Abnormal Psych

Disturbances

Thought Disturbances

A. Tangentiality

• Lacks focus and wanders off the question

• Does not answer the original question

B. Circumstantiality

• Answers in unrelated details

• Answers the original question

A. Flight of Ideas

• Jump from one topic to another

• (+) Rapid speech (+) connection between topics

B. Looseness of Association

• Fragmented ideas/topics

• Normal speech (-) Connection

More terms and definitions

• Thought insertion - Belief that other people are putting thoughts/ideas into their head

• Thought withdrawal - Belief that other people are taking away the client’s thoughts

• Thought blocking - Sudden/abrupt stopping of ideas in the middle of speaking

• Thought broadcasting - Belief that other people can hear what the patient is thinking

Speech Disturbances

A. Word salad

• Jumbled words/phrases with no connection

• Just words and phrases (-) connection (-) meaning

B. Clang association

• Ideas are connected based on rhyming

• (+) forming sentences (+) rhyming words (-) no meaning

A. Verbigeration

• Stereotype phrase repetition with or without meaning

• Phrase repetition

B. Perseveration

• Adherence to a single topic

• Topic repetition

A. Stilted language

• Use of unnecessary (poetic) choice of words

B. Neologism

• Inventing new words that only the patient understands

• Note: Clarify the statement of the patient

A. Echolalia

• Imitation of what the patient hears

• Repeat others words

B. Palilalia

• Repetition of what the patient says

• Repeat own words

More terms and definitions

• Mood: external emotions

• Affect: facial display of emotion

Affect Disturbance

(Disturbance : Definition : Disorder)

• Broad : Full range of expressions : N/A

• Flat : No expressions : Catatonia

• Restrictive : Only one expression : Paranoid

• Blunt : (+) Expressions but minimal : Depression

• Inappropriate : Opposite to emotion : Schizophrenia

• Labile : Sudden shift of emotions : Bipolar

Memory Disturbances

(Disturbance : Definition : Intervention/Disorder)

• Anterograde : Unable to form new memories from onset : Reorient the patient

• Retrograde : Unable to recall past memories from onset : Reminiscence therapy (use memorable item)

• Confabulation : Making up stories to fill in the gaps : Dementia

Behavioral Nursing Management for Patient with Psychiatric Disorders

Patients who are always alone

• RNs approach the patient

• If pt rejects the nurse:

  • Offer self and silence

  • Let pt feel that RN cares

• If pt begins to interact:

  • Give emotional rewards (not material)

  • Make an observation

  • Promote verbalization and validation (2 Vs)

• Activity characteristics

  • Achievable

  • Non competitive

Patients who are depressed

• If pt rejects the nurse:

  • Offer self and silence

  • Let pt feel that RN cares

• If pt feels sad and wants to cry/break down:

  • Promote validation and verbalization

  • Focus on positive aspects of self (recall their achievements)

• Activity characteristics (SAD)

  • Simple activity

    • Less effort to think

  • Achievable

    • Focus on increasing self esteem

  • Determined/scheduled

Patients who are suicidal

Suicidal ideation

• Active - thoughts with plan

• Passive - thoughts with no plan

  • Directly confront and assess the plan first

Manifestations (GCASH AIL)

• Giving away of valuables

• Cancelling appointments

• Apologetic

• Sudden cheerfulness

• Homicidal thoughts

• Actual/Imagined Loss

Nursing Interventions

• Approach - Authoritative (RN)

• Set a safety contract - “Next time if you want to commit, call immediately”

• Verbalize and focus on positive self

• Confiscate all dangerous items

• Observation

  • Frequent - irregular/unpredictable intervals

  • Safest (one on one) - less than 1M away (even in the bathroom)

• Distract with highly structured activities

Patients who have Major Depressive Disorder

• Criteria

  • Mood: Persistent depressive mood

  • Activities: Anhedonia (loss of joy)

  • Weight: Gain/Loss

  • Sleep: Insomnia/Hypersomnia

  • Fatigue: Anergia

  • Hallmark signs: Negative self aspect (worthlessness or helplessness)

• Length of symptoms - more than 2 weeks

• Effect of life - no ADLs

• Neurotransmitters: Low norepinephrine and serotonin

• Q: You are assessing a 30-year-old patient diagnosed with major depressive disorder and they mentioned that they want to kill themselves. What is your therapeutic response? A: “When do you want to kill yourself?” Remember to directly ask plans before asking about emotions.

