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psych-notes.docx
According to (A.P.A) DSM 5 TR
PREPARED BY HENRY EVALLE
PSYCHIATRIC NURSING
Is an interpersonal process whereby the professional nurse practitioner
assists an individual, family and community through the therapeutic use
of self. To promote mental health and prevent / cope with the
experience of mental illness and suffering.
Interpersonal – interaction between two parties
1. Client – most important / main focus of the entire NPR (nurse-patient
relationship)
2. Nurse – “active Listening”
Therapeutic use of Self - utilization of self to produce therapeutic
effect to the client by using Therapeutic Communication.
PSYCHOPHARMACOLOGY
Focuses on Neurotransmitters –
3 majors neurotransmitters
Mono Amines
DOPAMINE
SEROTONIN
NOREPINEPHRINE
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Amino Acids
GABA (Gamma Amino Butyric Acid)
Choline
ACETYLCHOLINE
ABNORMALITIES OF NEUROTRANSMITTERS
1. DOPAMINE
Increase in Dopamine
(+) signs of Schizophrenia
Decrease in Dopamine
Parkinson’s Disease – resting tremors / involuntary muscle movement
or motor movement
EPSE – Extrapyramidal Side Effects – involuntary motor problem
2. SEROTONIN
Increase in Serotonin
(-) signs of Schizophrenia
Mania
Decrease in Serotonin
Major Depression
Eating Disorder
OCRD (Obsessive Compulsive Related Disorder)
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3. NOREPINEPHRINE
Increase Norepinephrine
Mania
Decrease Norepinephrine
Major Depression
4. GABA
Decrease GABA
Anxiety Disorder
5. ACETYLCHOLINE
Decrease Acetylcholine
Dementia
Alzheimer’s
Parkinson’s
ANTIPSYCHOTICS
given clients with Schizophrenia
A.k.a NEUROLEPTICS / Major Tranquilizers / Ataractics / Psychic
Energizers
3 types of Antipsychotics:
1. Typical – old / Traditional / Conventional
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PRO-THO-ME-TRI-S-H
PRO – Prolixin
THO – Thorazine
ME – Mellaril
TRI – Trilafon
S – Stellazine
H – Haldol / Haloperidol
2. Atypical – New
C-RI-SE-Z
C – Clozaril
RI – Risperdal / Risperidol
SE – Seroquel
Z – Zyprexia
(1) TYPICAL (2) ATYPICAL
Time 1950’s - Thorazine 1990’s – Clozaril
Indication (+) signs of Schizophrenia (-)(+) signs of Schizophrenia
MOA decrease Dopamine only decrease Dopamine and serotonin
EPSE very severe Mild / rare
EPSE
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Mild
Moderate
Severe
Very Severe
3. DSS – Dopamine System Stabilizers – 2000’s
Abilify (Aripiprazole)
Side Effects of Antipsychotics:
“A-E-I-O-U”
A – Anti Cholinergic Side Effects (ACSE)
Agranulocytosis
Amenorrhea
E - EPSE
I – Increase Prolactin Level
O – Other: Orthostatic Hypotension
Photosensitivity
Hepatotoxicity
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Teratogenic
U – umakyat ang timbang – weight gain / Hyperglycemia
A. ACSE “ABCDEF”
A – Absence of Sweat (Anhydrosis)
B – Blurring of Vision
C – Constipation
D – Dry Mouth & Dilated Pupils (Mydriasis)
E – Elevated HR, (EHE) urinary retention
F – Fever
B. Agranulocytosis / Granulocytopenia / Leukopenia
abnormal reduction of granulocytes in the blood
decrease WBC – decrease immune system
increase risk for infection = FATAL
Most important Sign
FEVER + sore throat
Most common cause : Clozaril
Nursing Intervention – Monitor WBC Count
Normal – 5000-10000 cell/cumm
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C. Amenorrhea
Absence of menstruation
