Alcohol Abuse

Alcoholic Beverage
An alcoholic drink contains ethanol, commonly termed as alcohol. Alcohol is a psychoactive drug that is central
nervous system depressant and rapidly absorbed in the bloodstream. It can be addictive and the state of
alcohol addiction is known as alcoholism.

Physiologic Effects of Alcohol Use

When a person drinks alcohol, he or she may experience relaxation and loss of inhibitions initially. However,
when large amount of alcohol is ingested intoxication may occur. The person who is intoxicated may experience
the following manifestations.
Slurred speech
Unsteady gait
Lack of coordination
Decreased attention span
Reduced concentration
Impaired memory
Impaired judgment
An overdose of alcohol in a short period of time can result to the following manifestations:
Vomiting
Loss of consciousness
Respiratory depression
Physiologic Effects of Long-term Alcohol Use
Cardiac myopathy
Wernickes encepalopathy
Korsakoffs psychosis
Pacreatitis
Esophagitis
Hepatitis
Cirrhosis
Leucopenia
Thrombocytopenia
Ascites

Treatment of Alcohol Overdose
1. Gastric lavage or dialysis. The procedure is performed to remove the drug from the systemic circulation.
2. Support of respiratory and cardiovascular functioning.

Alcohol Withdrawal
When an alcoholic withdraws from alcohol use, withdrawal symptoms usually starts at about 4 to 12 hours after
a marked reduction or cessation of alcohol intake. The withdrawal may take 1 to 2 weeks. It can be life-
threatening thus, prompt treatment and management is required or necessary.
Symptoms of alcohol withdrawal are:
Coarse hand tremors
Sweating
Elevated pulse
Increase blood pressure
Insomnia
Anxiety
Nausea and vomiting

Delirium Tremens (DTs)
In cases where the withdrawal signs and symptoms are not treated or becomes severe, the condition may
progress to a condition called delirium tremens. Delirium tremens is an acute episode of delirium that is mainly
caused after a long period of drinking and being stop abruptly and the person experiences withdrawal. It may
also be triggered by head injury, infection, or illness in people with a history of heavy use of alcohol
Signs and Symptoms of delirium tremens:
Transient hallucinations
Seizures
Delirium

Management for Alcohol Withdrawal
1. Detoxification under medical supervision
2. For mild alcohol withdrawal symptoms and the client can abstain from alcohol, home treatment is possible.
3. For severe cases where the client cannot abstain from alcohol during detoxification, a short admission (about
3-5 days) is done.
4. Safe withdrawal is accomplished through the administration of benzodiazepines such as Chlordiaxepoxide
(Librium), Lorazepam (Ativan) or Diazepam (Valium) to suppress the withdrawal symptoms.

Alcohol Detoxification

Alcohol detoxification is the removal of alcohol from the body of an individual who is alcohol dependent or
alcoholic. It is the abrupt cessation of alcohol intake coupled with the substitution of alcohol with drugs used
to prevent alcohol withdrawal. Alcohol detoxification is not possible without support from friends and family.
Most of all it needs a commitment on the part of the individual who will undergo detoxification to abstain from
alcohol use.
Alcohol Detoxification Process
The process of alcohol detoxification requires that alcohol be eliminated from the human body and that any
withdrawal or other symptoms that are bound to occur are treated medically or psychologically or both. As
mentioned earlier, the detoxification process is largely determined by the alcoholic himself. The detoxification
process is determined by the persons condition and by his approach.
In some cases, patients who undergo the alcohol detoxification process may suffer from hallucinations, delirium
tremens and convulsions, which require immediate attention and treatment. To minimize these symptoms,
medical drugs are given. However, the administration of these medications has to be monitored and accurately
controlled. Usually such medications have are given at high dosages initially, but is gradually tampered down
over a week.
Withdrawal symptoms can be quite distressing and can even become fatal if the addiction to alcohol is very
severe. Safe withdrawal is accomplished with the administration of benzodiazepines to suppress the withdrawal
symptoms. Drugs under this category are:
Chlordiaxepoxide (Librium) is the benzodiazepine of choice in uncomplicated alcohol withdrawal due to its
long half-life.
Diazepam (Valium) is available as an injection for patients who cannot safely take medications by mouth.
Lorazepam (Ativan) is available as an injection for patients who cannot safely take medications by mouth.
This is also indicated in patients with impaired liver function because they are metabolized outside of the liver.
The most common drugs used for alcohol detoxification are benzodiazepines, with Chlordiazepoxide being the
most preferred benzodiazepine used. Diazepam is also widely used, but fatal effects may occur if it is mixed
with huge doses of alcohol. Hence, supervision is necessary for use of diazepam as a detoxifier.
Where is alcohol detoxification done?
In most cases, alcohol detoxification can be done at home. This is applicable when the alcohol consumption is
just moderate. However, in cases where hallucinations, severe withdrawal symptoms and multi-substance misuse
are noted, an inpatient detoxification is required.


Anorexia Nervosa

Definition

Anorexia Nervosa is a disorder with an insidious onset that often affects adolescent girls.

Sufferers are typically high achievers, with good grades and described by parents as perfect children.
Disorder occurs commonly in upper middle class families. Usually the youngest child is affected.
Unlike bulimics, anorexics uses denial and do not accept that they have a problem, thus, they are more difficult
to treat.
10-20 % of anorexics die and half of these deaths are due to suicide.
They are often not recognized because they eat normally in social situations but after eating they retreat to
the nearest bathroom and purge themselves.
In order to prevent themselves from eating and to help maintain their very restrictive dietary program, they
avoid socializations such as parties, even family meals, thus becoming increasingly socially isolated.
They often start as chubby children or overweight adolescents. The disorder begins with somebody took notice
of their being overweight. Because the self-esteem of this person is based on the acceptance of others, they
go on dieting to lose weight and feel accepted again.
The personality is perfectionist, introverted, with low self-esteem and often has problems with peer
relationships. They are good children who are conscientious, hard working, and ideal students. Typically they
are people pleasers who seek approval and avoid conflict.
The person may have low tolerance to change and do not adjust well to new situations. Often they are overly
engaged with or dependent on parents or family. Dieting may represent avoidance or, or ineffective attempts
to cope with, the demands of a new life stage such as adolescence.
They may fear growing up and assuming adult responsibilities including an adult lifestyle. The symptoms of
anorexia are thought to be a kind of symbolic language that expresses: Im not ready to grow up yet, or Im
starving for attention.
Another factor is that this individual may have felt worthless and helpless. They try to combat these feelings
by taking over those parts of their life that they can control, that is, their weight and the food that they eat.
Types:
1. Restricting weight loss by dieting, fasting and excessive exercise.
2. Binge eating or purging uses self induced vomiting, abuses laxatives, diuretics or enema.

Assessment
Behaviors directed toward weight loss like dieting, exercise and purging.
Withdrawn and socially isolated, refuses to eat with family on the table.
Distorted body image, they see themselves as fat despite being emaciated.
Intense fear of becoming fat.
Due to misconception that food can make them obese and look ugly, their life is dominated by behavior directed
at avoiding food intake and weight loss. They then become preoccupied with food and engage in bizarre
behaviors such as peculiar way on handling food, hoarding food, collecting recipes, rearranging food on plate
repeatedly, dawdling, reading multiple materials about food to the point of thinking that they have superior
knowledge
Depressed, sleep disturbances, suicidal tendencies and crying spells.
Compulsive rituals.
In women, amenorrhea for at least four months and lack of interest in sexual activity due to lack of
nourishment, menstruation can occur only if a woman is able to maintain at least 17% of body fat.
In men, level of sex hormones drop. Males develop eating disorders too. About 10% of patient with eating
disorders are male.
Physical symptoms include bradycardia, hypothermia, dehydration, dependent edema, hypotension due to
decreased metabolic rate as a compensatory mechanism of the body to low food intake.
Induce vomiting, uses enema, diet pills, excessive exercise, diuretics and laxatives.
As disease progresses, becomes deceitful, stubborn, hostile, and manipulative.

Nursing Interventions
1. Cognitive and Behavioral therapy to positive and negative reinforcement: focus is on clients responsibility to
gain weight.
o Privileges are gained with weight gain.
o Privileges are lost with weight loss.
2. Increase self-esteem by acceptance and non-judgmental approach so the patient will realize that they do not
need to artificial perfection they believe thinness provides. Assist to find other positive qualities about self.
3. Teach about the disorder. The more information they receive that validates their problem, the less likely they
will deny it.
4. Monitor weight three times a week but weigh with the patient facing away from the weighing scale to help
them reduce their focus on weight. Make sure the patient is not hiding heavy objects under her clothing.
5. As soon as the ideal weight is gained, allow patient to regulate his or her own progression and program.
6. High protein and high carbohydrate diet, serve foods the patient prefer in small frequent feedings. NGT if the
patient refuses to eat.
7. Setting limits to avoid manipulative behavior:
o Restrict use of bathroom for 2 hour after eating.
o Accompany to the bathroom to ensure that they will not self induce vomiting.
o Stay with client during meals.
o Do not accept excuses to leave eating area.
8. Help the patient identify and express feelings. Avoid being judgmental. People with eating disorders are
thought to be afraid of expressing strong emotions; they express their feelings unconsciously by vomiting,
starvation, and purging.
9. Help the patient to identify and express other bodily concerns such as hairstyle, clothing. Typically anorectic
patients have little bodily awareness other than a distorted perception of their size.
10. Identify the patients non-weight related interests. This could help reduce anxiety, become creative outlet for
energy, raise self-esteem and divert attention from eating and weight.
11. Avoid being confrontational and engaging in long discussions or explanations about food or body.
12. Ignore manipulative behaviors.
13. Refer to self-help groups.
Anxiety
Definition:
Is a subjective, individual experience characterized by a feeling of apprehension, uneasiness, uncertainty, or
dread.
It occurs as a result of threats that may be actual or imagined, misperceived or misinterpreted, or from a
threat to identity or self-esteem.
It often precedes new experiences.

Types of Anxiety:

1. Normal
o A healthy type of anxiety that mobilizes a person to action.
2. Acute
o Precipitated by imminent loss or change that threatens the sense of security.
3. Chronic
o Anxiety that the individual has lived with for a long time.

Levels of Anxiety:
1.Mild/ Alertness Level (+1)
This is the type of anxiety associated with the normal tension of everyday life.
The individual is alert
Perceptual field is increased
Produce growth and creativity, as it increases learning
The person uses adaptive coping mechanisms to solve problems and alleviate anxiety.
Nursing Interventions:
1. Recognize the anxiety by statements such as I notice you being restless today.
2. Explore causes of anxiety and ways to solve problems that cause anxiety by statements such as Lets discuss
ways to
2. Moderate/ Apprehension Level (+2)
The response of the body to immediate danger and focus is directed to immediate concerns.
Narrows the perceptual field to pay attention to particular details.
Selective inattentiveness occurs
The increased tension makes this the optimal time for learning

The person uses palliative coping mechanisms.
Nursing Interventions:
1. Provide outlets for anxiety such as crying or talking.
2. Tell client Its all right to cry.
3. Encourage in motor activity to reduce tension.
4. Make client be aware of his behavior and feelings by statements such as I know you feel scare
5. Encourage client to move from affecting (feeling) to cognitive mode (thinking).
6. Refocus attention
7. Encourage the client to talk about felings and concerns.
8. Help the client identify thoughts and feelings that occurred prior to the onset of anxiety.
9. Provide anti-anxiety oral medications.
3. Severe/ Free-floating Level (+3)
Creates a feeling that something bad is about to happen, or feeling of an impending doom.
Fight and flight response sets in
Narrow perceptual field occurs and focus is on specific details or scaterred details so that learning and
problem-solving is not possible.
All behaviors are directed at alternative the anxiety
The individual needs direction to focus
Dilated pupils, fixed vision
The person uses maladaptive coping mechanisms.
Nursing Interventions:
1. Do not focus on coping mechanisms
2. Stay calm and stay with the client
3. Give short and explicit direction
4. Modify the environment by setting limits or seclusion, limit interaction with others, and reduce environmental
stimuli to calm client.
5. Provide IM antianxiety medications.
4. Panic Level (+4)
Feelings of helplessness and terror
The personality and behavior is disorganized
The individual lessens perception of the environment to protect the ego from awareness and anxiety causing
distorted perceptions and loss of rational thoughts.
Is unable to communicate or function effectively
Inability to concentrate
If prolonged, panic can lead to exhaustion and death
The person uses dysfunctional coping mechanisms.
Behavior Modification
Definition

Behavior modification is a method of strengthening desired behavior or response through a positive or negative
reinforcement of adaptive behavior or the reduction of a maladaptive behavior through extinction, punishment
or therapy.

For example you are an employee. You worked extra hours just to finish your tasks, arrives at work on time and
sometimes you skip lunch just to complete the assigned job. A hard worker thats what you are! Now after a
month of hard work your paycheck is delayed. Weeks and months passed and still the salary is not released.
Would you perform the same effort towards your job now that you are still unpaid? You might still go to work
with a change behavior or stop working.

For working people, receiving a regular and on-time paycheck is a positive reinforcer that motivates the
employees to do their job well. If this motivating factor is lacking, expect a less efficient job performance
from the employees. Behaviorists believed that a behavior can be change through a system of rewards and
punishments.


Positive and Negative Reinforcement
A positive reinforcement is provided by giving a person attention and positive feedback. For example, a child
has successfully made it through the night without wetting the bed. The mother acknowledges the childs
behavior in front of the family during breakfast period.
A negative reinforcement on the other hand is done by removing a stimulus after a behavior occurred to
prevent it from occurring again. For example, a student becomes anxious when he is seated at the back during
classes. He or she may ask the professor to be seated in front to prevent such anxiety.

Indication
Obsessive-compulsive behavior (OCD)
Attention deficit hyperactivity disorder (ADHD)
Phobias
Enuresis (bed-wetting)
Generalized anxiety disorder
Separation anxiety disorder

Behavior Modification Techniques
ABC approach
A Antecedents
Antecedents are the events that occur before a particular behavior is demonstrated. What comes directly
before the behavior?
B Behaviors
The behavior developed as a result of the presence of antecedent. What does the behavior look like?
C Consequences
These are the events that occur after the behavior. What comes directly after the behavior?
After the ABCs are assessed, the data gathered is analyzed and identified as inappropriate and appropriate
behavior. Inappropriate behaviors are observed, targeted and stopped while the appropriate ones are
identified, developed, strengthened and maintained.

Some Behavioral Theories and Theorists
Theorists such as Ivan Pavlov and Burrhus Frederick Skinner focused on observable behaviors and factors that
bring about behavioral changes.
Classical Conditioning by Ivan Petrovich Pavlov
Ivan Pavlov is a Russian psychologist, physiologist and physician widely known for providing the best example of
classical conditioning through experimentation on dogs. Classical conditioning principle states that a behavior
can be modified or changed through conditioning of the external stimuli or conditions.
Operant conditioning by Burrhus Frederick Skinner
B.F. Skinner is an American psychologist who developed the operant conditioning. Operant conditioning states
that people learn their behaviors from their past experiences particularly those which as constantly
reinforced.

