic acidosis
NURSING ALERT Most fatal complication: ARRHYTHMIAS
Violent
SCHIZOTYPAL Acute discomfort in relationshipsEccentric behavior
Cluster BANTISOCIAL Breaks the law
Usually charming, wittyAs kids, were usually cruel to animals, steals, lieAs Adults, drug addicts-drives fast-unsafe sex-thrill seekerAre slick talkers
BORDERLINE Loves to split groupsLikes to keep sparesAfraid of being aloneManipulativeSelf-mutilationSuperficial Relationships
NARCISSISTIC “I love myself”Insensitive, ArrogantSelf-absorbedExaggerated
Cluster C
AVOIDANT Avoid people & groupsFears criticism, ↓ Self-esteemHave a talent but no confidence
DEPENDENT “Can’t live without you”↓ Self-EsteemPoor decision-making skills
OBSESSIVE-COMPULSIVE OrganizedConstancy in EnvironmentPerfectionists------Provide time to do rituals
OTHER CATEGORIES:
PASSIVE-AGGRESSIVE Always says “yes” but resistance is hiddenDEPRESSIVE Pattern of depressive cognitions & behaviors in a variety of context
NURSING INTERVENTION TO ALL: Improve Interpersonal RelationshipsBuild Trust
XI. SCHIZOPHRENIA
EGO Disintegration Impaired Reality Perception
Famous example: John Forbes Nash, Jr.
THEORIES OF CAUSATION:> Stress Diathesis Model - Stressful living pushes person to escape into fantasy
“Far better to be king in your fantasy world” idea> Genetic Vulnerability - Runs in families; genetic component (biological)> Unknown> Physiological Finding: ↑Dopamine in schizophrenic clients
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“My life is an empty glass”
(+)fill
friends
( - )suicidal
SplittingLabile affect
(sudden change of mood)
Physiology: “ON” switch “OFF” switch
OTHER SIDE EFFECTS OF ANTIPSYCHOTIC MEDICATIONS:
PhotosensitivityTeach patient to use sunscreen, wide-brimmed hat when going out
Agranulocytosis (↑ monocytes, ↑ lymphatic)Teach client to report SORE THROAT (1st sign of Blood Dyscrasia)
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↓Dopamine↓ACH
↑Dopamine
ACH D
ACH
D
↑ACH↑ACHD
ACHParkinson’s Schizophrenia
↓Dopamine
D
ACH
Antipsychotic agents → ↓DopamineClient manifest Parkinson-like symptoms known as
EXTRA PYRAMIDAL SIDE EFFECTS (Voluntary mov’t of the skeletal muscles) (↓D & ↑ACH)
A kathisia (restlessness, inability to stay still)* Most common A kinesia ( muscle rigidity) D ystonia ----earliest sign (1-5 days)
N.I.1. Develop Trust: Orientation2. One-to-one interaction3. Short but frequent visits4. Foods in sealed container Meals wrapped5. Consistent Approach
Scared/Withdrawn/Violent
N.I. 1. Keep door open 2. Don’t touch patient
3. Establish Eye contact4. Maintain 1 arm distance5. Have visibility: stand halfway6. Stay near door not window7. Call for reinforcement 8. Calm & Firm
RESIDUAL No more (+) or (-) Sx Social Withdrawal Withdrawn
UNCLASSIFIED or UNDIFFERENTIATED Mixed
classifications Cannot be
classified anymore
P
DA
NEOLOGISM Newly created words--------* NURSE can use CLARIFICATION
DELUSIONS Fixed, false beliefs
Persecutory “The FBI is after me” Grandeur “I am queen of the world” Ideas of Reference “They are talking about me.”
CONCRETE THINKING Inability to conceptualize the meaning of words & phrases* Test by asking client to tell the meaning of a proverb
ilosopo roverb
HALLUCINATIONS False sensory perceptions; without stimulus(-) for visual, auditory, tactile
ILLUSIONS Misinterpretations of real external stimuli(+) for stimuli, visual, tactile, auditory
MAGICAL THINKING Believes that he has magical power
MANAGEMENT TECHNIQUE
ALLUCINATIONS
CKNOWLEDGMENT“I know the voices are real to you…”
EALITY ORIENTATION----------Present reality“But I don’t hear them.”
