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JOSHUA F. FERNAN – Psychiatric notes

2011

PSYCHE NOTES ID

 Pleasure principle / immediate gratification  I, me, myself (I get what I want right NOW, I CAN’T wait)  Starts at INFANCY  dominant ID Manic, Antisocial, Narci EGO  Reality principle impaired reality schizophrenia  Uses defense mechanism  “I CAN wait”  Developed at TODDLERHOOD SUPEREGO  Conscience  “I SHOULD wait”  Small voice of God  Rewards and punishments  Developed at PRE-SCHOOL and SCHOOL AGE (OC-OC)  Dominant superego OC, Anorexia Nervosa Oral – 0 to 18mos Anal – 18 to 3y/o (toilet training phase) Phallic – 3 to 6y/o Latency – 6 to 12y/o Genitals – 12 to 19y/o Oral stage  If oral needs are UNMET ALCOHOLISM, smoker, binge eater  Let the baby cry for a while then give milk develop TRUST  Prolonged cry MISTRUST PARANOID Anal stage  Toilet training  Good Mom teach to control self, then result to INDEPENDENT  Bad Mom ANTISOCIAL (paglaki dura dito, dura doon. Mga umiihi sa pader)  Strict Mom – OC  If toilet training is MET, INDEPENDENT, if not result to ANTISOCIAL PERSONALITY Phallic stage  Complexes – elektra (female to her father), oedipal (male to his mother)  The child needs to graduate by identifying with same sex with parents  E.g. girl lipstick (motherly image), boy (gayahin ang porma ng ama)  Temper tantrums (naglulupasay sa floor pag hindi naibigay ang gusto)  Ignore the behavior (wag mag pa-uto!)  Do not let manipulated by child  When a child is exploring genital divert the attention (huwag pagalitan, hindi yun bastos! nag eexplore lang)  Castration anxiety – fear of body mutation (takot sa putol-putol)  Cover the affected part (kasi feel nila ok na)  Huwag takutin! SADISTA pag laki Latency stage  Focus on school  Says “I love my teacher/friends”, laging si teacher ang tama  Be supportive on his/her study

JOSHUA F. FERNAN – Psychiatric notes Genitals stage  Sexuality is awake (I love bf/gf)  Menarche (first menstruation), telarche (first breast) unconsciously (nagkukuyakoy )  Masturbation (normal, self gratification)  Risky behavior  Give love and attention

2011

females do masturbation sometimes

Levels of Consciousness  Consciousness (focused on awareness)  Sub consciousness (can be recalled)  Unconsciousness (largest part of mind, can never be recalled) DEFENSE MECHANISM  Unconscious adaptive efforts used by both mentally ill and mentally health COMMON DEFENSE MECHANISMS 1. Compensation  Kakulangan sa isang bagay, babawi sa isang area (to compensate)  Mahina sa test I, babawi sa test II 2. Conversion  Physical symptoms.  May exam bukas biglang nilagnat. 3. Denial  Unconscious refusal to admit unacceptable idea or behavior  Common to alcoholism 4. Displacement  Transfer to less threatening object  E.g. Gf nagalit sa bf kasi may nag text, binato ang cell phone 5. Fixation  Maturation  There was unresolved conflict during childhood  E.g. collection of things/toys during childhood that should be disposed, if not results to fixation 6. Introjections  Ginagaya ang katangian ng isang tao, bad or good  Common to those depressed 7. Identification  Idol yung mga “good qualities” lang, HINDI ang bad  Model oneself to respected person 8. Intellectualization  Act of getting away painful incident with the used of rationale explanation  Acknowledging the fact but not the emotion 9. Projection  Blaming others  Common to paranoid 10. Reaction formation  Deep inside galit, pero iba ang pinapakita  Showing opposite of what he/she feels 11. Rationalization  Justifying  The use of word “because”, “dahil”, “eh kasi” (with reasons)

JOSHUA F. FERNAN – Psychiatric notes

2011

12. Regression  Fetal position, thumb sucking  Dependent during hospitalization (utos ng utos pag nasa ospital kahit kaya naman)  Returning to an earlier and more comfortable developmental stage 13. Repression  Unconsciously forgetting  Common in raped victim (kasi tulala) 14. Suppression  Consciously forgetting  Common in anorexic client (sinasadyang kalimutan ang pag-kain) 15. Substitution  Replacing the desired unattainable goal to attainable goal  Gusto mag boracay, ilog pasig nalang 16. Sublimation  Re – channeling (unacceptable to acceptable)  Para mailabas ang tension, idadaan sa kanta 17. Symbolization  Use an objects, ideas, just to show your feelings  Mahal ang isang girl, bibigyan ng bulaklak 18. Undoing  To be guilt free, bawi ang masamang ugali  Make up for wrong doings DEFENSE MECHANISM UTILIZES BY SOME DISORDERS DISORDER Manic Depressed OC – OC Paranoid Catatonic Undifferentiated/disorganized