Bipolar and Unipolar Comparison

Bipolar
Results from disturbances in the areas of the brain that regulate mood
It involves periods of excitability (mania) alternating with periods of depression
This may affects men and women equally
Usually appears between ages 15 25
Cause
Unknown
It occurs more often in relatives of people with bipolar disorder
Symptoms
Manic Phase
1. Agitation or irritation
2. Elevated mood (hyperactivity, increased energy, lack of self-control, racing thoughts)
3. Inflated self-esteem (delusions of grandeur, false beliefs in special abilities)
4. Little need for sleep
5. Over-involvement in activities
6. Poor temper control
7. Reckless behavior (binge eating, drinking, and/or drug use, impaired judgment, sexual promiscuity, spending
sprees)
8. Tendency to be easily distracted
Depressed Phase
1. Difficulty concentrating, remembering, or making decisions
2. Eating disturbances
3. Fatigue or listlessness
4. Feelings of worthlessness, hopelessness and/or guilt
5. Loss of self-esteem
6. Persistent sadness and thoughts of death
7. Sleep disturbances
8. Suicidal thoughts
9. Withdrawal from activities that were once enjoyed
Medical Intervention
Proper History Taking and Observation
Antipsychotic medications (such as lithium and mood stabilizers or antidepressant for depressive phase)
Electroconvulsive therapy (ECT)
Nursing Interventions
1. Provide a calm environment
2. Giving health teachings about regular exercise, and proper diet
3. Explain to patient that getting enough sleep helps keep a stable mood

Unipolar
Another name for major depressive disorder
Occurs when a person experiences the symptoms for longer than a two-week period
Causes
The biopsychosocial model proposes that biological, psychological, and social factors all play a role in causing
depression
The diathesisstress model specifies that depression results when a preexisting vulnerability, or diathesis, is
activated by stressful life events
Symptoms
1. Depressed mood
2. A lack of interest in activities normally enjoyed
3. Changes in weight and sleep
4. Fatigue
5. Feelings of worthlessness and guilt
6. Difficulty concentrating
7. Has thoughts of death and suicide
Medical Interventions
Antidepressants
Tricyclic antidepressants
Monoamine oxidase inhibitors
Selective serotonin re-uptake inhibitors
Electroconvulsive therapy
Nursing Interventions
1. Interpersonal Therapy
2. Psychotherapy
3. Encourage client to have a regular exercise
4. Cognitive behavioral therapy
5. Behavioral modification therapy

Difference between Bipolar and Unipolar Disorder
UNIPOLAR BIPOLAR
Gender
and Age
of Onset
Affects women more
often than men, appears
later in life
Affects men and
woman equally,
average age of onset
suspected to be 18
years
Sleep Generally insomnia,
difficulty falling asleep
or waking repeatedly
during the night
Generally
hypersomnia,
excessive tiredness
and difficulty waking
in the morning
Appetite Often has a loss of
appetite and diminished
interest in eating
Often binge-eating
and cravings for
carbohydrates, may
alternate with loss of
appetite
Activity
Level
Agitated, pacing and
restlessness are more
common
Inactivity,
somnolence, a slowing
down of movements
(psychomotor
retardation) more
common
Mood Sadness, hopelessness,
feelings of
worthlessness
Same as for unipolar,
although guilt is often
much more prominent
Other Episodes often last
longer, sometimes more
responsive to treatment
Risk of drug abuse and
suicide higher than in
unipolar depression
Bipolar Disorder
Description

A mood disorder, formerly known as manic depression is characterized by recurrent episodes of depression and
mania. Either phase may be predominant at any given time or elements of both phases may be present
simultaneously.

Risk Factors

1. Biochemical imbalances
2. Family genetics one parent, child has 25% risk; two parents, 50-75% risk.
3. Environmental factors such as stress, losses, poverty, social isolation.
4. Psychological influences inadequate coping, denial of disordered behavior.

Specific Biological Factors
1. Possible excess of norepinephrine, serotonin, and dopamine.
2. Increased intracellular sodium and calcium
3. Neurotransmitters supersensitive to transmission of impulses
4. Defective feedback mechanism in limbic system.

Signs and Symptoms
1. Risk for self or others
2. Impaired social interactions
3. Mania

o Persistent elevated or irritable mood
o Poor judgment
o Increase in talking and activities, grandiose view of self and abilities.
o Impulsivity such as spending money, giving away money or possessions.
o Impairment in social and occupational functioning
o Decreased sleep
o Distractibility
o Delusions, paranoia, and hallucinations
o Dislike of interference or intolerance of criticism
o Denial of illness
o Agitation
o Attention seeking behavior
o Depression

Nursing Diagnoses
1. High risk for violence, directed at self or others
2. Impaired verbal communication
3. Anxiety
4. Individual coping, ineffective
5. Disturbance of self-esteem
6. Alteration in though processes
7. Alteration in sensory perceptions
8. Self-care deficits
9. Sleep pattern disturbances
10. Alteration in nutrition

Therapeutic Nursing Management
1. Environment
2. Psychological treatment
o Individual Psychotherapy may be used to identify stressors and pattern of behavior.
o Group therapy establishes a supportive environment and redirect inappropriate behavior.
o Family therapy verbalizes family frustration and establishes a treatment plan for outpatient use.
3. Somatic and Psychopharmacologic treatments
o electroconvulsive therapy
o Psychopharmacology

Nursing Interventions
1. Assess clients suicidal feelings and intentions and escalating behavior regularly.
2. Set consistent limits on inappropriate behavior to help the client de-escalate.
3. Establish a calm environment for the client.
4. Reinforce and focus on reality.
5. Provide outlets for physical activity but prevent client for escalating.
6. Client may be very likable during high periods. Staff members need to avoid participating in this behavior, at
other times, client may be very irritable and staff members should approach client quietly and with limits, if
necessary.
7. If the client cannot control self and other methods are not successful, staff may need to provide client
protection if a threat of a self-harm or injury to other exist.
8. Monitor clients nutrition, fluid intake and sleep.
9. Discuss with the client and family the possible environment or situational causes, contributing factors and
triggers for a mood disorder with recurrent episodes of depression and mania.
Bulimia Nervosa

Definition
The Diet-Binge-Purge Disorder.
Is a disorder characterized by alternating dieting, binging and purging through vomiting, enema, and laxatives.
The person engages in episodes of starvation and other methods of controlling weight (diet pills, excessive
exercise, enemas, diuretics, laxatives), then engages in uncontrolled and rapid eating for about two hours (over
8000 calories in 2 hours and 50,000 in 1 day) then terminates binging by inducing self to vomit, going to sleep
or going to social activities.
Weight fluctuations are due to alternating fasting and binging.
1. Bulimia means insatiable appetite.

2. Binging means eating an unusually large amount of food over a short period of time.
3. Purging is an attempt to compensate for calories consumed via self-induced vomiting or abuse of laxatives,
diuretics, or enemas.
A chronic disorder that usually manifest first during late adolescence and early adulthood, around the ages 15-
24 years. It almost always occurs after a period ofdieting.
The bulimic often belong to a family and society that place great value on external appearance. The person
strives to be thin to be accepted because they believe self-worth requires being thin.
Usually of normal weight or obese, extrovert, reports self loathing, low self-esteem, has symptoms of
depression, of fear of losing control, with self-destructive tendencies such as suicide.
These individuals are known to be perfectionist, achievers scholastically and professionally and highly
dependent on the approval of others to maintain self-esteem. They hide their disorder because of fear of
rejection.
Like anorexia, bulimia can kill. Even though bulimics put up a brave front, they are often depressed, lonely,
ashamed, and empty inside. Friends may describe them as competent and fun to be with, but underneath, when
they hide their guilty secrets, they are hurting. Feeling unworthy, they suffered from great difficulty talking
about their feelings, which almost always include anxiety, depression, self-doubt, and deeply buried anger.
Impulse control may be a problem like shoplifting, sexual adventurousness, alcohol and drug abuse, and other
kinds of risk taking behavior in which the person acts with little consideration of consequences.
The person is aware that the behavior is abnormal, but is unable to stop because she is immobilized by her fear
that she cannot stop her behavior voluntarily. The binge episode usually ends when the person becomes
exhausted eating, develops GIT discomfort, runs out of food or is noticed by others.
After the episode she becomes guilty and depressed that she was unable to control herself, and engages in
self-critism. Then she purges her self as a form of cleansing and punishment.

Common Complications Related to the Manner of Purging
Chronic inflammation of the lining of the esophagus due to induced vomiting, acidic gastric secretions irritates
esophageal mucosa.
Rupture of esophagus and stomach.
Electrolyte imbalance causing cardiac arrythmias, hypokalemia due to diarrhea,hypochloremia due to vomiting,
hyponatremia due to vomiting and diarrhea.
Dehydration.
Enlargement of the parotid gland.

Irritable bowel syndrome.
Rectal prolapse or abscess.
Dental erosion.
Chronic edema.
Fungal infection of vagina and rectum.

Nursing Diagnosis
Alterations in health maintenance.
Altered nutrition: Less than body requirements.
Altered nutrition: More than body requirements
Anxiety
Body image disturbance
Ineffective family coping; compromised
Ineffective individual coping
Self-esteem disturbance

Nursing Interventions
1. Patient with bulimia are aware of their problems and they want to be helped because they feel helpless and
unable to control themselves during episodes of binging. But because of their intense desire to please and need
to conform they may resort to manipulative behavior and tell half-truths during interview to gain trust and
acceptance of nurses. Create an atmosphere of trust. Accept person as worthwhile individual. If they know
that no rejection or punishment is forthcoming they disclose their problem, they will be more open and honest.
2. Develop strength to cope with problems. Encourage patient to discuss positive qualities about themselves to
increase self-esteem.
3. Help patient identify feelings and situations associated with or that triggers binge eating.
o Assist to explore alternative and positive ways of coping.
o Encourage making a journal of incident and feelings before-during and after a binge episode.
o Make a contract with the patient to approach the nurse when they feel the urge to binge so that feelings and
alternative ways of coping can be explored.
4. Encourage adhering to meal and snack schedule of hospital. This decreases the incidence of binging, which is
often precipitated by starvation and fasting.
5. Encourage participating in group activities with other persons having the same eating disorder to gain additional
support.
6. For young adolescent living at home, encourage family therapy to correct dysfunctional family patterns.
7. Cognitive behavioral therapy is the ideal therapy to help the bulimic understand the problem and explore
appropriate behaviors.
Cognitive Disorders
Definition

Cognitive disorders are characterized by the disruption of thinking, memory, processing, and problem solving.
Types of cognitive disorders include: delirium, dementia, and memory loss disorders (amnesia or dissociative
fugue).

Risk Factors
1. Physiological changes such as neurological, metabolic, and cardiovascular disease.
2. Cognitive changes
3. Family genetics
4. Infections
5. Tumors
6. Sleep disorders
7. Substance abuse
8. Drug intoxications and withdrawals

Signs and Symptoms
1. Irritability; mood most frequently seen in organic brain disorder.
2. Change in level of consciousness.
3. Difficulty thinking with sudden onset.
4. State of awareness ranging from hyper vigilance to stupor or coma.
5. Impairment in cognition and thought process, particularly short-term memory.
6. Anxiety
7. Confabulation

Therapeutic Nursing Management
1. The nurse plays a primary role in providing a safe environment for the client and others.
2. Exogenous stimuli in the environment can intensify the clients level of orientation.
3. Cognitive changes may often include a period of confusion or forgetfulness.
4. The nurse may encourage family members to bring photographs or familiar items as strategy to orient the
client.
5. Psychological treatment may focus more on the family to offer them support during this stressful time.
6. Cognitive changes affect the family and care providers. Cognitive decline often means a change in the family
roles and activities of daily living.
7. Pharmacologic therapy is implemented to reduce or alleviate the associated symptoms such as antianxiety
medications, antidepressants, and antipsychotics.

Nursing Interventions
1. Determine the cause and treatment of the underlying causes.
2. Remain with the client, monitoring behavior, providing reorientation and assurance.
3. Provide a room with a low level of visual and auditory stimuli.
4. Provide palliative care with the focus on nutritional support.
5. Reinforce orientation to time, place, and person.
6. Establish a routine.
7. Client protection may be required.
8. Have client wear an identification bracelet, in case she or he gets lost.
9. The client should not be left alone at home
10. Break test into small steps, giving one instruction at a time.
Crisis Intervention
Definition

Crisis is a situation or period in an individuals life that produces an overwhelming emotional response. This
event occurs when an individual is confronted by a certain life circumstance or stressor that he or she cannot
effectively manage by using his or her usual coping skills. Crisis is an unexpected event that can create
uncertainty to an individual and has been viewed as a threat to a persons important goals.

Stages of Crisis

The first stage of crisis occurs when the person is confronted by a stressor. Exposure to this stressor would
result to anxiety. The individual then tries to handle things by using his or her customary coping skills. Second
stage of crisis occurs when the person realizes that his usual coping ability is ineffective in dealing with
anxiety. As the person becomes aware of his unsuccessful effort in dealing with the perceived stressor, he
moves on to the next stage of crisis where the individual tries to deal with the crisis using new methods of
coping. The fourth stage of crisis takes place when the persons coping attempts of resolving the crisis fail.
The individual then experiences disequilibrium and significant distress.

Types of crisis
1. Maturational crisis also called developmental crisis. These are predictable events in a persons life which
includes getting married, having a baby and leaving home for the first time.
2. Situational crises unexpected or sudden events that imperils ones integrity. Included in this type of crisis
are: loss of a job, death of a loved one or relative and physical and emotional illness of a family member or an
individual.
3. Adventitious crisis also called social crisis. Included in this category are: natural disasters like floods,
earthquakes or hurricanes, war, terrorist attacks, riots and violent crimes such as rape and murder.

Crisis Intervention
Crisis intervention refers to the methods used to offer immediate, short-term help to individuals who
experience an event that produces emotional, mental, physical, and behavioral distress or problems.
Guide for an effective crisis intervention:
1. Assist the person to view the event or issue in a different perspective.
2. Assist the individual to use the existing support systems. It is vital to help the person find new sources of
support that can help in decreasing the feelings of being alone or overwhelmed.
3. Assist the individual in learning new methods of coping that will help resolve the current crisis and give him or
her new coping skills to be used in the future when dealing with another overwhelming situation.
Defense Mechanisms

People use defense, or coping, mechanisms to relieve anxiety. The definitions below will help you determine
whether your patient is using one or more of these mechanisms.
1. 1. Acting Out
o Acting out refers to repeating certain actions to ward off anxiety without weighing the possible consequences
of those action.
o Example: A husband gets angry with his wife and starts staying at work later.
2. Compensation
o Also called substitution.
o It involves trying to make up for feelings of inadequacy or frustration in one area by excelling or overindulging
in another.
o Example: An adolescent takes up jogging because he failed to make the swimming team.
3. Denial
o A person in denial protects himself from reality especially the unpleasant aspects of life by refusing to
perceive, acknowledge, or face it.
o Example: A woman newly diagnosed with end-stage-cancer says, Ill be okay, its not a big deal.
4. Displacement
o In displacement, the person redirects his impulses (commonly anger) from the real target (because that target
is too dangerous) to a safer but innocent person.
o Example: A patient yells at a nurse after becoming angry at his mother for not calling him.
5. Fantasy
o Fantasy refers to creation of unrealistic or improbable images as a way of escaping from daily pressures and
responsibilities or to relieve boredom.
o Example: A person may daydream excessively, watch TV for hours on end, or imagine being highly successful
when he feels unsuccessful. Engaging in such activities makes him feel better for a brief period.
6. Identification
o In identification, the person unconsciously adopts the personality characteristics, attitudes, values, and
behavior of someone else (such as a hero he emulates and admires) as a way to allay anxiety. He may identify
with a group to be more accepted by them.
o Example: An adolescent girl begins to dress and act like her favorite pop star.
7. Intellectualization
o Also called isolation.
o Intellectualization refers to hiding ones emotional responses or problems under a faade of big words and
pretending theres no problem.
o Example: After failing to obtain a job promotion, a worker explains that the position failed to meet his
expectations for climbing the corporate ladder.
8. Introjection
o A person introjects when he adopts someone elses values and standards without exploring whether they fit
him.
o Example: An individual begins to follow a strict vegetarian diet for no apparent reason.
9. Projection
o In projection, the person attributes to others his own unacceptable thoughts, feelings, and impulses.
o Example: A student who fails a test blames his parents for having the television on too loud when he was trying
to study.
10. Rationalization
o Rationalization occurs when a person substitutes acceptable reasons for the real or actual reasons that are
motivating his behavior.
o The rationalizing patient makes excuses for shortcomings and avoids self-condemnation, displacements, and
criticisms.
o Example: An individual states that she didnt win the race because she hadnt gotten a good nights sleep.
11. Reaction Formation
o In reaction formation, the person behaves the opposite of the way he feels.
o Example: Love turns to hate and hate into love.
12. Regression
o Under stress, a person may regress by returning to the behaviors he used in an earlier, more comfortable time
in his life.
o Example: A previously toilet-trained preschool child begins to wet his bed every night after his baby brother is
born.
13. Repression
o Repression refers to unconsciously blocking out painful or unacceptable thoughts and feelings, leaving them to
operate in the subconscious.
o Example: A woman who was sexually abused as a young child cant remember the abuse but experiences uneasy
feelings when she goes near the place where the abuse occurred.
14. Sublimation
o In sublimation, a person transforms unacceptable needs in acceptable ambitions and actions.
o Example: He may channel his sex drive into his sports or hobbies.
15. Undoing
o In undoing, the person tries to undo the harm he feels he has done to others.
o Example: A patient who says something bad about a friend may try to undo the harm by saying nice things about
her or by being nice to her and apologizing.
Developmental Theories

Theorists consider that emotional, social, cognitive and moral skills develop in stages.


