NCM 117 ELEARNING

Psychiactric Nursing Overview

a. Psychiatric Nursing: core, heart, basis, art of nursing

1. Interpersonal process
a. Communication
b. Caring
2. Goals
a. Dealing with emotional responses to stress and crisis
b. Satisfying basic needs
c. Learning more effective ways of behaving
d. Developing a healthy lifestyle
e. Achieving a realistic and positive self-concept

3. Responsibilities
a. Therapeutic relationship
b. Therapeutic environment
4. Uses nursing process
a. Assessment
b. Diagnosis
c. Planning
d. Implementation
e. Evaluation
5. Roles
a. Counselor
b. Teacher
c. Advocate
d. Leader, coordinator, manager

b. Theoretical Models of Treatment

1. Medical-biologic Model
a. Oriented to diagnosing mental disturbances as medical diseases
with specific classifiable manifestations
1. Diagnosis
a. History
b. Physical
c. DSM classification of disorders
2. Causes.
a. Biochemical
b. Psychological conditions
c. Psychophysiological conditions
 d. Structural problems

3. Focus
a. Accurate diagnosis
b. Selection of treatment modalities
c. Nurse's role is supportive, not therapeutic

b. Treatment
1. Physical or somatic
2. Interpersonal
c. Nursing Interventions
1. Assist doctor with somatic treatments
2. Prepare/teach client
3. Assist in interpersonal treatments of clients

2. Psychoanalytical Model (Sigmund Freud)

a. Oriented to uncovering childhood trauma and repressed feelings that
cause conflicts in later life
1. Psychopathology
a. Alterations in psychosocial behavior
b. Stress related behaviors
2. Structure of the mind
a. Id: contains instinctual primitive drives
b. Ego: mediates demands of primitive id and self-critical
superego
c. Superego: values and mores that guide behavior
d. Conscious: ability to recall or remember events
without difficulty
e. Unconscious: memories and thoughts that do not
enter awareness

3. Freud's psychosexual stages

a. Oral 0-1 years
b. Anal 1-3 years
c. Phallic (oedipal) 3-6 years
d. Latency 6-12 years
 e. Genital 12-young adult

b. Treatment modalities: clarify meaning of unconscious and

conscious events, feelings and behavior to gain insight
1. Transference (unconscious projection of feelings onto
others)
2. Countertransference
3. Free Association
4. Dream Analysis
5. Catharsis (talking it out)
c. Nursing Interventions
1. Guidelines for understanding human behavior
2. Determine adaptive/maladaptive personality traits
3. Individualize teaching based on psycho-sexual
development

3. Psychosocial Developmental Model: (Eric Erikson)

 Psychosocial tasks that are accomplished throughout the life cycle;
an individual who experiences failure in any stage is likely to have
greater difficulty achieving success in future stages of development
 Uses an interdisciplinary approach to treatment; wellness is on a
continuum

ERIKSON'S STAGES OF DEVELOPMENT

STAGE TASK BEHAVIOR
Trust Hopefulness, trusting
Infancy
vs vs
(0-18 mos)
Mistrust Withdrawn, alienated
Self-control
Autonomy
Early childhood vs
vs
(18 mos-3 yrs) Compliance and compulsiveness,
Shame, doubt
uncertainty
Initiative Realistic goals: explores, tests reality
Late childhood
vs vs
(3-5 yrs)
Guilt Strict limits on self-worry
Industry Explores, persistent, competes
School age
vs vs
(5-12 yrs)
Inferiority Incompetent, low self-esteem
 Identity Sense of self
Adolescence
vs vs
(12-20 yrs)
Role diffusion Confusion, indecision
Intimacy Commitment in love/work/play
Young adulthood
vs vs
(20-25 yrs)
Isolation Superficial, impersonal
Generativity Productivity, caring about others
Adulthood
vs vs
(25-65 yrs)
Stagnation Self-centered and indulgent
Integrity Sense of accomplishment
Old age
vs vs
(65 yrs-death)
Despair Hopelessness, depsression
ERIKSON'S STAGES DEFINED
     STAGE      DEFINITION
INFANCY(0-18 mos) Babies learn to trust one consistent caregiver
"Trust vs.   Mistrust" (not necessarily the mother)
Learning independence and self control: how
EARLY CHILDHOOD (18 mos - 3 years)
to affect the environment with direct
"Autonomy vs. Shame & Doubt"
manipulation
Personal exploration and selling goals that
LATE CHILDHOOD (3 - 5 years)
influence the environment: evaluating own 
Initiative vs. Guilt
behavior
SCHOOL AGE (5 - 12 years) Developing sense of self & competency:
Industry vs.  Inferiority learning to create and manipulate
Integrating life experiences for a sense of self
ADOLESCENCE (12 - 20 years) (trying new roles to see "what fits"; peer
Identity vs. role diffusion pressure creates tumultuous rebellions:
examines own sexual identity
Develop intimate or committed relationships:
YOUNG ADULTHOOD (20 - 25 years)
commit to work/ profession; seek balance in
Intimacy vs. isolation
life
Establishing and guiding next generation
ADULTHOOD (25 - 65 years)
"giving back" to society with creativity; 
Generativity vs. Stagnation
productivity and concern
Life review (necessary); accepting one's life
OLD AGE (65 years - death)
as fulfilling; worthwhile. successful: providing
Integrity vs. despair
a legacy
4. Basic Human Needs Model (Maslow): a hierarchy of needs; a belief that
needs are fulfilled in a progressive order
a. Levels
1. Physical
a. Air
b. Food
c. Sleep
d. Sexual expression
2. Safety
a. Avoiding harm
b. Feeling secure
3. Love and belonging
a. Group identity
b. Being cared about
c. Caring for others
d. Play
4. Self-esteem
a. Self-confidence
b. Self-acceptance
5. Self-actualization
a. Self-knowledge
b. Satisfying, interpersonal relationships
c. Environmental mastery
d. Stress management