Alcoholic

Anorexic Bulimic Raped victim

DEFENSE MECHANISM

Reaction formation Introjection Projection Introjection

Undoing Reaction Formation Isolation Projection Repression Regression Denial (hindi ako lasing) Rationalization (nag inom ako “kasi…”) Isolation (iwan mo ako) Projection (iniwan mo ako eh, kasalanan mo!) Supression (sinadyang kalimutan ang pagkain) Denial (dinala sa hospital, “wala akong sakit!”) Reaction formation (ayaw kumain pero kain2x pa din) Repression (nakatulala) Denial (this is not true)

JOSHUA F. FERNAN – Psychiatric notes

2011

PERSONALITY DISORDER  Rigid maladaptive patterns of functioning that are stable through time  Etiologic:  Genetic  Temperamental (kinds of environment)  Biologic (chemical imbalance)  Psychoanalytic (fixation) during childhood stages CLUSTER A (eccentric/weird)

Paranoid Schizoid Schizotypal

CLUSTER B – dramatic

Borderline Histrionic Antisocial Narcissistic

CLUSTER C – anxious/toxic

Avoidant Dependent OC

CLUSTER A (mild)  Paranoid  Duda sa lahat ng bagay (e.g. tinitingnan lagi ni gf ang phone ni bf baka may ibang katext)  Pag laging may nag like sa post ni bf sa facebook, check agad ni gf ang profile ng taong yun (tamang duda sa lahat ng bagay)  Cause: hindi agad naibigay ang milk nung sanggol (prolonged cry mistrust)  Be consistent (para makuha ang trust)  Schizoid (boredom)  “I avoid because I’m bored”  Mga “toud” at “boring” na tao  Lack of motivation (pinalaki sa yaya nung bata pa kaya kulang sa kausap)  Problem with maintaining a relationship (hindi tumatagal ang relasyon)  Not interested in sex  Natural ang “deadma”  Motivate these patients by giving active friends.  Schizotypal  “I have some psychotic traits” such as magical thinking/hallucinations  Further assessment (baka schizophrenic nga)  Divert the attention kapag bumubulong bulong CLUSTER B – dramatic  Borderline  “I feel like an empty glass”  Problem in chemical imbalance  Araw-araw may problema  Mga “emo”, madalas mag post ng dramatic sa facebook  Suicidal tendency risk for injury (self directed) give antidepressant as ordered!  Give active friends.  Histrionic  “I love the attention”  Inappropriate dressing (para mapansin lang)  Pinalaking bida/centro/bunso ng pamilya (spoiled)  Set limits!

JOSHUA F. FERNAN – Psychiatric notes  Antisocial  “I disregard the rights, law, and rules”  This is due to anal fixation (bad mother)  Nagnanakaw ng sagot (antisocial), nagpapakopya (narci)  Set limits and present consequences of his/her actions.  Nurse approach KIND AND FIRM APPROACH  Narcissist  “I love myself”  Self love, conceited (sya lang ang magaling)  Set limits. CLUSTER C – anxious/toxic  Avoidant  “I avoid because I hate rejections”  He/she doesn’t want to be the center of attraction  Poor self-esteem (pinalaki ng parents na laging sinasabihan ng “bobo, tanga”)  Increase the self-esteem of your client, by letting succeed in task  Dependent  “I can’t live if living is without you”  E.g. Kung ano sayo ganun na din sakin (they can’t decide on their own)  They need support from others (due to poor self-esteem)  Increase self-esteem (let the client succeed in a task)  Obsessive-Compulsive  Perfectionist (this is due to anal fixation)  Candidate for depression antidepressant  Set limits EATING DISORDER Maslow’s hierarchy  Necessary for survival  Part of everyday life  Social activity Adolescents

candidate for eating disorder

Etiologic factors of eating disorder

Biologic Ethnicity Abundant of food Unsuccessful relationship Thin is “in” Ideal woman Family problems (strict parents) Ultimate goal to be perfect Lack of control

sociocultural (kung ano ang uso)

BEAUTIFUL

Etiologic factor of eating disorder

2011

JOSHUA F. FERNAN – Psychiatric notes

2011

Anorexia  Pre-occupied with food  Favorite place is grocery  Goal to GAIN weight  Behavioral modification (e.g. nag sisit up si client sa room, stop her in that behavior)  Characterized by: Ms Anorexia Mood is depressed Severly underweight

