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Psych nursing lecture notes part 1

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Page 1: Psych Nursing Ppt 1

PSYCHIATRIC NURSING

Page 2: Psych Nursing Ppt 1

• MENTAL HEALTH– Is a balance in a

person’s internal life and adaptation to reality.

• MENTAL ILLNESS– Is a state of imbalance

characterized by disturbance in a persons thoughts, feelings and behaviours

Page 3: Psych Nursing Ppt 1

• PSYCHIATRIC NURSING– Is an interpersonal

process whereby the professional nurse practitioner, through the therapeutic use of self and nursing theories assist clients to achieve psychosocial well-being.

Page 4: Psych Nursing Ppt 1

• PERSONALITY– Integration of systems and

habits representing an individuals characteristics adjustments to his environment expressed through behaviours.

• MENTAL HYGEINE– Measures to promote

mental health, preventing mental illness and suffering and facilitate rehabilitation.

Page 5: Psych Nursing Ppt 1

SELF AWARENESS

• Is a clear perception about your personality, including strength and weakness, thoughts, beliefs, motivations and emotions.

Page 6: Psych Nursing Ppt 1

• It is knowing:– What you want in your life – Your strength and weaknesses– What you want to change

about yourself or about your life

– Your achievements so far– How to relate to others– What you need to improve as a

person– Your most important beliefs

and values– How you see yourself as a

person

Page 7: Psych Nursing Ppt 1

NEUROSIS

• Any long term mental or behavioural disorder in which contact to reality is retained, the condition is recognized by the patient as abnormal.

Page 8: Psych Nursing Ppt 1

PSYCHOSIS

• Mental or behavioural disorder wherein a patient looses contact with reality.

• Presence of delusions, hallucinations, thought disturbances, alteration of mood, abnormal behaviour.

Page 9: Psych Nursing Ppt 1

COMMON BEHAVIOURAL TERMS

• DISTURBANCES in PERCEPTION– Illusion– Hallucination• Auditory• Visual• Tactile

Page 10: Psych Nursing Ppt 1

DISTURBANCES IN THINKING and SPEECH

• Neologism• Word Salad• Verbigeration• Perseveration• Echolalia• Aphasia• Ambivalence• Flight of Ideas• Looseness of association• Clang association

Page 11: Psych Nursing Ppt 1

• Delusion– Delusion of Grandeur– Persecutory– Ideas of Reference– Somatic

• Concrete Association• Magical thinking

Page 12: Psych Nursing Ppt 1

DISTURBANCES in AFFECT

• Inappropriate• Blunt • Flat• Depersonalization• Derealization• Agnosia

Page 13: Psych Nursing Ppt 1

DISTURBANCES in MOTOR ACTIVITY

• Echopraxia• Waxy Flexibility• Ataxia• Akathesia• Dystonia• Tardive Dyskenisia• Apraxia

Page 14: Psych Nursing Ppt 1

DISTURBANCES in MEMORY

• Confabulation• Déjà vu• Jamais vu• Amnesia– Retrograde– anterograde

Page 15: Psych Nursing Ppt 1

Satisfaction of Human needs

• Physiologic• Safety and security• Love and belongingness• Self-esteem• Self-actualization

Page 16: Psych Nursing Ppt 1

Three divisions of the Mind

• Conscious• Subconscious• Unconscious

Page 17: Psych Nursing Ppt 1

THEORIES OF PERSONALITY DEVELOPMENT

• SIGMUND FREUD– Psychosexual Theory– Structure of Personality

• ID• EGO• SUPEREGO

• ERICK ERICSON– Psychosocial Theory

• JEAN PIAGET– Cognitive Theory

• Lawrence Kohlberg– Moral Development Theory

Page 18: Psych Nursing Ppt 1

DEFENSE MECHANISMS

• Unconscious intrapsychic adoptive efforts to resolve emotional conflict and cope with anxiety

Page 19: Psych Nursing Ppt 1

EXAMPLES of DEFENSE MECHANISMS

• Denial• Displacement• Projection• Introjection• Undoing• Compensation• Substitution• Repression• Supression

Page 20: Psych Nursing Ppt 1

EXAMPLES of DEFENSE MECHANISMS

• Reaction formation• Regression• Dissociation• Conversion• Fantasy• Identification• Intellectualization• Rationalization• Sublimation

Page 21: Psych Nursing Ppt 1

NURSE-PATIENT RELATIONSHIP

• Is a series of interaction between the nurse and patient in which the nurse assists the patient to attain positive behavioural change.

