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Abnormal Psychiatric Nursing

18 min read

References:

  • Comprehensive Nursing Licensure Review Book: Local and International Test Prep, Volumes 1 and 2, ISBN 978-971-51-3383-8, by Josie Quiambao-Udan (Vol. 1, Part 6)

Compilation

This is a compilation page. It’s meant to cover a lot of topics in a short period of time. By nature, it’s not as comprehensive as reading through these topics on their own pages one by one. It’s focused on the important topics that usually appear in the board exam, but is still essentially complete.

Anxiety Disorders

Panic Disorder

Sudden feelings of intense apprehension and dread; with severe, recurrent, intermittent anxiety attacks that last from 5 to 30 minutes.

  1. Manifestations: choking sensation, labored breathing, pounding heart, chest pain, dizziness, nausea, blurred vision, numbness or tingling of extremities, sense of unreality and restlessness, and intense fear of being trapped and dying.
  2. Management: Stay with the client, provide reassurance, and provide support. Advise the patient to take deep breaths as hyperventilation is a common concern. To prevent respiratory alkalosis due to hyperventilation, breathing into paper bags or cupped hands may help.

Phobic Disorders

Phobias are irrational fears of an object or situation that persists even with an understanding of its irrationality.

  1. Manifestations: Often, panic-level anxiety is induced in the presence of the triggering object, situation, or activity. Projection and displacement are defense mechanisms used by individuals with phobias.
  2. Specific Phobias: Agoraphobia (fear of the outside; public), social phobia (public speaking, performing, etc.), acrophobia (heights), astraphobia (electrical storms), cacophobia (ugliness), hydrophobia (water), monophobia (loneliness), mysophobia (dirt or germs), nyctophobia (darkness), pyrophobia (fire), xenophobia (strangers), zoophobia (animals).
  3. Implementation: relaxation techniques, behavior modification. A common method is desensitization or exposure therapy. The patient is not exposed to the phobic stimuli haphazardly, but rather in a controlled environment and situation. Exposure therapy starts with minimal exposure to the stimuli, such as dialogue about the situation or images of the object, before gradually increasing to the actual stimuli.
  4. Psychopharmacology: anxiolytics

Obsessive-Compulsive Disorders

Obsessions are recurring thoughts of violence, contamination, doubt, worry, orderliness, or religion. Compulsions are recurring, irresistible impulses to perform acts or rituals to prevent some events, divert unacceptable thoughts, and decrease anxiety. Persons with OCD set high standards for themselves and expect the same of others. The They become preoccupied with rules, lists, organization, and details.

  1. Rituals: These manifest as various types of rituals: checking rituals (re-checking if the door was locked, if the oven was closed, etc.), counting rituals (steps, tiles, desks in a classroom), touching rituals (feeling textures), symmetry rituals (arranging items on a desk, etc.), perseveration (repeated words or tunes), cleanliness, and hand washing rituals.
  2. Manifestations: individuals are indecisive until all facts have been accumulated. They act rigidly and may become controlling. Perfectionism interferes with fulfillment of tasks.
  3. Implementation:
    • Distract the client and substitute rituals with scheduled activities. Do not interrupt compulsive acts. They will likely simply start over from the beginning on the same activity.
    • Managing rituals: Rituals are given their own time, but is limited to promote safety and also gradually shortened in duration and lessened in frequency. A written contract can be established to improve cooperation by the client.
  4. Psychopharmacology: Prozac (Fluoxetine), Zoloft (Sertraline), Luvox (Fluvoxamine), Anafranil 3(Clomipramine), BuSpar (Busprione), Klonopin (Clonazepam)

Body Dysmorphic Disorders

Preoccupation with imagined or slight defects in physical appearance that causes a person much distress or impairment is social or occupational functioning. It is also associated with obsessive-compulsive disorder

Somatoform Disorders

Persistent worry or complaints regarding physical illness when there are no physical findings. Despite reported or detected somatic signs and symptoms, there is no real pathology associated with the disorder.