1. Psychosocial Erik Eriksons theory of psychosocial development is most widely used. At each stage, children
confront a crisis that requires the integration of personal needs and skills with social and cultural expectations.
Each stage has two possible components, favorable and unfavorable.
2. Psychosexual Sigmund Freud considered sexual instincts to be significant in the development of personality.
At each stage, regions of the body assume prominent psychologic significance as source of pleasure.
3. Cognitive Jean Piaget proposed four major stages of development for logical thinking. Each stage arises
from and builds on the previous stage in an orderly fashion.
4. Moral Lawrence Kohlbergs theory of moral development is based on cognitive development and consists of
three major levels, each containing two stages.
Stage Erikson Freud Piaget Kohlberg
Infancy
(birth to 1
year)
Trust vs.
mistrust
Oral Sensorimotor
(birth to 2
years)

Toddlerhood
(1-3 years
old)
Autonomy
vs. same and
doubt
Anal Sensorimotor
(1-2 years);
preoperational
(preconceptual)
(2-4 years)
Preconventional
Preschool
(3-6 years
old)
Initiative vs.
guilt
Phallic Preoperational
(preconceptual)
(2-4 years);
preoperational
(intuitive) (4-7
years)
Preconventional
School Age
(6-12 years)
Industry vs.
inferiority
Latency Concrete
operations
(7-11 years)
Conventional
Adolescence
(12-18
years)
Identity vs.
role
diffusion
(confusion)
Genital Formal
operations
(11-15 years)
Postconventional
Eating Disorders
Overview
Eating is very important in every human being. Not only that it is necessary for survival but it is also a social
activity and has been part of many occasions all around the world. For some individuals, eating is one source of
their worries, anxiety and problems.
Many people are worried and apprehensive about how they look. Most of the time, they can feel self-conscious
about their bodies. Amongst the population, the teens are the ones most concerned about their body figure.
This can be true, especially that they are going through puberty and they undergo dramatic physical changes
and face social pressures.


Definition
Eating disorders refer to a group of conditions that are described and typified by the abnormal eating habits
that are involved. The food intake in this case are either insufficient or excessive that results to detriment of
an individuals physical and emotional health.

List of Common Eating Disorders
Anorexia Nervosa (AN). AN is a life-threatening eating disorder. It is characterized by the clients refusal or
inability to maintain a minimally normal weight and an intense fear of gaining weight. Clients with anorexia
nervosa have a disturbed perception of the size and shape of their body. These people have body weight that is
85% or less of that expected for their age and height. Anorexia can cause menstruation to stop, and often
leads to bone loss, loss of skin integrity, etc. It greatly stresses the heart, increasing the risk of heart attacks
and related heart problems. The risk of death is greatly increased in individuals with this disease.
Bulimia Nervosa. Bulimia is characterized by recurrent binge eating followed by compensatory behaviors such
as purging (self-induced vomiting, excessive use of laxatives/diuretics, or excessive exercise). The amount of
food consumed during a binge episode is quite larger than a person would normally eat. Bulimics may also fast
for a certain amount of time following a binge. Clients with bulimia binge because of strong emotions which are
then followed by guilt and shame.
Binge Eating Disorder. This type of eating disorder is characterized by a compulsive overeating. However,
unlike bulimia nervosa no compensatory behavior is noted after the binge episode.
Purging Disorder. Individuals who are eating normally but are recurrently purging to promote weight loss are
under this category.
Pica. Individuals who cannot distinguish between food and non-food items have PICA. In this type of eating
disorder, a person is craving to eat, chew or lick non-food items or foods containing no nutrition. These things
include chalk, paper, plaster, paint chips, baking soda, starch, glue, rust, ice, coffee grounds and cigarette
ashes.
Electroconvulsive Therapy (ECT)
Definition
Electroconvulsive therapy or the shock treatment is used to treat depression in clients who do not respond to
antidepressants or those patients who have intolerable adverse reactions at administered therapeutic doses.
Despite the controversy about the therapy, it is proven to be effective for certain patients. Many depressed
(major) clients, particularly those with psychotic symptoms, dont respond to medications but do respond to
ECT.

Indications
Nowadays, ECT is not only used for major depression, but also for the treatment of:

mania (in bipolar disorder)
catatonia
quick relief for self-destructive behavior (suicide attempts)
ECT may only be indicated for the treatment of severely depressed clients that needs fast relief. Suicidal
clients may be given ECT. Giving antidepressant medication may take weeks before the full effects to occur.
That is an enough time for a self-destructive client to harm himself.
Can pregnant women undergo ECT?
Pregnant clients can also undergo an electroconvulsive therapy. The treatment poses no harm or injury to the
fetus. Thus, pregnant self-destructive women may undergo ECT to provide quick relief of depression and self-
directed violence. This prevents a fetus from suffering if an untreated the mother tries to hurt herself while
waiting for the medication to take full effect.

Contraindications and precautions
ECT stimulates a seizure episode to occur, however it does not cause a seizure disorder and patient with a
seizure disorder may undergo the therapy. No absolute contraindications are noted with ECT but a few
conditions have been associated with morbidity and mortality rate which includes the following:
recent myocardial infraction
stroke
sever hypertension
presence of intracerebral mass

Mechanism of action
The therapy induces a therapeutic tonic seizure (a seizure where the person loses consciousness and has
convulsions) which lasts for about 15 seconds. To do this, electrodes are applied to the head of the client which
will deliver an electrical impulse in the brain that causes a seizure. It is believed that the shock intensifies
brain chemistry to correct the chemical imbalance in depression (decrease serotonin and norepinephrine).
Frequency of treatment
A series of about 6-15 treatments are scheduled three times a week. Six treatments are needed to observe a
sustained improvement of depressive symptoms. Maximum effect or benefit is achieved in 12 to 15 treatments.

Side Effects
Confusion or Disorientation
Fatigue
Headache
Short-term memory impairment (temporary)

Nursing Interventions
Before ECT
1. Informed consent should be signed.
2. NPO post midnight.
3. Remove fingernail polish.
4. IV line initiation.
5. Administration of short-acting anesthetic.
6. Administration of a sedative or muscle relaxant (succinylcholine). Atropine is also given to decrease bronchial
secretions which could block the airways during seizures.
7. Let the client void before the procedure.
During ECT
1. Place electrodes on the clients head on one side (unilateral) or both (bilateral).
2. Brain monitoring through electroencephalogram (EEG).
3. Oxygen administration with an Ambu-bag.
After ECT
1. When the client is awake, reorient the client.
2. Obtain vital signs.
3. Assess client for the return of gag reflex.
4. Allow the client to eat (with a positive gag reflex).
Feeding and Eating Disorders of Infancy and Early Childhood

Definition

Feeding disorder of infancy or early childhood is characterized by the failure of an infant or child under six
years of age to eat enough food to gain weight and grow normally over a period of one month or more. The
disorder can also be characterized by the loss of a significant amount of weight over one month. The disorders
of feeding and eating included in this category are persistent in nature and are not explained by underlying
medical conditions. They include the following:
1. Pica
2. Rumination disorder
3. Feeding disorder
PICA
Pica is an eating disorder typically defined as the persistent ingestion of nonnutritive substances for a period
of at least 1 month at an age at which this behavior is developmentally inappropriate (eg, >18-24 mos). It is seen
more in young children than adults. Between 10 and 32% of children ages 1 6 have these behaviors.
Children with Pica may eat:
1. Animal feces
2. Clay
3. Dirt
4. Hairballs
5. Ice
6. Paint
7. Sand
This pattern of eating should last at least 1 month to fit the diagnosis of pica. It is not yet known what causes
pica, but research indicates that it may be related to mineral deficiencies such as an iron deficiency. However,
often the non-food items that an individual chooses to consume will not contain the mineral of which they are
deficient, so pica is not an alternative means of obtaining nutrients.
RUMINATION DISORDER
The term rumination is derived from the Latin word ruminare, which means to chew the cud. Rumination
disorder is the repeated regurgitation and re-chewing of food. With this disorder, the child brings the
partially digested food up into the mouth and usually re-chews and re-swallows the food. This regurgitation
appears effortless, may be preceded by a belching sensation, and typically does not involve retching or nausea.
In rumination, the regurgitant does not taste sour or bitter. To be considered a disorder, this behavior must
occur in children who had previously been eating normally, and it must occur on a regular basis, usually daily, for
at least one month. The child may exhibit the behavior during feeding or right after eating.
Symptoms of rumination disorder in babies and young kids include:
1. Repeated regurgitation of food
2. Repeated re-chewing of food
3. Weight loss
4. Bad breath and tooth decay
5. Repeated stomach aches and indigestion
6. Raw and chapped lips
This disorder is relatively uncommon and occurs more often in boys than in girls. It results in malnutrition,
weight loss, and even death in about 25% of affected infants.
FEEDING DISORDER
Feeding disorder of infancy or early childhood is characterized by persistent failure to eat adequately, which
results in significant weight loss or failure to gain weight. This disorder is equally common in boys and girls. It
occurs most often during the first year of life.
General Nursing Interventions for the Mental Health Client

Forming a one-to-one relationship with the client
It will help the client to enhance communication, problem solving, and social skills.
Coping skills and trust in relationships may be learned or enhanced.
The nurse who establishes this relationship needs to be clear about its purpose and provide positive interaction
with the client.
Establishment of a specific meeting time, expectations for interaction, and the duration of therapy are
important boundaries to establish.

Constructive Feedback
Given to the client so that the clients self-esteem will not be compromised.
When the confrontation technique is used, the nurse needs to discuss the discrepancies between the clients
verbalized intensions and non-verbal behavior carefully, without appearing to be attacking the client.

Trust
Essential to establish a therapeutic relationship.
Consistency is the key.
If the nurse cannot meet with client at an appointed time, the client must be informed at the earliest possible
time.
A new meeting time is scheduled.
Direct communication is essential for the building of a therapeutic relationship.
Other factors that facilitate trust within the nurse/client relationship include:
1. Recognizing the clients feelings.
2. Honesty
3. Respect for the client
4. Non-judgmental attitude

Emphasize Positive Results
Do not argue with the client.
Recognize that the client is experiencing pain but do not dwell on that pain.

Assessment
Critical of their behavior at the time of admission or initial treatment. Reassessment is indicated at
appropriate intervals.
The client must also learn how to self-monitor his or her symptoms.
This communicates to the client that he or she is respected and can control his or her symptoms.

Safety
The primary concern.
The client may require protection interventions; these must be provided in a safe manner with respect for the
client.
The milieu may need to be evaluated for safety

Environment
Provide privacy and time with decreased stimuli.
It should be a calm environment in which the client feels safe from psychological and physical threats.

Physical needs
Intricately related to psychological function.
Ensure that the clients nutritional, fluid, sleep, hygiene, activities of daily leaving, and exercise needs are met.

Treatment planning
The client should encourage to participate in every planning.

Medications
Approach the confused or combative client in a calm, firm manner when administering client.
Restrains or the assistance of another care provider may be necessary for injections.
Ensure that the client takes medications and is not hoarding pills.
Client will need to learn about his or her medications and hot to maintain this treatment without direct staff
supervision.

Education
Very important throughout treatment.

Discharge planning
Begins with the client is admitted, whether it is in the hospital, home care, or any other treatment program.
The family must be involved in the process to become successful.
Gestalt Therapy
Definition
Gestalt therapy is a form of psychotherapy, based on the experiential ideal of here and now, and
relationships with others and the world. It is an existential or experiential form of psychotherapy that
emphasizes personal responsibility. Gestalt therapy is used often to increase a clients self-awareness by
putting the past to rest and focus on the present.

History
Gestalt therapy was originally developed by Frederick Fritz Perls, Laura Perls, and Paul Goodman in the 1940s.
Perls believed that self-awareness leads to self-acceptance and responsibility for ones thoughts and feelings.
Gestalt therapy rose from its beginnings in the middle of the 20th century to rapid and widespread popularity
during the decade of the 1960s and early 1970s. During the 70s and 80s Gestalt therapy training
centers spread globally, but they were, for the most part, not aligned with formal academic settings.

Focus of the therapy
The therapy focuses upon the individuals experience in the present moment, the therapist-client relationship,
the environmental and social contexts of a persons life, and the self-regulating adjustments people make as a
result of their overall situation.

Goals that are encouraged to achieved by the patient during Gestalt Therapy
1. Identifying the persons action or becoming aware of what they are doing.
2. Becoming aware of how they are doing a certain behavior.
3. Learning how to change the behaviors that keeps him or her from achieving life goals.
4. Accepting and valuing him or herself as a person.
5. Emphasizes of what is being done, thought and felt at the present time rather than what might have been,
should have been, was or might be. It FOCUSES on what is happening instead of on the subject being
discussed.

Gestalt Techniques
1. Increasing the awareness of body language and of negative internal messages.
2. Making a client speak continually in the present tense and in the first person to emphasize self-awareness.
3. Creation of episodes by the therapist and diversions that clearly demonstrate a point rather that explaining in
words.
4. Asking the client to concentrate on a part of his or her personality or one emotion. The therapist would then
ask the client to address it as if it were sitting by itself in the clients chair.
5. To increase self-awareness the therapist often use this therapy by having then write and read letters, keep
journals and perform other activities designed to put the past tp rest and focus on the present.
Group Therapy
Definition
Group therapy is a form of psychotherapy which as small, carefully selected group of individuals meets
regularly with a therapist. The client participates in sessions with a group of people. These individuals share a
common purpose and are expected to contribute to the group to benefit from others in return.
In group therapy approximately 6-10 individuals meet face-to-face with a trained group therapist. During the
group meeting time, members decide what they want to talk about. Members are encouraged to give feedback
to others. Feedback includes expressing your own feelings about what someone says or does. Group rules are
established that all members must observe. These set of rules vary according to the type of group.

Purpose of a Group Therapy
1. It helps an individual gain new information or learning
2. It helps an individual gain inspiration or hope.
3. The group also allows a person to develop new ways of relating to people.
4. During group therapy, people begin to see that they are not alone and that there is hope and help. It is
comforting to hear that other people have a similar difficulty, or have already worked through a problem that
deeply disturbs another group member.
5. In a group, a person feels accepted.
6. Group therapy sessions allow an individual to interact freely with other members that shares the same past or
present difficulties and problems. The individual then, becomes aware that he is not alone and that others
share the same problem.
7. A person gains insight into ones problem and behaviors and how they affect to others.
8. Altruistic behavior is practiced. Altruism is the giving of oneself for the benefit of others.
As the group members begin to feel more comfortable, they will be able to speak freely. The psychological
safety of the group will allow the expression of those feelings which are often difficult to express outside of
group. The client will begin to ask for the support he or she needs.

Types of Group Therapy
1. Psychotherapy Groups
2. Family therapy
3. Education groups
4. Support groups
5. Self-help group
Human Growth and Development

The term growth and development both refers to dynamic process. Often used interchangeably, these terms
have different meanings. Growth and development are interdependent, interrelated process. Growth generally
takes place during the first 20 years of life.; development continues after that.
Growth:
1. Is physical change and increase in size.
2. It can be measured quantitatively.
3. Indicators of growth includes height, weight, bone size, and dentition.