b. Treatment
1. Interdisciplinary: shared roles
2. Developmental: interpersonal view of the self
3. Goal: fill needs in progressive manner
c. Nursing Interventions
1. Use needs and psychosocial development for assessment
2. Prioritize care based on needs according to hierarchy
3. Help client fulfill needs to relieve stress
4. Help client advance through stages to become more able to
fulfill own needs
5. Help client develop new behaviors to reduce stress and
prevent recurrences of mental illness and dysfunction
5. Behaviorist Model (behavior modification): "maladaptive behavior is learned"
a. Changes behavior by using learning theory: replaces nonadaptive
behavior with more adaptive behavior
b. Treatment
1. Reconditioning: unlearning learned or maladaptive behavior
2. Reinforcement: increases the probability of positive behavior
recurring
a. Positive reinforcement: per contract. use rewards to
increase or reinforce desired behavior (for example:
adding something such as food, attention, phone
privileges)
b. Negative reinforcement: per contract, extinguish
undesirable behavior by removing aversive
consequences (for example: removal of imposed
restrictions)
3. Positive punishment: decrease behavior by adding aversive
consequences (for example: quiet time)
4. Negative punishment: decrease behavior by withdrawing a
reward (for example. privilege, such as an outing or calls)

c. Main uses
1. Children
2. Severely regressed individuals
3. Personality disorders
4. Anxiety disorders such as phobias
5. Eating disorders
6. Mentally disabled clients
d. Nursing Interventions
1. Assess behavior
2. Implement specific behavioral interventions either negative or
positive reinforcement (contracts, roleplay, progressive
relaxation)
3. Emphasis is on positive reinforcement as a primary nursing
intervention
4. Evaluate progress; change behavioral interventions specific
to client need

6. Community Mental Health Model (psychosocial rehabilitation): individual

interacting with environment
a. Uses interdisciplinary team approach; nurse works as case manager
and supervises the team
 b. Emphasis is on providing treatment services in the least restrictive
setting
c. Treatment Modalities
1. Primary prevention: maintenance and promotion of health by
teaching (for example: risk factors, medication management,
health promotion and wellness)
2. Secondary prevention: early diagnosis and treatment (for
example: crisis intervention, partial hospitalization, acute care
hospitalization)
3. Tertiary prevention: rehabilitation, follow-up to avoid
permanent disability (for example: psychiatric "Day Care")
d. Nursing Interventions
1. Holistic care
2. Therapeutic use of self in the nurse/client relationship
3. Uses primary, secondary, tertiary prevention
4. Identify client needs, strengths, and community resources

c. Treatment Modes
1. Crisis Intervention
a. Definitions
1. Crisis: a sudden, disequilibrating event in one's life when
previous methods of problem solving are ineffective
2. Crisis intervention: brief treatment used to help clients cope
with or adapt to stressors
b. Type of crisis
1. Situational (unanticipated; for example: death, divorce, being
fired)
2. Transitional (maturational, anticipated; for example: birth,
marriage)
3. Cultural/social (for example: war)
c. Responses to crisis
1. Physiological (nervous system)
2. Psychological (panic, fear, helplessness)
3. Behavioral (extremes; talkative to withdrawn)

d. Principles of crisis management

1. Requires prompt intervention in calm, controlled atmosphere
2. Focus on client strengthens positive coping skills
3. Time limited (6-8 weeks)
e. Nursing Interventions
1. Provide therapeutic interventions to keep client focused on
immediate problem
 2. Set specific goals for resolution
3. Help client develop more adaptive coping behaviors; sense
of mastery
4. Reinforce client's own responsibility to act (collaborate)

