Prepared by: Group 6

Supervised by:
▪ Dr/Hend Karem
▪ Dr/Nora Nasser

Psychiatric and Mental Health Nursing department

First Term 2025 – 2026
Outlines
1. Introduction about schizophrenia
2. Definition of schizophrenia
3. Causes of schizophrenia
4. Phases of schizophrenia
5. Signs and Symptoms of schizophrenia
6. Types of schizophrenia
7. Diagnostic criteria of Schizophrenia
8. Management of schizophrenia
9. Nursing care plan of schizophrenia
10. Health education of schizophrenia
11. References
 Introduction about schizophrenia
➢ Schizophrenia is a serious and chronic mental illness that affects how a person thinks, feels, and
behaves. It is characterized by thoughts or experiences that are out of touch with reality
(psychosis), which can include delusions (strong beliefs not based in reality) and hallucinations
(seeing or hearing things that are not there). Other symptoms include disorganized speech or
behavior and decreased participation in daily activities. Contrary to popular belief,
schizophrenia is not a split personality. It is a complex brain disorder that, while not curable, has
highly effective treatments available to manage its symptoms
 Incidence of schizophrenia
➢ It is one of the most common serious mental disorders.
➢ The most typical age for onset of schizophrenia during the adolescence and early adulthood
➢ According to WHO, Schizophrenia affects about 24 million people or 1 in 300 people (0.32%)
worldwide
➢ The prevalence of schizophrenia in Egypt is around 1.4 to 4.6 cases per 1,000 people annually,
 Definition of schizophrenia
➢ Schizophrenia is a severe chronic mental disorder characterized by profound disruptions in
thinking, affecting language, perception, and the sense of self. It often includes psychotic
experiences, such as hearing voices (hallucinations) or holding fixed, false beliefs (delusions).
The disorder can impair functioning in many aspects of daily life, including personal, family,
social, educational, and occupational domains. People with schizophrenia often experience
persistent difficulties with cognitive functions like memory, attention, and problem-solving.
 Causes of Schizophrenia
➢ The exact cause of schizophrenia remains unknown, it's believed to result from a combination of
predisposing factors:
Biopsychosocial
A. Biological factors
1. Genetic influences
▪ Family history : A family history of schizophrenia significantly increases the risk
▪ Genes deficit : Multiple genetic variations, each with a small effect, can combine to increase
vulnerability.
2. Biochemical influences
▪ ↑ Mesolimbic dopamine → positive symptoms.
▪ ↓ Mesocortical dopamine → negative & cognitive symptoms.
▪ Glutamate hypothesis: N-Methyl-D-Aspartate (NMDA) receptor hypofunction → cognitive &
negative symptoms.
▪ Serotonin involvement: 5-HT2A dysregulation → explains effect of atypical antipsychotics
B. Physiological factors
1. Viral infection
➢ No single virus causes schizophrenia. But prenatal viral infections (like influenza, rubella, CMV,
HSV-2) and possibly later infections (EBV, coronaviruses, etc.) are associated with a modestly
increased risk. The mechanism is thought to be maternal immune activation and neuroinflammation,
acting on a genetically vulnerable brain.
2. Anatomical abnormalities
▪ Enlarged ventricles → loss of brain tissue.
▪ Reduced gray matter in prefrontal cortex, hippocampus, and temporal lobes.
▪ Abnormal connectivity between frontal and temporal regions

C. Psychological Factors
➢ Early conceptualizations of schizophrenia focused on family relationship factors as major

influences in the development of the illness, probably in light of the conspicuous absence of
information related to a Stressful life events also may be associated with ex acerbation of
schizophrenic symptoms and increased rates of relapse
D. Environmental Factors
1. Sociocultural Factors
➢ Epidemiological studies show higher rates of schizophrenia in lower socioeconomic groups
➢ Contributing conditions:
▪ Crowded housing
▪ Poor nutrition
▪ Lack of prenatal care
▪ Limited coping resources
▪ Feelings of hopelessness
➢ Downward drift hypothesis:
▪ Suggests the opposite direction — schizophrenia symptoms make it difficult to maintain work,
leading patients to “drift down” into lower socioeconomic status.
▪ Here, poverty is seen as a consequence rather than a cause.
2. Stressful Life Events
➢ Stress does not cause schizophrenia.
➢ But stress can precipitate or worsen episodes in individuals who already have genetic
vulnerability.
➢ Extreme stress can trigger psychotic episodes.
➢ Stress therefore influences the course and severity of illness, not its root cause
 Phases of schizophrenia
Phase Characteristics Symptoms Notes / Intervention
Phase I – Occurs before clear ➢ Social maladjustment, ➢ Early personality
Premorbid illness withdrawal, irritability, traits may resemble
antagonistic schizoid/schizotypal
thoughts/behavior personality
➢ Shy, introverted, few/no
friends
➢ Poor peer relationships, poor
school performance
➢ Preference for solitary
activities
Phase II – Transition period ➢ Functional impairment (poor Average duration 2–5
Prodromal from premorbid to role functioning, years; early
active psychosis school/work decline) intervention here may
➢ Nonspecific symptoms: delay onset of
sleep disturbance, anxiety, psychosis
irritability, depressed mood,
poor concentration, fatigue
➢ Social withdrawal
➢ Late prodrome: perceptual
abnormalities, ideas of
reference, suspiciousness
Phase III – Active Illness fully ➢ Prominent positive Requires immediate
(Acute) developed symptoms: hallucinations, medical attention;
delusions antipsychotics +
➢ Disorganized speech, structured treatment
thinking, and behavior plan
Phase IV – After an acute episode ➢ Reduction or absence of Ongoing treatment
Residual positive symptoms Medication helps
➢ Persistent negative prevent relapse
symptoms: lack of
motivation, flat affect, social
withdrawal

 Signs and Symptoms of schizophrenia

i. Positive Symptoms
➢ “added experiences” — behaviors, thoughts, or perceptions that are present in schizophrenia but
should not normally be there.
▪ Hallucinations (mostly auditory, sometimes visual, tactile, or olfactory)
▪ Delusions (false beliefs, e.g., persecution, grandiosity)
▪ Disorganized speech
▪ Disorganized or catatonic behavior
[Link] Symptoms
➢ are “losses or decreases” — reductions in normal emotional, cognitive, or social abilities.
▪ Affective flattening/Apathy : A marked reduction or absence of emotional expression
▪ Avolition (lack of motivation)
▪ Anhedonia (loss of pleasure and interest)
▪ Asociality
▪ Alogia (poverty of speech)
▪ Anergia (lack of energy)
[Link] Symptoms
▪ Impaired attention and concentration
▪ Poor working memory
▪ Executive dysfunction (problems with planning, problem-solving, decision-making)
▪ Lack of insight
 Types of Schizophrenia
1. Paranoid Schizophrenia
▪ The most common type
▪ Dominated by delusions (often persecution or grandeur)
▪ Frequent auditory hallucinations
▪ Cognitive functioning often preserved
▪ Less disorganized behavior compared to other types
2. Disorganized Schizophrenia
▪ Disorganized speech and behavior
▪ Flat or inappropriate affect
▪ Difficulty in daily functioning
▪ Poor prognosis if untreated
3. Catatonic Schizophrenia
➢ A subtype of schizophrenia marked by severe motor disturbances.
Forms:
a. Catatonic stupor → extreme psychomotor retardation:
▪ Very little movement or activity
▪ Mutism: no speech
▪ Negativism: resists instructions or movement without reason
▪ Waxy flexibility: person maintains bizarre or rigid postures for long periods, resists repositioning
b. Catatonic excitement (opposite) → extreme psychomotor agitation (frenzied, purposeless
movement, shouting, aggression).
▪ Needs urgent medical care
4. Undifferentiated Schizophrenia
▪ Symptoms don’t clearly fit into other types
▪ Mixed features from paranoid, disorganized, or catatonic types
▪ Diagnosis made when symptom clusters overlap
5. Residual Schizophrenia
▪ Past history of schizophrenia
▪ Current presentation: mostly negative symptoms
▪ Delusions and hallucinations less prominent
▪ Patient often socially withdrawn
6. Schizoaffective Disorder
➢ A disorder with both schizophrenia symptoms and mood disorder symptoms (depression
or mania).
Symptoms:
➢ Mood symptoms:
▪ Depression → low mood, slowed activity, suicidal thoughts
▪ Mania → euphoria, grandiosity, hyperactivity
➢ Schizophrenia symptoms:
▪ Delusions
▪ Hallucinations
▪ Disorganized speech
▪ Catatonic behavior
▪ Blunted/inappropriate affect
▪ Diagnosis key: Schizophrenic symptoms are present in addition to mood disorder
symptoms.
Prognosis:
▪ Better than schizophrenia alone
▪ Worse than mood disorders alone
 Diagnostic criteria of Schizophrenia
➢ According to DSM-5 the following criteria to make a diagnosis of schizophrenia:
A. Core Symptoms: At least two of the following symptoms must be present for a
significant portion of time during a one-month period
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g., frequent derailment or incoherence )
4. Disorganized behavior
5. Negative symptoms
B. Duration ≥ 6 months
C. Social / occupational dysfunction
D. Schizoaffective and mood disorder exclusion
E. Not due to substance/medical condition
 Management of Schizophrenia
➢ The goals in treating schizophrenia include targeting symptoms, and increasing adaptive
functioning so that the patient can be integrated back into the community
➢ There are two line of management: -
▪ Pharmacological management.
▪ Non-pharmacological management.
A. Pharmacological Management
▪ Antipsychotic drugs.
▪ Antiparkinsonian drugs.
▪ Mood stabilizer drugs.
B. Non-pharmacological
1. Hospitalization: Used for severe crises (e.g., hallucinations, self-harm) to ensure patient safety,
provide basic care (nutrition, sleep, hygiene), and stabilize symptoms. Treatment typically lasts 3
weeks to 2 months, followed by mandatory continued medication and doctor follow-ups.
2. Brain Synchronization Therapy (BST): Reserved for patients who do not respond to medication.
It is indicated for severe catatonia (stupor or excitement), uncontrolled acute episodes, and high-
risk situations involving suicide or violence.
C. Psychotherapy:
1. Individual Therapy: Helps patients understand their illness, distinguish reality from delusions,
and develop coping strategies for their thoughts and behaviors.
2. Cognitive Behavioral Therapy (CBT): Teaches patients to identify and change negative thought
patterns and behaviors, specifically to better manage hallucinations and delusions.
3. Group Therapy: Involves multiple patients focusing on real-life problem-solving, social skills,
and sharing experiences. It is most beneficial for outpatients.
4. Family Therapy: Educates and supports families, teaching them effective communication, stress
management, and coping strategies to create a supportive environment for the patient.
5. Art Therapy: Provides a creative outlet for patients to express feelings, process experiences,
connect with others, and can help reduce symptoms. Sessions can be individual or in a small
group.
6. Assertive community treatment : An intensive, team-based approach to provide comprehensive,
community-based psychiatric treatment, rehabilitation, and support for individuals with severe
mental illness (like schizophrenia).
7. Milieu Therapy
➢ A therapeutic community approach focusing on the environment to support treatment.
➢ Works best when combined with psychotropic medications.
➢ Emphasizes group and social interaction.
➢ Rules & expectations enforced by peer pressure to encourage normal behavior.
➢ Patients treated as responsible individuals → reduces “sick role” mentality.
 Nursing care plan for schizophrenia
Nursing diagnosis Expected outcome Nursing intervention
Risk for self – Within a specified 1- Observe client’s behavior frequently. Do this through
directed violence or time, client will routine activities and interactions to avoid appearing
other – directed recognize signs of watchful and suspicious. Clients at high risk for
violence related to increasing anxiety violence require close observation to prevent harm to
lack of trust or and agitation and self or others.
delusional thinking report to staff for 2- Observe for suicidal behaviors: verbal statements,
assistance with such as “I’m going to kill myself” or “Very soon my
intervention. mother won’t have to worry herself about me any
➢ Long – term longer,” or nonverbal behaviors, such as giving away

goals - Client will cherished items or mood swings. Most clients who

not harm self or attempt suicide have communicated their intent, either

others. verbally or nonverbally.

3- Determine suicidal intent and available means. Ask,
“Do you plan to kill yourself?” and “How do you plan
to do it?” Direct, closed-ended questions are
appropriate in this instance. The client who has a
usable plan is at higher risk than one who does not.
4- Obtain verbal or written contract from client agreeing
not to harm self and agreeing to seek out staff in the
event that such ideation occurs. Discussion of suicidal
feelings with a trusted individual provides a degree of
relief to client. A contract gets the subject out in the
open and places some of the responsibility for his or
her safety with client. An attitude of acceptance of
client as a worthwhile individual is conveyed.
5- Help client to recognize when anger occurs and to
accept those feelings as his or her own. Have client
keep an “anger notebook,” in which a record of anger
experienced on a 24-hour basis is kept. Information
 regarding source of anger, behavioral response, and
client’s perception of the situation should also be
noted. Discuss entries with client, suggesting
alternative behavioral responses for those identified as
maladaptive.
6- Act as a role model for appropriate expression of
angry feelings, and give positive reinforcement to
client for attempting to conform. It is vital that client
express angry feelings, because suicide and other
self-destructive behaviors are often viewed as a
result of anger turned inward on the self.
7- Remove all dangerous objects from client’s
environment. Client’s physical safety is a nursing
priority.
8- Try to redirect violent behavior with physical outlets
for client’s anxiety (e.g., punching bag, jogging,
volleyball). Anxiety and tension can be relieved
safely and with benefit to client in this manner.
9- Be available to stay with client as anxiety level and
tensions begin to rise. The presence of a trusted
individual provides a feeling of security.
10- Staff should maintain and convey a calm attitude to
client. Anxiety is contagious and can be
communicated from staff to client and vice versa. A
calm attitude conveys a sense of control and a
feeling of security to client.
11- Have sufficient staff available to indicate a show of
strength to client if it becomes necessary. This
conveys to client an evidence of control over the
situation and provides some physical security for
staff.
12- Administer tranquilizing medications as ordered by
physician, or obtain an order if necessary. Monitor
medication for effectiveness and for adverse side
effects. Short-term use of antianxiety medications
(e.g., chlordiazepoxide, alprazolam, lorazepam)
provides relief from the immobilizing effects of
anxiety and facilitates client’s cooperation with
therapy.
Nursing diagnosis Expected Nursing intervention
outcome
Social Isolation Short-term: 1. Convey an accepting attitude by making brief, frequent
related to lack of • Client will contacts. An accepting attitude increases feelings of self-
trust, anxiety, worth and facilitates trust.
willingly
regression, 2. Show unconditional positive regard. This conveys your belief
attend therapy
delusional in the client as a worthwhile human being.
activities with
thinking, past 3. Be with the client to offer support during group activities that
support of a
negative may be frightening or difficult for him or her. The presence
trusted staff
experiences, and of a trusted individual provides emotional security for the
member within
repressed fears as client.
1 week.
evidenced by 4. Be honest and keep all promises. Honesty and dependability
Long-term:
withdrawal, promote a trusting relationship.
• Client will
avoidance of eye 5. Orient client to time, person, and place, as necessary.
voluntarily
contact, sad affect, 6. Be cautious with touch. Allow client extra space and an
engage in
and expression of avenue for exit if he or she becomes too anxious. A
group
rejection/alonenes suspicious client may perceive touch as a threatening gesture.
activities with
7. Administer tranquilizing medications as ordered by
peers and staff,
physician. Monitor for effectiveness and for adverse side
demonstrating
effects. Antipsychotic medications help to reduce psychotic
improved
symptoms in some individuals, thereby facilitating
social
interactions with others.
interaction.
8. Discuss with client the signs of increasing anxiety and
techniques to interrupt the response (e.g., relaxation
exercises, thought stopping). Maladaptive behaviors such as
withdrawal and suspiciousness are manifested during times
of increased anxiety.
9. Give recognition and positive reinforcement for client’s
voluntary interactions with others. Positive reinforcement
enhances self-esteem and encourages acceptable behaviors
Nursing diagnosis Expected outcome Nursing intervention
Disturbed Short-term: 1. Observe client for signs of hallucinations (listening pose,
Sensory • Client will laughing or talking to self, stopping in mid-sentence).
Perception maintain Early intervention may prevent aggressive responses to
related to orientation to command hallucinations.
alteration in brain time, place, 2. Avoid touching the client before warning him or her that
function (e.g., person, and you are about to do so. Client may perceive touch as
vascular disease, circumstances threatening and respond in an aggressive manner.
cerebral hypoxia, with caregiver 3. An attitude of acceptance will encourage the client to
substance abuse, assistance share the content of the hallucination with you. This is
environmental during important in order to prevent possible injury to the client
toxins) as specified or others from command hallucinations.
evidenced by period. 4. Do not reinforce the hallucination. Use words such as “the
hallucinations, Long-term: voices” instead of “they” when referring to the
sensory • Client will hallucination. Words like “they” validate that the voices
distortions, poor demonstrate are real.
concentration, accurate 5. Try to connect the times of the hallucinations to times of
disorientation, perception of increased anxiety. Help the client to understand this
suspiciousness, environment by connection. If client can learn to interrupt escalating
and inappropriate responding anxiety, hallucinations may be prevented.

responses. appropriately to 6. Try to distract the client away from the hallucination.
real stimuli. Involvement in interpersonal activities and explanation of
the actual situation will help bring the client back to
reality.
7. Listening to the radio or watching television helps distract
some clients from attention to the voices. Others have
benefited from an intervention called voice dismissal.
With this technique, the client is taught to say loudly, “Go
away!” or “Leave me alone!”, thereby exerting some
conscious control over the behavior.
Nursing diagnosis Expected outcome Nursing intervention
Disturbed Thought Short-term goal: 1. Convey your acceptance of client’s need for the
Processes related – Within 1 week, false belief, while letting him or her know that you
to panic-level client will verbalize do not share the belief. It is important to
anxiety as that false ideas occur communicate to the client that you do not accept
evidenced by during periods of the delusion as reality.
delusional increased anxiety. 2. Do not argue or deny the belief. Use reasonable
thinking doubt as a therapeutic technique: “I understand that
Long-term goal: you believe this is true, but I personally fi nd it hard
– By discharge, client to accept.” Arguing with the client or denying the
will demonstrate belief serves no useful purpose, because delusional
reality-based thinking ideas are not eliminated by this approach, and the
and differentiate development of a trusting relationship may be
between delusions and impeded.
reality. 3. Help client trye to connect the false beliefs to times
of increased anxiety. Discuss techniques that could
be used to control anxiety (e.g., deep-breathing
exercises, other relaxation exercises, thought
stopping techniques). If the client can learn to
interrupt escalating anxiety, delusional thinking
may be prevented.
4. Reinforce and focus on reality. Discourage long
ruminations about the irrational thinking. Talk
about real events and real people. Discussions that
focus on the false ideas are purposeless and useless,
and may even aggravate the psychosis.
5. Assist and support client in his or her attempt to
verbalize feelings of anxiety, fear, or insecurity.
Verbalization of feelings in a nonthreatening
environment may help client come to terms with
long-unresolved issues.
Nursing diagnosis Expected outcome Nursing intervention
Self-Care Deficit Short-term: 1. Provide simple, structured environment → minimizes
related to • Client will confusion and enhances independence.
cognitive participate in ADLs 2. Identify self-care deficits and assist as needed →
impairment as with caregiver ensures unmet needs are recognized and addressed.
evidenced by assistance. 3. Allow adequate time for tasks → reduces frustration
inability to wash Long-term: and promotes self-esteem.
body, put on • Client will 4. Guide client step by step during ADLs → supports
clothing, bring perform ADLs to memory and encourages independent action.
food to mouth, and the best of ability. 5. Maintain consistent schedule and caregivers →
toilet self without • Caregiver will promotes stability, familiarity, and reduces anxiety.
assistance.. meet unfulfilled 6. Ensure ADLs follow client’s home routine as much as
needs. possible → enhances comfort and cooperation.
• Client will 7. Assess client’s ability to meet nutritional, safety, and
maintain safety and medication needs before discharge → ensures continuity
dignity during care. of care and safety at home.
8. Educate caregivers about community support systems
(e.g., Alzheimer’s support groups, home care services) →
provides resources and reduces caregiver burden.
Nursing diagnosis Expected outcome Nursing intervention

Ineffective Coping Short-term: 1. Encourage child/adolescent to discuss distressing

related to • Client will verbalize situations and responses → increases awareness of the

unresolved correlation between relationship between stress and symptoms.

separation somatic symptoms and 2. Include parents in discussion → promotes

conflicts and fear of separation. understanding and family support in managing stress.
inadequate coping Long-term: 3. Help client recognize unrealistic/perfectionistic
skills as evidenced • Client will self-expectations → links unmet expectations to
by somatic demonstrate use of somatic symptoms and begins change process.
complaints in adaptive coping 4. Encourage family and client to identify adaptive
response to strategies (instead of coping strategies (e.g., relaxation, problem-solving,

separation from physical symptoms) positive self-talk) → provides alternatives to

attachment figure when faced with maladaptive responses.

stress. 5. Role-play coping strategies → enhances confidence
..
and likelihood of using adaptive skills in real
situations.
Nursing diagnosis Expected outcome Nursing intervention

Caregiver Role Short-term: 1. Assess caregivers’ ability to anticipate and fulfill

Strain related to • Caregiver will client’s unmet needs. Provide information to assist

severity and verbalize caregivers with this responsibility. Ensure that

chronicity of care understanding of ways caregivers encourage client to be as independent

receiver’s illness, to facilitate the as possible. Caregivers may be unaware of what

caregiver’s caregiving role. the client can realistically accomplish. They may

competing Long-term: be unaware of the nature of the illness.

commitments, lack • Caregiver will 2. Ensure that caregivers are aware of available

of respite, and demonstrate effective community support systems from which they can

complexity of problem-solving skills seek assistance when required. Examples include

caregiving as and adaptive coping respite care services, day treatment centers, and

evidenced by mechanisms to adult day-care centers. Caregivers require relief

apprehension about maintain equilibrium from the pressures and strain of providing 24-hour

institutionalization, care for their loved one. Studies have shown that

difficulty abuse arises out of caregiving situations that place

performing required overwhelming stress on the caregivers.

tasks, and concerns 3. Encourage caregivers to express feelings,

about ability to particularly anger. Release of these emotions can

provide care. serve to prevent psychopathology, such as

depression or psychophysiological disorders, from
..
occurring.
4. Encourage participation in support groups
composed of members with similar life situations.
Provide information about support groups that
may be helpful
 Health education of schizophrenia
 for Client/Family Education Related to Schizophrenia:
1. Nature of Illness
▪ What to expect as the illness progresses.
▪ Symptoms associated with the illness.-
▪ Ways for family to respond to behaviors associated with the illness
2. Management of the Illness
▪ Connection of exacerbation of symptoms to times of stress
▪ Appropriate medication management.
▪ Side effects of medications.
▪ Importance of not stopping medications
▪ When to contact health-care provider.
▪ Relaxation techniques.
▪ Social skills training.
▪ Daily living skills training
3. Support Services
▪ Financial assistance
▪ Legal assistance.
▪ Caregiver support groups.
▪ Respite care
▪ Home health care
4. Patient and Family Education
▪ Explain to patient and family about thought disturbances, mood changes, hallucinations.
▪ Instruct family to hospitalize immediately if risk of self-harm or aggression.
▪ Teach recognition of stressors that trigger symptoms and how to prevent them.
▪ Clarify schizophrenia is a chronic disorder affecting thought, mood, emotions, and social life.
▪ Encourage communication with supportive people
5. Treatment education
▪ Take medication regularly.-
▪ Teach about side effects: dizziness, dry mouth, anxiety, weight gain, high blood pressure.
▪ Explain therapeutic vs non-therapeutic effects of antipsychotics.
▪ Report severe or persistent side effects to doctor immediately
6. Relapse Education
▪ Follow up regularly
▪ Stick to your medication
▪ Learn early warning signs: sleep changes, withdrawal, suspiciousness.
7. Lifestyle Education
▪ Avoid smoking and alcohol.-
▪ Use coping strategies for stress.-
▪ Exercise, sleep well, keep social contact.-
▪ Eat a balanced diet.-
▪ Limit exposure to stressful situations
8. Psycho-social Support
▪ Encourage participation in support groups to reduce isolation and share coping experiences.
▪ Educate about stigma and managing discrimination.
▪ Guide family on how to create a supportive home environment with patience, understanding, and
reduced criticism.
▪ Support development of life skills: communication, problem-solving, decision-making, and
relaxation techniques
 Resources for people with schizophrenia in Egypt: The areas or hospitals are
available
➢ Hospitals specializing in psychiatry

▪ Cairo: Abbasiya Hospital, Helwan Hospital, Khanka Hospital

▪ Alexandria: Maamoura Hospital, Abbas Helmy Hospital
▪ Delta and Qanal Governorates: Benha Hospital, Damietta Hospital, Mansoura Hospital,
Port Said Hospital
➢ Health units

▪ Cairo (Seventh – Haggana – Saqr Quraish – Maadi Al-Khubari)

▪ Giza (Talbeya – Omrania – Kafr Nassar – Mit Oqba – West Airport – Zayed – Sixth –
Hosary)
▪ Request mental health and psychosocial support services at a nearby clinic
➢ Public hospitals

▪ Ahmed Maher Hospital, Al Sahel Hospital, Zayed General Hospital, Umm Al Masryeen Hospital,
Nervous System Institute

➢ University Hospitals:

▪ Ain Shams University Hospital, Kasr Al-Ainy Hospital, Alexandria University Hospital,
Mansoura University Hospital

➢ Hotline number:16328
 ‫‪Nursing Care For Depression‬‬

‫‪Prepared By:‬‬
‫‪‬‬ ‫نورهان هاني‬
‫‪‬‬ ‫محمد عبدالمنعم‬
‫‪‬‬ ‫عبدالرحمن على‬
‫‪‬‬ ‫نورهان عماد‬
‫‪‬‬ ‫عبدالرحمن محمد احمد‬
‫‪‬‬ ‫نورهان محمود محمود‬
‫‪‬‬ ‫عبدالرحمن محمد محمد‬
‫‪‬‬ ‫نورهان مصطفى‬
‫‪‬‬ ‫فيرونيا عجايبي‬
‫‪‬‬ ‫هاجر اشرف‬
‫‪‬‬ ‫نسمه عالء الدين‬
‫‪‬‬ ‫بسمه السيد‬
‫‪‬‬ ‫نعيمه محمد‬
‫‪‬‬ ‫بسنت رجب‬
‫‪‬‬ ‫نور الهدي محمود‬
‫‪‬‬ ‫ميرنا سامى‬
‫‪‬‬ ‫نورا عادل‬
‫‪‬‬ ‫مني ممدوح‬
‫‪‬‬ ‫نهى احمد‬
‫‪‬‬ ‫نورهان عالء‬

‫‪Under Supervision:‬‬
‫‪Dr/Hend Karem‬‬
‫‪Demo/Mariam Tarek‬‬ ‫‪First Semester‬‬
‫‪2025:2026‬‬

‫‪1‬‬
Out Line

 Introduction of depression disorders.

 Definition of depression disorders.
 Etiology of depression disorders .
 Common types of depression disorders.
 Managment of depression disorders.
 1-pharmacological and.
 2- Non pharmacological.
 Health education for family having patient with depressive disorder
Health education for patien with depressive disorder.
 Nursing care plan for depression disorders.
 References.

2
 Introduction:

Depressive disorder (also known as depression) is a common mental disorder. It

involves a depressed mood or loss of pleasure or interest in activities for long
periods of time.

Depression is different from regular mood changes and feelings about everyday
life. It can affect all aspects of life, including relationships with family, friends and
community. It can result from or lead to problems at school and at work.

Major depressive disorder (also known as depression) is a common mental

disorder that involves a low mood or loss of pleasure or interest in activities for
long periods of time. An estimated 4% of the population suffers from depression.
Depression is about one and a half times more common among women than men,
and about 727 people lost their lives due to suicide, which is the third leading
cause of death among people aged 15 to 29.

3
 Definition:

Major depressive disorder (also known as depression) is a common mental

disorder that involves a low mood or loss of pleasure or interest in activities for
long periods of time. An estimated 4% of the population suffers from depression.
Depression is about one and a half times more common among women than men,
and about 727 people lost their lives due to suicide, which is the third leading
cause of death among people aged 15 to 29.