Amenorrhea (the reason why she goes to hospital for consultation) Nitrogen and urea increased in the blood Overly concerned not to gain weight (fluid & electrolytes imbalance ARRHYTMIAS) Resistant to treatment (DENIAL) Environment control (OC-OC) X (x) tolerate cold temp (will have lanugo for protection) Image disturbances Always thinking of food  Nursing diagnosis  Altered nutrition: less than body requirements  Altered health maintenance  Body image disturbances (haldol)  Fluid and electrolytes imbalance (candidate for cardiac arhythmias)  Potential for self directed violence SUICIDAL antidepressant  Therapy  Family therapy  Behavioral modification (includes rewards and punishments)  Meds: Elavil (antidepressant) Haldol (for body image disturbance) Antihistamine (to increase appetite) Bulimia  Binge (matakaw) weak enamel (due to acid)  Purging (sinusuka ang kinain) oral condition tonsil is red (acid) ORAL CARE  diet binge purging (cycle) at risk for esophaegeal varices  Very compulsive behavior  REMEMBER:  Nagsusuka metabolic alkalosis  Laxatives metabolic acidosis  purging my guilt feeling kaya pinipilit na isuka/ilabas ang kinain  Menstruation is irregular Seems happy Binge eating Underweight or overweight Laxative and diuretic abuse Induced vomiting Metabolic acid/alkalosis Increased dental caries Amylase are mildly increase

JOSHUA F. FERNAN – Psychiatric notes

2011

 Nursing diagnosis  Altered nutrition More than body requirements  Altered health maintenance  Body image disturbance  Potential self directed violence SUICIDAL give antidepressant  Therapy  Family therapy  Behavior modification  Gestalt therapy (target is self awareness) o Includes writing their thoughts, ideas, tasks in given diary, manual  Medications: o Haldol (for body image) o Tofranil (antidepressant) can cause URINE RETENTION (let the client void 1st )  Rules of weighing o Morning at the same time everyday o Light clothing or hospital gown o Weigh BEFORE meals and AFTER VOIDING o Check pocket and check hands  REMEMBER:  Stay with the client 1 to 2 hours after meals (to avoid purging)  Or let the client stays in the public place/area (continuous monitoring ) CHILDHOOD DISORDERS

ADHD (ihi)  Inattention (easily distracted, usually have an unfinished project) Hyperactivity Impulsivity  Onset: 7y/o below  Nursing diagnosis: risk for injury (others)  Therapy  Behavior modification (STOP or SET LIMITS)  Milieu therapy (pertains to environment, ayusin ang paligid dapat SAFE ENVIRONMENT)  Refer to SPET  Medication  Ritalin  Cylerc STIMULANT watch out for: Growth supression  Dexedrine Insomnia (give in the morning after meal) Appetite suppressant (or 6hours before sleep) AUTISM  Impaired interpersonal functioning (more on object)  Ritualistic behavior  Flat affect  Onset: 2y/o  Nursing diagnosis  Risk for injury  Impaired social interaction  With tantrums 3 H’s EAD BANG ELMET ALDOL

JOSHUA F. FERNAN – Psychiatric notes Safety

ADHD - dirty looking

Safety

- clumsy (risk for injury) - hyperactive

Schedule

- impatient

SET LIMITS

Talkative Out of class Blurts

2011

AUTISM Clean Flat affect SAFETY Consistent movement Repetitive Ritualistic behavior PROVIDE Security blanket CONSISTENCY Echolalia Incomprehensible USE SHORT words SENTENCES

MENTAL RETARDATION  Inadequate mental functioning  I.Q. less than 70  Can be cause by: alcoholic mother FAS (small heads, cheeky eyes, no filtrum)  SUPPORTIVE THERAPY  FOCUS: 5 R’s italin (to stimulate) estructured environment epitition of instruction ole modeling emotivation

R

SEXUAL DISORDERS Sexual desire disorder  Little or no sexual desire  Explore the past Sexual arousal disorder  Cannot comply the sexual requirement Orgasm disorder  Problem with those who cannot complete sexual response cycle  Male premature ejaculation (due to excitement)  Needs relaxation technique Sexual pain disorder  Dyspareunia  Explore unresolved conflict  Vaginismus (quickly excitement)  Due to raped victim  Spasm of the muscle muscle relaxant  Needs relaxation technique (kigel’s exercise) PARAPHILIAS 1. Exhibitionism  Recurrent intense sexually arousing fantasies, sexual urge or behaviors involving EXPOSING ONES GENITALS  Set limits! 2. Fetishism  Sexual urge through object (e.g. panty, brief) 3. Frotteurism  Robbing of body part (e.g. breast, legs)  Common in crowded area

JOSHUA F. FERNAN – Psychiatric notes

2011

4. Pedophilia  Most common type of paraphilia  Sexual desire/urge to younger people 5. Sexual masochism  Receiver of pain  From violent family and may be a victim of child abuse 6. Sadism  Giver of pain  Inflecting pain. From violent family 7. Voyeurism  Act of observing an unsuspecting person who is naked in the process of disrobing or engaging in sexual activity  Do masturbation when he/she sees a naked person (e.g. ung mga girls na nagbibihis) 8. Transvestic fetishism  Boys: ginagamit ang panty ng girls (and vice versa) 9. Necrophilia  Sex with the dead person  Poor self esteem and feels rejection 10. Zoophilia  Sex with animals  Poor self esteem and feels rejection 11. Scatologia  Sex on phone 12. Partialism  Sexual interest focus on body part  Felacio: insertion of pennis on mouth  Analingus: tongue to anus  Canalingus: tongue to vulva 13. Coprophilia  Sexual activity involving feces 14. Klismaphilia  Sexual activity with enema 15. Urophilia  Sexual activity involving urine 16. Masturbation  Form of self gratification Nursing intervention (SEXUAL DISORDERS)  Individual or group psychotherapy  Anti anxiety meds  Accept the person as individual  Avoid judgmental remarks  Protect the individual  SET LIMITS  Divertional activity  OBSERVE FOR DEPRESSION

