Psychiatry Reinforcement

8/3/2019 Psychiatry Reinforcement

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TODDLER

Push – pull toys; parallel play

Rituals & routines; regression

Autonomy vs shame and doubt;accidents

Involve parentsSeparation anxiety

Elimination; explore



p

PRESCHOOL

Mutilation

Associative play; abandonment

Guilt

Initiative; imaginary playmate;

imaginationCurious



SCHOOLE AGE

Death

Industry vs inferiority;

immunizationModesty

PeersLoss of control

Explanation of procedures



ADOLESCENT

Peer group

Altered body image

Identity - image

Role diffusion

Separation from peers



TRUST

TRY EXPRESSION

REFLECTION OF WORDSUSE OF SILENCE

SETTING LIMITS

TIME WITH CLIENT



TRUST

Trust

RapportUnconditional positive regard

Setting limits

Therapeutic communication



JOHARI’S WINDOW

Known

to self

Not known to

self

Known to

othersOPEN BLIND

Not known toothers

HIDDEN UNKNOWN



EATING DISORDERS

Encourage express of feelings

Always use the same scale

To promote feelings of control

Include dietitian

No signs of malnutrition

Goal



EATING DISORDERS

Amenorrhea

No organic factor accounts for weight loss

Obviously thin but feels fatRefusal to maintain normal body weight

Epigastric discomfort is common

X symptoms (hiding of foods)

Intense fear of gaining weight

Always thinking of food



EATING DISORDERS

Binge eating

Under strict dieting or vigorous exercise

Lacks control over eating bingesInduced vomiting

Minimum of 2 binge episode/week for 3 mos

Increase/persistent concern of body

shape/size

Abuse of diuretics and laxatives



ANXIETY INTERVENTIONS

Calm

Anxiety - aware

ListenMedications

Environment

Reassurance



ANXIOLYTICS

Valium

Librium

Ativan

Serax

Tranxene

VLAST ME VAIB



ANXIOLYTICS

Miltown

Equanil

Vistaril

AtaraxInderal

Buspar



ANXIOLYTICS

Librium

Equanil

Atarax

Valium

Serax

LEAVS



DEPRESSION

Flat affect

LethargicApathy

Tearful



DEPRESSION MANAGEMENT

Prevent suicide

EnvironmentEsteem

Relationships



ANTI - DEPRESSANTS

Asendin

Norpramin

Tofranil Sinequan

Aventyl; Anafranil Vivactil

Elavil



ANTI - DEPRESSANTS

Prozac

Paxil

Zoloft Marplan

Nardil

Parnate



TRICYCLICS

Each ELAVIL

Victim’S VIVACTIL

SINEQUAN

A AVENTYL

Tough TOFRANIL

Neurotic NORPRAMIN



MAOI’S

• TYRAMINE RICH FOODS

– Beer, wine, cheese, livers, yeast rolls,

cola, chocolate, over the counter coldmedicines

• Leads to HYPERTENSIVE CRISIS



BIPOLAR DISORDER

Mood elevated

A grandiose delusion

Needs for sleep, eat

Inappropriate

C langing, loud,

vulgar



BIPOLAR DISORDER

Depressed

O out for suicide Won’t sleep, eat

Negative



DRUG FOR MANIA

Levels

Incontinence

Thirst; ThyroidHand tremors

Increase fluids

Unsteady

Manic; Many salts



SCHIZOPHRENIA

Hallucinations

Affects; ambivalence; autism;

associative looseness

Relationship

Delusions



CHARACTERISTICS of

ALCOHOLICS

Domineering

DenialDisatisfied

DemandingDependent



ALCOHOLISM

Coping mechanism

Orient to community resourcesPlan may include antabuse

Encourage vitamin B, folic acidSeizures



COMBAT

Control immediate situation

Out of situation

Maintain calm

Be firm and set limits

Avoid restraints

Try consequences



• Impairment incommunicationskills (all vowels – use short sentencesin communicating)

• Presence of stereotypedbehavior, interestsand activities(routines –

consistency;headbanging – protect head)

