Psychiatric Nursing

PSYCHIATRIC NURSING

Beliefs—Feelings—Behavior

Sigmund Freud – Father of Psychoanalysis
-structure of personality

Id- impulsive part, pleasure principle
-eat, urinate, have sex
-it’s all “I”

Superego – small voice of God
-conscience
-should not eat yet, should not eat yet

Ego- arbiter, decision maker
-in touch with reality

Id___________________Superego
EGO

ID DOMINANT – needs a superego-needs a conscience
M- manic
A- antisocial – serial killer
N- narcissistic

SUPEREGO DOMINANT –needs an Id
O- Obsessive Compulsive
A- Anorexia nervosa

EGO – impaired reality perception (RN will present reality)
S- schizophrenia- cant distinguish fact from reality

Libido- sexual energy
FREUD - PSYCHOSEXUAL THEORY
ORAL – 0-18 months
Cry, suck – mouth- survival
Id dominant
Maternal deprivation if not feed, not given milk/water, not kept warm.

Narcissistic – seeks the Id – I love myself
Regression – return to an earlier stage or earlier level
Fixation – stopped in a stage

ANAL- 18 mos-3yrs
Toilet training
Mom is superego.
Superego is being formed
Child is caught in ambivalence – pulled in 2 opposing factors

Too much toilet training with punishment will result to a child who is:



Obedient, organized, clean Rebel, dirty, disobedient
= OC =Anti-social
=anal retentive =anal expulsive


PHALLIC – 3-6 yrs old
-penis & vagina
-love of parent of opposite sex
Oedipal-boy loves mom
Electra-girl loves dad

Identification- boy imitates dad
Castration fears- fear that dad is angry at him and will cut off penis
Penis envy- girls envy little boys

Dr. Karen Horney- detractor of Freud, didn’t believe in penis envy. Freud said that it is maybe in her unconscious mind.
Or repressed.

Conscious- highest level of awareness
Pre-conscious- at tip of tongue
Unconscious – forgotten

Repression-kept in unconscious. Unconscious forgotten.
Suppression – conscious forgetting

LATENT- 6-12 years old Latent- Logtu = sexual energy asleep
School age – School phobia- 1st time to go to school – Separation anxiety
Child is busy with Reading, writing, arithmetic.
Sublimation –putting anger into something more productive
putting all energies into schooling
Ex. Angry at life, pour anger in singing.

GENITAL –12 years old Genital-Gising sexual energy
Sexual intercourse most important in this stage!!

PHARMA MOMENTS
Anti-anxiety Drugs (used also for alcohol withdrawal)
Valium Librium Ativan Serax Tranxene
Miltown Equanil Vistaril Atarax Inderal Buspar

ERIK ERIKSON

STAGE (+) (-) FACTOR
0-18 months (Oral) Trust vs Mistrust Feeding
18 mos- 3yrs old (Anal) Autonomy vs
Au-(anal)
To-ilet training
No-No! Favorite word.
My Shame/doubt Toilet training
3-6 yrs old (Phallic) Initiative vs
(Initiate 1st steps)
Phallic-oedipal,electra Guilt –anger turned inward
Independence
6-12 yrs old (Latent) Industry vs Inferiority Industry
Induskul
12-20 (Genital) Identity vs Role confusion Peers
20-25 Intimacy vs Isolation Love
25-45 Generativity vs Stagnation Parenting
45 up Ego Integrity vs Despair Reflection

Newly admitted pt- develop trust 1st
-pts are dependent=self care deficit
-develop/teach autonomy
-then pt will develop initiative
-etc



Frontal lobe- personality, learning, judgment, language
Occipital- vision
Temporal- hearing, smell
Parietal-taste, touch

Sensory Integration Motor

Somatic nervous system- voluntary movements
Acetylcholine- responsible for voluntary movements
- on switch of movement

Autonomic nervous system- involuntary movements
-Sympathetic(Anti cholinergic) and parasympathetic (cholinergic)

