1. PSYCHIATRIC NURSING Presented by: Dave Jay Sibi. Manriquez, RN 2.

Introduction MENTAL HEALTH balance in a persons internal life and adaptation to reality Mental ILL Health state of imbalance characterized by a disturbance in a persons thoughts, feelings and behavior 3. Psychiatric nursing interpersonal process whereby the professional nurse practitioner ,through the therapeutic use of self (art) and nursing theories (science), assist clients to achieve psychosocial well being. Core : interpersonal process 4. Related Terms Mental hygiene measures to promote mental health , prevent mental illness and suffering and facilitate rehabilitation Main tool: therapeutic use of self It requires self-awareness Methods to increase self-awareness: Introspection Discussion Experience Role play 5. Assessment (psychosocial processes ) Appearance , behavior or mood Speech , thought content and thought process Sensorium Insight and judgment Family relationships and work habits Level of growth and development 6. Common Behavioral Signs and Symptoms 7. Disturbances in perception Illusion misinterpretation of an actual external stimuli Hallucinations false sensory perception in the absence of external stimuli PERCEPTION 8. PERCEPTION 9. PERCEPTION 10. PERCEPTION 11. PERCEPTION 12. Disturbances in thinking and speech neologism coining of words that people do not understand Circumstantiality over inclusion of inappropriate thoughts and details Word salad incoherent mixture of words and phrases with no logical sequence THINKING & SPEECH 13. Verbigeration meaningless repetition of words and phrases Perseveration persistence of a response to a previous question Echolalia pathological repetition of words of others Aphasia speech difficulty and disturbance Expressive , receptive or global THINKING & SPEECH

14. Flight of ideas- shifting of one topic from one subject to another in a somewhat related way Looseness of association-incoherent illogical flow of thoughts (unrelated way) Clang association sound of word gives direction to the flow of thought THINKING & SPEECH 15. Delusion persistent false belief, rigidly held Delusions of grandeur: special /important in a way Persecutory: threatened Ideas of reference: situation/events involve them Somatic: body reacting in a particular way THINKING & SPEECH 16. Jealous: thinking that their partner is unfaithful Erotomanic: person, usually of high status, is in love with the client Religious: illogical ideas about God and religion exhibited by extreme or extraneous behavior Mixed: combination of above without a predominant theme THINKING & SPEECH 17. Magical thinking primitive thought process thoughts alone can change events Autistic thinking regressive thought process; subjective interpretations not validated with objective reality Dereism unorganized thinking THINKING & SPEECH 18. Disturbances of affect Inappropriate disharmony between the stimuli and the emotional reaction Blunted affect severe reduction in emotional reaction Flat affect absence or near absence of emotional reaction Apathy dulled emotional tone AFFECT 19. Depersonalization feeling of strangeness from ones self Derealization feeling of strangeness towards environment Agnosia lack of sensory stimuli integration AFFECT 20. Disturbances in motor activity Echopraxia imitation of posture of others Waxy flexibility maintaining position for a long period of time Ataxia loss of balance Akathesia extreme restlessness MOTOR ACTIVITY 21. Dystonia- uncoordinated spastic movements of the body Tardive dyskinesia involuntary twitching or muscle movements Apraxia involuntary unpurposeful movements MOTOR ACTIVITY 22. Disturbances in memory Confabulation filling of memory gaps Dj vu something unfamiliar seems familiar Jamais vu- something familiar seems unfamiliar Amnesia memory loss (inability to recall past events) Retrogradedistant past Anterograde immediate past Anomia lack of memory of items MEMORY

23. Dynamics of Human Behavior Behavior the way an individual reacts to a certain stimulus Conflict situation arising from the presence of two opposing drives Need - organismic condition that requires a certain activity 24. Dynamics of Human Behavior Personality totality of emotional and behavioral traits that characterize the person in day to day living under ordinary conditions; it is relatively stable and predictable. 25. FORMATION OF PERSONALITY TEMPERAMENT biological-genetic template that interacts with our environment. a set of in-built dispositions we are born with mostly unalterable our nature. CHARACTER the outcome of the process of socialization, the acts and imprints of our environment and nurture on our psyche during the formative years (0-6 years and in adolescence). the set of all acquired characteristics we posses, often judged in a cultural-social context. Sometimes the interplay of all these factors results in an abnormal personality 26. THEORIES OF PERSONALITY DEVELOPMENT 27. Freuds PSYCHOSEXUAL THEORY 28. Libido inner drive Parts of body focus of gratification Unsuccessful resolution - fixation Structures of personality Id: pleasure principle-instinct Ego: controls action and perception reality principle Superego: moral behavior conscience 29. 0-18 m0s ;oral mouth trust and discriminating 18 mos. 3 years ; anal bowels holding on or letting go Negativism and toilet training age 3 -6 years phallic ; genitals exploration and discovery ( inc. sexual tension) Gender identification and genital awareness Oedipus and Electra complex Castration anxiety and penis envy 30. 6-12 years latency (quiet stage) sexual energy diverted to play. Institution of superego: control of instinctual impulses 12 young adult genital ; reawakening of sexual drives relationships Sexual maturation Sexual identity ,ability to love and work 31. Eric Ericksons PSYCHOSOCIAL THEORY 32. 0-12mos 1-3y 3-6 6-12 12-18 18-25 25-60 60 and above TRUST vs. MISTRUST AUTONOMY vs. SHAME & DOUBT INDUSTRY vs. INFERIORITY INITIATIVE vs. GUILT IDENTITY vs. IDENTITY CONFUSION INTIMACY vs. ISOLATION EGO INTEGRITY vs. STAGNATION GENERATIVITY vs. DESPAIR

33. INFANCY CONSISTENT MATERNAL CHILD INTERACTION TRUST INNER FEELING OF SELF WORTH HOPE 34. TODDLER ALLOW EXPLORATION PROVIDE FOR SAFETY NO, NO NEGATIVISM OFFER CHOICES / REVERSE PSYCHOLOGY TOILET TRAINING 18 MOS.-BOWEL DAYTIME BLADDER: 2 yo NIGHTIME BLADDER: 3 yo REWARD W/ PRAISE AND AFFECTION INDEPENDENCE 35. PRE-SCHOOL PROVIDE PLAY MATERIALS SATISFY CURIOSITY TEACH AND REINFORCE(HYGIENE,SOCIAL BEHAVIOR) SIBLING RIVALRY WILLPOWER 36. SCHOOL AGE HOW TO DO THINGS WELL-SUPPORT EFFORTS CHUMS AND HOBBIES NEEDS TO EXCEL/ACCOMPLISH NEED FOR PRIVACY AND PEER INTERACTION COMPETENCE 37. ADOLESCENCE MAKE DECISION,EMANCIPATION FROM PARENTS BODY IMAGE CHANGES NEED TO CONFORM BUT KEEP INDIVIDUALITY SELF - AWARENESS 38. YOUNG ADULT COMMITMENT AND FIDELITY RESPONSIBILITY ACHIEVEMENT OF INDEPENDENCE 39. MIDDLE ADULTHOOD SUPPORT-PERIOD OF ROLE TRANSITIONS MIDLIFE CRISIS ADJUSTMENT AND COMPROMISE MOST PRODUCTIVE AND CREATIVE ALTRUISM 40. LATE ADULTHOOD SELF ACCEPTANCE SELF WORTH WISDOM 41. Jean Piagets COGNITIVE THEORY 42. 0-2 SENSORIMOTOR REFLEXES IMITATIVE REPETITIVE BEHAVIOR SENSE OF OBJECT PERMANENCE AND SELF SEPARATE FROM ENVT. TRIAL AND ERROR RESULTS IN PROBLEM SOLVING 43. 2-7Y PRE-OPERATIONAL SELF-CENTERED,EGOCENTRIC CANNOT CONCEPTUALIZE OTHERS VIEW ANIMISTIC THINKING IMAGINARY PLAYMATE SYMBOLIC MENTAL REPRESENTATION CREATIVITY 2-4 PRE-CONCEPTUAL (PRE-LOGICAL) 4-7 INTUITIVE (UNDERSTANDING OF ROLES) 44. 7-12Y CONCRETE OPERATIONAL LOGICAL CONCRETE THOUGHT INDUCTIVE REASONING (SPECIFIC TO GENERAL) CAN RELATE, PROBLEM SOLVING ABILITY REASONING AND SELF-REGULATION