– T: trust– R: rapport– U: unconditional positive regard– S: setting limits– T: therapeutic communication

Page 22: Psych Nursing Ppt 1

PHASES

• Pre-interaction– Self-awareness

• Orientation – Developing a mutually acceptable contact

• Working– Identification and resolution of the patient’s problem

• Termination– Assist patient to review what he has learned and

transfer his learning to his relationship with others

Page 23: Psych Nursing Ppt 1

When to terminate NPR

• Goals are accomplished• Emotionally stable• Greater independence• Able to cope with anxiety, fear, loss and

separation

• Common effect: regression

Page 24: Psych Nursing Ppt 1

Common problems in NPR

• Transference• Counter-transference

Page 25: Psych Nursing Ppt 1

Principles of CARE

• Accept patient as unique with inherent value and worth

• Patient is viewed as holistic human beings with interdependent and interrelated needs

• Focus on the patient’s strength’s and assets.• Non-judgemental assistance towards coping• Explore the patient’s behaviour and the need

to meet the message it is communicating

Page 26: Psych Nursing Ppt 1

Therapeutic Communication

• Offer self• Exploration• Silence• Active listening• Make observation• Broad Opening• Clarification• Restating• General leads• Refocusing• focusing

Page 27: Psych Nursing Ppt 1

Non-therapeutic Communication

• “don’t worry be happy”• “why?”• Ignoring• Flattery• Arguing with the patient

Page 28: Psych Nursing Ppt 1

TYPES of PSYCHOTHERAPIES

• Remotivation therapy• Music Therapy• Play therapy• Group therapy• Milieu therapy• Family therapy• Hypnotherapy• Behaviour modification

Page 29: Psych Nursing Ppt 1

• Types of behavioural modification:– Operant conditioning– Desensitization– Aversion

Page 30: Psych Nursing Ppt 1

PSYCHOPHARMACOLOGY

• Are the use of medication to treat or control mental and behavioural problems.

Page 31: Psych Nursing Ppt 1

ANTI-PSYCHOTICS/NEUROLEPTICS

• PHENOTHIAZINES– chlorpromazine (Thorazine)– fluphenazine (Prolixin)– perphenazine (Trilafon)– prochlorperazine (Compazine)– thioridazine (Mellaril)– triflouperazine (Stelazine)

Page 32: Psych Nursing Ppt 1

• NON-PHENOTHIAZINES– clozapine (Clozaril)– haloperidol (Haldol)– olanzapine (Zyprexia)– resperidone (Risperdal)

Page 33: Psych Nursing Ppt 1

Mechanism of Action

• Antagonizes dopamine in the CNS by blocking dopamine receptors and reducing dopamine activity.

• INDICATION:– Relieves psychotic symptoms of schizophrenia and

mania– Acute management of agitation and hyperactivity

Page 34: Psych Nursing Ppt 1

Side/Adverse effects

• Extrapyramidal Side effect– Acute dystonia– Pseudoparkinsonism

• Stiff stooped posture• Mask-like faces• Shuffling, festinating gait• Drooling• Pill rolling tremors/resting tremor

– Akathisia– Torticollis– Opisthotonus– Oculogyric crisis

Page 35: Psych Nursing Ppt 1

Side/Adverse effects

• Neuroleptic Malignant Syndrome– Rigidity– High fever– Unstable BP– Diaphoresis and pallor– Elevated enzymes: creatinine and phosphokinase– Confused/mute

• Discontinue medication ASAP!

