notes on psyche

8/7/2019 notes on psyche

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ELECTROCONVULSIVE THERAPY

An accepted, safe, and efficacious form of treatment for majordepression



Indications

� Need for rapid, definitive response when a

client is suicidal or homicidal

� Extreme agitation or stupor� Risk of other treatment outweighs the risk of

ECT

�History of poor drug response , history of good ECT response

� Client prefers it.

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Indications� MDD & bipolar disorder

� manic clients resistant to lithium &antipsychotic drug

� rapid cycler clients (schizophrenia,

schizoaffective syndrome� psychotic clients who are pregnant

� clients with Parkinsond s disease)



Contraindication

recent MI CVA

CVmalformation

intracranialmass lesion



Not for

DD

atypical depression and personality disorder

drug-dependent

depression secondary situational or social

Dosage

2-3x/wk, 6-12 treatment



Procedure



Preparing the client

� Pretreatment PE, labs, baseline memory abilities

� Signed informed consent

� Benzodiazepine or barbiturates should be eliminated

� Should be done by trained professional

� Nursing responsibilities

± NPO for 6-8 hours except cardiac and HPN dx

± Administer atropine one hour before tx

± Remove hairpins, contact lenses, hearing aid anddentures

± Monitor VS

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During ECT

� Maintain IV line

� Place electrodes at sides of the head

� Administer Methohexital (Brevital) short-acting barbiturate

� Mechanical ventilation

� Nursing responsibilities

� Mechanically ventilate with 100% O2

� Monitor respiratory problem

� Administer benzodiazepine� Observe patient until stable

� Document and record



Disadvantage

T rary r li f

M ry i air nt

Cardiac ff cts HPN, arrhyth ia, alt rati n in cardiacut ut, chang s in CV dyna ics

H dyna ics incr as uscl t n , hy natr ia,

igrain

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CRISISIt is an overwhelming reaction to a

threatening situation in which an individuals

usual problem-solving skills and coping

responses are inadequate for maintaining

psychological equilibrium



General Consideration1.Crisis occurs in all individuals at one time or

another2.Crisis is not necessarily pathological, it can

provide stimulus for growth & learning

3.Crisis is time limited and is usually resolve oneway or another in a brief period (4-6 weeks)

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Successful crisis resolution occurswhen functioning is restored orenhanced through new learning

Unsuccessful crisis resolution is whenfunctioning is not restored to pre-crisis

level, and the individual experiencesdecreased level of functioning



Type of Crisis� Developmental crisis - occurs from transition fromone stage of maturation to another in the life cycle

� Situational crisis occurs to a sudden, unexpectedevent in an individual life. These events is all aboutexperiences of loss.

� Adventitious crisis occurs in response to severe

trauma or natural disaster. These crisis can affectindividuals, communities and even nation

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Sequence of Crisis Development

1. Pre-Crisis period individual has emotionalequilibrium

2. Crisis period individual has the subjective

experience of being upset, failure of usualcoping mechanism, symptoms areexperienced

3. Post-Crisis period resolution of crisis



Symptoms common in individual

experiencing crisis� Physical symptoms somatic complaints

� Cognitive symptoms confusion, difficultyconcentrating, racing thoughts, inability tomake decisions

� Behavioral symptoms disorganization,impulsive, angry outburst, withdrawal from

social interaction� Emotional symptoms anxiety, anger, guilt,

sadness, depression, paranoia, suspicion,helplessness, powerlessness



Crisis Intervention1. Assistance

± Assistance for an individual affected by a crisis± Assistance for groups or communities affected

by crisis

� Mobile crisis team

� Disaster response team

� Critical incident stress debriefing assistance

is directed at groups of professional

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Role of the Nurse

� Nurse provides direct services to people in crisis and serve as

members of crisis intervention teams

� In acute and chronic hospital setting assist individuals andfamilies responding to the crisis of serious illness,

hospitalization and death

� In community setting provide assistance to individuals and

families in developmental and situational crisis� Nurses working with a particular group of client should

anticipate situations in which crisis may occurs. They also

collaborate with other health team members to help an

individual resolve crisis



� the goal of crisis intervention is to return the

individual to pre-crisis level of functioning

�Emphasis is on strengthening and supportinghealthy aspects of individuals functioning



Principles of crisis intervention

� A problem-solving approach is use in a systematic

manner

± Assessing the individuals perception to problem

assessing strengths and weaknesses of the individual

and family support system

± Planning specific outcomes or goals based on

priorities

± Providing direct intervention

± Evaluation outcome and results of intervention

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Principles of crisis intervention

� Use the framework of Maslows hierarchy of

needs to determine the priorities forintervention

± Physical resources necessary for survival

± Social resources necessary for regaining sense

of belonging

± Psychological resources necessary for regaining

self-esteem



Role of crisis intervention worker

� Establishes rapport and communities

hope and optimism� Assumes an active, directive role if

necessary

� Make suggestions and offer alternatives



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Terms

� Substance abuse ingestion of chemical active agent

� Addiction an illness characterized by compulsion, loss of control, & continues

patterns of abuse despite with a dysfunction habit (ANA)