45. 12-ABOVE: FORMAL OPERATIONAL THOUGHT Abstract thinking Separation of fantasy and fact Reality oriented Deductive reasoning Apply scientific method 46. Havighursts DEVELOPMENTAL TASKS 47. Baby to early childhood Right from wrong and Conscience Late childhood Physical skills, wholesome attitude, social roles Conscience morality and values Fundamental skills in academics Personal independence 48. Adolescence Sexual social roles Relationships Independence and ideology Early adulthood Career Selecting a mate Finding Civic or social responsibility 49. Middle age Achieving Civic or social responsibility Adjusting to changes Satisfactory career performance Adjusting to aging parents Adjusting to parental roles Old age Adjusting to changes Establishing satisfactory living arrangements and affiliations 50. Kohlbergs MORAL DEVELOPMENT/ THINKING/ JUDGEMENT 51. PRE-CONVENTIONAL (0-6) PUNISHMENT AND OBEDIENCE OBEDIENCE TO RULES TO AVOID PUNISHMENT CONVENTIONAL ( 6-12 ) MUTUAL INTERPERSONAL EXPECTATIONS,RELATIONSHIPS AND CONFORMITY SOCIAL SYSTEM AND CONSCIENCE MAINTENANCE BEING GOOD IS IMPORTANT SELF RESPECT OR CONSCIENCE 52. POST CONVENTIONAL (12 18 Y) PRIOR RIGHT OR SOCIAL CONTRACT UNIVERSAL ETHICAL PRINCIPLE ABIDE FOR COMMON GOOD RATIONAL PERSON-VALIDITY OF PRINCIPLES-AND BECOME COMMITTED TO THEM INNER CONTROL OF BEHAVIOR UNDERSTANDING THE EQUALITY OF HUMAN RIGHTS AND DIGNITY OF HUMAN BEINGS AS INDIVIDUALS 53. Harry Stack Sullivans INTERPERSONAL THEORY 54. INFANCY NEED FOR SECURITY-INFANT LEARNS TO RELY ON OTHERS TO GRATIFY NEEDS AND SATISFY WISHES, DEVELOPS A SENSE OF BASIC TRUST, SECURITY AND SELF WORTH WHEN THIS OCCURS 55. TODDLERHOOD / EARLY CHILDHOOD CHILD LEARNS TO COMMUNICATE NEEDS THROUGH USE OF WORDS AND ACCEPTANCE OF DELAYED GRATIFICATION AND INTERFERENCE OF WISH FULFILLMENT

56. PRE-SCHOOL DEVELOPMENT OF BODY IMAGE AND SELFPERCEPTION ORGANIZES AND USES EXPERIENCES IN TERMS OF APPROVAL AND DISAPPROVAL RECEIVED BEGINS USING SELCTIVE INATTENTION AND DISASSOCIATES THOSE EXPERIENCES THAT CAUSE PHYSICAL OR EMOTIONAL DISCOMFORT AND PAIN 57. SCHOOL AGE THE PERIOD OF LEARNING TO FORM SATISFYING RELATIONSHIPS WITH PEERS-USES COMPETITION,COMPROMISE AND COOPERATION THE PRE-ADOLESCENT LEARNS TO RELATE TO PEERS OF THE SAME SEX 58. ADOLESCENCE LEARNS INDEPENDENCE AND HOW TO ESTABLISH SATISFACTORY RELATIONSHIPS WITH MEMBERS OF THE OPPOSITE SEX 59. YOUNG ADULTHOOD BECOMES ECONOMICALLY, INTELLECTUALLY AND EMOTIONALLY SELF SUFICIENT 60. LATER ADULTHOOD LEARNS TO BE INTERDEPENDENT AND ASSUMES RESPONSIBILITY FOR OTHERS 61. SENESCENCE DEVELOPS AN ACCEPTANCE OF RESPONSIBILITY FOR WHAT LIFE IS AND WAS AND OF ITS PLACE IN THE FLOW OF HISTORY 62. TREATMENT MODALITIES 63. REMOTIVATION THERAPY TREATMENT MODALITY THAT PROMOTES EXPRESSION OF FEELINGS THROUGH INTERACTION FACILITATED BY DISCUSSION OF NEUTRAL TOPICS STEPS : climate of acceptance creating bridge to reality sharing the world we live in appreciation of works of the world climate of appreciation 64. MUSIC THERAPY Involves use of music to facilitate expression of feelings, relaxation and outlet of tension 65. PLAY THERAPY enables patient to experience intense emotion in a safe environment with the use of play children express themselves more easily in play. revealing as reflection of childs situation in the family provide toys and materials facilitate interaction observe and help child resolve problems through play 66. Group therapy Treatment modality involving three or more patients with a therapist to relieve emotional difficulties, increase self esteem, develop insight ,

LEARN NEW ADAPTIVE WAYS TO COPE WITH STRESS and improve behavior with others IDEAL 8 10 MEMBERS

67. MILIEU THERAPY Consists of treatment by means of controlled modification of the patients environment to facilitate positive behavioral change Increase patients Awareness of feelings Sense of responsibility and Help return to community clients plan social and group interaction token programs , open wards and self medication are done 68. FAMILY THERAPY A METHOD OF PSYCHOTHERAPY WHICH FOCUSES ON THE TOTAL FAMILY AS AN INTERACTIONAL SYSTEM PROBLEM IS A FAMILY PROBLEM focus on sick members behavior as source of trouble / symptom serve a function for the family members develop sense of identity points out function of the sick member for the rest of the family 69. PSYCHOANALYTIC focuses on the exploration of the unconscious, to facilitate identification of the patients defenses ANXIETY RESULTS BETWEEN CONFLICTS OF ID AND EGO Becomes aware of unconscious thoughts and feelings to understand anxiety and defenses 70. HYPNOTHERAPY Various methods and techniques to induce a trance state where patient becomes submissive to instructions 71. BEHAVIOR MODIFICATION Application of learning principles in order to change maladaptive behavior Believes that psychological problems are a result of learning Everything learned can be unlearned 72. BEHAVIOR MODIFICATION OPERANT CONDITIONING Use of rewards to reinforce positive behavior Perceived and self-reinforcement becomes more important than external reinforcement DESENSITIZATION Slow adjustment or exposure to feared objects (phobias) Periodic exposure until undesirable behavior disappears or lessens 73. AVERSION THERAPY An example of behavior modification Painful stimulus is introduced to bring about an avoidance of another stimulus End view: behavioral change 74. HUMOR THERAPY To facilitate expression and enhance interaction ACTIVITY THERAPY Group interaction while working on a task together OTHER THERAPIES