SYMPATHETIC (alert) PARASYMPATHETIC (relax)
Heart tachycardia bradycardia
Respiratory tachypnea bradypnea
GI (opposite effect) Slow, constipation diarrhea
GU (opposite effect) Slow, oliguria, retention Polyuria, frequency
Dry mouth Moist mouth
Neurotransmitter Epinephrine, Norepinephrine Acetylcholine (AcH)
Pupils Dilated (dilat when alert) (Midriasis) Constricted (Myotic)
Blood vessels vasoconstriction vasodilated
BP increased decreased

Anti-cholinergic / anti-parasympathetic =effect is sympathetic!

Sympathetic drug classifications:
A- anxiety
P- psychotic
Anti C- cholinergic
D- depressants

MONO AMINE OXIDASE INHIBITORS:

mARplan
nARdil
pARnate
















DEFENSE MECHANISMS: coping mechanism from stress:

DISPLACEMENT- -------------Your boss shouts at you, you shout at your subordinate.
SUBLIMATION - ---------------putting anger into something more productive or +
putting all energies into schooling
Ex. Angry at life, pour anger in singing.
DENIAL- ----------------------“I am not” an alcoholic!
DISSOCIATION – --------------psychological flight from self. Amnesia. Ex. Rape, trauma
REGRESSION – ----------------RETURN to an earlier developmental stage
FIXATION – ---------------------stuck in a stage of development
REPRESSION – -----------------unconscious forgetting
SUPPRESSION – ---------------conscious forgetting. Avoidance. “I don’t want to talk about it. I don’t want to remember it.”
RATIONALIZATION – -------uses “because”. Has illogical reasoning. “I drink because I don’t want to waste the beer in the ref.”
REACTION FORMATION----plastic. Doing opposite of intention.
UNDOING- ----------------------show true feeling/color then feels guilty after.
IDENTIFICATION – -----------models a certain behavior from a certain role model.
PROJECTION – -----------------blame other people, pass load to others. Looks for a scapegoat. “Not me, but them.”
INTROJECTION – --------------assume another persons trait as your own. “Not just you, me too.” “Ako din, gusto ko yan.”
CONVERSION – repression. Anger turned inward to herself. Converted to physical symptoms.
Sensory-numbness. Motor-paralyzed, tremors.
COMPENSATION – -----------defects of the person, overachieve to cover a defective part.
SUBSTITUTION – -----------when you replace a difficult role with a more accessible one.
Ex.Wants to go to Disneyland but can’t afford it. Went to Enchanted Kingdom instead.


Defense mechanism: Affects/interferes with ADL
Harm to self or others

Behavior Model – Ivan Pavlov

Classical Conditioning -behavior learned-repeated (+)

BF Skinner – operant conditioning-reinforcement
Confront (-) behavior to make it extinct.

MASLOW’S HEIRARCHY OF NEEDS:

5. Self-actualization
4. Self-esteem
3. Love and belonging
2. Safety and security
1. Air, food, water, shelter, clothing, sex –Basic physiologic needs

LEVELS OF PREVENTION
PRIMARY SECONDARY TERTIARY
Healthy ill Relapse avoidance
Community teaching Crisis intervention Rehab centers
Community demographics Treatment and diagnosis Al anon

STAGES OF INTERACTION
ORIENTATION WORKING TERMINATION
Assessment Problem solving Evaluation
Establishment of trust Discussion Summarize
Tell patient about termination Patient is most cooperative Say goodbye
Set contract Grief-ANGER-focus of RN
Patient is resistant Pt might become violent/suicidal



ANTI-PARKINSON DRUGS (Capables) –used with anti-psychotics



Anti-cholinergic Dopaminergic ABC PLSE

C- Cogentin
A- Artane
P- Parlodel
A- Akineton
B- Benadryl
L- Larodopa
E- Eldepryl
S- Symmetrel