� Psychological dependence continuous or intermittent craving for a substance to

avoid a dysmorphic or unpleasant mood state emotional dependence

� Tolerance ability to obtain a desired effect from a specific dose of a drug

� Physiologic dependence physical defects resulting from the multiple episodes of

a substance use - withdrawal Sx

� Behavioral dependence substance-seeking & pathological use patterns of the

person using the substance

� Codependency all the behavior patterns of family members who have been

significantly affected by another family members substance use or abuse



Milieu management

� For disruptive patients:

± Set limits

± Frequently observe escalating patients to intervene

± Modify the environment to minimize objects that can be used

as weapons

± Be careful in stating what the staff will do if a patient acts out

± When using restraints, provide for safety by evaluating the

patients status of hydration, nutrition, elimination, &

circulation



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Milieu management

� For withdrawn patients:

±Arrange non-threatening activities that involve

these patient in doing something

±Arrange furniture in a semicircle or around a table

±Help client to participate in decision making

±Reinforce appropriate grooming & hygiene

±Provide psychosocial rehabilitation



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Milieu management

� For patient with hallucinations:± Attempt to provide distracting activities

± Discourage situation in which patient talk to others about

their disordered perception± Monitor television selection

± Monitor for command hallucination that might increasethe potential for patient to become dangerous

± Have staff members available in the dayroom so thatpatient can talk to real people about real people or realevents



Milieu management

� For disorganized patients:

±Remove disorganized patient to a lessstimulating environment

± Provide a calm environment

± Provide safe & relatively simple activitiesfor these patients



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Nursing guidelines

± Build a therapeutic alliance with patient

1. Be calm

2. Accept patient

3. Keep promises

4. Be honest

5. Do not reinforce hallucinations or delusions

6. Do not touch patient without warning

7. Reinforce positive behaviors8. Avoid competitive activities

9. Do not embarrass patient

10.Allow & encourage verbalization of feelings



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SCHIZOPHRENIA LIKE DISORDERS

1. Schizoaffective disorders

± Uninterruptive period of illness during which at some point the patient

experiences a MDD, manic or mixed episodes along with the negative

symptoms of schizophrenia

± In the absence of prominent mood symptoms, patient exhibits delusion or

hallucination

2. Schizophreniform disorder

± Patient exhibits features of schizopohrenia for more than 1 month butfewer that 6 months

± No impaired social or occupational function

3. Brief psychotic disorder

± Onset of at least 1 or more positive symptoms of psychosis

± Occur at least 1 day to less that an month then full recovery

4. Psychotic disorder due to a general medical condition

± Presence of prominent hallucination or delusion determined as resulting

from the direct physiologic effect of a specific medical condition



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Nursing Interventions

Strengthening Differentiation Between Delusionsand Reality

� Provide patient with honest and consistent

feedback in a nonthreatening manner.� Avoid challenging the content of patient's

behaviors.

� Focus interactions on patient's behaviors.

� Administer drugs as prescribed whilemonitoring and documenting patient's responseto the drug regimen.

� Use simple and clear language when speakingwith patient.



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Improving Activity Tolerance

� Assess patient's response to prescribed antipsychotic drug.

� Collaborate with patient and occupational and physical therapyspecialists to assess patient's ability to perform ADLs.

�Collaborate with patient to establish a daily, achievable routine withinphysical limitations.

� Teach strategies to manage adverse effects of antipsychotic drug thataffect patient's functional status, including:

± Change positions slowly

± Gradually increase physical activities

± Limit overdoing it in hot, sunny weather± Use sun precautions

± Use caution in activities if extrapyramidal symptoms develop.




Improving Coping with Thoughts and Feelings

�Encourage patient to express feelings.

�Focus on patient's feelings and behavior.

�Provide honest perceptions of reality andfeedback about symptoms and behaviors.

�Encourage patient to explore adaptivebehaviors that increase abilities and success in

socializing and accomplishing ADLs.�Decrease environmental stimuli.




Ensuring Safety

� Monitor patient for behaviors that indicateincreased anxiety and agitation.

� Collaborate with patient to identify anxiousbehaviors as well as the causes.

� Tell patient that you will help with maintainingbehavioral control.

� Establish consistent limits on patient's behaviorsand clearly communicate these limits to patient,family members, and health care providers.

�Secure all potential weapons and articles fromatient's room and the unit environment that



Ensuring Safety

� To prepare for possible continued escalation, form a psychiatricemergency assist team and designate a leader to facilitate aneffective and safe aggression-management process.

� Determine the need for external control, including seclusion orrestraints. Communicate the decision to patient and put plan intoaction.

� Frequently monitor patient within the guidelines of facility's policyon restrictive devices and assess the patient's level of agitation.

� When patient's level of agitation begins to decrease and self-control

is regained, establish a behavioral agreement that identifies specificbehaviors that indicate self-control against a reescalation of agitation.



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Community and Home Care Considerations

� Patients with these disorders may be insupportive housing, such as transitional living

halfway houses, foster homes, and board andcare homes. Supervision and drug managementare important areas of concern for the nurseworking in the community.

� Psychosocial rehabilitation approach may beused in the community setting, where skillsnecessary for independent living are taught. Thepatient who has been symptomatic since early

adulthood may not have learned these skills The

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