75. BIOLOGICAL/ MEDICAL THEORY EMOTIONAL PROBLEM IS AN ILLNESS cause may be inherited or chemical in origin FOCUS OF TREATMENT IS MEDICATIONS AND ECT 76. BIOLOGICAL THERAPY ELECTROCONVULSIVE THERAPY Artificial induction of a grand mal seizure by passing a controlled electrical current through electrodes applied to one or both temples mechanism of action unclear voltage: 70 150 volts Duration: 0.5 2.0 seconds 6 to 12 treatments intervals of 48 hours indicators of effectiveness occurrence of generalized tonic clonic seizures 77. indications depression , mania and catatonic schizophrenia s/e: confusion, disorientation, short -term memory loss, seizure (30-60 sec) NPO prior Contraindications Fever, pregnancy Inc ICP, fracture retinal detachment TB with hemoptysis cardiac d/o consent needed Reorient after, supportive care 78. medications given : Atropine sulfate: decrease secretions Succinylcholine (Anectine): promote muscle relaxation Methohexital Sodium ( Brevital ): serves as an anesthetic agent common complications: loss of memory headache apnea fracture respiratory depression 79. Psychopharmacologic Therapy 80. Benzodiazepines Indications Anxiety Sedation/sleep Muscle spasm Seizure disorder Alcohol withdrawal syndromes Benzodiazepines 81. Anti-anxiety drugs Generic Trade name Alprazolam Xanax Chlordiazepoxide Librium Clorazepate Tranxene Diazepam Valium Lorazepam Ativan Oxazepam Serax Busipirone BuSpar Benzodiazepines 82. Side effects Drowsiness/ sedation Ataxia Feelings of detachment Increase irritability and hostility Anterograde amnesia Increased appetite & weight gain Nausea Headache, confusion Benzodiazepines 83. Anti-depressants Indications Depression Bipolar depression Panic disorder Bulimia Obsessive-compulsive d/o Possibly Attention deficit/Hyperactivity d/o Post Traumatic Stress D/o Conduct d/o Anti-depressants 84. Tricyclic (TCA) Generic Trade name Amitriptyline Elavil Imipramine Tofranil Trimipramine Surmontil Nortriptyline Pamelor Trazodone Desyrel Bupropion Wellbutrin Anti-depressants

85. Side effects Orthostatic hypertension Anticholinergic effect Dry mouth, blurred vision, constipation, excessive sweating, urinary hesitancy/ retention, tachycardia, agitation, delirium, exacerbation of glaucoma Neurologic effects sedation, psychomotor slowing, poor concentration, fatigue, ataxia, tremors Decrease libido and sexual performance Anti-depressants 86. Monoamine Oxidase inhibitors Generic Trade name Isocarboxazid Marplan Phenelzine Nardil Tranylcypromine Parnate Anti-depressants 87. Side effects Postural lightheadedness Constipation Delay ejaculation or orgasm Muscle twitching Drowsiness Dry mouth Anti-depressants 88. Dietary restrictions Cheese, esp. aged and matured Fermented or aged protein Pickled or smoked fish Beer, red wine, sherry; liquor & cognac Yeast Fava or broad beans Beef or chicken liver Spoiled/ overripe fruits; banana peel yogurt Tyramine Hypertensive Crisis Anti-depressants 89. Hypertensive Crisis Signs Sudden elevation of BP Explosive headache, occipital may radiate frontally Head & face flushed Palpitations, chest pain Sweating, fever Nausea, vomiting Dilated pupils, photophobia Intracranial bleeding Anti-depressants 90. Treatment Hold next MAO dose Dont let pt. lie down IM chlorpromazine 100 mg Fever: manage by external cooling techniques Anti-depressants 91. Serotonin Reuptake Inhibitors Generic Trade name Fluoxetine Prozac Sertraline Zoloft Paroxetine Paxil Venlafaxine Effexor Anti-depressants 92. Side effects Nausea Diarrhea Insomnia Dry mouth Nervousness Headache Male sexual dysfunction Drowsiness Dizziness Sweating Anti-depressants 93. Mood stabilizing drugs Indications Acute mania Bipolar prophylaxis Possibly Bulimia Alcohol abuse Aggressive behavior schizoaffective Mood stabilizing 94. Mode of action Normalizes the reuptake of certain neurotransmitters such as serotonin, norepinephrine, acetylcholine and dopamine Reduces the release of norepinephrine thru competition with calcium Effects intracellularly Lag period: 710 to 14 days Mood stabilizing 95. Lithium carbonate Trade names Eskalith Lithotabs Lithane Lithonate MOA: unclear; interfere with metabolism of neurotransmitters; alter Na transport in nerves and muscle cells Prelithium workup Urinalysis (BUN and creatinine) ECG,

FBC, CBC Mood stabilizing Preparation: tab, cap, liq & SR form Dose: 900 to 3600 mg/day

96. Side effects Early Nausea and diarrhea Anorexia Fine hand tremor (propranolol) Thirst, Polydipsia (dec. crea, inc. albumin) Metallic taste Fatigue Lethargy Late Weight gain acne Mood stabilizing 97. Contraindications Brain damage/ CV disease Epilepsy Elderly/ debilitated Thyroid and renal disease Severe dehydration Pregnancy (1 st trimester) Can augment the effects of anti-depressants Mood stabilizing 98. Nursing considerations Therapeutic serum level: 0.5 1.2 meq/L Maintenance level: 0.6 -1.2 meq/L Toxic Mild to moderate: 1.5 to 2 meq/L Moderate to severe: 2 2.5 meq/L Needs dialysis: 3 meq and above Early signs of toxicity Lethargy, mild nausea, vomiting, fine hand tremors, anorexia, polyuria, polydipsia, metallic taste, fatigue Late signs of toxicity Ataxia, giddiness, tinnitus, blurred vision, polyuria Mood stabilizing 99. Nursing considerations Lithium levels should be checked q 2-3 mos Serum drawn in the AM, 12H after last dose Common causes of inc. levels Dec. Na intake Diuretic therapy Dec. renal functioning F&E loss Medical illness Overdose NSAIDS Mood stabilizing 100. Nursing considerations Diet: adequate Na+ and fluid 3g NaCl/ day 6-8 glasses of H2O No caffeine No driving: wait for clinical effect Mood stabilizing 101. Management Moderately severe toxicity Osmotic diuresis: urea/ mannitol Aminophylline & PLR IV Adequate NaCl Peritoneal/ hemodialysis Severe toxicity Assess hx quickly Hold next lithium dose Check BP, rectal T, RR, LOC, support O2 Obtain labs ECG Emetic, NGT lavage Hydrate: 5-6L/day c PLR; FBC-CDU Mood stabilizing 102. Other drugs Carbamazepine (Tegretol) Side effects Dizziness Ataxia Clumsiness Sedation Dysarthria Diplopia Nausea & GI upset Preparation: liq, tab, chewable tab Mood stabilizing 800 to 1200 mg/day 103. Nursing considerations Assess drug levels q 3-4 days Monitor salt and fluid intake Avoid alcohol and non-prescription drugs Refer dec. in UO Dont stop abruptly C/I: pregnancy Take with meals Mood stabilizing 104. Other drugs Valproic acid (Depakote, Depakene) Side effects Nausea Hepatoxicity Neurotoxicity Hematological toxicity Pancreatitis Prep: tab, cap,

sprinkles MOA: inc. levels of GABA; inhibits the kindling process or snoball-like effect seen in mania & seizures Mood stabilizing