2. Group Therapy
a. Definition: collection of 7-10 individuals interacting together with a
shared purpose
b. Dynamics and concepts
1. Content: work is done to problem solve and fulfill the group
functions and goals
2. Process: what is happening in the group; interactions,
seating, participation
3. Cohesiveness: feeling of belonging, helpfulness, problem
solving, sharing
4. Norms: standards of behavior adhered to by group

c. Nursing Interventions
1. Assume leadership role
2. Promote problem solving
3. Direct group towards common goals and tasks.
4. Set limits and prevents scapegoating within group
5. Clarify issues and promote consistency
6. Support members

d. Types of groups
1. Supportive, therapeutic
2. Psychotherapy
3. Task groups
4. Teaching groups
5. Peer support
6. Self-help groups
a. 12 Step (Alcoholics Anonymous (AA),
Al-anon, Alateen, Overeaters
Anonymous)
b. Recovery, Inc.
c. Ostomy Clubs
 3. Family Therapy
a. Definition: psychotherapy in which the focus is on the
family as the unit of treatment, not just one individual
b. Concepts
1. Systems approach: member with the
manifestations, illness
2. Scapegoating: the object of blame or
displaced aggression, usually one member of
the family
3. Family involvement is necessary for treatment

c. Nursing Interventions
1. Help family reestablish communication between members
2. Help family redefine roles and rules
3. Clarify ambiguous communication patterns between family
members
4. Support individual family members
5. Teach family problem solving techniques
6. Help the family accept differences among the members

4. Milieu Therapy
a. Definition: management of the client's environment to promote a
positive living experience and facilitate recovery (holistic approach)
b. Concepts
1. Client government: groups and meetings between client and
staff to promote shared responsibility and cooperation
2. The environment in the facility is as close to the "real world"
as possible and has potential for therapeutic value
c. Nursing Interventions
1. Guidance in developing new ways of relating and learning to
cope more effectively
2. Help client maintain strengths
3. Management of day-to-day activities
4. Provide a positive, therapeutic environment through
environmental manipulation
5. Assist in developing effective relationship and coping skills

5. Adjunctive Therapies
a. Definition: therapies used to aid assessment, increase social skills,
 encourage expression of feelings and provide opportunities to raise
self-esteem, relieve tension and be creative
b. Types:
1. Dance: movement
2. Recreational: picnic, volleyball
3. Occupational: painting, hand work
4. Art: clay, painting, drawing
5. Alternative therapies: pet therapy, reminiscence therapy,
music therapy

6. Interdisciplinary Team Approach

a. Definition: A team with members of different disciplines involved in a
formal arrangement to provide client services while maximizing
educational interchange
b. Members of the team:
1. Nurse
2. Primary Care Provider
3. Social Work
4. Psychologist
5. Case Manager
6. Occupational Therapist
7. Recreational Therapist
8. Job Coaches
9. Mental Health Technicians
c. Nursing interventions: The nurse works collaboratively with the
interdisciplinary team to promote and maintain health

d. Mental Health & Mental Illness Continuum

1. Mental Illness
a. Inability to cope/manage stress
b. Development of maladaptive behavior
c. Disruption in ability to relate successfully with others
d. Inability to meet basic needs in a socially acceptable
way

2. Mental Health
a. Positive attitude toward self
b. Growth, development, self-actualization, autonomy
c. Ability to cope with stress
d. Reality perception and environmental mastery
3. Defense Mechanisms
a. Definition: unconscious operations used to defend
against anxiety or stress and relieve emotional
conflict
b. In contrast, coping mechanisms are conscious efforts
to deal with daily frustrations and conflicts
c. Unconscious defense mechanisms
1. Sublimation: directing energy from
unacceptable drives into socially acceptable
behavior (for example: aggressive person
becomes a star football player)
2. Isolation: splitting-off response in which
person blocks feeling associated with
unpleasant experience (for example: planning
out funeral details of a loved one)
3. Reaction formation: involves displaying overt
behavior or attitudes in precisely the opposite
direction of unacceptable conscious or
unconscious impulses (for example: feeling
compassion for a person you dislike)
4. Undoing: a compulsive response that negates
or reverses a previous unacceptable act (for
example: washing hands [of guilt] after
touching germs)
5. Compensation: putting forth extra effort to
achieve in areas of real or imagined deficiency
(for example: an unpopular student excels as
a scholar)
6. Projection: attributing own thoughts or
impulses to another person (for example: "You
made me take a wrong turn.")
7. Introjection: incorporating the traits of others
(for example: a depressed client causes the
nurse to become depressed)

