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Psychiatric Nursing | Preparation to NLE | NCLEX

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I. Basic Concepts in Psychiatric Nursing

Mental Health

Mental Ill Health

Psychiatric Nursing

-Interpersonal process whereby the professional nurse practitioner through the therapeutic use of self, assist an individual family, group or community to promote mental health, to prevent mental illness and suffering, to participate in the treatment and rehabilitation of the mentally ill and if necessary to find meaning in these experiences.

Both a Science and Art

Core of Psychiatric Nursing:

-Interpersonal process


-Individual, family and the community

- Both mentally healthy and mentally ill

Main Tool of the Nurse

-Therapeutic use of Self


Use of Self

Therapeutic use of self - positive use of one’s self in the process of therapy

- it requires self-awareness

Basic Principles

Basis: Joharis Window

Known to self

Not Known to self

Known to others

Public Self


Semi-public Self


Not known to others

Private self III

Areas of the Unknown


Goal: To increase quadrant I, decrease quadrant II and III

Methods Used to Increase Self- Awareness

  1. Introspection:

-Viewing one’s self as honestly as possible

  1. Discussion:

- Learning about oneself through association with others

  1. Enlarging One’s Experience:

- Engage in a particular activity and noting one’s reaction to it.

  1. Role playing:

- A situation in which participants enact a role

Core Concepts on the Care of the Psychotic Patient

On Admission of the Client

  1. Priority
  2. Determine the reason why the client sought help
  3. Client’s rights
  4. Initial assessment







Common Behavioral Signs and Symptoms

  1. Disturbance in perception:

Illusion -misperception of an actual external stimuli

Hallucination -false sensory perception in the absence of external stimuli

Visual -seeing

Tactile -feeling that there are some insects crawling on the skin

  1. Disturbances in thinking

Neologism - pathologic coining of words

Circumstantiality - over inclusion of details

Word Salad - incoherent mixture of words and phrases

Verbigeration - incoherent mixture of word or phrases

Perseveration - persistence of a response to a previous question

Echolalia - pathological repetition of words

Flight of ideas - shifting from of one topic from one subject to another in a somewhat related way

Looseness of association - shifting of a topic from one subject to another in a completely unrelated way

Clang association - the sound of the word gives direction to the flow of thought

Delusion - false belief which is inconsistent with one’s knowledge and culture

  1. Disturbances of affect

Inappropriate affect - disharmony between the stimuli and the emotional reaction

Blunted effect - severe reduction in emotional reaction

Flat affect - absence or near absence of emotional reaction

Apathy - dulled emotional tone

Ambivalence - presence of two opposing feelings

Depersonalization - feeling of strangeness towards one’s self

Derealization - feeling of strangeness towards the environment

  1. Disturbances in Motor Activity

Echopraxia - the pathological imitation of posture/action of others

Waxy flexibility – maintaining the desired position for long periods of time without discomfort

  1. Disturbances in memory

Confabulation - filling in of memory gaps

Amnesia - inability to recall past events

Anterograde amnesia - loss of memory of the immediate past

Retrograde amnesia - loss of memory of the distant past

Déjà vu - feeling of having been to a place which one has not yet visited

Jamais vu - feeling of having been to a place which one has visited before

Use of Appropriate Communication Techniques


Reciprocal exchange of ideas between or among persons.

Modes of communication:

1. Verbal - written/spoken

2. Non-verbal - posture, tone of voice, facial expression

3. Meta communication - based on role expectations/hidden meaning of words

Elements of Communication

Sender - originator of information

Message - information being transmitted

Receiver - recipient of information

Channel - Mode of communication

Feedback - return response

Context - the setting of communication

Criteria of successful communication





Common Problems in Communication

  1. Dysfunctional communication
  2. Double bind communication
  3. Denotative vs. connotative meaning
  4. Incongruent communication

Techniques of Communication

If your goal is:

To initiate conversation:

Giving broad opening

Giving recognition

To establish rapport and build trust:

Giving information

Use of silence

To gather information:






To close a conversation:


How to Choose a Therapeutic Response in The Board Exam

Establish Nurse Patient Relationship

Nurse-Patient Relationship

Series of interaction between the nurse and the patient in which the nurse assists the patient to attain positive behavioural change.