Nursing Intervention: Family Planning
D. EPSE (Involuntary Motor / Muscle Problem
Meds: “ABCDEFS”
A – Artane, Akineton
B – Benadryl – most common most common
C – Cogentin – new DOC Lesser SE
D – Dopamine Sinemet / Levodopa
E – Eldepril
F – Pergulide
S – Symmetrel
Types of EPSE
1. Dystonia
Involuntary rigidity of the muscles
Face, neck, tongue, back, and extremities
Earliest EPSE occur
Occurs: 1-2 days
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Meds: ABC
2. Neuroleptic Malignant Syndrome (NMS)
most rare EPSE (1%)
unstable most FATAL of ALL
most important sign: FEVER + muscle rigidity
most common cause: HALDOL
occurs 3-9 days after treatment
DOC: Dantrolene Sodium
3. Pseudoparkinsonism
“false” temporary
Resting tremors
Pill rolling
Shuffling gait
Bradykinesia - slow speech and slow movement
Occurs – 1-3 weeks after the treatment
Medication: ABC
4. Akathisia
Inability to sit / stand still
Ants in the Pants
Most common of all EPSE
Occurs 2-3 weeks after treatment
MEDS: ABC
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5. Tardive Dyskinesia
Involuntary jerky movements
Focuses – mouth
Lip smacking
Teeth grinding
Tongue rolling
Tongue Protrusion
Occurs months – years after the treatment
Irreversible EPSE
DOC: Bromocriptine (Parlodel) – Dopamine Receptor Antagonist
E. Increase Prolactin Level
Female Galactorrhea
Male Gynecomastia
Most common cause: Risperdal
F. Orthostatic Hypotension
Sudden drop of BP when client changes his position form supine to
sitting/ standing
5 mins. From sitting
5 mins from standing while holding side rails
G. Photosensitivity / Sunburn
Avoid sunlight / hot places 1st degree burns
To avoid 1st degree burn – wear long sleeves, umbrella, wide hat,
sunblock SPF– 15%, shades
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Common Cause: Thorazine
H. Hepatotoxicity – Liver
Jaundice / Icterus
Yellow skin / sclera
Pale Color of Stool
Dark colored urine
FATAL
I. Teratogenic
Nursing Intervention: Family planning
J. Weight gain & Hyperglycemia
nursing intervention: Exercise
ANTIDEPRESSANTS
MAJOR DEPRESSION
A.k.a Thymoleptic / mood elevators
Goals for management of Depression:
1. Remove signs and symptoms of Depression
2. Restore Psychosocial Function
3. Prevent recurrence of Depression
3 Classifications
SSRI – Selective Serotonin Reuptake Inhibitor
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1st line to treat major depression
Lesser side effect
Expensive
“PPLLZ CEL”
P – Prozac
P – Paxil
L – Luvox
L – Lexapro
Z – Zoloft
Cel – Celexa
LAG period: 2-4 weeks
Given: It depends upon the effects of the drugs
Insomnia – Morning
Nervousness – Morning
Sedation – Evening
Side Effects:
Weight loss
Photosensitivity
Headache and nervousness
N&V
Sexual dysfunction
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TCA – Tricyclic Antidepressants
2nd line to treat MD
Most sedation
“VP mo SI ATE”
V – Vivactyl
P – Pamelor
Si – Sinequan
A – Anafranil
T – Tofranil – 1950’s
E – Elavil – most CARDIOTOXIC
Lag Period: 2-4 weeks
Given: Evening – because most sedation
SIDE EFFECTS:
Weight gain & Cardiotoxicity
ACSE & Ataxia
Eye pain & Nightmares
Orthostatic Hypotension
Sexual Dysfunction
MAOI- Mono-Amine Oxidase Inhibitor
Last resort for treating MD / 3rd line
Most side effects
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Pinaka mura na gamot
“Pa Ma Ma Na”
Pa – Parnate
Ma – Marplan
Ma – Manerix (Moclobemide) – NEW!