THERAPEUTIC COMMUNICATION NON- THERAPEUTIC
1. Offer self- “I’ll stay/sit with you.” “Don’t worry, be happy.”
2. Explores –use what, when, where, how Why? – Puts pt in defensive position.
3. Silence Change the subject.
4. Active listening-nodding, eye contact, leaning
forward-show active participation. “Everything’s going to be alright.” – giving
False reassurance.
5. Make observations. “You see/ I have observed/
I have noticed…” Ignore the patient.
6. Broad opening- “How are you?”
“You have combed your hair today.” Prejudicial. “Nice weather today.” –value based judgment.
7. Clarification-“What do you mean by
ploopplank?” Flattery – don’t use too much adjectives. “You have the most beautiful hair in the ward.”
8. Restating-“I don’t want to eat.” (Word per word repetition!) “You don’t want to eat?” Arguing with the patient
Don’t impose your opinion.
9. General leads- “And then/What else/Go on…”
10. Refocusing-“We were talking abt the exam…”
11. Focusing-“Tell me more abt this.”

ABG ANALYSIS
Ph & PCO2-Respiratory-opposite signs
Ph & HC02-Metabolic – same signs

Compensation: Ph is normal=Fully compensated.
C02 & HC03 –same signs = Partially compensated

ANXIETY
-vague sense of impending doom. Sympathetic activation.

Assessment: Level of anxiety

MILD-------------------sit restlessly, widened perceptual field, enhanced learning experience. “You seem anxious.”
MODERATE----------patient is pacing, selective inattention. Give PRN meds-Anti-anxiety drugs-valium…
SEVERE----------------patient can’t make decisions. “I don’t know what to do or say.” RN directs patient. “Sit down on the
chair.” – Directive.
PANIC- highest level of anxiety. Suicidal. Priority: safety. Stay with patient. Don’t touch pt. Sympathetic activation.
“I think I’m having a heart attack!”

Nrs Dx: -----------------Ineffective Individual Coping
P/I: Decrease anxiety, decrease stimuli
HT: relaxation technique
E: Effective Individual Coping

GENERALIZED ANXIETY DISORDER – 6 months excessive worrying. Patient knows what the problem is.
Cant sleep, concentrate, seat
Fatigue and palpitations

PANIC ATTACK – ------------------------------15-30 minutes, happens without warning. SNS activation.
-with or without agoraphobia -------------------- fear of open space
-social phobia –------------------------------------- fear of public

-provide safety
-Alkalosis-brown bag
-stay with patient
-be directive

POST TRAUMATIC STRESS DISORDER

Victims – rape, accident, war zone, disaster, trauma

1. Survivor
2. Flashback > 1 month
3. Memory – nightmares

MALINGERING------------------------------------- no organic basis (no tissue change)
-pretending to be sick, conscious
-decrease anxiety – for primary gain
-increase attention from RN– secondary gain

SOMATOFORM DISORDER –------------------unconscious, not pretending, no organic basis
- goes doctor hopping





Nervous system Minor discomfort BODY DYSMORPHIC DISORDER
CONVERSION -Feels like illness -illusion of structural defect
-loss of sensory/motor fx -HYPOCHONDRIASIS -S/sx not real
-s/sx real (biglang nabulag)

PSYCHOSOMATIC DISORDER (Psychophysiologic)– real illness, real s/sx, real pain, with organic basis (with change in tissue)
- stress ulcers, migraine, HPN

PHOBIA---------------------------------------------------------- irrational fear
Etiology – knowledge, experience

Immediate nsg intervention: Remove object of fear
(Increase stimuli=increase level of anxiety)
(Decrease stimuli=decrease anxiety)

Belief Feeling Behavior
Object will hurt patient Scared Avoidant=interferes with ADL