105. Nursing considerations Therapeutic level: 50 100 ug/mL Dose: 1, 000 1,500 mg/day Monitor serum levels 12H after last dose Toxic effects Severe diarrhea, vomiting, drowsiness, mm. weakness, lack of coordination Renal failure, coma, death Mood stabilizing 106. Anti-psychotic drugs Indications Psychotic symptoms of schizophrenia, acute mania and depression Gilles de Tourette disorder Treatment-resistant bipolar disorder Huntingtons disease and other movement disorder Possibly Paranoid Childhood psychoses Anti-psychotic 107. MOA: block receptors of dopamine (D2, D3, D4) If unresponsive after 6 weeks of therapy, another class is tried General considerations Calms without producing impairment of sleep High therapeutic index Non addicting, no tolerance Avoided in pregnancy Anti-psychotic 108. TYPICAL: High Potency Fluphenazine (Prolixin) Haloperidol (Haldol) Thiothexene (Navane) Trifluoperazine (Stelazine) Anti-psychotic 109. Moderate Potency Loxapine (Loxitane) Molindone (Moban) Perphenazine (Trilafon) Anti-psychotic 110. Low Potency Chlopromazine (Thorazine) Chlorprothixene (Taractan) Mesoridazine (Serentil) Thioridazine (Mellaril) Anti-psychotic 111. ATYPICAL Clozapine (Clozaril) Resperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) Sertindole (Serlect) Ziprasidone (Zeldox) Antipsychotic 112. Contraindications CNS depression: brain damage, excess alcohol/ narcotics Parkinsons disease Allergy Blood dyscrasias Acute narrow angle glaucoma BPH Anti-psychotic 113. Hypotension Sedation Dermal and ocular syndrome Neuroleptic malignant syndrome Anticholinergic syndrome Movement syndrome (Extrapyramidal Syndrome) Atropine psychosis Agranulocytosis Seizures Side effects New! Antipsychotic 114. Neuroleptic Malignant Syndrome A potentially fatal, idiosyncratic reaction to an antipsychotic drug 10-20% mortality rate Sx: rigidity, high fever, autonomic instability (BP, diaphoresis, pallor, delirium, elev. CPK), confused or mute,

fluctuate from agitation to stupor Occurs in the first 2 weeks of therapy Risk: high dose of high-potency drugs; dehydration, poor nx, concurrent med illness Antipsychotic TTT: dantrolene (Dantrium), Bromocriptine (Parlodel)

115. Movement Syndromes Akathisia Dystonia Tardive dyskinesia Bradykinesia Parkinsonism Anti-psychotic 116. Other s/e Atropine psychosis (geriatrics) Hyperactivity, agitation, confusion, flushed skin, sluggish reactive pupils TTT: IM physostigmine Agranulocytosis (Clozapine) Occurs 3-8 wks after Medical emergency s/s: fever, malaise, sore throat, leukopenia TTT: d/c, reverse iso, antibiotics Seizures (Clozapine) Occurs in 5% of patients; TTT: D/c drug Anti-psychotic New! 117. Anticholinergics Benztropine (Cogentin) Trihexyphenidyl (Artane) Biperiden (Akineton) Procyclidine (Kemadrin) Not withdrawn abruptly Provide cool environment Anti-psychotic 118. ANTIPARKINSONIAN MEDICATIONS Adjunct to anti-psychotic agents to balance dopamine/ acetylcholine in the brain s/e: glaucoma, tachycardia, HPN, cardiac dx, asthma, duodenal ulcer A/e: blurred vision, photosensitivity, drowsiness, orthostatic hypotension, CHF, hallucinations 119. COMMON DRUGS: Trihexyphenidyl (Artane) benztropine (Cogentin) Biperiden (Cogentin) Selegiline (Eldepryl) Pergolide (Permax) ANTIHISTAMINE Diphenhydramine HCl (BENADRYL) DOPAMINE RELEASING AGENT Amantadine (SYMMETREL) 120. Nursing considerations Best taken after meals Avoid driving Check BP Alcohol increases sedative effects Avoid sudden position change Drug is not withdrawn abruptly 121. PSYCHIATRIC DISORDERS 122. ANXIETY DISORDERS PANIC DISORDERS SPECIFIC PHOBIA SOCIAL PHOBIA OCD PTSD ACUTE STRESS DISORDER GENERALIZED ANXIETY DISORDER ANXIETY DISORDERS 123. PANIC ATTACKS Discrete period of intense fear or discomfort in which at least 4 if the ff sx develop abruptly and peak within 10 mins: Palpitations, pounding heart, or accelerated HR Sweating Trembling or shaking Sensations of SOB and smothering Feeling of choking ANXIETY DISORDERS

124. Chest pain or discomfort Nausea or abd. Pain Feeling dizzy, unsteady, lightheaded or faint Derealization or depersonalization Fear of losing control or going crazy Fear of dying Paresthesias Chills or hot flashes ANXIETY DISORDERS 125. SPECIFIC-> PHOBIA SOCIAL Excessive and unreasonable cued by the presence or anticipation of a specific object or situation Defense mech commonly used include repression and displacement Fear of social performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others ANXIETY DISORDERS 126. OBSESSION COMPULSION Recurrent and persistent thoughts, impulses, or images are experienced during the disturbance as intrusive and inappropriate Cause anxiety or distress Px knows that these are just product of ones own mind. Px feels driven to perform repetitive behaviors or mental acts in response to obsession or according to the rules that one deems must be applied rigidly. Aimed at reducing anxiety ANXIETY DISORDERS 127. OBSESSION COMPULSION Fear of dirt & germs Fear of burglary or robbery Worries about discarding something important Concerns about contracting a serious illness Worries that things must be symmetrical or matching Excessive hand washing Repeated checking of door and window locks Counting and recounting of objects in everyday life Hoarding of objects Excessive straightening, ordering, or of arranging things Repeating words or prayers silently ANXIETY DISORDERS 128. POST TRAUMATIC STRESS SYNDROME Person has experienced, witnessed or been confronted with an event that involved actual or threatened death or serious injury, or a threat to physical integrity Person reexperiences these in the mind Involves intense fear, helplessness, or horror and numbing of general responsiveness (PSYCHIC NUMBING) ANXIETY DISORDERS 129. ACUTE GENERALIZED STRESS ANXIETY Meets the criteria for exposure to a traumatic event and person experiences 3 of the ff sx: sense of detachment, reduced awareness of ones surroundings, derealization, depersonalization, dissociated amnesia Excessive anxiety or worry, occurring in more days than not for at least 6 mos, about a number of events or activities Finds it difficult to control the worry ANXIETY DISORDERS 130. MOOD/ AFFECTIVE DISORDERS BIPOLAR D/O BIPOLAR I: current or past experience of manic episode, lasting at least a week, that is severe enough to cause extreme impairment in social or occupational functioning. MANIA: hyperactivity DEPRESSED: extreme sadness or withdrawal MIXED BIPOLAR II:

hx of 1 or more mj depressive episodes & at least 1 hypomanic episode; no mania MOOD DISORDERS

131. MAJOR DEPRESSIVE D/O @ least 5 sx of same 2- wk period with one being either depressed mood or loss of interest or pleasure. Single episode or recurrent Other sx: wt loss, insomnia, fatigue, recurrent thoughts of death, diminished ability to think, psychomotor agitation or retardation, feelings of worthlessness. MOOD DISORDERS 132. CYCLOTHYMIC D/O Hx of 2 yrs of hypomania with numerous periods of abnormally elevated, expansive or irritable moods. Does not meet the criteria of mania or depression. DYSTHYMIC D/O @ least 2 yrs of usually depressed mood and at least 1 of the sx of mj depression without meeting the criteria for it SEASONAL AFFECTIVE D/O Depression that comes with shortened daylight in fall and winter that disappears during spring and summer. MOOD DISORDERS 133. Dealing with Inappropriate Behaviors AGGRESSIVE BEHAVIOR Assist the client in identifying feelings of frustration and aggression Encourage the client to talk out instead of acting out feelings of frustration Assist the client in identifying precipitating events or situations that lead to aggressive behavior Describe the consequences of the behavior on self and others Assist in identifying previous coping mechanisms Assist the client in the problem-solving techniques to cope with frustration or aggression MOOD DISORDERS 134. DEESCALATION TECHNIQUES Maintain safety Maintain large personal space and use nonaggressive posture Use calm approach and communicate with a calm, clear tone of voice (be assertive not aggressive Determine what the client considers to be his or her need Avoid verbal struggles Provide clear options that deal with behavior Assist with problem-solving and decision making regarding the options MOOD DISORDERS 135. MANIPULATIVE BEHAVIORS Set clear, consistent, realistic, and enforceable limits and communicate expected behaviors Be clear about consequences associated with exceeding set limits Discuss behavior in nonjudgmental and nonthreatening manner Avoid power struggles Assist in developing means of setting limits on own behavior MOOD DISORDERS 136. SCHIZOPHRENIA characterized by impairments in the perception or expression of reality and by significant social or occupational dysfunction. Once considered as a deadly disease There is lack of insight in behavior Dx: late adolescence and early adulthood 15-25 y.o. (men); 25-35 y.o. (women) Obsolete term: dementia praecox = cognitive deterioration early in life Eugene Bleuler: schiz split; phren mind SCHIZOPHRENIA