Page 36: Psych Nursing Ppt 1

Side/Adverse effects

• Tardive dyskinesia– Involuntary movements of the tongue, facial and

neck muscle– Tongue protrusion and thrusting– Lip smacking– Blinking– grimacing

Page 37: Psych Nursing Ppt 1

Contraindication

• Glaucoma• Pregnancy and lactation• Elderly clients

Page 38: Psych Nursing Ppt 1

Nursing Guidelines

• Give the medication after meals• Instruct the client to rise slowly from a lying

position• Instruct the client to report sore throat, fever or

muscular rigidity• Inform the client that the medication will achieve

its full therapeutic effect within 6-8 weeks• Monitor client’s BP and body temperature, blood

levels, presence of seizure, NMS and EPS

Page 39: Psych Nursing Ppt 1

ANTIDOTES• NMS– bromocriptine or amantadine– dantrolene– Muscle relaxants

• Dystonia– dyphenhydramine– benztropine– diazepam– lorazepam

• Pseudoparkinsonism– Antiparkinsonian

• Tardive dyskinesia– Early referral- dose reduction

Page 40: Psych Nursing Ppt 1

ANTIPARKINSONIAN AGENTS

• Dopaminergic drugs– Enhances dopamine activity, slows deterioration

of dopaminergic nerve cells

• carbidopa-levodopa (Sinemet)• amantadine (Symmetrel)• bromocriptine mesylate (Parlodel)• levodopa (Larodopa)

Page 41: Psych Nursing Ppt 1

ANTIPARKINSONIAN AGENTS

• Anticholinergic Agents– Inhibit excess in cholinergic activity– Decreases signs and symptoms like:• Tremors, rigidity, drooling, and promotes optimal

levels of motor functions (gait, posture, speech)

• trihexypheiedil (Artane)• biperidine Hydrochloride (Akineton)• benztropine myselate (Cogentin)• diphenhydramine HCL (Benadryl)

Page 42: Psych Nursing Ppt 1

• Side Effects– Blurring of vision, constipation, orthostatic

hypotension, sorethroat*, headache, photosensitivity, drowsiness

• Contraindications– Glaucoma, tachycardia, hypertension, duodenal

ulcer

Page 43: Psych Nursing Ppt 1

Nursing Guidelines

• Inform the client that tremors and rigidity will be decreased after 2-3 days of drug therapy

• Give the medication after meals• Avoid sudden position change• Inform the client to avoid Vit. B6 and protein rich

foods• Encourage the client to avoid alcohol

consumption• Do not withdraw the medication abruptly

Page 44: Psych Nursing Ppt 1

ANTIDEPRESSANTS

• TRICYCLIC ANTIDEPRESSANTS– Prolongs the action of norepinephrine dopamine

and serotonin by blocking the reuptake of this neurotransmitters

• imapramine (Tofranil)• amitriptyline (Elavil)• clomipramine (Anafril)• doxepin (sinequan)

Page 45: Psych Nursing Ppt 1

ANTIDEPRESSANTS

• MONOAMINE OXIDASE INHIBITORS– Blocks the metabolic destruction of

neurotransmitters by the enzyme monoamine oxidase

• tranylcypromine (Parnate)• isocarboxacid (Marplan)• phenelzine (Nardil)

Page 46: Psych Nursing Ppt 1

ANTIDEPRESSANTS

• Selective Serotonin Reuptake Inhibitors– Inhibits reuptake and destruction of serotonin to

prolong its action

• fluoxetin (Prozac)• paroxetine (Paxil)• sertraline (Zoloft)• fluvoxamine (Luvox)

Page 47: Psych Nursing Ppt 1

ANTIDEPRESSANTS

• CNS STIMULANTS– Increases levels of neurotransmitters in the brain

thereby increasing CNS activity and decreasing hyperactivity

• methylphenidate (Ritalin)• amphetamine (Benzedrine)

Page 48: Psych Nursing Ppt 1

SIDE EFFECTS

• TCA’s– Cardiac arrhythmias– Palpitation, orthostatic hypotension– Constipation– Sedation, Confusion

• MAOI– Hypertensive crisis– Liver and cardiovascular disease– Weight gain– Sexual dysfunction– Photosensitivity