4. Growth rates vary during different stages of growth and development.
5. The growth rate is rapid during the prenatal, neonatal, infancy and adolescent stages and slows during
childhood.
6. Physical growth is minimal during adulthood.
Development:
1. Is an increase in the complexity of function and skill progression.
2. It is the capacity and skill of a person to adapt to the environment.
3. Development is the behavioral aspect of growth

Freuds Psychosexual Development Theory
STAGE AGE CHARACTERISTICS
1. Oral Birth to
1 y/o
Center of pleasure: mouth (major source of gratification &
exploration)
Primary need: Security
Major conflict: weaning
2. Anal 1 to 3
y/o
Source of pleasure: anus & bladder (sensual satisfaction &
self-control)
Major conflict: toilet training
3. Phallic 4 to 6 y/o Center of pleasure: childs genital (masturbation)
Major conflict: Oedipus & Electra Complex
4.
Latency
6 y/o to
puberty
Energy directed to physical & intellectual activities
Sexual impulses repressed
Relationship between peers of same sex
5.
Genital
Puberty
onwards
Energy directed towards full sexual maturity & function &
development of skills to cope with the environment

Eriksons Stages of Psychosocial Development Theory
STAGE AGE CENTRAL
TASK
(+)
RESOLUTION
(-)
RESOLUTION
1. Infancy Birth-
18 mos
Trust vs
Mistrust
Learn to trust
others
Mistrust,
withdrawal,
estrangement
2. Early
childhood
1 to 3
y/o
Autonomy
vs Shame &
doubt
Self control w/o
loss of self
esteem
Ability of
cooperate &
express oneself
Compulsive,
self-restraint
or compliance.
Willfulness &
defiance.
3. Late
childhood
3 to 5
y/o
Initiative vs
guilt
Learns to
become
assertive
Ability to
evaluate ones
own behavior
Lack of self-
confidence.
Pessimism, fear
of wrongdoing.
Over-control &
over-
restriction.
4. School
Age
6 to 12
y/o
Industry vs
Inferiority
Learns to
create, develop
& manipulate.
Develop sense of
competence &
perseverance.
Loss of hope,
sense of being
mediocre.
Withdrawal
from school &
peers.
5.
Adolescence
1220
y/o
Identity vs
role
confusion
Coherent sense
of self.
Plans to
actualize ones
abilities
Feelings of
confusion,
indecisiveness,
& possible anti-
social behavior.
6. Young
Adulthood
18-25
y/o
Intimacy vs
isolation
Intimate
relationship with
another person.
Commitment to
work and
relationships.
Impersonal
relationships.
Avoidance of
relationship,
career or
lifestyle
commitments.
7.
Adulthood
25-65
y/o
Generativity
vs
stagnation
Creativity,
productivity,
concern for
others.
Self-
indulgence,
self-concern,
lack of
interests &
commitments.
8. Maturity 65 y/o
to
death
Integrity vs
despair
Acceptance of
worth &
uniqueness of
ones own life.
Acceptance of
death.
Sense of loss,
contempt for
others.

Havighursts Developmental Stage and Tasks
DEVELOPMENTAL STAGE DEVELOPMENTAL TASK
1. Infancy & early childhood eat solid foods
walk
talk
control elimination of wastes
relate emotionally to others
distinguish right from wrong through development of a
conscience
learn sex differences and sexual modesty
achieve personal independence
form simple concepts of social & physical reality
2. Middle childhood learn physical skills, required for games
build healthy attitudes towards oneself
learn to socialize with peers
learn appropriate masculine or feminine role
gain basic reading, writing & mathematical skills
develop concepts necessary for everyday living
formulate a conscience based on a value system
achieve personal independence
develop attitudes toward social groups & institutions
3. Adolescence establish more mature relationships with same-age individuals
of both sexes
achieve a masculine or feminine social role
accept own body
establish emotional independence from parents
achieve assurance of economic independence
prepare for an occupation
prepare for marriage & establishment of a family
acquire skills necessary to fulfill civic responsibilities
develop a set of values that guides behavior
4. Early Adulthood select a partner
learn to live with a partner
start a family
manage a home
establish self in a career/occupation
assume civic responsibilities
become part of a social group
5. Middle Adulthood fulfill civic & social responsibilities
maintain an economic standard of living
assist adolescent children to become responsible, happy adults
relate ones partner
adjust to physiological changes
adjust to aging parents
6. Later Maturity - adjust to physiological changes & alterations in health status
- adjust to retirement & altered income
- adjust to death of spouse
- develop affiliation with ones age group
- meet civic & social responsibilities
- establish satisfactory living arrangements

Levinsons Seasons of Adulthood
AGE SEASON CHARACTERISTICS
18-20 yrs Early adult
transition
Seeks independence by separating from family
21-27 yrs Entrance into
the adult world
Experiments with different careers & lifestyles
28-32 yrs Transition Makes lifestyle adjustments
33-39 yrs Settling down Experiences greater stability
45-65 yrs Pay-off years Is self-directed & engages in self-evaluation

Sullivans Interpersonal Model of Personality Development
STAGE AGE DESCRIPTION
1. Infancy Birth to
1 yrs
Infant learns to rely on caregivers to meet needs &
desires
2. Childhood 1 to 6
yrs
Child begins learning to delay immediate
gratification of needs & desires
3. Juvenile 6 to 9 yrs Child forms fulfilling peer relationships
4. Preadolescence 9 to 12
yrs
Child relates successfully to same-sex peers
5. Early
Adolescence
12 to 14
yrs
Adolescent learns to be independent & forms
relationships with members of opposite sex
6. Late Adolescence 14 to 21
yrs
Person establishes an intimate, long-lasting
relationship with someone of the opposite sex

Piagets Phases of Cognitive Development
PHASE AGE DESCRIPTION
a. Sensorimotor Birth to 2
yrs
Sensory organs & muscles become more functional
Stage 1: Use of
reflexes
Birth to 1
month
Movements are primarily reflexive
Stage 2: Primary
circular reaction
1-4
months
Perceptions center around ones body.
Objects are perceived as extensions of the self.
Stage 3: Secondary
circular reaction
4-8
months
Becomes aware of external environment.
Initiates acts to change the movement.
Stage 4:
Coordination of
secondary
schemata
8-12
months
Differentiates goals and goal-directed activities.
Stage 5: Tertiary
circular reaction
12-18
months
Experiments with methods to reach goals.
Develops rituals that become significant.
Stage 6: Invention
of new means
18-24
months
Uses mental imagery to understand the
environment.
Uses fantasy.
b. Pre-operational 2-7 years Emerging ability to think
Pre-conceptual
stage
2-4 year Thinking tends to be egocentric.
Exhibits use of symbolism.
Intuitive stage 4-7 years Unable to break down a whole into separate parts.
Able to classify objects according to one trait.
c. Concrete
Operations
7-11
years
Learns to reason about events in the here-and-now.
d. Formal
Operations
11+ years Able to see relationships and to reason in the
abstract.


Kohlbergs Stages of Moral Development
LEVEL AND STAGE DESCRIPTION
LEVEL I: Pre-conventional Authority figures are obeyed.
(Birth to 9 years) Misbehavior is viewed in terms of damage done.
Stage 1: Punishment & obedience
orientation
A deed is perceived as wrong if one is punished; the
activity is right if one is not punished.
Stage 2: Instrumental-relativist
orientation
Right is defined as that which is acceptable to &
approved by the self.
When actions satisfy ones needs, they are right.
LEVEL II: Conventional Cordial interpersonal relationships are maintained.
(9-13 years) Approval of others is sought through ones actions.
Stage 3: Interpersonal
concordance
Authority is respected.
Stage 4: Law and order
orientation
Individual feels duty bound to maintain social order.
Behavior is right when it conforms to the rules.
LEVEL III: Post-conventional Individual understands the morality of having
democratically established laws.
(13+ years)
Stage 5: Social contract
orientation
It is wrong to violate others rights.
Stage 6: Universal ethics
orientation
The person understands the principles of human rights &
personal conscience.
Person believes that trust is basis for relationships.

Gilligans Theory of Moral Development
LEVEL CHARACTERISTICS
I. Orientation of Individual
Survival Transition
Concentrates on what is best for self.
Selfish.
Dependent on others.
Transition 1: From Selfishness to
Responsibility
Recognizes connections to others.
Makes responsible choices in terms of self and others.
II. Goodness as Self-sacrifice Puts needs of others ahead of own.
Feels responsible for others.
Is dependent.
May use guilt to manipulate others when attempting to
help.
Transition 2: From Goodness to
Truth
Decisions based on intentions & consequences, not on
others responses.
Considers needs of self and others.
Wants to help others while being responsible to self.
Increased social participation.
III. Morality of Nonviolence Sees self and others as morally equal
Assumes responsibilities for own decisions.
Basic tenet to hurt no one including self.
Conflict between selfishness and selflessness.
Self-judgment is not dependent on others perceptions
but rather on consequences & intentions of actions.

Fowlers Stages of Faith
STAGE AGE CHARACTERISTICS
Pre-stage:
Undifferentiated
faith
Infant Trust, hope and love compete with
environmental inconsistencies or threats if
abandonment.
Stage 1: Intuitive-
projective faith
Toddler-
preschooler
Imitates parental behaviors and attitudes
about religion and spirituality.
Has no real understanding of spiritual
concepts.
Stage 2: Mythical-
literal faith
School-aged
child
Accepts existence of a deity.
Religious & moral beliefs are symbolized by
stories.
Appreciates others viewpoints.
Accepts concept of reciprocal fairness.
Stage 3:
Synthetic-
conventional faith
Adolescent Questions values & religious beliefs in an
attempt to form own identity.
Stage 4:
Individuative-
reflective faith
Late adolescent
& young adult
Assumes responsibility for own attitudes &
beliefs.
Stage 5:
Conjunctive faith
Adult Integrates other perspectives about faith into
own definition of truth.
Stage 6:
Universalizing
faith
Adult Makes concepts of love & justice tangible.

Johari Window
As a nurse, dealing with physically and/or mentally ill patients requires a great deal of patience and
understanding. However, before a person can understand and empathize with others, he or she must first know
himself or herself. The process of knowing ones own principle, beliefs, feelings, personality, strengths,
weaknesses, preconceptions, attitudes and responses in different situations is called self awareness.
Discerning ones own capabilities and limitations allow a nurse to consider, observe and pay attention to the
bizarre or subtle reactions of clients.

Self-awareness gives the nurse a skill in establishing relationships with clients of different values, beliefs,
attitudes and principles. This is achieved by the nurses utilization of aspects in his or her personality, values,
feelings and coping skills commonly known as the therapeutic use of self.
Johari window is a psychological tool used to develop self-awareness and promote better relationships among
people. It was created by two American Psychologists Joseph Luft and Harry Ingham in 1955. The word
JOHARI comes from the first names of its developers Joseph and Harry (Joharry). It is also known
as disclosure or feedback model of self awareness.
Utilizing this tool creates a portrait of someone; this is done by giving the person a psychosocial exercise. A
list of 56 adjectives is given to the subject and he or she is instructed to choose five or six words that best
describe him or her. The same list is given to the subjects peers, friends and colleagues. These people will also
choose 5 or 6 adjectives that best describe the subject. After the test, the answers are mapped, compared
and categorized in four areas. The four areas are as follows:
Quadrant 1: Open Arena or Public self
These pertain to the qualities known to others and the subject himself.
If quadrant 1 is the longest, it means that the subject is open to others and has gained self-awareness.
If this area is the shortest, the subject shares little about him or her.
Area or Quadrant 2: Blind spot or Blind Area
These refer to the subjects attributes that are unknown to him but are known by his or her peers.
Area or Quadrant 3: Hidden or Private self
The things that the subject knows about himself.
Area or Quadrant 4: Unknown
An empty quadrant which symbolizes the qualities undiscovered by the neither the subject nor others.
The success of the test depends on the honesty of the opinions given. A person is represented with little
insight if quadrants 1 and 3 have the smallest adjective listed. The main goal the subject is to work towards
moving the qualities from quadrants 2, 3, and 4 to the first area.
Korsakoffs Syndrome (Korsakoffs Psychosis)
Definition
Korsakoffs syndrome is a condition that mainly affects chronic alcoholics. It is also called Korsakovs
syndrome, Korsakoffs psychosis or amnesic-confabulatory syndrome. It is a brain or neurological disorder
caused by thiamine or Vitamin B1 deficiency. The syndrome is named after Sergie Korsakoff, a
neuropsychiatrist who popularized the theory.


Causes
1. Chronic Alcoholism. This syndrome is due to the direct effects of alcohol or to the severe nutritional
deficiencies that are associated with chronic alcoholism. A lack of Vitamin B1 is common in people with
alcoholism thus, Vitamin B deficiency is noted. In chronic alcoholism the condition usually occurs following
delirium tremens.
2. Malabsorption. It is also common in persons whose bodies do not absorb food properly (malabsorption).
3. Other severe brain disturbances. The syndrome also occurs in other severe brain disturbances such as
paralysis, dementia, brain damage, infections and poisonings.
4. Dietary deficiencies
5. Prolonged vomiting
6. Eating disorders
7. Effects of chemotherapy
8. Hyperemesis gravidarum
9. Severe malnutrition. Alcoholism may be an indicator of poor nutrition, which in addition to inflammation of the
stomach lining causes thiamine deficiency.

Disease Process
A deficiency of thiamine or Vitamin B causes damage to the medial thalamus and to the mammillary bodies of
the hypothalamus. As a result, generalized cerebral atrophy may occur. In cases where Wernickes
encephalopathy, a neurological disorder that causes brain damage in lower parts of the brain called the
thalamus and hypothalamus, accompanies Korsakoffs syndrome the disorder is called Wernicke-Korsakoff
syndrome.
In most cases, Korsakoff syndrome, or Korsakoff psychosis, tends to develop as Wernickes symptoms go away.
It results from damage to areas of the brain involved with memory, thus, Korsakoffs syndrome involves:
Neuronal loss or damage to neurons
Gliosis, which is a result of injury to the supporting cells of the central nervous system.
Hemorrhage or bleeding of the mammilary bodies.

Signs and Symptoms
1. Anterograde amnesia or the inability to form new memories
2. Retrograde amnesia or the loss of memory (can be severe)
3. Confabulation or the reciting of imaginary experiences.
4. Lack of insight
5. Apathy or the absence of interest in or concern about emotional, social, or physical life
6. Hallucinations or seeing and hearing things are not really present
7. Delirium
8. Anxiety
9. Fear
10. Depression
11. Confusion
12. Delusions and insomnia
13. Painful extremities

Treatment
1. Thiamine by injection into a vein or a muscle or by mouth. Usually, thiamine does not improve loss of memory
and intellect that occur with Korsakoffs psychosis. However it may improve symptoms such as delirium or
confusion.
2. Stopping alcohol use to prevent additional loss of brain function and damage to the nerves.
3. Eating a well balanced and nourishing diet with increase intake of foods containing Vitamin B1.
Kubler-Ross Stages of Dying / Grie

Precipitating Factors of Grief
Death in family
Separation
Divorce
Physical Illness
Work failure disappointments

1. Denial
Initial response to protect the self from anxiety.
No not me, Its not true, Its not impossible
May continue to make impractical/unrealistic plans
May comment that a mistake has been made about the diagnosis of terminal illness
May appear normal and can continued ADL as if nothing is wrong
May not conform with the advised treatment regimen
Adaptive response crying, verbal denial
Maladptive response absence or reaction such as crying.
2. Anger
Individual feel that they are victims of incompetence or a vengeful God (they did something wrong so they are
being punished), fate (karma), circumstances (wrong place and wrong time).
Why me, What did I do to deserve this?
They seek for reasons, answers and explanations
May express anger overtly being irritable, impatient, critical verbally abusive.
May express anger covertly by neglecting self, not eating, nor going to check ups, committing suicide, drinking
alcohol.
Adaptive response verbal expression
Maladaptive persistent guilt or low self esteem, aggression, self destructive ideation or behavior.
3. Bargaining
The person try to inhibit good behavior, make up for perceived wrong doings or other engage in behaviors that
would please GOD so he will be given more time-an extension of life or granted recovery.
Yes, me but
If I live until Christmas or until my childs graduation ( So many ifs), I will do this
Adaptive response bargains for treatment control, express wish to be alive for specific events in the near
future.
Maladaptive response bargains for unrealistic activities or events in the distant future.
4. Depression
Occurs when the reality of loss or impending loss cannot be ignored anymore and the person grieves for himself
and those he will leave behind, for the things that he can no longer accomplish or experience.
Yes, Im dying
Withdrawn, has no energy and interest to interact.
Cries
Makes few demands
Adaptive response crying, withdrawing from interaction
Maladaptive response self destructive actions, despair.
5. Acceptance
Occurs when the person has come to peace with himself and others
Yes, I am ready
Stage of affective void not happy nor sad
Only persons who are highly significant to him stimulates a reaction. Others are merely tolerated.
Makes realistic preparation
Adaptive response may wish to be alone, limit conversation, complete personal and family business.

