Anxiety
Levels of Anxiety
1. Mild
2. Moderate
3. Severe
4. Panic Anxiety
Treatment
● Assess client's anxiety level continuously
● Moderate Anxiety
○ ensure that client follows your instructions
○ Refocus client with calm imagery
○ speak in short, simple, easy to understand sentences
○ assess client continuously if he/she understand your instructions
● Severe Anxiety
○ lower client's anxiety level (ensure safety and grounding)
○ remain with the client
○ talk in calm, low voice
○ if restless walk with the client while talking
● Panic Anxiety
○ safety is primary concern
○ keep talking to client in a comforting manner
○ proceed to a small quiet non -stimulating environment
○ reassure that it is only anxiety
○ remain with the client until panic recedes (5 - 30 minutes)
Rape
Types of Male Rapist
1. Sexual sadist
2. Exploitive predators
3. Inadequate men
4. Displace expression of anger and rage
Assessment
● Complete Physical Assessment
○ done before the victim has showered, brushed teeth, changed clothes or
undergone douching – this is to PRESERVE EVIDENCE OF THE CRIME
Nursing Interventions
1. Safety and security– remain w/ client
2. Treat injuries
3. Prophylactic tx – risk STDs
4. Allow pt to make decisions
5. Obtain consent prior to collection of samples
6. Emotional support
7. Refer –police, counsellor
8. Individual/ group therapy
9. Grounding techniques – remind client that he or she is in the present, as an adult,
and is safe
Child Abuse
Types of Child Abuse
● Physical Abuse
○ children will show scars, multiple fractures, multiple bruises during physical
assessment
● Sexual Abuse
○ incest, rape, sodomy, rubbing/fondling, exposing adult's genitals to the child
● Neglect
○ malicious or ignorant withholding of physical, emotional or educational
support to the child
● Psychological Abuse
○ blaming, screaming, constant family discord, withholding affection, love and
nurturing, exposure to alcoholism, drug abuse or prostitution.
Assessment - Warning Signs
● Injuries at different stages of healing
● Delayed treatment or no treatment of injuries
● inconsistent history of the injury
● Unusual injuries for a child's age, level of development
● UTI, bruised genitalia, tears/ bruising of vagina or rectum
● old injuries not reported/ cannot explained by parent/guardian
Nursing Interventions
1. Safety
2. Full psychiatric Evaluation
3. Play therapy
4. Refer
Elder abuse
Types
1. Physical
2. Psychosocial
3. Neglect
4. Material
5. Self-neglect
Nursing Intervention
● Assistance to family members or caregivers
● Removal of the elderly from the home and referral to an elderly facility (intentional
abuse)
● Intensive treatment and care of the elderly’s medical condition
● Safety and security
ANXIETY – RELATED DISORDERS
1. Panic Attack/Disorder
● panic attacks lasting 15 - 30 minutes
● Recurrent, unexpected panic attacks followed by 1 month of persistent worry
over future attacks
● Avoidance Behavior
○ Primary gain
○ Secondary gain
● Tx: Benzodiazepines (acute), CBT
2. Phobias
● Agoraphobia
● Specific Phobia
● Social Phobia
● Tx:
○ CBT
○ Systematic desensitization
○ Flooding - rapid desensitization
3. Generalized Anxiety Disorder (GAD)
● Occurs more than 6 months
● Excessive worries about daily activites / events
4. Social Anxiety Disorder
● Occurs more than 6 months
● anxiety about being embarrassed, humiliated, looked down by social