It can lessen Hypertensive Crisis
Na – Nardil
Lag Period: 2-4 weeks
Given: Morning
SIDE EFFECTS:
Insomnia
Hypertensive Crisis
TYRAMINE rich food should be avoided
“ABCDEFG”
A – Aged Cheese, Avocado
B – Banana
C – Caffeine (soda, coffee, energy drink)
D – Dry foods
E – Embotido (meat, raisins, cheese, hotdog, ham, carrots)
F – F (P)izza. Papaya, Fermented food (yakult, Yogurt, all alcohol
beverages)
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G – Gravy, Ginseng
UNIQUE S/Sx of Hypertensive Crises:
1. Severe Sweating
2. Severe Nausea and vomiting
3. Occipital Headache
4. Sore Neck & Stiff Neck
MEDS / DOC: Phentolamine (5mg) IV – Non-Selective Alpha Adrenergic
Antagonist
ST. JOHN WORT – Herbal
Can treat Major depression
ADHD (Attention Deficit Hyperactive Disorder)
NOTE:
Do not mix different Antidepressant Drugs can cause serotonin
syndrome (FATAL)
Best time to commit suicide is during the drug intake increase
neurotransmitter
ANTIMANIC
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For Manic Patients (elevated mood)
Unique Sign: Pleasure Principle (Sex Addicts)
A.k.a Mood stabilizers
Lag time: 7-10 days
Meds: “ES – TE – DE”
ES – Eskalith (Lithium) 1950’s
TE – Tegretol (Carbamazepine) for pregnant Manic
DE – Depakene (Valproic Acid) can cause neural tube defect
Therapeutic Dose:
300-600mg TID
Therapeutic Blood Lithium Level:
0.5-1.5 meqs/ liter OLD
0.6-1.2 meqs / liter NEW!
Contraindications of Lithium:
Heart Problem
Liver Cirrhosis
Renal Failure
Lithium Allergy
Cancer
Pregnant
Dehydration
Parkinson’s
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Epilepsy
Relationship of Na and Li:
Inversely Proportional
Increase Na , Decrease Li Effectiveness
Decrease Na , Increase Lithium Lithium Toxicity
Meds Given for Lithium toxicity: “DAMU”
D – Di-amox
A – Aminophylline
M – Mannitol
U – Urea
Meds that alters Lithium Level (DL)
D – Diuril
L – Lasix
Signs/symptoms of Lithium Toxicity: SEVERE
Diarrhea
Vomiting
Diaphoresis
Muscle weakness
Coarse tremors
HENRY’S Lithium Precaution:
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H – Herbal Tea / Milktea
E – Excessive Exercise
N – Nescafe (Coffe)
R – Red bull, sting, cobra
Y – you should avoid hot places
S – Salt intake /day 2-3gms without condiments
Water intake/ day 2-3Liter
Other Antimanic Drugs:
Gabapentin
Topamax
Trileptal
Lamictal
ANTIANXIETY
A.k.a Anxiolytics / Minor Tranquilizers / Benzodiazepines
Other Purpose: “P-A-R-I-S”
P – Pre- operative medications
Diazepam (Valium)
A – Alcohol Withdrawal Syndrome
Librium (Chlordiazepoxide)
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R – Restraints
Diazepam (Valium)
I – Insomnia
Diazepam (Valium)
S – Seizure
Lorazepam (Ativan)
Medications: “LIBRE – TRANSPO – BUS”
Librium - 1950’s
Transxene
Buspar
-zepam -zolam
diazepam triazolam
Lorazepam midazolam
oxazepam – elderly people alprazolam
clonazepam
Side / Adverse Effects: “RAD”
R – Respiratory Depression
A – Altered LOC (CNS Depression)
D – Dependency very addicting drugs
Nursing Intervention: “RAD”
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R – RR – monitors
A – Avoid Activities: Avoid operating machines, driving, swimming
D – Decrease the dosage of the drug GRADUALLY before stopping it
TAPERING
ANTIDEMENTIA / ANTIALZHEIMERS
Aka Anticholinesterase / Choline sterase inhibitor
Medication: “CARE”
C – Cognex – 1945 OLD
A – Aricept –DOC
R – Razadyne / Reminyl
E – Exelon
Levels of Remarks/
Perceptual field Nursing intervention
Anxiety assessment
Relaxation technique
Deep breathing
HEALTHY
Music therapy
Best for learning
MILD (+1) INCREASE (PF) Eating
Very sharp and
Meditation / Yoga
alert
Verbalization of
feelings
Refocus the client
Selective
Can give anxiolytics
MODERATE Narrow going inattention
initially
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(+2) down PF Decrease focus ROUTE: ORAL
Rapid pacing
Hyperventilation
Tremors K.I.S.S
Palpitations
Shouting / Keep it short and
SEVERE Greatly reduced
screaming simple instructions
(+3) PF
Difficulty in Can give Anxiolytics
communication Route: IM
Fixed vision
(Tulala)
Loss of rational
thoughts
Loss of
SAFETY
communication
PANIC Can give Anxiolytics
Loss/ Block PF Feeling of
(+4) Route: IM
impending doom
Tunnel Vision
Violent
ANXIETY DISORDERS
A. Separation Anxiety Disorder (SAD)
Excessive & persistent anxiety or fear concerning separation from
home or to those whom the individual is attached` to.