Definition 2 (World Health Organization – WHO):

“Depression is a common mental disorder. It is characterized by persistent

sadness and a lack of interest or pleasure in activities that a person normally
enjoys, accompanied by an inability to carry out daily activities, for at least

 Etiology of depression :

According to the World Health Organization's (WHO) :

the etiology of depression is multifactorial, involving a combination of biological,

genetic, environmental, and psychosocial factors that interact with one another.

1-Biological Factors :

a. Brain Chemistry: Imbalances in neurotransmitters, such as serotonin,

norepinephrine, and dopamine, are thought to play a significant role in the
development of depression.

4
b. Brain Structure: Some research suggests changes in brain structures like the
hippocampus and amygdala, which are involved in memory, emotion, and stress
response, may be associated with depression.

2- Genetic Factors : A family history of depression can increase the likelihood of

developing the condition, suggesting a genetic component.

3- Environmental Factors :

a. Stressful Life Events:

Significant life events, including bereavement, divorce, job loss, and ongoing
violence or abuse, can trigger episodes of depression, particularly in vulnerable
individuals.

b. Childhood Adversity:

Early-life adversity, such as neglect or trauma, can be a major risk factor for
developing depression later in life.

4- Socioeconomic Factors:

Difficult social and economic circumstances have also been linked to an increased
risk of depression.

4-Psychosocial Factors:

a. Personality Traits:

People with characteristics like low self-esteem, pessimism, or tendencies to be

easily overwhelmed by stress may be more susceptible to depression.

5
b. Social Support:

A lack of social support and feelings of isolation can contribute to the onset and
worsening of depressive symptoms.

[Link] Mental Health Conditions:

The presence of other psychiatric disorders can also increase the risk of major
depressive disorder.

In summary, depression doesn't have a single cause but arises from a complex
interplay of these various factors, with an individual's specific combination of
vulnerabilities and experiences determining their risk.

6
 Types of Depressive Disorders

1-Major Depressive Disorder (MDD)

2-Persistent Depressive Disorder (Dysthymia)

3-Seasonal Affective Disorder (SAD)

4-Postpartum Depression (PPD)

5-Premenstrual Dysphoric Disorder (PMDD)

1. Major Depressive Disorder (MDD)

Definition:

Major depressive disorder is characterized by a persistently depressed mood or

loss of interest/pleasure lasting for at least 2 weeks, causing significant distress or
impairment.

Diagnostic Criteria (DSM-5):

Depressed mood most of the day.

Markedly diminished interest or pleasure.

Sleep disturbance (insomnia or hypersomnia).

Fatigue or loss of energy.

7
2. Persistent Depressive Disorder (Dysthymia)

Definition:

Persistent depressive disorder is a chronic form of depression with low mood

most of the day, more days than not, lasting at least 2 years in adults (1 year in
children/adolescents).

Diagnostic Criteria (DSM-5):

Depressed mood for most of the day.

Poor appetite or overeating.

Low energy or fatigue.

Hopelessness or low self-esteem.

3. Seasonal Affective Disorder (SAD)

Definition:

A type of depression that occurs at a specific time of the year (usually winter) and
remits in other seasons.

Diagnostic Criteria (DSM-5 – with seasonal pattern):

1. Depressive episodes begin at a specific time of year (e.g., fall/winter).

8
2. Remission happens at another specific time (e.g., spring).

3. This pattern occurs for at least 2 consecutive years.

4. Seasonal episodes are more frequent than non-seasonal ones.

4. Postpartum Depression (PPD)

Definition:

Postpartum depression (PPD), also called perinatal depression, is a mood disorder

which may be experienced by pregnant or postpartum women.

Diagnostic Criteria (DSM-5):

Depressed mood most of the day.

Marked loss of interest or pleasure.

Feelings of worthlessness or guilt.

Disturbance in sleep or appetite.

---

9
5. Premenstrual Dysphoric Disorder (PMDD)

Definition:

A severe premenstrual condition involving mood and physical symptoms,

occurring in the week before menstruation and improving after onset of menses.

Diagnostic Criteria (DSM-5):

Mood swings or irritability.

Depressed mood or hopelessness.

Anxiety or tension.

Physical symptoms (bloating, breast tenderness, sleep/appetite changes).

10
 Management of depression disorders
 1- pharmacological
 2-Non pharmacological

1_ Pharmacological : medication is a Kay component in Managing depression .

Used alone or in combination with other therapies

a_ Anti depression medication

-Selective serotonin reuptake inhibitors
-Serotonin-norepinephrine reuptake inhibitors
-Tricyclic antidepressants -Monoamine oxidase inhibitors

b- Augmentation strategy
-Lithium: This mood stabilizer(Bipolar)
-Thyroid Hormones: Triiodothyronine (T3) and thyroxine (T4) are frequently
used due to their generally favorable side effect profiles
-Buspirone: This partial serotonin receptor agonist may accelerate or augment
the effects of SSRIs

c- Investigational novel approch

-They reduce depressive symptoms

→ Anti-inflammatory agents have been shown to reduce symptoms of
depression compared to placebo, based on a meta-analysis of 26 clinical trials.

11
-They increase treatment response rates
→ People who took anti-inflammatory agents had a higher response to
treatment than those who took a placebo.

-Effective as monotherapy or adjunctive treatment

→ "Subgroup analysis showed a greater reduction in symptom severity in both
the monotherapy and adjunctive treatment groups."

2_Non pharmacology

a- psychotherapy.; (talk therapy) is a variety of treatment techniques that aim

to help you identify and change unhealthy emotions, thoughts and behaviors
through having conversations with a mental health professional.

b- Brain stimulation therapy.

-Electroconvulsive therapy
-Repetitive transcranial magnetic stimulation
-Vagus nerve stimulation

c- light therapy .
_works on your biological clock (circadian rhythm)
_balances the activation of serotonin in your brain,

12
_contributes to stable and consistent sleep patterns
_increases alertness

d- total or partial sleep .

deprivation workfulness therapy

-Sleep deprivation may have a transient effect on depressive symptoms in a

subgroup of patients.

-It is uncertain whether sleep deprivation affects the health‐related quality of

life, everyday functioning, quality of sleep and length of hospital stay.

-The transient effect of sleep deprivation limits its clinical relevance as an

add‐on treatment to current antidepressants.

e- manging seizure therapy.

(MST): is a noninvasive procedure that uses high-powered magnetic
stimulation to induce seizures. The seizures are targeted to a specific site in
the brain.

f -lify style behavior strategy : -Diet, exercise, mental health, -mindfulness,

resilience, sleep -social connectedness

13
 Health education for family having patient with depressive
disorder. ( or )
 Health education for patian with depressive disorder.

[Link] symptoms:
•Persistent low mood / sadness
•Fatigue / loss of energy
•Loss of interest / pleasure
•Appetite / weight changes
•Sleep problems (insomnia / hypersomnia)
•Poor concentration / indecisiveness
•Psychomotor changes (slow / restless)
•Feelings of worthlessness / guilt
•Suicidal thoughts / self-harm

2. Encourage Help:
* Acknowledge that depression is a real illness:
Explain that depression is not a weakness, but a medical condition that needs
treatment.

* Speak with kindness and without judgment:

Use phrases like “I’m worried about you and I care about you” instead of “Just
snap out of it.

14
* Be patient and avoid pressure:
Encouragement should be gentle and ongoing, not forceful, since resistance is
common at first.
* Share reliable information:
Provide articles or leaflets from trusted medical websites so the person knows
they are not alone and treatment is effective.
•Highlight the benefits of treatment:
Remind them that treatment can relieve symptoms and help them return to
daily activities.
•Reassure them about confidentiality:
Remind them that conversations with a doctor are private, which may ease
fear of stigma.

3. warning signs:
* Talking about wanting to die or kill oneself
•Looking for a way to attempt suicide (e.g., searching for methods, collecting
pills, weapons, or sharp objects)
•Expressing feelings of hopelessness or having no reason to live
•Engaging in self-harm or suicide attempts

•Severe agitation, confusion, or inability to care for oneself (not eating,

drinking, or moving)
•Hearing voices or seeing things that aren’t there (hallucinations)

15
4. Understanding suicidal riske:

* .Direct Warning Signs:

. Talking about death or suicide.

. Searching for ways to commit suicide (medications, weapons, sharp objects).
. Previous suicide attempts or self-harm.
. Expressing hopelessness or loss of hope.
. Behavioral and Emotional Signs:

* . Social withdrawal

. Sudden mood changes.

. Loss of interest in personal hygiene, food, or daily activities.
. Intense feelings of worthlessness or guilt.

5. providing supporting:
•Listen without judgment.
•Ask directly about suicidal thoughts.
•Stay with the person if risk is high.
•Offer to make or attend appointments together.
•Remove or secure access to means.
•Help connect to emergency or crisis services when needed.
•Check in regularly and keep communication open.
•Encourage professional treatment and follow-up.

16
 Nursing Care Plan for Depression:

1. Nursing Assessment

Mental Health Assessment:

- Persistent sadness, hopelessness, and loss of interest in activities.

- Suicidal thoughts or self-destructive impulses.

- Impaired concentration and decision-making.

- Sleep disturbances (insomnia or hypersomnia).

- Fatigue and loss of energy.

- (Mayo Clinic, 2023; NIMH, 2024)

Physical Assessment:
- Changes in appetite and weight (loss or gain).

- Poor hygiene and neglect of self-care.

- Psychomotor agitation or retardation.

- Somatic complaints (headache, fatigue, body pain).

- (Mayo Clinic, 2023)

Functional / Social Assessment:

- Withdrawal from family, friends, and social activities.

- Impaired work or school performance.

- Loss of role function or inability to fulfill daily responsibilities.

- (NIMH, 2024; NurseTogether, 2023)

2. Expected Outcomes (SMART)

- The patient will verbalize decreased suicidal ideation within 72 hours.

17
- The patient will demonstrate improved sleep (6–8 hours per night) within 1
week.

- The patient will participate in at least one social activity within 5 days.

- The patient will maintain adequate nutrition (3 balanced meals daily) within 7
days.

- The patient will perform self-care activities independently within 1 week.

3. Nursing Diagnoses (NANDA)

• Risk for Suicide related to depression as evidenced by verbalization of suicidal
thoughts.

• Dysfunctional Grieving related to depression as evidenced by prolonged sadness

and preoccupation with the deceased.

• Low Self-Esteem related to depressionas evidenced by verbal expressions of

worthlessness.

• Impaired Social Interaction related to depression as evidenced by lack of

communication and avoidance of social contact.

• Powerlessness related to depression events as evidenced by verbalization of

helplessness.

• Spiritual Distress related to depression as evidenced by verbal expressions of

hopelessness.

• Disturbed Thought Processes related to depression as evidenced by difficulty

concentrating and indecisiveness.

• Self-Care Deficit related to depression as evidenced by poor hygiene and

inability to perform ADLs.

• Imbalanced Nutrition: Less Than Body Requirements related todepression&

decreased appetite as evidenced by weight loss.

18
• Disturbed Sleep Pattern related to depressive symptoms as evidenced by
insomnia and fatigue.

4. Detailed Nursing Care Plans

INTERVENTION RATIONALE

Assess suicide risk frequently using Regular screening detects changes

validated tools. early and guides timely interventions
: Maintain close observation (1:1 if necessary). Continuous supervision provides safety and
prevents suicide attempts
: Ensure removal of potentially harmful objects Providing a safe environment minimizes
(e.g., sharp objects, ropes, medications).
opportunities for self-harm.
: Encourage the patient to verbalize Open communication reduces
feelings of hopelessness and despair. emotional burden and fosters coping.

: Collaborate with psychiatrist to initiate Combined professional interventions

therapy and pharmacological address underlying causes of suicidal
management. ideation.
: Encourage the patient to express Verbalizing negative thoughts helps
negative self-perceptions in a decrease internalized distress.
supportive setting.
: Reinforce strengths and provide Recognition of achievements enhances
positive feedback for small confidence and builds self-worth
accomplishments.

Involve the patient in realistic goal- Active participation increases sense of

setting and care planning. control and self-efficacy.

19
Refer to group therapy or support Peer interaction reduces isolation and
programs. promotes positive self-concept.
Assess barriers to self-care such as Rationale: Identifying specific barriers
fatigue, anhedonia, or cognitive helps tailor interventions effectively
impairment.
Assist with hygiene initially, then Rationale: Support ensures safety while
gradually encourage independence. promoting autonomy in ADLs
Establish a structured routine for Rationale: Consistency enhances
hygiene, grooming, and nutrition. adherence and fosters healthy habits.
: Provide education on the importance Rationale: Knowledge motivates
of personal hygiene for physical and engagement in daily self-care practices.
mental health.
Assess sleep habits, daily routine, and Rationale: Identifying triggers allows
factors contributing to poor sleep. targeted management of sleep
problems.
Encourage adherence to sleep hygiene Rationale: Healthy habits support
(regular bedtime, quiet environment, circadian rhythm regulation and sleep
avoidance of stimulants). quality.

20
 Anti-depressant drugs

Supervised by:
DR: Amgad said
DR: Ahmed Zaher
Prepared by:
Fouad Osama Fouad Nigme Mohamed El Shahat Osman
Mostafa Ahmed Mostafa Martha Zaky Marcos
Marwa Yahiya Abbas Mariam Abd El Nasser Kamal
Mariam Mohamed Helmy Malak Ahmed Mahmoud
Menna Mahmoud Abdel-bar Mai Ahmed Amin
Mayada Abu El-Ikhlas Mohamed Mohamed Ragab Ahmed
Mostafa Mahmoud Ali Marwa Salah Soliman
Manar Gamal Ali Manar Mahmoud Mohamed
Manar Youssef Mohamed Maha Mansour Mohamed
Mayada Ibrahim Saber Mirna Yosry Mohamed
Mennatullah Saeed Ahmed
First term 2025-2026

1
Outlines
 Introduction of anti-depressant drugs.

 Indications of anti-depressants drugs.

 Classifications of anti-depressants drugs.

 Tricyclic anti-depressants drugs(TCAs).

 Monoamine oxidase inhibitors anti- depressants drugs (MAOIs).

 Selective serotonin reuptake inhibitors (SSRIs).

 Serotonin-norepinephrine reuptake inhibitors (SNRIs).

 Norepinephrine and dopamine reuptake inhibitors (NDRIs).

 Nursing intervention for side effects of anti-depressant drugs.

 Health education for patients taking Anti-depressant drugs.

 References

2
Introduction of anti-depressants drugs:
Antidepressants are a class of drugs that reduce symptoms of depressive disorders
by correcting chemical imbalances of neurotransmitters in the brain. Chemical
imbalances may be responsible for changes in mood and behavior.
 Indications of anti-depressants drugs:
Psychiatric and Non-Psychiatric Uses of Antidepressants

[Link] Uses  Non-Psychiatric Uses

1. Major Depressive Disorder (MDD) 1. Premenstrual Dysphoric Disorder

2. Generalized Anxiety Disorder (PMDD) – SSRIs are commonly used
(GAD) 2. Smoking Cessation – Bupropion is FDA-
3. Obsessive-Compulsive Disorder approved for quitting smoking
(OCD) 3. Post-Stroke Recovery – Some
4. Panic Disorder (PD) antidepressants aid in motor and
5. Post-Traumatic Stress Disorder cognitive recovery
(PTSD) 4. Chronic Fatigue Syndrome (CFS) – May
6. Social Anxiety Disorder (SAD) help with fatigue and associated
7. Bipolar Disorder depressive symptoms
8. Eating Disorders 5. Menopausal Symptoms – SSRIs and
9. Sleep Disorders SNRIs can reduce hot flashes
6. Nocturnal Enuresis (Bedwetting) – TCAs
like Imipramine are sometimes used

Classifications of anti-depressants drugs:

1. Tricyclic anti-depressants drugs(TCAs):-
A-Pharmacodynamics:

TCAs block reuptake of norepinephrine, serotonin and dopamine. Where they

increase in synapse in order to enhance the mood and relive depression on the
other hand.
*N.B The TCAs may take 4 to 6 weeks to be effective.
3
B-Pharmacokinetics:-
o TCAs are absorbed in the GIT
o Distributed with in blood
o Metabolized in liver
o Excreted by kidney(Urine)
Common generic and trade name of TCAs:

Generic name Trade name

Imipramine Tofranil
Clomipramine Anafronil
Amitriptyline Elavil
 Indications of TCAs:
General uses Other uses
1. Major depressive disorder. a. Sedation
2. Obsessive compulsive disorder.
b. Lethargy.
3. Panic disorder.
4. Bedwetting. c. Improve appetite.
5. Pre menstrual symptoms. d. Anxiety reduction
6. Dysthymia.
7. Anxiety disorders.
8. Eating disorders like anorexia nervosa and bulimia
nervous.
9. Certain personality disorders such as(borderline
personality disorder).

• Side effect of:

1. Anti-cholinergic side effects (Blurred vision - dry mouth – Urinary retention
– Tachycardia – constipation and drowsiness).
1. Cardiac effect: Tachycardia, arrhythmia and Orthostatic – hypotension
1. Sedation: in the first week occurs because of histamine H1antagonism

4 - Suicide: Anti-depressant drugs can energize patients who have been too
depressed to action their suicidal thoughts. Therefore, depressed patients who
are suicidal warrant special nursing consideration after anti-depressant therapy
has been initiated. The TCAs may take 4 to 6 weeks to be effective.

4
 o Nursing intervention for side effects of TCAs:
Dry mouth  Offer the client sugar less candy, ice, frequent sips of
water.
 Strict oral hygiene is very important.
Blurred vision  Offer reassurance that this symptom should subside
after a few weeks.
 Instruct the client not to drive until vision is clear.
 Clear small items from routine pathway stop revent falls.
Constipation  Order foods high in fiber; increase fluid intake
 Encourage the client to increase physical exercise, if
possible
Sedation  Request an order from the physician for the drug to be
given at bedtime.
 Request that the physician decrease the dosage or
perhaps order a less sedation drug.
 Instruct the client not to drive or use dangerous
equipment while experiencing sedation.
Urinary retention  Instruct the client to report hesitancy or inability to
urinate.
 Monitor intake and output.
 Try various methods to stimulate urination, such as
running water in the bath room or pouring water over the
perennial area.
Orthostatic  Instruct the client to rise slowly from a lying or sitting
hypotension position.
 Monitor blood pressure (lying and standing) frequently,
and document and report significant changes.
 Carefully monitor blood pressure and pulse rate and
rhythm, and any significant change
2. Monoamine Oxidase Inhibitor Antidepressants Drug (MAOIs): -
 Pharmacodynamics:
 Monoamine oxidase enzymes are responsible for breaking down
neurotransmitters(dopamine, norepinephrine and serotonin)in the brain.
 Low level of these three neurotransmitters has been associated with depression
and anxiety.
 MAOIs inhibit the breakdown of these three neurotransmitters from the brain by
blocking the effects of monoamine oxidase enzymes, result in increasing the
concentration of these neurotransmitters and relieving symptoms associated with
depression such as sadness or anxiety
5
N.B Approximately 2 to 4 weeks is required for the antidepressant effect of
MAOIs to occur

 Pharmacokinetics:

o Readily absorbed from GIT and metabolized in liver and excreted rapidly in
the urine
o Distributed within blood
o Antidepressant effects require at least 2 to 4 weeks of treatment
Common generic and trade name of MAOIs:

Generic name Trade name

Isocarboxazid Marplan

Phenelzine Nardil

Tranylcypromine Parnate

6
Indications of MAOIs:
MAOIs currently have FDA labeled indications to treat the following conditions:

1. Major Depressive Disorder (MDD Particularly effective for atypical

depression characterized by mood reactivity and hypersomnia.
2. Panic Disorder and Social Anxiety Used when other treatments
are ineffective.
3. Parkinson’s Disease Selective MAO-B inhibitors like selegiline are
used to manage motor symptoms.
4. Treatment-Resistant Depression Considered when patients do not
respond to other classes of antidepressants

Side effect of MAOIs:

Anti-Cholinergic side effect: •Blurred vision
•Dry mouth
•Urination retention
•Insomnia
•Drowsiness
Cardiovascular side effect: Low blood pressure
Hypertensive crisis
Orthostatic hypotension
General side effect: Reduced sexual desire
Weight gain
Muscle cramps
Prickling or tingling sensation in the skin

Hypertensive crisis(Tyramine reaction):it is a sever increase in blood pressure

may occur when there is excess level of tyramine in the blood.
Examples of food high in tyramine:

Yeastandyeastproduct Yogurt
Banana Avocado
Beeforchicken liver Soyorbroadbeans
Fish liver Caffeineliketeaandcoffee

Cheeseespeciallyaged MeatextractedTenderizersandsmokedmeat
Sour cream Pickled or fermented food
Canned figs Alcoholic beverages

7
Sign and symptom of hypertension crisis:

Sever chest pain Nausea and vomiting

Sever anxiety Sever headache accompanied by confusion and
blurred vision
Fever Shortness of breathing
Seizures Marked increase in blood pressure
Palpations Flushing and sweating

Management of hypertensive crisis:

 Stop intake of MAOIs
 Rapid reduction of BP
 Remaining calm and using a benzodiazepine, which will lower BP safely
 significant and sufficient extent Observation and BP monitoring
 Discontinue drug immediately
 Monitor vital signs and Use external cooling measures to control
hyperpyrexia
 Administer short-acting antihypertensive drugs , as ordered by physician.
3. Selective serotonin reuptake inhibitors(SSRIs):-

8
A: Pharmacodynamics (the effect of drugs on body):
Serotonin is one of neurotransmitters that have been synthesis in the vesicles in
presynaptic and responsible to regulate the mood and reduce depression. SSRIs
help makes serotonin more available by blocking the re absorption of serotonin in
presynaptic to post synaptic through synapsis to make its action and regulate the
mood. They have fewer side effects than TCAS and less danger than MOAIs , So
they consider as first line for treatment of depression

N.B SSRIs may be effective in 2-3 weeks

B:Pharmacokinetics(the effect of body on drugs):
o SSRIs are absorbed in the GIT
o Distributed within blood
o Metabolized in liver.
o Excreted by kidney(Urine).
Common generic and trade name of SSRIs:
Generic name Trade name
Citalopram Celexa
Escitalopram Lexapro
Fluoxetine Prozac, Serafem, Symbyax
Sertraline Zoloft

Indications:
SSRIs currently have FDA labeled indications to treat the following conditions:

Major depressive disorder. Generalized anxiety disorder

Bulimia nervosa Bipolar depression

Obsessive-compulsive disorder Panic disorders

Premenstrual dysphoric disorders Treatment-resistant depression

Post-traumatic stress disorders Social anxiety disorders

9
 Other off label uses include 1. Binge eating disorder

but are not limited to 2. Body dysmorphic disorder

3. fibromyalgia,
4. premature ejaculation,
5. paraphilias
6. autism
7. Raynaud phenomenon,
8. Vasomotor symptoms associated
with menopause.

Side effectof SSRIs:

GIT system: CNS system Reduced sexual desire
o Loss of appetite o Headache Difficulty reaching orgasm
 Diarrhea o Dizziness Erectile Dysfunction
o Weight loss o Tremors Inability to maintain an
erection
 Nausea and vomiting  Insomnia
 Dry mouth  Drowsiness

Serotonin syndrome:
 It is a status of negative drug action it occurs where there is increase in serotonin
drug level due to too much serotonin builds up in body, result to take different
prescribed medication together.
 It caused by combination of two or more medication or nutritional supplements
that increase serotonin levels in the body or due to overdose or absence of
washing time for body before transferring another medication from same group.

10
Symptoms of Serotonin Syndrome:
 Nursing intervention for most commonly side effects SSRIs:

Serotonin ■ Discontinuation of all serotonin agents, that causes

syndrome syndrome. Syndrome resolves often within 24 hours of
discontinuation.
■ Muscle relaxants, Benzodiazepines such as diazepam
valium or lorazepam (antivan) Can help control agitation,
seizures and muscle stiffness
■ Monitoring vital signs.
■ Give oxygen and intravenous fluid, for hyperthermia and
fluid depletion.
■ For severe hypertension and tachycardia, give short-
acting agents like esmolol or nitroprusside.
■ Administration of serotonin antagonists Cyproheptadine is
the recommended antidote. It can only be given orally. Initial
dose is 12mg by mouth or crushed through NGT, then 2mg
every 2 hours until clinical response seen. Possible effects
are sedation which is consistent with the treatment goal and
transient hypotension which usually responds to intravenous
fluids.
■ Go to sleep at the same time each night and get up at the
Insomnia same time each morning.
■ Try not to take naps during the day, because they may
make you less sleepy at night.
■ Avoid caffeine, nicotine, and alcohol late in the day
■ Don't eat a heavy meal late in the day
■ Make your bedroom comfortable: dark, quiet
■ Ensure that client is provided with caloric intake sufficient
Weight loss to maintain desired weight.
■ Caution should be taken in prescribing these drugs for
anorectic clients. -Weight client daily or every other day, at
the same time, and on the same scale, if possible.
Headache ■ Assess the characteristics of pain.
■ Teach the patient about relaxation technique.
■ Give analgesic as prescribed.
■ Request that the physician order another SSRI or another
class of antidepressants.

Sexual ■ Exercise regularly.

dysfunction ■ Try to reduce anxiety and depression.
■ Take some medication that increased blood flow.

11
4. Serotonin-norepinephrine reuptake inhibitors(SNRIs):-
A:Pharmacodynamics:

SNRIs block the reabsorption (reuptake) of the neurotransmitters serotonin and

norepinephrine in the brain leading to increase serotonin and noradrenaline in the
synaptic cleft and subsequent the concentration returns to within the normal range.

B: Pharmacokinetics:
SNRIs are absorbed in the GIT then distributed within blood and finally Metabolized
in liver and excreted by kidney (Urine).
Common generic and trade name of SNRIs
Generic name Trade name
Desvenlafaxine pristiq,khedezla
Duloxetine Cymbalta,Irenka
Levomilnacipran Fetzima

Indications of SNRIs:
1. Major depressive disorder.
2. Anxiety, Panic disorder.
3. Post-partum depression.
4. Back Pain
5. Autism spectrum disorder.
6. Diabetic Peripheral neuropathy.
7. Osteoarthritis
8. Social anxiety disorders

12
 Side effect of SNRIs:
Reproductive
GIT system Urinary system CNS systems
system
o Dizziness
o Decrease libido
o Nausea o Insomnia
o Erectiledys
o constipation Difficulty in o Headache
urination function Agitation
o Dry mouth o
o Sexualdys
o Loss of appetite o Blurred of
function
o Weight change vision
o Delay Orgasm
(in men)

N.B
 For many individuals , sexual dysfunction is a major factor indecisions
about compliance.
 Interaction with other drugs : combining SSRIs with MAOIs or other drugs
that increase serotonin , such as tryptophan ,amphetamines or other
psychostimulants may be result in phenomena called serotonin syndrome .
 Nursing intervention for most commonly side effects SNRIs:

Vomiting  Instruct patient to eat frequent small meals to

avoid nausea and vomiting.
 Teach the patient to take SNRI drugs with food.

Constipation  Instruct patient to increase fluid intake and

Increase intake of food rich in fiber.
 Advice patient to do exercises strengthen
abdominal muscles.
 Privacy allows the patient to relax, which can
help promote defecation.
 Explain the use of pharmacological agent as
ordered.
 The use of laxatives or enemasis indicated for
short- term management of constipation

Dry mouth  Provide client with sugarless candy, ice.

 Instruct client to avoid spicy or salty foods
 Increase of fluid intake
 Ensure that client practice strict oral hygiene.

13
5. Norepinephrine and dopamine reuptake inhibitors (NDRIs):
A:Pharmacodynamics:
The NDRTs block the reuptake of both Norepinephrine and dopamine .this in turn
leads to increase extracellular concentration of both Norepinephrine and dopamine
leading to regulate mood and alleviate depression

B: Pharmacokinetics:
NDRIs is absorbed in the GIT, distrusted in blood, metabolized in liver and excreted
Indications of NDRIs:
1. Depression
2. Narcolepsy
3. Attention deficit hyperactivity disorder(ADHD)
4. May be used with transdermal nicotine, most effective for smoking cessation
because it affect levels of norepinephrine and dopamine in brain and this leads to
decrease craving of cigarettes and symptoms of nicotine withdrawal.
Common drugs of NDRIs:
Bupropion (Wilburton): is the only drug in this category and is unique in two ways: it
is the only anti-depressant that primary inhibits dopamine reuptake and the only one
that does not affect serotonin symptoms, Bupropion also inhibits norepinephrine
reuptake and is considered a novel anti-depressant.