JOSHUA F. FERNAN – Psychiatric notes CRISIS    

Temporary state of DISEQUILIBRIUM due to high anxiety Problem solving skills failed Coping mechanism failed and support system Nursing diagnosis: ineffective individual coping

Types of crisis SAM 1. Situational (unexpected) and Social (mother earth PREDICTED)  E.g. raped victim 2. Adventitious (mother earth UNPREDICTED) 3.

2011

The heart of crisis intervention is:  Care  Welfare  SAFETY (the no.1)  Security

Maturational

 Also called DEVELOPMENTAL  Something to do with age  Can be PREDICTED or ANTICIPATED (napag hahandaan)  Resolved first ASPECTS OF CRISIS INTERVENTION aim to return to PRE-CRISIS  LAST: 4-6 weeks return to OPTIMUM LEVEL of FUNCTIONING  Intervention: 6-8 weeks to solve IMMEDIATE PROBLEM  RESOLVED: 2-6 months Nursing intervention (how to resolve)  New defense mechanism (coping ability)  Support system  Nurse CONSISTENT, ACTIVE, DIRECTIVE, (someone who can guide) RAPED VICTIM  No consent 



 

Oral Vagina Anal Rapist attitude (or reason why people do it) o Powertrip (trip ko yan) o Anger (nanliligaw si boy, hindi sinasagot ni girl at ginagamit lang) o Sadist Nursing intervention o Safe environment o Physical examination immediately (without changing clothes, do not remove things) o DO NOT TOUCH! o Physical exam done by Obstetrician (OB doctor) Major responsibility PRESERVATION OF EVIDENCE Nursing diagnosis INEFFECTIVE INDIVIDUAL COPING

JOSHUA F. FERNAN – Psychiatric notes BATTERED WIFE SYSNDROME  Cycle of violence: tension  Attitudes: ABUSER o From violent family o Very low self esteem o Antisocial personality o Drug or alcohol user o Victim of abuse o Increase sense of control

acute battering

o o o

o o

undoing

2011

honeymoon

ABUSED From violent family Low self esteem Dependent personality

Uses denial Emotional acceptance of guilt for the abuser

 Nursing diagnosis: impaired skin integrity (bruises, lacerations)  Major responsibility PROVISION OF SHELTER/SAFETY! Report to women’s desk

S

CHILD ABUSED pecial child (poor eye contact due to poor self esteem) pecial parents (with history of victims of child abuse or UNRESOLVED CONFLICT) tressful (poverty, unemployment – displacement to child) ituations  Assessment o Head to toe (look for marks) o Fractures (old and new) o Visits (frequency)  Nursing diagnosis: impaired skin integrity  Major responsibility: report suspected child abused to DSWD, bantay bata 163 ANXIETY  Sense of impending doom  Emotional response to stress  G-amma A-mino chemical imbalance if decrease cause of anxiety B-utiric Nsg. Dx: ineffective individual coping A-cid Anxiety Powerlessness  Causes of anxiety: Impaired skin integrity o Conflict between the ID and SUPER EGO o Product of frustration Planning/implementation: o Exposure to early life fearful events  Assess the level then ask (what’s going on?) o Can run in the family  Decrease the level of anxiety and stay  MILD  Decrease or remove environmental stimuli o Attentive and alert  Relaxation technique o Minimal use of defense mechanism o Deep breathing  MODERATE o Showing pictures of flowers o Restlessness, GI irritation o Hearing sounds of chirping birds o Narrowed perceptual field o Selectively inattention Evaluation: Effective individual coping o Use of defense mechanism (moderate)

JOSHUA F. FERNAN – Psychiatric notes

2011

 SEVERE first priority is to move person away from all stimuli, then talk calmly o s/sx becomes the focus o GREATLY narrowed perceptual field o Use of defense mechanism starts to FAIL o Amnesia or dissociation can occur

o o o o o

Anxious Panic PTSD Phobia GAD OC

ANXIETY RELATED DISORDER Somatoform o Somatization o Psychogenic pain o Hypochondriasis o Conversion o Body dysmorphic

o o o o

Dissociative Amnesia Depersonalization Psychogenic fuge DID

 PANIC o o o o

Signs and symptoms of exhaustion are ignored Personality disorganization Defense mechanism FAILED Panic attacked:  P-alpitation A-goraphobia N-umbness/nausea I-ncreases V/S C-hest pain o Precaution: AFETY UICIDAL STAY TIMULI REMOVE  Nursing Diagnosis: o Ineffective individual coping o Anxiety  Nursing care: be CALM o C-alm and stay! A-nxiolytics as ordered L-isten to the patient’s concern M-inimize environmental stimuli PTSD  Flashbacks/nightmares (main symptoms)  E.g. raped victim, soldiers  Intervention: o Anxiolytics o Antidepressant o Group therapy Phobia  Irrational fear  Xenophobia (fear of strangers)  Agoraphobia (fear of market place)  Intervention: immediate nursing action o SYSTEMATIC DESENSITIZATION (gradual)  From least to maximum anxiety  Promotes relaxation  Enters reality o Meds (anxiolytics)