Gradual exposure to feared object- SYSTEMATIC DESENSYTHEZATION

Individual Therapy
1. Hypnosis – --------------relaxed state
2. Free association –------ ideas shared to psychoanalyst
3. Catharsis – --------------free to express feeling
4. Transterence- -----------patient feels something for psychoanalyst
5. Countertransterence –--RN feels something for patient



Green light-Go – Epi & Norepinephrine
Red light – Stop – G-gamma
A-amino
B-butyric
A- acid

Anxiety



Increase GABA Anti-cholinergic S/E
GI-constipation
GU-retention


Effect of GABA:
Drowsy, drink, don’t drive, orthostatic hypotension
Anti-anxiety drug


Withdrawal from drug – abrupt – REBOUND PHENOMENA – leads to seizures. 1 week effect.
Gradual withdrawal – tapered dose
Dependence- Can’t live without valium

ANTI-PSYCHOTIC AGENTS – Sympathetic effect.
Effect – 2-4 weeks

STELAZINE CLOZARIL
SERENTIL MELLARIL
THORAZINE HALDOL
TRILAFON PROLIXIN

SCHIZOPHRENIA-------------------------------impaired reality perception. Ego disintegration. Genetic vulnerability. Stress.
-Chose fantasy over reality. Increase dopamine theory. Cause: unknown.
Increase dopamine, increase schizophrenia.
4 A’s:
1. Affect---------------------------------------------feelings & emotions (smiles, laughs). External, readily observable.
Mood, internal, does not match affect. (sad inside)
2. Ambivalence-------------------------------------pulled between 2 opposing forces
3. Autism --------------------------------------------self absorbed. Trapped in his own world.Attached to odd objects.Poor eye contact.
4. Associative looseness---------------------------talk about so many things but unrelated ideas.

Disturbed thought process-------------------------Nsg dx

Content of thought---------------Hallucinations/Illusions------------ADL----------------------------Harm


Disturbed thought process
Disturbed sensory Self care deficit Self Other
Perception Directed Violence

P/I: Reality/Orient/Safety
Eval: Improved thought process
S & Sx of Schizophrenia:
(-)neg sx (+) positive sx
hypoactive hyperactive flight of ideas
withdrawn restless hallucinations
quiet, flat affect talkative delusions many ideas
poverty of words queen of the world illusions

Types of schizophrenia:

1. Disorganized schizo---------------------------------sad inside, happy outside – inappropriate affect (+)
flat affect – no affect (-)
disorganized manner/speech –flight of ideas (+)
Hebephrenic- giggling (+)
Sx: both (+) and (-).

2. Catatonic ---------------------------------------------ambivalence –anal stage (-)
No! Negativisim-rebel-anal (-)
Waxy flexibility--------------raise arm of patient. Patients arm remains up for a long time. (-)
(-) > (+)

3. Paranoid ----------------------------------------------uses projection.
Mistrust Scared/withdrawn/violent Based on history



Develop trust: orientation -Leave door open
-1:1 interaction -Distance from pt: 1 arms length
-consistent approach -stay near door not window
-short/frequent interaction -have visibility:stand halfway in & out
-food: sealed container to be able to call for reinforcement.
-meds: wrapped in tamper resistant foil -calm and firm

