Psychiatric Nursing Review Lecture Notes from The Royal Pentagon Review Specialist, Inc.
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PSYCHIATRIC NURSING Royal Pentagon Rvw Ctr 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 1
Transcript
PSYCHIATRIC NURSING Royal Pentagon Rvw Ctr
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___________________SuperegoEGO
ID DOMINANT – needs a superego-needs a conscienceM- manicA- antisocial – serial killerN- narcissistic
SUPEREGO DOMINANT –needs an IdO- Obsessive CompulsiveA- Anorexia nervosa
EGO – impaired reality perception (RN will present reality)S- schizophrenia- cant distinguish fact from reality
Libido- sexual energyFREUD - PSYCHOSEXUAL THEORYORAL – 0-18 months
Cry, suck – mouth- survivalId dominantMaternal deprivation if not feed, not given milk/water, not kept warm.
Narcissistic – seeks the Id – I love myselfRegression – return to an earlier stage or earlier levelFixation – stopped in a stage
ANAL- 18 mos-3yrsToilet trainingMom is superego.Superego is being formedChild is caught in ambivalence – pulled in 2 opposing factors
Too much toilet training with punishment will result to a child who is:
PHALLIC – 3-6 yrs old-penis & vagina-love of parent of opposite sexOedipal-boy loves momElectra-girl loves dad
Identification- boy imitates dadCastration fears- fear that dad is angry at him and will cut off penisPenis 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 awarenessPre-conscious- at tip of tongueUnconscious – forgotten
Repression-kept in unconscious. Unconscious forgotten.Suppression – conscious forgetting
LATENT- 6-12 years old Latent- Logtu = sexual energy asleepSchool age – School phobia- 1st time to go to school – Separation anxietyChild is busy with Reading, writing, arithmetic.
Sublimation –putting anger into something more productive putting all energies into schoolingEx. Angry at life, pour anger in singing.
GENITAL –12 years old Genital-Gising sexual energySexual intercourse most important in this stage!!
PHARMA MOMENTS Anti-anxiety Drugs (used also for alcohol withdrawal)Valium Librium Ativan Serax TranxeneMiltown Equanil Vistaril Atarax Inderal Buspar
ERIK ERIKSON
STAGE (+) (-) FACTOR0-18 months (Oral) Trust vs Mistrust Feeding18 mos- 3yrs old (Anal) Autonomy vs
Au-(anal)To-ilet trainingNo-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 IndustryInduskul
12-20 (Genital) Identity vs Role confusion Peers20-25 Intimacy vs Isolation Love25-45 Generativity vs Stagnation Parenting45 up Ego Integrity vs Despair Reflection
Newly admitted pt- develop trust 1st
-pts are dependent=self care deficit
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-develop/teach autonomy-then pt will develop initiative-etc
Frontal lobe- personality, learning, judgment, languageOccipital- visionTemporal- hearing, smellParie t al -taste, touch
Sensory Integration Motor
Somatic nervous system- voluntary movementsAcetylcholine- responsible for voluntary movements
- on switch of movement
Autonomic nervous system- involuntary movements -Sympathetic(Anti cholinergic) and parasympathetic (cholinergic)
Anti-cholinergic / anti-parasympathetic =effect is sympathetic!
Sympathetic drug classifications: A- anxiety
P- psychotic
Anti C- cholinergic D- depressants
MONO AMINE OXIDASE INHIBITORS:
mARplannARdilpARnate
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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 schoolingEx. Angry at life, pour anger in singing.
DENIAL- ----------------------“I am not” an alcoholic!DISSOCIATION – --------------psychological flight from self. Amnesia. Ex. Rape, traumaREGRESSION – ----------------RETURN to an earlier developmental stageFIXATION – ---------------------stuck in a stage of developmentREPRESSION – -----------------unconscious forgettingSUPPRESSION – ---------------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 ADLHarm to self or others
BF Skinner – operant conditioning-reinforcementConfront (-) behavior to make it extinct.