interaction
● Afraid of public speaking
5. Separation Anxiety Disorder (SepAnx)
● at least 4weeks children & 6months in adult
Treatment
● SSRIs
● CBT
Schizophrenia
DSM-5 Criteria for Schizophrenia
● At least 2 or more of the following for 1-month period with at least one being:
○ delusions
○ hallucinations
○ disorganized speech
■ grossly disorganized or catatonic behavior
■ negative symptoms
● disturbance must persist for at least 6 months
Causes
● Genetics
● Excessive dopamine & serotonin
● Immunovirological – viral infection
⬇️
Tx: Schizophrenia
⬇️
1. Typical Antipsychotics (1st Gen) – “zindol”, dopamine
2. Atypical Antipsychotics (2nd Gen) – “pine/done”, serotonin
3. 3rd Gen – Aripiprazole
Other Psychotic Disorders
1. Schizophreniform Disorder – more than 1 month but less than 6 months (1-6
months)
2. Schizoaffective Disorder – psychotic illness + intermittent mood episodes
3. Delusional Disorder – 1 month of bizarre/non-bizzare delusions
4. Brief Psychotic Disorder – less than 1 month
5. Shared Psychosis/ Shared Psychotic Disorder – 2 people sharing similar delusion
Interventions For Psychosis
1. Safety
2. Trust
3. Therapeutic communication
4. Delusion
a. Do not confront or argue
b. Orient patient – reality
c. Distract – recreational activity
d. (+) Positive thinking
5. Hallucinations
a. Reality – frequent contact & orientation
b. Let patient describe
c. Calm/ reassure
d. Reality-based act. – music, read
6. Redirect
7. factual, non-judgemental
8. DO NOT SCOLD / Punish
9. Teavh social skills
Personality Disorder
Cluster A (PSS)
● Paranoid –suspicious “Walang tiwala”
● Schizoid – social isolation “Alone, aloof, asocial” (LONERS)
● Schizotypal– superstitious “Fantasies”, magic
● Tx: teach the client social skills
Cluster B (BAHN)
● Borderline– unstable emotions, (SPLITTING- ego defense)
● Antisocial– law breakers, irresponsible, “Bully”
● Histrionic– attention seekers “SOBRANG OA”
● Narcissistic– self-entitlement “Feeling SUPERIOR”
● Tx: set firm limits
Cluster C (ADOP)
● Avoidant– sensitivity to criticism “INTROVERT OVERLOAD”
● Dependent– extreme submissiveness, “ Kailangan may kasama Lagi”
● Obsessive Compulsive– extreme neatness “PERFECTIONIST”
● Passive aggressive– negativistic “PLASTIC / PAASA”
● Tx: CBT / Cognitive Restructing
Depression
Risk Factors for Depression
● Genetics
● Personality – low self esteem
● Environment– violence, neglect, poverty
● Neurotransmitter- imbalances of SEROTONIN, NOREPINEPHRINE, DOPAMINE
Types of Depressive Disorders
1. Major Depressive Disorder (Clinical Depression)
● 2 or more weeks of a sad mood or lack of interest in life
● + 4 symptoms of depression
○ S/Sx depression: anhedonia, changes of weight, sleep, energy,
concentration, decision making, self-esteem, goals
● Women– Single and divorced people
2. Persistent depressive disorder
● ≥ 2 years without remission
3. Premenstrual dysphoric disorder
● ≥ 5 symptoms during the week before menstruation
● ≥ 1 of the following:
○ ✓ mood swings (suddenly feeling sad or tearful)
○ ✓ irritability or anger or increased interpersonal conflicts
○ ✓ depressed mood, hopelessness, self-deprecating thoughts
○ ✓ anxiety, tension, or an on-edge feeling
Treatment Depression
● Antidepressant – TCAs, SSRI, SNRI, MAOs
● Psychotherapy – CBT
● Electroconvulsive
Nursing Interventions
1. Safety
2. Suicide precautions