14
Side effect of NDRIs:

 General symptoms:  CNS systems:

o Ringing in the ear.  Headache.
o Sore throat. o Seizures.
 Rash  Anxiety.
o Sweating. o Insomnia.
o Dry mouth. o Dizziness.
 GIT system: o Cardiac system:
o Vomiting.  Fast heart rate
o Abdominal pain.  Tachycardia
o Weight loss.
 Nausea.  Palpitations
o Constipating.  Hypertension

 Nursing intervention for most commonly side effects NDRIs:

Assessment
o Asses for hypersensitivity to bupropion.
o Assess for history of seizure disorder, bulimia or anorexia.
o Assess for head trauma, CNS tumor.
o Assess for treatment with MAOIs.
o Assess for renal or hepatic disease and heart disease.
Interventions
 Increase dosage slowly to reduce the risk of seizures.
 Arrange for patient evaluation after 6 weeks.
 Discontinue MAOI therapy for at least 14 days before beginning bupropion.
 Monitor hepatic and renal function tests in patients with a history of hepatic or
renal impairment.
 Observe for allergy
 Instruct patient if experience any of these symptoms: Dizziness, lack of
coordination, tremor to avoid driving or performing tasks that require alertness
 Educate patient about the importance of mouth care to treat dry mouth.
 Health education for patients taking Anti-depressant drugs.

15
 Instruct patient not stop taking antidepressants drugs alone without consulting
the doctor.
 Instruct patient not to mixed antidepressant drugs and other drug without
consulting the doctor because some drugs although safe when taken alone can
cause severe and dangerous side effects if taken with other drugs
 Instructpatienttotellotherdoctorsabouttakingaspecificantidepressants drug and the
dose
 Patients’ family and caregivers should monitor patients carefully for sociality.
 Tell the patient not to accelerate the effect of antidepressant drugs because it
may take the patient 2-3 weeks of SSRIs, 2-4 weeks of MAOIs, and 4-6 weeks of
TCAs to feel better.
 Reassure patient with sexual problems and tell him that it is temporary problem.
 Increase patient awareness about side effects of antidepressants and how to
avoid or treat it.
 Tell patient that stopping antidepressant drugs treatment abruptly or missing
several doses may cause withdrawal like symptoms this is sometimes called
discontinuation syndrome Drowsiness
Withdrawal-like symptoms can include:
Dizziness Headache
Flu-like symptoms such as Irritability or agitation
tiredness, chills and muscle aches
Nausea Insomnia
Diarrhea Sleep disturbance such as
nightmares

16
 Nursing care for bipolar disorder

Supervised by
Ass. Prof/ Hanaa Ezz-eldin
Ass. Lec/ Abdelmouttelb Abdelqawy

Prepared by:

-Ahmed Bilal Abdelkhalek -Sarah Hamdy Hussein

-Ahmed Hamdy Mohamed -Salma Ibrahim Ismail
-Ziad Mohamed Ahmed -Salma Ibrahim Abdelgawad
-Abdelrahman Samy -Salma Raafat Abdelazim
-Abdel Zaher Nasr -Salma Salah Hussein
Abdelzaher -Salma Adel Mohamed
-Rowan Tarek Mohamed -Sama Ismail Abdelfattah
-Remah Hany Basyouny -Mohamed Ahmed Saeed
-Zainab Aboul-Naga Ahmed -Ahmed Ayman Hamed Bakr
-Zainab Ayman Mohamed
-Sarah Ibrahim Abdelgawad

Psychiatric Mental Health Nursing Department

First semester 2024-2025
• Outlines
- Introduction of bipolar disorder (page 3)

- Definition of bipolar disorder (page 3)

- Epidemiology for bipolar disorder (page 3)

- Causes of bipolar disorder (page 4)

- Stages of Mania (page 5)

- Types of bipolar disorder(page 7)

- Signs & symptoms of bipolar disorder (page 8)

- Nursing intervention (pharmacological, no pharmacological) (page 9)

- Nursing Care plan for bipolar disorder (page 11)

- Health education for patients with bipolar disorders (page 14)

- Health education for caregivers (page 15)
- Summary (Page 16)

- Reference (page 17)

2
 ➢ Introduction
Bipolar disorder is a mental health condition characterized by extreme and intense
shifts in mood, energy levels, concentration, and the ability to carry out day-to-day
tasks. These shifts are categorized into distinct mood episodes, which range from
elevated, energetic heights known as manic or hypomanic episodes, to profound
emotional lows known as depressive episodes. These mood swings are significantly
more severe than the typical ups and downs most people experience and can impact
relationships, job or school performance, and daily functioning. Bipolar disorder is a
chronic, lifelong condition that requires long-term management

➢ Definition
Bipolar Disorder is a mental health disorder characterized by extreme and unusual
shifts in a person's mood, energy, activity levels, and concentration. These shifts
manifest as distinct mood episodes, which alternate between periods of elevated
energy and euphoria (manic or hypomanic episodes) and periods of sadness and loss
of energy (major depressive episodes).
➢ Epidemiology
Epidemiological studies have suggested a lifetime prevalence of around 1% for
bipolar type I in the general population.54,55 A large cross-sectional survey of 11
countries found the overall lifetime prevalence of bipolar spectrum disorders
was 2.4%, with a prevalence of 0.6% for bipolar type I and 0.4% for bipolar type
II.
Middle East and North Africa (MENA)
The epidemiology of bipolar disorder across the MENA region shows several
distinct patterns: Prevalence: Studies from various MENA countries report a
global prevalence range of 1%–5%. For example, research from Saudi Arabia
indicates a prevalence of about 3%.
Egypt
National survey on mental disorders in Egypt found that mood disorders in
general had a prevalence of 6.43%, though it didn't specify the exact prevalence
of bipolar disorder. A different study found that in a sample of psychiatric
patients, 20.3% were diagnosed with bipolar disorder. However, a major
challenge in diagnosis is the high rate of misdiagnosis.
➢ Causes of bipolar disorder
The exact cause of bipolar disorder is unknown. However, research suggests that a
combination of factors may contribute to illness.

3
 Genetic factors
Different studies indicated that bipolar disorders have high genetic transmission risks.
Some of evidence for genetic transmission of bipolar disorders are:
Family studies:
Studies indicate that bipolar disorders run in families. First degree relatives of
people with bipolar I disorder are approximately 7 times more likely to develop
bipolar 1 disorder than the general population
Twin studies:
Twins who are brought up together share a similar environment during their development.
Monozygotic twins (MZ) share 100% genetic material, whereas dizygotic twins (DZ)
share only 50%. Twin studies established a concordance of 33%-90% for bipolar I disorder
in identical twins.
Chemical Imbalance:
• Mainly disturbances of dopamine, serotonin, norepinephrine (Imbalance
synthesis, increase release, reuptake, metabolism)
• Imbalance level of GABA
• Imbalance level of Glutamate
• Imbalance Ca+, and Na+ led to alteration of action-potential process
Hormonal imbalances:
• Pituitary gland imbalance (growth hormone, TSH & oxytocin).
• Thyroid hormones, T3& T4.
• Sex hormone such as estrogen, progesterone, and testosterone.
• Supra-renal gland (Cortisol).
Vitamins and Minerals:
Vitamin D:
• Low levels are linked with depression & mood instability.
Vitamin B12 & Folate (B9)
• Important for neurotransmitters; deficiency may worsen depressive
symptoms.
Omega-3 Fatty Acids:
• Low intake associated with more severe mood swings.
• Magnesium Deficiency may increase irritability, anxiety, and depression
Zinc:
• Low levels observed in mood disorders, important for brain function.
Iron:
• Deficiency can cause fatigue, low mood, and cognitive problems.
4
Childhood Trauma or Abuse Factors:

• Stressful life events, such as relationship problems, the loss of a loved one, or
financial difficulties.
• Use of recreational drugs, such as cannabis or cocaine
• Infection with the parasite Toxoplasma gondii (which causes toxoplasmosis)
Social Factors:
• Stressful life events, traumatic or unpleasant or disturbing life experiences
• Social pressures
• Rejection of children by parents
• Difficult or strained interpersonal relationships
• Sociocultural factors
• Loss of loved ones (real or symbolic)
• Financial difficulties
Psychological Factors:
• Maladaptive coping strategies in response to stress
• Cognitive distortions and negative thinking patterns
• Personality traits such as high impulsivity or cyclothymic temperament
• Learned behaviors from early dysfunctional family environments.

➢ . Stages of Mania
Stage Duration Symptoms Severity
Hypomania At least 4 - Increased Energy - Symptoms are
consecutive - Decreased Need for noticeable by others,
days. Sleep, but not severe enough
- Talkativeness, to cause marked
- Racing Thoughts, impairment in social or
- Distractibility, occupational
- Increased Goal- Directed functioning.
Activity, - No hospitalization is
- Mild Impulsiveness. required, and no
psychotic features are
present.

5
Stage Duration Symptoms Severity
Acute Mania At least 1 - Markedly Elevated or - Causes significant
week Irritable Mood, impairment in work,
- Inflated Self-Esteem or school, or social
Grandiosity, relationships.
- Little Or No Sleep, - May require medical
- Pressured Speech, intervention or
- Flight Of Ideas, hospitalization.
- Distractibility,
- Hyperactivity,
- Risky Behaviors (E.G.,
Overspending, Unsafe
Sex).

Delirious May develop -Severe manic symptoms The most dangerous form
(Psychotic) rapidly, combined with psychosis: of mania.
often within - Hallucinations, - Requires immediate
Mania
days. - Delusions, hospitalization.
Needs to be -Disorganized Thinking, - High risk of harm
hospitalized -Extreme Agitation, to self or others.
immediately -Confusion,
-Sometimes Violent
Behavior.

6
Types of bipolar disorder
There are four types of bipolar disorder. Type I and type II are the most
diagnosed types of this condition:
Type Bipolar Bipolar Cyclothymic Other
I II
Definition Defined as a Defined by Defined by
clinical course involves a Disorders
periods of
characterized by pattern of experience
hypomanic
the occurrence of depressive symptoms
symptoms as
one or more episodes and that do not
well as
manic episodes, hypomanic fall into
depressive
or mixed episodes, which symptoms the above
episodes. Often are less severe categories.
lasting for at
individuals have than manic least 2 years,
also had one or episodes. though not as
more major extreme as full
depressive mania or
episodes. depression
Criteria Involves manic This features These The symptoms
episodes both mania and symptoms do may stem from
lasting 7 days depression, but not fit the drug or alcohol
or more, or the mania is less criteria for use or medical
severe mania severe than in wholly manic conditions, for
that requires bipolar I, and or depressive example.
hospitalization. call it episodes. Bipolar I and
The person hypomania. A II are the most
may also person with common
experience a bipolar II may subtypes, with
major experience a bipolar I being
depressive major depressive more severe in
episode that episode or terms of manic
lasts 2 weeks following a symptoms
or more. manic episode.

7
Clinical Manifestations:
Manic Episode (High mood / Hyperactivity)
1. Elevated or irritable mood
2. Increased energy and activity
3. Decreased need for sleep
4. Rapid or pressured speech
5. Racing thought
6. Distractibility
7. Inflated self-esteem / grandiosity
8. Risk-taking behaviors (spending, risky driving, unsafe sex, etc.)
Depressive Episode (Low mood)
1. Persistent sadness or emptiness
2. Fatigue, loss of energy
3. Decreased interest or pleasure in activities
4. Changes in appetite and weight (increase or decrease)
5. Sleep problems (insomnia or oversleeping)
6. Difficulty concentrating or making decisions
7. Feelings of worthlessness or guilt
8. Thoughts of death or suicide
Mixed Episode
• Symptoms of mania and depression occurring together
• For example: high energy with sadness or irritability

8
 ➢ Pharmacological and Non-Pharmacological Management
of Bipolar Disorder
Stage / Type Pharmacological Non-Pharmacological
- Lithium (classic mania) -Hospitalization if severe
- Valproate (rapid cycling, - Psychoeducation for
Manic Episode patient & family
aggression, mixed)
- Carbamazepine (alternative) - Sleep hygiene & routine

- Atypical antipsychotics - Reduce Environmental

(Olanzapine, Risperidone, Stimulation
Quetiapine, Aripiprazole, - Family involvement for safety

Ziprasidone)
- Combination (mood stabilizer
+ antipsychotic)
if severe
Lithium (suicide prevention)
- -Psychotherapy: CBT, IPSRT,

Bipolar - Lamotrigine (prevent depressive Behavioral Activation

relapses) - Lifestyle: exercise,
Depression healthy diet, avoiding
- Quetiapine
- Lurasidone (± lithium/valproate) substances
- *Avoid antidepressant - ECT for severe or suicidal

monotherapy* (risk of mania cases

switch)
- Valproate (first choice) - Close monitoring (high suicide
- Atypical antipsychotics risk)
Mixed Episodes
(Olanzapine, Aripiprazole, - Family-focused therapy
Risperidone, etc.) - Psychoeducation about
- Carbamazepine (alternative) adherence & relapse
- *Avoid antidepressants* prevention
- Structured
environment to
reduce
overstimulation

9
 - Lithium (gold standard, - Long-term psychotherapy:
prevents both mania & CBT, IPSRT, Family-
Maintenance
depression) Focused Therapy
/ Prophylaxis - Valproate (good for rapid - Psychoeducation
cycling) (triggers, early signs,
- Lamotrigine (better for adherence)
depressive prevention) - Lifestyle modification:
- Atypical antipsychotics stable sleep, stress
(Quetiapine, Olanzapine. management,
mindfulness
- Support groups &
relapse prevention

10
 Nursing Care Plan for Bipolar Disorders
Nursing Diagnosis Nursing Intervention Evaluation
1-Risk for Suicide / Self-harm • Provide 1:1 observation if suicidal risk is high. Patients remained
as manifested by verbalized • Conduct a thorough search of the patient’s belongings and room safe during
suicidal thoughts and potential to remove any items that could be used for self-harm, such as hospitalization,
verbalized suicidal
for self-harm. sharp objects, belts, or medications.
thoughts, and
• Initiate a no-harm contract (physical restraints or seclusion) with identified coping
Expected Outcome: the patient, if appropriate, to establish a verbal or written strategies.
Immediate: agreement to seek staff help when they have self-harming Demonstrated ability
-Patient will remain safe and thoughts. to use coping
free from self-harm during • Place the patient in a room close to the nursing station for mechanisms.
hospitalization. increased visibility and quick access.
Short-term: • Encourage patients to verbalize feelings.
Patient will verbalize suicidal • Teach relaxation and distraction techniques.
thoughts and identify at least 1 • Collaborate with psychiatrist for medication compliance.
coping strategy within 3–5
• Involve family or trusted support in care planning (with consent).
days.
• Educate the patient and family about warning signs of suicide
Long-term:
(sudden calmness, giving away belongings, talking about death).
Patient will demonstrate use of
healthy coping mechanisms
• Collaborate with the interdisciplinary team (psychiatrist,
therapist, social worker).
and remain free from suicidal
behavior.
 Nursing Diagnosis Nursing Intervention Evaluation
2. Risk for Injury as • Involve family in safety planning.
manifested by a • Maintain safe environment (remove sharp objects, reduce Patient remained
need for close clutter). free from
supervision during • Provide close supervision, especially during manic episodes. physical injury,
• Encourage rest periods between activities.
manic episodes and verbalized safety
• Limit physically exhausting activities.
the potential for measures, and
• Use calm, firm approach to set limits on impulsive behavior.
impulsive behavior.
• Collaborate with team for medication adjustment.
demonstrated
Expected Outcome: • Teach the patient alternative, safe behaviors for managing their safe behaviors
Immediate: energy and impulses. before discharge
Patient will remain • Educate the patient on recognizing triggers for impulsive
free from physical behavior, such as overstimulation or fatigue.
injury during • Set firm limits on aggressive or risky behavior.
hospitalization.
Short-term:
Patient will
verbalize at least 2
safety measures to
reduce risk of
injury within 3
days.
Long-term:
Patient will
Demonstrate safety
behaviors and
absence of injury
before discharge.
 Nursing Diagnosis Nursing Intervention Evaluation
3-Disturbed Thought • Provide calm, low stimulus environment.
Processes as manifested by • Use short, simple, and clear instructions. Patient showed
hyperactivity, decreased • Limit group stmulation reduced
concentration, and • Redirect patient when behavior is inappropriate.
disorganized thinking
hyperactivity,
• Monitor medication effectiveness (mood stabilizers, improved
Expected Outcome: antipsychotics).
concentration,
Immediate: • Redirect the patient’s attention away from disorganized or
inappropriate behaviors and toward realitybased topics and more
Patient will organized
• Engage the patient in one-on-one structured activities, such as
demonstrate thinking before
puzzles or simple crafts, to help them practice concentration and
decreased focus discharge
hyperactivity within
24–48 hours .
Short-term:
Patient will show
improved
concentration by
participating in
structured
activities within 5
days.
Long-term:
Patient will
display organized
thinking and
appropriate
behavior at
discharge
 Nursing Diagnosis Nursing Intervention Evaluation
4-Sleep Pattern Disturbance • Provide a quiet, dimly lit room for the patient to rest.
as manifested by a need for a • Administer prescribed sedatives or mood stabilizers as ordered to Patient rested in
quiet environment and help the patient achieve sleep. safe
prescribed sedatives to • Encourage relaxation techniques before bedtime, such as
establish a regular sleep environment,
listening to calm music or reading abook, to promote rest.
routine. achieved
• Discourage naps during the day to help consolidate sleep at
Expected Outcome: night. Educate the patient on the importance of a regular sleep adequate sleep
Immediate: schedule and the impact of sleep on mood. hours, and
Patient will rest in • Advise the patient to avoid stimulants like caffeine and nicotine, established
a safe, quiet especially in the evening. regular sleep
environment. routine before
Short-term: discharge.
Patient will sleep
at least 45 hours
per night within 3
days.
Long-term:
Patient will
establish regular
sleep routine
before discharge.
 Nursing Diagnosis Nursing Intervention Evaluation
5-Imbalanced Nutrition: Less • Provide highc alorie, nutritious finger foods and snacks that the
than Body Requirements as patient can eat while on the move, as they may be too agitated to Patient accepted
manifested by the need for sit down for a meal. food and fluids,
high calorie snacks and • Encourage frequent sips of fluids to prevent dehydration.
monitoring of intake to improved intake,
• Sit with the patient during meals to provide a calming presence
ensure adequate nutrition and maintained
and encourage them to eat at least 50-75% of their meals.
Expected Outcome: • Monitor and record the patient's intake and output to track their adequate
Immediate: nutritional status. Weigh the patient daily at the same time to nutrition and
Patient will accept monitor for weight loss or gain. weight at
food and fluids • Educate the patient on the importance of nutrition in maintaining discharge.
offered energy levels and mood stability.
Short-term:
Patient will eat
50–75% of meals
with nursing
support within 5
days
Long-term:
Patient will
maintain adequate
nutrition and stable
weight at
discharge.
 Nursing Diagnosis Nursing Intervention Evaluation
6-Altered Sensory Perception Immediate (Within 24 Hours) Interventions
relates to the client’s • The primary goal is to de-escalate the patient's acute symptoms The effectiveness
distorted perception of and establish a safe, calm environment. of interventions
reality, which can include • Establish a safe and low-stimulus environment: Remove any
hallucinations or delusions.
for altered
potential sources of agitation, such as bright lights, loud noises,
or crowded spaces. A quiet room helps to reduce sensory
sensory
Expected Outcome: perception is
overload, which can exacerbate a manic state and the risk of
Immediate(within 24 hours): evaluated by
hallucinations or delusions.
-The client will • Administer medications as prescribed: Provide PRN (as needed) assessing the
remain free from or scheduled antipsychotics and mood stabilizers. These client’s return to
injury related to medications are crucial for stabilizing the patient's mood and
their altered reality-based
reducing psychotic symptoms like hallucinations and delusions. thought
perception.
• Maintain a calm and consistent demeanor: The nurse should
-The client will processes and
speak with a soothing tone and avoid rapid movements. A calm
respond to reality-
presence can help regulate the patient's agitated state and prevent behaviors
based
further escalation.
communication
• Utilize validation and reality orientation: Gently but firmly orient
from the nurse.
the patient to reality without arguing about their delusions or
-The client’s
hallucinations. For example, if a patient states they are seeing an
agitation will
angel, you can say, "I know you believe you are seeing an angel,
decrease, and they
but I don't see one." This acknowledges their experience without
will be able to sit
validating the delusion.
calmly for brief
periods.
Short-Term (Within 1-2 Weeks) Interventions
Short-
• The focus shifts to promoting stability and encouraging
term:(within 1-2 engagement in therapeutic activities.
weeks): • Monitor and document the patient's mood and thought process:
-The client will Use a mood chart or a standardized rating scale to track daily
verbalize a fluctuations. This provides objective data on the effectiveness of
decrease in the interventions and helps identify patterns or triggers.
frequency or • Structure the patient's day with therapeutic activities: A
intensity of their
hallucinations or predictable routine can help regulate the patient's internal clock
delusions. and reduce the chaotic nature of manic thinking. Include quiet,
-The client will non-competitive activities like drawing, listening to music, or
begin to light exercise.
differentiate • Encourage participation in psychoeducation: Teach the patient
between reality and about their illness, the importance of medication adherence, and
their altered the early warning signs of mood episodes. Understanding their
perceptions with condition helps them feel more in control and reduces the fear
gentle reminders associated with their symptoms.
from staff. • Introduce journaling or thought-tracking exercises: Encourage the
-The client will patient to write down their thoughts and feelings. This can help
report no longer them recognize the difference between their normal thought
acting on their patterns and those influenced by mania or psychosis.
hallucinations or
delusions. Long-Term (By Discharge/Within a Month) Interventions
Long-term:(by • The aim is to equip the patient with skills for long-term
discharge or management and relapse prevention.
within a month): - • Facilitate consistent medication management: Ensure the patient
-The client will understands the purpose, dosage, and side effects of their
independently medications. This is the single most important intervention for
preventing future episodes and maintaining a stable mood.
recognize when
• Develop a personalized wellness recovery action plan (WRAP):
their sensory This plan should detail the patient's triggers, early warning signs,
perceptions are coping strategies, and a list of emergency contacts. It empowers
altered and seek the patient to manage their own health and anticipate potential
staff for reality crises.
orientation. • * Promote self-monitoring and coping skills: Teach the patient
-The client will be how to use techniques like deep breathing or mindfulness to
able to describe at manage anxiety and prevent mood swings. Encourage them to
least one factor regularly check in with their feelings and thoughts to catch any
that triggers their subtle changes.
altered
perceptions. • Establish a support system: Connect the patient with support
-The client will groups, outpatient therapy, or community resources. A strong
demonstrate a support network is crucial for maintaining long-term stability and
stable mood and a sense of belonging.
thought process, • Reinforce the importance of a healthy lifestyle: Educate the
free from the patient on the impact of sleep, diet, and exercise on mood
influence of regulation. A consistent sleep schedule is particularly vital for
hallucinations or preventing manic relapses.
delusions.
 Nursing Diagnosis Nursing Intervention Evaluation
7-Ineffective Coping related Immediate (Within 24 Hours) Interventions
to the client’s inability to • For self-harm or aggressive behaviors: The effectiveness
manage stressors and • Conduct frequent, close observation and supervision, including of coping
regulate emotions, which can one-to-one observation if the risk is high.
lead to risky behaviors or a
interventions is
• Maintain a calm, quiet, and low-stimulus environment to
worsening of symptoms. evaluated by
minimize agitation.
Expected Outcome: • Remove any potentially dangerous objects from the patient's observing the
Immediate(within 24 hours): room and immediate surroundings. client’s ability to
-The client will be • Use therapeutic communication to de-escalate the situation, manage stressors
free from self-harm such as using a calm tone, simple sentences, and offering and by their use
or aggressive choices when possible. of healthy
behaviors. • Administer prescribed PRN (as needed) medications for coping
-The client will agitation or anxiety as ordered by the physician. mechanisms.
agree to participate • For participation in structured activities:
in one structured, • Offer the patient a choice of a single, non-competitive activity,
non-competitive such as listening to music, walking with a staff member, or
activity. coloring.
-The client will • Start with brief activities and gradually increase the duration as
verbalize their the patient's tolerance improves.
feelings of • Provide positive reinforcement for any participation, no matter
frustration or how small.
agitation to staff • For verbalizing feelings:
instead of acting on • Acknowledge the patient's feelings of frustration or agitation
them. without judgment.
Short-
• Model appropriate communication by using "I" statements
term:(within 1-2 (e.g., "I see you're getting frustrated, what can we do to help?").
weeks): • Help the patient label their emotions and encourage them to
-The client will use their words instead of physical actions.
identify at least one
stressor or trigger
that leads to
ineffective coping. Short-Term (Within 1-2 Weeks) Interventions
-The client will • Collaborate with the patient to keep a mood and trigger
demonstrate the use log. This helps them track their mood shifts and the
of a new, healthy events or situations that preceded them.
coping skill when • Educate the patient on common triggers for bipolar
faced with a episodes, such as sleep deprivation, stress, and
stressful situation medication non-compliance.
(e.g., deep • Help the patient connect their feelings and behaviors to
breathing, walking specific triggers.
away). • For demonstrating new coping skills:
-The client will • Teach and practice specific coping skills with the
participate in group patient. Examples include deep breathing exercises,
therapy or other progressive muscle relaxation, or using a "thought-
therapeutic stopping" technique.
activities to learn • Role-play stressful situations and practice the new
new coping coping skills in a safe environment.
strategies.
• Encourage the patient to use these skills in real-time
when faced with a minor stressor.
Long-Term
• For participating in therapeutic activities:
Outcomes (by
• Encourage and assist the patient in attending group
discharge or
within a month): therapy sessions, psychoeducational groups, and other
unit activities.
-The client will
consistently use a • Engage the patient in discussions during these groups
variety of healthy and encourage them to share their insights and
coping mechanisms experiences.
to manage • Help the patient identify and learn from the coping
stressors. strategies used by others in the group.
-The client will
verbalize a plan for
how to manage
future stressful Long-Term Interventions (By Discharge or Within a Month)
events and a list of • For consistent use of healthy coping mechanisms:
people they can • Continue to reinforce the use of previously taught coping skills and
contact for support. introduce a variety of new strategies, such as mindfulness,
journaling, or engaging in hobbies.
-The client will
• Assist the patient in developing a personalized coping toolbox they
independently seek
support from their • Review the patient's progress and h ighlight their successful use of
identified support coping mechanisms to build their confidence.
system when • For a plan for future events and support:
needed. • Collaborate with the patient to create a detailed relapse prevention
and crisis plan. This plan should outline warning signs of an
impending episode and specific steps to take.
• Help the patient identify their support system, including family,
friends, and community resources.
• Provide the patient with contact information for outpatient mental
health services, support groups (e.g., Depression and Bipolar
Support Alliance), and crisis hotlines.
• Educate the patient and their family about the importance of
medication adherence, sleep hygiene, and maintaining a healthy
lifestyle to prevent future episodes.
 Nursing Diagnosis Nursing Intervention Evaluation
8-Impaired Verbal Immediate (Within 24 Hours) Interventions
Communication related to • Focus on one-on-one interactions. Keep the environment as calm The success of
pressured speech, flight of and low-stimulus as possible. This helps to minimize distractions communication
ideas, and a short attention that could worsen the patient's agitation and communication
span, which are common
interventions is
difficulties.
during a manic episode. evaluated by
• Use simple, direct language. Ask questions that require only a
observing the
"yes" or "no" response. This reduces the cognitive load on the
Expected Outcome: patient and increases the likelihood of a successful interaction. client’s ability to
Immediate(within For example, instead of asking "How are you feeling?", ask "Are engage in clear,
24 hours): you feeling okay?". logical, and
-The client will • Give one-step commands. Break down tasks into a single action goal-directed
respond to simple, to make them easier to follow. For instance, say "Please sit conversations.
direct questions with down" instead of "Please come over here and sit down with me".
"yes" or "no" • Provide a structured routine. A predictable schedule helps to
answers. ground the patient and can reduce feelings of chaos and anxiety,
-The client will be which often contribute to pressured speech and disorganized
able to follow one- thought.
step commands.
• Model slow, deliberate speech. By speaking at a slower pace
-The client's speech
with frequent pauses, the nurse can encourage the patient to
will be less
pressured, allowing naturally slow their own speech and make it more
for brief pauses. understandable.
Short-
term:(within 1-2
Short-Term (Within 1-2 Weeks) Interventions
weeks): • Gradually increase the duration of interactions. Start with short,
-The client will be structured one-on-one sessions and gradually increase the time
able to participate to 5 minutes or more as the patient's focus improves.
in a structured, • Encourage the patient to express basic needs. Create
one-on-one opportunities for them to communicate simple needs. For
conversation for at example, ask "What would you like to eat for breakfast?" and
least 5 minutes. prompt them to respond with a simple statement like "I want
-The client will be toast".
able to clearly • Use therapeutic communication techniques. Employ active
communicate their listening and validate the patient's attempts to communicate,
basic needs (e.g., even if their speech is still somewhat disorganized. This
"I am hungry," "I includes paraphrasing and reflecting to show that you are trying
need to use the to understand them.
bathroom"). • Guide the conversation back to the topic. When the patient
-The client will exhibits a flight of ideas, gently redirect them. For example, say,
demonstrate a "You were talking about your family a moment ago; let's stick
decrease in flight with that for now."
of ideas, with a • Introduce group therapy or activities gradually. Begin with
more logical and small, supervised groups to help them practice communication
organized thought skills in a social setting.
process.
Long-term:(by Long-Term (By Discharge/Within a Month) Interventions
discharge or • Reinforce goal-directed communication. Provide positive
within a month): feedback when the patient stays on topic and engages in a
-The client will coherent conversation. This encourages the repetition of desired
consistently behaviors.
engage in goal- • Teach and practice social communication skills. Role-play
directed scenarios that require turn-taking, active listening, and
conversations. appropriate nonverbal cues. This helps the patient apply these
-The client will skills in real-world situations.
independently use • Facilitate family communication sessions.
effective • Involve family members in therapy to help the patient verbalize
communication feelings and needs within their support system. Teach family
techniques (e.g., members how to communicate effectively with the patient to
active listening, prevent misunderstandings and conflict.
taking turns • Develop a relapse prevention plan. This plan should include
speaking) in social strategies for maintaining communication skills, identifying
interactions. early warning signs of an impending manic episode, and
knowing when to seek help. This ensures the patient can
-The client will be continue to manage their communication post-discharge.
able to verbalize • Promote self-advocacy. Encourage the patient to express their
their feelings and feelings and needs directly to their healthcare providers and
needs to family others. This empowers them to take control of their health and
well-being.
members and
healthcare
providers
 Nursing Care Plan for Bipolar Disorder (Manic and Depressive
Phases)
Nursing Diagnosis: Risk for Injury
Related to: Extreme hyperactivity, impulsive behavior, and poor judgment.
Goal: The patient will not harm themselves or others throughout the hospital stay.