Nursing Interventions:
Assess; specific loss, meaning of loss, coping skills, support persons.
Accept the client; do not respond personally to the client.
Support adaptive responses; allow to express feelings
Support defense mechanism reassure client that denial and wanting to be alone is normal.
Help find constructive outlets of anger. Do not take clients hostility personally. Do no retaliate.
Monitor for self destructive behaviors
Help express feelings: Ask how they feel
Meet needs
Allow as much decision making as possible to maintain dignity by giving choices and alternatives.
Major Depressive Disorder
Description

A mood disorder may include symptoms of depressed mood, feelings or hopelessness and helplessness,
decreased interest in usual activities, disinterest in relationship with others or cycles of depression and mania.
Depression is often concurrent with other psychiatric diagnoses. Almost have of clients with major depressive
disorders have histories of non-mood psychiatric disorders.
A high incidence exists for persons with chronic illness or prolonges hospitalization or institutional care.

Risk Factors
1. Biological factors brainchemicals
2. Family genetics parent with depression, child 10-13% risk of depression.
3. Gender higher rate for women
4. Age often less than 40 when begins
5. Marital status more frequently single, widowed
6. Season of year Seasonal Affective Disorder (SAD) occurs when client experiences recurrent depression that
occurs annually at the same time.
7. Psychological influences low self-esteem, unresolved grief.
8. Environmental factors lack of social support, stressful life events.
9. Medical co-morbidity clients with chronic or terminal illness, postpartum, and current substance abuse are
especially prone to becoming depresses.

Signs and Symptoms
1. Sexual disinterest
2. Suicidal and homicidal ideations
3. Decrease in personal hygiene
4. Tearfulness, crying, and melancholy
5. Altered thought process; difficulty concentrating, self-destructive behavior.
6. Loss of energy or restlessness
7. Anhedonia or loss of pleasure
8. Gain or loss of weight
9. Anger, self-directed
10. Psychomotor retardation or agitation
11. Insomnia or hypersomnia
12. Feelings of hopelessness, worthlessness, and helplessness.

Nursing Diagnoses
Risk for violence, self-directed or directed at others
Impaired verbal communication
Decisional conflict
Altered role performance
Hopelessness
Deficit in diversional activity
Fatigue
Sel-care deficit
Altered thought processes
Self-esteem
Anxiety

Therapeutic Nursing Management
1. Safe environment
2. Psychological treatment
o Individual psychotherapy long term therapeutic approach or short term solution-oriented, may focus on in-
depth exploration, specific stress situations, or problem solving.
o Behavioral therapy modifying behavior to assist in reducing depressive symptoms and increasing coping skills.
o Behavioral contacts focus on specific client problems and need to help the client resolve them.
3. Social treatment
o Milieu therapy incorporates day to day living experiences in a therapeutic environment to expect changes in
perception and behavior.
o Family therapy aimed at assisting the family cope with the clients illness and supporting the client in
therapeutic ways.
o Group therapy focuses on assisting clients with interpersonal communication, coping, and problem-solving
skills.
4. Psychopharmacologic and Somatic treatments
o Administer antidepressant medications
o Continued assessment by monitoring clients mental health status is critical, particularly interms of agitation
and suicidal ideation.
o Electroconvulsive therapy

Nursing Interventions
1. Priority for care is always the clients safety.
2. Use of behavioral contacts. Use this technique to meet outcomes relating to no self-harm or no suicidal
ideation or plan.
3. Assess regularly for suicidal ideation or plan.
4. Observe client for distorted, negative thinking.
5. Assist client to learn and use problem solving and stress management skills.
6. Avoid doing too much for the client, as this will only increase clients dependence and decrease self-esteem.
7. The nurses role in the physical care of the client experiencing major depressive disorder is to provide
assessment and interventions related to appropriate nutrition, fluids, sleep, exercise, and hygieme, and to
provide health education.
8. Explore meaningful losses in the clients life.
9. Help the client and family to identify the internal and external indicators of major depressive disorder.
Obsessive Compulsive Disorder (OCD)
Description

Obsessive Compulsive Disorder (OCD) is characterized by persistent thought and urges to perform repeated
acts or rituals, usually as a means of releasing tension or anxiety. The frequency and intensity of the ritualistic
behaviors, such as handwashing, ordering, or checking, are time consuming (taking more than one hour per day)
and cause marked distress, significant impairment, or interfere with daily living.
1. Obsession
o The person experiences recurrent and persistent thoughts, impulses, images that are intrusive, disturbing,
inappropriate, and usually triggered by anxiety.
o The thoughts, images, and impulses are not simply excessive worries about real life problems.
o The person recognizes the thoughts, images, and impulses are from within own mind.
2. Compulsion
o Repetitive behaviors or mental acts that a person feels driven to perform, which usually adhere to a rigid and
specifically defined routine.
o The behaviors and ideations are typically aimed at reducing anxiety or preventing some dreaded situation from
occurring.

Specific Biological Factors
There is some evidence that indicates OCD is linked to a deficiency in serotonin.
Clients have also been shown to have abnormalities in frontal lobes and basal ganglia; it is unclear what the
implications are for clinical care.

Signs and Symptoms
Obsessions recurrent, persistent ideas, thoughts or impulses, involuntarily coming to awareness.
Ruminations forced preoccupation with thoughts about a particular topic, associated with brooding and
inconclusive speculation.
Cognitive rituals elaborate series of mental acts the client feels compelled to complete.
Compulsive motor rituals elaborate rituals of everyday functioning such as grooming, dressing, eating, washing
or checking doors or appliances.
Other symptoms chronic anxiety, low self-esteem, difficulty expressing positive feelings and depressed mood.

Nursing Diagnoses
Anxiety
Powerlessness
Ineffective verbal communication
Self-esteem disturbance
Impaired social interaction
Risk for injury
Sleep pattern disturbances
Ineffective breathing pattern

Nursing Interventions
1. Limit, but do not interrupt, the compulsive acts.
2. Teach the client to use alternate coping methods to decrease anxiety.
3. Clients behavior maybe frustrating to staff and family. Power struggles often result. Consistency to the
approach to care is critical.
4. Assess the clients needs carefully.
5. Provide an environment that has structure and predictability as a strategy to decrease anxiety.
6. Risk associated with the use of alcohol and drug abuse.
Obsessive Compulsive Disorder (OCD)
Description

Obsessive Compulsive Disorder (OCD) is characterized by persistent thought and urges to perform repeated
acts or rituals, usually as a means of releasing tension or anxiety. The frequency and intensity of the ritualistic
behaviors, such as handwashing, ordering, or checking, are time consuming (taking more than one hour per day)
and cause marked distress, significant impairment, or interfere with daily living.
1. Obsession
o The person experiences recurrent and persistent thoughts, impulses, images that are intrusive, disturbing,
inappropriate, and usually triggered by anxiety.
o The thoughts, images, and impulses are not simply excessive worries about real life problems.
o The person recognizes the thoughts, images, and impulses are from within own mind.
2. Compulsion
o Repetitive behaviors or mental acts that a person feels driven to perform, which usually adhere to a rigid and
specifically defined routine.
o The behaviors and ideations are typically aimed at reducing anxiety or preventing some dreaded situation from
occurring.

Specific Biological Factors
There is some evidence that indicates OCD is linked to a deficiency in serotonin.
Clients have also been shown to have abnormalities in frontal lobes and basal ganglia; it is unclear what the
implications are for clinical care.

Signs and Symptoms
Obsessions recurrent, persistent ideas, thoughts or impulses, involuntarily coming to awareness.
Ruminations forced preoccupation with thoughts about a particular topic, associated with brooding and
inconclusive speculation.
Cognitive rituals elaborate series of mental acts the client feels compelled to complete.
Compulsive motor rituals elaborate rituals of everyday functioning such as grooming, dressing, eating, washing
or checking doors or appliances.
Other symptoms chronic anxiety, low self-esteem, difficulty expressing positive feelings and depressed mood.

Nursing Diagnoses
Anxiety
Powerlessness
Ineffective verbal communication
Self-esteem disturbance
Impaired social interaction
Risk for injury
Sleep pattern disturbances
Ineffective breathing pattern

Nursing Interventions
1. Limit, but do not interrupt, the compulsive acts.
2. Teach the client to use alternate coping methods to decrease anxiety.
3. Clients behavior maybe frustrating to staff and family. Power struggles often result. Consistency to the
approach to care is critical.
4. Assess the clients needs carefully.
5. Provide an environment that has structure and predictability as a strategy to decrease anxiety.
6. Risk associated with the use of alcohol and drug abuse.
Paraphilias

Definition
Paraphilias are complex psychiatric disorders that are manifested as unusual sexual behavior. Diagnostic and
Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR) defined it as a recurrent, intensely
sexually arousing fantasies, sexual urges, or behaviors generally involving:
Inanimate objects (non-human objects)
Suffering or humiliation of oneself or partner
Children
Nonconsenting person

Diagnosis
The criteria for diagnosing this disorder are:
Criterion A: the unusual sexual behavior should occur over a period of 6 months
Criterion B: the sexual behavior caused a clinically significant distress or impairment in social, occupational or
other important areas of functioning. Criterion B differs in for some disorders.
For pedophilia, voyeurism, exhibitionism and frotteurism, the diagnosis is formulated if acting out on these
urges or if the urge itself caused a significant distress or interpersonal difficulty.
For sadism, a diagnosis is made if these urges are done to a nonconsenting person.
For the other paraphilias, a diagnosis created when the sexual behavior, urges or fantasies caused a clinically
significant distress or impairment in social, occupational or other important areas of functioning.

Eight specific disorders of paraphilia
1. Exhibitionism the repeated urge or behavior of exposing ones genitals to strangers or masturbating in public
areas.
2. Exhibitionism this is characterized by the use of inanimate objects (fetish) to achieve orgasm or gain sexual
excitement. Common fetishes are womens undergarments (brassiere, lingerie, and panty), shoes and other
apparels. An individual with this disorder masturbates while holding or rubbing the object to them.
3. Frotteurism persistent urges of touching or rubbing against a nonconsenting person in a place where a person
with this disorder can make a quick escape (e.g. crowded places, public transportation, shopping mall or a
crowded sidewalk). The person rubs his hands against a victims breasts or genitalia or he can rub his genitals
against the victims thigh or buttocks.
4. Pedophilia a sexual activity done with a child 13 years younger is a characteristic of this disorder. The
pedophile should be at least 16 years old or at least 5 years older than the victim.
5. Sexual masochism the intense and persistent sexual urge involving acts of suffering (beaten or bound) and
being humiliated.
6. Sexual sadism sexual urge involving acts in which the pain, suffering or humiliation of a partner is arousing a
person.
7. Transvestic fetishism sexual fantasies, urge and behaviors involving cross-dressing by a heterosexual male.
8. Voyeurism sexual arousal by observing an unsuspecting person who is naked, in the process of undressing or
engaging in sexual activity.
Personality Disorders
Definition

Personality disorder is defined as the totality of a persons unique biopsychosocial and spiritual traits that
consistently influence behavior.
The following traits are likely in individuals with a personality disorder:
1. Interpersonal relations that ranges from distant to overprotective.
Contents
1. 1 Definition
2. 2 Diagnosis
1. 2.1 Cluster A: Personality Disorders ( The Eccentric and Mad group)
2. 2.2 Cluster B: Personality Disorders ( The Erratic and Bad group)
3. 2.3 Cluster C: Personality Disorders ( The anxious and Sad group)
3. 3 Signs and Symptoms
4. 4 Nursing Diagnoses
5. 5 Nursing Interventions
2. Suspiciousness
3. Social anxiety
4. Failure to conform to social norms.
5. Self-destructive behaviors
6. Manipulation and splitting.
Prognosis is poor, and clients experience long term disability and may have other psychiatric disorders.


Diagnosis
A personality disorder is diagnosed when a person exhibits deviation on the following areas:
1. Cognition ways a person interprets and perceives him or herself, other people and events.
2. Affect ranges, lability and appropriateness of emotional response
3. Impulse control ability to control impulses or express behavior at the appropriate time and place.
Cluster A: Personality Disorders ( The Eccentric and Mad group)

1. Paranoid Personality disorder- People with a paranoid personality disorder are characterized by an overly
suspicious and mistrustful behavior.
Clinical Manifestations:
1. Aloof and withdrawn
2. Appear guarded and hypervigilant
3. Have a restricted affect
4. Unable to demonstrate a warm and empathetic emotional responses

5. Shows constant mistrust and suspicion
6. Frequently see malevolence in the actions when none exists
7. Spends disproportionate time examining and analyzing the behavior and motive of others to discover hidden and
threatening meanings
8. Often feel attacked by others
9. Devises plans or fantasies for protection
10. Uses the defense mechanism of projection (blaming other people, institution or events for their own
difficulties)
2. Schizoid Personality Disorder- People who are showing a pervasive pattern of social relationship
detachment and a limited range of emotional expression in the interpersonal settings falls under this type of
personality disorder.
Clinical Manifestations:
1. Displays restricted affect
2. Shows little emotion
3. Aloof, emotionally cold and uncaring
4. Have rich and extensive fantasy life
5. Accomplished intellectually and often involved with computers or electronics in hobbies or job
6. Spends long hours solving puzzles and mathematical problems
7. Indecisive
8. Lacks future goals or direction
9. Impaired insight
10. Self-absorbed and loners
11. Lacks desire for involvement with others
12. No disordered or delusional thought processes present
3. Schizotypal Personality Disorder- Schizoid and schizotypal personality disorder are both characterized by
pervasive pattern of social and interpersonal deficits, however, the latter is noted with cognitive and
perceptual distortions and behavioral eccentricities.
Clinical Manifestations:
1. Odd appearance (stained or dirty clothes, unkempt and disheveled)
2. Wander aimlessly
3. Loose, bizarre or vague speech
4. Restricted range of emotions
5. Ideas or reference and magical thinking is noted
6. Expresses ideas of suspicions regarding the motives of others
7. Experiences anxiety with people
Cluster B: Personality Disorders ( The Erratic and Bad group)
1. Antisocial Personality Disorder- Antisocial Personality disorder is characterized by a persistent pattern of
violation and disregard for the rights of others, deceit and manipulation
Clinical Manifestations:
1. Violation of the rights of others
2. Lack of remorse for behaviors
3. Shallow emotions
4. Lying
5. Rationalization of own behavior
6. Poor judgment
7. Impulsivity
8. Irritability and aggressiveness
9. Lack of insight
10. Thrill seeking behaviors
11. Exploitation of people in relationships
12. Poor work history
13. Consistent irresponsibility
2. Borderline Personality Disorder- Borderline personality disorder is the most common personality disorder
found in clinical settings. This disorder is characterized by a persistent pattern of unstable relationships, self
image, affect and has marked impulsivity. It is more common in females than in males. Self-mutilation injuries
such ascutting or burning are noted in this type of personality disorder.
Clinical manifestations:
1. Fear of abandonment (real or perceived)
2. Unstable and intense relationship
3. Unstable self-image
4. Impulsivity or recklessness
5. Recurrent self-mutilating behavior or suicidal threats or gestures
6. Chronic feelings of emptiness and boredom
7. Labile mood
8. Irritability
9. Splitting
10. Impaired judgment
11. Lack of insight
12. Transient psychotic symptoms such as hallucinations demanding self-harm
3. Narcissistic Personality Disorder- A person with a narcissistic personality disorder shows a persistent
pattern of grandiosity either in fantasy or behavior, a need for admiration and a lack of empathy.
Clinical Manifestations:
1. Arrogant and haughty attitude
2. Lack the ability to recognize or to empathize with the feelings of others
3. Express envy and begrudge others of any recognition of material success (they believe it rightfully should be
theirs)
4. Belittle or disparage others feelings
5. Expresses grandiosity overtly
6. Expect to be recognized for their perceived greatness
7. Preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love
8. Compares themselves with famous or privileged people
9. Poor or limited insight
10. Fragile and vulnerable self-esteem
11. Ambitious and confident
12. Exploit relationships to elevate their own status
4. Histrionic Personality disorder- Excessive emotionality and attention-seeking behaviors are pervasive
patterns noted in people with a histrionic personality disorder.
Clinical manifestations:
1. Exaggerate closeness of relationships or intimacy
2. Uses colorful speech
3. Tends to overdress
4. Concerned with impressing others
5. Emotionally expressive
6. Experiences rapid mood and emotion shifts
7. Self-absorbed
8. Highly suggestible and will agree with almost anyone to gain attention
9. Always want to be the center of attraction
Cluster C: Personality Disorders ( The anxious and Sad group)
1. Avoidant Personality Disorder
Avoidant personality disorder is characterized by a persistent pattern of:
1. Social uneasiness and reticence
2. Low self-esteem
3. Hypersensitivity to negative reaction
Clinical Manifestations
1. Shy
2. Unusually fearful of rejection, criticism, shame or disapproval
3. Socially awkward
4. Easily devastated by real or perceived criticism
5. Have a very low self-esteem
6. Believes that they are inferior
2. Dependent Personality Disorder- People who are noted to excessively need someone to take care of them
that lead to their persistent clingy and submissive behavior have a dependent personality disorder. These
individuals have fear of being separated from the person whom they cling on to. The behavior elicits caretaking
from others.
Clinical Manifestations
1. Pessimistic
2. Self-critical
3. Can be easily be hurt by other people
4. Frequently reports feeling unhappy or depressed ( due to actual or perceived loss of support from a person)
5. Preoccupied with unrealistic fears of being alone and left alone to take care for themselves
6. Has difficulty deciding on their own even how simple the problem is
7. Constantly seeks advice from others and repeated assurances about all types of decisions
8. Lacks confidence
9. Uncomfortable and helpless when alone
10. Has difficulty initiating or completing simple daily tasks on their own
3. Obsessive Compulsive Personality Disorder- Individuals who are preoccupied with perfectionism, mental
and interpersonal control and orderliness have an obsessive compulsive personality disorder. Persons with an
obsessive compulsive personality are serious and formal and answer questions with precision and much detail.
These people often seek treatment because of their recognition that life has no pleasure or because they are
experiencing problems at work and in their relationships.
Clinical Manifestations
1. Formal and serious
2. Precise and detail-oriented
3. Perfectionist
4. Constricted emotional range (has difficulty expressing emotions)
5. Stubborn and reluctant to relinquish control
6. Restricted affect
7. Preoccupation to orderliness
8. Have low self-esteem
9. Harsh
10. Have difficulty in relationships