Fear from separation from Home
Children: at least 1 month
Adult – 6 months
Nursing Intervention of SEPANX:
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F – Family Therapy / support system
E – Encourage Verbalization
A - Anxiolytics
R – Relaxation Technique
S – SAFETY & Stay with the client
B. Selective Mutism
A person who is normally capable of speech does not speak in specific
situation to specific people
Selective Mutism usually co-exist with extreme shyness or strong
social anxiety
Common to children – 5y/o for at least 6 mos.
Trusted: MAMA/ Mother
Nursing Intervention: “MUTE”
M – Medication: Anxiolytics
U – Understand the child’s situation
T – Therapy: Play / Family / Group Therapy
E – Encourage the child to talk/speak slowly (SHAPING)
Operant Conditioning - reward and punishment
C. Phobia
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intense or irrational fear of objects, things, places, events, situation,
animals and person .
Level of Anxiety: Severe-panic type
Types of Phobia
1. Agoraphobia – fear of being alone in an open or public space where
escape is impossible
MONOPHOBIA – fear of being alone
2. Social Phobia – fear of situation that may cause shame or
embarrassment
3. Simple Phobias / Specific Phobia
Acrophobia – heights
Arachnophobia – spiders
Xenophobia – strangers
Claustrophobia – close space
Monophobia –being alone
Defense Mechanism: Symbolization / Displacement
Nursing Intervention: “PHOBIA”
P – Phobia attacks: stay with the client
H – Health teaching
Systematic Desensitization – gradual exposure to the phobic exposure
Flooding – abrupt/ sudden exposure
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O – Offer relaxation Technique
B –Bervalization / Catharsis
I – Important: Safety
A – Anxiolytics
D. Panic Attacks
intermittent occurrence of panic level of anxiety
P – Palpitations
A – Agitations
N – Numbness/ nervousness most important sign
I – Intense Fear
C – Chest Pain
G – Generalized Anxiety D/O (GAD)
Free floating anxiety disorder
Persistent worrying of two or more life events for at least 6 months.
Ex: Problema ko … Problema ko yun
Problema mo – Problem ko
GAD PANIC
continuity of
Continous Intermittent
anxiety
Moderate to severre Level of Anxiety PANIC
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overuse of substance
PRONe to overuse of anxiolytics
abuse
Anxiolytics DOC Prozac
Psycho, individ, bahevioral Psycho, individ, bahevioral
MGT
therapy therapy
OBSESSIVE COMPULSIVE AND RELATED DISORDERS (OCRD)
5 types of OCRD: “OBETH”
O - Obsessive Compulsive Disorder
B - Body Dysmorphic Disorder
E- Excoriation Disorder
T - Trichotillomania Disorder
H – Hoarding Disorder
A. OCD
O – OBSESSION - unwanted repetitive thoughts / thinking that
increases level of anxiety
C – COMPULSION - unwanted repetitive actions that decreases level
anxiety = RITUAL X ADL’s
D – Decrease Serotonin Level
during – Toddler Age: because of MOTHER strict toilet training
Erik ERICKSON theory
School age : common MALE
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Adolescent stage: common FEMALE
NURSING INTERVENTION
O – Offer & allow rituals: initially
C – Contract: Limit Setting
D – Diversional Activity, Cognitive Behavioral Therapy (CBT)
DOC: TCA – Anafranil - 1st
SSRI – Luvox – 2nd
DEFENSE MECHANISM: “ DOCU”
Obsession - Displacement
Compulsion – Undoing
B. BODY DYSMORPHIC DISORDER (BDD)
characterized by an imaginary defect which appears normal to other
Adolescent Stage
common among FEMALE
NURSING INTERVENTION: “MASK”
M – Mirror manipulation
to increase public self-awareness
A – Anti- Depressant: SSRI (PPLLZ-Cel)
S – Self – esteem increase
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K – Cognitive behavioral therapy (CBT)
C. EXCORIATION / DERMTOMIMANIA
SKIN PICKING DISORDER
Uncontrolled & repeated scratching of the skin because of high anxiety
or boredom, resulting to skin lesions for at least 6 mos.