137. Risk factors Genetics: identical twins 50%, 15% for fraternal twins Biochemical factors Dopamine hypothesis: overactive Serotonin imbalance Decreased brain volume, enlarged ventricles, deeper fissures, and loss or underdeveloped brain tissue Psychoanalytic lack of trust during the early stages Weak ego Defenses: REPRESSION, REGRESSION, PROJECTION Environment influences: poverty, lack of social support, hostile home environment, isolation, unsatisfactory housing, disruption in interpersonal relationships (divorce or death), job pressure or unemployment SCHIZOPHRENIA 138. Subtypes Catatonic type prominent psychomotor disturbances are evident. Symptoms can include catatonic stupor and waxy flexibility Disorganized type where thought disorder and flat affect are present together Paranoid type where delusions and hallucinations are present but thought disorder, disorganized behavior, and affective flattening are absent SCHIZOPHRENIA 139. Residual type where positive symptoms are present at a low intensity only Undifferentiated type psychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types has not been met SCHIZOPHRENIA 140. Symptoms According to Bleuler: 4 As Affect is inappropriate Associative looseness Autistic thinking Ambivalence SCHIZOPHRENIA 141. Positive symptoms delusions, auditory hallucinations and thought disorder and are typically regarded as manifestations of psychosis. Negative symptoms considered to be the loss or absence of normal traits or abilities E.G. flat, blunted or constricted affect and emotion, poverty of speech and lack of motivation. Symptoms SCHIZOPHRENIA 142. Symptoms S ocial isolation C atatonic behavior H allucinations I ncoherence (marked looseness of association) Z ero/ lack of interest, energy and initiative O bvious failure to attain expected level of devt P eculiar behavior H ygiene and grooming impaired R ecurrent illusions and unusual perception experiences E xacerbations and remissions are common N o organic factors accounts for the symptoms I nability to return to baseline functioning after relapse A ffect is inappropriate SCHIZOPHRENIA 143. Nsg Dx: Abnormal thought process BLOCKING: sudden cessation of a thought in the middle of a sentence, unable to continue the train of thought CIRCUMSTANTIALITY: before getting to the point of answering a question, the individual gets caught up in countless details and explanations CONFABULATION LOOSENESS OF ASSOCIATION NEOLOGISM WORD SALAD SCHIZOPHRENIA

144. Interventions Assess physical needs Set limits Maintain safety Initiate oneon-one interaction & progress to small groups Spend time with clients Monitor for altered thought process Maintain ego boundaries, avoid touching Limit time of interaction Be neutral Do not make promises that cant be kept SCHIZOPHRENIA 145. Establish daily routines Do not go along with the clients delusions or hallucinations Provide simple complete activities Reorient Speak to the client in simple direct and concise manner Set realistic goals Explain everything that is being done Decrease stimuli Monitor for suicide risk SCHIZOPHRENIA 146. Environment Provide safe environment Limit stimuli Psychological Ttt Behavior therapy Social skills training Self-monitoring Social ttt Milieu therapy Family therapy Group therapy (long-term ttt) SCHIZOPHRENIA 147. Related psychotic disorders SCHIZOAFFECTIVE DISORDER schiz + mood disorder (mania/ depression) BRIEF PSYCHOTIC DISORDER sudden onset of psychotic symptoms, lasts less than 2 mos and client returns to premorbid level of functioning SCHIZOPHRENIFORM DISORDER schiz sx lasting between 1 month and <6mos DELUSIONAL DISORDER characterized by prominent, nonbizarre delusions SCHIZOPHRENIA 148. PERSONALITY DISORDERS CLUSTER A (odd & eccentric) paranoid, schizoid, schizotypal CLUSTER B (bad, dramatic & erratic) antisocial, borderline, histrionic, narcissistic CLUSTER C (anxious & fearful) avoidant, dependent, OCD PERSONALITY D/O 149. CLUSTER A: ODD & ECCENTRIC PARANOID chronic hostility projected to others; suspicious and mistrusts people Seen mostly in men SCHIZOID social detachment = loner & introvert Restriction of emotions Attention fixed on objects rather than people Functions well in vocations SCHIZOTYPAL: interpersonal deficits Magical thinking, telepathy Apparent in childhood or adolescence PERSONALITY D/O 150. Interventions for PARANOID D/O Asses for suicide risk Avoid direct eye contact Establish trusting relationship Promote increased self-esteem Remain calm, nonthreatening and nonjudgmental Provide continuity of care Respond honestly to the client PERSONALITY D/O 151. Follow thru on commitments Provide a daily schedule of activities Gradually introduce client to groups Do not argue with delusions Use concrete, specific words PERSONALITY D/O

152. Do not be secretive with client Do not whisper in presence of client Assure that the client will be safe Provide opportunity to complete small tasks Monitor eating, drinking, sleeping and elimination patterns Limit physical contact Monitor for agitation and decrease stimuli as needed PERSONALITY D/O 153. CLUSTER B: ERRATIC, DRAMATIC, OR EMOTIONAL ANTISOCIAL Syn: sociopath, psychopathic & semantic d/o Etiology: Genetics interfere in the devt of positive interpersonal relationships Brain damage or trauma Low socioeconomic status Faulty family relationships: neglect Secondary gains 15-40 y.o. PERSONALITY D/O 154. Signs Lack of remorse or indifference to persons hurt Immediate gratification Failure to accept social norms Impulsivity Consistent irresponsibility Aggressive behavior Reckless behavior that disregards the safety of others 8090% of all crime is committed by antisocials (NIHM, 2000) ANTISOCIAL PERSONALITY D/O 155. BORDERLINE Latent, ambulatory and abortive schizophrenics Between moderate neurosis and frank psychosis but quite stable Theories faulty separation from mother; parent and child are bound by guilt Trauma at 18 mos (weakening of ego) Unfulfilled need for intimacy BORDERLINE PERSONALITY D/O 156. Signs instability Impulsivity: unpredictable gambling, shoplifting, sex & substance abuse hypersensitivity, self-destructive, profound mood shifts unstable & intense relations Disturbance in self concept Common in women Defenses: denial, projection, splitting, projective identification BORDERLINE PERSONALITY D/O 157. HISTRIONIC Pattern of theatrical or overtly dramatic behavior Signs Discomfort when the client isnt the center of attention Self-dramatization and exaggerated emotions uses physical appearance, sexually seductive and provocative behavior Excessively impressionistic speech lacking in detail (labile emotions) Problems in dependence & helplessness More frequent in women HISTRIONIC PERSONALITY D/O 158. NARCISSISTIC Exaggerated or grandiose sense of self-importance Develop early in childhood Preoccupied with fantasies of unlimited success, power and beauty Signs arrogance, need for admiration, lack of empathy, seductive, socially exploitative, manipulative Occurs more in men NARCISSISTIC PERSONALITY D/O