Nursing Interventions How to Apply It in a Real-World Setting

(Practical Application)
Maintain a safe, low-stimulus environment. Action: Place the patient in a quiet room,
away from the nurses' station if possible. Dim
the lights and reduce noise levels. Remove
any potentially dangerous objects (sharps,
belts, cords). This reduces sensory input that
can escalate hyperactivity.
Set firm, consistent limits on behavior. Action: Use a calm, neutral tone of voice.
State rules clearly and concisely, e.g., 'It is not
safe to be on top of the table. Please come
down.' Avoid arguing or debating. All staff
members must enforce the same rules
consistently.
Provide structured, non-competitive activities. Action: Engage the patient in simple, solitary
tasks that use their excess energy, such as
folding laundry, walking with a staff member,
or using a stationary bike. Avoid group
activities that are competitive, as these can
trigger agitation and conflict.
Administer prescribed medications as ordered. Action: Offer medications like mood
stabilizers (e.g., Lithium) or antipsychotics as
prescribed. If the patient is too agitated to
swallow pills, communicate with the
physician about getting an order for an
intramuscular (IM) injection.
Use de-escalation techniques and offer PRN Action: If you see signs of escalating agitation
medication. (pacing, loud voice), intervene early. Calmly
ask, 'You seem upset. How can I help?'
Redirect them to a quieter area. Offer PRN
(as-needed) medication before the behavior
becomes unmanageable.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to: Inability to sit still long enough to eat, lack of interest in food.
Goal: The patient will consume adequate calories and maintain a stable weight.

Nursing Interventions How to Apply It in a Real-World Setting

(Practical Application)
Provide high-calorie, high-protein 'finger Action: Instead of a meal on a tray, offer
foods.' foods the patient can eat while walking. Good
examples include sandwiches, cheese sticks,
fruit, granola bars, and milkshakes.
Offer frequent snacks and fluids. Action: Approach the patient every hour with
a snack or a drink. A simple prompt like,
'Here is a snack for you,' is often more
effective than asking if they are hungry. Keep
a record of their intake.
Monitor intake, output, and weight. Action: Weigh the patient daily at the same
time. Keep a strict food and fluid chart to
track what they actually consume. This
provides objective data to evaluate if the
interventions are working.

Nursing Diagnosis: Risk for Suicide

Related to: Feelings of hopelessness, worthlessness, and overwhelming psychic pain.
Goal: The patient will not attempt to harm themselves and will verbalize feelings of hope for the future.

Nursing Interventions How to Apply It in a Real-World Setting

(Practical Application)
Assess for suicidal ideation directly. Action: Ask direct questions in a supportive,
non-judgmental way: 'Are you having
thoughts of killing yourself?' or 'Do you have
a plan to harm yourself?' Being direct does
not 'give them ideas'; it is the most important
step in assessing risk.
Implement suicide precautions. Action: Depending on the assessed risk level,
this can range from checking on the patient
every 15 minutes to providing 1:1 constant
observation. Remove all potentially harmful
items from the environment (shoelaces,
razors, plastic bags, etc.).
Encourage expression of feelings. Action: Spend time sitting with the patient,
even if they don't talk. Say, 'I'm going to sit
with you for 10 minutes.' This shows you care
and builds trust. When they do talk, listen
actively without judgment.
Develop a 'Safety Plan' with the patient. Action: Collaborate with the patient to create
a written plan for when they feel suicidal.
This includes identifying personal warning
signs, coping strategies (e.g., listening to
music, talking to a specific person), and
listing emergency contacts and professionals
they can call for help.
Nursing Diagnosis: Social Isolation
Related to: Lack of energy, low self-esteem, and lack of interest in activities (anhedonia).
Goal: The patient will willingly attend and participate in one group therapy session per day.

Nursing Interventions How to Apply It in a Real-World Setting

(Practical Application)
Initiate brief, frequent, non-demanding Action: Start small. Approach the patient and
interactions. make a simple, neutral observation: 'I see you
are watching TV.' This avoids putting
pressure on them to have a long conversation.
Encourage, but do not force, participation in Action: Invite the patient to a group activity
group activities. personally. Initially, they might just observe,
which is a positive first step.
Give positive reinforcement for any social Action: Acknowledge their efforts, no matter
interaction. how small. 'It was good to see you in the
group meeting today.'
Help with grooming and appearance (ADLs). Action: Feeling clean and dressed can
improve self-esteem. Assist with showering
and choosing clothes for the day.

Nursing Diagnosis: Disturbed Sleep Pattern

Related to: Hyperactivity, racing thoughts, and environmental overstimulation.
Goal: The patient will sleep for 4-6 hours per night and report feeling more rested within one week.

Nursing Interventions How to Apply It in a Real-World Setting

(Practical Application)
Establish a structured pre-sleep routine. Action: Encourage calming activities before
bedtime such as a warm bath or soft music.
Limit caffeine and sugary foods/drinks. Action: Ensure the patient avoids caffeine or
sugar in the evening.
Maintain a dark, quiet, and cool environment. Action: Use blackout curtains, close door to
reduce noise, adjust room temperature.
Administer prescribed sedative medications. Action: Administer prescribed sleep aids and
monitor for side effects.

Nursing Diagnosis: Self-Care Deficit (Hygiene and Grooming)

Related to: Lack of energy and motivation, decreased interest in personal well-being.
Goal: The patient will independently perform basic personal hygiene and grooming activities daily by the time of
discharge.

Nursing Interventions How to Apply It in a Real-World Setting

(Practical Application)
Assess the patient's current ability to perform Action: Observe and ask about the patient’s
ADLs. daily routine.
Break down tasks into small, manageable Action: Guide through single tasks like
steps. brushing teeth then combing hair.
Assist with hygiene while promoting Action: Encourage the patient to do as much
independence. as possible while assisting when needed.
Provide positive reinforcement for all efforts. Action: Praise every achievement to build
motivation and confidence.
Nursing Diagnosis: Impaired Social Interaction
Related to: Egocentric and intrusive behavior, inability to recognize the needs and boundaries of others.
Goal: The patient will engage in appropriate social interactions with staff and peers, demonstrating respect for
boundaries, by the time of discharge.

Nursing Interventions How to Apply It in a Real-World Setting

(Practical Application)
Set and maintain firm boundaries on intrusive Action: If a patient interrupts or invades
behavior. space, calmly set limits and enforce them.
Role-model respectful communication. Action: Speak to the patient respectfully even
when they are provocative.
Help the patient recognize the consequences Action: After an incident, discuss it privately
of their behavior. using 'I' statements.
Protect other patients from intrusive behavior. Action: Redirect disruptive patients or move
others to quiet areas.

Nursing Diagnosis: Low Self-Esteem

Related to: Unrealistic negative self-appraisal, feelings of worthlessness, and history of failures or negative feedback.
Goal: The patient will verbalize at least three personal strengths or positive attributes by the end of the week.

Nursing Interventions How to Apply It in a Real-World Setting

(Practical Application)
Focus on the patient's strengths, not their Action: Shift focus to positive qualities and
weaknesses. achievements.
Assign simple, achievable tasks to promote Action: Give small, successful tasks like
success. watering plants or folding towels.
Gently challenge and reframe negative self- Action: Use examples of success to counter
talk. negative thoughts.
Limit rumination on past failures. Action: Acknowledge feelings, then redirect
to present-focused activities.

Nursing Diagnosis: Impaired Verbal Communication

Related to: Pressured speech, flight of ideas, and short attention span.
Goal: The patient will engage in goal-directed and coherent conversations, effectively communicating their needs to staff
on a consistent basis before discharge.

Nursing Interventions How to Apply It in a Real-World Setting

(Practical Application)
Use a calm, patient, and accepting approach. Action: Listen without interrupting, even if
the patient speaks rapidly.
Speak in short, simple sentences. Action: Ask one question at a time, clearly
and slowly.
Listen for themes and recurring topics. Action: Identify main ideas and gently focus
on them.
Gently redirect and refocus the conversation. Action: Bring the topic back to the present
without dismissing the patient.
Reduce environmental stimuli during Action: Talk in quiet, calm settings to help the
interactions. patient concentrate.

Nursing Diagnosis: Ineffective Coping

Related to: Inability to manage stressors and regulate emotions, leading to passivity, withdrawal, or self-destructive
behaviors.
Goal: The patient will identify one current stressor and demonstrate the use of one new, healthy coping strategy to
manage it by the end of the week.
Nursing Interventions How to Apply It in a Real-World Setting
(Practical Application)
Help the patient identify and verbalize Action: Ask gentle questions about challenges
feelings and stressors. or emotions.
Teach and practice structured problem- Action: Walk through defining a problem and
solving. listing solutions.
Introduce and rehearse simple relaxation Action: Teach deep breathing or muscle
techniques. relaxation techniques.
Encourage journaling or writing down Action: Suggest writing thoughts to identify
thoughts. emotional patterns.
Give positive reinforcement for any coping Action: Praise small efforts to strengthen
attempt. positive coping behaviors.

Nursing Diagnosis: Altered Sensory Perception

Related to: Biochemical imbalances and severe psychological stress, as evidenced by hallucinations (auditory/visual) or
delusions (paranoid/grandiose).
Goal: The patient will report feeling less threatened by hallucinations and will be able to distinguish between delusional
thoughts and reality with staff assistance.

Nursing Interventions How to Apply It in a Real-World Setting

(Practical Application)
Assess for command hallucinations. Action: Ask about voices or commands to
harm and ensure 1:1 observation if risk
present.
Orient to reality without challenging the Action: Validate feelings but present reality
delusion. calmly.
Focus on the feeling behind the symptom. Action: Acknowledge emotions like fear and
stay with the patient until calmer.
Reduce environmental stimuli. Action: Move to a quiet room, dim lights, and
reduce noise.
Engage in reality-based activities. Action: Use distractions like music, stress
balls, or describing sensory details.
 ➢ Health education for patients with bipolar disorders
Understanding Bipolar Disorder: Explain the illness, including its symptoms
(like the stress-vulnerability model), and the difference between
manic/hypomanic and depressive episodes.
• Medication Management: Emphasize the importance of taking medications
exactly as prescribed, even during periods of stability. Educate on the
purpose of each medication (e.g., mood stabilizers, antipsychotics), potential
side effects, and the risks of stopping medication abruptly.
• Symptom Monitoring: Teach patients how to use mood charts or journals to
track their moods, sleep patterns, daily activities, and potential triggers. This
helps them identify early warning signs of a mood shift (relapse prevention).
• Lifestyle and Wellness: Promote healthy habits that can stabilize mood.
These include:
• Consistent routine: Maintaining regular sleep, meal, and activity schedules is
crucial.
• Healthy diet: Discuss the role of nutrition and how it can affect mood and
medication.
• Exercise: Explain how regular physical activity can help manage stress and
improve overall mood.
• Substance avoidance: Educate on the negative impact of alcohol and
recreational drugs on mood stability and medication effectiveness.
• Coping Strategies: Provide practical skills for managing symptoms and
stress, such as:
• Stress management techniques: Deep breathing, mindfulness, and relaxation
exercises.
• Problem-solving skills: A structured approach to dealing with difficult
situations.
• Developing a "wellness toolbox": A list of activities and resources to use
when symptoms emerge.

14
 ➢ Health education for caregivers
Understanding Bipolar Disorder: Caregivers should learn about the illness,
including the different types of episodes (manic, hypomanic, depressive,
mixed), the concept of mood swings, and the potential triggers. This
knowledge helps them understand the patient's behavior as part of the illness,
reducing frustration and blame.
• Recognizing Warning Signs: Teach caregivers to identify the early warning
signs of a mood episode. This might include changes in sleep patterns,
increased talkativeness, unusual spending habits, or a sudden loss of interest
in hobbies. Early detection allows for timely intervention, potentially
preventing a full-blown crisis.
• Medication Management Support: Caregivers can help by gently reminding
the patient to take their medication as prescribed and by being aware of
potential side effects. It's important to understand that medication adherence
is a key factor in stability.
• Creating a Supportive Environment: Encourage a structured, low-stress
environment. This includes promoting a consistent routine for sleep, meals,
and activities. Caregivers should also learn to communicate calmly and
avoid arguments during mood episodes.
• Developing a Crisis Plan: Caregivers should be involved in creating a
detailed crisis plan with the patient and their healthcare team. This plan
should outline emergency contacts, what to do in a crisis, and who to call.
Knowing what to do in an emergency reduces anxiety and ensures a swift
response.
• Setting Boundaries and Self-Care: Caregiving for someone with bipolar
disorder can be emotionally and physically draining. Educate caregivers on
the importance of setting personal boundaries, taking breaks, and engaging
in their own self-care activities. Remind them that they cannot pour from an
empty cup and that their own health is a priority.

15
➢ Summary
• Bipolar Disorder is a mental health disorder characterized by extreme and
unusual shifts in a person's mood, energy, activity levels, and concentration.
These shifts manifest as distinct mood episodes, which alternate between
periods of elevated energy and euphoria (manic or hypomanic episodes) and
periods of sadness and loss of energy (major depressive episodes)., causes
extreme mood swings, including emotional highs known as mania or
hypomania, and lows known as depression. These mood episodes are far
more severe than typical emotional changes and can disrupt every aspect of
a person's life, including their sleep, energy, judgment, and ability to think
clearly.
• While the exact cause remains unknown, research points to a combination of
factors. There is a strong genetic component, as individuals with a first-
degree relative with Bipolar I are about seven times more likely to develop
it. Environmental triggers such as childhood trauma, stressful life events,
and substance use are also significant contributing factors.
• The main types include Bipolar I Disorder, defined by at least one manic
episode, and Bipolar II Disorder, which requires at least one hypomanic and
one major depressive episode. Cyclothymic Disorder involves chronic but
milder, more persistent mood fluctuations. Manic states can progress
through three stages: hypomania (elevated mood), acute mania (impaired
judgment and possible delusions), and delirious mania (severe confusion and
psychosis).
• Nursing care is multifaceted, combining pharmacological and non-
pharmacological approaches. Pharmacological interventions center on
administering mood stabilizers like lithium and antipsychotics, while
carefully monitoring for side effects and therapeutic levels. Non-
pharmacological care is equally vital and includes psychotherapy, such as
Cognitive Behavioral Therapy (CBT), to improve coping skills.
• Nurses play a key role in creating a safe, low-stimulus environment,
especially during manic episodes, to prevent injury. They also establish
structured routines for sleep and meals to promote stability, using
approaches like Interpersonal & Social Rhythm Therapy (IPSRT). The
nursing care plan prioritizes managing disturbed thought processes, reducing
the risk of self-harm, and providing psychoeducation to the patient and their
family to encourage medication adherence and early detection of relapses.
16
 ANTI-MANIC DRUGS

(LITHIUM)

Supervised by:

▪ Dr. Hend Karem

▪ Demonstrator. Aya Abd El Azeem
Psychiatric Mental Health Nursing Department

First Semester

(2025-2026)

1
Outlines:

▪ Introduction.
▪ Mechanism of action (Pharmacodynamics).
▪ Pharmacokinetics.
▪ Classification of anti-manic drugs.
▪ Indications of anti-manic drugs.
▪ Side effects of anti-manic drugs.
▪ Contraindications of anti-manic drugs.
▪ Lithium toxicity.
▪ Nursing management of lithium toxicity.
▪ Health teaching for patient receiving lithium.
▪ References.

3
Introduction:
Anti-Manic drugs also known as mood stabilizers are medications used in the
treatment of bipolar disorder, where a person’s mood changes from a depressed
feeling to a high “manic” feeling or vice versa. One of the most common mood
stabilizer is Lithium which was approved by the Food and Drug Administration
(FDA) for the treatment of mania in 1970 and it is considered to be the gold
standard in preventing recurrences in BD I (mania and depressive episodes) and
BD II(hypomania and depressive episodes).
Mechanism of action:
Lithium’s mechanism of action in mood stabilization remains unclear but there are
many theories explains how it works:

Effect on enzymes:
- Lithium Inhibit Inositol Monophosphatase enzyme: (IMPase plays
an important role in producing intracellular Ca+ which lead to ↑ cellular
excitability) .
- Lithium inhibit Glycogen Synathase Kinase-3 enzyme:
( in bipolar : ↑GSK3 →↑Dopamine, ↓Seritonine).

Effect on Electrolytes:
Lithium and sodium are both monovalent cation and thier ionic radii are
close so the body mistake lithium for sodium.
Lithium reduces Na+ levels by replacing intracellular Na+.

Effect on Neurotransmitters:
lithium → ↓ Glutamate → ↓ Excitability
Lithium → ↓ Dopamine → ↓ Excitability
lithium →↑ Seritonine, GABA → ↑Calming effect

4
Pharmacokinetics:

❖ Absorption:
• Lithium is readily absorbed from the gastrointestinal tract. Peak
plasma concentrations of lithium are attained within 0.25 to 3
hours following oral intake of immediate-release formulations
and between 2 and 6 hours with sustained release (SR)
formulations.
❖ Distribution:
• Lithium distributed across total body fluids.
• Lithium shows preferential uptake in certain compartments such
as kidney, brain, thyroid gland.
❖ Metabolism:
• Lithium not metabolized and not bind to plasma protein.
❖ Elimination:
• About 95% excreted by the kidneys and small amount excreted
in sweat and feces.

Classification of anti-manic drugs:

Generic Name Trade Name

• Eskalith • Duralith
Lithium Carbonate • Lithobid • lithonate
• Carbolith (prianil CR)
Lithium Acetate • Lithium Acetate Dihydrate AR
Lithium Citrate • Cibalith-S (oral syrup solution).
• Li-Liquid

5
Indications of lithium:

1. Acute Mania: First-line treatment for acute manic episodes.

2. Maintenance treatment for bipolar disorder.

3. Suicide Prevention.

4. Aggression and impulsivity.

5. Treatment for Resistant Depression (TRD).

6. Schizoaffective disorder.

Adverse effects:

Systems Adverse effects

• Fine hand tremors
• Fatigue or lethargy
• Dizziness
Nervous System • Ataxia
• Headache
• Weakness
• Cognitive impairment
• memory problems
• Nausea and vomiting
• Diarrhea
Gastrointestinal System • Abdominal discomfort
• Polydipsia
• Metallic taste
Endocrine and • Hypothyroidism
• Hyperparathyroidism leading to
increased calcium levels in the
blood.
• Weight gain

6
 • Hypotension
Cardiovascular System • Arrhythmia
• changes in ECG, such as T wave
flattening.
Urinary Systems • Polyurea
• Polydipsia
• Nephrotoxicity (long term use)
Contraindications of lithium:

1. Known hypersensitivity to lithium.

2. Renal failure or chronic kidney disease.
3. Thyroid disorders (may worsen hypothyroidism).
4. Pregnancy (especially 1st trimester → risk of Ebstein’s anomaly).
5. Breastfeeding.
6. Severe cardiac disease (arrhythmias, conduction defects).
7. Hyponatremia or dehydration (↑ risk of lithium toxicity).
8. Concurrent Use of Medications That Interact with Lithium.
Lithium toxicity:

Lithium has a narrow therapeutic index, and toxicity may occur at levels
close to therapeutic concentrations. The therapeutic level for lithium to
avoid toxicity is 0.6 to 1.2 mEq/L.
Etiology Of lithium toxicity:
Lithium toxicity can occur either due to excessive intake or impaired
excretion.
1. Acute toxicity → intentional/accidental ingestion (overdose).
2. Chronic toxicity → reduced clearance in case of:
• Renal impairment → ↓ lithium clearance
• Dehydration due to fluid loss (diarrhea and vomiting).
• Sodium depletion (low salt intake).

7
 • Drug interactions (such as NSAIDs, ACE inhibitors,
Diuretics) which increase lithium level.
• Hot weather and excessive sweating.
Levels of lithium toxicity:
Types Mild Moderate Severe
Lithium 1.5–2.0 mEq/L 2.0–2.5 mEq/L >2.5 mEq/L
level
• Persistent
•Nausea,vomiting • Generalized
• Severe diarrhea
nausea,vomiting. convulsions
Clinical • muscle • Dehydration • Oliguria (renal
picture weakness • Convulsions failure)
• lethargy, • Delirium • Arrythmia
Drowsiness • Syncope • Coma
• Tremors • Stupor • Death
• Discontinue lithium.
• Serum lithium level, electrolytes, renal function tests, and
ECG should be obtained as soon as possible.
• Monitor vital signs and neurological status of the patient.
• Gastric lavage • Gastric lavage and • Vigorous
within 1hr whole bowel hydration and
from ingestion irrigation in cases maintenance of
Nursing • Whole bowel of ingestion. electrolyte
Management irrigation • Vigrious hydration balance.
within 12hr • Correction of • Hemodialysis
from ingestion hemodynamic may be required
• Encourage imbalance every 6–10 h,
fluid intake to • Administer IV until the lithium
maintain normal saline level is within
electrolytes (0.9%) to promote nontoxic range
balance lithium excretion. and the patient
has no signs or

8
 symptoms of
lithium toxicity.
• Mechanical
ventilation may
be required.
• Provide proper
management of
seizures.
Health teaching for patient receiving lithium:

❖ Purpose of medication:
• Lithium is a mood stabilizer drug used to decrease intensity and
frequency of mania.
❖ Onset of Effect:
• Therapeutic effect requires 1–3 weeks to appear.
❖ Administration instructions
• Take lithium with or after meals to minimize adverse effects.
• Maintain normal fluid (6 to 8 large glasses of water each day),
normal sodium intake and avoid excessive use of beverages
containing caffeine (coffee, tea, colas) during therapy.
• Avoid driving or operating dangerous machinery until lithium
levels are stabilized.
• Carry card or other identification noting that patient is taking
lithium.
• Caution patient not to stop taking lithium or adjust dosage
without first consulting the doctor.

9
❖ Adherence to therapy
• Take medication on a regular basis, even when feeling well.
Discontinuation can result in return of symptoms.
❖ Side effects and toxicity
• Inform patient that frequent urination and thirst may occur
during the first few days of the treatment.
• Be aware of side effects and symptoms associated with toxicity.
• Notify the physician if any of the following symptoms occur:
persistent nausea and vomiting, severe diarrhea, ataxia, blurred
vision, excessive output of urine, increasing tremors, or mental
confusion.
❖ Specific considerations
• Be aware of risks of becoming pregnant while receiving
lithium therapy.
• Notify the physician as soon as possible if pregnancy is
suspected or planned.
• Patient must consult physician before starting other
medication.
• Prevent alcohol intake during lithium therapy

10
❖ Follow up
• Pre‐treatment tests:

Before starting lithium renal function test, thyroid function

test, ECG, Urine analysis, Pregnancy test, serum electrolytes,
CBC, weight should be checked.

• On treatment monitoring:

Test When to Check

• Blood sample must be drawn 12 h
after a given dose.
• Monitor serum lithium level after 5
days of initiation then weekly until
Serum Lithium lithium levels become stable.
• Then every 2:3 months during the first
year of administration.
• Then every 6 months after 1 year of
stable treatment.
• Every 2-3 months during the first 6
Renal function months of therapy.
test • Every 6 : 12 months thereafter.
Thyroid • Every 2-3 months during the first 6
function test months of therapy.
• Every 6 : 12 months thereafter.
Electrolytes • Every 6–12 months
(Na⁺, K⁺, Ca²⁺)
ECG • As needed if cardiac symptoms
develop.
Weight & BMI • Every 6–12 months

11
 Antipsychotic drugs

Prepared by: Under supervision of:

G1. . Dr amged saeed
[Link] Menatallah mohsen
[Link] Aya sanad
Outlines:
1. Introduction.
2. Mechanism of action.
3. Classification (typical-atypical).
4. Pharmacokinetics.
5. Indication.
6. Adverse effects (Neurological-non neurological).
7. Contraindication.
8. Nursing intervention to side effects of antipsychotic.
9. Health teaching for family and patient who receive
antipsychotic drugs.
10. References.

|Page1
Introduction
Antipsychotic or Neuroleptic or Major Tranquilizers or Dopamine receptors blockers
are medications used to treat psychiatric disorder (schizophrenia, bipolar disorder and
depression) or psychosis related to other psychiatric and medical disorders.
Antipsychotics are commonly categorized into two classes, First-generation
antipsychotics (FGAs), also known as “typical antipsychotics”, were developed in the
1950s, and Second-generation antipsychotics (SGAs), also known as “atypical
antipsychotics”, emerged in the 1980s.
(SGAs), have been classified according to their chemical structure, which includes
serotonin-dopamine antagonists and multi-acting receptor-targeted serotonin 5-HTA2
receptors.

Mechanism of action
The antipsychotics drugs are thought to work by blocking postsynaptic dopamine
receptors in the basal ganglia, hypothalamus, limbic system, brain stem, and medulla.

Dopaminergic pathways:

1-Mesolimbic tract: is involved in emotional and

sensory function Dopamine
positive signs of schizophrenia

|Page2
2-Mesocortical tract: is involved in cognitive function, Antipsychotic drugs Treats
negative and cognitive symptoms.
3-Nigrostriatal tract:
is involved in motor function, Antipsychotics
drugs Causes extrapyramidal symptoms.

4-Tuberoinfundibular tract:
The release of dopamine in this pathway
regulates prolactin secretion by the pituitary
gland, antipsychotics causes
hyperprolactinemia.