  1. Conversion or Hysteria: alterations in physical function (most commonly blindness, mutism, deafness, or paralysis).
    • “La Belle Indifference”: a key feature of the disorder is an indifference towards one’s symptoms.
    • Low self esteem and a feeling of inadequacy may be present. The behavior may even be experienced unconsciously as a method for obtaining secondary gain. The presence of physical symptoms themselves may also be enough to reduce anxiety.
    • The disorder does not have an organic cause that can be determined.
    • Implementation: do not reinforce the sick role (providing secondary gain). However, do convey that the physical symptoms are real to the client and that the patient understands that. Allow a specific time period to discuss physical complaints because the client will feel less threatened if this behavior is limited rather than stopped completely. Diversion activities may decrease the client’s focus on the self.
  2. Hypochondriasis: a debilitating exaggerated preoccupation with physical health or fear of having serious illness despite no evidence of physical illness. Social and occupational functioning may become impaired. Frequent somatic complaints are reported, including fatigue and insomnia. Anxiety is persistent, and feelings may become difficult to express.
    • The client may show extensive use of home-based remedies, non-prescription medications, and appointments with healthcare providers despite repeated reassurance and normal test results.
    • Hypochondriasis may also manifest as an attempt at eliciting secondary gain.
  3. Somatization Disorder: multiple physical complaints involving a number of body systems, including pain, denial of emotional problems, signs of anxiety, fear, and low self-esteem may be present. These are presumably caused by psychological causes. This may also be related to secondary gain.
    • Implementation:
      • Set limits (not restrictions) on rumination; do not feed into the patient’s manifestations. Discourage verbalization about physical symptoms by not responding with positive reinforcement. Again, show an understanding of the reality of the symptoms to the patient but assure the client that physical illness has been ruled out.
      • Explore the source of anxiety and stimulate verbalization of anxiety. Encourage the use of relaxation techniques as anxiety increases. Encourage diversion activities.
    • Psychopharmacology: anxiolytics
  4. Psychosomatic Disorders: stress-related disorders with true pathology. These include migraines, cancers, hypertension, Meniere’s disease, ulcerative colitis, etc. These are disorders that arise from the effects of stress on the body.

Dissociative Disorders (Hysterical Neurosis)

Episodes of psychological flight, e.g., multiple personality, fugue episode, amnesia, and depersonalization.

  1. Dissociative Identity Disorder (Multiple Personality): the presence of two or more developed distinct and unique personalities within a person.
  2. Dissociative Amnesia: inability to recall important personal information because it provokes anxiety.
  3. Dissociative Fugue: the assumption of a new identity in a new environment. Individuals may drift from place-to-place. When the fugue lifts, the client returns home and is unable to recall the fugue state.
  4. Depersonalization Disorder: an altered self-perception in which one’s own reality is temporarily lost or changed.
    • Implementation: develop a trusting nurse-client relationship. Encourage verbalization of painful experiences, anxieties, and concerns. Group therapy may be used.

Munchausen Syndrome

A type of factitious disorder or mental illness in which a person repeatedly acts as if he/she has a medical disorder when, in truth, he or she has caused the symptoms. People act this was because of an inner need to be seen as ill or injured, not to achieve a concrete benefit, such as financial gain. They are willing to undergo painful or risky tests and operations in order to get the sympathy and special attention given to people who are truly ill. Some even secretly injure themselves to cause signs like blood in the urine or cyanosis of a limb. This mental disorder is often accompanied by severe emotional difficulties.

The need for sympathy can extend to one’s child, becoming a form of child abuse—Munchausen Syndrome by Proxy. The caretaker, often a mother, makes up fake symptoms or causes real symptoms to make it look like the child is sick. Measures may become extreme, such as withholding food to induce weight loss, heat up thermometers, make up lab results, give the child drugs, or infect an intravenous line.

  1. Caretakers often work in health care and is knowledgeable about medical care. They can describe the child’s symptoms in great medical detail. They may display caring for the child, which builds rapport with the health care team. They remain very outwardly involved with and devoted to the care of the child.
  2. Children may have a history of many procedures, tests, surgeries, appointments, and hospitalizations. The mother reports symptoms that are unseen by the health care professionals and don’t quite fit any disease. Laboratory results are inconsistent. Symptoms are “resolved” within the hospital, but arise once again when the child is sent home.
  3. The child requires protection. They may need to remove from the direct care of the parent. Medical care may actually be required to treat complications from induced injuries, infections, medications, surgeries, or tests. Psychiatric care may be required to deal with depression, anxiety, and PTSD that may occur with the child abuse. Both individual and family therapy may be indicated.
  4. The syndrome must be reported to the authorities because it is a form of child abuse.