159. CLUSTER C: ANXIOUS OR FEARFUL AVOIDANT Sensitive to rejection, criticism, humiliation, disapproval, or shame Interferes with participation in occupational activities, devt of relationships, and take personal risks social inhibition, longs for relationships Anxiety, anger and depression are common Social phobia may occur Seen in 10% of clients in mental clinics AVOIDANT PERSONALITY D/O 160. DEPENDENT Lacks confidence and unable to function in an independent role Allows other persons to be responsible of their lives Most frequent personality disorder in the mental health clinic submissive behavior, low selfesteem, inadequate, helpless DEPENDENT PERSONALITY D/O 161. OBSESSIVE-COMPULSIVE Preoccupied with rules & regulations, overly concerned about trivial detail, excessively devoted to their work Depression is common Men are more affected than women O-C PERSONALITY D/O 162. UNDER STUDY PERSONALITY D/O PASSIVE-AGGRESSIVE: sullen and argumentative, resents others, resists fulfilling responsibilities, complains of being unappreciated DEPRESSIVE: gloomy, brooding pessimistic, guilt-prone, highly critical of self and others, cheerless. PERSONALITY D/O 163. Interventions Maintain safety against self-destructive behaviors Allow the client to make choices and be as independent as possible Encourage the client to discuss feelings rather than act them out Provide consistency in response to the clients acting out Discuss expectations and responsibilities with the client Inform the client that harm to self, others, and property is unacceptable PERSONALITY D/O 164. Identify splitting behavior Assist the client to deal directly with anger Develop a written contract with the client Encourage the client to participate in group activities, and praise nonmanipulative behavior Set and maintain limits Remove the client from group situations in which attention-seeking behaviors occur Provide realistic praise for positive behaviors in social situations PERSONALITY D/O 165. Hypoactive sexual disorder (asexuality) Sexual aversion disorder (avoidance of or lack of desire for sexual intercourse) Female sexual arousal d/o (failure of normal lubricating arousal response) Male erectile d/o Female orgasmic disorder Male orgasmic disorder Premature ejaculation PSYCHOLOGICAL SEXUAL D/O SEXUAL DISORDERS 166. Vaginismus Secondary sexual dysfxn Paraphilias Gender identity d/o PTSD due to genital mutilation or childhood sexual abuse Other sexual problems

Sexual dissatisfaction (non-specific) Lack of sexual desire anorgasmia Impotence STD SEXUAL DISORDERS

167. Infidelity Delay or absence of ejaculation, despite adequate stimulation Inability to control timing of ejaculation Inability to relax vaginal muscles enough to allow intercourse Inadequate vaginal lubrication preceding and during intercourse Burning pain on the vulva or in the vagina with contact to those areas SEXUAL DISORDERS 168. Unhappiness or confusion related to sexual orientation Persistent sexual arousal syndrome Sexual addict hypersexuality Post Ejaculatory Guilt Syndrome, the feeling of guilt after the male orgasm SEXUAL DISORDERS 169. SEXUAL EXPRESSION HETEROSEXUALITY HOMOSEXUALITY BISEXUALITY TRANSVESTISM SEXUAL DISORDERS 170. PARAPHILIAS EXHIBITIONISM: the recurrent urge or behavior to expose one's genitals to an unsuspecting person. FETISHISM: the use of non-sexual or nonliving objects or part of a person's body to gain sexual excitement. Partialism refers to fetishes specifically involving nonsexual parts of the body. FROTTEURISM: the recurrent urges or behavior of touching or rubbing against a nonconsenting person. SEXUAL DISORDERS 171. SEXUAL MASOCHISM: the recurrent urge or behavior of wanting to be humiliated, beaten, bound, or otherwise made to suffer. SEXUAL SADISM: the recurrent urge or behavior involving acts in which the pain or humiliation of the victim is sexually exciting. TRANSVESTIC FETISHISM: a sexual attraction towards the clothing of the opposite gender. SEXUAL DISORDERS 172. PEDOPHILIA: the sexual attraction to prepubescent or peripubescent children. VOYEURISM: the recurrent urge or behavior to observe an unsuspecting person who is naked, disrobing or engaging in sexual activities, or may not be sexual in nature at all. SEXUAL DISORDERS 173. Other paraphilias not otherwise specified (&quot;Sexual Disorder NOS&quot;) telephone scatalogia (obscene phone calls) necrophilia (corpses) partialism (exclusive focus on one part of the body) zoophilia(animals) coprophilia (feces) klismaphilia (enemas) urophilia (urine) SEXUAL DISORDERS 174. SOMATOFORM D/O SOMATIZATION D/O: hx of many physical complaints beginning before the age of 30 occurring over a pd of several yrs resulting in ttt being sought or significant occupational or social fxning. CONVERSION D/O: 1 or more sx of deficits affecting voluntary motor or sensory function suggesting a

neurological or general medical condition; preceded by conflicts or stressors; cant be explained and sanctioned by cultural behavior. Most common: blindness, deafness, paralysis, inability to talk La belle indifference

175. HYPOCHONDRIASIS: preoccupation with fears of having, or ideas that one has, a serious dse based on the persons misinterpretation of bodily sx and persist despite appropriate medical eval and reassurance and has existed for @ least 6 mos. (e.g.:extensive use of home remedies) PAIN D/O: pain in 1 or more anatomical sites severe enough to warrant clinical attention and causes clinically significant distress or impairment in fxning. 176. Interventions Do not reinforce the sick role Discourage verbalization about physical symptoms by not responding with positive reinforcement Explore with the client the needs being met by the physical symptoms Convey understanding that the physical symptoms are real to the client Report and assess any new physical complaint next 177. EATING DISORDER BEHAVIORS BINGE: rapid consumption of large quantities of food in a discrete period of time. (A: hundrends of Cal; B: thousands of Cal at a sitting) PURGE: Maladaptive eating regulation response that includes excessive exercise, forced vomiting, OCD Rx diuretics, diet pills, laxatives and steroids. FAST/ RESTRICT: Includes vegetarian diet eliminating all meat without substituting nonanimal sources of protein, OC about food choices, and eating habits. EATING DISORDERS 178. ANOREXIA BULIMIA Rare vomiting or diuretic/laxative abuse More severe wt loss Slightly younger More introverted Hunger denied Eating behavior may be considered normal and a source of esteem Sexually inactive Obsessional and perfectionist features dominate Frequent Less wt loss Slightly older More extroverted Hunger experienced Eating behavior considered foreign and source of distress More sexually active Avoidant, dependent, or borderline features as well as obsessional features EATING DISORDERS 179. ANOREXIA BULIMIA complications Death from starvation (or suicide, in chronically ill) Amenorrhea Fewer behavioral problems (these increase with level of severity) Death from hypokalemia or suicide Menses irregular or absent Drug and alcohol abuse, self-mutilation, and other behavioral problems EATING DISORDERS 180. DELIRIUM The medical dx term that describes an organic mental disorder characterized by a cluster of cognitive impairments with an acute onset with a specific precipitating factor. Sx: diminished awareness of the environment, disturbances in psychomotor activity and sleep-wake cycle. COGNITIVE: the

mental process characterized by knowing, thinking, and judging. COGNITIVE DISSONANCE: arises when 2 opposing beliefs exists at the same time. COGNITIVE DISTORTIONS: (+) or (-) distortions of reality that might include errors of logic, mistakes in reasoning, or individualized view of the world that do not reflect reality. Term: confusion = cognitive impairment See dementia COGNITIVE DISORDERS