8. Suppression: deliberate forgetting of

unacceptable or painful thoughts, impulses,
acts
9. Repression: unconscious, involuntary
forgetting of unacceptable or painful thoughts,
impulses, feelings, or actions (for example:
forgetting what was on a difficult exam)
10. Denial: avoidance of disagreeable reality by
ignoring or refusing to recognize it
11. Rationalization: offering a socially acceptable
or logical explanation for otherwise
unacceptable impulses, feelings, and
 behaviors (for example: "I failed the NCLEX-
RN because it is a poor test.")
12. Regression: going back to an early level of
emotional development (for example:
becoming dependent on someone else for all
decisions)
13. Fixation: Being stuck in a particular level of
development
14. Displacement: transferring painful feelings to a
neutral object (for example: you're angry at
your brother so you kick the dog)

e. Nurse & Client Relationship: an interpersonal, collaborative helping

process and organized sequence of events leading toward a
mutually identified goal
1. Characteristics
a. Professional vs. social
b. Purposeful
c. Nonjudgmental
d. Designated setting and time
e. Organized sequence of events
f. Goal directed to facilitate client's growth vs. reciprocal

1. Collaborative contract that outlines and

clarifies role expectations
2. Confidential

2. Phases of the nurse/client relationship

a. Preinteraction phase
1. Gather data from secondary source
2. No prejudgment
3. Assess nurse's feelings
4. Assess client's feelings
b. Orientation phase: assessment
1. Introduction: purpose, roles, responsibilities
2. Establish trust
a. Honest
b. Nonjudgmental
c. Empathetic
d. Offer self
3. Assess client
a. Orientation
b. Activities of daily living (degree of
ability lo perform)
c. Physical status
d. Memory (recent and remote)
e. Emotional state
f. Intellectual capacity
g. Family history
h. Spiritual history
 i.Alcohol and drug history (OTC and
prescription)
j. Identify problem
4. Formulate contract
a. Time of meeting
b. Confidentiality
c. Focus: goals that arc behaviorally
stated

c. Working phase: planning and intervention

1. Establish specific collaborative goals
2. Explore thoughts, feelings, actions
3. Establish nursing diagnosis
4. Problem solve

KEY INFORMATION

5. Communication tools
a. Listening: nonverbal, use eye contact
b. Offering self: "I'll stay with you."
c. Focusing: on "here and now" and on
the client
d. Broad openings: "How are things going
today?"
e. Clarifying: "What does that mean to
you?”
f. Reflecting: directing back ideas,
feelings, and content, "You feel tense
when you fight."
g. Empathy: stating a feeling implied by
the client
h. Summarizing: "Today we have
discussed..."
i. Silence: sitting, conveying nonverbal
interest
j. Sharing perceptions: "You seem
angry"
k. Restating: repeating the main thought
"You are sad"
l. Validating: "Are you saying..."
m. Giving information (for example:
answering a direct question, teaching)

6. Communication blocks
a. False reassurance: "Don't worry."
b. Agreeing and disagreeing: "I think you
did the right thing."
c. Advice: "You should . . ."
d. Judging: "That was good."
e. Belittling: "Everyone feels like that."
 f. Defending: "All the doctors here are
great."
g. Approval: good or bad
h. Focus on nurse: "I feel that way, too."
i. Changing the subject
j. Ignoring a client
k. Changing client's words or assuming
feelings

d. Termination phase: termination begins on admission

or first contact. The nurse prepares the client for this
eventuality during the first meeting
1. Evaluation of behavioral goals
2. Transfer to other support systems
3. Assess for separation reactions such as
regression, acting out, anger, withdrawal
4. Help express and work through feelings
5. Be alert to nurse's response to separation
6. Do not promise to continue the relationship or
schedule future appointments

LESSON 2

Anxiety

a. Definition: anxiety and apprehension are tension in response to a perceived

physical or psychological threat (internal or external) resulting in feelings of
helplessness and uncertainty
b. Responses
1. Psychological
a. Fear
b. Impending doom
c. Helplessness
d. Insecurity
e. Low self-confidence
f. Anger
g. Guilt
2. Defense mechanisms
a. Displacement
b. Regression
c. Repression
d. Sublimation