Classification (typical-atypical)

Typical antipsychotic drug Atypical antipsychotic drug

Block (D2) dopamine receptor Block (D2) dopamine & (5-HT2A)

serotonin receptor
Classical , oldest Newer , novel
First generation Second generation
conventual uncongenial
More side effect Less side effects
High risk for EPSES Low risk for EPSES
More effective Less effective
Less expensive More expensive

Typical Generic name Trade name

Examples Chlorpromazine Thorazine

|Page3
 Thioridazine Mellaril

Pherphenazine Trilafon

Haloperidol Haldol

Fluphenazine Prolixin

Atypical Generic name Trade name

Risperidone Risperdal

Examples Clozapine Clozaril

Ziprasidone Geodon

Pharmacokinetics
1- Absorption:
Antipsychotics can be administered orally or parenteral.
Oral medication are absorbed in the gastrointestinal tract and reach blood stream 2-
Distribution:
Lipophilic (cross lipoidal membranes freely) and bind to proteins 3-
Metabolism:
Takes place in liver (hepatic microsomal enzyme) 4-
Excretion:
Enterohepatic circulation (liver and kidney)

Indication
Antipsychotics treat mood disorders, including:
• Schizophrenia (and its related spectrum of disorders, including schizoaffective
disorder and schizophreniform disorder)

|Page4
 • Bipolar disorder
• Mania
• Major depressive disorder with some psychosis
• Delusional disorder
• Severe agitation
• Borderline personality disorder
• Dementia with psychotic features
• Delirium
• Substance-induced psychotic disorder Other indications include:
• Tourette syndrome:
A neurological disorder that causes repetitive, involuntary movements and vocal
sounds called tics. It often starts in childhood and can range from mild to severe.

Adverse effects:
Adverse Effects of Antipsychotic Drugs are classified into

Neurological Non neulogical

1. Neuroleptic malignant syndrome 1. Anticholinergic Side Effects
(NMS) 2. Blood Disorders
2. Extra pyramidal syndrome which 3. Eye Problems
includes: 4. Sedation (Sleepiness)
a. Acute Dystonia 5. Endocrine Side Effects
b. Pseudo Parkinsonism 6. Skin Problems
c. Akathesia
7. Heart Problems
d. Tardive Dyskinesia
8. Hypersalivation (with clozapine)

Neurological adverse effect of antipsychotic drugs

Neuroleptic malignant syndrome (NMS) :

|Page5
- it is a rare but serious complication of
antipsychotics drugs
- onset is rapid within 24-72 hours from drug
initiation
Symptoms are:
1. diaphoresis (increase sweating) and fever to a
dangerous level
2. Rigidity (feeling stiff and unable to move) or
loss of movement
3. Tachycardia and hypertension
4. Disturbed of consciousness including stupor
5. Increase CPK level (Creatine phosphokinase is an enzyme a Protein that helps to
elicit chemical changes)
6. Fever can rise to high levels and even may lead to death. NMS is a medical
emergency .

Antipsychotic medications should be discontinued, and immediate medical attention is

necessary to save a patient's life.
Extra pyramidal syndrome:

|Page6
➡️ Dystonia: These are involuntary muscular spasms of the cheek, eyes, tongue and
jaws, head and neck. it is a rare neurological movement disorder in which the
muscles contract involuntarily. These symptoms occur within 48 hours following
initiation of therapy, Dystonia is painful and may
frighten the patient Oculogyric crisis: (upward
lateral movement of eye) oculogyric crisis should be
treated as an emergency. The physician should be
contacted and intravenous or intramuscular
benztropine mesylate (Cogentin) is commonly
administered.
Types of dystonia:
A. Torticollis: contracted positioning of the neck
B. Reteocollis: rolling back of the neck
C. Larengeal spasm: is a spasm of the vocal cord
constriction, asphyxia death may occur. D. Latero
collis: contracted to the side E. Antero Collis:
Contracted to forward ➡️ Pseudo Parkinsonism:
It is a drug induced Parkinsonism. The patient may
show the symptoms of Parkinson's disease. Motor
symptoms such as:
Difficulty in mastication, muscle fatigue, tremors,
muscle rigidity, increased salivation, slurred speech,
slow movements, difficulty in walking and shuffling
gait
These symptoms occur between 5-7 days following
initiation of therapy ➡️ Akathesia:
It is a movement disorder characterized by
restlessness and inability to sit or stand still.

These symptoms occur 50:60 days following the initiation of therapy

|Page7
➡️Tardive Dyskinesia:
Involuntary irreversible movement especially of
the tongue and lips. Other symptoms may include
protrusion of tongue, sucking movements,
grimacing, Slow and irregular movements.
These symptoms occur within months or years
Non neurological adverse effects of
antipsychotic drugs:
1. Anticholinergic Side Effects
Anticholinergic side effects occur due to the blockade of acetylcholine and are
common with typical and some atypical antipsychotics.
These effects include:

− Dry mouth
− Slowed gastric motility
− Constipation
− Urinary hesitancy or retention
− Vaginal dryness
− Blurred vision
− Dry eyes
− Nasal congestion
− Confusion or decreased memory

2. Blood Disorders
Certain blood disorders may occur as a side effect of antipsychotics, especially
clozapine. One of the most concerning conditions is *agranulocytosis* , which
involves a loss of neutrophils, leading to neutropenia. This weakens the immune
system, increasing the risk of infections.
Symptoms include:
− Sore throat
− Mouth ulcers
− Fever or chills
− Clozapine is more strongly associated with this side effect compared to other
antipsychotics.

|Page8
3. Eye Problems
Some antipsychotics can cause various eye-related side effects, such as:

− Blurred vision
− Difficulty reading
− Build-up of granular deposits in the cornea and lens (usually does not affect vision)
− Retinal degeneration, which may impair vision
− Miscellaneous "photosensitivity or retinitis pigmentosa
− Glaucoma, a serious eye condition

4. Sedation (Sleepiness)
Sedation is a common side effect, especially with chlorpromazine and olanzapine. It
can occur both during the day and at night, making it difficult to wake up in the
morning or stay active throughout the day.

5. Endocrine Side Effects

A-sexual side effects:
These side effects occur primarily due to dopamine blockade in the tuberoinfundibular
pathway, leading to elevated prolactin levels.

− In males:
▪ Gynecomastia (enlarged breast tissue)
▪ Erectile dysfunction
▪ Retrograde ejaculation (semen enters the bladder instead of exiting through
the penis during orgasm)
− In females:
▪ Amenorrhea (absence of menstruation)
▪ Galactorrhea (abnormal milk secretion)
B. Metabolic Syndrome
Metabolic syndrome refers to a cluster of health issues that may arise as a result of
antipsychotic use, including:

− Weight gain and obesity

− High blood sugar
− Diabetes
− High blood pressure

|Page9
− High cholesterol

| P a g e 10
 − These metabolic effects are particularly concerned with some atypical
antipsychotics.

6. Skin Problems
Antipsychotics may cause various skin reactions, including:

− Allergic rashes: Typically occur within the first two months of

treatment and usually resolve upon stopping the medication.
− Increased sensitivity to sunlight, especially at high doses.
− Blue-grey skin discoloration in some individuals.

7. Heart Problems
Some antipsychotics can negatively affect the heart, leading to:

− Increased heart rate

− Heart palpitations (noticeable or irregular heartbeats)
− Heart rhythm disturbances, which in extreme cases may cause sudden death,
particularly with high doses or multiple antipsychotics taken simultaneously.

8. Hypersalivation (with clozapine)

− A significant number of clients receiving clozapine (clozaril) therapy experience
extreme salivation.
− Offer support to the client because this may be an embarrassing situation.
− It may even be a safety issue (e.g., risk of aspiration) if the problem is very severe

Contraindications
1) Hypersensitivity to the drug.
2) Use of central nervous system depressants like barbiturates, benzodiazepines,
opioids.
3) With anticholinergic medication like scopolamine or the use of phencyclidine.
4) Severe cardiac abnormalities.
5) History of seizure disorder.
6) Narrow-angle glaucoma or prostatic hypertrophy.
7) History of or ongoing tardive dyskinesia.
8) during pregnancy, especially in the first trimester, and should be used only if the
benefits outweigh the risks of treatment.
9) Antipsychotics are secreted in breast milk, and it is advisable to avoid breastfeeding

| P a g e 11
Nursing Intervention to Side Effects of Antipsychotic:
Extrapyramidal Side effect

• Neuroleptic malignant 1. Report on the extrapyramidal side effects

syndrome immediately to doctor
• Pseudo Parkinson's
diseases 2. Quite the next dose of prescribed antipsychotics
• Akathisia and inform the same to doctor

Autonomic Side effect Nursing intervention

Dry mouth 1. Maintain oral hygiene

2. Use sugarless chewing gum

Constipation 1. High fiber diet

2. More intake of water
3. Increase physical activity
Orthostatic hypotension 1. Monitor Blood pressure regularly
2. Advice the client to get up from lying or sitting in a
slow manner

Central Anticholinergic 1. Preventing falls

syndrome 2. Provide safety measures
3. Orient the patient
Urinary retention 1. Maintain intake output chart
2. Assess for bladder distension
3. Advice the client to report the difficulties in voiding
4. Pour water in patient's back to stimulate urination

| P a g e 12
 Agranulocytosis 1. Discontinue antipsychotic drugs immediately and
identify physician (clozapine)
2. Observe for symptoms of sore throat, fever and
malaise.
3. Complete blood count should be monitored if
symptoms appear

Sedation 1. Discuss with physician possibility of administering

drug at bedtime.
2. Discuss with physician possible decrease in dosage or
order for Less sedating drug.
3. Instruct clients not to drive or operate dangerous
equipment while experiencing sedation.

Metabolic and endocrine Side effect

1. Monitor the weight regularly

2. Diet control
• Weight gain
3. Exercise
4. Change to other safer medication as prescribed

Cardiac Side effect

1. Check pulse and blood pressure

• ECG Changes 2. Report immediately if chest pain is felt by patient

Photosensitivity

[Link] that patient wear protective sunglasses and full sleeves while spending
outdoor.
[Link] that patient use sunblock lotion.

Hypersalivation (with clozapine)

| P a g e 13
 [Link] support to the client, as this may be an embarrassing situation. It may even
be a safety issue (e.g., risk of aspiration), if the problem is very severe.

Health education for the patient and family for receiving

antipsychotics drug:

1. Avoid alcohol and sleeping pills

− as they may cause drowsiness and reduce awareness of environmental hazards.

2. Do not drive or operate hazardous machinery while taking antipsychotic
medications 3. Avoid prolonged direct sunlight

− exposure to prevent sunburn or skin hyperpigmentation.

4. Do not change the dosage or stop taking the medication without consulting a
doctor

− discontinuation should be gradual to prevent nausea or seizures.

5. Avoid taking antacids during therapy

| P a g e 14
− as they may reduce the drug’s absorption and effectiveness.
6. Be cautious of dizziness or fainting when changing positions

− As this may occur due to a drop in blood pressure; take extra care when walking to
prevent falls.

[Link] good oral hygiene

− To prevent infections, tooth decay, and ill-fitting dentures; visit a dentist annually.
8. Store medications safely

− especially if children are present, as they may mistake pills for candy.
9- Emotional and Psychological Support

− Provide a safe and stable environment, minimizing stress and anxiety.

− Be patient and understanding, especially during mood changes or medication side
effects.
− Encourage open communication and listen to the patient’s feelings without
judgment.
10. Helping with Treatment Adherence

− Remind the patient to take their medication on time and attend medical follow-ups.
− Observe any behavioral or health changes and inform the doctor if needed.
− Support the patient in following health guidelines, such as avoiding alcohol,
maintaining a balanced diet, and engaging in light physical activities.
11. Encouraging Social Interaction

− Motivate the patient to engage with family and friends to reduce social isolation.
− Participate in recreational activities and hobbies that help improve mood.
− Consider joining support groups or seeking professional counseling if needed.
12. Educating the Family about the Condition and Treatment

− Learn about the nature of the illness, its symptoms, and how to manage them
effectively.
− Understand the possible side effects of medication and how to respond
appropriately.
− Know when to seek medical help if serious or unusual symptoms appear.

| P a g e 15
 Anti parkinsonism drugs

Prepared by: Under supervision:

G1 Dr Amged Saeed
[Link] Menatallah mohsen
[Link] Aya sanad

1|Page
Out lines
- Introduction
- Classification of anti parkinsonism drugs
- Pharmacodynamics of anti parkinsonism drugs
- Pharmacokinetics of anti parkinsonism drugs
- Indication of anti parkinsonism drugs
- Side effect of anti parkinsonism drugs
- Contraindications of anti parkinsonism drugs
- Nursing intervention of anti parkinsonism drugs
- Health education for the patient and family who receiving
anti parkinsonism drugs.
- References

2|Page
Introduction:

Parkinson Disease Is the Second-Most Common Neurodegenerative Disorder That

Affects 2–3% Of the Population≥ 65 Years Of Age. Neuronal Loss in The Substantia
Nigra, Which Causes Striatal Dopamine Deficiency
Parkinson’s disease (pd) is a degenerative, chronic, and progressive neurological
disorder in which nerve cells in the brain that control movement and produce
dopamine fail to work properly.

3|Page
Classification of anti-parkinsonism drugs: -

4|Page
A: Dopaminergic Drugs: dopamine agonists work by directly stimulating
dopamine receptors in the brain for controlling the symptoms of Parkinson’s
disease.

B: Anticholinergic Drugs: anticholinergic drugs were the first pharmacological

agents used in the treatment of Parkinson’s disease and it reduce tremor by
blocking acetylcholine, a brain chemical that influences movement.

Most Common of Dopaminergic Drugs:

Generic Name Trade Name

Carbidopa/Levodopa Sinemet/Atamet

Amantadine GOCOVRI

-Most common of anticholinergic drugs:

Generic Name Trade Name

trihexyphenidyl Artane / Parkin/ Pacitane

Biperiden Akinetone

Benztropine Cogentin

5|Page
-Pharmacodynamics of anti-parkinsonism drugs
Anti-parkinsonism’s agent restores the neutral balance of dopamine and
acetylcholine in CNS (basal ganglia) the imbalance is deficiency in dopamine that
results in excessive cholinergic activity.
In psychiatric field we only use anticholinergic drug group to overcome the side
effect of antipsychotic drugs.

Dopaminergic drugs Anticholinergic drugs

Inhibit the reuptake and storage of Block of ach to diminish excess

central dopamine receptors there by cholinergic effect by blocking the
prolonging the action of dopamine. receptors for ach it between ach and
dopamine and reduce extra pyramidal
syndrome.

6|Page
 - Pharmacokinetics of anti-parkinsonism drugs
*Definition of pharmacokinetics of anticholinergic drugs the branch of
pharmacology which concerned with the movement drugs within the body.
- Absorbed by small intestine by an active transport system.
- Distributed to side of working in the brain.
- Metabolized in the liver.
- Excreted by the kidney.

-Indications of anticholinergic drugs in psychiatric field :

Anti-cholinergic drugs are used in psychiatric field in patient taken anti psychotic’s
drugs overcome or prevent EPSES that caused by the imbalance between
dopamine and acetylthiocholine.

-Side effects of anticholinergic drugs:

7|Page
8|Page
Contraindications of anticholinergic drugs:
Anticholinergics can be used to treat many conditions, but they are not for everyone.
anticholinergic medications should be used with caution in people have the following
conditions.

1. Hypersensitivity:
people with hypersensitivity for anti-parkinsonism drugs, should stop the
drugs; especially, elderly patients can be particularly sensitive to the
anticholinergic action of drugs because of physiological and pathophysiological
changes that often accompany the aging process.
2. Myasthenia Gravis: " a rare long-term condition that causes muscle
weakness. It most commonly affects the muscles that control the eyes
and eyelids, facial expressions, chewing, swallowing and speaking. "
If A Person Has Myasthenia Gravis, He Should Not Take Anticholinergics
Drugs. Because Antimuscarinic Agents Have Anticholinergic Effects
3. Cardiovascular Disease: people with cardiovascular disease should not
use antiparkinsonian drugs, because m2 receptors are present in the heart as
well and are responsible for slowing heart rate, thus blocking these receptors
may lead to tachycardia.
4. Glaucoma: this can cause glaucoma in individuals with narrow anterior
chamber angles by dilating the pupil and causing pupillary block.
5. Liver Disease: tolcapone is contraindicated in patients with liver
dysfunction, safinamide is contraindicated in patients with severe hepatic
impairment.
6. Renal Disease: amantadine should be avoided or is contraindicated in end-
stage renal failure.
7. Peptic Ulcer: antimuscarinic agents may cause a delay in gastric emptying
and antral stasis in patients with gastric ulcer. therapy with antimuscarinic
agents should be administered cautiously to patients with gastric ulcer.

10 | P a g e
8. Mega Colon: all the medications which can aggravate the megacolon, such
as opioids, anticholinergics, should be stopped.

8|Page

11
 9. Intestinal or urinary obstruction or retention: anticholinergics
block acetylcholine from binding to its receptors on certain nerve cells.
they inhibit actions called parasympathetic nerve impulses.
10. Prostatic hypertrophy: elderly men with prostatic hypertrophy, are
at risk for severe urinary retention after taking anticholinergics.

- Nursing intervention of anti-parkinsonism drugs:

Blurred Vision:
1- Arrange patient's self-care items within reach or orient him to their placement.
2- Avoid dim light and problems o night vision.
3- Improve air quality by using humidifier to prevent dry eye.
4- Administration of eye drops.

Constipation:
1. Check frequency and consistency of stool.
2. Go to toilet as soon as you feel the urge to pass a bowel motion.
3. Use correct posture on toilet to help you pass bowel motion.
4. Increase fluid intake.
5. Increase fiber intake such as brown rice, pasta, and bread.
6. Moderate exercise.

7. Take laxative

Nausea And Vomiting:

1. Give frequent, small amounts of foods that appeal to the patient.
2. Educate and assist patient about oral hygiene.
3. Provide an emesis basin for the patient.
4. Eliminate strong odors from the surrounding as perfumes.
5. Allow the patient to use nonpharmacological nausea control techniques
12 | P a g e
 |Page
6. Inform the patient to avoid foods and smells that trigger nausea.
Dry Mouth:
1. Sip water to keep the inside of mouth moist and hydrated.
2. Select an alcohol-free mouth rinse and use tap water or normal saline to
provide oral care.
3. Limit caffeine and smoking.

4. Use of lubricating ointment on the lips.

Dyspnea:
1. Assess and record respiratory rate and depth.
2. Assist in patient positioning for maximum breathing.
3. Encourage deep breathing exercise.
4. Schedule activities of daily living and rest period of the patient.
5. Advice taking of small, frequent meals.
6. Educate patient on pursed lip breathing, abdominal breathing, and relaxation
techniques.
7. Maintain a clear air way and give respiratory medication as doctor order.
Urinary Retention:
1. Encourage adequate fluid intake (2-4 l per day).
2. Induce the patient to void at least every 4 hours.
3. Promote continued mobility to prevent risk of developing UTI.
4. Observe for cloudy, bloody urine or foul odor, signs of urinary tract infection.
5. Recommend good hand washing and proper perineal care.
6. Teach the patient about Kegel exercise and listen running water during voiding

13
Hyperthermia:
[Link] and monitor environmental factors like room temperature and bed linens
as indicated.
[Link] or remove excess clothing and covers.
3-Provide additional cooling mechanisms commensurate with the significance of
temperature elevation as ice packs.
[Link] antipyretic medications as prescribed
[Link] the patient about the importance of increased fluid intake to avoid
dehydration.

health education for the patient and family who are receiving
ant parkinsonism:
1 -Instruct the patient to drink 6 to 10 glasses of water
2 -Educate patient about medications and how to take them
3 -Increase patient awareness about physical activity
4- Instruct the patient to take prescribed medications as ordered
5 -Instruct the patient to don't stop medication or change them without doctor
order
6- Educate the patient to have a routine for taking medication
7- Educate the patient to keep a medication calendar and note every time to take
the dose
8 -Educate the patient to don't panic if he missed a dose
9- Instruct the patient to store drugs in a dry area away from moisture
10-Instruct the patient not to share his medication with other
11 -Instruct patient and his family members about the medication because
confusion or other common effects

14 | P a g e
12- Instruct the patient to report difficult or painful urination , constipation, rapid
heart rate, chills , fatigue, eye pain, hallucinations
13 -Instruct the patient that decrease perspiration may occur, so the patient
should remain indoors in an air condition during hot weather
14- Increase patient awareness about increase activity, fluid in diet to minimize
constipating effects of medications
15- Instruct the patient to avoid alcohol, sedatives and over the counter drugs
that could cause dangerous effect

15 | P a g e
 Nursing care for Suicide

Under supearvision:
Dr/ Tabasem Fayez
[Link] / Nora Said Mohamed
Prepared by :
Group : ( 9)

2025-2026
First-Semester
Psychiatric/Mental health nursing
Outlines :
• Introduction
• Definition of suicide
• Prevelance of suicide
• Risk Factor of suicide
• Warning signs of suicide
• Method of suicide
• Management of suicide (pharmalogical &non pharmalogical)
• Nursing care plan of suicide
• Stratiges to reduce suicide
• Health Education for patient and family of suicide
• References

2
Introduction:
Suicide is the act of intentionally causing one's own death. Some suicides
are impulsive acts due to stress, such as financial difficulties, troubles
with relationships, or bullying. Those who have previously attempted
suicide are at a higher risk for future attempts. Suicide has strong
emotional repercussions for it survivors and for the families of there
victims.
- More than 720,000 people die due to suicide every year.
- Seventy-three percent of global suicides occur in low- and middle-
income countries.

3
 Definition of suicide :
_ Suicide is defined as death caused by self-directed injurious behavior
with intent to die as a result of the behavior .
Terms related to suicide :
Suicidal Ideation:
Suicidal ideation refers to the presence of thoughts, ideas, or
preoccupations about ending one’s life. These thoughts can range from
passive wishes of not wanting to live anymore (e.g., “I wish I were dead”)
to active planning of suicide methods.
Suicide Attempt:
A suicide attempt is a self-directed, potentially harmful behavior carried
out with at least some intention of ending one’s life. Unlike completed
suicide, the attempt does not necessarily result in death, but it is defined
by the individual’s intent to die.
Complete suicide:
Complete Suicide:
The successful outcome of a self-inflicted act where the person’s intention
was to die, and death actually occurs.

4
Prevalence:
- According to WHO in 2024, the global suicide prevalence is about 9 per
100,000, while in Egypt it is <5 per 100,000. In 2024, around 7,881
suicides were reported in Egypt compared to 3,022 in 2019.
-The rate among males (~4/100,000) is roughly double that of females
(≈2/100,000).
-Worldwide, suicide is the 3rd leading cause of death in people aged 15-29
showing a major public health concern.

5
Risk Factor of suicide :
1. Individual Factors:
• Mental or substance use disorders
• Family history of suicide
2. Psychological Factors:
• Feelings of hopelessness
• Experiences of shame or humiliation
3. Social/Environmental Factors:
• Isolation and Bullying
• Financial or job stress

6
Warning Signs of suicide :
Warning signs that someone may be at immediate risk for attempting
suicide:
- Talking about wanting to die or wanting to kill themselves.
- Making a plan or looking for ways to kill themselves (searching online
for methods, stockpiling pills, buying a gun).
- Giving away important possessions / Saying goodbye to friends or
family.
- Putting affairs in order (e.g., making a will).
- Having access to lethal means (firearms, large amounts of medication).
- Saying goodbye to family and friends.
*• Other serious warning signs:*
- Talking about feeling hopeless, empty, or having no reason to live.
- Talking about feeling trapped or that There are no solutions.
- Talking about being a burden to others.
- Talking or thinking about death often.
- Feeling unbearable emotional.
- Expressing great guilt or shame.
7
8
 Warning Signs of suicide

• Behavioral and mood changes:

- Withdrawing from family and friends / Social isolation.
- Increasing use of alcohol or drugs.
- Acting anxious, agitated, or restless.
- Displaying extreme mood swings (sudden shift from very sad to calm ).
- Showing rage or talking about seeking revenge.
- Changes in eating or sleeping habits (insomnia, oversleeping)
- Loss of interest or pleasure in activities (anhedonia).
- Focusing on past failures and anticipating no future.
9
Methods of suicide :
When discuss suicide as a public health issue, it's crucial to understand that
not all methods are equal in their severity. Research and field studies
classify these methods based on their lethality—that is, the probability that
a particular method will result in death. This classification helps to
Understand risk factors and develop appropriate prevention strategies.
High-Lethality Methods
These methods are the most fatal, with an extremely high probability of a
fatal outcome. They often leave little to no opportunity for intervention or
survival. These methods include:
-Firearms: Considered one of the most lethal methods.
- Hanging: A common method with a high probability of death.
Jumping from high places: cause severe and often fatal injuries.
- Drowning: A method that makes intervention and rescue very difficult.
-High-dose poisoning: Especially with highly toxic substances like certain
pesticides.

10
Low-Lethality Methods
On the other hand, these methods have a lower probability of being fatal.
While they are often associated with non-fatal attempts, this does not
diminish their seriousness. They often allow for a greater opportunity for
intervention and rescue. These methods include:
Pill ingestion / Drug poisoning: An overdose may not always be fatal,
allowing more time for medical intervention.
Self-inflicted wounds: Such as wrist-cutting, which are often non-lethal.
Domestic gas inhalation: may not always be fatal depending on the type
of gas and ventilation

11
Management of suicide :
Pharmacology
Lithium→ Effective mood stabilizer is approved for the treatment of
mania and the maintenance treatment of bipolar disorder.
➢ Antidepressants→ Suicide is strongly associated with poor mental
health especially mood disorders, antidepressants are most common
treatment for mood disorders Such as: Fluoxetine (Prozac), paroxetine
(Paxil), fluvoxamine (Luvox), citalopram (Celexa), escitalopram (Cipra
Lex) and sertraline (Zoloft).
➢ Antipsychotics→ Be used as treatment augmentation in the
management of the major depressive disorders Such as: - Risperidone
(Risperdal), quetiapine (Seroquel), olanzapine (Zyprexa), ziprasidone
(Zeldox), paliperidone (Invega), aripiprazole (Abilify) and clozapine
➢ Anti-anxiety agent→ Anxiety is a significant and modifiable risk
factor for suicide and use of anti-anxiety agents have the potential to
decrease this risk Such as: Alprazolam (Xanax); chlordiazepoxide
(Librium); clonazepam (Klonopin); diazepam.

12
Non-pharmacological management
1. _Reduce stress_ → Ways to reduce stress and cope negative feelings:
- Keep social schedule
- Keep a journal
- Exercise
- Practice mindfulness and meditation
- Spend time outdoor
- Engage your senses
2. _Cognitive behavioral therapy–suicide prevention (CBT-SP)_:
Manualized cognitive behavioral psychotherapy for suicide prevention
and to reduce suicidal behavior and thoughts.
It is therapy that helps prevent suicide by by changing negative thoughts
and behaviors . It improves symptoms of suicidal ideation by identifying
and challenging distorted thinking patterns ,enhancing problem-solving
skills and promoting safety planning .

13
3. _Dialectical behavior therapy(DBT)_:
Effective for reducing repeat suicidal attempts among highly suicidal
adolescents. It is reduces repeat suicidal attempts by teaching individuals
skills to manage emotions , tolerance distress , and improve
relationships . It is particularly effective for individuals with borderline
personality disorder or those experience intense emotional
dysregulation .

4. _Attachment based family therapy_:

Evidence-based approach treating depression and preventing suicide via

focus on empathy and authentic parent-child connection.
5. _Create a safety plan_: Includes support people, hotlines,
affirmations, ways to reframe thoughts and hope when feeling unsafe.
6. _Prolonged grief therapy (PGT)_:14Aims to repair grief after death of
4. _Attachment based family therapy_:
Evidence-based approach treating depression and preventing suicide via
focus on empathy and authentic parent-child connection.
5. _Create a safety plan_:
Includes support people, hotlines, affirmations, ways to reframe thoughts
and hope when feeling unsafe.
6. _Prolonged grief therapy (PGT)_:
Aims to repair grief after death of someone close, helping healing process
especially when complicated by trauma.

15
Nursing care plan of suicide:
Assessment
A comprehensive suicide assessment aims to determine the severity and
immediacy of suicide risk to guide clinical decisions such as
hospitalization, observation, or outpatient management.
Suicide Risk Assessment Using the (SAD PERSONS Scale):
Purpose:
Quick screening tool for suicide risk in emergency settings.
Structure:
Each letter stands for a risk factor.
Letter Meaning :
S Sex (male)
A Age (<19 or >45)
D Depression
P Previous attempt
E Ethanol abuse
R Rational thinking loss
S Social supports lacking
16
O Organized plan
N No spouse
S Sickness (chronic illness)
Scoring:
0–4 = Low risk
5–6 = Moderate risk
7–10 = High risk → requires hospitalization

17
 Nursing Care Plan of suicide

Nursing Diagnosis Intervention

Risk for Suicide -Maintain Safety:Provide close,continuous

related to feelings observation, especially during unstructured times
of hopelessness, such as nights and weekends.
worthlessness, and - Remove all potentially harmful
inability to cope
objects from the client’s environment.
with stress, as
-Promote Expression of Feelings:
evidenced by
Encourage the client to express
suicidal ideation,
thoughts .
plans, or previous
-Encourage Safe Outlets for Emotion:
attempts
Provide opportunities for verbal
expression, physical activity, or
creative outlets such as drawing or
writing.