• Q: Which is the most important outcome that a patient admitted with major depressive disorder should achieve upon discharge? A: The client at home will call the nurse when they are at risk for suicide.

Patients who have Manic Disorder

• Bring to non stimulating environment (quiet, private, safe)

In cases of inappropriate behavior

• Do not argue/ignore

• Provide limit setting interventions

  • Point out the inappropriate behavior

  • Inform the patient of appropriate behavior

  • Identify with the client consequences if behavior is repeated

• Finger foods with high calories

• Gross motor activities (big movements) & non competitive like walking

• Remove all dangerous objects

• Promote effective ADLs

• Q: Suddenly, a nursing assistant called you in panic stating that the client is alone in the bathroom. You immediately go to the restroom and find your patient almost hanging themself. After putting the client out of the situation, they still insist on hanging themself. What is your priority intervention? A: Remove the client from the situation and assess need for 4-point restraints. This is actual suicide so it is crisis.

Patients who have Bipolar Disorders

• Bipolar I (Manic) - Hyperactive with delusions / Depressed

• Bipolar II (Hypomanic) - Hyperactive only / Depressed

Criteria

• Flight of ideas

• Grandiose in BP I

• Distracted and engage in risky activities

• Length - at least 1 week

• Neurotransmitters: High norepinephrine and serotonin

Q: Which of the following is considered a fact in mood disorders? A: People with bipolar disorder cycle between mania, normalcy, depression or between mania and normalcy or depression and normalcy.

Patients who are angry/aggressive

Triggering phase

• S/sx of anger + noncompliance

• Promote verbalization

• Validate the feelings

• Non competitive activities

• If patient does not want to talk

Escalation Phase

• Verbal aggression

• Limit setting interventions

• Calm approach

• Bring to non stimulating room

• Priority is safety (Offer oral meds as prescribed)

• If uncooperative - show of force (4-6 staff)

Crisis Phase

• Physical aggression (Harm to self, others, etc.)

• Restorative (Last resort):

  • Seclusion/Restraints - Book based, restraints require doctor’s order. This can be obtained within one hour after action.

  • This time, patient loses right to refuse temporarily

• Seclusion room: Consent is required from significant others (room must be lockable and observable from outside)

• One on one monitoring for 1 hour

• Number of staff (4 limbs + 1 head + 1 torso)

• Anchor on stable part of bed (bed frame)

• Constant monitoring

• Duration of restraints (maximum)

  • Adults: 4 hours

  • Children: 2 hours

  • Children below 9: 1 hour

• Removal (Doctor’s order)

  • Non dominant hand > leg on the other side > other leg > dominant hand, 10 mins each (one at a time)

• Skin and circulation

Recovery Phase

• Physical fatigue (tired and sleepy)

• If patient can talk:

  • Explore feelings about situation

  • Promote verbalization and validation

  • 2 hours max (?)

• If patient is too tired:

  • Let patient sleep

  • Assess self and other for injuries

Post Crisis Phase

• Remorse (guilty, crying, and ashamed)

• Perfect time for removal of restraints

• Formulating a plan of action (call the nurse)

• To other patients, significant others, and family:

  • Assist patient in expression (Nurse’s are not responsible to feel sorry)

  • Social environment promote interaction

Patients with Delusions

• False belief (fixed)

• Assess first before presenting reality

Types:

• Grandiose - superiority and invulnerability

• Persecutory - someone is planning to harm then

• Somatic - functions - body

• Nihilistic - shape/figure - body

• Erotomania - a specific person is in love with them

• Ideas of reference - general national events are about them

• Religious - preaches about second coming of a figure

• Sexual - sexual behaviors exposed to others

Interventions (CAVE: in order)

• C - clarify the meaning behind the illusion (assess)