181. DEMENTIA The medical dx term that describes an organic mental d/o characterized by a cluster of cognitive impairments of generally gradual onset and irreversible without identifiable precipitating stressors. Types: VASCULAR or MULTI-INFARCT VASCULAR WITH ALZHEIMERS DSE AD: most common DEMENTIA WITH LEWY BODIES: 2 nd most common; neurofilament material PARKINSONIAN DEMENTIA AIDS DEMENTIA COMPLEX COGNITIVE DISORDERS 182. FRONTAL LOBE DEMENTIA or PICKS DSE: cytoplasmic collections; 3 rd most common; loss of expressive language & comprehension CREUTZFELDTJAKOB DSE: prion ( proteinaceous infectious particles) = spongy brain; related to TSE & BSE in mad cow dse CORTICOBASAL DEGENERATION or HUNTINGTONS DSE/CHOREA: jerky movts SUPRANUCLEAR PALSY: clumping of protein tau = slow movt, weak eye movt (esp. downward), impaired walking &balance COGNITIVE DISORDERS 183. Reversible Causes: Subdural hematoma Tumor (meningioma) Cerebral vasculitis Hydrocephalus Terms: disorientation, memory loss (sensory, primary, secondary, tertiary, working memory), confabulation, confusion Disturbing behaviors Aggressive psychomotor Nonaggressive psychomotor Verbally aggressive Passive Functionally impaired: loss of ability to do self-care COGNITIVE DISORDERS 184. DELIRIUM vs. DEMENTIA Rapid onset w/ wide fluctuations Hyperalert to difficult to arouse LOC Fluctuating affect Disoriented, confused Attention & sleep disturbed Memory impaired Disordered reasoning Gradual, chronic with continuous decline Normal LOC Labile affect Disoriented, confused Attention intact, sleep usually normal Memory impaired Disordered reasoning & calculation COGNITIVE DISORDERS 185. DELIRIUM vs. DEMENTIA Incoherent, confused, delusional, stereotyped Illusions, hallucinations Poor judgment Insight may be present in lucid moment Poor but variable in MSE next Disorganized, rich in content, delusional, paranoid No change in perception Poor judgment No insight Consistently poor & progressively worsens in MSE COGNITIVE DISORDERS

186. ALZHEIMERS DEMENTIA Most common type of dementia Stages: MILD: impaired memory, insidious loses in ADL, subtle personality changes, socially normal MODERATE: obvious memory loss, overt ADL impairment, prominent behavioral difficulties, variable social skills, supervision needed SEVERE: fragmented memory, no recognition of familiar people, assistance needed with basic ADL, fewer troublesome behaviors, reduced mobility (4 As) COGNITIVE DISORDERS 187. Symptoms AGNOSIA: Difficulty recognizing well-known objects APHASIA: Difficulty in finding the right word APRAXIA: Inability or difficulty in performing a purposeful organized task or similar skilled activities AMNESIA: Significant memory impairment in the absence of clouded consciousness or other cognitive symptoms COGNITIVE DISORDERS 188. PSYCHIATRIC D/O IN CHILDREN MENTAL RETARDATION PERVASIVE DEVTAL D/O AUTISM RETTS D/O CHILDHOOD DISINTEGRATIVE D/O ASPERGERS D/O PDD NOS LEARNING D/O READING MATHEMATICS WRITTEN EXPRESSION ACADEMIC PROBLEM LEARNING D/O NOS CHILDHOOD DISORDERS 189. MOTOR SKILLS D/O COMMUNICATION D/O EXPRESSIVE LANGUAGE MIXED RECEPTIVE/EXPRESSIVE PHONOLOGICAL STUTTERING SELECTIVE MUTISM COMMUNICATION D/O NOS MOVT & TIC D/O DEVTAL COORDINATION TRANSIENT TIC CHILDHOOD DISORDERS 190. CHRONIC MOTOR&VOCAL TIC TOURETTES D/O STEREOTYPIC MOVT D/O TIC D/O NOS DISORDERS OF INTAKE & ELIMINATION PICA RUMINATION FEEDING D/O ENURESIS ENCOPRESIS OTHER: BULIMIA, ANOREXIA CHILDHOOD DISORDERS 191. ADHD & DISRUPTIVE BEHAVIOR D/O ADHD ADHD NOS CONDUCT D/O OPPOSITIONAL DEFIANT CHILD ANTISOCIAL DISRUPTIVE BEHAVIOR NOS MOOD D/O MJ DEPRESSIVE D/O BIPOLAR I OR II DYSTHYMIC MIXED EPISODE HYPOMANIC EPISODE MOOD D/O DUE TO MEDICAL CONDITION SUBSTANCE-INDUCED MOOD D/O CHILDHOOD DISORDERS 192. ANXIETY D/O D/O OF RELATIONSHIP SEPARATION ANXIETY REACTIVE ATTACHMENT OF INFANCY OR EARLY CHILDHOOD PARENTCHILD RELATIONAL PROBLEM SIBLING RELATIONAL PROBLEM PROBLEMS RELATED TO ABUSE OR NEGLECT CHILDHOOD DISORDERS 193. MENTAL RETARDATION an IQ below 70, significant limitations in two or more areas of adaptive behavior (i.e., ability to function at age level in an

ordinary environment), and evidence that the limitations became apparent in before 18 y.o. The following ranges, based on the Wechsler Adult Intelligence Scale (WAIS), are in standard use today: Class IQ Terms Profound Below 20 Idiot Severe 2034 Imbecile Moderate 3549 Moron Mild 5069 Borderline 70 79 CHILDHOOD DISORDERS

194. RETTS D/O Development is normal until 6-18 months, when language and motor milestones regress, purposeful hand use is lost Acquired deceleration in the rate of head growth (resulting in microcephaly in some) Hand stereotypes are typical and breathing irregularities such as hyperventilation, breath holding, or sighing are seen in many. Early on, autistic-like behavior may be seen Common in females CHILDHOOD DISORDERS 195. CHILDHOOD DISINTEGRATIVE D/O or HELLERS SYNDROME CDD has some similarity to autism, but an apparent period of fairly normal development is often noted before a regression in skills or a series of regressions in skills. characterized by late onset (>3 years of age) of devtal delays in language, social function and motor skills; skills apparently attained are lost CHILDHOOD DISORDERS 196. ASPERGERS D/O characterized by difference in language and communication skills, as well as repetitive or restrictive patterns of thought and behavior. Signs: unable to interpret or understand the desires or intentions of others and thereby are unable to predict what to expect of others or what others may expect of them Narrow interests or preoccupation with a subject to the exclusion of other activities Repetitive behaviors or rituals Peculiarities in speech and language Extensive logical/technical patterns of thought Socially and emotionally inappropriate behavior and interpersonal interaction Problems with nonverbal communication Clumsy and uncoordinated motor movts CHILDHOOD DISORDERS 197. CHRONIC MOTOR/ VOCAL TIC TIC is a sudden, repetitive, stereotyped, nonrhythmic, involuntary movement (motor tic) or sound (phonic tic) that involves discrete groups of muscles. can be invisible to the observer (e.g. abdominal tensing or toe crunching) CHILDHOOD DISORDERS 198. TOURETTES D/O characterized by the presence of multiple physical (motor) tics and at least one vocal (phonic) tic; these tics characteristically wax and wane TTT: Neuroleptic medications haloperidol (Haldol) pimozide (Orap) CHILDHOOD DISORDERS 199. ADHD Inattention: Failure to pay close attention to details or making careless mistakes when doing schoolwork or other activities Trouble keeping

attention focused during play or tasks Appearing not to listen when spoken to Failure to follow instructions or finish tasks Avoiding tasks that require a high amount of mental effort and organization, such as school projects Frequently losing items required to facilitate tasks or activities, such as school supplies Excessive distractibility Forgetfulness Procrastination, inability to begin an activity Difficulties with household activities (cleaning, paying bills, etc.) Difficulty falling asleep, may be due to too many thoughts at night Frequent emotional outbursts Easily frustrated Easily distracted Hyperactivity-impulsive behaviour Fidgeting with hands or feet or squirming in seat Leaving seat often, even when inappropriate Running or climbing at inappropriate times Difficulty in quiet play Frequently feeling restless Excessive speech Answering a question before the speaker has finished Failure to await one's turn Interrupting the activities of others at inappropriate times Impulsive spending, leading to financial difficulties CHILDHOOD DISORDERS