18
- Enhance Problem-Solving Skills: Teach the client
the problem-solving process: identify the problem
and explore alternative solutions
- Promote Social Interaction: Encourage the client to

interact with staff and peers; reinforce positive social

behaviors with feedback and support.
- Provide Psychoeducation: Teach about depression,
self-destructive behavior, and warning signs of suicidal
thoughts.
-Support Discharge Planning: Help the client identify
supportive individuals and community resources;
arrange follow-up therapy or group support.

19
Nursing Diagnosis Interventions

1. Assess current coping, triggers, and past

• Ineffective coping successful strategies. Rationale: Baseline
related to guides individualized teaching.
inadequate coping 2. Teach problem-solving model (STOP-
strategies and poor THINK-PLAN-DO). Rationale: Structures
problem-solving cognition and action under stress.
skills secondary to 3. Cognitive restructuring for
chronic stress and catastrophizing/all-or-nothing thoughts.
emotional conflict, Rationale: Reframing reduces emotional
as evidenced by intensity and avoidance.
withdrawal, 4. Behavioral activation: schedule
avoidance, pleasant/valued activities daily. Rationale:
helplessness, and Increases reinforcement and counters inertia.
negative self-talk.

20
5. Relaxation training: diaphragmatic breathing
and progressive muscle relaxation 10 min bid.
Rationale: Lowers sympathetic arousal and
improves control.
6. Journaling of triggers, thoughts, feelings,
actions, outcomes. Rationale: Builds insight and
tracks efficacy.
7. Teach communication skills (DESC script; I-
statements) and boundary setting. Rationale:
Improves interpersonal problem resolution.
8. Facilitate group therapy participation.
Rationale: Models adaptive coping and provides
social reinforcement.
9. Link to community resources (support groups,
hotlines). Rationale: Extends coping supports
post-discharg.

21
• Chronic Low Self- 1. Use unconditional positive regard and
Esteem related to accurate, specific praise for efforts, not traits.
negative self- Rationale: Builds credible self-efficacy and
perception, history combats global negative self-views.
of failure, and
2. Strengths discovery: guided life review and
internalized
competency mapping. Rationale: Makes abilities
criticism, as
salient and retrievable
evidenced by self-
3. Cognitive restructuring of “I’m worthless”
deprecating
with evidence testing. Rationale: Challenges core
statements, social
schemas maintaining low self-esteem.
withdrawal, and
4. Graded task assignment with early achievable
expressions of
goals. Rationale: Success experiences
worthlessness.
accumulate mastery.

22
5. Social skills rehearsal / role-play (greeting,
eye contact, closing). Rationale: Improves
social feedback loops that sustain esteem.

6. Encourage self-care rituals (hygiene, dress)

and activity scheduling. Rationale: Embodied
behaviors influence mood and identity.

6. Family education to reduce criticism and

increase supportive communication.
Rationale: Modifies maintaining interpersonal
environment.

23
• Hopelessness 1. Elicit and validate feelings; avoid false
related to chronic reassurance; use hope-instilling language
illness, situational grounded in facts. Rationale: Authenticity
crisis, or preserves trust and opens space for hope.
perception of lack
of control, as 2. Goal-setting with SMART micro-goals; track
evidenced by completion visually. Rationale: Visible
verbal expressions progress counters global hopelessness.
of hopelessness,
lack of goal- 3. Teach behavioral activation and energy
directed behavior, pacing. Rationale: Action precedes
and suicidal motivation; success fuels hope.
ideation.
4. Use problem-solvable focus and decision
aids for one daily choice. Rationale: Restores
agency via small wins.

24
5. Share recovery narratives and peer support
where appropriate. Rationale: Vicarious
experience increases outcome expectancy.

[Link] consistent team messages and

predictable routines. Rationale: Predictability
reduces helplessness.

7. Monitor for suicidality concurrently; escalate

safety measures if risk rises. Rationale:
Hopelessness is a strong predictor of suicide.

25
• Powerlessness 1. Offer structured, limited choices—not open-
related to ended. Rationale: Reduces overwhelm while
dependence on building agency.
others, perceived 2. Acknowledge past experiences of lack of
lack of resources, control; normalize incremental change.
or chronic mental Rationale: Validation precedes engagement.
illness, as 3. Teach assertiveness skills and rights
evidenced by education; role-play requests/refusals.
passive decision- Rationale: Skills convert intention to
making, “nothing behavior.
will help” 4. Assign manageable tasks with visible
statements, and outcomes (making bed, calling family).
deferring all Rationale: Task completion increases
choices to staff. perceived control.

26
5. Use decision worksheets (pros/cons, values
alignment). Rationale: Externalizes thinking
and supports autonomy.

6. Model and reinforce independent actions;

fade prompts gradually. Rationale: Promotes
internal control locus.

7. Involve patient in care planning and schedule

setting. Rationale: Shared decision-making
improves ownership

27
• Impaired Social 1. Begin with brief, predictable 1:1 contacts;
Interaction related increase gradually. Rationale: Graded exposure
to social reduces social anxiety/withdrawal.
withdrawal,
mistrust, and poor 2. Model calm, respectful communication; avoid
self-concept, rapid questioning. Rationale: Lowers arousal and
secondary to builds trust.
depression and
suicidal ideation, 3. Teach and rehearse micro-skills (greeting
as evidenced by scripts, active listening, closing). Rationale:
minimal Concrete skills make interaction manageable.
verbalization,
avoidance of [Link] role-play and feedback; video or mirror if
others, and lack of acceptable. Rationale: Immediate feedback
eye contact accelerates skill acquisition.

28
5. Structure seating/space to support
engagement (45-degree angle, arm’s length).
Rationale: Environment shapes interaction
quality.

6. Reinforce any social approach behaviors

promptly and specifically. Rationale: Positive
reinforcement increases frequency.

7. Facilitate graded group participation (start

with observer role). Rationale: Stepwise
exposure prevents overwhelm.

8. Coordinate with OT/recreation therapy for

cooperative tasks. Rationale: Shared goals ease
conversation demands.

29
Stratiges to reduce suicide:
[Link] Economic Supports
- Improve household financial security
- Stabilize housing
[Link] Protective Environments
- Reduce access to lethal means among persons at risk of suicide
-Create healthy organizational policies and culture
- Reduce substance use through community-based policies and practices
[Link] Access and Delivery of Suicide Care
-Cover mental health conditions in health insurance policies
- Increase provider availability in underserved areas
-Provide rapid and remote access to help
-Create safer suicide care through systems change
[Link] Healthy Connections
-Promote healthy peer norms
-Engage community members in shared activities

30
[Link] Coping and Problem-Solving Skills
-Support social-emotional learning programs
-Teach parenting skills to improve family relationships
-Support resilience through education programs
6. Identify and Support People at Risk
-Train gatekeepers
- Respond to crises
-Plan for safety and follow-up after an attempt
-Provide therapeutic approaches
[Link] Harms and Prevent Future Risk
-Intervene after a suicide (postvention)
- Report and message about suicide safely

31
32
Health Education for patient and family :
How to Help Someone with Suicidal Thoughts
A. Ask directly and calmly
Use simple, caring words like: “Are you thinking about ending your life?”
Asking directly does not increase the risk — it opens the door to talk.
B. Listen without judgment
Show empathy with body language: sit nearby, make eye contact, nod.
Avoid dismissive phrases like “It’s not a big deal” or “You’ll get over it.”
C. Ask about a plan and means
“Do you have a specific way in mind?”
“Have you thought about when or where?”
If they have access to dangerous means (like pills, weapons, high places)
remove or secure them immediately.
D. Immediate safety steps
1. Do not leave the person alone if they are at immediate risk.
2. Remove medications, sharp objects, or anything that could be used for
self-harm.
3. If the risk is serious or urgent, call emergency services away .
33
Important Messages for Patients
1. Normalize feelings:
“It’s okay to feel this way — it’s a health issue, not weakness. And it can
be treated.”
2. Show care and stay present:
“You’re not alone. I’m here with you, and we’ll find the right support
together.”
3. Ensure safety:
“If you feel unsafe, please call emergency services or go to the hospital.”
“If not urgent, let’s make a safety plan — reasons to live, people to call,
quick coping steps.”
4. Encourage professional help:
“Therapy or medication can really help — it’s like treating any other
illness.”
5. Offer simple coping ideas:
“Try slow breathing, a short walk, calling a friend, or doing one small
thing you enjoy.”
34
6. Care for yourself :
“Supporting someone in crisis can be heavy — reach out for help if you
need it.”

35
How family involvement helps patients
1 . Protecting patients from self-harm :
By restricting access to means (e.g., medications, sharp objects) and
creating a safer environment
2. Providing distraction and emotional support :
Engaging patients in positive activities and offering presence to reduce
suicidal thoughts.
3. Supplying crucial information to clinicians :
Families can describe the patient’s baseline functioning and recent
changes.
4. Bridging communication gaps :
When patients are unable or unwilling to share, families can convey
important details.
5. Offering daily practical support :
Reminding about medication, attending appointments, or assisting with
routines

36
6. Encouraging engagement in treatment :
Motivating patients to follow safety plans and adhere to therapeutic
recommendations.

37
 Nursing care for Aggression

prepared by group (3):

Yousef Ahmed Abdel Salam - Yasmine Safy
Yousef Gomaa Mhamoud - Ibrahim Ayman
Yousef Gamal Hassan. - Mariem Ahmed
Hagar Ahmed Mohamed - Mariem Mamdouh
Hagar Khaled Abdallah. - Norhan Ramadan
Hagar Sayed Abo Elhaggag - Norhan Ashraf
Hagar Mokhtar Ibrahim - Norhan Ibrahim
- Hala Mostafa Ismail - Nora Hatem
-Hala Ahmed Idris - Nada Anber
-Heba Emam Amin

Under Supervision:
Dr. Amgad Said
Dr. Salma Bakry

First term (2025-2026)

1
Outline
• Introduction.
• Concept of aggression and violence and anger
• Etiology and predisposing factors for aggression
• Characteristics of aggression and violence
• Types of aggression
• Phases of aggression
• Medical management
• Nursing management
• Health teaching
• References

2
 • Introduction:
Aggression is a phenomenon that can take many forms, ranging from
relatively minor acts (such as name calling or pushing) to more serious
acts (such as hitting. kicking, or punching) to severe acts (such as
stabbing, shooting, or killing).

Aggressive and violent behaviors are best conceptualized as being on a

continuum of severity with relatively minor acts of aggression (e.g.
Pushing) at the low end of the spectrum and violence (cg., homicide)at the
high end of the spectrum.

• Concept of anger, aggression and violence:

*Anger:*
Anger is a normal human emotion, which is a strong, uncomfortable,
emotional response to a real or perceived provocation.
Anger is an emotional state that varies in intensity from mild
irritation to intense fury and rage.
*Aggression :*
Is most commonly defined as a behavior that is intended to
harm another person who is motivated to avoid that harm ، This harm
can take many forms such as physical injury, hurt feelings, or
damaged social relationships
*Violence:*
Violence is an extreme form of aggression that has severe physical harm
(e.g., serious injury or death) as its goal .Like aggression, a behavior does
not have to cause actual harm to be classified as violent.

3
 • Etiology and predisposing factors for
aggression:
• Biological Factors:
o Neurotransmitter like serotonin plays a major inhibitory role in aggressive
behavior, hence low serotonin levels may lead to increased aggressive
behavior.
o GABA (Gamma-aminobutyric acid) is the brain’s main inhibitory
neurotransmitter, and its primary role in aggression is to suppress or dampen
aggressive impulses and maintain behavioral control.
o Reduced GABA function or low levels of GABA in specific areas (like the
Anterior Cingulate Cortex) are associated with increased impulsive aggression
and anger, as the brain loses its “braking” mechanism.
o Increased levels of dopamine, norepinephrine in the brain is associated with
violent behavior.
o Structural change in the limbic system and the frontal, temporal lobes of brain
may alter the person’s ability and cause aggressive behavior.
o Glucocorticoids moreover play an important role in regulating aggressive
behavior.
o Medical conditions
o For example, chronic pain, neurobiological disorders, infectious diseases,
endocrine disorders, metabolic disorders, rheumatologic disorders, vitamin
deficiencies, exogenous toxins, Brain lesions
o Genetic factors
o Gender differences
o women traditionally were not permitted to express anger openly and directly
because doing so would not be “feminine” and would challenge male
authority.

4
• Psychological Factors
• Psychiatric Disorders
❖ Anti social personality disorder in adults
❖ Paranoid schizophrenia
❖ Bipolar disorder
❖ Delusional disorder
❖ Dementia
❖ Dissociative personality disorder
❖ Dissociative identity disorder
❖ Impulse control disorder
❖ Oppositional defiant disorder
❖ Paranoid personality disorder
❖ Post-traumatic stress disorder
❖ Attention deficit hyperactivity disorder (ADHD)
❖ Conduct disorder in children
• Sociocultural Factors
o Exposure to aggressive models may occur in families, in sub
culture, e.g. gangs; video games; movies and TV violence
o Lower socioeconomic status are at high risk of failing to develop socially
appropriate behavior
o Other factors such as:
* Culture bound syndromes
* Low educational attainment, inferiority feelings
* Decreased residential stability
* Poor nutrition
* Drug abuse, alcoholism
* Deinstitutionalization
* Broken family
* Children in dysfunctional families with poor parenting
* Operant conditioning

5
• Environmental factors:
1. Temperature :
• Hot temperatures are linked to higher aggression, while extremely high heat
tends to reduce aggressive behavior.
• 2. Substance use:
• Drugs like cocaine, amphetamines, hallucinogens, and anabolic steroids are
associated with increased violent behavior and more frequent aggressive
outbursts.
• 3. Crowding:
• Physical crowding may increase violence due to more frequent contact
between people and reduced personal space.

• Characteristics of Aggressive behavior:

• 1_Behavioural symptoms:
• _Yelling _ Swearing
• _Throwing things _ Biting
• _Screaming _ Threatening
• _Loud voice

6
 2_Physical symptoms:
• _Rapid breathing _Muscle tension
• _Flushed face _Clenched fists
• _Threatening gestures

3_Emotional and Mental symptoms:

_ Anxiety
_ Restlessness
_ Irritability
_ loss ability to solve problems
_Agitated
_Inability to communicate clearly.
_hostility

7
 • Types of aggression:
1_PhysicalAggression:
• The most common form of aggressive behavior reported is physical
aggression, which includes behaviors enacted to harm others physically .
• Physical aggression is defined as anyone, or combination, of the following
acts.
• Examples include:
• Hit: Striking another person with a fist, open
hand, or object.
• Kick: Kicking another person with the foot.
• Poke: Poking or prodding another person with a finger or sharp object (e.g.,
pen, paintbrush).
• Pull: Pulling another person, their clothing, or hair using one or both hands.
• Push: Using one or both hands (or the body) to push another person backward,
forward, or to the side
2_ Verbal aggression:
• Verbal aggression is distinguished from physical aggression; it includes
actions to hurt another with spoken words (e.g., screaming and name-calling).
• Verbal aggression is often conceptualized under “psychological” aggression
intended to hurt others’ feelings and cause psychological pain.

8
3 _ Relational aggression ( Social aggression) :
Relational aggression is distinctive from overt
aggression (e.g., open confrontational acts like
physically harming others) as the goal of this
aggressive action is to manipulate and damage others’
relationships
An example of relational aggression in the romantic
context involves flirting to induce a partner’s jealousy, giving them the silent
treatment when angry, or using threats to gain

4 _Proactive aggression:
Proactive aggression involves a purposeful, planned attack with an external or
internal reward as a goal.

**It is characterized by attention to a consistent target and often by a lack of

emotional arousal.
**Examples include bullying, stalking, ambushes, and premeditated homicides,
whether by a single killer or a group.

5 _Reactive aggression:
Reactive aggression is a response to a threat or
frustrating event, with the goal being only to
remove the provoking stimulus.
***Characteristics:
1_ Always associated with anger.
2_Accompanied by a sudden increase in sympathetic activation.
3_Involves a failure of cortical regulation.
4_Shows easy switching among targets.
**Examples :
bar fights arising from mutual insults and crimes of passion immediately after the
discovery of infidelity.
9
Phases Of Aggression:
[Link]
Definition: An event or circumstances in the
environment initiates the client's response, which is
often anger or hostility.

Signs, symptoms: Restlessness, anxiety, irritability, pacing, muscle tension, rapid

breathing perspiration, loud voice, anger.

*Nursing role:
-The nurse should approach the client in a non-threatening, calm manner to de-
escalate emotion and behavior.

-Convey empathy toward the client’s anger or frustration.

-Encourage the client to express angry feelings verbally to maintain control.

-Use clear, simple, short statements.

-Suggest that the client goes to a quiet area or decreases stimulation.

-Offer PRN medication if ordered.

-Encourage the use of relaxation techniques and physical activity such as walking.

-Help the client analyze the situation or solve any conflict that may exist.

2. Escalation
Definition: client's responses represent escalating behaviors that indicate
movement toward a loss of control.

Signs and symptoms: pale or flushed face, yelling, swearing, agitated,

threatening, demanding, clenched fists, threatening gestures, hostility, loss of ability
to solve the problem or think clearly.

10
*Nursing role:
-If the client’s behavior continues to build toward loss of control, the nurse must
take control of the situation.

-Provide directions to the client in a calm, firm voice.

-Direct the client to take a time-out in a quiet area or his/her room.

-Tell the client that aggressive behavior is not acceptable and that the nurse is there
to help regain control.

-If the client refuses medication, offer it again calmly.

-If this behavior continues, obtain assistance from other staff members.

-Staff members should remain within sight but not too close to the client.
-A “show of force” (presence of several staff members) indicates that the staff will
control the situation if the client cannot.

3. Crisis
Definition: During a period of emotional and
physical crisis, the client loses control.

Signs and symptoms: loss of emotional and

physical control, throwing objects, kicking, hitting,
spitting, biting, scratching, shrieking, screaming, inability to communicate clearly.
*Nursing role:
-If the client becomes physically aggressive or violent, staff must take immediate
control to ensure safety.

-Four to six trained staff members are required to restrain the client safely.

-The client should be informed that the staff is taking control to prevent injury and
maintain safety.

-Each staff member takes control of one limb, and restraints are applied as ordered
and fastened to the bed frame.

11
-If PRN medication (Pro-Re-Nata) has not been taken earlier, the nurse may
obtain an order for intramuscular (IM) medication in this emergency.

4. Recovery
Definition: client regains physical and emotional control.
Signs and symptoms: lowering of voice, decrease muscle tension, clearer, more
rational communication, and physical relaxation.

*Nursing role:
-Once the client regains control, the nurse assesses any injuries and ensures proper
documentation (incident report, debriefing).

-Staff should review the event to discuss what

worked or needed improvement.

-Encourage other clients to express their feelings

but do not discuss the aggressive client’s behavior
with them

5. Post crisis
Definition: client attempts reconciliation with
others and returns to the level of functioning
before the aggressive incident and its antecedents.
Signs and symptoms: Remorse; apologies,
crying, quiet, withdrawn behavior
*Nursing role:
-The client Is removed from restraint or seclusion
as soon as behavioral criteria are met.

-The nurse should not lecture or chastise the client.

-Discuss the behavior in a calm, rational manner.

-Provide feedback and help the client plan to express feelings Non aggressively in
the future.

-Reintegrate the client into the milieu and activities as soon as possible
12
 • The Medical Management of Aggression
Involves a multi-faceted approach, including both non-pharmacological
interventions and, when necessary, pharmacological treatments. The goal is to de-
escalate the situation, ensure safety for all individuals, and address the underlying
causes of the behavior.

1. Non-Pharmacological Management

Non-pharmacological strategies are the first line of defense and are crucial for de-
escalation. These techniques focus on communication, creating a safe environment,
and addressing the root causes of the behavior.

°Restraining

Its the condition that used for help psychiatric patient enable to control their
emotions and behaviors

Goal

-Engage the patient in calming down and dealing with anger

-change the behaviors of patient and improve quality of life and supporting them

-reduce immediately their suffering and minimize risk of injury (chemical

Restraining)

13
Types of Restraining

1-Physical

Referring to trained staff using recognized techniques of physical

contact to hold patient and restrict their movement

The use of devices or means to partially or completely restrict a patient's

physical movement, such as belts, slings, gloves, or limb restraints.

Example: Tie a patient's arms to a bed to prevent self-harm.

Use only with a doctor's permission, for a limited time, and under
constant supervision.

2-Chemical Restraint

The use of medications such as sedatives or antipsychotics in emergency

doses to reduce aggressive or violent behavior.

Example: Injecting a patient with a dose of Haloperidol or Lorazepam

to calm them down.

Should only be used when there is a medical emergency.

3-Mechanical Restraint

The use of devices or tools that restrict body movement, such as leather
belts or restraint chairs, and are usually secured to a bed or chair.

Example: Secure a patient to a bed using a special belt to prevent falls

or injury.

14
4-Geographical restraint
Geographical restraint essentially involves moving the patient to an environment
where they can more safely be managed. This might be a more secure setting such
as a psychiatric intensive care unit or even a forensic unit, a less stimulating part of
the ward or a seclusion room.

*Technique
-Having an enough staff

-staff member should be educated and equipped with skill to protect themselves and
patient

-should be available security and police called to help

-patient positioning in prone position and head elevaled

-ensure the airway of patient and breathing are not compromised

-restain patient for shortest period possible

-physical Restraining should be used with consideration for the self respect ,
dignity,privacy ,cultural and

Special need of patient

-offer the patient medication as order(chemical Restraining)

-staff should obtain the patient to receive any medication

-the patient should be able to respond to the spoken(chemical Restraining)

-carefully monitoring the patient response

Duration of physical restraints:
For adult: (18 years more) for 2 hours

For children: (10-17 years) for 1 hour

For less than 9 years for 30minute

15
Seclusion:
It is the involuntary confining of a person in a room alone from which the patient
physically prevented from leaving.

The use of seclusion is based on 3 therapeutic principles:

A. Seclusion must never be useful for staff convenience or to punish.

B. Seclusion must be used for the minimal amount of time necessary and only to
ensure the physical safety of the patient

C. Organizational culture.

Types of seclusion:
1. Therapeutic Seclusion

Purpose: Used as part of a treatment plan to help the patient regain self-control and
reduce sensory stimulation.

Characteristics:

Conducted in a calm, safe, and monitored environment.

Used temporarily until the patient becomes calm.

Always based on a therapeutic goal, not as punishment.

Example: A patient with severe mania is placed in a quiet seclusion room to

minimize stimulation.

16
2. Emergency (Safety) Seclusion
Purpose: Implemented to prevent immediate harm to the patient or others during a
crisis.

Characteristics:

Used when other de-escalation methods (verbal or medication) fail.

Usually short-term and under continuous observation.

Example: A patient becomes physically violent toward staff and needs to be

secluded until safe.

3. Short-Term Seclusion
Purpose: To manage acute, temporary behavioral outbursts.

Duration: Typically minutes to a few hours, depending on hospital policy.

Goal: Allow the patient to calm down and regain control.

4. Long-Term (Extended) Seclusion

Purpose: Rarely used; applied when a patient remains a continuing danger despite
other interventions.

Characteristics:
- Requires frequent review by physicians and mental health staff.
- Strictly regulated by law and ethics.

Example: In cases of severe psychosis with repeated violent episodes.

5. Non-Therapeutic or Punitive Seclusion (Not Recommended)

Purpose: Used as punishment or for staff convenience — this is unethical and

[Link] patient rights and professional standards.

17
 Main Indications:
1. To Prevent Harm to Self
When a patient is attempting or threatening self-injury or suicide.

Example: A depressed patient trying to harm themselves despite

supervision.

2. To Prevent Harm to Others

When a patient becomes physically aggressive or violent toward staff, other
patients, or visitors.

Example: A psychotic patient attacking another person due to delusions.

3. To Control Severe Agitation or Violence

When the patient is extremely agitated, aggressive, or destructive, and
cannot be calmed by verbal or pharmacological means.

Example: A manic patient shouting, throwing objects, or refusing to stop

aggressive actions

4. To Prevent Damage to Property or Hospital Equipment

When a patient’s actions cause or may cause serious property damage that
endangers safety.
Example: Breaking windows or furniture during an outburst.

5. To Reduce Overstimulation in Certain Psychiatric

Conditions
In cases of acute psychosis or mania, where excessive environmental
stimulation worsens symptoms.
Seclusion provides a quiet, low-stimulation environment for recovery.

18
 6. To Maintain Treatment Safety
When necessary to ensure safe administration of emergency medication or
medical procedures.
Example: Secluding a patient to safely administer sedatives after
aggressive refusal.

2. Pharmacological Management

• Benzodiazepines

They facilitate the binding of GABA, an inhibitory neurotransmitter,

throughout the central nervous system, essentially ‘slowing down’ activity in
the brain.

• Antipsychotic Medications

First- and second-generation neuroleptic medications, also called

antipsychotic medications, belong to classes of medications that block
dopamine receptors in the brain (first-generation) or combinations of
dopamine and serotonin (second-generation).

• Anticholinergic and Antihistaminergic Medications

Anticholinergic and antihistaminergic medications such as benztropine and

diphenhydramine are frequently used in the context of the management of
aggression through sedation and reduction of involuntary muscle movement
due to acetylcholine blockade.

19
 • Additional Medications

> Droperidol is a dopamine antagonist related to haloperidol that is used to

prevent and treat postoperative nausea and vomiting. It has been used
primarily in the ED as a sedative or tranquilizer via the IM or IV route in
patients with acute agitation, as it has a more rapid onset and shorter duration
of action than haloperidol.

Nursing Care Plan for Aggression

Nursing Expected Out Nursing Rational Evaluation

Diagnosis Come Intervention

-Maintain a safe -Reduces risk of

environment harm to
**Risk for patient will (remove self/others. Patient did
violence demonstrate harmful objects, not harm
related to self-control ensure adequate self/others;
impaired and absence of staff). controlled
impulse aggressive aggression
control and behavior - Approach -Calm approach and followed
anger within hospital patient in calm, decreases safety rules.
stay non-threatening escalation.
manner.
- Set clear,
consistent limits - Consistency
on aggressive builds trust and
behavior. control.

-Administer - Medications
prescribed reduce agitation
medications(anti and aggression.
psychotics,
benzodiazepines
) as needed.

20
**Ineffective Patient will - Encourage -Verbal Patient
coping related verbalize patient to expression expressed
to inability to feelings of express feelings prevents anger
express anger anger in a verbally. physical verbally and
appropriately constructive aggression. used coping
manner within strategies
3 days. - Teach - Relaxation appropriately
relaxation reduces
techniques physiological
(deep breathing, arousal.
time-out,
physical
activity).

-Role-model - Modeling
appropriate provides
communication positive
and problem- learning.
solving.
**Impaired Patient will - Provide - Reinforcement Patient
social demonstrate positive strengthens participated
interaction improved reinforcement desired in group
related to social skills for non behavior. activities
aggressive and interact aggressive without
behavior with others interactions aggression;
without family
aggression. . - Encourage - Group therapy reported
participation in promotes improved
group therapy sharing and interaction.
sessions. reduces
isolation

- Educate - Family
family about support
supportive improves
communication. outcomes and
reduces relapse.

21
**Anxiety Patient will -Identify -Identifying Patient
related to report triggersfor triggers helps identified
environmental reduced anxiety and prevention. triggers,
stressors and anxiety and aggression. requested
unmet needs demonstrate time-out
relaxation when
within 48 anxious,
hours. - Provide quiet - Quiet setting and used
environment reduces relaxation
with minimal overstimulation techniques
stimuli. effectively
-Stress
-Encourage use Management
of stress promotes self-
management control
techniques

22
Health teaching:
For the patient
1 _Teach the patient to recognize early signs of anger and express feelings
verbally.
2_Encourage the client to take responsibility for personal anger and
behavior.
3_Promote the use of coping skills such as deep breathing, relaxation
techniques, and taking time-out.
4_Teach safe expression of anger through assertive communication (e.g.,
“I feel upset when…”).
5_Emphasize the importance of avoiding yelling, name-calling, or
physical
inappropriate behavior.
6_Encourage the client to keep a diary to record triggers, angry feelings,
and coping responses.
6_Provide safe outlets for anger release, such as physical exercise or
punching a pillow.
7_Help the patient to identify true sources of anger rather than displacing
it on others.
8_Educate the patient to avoid risky behaviors during anger (e.g.,
substance use, violent reactions).
9_Teach relaxation strategies including deep breathing, meditation, and
physical activity.