Signs and Symptoms
1. Inappropriate response to stress and inflexible approach to problem solving.
2. Long term difficulties in relating to others, in school and in work situations.
3. Demanding and manipulative.
4. Ability to cause others to react with extreme annoyance or irritability.
5. Poor interpersonal skills.
6. Anxiety
7. Depression
8. Anger and aggression
9. Difficulty with adherence to treatment.
10. Harm to self or others.

Nursing Diagnoses
Ineffective individual coping
Social isolation
Impaired social interaction
High risk for violence to self or others
Anxiety

Nursing Interventions
1. Work with the client to increase coping skills and identify need for improvement coping.
2. Respond to the clients specific symptoms and needs.
3. Keep communication clear and consistent.
4. Client may require physical restraints, seclusion/observation room, one to one supervision.
5. Keep the client involved in treatment planning.
6. Avoid becoming victim to the clients involvement in appropriate self-help groups.
7. Require the client take responsibility for his/her own behavior and the consequences for actions.
8. Discuss with the client and family the possible environment and situational causes, contributing factors, and
triggers.
Phobias
Definition

A phobia is an anxiety disorder characterized by obsessive, irrational, and intense fear of a specific object an
activity, or a physical situation.
The fear, which is out of proportion to reality, usually results from early painful or unpleasant experiences
involving a particular object or situation.
A phobia may arise from displacing an unconscious conflict on an object that is symbolically related.

Types of Phobias
1. Agoraphobia
o Fear of being in places or situations from which escape may be difficult or help may not be readily available.
2. Social Phobia
o Also called Social Anxiety Disorder
o Characterized by persistent fear of appearing shameful, stupid or inept in the presence of others.
3. Specific Phobia
o Also called Simple Phobia
o A persistent fear of a specific object or situation, other than of two phobias mentioned above.
o Sub-categories:
1. Injury-blood-injection
2. Situational
3. Natural environment
4. Animals
5. Other (fear of costumed character, space, etc)

Risk Factors
1. Learning theory
o The belief that phobias are learned and become conditioned responses when the client needs to escape an
uncomfortable situation.
2. Cognitive theory
o Phobias are produced by anxiety-inducing self-instructions of faulty cognitions.
3. Life experiences
o Certain life experiences, such as traumatic events, may set the sage for phobias later in life.

Signs and Symptoms
1. Withdrawal
2. High levels of anxiety
3. Inability to function and meet self-care needs
4. Inappropriate behavior used to avoid the feared situation, object or activity
5. Dysfunctional social interactions and relationships

Nursing Diagnoses
1. Anxiety
2. Powerless
3. Ineffective individual coping
4. Impaired verbal communication
5. Altered thought processes
6. Self-esteem disturbance
7. Impaired social interaction
8. Risk for injury

Therapeutic Nursing Management
1. Systematic desensitization
o This process of gradual exposure to phobic object or situation aimed at decreasing the fear and increasing the
ability to function in the presence of phobic stimulus.
Reality Therapy
Definition
Reality therapy is devised by William Glaser in 1965 which focuses on the persons behavior and how that
behavior keeps him or her from achieving life goals. The approach was developed while Glaser is working with
persons with delinquent behavior, unsuccessful school performance and emotional problems. This therapy is
considered a cognitive-behavioral approach to treatment.

Approach of Reality Therapy
William Glaser believed that people who are unsuccessful often blame their problems on other people, the
system or the society. It is Glasers belief that these types of people can only find their own identities through
a responsible behavior. The focus of approach of counseling and problem solving in reality therapy focuses on
the here-and-now of the client and how to create a better future.
In this therapy, the individual is challenged to examine himself for ways in which his own behavior obstructs his
attempts of achieving his life goal. The focus of Reality Therapy is to help counselees take ownership of their
behavior and responsibility for the direction their lives take.
With reality therapy, whatever happened in our lives or what has been done in the past, the person can still
choose behavior that will help him meet his needs more effectively in the future. It is believed that these
needs that a person has to effectively meet are the following:
1. Power this includes a persons achievement and feeling worthwhile. Winning is also included here.
2. Love and belonging this includes families, loved ones, relatives and groups.
3. Freedom independence, autonomy, personal space
4. Fun pleasure and enjoyment
5. Survival nourishment, shelter

Process Involved in Reality Therapy
In practicing reality therapy, two major components should be considered:
A trusting environment should be created.
Therapeutic techniques should be utilized to help a person discover what they really WANT, reflect on their
current activities and behavior and devise a new plan to fulfill that WANT effectively in the future.
The processes taking place in reality therapy are:
1. Developing a good RAPPORT with the client. To make the entire process effective, trust and rapport should be
built at the beginning.
2. The current behavior (not the previous one) should be examined and evaluated by the client with the help of a
psychotherapist. The therapist will ask the client to make a value judgment about his current behavior.
3. Help the client plan a new behavior that can be possibly done that works better than the current one.
4. The participant must make a commitment to carry out the plan.
5. There should be no punishment to be implemented. The therapist however, should stress to the client that
there are no excuses and to never give up.

Summary of Facts about Reality Therapy
Focus of Reality Therapy: Help counselees take ownership of their behavior and responsibility for the
direction their lives take.
Basic Premise of Reality Therapy: Regardless of what has happened to us in our lives, or what we have done in
the past, we are living and making choices here and now.
Restraint Application
Definition
Restraint application is a technique of physically restricting a persons freedom of movement, physical
activity or normal access to his body. A physical restraint is a piece of equipment or device that restricts a
patients ability to move. It is any manual method or physical or mechanical device, material, or equipment
attached or adjacent to the residents body that the individual cannot remove easily which restricts freedom
of movement or normal access to ones body.
The definition of restraint is based not on the equipment or device but rather on the functional status of the
client. If the client cannot release himself from the device physically, then the said device is considered a
restraint.

Purpose of Restraint Application
Restraints are used to control a patient who is at risk of harming him or her self and/or others. In some cases,
restraints are also used for children who are not capable of remaining still when they are frightened or in pain
during administration of medication or performing other procedures. However, using restraints in any health
care facility should be used as the last option in dealing with patients.
When to use restraints?
Physical restraint should be used only when other, less restrictive, measures prove ineffective in protecting
the patient and others from harm.



Types of Restraints
1. Soft restraints. This type of physical restraint device is used to limit movement of patients who are confused,
disoriented or combative. The main goal of using this restraint is to prevent the patient from injuring him or
her self and/or others.
2. Vest and Belt Restraints. In using this device full movement of arms and legs are permitted. This is used to
prevent the patient from falling from bed or a chair.
3. Limb Restraints. Patients who are removing supportive equipments such as I.V. lines, indwelling catheters,
NGTs and etc. are placed on limb restraints. This device allows only slight limb motion.
4. Mitts. This device prevents the patient from removing supportive equipment, scratching rashes or sores and
injuring him or herself and/or others.
5. Body restraints. When patients become combative and hysterical they can be controlled by applying body
restraints. This immobilizes almost all of the body.
6. Leather Restraints. This restraint is only used when soft restraints are not sufficient to control the patient
and when sedation is either dangerous to the patient or ineffective.

Precautions of Restraint Application
1. Before applying restraints it is important to try other methods of promoting patient safety. Alternative
methods that might be effective are reorientation of the patient to the physical surroundings, moving the
patients room near to the staff members, teaching relaxation techniques in order to decrease anxiety and fear
and decrease overstimulation.
2. Documentation of any alternative method used is extremely important. Restraint application should be
documented thoroughly.\


Situations that Requires Restraint Application
1. Confused client tries to endanger him or herself
2. Confused client attempts to remove supportive equipments such as necessary tubes, IV lines or protective
dressings.
3. The client is at risk for falls.
4. The client is suicidal.
5. The client poses harm or threat of inflicting harm to health care staff, other clients and/or visitors.
6. A child is unable to remain still during a minor surgical procedure.

Equipments
Soft restraints
Vest restraint
Limb restraint
Mitt restraint
Belt restraint
Body restraint as needed
Padding if needed (large gauze pads can be used)
Restrain flow sheet (washcloth can be used)
Leather restraints
Two wrist and two ankle leather restraints
Four straps
Key
Large gauze pads this is used to cushion each extremity
Restraint flow sheet (washcloth can be used)
Restraint Application Key Steps
1. Make sure that the restraints are correct size for the patients build and weight.
2. Explain the need for restraint to the patient. Assure him or her that they are used to protect him from injury
rather than to punish him. It is necessary to inform the patient of the conditions necessary to release him or
her from restraints.
3. Restraints are ONLY used when all other methods have failed to keep the patient from harming himself or
others. Restraints used should be least restrictive to the patient.
4. Obtain adequate assistance to manually restrain the patient.
5. After an hour of placing a restraint, the patient should be evaluated by a licensed independent practitioner and
an order must be written for restraints.
6. The order must ne time limited: 4 hours for adults; 2 hours for patients ages 9 to 17 years old; 1 hour for
patients younger than 9 years old.
7. The original order expires in 24 hours. Thus, the same order cannot be used the following day.
8. To promote safety and ensure the patient is not harmed with restraint application, the patient should be
assessed every 2 hours or according to the facility policy.
9. In cases where the client consented to have his family informed of his care, the family should be notified of
the use of restraints.
Schizophrenia
DEFINITION

Schizophrenia is an extremely complex mental disorder: in fact it is probably many illnesses masquerading as
one. A biochemical imbalance in the brain is believed to cause symptoms. Recent research reveals that
schizophrenia may be a result of faulty neuronal development in the fetal brain, which develops into full-blown
illness in late adolescence or early adulthood.
Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and behavior. It
cannot be defined as a single illness;
Contents
1. 1 DEFINITION
2. 2 PATHOPHYSIOLOGY
3. 3 TYPES OF SCHIZOPHRENIA:
1. 3.1 Paranoid Schizophrenia
2. 3.2 Disorganized Schizophrenia
3. 3.3 Catatonic Schizophrenia
4. 4 DIAGNOSTIC TEST:
5. 5 TREATMENTS AND MEDICATIONS:
rather thought as a syndrome or disease process with many different varieties and symptoms. It is usually
diagnosed in late adolescence or early adulthood. Rarely does it manifest in childhood. The peak incidence of
onset is 15 to 25 years of age for men and 25 to 35 years of age for women.
The symptoms of schizophrenia are categorized into two major categories, the positive or hard
symptoms which include delusion, hallucinations, and grossly disorganized thinking, speech, and behavior,
and negative or soft symptoms as flat affect, lack of volition, and social withdrawal or discomfort. Medication
treatment can control the positive symptoms but frequently the negative symptoms persist after positive
symptoms have abated. The persistence of these negative symptoms over time presents a major barrier to
recovery and improved the functioning of clients daily life.

PATHOPHYSIOLOGY

TYPES OF SCHIZOPHRENIA:
The diagnosis is made according to the clients predominant symptoms:
Schizophrenia, paranoid type is characterized by persecutory (feeling victimized or spied on) or grandiose
delusions, hallucinations, and occasionally, excessively religiosity (delusional focus) or hostile and aggressive
behavior.
Schizophrenia, disorganized type is characterized by grossly inappropriate or flat affect, incoherence, loose
associations, and extremely disorganized behavior.
Schizophrenia, catatonic type is characterized by marked psychomotor disturbance, either motionless or
excessive motor activity. Motor immobility may be manifested by catalepsy (waxy flexibility) or stupor.
Schizophrenia, undifferentiated type is characterized by mixed schizophrenic symptoms (of other types) along
with disturbances of thought, affect, and behavior.
Schizophrenia, residual type is characterized by at least one previous, though not a current, episode, social
withdrawal, flat affect and looseness of associations.

Paranoid Schizophrenia

Is characterized by persecutory or grandiose delusional thought content and, possibly, delusional jealousy.
Some patients also have gender identity problems, such as fears of being thought of as homosexual or of being
approached by homosexuals.
Stress may worsen the patients symptoms.
Paranoid schizophrenia may cause only minimal impairment in the patients level of functioning as long as he
doesnt act on delusional thoughts.
Although patients with paranoid schizophrenia may experience frequent auditory hallucinations (usually related
to a single theme), they typically lack some of the symptoms of other schizophrenia subtypes notably,
incoherent, loose associations, flat or grossly inappropriate affect, and catatonic or grossly disorganized
behavior.
Tend to be less severely disabled than other schizophrenia.
Those with late onset of disease and good pre-illness functioning (ironically, the very patients who have the
best prognosis) are at the greatest risk for suicide.
Signs and Symptoms
Persecutory or grandiose delusional thoughts
Auditory hallucinations
Unfocused anxiety
Anger
Tendency to argue
Stilted formality or intensity when interacting with others
Violent behavior
Diagnosis
Ruling out other causes of the patients symptoms.
Meeting the DSM-IV-TR criteria.
Treatment
Antipsychotic drug therapy.
Psychosocial therapies and rehabilitation, including group and individual psychotherapy.
Nursing Interventions
1. Build trust, and be honest and dependable, dont threaten or make promises you cant fulfill.
2. Be aware that brief patient contacts may be most useful initially.
3. When the patient is newly admitted, minimize his contact with the staff.
4. Dont touch the patient without telling him first exactly what youre going to be doing and before obtaining his
permission to touch him.
5. Approach him in a calm, unhurried manner.
6. Avoid crowding him physically or psychologically; he may strike out to protect himself.
7. Respond neutrally to his condescending remarks; dont let him put you on the defensive, and dont take his
remarks personally.
8. If he tells you to leave him alone, do leave- but make sure you return soon.
9. Set limits firmly but without anger, avoid a punitive attitude.
10. Be flexible, giving the patient as much control as possible.
11. Consider postponing procedures that require physical contact with hospital personnel if the patient becomes
suspicious or agitated.
12. If the patient has auditory hallucinations, explore the content of the hallucinations (what voices are saying to
him, whether he thinks he must do what they command) tell him you dont hear voices, but you know theyre real
to him.