4. Unclassified/ Undifferentiated-----------------------can’t be classified anymore.

5. Residual-------------------------------------------------no more (+), (-). Social withdrawal


THOUGHT PROCESS DISTURBANCE
1. LOOSENESS OF ASSOCIATION----------------topics have connection but no thought. “I am going to the mall. The mall is in
town. The town flies. Flies are here.”
2. FLIGHT OF IDEAS ---------------------------------New unrelated topics. “I am going to the mall. Where is the light? I treasure this
chalk. Hurray!”
3. AMBIVALENCE-------------------------------------Pulled by 2 opposing forces.
4. MAGICAL THINKING----------------------------- believes he has magical powers. “I can turn you into a frog.”
5. ECHOLALIA------------------------------------------repeat what is said. Parrots.
6. ECHOPRAXIA----------------------------------------repeats what you do. Repeats what is seen.
7. WORD SALAD----------------------------------------mixes words that don’t rhyme.
8. CLANG ASSOCIATION----------------------------uses words that rhyme. “Flank, blank, prank.”
9. NEOLOGISM------------------------------------------invents new words not in the dictionary. “Ploopplank, pisnok.”
10. DELUSIONS-----------------------------------------false belief
Grandeur--------------I am a queen/ king/millionaire!
Persecution------------NBI out to get me!
Ideas of reference-----They talk and write about me!
11. CONCRETE ASSOCIATION-----------------------pilosopo. “What will you wear tomorrow?” “Clothes!”
12. HALLUCINATIONS----------------------ILLUSIONS (with stimuli)
Stimuli N Y
Visual N Y
Auditory N Y
Tactile N Y

Present reality!!! H A R D-Directive. “Let’s go in the garden.”



Acknowledge: “I know the voices are real to you. Present reality. “But I can’t hear them.”
=Assess what voices are saying to know if patient will harm himself.


Increase Dopamine = increase schizo
Decrease dopamine = decrease schizo

Extra Pyramidal Side Effects (EPSE) (Happens when acetylcholine is up and dopamine is down)
1. AKATHISIA-------------------------- restless, inability to sit still.
2. AKINISIA ---------------------------- rigidity
3. DYSTONIA--------------------------- affects neck
TORTICOLLIS -------------wry neck
OCULOGYRIC CRISIS – fixed stare
OPISTHOTONUS ---------arched back, contracted
4. TARDIVE DYSKINESIA------------lip smacking, tongue is protruding, puffy cheeks. Irreversible!
5. NEUROLEPTIC MALIGNANT SYNDROME- hyperthermia, unstable BP, increase CPK, diaphoresis, pallor
-discontinue meds, medical emergency.
6. PHOTOSENSITIVITY------------------wear shades, sunscreen
7. WBC- Agranulocytosis---------------sore throat, fever, malaise, leukopenia

AUTISM- boys > girls. 1:100 kids gift-autistic savants
-echolalis, poor eye contact, can’t express verbally.
Assess:
A- appearance- neat, OC, wants constancy
B- behavior- ritualistic behavior, flat affect, repetitive
C- communication – difficulty communicating

Nsg Dx: Impaired social interaction – cant form IPR (Interpersonal relationship)
Impaired verbal communication
Self mutilation – cant express anger. Express it inward.
Risk for injury

P/I: constancy, promote safety
Expressive therapy – uses art, music, poetry, decreasing risk for injury, improved social interaction, be able to express feelings.
E: -Safety


ADHD- ATTENTION DEFICIT HYPERACTIVITY DISORDER (can progress to conduct disorder to anti-social behavior)
Cant focus on anything.
Onset 7 yrs old and below
Duration >6 months
Setting: House & school
ID dominant: Mom or RN will act as superego

Assessment:
A- appearance: dirty
B- behavior: clumsy, impatient, easily distracted
C- talkative

Nsg Dx: High risk for injury

Safety
Structure- provide place to study, eat, play,bath,etc.
Schedule – time for everything
Set limits

Residual ADHD grows up not anti-social

Meds: Ritalin, Dexedrine,Pemoline, Adderal
Best time to give meds: If once a day give AFTER MEALS- to prevent loss of appetite.
Don’t give at bedtime-it’s a stimulant-will cause insomia. Can be given 6hours before bedtime (if q2d)



ANOREXIA NERVOSA – diet, underweight < 85% of expected fat, 3 months amenorrhea, failure to recognize problem.
BULIMIA NERVOSA – induce vomiting, takes laxative, normal weight, irregular menstruation, dental carries, diarrhea
- knows problem but ashamed and embarrassed,

Priority: Fluid volume balance
Weight gain – monitor weight, eating pattern, stay 1 hour after eating, accompany in toilet