• Impairment insocial interactions

• Subaverage

intellectual

functioning

resulting inimpairment

in adaptive

behavior

• Persistentpattern of inattention

• Hyperactiveandimpulsivebehavior



• Diagnosed at

age 2

• Impaired

interpersonal

functioning

• Brain anoxia,

intake of

drugs

• Before age

18

• Inadequate

mental

functioning

• Multi-

factorial

• Before age

• Inattention• Hyeractivity

• Impulsivity

• Frontal lobehypoperfusion& drug use by

mom



• Crying tantrums

• Loves to spinobjects

• Echolalia

• Acts as deaf

• Resist normalteaching method

• Silly laughing

• Insensitive topain

• No fear of danger

• Educable

(50/55-70)

• Trainable

(35/40-50/55)

• Needs close

supervision

(20/25-35-40)

• Needs cutodial

care (below 20-

25)

• Difficulty

remaining

seated

• Easily distracted

• Fidgeting

• Interupts others

• Child

hyperactive

• Indulge in

destructive

behavior

• Talks excessively



• Difficultyinteracting withothers

• Attachment toinanimateobjects

• Wants block notball

• No eye contact

• Resist change inroutine

• Points toanything

• Not cuddly



• Risk for injury • Repetition

• Role

modeling

• Restructuring

the

environment

• Risk for injury

• Nutrition

• Safety

• DOC:RITALIN(methyl -

penidate)



TYPES OF BODY PHYSIQUE

(Kretschmer)

• Pyknic type

– usually short stature; stocky, round body figure; barrel-shaped chest and abdomen; short, but large extremities;round facial features, ruddy complexion; tendency toaccumulate fat.

• Asthenic type

– height usually normal; a few are short; slender, thin-

boned body figure; thin, sunken-appearing chest andabdomen; poor muscular development; oval facialfeatures; pale or sallow complexion.



TYPES OF BODY PHYSIQUE

(Kretschmer)

• Athletic type

– strong muscular development, especially around theneck, shoulders, legs, and arms, broad shoulders,narrow hips, square facial features with bonyprominences.

• Dysplastic type

– variations in physique are composed of combinations of

the three main body types. – a tendency to accumulate fat in some particular part of

the body, such as around hips or shoulders.

– a large percentage of persons of the dysplastic type areafflicted by endocrine disorders.



3 Main Temperament Types

(Carl Jung)• Extrovert

– actively aggressive, ambitious, enthusiastic,uninhibited; expresses feeling and relates to

other persons readily – inclined to engage in organization, political,

business activities

– this type has been linked to the pyknic body

physique and manic depressive disorders.




(Carl Jung)• Introvert

– reserved, quiet, shy, contemplative, serious,studious, sensitive

– limits social relations and feeling expressions – interests and attention are subjectively

directed

– inclined to engage in scientific pursuits and

the creative arts – has been linked to the leptosomic body

physique, especially the asthenic type andschizophrenic reactions.




(Carl Jung)• Ambivert

– possesses characteristics of both theintrovert and extrovert, but does not lean too

heavily in either direction. – Most persons manifest this middle type of

personality temperament.



COMMON PROBLEMS

ENCOUNTERED BY THE NURSE

IN MAINTAINING ATHERAPEUTIC RELATIONSHIP

AND THE APPROPRIATE

NURSING ACTION



Problems of Scheduling

The patient doesn’t come to the session • locate the patient

• re-schedule the appointment

• remind the patient ahead of time

• give the patient an appointment card

The patient is habitually late

1.determine the patient’s orientation to time

2.be on time and wait for the patient

3.explore with the patient his reasons for lateness

4.close the session on time



The nurse is late or has to change the scheduled time

• notify the patient directly or thru a writtenmessage

• apologize

• re-schedule the appointment when

appropriate

The patient asks to cut the session short or change the time of the meeting

• explore the expressed needs• re-orient the patient to the time schedule as

per initial agreement



The patient abruptly leaves the session

• ask the patient where he/she is going• tell the patient that you are going to wait for

her until the end of the session

• remain in the room

• wait expectantly for the patient’s return anddo not become involved in any other activity.



