05 psychiatric nursing

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Levels of Levels of Interventions in Interventions in

Psychiatric Nursing Psychiatric Nursing

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Primary• Interventions aimed at the promotion

of mental health and lowering the rate of cases by altering the stressors

• Examples– Health education– Information dissemination– Counseling

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Secondary • interventions that limits the severity

of a disorder.

2 Components• Case finding• Prompt treatment

Examples:• Crisis intervention• Drug administration

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Tertiary• Interventions aimed at reducing the

disability after a disorder

2 Components• Prevention of complication• Active program of rehabilitation

Examples:Alcoholics anonymousOccupational therapy

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The Psychiatric The Psychiatric Nurse Nurse

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CharacteristicsCharacteristics• Empathy - the ability to see beyond

outward behavior and sense accurately another persons’ inner experiencing

• Genuineness/congruence – ability to use therapeutic tools appropriately

• Unconditional positive regard - respect

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Roles of the Nurse in Roles of the Nurse in Psychiatric SettingPsychiatric Setting

• Ward manager • Socializing agent• Counselor• Parent surrogate• Patient advocate• Teacher• Technician• Therapist• Reality based• Healthy role model

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Principles of Care in Psychiatric Principles of Care in Psychiatric SettingsSettings

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

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

• The nurse should focus on the patients strengths and assets and not on his weakness and liabilities

• The nurse views the patient's behavior non-judgmentally, while assisting the patient to learn more adaptive ways of coping

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• The nurse should explore the patient's behavior for the need it is designed to meet and message it is communicating

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

• The quality of the nurse - patient relationship determine the degree of positive change that can occur in the patient's behavior

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BASIC CONCEPTS ON BASIC CONCEPTS ON PSYCHOPHARMACOLOGY PSYCHOPHARMACOLOGY

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Major Major Tranquilizers/Antipsychotics Tranquilizers/Antipsychotics

Indication: Schizophrenia and Other Psychosis

Examples:• Haloperidol (Haldol) • Prochlorperazine (Compazine) • Fluphenazine (Prolixin)

• Chlorpromazine (Thorazine)

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Desired Effect: Control of symptoms

Nursing Implications:• Best taken after meals• Report sorethroat • avoid exposure to sunlight• Report elevated temperature • Check the BP

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Side effects:• Blurred vision, dry mouth, tachycardia,

palpitation, constipation, urinary retention• Skin: Photosensitivity• BP: Orthostatic hypotension• EPS-Extra Pyramidal Symptoms

– Pseudoparkinsonism - pill-rolling tremors, mask-like face, cog-wheel ,rigidity, propulsive gait

– Akathisia - restless leg syndrome– Dystonia - defect in muscle tone

Adverse effect:• Tardive dyskinesia-lip smacking• Agranulocytosis• Hepatotoxicity

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MINOR TRANQUILIZERS/ MINOR TRANQUILIZERS/ ANXIOLYTICSANXIOLYTICS

Common indication: Anxiety disordersDesired Effect: Decreased anxiety, adequate

sleep

Examples: Diazepam (Valium) Oxazepam (Serax)Chlordiazepoxide (Librium)Chlorazepate Dipotassium (Tranxene)Alprazolam (Xanax)

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Nursing Implications:• Best taken before meals, food in the

stomach delays absorption • Avoid driving, intake of alcohol and

caffeine containing foods, since it alters the effect of the drug

• Administer it separately, it is incompatible with any drug

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AntidepressantsAntidepressantsDesired effects: Desired effects:

increased appetite, increased appetite, adequate sleepadequate sleep

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TRICYCLIC TRICYCLIC ANTIDEPRESSANTSANTIDEPRESSANTS

Indication: Depression• increase the level of serotonin

neurotransmitters or norepinephrine in the space between nerve endings

• Deficiency depressionExamples:

Imipramine (Tofranil) Amitriptyline (Elavil)

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Nursing Implications:• Best given after meals • Therapeutic effects may become evident

only after 2-3 weeks of intake • Check the BP, it causes hypotension• Check the heartrate, it causes cardiac

arrythmias

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MAO INHIBITORSMAO INHIBITORS • Prevent metabolism of

neurotransmitters which carry message from one nerve cell to another.

• Toxic when taken with tyramine / tryptophan

Examples:Tranylcypromine (Parnate) Phenelzine (Nardil) Isocarboxazid (Marplan)

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Nursing Implications:• Best taken after meals• Report headache; it indicates

hypertensive crisis• Avoid tyramine containing foods like:

– Avocado– Banana– Cheddar and aged cheese

• Soysauce and preserved foods• It takes 2-3 weeks before initial

therapeutic effects become noticeable • Monitor the BP• There should be at least a two-week

interval when shifting from one anti-depressant to another

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Selective Serotonin Selective Serotonin Reuptake InhibitorsReuptake Inhibitors

• Indications: Depression, anxiety, panic attacks, eating disorders

• MOA: inhibition of the serotonin uptake thereby increases the synaptic transmitter levels to exert an antidepressant effect.

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• Examples:– Fluoxetine (Prozac) – Celatopram (Celexa)– Sertraline (Zoloft) – Paroxetine (Paxil)– Fluvoxamine (Luvox)

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Nursing Implications• Avoid the use of diazepam, alcohol,

and tryptophan because these may alter the effect of these drugs.

• Monitor PTT, PT• Never give to pregnant / lactating

mothers.

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ANTI-MANIC AGENTANTI-MANIC AGENT • Cause augmentation of serotonin

function in the CNS preventing increased nerve impulse transmission

Examples:Lithium Citrate (Cibalith – S)Lithium Carbonate (Eskalith, Lithane, Lithobid)

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• Nursing implications:• Best taken after meals• Increase fluid intake (3 L /day) and sodium

intake (3 gm/day)• Avoid activities that increase perspiration • Never give to pregnant mothers• It takes 10-14 days before therapeutic

effect becomes evident.• Antipsychotic is administered during the

first two weeks • Monitor serum level, normal is .5-1.5

mEq/L

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Signs of toxicity: •Vomiting•Anorexia•Nausea,•Diarrhea •Abdominal cramps

Antidote: Mannitol

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ELECTRO-CONVULSIVE ELECTRO-CONVULSIVE THERAPYTHERAPY

• Exact mechanism is unknown• Requires a consent• Usually given at 70-150 volts for

about .5-2 seconds• It takes 6-12 treatments with at least

48 hour interval to notice the effect• Indicator of effectiveness: tonic-

clonic seizure

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Indications of use:• Depression• Mania• Catatonic schizophrenia

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Contraindications (not absolute)• Fever• Increased ICP• Cardiac conditions• TB with history of hemorrhage• Unhealed fracture• Retinal detachment• Pregnancy

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Before the procedure:• Diagnostic procedures

– X-ray– ECG– EEG

• Drugs given– Atrophine sulfate (decrease secretions)– Anectine (Succinylcholine) – relax muscles– Methohexital Na (Brevital) - anesthetic

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During the procedure:• Observe for tonic-clonic seizure

After the procedure:• Position• Check vital signs• Reorient the client• Watch out for complications:

– Memory loss– Headache– Apnea– Fracture– Respiratory depression