Problem: Body image Disturbance
NI: 1. Establish nutrition pattern
2. Teach stress management, journal keeping
3. Monitor eating pattern and weight.
4. Anti-depressant
MANIA – needs mood stabilizing agents- Lithium. Group therapy

L- 0.5-1.5 mEq/L (If level is near 2.5-3 mEq/L –will cause ataxia and mental confusion)
I- increase urination
T- tremors
H- H20- 3L/d
I- increase
T- uu
M- mouth dry
N- Na- 135-145 mEq/L – to hold water

Check kidney(blood level) before administration of Lithium – BUN, CREA, electrolyte
Lithium toxicity – n/v, diarrhea = Diamox

BIPOLAR DISORDER – 2 poles, happy (more dominant) & sad
-female, >20 yrs old, stress, obese
Self actualization
Task to decrease self esteem
Family therapy
Risk for injury, risk for other directed violence
Decrease eat, decreased sleep, hyperactive, increase sex – masturbate in front of others

Nsg Dx: High risk for self or other directed violence
Risk for injury

Give task, no group games, any competition will increase anxiety, water the plants, activities using gross motor skills, escorted walk, punching bag-displacement.

3 or more signs confirms disorder:
G – grandiose, increase risk activities
F – flt of ideas
S - sleeplessness
P – pressured speech
E – exaggerated SE
E – extraneous stimuli (easily distracted)
D – distractability

PERSONALITY DISORDER

1. Schizoid – --------doesn’t care about people, believes that he can stand on his own, never had a best friend
avoid groups & activities – no enjoyment
cares more about computers, pets
2. Avoidant ----------avoid group – fear criticism, have talent but no confidence.
3. Anti-social– ------as child steal, lie, always get reprimanded
Adult – grand robbery, illegal activities against the law.
drug addiction, drives fast, unsafe sex, thrill seeker.
Good talker, charmer, witty, manipulator. Motto – “I will break the law”


4. Borderline -------Favorite line – “ life is an empty glass.” Splitting, suicidal, superficial relationship, labile-sudden change of
Mood, self mutilation.
(+) (-)
fill glass with friends suicide
have happy moments LABILE AFFECT sad moment

labile- change from good to bad in a split moment

5. Dependent ---------Decrease self esteem, dependent
Poor decision making skills
“I cant live if living is without you”

6. Histrionics ----------excited, dramatic, manipulative
- CENTER OR ATTENTION
-
7. Narcissistic----------“I love myself” – insensitive, arrogant, self absorbed
- exaggerated Self esteem, ambitious “I am the best”
-
8. OC ------------------ perfectionist, organized, constancy in environment. Provide time to do rituals.

9. Paranoid ----------- always jealous, suspicious, violent


10. Passive aggressive ------always say “yes”, but resistance is hidden.

Nsg Intervention: Improve IPR, build trust


A-LCOHOL ABUSE ----------------------happy – socializing Narcotic oversode-give Narcan
-escape from problem Narcotic detox- Methadone
-peer pressure Aversion therapy-Antabuse

B-blackout ---------------- awake but unaware
C-confabulation ---------- invent stories to increase Self-Esteem
D-denial -------------------“ I am at not an alcoholic.”
D-dependence ------------“ I cant live without alcohol.”
a. physical – tremors, tachycardia, restless
b. psychological – craving
E-enabling/codependency (significant others tolerate abusers)


DISULFIRAM
voids alcohol beer
version therapy
ntabuse (DISULFIRAM)
lcoholics anonymous n/v
hypotension
interval of alcohol & antabuse:
12h interval after alcohol intake
B1 – Thiamine
Complications wernickes
Encephalopathy
Korsakoff psychosis

Wernickes – VROOM – Motor sx effect
Korsakoff – memory- confabulation

24 – 72h after alcohol intake
Delirium tremors – happens due SNS activation
Tremors, hallucinations, illusions. Well lit room – to avoid hallucinations

ANTI DEPRESSANTS – decrease serotonin problem
Anti depressants – full stomach
All meds take on a full stomach, except anti anxiety.