3. Physiological: nervous system

 a. Dry mouth
b. Elevated vital signs
c. Diarrhea
d. Increased urination
e. Palpitations
f. Diaphoresis
g. Hyperventilation
h. Fatigue
i. Insomnia
j. Sexual dysfunction
k. Irritability
l. Fidgeting, pacing
4. Behaviors
a. Fight or flight response
b. Talkative, giggly, angry, withdrawn

LEVELS OF ANXIETY
PHYSIOLOGIC COGNITIVE BEHAVIORAL CHANGES NURSING
RESPONSE STATE INTERVENTIONS
Slight discomfort,  Perceptual field *- Restlessness (inability to *- Listen
restlessness; tension can be heightened; work toward goal) *- Promote
relief; fidgeting, tapping learning can occur *- Examine alternatives problem solving
Increased  pulse, Perceptual field *   Focus on immediate *- Calm,  
respirations, shakiness, narrows: selective events discussion
voice tremors, difficulty in attention *- Benefits from guidance of  - Relaxation
concentrating, pacing others exercises
Elevated BP Perceptual field - Feelings of increasing threat;  +- Listen
tachycardia, somatic  greatly reduced; purposeless activity *- Encourage
complaints, attention  * - Feeling of impending doom expression of
hyperventilation, scattered; cannot feelings
confusion attend to events * - Concrete activity
   even when pointed Reduce stimuli
out (channel energy
into simple
- Immobility or severe - Perceptual field - Mute  or psychomotor * - Isolate
hyper- activity; cool, closed agitation stimuli
clammy skin; pallor: * - Hallucinations  * - May strike out physically or * - Stay with client
dilated pupils; severe or delusions may withdraw * - Remain very
shakiness occur - Loss of control calm
*- Prolonged anxiety can * - Effective * - Decrease
lead to exhaustion decision making is demands
impossible * - Protect client
 safety
* - Do not touch
client
Important      

Maladaptive Resposes to Anxiety

1. Anxiety disorders: characterized by fear that is out of proportion to external events;

attacks lasting minutes to hours
a. Panic disorders
1. Definition: sudden onset of intense apprehension, fear or terror
(panic attacks)
2. Physical Manifestations
a. Dyspnea
b. Palpitations
c. Chest pain
d. Faintness, dizziness
e. Fear of dying or going crazy (out of control)
f. Choking
g. Depersonalization or derealization
h. Hyperventilation

3. Nursing Interventions
a. Stay with client and remain calm
b. Reassurance and support
c. Remove anxiety-producing stimuli
d. Have client take deep breaths
e. Distract client from anxiety producing stimuli
f. Provide a paper bag for hyperventilation

b. Phobic disorders
1. Definition: persistent or irrational fear of a specific object, activity, or
situation that leads to avoidance (for example: fear of flying)
2. Types
a. Agoraphobia: fear of being away from a safe place or person in
which there is no escape
b. Simple: irrational fear of object or situation
c. Social (Social anxiety disorder): irrational fear that social situations
expose one to possible ridicule or embarrassment
3. Defense Mechanism
a. Repression
b. Displacement
c. Avoidance
4. Nursing Interventions
a. Teach client relaxation techniques
b. Avoid major decision making
c. Utilize behavior modification techniques
d. No competitive situations
e. Provide gradual desensitization experiences
f. Assist client in verbalizing thoughts and feelings of anxiety

c. Obsessive-compulsive disorders (OCD)

1. Definition: recurring obsessions or compulsions
a. Obsessions: recurring thoughts of violence, contamination, doubt,
and worry that cannot be voluntarily removed from consciousness.
b. Compulsions: recurring, irresistible impulse to perform acts (for
example: touching, rearranging, checking, opening and closing,
washing)
c. Obsessions and compulsions may occur together or separately
d. Client's attempt to reduce anxiety

2. Characteristics
a. Irrational coping to handle guilt
b. Feelings of inferiority and low self esteem
c. Compulsion to repeat act
d. Repeating act prevents severe anxiety
e. Defense Mechanisms
1. Displacement
2. Undoing
3. Isolation
4. Reaction formation

3. Nursing Interventions: nursing interventions are aimed at reducing client anxiety.

a. Distract: substitute
b. Do not interrupt compulsive act
c. Schedule time to complete ritual; gradually decrease the time and number
of times ritual performed
d. Provide safety
e. Maintain structure, schedules, activities
 f. Demonstrate acceptance of individual
g. Encourage expression of feelings
h. Antianxiety medications may be used to relieve manifestations

d. Post Traumatic Stress Disorder

1. Description: Significant, recognizable stressor or trauma outside the usual
range of experience; results in recurrent subjective reexperiencing of the
trauma.
2. Characteristics
a. Recurrent and intrusive
b. Distressing dreams
c. Intense psychological stress
d. Avoidance of stimuli