3. spending non-demanding time with the client
4. Assist on ADLs as necessary
5. Nutrition and hydration
6. Promote sleep and rest
7. Let pt VERBALIZE
Depressed Client
● Kind Firmness
● Silence
● Offering Self
● Motivate- by letting them recall previous achievements
○ Engage in highly structured/ highly scheduled activities
■ Step-by-step
■ Baking, cooking
■ To allow the patient to focus on the instructions and forget their
problems and give no time for overthinking (provide distraction)•
Rather than asking the client on what to do, giveschedule activities
BIPOLAR DISORDERS
● Mania
○ severe symptoms
○ longer duration (≥ 1 week)
● Hypomania
○ less severe symptoms than with mania
○ > 4 consecutive days but < 1 week
○ duration (< 1 week) without need for hospitalization
● Depressive episode:
○ low mood, with lethargy, hopelessness, and changes in appetite and sleep
Types of Bipolar
1. Bipolar I
● 1 manic eps in a lifetime
● Manic eps– 1 week extremely high-spirited / irritable
2. Bipolar II
● ≥ 1 hypomanic episode
● ≥ 1 MDD episode
● No history of manic episodes
3. Cyclothymic disorder
● Symptoms recur in ≥ 2 consecutive years, present ≥ ½ the time, not absent
for > 2 consecutive months
● Milder, many “mood swings” + hypomania & depressive
● Less severe
Treatment
1. Lithium –stimulants
a. N = 0.6 - 1.2 mEq/L or 1.0 - 1.5
b. Toxicity S/Sx:
i. N/ V, diarrhea
ii. Drowsiness, slurred Speech, muscle weak
iii. Blurred vission, hypotension, cardiac arrhythmias, coma?
● Intervention to Lithium Toxicity
○ Mild= Stop + Increase FLUID intake
○ Severe toxicity
■ VS monitor
■ Start IV fluids
■ Gastric suctioning
■ Whole bowel irrigation
■ Hemodialysis
2. Anticonvulsants
3. Psychotherapy
PTSD
● “Survivors guilt”
● Full dx not met until at least 6 months after the trauma
● Symptoms last more than 1 month
● At least 1 month of:
○ 1 re-experiencing– flashbacks, bad dreams, “Intrusions”
○ 1 avoidance–
○ 2 arousal & reactivity– easily startled, angry outburst, sleep
○ 2 cognitive & mood symptoms–repression, guilt/Blame, loss of interest
● Tx: CBT and eye movement desensitization, antidepressant
Acute Stress Disorder
● Occurs within 1 month, PTSD happen any point in past
● Symptoms last more than 3 days and less than 1 month
Adjustment Disorder
● Response to identifiable Stressors
● < 3 months from exposure and lasting < 6 months
● Lack of reactive Sx (intrusion, negative mood, arousal Sx)
Treatment
⬇️
● CBT
● Exposure therapy – virtual reality technology, flashbacks/nightmares
● Eye movement desensitization and reprocessing (EMDR)
● Psychopharmacology – antidepressant/ anti-anxiety
PSYCHOTHERAPY For PTSD
1. Defusing – stress management
2. Debriefing – counselling
3. Exposure therapy – confronting trauma
4. Adoptive closure therapy – “empty chair technique”
5. Catharsis – use art & music
🌟 Psychotherapy is the #1 treatment for Trauma
OCD
● Undoing – ego Defense mechanism
Obsession
- Repetitive thoughts
- Begins w/ the mind
- Ex. Contamination, safety, scrupulosity
- Main course of anxiety
Compulsion
⬇️
- Repetitive actions (rituals)
- To anxiety / guilt
- Ex: Checking rituals, washing hands, hoarding items
Nursing Interventions OCD
1. Allow the patient to perform the ritual
2. Adjust the schedule of the patient
3. Gradually limit the ritual
4. CBT
Body Dysmorphic Disorder (BDD)
● imagined defect in appearance
● S/Sx:
○ Worry a lot to specific area
○ Spend time comparing looks w/ others
○ Lot of effort to conceal flaws– spend time combing hair, makeup
Treatment for BDD
1. SSRI
2. TCAs
3. Neuroleptics
4. Lithium
5. MAOIs
Hoarding Disorder
● difficulty in discarding or parting with possessions
● Tx: CBT & exposure therapy
Trichotillomania
● ”Rapunzel’s syndrome”
● hair-pulling disorder
● Common in scalp
● Onset 9-13 y/o
● Tx: Antidepressants⎯ Anxiolytics⎯ CBT
Excoriation (skin-picking) disorder
● repetitive scratching
● Management
○ Set limits
○ Habit reversal training – squeezing a rubber ball
○ Stimulus control– wearing gloves or Band-Aids, cover mirrors
● Drugs:
○ Antipsychotic
○ Antianxiety
○ Antidepressant
○ Topical cortisone
○ Antiepileptic agent
EATING DISORDERS
- Body image disturbance
- Main problem→perception of client to their body
Anorexia Nervosa
● “Perfectionist” – Life-threatening
● Self- imposed dietary restrictions
● “UNDERweight”
● No medication has yet been FDA approved
● Compulsive exercising
○ Tx: DISTRACT – do other activities
● do calorie counting
● do not acknowledge their problems
● Cut food into small pieces & eat it slowly
● S/sx:
○ Amenorrhea
○ Alopecia
○ Anemia
○ Lanugo
Bulimia Nervosa
● Hunger- anger cycle + Binge- purge syndrome
● normal body weight
● Use of enema and laxatives
● S/Sx
○ Russel’s sign- scarring/teeth marks on knuckles
○ Tooth decay
○ Rectal bleeding
○ Gastric ulcers
○ Hypokalemia
● Tx: SSRI (Fluoxetine)
Binge- Eating Disorder
● binge-eating not followed by purging
● overweight or obese
● Eat large amount of food even if full
● Tx:
○ Antidepressants
○ antiseizure (Topiramate)
○ Vyvanse– ADHD meds w/c suppresses appetite
Nursing Interventions for Eating Disorder
1. Plan meals with the client
2. Set time limit during meals
3. Supervise client after eating
4. Psychotherapy- self-monitoring
a. Diary of food
5. Evaluation- normal BMI
6. Sit with the client during meals and snacks.
7. Observe pt for 1-2 hours
NEURODEVELOPMENTAL DISORDERS
Intellectual Disability (formerly called Mental Retardation)
● Below Average intelligence
● Start as early as Infancy
● Can & do learn skills – BUT SLOW PROGRESSION
● Primary Limitations
○ Intellectual functioning (IQ) –
■ N = 85 - 115, average 100
■ Less than 70 - 75 = Intellectual disabled
○ Adaptive behaviors – interpersonal, communication
■ Conceptual area: memory, reading, math
■ Social area: aware of others thought
■ Practical area: personal care, health safety
● Causes
○ Inherited
○ Down syndrome
○ Pregnancy– malnutrition, infection, alcoholic/ drugs
○ During birth– hypoxia, premature
○ After birth– brain infections, head injury, poison
● Signs
○ Trouble Talking
○ Rolling over, sitting up, crawling
○ Slow master things
○ Difficulty remembering things
○ Explosive tantrums
○ Difficulty with problem
ADHD
- Inattention (lack of focus)
- Hyperactivity
- Impulsivity
Diagnosis
● Before the age of 12
● Symptoms occur in 2 or more setting (home, school)
● >6 months duration
●
3 TYPES OF ADHD
1. Predominantly inattentive presentation
● “Lack of focus”
● Challenges w/ staying on task, focusing, organization
● Ex.
○ Doesn't pay close attention to details / makes careless mistakes in
school/ jobs
○ Doesn't listen when spoken to
2. Hyperactive / impulsive Type
● “Restless”
● Excessive movement– fidgeting, excessive energy, NOT sitting still, being
talkative
● Ex.