ASENDIN TCA
NORPRAMIN TCA
TOFRANIL TCA
SINEQUAN TCA
ANAPRANIL TCA - OC
AVENTYL TCA
VIVACTIL TCA
ELAVIL TCA
PROZAC SSRI
PAXIL SSRI
ZOLOFF SSRI
LUVOX SSRI
Serotonin ---------makes us happy
Decrease serotonin – pt becomes sad – depression
Increase serotonin – antidepressant
SSRI:

Selective S
Serotonin S – (decrease S/E)
Reuptake R –
Inhibitors I – (1 – 4 weeks)

If SSRI don’t work, give TCA

Tri Cyclic Antidepressants –( TCA) ----------2 – 4 wks has increased S/E
increased Serotonin & Norephinephrine

MAOI-------------------------- effect 2 – 6wks
Increase E, NE, serotonin kills serotonin - MAOI
increase MAO = decrease serotonin
* decrease MAO = increase serotonin
give MAOI
Most dangerous, most S/E
Diet – avoid tyramine food – eat SARIWA, fresh foods
HPN crisis – dangerous! Increase CR, diaphoresis

Tyramine rich food:
Avocado Pickles
Alcohol Fermented foods
Beer Eggplant
Chocolate preservatives – tocino, bologna,canned meat etc.
Cheese – mozerella, swiss cheese
W – ine
S – soysauce

Anticholinergic = antidepressants – antiparasympathetic
Dry, constipation, retention, tachycardia
Male erectile dysfunction


MAOI
mARplan
NARdil
PARnate

DEPRESSION – decrease serotonin. If unresponsive to drugs, ECT-electroconvulsive therapy
Assess:
1. Denial – this cant be happening. This cant be real.
2. Anger – Why me, why now, why God?!
3. Bargaining – If returned, I will give reward.
4. Depression – 2 wks or more of sx = clinical depression
5. Acceptance – client acts according to situation. Pt prepares living will.

Increase risk for self directed violence.

Maslows:
5 –
4 – decrease Self-esteem – give TASK
3 – Pt is withdrawn
2 – Risk for self directed violence suicide
1 – eat (wt gain) or not eat(wt loss), sleep or not sleep, hypoactive, decrease sex

SUICIDE CUES:
“I wont be a problem any longer”
“Remember me when I’m gone”
“This is my last day”
“This is my wedding ring. Give it to my son”
- Sudden change in mood.

Pt is suicidal, RN should: D –d irect question – “Are you going to commit suicide?
I – irregular interval of visit to pt room
E – early am & endorsement period - time pt’s commit suicide.

Who will commit suicide?

S – sex – male (more successful)/female (hesitant)
A – age – 15 – 24yo or above 45
D – depression
P – pt with previous attempts will try again
E – ETOH – (Ethanol) alcoholics
R – irrational
S – lacks social support
O – organized plan – greater risk
N – no family
S – sickness, terminal

Suicide Triad:
- Loss of spouse
- Loss of job
- Aloneness

Best approach for suicide: Direct approach
Nursing Mgt: close surveillance

Hospital area majority suicide happens at: weekends 1 – 3 am Sunday
Weekend – less staff personnel
Early am – every one is asleep

Give simple task. Don’t give complex task – no jigsaw puzzle
Water the plants
Wash the dishes except sharp objects




SUBSTANCE ABUSE
Type of Addict:
1. Nervous -----tremors
Give downers

Sx of overdose
1. Identify if drug is upper or downer
2. Check effect
3. Sx of withdrawal
If patient takes a downer, all vital signs are down! If he stops taking it (during withdrawal), patient will experience the opposite effect of a downer. All his vital signs will shoot up! Same with uppers.
Ex: Pt had cocaine intoxication. Pt will manifest hyperactivity, tachypnea, seizure. During withdrawal, pt will manifest bradypnea or coma.