IVERSION“Let’s go to the garden.”
IRECTIVE
XII. ALZHEIMER
nomia Don’t know name of objectgnosia Problem with senses (smell, taste , hear, touch)
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HAR
Auditory hallucinations are common. IMPORTANT: Also ask what the voices
are saying because 10% of schizophrenic clients are suicidal.
D
phasia Can’t say itpraxia Can’t do it
issociative Fugue Takes a new personality from a far away place. New Place, New Identity
issociative Identity Disorder Multiple Personality issociative Amnesia Don’t know who/where I am epersonalization Believe that they are not persons anymore+ Perseveration “I want to talk about something, this is what I want to do…."
Mngt: ECT Therapy
XIII. DISORDERS OF THE CHILD
1. AUTISM Trapped in own world/ live in a fantasy world
Unresponsive to people Echolalia Poor eye contact Cannot express feelings verbally----root of self-directed violence/self-mutilation Boys > Girls
Autistic-savant (gifted) - about 1% of all autistics
Cannot focus on anything Can progress to Conduct Disorder----to---Antisocial Behavior---Future
Criminal ID dominant: Mother & RN will act as SUPEREGO
ID dominant may grow up to be ANTISOCIALResidual ADHD may not be antisocial
Onset: 7 years old & belowDuration: 6 months & aboveSettings: Must appear in 2 (home & school)
ASSESSMENT:
APPEARANCE Usually dirty
BEHAVIOR ClumsyHyperactive
Impatient, Easily Distracted
COMMUNICATION Talkative, Blurts out in class
Nx Dx: Risk for InjuryImpaired Social Interaction
PLANNING/ IMPLEMENTATION
MILIEU THERAPY
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S
B
Tructure ----Provide place to study,eat,play,bathChedule ----Time for everythinget limitsafety
EVALUATION: Minimize risk for injuryImproved social interactionSafety
3. MENTAL RETARDATION
Levels Of Mental Retardation:
Profound Severe Moderate Mild Borderline Normal IQ 20 35 50 70 90 110
Profound: <20 Thinks like an INFANT---Cannot be trained-----Stay with the Client
Severe: 20-35
Moderate: 35-50 Can be trained. Mental age is 2-7 y/o------------Pre-operational Stage
Mild: 50-70 Can go to school. Mental age is 7-12 y/o
XIV. CHILD ABUSE
Burns Bruises Bone Fractures (Bungi) Body of Evidence should not be lost ( Don’t bathe child, Don’t brush teeth) BANTAY BATA 163
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Medical Mgt: RITALIN
↓ Glucose ↑ Glucose
↓ Frontal lobe ↑ Frontal lobe
↓ judgment ↑ judgment
S/Sx of ADHD
Ritalin ( a stimulant) Given after meals to prevent loss of appetite Last dose given 6˚ hs Don’t give at bedtime ---- will cause insomnia
Compensation: S/Sx: flamboyant, heavy make-up, loud voice
XV. MOOD DISORDERS
A. BIPOLAR 2 poles------ Happy (dominant) & Sad Too self-actualize
BIPOLAR I MANIC TYPE * Mania is not a Dx but an episode BIPOLAR II MANIC-DEPRESSIVE TYPE of bipolar disorder
BIPOLAR I USUAL PROFILE: Female Usually 20 years old & above Under stress Obese
DRUG OF CHOICE: Lithium ( for mania) ↓ NE ------Takes 2-4 weeks to work
ASSESSMENT: Use Maslow’s Hierarchy of Needs
3 Or More Signs Confirms Disorder:
G grandiose, ↑ risk activities
F flight of ideas
S sleeplessness
P pressured speech
E exaggerated SE
E extraneous stimuli (easily distracted)
D distractibility
MANAGEMENT:
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↓ Self -Actualized
Impaired Social Interaction
Risk For Injury/ Other-Directed Violence
↓ Eat ↓ Sleep Hyperactive ↑ Sex
Manifested by Defensiveness & Compensation↑Self Esteem by giving TASK
Caregiver Role: Train / Safety
Impulsive so ensure safetyLock doors & windowsPlace in room with low stimulusNot with other manics or depressives
Manic clients usually masturbate because of worrying