Schizophrenia

Schizophrenia is a brain disorder that results in distorted and bizarre thoughts, perceptions, emotions, movements, and behavior. It is believed to be associated with hyperactivity of the neurotransmitter dopamine.

  1. Manifestations:
    • Bleuler’s 4 A’s represents the key symptoms of schizophrenia: autism, ambivalence, affect, and associations. Autism may show preoccupation with the self; affection is inappropriate, flat, or blunted. Ambivalence results in conflicting, strong feelings. Association becomes loose, with thinking and cognition becoming disorganized.
    • Positive Symptoms (symptoms that “add on to” normal behavior): hallucinations, delusions, paranoia, bizarre behavior, agitation, incoherent speech
    • Negative Symptoms (symptoms that “take away from” normal behavior): poverty of speech (alogia) and thought, poor self-care, social withdrawal, blunted affect, loss of motivation (avolition), and inability to experience pleasure or joy (anhedonia).
    • Cognitive Symptoms: inattention, easily distracted, impaired memory, poor problem-solving skills, illogical thinking, and impaired judgment.
    • Mood Symptoms: dysphonia (altered voice quality), suicidality, and hopelessness
    • In general, all of these dimensions will interfere with the client’s ability to work, interpersonal relationships, self-care abilities, social functioning, and quality of life.
  2. Variants:
    • Paranoid Schizophrenia: profound suspiciousness of others, which may result in hostility, anxiety, anger, and violence. Delusions and auditory hallucinations follow persecutory themes placing the client in a vulnerable and threatened state.
    • Disorganized Schizophrenia: marked disruptions in thinking, speech, and behavior. Flat or inappropriate affect may also be present. This results in extreme social withdrawal and an inability to perform ADLs.
    • Catatonic Schizophrenia: marked psychomotor disturbances, primarily of immobility. Waxy flexibility, stereotyped or repetitive behavior, and automatic obedience may be present. The client switches rapidly between stupor and excitement. Speech may become echolalic.
    • Undifferentiated Schizophrenia: an uncategorized form of schizophrenia, displaying delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, flattened affect, and social withdrawal.

Schizophrenic Thought, Content, and Speech Patterns

  1. Delusions: false persistent beliefs that are unaffected by logic or persuasion.
    • Delusion of grandeur: beliefs of being very powerful and important.
    • Delusion of persecution: beliefs of being singled out or targeted by others.
    • Delusion of jealousy: beliefs of partners cheating.
    • Delusion of thought withdrawal or thought insertion: false beliefs that one’s thoughts are being read by others, or that external forces are imposing their thoughts on them.
  2. Hallucinations: false sensory perceptions that appear without external stimuli. This may appear as auditory (most common), visual, olfactory, or tactile hallucinations. **This is a common early manifestation of schizophrenia.
  3. Illusions: false sensory perceptions based on misinterpreted stimuli in reality, e.g., perceiving a hose as a snake.
  4. Ideas of Reference: inaccurate interpretation of general events as being related to or targeted towards the client, e.g., hearing a speech on the television and believing it to be directed at the client.
  5. Clang associations: a speech pattern where used words are those that rhyme or sound alike.
  6. Echolalia: “echoing” or repeating words that is heard from another.
  7. Neologisms: creation of words that only have meaning to the client.
  8. Flight of Ideas: rapidly switching between loosely connected trains of thought with a constant flow of speech.
  9. Blocking: sudden cessation of thought in a middle of a sentence, “I forgot what I was talking about.” New thoughts, often unrelated, usually come up afterwards.
  10. Circumstantiality: speech that includes excessive, often irrelevant, details before eventually reaching the main point. Tangentiality is speech that veers off-topic, and never returns to the main point.
  11. Confabulation: creation of false memories to fill in gaps in memory. The detailed fantasy is believed by the client.
  12. Word Salad: a mixture of words that display no coherent thought. Words are real, but convey no message.
  13. Perseveration: persistent repetition of verbal or motor responses, even with varied stimuli.