  1. Characteristics

NPR Social Relationship

  1. Phases

  1. Pre-Interaction Phase

- begins when the nurse IS assigned/chooses a patient

- phase of NPR in which patient is excluded as an active participant

- nurse feels certain degree of anxiety

- includes all of what the nurse thinks and does before interacting with the patient

Major task of the nurse:

to develop self-awareness

Other tasks:

data gathering, planning for first interaction

  1. Orientation Phase

- when the nurse-patient interacts for the first time

- parameters of the relationship are laid

- nurse begins to know about the patient

Major task:

to develop a mutually acceptable contract

Other tasks:

determine why the patient sought help

establish rapport, develop trust, assessment

  1. Working Phase

- it is highly individualized

- more structured than the orientation phase

- the longest and most productive phase of the nurse-patient relationship

- limit setting is employed

Major task:

identification and resolution of the patient’s problems

Other tasks:

Planning and implementation

  1. Termination Phase

- it is a gradual weaning process

- it is a mutual agreement

- it involves feeling of anxiety, fear and loss

- it should be recognized in the orientation phase

- it should be recognized in the orientation phase

Major task:

to assist the patient to review what he has learned and transfer his learning to his relationship with others.

Other task:


When to terminate?

How to terminate?

Common Problems Affecting NPR

1. Transference - the development of an emotional attitude of the patient either positive or negative towards the nurse.

2. Resistance - development of ambivalent feelings towards self-exploration.

3. Counter Transference - as experienced by the nurse

Initial Interventions

Principles of Care in Psychiatric Settings

1. The nurse views the patient as a Holistic human being with interdependent and interrelated needs.

2. The nurse accepts the patient as a unique being with inherent value and worth exactly as he is.

3. The nurse should focus on the patient’s strengths and assets and not on his weakness and liabilities.

4. The nurse views the patient’s behaviour non-judgmentally, while assisting the patient to learn more adaptive ways of coping.

5. The nurse should explore the patient’s behaviour for the need it is designed to meet and message it is communicating.

6. The nurse has the potential for establishing a nurse-patient relationship with most if not all patients.

7. The quality of the nurse-patient relationship determine the degree of positive change that can occur in the patient’s behaviour.

Level of Interventions in Psychiatric Nursing

Primary – Interventions aimed at the promotion of mental health and lowering the rate of cases by altering the stressors.

Secondary – interventions that limits the severity of a disorder.

2 Components

1. Case Finding

2. Prompt treatment

Tertiary – interventions aimed at reducing the disability after a disorder.

2 Components

1. Prevention of complication

2. Active program of rehabilitation

Characteristics of a Psychiatric Nurse

1. Empathy – the ability to see beyond outward behaviour and sense accurately another person’s inner experience.

2. Genuineness/Congruence – ability to use therapeutic tools appropriately.

3. Unconditional Positive Regard – respect

Roles of the Nurse in Psychiatric Settings

1. Ward Manager


2. Socializing Agent


3. Counselor


4. Parent Surrogate


5. Patient Advocate


6. Teacher


7. Technician


8. Therapist


9. Reality Base


10. Healthy Role Model


Types of Interventions

7.1 Biologic

7. 1. 1 Pharmacologic

II. Basic Concepts on Psychoparmacology



Classification of Psychopharmacologic Agents

A. Major Tranquilizers/Antipsychotics:




Haloperidol (Haldol)

Fluphenazine ( Prolixin

Prochlorperazine (Compazine)

Chlorpromazine (Thorazine)

Side effects:

Blurred vision, dry mouth, tachycardia, palpitation, constipation, urinary retention

Skin: Photosensitivity

BP: Orthostatic hypotension

EPS: Extra Pyramidal Symptoms

- Pseudoparkinsonism

-pill-rolling tremor, mask-like face, cog-wheel rigidity, propulsive gait

- Akathisia

-restless leg syndrome

- Dystonia

- defect in muscle tone

Adverse effect:

1. Tardive dyskinesia-lip smacking

2. Agranulocytosis

3. Hepatoxicity

Principles of Nursing Care






B. Anti-Parkinsonian Agents:


2 Types:

1. Dopaminergic Drugs


Examples: Amantadine (Symmetrel)

2. Anticholinergic Drugs


Trihexyphenidyl (Artane)

Biperiden Hydrochloride (Akineton)

Benztropine Mesylate (Cogentin)

Diphenhydramine Hydrochloride (Benadryl)

Side effects:

Anticholinergic: blurred vision, constipation, orthostatic hypotension

Adverse effects:

Dry mouth, urinary retention, sore throat

Principles of Nursing Care






C. Minor Tranquilizers/Anxiolytics




Diazepam (Valium)

Chlordiazepoxide (Librium)

Aprazolam (Xanax)

Oxazepam (Serax)

Chlorazepate Dipotassium (Tranxene)

Side effects:

Adverse effects:

Principles of Nursing Care:






D. Antidepressants

Common Types:

  1. Tricyclics
  2. MAO inhibitor
  3. Stimulants



Imipramine (Tofranil)

Amitriptyline (Elavil)

Tranylcypromine (Parnate)

Isocarboxazid (Marplan)

Phenelzne (Nardil)

Ritalin (Methylphenidate)

Amphetamine (Benzedrine)

Adverse effect:

Cardiac arrhythmia, hypertensive crisis, growth suppression

Side effect:

Principles of Nursing Care:






Drug update: SSRI – Selective Serotonin Reuptake Inhibitor

- inhibits serotonin uptake

Example : Fluoxetine (Prozac)

Side effects : GI Discomforts

Adverse effects: Tremors, decrease in libido

E. Anti-manic agents

1. Lithium Carbonate







2. Carbamazepine

7. 1. 2. Somatic Therapy

Electro-convulsive Therapy




Number of treatment


Indicators of effectiveness:


  1. Depression
  2. Mania
  3. Catatonic schizo

Contraindications: (relative) – there is no absolute contraindication to ECT

  1. Fever
  2. ICP brain tumor
  3. Cardiac
  4. TB with history of hemorrhage
  5. Recent fracture
  6. Retinal detachment
  7. Pregnancy

Patient Preparation:

Before the procedure:


Physical exam:






Administration of Atropine SO4

Anectine (Succinylcholine)

Methohexital Na (Brevital)

During the procedure:

Observe the patient tonic-clonic contraction

After the procedure:


Vital signs

Reorient the patient

Common complications: Memory loss, headache, fracture, apnea

7.2 Psychosocial Interventions

III. Common Psychotherapeutic Interventions

  1. Remotivation therapy

5 Different Steps

    1. Climate of acceptance
    2. Creating of bridge to reality
    3. Sharing the world we live in
    4. Appreciation of the works of the world
    5. Climate of appreciation

  1. Music Therapy

  1. Play Therapy

  1. Group Therapy

  1. Psychodrama

  1. Milieu Therapy

  1. Family Therapy

  1. Psychoanalysis

  1. Hypnotherapy

  1. Humor Therapy

  1. Transactional Analysis

  1. Behavior Modification

  1. Aversion Therapy

  1. Token Economy

  1. Gestalt Therapy

IV. Dynamics of Human Behavior

Need – is an organismic condition which requires a certain activity

Stress – pressure of varying degrees: Distress – unhealthy stress

Eustress – healthy stress

Behavior – way in which an organism responds to a stimulus

Conflict – situation that arise from the presence of two opposing drives


Approach-Approach -both of each chosen have positive attributes

Avoidance-Avoidance -negative attribute

Approach-Attribute - choice have positive and negative attributes Double approach - avoidance

V. Basic Concepts on the Client


- The integration of those systems and habits that represents an individuals characteristic adjustment to his environment

- Expressed through behaviour.

2 Characteristics of Personality

1. Distinctiveness - each individual is unique

2. Stability and consistency personality is predictable


1. Psychological - type of climate at home

2. Cultural - customs and traditions

3. Biological - personality is not inherited

4. Familial - parenting style

3 divisions of the mind:

1. Conscious - part of the mind that is focused on awareness

2. Subconscious - part of the mind that contains information that can be recalled at will.

3. Unconscious - largest part of the mind; contains materials and information that can never be recalled.

Structures of Personality


Theories of Personality Development

A. Freud’s Psychosexual theory

First to identify/classify the stages of development

0-18 mos: Oral Stage

Area of Gratification:

Indicators of Fixation:

18 mos – 3 years: Anal Stage

Area of Gratification:

Indicators of Fixation:

3-6 years: Phallic Stage

Area of Gratification:

Indicators of Fixation:

6-12 years Latency: (Quiet Stage)

Area of Gratification:

Indicators of Fixation:

12 -21 years Genital Stage

Area of Gratification:

Indicators of Fixation:

B. Erikson’s Psychosocial Theory

First to include adulthood as a stage of development

0-12 mos: Trust vs. Mistrust

If the needs of the child is consistently met, trust develops.