Disorganized Schizophrenia
Is marked by incoherent, disorganized speech and behaviors and by blunted or inappropriate affect.
May have fragmented hallucinations and delusions with no coherent theme.
Usually includes extreme social impairment.
This type of schizophrenia may start early and insidiously, with no significant remissions.
Signs and Symptoms
Incoherent, disorganized speech, with markedly loose associations.
Grossly disorganized behavior.
Blunted, silly, superficial, or inappropriate affect.
Grimacing
Hypochondriacal complaints.
Extreme social withdrawal.
Diagnosis
Ruling out other causes of the patients symptoms.
Meeting the DSM-IV-TR criteria.
Treatment
Treatments described for other types of schizophrenia.
Antipsychotic drugs and psychotherapy.
Nursing Interventions
1. Spend time with the patient even if hes mute and unresponsive, to promote reassurance and support.
2. Remember that, despite appearances, the patient is acutely aware of his environment, assume the patient can
hear speak to him directly and dont talk about him in his presence.
3. Emphasize reality during all patient contacts, to reduce distorted perceptions (for example, say, The leaves on
the trees are turning colors and the air is cooler, Its fall)
4. Verbalize for the patient the message that his behavior seems to convey, encourage him to do the same.
5. Tell the patient directly, specifically, and concisely what needs to be done; dont give him choice (for example,
say, Its time to go for a walk, lets go.)
6. Assess for signs and symptoms of physical illness; keep in mind that if hes mute he wont complain of pain or
physical symptoms.
7. Remember that if hes in bizarre posture, he may be at risk for pressure ulcers or decreased circulation.
8. Provide range-of-motion exercises.
9. Encourage to ambulate every 2 hours.
10. During periods of hyperactivity, try to prevent him from experiencing physical exhaustion and injury.
11. As appropriate, meet his needs for adequate food, fluid, exercise, and elimination; follow orders with respect
to nutrition, urinary catheterization, and enema use.
12. Stay alert for violent outbursts; if these occur, get help promptly to intervene safely for yourself, the patient,
and others.


Catatonic Schizophrenia
Is a rare disease form in which the patient tends to remain in a fixed stupor or position for long periods,
periodically yielding to brief spurts of extreme excitement.
Many catatonic schizophrenia have an increased potential for destructive, violent behavior when agitated.
Signs and Symptoms
Remaining mute; refusal to move about or tend to personal needs.
Exhibiting bizarre mannerisms, such as facial grimacing and sucking mouth movements.
Rapid swing between stupor and excitement (extreme psychomotor agitation with excessive, senseless, or
incoherent shouting or talking).
Bizarre posture such as holding the body (especially the arms and legs) rigidly in one position for a long time.
Diminished sensitivity to painful stimuli.
Echolalia (repeating words or phrases spoken by others).
Echopraxia (imitating others movements).
Diagnosis
Ruling out other possible causes of the patients symptoms.
Meeting the DSM-IV-TR criteria.
Treatment
ECT and benzodiazepines (such as diazepam or lorazepam) for catatonic schizophrenia.
Avoiding conventional antipsychotic drugs (they may worsen catatonic symptoms).
Investigating atypical antipsychotic drugs to treat catatonic schizophrenia (requires further evaluation).
Nursing Interventions
1. Spend time with the patient even if hes mute and unresponsive, to promote reassurance and support.
2. Remember that, despite appearances, the patient is acutely aware of his environment, assume the patient can
hear speak to him directly and dont talk about him in his presence.
3. Emphasize reality during all patient contacts, to reduce distorted perceptions (for example, say, The leaves on
the trees are turning colors and the air is cooler, Its fall)
4. Verbalize for the patient the message that his behavior seems to convey, encourage him to do the same.
5. Tell the patient directly, specifically, and concisely what needs to be done; dont give him choice (for example,
say, Its time to go for a walk, lets go.)
6. Assess for signs and symptoms of physical illness; keep in mind that if hes mute he wont complain of pain or
physical symptoms.
7. Remember that if hes in bizarre posture, he may be at risk for pressure ulcers or decreased circulation.
8. Provide range-of-motion exercises.
9. Encourage to ambulate every 2 hours.
10. During periods of hyperactivity, try to prevent him from experiencing physical exhaustion and injury.
11. As appropriate, meet his needs for adequate food, fluid, exercise, and elimination; follow orders with respect
to nutrition, urinary catheterization, and enema use.
12. Stay alert for violent outbursts; if these occur, get help promptly to intervene safely for yourself, the patient,
and others.

DIAGNOSTIC TEST:
1. Clinical diagnosis is developed on historical information and thorough mental status examination.
2. No laboratory findings have been identified that are diagnostic of schizophrenia.
3. Routine battery of laboratory test may be useful in ruling out possible organic etiologies, including CBC,
urinalysis, liver function tests, thyroid function test, RPR, HIV test, serum ceruloplasmin ( rules out an
inherited disease, wilsons disease, in which the body retains excessive amounts of copper), PET scan, CT scan,
and MRI.
4. Rating scale assessment:

o Scale for the assessment of negative symptoms.
o Scale for the assessment of positive symptoms.
o Brief psychiatric rating scale

TREATMENTS AND MEDICATIONS:
Currently, there is no method for preventing schizophrenia and there is no cure. Minimizing the impact of
disease depends mainly on early diagnosis and, appropriate pharmacological and psycho-social treatments.
Hospitalization may be required to stabilize ill persons during an acute episode. The need for hospitalization will
depend on the severity of the episode. Mild or moderate episodes may be appropriately addressed by intense
outpatient treatment. A person with schizophrenia should leave the hospital or outpatient facility with a
treatment plan that will minimize symptoms and maximize quality of life.
A comprehensive treatment program can include:
Antipsychotic medication
Education & support, for both ill individuals and families
Social skills training
Rehabilitation to improve activities of daily living
Vocational and recreational support
Cognitive therapy
Medication is one of the cornerstones of treatment. Once the acute stage of a psychotic episode has
passed, most people with schizophrenia will need to takemedicine indefinitely. This is because vulnerability to
psychosis doesnt go away, even though some or all of the symptoms do. In North America, atypical or second
generation antipsychotic medications are the most widely used. However, there are many first-generation
antipsychotic medications available that may still be prescribed. A doctor will prescribe the medication that is
the most effective for the ill individual
Another important part of treatment is psychosocial programs and initiatives. Combined with medication, they
can help ill individuals effectively manage their disorder. Talking with your treatment team will ensure you are
aware of all available programs and medications.
In addition, persons living with schizophrenia may have access to or qualify for income support
programs/initiatives, supportive housing, and/or skills development programs, designed to promote integration
and recovery.
Somatoform Disorders
Definition
Somatoform disorders are characterized by physical symptoms, which suggest medical diseases, but without
organic pathology to support the illness.
It refers to all mechanisms by which anxiety is translated into physical illness.
Somatoform disorders include somatization disorder.

Types of Disorder
1. Somatization disorder
o This chronic syndrome is characterized by multiple somatic symptoms that cannot be explained medically.
o The physical symptoms are associated with psychological stress.
2. Conversion disorder
o A loss or change in bodily function is the result of psychological conflict, allowing the client to resolve the
conflict through loss of a physical function.
o The client often exhibits a lack of concern about the severity of the disease (la belle indifferences).
3. Sleep disorder
o This is characterized by difficulty initiating or maintaining sleep.
o Sleep disorders include hypersomnia or excessive sleepiness, narcolepsy, parasomnias, undesirable behaviors
that occur during sleep.
o In sleep disorders, the sleep-wake schedule and circadian rhythm are disturbed.
4. Hypochondriasis
o This is a persons unwanted fear or belief that he or she has a serious disease without significant pathology.
o Hypochondrias interferes with clients work and social relationships.
5. Body dysmorphic disorders
o The client is preoccupied with an image defect in appearance when there is no abnormality.
o Client obsesses about imaged bodily defects (facial flaws, heavy buttocks or thighs) and becomes embarrassed
about them.
6. Pain disorder
o The pain is unrelated to a medical disease.
o The individual experiences severe pain that is in disproportion to the originating source.

Risk Factors
1. Gender: Female
2. Age: Children and older adults

Signs and Symptoms
1. Pain in the absence of organic pathology.
2. Preoccupation with physical symptoms, disease, physical flaws, and oneself.
3. Dependence on addictive substances for relief of pain that is unsubstantiated by physical findings.
4. Frequent visits to health care providers.
5. Symptoms of anxiety and/or depression.
6. Hydrochondriasis is not a conscious decision on the part of the client; they believe that they are ill.

Nursing Diagnoses
Impaired adjustment
Chronic pain
Sleep pattern disturbance

Nursing Interventions
1. Alternative therapeutic interventions may be used, such as therapeutic touch, imaging, and acupuncture.
2. Assist the client in identifying and describing in stress he/she experiences.
3. Assist the client in monitoring stress and knowing when to intervene.
4. Teach the client about medications and to avoid alcohol and other such drugs used to alleviate stress
approximately.
5. Recognize medical problem.

Complications
1. Risk to self and others.
2. Dependency on addictive medications.
3. Withdrawal symptoms related to discontinuation of sedatives, hypnotics, and narcotics.
Suicide
Definition

Self imposed death stemming from depression.


Risk Factors
1. Theories of Suicide
o Anger turned inward: anger that was previously directed at someone else is turned inward.
o Hopelessness, depression, and guilt: desperate feelings of the client.
o A history of aggression and violence: rage and violent behavior is correlated with suicides.
o Shame and humiliation: suicide viewed as a saying face or saving the family name following a suicidal defeat.
o Developmental stressors: certain stressors at developmental stages have been identified as precipitating
factors to suicide.
2. Biological theories
o Generic tendency: Twin studies have indicated a predisposition toward suicidal behavior.
o Neurochemical factors: Postmortem studies have revealed a decreased serotonin level in the brainstem and
spinal fluid.

Signs and Symptoms
1. Self mutilation
2. Unexplained decrease in daily functioning
3. Isolation and withdrawal, decreased social interaction
4. Channeling of anger and hostility towards self
5. Inability to discuss the future
6. Destructive coping mechanisms
7. Express anger toward self
8. Previous suicide attempts
9. Low self-esteem
10. Anxious and apprehensive
11. Non-verbal cues such as giving away possessions

Assessment
1. Suicidal Assessment: Question to ask the client to assess how realistic the clients plan is.
o Do you have thoughts of harming or killing yourself?
o Do you have a plan to harm or kill yourself?
o What is the plan?
o Is it possible to implement the plan?
o When do you plan to do it?
2. A person is considered at a high-risk for suicide if the plan could be carried out within 24-48 hours. Other
issues in determining risk include the lethality of the method and the plan of discovery after death.

Nursing Diagnoses
High risk for violence, self-directed or directed at others
Risk for self mutilation
Ineffective individual coping
Ineffective family coping
Spiritual distress

Therapeutic Nursing Management
1. Establish a therapeutic relationship
2. Talk directly with the client about suicide and plans
3. Communicate the potential for suicide to team members and family
4. Stay with the client
5. Accept the person. Listen to the person.
6. Secure a no suicide/harm contract
7. Give the person a message of hope based on reality
8. When client is able, encourage gradual increase in activities
9. Maintain suicide precautions, be particularly concerned with personal items the client may used to harm self,
remove all dangerous and potentially dangerous items (belts, glass, sharps).
Therapeutic and Non-Therapeutic Communication
Effective Communication:

1. Open ended questions
2. Focus on feelings
3. State behaviors observed
4. Reflect, restate, rephrase verbalization of patient
5. Neutral responses
6. Appropriate
7. Simple
8. Adaptive
9. Concise
10. Credible

Therapeutic relationship - is a relationship that is established between a health care professional and a client
for the purpose of assisting the client to solve his problems.

Components of a Therapeutic Relationship

One of the most important skills of a nurse is developing the ability to establish a therapeutic relationship with
clients. For interventions to be successful with clients in a psychiatric facility and in all nursing specialties it is
crucial to build a therapeutic relationship. Crucial components are involved in establishing a therapeutic nurse-
patient relationship and the communication within it which serves as the underpinning for treatment and
success. It is essential for a nurse to know and understand these components as it explores the task that
should be accomplish in a nurse-client relationship and the techniques that a nurse can utilize to do so.
TRUST
Without trust a nurse-client relationship would not be established and interventions wont be successful. For a
client to develop trust, the nurse should exhibit the following behaviors:
Friendliness
Caring
Interest
Understanding
Consistency
Treating the client as human being
Suggesting without telling
Approachability
Listening
Keeping promises
Providing schedules of activities
Honesty
GENUINE INTEREST
Another essential factor to build a therapeutic nurse-client relationship is showing a genuine interest to the
client. For the nurse to do this, he or she should be open, honest and display a congruent behavior. Congruence
only occurs when the nurses words matches with her actions.
EMPATHY
For a nurse to be successful in dealing with clients it is very essential that she empathize with the client.
Empathy is the nurses ability to perceive the meanings and feelings of the client and communicate that
understanding to the client. It is simply being able to put oneself in the clients shoes. However, it does not
require that the nurse should have the same or exact experiences as of the patient. Empathy has been shown
to positively influence client outcomes. When the nurse develops and utilizes this ability, clients tend to feel
much better about themselves and more understood.
Some people confuse empathizing with sympathizing. To establish a good nurse-patient relationship, the nurse
should use empathy not sympathy. Sympathy is defined as the feelings of concern or compassion one shows for
another. By sympathizing, the nurse projects his or her own concerns to the client, thus, inhibiting the clients
expression of feelings. To better understand the difference between the two, lets take a look at the given
example.
Clients statement:
I am so sad today. I just got the news that my father died yesterday. I should have been there, I feel so
helpless.
Nurses Sympathetic Response:
I know how depressing that situation is. My father also died a month ago and until now I feel so sad every time
I remember that incident. I know how bad that makes you feel.
Nurses Empathetic Response:
I see you are sad. How can I help you?
When the nurse expresses sympathy for the client, the nurses feelings of sadness or even pity could influence
the relationship and hinders the nurses abilities to focus on the clients needs. The emphasis is shifted from
the clients to the nurses feelings thereby hindering the nurses ability to approach the clients needs in an
objective manner.
In dealing with clients their interest should be the nurses greatest concern. Thus, empathizing with them is
the best technique as it acknowledges the feelings of the client and at the same time it allows a client to talk
and express his or her emotions. Here a bond can be established that serves as a foundation for the nurse-
client relationship.
ACCEPTANCE
Clients are unpredictable. There are times that they outburst with anger or act out their inappropriate desires.
A nurse, who does not judge the client or person no matter what his or her behavior, is showing acceptance.
Acceptance does not mean accepting all the inappropriate behavior but rather acceptance of the person as
worthy. When the client displays an improper behavior, the nurse can communicate with the client by being firm
and clear without anger or judgment. In this way, the nurse allows the client to feel intact but at the same time
aware that his certain behavior is unacceptable. Lets take a look at the given example.
Situation: A client tries to kiss the nurse.
Inappropriate response: What the hell are you doing?! Im leaving maybe Ill see you tomorrow.
Appropriate response: Adam, do not kiss me. We are working on your relationship with your girlfriend and that
does not require you to kiss me. Now let us continue.
POSITIVE REGARD
Positive regard is an unconditional and nonjudgmental attitude where the nurse appreciates the client as a
unique worthwhile human being that shows respect for the client regardless of his or her
behavior background and lifestyle. The following ways are example of how to promote respect and positive
regard to a client:
Calling the client by name
Spending time with the client
Listening to the client
Responding to the client openly
Considering the clients ideas and preferences when planning care
SELF-AWARENESS
Self-awareness is the process of understanding ones own values, beliefs, thoughts, feelings, attitudes,
motivations, prejudices, strengths and limitations. Before a nurse can understand clients he or she should be
able to understand him or herself. The first step in preparing oneself to build a therapeutic nurse-patient
relationship is to understand oneself.
THERAPEUTIC USE OF SELF
A nurse can only use his or her personality, experiences, values, feelings, intelligence, needs, coping skills and
perceptions to build a relationship with clients (therapeutic use of self) when he or she has developed self-
awareness and self-understanding.