Management

  1. Psychopharmacology: atypical antipsychotics, e.g., Clozaril (Clozapine), Zyprexa (Olanzapine), Seroquel (Quetiapine), Risperdal (Risperidone), and Serlect (Sertindole) are effective in treating both positive and negative symptoms of schizophrenia.
  2. Nursing Interventions:
    • Hallucinations: do not confront, deny, or refute the hallucination. Acknowledge that the hallucination is real to the client, but point out that you do not share the same perception. In the presence of hallucinations, the client should not be left alone. Do not touch the client. Diversional activities can be given for the client.
    • The least restrictive environment is used. Restraints should not be used when unnecessary.
    • Positive reinforcement can promote behaviors but should be done in a consistent manner.
    • Provide physical care and safety.
    • Nurse-client relationships is normally made on a one-to-one basis. Interactions should be short, simple, and concrete. The client should be accepted unconditionally, but care should be provided manner-of-factly (practical, unemotional).
    • Orient the client to reality.

Paranoid Personality Disorders

Consistent distrust, suspiciousness of others. This is often viewed by others as hostile, stubborn, and defensive, hypersensitive, humorless. The use projection as their primary defense mechanism, as they project their suspicion and hostility towards others and believe others share the same hostility towards them.

Management

  1. Persecutory Delusions should not be agreed with nor confronted. Responses to the patient’s delusions should present reality. It is helpful to steer the conversion away~~ from the topic of delusion.
  2. Aggression/Hostility: limit-setting is very important. The nurse keeps their distance, uses a calm and controlled tone, and reduces stimulation (e.g., with timeout). Other patients should be kept away. Seclusion should be a last resort; restraints should be applied quickly and safely if necessary. Explore alternative methods of expression with the patient, including verbal expressions and other outlets of aggression.
  3. Fear of being poisoned can impede nutrition. Food and medications should be served in containers or wrapped. Medications should not be put in juice—this can induce greater paranoia and loss of trust. Similarly, do not threat the patient in order to coerce them to eat. If any aggression is present, attempt to de-escalate and an opportunity to gain control.

Pervasive Developmental Disorders

  1. Autism becomes apparent at 2 to 3 years of age. It is characterized by impairment in reciprocal social interaction and in verbal and nonverbal communication.
    • The child is self-absorbed and is unable to relate to others. Solitary play is common and temper tantrums arise when they are interrupted.
    • Persons with autism may tend to repeat words or phrases meaninglessly or repeat previously heard speech.
    • Significant objects may become subjects to intense or unusual attachment.
    • Autoerotic behaviors (e.g. rocking, masturbation), spinning, twirling, self-mutilation, and other bizarre behaviors
    • Implementation: routines are very helpful in caring for a child with autism. Take into account their preferences and methods of communication to plan activities. Promote safety and avoid placing demands on the child. Referrals and support to the parents are helpful.
  2. Attention Deficit/Hyperactivity Disorder (ADHD) is characterized by inappropriate degrees of inattention, overactivity, and impulsivity. This includes somatic manifestations such as fidgeting with hands and feet. The child is easily distracted with poor attention span, and have difficulty in following through on instructions, completing activities, and conversation. They talk excessively and interrupts or intrudes on others. They may engage in potentially dangerous activities without considering possible consequences.
    • Implementation: Most importantly, promote safety. Inattention can increase a child’s vulnerability to hazards. Because of reduced capacities, the nurse should help enhance the child’s capabilities and self-esteem. Referrals and support to the parents are helpful.
    • Psychopharmacology: Arraxal, Strattera. Adderall, Methylphenidate (Ritalin), Pemoline (Cylert), Dextroamphetamine (Dexedrine) should be given after meals to prevent anorexia or 6 hours before sleep to prevent insomnia. A common side effect of ADHD medications is growth retardation.
  3. Tourette’s Disorder: recurrent involuntary and rapid movements affecting various parts of the body, accompanied by vocal noises (“tics”) such as barks, grunts, or profanities. This may be accompanied by ADHD, OCD, and other behavioral problems.
    • Implementation: promote safety; administer Haloperidol (Haldol) as ordered to decrease tic severity.

Mood Disorders and Associative Disorders

Depression and Elation

The loss of a loved one is a common cause for depression. The grieving process usually takes two years for full recovery.