Problems on Responses and Questioning

The patient asks personal questions

1. briefly answer factual and self-evidentquestions and refocus

2. explore with the patient his need to ask

3. redirect the focus of communication toward thepatient

The sessions are interrupted by patients or staff.

1. clearly state to the interrupting individual thatthe therapy session is in progress

2. review with the patient previous agreement



The patient doesn’t want to talk:

1. sit quietly beside the patient

2. look at patient with an interested expectantexpression

3. observe nonverbal behavior

4. remind the patient of the remaining time

5. tell the patient that you are there when he is readyto talk.

The patient says I have nothing to say or I don’t know:

1. rephrase the question2. sit quietly, wait and be patient

3. continue to explore areas of interest and concern

4. be persistent – don’t give up



The patient tells the nurse to go away or says “don’t bother me”

• remain calm; assess the patient’s level of hostility

• make judgment based on assessment and setaccordingly

• leave the patient with a promise to return at a latertime or

• remain and explore the patient’s feelings

The nurses questions upset the patient or make him more nervous:

• it’s a good sign – something is happening

• maintain focus on the topic – don’t avoid it

• identify the topic• help the patient to recognize the topic

• review and analyze data to prevent:

– Prying; pushing beyond the patient’s level of readiness; uncooperativeness



• According to Busch (1987), there may be at leastthree styles of the “noninvolved client”:

– Resistant• the patient who is afraid to face emotions,

clings to his defenses, and is afraid tochange.

– Reluctant

• the patient who is coerced or forced to gettreatment and claims he does not need it(denial).

– Uncommitted

• the patient whose goals for treatment areincompatible with the treatment modality orthe therapist’s beliefs.



Hallucinations

• Initial approach with a patient who appears to belistening to or talking with “voice” is to comment on hisbehavior: “You look as if you are listening tosomething. What do you hear?”

• If the patient acknowledges hearing something the

nurse cannot hear, the nurse can say, “I don’t hearanything. Tell me what you hear.”

• The early assessment of hallucinations is of the contentof messages that reveal dynamics of the patient – THEMEANING, such as themes of powerlessness, guilt,

loneliness, or suicide.• Once the content is known, there is no need to focus onthe hallucinations; doing so could reinforce them: “Iknow the voices are important to you, but let’s talk about your loneliness right now.”



Delusions

• The initial approach with respect to delusionsas clarification of meanings, such as, “Who doyou think is trying to hurt you?” or “Tell me

about this power you think you have.”• As with hallucinations, delusions are not

discussed once the meanings are clarified.

• The underlying themes reflected in the

delusions are more appropriately addressed ininterventions, such as helping the patient whosays she is a queen feel important in realisticways.



Sexual innuendos or inappropriate touch

• Patients generally stop these behaviors whenasked and when they are reminded that theyare inappropriate

• The nurse then discusses the underlying need.If they do continue, the limit setting can bestronger: “I want to talk to you but not if youcontinue to touch me. If you don’t stop, I willhave to leave and come back later.”

• It may also help to pair a sexually acting-outpatient who has poor impulse control with astaff member of the same sex until he is furtheralong in treatment.



Manipulation

• Common manipulations are for attention, sympathy(“poor me”), control, and dependence for others to takeresponsibility.

• Often manipulation is not reorganized until it hasalready “worked”. Then the nurse may experience

anger or embarrassment• The initial approach is to point out what is happening

(or has happened): “I’m getting the feeling you like meto tell you what to do. What scares you about thisdecision? Or “You are experiencing a lot of pain and

would like me to relieve it for you. Let’s talk aboutwhat you can do to relieve it.” Limit setting is usefulwith manipulative patients.

• A power struggle with the patient is useless. Helping apatient relate effectively with others is more fruitful.



Hyperactivity

• Excessive physical and emotional activity in the

patient is upsetting to the staff, to otherpatients, and often to the patient himself.

• Even unintentionally the patient may harmhimself or others. The patient needs to be in a

quiet area with minimal auditory and visualstimulation.

• Physical activity, such as walking or using astationary bicycle, may help drain excessenergy.

• The nurse must remain calm, speak slowly andsoftly, and respect the patient’s personal space.

• Directions are given in a kind, simple, but firmmanner.

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Psychiatry Reinforcement

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