23
10_Encourage the patient to seek staff or supportive persons when feeling
overwhelmed.
11_Role-model calm and constructive behavior when handling anger.
12_Teach the patient to recognize early warning signs of aggression (e.g..
clenched fists, pacing, raised voice).
13_Instruct the client on steps to follow in a crisis (call staff, move to a
safe area, take PRN medication if prescribed).

For the Family and caregiver

1_ Educate family members that aggression may have underlying Causes
(e.g: mental illness, stress, trauma.)
2_ Encourage the use of calm, non-threatening language during outbursts.
3_Create a safe, low-stress home environment.
4_Remove potential hazards during high-risk periods.
5_Demonstrate calm and respectful behavior.
6_Educate family members to avoid touching or threatening the client
during anger outbursts.
7_Involve family and community in creating a supportive environment.
8_Discourage negative role modeling such as shouting or using violence.
9_Encourage consistent consequences for inappropriate behavior.

24
25
Dr: Tabasem Fayez
Demo: Samira Said
First term
2025-2026

1
Objectives:
At the end of this lecture, every student should be able to:
 Differentiate between fear and anxiety.
 Identify levels of anxiety.
 Define anxiety disorders
 Discuss etiology of anxiety disorders.
 Discuss prevalence of anxiety disorders.
 Enumerate types of anxiety disorders.
 Illustrate management of anxiety disorders.
 Discuss nursing care plan for anxiety disorders.

3
Outlines:
 Introduction of Anxiety Disorders
 Difference between Fear and Anxiety. Levels of Anxiety.
 Definition Anxiety Disorders
 Prevalence of Anxiety Disorders.
 Etiology of Anxiety Disorders
 Types of Anxiety Disorders.
 Signs and symptoms of anxiety disorder
 Management of Anxiety Disorders.
 Nursing Care Plan for Anxiety Disorders.
 References

4
Anxiety is a core and normal aspect of human life, serving
a functional role that ranges from beneficial to detrimental.
It responds to stress, regardless of whether the stressor is
positive or [Link] experienced at a low level,
anxiety can be a powerful motivator. It provides a
necessary boost to energy and alertness to individual .
The harmful side when anxiety is excessive, it results in
significant distress and actively impairs daily functioning.
This severe form hinders performance across critical life
domains, including social interactions, educational
pursuits, and occupational effectiveness

Fear: is an automatic neurophysiological state of alarm

characterized by a fight or flight response to a cognitive
appraisal of present or imminent danger (real or perceived).
Anxiety: is linked to fear and manifests as a future-oriented
mood state that consists of a complex cognitive, affective,
physiological, and behavioral response system associated with
preparation for the anticipated events or circumstances
perceived as threatening.

5
6
Level of anxiety Description Symptoms
Mild Mild anxiety is part include restlessness,
of everyday living irritability, or mild
and can help an tension-relieving
individual use their behaviors such as
senses to perceive finger tapping,
reality in sharp fidgeting, or nail
focus. biting.
Moderate Perceptual field Physical symptoms
begins to narrow; more noticeable
reduced ability to (e.g. faster heart
observe all rate, perspiration).
surroundings.
Thinking, learning,
problem solving
become somewhat
impaired under
stress.
Severe The perceptual field hyperventilation, a
of a person pounding heart,
experiencing severe insomnia, and a
anxiety is greatly sense of impending
reduced. They may doom.
either focus on one
particular detail or
on many scattered
details. They often
have difficulty
noticing what is
7
 going on in their
environment, even
if it is pointed out;
they may appear
dazed or confused
with automatic
behavior. Learning,
problem-solving,
and critical thinking
are not possible at
this level.
Panic the most extreme pacing, running,
level of anxiety that shouting,
results in screaming, or
significantly withdrawal, and
dysregulated hallucinations may
behavior. The occur. Acute panic
individual is unable can lead to
to process exhaustion.
information from
the environment and
may lose touch with
reality.

8
Group of conditions that share a key feature of excessive
anxiety with ensuing behavioral, emotional, cognitive, and
physiologic responses. The suffering from anxiety
disorders can demonstrate unusual behaviors, the
experience of a significant distress over time, and the
disorder significantly impairs the daily routines, social
lives.

According to WHO:
An estimated 4.4% of the global population currently
experience an anxiety disorder . In 2021, 359 million
people in the world had an anxiety disorder, making
anxiety disorders the most common of all mental disorders
More women are affected by anxiety disorders than men.
Symptoms of anxiety often have onset during childhood or
adolescence

- Till now the etiology is unknown .

1-Psychodynamic Theory :
Anxiety results from unconscious conflicts, repressed
impulses, and early childhood experiences. It reflects inner
struggles between the Id, Ego, and Superego, as
9
described by Freud, emphasizing the influence of early
emotional experiences and unresolved issues
2-Cognitive Theory :
Anxiety develops from distorted or negative thought
patterns. People with anxiety tend to interpret situations as
more dangerous than they are, leading to overreaction
and persistent worry. These maladaptive thoughts,
combined with biological vulnerability, contribute to anxiety
symptoms.
3-Behavioral (Learning) Theory:
Anxiety especially phobias can develop through classical
conditioning, where a neutral event becomes linked to fear
after being paired with something threatening. Learned
associations and avoidance behaviors help maintain
anxiety over time

1-Brain chemistry: Imbalances in neurotransmitters (like

Serotonin and Dopamine, GABA, Norepinephrine ) that
regulate mood.
2-Genetic Factors: A family history of anxiety disorders
can increase susceptibility.

10
3-Cognition or thinking: the prediction that the result of a
specific situation will be embarrassing or harmful.
4-Life events: Trauma, abuse, or major life changes
(divorce, death of a loved one, job Loss).
5-Occupation: Certain professions, particularly those
involving high exposure to trauma (e.g., military personnel,
first responders)

1) Panic disorder
2) Obsessive-Compulsive Disorder (OCD)
3) Generalized anxiety disorder(GAD)
4) Post-traumatic stress disorder (PTSD)
5) Phobia.

11
Panic disorder:
It is an type of anxiety disorder It causes repeated panic attacks,
which are sudden periods of intense fear, discomfort, or a sense
of losing control. These attacks happen even though there is no
real danger. They often cause physical symptoms.
Panic disorder is not life-threatening, but it can be upsetting and
affect your quality of life. And if it is not treated, it can
sometimes lead to other health conditions, including depression
and substance use disorders.

Prevalence of Panic Disorder Among Adults:

Prevalence estimates were 1.7% for panic disorder with a
median age of onset of 32
What are the Signs and Symptoms of Panic Disorder?
Psychological Signs :
 Sudden and Repeated Panic Attacks: Overwhelming
anxiety and fear.
 Feeling of Being Out of Control: Difficulty managing
one’s emotions or actions.

12
  Fear of Death or Impending Doom: Strong belief
something terrible is about to happen.
 Intense Worry About Next Attack: Persistent worry about
when or where the next attack will happen.
 Avoidance Behavior: Avoiding places where panic attacks
occurred before.
Physical Signs:
 Pounding or Racing Heart: Rapid heartbeat or
palpitations.
 Difficulty Breathing: Shortness of breath or feeling of
choking.
 Sweating or Chills: Excessive perspiration, often cold or
clammy.
 Trembling or Shaking: Involuntary shaking of hands or
body.
 Chest Pain: Discomfort or tightness in the chest area.
 Weakness or Dizziness: Feeling faint or unsteady.
 Stomach Pain or Nausea: Upset stomach or a feeling of
nausea.
 Tingly or Numb Hands: Sensations in the hands, feet, or
face.
Duration of a Panic Attack:
A panic attack can last from a few minutes to an hour or
sometimes longer.

13
Obsessive-Compulsive Disorder (OCD) is a mental health
condition characterized by:

Obsessions: recurrent, intrusive, and unwanted thoughts,

images, or urges that cause distress or anxiety.
Compulsions: repetitive behaviors or mental acts performed to
reduce the anxiety caused by obsessions or to prevent a feared
event.
Prevalence:
 OCD is a prevalent psychiatric disorder affecting 1% to 3% of
the global population
Types of OCD:
OCD is categorized into symptom themes rather than strict
“types”:
1) Contamination / Cleaning – fear of dirt, germs → excessive
washing/cleaning
2) Checking – repeated checking to prevent harm or mistakes
3) Symmetry / Ordering / Counting – arranging, ordering, or
counting rituals

14
4) Hoarding – difficulty discarding items (now a separate
disorder but overlaps with OCD)
5) Forbidden / Taboo Thoughts – intrusive sexual, religious, or
aggressive thoughts
6) Primarily Obsessional OCD (“Pure O”) – mostly intrusive
thoughts with mental rituals rather than visible behaviors

Signs and symptoms of OCD

People with OCD can have:

Signs and Symptoms of OCD:

1-Common obsessions(psychological ) include:
Fear of contamination by germs, dirt, or illness.
Doubts — e.g., “Did I lock the door or turn off the stove”?
Need for symmetry, order, or exactness.
Aggressive or violent thoughts toward self or others.

15
Unwanted taboo thoughts (sexual, religious, or
blasphemous). Intrusive images or urges that are
disturbing or immoral.

2-Common compulsions (physiological) include:

Excessive cleaning or [Link] checking
(doors, appliances, locks).Counting, tapping, or repeating
words silently.
Arranging things in a precise or symmetrical way.
Seeking reassurance repeatedly from others.
Performing rituals to neutralize intrusive thoughts (e.g.,
silent prayers).

* a cycle of repetitive thoughts (obsessions) and actions or

rituals (compulsions) that disrupts their daily life and affects
their mental well-being
* obsessive thoughts or feelings that are very hard to stop and
are often of an upsetting nature (e.g. with aggressive, obscene or
sexual content)
* compulsions, which are actions repeated over and over again
such as counting, checking, touching or washing to try to reduce
anxiety or stress around the obsessive thought or feeling.

16
Generalized Anxiety Disorder (GAD) is a mental health
condition characterized by:
 Excessive, persistent, and uncontrollable worry about
everyday life events (work, health, family, the future)
 Anxiety that is disproportionate to the actual situation and
difficult to control
 Symptoms must be present for at least six months
 Causes significant distress or impairment in daily functioning
Prevalence:
-Worldwide, about 3.7% of people will experience GAD in their
lifetime.
 Among the most common anxiety disorders
 More frequent in women than men

Signs and Symptoms:

Psychological Symptoms
 Excessive and uncontrollable worry about multiple aspects of
life
 Difficulty concentrating or mind going blank
 Restlessness and feeling “on edge”

17
 Irritability
 Persistent overthinking and expecting the worst
Physiological Symptoms
 Fatigue and easy tiring
 Sleep disturbances (insomnia, restless sleep)
 Muscle tension and body aches
 Palpitations or rapid heartbeat
 Trembling or shaking
 Sweating and increased sensitivity to stress
 Gastrointestinal problems (nausea, diarrhea)

PTSD is a mental disorder that can develop after exposure to

one or more traumatic (extremely stressful)
Events involving actual or threatened death, serious injury.

Prevalence:
According WHO Globally, about 3,9% of people
experience PTSD during their lifetime.

18
Signs and symptoms:
Physiological symptoms
1. Hyperarousal
- Increase heart rate - Elevated blood pressure
- Sweating - Rapid breathing
2. Sleep disturbances
 Insomnia, restless sleep, frequent awakenings
3. Autonomic reactions
 When exposed to trauma cues: sweating, trembling, nausea,
or shortness of breath.
4. Gastrointestinal problems
 Nausea, change in appetite
5. Physical pain
 Muscle tension, headache
Psychological Symptoms
1. Intrusive Memories
 Recurrent, unwanted memories of the traumatic event
 Distressing dreams related to the trauma
2. Difficulty concentrating, memory problems
3. Persistent and intense fear
4. Social Withdrawal
19
 Isolating from friends and family
 Difficulty forming or maintaining relationships.
5. Avoidance of thoughts, feelings, people, places, or activities
that remind the person of the trauma.
6. Emotional numbness: Loss of interest in previously enjoyed
activities.

Definition (What are phobias?) :

- Phobias are irrational and uncontrollable fears triggered by
a situation, object or activity.
- The fear is often overwhelming and intense, causing a
person to experience profound anxiety and panic and to
avoid the source of the fear.
- Phobias differ from normal fears because they are out of
proportion to the actual threat and can have significant
impacts on a person’s daily life.
prevalence :
Prevalence of specific phobia around the world ranges from 3%
to 15%, with fears and phobias concerning heights and animals
being the most common.

20
Types of phobias:
A-Specific phobia: circumscribed dread of a discrete object or
situation for ex, dread of spiders or snakes).
B-Social phobia: dread of public humiliation, as in fear of
public speaking, performing, or eating in public.
C-Acrophobia dread of high places.
D-Agoraphobia: dread of open places.
E- Claustrophobia: dread of closed places.
F- Algophobia : fear of pain.
G- Aerophobia : fear of flying.
Common signs and symptoms of phobias:
1- Tightness in the chest
2- Increased heart rate
3- Rapid or difficult breathing
4- Increased anxiety or worry
5- Confusion or dizziness
6- Nausea or digestive problems
7- Sweating, shaking or trembling
8-The need to escape the situation immediately

21
A. Pharmacological Treatment of Anxiety Disorders:
1. Antidepressants (First-line therapy)
Main type: SSRIs
Ex: Fluvoxamine.
2. Anxiolytics (Benzodiazepines)
Ex: Diazepam.

22
3. Beta-blockers
Example: Propranolol.
B. Nonpharmacological Management:
1. Psychological techniques (Cognitive Therapy)
A. Arousal management: The goal is to reduce physical
symptoms of anxiety through relaxation and exercise. This can
include muscle tensing exercises – an approach called ‘applied
relaxation and breathing exercises.
B. Graded exposure: The patient gradually faces the causes of
their anxiety symptoms, learning to think differently about these
situations through experience.
C. Safety response inhibition: The patient restricts anxiety-
reducing behavior’s (such as escape or need for reassurance),
thereby decreasing negative reinforcement, and breaking cycles
of anxiety.
D. Surrender of safety signals: The patient removes safety
signals (such as the presence of a companion or mobile phone,
or knowledge of the location of the nearest toilet), thereby
learning how to adapt and cope in these situations.
E. Cognitive strategies: The patient practices changing thinking
patterns (called cognitive restructuring) targeting their
exaggerated perception of danger.
2. Behavioral therapy

23
Flooding Is a form of rabid desensitization in which theire
is confrontation with the phobic objective until it no longer
produces anxiety.
A- Systematic Desensitisation :
Systematic desensitization is a structured form of exposure
therapy that combines relaxation training with gradual exposure
to anxiety-provoking situations.
This approach typically begins with the development of
relaxation skills, such as deep breathing or progressive muscle
relaxation. Once a person can reliably induce a relaxed state,
they are gradually introduced to the feared situation using a step-
by-step process.
B- Exposure Therapy :
Exposure therapy is a behavioral intervention that involves
confronting feared situations or stimuli in a gradual and
controlled manner.
Reduction in emotional and Physiological responses following
repeated exposure to a stimulus over time.
Exposure can be conducted in several formats:.
-Prolonged exposure therapy : This approach involves
gradually coming closer to trauma-related memories, feelings
and situations. It typically lasts about three months with weekly
individual sessions, resulting in eight to 15 sessions. Therapists
most often use this approach for people with PTSD
24
C. Imaginal exposure therapy: This therapy involves vividly
imagining the thing, situation or activity you fear. For example,
if you have PTSD, your therapist may ask you to describe
aspects of the trauma.
D. Relaxing technique by:
1. Progressive Muscle Relaxation: involves tensing and then
slowly releasing each muscle group. This process helps
reduce physical tension and stress.
2. Deep Breathing Techniques: Breathing techniques are
essential tools for managing anxiety. They help regulate
your nervous system .
3. Mindfulness Meditation: Mindfulness meditation
encourages present-moment awareness. Mindfulness
techniques for anxiety are a powerful way to help manage
anxious thoughts.
4. Yoga: Yoga combines physical movement, meditation and
breathing exercises to promote relaxation and reduce
anxiety.
5. Physical techniques: such as walking or running.
6. Listen to music.

25
[Link] of family in anxiety :
Family support offers various forms of assistance that are
essential for managing anxiety disorders:
-Emotional Support: Family members provide comfort,
understanding, and validation, which are critical in helping
individuals cope with their anxiety.
-Practical Help: Assistance can include helping with daily
activities, facilitating access to mental health services, and
helping individuals practice coping strategies learned during
therapy.
-Information and Resources: Families can educate
themselves about anxiety disorders, ensuring they understand
the struggles their loved one faces and the methods available for
treatment.

26
Nursing Nursing Nursing Rationa l Evaluation
Diagnosis Outcomes Intervention
1- Panic  Client 1. Stay with the client 1. Presence of a trusted  Client
anxiety remains safe during panic attacks; individual provides a verbalized at
related to during offer reassurance of sense of safety, least two
real or episodes of coping
perceived
safety and security decreases fear of losing
panic strategies
threat to and avoid leaving the control, and prevents (e.g., deep
biological  Client reports client alone potential self-harm breathing,
integrity reduced meditation,
or self- frequency 2. Maintain calm, non- 2. Anxiety can be exercise) to
concept as and intensity threatening, and contagious; a calm use during
evidenced of panic matter-of-fact approach helps reduce anxiety
by the attacks
presence
manner when the client’s escalating
 Clients
of interacting with the anxiety and instills
 Client successfully
physical demonstrates client feelings of stability identified
symptoms use of personal
(e.g., relaxation 3. Use simple, clear, 3. In panic state, the triggers (e.g.,
palpitatio techniques and brief statements client’s perceptual field crowded
ns, when anxiety when explaining narrows, making it places,
trembling, increases stressful
sweating,
hospital procedures difficult to process
events)
shortness or providing complex information
 Client
of identifies
directions
breath, di personal 4. A less stimulating
zziness triggers that 4. Keep immediate environment
contribute to environment low in minimizes sensory
anxiety stimuli (dim lights, overload that could
1
 reduce noise, avoid intensify anxiety  Client
crowding) 5. Medication provides demonstrated
rapid relief from acute correct
 Client performance
5. Administer symptoms, prevents
participates in of relaxation
therapeutic prescribed further physiological techniques
activities and antianxiety or distress, and promotes during
communicate tranquilizing ability to engage in teaching
s medications (e.g., therapy session
needs effectiv benzodiazepines) and
ely monitor response 6. Recognition of triggers  Client
is the first step toward reported
decreased
6. Encourage the client developing preventive frequency of
to identify and strategies panic attacks
verbalize possible over the
triggers or 7. Early recognition course of
precipitating events allows the client to hospitalizatio
once anxiety intervene before n
subsides reaching panic level
 Client
verbalized
7. Teach early warning 8. Relaxation produces feelings of
signs of anxiety (e.g., physiological changes safety when
palpitations, rapid opposite to the anxiety accompanied
breathing, response, reducing by nurse
nervousness) and tension and restoring during panic
appropriate coping calm episodes
techniques

2
8. Instruct and practice
relaxation techniques
such as deep
breathing, 9. Physical activity helps
 Client
progressive muscle release excess energy adhered to
relaxation, guided in a constructive prescribed
imagery, and manner and improves medication
meditation mood regimen
without major
9. Encourage use of 10. Knowledge reduces side effects
physical exercise misconceptions,
 At discharge,
(e.g., brisk walking, stigma, and enhances client stated
jogging, yoga) to compliance with therap confidence in
reduce tension y ability to
manage early
10. Provide signs of
psychoeducation anxiety and
about panic disorder, prevent
escalation to p
its biological basis, anic
and the importance
of
adherence to treatme
nt

3
Nursing Diagnosis Nursing Nursing Rational Evaluation
Outcomes Intervention
Short-term 1. Allow client 1. Providing • Patients
2- goal: to take as choices will expressed
Powerlessness related - Client will much increase reduced feelings
to prolonged anxiety participate in responsibility client's feelings of powerlessness.
and impaired cognition, decision as possible of control. • Patients
as evidenced by: Verbal making for self-care 2. Unrealistic participated in
expression of no regarding own practices. goals set the decision making.
control over life care. Examples client up for • Patient
situation and non- include: failure and demonstrated
participation in Long-term a. Allow client reinforce coping techniques.
decision making related goal: to establish feelings of
to own care or life - Clients will own schedule powerlessness.
situation. be able to for self-care 3. Client's
effectively activities. emotional
solve ways to b. Include condition
take control of client in interferes with
life situation, setting goals the ability to
thereby of care. solve
decreasing c. Provide problems.
feelings of client with 4. Assistance is
powerlessness privacy as required to
and anxiety. need is perceive the
determined. benefits and
d. Provide consequences
positive of available
4
feedback for alternatives
decisions accurately.
made. 5. This will
Respect assist the client
client’s right in dealing with
to make unresolved
those issues and
decisions learning to
independently accept what
and refrain cannot be
from changed.
attempting to
influence him
or her toward
those that
may seem
more logical.

2. Assist
client to set
realistic
goals.
3. Help
identify areas
of life
situation that
client can
5
control.
4. Help client
identify areas
of life
situation that
are not within
his or her
ability to
control.
5. Encourage
verbalization
of feelings
related to this
inability.

6
Nursing Goals / Nursing Rationale
Diagnosis Expected Interventions
Outcomes
1- Short-Term 1. Convey an 1. These interventions increase
Social Isolation related Goal accepting feelings of self-worth and facilitate
to: Fears of being in a Client will attitude and a trusting relationship.
place from which one is willingly attend unconditional 2. The presence of a trusted
unable to escape therapy positive individual provides emotional
Evidenced by: Staying activities regard. Make security.
alone; refusing to leave accompanied brief, frequent 3. A person in panic anxiety may
room or home by trusted contacts. Be perceive touch as threatening.
support person honest and 4. Antianxiety medications, such as
within 1 week. keep all diazepam, chlordiazepoxide, or
promises. alprazolam, help to reduce level of
Long-Term 2. Attend anxiety in most individuals, thereby
Goal group facilitating interactions with others.
Client will activities with 5. Maladaptive behaviors, such as
voluntarily client if it may withdrawal and suspiciousness,
spend time be frightening are manifested during times of
with other for him or her. increased anxiety.
clients and 3. Be cautious 6. This enhances self-esteem and
staff members with touch. encourages repetition of
in group Allow client acceptable behaviors.
activities by extra space
time of and an
7
discharge from avenue for
treatment. exit if anxiety
becomes
overwhelming.
4. Administer
tranquilizing
medications
as ordered by
physician.
Monitor for
effectiveness
and adverse
side effects.
5. Discuss
with client
signs and
symptoms of
increasing
anxiety and
techniques to
interrupt the
response
(e.g.,
relaxation
exercises,
“thought
stopping”).
8
6. Give
recognition
and positive
reinforcement
for voluntary
interactions
with others.

9
Nursing diagnosis Outcome Nursing Rationale
Criteria Interventions
2- Short-Term 1. Reassure 1. At the panic level of anxiety,
Fear Related to: Causing Goal: client that he or client may fear for his or her own
embarrassment to self in Client will she is safe. life.
front of others, being in a discuss the 2. Explore 2. It is important to understand
place from which one is phobic object client’s client’s perception of the phobic
unable to escape, or a or situation perception of object or situation to assist with
specific stimulus with the the threat to the desensitization process.
Evidenced by: Behavior health-care physical 3. Client must accept the reality of
directed toward provider integrity or the situation (aspects that cannot
avoidance of the feared within (time threat to self- change) before the work of
object or situation specified). concept. reducing the fear can progress.
3. Discuss 4. Allowing the client choices
Long-Term reality of the provides a measure of control and
Goal: situation with serves to increase feelings of self-
By time of client to worth.
discharge recognize 5. Fear is decreased as the
from aspects that physical and psychological
treatment, can be sensations diminish in response
client will be changed and to repeated exposure to the
able to those that phobic stimulus under
function in cannot. nonthreatening conditions.
presence of 4. Include 6. Exploring underlying feelings
phobic object client in may help the client to confront
10
or situation making unresolved conflicts and develop
without decisions more adaptive coping abilities.
experiencing related to
panic anxiety. selection of
alternative
coping
strategies
(e.g., client
may choose
either to avoid
the phobic
stimulus or to
attempt to
eliminate the
fear associated
with it.)
5. If client
elects to work
on elimination
of the fear,
techniques of
desensitization
or implosion
therapy may
be employed.
6. Encourage
client to
11
explore
underlying
feelings that
may be
contributing to
irrational fears,
and to face
them rather
than suppress
them.

12
Nursing Diagnosis Outcome Nursing Rationale
Criteria Interventions
Ineffective coping related to Short-Term 1. Work with 1. Recognition of precipitating
underdeveloped ego, Goal: client to factors is the first step in teaching
punitive superego, Within 1 determine the client to interrupt the
avoidance learning, week, the types of escalating anxiety.
possible biochemical client will situations that 2. Sudden and complete
changes evidenced by decrease increase elimination of all avenues for
ritualistic behavior or participation anxiety and dependency would create intense
obsessive thoughts. in ritualistic result in anxiety on the part of the client.
behavior by ritualistic Positive reinforcement enhances
half. behaviors. self-esteem and encourages
2. Initially meet repetition of desired behaviors.
Long-Term the client’s 3. To deny client this activity may
Goal: dependency precipitate panic anxiety.
By time of needs as 4. Client may be unaware of the
discharge required. relationship between emotional
from Encourage problems and compulsive
treatment, independence behaviors. Recognition is
client will and give important before change can
demonstrate positive occur.
ability to cope reinforcement 5. Structure provides a feeling of
effectively for security for the anxious client.
without independent 6. Anxiety is minimized when
resorting to behaviors. client is able to replace ritualistic
13
obsessive- 3. In the behaviors with more adaptive
compulsive beginning of ones.
behaviors of treatment, 7. Positive reinforcement
increased allow plenty of enhances self-esteem and
dependency. time for rituals. encourages repetition of desired
Do not be behaviors.
judgmental or 8. Knowledge and practice of
verbalize coping techniques that are more
disapproval of adaptive will help client change
the behavior. and let go of maladaptive
4. Support responses to anxiety.
client’s efforts
to explore the
meaning and
purpose of the
behavior.
5. Provide
structured
schedule of
activities for
client, including
adequate time
for completion
of rituals.
6. Gradually
begin to limit
amount of time
14
allotted for
ritualistic
behavior as
client becomes
more involved
in other
activities.
7. Give positive
reinforcement
for no ritualistic
behaviors.
8. Help client
learn ways of
interrupting
obsessive
thoughts and
ritualistic
behavior with
techniques
such as
thought
stopping,
relaxation, and
physical
exercise.