1-3 years: Autonomy vs. Shame and Doubt

If toilet training is not hurried, autonomy develops.

3-6 years: Initiative vs. Guilt

If the child’s sexual curiosity is handled without anxiety, initiative develops.

6-12 years: Industry vs. Inferiority

If the child’s efforts at learning is supported, industry develops.

12-18 years: Identity vs. Role Diffusion

If the adolescent’s vocational decision is supported, identity develops.

18-25 years: Intimacy vs. Isolation

If the adolescent’s decisions regarding love relationship is supported, intimacy develops.

25-65 years: Generativity vs. Stagnation

If an individual enjoys support from the family, generativity develops.

65 onward: Integrity vs. Despair

If the person has a satisfying past recollection, integrity develops.

C. Piaget’s Cognitive Theory of Development.

First to Focus on Cognitive Development

0-2 years: Sensory Motor Stage

Development proceeds from reflex activity to sensory motor learning

Child learns that he is separate from the environment

Child learns the concept of object permanence

2-7 years: Pre-operational Stage

2-4 yrs: pre-conceptual development proceeds from sensory motor learning to pre-logical thought.

The child learns language and symbols.

4-7 yrs: intuitive thought: The child is able to think in terms of class.

The child is able to determine that individuals have roles.

7-12 years: Concrete Operational Stage

Development proceeds from pre-logical concrete thought.

12 years to adulthood: Formal Operational Stage

The child is able to think abstractly, able to apply the scientific method.

VI Crisis and Crisis Intervention

Crisis – situation that occurs when an individual’s habitual coping ability becomes ineffective to meet the demands of a situation.


Types of Crisis:

1. Maturational/developmental crisis - expected, predictable and internally motivated.

Example: growth

2. Situational/accidental - unexpected, unpredictable and externally motivated.

Example: car accident

3. Social crisis - due to acts of nature

Example: earthquake

Crisis intervention

A way of entering into the life situation of an individual, family, group, or community to help them mobilize their resources and to decrease the effect of a crisis inducing stress.

Phases of Crisis

Denial – initial reaction

Increased tension – the person recognizes the presences of a crisis and continues to do activities of daily living.

Disorganization – the person is preoccupied with the crisis and is unable to ADL.

Attempts to reorganize – individual mobilizes previous coping mechanism.

Some Conditions Requiring Crisis Intervention

  1. Rape

Some Facts of Rape:





Essential Elements Necessary to Define an Act of Rape

  1. Use of threat/force
  2. Lack of consent of the victim
  3. Actual penetration of the penis into the vagina

Different Kinds of Rape




Principles of Nursing Care:

Rape Trauma Syndrome (RTS)

1. acute phase

2. denial

3. heightened anxiety

4. stage of reorganization

Battered Wife Syndrome (BWS)

Characteristics of Abusive Husband:

1. They usually come from violent families

2. They are immature, dependent and non-assertive

3. They have strong feelings of inadequacy


1. Tension building phase

2. Acute battering incident

3. Aftermath/honeymoon stage

Principles of Nursing Care:

Child Abuse

Abuse - is what happens when an adult takes advantage of his authority over a child.

Violence - refers to the use of force.

Neglect - lack of provision of those things which are necessary for the child’s growth and development.

Physical abuse - abuse in the form of inflicting pain

Emotional abuse - insult and undermining one’s confidence

Sexual abuse - abuse in the form of unwanted sexual contact

Characteristic of Abusive Parents

- they come from violent families

- they were also abused by their parents

- they have inadequate parenting skills

- they are socially isolated because they don’t trust anyone

- they are emotionally immature

- they have negative attitude towards the management of the abused

Indicators of Child Abuse

Principles of Nursing Care:

Where to report:

Whom to report:



Causes of Anxiety

2 classification factors

  1. Predisposing factor

Factors that make you at risk

  1. Precipitating factor

Factors that cause direct effect

Psychoanalytic theory

Anxiety is caused by a conflict between the Id and the Superego

Interpersonal Theory

Cause of anxiety is fear of interpersonal rejection

Behavioral Theory

Anxiety is a product of frustration

Learning Theory

Exposure to early life fearful experiences causes anxiety

Conflict theory

Presence of opposing drives

Biologic Theory

Anxiety may accompany physical ailments/diseases

Family Studies

Anxiety can run in families

Precipitating factors

Threat to one’s biological integrity

e. g. surgery

Threat to one’s self system

e. g. insult

Signs and Symptoms of Anxiety

Signs and Symptoms






PR, RR, Pupillary dilatation, sweating

nausea, anorexia, vomiting, diarrhea, constipation, restlessness

S/Sx becomes the focus of attention

S/Sx of exhaustion are ignored


Attentive and alert

narrowed perceptual field and selective inattention

perceptual field is greatly narrowed; focus of attention is trivial events

personality disorganized


Minimal use of defenses

use of any defense mechanism available

defense mechanisms operate to prevent panic, amnesia, and dissociation

defense mechanisms fail

Nursing Diagnosis

Principles of Nursing Care:





Defense Mechanisms:

Unconscious, specific intrapsychic adaptive efforts which are employed by the individual to resolve emotional conflict and to cope with anxiety


It is automatic

It is not the defense mechanism that is pathological but it is the frequent use of it

Used by both mentally healthy and mentally ill individuals


Compensation - an attempt to overcome a real or imagined shortcoming

Conversion - emotional problems are converted to physical symptoms

Denial - failure to acknowledge an intolerable thought, feeling, experience or reality

Displacement - the redirection of feelings to a less threatening object

Dissociation - detachment of certain activities from normal consciousness which then function alone

Fantasy - conscious distortion of unconscious feelings or wishes

Fixation - arrest of maturation at certain stages of development

Isolation - cutting of or blunting of an unacceptable aspect of a total experience

Introjection - symbolic assimilation or taking into one’s self a love/hatred object

Identification - conscious patterning of one’s self from another person

Intellectualization - over use of intellectual concepts by an individual to avoid expression of feelings

Projection - attributing to other’s one’s unconscious wishes/fears

Reaction formation - expression of feelings that is the direct opposite of one’s real feelings

Rationalization - justifying one’s actions which are based on other motives

Regression - returning to an earlier level of development in the face of stress

Repression - unconscious forgetting

Suppression - conscious forgetting

Substituting - replacing the desired unattainable goal with one that is attainable

Sublimation - the channelling of unacceptable instinctual drive with one that is acceptable

Symbolization - less threatening object is used to represent another

Undoing - an attempt to erase an act, thought, feeling or desire

Anxiety Disorders

Panic Attacks




Social Phobia


Simple Phobia


Obsessive-compulsive behaviour


General Anxiety Disorder


Post-traumatic Stress Disorder


Nursing Diagnosis

Drug of Choice:

VII. Personality Disorders

Etiological Factors

  1. Genetic Factors
  2. Temperamental Factors
  3. Biological Factors
  4. Psychoanalytic Factors



Anti-social - habitually breaks the law; with low self-esteem; lacks sense of guilt.

Dependent - incessant demands for attention from others

Schizoid – withdrawn, last to catch up in fashion, introvert, aloof

Shizotypal – bizarre behaviour, silly laughter

Borderline - fears separation; impulsive; unstable but intense relationships

Histrionic – overly concerned with physical appearance, attention seeking behaviour


Avoidant – fears rejection

Paranoid – extreme mistrust and suspiciousness

Passive-Aggressive – loves to procrastinate, expresses anger through passivity

Emphatic Narcissistic – (self-love), believe that they are special and they demand special attention

Obsessive-Compulsive – repetitive thoughts and action, perfectionist, inflexible, rigid

Nursing diagnoses;

  1. Ineffective individual coping
  2. Self- esteem disturbance

Principles of Nursing Care

  1. consistency
  2. limit setting

VIII Autism

Treatable but not curable

More common among boys

Usually diagnosed at age 2

Main Problem: Interpersonal functioning

Most Acceptable Cause:

Biological factors – brain anoxia, intake of drugs

Signs and symptoms

  1. resist normal teaching method
  2. silly laughing or giggling
  3. echolalia
  4. acts as if deaf
  5. no fear of danger
  6. insensitive to pain
  7. crying tantrums
  8. loves to spin objects
  9. resists change in the routine
  10. not cuddly
  11. sustained odd play
  12. difficulty interacting with others
  13. no eye contact
  14. wants blocks not ball
  15. points to anything
  16. attachment to inanimate objects