Page 49: Psych Nursing Ppt 1

SIDE EFFECTS

• SSRI’s– Tremors– Decreased libido– Nervousness– Insomnia– Anxiety

• CNS stimulants– Growth suppression – insomnia

Page 50: Psych Nursing Ppt 1

CONTRAINDICATIONS

• Liver disease• Cardiovascular disease• Glaucoma• Hypertension

Page 51: Psych Nursing Ppt 1

NURSING GUIDELINES

• TCA’s– Give the medication after meals.– Inform the client that the initial effect of the

medication happen after 2-3 weeks.– Tell the client that the full therapeutic effect

occurs within 3-6 weeks of compliance– Emphasize compliance of medication regimen– Avoid citrus foods– Monitor client’s BP, HR, and ECG

Page 52: Psych Nursing Ppt 1

NURSING GUIDELINES

• MAOI– Give the medication after meals– Inform client that initial effect of the medication

occurs after 2-3 weeks– The full therapeutic effect is achieved after 3-4

weeks– Avoid tyramine rich foods– Monitor BP and food items

Page 53: Psych Nursing Ppt 1

NURSING GUIDELINES

• SSRI– Give the medication after meals– Initial effect occur after 2-3 weeks of therapy– Full therapeutic effect is achieved after 3-4 weeks

• CNS STIMULANTS– Give the medication in the morning or before 2

PM

Page 54: Psych Nursing Ppt 1

ANTI-MANIC

• Alters the level of dopamine and other neurotransmitters.

– lithium carbonate (Eskalith)– carbamazepine (Tegretol)

Page 55: Psych Nursing Ppt 1

SIDE EFFECTS

• Fine tremors leading to coarse tremors• Thirst• Nystagmus• Nephrotoxicity• Cardiac toxicity• Hyperthyroidism

Page 56: Psych Nursing Ppt 1

CONTRAINDICATION

• Cardiovascular disorders• Renal disorders• Hyponatremia• On diuretic therapy• Brain damage• Pregnancy and lactation

Page 57: Psych Nursing Ppt 1

NURSING GUIDELINES

• Inform client that the initial effect occurs after 10-14 days

• Full therapeutic effect is achieved within 3-4 weeks of drug compliance

• Give the medication with food or milk or after meals• Instruct the client to include sodium rich foods in

the diet not exceeding to 6-10 grams a day• Tell the client to avoid caffeine, diuretics and

activities that increase perspiration

Page 58: Psych Nursing Ppt 1

NURSING GUIDELINES

• Monitor serum levels once a month in the morning 12 hours after the last dose– Maintenance dose: .5 – 1.2 mEq/L– Acute level : 1.5 mEq/L– Level for the elderly client: .4 -10 mEq/L

• Antidote for lithium toxicity– mannitol (Osmitrol)– acetylzolamide (Diamox)

Page 59: Psych Nursing Ppt 1

ANTI ANXIETY

• Depresses the reticular activating system and reduces anxiety by stimulating the action of neurotransmitter GABA

Page 60: Psych Nursing Ppt 1

ANTI ANXIETY• BENZODIAZEPINES

– alprazolam (Xanax)– chlordiazepoxide (Librium)– diazepam (Valium)– lorazepam (Ativan)– oxazepam (Serax)

• AZASPIRONES– buspirone (Buspar)

• NON-BENZODIAZEPINES– hydroxyzine (Vistaril)– meprobamate (Equanil)

Page 61: Psych Nursing Ppt 1

SIDE EFFECTS

• Sedation, dizziness, drowsiness• Dry mouth• Dependency• hepatotoxicity

Page 62: Psych Nursing Ppt 1

CONTRAINDICATIONS

• Glaucoma• Liver and kidney dysfunction• Pregnancy and lactation

Page 63: Psych Nursing Ppt 1

NURSING GUIDELINES

• Give the medication before meals• Instruct client to rise uo slowly• Avoid caffeine and alcohol• Monitor blood levels• Report presence of sore throat, jaundice,

weakness and fever