3. Nursing Interventions
a. Teach relaxation techniques
b. Assess for suicide potential
c. Encourage client to express feelings

2. Somatoform disorders: physical manifestations and complaints without organic

impairment (no real pathology, for example: soldiers paralyzed during war with no
real injury)
a. Conversion disorders (hysteria)
1. Definition: alteration in physical function that is an expression of an
unconscious psychological need
2. Characteristics of manifestations
a. Sensory: blindness, deafness, loss of sensation in
extremities
b. Motor: mutism, paralysis of extremities, ataxia, dizziness
c. Visceral: headaches, difficulty breathing
d. Convulsive disorder with a typical seizure response
e. Little concern about manifestations: la belle indifference
f. Defense mechanism: repression of conflict and conversion of
anxiety into manifestations
g. Primary gain: suppressing conflict
h. Secondary gain: sympathy or avoidance of unpleasant
activity gained
3. Nursing Interventions
a. Redirect client away from manifestations
b. Encourage client to express feelings
c. Utilize stress reduction techniques
d. Teach client relaxation techniques
e. Understand the symptoms are real to the client
f. Engage client in schedule of daily activities to decrease time spent focusing
on symptoms and counter secondary gain

b. Hypochondriasis
1. Definition: exaggerated preoccupation with physical health, not based on
real organic disorders, not pathology
2. Characteristics
a. Multiple manifestations
b. Worried/anxious about manifestations
c. Seeks medical care frequently from multiple health care providers
3. Nursing Interventions
a. Help client express feelings
b. Set limits on rumination
c. Do not feed into the manifestations

3. Psychophysiological/psychosomatic disorders (Stress-related disorders)

1. Definition: stress-related medical disorders with true pathology:
psychosocial factors pre-dispose client to episodes of illness and influence
the progression of manifestations; can be fatal if not treated adequately.
These disorders are characterized by increasing anxiety in addition to the
physical manifestations. Clients are often first treated in medical facilities.
2. Defense Mechanism
a. Repression
b. Introjection

3. Types
a. Migraine
b. Ulcerative colitis
c. Peptic ulcer
d. Eczema
e. Cancer
f. Rheumatoid arthritis
 4. Nursing Interventions
a. Care for physical signs
b. Educate client about body/mind relationship
c. Teach client relaxation techniques (for example: biofeedback imagery,
progressive relaxation)
d. Assist client to express thoughts and feelings
e. Encourage self health promotion and regulation activities (for example:
relaxation, exercise)
f. Promote positive lifestyle changes

4. Dissociative disorders (hysterical neuroses)

1. Definition: splitting off an idea or emotion from one's consciousness;
"psychological flight" from anxiety (common with abused children)
2. Types
a. Multiple personality
b. Psychogenic fugue
c. Psychogenic amnesia
d. Depersonalization

3. Nursing Interventions
a. Assess client to rule out organic pathology
b. Help client recognize when dissociation occurs
c. Help client express feelings
d. Initiate individual, group, and family psychotherapy

5. Somatic treatment for maladaptive responses to anxiety, insomnia, and stress-

related conditions

ANTIANXIETY AGENTS
CHEMICAL CLASS GENERIC NAME TRADE NAME MEDICATION ALERTS
Benzodiazepine - chlordiazepoxide - Librium - Benzodiazepines: Warn clients
compounds - diazepam - Valium about sedating effects,
- oxazepam - Serax - Avoid activities requiring mental
- clorazepate - Tranxene alertness
- lorazepam - Ativan - Monitor for signs of drug
- alprazolam - Xanax dependence.
 - clonazepam - Klonopin - Withdrawal up to two weeks; risk
- clomipramide - Anafranil for seizure.
HCL - Anafranil, commonly used for
OCD, should be cautiously used in
clients with cardiovascular disease
and is potentially
fatal in overdose
Mephenesm-like meprobamate Miltown, Equanil  
compounds
Sedating hydroxyzine Vistaril, Atarax Antihistamines tend to cause drying
antihistamines and sedation
Beta-blockers propranolol Inderal  
(SSRI) Selective paroxetine Paxil Shown to be effective with Social
Serotonin Reuptake Anxiety Disorder. Allow 2-3 weeks
Inhibitors to note effects
Anxiolytics buspirone BuSpar BuSpar-non-sedatmg, allow 2-3
weeks to note effects. Do not use
concurrently with alcohol or history
of hepatic disease
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LESSON 3