Management of priority problems

Tantrum - involves headbanging = place a helmet on the head

Communication – all vowels = use build up and break down

Routines – consistency

Nursing diagnosis:

Potential for injury

IX. Mental Retardation

IQ less than 70

Not a mental illness

Main problem: Inadequate mental functioning

Age of Onset: 18 years old


Maternal infection

Exact gestational age is not reached (premature)

Birth injuries

Nutritional deficiency



Lead poisoning

Recent infection – measles

Environmental factors

Thyroid deficiency

Alcoholic Mother

RH Incompatibility

Damage to brain from various causes



Inherited factor

Opiate intoxication

Neurological/neurodevelopment impairment

Levels of Mental Retardation

1. Mild/Moron IQ: 50/55-70 Educable

2. Moderate/Imbecile IQ: 35/40 -50/55 Trainable

3. Severe/Idiot IQ: 20/25 -35/40 Needs close supervision

4. Profound Below 20-25 Needs custodial care

Nursing diagnosis:

Principles of Nursing Care:

  1. Repetition
  2. Role Modeling
  3. Restructuring

Focus of Education:

Reading, writing, basic arithmetic

X. Attention Deficit Hyperactivity Disorder

Common in boys

Usually diagnosed before age 7

Main problem: Inattention, hyperactivity, and impulsivity


Neurologic impairment

Pre-natal trauma

Early malnutrition

Frontal lobe-hypoperfusion

Use of drug by mother

Signs and symptoms:

Difficulty remaining seated

Easily distracted by extraneous stimuli


Interrupts/intrudes on others

Child exhibits hyperactivity

Indulges in destructive behaviour

Talks excessively

Nursing diagnosis: Potential for injury

Principles of Nursing Care:



Drug of Choice: Methylphenidate (Ritalin)

XI. Eating Disorders

Common among females (adolescents)

Most common cause:

Psychological factors

Individual factors (conflict about growing up)

Parental factors (domineering parents)

Socio-cultural factors


Main sign: fear of gaining weight


No organic factor accounts for weight loss

Obviously thin but feels fat

Refusal to maintain normal body weight

Epigastric discomfort

X symptoms (peculiar symptoms)

Intense fear of gaining weight

Always thinking of food


Binge eating

Under strict dieting or vigorous exercise

Lacks control over eating binges

Induced vomiting

Minimum of 2 binge eating episode a week for 2 months

Increased/persistent concern of body size/shape

Abuse of diuretics and laxatives

Nursing diagnosis: Body image disturbance/self-esteem disturbance

Ineffective individual coping

Principles of Nursing Care:

  1. Monitor patient’s weight
  2. Oral hygiene
  3. Stay with the patient during mealtime and within 2 hours after meals
  4. encourage the patient to remain in a public place after meals
  5. behaviour modification

XII. Sexual Disorders

Cause: Psychological factors, unresolved oedipal complex

Paraphilia – a term which generally refers to abnormal sexual behaviour

Types: Sexual Stimulus

Exhibitionism - publicly showing the genitals

Fetishism - from inanimate objects

Anilingus - tongue brushing the anus

Cunnilingus - tongue brushing the vulva

Fellatio - inserting the penis into the mouth

Partialism - inserting the penis into the other parts of the body

Pedophilia - sexual intercourse with a child

Urophilia - urinating on the partner

Coprophilia - smearing feces on the partner

Masochism - sexual gratification from experiencing pain

Sadism - inflicting pain

Telephone scatologia - sex on phone

Voyeurism - sexual gratification by seeing others in the nude

Frotteurism - rubbing the genitalia to the body parts

Transvestism - using the apparel of the opposite sex

Nursing diagnosis: Altered sexual functioning

Principles of Nursing Care:

  1. Limit setting
  2. Behavior Modification

XIII. Schizophrenia

Split Mind”

Not a single disease but a combination of disorders

Main Problem:

Signs and Symptoms:

1. Associative looseness

2. Autism

3. Apathy

4. Ambivalence

5. Auditory Hallucination

Most acceptable theory on the cause of Schizophrenia, Biologic Theory

Signs and Symptoms

Social isolation

Catatonic behaviour


Incoherent/marked looseness of association

Zero/lack of interest, energy, and initiative

Obvious failure to attain expected levels of development

Peculiar behaviour

Hygiene and grooming are impaired

Recurrent illusions and unusual perceptual experiences

Exacerbation and remissions are common

No organic factor accounts for signs or symptoms

Inability to return to baseline functioning after each relapse

Affect is inappropriate

Different Types








Distinguishing feature

Abnormal motor behavior

Bizarre behavior

Suspiciousness and ideas of reference

Defense mechanism




Nursing diagnosis

Impaired motor activity

Impaired social functioning

Potential for injury directed at others

Priority nursing care

Circulation Nutrition

Assistance with ADL

Nutrition and Safety





Other types: Undifferentiated

Residual – with minimal symptoms

Criteria for Prognosis

Favorable Prognosis

Unfavorable Prognosis

1. Good socialization

2. Late/acute onset

3. Adequate support system

4. Family history of mood disorder

  1. Poor/no socialization
  2. Early and insidious prognosis
  3. Few//no support system
  4. History of chronicity/many relapses

XIV. Mood Disorders

Predisposing Factors:

Genetic: If one parent ahs bipolar disorder, 25 percent chance of transmission to the child.

Aggression turned inward theory: overdeveloped superego

Object loss theory: loss of parent before age 11

Personality Organization Theory: Obsessive-Compulsive theory, Oral dependent, hysterical personalities have higher predisposition to mood disorders.

Cognitive Theory: Mood disorder results from (-) view of self, (-) view of future, (-) interpretation of experience

Learned Helplessness Theory: Mood disorder is caused by a belief that one has no control over his environment

Psychoanalytic Theory: Mania is a defense against an underlying depression

Depression due to rigid SE

Biologic Factor: Mania is cause by increased norepinephrine while depression is cause by low norepinephrine

Precipitating Factors

1. Loss of a loved one

2. Major life events

3. Roles strain

4. Decreased coping resources

5. physiological changes

Types of Mood Disorders

  1. Depression
    1. Major Depression-severe, lasts for at least 2 weeks
    2. Dysthymic Depression-less severe (2 years)
    3. DNOS – lasts for 2 days – 2 weeks

  1. Bipolar Disorders
    1. Manic-severe, lasts for at least 1 week
    2. Hypomanic-lasts for at least 4 days
    3. Bipolar I – with history of mania

Bipolar II – with no history of mania

    1. Cyclothymic – numerous episodes of hypomania and depressed mood that lasts for at least 2 years

Signs and symptoms:

Mania Depression

Appearance Colorful Sad

Behavior Highly driven, hyperactive Passivity/Psychomotor


Communication Talkative (Flight of ideas) Monotonous

Nursing Diagnosis Risk for injury Risk for injury to self

directed at others

Nursing Care Lithium ECT

Milieu Therapy Non-stimulating Stimulating

Activity Quiet Type Monotonous activity

Avoid competitive e. g. counting

Attitude therapy Matter of Fact Kind firmness

(attitude of casualness)


Ultimate form of self-destruction

“cry for help”

Major intervention: Prevention


Risk Factors

Sex (more female attempts at suicide but more males commit suicide)

Unsuccessful previous attempt

Identification with a family member who committed suicide


Illness (e.g. Cancer)

Depression/Dependent personality

Age (18-25 and 40)/Alcoholism

Lethality of previous attempt/Losses

Nursing Diagnosis: Risk for self-directed injury

Nursing Care:

  1. One-on-one monitoring
  2. Frequent unscheduled rounds
  3. Avoid use of metals and glass utensils
  4. Monitor for the signs of impending suicide (e.g. giving away of prized possession)

XV. Conditions Common in the Elderly

Delirium Dementia

Disorientation Loss/impairment of memory

Acute Chronic

Involves young and old Exclusive in the elderly

Clouded sensorium Clear sensorium

Reversible Irreversible

Good prognosis Poor prognosis

Alzheimer’s disease: Irreversible

Main pathology: presence of senile plaques-destroys neurons (decreased acethylcholline)

Signs and symptoms:

Aphasia-inability to talk

Agnosia- inability to recognize object

Apraxia-inability to perform ADL

Amnesia/Memory Loss/Mnemonic disturbance

3 phases

  1. Forgetfulness Phase-difficulty of remembering appointments
  2. Advance Phase-difficulty of remembering past events but not recent events
  3. Terminal Phase-death occurs in 1 year

Nursing Diagnosis: Altered thought processes

Nursing Care:

- Calendar

- Clock (frequent orientation)

- Color

- Consistency (one nurse to lessen confusion)

XVI. Substance Abuse and Substance Dependence

Substance Abuse: use of a substance for other than its legitimate medical purpose

Substance Dependence: physiological and psychological dependence of the body on a substance as evidenced by tolerance and withdrawal

Tolerance: need for an increasing amount of the substance to produce its desired effect or it refers to the declining effect of the drug.