S

REMOVE THE STIMULI

JOSHUA F. FERNAN – Psychiatric notes

2011

GENERAL ANXIETY DISORDER  6 months or more apprehension (takot)  Nursing responsibility: o Assists with ADLs o Anxiolytics o Let the client express feelings OBSESSIVE-COMPULSIVE  Obsession (repetitive thoughts)  Compulsion (repetitive actions)  They do their “rituals” to decrease anxiety o Let the client do the rituals o Start the rituals earlier o Do not stop the rituals (pag pinigilan mo, lalong tataas ang anxiety) unless harmful  THERAPY: o Behavior modification o Meds: anxiolytics Antidepressant (anafranil, luvox) Anti O.C SOMATOFORM

SOMATIZATION  Feeling of loss of function  Causes poor self-esteem, high superego  Interventions: o Anxiolytics o Analgesics (for pain) o Divert o Listen to the problem o Normal PSYCHOGENIC PAIN  With pain but with normal lab results  Causes: stressful situation

HYPOCHONDRIASIS  Aggression  Misinterpreted symptoms (minor discomfort interpreted as MAJOR)  Causes: internal aggression turned toward self  G.I disturbances (always complaint)  Intervention: o Anxiolytics o Antidepressant o Divert and listen CONVERSION  Anxiety is converted to PHYSICAL SYMPTOMS  Causes: traumatic experience, stressful situations  Intervention: o Anxiolytics o Antidepressant o Divert and listen

JOSHUA F. FERNAN – Psychiatric notes BODY DYSMORPHIC  Unknown cause  Lipo, plastic surgery  Wants body perfection  Causes: poor self esteem, unknown  Intervention: o Anxiolytics o Antidepressant o Divert/listen DISSOCIATION  Nawawala sa sarili  Out of body experience  Amnesia o Retro/ante o Causes: anatomical anxiety related o Intervention:  Anxiolytics  Vitamin supplement  Group therapy  Depersonalization o Strangers towards the body o Causes: high superego o Intervention:  Anxiolytics  Antidepressant  Divert/listen  “feeling nya kamay nya ay naging kahoy”  Psychogenic fuge o Amnesia during travelling o Causes: anatomical, anxiety o Intervention:  Anxiolytics  Antidepressant supp.  Group or hypnotherapy  Dissociative identity disorder o Nag change ng voice o Several personality arising o Causes: traumatic childhood, victims of child abuse o Intervention:  Anxiolytics  Antidepressant  Hypnotherapy MOOD DISORDERS  Group of disorders characterized by decrease or entire loss of control over mood  Precipitating factors: o Loss of love ones o Major life events o Role strain o Decrease coping resources o Physiologic changes

2011

JOSHUA F. FERNAN – Psychiatric notes

2011

TYPES OF MOOD DISORDERS 1. Depression a. Major depression – severe, lasts for atleast two weeks. (NEEDS ECT) b. Dysthymic depression – less severe, lasts for two years or more c. Depression (not specified) – 2 days to 2 weeks 2. Bipolar disorder a. Manic – severe, lasts for atleast 1 week b. Hypomanic – less severe, last for atleast 4 days c. Bipolar I – with history of mania d. Bipolar II – no history of mania, hypomanic, with episodes of mania and depression e. Cyclothymia – episodes of hypomania and depressed mood atleast 2 years MANIC  Hyperactive  Talkative  Colorful  Environment: NON – STIMULATING  Activity: E.g. LET THE CLIENT ARRANGE THE BOOK SHELF  Meals: FINGER FOODS (sandwich, increased calorie foods, cheese burger, finger foods)  Nursing diagnosis: RISK FOR INJURY (directed to others), altered nutrition less than body requirement  Approach: MATTER OF FACT, PASSIVE FRIENDLINESS  Treatment: antipsychotic (haldol), antimanic (lithium) o LITHIUM  Initial dose 300mg  Maximum/day 900mg  Umaga binibigay (due to its diuretic effect)  10 – 14 days bago umipekto  3grams salt, 3 Liters of water DIET  Normal level: 0.5 – 1.5 meq/L  Maintenance level: 0.6 – 1.2 meq/L  Elderly: less than 1.0  Bawal sa buntis (teratogens!!)  Laboratory:  Every 2 weeks INITIAL  MONTHLY if regular lab result  Mag extract ng dugo after 8 -12 hours of last dose  TOXICITY: (NAVDAT) N – ausea A – norexia V – omitting ANTIDOTE: mannitol, diamox D – iarrhea A – bdominal pain T – remors (fine & course)  “pag mababa ang lithium under dose MANIC  “pag mataas overdose TOXICITY mannitol, diamox (antidote)