Schizophrenia

a. Definition: group of psychotic disorders characterized by regression, thought

disturbances(including delusions and hallucinations), bizarre dress and behavior,
poverty of speech, abnormal motor behavior, and withdrawal

b. Manifestations
1. Delusions: fixed false beliefs; can be paranoid, grandiose, or somatic
delusions
2. Hallucinations: sensory perceptions without any environmental stimuli (for
example: hearing voices, seeing spiders, smelling foul)
3. Illusions: misidentification of actual environmental stimuli; client may see an
 electrical cord as a snake
4. Ideas of reference: personalizing environmental stimuli (for example: client
believes static on telephone is wiretapping)
5. Neologisms: made up words
6. Circumstantiality: can't come to point, includes nonessential details
7. Blocking: interrupt flow of speech due to distracting thoughts, words, ideas,
subjects
8. Regressive behavior: behavior appropriate at earlier stage of development
9. Echolalia: repetition of words or phrases heard from another person
10. Clanging: repeating words or phrases that sound the same but not related
11. Pressured speech: words rush out quickly
12. Poor interpersonal relationships
13. Declining ability to work, socialize, care for self

c. Types
1. Disorganized: incoherent, severe thought disturbance, shallow,
inappropriate, often silly behavior and mannerisms
2. Catatonic (psychomotor)
a. Stupor: lessening of response
b. Excitement: increase in activity
c. Waxy flexibility: bizarre posturing
d. Negativism: doing the opposite of what is being asked
e. Mutism: continuous refusal to speak
f. Severe withdrawal

3. Paranoid (can be dangerous)

a. Hallucination: grandiose or persecutory
b. Delusions: persecution and grandeur
c. Emotions: angry, suspicious, argumentative, mistrust, excessive
religiosity of a punitive nature
4. Undifferentiated
a. Mixed characteristics
b. Meets criteria of more than one type

d. Nursing Interventions
a. Provide physical care
b. Promote client safety
c. Increase client trust with a 1:1 nurse/client relationship
 d. Orient to reality
e. Provide structure to the day
f. Involve family
g. Interactions should be simple and concrete; often nonverbal and short
h. Help work through regressive behavior
i. Decrease bizarre behavior, anxiety, agitation, aggression
j. Deal with hallucinations
1. Distract client
2. Do not confront; do not deny
3. Point out that you do not share the same perception, but
acknowledge that the hallucination is real to client
4. Seek to establish feelings
5. Avoid leaving client alone (client will hallucinate more)
6. Engage client in activities (for example: current events discussion
groups)

e. Nursing Focus
a. Provide least restrictive environment, avoid restraining
b. Provide care in a firm matter-of-fact manner that allows participation
c. Provide consistency, positive reinforcement, and unconditional acceptance
of client

Paranoid Personality Disorder

a. Definition: insidious development of a permanent and unshakable delusional

system accompanied by preservation of clear and orderly thinking
b. Characteristics
1. Projection: unacceptable feelings are attributed to others
2. Delusions of grandeur and/or persecution
3. Ideas of reference (for example: personalizing environmental stimuli)
4. Resistance to treatment
5. Loneliness and distrust (failed Erikson's Stages)
6. Refusal to eat
7. Suspiciousness and fear
8. Emotional expressions are appropriate to content of delusional system
9. Argumentative and hostile

c. Nursing Interventions
1. Persecutory delusions
a. Do not argue or confront
 b. Interject reality when appropriate
c. Get to feeling level
d. Discuss topics other than delusions
2. Aggression and hostility
a. Help client express self verbally
b. Set limits and offer alternatives
c. Keep at a safe distance
d. Don't respond with aggression; use calm controlled tone
e. Use direct, simple statements
f. Keep other clients away
g. Decrease stimulation with time out
h. Have back up and use speed when restraining
i. Seclude as last resort
j. Provide outlet for aggression
k. Monitor

3. Fear of being poisoned

a. Serve food in containers
b. Medications should be wrapped or in containers
c. Do not covertly put meds in juice
d. Open meds in presence of client

d. Nursing Focus
a. Attempt to de-escalate client's aggression, allow opportunity to gain control
b. Avoid verbal and nonverbal communication that could be interpreted as a
threat
c. Respect the client's personal space and avoid touching as they may strike
out in response to fear and anxiety