In skin picking: they use rubbing, squeezing, lancing/ cutting & biting.
Common Site: face, Arms, Hands
Sexual Preference: FEMALE
NURISNG INTERVENTION: “ SKIN”
S – SSRI
K – CBT
I – instruct to is Unna Sleeves
N – Needs Supervision & Dermatological Skin Care
D. TRICHOTILLOMANIA - HAIR PULLING d/o
- Uncontrolled & repeated pulling out of one’s own hair, resulting in hair
loss for at least 6 mos.
Common Site: Scalp, eyelids, eyebrow & pubic region
Sexual Preference: Female
*RITUAL: eating the hair
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NURSING INTERVENTION: “hair”
H – hair pulling : CBT
A- Anti- Depressant: SSRI
I – Instruct Diversional Activities & Relaxation Technique
R – Ritual: Strict Supervision
E. HOARDING DISORDER
- persistent difficulties discarding or parting with possessions,
regardless of their actual value, resulting in the accumulation of
possessions that congest and clutter active living areas for at least 6
months
Sexual Preference: Female
NURSING INTERVENTION: “HOARD”
H – Hygiene
O – Offer cognitive – behavioral
A – Anti- Depressant: SSRI
R – Requires: Safety
D – Diversional Activity
MOOD DISORDER / AFFECT
MAJOR DEPRESSION BIPOLAR DISORDER
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Most depress mood / depress mood( 1month) + mood
important severe sadness elevation (1month)
sign mood swing
early mid 20’s Early adulthood
Age of Onset 20-25 y/o 15-25 y/o
Sexual FEMALE Equally distributed
Preference
Depressed – SSRI
DOC SSRI
Mood Elevation - LITHIUM
I. MAJOR DEPRESSION
- characterized by severe sadness + anhedonia inability to feel
pleasure / happiness
Without episodes of mania/ hypomania
“all depress clients r potentially suicidal
Cause: unknown
NT: decrease serotonin
Confirmation: 2 weeks / 14 days
S/SX: “DEPRESS”
D – DEPRESS / severe sadness & ANHEDONIA
E – INSOMNIA / Hypersomnia
P – PHYSICAL ACTIVITY DECREASE
R – Recurrent suicidal thought
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E – Excessive Guilt / Conscience
S – Self-esteem decrease (hopeless , helpless, worthless)
S – self- blaming introjection
II. BIPOLAR DISORDER
Characterized by severe sadness + episodes of mania and hypomania
2 types of Bipolar Disorder
BIPOLAR I – MD to MANIA: complete mood swing
BIPOLAR II - MD to HYPOMANIA
NURSING INTERVENTION: “SAFE”
S - Safety: suicidal tendencies
sudden change in mood / behavior
verbalization of suicidal plans
giving prize possession
catharsis
putting away harmful object
irregular but frequent visits
A – Anti Depressant – SSRI TCA MAOI
F – Food, hygiene, rest & sleep
E – ECT Last Resort
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III. MANIA
extreme or exaggerated
Euphoric that leads to acceleration of physical & mental activity that
affects the ADL’s, mood elevation Risk for injury r/t others
“all manic client can be violet”
Cause: unknown
NT: increase serotonin & norepinephrine
Confirmation: 1 week / 7 days
DM: Denial – 1st
Reaction formation – 2nd
SIGNS & SYMPTOMS: “MANICS”
M – Mood elevation / elevated mood/ euphoria, manipulated, mayabang
/ grandiosity
A – Ayaw matulog , they have limitless energy
N – Nananakit (violent) , neologism
I – increase activity
C – Cannot concentrate (easily distracted) / Clang Association –
rhyming of words
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S – Sex addicts & all other pleasurable activity = ID / shifting rapidly