200. Frequently prescribed stimulants are methylphenidate (Ritalin and Concerta), amphetamines (Adderall) and dextroamphetamines (Dexedrine) Feingold diet which involves removing salicylates, artificial colors and flavors, and certain synthetic preservatives from children's diets. CHILDHOOD DISORDERS 201. CONDUCT D/O repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, AGGRESSION TO PEOPLE & ANIMALS DESTRUCTION OF PROPERTY DECEITFULNESS OR THEFT SERIOUS VIOLATIONS OF RULES Beginning before age 13 CHILDHOOD DISORDERS 202. OPPOSITIONAL DEFIANT characterized by an ongoing pattern of disobedient, hostile, and defiant behavior toward authority figures that goes beyond the bounds of normal childhood behavior Signs Losing temper Arguing with adults Refusing to follow the rules Deliberately annoying people Blaming others Easily annoyed Angry and resentful Spiteful or even revengeful next CHILDHOOD DISORDERS 203. SUBSTANCE ABUSE Excessive or unhealthy use of substances, such as alcohol, tobacco or drugs, or use of products such as food Terms: TOLERANCE: the declining effect of the same drug dose when it is taken repeatedly over time HABITUATION: a psychological dependence of the use of a drug ADDICTION: the biological and/ or psychological behaviors related to substance dependence WITHDRAWAL SYMPTOMS: result from a biological need that develops when the body becomes adapted to having an addictive drug in the system; occurs when serum levels decrease SUBSTANCE ABUSE

204. ADDICTION ALCOHOL: blood alcohol levels of 0.1% (100mg alcohol/dl of blood) or higher WITHDRAWAL Anorexia Anxiety Easily startled Hyperalertness HPN Insomnia Irritability Jerky movt Possibly: hallucinations, illusions or vivid nightmares Seizures (7-48 hrs after cessation) Tachycardia tremors SUBSTANCE ABUSE 205. WITHDRAWAL DELIRIUM Agitation Anorexia Anxiety Delirium Diaphoresis Disorientation with fluctuating levels of consciousness Fever (100 to 103 F) Hallucinations and delusions Insomnia Tachycardia and HPN Disulfiram (Antabuse) therapy SUBSTANCE ABUSE 206. Nursing care Obtain info about drug type and amount consumed Assess v/s Remove unnecssary obj from environment Provide one-on-one supervision if necessary Provide a quiet, calm environment with minimal stimuli Maintain orientation Ensure safety Use restraints Provide physical needs Provide food and fluids as tolerated Administer medications Collect blood and urine samples for drug screening SUBSTANCE ABUSE 207. SPOUSE ABUSE Battering precipitates 1:4 suicide attempts of all women Wives explain the injuries as being self-inflicted or accidental Phases Tensionbuilding: series of small incidents that leads to beating Acute beating phase: wife becomes object of assault behavior Loving phase: batterer is remorseful and assures spouse that he will not harm her again. This leads to reconciliation. ABUSE 208. Myths They believe that if they try not to antagonize with their husband, he will change. Efforts to coerce the wife out of the victim role can be fruitful. Facts Women stay in relationships with men who batter because they feel guilty or responsible of the husbands behavior Wife develops little sense of self-worth, immobilized and unable to remove self from the relationship. Assessment: injuries, other evidence Interventions: with consent ABUSE 209. CHILD ABUSE PHYSICAL BATTERING EMOTIONAL SEXUAL NEGLECT ABUSE 210. ELDERLY ABUSE A variety of behaviors that threaten the health, comfort, and possibly the lives of the elderly, including physical and emotional neglect, emotional abuse, violation of personal rights, financial abuse, and direct physical abuse. Commonly committed by care givers. ABUSE 211. SEXUAL ABUSE Components Sexual Misuse: inappropriate sexual activity Rape: there is actual penetration Incest: refers to the relationship between the

victim and abuser blood relative or step parent role Interventions Children: thru play or role playing with puppets Prevention of further sexual abuse next ABUSE

212. COMPLETED SUICIDE Self-inflicted death LEVELS OF SUICIDE Ideation: thought Attempt: acted upon but failed Completed SUICIDE 213. CHEMICAL RESTRAINT CHEMICAL RESTRAINTS: Medications used to restrict the patients freedom of movement or for emergency control of behavior but are not a standard treatment for the pxs medical or psychiatric condition. PHYSICAL RESTRAINTS: Are any manual method or physical or mechanical device attached to or adjacent to the pxs body that he or she cannot easily remove and that restricts freedom of movement or normal access to ones body, material or equipment. 214. SECLUTION AND RESTRAINTS SECLUTION: the involuntary confinement of a person alone in a room from which the person is physically prevented from leaving. No therapeutic evidence other than a last resort to ensure safety. Evidence suggest that it adds to further trauma and physical harm 215. GUIDELINES All hospital staff who have direct contact with the px should have ongoing education and training in the proper use of seclusion and restraints and other alternatives Physician or licensed practitioner should evaluate need within 1 hour after the initiation of this intervention. Max of 4 hours for adults, 2 hours for ages 9-17, and 1 hour for children under 9 yrs Orders may be renewed for 24 hrs before another face to face evaluation Continuous assessment, monitoring and evaluation; recorded Good nursing care For both restrained and secluded: constant monitoring face to face or by both audio and video equipment. Px should be released ASAP 216. OTHER GUIDELINES SECLUSION Room should allow observation and communication with px Remove all items that px might use to harm self Document: rationale, response to intervention, physical condition, nsg care, & rationale for termination RESTRAINTS Give support & reassurance Position in anatomical position Privacy is important v/s & Circulation check Should be released q 2hrs Avoid tying to the side rails of bed Assist in periodic change in body positions 217. TERMINATING THE INTERVENTION As soon as met the criteria for release Review with px the behavior that precipitated the intervention & pxs capacity to exercise control over behavior DEBRIEFING: reviewing the facts related to an event & processing the response to them; can be used after any stressful event next

218. THERAPEUTIC IMPASSES Are blocks in the progress of the nurse-pt relationship Provokes intense feelings in both the nurse and patient RESISTANCE TRANSFERENCE COUNTERTRANSFERENCE BOUNDARY VIOLATIONS 219. RESISTANCE Reluctance or avoidance of verbalizing or experiencing troubling aspects of oneself Eg: suppression or repression, intensification of sx, self-devaluation or hopelessness, intellectual inhibitions, acting out or irrational behavior, superficial talk, intellectual insight/ intellectualization, transference reactions. 220. TRANSFERENCE Unconscious response in which the px experiences feelings and attitudes toward the nurse that were originally associatated with other significant figures in his or her life. HOSTILE TRANSFERENCE: anger and hostility, resistance DEPENDENT TRANSFERENCE: submissive, subordinate and regards the nurse as a god-like figure; views relationship as magical 221. What do you do? LISTEN CLARIFY REFLECT EXPLORE/ ANALYZE 222. COUNTERTRANSFERENCE Created by the nurses specific emotional response to the qualities of the patient; inappropriate in the context, content and intensity of emotion; nurses identify the px with individuals from their past, and personal needs Types: Reactions of INTENSE love or caring Disgust or hostility Anxiety, often in response to resistance by the px 223. Eg. Difficulty empathizing Feelings of depression before or after the session Carelessness about implementing the contract Drowsiness during the sessions Encouragement of the pxs dependency Arguments with the px Personal or social involvement with the px Sexual or aggressive fantasies toward the px Tendency to focus on only one aspect or way of looking at information presented by the px Attempts to help the px with matters not related to the identified nursing problems Feelings of anger or impatience because of the pxs unwillingness to change Dreams about or preoccupation with the px