15
 Nursing Nursing Nursing Rational Evaluation
Diagnosis Outcomes Intervention
1) Anxiety  Client will 1. Establish a 1. Use calm,  Client reports
related to past verbalize therapeutic nonjudgmental reduced
decreased relationship communication to frequency of
traumatic intrusive
experiences as anxiety promote trust and thoughts
evidenced by within one 2. Provide a safe and encourage expression of
restlessness, week quiet environment feelings  Client sleeps at
hypervigilance, least 6 hours
and intrusive  Client will 3. Teach grounding 2. Reduces stimuli that per night
thoughts report at least techniques (e.g., 5-4- may trigger flashbacks without
5–6 hours of 3-2-1 sensory or hyperarousal frequent
restful sleep exercise)  Client interacts
within 7 days 3. Helps the client manage with peers or
4. Encourage relaxation dissociation and anxiety family at least
 Client will methods such as during flashbacks once daily
engage in at deep breathing, awakenings
least one guided imagery, or 4. Encourage regular sleep
social progressive muscle schedule, avoid caffeine
interaction relaxation to reduce before bed, and provide
daily anxiety and improve a calm bedtime routine
sleep

16
 Client will 5. Promote sleep
demonstrate hygiene  Client
demonstrates
use of at least effective
two positive 6. Encourage coping
coping verbalization of strategies
strategies trauma-related when
(e.g., deep feelings but avoid discussing or
breathing, forcing detailed recalling traum
journaling) wi disclosure until the a
thin a week client is ready this
prevents
retraumatization

7. Collaborate with
mental health team

17
 Nursing Nursing Nursing Rational Evaluation
Diagnosis Outcomes Intervention
Disturbed Sleep After 1 week of 1. Assess sleep patterns 1. Understanding the After 1 week of
Pattern related to nursing and habits, including patient's sleep habits nursing
difficulty falling interventions, bedtime routine, diet, and routine can help interventions,
asleep, the patient will and exercise habits identify areas for the patient
maintaining report falling 2. Educate patients on improvement reported falling
sleep, or asleep within sleep hygiene and asleep within
early awakening, 30 minutes of strategies to promote 2. Educating the patient on 30 minutes of
as evidenced by: going to bed, relaxation relaxation techniques going to bed,
patient reports of staying asleep 3. Encourage the can help reduce anxiety staying asleep
insomnia for at least 6 patient to practice and promote restful for at least 6
symptoms, such hours, and good sleep habits, sleep hours, and
as difficulty feeling including a regular feeling rested
initiating or rested upon sleep schedule, 3. Good sleep hygiene upon waking,
maintaining waking avoiding caffeine practices can help meeting the
sleep, waking up and alcohol before establish a regular sleep stated goal
too early, or non- bedtime, and keeping pattern and promote
restorative sleep the sleeping healthy sleep habits
environment dark
and quiet 4. Comfortable sleeping
4. Provide a environment can help
comfortable sleeping the patient fall
environment with asleep and stay asleep
comfortable
bedding and pillows

18
 Anti-anxiety drugs

Under supervision:
Dr/ Tabasem Fayez
Demo/ Ahmed Adel

Prepared by: G5
Psychiatric Mental Health Nursing Department
First Semester 2025 / 2026
 Outlines: -
❖ Introduction of Anti-anxiety drugs.
❖ Explain Classification, most common drugs and mechanism of action of
anti-anxiety drugs (Benzodiazepines & Buspirone).
❖ Identify indications, Contraindications and side effects of anti-anxiety
drugs.
❖ Compare between Benzodiazepines and Buspirone.
❖ Apply nursing interventions and health education for antianxiety drugs.
❖ Discuss health education with family of patient talking anti-anxiety
drugs.

1
Introduction of Anti-anxiety drugs
Antianxiety drugs, (also called anxiolytics or minor tranquillizer) are medications used to
reduce excessive anxiety, fear, or tension. These drugs are commonly prescribed for conditions
such as generalized anxiety disorder (GAD), panic disorder, social anxiety disorder, and short-
term relief of acute stress or insomnia.

Antianxiety drugs are not just “calming pills.” When prescribed responsibly, they can give
patients the stability they need to engage in therapy, work, relationships, and daily activities.

Antianxiety drugs play a vital role in modern psychiatry: they provide relief from distress,
open the door to psychological healing, and help patients rebuild healthier, more fulfilling lives.

Classification of Anti-anxiety drugs

Anti-anxiety drugs are classified into two categories:

Category Main Types (Primary) Supportive / Secondary Types

Definition Drugs that are directly prescribed to Drugs not primarily anxiolytics but
treat anxiety disorders (first-line or used to relieve symptoms or in
standard treatment). special cases.

Examples ❖ Benzodiazepines. ❖ Beta-blockers.

❖ Azapirones (Buspirone). ❖ Antihistamines.
❖ Antidepressants (SSRIs, SNRIs) ❖ Anticonvulsants.
❖ Barbiturates.

Manage associated symptoms (e.g.,

palpitations, tremors, insomnia) or
Role Treat anxiety disorders.
used when main drugs are unsuitable.

Use in First choice for most anxiety disorders Adjunct or alternative therapy in
Practice (acute and chronic). selected cases.

2
 Benzodiazepines
❖ Mechanism of action (Pharmacodynamics):
➢ Anti-anxiety drugs depress subcortical levels of the CNS, Particularly the limbic system
and reticular formation. They may potentiate the effects of the powerful inhibitory
neurotransmitter gamma-amino butyric acid (GABA) in the brain, thereby producing a
calmative effect.
➢ Benzodiazepines increase binding to GABA receptors which Increase frequency of
opening chloride channel in and postsynaptic membranes of many neurons, thereby
reducing the neurons excitability.

❖ Most Common Drugs

Generic Name Diazepam Lorazepam Alprazolam Clonazepam Midazolam

Trade Name Valium Ativan Xanax Klonopin Versed

Classification Example Notes

Short acting Midazolam Fast onset, high potency, but risk of rebound
(2–6 h)
insomnia/anxiety
Intermediate-acting Lorazepam. LOT (Lorazepam, Oxazepam, Temazepam) are
(10–20 h) Alprazolam. safer in elderly & liver disease (no active
metabolites)
Long-acting Diazepam. Long half-life + active metabolites → risk of
(20–100 h)
daytime sedation & accumulation

3
 ❖ Pharmacokinetics of Anti-anxiety drugs:
A. Absorption:
• Rapid and nearly complete after oral intake.
• Highly lipophilic → fast CNS penetration → quick onset of action.
• Not preferred intramuscularly due to muscle irritation and delayed absorption (except
Lorazepam).
B. Distribution: Rapidly cross the blood–brain barrier due to lipid solubility.
C. Metabolism: Primarily metabolized in the liver via CYP3A4 and CYP2C19
enzymes.
D. Excretion: Eliminated mainly by kidneys as metabolites.
❖ Indications of Benzodiazepines
Psychiatric Non-Psychiatric
Generalized Anxiety Disorder (GAD) Seizure Disorders & Status Epilepticus.
Panic Disorder Alcohol Withdrawal Syndrome
Phobias / Social Anxiety (short-term use). Preoperative Sedation / Anesthesia
Insomnia & Sleep Disorders adjunct – midazolam (rapid onset).
Acute agitation / psychiatric emergencies. Muscle Spasms & Spasticity –
diazepam.
Catatonia (in psychiatry & neurology).

❖ Most Common Benzodiazepine Side Effects and Nursing Interventions

Side Effect Nursing Interventions
Central nervous system (CNS)
• Assess level of consciousness.
• Monitor vital signs.
➢ Drowsiness /
• Ensure airway patency and position (head elevation; lateral if vomiting
Sedation
risk).
• Implement fall precautions (low bed, rails as needed, call bell within
reach, assist with ambulation).
• Reduce environmental stimuli (quiet, dim lights) to prevent further
disorientation.
• Check medication chart and last dose; hold any scheduled sedative if
excessive sedation.
• Assist patient with slow position changes and transfers to prevent
dizziness/falls.
➢ Dizziness • Monitor orthostatic blood pressure.

4
 /Lightheaded• Encourage slow position changes (sit before standing).
ness • Assist with ambulation and self-care.
• Keep environment clutter-free and well-lit.
• Encourage adequate hydration and nutrition.
➢ Fatigue / • Assess the level, pattern, and contributing factors of fatigue.
Lethargy • Monitor vital signs, sleep patterns, and activity tolerance.
• Encourage rest periods between activities and provide a quiet
environment.
• Promote balanced nutrition and adequate fluid intake.
• Encourage gradual increase in physical activity as tolerated.
• Teach energy conservation techniques (e.g., sitting during tasks).
• Address underlying causes such as anemia, poor sleep, or medication
effects.
• Provide emotional support and encourage expression of feelings.
• Evaluate effectiveness of interventions and adjust care plan.
➢ Ataxia / • Assess degree of ataxia, gait pattern, and muscle strength regularly.
Impaired • Ensure safety: assist with ambulation, use gait belt if needed, and keep
Coordination bed in low position.
• Provide supportive devices such as walker, cane, or handrails.
• Maintain clutter-free environment to prevent falls or injuries.
• Encourage slow, deliberate movements and avoid sudden position
changes.
• Supervise during mobility or transfers until stability improves.
• Implement fall precautions: non-slip footwear, adequate lighting, and
close supervision.
• Coordinate with physical therapy for balance and coordination
exercises.
➢ Confusion / • Assess the level of memory and concentration impairment through
Memory observation and simple recall tasks.
Impairment • Provide a calm, structured environment with minimal distractions.
• Use repetition and consistency in daily routines to enhance recall.
• Offer written reminders, calendars, or visual cues for orientation and
task completion.
• Speak slowly and clearly.
• Encourage focus on one activity before moving to another.
• Allow extra time for the patient to respond or complete tasks.
• Promote adequate rest, nutrition, and hydration to improve cognitive
function.
• Avoid overstimulation and provide quiet periods for mental rest.
• Monitor for worsening confusion and report promptly.

5
➢ Blurred ✓ Assess severity and duration of visual changes.
Vision ✓ Ensure safety by assisting with ambulation and removing hazards.
✓ Provide adequate lighting and a calm environment.
✓ Advise patient to avoid driving or operating machinery.
✓ Encourage rest and limit activities requiring clear vision.
✓ Monitor for related symptoms like dizziness or headache.
✓ Report persistent or worsening vision changes to the physician.
✓ Document assessments, safety measures, and patient responses.
Gastrointestinal (GI)
➢ Nausea / GI • Assess oral condition and ability to express discomfort.
Upset • Observe for cracked lips, thick saliva, or difficulty
speaking/swallowing.
• Offer frequent sips of water and keep it accessible if safe.
• Provide sugar-free gum or candies to stimulate saliva.
• Assist with regular oral hygiene and rinsing after meals.
• Avoid caffeine, alcohol, and smoking.
• Offer ice chips or mild saltwater rinses for comfort.
• Use saliva substitutes if prescribed.
• Remind or assist patients with self-care if needed.
➢ Dry Mouth • Assess severity and impact of dry mouth.
• Encourage frequent sips of water or sugarless fluids.
• Offer sugar-free gum or candies to stimulate saliva.
• Promote good oral hygiene practices.
• Avoid caffeine, alcohol, and smoking.
• Use saliva substitutes or mouth moisturizers if needed.
Cardiovascular (CVS)
➢ Orthostatic ➢ Monitor blood pressure in lying, sitting, and standing positions.
Hypotension ➢ Observe for dizziness, weakness, or fainting.
➢ Instruct patient to rise slowly from bed or chair.
➢ Assist with ambulation and ensure a safe environment.
➢ Encourage sitting briefly before standing up.
➢ Maintain adequate hydration.
➢ Avoid sudden position changes and alcohol use.
➢ Educate patient to report lightheadedness or fainting.
➢ Document vital signs, safety measures, and patient response.
❖ Serious Side Effects of Benzodiazepine with Nursing Interventions
Serious Side Nursing Interventions
Effect
Respiratory System
6
 • Monitor respiratory rate, depth, and oxygen saturation closely.
• Observe for shallow breathing, cyanosis, or snoring respirations.
➢ Respiratory • Keep oxygen and emergency airway equipment nearby.
Depression • Position patient in semi-Fowler’s for optimal ventilation.
• Avoid concurrent CNS depressants (alcohol, opioids).
• Notify physician immediately if RR < 10/min.

Systemic / Dependence
✓ Assess medication history and observe for signs of physical or
psychological dependence (e.g., craving, anxiety, withdrawal
symptoms).
➢ Dependence ✓ Monitor drug effects and report reduced response or misuse.
✓ Administer medications as prescribed; avoid abrupt withdrawal.
✓ Support gradual dose reduction under supervision.
✓ Teach non-drug coping methods such as:
• Deep breathing and relaxation techniques.
• Meditation or mindfulness exercises.
• Physical activity or regular exercise.
• Engaging in hobbies or social activities.
• Attending therapy or support groups.
✓ Ensure safety during withdrawal and refer to counseling or
rehabilitation if needed.
➢ Withdrawal Symptoms

Nursing Interventions for Benzodiazepine Withdrawal

1. Physical Interventions
Focus on maintaining body stability and relieving physical symptoms.
• Monitor vital signs (BP, pulse, respiration, temperature) regularly.
• Observe for physical symptoms: tremors, sweating, nausea, muscle pain, insomnia.

7
 • Encourage adequate rest, nutrition, and hydration.
• Offer small, frequent meals to prevent nausea and vomiting.
• Administer prescribed medications (anticonvulsants, antiemetics, analgesics).
• Provide warm compresses for muscle aches and chills.
• Promote regular sleep pattern; reduce light, noise, and caffeine before bedtime.
• Monitor input and output; prevent dehydration and electrolyte imbalance.
2. Psychological Interventions
Focus on reducing anxiety, agitation, and emotional distress.
• Provide reassurance and supportive communication.
• Encourage verbal expression of feelings and fears.
• Use relaxation techniques (deep breathing, guided imagery, soft music).
• Maintain a calm and quiet environment to reduce anxiety.
• Establish a trusting nurse–patient relationship.
• Orient patient frequently to time, place, and person.
• Encourage family involvement for emotional support.
• Refer to counseling, psychotherapy, or support groups after stabilization.

3. Safety Interventions
Focus on preventing injury and managing serious complications.
• Stay with patient during periods of agitation or confusion.
• Keep environment safe: remove sharp or hazardous objects.
• Pad bed rails and keep airway equipment available for seizure precautions.
• Protect patient from injury during seizure; do not restrain.
• Monitor for suicidal ideation or self-harm behavior.
• Supervise continuously during severe withdrawal.
• Report severe symptoms (seizures, hallucinations, tachycardia) promptly to physician.
• Follow gradual benzodiazepine tapering as prescribed to prevent severe withdrawal.

Psychiatric (behavioral & emotional)

• Assess for signs of paradoxical reaction (increased anxiety, agitation,
irritability, insomnia).
• Withhold the medication and notify the physician immediately.
➢ Paradoxical • Monitor vital signs and mental status closely.
Reactions • Provide a calm, quiet, and safe environment.
• Offer reassurance and emotional support.
• Administer prescribed antidote (Flumazenil) or alternative medication
if ordered.
• Collaborate with healthcare team to adjust or change the medication.
• Assess mood, thoughts, and risk for self-harm each shift.
• Maintain safe environment (no sharps or ligatures).

8
➢ Depression or • Provide one-to-one observation if suicidal risk is high.
Suicidal • Encourage patient to verbalize feelings.
Ideation • Report any suicidal ideation immediately.
• Collaborate with the multidisciplinary team for support.

Cognitive / Long-Term Use

➢ Cognitive • Schedule regular cognitive assessments (memory, attention).
Impairment • Encourage cognitive activities (reading, puzzles).
(Chronic Use) • Educate on the effects of long-term use on cognition.
• Plan gradual dose reduction if clinically safe.
• Reinforce use of non-pharmacologic anxiety management (relaxation,
CBT).

Musculoskeletal / Elderly Risk

• Implement strict fall precautions.
• Maintain clutter-free environment with adequate lighting.
➢ Falls and • Provide non-slip footwear and assistive devices.
Fractures • Supervise ambulation and toileting.
• Educate patient and caregivers about fall prevention.
• Review medications to minimize CNS depressant combinations.

Benzodiazepine Overdosage (toxicity): occurs when a patient takes a dose

of benzodiazepine that exceeds the body’s ability to metabolize and excrete the drug
safely, leading to excessive CNS depression and potentially life-threatening
complications.
Nursing Interventions

Priority Nursing Action

Airway, Breathing, Ensure patent airway, monitor oxygen saturation,
Circulation (ABC) prepare for intubation if needed
Monitor vital signs & Continuous cardiac and neurological monitoring
LOC
Administer antidote if Flumazenil (Romazicon) — benzodiazepine antagonist
ordered given IV slowly
Prevent aspiration Position patient on side (recovery position)
Avoid additional CNS Withhold alcohol, opioids, sedatives
depressants
Supportive care IV fluids, oxygen therapy
Psychiatric follow-up After recovery, assess for suicidal intent or misuse

9
 ❖ Contraindications of Benzodiazepines
Absolute Contraindications Relative Contraindications

Hypersensitivity to History of substance use disorders.

benzodiazepines. Pregnancy.
Severe respiratory Breastfeeding – excreted in breast milk → sedation
insufficiency. in infants.
Severe sleep apnea syndrome. Elderly patients → ↑ risk of sedation, confusion,
Severe hepatic impairment. memory problems, falls.
(esp. diazepam, Concomitant use with other CNS depressants
chlordiazepoxide; except “LOT (opioids, alcohol, barbiturates) → ↑ risk of
drugs” – Lorazepam, respiratory depression.
Oxazepam, Temazepam).
Acute narrow-angle glaucoma. Depression or suicidal tendencies → may worsen
mood or lead to misuse.
Health Education and Precautions for Patients Taking Benzodiazepines
1. General Information
• Benzodiazepines are medicines used for anxiety, insomnia, seizures, alcohol withdrawal,
and muscle spasms.
• They work by calming the brain and nervous system.
• Examples: Diazepam (Valium), Lorazepam (Ativan), Alprazolam (Xanax).

2. How to Take Medication

• Take exactly as prescribed by your doctor.
• Do not increase the dose or take it more often, even if you feel anxious.
• Swallow tablets with water; do not crush unless instructed.
• If you miss a dose, take it as soon as you remember — but skip it if it’s almost time
for your next dose. Never double the dose.

3. Safety Precautions
• Do not drive, operate heavy machinery, or do risky tasks until you know how the drug
affects you (may cause drowsiness or dizziness).
• Avoid alcohol and other sedative drugs → dangerous interaction, risk of breathing
problems.
• Using caution when standing up → may cause dizziness and fall.
• Keep away from children, risk of overdose.
4. Possible Side Effects
• Common: sleepiness, fatigue, dizziness, poor coordination, memory problems.

10
 • Serious (call doctor immediately): difficulty breathing, severe confusion, unusual mood or
behavior changes (agitation, aggression).
• Long-term use: risk of dependence and withdrawal symptoms if stopped suddenly.
5. Special Advice
• Do not stop suddenly → may cause withdrawal symptoms (anxiety, insomnia, tremors,
seizures). Always taper slowly under medical supervision.
• Elderly patients: higher risk of confusion and falls.
• Pregnant or breastfeeding women: should avoid unless prescribed by a specialist (risk to
baby).
• Inform doctor about all other prescribed medications(including over the counter and herbal
products).
6. Lifestyle & Self-Care
• Practice stress management: deep breathing, relaxation, exercise, healthy sleep routine.
• Avoid caffeine, nicotine, and stimulants that may worsen anxiety.
• Use the medication as a short-term aid, while also working on long-term coping strategies.

Azapirones (Buspirone) – (Non-Benzodiazepine)

Azapirones are a class of anti-anxiety (anxiolytic) drugs that are chemically and
pharmacologically different from benzodiazepines.
Generic Name Trade / Brand Name
Buspirone Buspar
Zolpidem Ambien

❖ Mechanism of action (Pharmacodynamics):

Serotonin System (Main Action)
• Acts as a partial agonist at 5-HT1A receptors (both presynaptic and postsynaptic).
• Presynaptic action: ↓ serotonin release (negative feedback).
• Postsynaptic action: helps regulate mood and reduce anxiety.
• Result = overall modulation of serotonin activity, leading to anxiolytic effects.

11
 Dopamine System (Secondary Action)
• Acts as a weak antagonist at dopamine D2 receptors.
• Contributes to anxiolytic effect but without strong antipsychotic activity.
No GABA Effect
• Unlike benzodiazepines, buspirone does not act on GABA-A receptors.
• Therefore: no sedation, muscle relaxation, anticonvulsant action, or dependence risk.

❖ Pharmacokinetics of Anti-anxiety drugs:

A. Absorption: Well absorbed orally.
B. Distribution: Less lipophilic than benzodiazepines → slower entry into the CNS.
C. Metabolism: Hepatic metabolism mainly by CYP3A4.
D. Excretion: Excreted primarily by the kidneys, some via bile/feces.

❖ Indications of Buspirone:
Generalized Anxiety Disorder (GAD).
Mixed anxiety–depression states.
Augmentation in depression.
Patients with substance abuse history.
Elderly patients with anxiety.

❖ Side Effects of Buspirone with Nursing Interventions

Side Effect Nursing Interventions
➢ Dizziness / ✓ Instruct patient to rise slowly from sitting/lying position to prevent
Lightheaded falls.
ness ✓ Monitor for risk of injury.
✓ Advise avoiding driving or operating heavy machinery until response
is known.
✓ Assess onset, location, and severity of headache.
✓ Monitor vital signs and related symptoms.
✓ Encourage rest in a quiet, dark environment.
➢ Headache ✓ Administer prescribed analgesics as needed.
✓ Promote adequate hydration and regular meals.
✓ Apply cool compresses for comfort.
✓ Teach relaxation or stress-reduction techniques.
✓ Advise avoiding caffeine, alcohol, or stress triggers.
✓ Report persistent or worsening headache to the physician.

12
 • Assess onset, duration, and severity of nausea or gastrointestinal
discomfort.
➢ Nausea / GI • Observe for vomiting, abdominal pain, or changes in appetite.
upset • Administer prescribed antiemetics or GI protectants as ordered.
• Encourage small, frequent meals and avoid fatty, spicy, or strong-
smelling foods.
• Offer clear fluids to maintain hydration and prevent dehydration.
• Advise the patient to take medication with food or milk (if not
contraindicated).
• Keep the environment well-ventilated and free from strong odors.
• Encourage slow, deep breathing or relaxation techniques to reduce
nausea.
• Monitor for persistent or worsening symptoms and report to the
physician.

➢ Nervousness / ✓ Provide calm environment and reassurance.

Excitability ✓ Monitor anxiety levels and report worsening symptoms.
✓ Teach relaxation techniques (deep breathing, guided imagery).

• Assess sleep pattern and possible causes of disturbance.

• Encourage a consistent bedtime and wake-up routine.
• Provide a quiet, dark, and comfortable environment.
➢ Insomnia /
• Limit caffeine, nicotine, and alcohol before bedtime.
Disturbed
sleep • Promote relaxation techniques before sleep.
• Avoid screen use, heavy meals, or stimulating activities at night.
• Encourage light daytime exercise.
• Administer prescribed sleep aids if ordered.
• Offer emotional support to reduce anxiety.

➢ Blurred ✓ Instruct patient to avoid driving until vision clears.

vision ✓ Provide safe environment (adequate lighting, fall precautions).
✓ Report persistent visual changes.

➢ Tachycardia / ✓ Monitor vital signs regularly.

Palpitations
✓ Report sustained tachycardia, chest pain, or dyspnea.
(rare)
✓ Teach patient to report palpitations promptly.

➢ Skin rash / ✓ Monitor for rash, itching, swelling.

Allergic
13
 reaction ✓ Discontinue medication and notify provider if reaction occurs.
(rare) ✓ Educate patient on early signs of hypersensitivity.

❖ Contraindications of Buspirone

Absolute Relative
➢ Hypersensitivity to buspirone ➢ Severe hepatic impairment
➢ Concomitant use with MAO ➢ Severe renal impairment
inhibitors (within 14 days) ➢ Pregnancy & breastfeeding
➢ History of drug/alcohol abuse

Health Education and Precautions for patients talking Buspirone

❖ Purpose of Medication
o Buspirone is prescribed to reduce symptoms of anxiety.
o The medication works differently from sedatives such as benzodiazepines.
❖ Onset of Action
o Therapeutic effect requires 1–2 weeks to appear.
o Immediate relief of anxiety is not expected.
❖ Administration Instructions
o Medication should be taken at the same time every day to maintain consistent
blood levels.
o Missed doses should not be doubled; the next scheduled dose should be taken.
❖ Food and Drink Interactions
o Grapefruit juice should be avoided, as it may increase drug concentration and
side effects.
o Alcohol and other sedatives should be avoided to prevent excessive drowsiness
or dizziness.
❖ Safety Precautions
o Possible dizziness or drowsiness may occur, especially during initiation.
o Driving, operating machinery, or engaging in hazardous activities should be
avoided until individual response is known.
❖ Side Effects
o Common: dizziness, headache, nausea, restlessness.
o Serious but rare: chest pain, confusion, or mood changes. Medical advice should
be sought if this occurs.

14
 ❖ Adherence to Therapy
o Buspirone should be taken regularly rather than on an “as needed” basis.
o Discontinuation should only occur under medical supervision to avoid recurrence
of anxiety symptoms.
❖ Special Considerations
o Use during pregnancy or breastfeeding requires medical evaluation.
o All concurrent medications, especially MAO inhibitors, SSRIs, and other
psychiatric drugs, must be disclosed to the healthcare provider.
❖ Follow-Up: Regular follow-up appointments are necessary to monitor progress and
adjust dosing if required.
❖ Supportive Measures: Best outcomes are achieved when combined with stress
management techniques, adequate sleep, balanced nutrition, physical activity, and
counseling if recommended.

Comparison between Benzodiazepines vs Buspirone

Feature Benzodiazepines Buspirone
Examples Diazepam, Lorazepam, Buspirone (Buspar)
Alprazolam, Clonazepam
Onset of Action Rapid (minutes to hours) Slow (1–2 weeks for effect)
Mechanism of Enhance GABA activity (CNS Partial agonist at serotonin (5-
Action depressant) HT1A) receptors
Acute anxiety, panic attacks, Generalized Anxiety Disorder
Indications insomnia, seizures, alcohol (GAD)
withdrawal
Risk of Dependence High (tolerance and withdrawal None (non-habit forming)
possible)
Sedation Common (causes drowsiness, Minimal or none (non-sedating)
cognitive impairment)
Use in Long-Term Not recommended due to Suitable for long-term
Treatment dependence management of GAD
Interactions Potentiated by alcohol, opioids, Avoid MAO inhibitors and
other sedatives grapefruit juice
Withdrawal Yes (rebound anxiety, insomnia, No significant withdrawal
Symptoms seizures) symptoms
Nursing Monitor for sedation, respiratory Educate about delayed onset,
Considerations depression, signs of misuse importance of regular dosing

15
Health education with family of patient talking antianxiety drugs.
"Be a partner in care — supervise safely, observe carefully, support emotionally, and
communicate openly with the healthcare team.
Your understanding and involvement are essential for the patient’s safety and long-term
recovery.
1. Understanding the Medication
• Know the name, dose, and purpose of the drug.
• These medicines help reduce anxiety and promote calmness.
• The drug must be taken only under medical supervision.
2. Safe Medication Use
• Give the drug exactly as prescribed — no skipping or doubling doses.
• Do not stop suddenly; withdrawal can cause anxiety, tremors, or seizures.
• Keep a medication schedule or chart to avoid missed or repeated doses.
• Encourage the patient to take the medicine at the same time each day.
• Remind that this medicine is personal — never share with others.
3. Storage and Safety
• Store medicine safely in a closed or locked cabinet, away from children.
• Dispose of expired or unused medication properly (return to pharmacy if possible).
• Assist the patient in walking or standing if they feel dizzy or sleepy.
• Ensure the home is free from fall hazards — good lighting, no slippery floors.
4. Side Effects to Observe
• Watch for drowsiness, dizziness, blurred vision, or poor coordination.
• Monitor for confusion, forgetfulness, or behavior changes.
• Report immediately if patient shows severe sleepiness, breathing problems, or rash.
• Inform the doctor if the patient seems more anxious, irritable, or depressed after taking
the drug.
5. Avoid Harmful Interactions
• No alcohol or other sedatives while taking this medication.
• Avoid using sleeping pills, antihistamines, or painkillers unless prescribed.
• Limit caffeine (coffee, tea, cola) — it may reduce drug effect or increase anxiety.
• Tell all healthcare providers that the patient is on an antianxiety drug.
6. Promote Healthy Lifestyle
• Encourage balanced meals and plenty of fluids.
• Maintain good sleep hygiene — quiet environment, fixed bedtime, avoid screens before
sleep.
• Support regular light exercise like walking or yoga to reduce tension.
• Encourage relaxation practices such as deep breathing or meditation.
7. Emotional and Psychological Support
• Listen with patience and empathy — avoid judgment or criticism.
• Encourage the patient to express feelings and worries freely.
• Support participation in therapy sessions or support groups.

16
 • Reinforce that healing takes time — family encouragement promotes recovery.
8. Watch for Dependence or Misuse
• Observe for requests for higher doses, using medicine more often, or secretive behavior.
• Remind that benzodiazepines are for short-term use only unless otherwise directed.
• Notify the healthcare team if any sign of dependence or overuse appears.
9. Emergency Situations
Call the doctor or emergency services if:
• The patient is hard to wake up, very confused, or has breathing difficulty.
• Shows thoughts of self-harm or suicide.
• Experiences seizures or allergic reactions (swelling, rash).
10. Family’s Role in Ongoing Care
• Help the patient take medicine regularly and attend all follow-up visits.
• Observe and record any mood or behavior changes to report to the nurse or doctor.
• Maintain consistent routines — stable sleep, meals, and activity schedules.
• Provide a calm, supportive home atmosphere to reduce stress and promote recovery.

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