from one topic to another topic ( flight of ideas)
NURSING INTERVENTION: “MANIAS”
M – Madaling hawakan / kainin / finger foods
A – Anti Manic Drug – (Es – Te – De)
Lithium - DOC
N – non – competitive & non-contact sport
I – iwas sa concentration na work / activity Ex: Chess
A – Allow rest / sleep
S – Safety / solitary activity – nag iisa lang – holticulture / gardening
Other Mood Disorders:
Disruptive Mood Dysregulation Disorder (DMDD) AKA PEDIATRIC
BIPOLAR DISORDER
6-18 YEARS OLD
19 pataas = BIPOLAR DISORDER
School age : Male
Adolescent: Female
Temper outburst / tantrums
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Severe irritability
Overreaction to stimuli
Most of the time they feel angry
violent
NURSING INTERVENTION “SISA”
S – SUPPORT SYSTEM “family”
I – individual therapy / play therapy
S – Safety
A - anti depressants (SSRI) - lungkot
Lithium – mood elevation – saya
Premenstrual Dysphoric Disorder (PMDD)
is a more SEVERE form of premenstrual syndrome (PMS)
EXTREME mood shifts that can disrupt your work and ADL’s
PMDD usually begin 7-10 days before your period starts and continue
for the first few days that you have your period
Signs and Symptoms:
1. Physiological / Physical
- bloating
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- Breast tenderness
- Headache
- Joint or muscle pain
- Fatigue or low energy
- Easily get bruises
- Pimples / acne
2. AFFECTIVE / MOOD
- Extreme & unstable mood swing
- Severe sadness /depression
- Hopelessness
- Suicidal thoughts
3. BEHAVIOR
- Increase Anxiety
- Feeling out of control
- diff. to think/ focus & comm.
- irritability & anger
- difficulty to sleep
- lack of interest in ADL’s / relationship
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- verbal / physical aggressive
- food cravings
NURSING INTERVENTION “MENS”
M – MEDS SSRI & pill hormones (danzol & zoldex
E – Encourage verbalization of feelings
N – Nutritional supplements (Vit. B & calcium
S – Support System
THOUGHT DISORDER / PSYCHOSIS
SCHIZOPHRENIA
H – Hallucinations – Perception
Without things
I – Illusion – Perception
With things
D - Delusion - Thought (worst)
Aka: dementia Precox (old)
Split mind (new)
Cause: unknown
Age: 15-25 LA -EA
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Sexual Preference: Equally Distributed
Confirmation of Schizophrenia:
2 weeks to <1 month HID : Brief Psychotic D/ O
1 month - <6 mos. HID: Schizopreniform
>6mos HID: Schizophrenia
Nursing Diagnosis:
1. for Hallucination
- Impaired sensory Perception
2. for illusion
- impaired Sensory Perception
3. for Delusion
- Altered thought Process
(+) sign of schizophrenia (-) sign of SChiz
Hallucination Apathy / anhedonia
Illusion Blunted & flat affect
Delusion Communication Disturbance
Excitement
Suspiciousness
Bizarre Behavior
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Agitation
Grandiosity
EUGENE BLEULER 4A’S of Schizophrenia
1. Affect
- blunted
- inappropriate
- flat
- labile
- latent
2. Autism - socially withdrawn
3. Ambivalence – 2 opposite feeling at the same time
4. Associative Looseness – stringing together of unrelated topics
NURSING INTERVENTION:
S - SAFETY
A – ANTI PSYCHOTIC
P – Physiologic Needs (food, rest & sleep, hygiene)
E – Environment (milieu)
T – Trust – consistency, availability, reliability (CAR)
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Y – you should orient the client to reality. (ego)