JOSHUA F. FERNAN – Psychiatric notes

2011

DEPRESSED  Anergia (lack of energy)  Avolition (no will)  Monotonous speech  Environment: stimulating, near nurse station  Activity: counting activity to express internal hostility (e.g. bingo)  Meals: assist in eating  Nursing diagnosis: risk for injury self directed (irregular visits dapat)  Approach: kind firm approach (kapag kailangan ng kausap at kapag suicidal ang patient)  Treatment o Antidepressant o ECT if major depression o ECT  Mechanism of action in unknown  70 – 150 volts  0.5 – 2 seconds (restrain during ECT)  6 – 12 sessions  PREPARATION  NPO 6 – 8 hours post midnight  General anesthesia preparation  PRE – ECT  Consent syempre!! (from family)  V/S  Remove metal, jewelries and dentures (RISK FOR ASPIRATION)  Explain that there will be temporary memory loss for 2 weeks  POST – ECT  V/S  Re – orient  With headache (tolerable)  DOB (respi dep)  ECT MEDS:  Atropine sulfate (decrease salivation to avoid aspiration)  Brevital (anesthetic para makatulog)  Anectine (relaxant, para sa DOB respi eh!) Endogenous Depression  Nagising kang malungkot ng walang dahilan (ewan kung bakit)  Something with chemical imbalance  Treatment: antidepressant Exogenous  Nagising ka na malungkot kasi may dahilan  Treatment: psychotherapy or kausap SUICIDE  Outcome of person inability to deal with catastrophic stress resulting from biological or including mood disorders  Risk factors o Depression o General medication, illness o Male o Living alone o Poor suicide attempt (nag attempt pero nabuhay) o Age 60 or older o Unemployed or financial problem

JOSHUA F. FERNAN – Psychiatric notes

2011

 Signs of suicide: o G – iving of valuables o S – udden change of mood (biglang sumaya) o M – entioning plan  Nursing responsibilities: o Explore kung ano yun!  Nursing diagnosis: o Risk for injury (self) o Potential for self directed violence  Interventions: o ROOM – near the nurse station, always open o Make sure that the room has no glass, sharps, bottles, strings o Give client self awareness o Visits – irregular manner. Silipin kahit anong oras. Usually 2am. o ALCOHOLISM (ABCDDE) 

Alcohol

Block out (awake but unaware)

o o o o

Alcohol CNS depressant Downer Most abused substance Intoxicated: 150/100ml of blood

o o o o o

Confabulation Denial, Dependence

Enabling

Alcoholic Oral fixation (weak ego, superego) Sociocultural (kailangan tanggapin ako ng society) Learned behavior (bad example by parents) Peers (influence by friends) Media (babae model ng alak, iinom din ako nyan)

 When present to ER o When was the last drink? o Amount? (to monitor withdrawal symtoms)  WITHDRAWAL SYMPTOMS: o Starts 4 – 8 hours o Peaks within 48 hours o Ends on 5th day o Signs and symptoms: (SEDATE) S – weating/seizure E – levated BP  Visual and tactile hallucination D – elirium tremens  Provide quiet and well lighted room A – nxiety T – achy/tremors E – levated pulse rate  Complication of alcoholism KORSAKOFF (thiamine and niacin deficiency) o R – etrograde amnesia (recent past) A – nterograde amnesia (immediate past) C – onfabulation K – orsakoff

WERNICKES (thiamine defficiency) o C – onfusion O - pthalmophlegia A – taxia (balance problem) T – hiamine deficiency

JOSHUA F. FERNAN – Psychiatric notes  Medication 1. Antabuse (disulfiram)

if using antabuse avoid “CALM FV” due to alcohol content C – ough syrups A – after shaves L – otions M – outhwash F – ruits extract V – inegar

2. Anxiolytics (lessen the withdrawal sx)  V – alium A – tivan L – ibrium  Nursing diagnosis: o Ineffective individual coping  Remember: 5 A’s ntabuse (bawal with renal failure) version therapy (introducing a stimuli para umiwas) l – anon (family) lcoholic anonymous (patient) nxiolytics

A

UPPERS: C – cocaine H – allucinogen A – mphitamine DOWNERS: A – lcohol M – arijuana B – arbiturate O – piates N – arcotic

2011

sign and symptom is downers!

sign and symptom is uppers!