○ Taps hands or feet, squirms in seat
○ Talks too much
○ Always “on the go”
3. Combined type
● Inattentive + hyperactive/impulsive
🌟
Treatment ADHD
1. Methylphenidate (Ritalin) – best
2. Therapeutic play
🌟
Nursing Interventions
1. Safety
2. Positive feedback
3. Simplify instructions
4. Structured daily Routine
5. Listen to parents feelings
AUTISM SPECTRUM DISORDER (ASD)
● common in males, 3 years of age
● Genetics
● Deficits In:
○ Social communications
○ Social interaction
○ Persistent Repetitive behavior
● Signs:
○ Little eye contact
○ Few facial expressions – NO emotional affect/ moods
○ Do not use gestures to communicate (Waxy Flexibility)
○ Cannot engage in play / make-believe in toys
○ Stereotyped motor behaviors– handflapping, body-twisting, head-banging
🌟
Nursing Interventions AUTISM
1. Safety
2. Give familiar objects– toys / blankets
3. Let them interacts w/ others
4. Fulfill Child's needs – STRONG SUPPORT
5. Seek clarification & validation – Ask question
6. Give (+) reinforcement– food / familiar object
7. Gradually replace w/ SOCIAL Reinforcement–touch, smiling, hugging
8. Independently– self care activities
SUBSTANCE USE ABUSE
Alcohol
● Tx: Benzodiazepines (Lorazepam, Diazepam) → to suppress withdrawal
Intoxication Withdrawal
● Slurred speech ● tremors
● unsteady gait ● sweating
● lack of coordination ● elevated pulse and BP
● insomnia
● impaired attention
● anxiety
● concentration, memory and ● hallucinations
judgment ● delirium
● aggressive or inappropriate sexual ● seizures
behaviors
● vomiting
● unconsciousness
● respiratory depression
Sedatives, Hypnotics, Anxiolytics
● Tx:
○ tapering the amount of drug
Intoxication Withdrawal
●
●
Slurred speech
lack of coordination
●
●
⬆️pulse,BP, RR, temperature
hand tremor
● unsteady gait ● insomnia
● labile mood ● anxiety
● lethargic ● nausea
● confused ● psychomotor agitation
● impaired attention or memory
● stupor and coma
Stimulants (Cocaine, Amphetamines)
-
Intoxication Withdrawal
● High or euphoric feeling, ● Marked dysphoria
● hyperactivity ● fatigue
● hypervigilance ● vivid
● talkativeness ● unpleasant dreams
● anxiety ● insomnia
● grandiosity / hallucinations, ● hypersomnia
● stereotypic or repetitive behavior, ● increased appetite
● anger, fighting ● psychomotor retardation or agitation
● impaired judgment
● tachycardia
● elevated BP
● dilated pupils
● perspiration or chills
● nausea
● chest pain
● confusion
● cardiac dysrhythmias
● seizure / coma
Cannabis (Marijuana)
-
Intoxication Withdrawal
● High feeling similar to that w/ alcohol ● muscle aches
● lowered inhibitions ● sweating
● relaxation ● anxiety
●
●
●
⬆️
euphoria
appetite
impaired motor coordination
● tremors
● inappropriate laughter
● impaired judgment
● short-term memory
● distortions of time and perception;
● anxiety
● dysphoria
● social withdrawal
Opioids (Morphine, Heroin)
- Tx:
- DOC: Naloxone (Narcan) –for toxicity
- Methadone – substitute– for withdrawal
Intoxication– DOWNERS ⬇️⬇️ Withdrawal
● Apathy ● Initial symptoms
● lethargy ○ anxiety, restlessness, aching
● listlessness back and legs, cravings for
● impaired judgment more opioids
● psychomotor retardation or ● nausea/ vomiting
agitation, ● dysphoria
● constricted pupils ● lacrimation
● drowsiness ● rhinorrhea
● slurred speech ● sweating
● impaired attention and memory, ● diarrhea
● respiratory depression ● yawning
● unconsciousness – death ● fever
● insomnia
Hallucinogens (Ecstasy, LSD)
Intoxication Withdrawal
● Anxiety, depression ●
● paranoid ideation, ideas of reference
● fear of losing one’s mind
● jumping out a window in the belief
that one can fly
● sweating, tachycardia, palpitations,
● blurred vision
● tremors
● lack of coordination
● belligerence
● aggression
● impulsivity
● unpredictable behavior