MASLOW’S HEIRARCHY OF NEEDS:
5. Self-actualization4. Self-esteem3. Love and belonging2. Safety and security1. Air, food, water, shelter, clothing, sex –Basic physiologic needs
LEVELS OF PREVENTIONPRIMARY SECONDARY TERTIARYHealthy ill Relapse avoidanceCommunity teaching Crisis intervention Rehab centersCommunity demographics Treatment and diagnosis Al anon
STAGES OF INTERACTION ORIENTATION WORKING TERMINATIONAssessment Problem solving EvaluationEstablishment of trust Discussion SummarizeTell patient about termination Patient is most cooperative Say goodbyeSet contract Grief-ANGER-focus of RNPatient is resistant Pt might become violent/suicidal
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ANTI-PARKINSON DRUGS (Capables) –used with anti-psychotics
THERAPEUTIC COMMUNICATION NON- THERAPEUTIC1. 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 patientDon’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 ANALYSISPh & PCO2-Respiratory-opposite signsPh & HC02-Metabolic – same signs
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.
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
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 DISORDERCONVERSION -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
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 doseDependence- Can’t live without valium
Mood, internal, does not match affect. (sad inside)2. Ambivalence-------------------------------------pulled between 2 opposing forces3. 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 processDisturbed sensory Self care deficit Self OtherPerception Directed Violence
P/I: Reality/Orient/SafetyEval: Improved thought processS & Sx of Schizophrenia: (-)neg sx (+) positive sxhypoactive hyperactive flight of ideaswithdrawn restless hallucinationsquiet, flat affect talkative delusions many ideaspoverty of words queen of the world illusions
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 DISTURBANCE1. 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 YAuditory N YTactile 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.
Extra Pyramidal Side Effects (EPSE) (Happens when acetylcholine is up and dopamine is down)1. AKATHISIA-------------------------- restless, inability to sit still. 2. AKINISIA ---------------------------- rigidity3. DYSTONIA--------------------------- affects neck
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 safetyExpressive 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 belowDuration >6 monthsSetting: House & schoolID dominant: Mom or RN will act as superego
Family therapyRisk for injury, risk for other directed violenceDecrease eat, decreased sleep, hyperactive, increase sex – masturbate in front of others
Nsg Dx: High risk for self or other directed violenceRisk 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 activitiesF – flt of ideasS - sleeplessnessP – pressured speechE – exaggerated SEE – 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 enjoymentcares 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”
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4. Borderline -------Favorite line – “ life is an empty glass.” Splitting, suicidal, superficial relationship, labile-sudden change of
Mood, self mutilation. (+) (-)
fill glass with friends suicidehave 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.
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 unawareC-confabulation ---------- invent stories to increase Self-EsteemD-denial -------------------“ I am at not an alcoholic.”D-dependence ------------“ I cant live without alcohol.”
a. physical – tremors, tachycardia, restlessb. psychological – craving
DEPRESSION – decrease serotonin. If unresponsive to drugs, ECT-electroconvulsive therapyAssess:
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 depression5. Acceptance – client acts according to situation. Pt prepares living will.
Increase risk for self directed violence.
Maslows:5 – 4 – decrease Self-esteem – give TASK3 – Pt is withdrawn2 – 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 45D – depressionP – pt with previous attempts will try againE – ETOH – (Ethanol) alcoholicsR – irrationalS – lacks social supportO – organized plan – greater riskN – no familyS – sickness, terminal
Suicide Triad:- Loss of spouse- Loss of job- Aloneness
Best approach for suicide: Direct approachNursing Mgt: close surveillance
Hospital area majority suicide happens at: weekends 1 – 3 am SundayWeekend – less staff personnelEarly am – every one is asleep
Give simple task. Don’t give complex task – no jigsaw puzzleWater the plantsWash the dishes except sharp objects
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SUBSTANCE ABUSEType of Addict:1. Nervous -----tremors Give downers
Sx of overdose1. Identify if drug is upper or downer2. Check effect3. 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.
LEVELS OF MENTAL RETARDATIONProfound 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 20-35Moderate 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- 70-90Normal- 90-110
JOHN PIAGET COGNITIVE THEORY0-2 yrs old – S-ensory motor. Baby can sense, see, perceive and hear. Object permanence2-4 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. Multidemensional12yo- 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
ALZHEIMERAnomia- don’t know name of objectAgnosia – problem with senses (smell, taste, hear, touch)Aphasia – can’t say itApraxia – can’t do it
Dissociative Fugue- takes a new personality from a tar away place. New place new identity.Dissociative Identity Disorder – multiple personalityDissociative Amnesia – don’t know who/where I am.
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DEPERSONALIZATION- believe that they are not persons anymorePERSEVERATION- 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.