M – orphine C – odaine H – eroine COMMON BEHAVIORAL SIGNS AND SYMPTOMS 1. Disturbances in perception  Illusion – misperception of an actual stimuli  Hallucination – false sensory perception in the absence of external stimuli 2. Disturbances in thinking  Delusion – false belief which inconsistent with ones knowledge and culture  Delusion of grandeur (believes to be a famous)  Delusion of persecution (may papatay sakin, ayan na sila)  Religion (ako si cristo)  Neologism  coining of new words (may sariling salita)  Circumstantiality  over inclusion of details. (hindi agad sumasagot pag tinanong mo)  Word salad  incoherent mixture of words (no connection)

JOSHUA F. FERNAN – Psychiatric notes

2011

 Verbigeration  meaningless repetition of own words (walang ginagaya, sariling salita)  Perseveration  persistence response to a previous question (same answer to question)  Echolalia  pathological repetition of words by others (I repeat what you say)  Flight of ideas  shifting of one topic to another in RELATED way  Loose of association  shifting of one topic in NOT RELATED way  Clang association  rhyming (e.g. fliptop) 3. disturbances in affect a. inappropriate affect  disharmony between the stimuli and emotional reaction  “Masaya daw pero wala sa mukha nya” b. Blunted affect  Severe reduction in emotional reaction c. Flat affect  Absence or near absence of emotional reaction d. Apathy  Dulled emotional tone e. Ambivalence  Presence of two opposing feelings ( ) f. Depersonalization  Strangeness towards one’s self/body g. Derealization  Strangeness towards environment (duda sa piligid) 4. Disturbances in motor activity a. Echophraxia  Pathological imitation/repetition of posture/action of others  “I repeat what you do” (ginagaya ang position ng kaharap) b. Waxy flexibility  Maintaining the desired position for a long period of time without discomfort  “I will be forever like this position” 5. Disturbances in memory a. Confabulation – filling in memory gaps b. Amnesia – inability to recall past events  Anterograde – loss of immediate past  Retrograde – loss of memory in distant past c. Dejavu – feeling of having been to place where one has NOT YET VISITED d. Jamais vu – feeling of not having been to a place which one HAS VISITED PSYCHOTHERAPY  Treatment of mental and emotional disorders using psychological methods THERAPY 1. Remotivation  Insight or self awareness 2. Music  Creating a positive attitude with the use of music  E.g. if depressed, slow to rock music 3. Play  To promote socialization and know the real condition of the child inside the house

JOSHUA F. FERNAN – Psychiatric notes

2011

4. Group  Minimum of 3 persons. 8 – 10 members ideal  “magkukwento ako sa ka member ko” (should have feedback)  Nurse ay observant lang!! 5. Milieu  Safety  Structured environment  Needs  Flexible nurse (para maka adjust agad) 6. Family  Interpersonal relationship, support each other  Minimum of 3 members. Minimum age is 5 7. Psychoanalysis Exploring the unknown. (usually referred to patient with dissociative disorder) 8. Hypnotherapy 9. Humor  Typical conversation (patient relaxed dapat)  Ginagawa ito ng mga affiliating nursing students sa NCMH 10. Behavior modification  Correcting what is presented as a wrong behavior.  It includes rewards and punishment  Extinction of the wrong behavior (wag ng ulitin)  To learn new behavior 11. Aversion  Introducing a stimuli (para umiwas manadya ka!) 12. Token  Rewards lang 13. Desensitization  Gradually expose to least to maximum anxiety followed by relaxation then present realilty 14. Cognitive  Thought. Immediate problem, immediate solution  Presenting reality 15. Gestalt  Includes manual, diary (para ilagay ang thoughts, ideas) SCHIZOPHRENIA  Split mind  Impaired ego  Characterized by disturbances in “BEMS” B – ehavior E – motions M – ovements S – ensory perception  Onset  Late adolescent or early adulthood  Gender: men 15 – 25; women 25 – 35

JOSHUA F. FERNAN – Psychiatric notes

PARANOID o One or more delusions or frequent hallucinations o Intervention:  Gain trust  Sealed foods  Don’t laugh or whisper  Don’t touch, distant at least 4ft  Consistent nurse

TYPES OF SCHIZOPHRENIA UNDIFFERENTIATED RESIDUAL DISORGANIZED CATATONIC o In needs or o Motor immobility o Pasumpong o There is personal assistant o Waxy flexibility sumpong continuing (nurse) Autism o Criteria for paranoid, evidence o All of the ff are Xtreme negativism catatonic, such as prominent: Isolation disorganized presence of o Peculiar movement subtypes are not met negative and  Disorganized o Prominent mannerism positive speech and grimacing symptoms  Disorganized o Echolalia and behavior echophraxia  Flat and o Interventions: inappropriate  Maximize affect circulation o Interventions:  Problem and loss of  Less muscle tone stimulating  Adequate diet area  Exercise and rest  Provide info boards or calendar with schedule  Give high calorie foods

Defense mechanism Nursing diagnosis PRIORITY Nursing care Prognosis

2011

CATATONIC Repression Impaired motor activity Circulation Nutrition Good

SYMPTOMS: POSITIVE or TYPE 1 (TYPICAL)  Ambivalence  Associative  Delusions  Echophraxia  Flight of ideas  Hallucinations  Ideas of reference  Perseveration