Substance Abuse Moments
(downer)
A – alcohol
B – barbiturates
O – opiates Antidote
N – narcotics - Narcan (narcotic antagonist)
M – marijuana

Morph
CODE
HERO

(uppers)

C – cocaine
H – Hallucinogens
A – amphetamines


Uppers Downers
Seizure decrease RR, decrease HR
Tachypnea Para constricted pupil
Moist mouth
Dilated Blood Vessels
Coma
Asleep
Decreased GI constriction
Decrease GU retention
Decrease BP
State of euphoria

Sx of withdrawal – reverse of effect
1. Know if upper or downer
2. Opposite of effect


Overdose Withdrawal (opposite of withdrawal is overdose)
Alcohol – coma seizure
Morphine – bradypnea tachypnea

Detox – withdrawal with MD supervision
Methadone

2. Depressed - Sits down on chair


Uppers
Codeine increased heart increase - BP increase, awake
Hallucinogen sympathetic HR increase seizure
Amphetamine pupils- dilate GI - diarrhea
Mouth – dry
Decrease appetite - thin

Stop uppers
Tremors crash syndrome Depressed Suicide
Fatigue



LEVELS OF MENTAL RETARDATION
Profound severe moderate mild borderline normal

IQ 20 35 50 70 90 110

Profound Mental retardation IQ <20 =thinks like an INFANT. Cant be trained. Stay with patient.
Severe MR 20-35
Moderate 35-50 = Can be trained. Mental age is 2-7yo. Pre-operational stage.
Mild 50-70 = (mild 7) Mental age is 7-12. Educable. Can go to school.
Borderline- 70-90
Normal- 90-110


JOHN PIAGET COGNITIVE THEORY
0-2 yrs old – S-ensory motor. Baby can sense, see, perceive and hear. Object permanence
2-4 yo- P-reconceptual- language.
4-7 yo- I-ntuitive stage. Unidimentional classification or unidimentional characteristic.
Child can fix toys according to size, color, height=one at a time only.
7-12 yo- C-conservation/concrete association. Multidemensional
12yo- F-ormal operation – good in abstract thinking. Can interpret proverbs.



CHILD ABUSE

B=burns, bruises, bone fractures, bungi
Don’t bathe child. Don’t brush teeth. Body of evidence will be lost.
Bantay Bata 163


ALZHEIMER
Anomia- don’t know name of object
Agnosia – problem with senses (smell, taste, hear, touch)
Aphasia – can’t say it
Apraxia – can’t do it

Dissociative Fugue- takes a new personality from a tar away place. New place new identity.
Dissociative Identity Disorder – multiple personality
Dissociative Amnesia – don’t know who/where I am.




DEPERSONALIZATION- believe that they are not persons anymore
PERSEVERATION- kulit. “I want to talk about something because this is something that I want to do. It is something that I need to talk about. This is something that I want to do.”

ELECTROCONVULSIVE THERAPY- sign informed consent. For depressed pt. If meds don’t work, use ECT.

Pre-ECT
N-npo 6 hours
A-atropine sulfate – dry mouth
B-barbiturate
S- succinylcholine chloride – to relax muscles

Post-ECT
Side-lying- lateral
S/E headache, dizziness, temporary memory loss (distinct sx)=RN-orient pt.



EXAMS:
Nsg intervention:

Look for words like:
S=safety, support, stay, set limits, assist
Provide safety. Mobilize support system. I will stay with you. Assist in activity.
Set limit- don’t allow patient to misbehave.

Look for words like:
Orient=orient pt post delirium, ECT, pt with dementia
Accept
“Seem, observed, noticed, comment, feelings…”

Group therapy- facilitator is RN.
Rape, battered pt

ALTRUISM – Victim becomes a counselor, shares experience to new victim.

Self-help group=facilitator is the pt themselves. AL ANON groups –Alcoholics Anonymous