• A - acknowledge the feelings behind (validate)

• V - voice doubt then present reality (avoid challenging or reinforcing)

• E - engage in reality based activity (distract)

Patients with Hallucinations

• Illusions are based on reality - Clarify reality to patient

• Hallucinations are not based on reality -

Types of hallucinations

• Auditory is based on hearing (most common)

  • Command is most dangerous (hearing instructions of harm to others)

• Visual is based on sight (second most common)

• Tactile is based on touch (in alcohol withdrawal)

• Olfactory is based on smell in seizure aura

• Gustatory is based on taste in seizure aura

• Cenesthetic is feeling undetectable body functions

• Kinesthetic is feeling body movements despite motionless

• Synesthesia is sensory mixing (seeing sounds/tastes color)

Interventions (HARDER)

• Hallucinations must be recognized

• Assess the content of hallucinations

• Reality presentation

• Divert attention to environment

• Engage a reality based activity

• Reintegrate to social environment (alone increase hallucination)

Other interventions

• Ask patient to talk back to voices (for auditory)

• The more anxious the patient, the more the hallucinations

• Use relaxation techniques

Patients with Schizophrenia

Also known as Dementia Precox

Risk factors

• Genetics (1 parent = 15% chance / 2 parents = 30% chance)

• Low socioeconomic status increases chance

• Vices during pregnancy

Biological

• Decreased brain size and CSF

• Neurotransmitters: High Dopamine and Serotonin

• 2 or more hard or soft symptoms for 6 months or more

Positive/Hard Symptoms

• Ambivalence - contradictory (sudden shift of mood)

• Echopraxia - imitates others actions

• Bizarre behavior - unusual appearance or actions

• Looseness of association, delusions, flight of ideas, hallucinations, ideas of reference, perseveration

  • Caused by high dopamine levels

Negative/Soft Symptoms

• Alogia is absence of speech (mutism)

• Anhedonia is absence of pleasure/joy

• Apathy is indifference to others

• Asociality is no social relationships

• Catatonia is psychologically induced immobility

• Avolition is absence of motivation/will to function

• Inattention

• Blunt/Flat affect

  • Caused by high serotonin levels

Types of Schizophrenia (S/sx for 6 months or more)

Outdated

• Catatonic

• Disorganized (thought/speech disturbances)

• Paranoid

Updated

• Brief psychotic disorder (S/sx for <1 month)

• Schizophreniform (S/sx for 1 month so 6 months)

• Shared psychotic “Folie à deux“ (Close relationship of pt also developed psychosis)

• Schizoaffective disorder (psychotic + mood disorder)

Initial early sign: Avolition

Other signs: Self care deficit

Anxiety

Levels of anxiety

Patients who are abused

Accidental or nonaccidental? NON ACCIDENTAL

• Physical - infliction of physical harm

• Emotional - shaming, bullying, and manipulation

• Neglect - omission of physical/emotional care

• Sexual abuse - non consensual infliction of sexual acts

• Financial - withholding or misuse of money or properties

• Shaken baby syndrome - violent shaking

  • People most at risk: Females, Children, Older adults, Dependents, LGBTQ

Warning signs of abused/neglected children

• Serious injury with no obvious physical trauma

• (+) Significant injury but delayed treatment seeking

  • Inconsistencies between injury and claimed history

• With regards to age (unusual injuries)

• Genitourinary (repeated UTI)

• Old injuries with varying stages of healing

Interventions

• Physiological injuries first before emotional

• Healthcare professionals are required to report suspected/actual abuse in social services

  • If child abuse: MAKABATA 1683

  • If elder abuse: VAWC Desk

• Nurses do not have to be certain of abuse before reporting

• During assessment, ensure privacy and confidentiality

  • If sexual abuse: assist doctor in collecting evidence (offer shower and fresh clothing)

• Develop a plan - safety plan of escape

  • Provide information about hotlines and shelters

• Refer to Crisis Therapy

• Q: The following are signs that child abuse is most likely present in a pediatric client, except? A: Abrasions on knees due to a bicycle crash, as reported by the parent (Always read except)