  1. Major Depression is characterized by suicidal ideation, and most commonly accompanies a change in weight of over 10 lbs. in a short period of time with no obvious physiological cause.
    • Implementation: suicide precautions; maintain suicide, build trust. Diversional, non-intellectual activities (e.g., folding table napkins) can be given.
  2. Mania is characterized by a delusion of grandeur and flight of ideas. The individual becomes very easily stimulated and has an abnormally elevated or irritable mood.
    • Appearance: the use of heavy make-up and (possibly inappropriate to weather/situation) colorful, flamboyant clothing.
    • Behavior: mania will appear as hyperactivity and irritability. They may act seductive.
    • Communication: individuals are talkative, possibly explicit or inappropriate, and loud.
    • Implementation: lack of focus can impede nutrition—schedule small, frequent feedings of high calorie finger foods. To reduce symptoms of mania, reduce stimuli. Communicate calmly. Scheduled activities should be safe and make use of the client’s energy.
  3. Bipolar Disorder is a disorder of alternating episodes of depression and mania. Suicidal potential is greatest during periods of “normalcy”, which is when the patient is coherent and energetic enough to implement plans of suicide.

Suicide

Clients who are depressed, hallucinating, delusional, substance abusers, elderly, in chronic pain, conflicted with sexual identity, terminally ill, and those with a history of suicide attempts may attempt suicide. Danger signs of suicide include:

  • Statement of a plan. The immediate concern in such a case would be for the nurse to ascertain what the client’s plans are.
  • Giving away personal items
  • Completing wills
  • Finalizing personal and business matters
  • Making amends
  • Changes in behavior. A common theme is sudden “relief” or joyfulness that accompanies a feeling of upcoming freedom from their pain.
  • Gesture or history of attempt
  • Statements, either direct (overt) or indirect (covert)

The most common time of implementing suicide plans is during the change of shift period when the client is unattended.

In the event that a patient is suspected of committing suicide or is a risk demographic, the nurse initiates suicide precautions:

  1. Stay with the client. Safety is always priority.
  2. Engage in a safety contract with the patient: “No suicide”, “No harm”, and “No self-injury” statements that the client with self-destructive impulses agree with.
  3. Remove sharp or otherwise potentially harmful objects.
  4. Engage in personal contact—show care and concern with a neutral tone. Maintain hope and goals.
  5. Diversional activities that wean a withdrawn and isolated person with increasing numbers of people.

Management

Refer to Psychopharmacotherapy for the discussion on antidepressants.

  1. Antidepressants: TCAs, SSRIs, MAOIs, Atypical Antidepressants
  2. Antimanic Agents: Lithium Carbonate/Lithium Cirtrate (Esklaith, Lithane, Lithonate, Lithobid) is a common antimanic medication used in psychiatric patients. Its use requires close monitoring due to its narrow therapeutic window. Regular monitoring of lithium levels is essential. The therapeutic range is typically between 0.6 to 1.2 mEq/L (may be 0.5 to 1.5 mEq/L). Blood levels should be checked 5 days after starting treatment or after any dose change, then every 2-3 months. Monitor for symptoms of lithium toxicity if levels exceed 1.5 mEq/L. Educate the patient about the importance of regular blood level checks. Adjust the lithium dose based on serum levels and clinical response.
    • Kidney Function Tests: Lithium can affect renal function, necessitating periodic kidney function tests (e.g. Crea and BUN). Monitor trends in renal function tests and adjust lithium therapy as needed. Identify any signs of renal impairment. Schedule regular monitoring of kidney function. Educate the patient about the importance of kidney function tests.
    • Toxicity: Headache, lethargy, drowsiness, dizziness, tremors, slurred speech, dry mouth, anorexia. nausea and vomiting, diarrhea, polyuria, hypotension, abdominal pain, muscle weakness, restlessness.
  3. Electroconvulsive Therapy (Etc) may be used for rapid improvement of symptoms of severe depression, mania, and psychosis. It is a procedure done while under general anesthesia that delivers electrical stimulation (70 to 110 volts) to the brain to induce controlled seizures (grand mal seizures for 0.1 to 1.0 second).
    • Preparation: written consent is required. The client is instructed to remain on NPO the midnight before (6 to 8 hours) the procedure. Just before the procedure, jewelry and prostheses are removed, and the client is instructed to void (prevent incontinence). A set of baseline vital signs are obtained.
    • Prior to the procedure, atropine (dry mouth), barbiturates, and a succinylcholine can be given
    • Aftereffects: Hypotension, airway obstruction, and aspiration—monitor vital signs and maintain a patent airway; position the patient in a side-lying position. Disorientation is expected with transient memory loss. Reorient the person to persons, place, and time. Headaches or nausea may be present.

Personality Disorders

Substance Use Disorders

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