Therapeutic Technique
1. Offering Self
making self-available and showing interest and concern.
I will walk with you
2. Active listening
paying close attention to what the patient is saying by observing both verbal and non-verbal cues.
Maintaining eye contact and making verbal remarks to clarify and encourage further communication.
3. Exploring
Tell me more about your son
4. Giving broad openings
What do you want to talk about today?
5. Silence
Planned absence of verbal remarks to allow patient and nurse to think over what is being discussed and to say
more.
6. Stating the observed
verbalizing what is observed in the patient to, for validation and to encourage discussion
You sound angry
7. Encouraging comparisons
asking to describe similarities and differences among feelings, behaviors, and events.
Can you tell me what makes you more comfortable, working by yourself or working as a member of a team?
8. Identifying themes
asking to identify recurring thoughts, feelings, and behaviors.
When do you always feel the need to check the locks and doors?
9. Summarizing
reviewing the main points of discussions and making appropriate conclusions.
During this meeting, we discussed about what you will do when you feel the urge to hurt your self again and
this include
10. Placing the event in time or sequence
asking for relationship among events.
When do you begin to experience this ticks? Before or after you entered grade school?
11. Voicing doubt
voicing uncertainty about the reality of patients statements, perceptions and conclusions.
I find it hard to believe
12. Encouraging descriptions of perceptions
asking the patients to describe feelings, perceptions and views of their situations.
What are these voices telling you to do?
13. Presenting reality or confronting
stating what is real and what is not without arguing with the patient.
I know you hear these voices but I do not hear them.
I am Lhynnelli, your nurse, and this is a hospital and not a beach resort.
14. Seeking clarification
asking patient to restate, elaborate, or give examples of ideas or feelings to seek clarification of what is
unclear.
I am not familiar with your work, can you describe it further for me.
I dont think I understand what you are saying.
15. Verbalizing the implied
rephrasing patients words to highlight an underlying message to clarify statements.
Patient: I wont be bothering you anymore soon.
Nurse: Are you thinking of killing yourself?
16. Reflecting
throwing back the patients statement in a form of question helps the patient identify feelings.
Patient: I think I should leave now.
Nurse: Do you think you should leave now?
17. Restating
repeating the exact words of patients to remind them of what they said and to let them know they are heard.
Patient: I cant sleep. I stay awake all night.
Nurse: You cant sleep at night?
18. General leads
using neutral expressions to encourage patients to continue talking.
Go on
You were saying
19. Asking question
using open-ended questions to achieve relevance and depth in discussion.
How did you feel when the doctor told you that you are ready for discharge soon?
20. Empathy
recognizing and acknowledging patients feelings.
Its hard to begin to live alone when you have been married for more than thirty years.
21. Focusing
pursuing a topic until its meaning or importance is clear.
Let us talk more about your best friend in college
You were saying
22. Interpreting
providing a view of the meaning or importance of something.
Patient: I always take this towel wherever I go.
Nurse: That towel must always be with you.
23. Encouraging evaluation
asking for patients views of the meaning or importance of something.
What do you think led the court to commit you here?
Can you tell me the reasons you dont want to be discharged?
24. Suggesting collaboration
offering to help patients solve problems.
Perhaps you can discuss this with your children so they will know how you feel and what you want.
25. Encouraging goal setting
asking patient to decide on the type of change needed.
What do you think about the things you have to change in your self?
26. Encouraging formulation of a plan of action
probing for step by step actions that will be needed.
If you decide to leave home when your husband beat you again what will you do next?
27. Encouraging decisions
asking patients to make a choice among options.
Given all these choices, what would you prefer to do.
28. Encouraging consideration of options
asking patients to consider the pros and cons of possible options.
Have you thought of the possible effects of your decision to you and your family?
29. Giving information
providing information that will help patients make better choices.
Nobody deserves to be beaten and there are people who can help and places to go when you do not feel safe at
home anymore.
30. Limit setting
discouraging nonproductive feelings and behaviors, and encouraging productive ones.
Please stop now. If you dont, I will ask you to leave the group and go to your room.
31. Supportive confrontation
acknowledging the difficulty in changing, but pushing for action.
I understand. You feel rejected when your children sent you here but if you look at this way
32. Role playing
practicing behaviors for specific situations, both the nurse and patient play particular role.
Ill play your mother, tell me exactly what would you say when we meet on Sunday.
33. Rehearsing
asking the patient for a verbal description of what will be said or done in a particular situation.
Supposing you meet these people again, how would you respond to them when they ask you to join them for a
drink?.
34. Feedback
pointing out specific behaviors and giving impressions of reactions.
I see you combed your hair today.
35. Encouraging evaluation
asking patients to evaluate their actions and their outcomes.
What did you feel after participating in the group therapy?.
36. Reinforcement
giving feedback on positive behaviors.
Everyone was able to give their options when we talked one by one and each of waited patiently for our turn to
speak.
Avoid pitfalls:
1. Giving advise
2. Talking about your self
3. Telling client is wrong
4. Entering into hallucinations and delusions of client
5. False reassurance
6. Clich
7. Giving approval
8. Asking WHY?
9. Changing subject
10. Defending doctors and other health team members.

Non-therapeutic Technique
1. Overloading
talking rapidly, changing subjects too often, and asking for more information than can be absorbed at one time.
Whats your name? I see you like sports. Where do you live?
2. Value Judgments
giving ones own opinion, evaluating, moralizing or implying ones values by using words such as nice, bad,
right, wrong, should and ought.
You shouldnt do that, its wrong.
3. Incongruence
sending verbal and non-verbal messages that contradict one another.
The nurse tells the patient Id like to spend time with you and then walks away.
4. Underloading
remaining silent and unresponsive, not picking up cues, and failing to give feedback.
The patient ask the nurse, simply walks away.
5. False reassurance/ agreement
Using clich to reassure client.
Its going to be alright.
6. Invalidation
Ignoring or denying anothers presence, thoughts or feelings.
Client: How are you?
Nurse responds: I cant talk now. Im too busy.
7. Focusing on self
responding in a way that focuses attention to the nurse instead of the client.
This sunshine is good for my roses. I have beautiful rose garden.
8. Changing the subject
introducing new topic
inappropriately, a pattern that may indicate anxiety.
The client is crying, when the nurse asks How many children do you have?
9. Giving advice
telling the client what to do, giving opinions or making decisions for the client, implies client cannot handle his
or her own life decisions and that the nurse is accepting responsibility.
If I were you Or it would be better if you do it this way
10. Internal validation
making an assumption about the meaning of someone elses behavior that is not validated by the other person
(jumping into conclusion).
The nurse sees a suicidal clients smiling and tells another nurse the patient is in good mood.

Other ineffective behaviors and responses:
1. Defending Your doctor is very good.
2. Requesting an explanation Why did you do that?
3. Reflecting You are not suppose to talk like that!
4. Literal responses If you feel empty then you should eat more.
5. Looking too busy.
6. Appearing uncomfortable in silence.
7. Being opinionated.
8. Avoiding sensitive topics
9. Arguing and telling the client is wrong
10. Having a closed posture-crossing arms on chest
11. Making false promises Ill make sure to call you when you get home.
12. Ignoring the patient I cant talk to you right now
13. Making sarcastic remarks
14. Laughing nervously
15. Showing disapproval You should not do those things.
Therapeutic Community ( Milieu Therapy)
Sullivan envisioned the goal of treatment as the establishment of satisfying interpersonal relationships. The
therapist provides a corrective interpersonal relationship forthe client. Sullivan coined the term participant
observer for the therapists role, meaning that the therapist both participates in and observes the progress of
the relationship.

Credit is also given to Sullivan for the developing the first therapeutic community or milieu therapy with
young men with schizophrenia in 1929 (although that term was not used extensively until Maxwell Jones
published The Therapeutic Community in 1953). In the concept of therapeutic or milieu therapy, the interaction
among clients is seen as beneficial, and treatment emphasizes the role of this client-to-client interaction. Until
this time, it was believed that the interaction between the client and psychiatrist was the one essential
component to the clients treatment. Sullivan and later Jones observed that interactions among clients in safe,
therapeutic setting provided great benefits to clients. The concept of milieu therapy, originally developed by
Sullivan, involved clients interactions with one another; i.e., practicing interpersonal relationship skills, giving
one another feedback about behavior, and working cooperatively as a group to solve day-to-day problems.
Milieu therapy was one of the primary modes of treatment in the acute hospital setting. In todays health care
environment, however, inpatient hospital stays are often too short for clients to develop meaningful
relationships with one another. Therefore the concept of milieu therapy receives little attention. Management
of the milieu or environment is still a primary role for the nurse in terms of providing safety and protection for
all the clients and promoting social interaction.
Therapeutic Therapy
Definition

A simple type of milieu therapy by which the total social structure of the treatment unit is involved in the
helping process.

Goal and Objectives
1. To help the patient develop a sense of self-esteem and self- respect.
2. To help him learn to trust others.
3. To improve his ability to relate to others and with authority.
4. To return him to the community, better prepared to resume his role in living and working.

Elements
1. People
2. Organized activities
3. Environment

Characteristics of therapeutic community
1. Emphasis on social and group interaction
2. Focusing communication
3. Sharing responsibilities with patient
4. Living and learning abilities

Therapeutic Activities
1. Music appreciation thru arts
2. Craft and occupation therapy
3. Newspaper discussion
4. Bibliotherapy
5. Activities of daily living
6. Calisthenics
7. Indoor/ outdoor games
8. Play therapy

Therapeutic Meetings
1. Circle meeting highlights of 24 hours
2. Small group personal problems of patient
3. Community meeting problems of patient encountered in the ward of general interest
4. Treatment planning treatment regimen of a patient
5. Discharge planning conference discharge plan for patient
6. Patient government meeting officers of the patients discuss issue related to their welfare
7. Staffs shift-to-shift meeting discussion of the demotion and promotion of patient status

Attitude therapy
Prescribed ways on how to handle mentally ill patients according to the behavior symptoms they manifest.

Types of attitude therapy
1. Active friendliness withdrawn patient
2. Passive friendliness paranoid patient
3. Kind-firmness depressed client
4. Matter-of-fact manipulative/ demanding client related
5. No demand furious in rage

Characteristics of attitude therapy
1. Consistency must be used in order for the client to reach the maximum therapeutic value.
2. All persons who come in contact with the patient should have a uniform attitude.
3. Should be prescribed by the physician and should be individualized depending on the individual needs.

Wernickes Encephalopathy
Definition
Wernickes encephalopathy is a serious neurological condition that results primarily from a deficiency of the
nutrient thiamine which is also known as Vitamin B1. This condition is an inflammatory, hemorrhagic,
degenerative condition of the brain. It is characterized by lesions in several parts of the brain, including the
hypothalamus, mammillary bodies, and tissues surrounding the ventricles and aqueducts, double vision,
ophthalmoplegia, involuntary and rapid movements of the eyes, lack of muscular coordination, and decreased
mental function, which may be mild or severe. The disease is comprised of three main symptoms: mental
confusion, lack of muscle coordination, and a paralysis of the muscles which control eye movements.

Frequency
The male-to-female ratio is 1.7:1, likely owing to alcoholism being 3-4 times more frequent in men than in
women.
Wernicke encephalopathy have placed the incidence between 0.8% and 2.8% of the general population
The incidence can be as high as 12.5% in a population of alcoholics

Causes
This disease is caused by a lack of thiamin (vitamin B1), which leads to problems with the normal functioning of
the brain.
Thiamine deficiency is characteristically associated with chronic alcoholism, because it affects thiamine
uptake and utilization. Most cases of Wernickes encephalopathy are rooted in chronic alcohol abuse. Alcohol
can, over time, severely impair the bodys ability to absorb thiamine, gradually leading to a deficiency of this
nutrient. When someone who is known to abuse alcohol has symptoms such as confusion and gait ataxia, meaning
lack of coordination in walking, Wernickes encephalopathy should be considered as a possible cause.
Wernicke encephalopathy may develop in nonalcoholic conditions such as:
1. prolonged starvation
2. hyperemesis gravidarum (continuous nausea and vomiting during pregnancy)
3. bariatric surgery and other gastric bypass surgeries
4. HIV-AIDS
5. healthy infants given the wrong formulas
6. malnutrition
7. complication of GI tract disease
8. Cancers that have spread throughout the body
9. Heart failure (when treated with long-term diuretic therapy)
10. Long periods of intravenous (IV) therapy without receiving thiamine supplements
11. Long-term dialysis
12. Very high thyroid hormone levels (thyrotoxicosis)
13. Chronic renal failure
14. Carbohydrate loading in the presence of marginal thiamine stores (feeding after starvation)
15. Absence of thiamine from the diet (in the case of infants fed formula without the addition of thiamine)
16. Congenital transketolase function abnormalities


Signs and Symptoms
TRIAD SYMPTOMS
The 3 components of the classic triad of Wernicke encephalopathy are encephalopathy, ataxic gait, and some
variant of oculomotor dysfunction.
Encephalopathy. Encephalopathy is characterized by a global confusional state, disinterest, inattentiveness, or
agitation. The most constant symptoms of Wernicke encephalopathy are the mental status changes.

Stupor and
coma are rare.
Loss of muscular coordination (ataxia) Leg tremor. Gait ataxia is often a presenting symptom. Ataxia is
likely to be a combination of polyneuropathy, cerebellar damage, and vestibular paresis. Vestibular dysfunction,
usually without hearing loss, is universally impaired in the acute stages of Wernicke encephalopathy.
Ocular Abnormalities. Ocular abnormalities are the hallmarks of Wernicke encephalopathy. The oculomotor
signs are:
1. Abnormal eye movement (back and forth movements called nystagmus) most common
2. Double vision
3. Eyelid drooping
4. bilateral lateral rectus palsies
5. conjugate gaze palsies reflecting cranial nerve involvement of the oculomotor, abducens, and vestibular nuclei
6. pupillary abnormalities such as sluggishly reactive pupils, ptosis, scotomata, and anisocoria
OTHER SYMPTOMS
Vestibular dysfunction

Hypotension. Hypotension can be secondary to thiamine deficiency either through cardiovascular beriberi or
thiamine deficiencyinduced autonomic dysfunction.
Hypothermia. Thiamine deficiency often affects the temperature-regulating center in the brainstem, which can
result in hypothermia.
Coma
Wet beriberi
Nutritional polyneuropathy
Muscle atrophy,
Cold skin.
Loss of memory, can be profound.
Swallowing difficulties,
Double vision.
Abnormal eye movements.
Inability to form new memories.
Dry skin,
Staggering gait.
Eye movement abnormalities.
Difficulty with speech,
Confabulation (making up stories).
Reduced eye movement.

Diagnosis
No specific laboratory test is available for diagnosing Wernicke encephalopathy. Wernicke encephalopathy is a
clinical diagnosis, and normal electrolyte levels may only give false reassurance and delay therapy. This is
particularly the case where malnutrition is likely to be present. The motto should be If in doubt, treat, as
administration of thiamine does not pose potential harm.
A Diagnosis can be made by treating the patient with thiamin and watching the symptoms improve. There are
blood and urine tests available to check the level of thiamin, but giving the patient thiamin and seeing the
response is the best way to diagnose this condition.
When a person appears poorly nourished (malnourish). The following should be done to check the patients
nutrition level:
1. Serum albumin. This test relates to the persons general nutrition
2. Serum vitamin B1 levels
3. Transketolase activity in the red blood cells. The level of this is reduced in people with thiamine deficiency.
Blood pyruvate and lactate measurements. These tests are sensitive and helpful, as thiamine is a cofactor of
the pyruvate dehydrogenase enzyme, an important enzyme in aerobic metabolism.
Toxic drug screening is performed to exclude some causes of drug-induced altered mental status.
To exclude hypoglycemia and hyperglycemia, serum glucose levels should be obtained.
Complete blood cell (CBC) count rules out severe anemias and leukemias as causes of altered mental status.

Treatment
Intravenous thiamine is given to the patient for a few days until it can be given by mouth.
The most effective treatment is to eat properly.
Start thiamine prior to or concurrently with treatment of intravenous glucose solutions, and continue until the
patient resumes a normal diet.
Patients with Wernicke encephalopathy are likely hypomagnesemic and should be treated empirically with
parenteral magnesium sulfate, as they may be unresponsive to parenteral thiamine in the presence of
hypomagnesemia. After correction of hypomagnesemia in conjunction with thiamine repletion, the blood
transketolase activity can return to normal and clearing of the clinical signs may occur.
Stabilize airway, ensure oxygenation and maintain the patients blood pressure as patients with Wernickes
encephalopathy present with an altered mental status in prehospital settings.
Promoting hydration.
Providing proper nutrition.