“Tell pt. it is not allowed”
↓ Self -esteem
iidneysK
N ausea, vomiting, diarrheaa ( ↑ sodium intake to correct FVD) (Na: 135-145 mEq/L)
iidneys
Finger foods Private room ↓ anxiety
What are appropriate tasks? No competition or group games, sports e.g. basketball-------------↑ Anxiety Gross motor skills e.g. watering plants, sweeping the floor to put energies to productive endeavors Avoid activities with fine motor skills e.g. sewing Escort outdoors Punching bag------“Displacement”B. MANIA
Needs a mood stabilizing agents------ LITHIUM & GROUP THERAPY
↑ NE
LITHIUM - drug of choice
3 Signs of Lithium Toxicity
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L
I
T
H
I
U
M
evel : 0.5 – 1.5 mEq/ dL
ncrease urination
remors, fine hand
ydration 3 l/day
ncrease “PUPU”
outh, dry *
* Lithium absorbs water
Check first before beginning therapy (BUN, Creatinine)
Only 90% absorb by kidneys
If level is near 2.5- 3 mEq/L Ataxia Mental Confusion
C. DEPRESSION ↓ Serotonin If unresponsive to drugs------- ECT Therapy
THE GRIEF PROCESS
Denial Anger Bargaining Depression
2 wks or more is a sign of MAJOR CLINICAL DEPRESSION Acceptance
ASSESSMENT
5
4
3
2
1
MANAGEMENT OF DEPRESSED PATIENT:
1. Give Antidepressants
2. If Drugs not working----Electroconvulsive Therapy (ECT)
Exclusions By Other Psychiatric Illness Other Exclusions
Somatization Disorder
History of many physical complaints; 4 pain sites or functions: 2 nonpain GI, 1 sexual or reproductive, 1 pseudoneurologic
Onset <30 y of age
Not specified Not explained by general medical condition or substance effect
Undifferentiated somatoform disorder
One or more physical complaints
Duration >6 mo Not accounted for by another mental disorder
Not explained by medical condition or pathophysiologic mechanism
Conversion Disorder
Symptoms affecting voluntary motor and/or sensory function suggesting neurologic and/or medical condition
Associated psychological factors
Not limited to pain or sexual dysfunction; not exclusively during course of somatization disorder; not better accounted for by other mental disorder
Not intentionally produced or feigned; not explained by other neurologic or medical condition, substance effect, or culturally sanctioned behavior and/or experience
Pain Disorder Pain is predominant focus; severe enough to warrant clinical attention
Psychological factors in important role
Not better accounted for by mood, anxiety, or psychotic disorder; does not meet criteria for dyspareunia
Not specified
Hypochondriasis Preoccupation with fear of having or idea that one has serious disease based on misinterpretation of bodily symptoms;
Duration >6 mo Not exclusively during obsessive compulsive disorder (OCD), generalized anxiety, panic disorder, major depressive episode,
Not of delusional intensity; not restricted to circumscribed concern about appearance
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DEPRESSION
↑ all
↓SerotoninMAOIsMNP
NO to Tyramineor else
HYPERTENSIVECRISIS
persistent fear and idea despite medical evaluation and reassurance
separation anxiety, or other somatoform disorder
Body Dysmorphic disorder
Preoccupation with imagined defect in appearance or excessive concern about slight physical anomaly
Not applicable Not better accounted for by other mental disorder
Not specified
Somatoform disorder, not otherwise specified
Somatoform symptoms Can be <6 mo duration
Does not meet criteria for any other somatoform disorder
Not specified
Note.—To qualify for this category of diagnoses, the symptoms must cause clinically significant distress or impairment in social, occupational, or other areas of functioning.