DISORGANIZED Regression Impaired social functioning Assist with ADLs

PARANOID Projection Potential for injury directed to others Nutrition and safety

Poor

Good

SYMPTOMS: NEGATIVE or TYPE 2 (ATYPICAL)  Anergia  Anhedonia  Avolition  Blunted affect  Communication difficulties

JOSHUA F. FERNAN – Psychiatric notes DRUGS

2011

1. Anti – psychotic  Decrease delusions, hallucinations and looseness of association  Antagonizes dopamine in the CNS  Effects is 2 – 4 weeks a. TYPICAL (for positive symptoms) o Stelazine (trifluoperazine) o Thorazine (chlorpromazine) o Mellaril (thioridazine HCL) leads to retinal pigmentation  Maximum of 800mg/day o Haldol (haloperidol) b. ATYPICAL (for positive and negative symptoms)  Clozapine (clorazil)  Causes leucopenia  Reports sore throat  Respiridon (risperdal)  Olanzapine (xyprexa) REMEMBER: (BLUEE PAANTS) BP monitoring (for orthostatic hypotension) Leukopenia (weekly CBC monitoring) o mask – like face Urinary retention (void first) o congentin EPS pseudoparkinsonism antiparkinsonian drugs Eyes blurring (safety!!) o artane Photosensitivity (umbrella, shades, sunblock) Akathisia (restless leg syndrome) Agranulocytosis (reports fever and sorethroat) NMS Tardive dyskinesia (irreversible) Some dizziness and sweating (SAFETY!)

2. Anxiolytics  Decrease anxiety for adequate sleep and given as muscle relaxant a. Diazepam (valium) Oxazepam (serax) Lorazepam (ativan) Chlordiazepoxide (Librium) REMEMBER: DACOT D – rowsiness (avoid driving or operate machine) A – lcohol is contraindicated C – BC monitoring (because anxiolytics can cause bone marrow depression O – rthostatic hypotension (sit first in bed, dangling feet then stand) T – ranquilizers are not allowed

JOSHUA F. FERNAN – Psychiatric notes 3. ANTI – PARKINSONIAN  Prevention of pseudoparkinsonism ANTICHOLINERGIC (ABC) A – kineton A – rtane B – enadryl C - ongentin

DOPAMINERGIC (PELS) P - arlodel E - ldepryl L - evodopa S - ymmetrel

2011

REMEMBER: “HALOS GAP” H – epatotoxity (monitor liver profile) A – void alcohol L – eukopenia (WBC monitoring) O – rthostatic hypotension S – eizures (SAFETY is PRIORITY!) G I irratation Avoid vitamin B6 Protein rich foods give

 Antiparkinsonian drugs in general “CAPABLES” o C – ongentin A – akineton P – arlodel A – rtane B – enadryl L – evodopa E – ldepryl S – ymmetrel 4. ANTI – DEPRESSANT a.SSRI (selective serotonin reuptake inhibitor) o Inhibit serotonin reuptake & destruction of serotonin to prolong its action o C italopram (celexa) Fluoxetine (prozac) Paroxetine (paxil) Setraline (zoloft) Fluvoxamine (luvox) o

Side effects: “WIND” W – eight loss (MIO, weight patient) I – nsomia (sa umaga ibigay) N – ervousness D – iarrhea b. TCA (tricyclic antidepressant) o Blocks reuptake the norepinephrine and serotonin @ presynaptic neuron o Drugs “ANTSAVE” Side effects “SWAP DOC”  A – sendin N – orpramin S – edation (SAFETY!) T – ofranil W – eight gain S – inegua A – nafranil A – nxiety (assess level) A – ventyl P - hotosensitivity V – ivactyl E – lavil D – ifficulty voiding O – rthostatic hypotnsion C – ardiodisturbances

JOSHUA F. FERNAN – Psychiatric notes

2011

c. MAOIs  Inhibit enzyme which is present in brain, blood, platelets, liver, kidney, spleen  Drugs “PA-NA-MA-MA” o Parnate Nardil Marphan Manerix o

o

o o o o

o o o o o o o

AVOID:     

Avocados Banana Cheese Fermented foods With preservatives

leads to hypertensive crisis ANTIDOTE Phentolamine 5 – 10 mg/IM

Watch out for “WOW GIRL”  W – eight gain O – rthostatic hypo W - eakness

THERAPEUTIC COMMUNICATION Offer self “I will stay with you” Silence Making observation “you seem sad” Active listening  Nodding  Eye contact  Lean forward Who, when, what, where General leads “go on I’m listening, what else” Broad opening – best opening line  How are you today? Restating Clarification Refocusing “we are talking about” Focusing  Tell me about  Today you are going to…

GI irritation Increase appetite Rrestlessness Lethargy (risk for injury

o o o o o o o o o o o

SAFETY!)

NON – THERAPEUTIC Don’t worry be happy Everything will be ok/alright Ignoring the client Changing the subject You are the most beautiful client Why Arguing Flattery You should do this now In my opinion Don’t ask question that is answerable by “YES” or “NO” (first to eliminate)