Withdrawal: syndrome or a group of symptoms experienced by the patient when the amount of the substance is reduced or when the intake is stopped.



WHO- alcoholism is a chronic disease or a disorder characterized by excessive alcohol intake and interference in the individual’s health, interpersonal relationship and economic functioning.

Alcoholism – considered to be present when there is 1% or 10 ml for every 1000 ml of blood.

What happens at level:

.1-.2% (low coordination)

.2-.3% (presence of ataxia, tremors, irritability, stupor)

.3 and above (unconsciousness)

Theories of Causation

  1. Psychoanalytic Theories
  2. Learning Theories
  3. Biological Theories
  4. Socio-Cultural Theories

Progression of Alcoholism

  1. Pre-alcoholic Phase – starts with social drinking tolerance begins to develop
  2. Prodromal Phase – Alcohol becomes a need, blackout’s occur; denial begins to develop
  3. Crucial Phase – cardinal symptoms of alcoholism develops (loss of control over drinking)
  4. Chronic Phase – the person becomes intoxicated all day


Brain Damage

Alcoholic Hallucinosis


Common Behavioral problems of the Alcoholic Patient

Denial Dependency Demanding Destructive Domineering

Common Withdrawal Signs and Symptoms


Increased vital signs


Sweating and Seizure

Criteria D. Tremens Korsakoff Psychosis Wernickes P.

Cause Faculty metabolism Thiamine & Niacin Thiamine

of alcohol deficiency deficiency

Onset Acute Chronic Chronic

Essential Delirium Memory disturbances


Other S/Sx Vital Signs Retrograde A Confusion

Visual and tactile Anterograde A Opthalmoplegia

Coarse tremors Confabulation Ataxia

Korsakoff’s P. Thiamine def.

Long terms of care

Community resources

Other coping means aside from denial

Personal responsibility for not drinking


Nutrition Vitamin B & C, CHO diet

Group therapy

Nursing diagnosis: Ineffective individual coping

Principles of Nursing Care:

  1. Well-lighted room
  2. DAT
  3. Monitor vital signs
  4. Administration of glucose
  5. Vitamins

Drug of choice: Disulfiram (Anti-abuse) – delays the metabolism of alcohol


Mouth wash

Over the counter cold remedies

Food sauces made up of wine

Fruit flavoured extracts

Aftershave lotion


Skin products

Commonly Abused Substances

Substance Physical signs Withdrawal Effect

a. Stimulants

Amphetamine (shabu) Weight loss, hyperactivity depression


Cocaine perforated nasal septum psychomotor agitation

b. Narcotics

Heroin pinpoint pupils, drowsiness piloerection & runny nose

c. Hallucinogens

LSD dilated pupils & hallucinations none

Nursing Diagnosis:

Ineffective individual coping

Nursing interventions for substance abusers:

Behavior Modification (Firmness-matter of fact)


Antihypertensive; anti-anxiety- administered to patients who are abusing stimulants

Anti-anxiety; anti-depressants- administered to patients who are abusing depressants

Anti-anxiety (Librium), disulfiram (anti-abuse);- administered to patients who are abusing alcohol

XVII. Concept of Loss

Grief/Grieving-George Engel

  1. Shock, Numbness, Disbelief- Searching behaviour
  2. Yearning and Protest – anger towards God
  3. Anguish, Disorganization, and Despair – reality of the loss is accepted
  4. Identification stage- a family member imitates some characteristics of the dead person.
  5. Reorganization/restitution- life normalizes

Death/Dying: Elizabeth Kubler-Ross


Denial – “No, Not me!”

Anger - “Why me?”

Bargaining- “If only…”

Depression – silence

Acceptance – “Yes, it’s me.”

Nursing Diagnosis: Ineffective individual coping

Nursing Care:

  1. Be physically present
  2. Be non-judgmental
  3. Encourage verbalization of feelings
  4. Allow the patient to cry
  5. Recognize your own thoughts about death and dying


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