Pervasive Developmental Disorders

1. Autistic Disorders
a. Characteristics
1. Lack of interest in human contact
2. Compulsive need for following routines; distressed by slight
environmental changes
3. Abnormal or no social play
4. Autoerotic behavior (for example: rocking. excessive masturbation)
5. Abnormal nonverbal communication
6. Self-mutilation (for example: head banging)
7. Impaired ability to form peer relationships
8. Abnormal production of speech and content
9. Obsessional attachments to inanimate objects
 10. Impaired ability to form peer relationships

b. Nursing Interventions
1. Assess social and physical aspects of client
2. Assess family understanding and coping
3. Facilitate communication (verbal and/or nonverbal)
4. Maintain optimum level of functioning and prevent regression

2. Attention Deficit/ Hyperactivity Disorder

a. Characteristics
1. Fails to complete task
2. Easily distracted
3. Difficulty concentrating
4. Acts before thinking, impulsive
5. Has difficulty sitting still

b. Nursing Interventions
1. Assist to communicate effectively
2. Set stage for improving ego function
3. Help learn more adaptive coping behaviors
4. Initiate supportive and educative methods for assisting parent and
child
5. Promote client safety when head banging or other self-destructive
behaviors are exhibited
6. Techniques to use:
a. Play therapy
b. Cognitive-behavioral
c. Family therapy
d. Psychopharmacology: methylphenidate (Ritalin)

Medications: antipsychotics (for schizophrenic and paranoid behavior patterns);

compliance is a problem secondary to adverse reactions

1. Block dopamine receptors

a. Target positive manifestations
 1. Negativism
2. Combativeness
3. Disorganization
4. Hallucinations, delusions
5. Hostility
6. Suspiciousness
7. Seclusiveness
8. Self-care deficits
b. Negative manifestations not affected
1. Apathy
2. Withdrawal
3. Insight
4. Lack of interest
5. Blunted affect
6. Judgment

ANTIPSYCHOTIC AGENTS
CHEMICAL CLASS GENERIC NAME TRADE NAME MEDICATION
ALERT
Phenithiazine, Chlorpromazine Thorazine  
aliphatic
Phenothiazine, -thioridazine -Mellaril  
piperidine -mesoridazine -Serentil
Phenothiazine, -fluphenazine -Prolixin  
piperazine -perphenazine -Trilafon
-triflouperazine -Stelazine
Thioxathene, Thiothixene Navane  
piperazine
Butyrophenone haloperidol Haldol  
Dibenzoxapine -loxapine -Loxitane -Clozaril is an
-clozapine -Clozaril effective
antipsychotic
especially in clients
not responding to
other neuroleptics
-Clozaril requires
weekly CBCs
Thienobenzodiazepin -olanzapine -Zyprexa Zyprexa is mirrored
e -quetiapine -Seroquel after Clorazil with
 -sertindole -Serlect fewer adverse
reactions. Does not
require weekly
CBCs
Benzisoxazole risperidone Risperdal -Risperdal has
fewer EPS and
targets negative
and positive
symptoms
-Can be used
safely in the elderly

ANTIPSYCHOTIC AGENTS’ ADVERSE REACTIONS

ADVERSE REACTIONS NURSING INTERVENTIONS MEDICATION ALERT

Sedation Most common in low- Sedation is common in
potency antipsychotics; ask Thorazine and Mellaril
primary care provider if
entire dose can be given at
bedtime
Extrapyramidal effects Report to the primary care EPS is usually
(EPS): parkinsonian provider; specific medication associated with high
symptoms (for example: may be changed; potency (Stelazine,
fine hand tremors, pill antiparkinsonian medication Navane, Haldol, and
rolling, drooling, muscle is given to control Loxitane); least likely to
stiffness) manifestations have EPS with Mellaril
Dystonia: muscle spasm of Report to primary care  
the face and neck; eyes provider; usually an
rolling back in head antiparkinsonian medication
is given and the
antipsychotic medication is
changed
Akathisia: restlessness, Call primary care provider; if  
inability to sit still treated with antiparkinsonian
medications, may need to
change antipsychotic
medication
Tardive dyskinesia: lip Careful observation in early  
smacking, sucking, tongue steps of treatment;
protrusion, jerking of the discontinue medications at
head and neck, extension first sign to prevent
and flexion of the fingers, permanent disability;
back and forth movement Abnormal Involuntary
of spine, movement of the Movement Scale (AIMS) is
arms used to assess clients for
permanent adverse
reactions

Adverse reactions: anticholinergic

1. Blurred vision
2. Dry mouth
3. Constipation
4. Urinary retention
5. Drowsiness
6. Nervousness
7. Photosensitivity
8. Hypotension

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