Slide 1 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Chapter...

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Chapter 35

Care of the Patient with a

Psychiatric Disorder

-Overview of Treatment Methods

-Application of Nursing Process

Chapter 35

Care of the Patient with a

Psychiatric Disorder

-Overview of Treatment Methods

-Application of Nursing Process


Overview of Treatment MethodsOverview of Treatment Methods

• Communication and Therapeutic Relationship Confidentiality is a dilemma when therapeutic

effectiveness of care depends on patient’s willingness to talk about feeling and thoughts

Let patient know information is shared among healthcare team

• To curtails patients’ manipulating the staff, or pitting one staff member or patient against another

Nurse has duty to report child abuse and must also warn

• Patient may threaten to kill some one or hurt someone Nurse must report to proper authority



• Communication and Therapeutic Relationship Therapeutic techniques for psychiatric disorders

• Psychotherapy

• Electroconvulsive therapy (ECT)

• Psychopharmacology Key component to psychiatric-mental health treatment

• To develop helping–trust relationship Maximizes patient’s strengths, maintains self-esteem,

and assists patient to develop and use coping skills

Nurse assists patient in learning new ways of responding to people and situation

• Therapeutic Dialogue, pg 1153



• Communication and Therapeutic Relationship Psychotherapy

• Psychiatric problems are treated using one or more of the following psychological techniques:

Behavior therapy Cognitive therapy Group therapy Play therapy Hypnosis Psychoanalysis Adjunctive therapies




• Behavioral therapy To relieve anxiety by conditioning and retraining of

behavioral responses by repetition Phobias may be resolved by this technique

• Cognitive therapy Focuses on breaking negative thought patterns and

developing positive feelings about memories or thoughts

• Group therapy Used in a hospital setting or day treatment programs Patients with similar problems gain insight through

discussion and role palying




• Play therapy Used to help children express themselves by using

toys such as puppets as their “spokesperson” of feelings

• Hypnosis To help person recover deeply repressed emotions

and speed recovery Help change habits like smoking




• Psychoanalysis Developed by Sigmund Freud Long-term and intense form of therapy that allows

individual to bring unconscious thoughts to surface Free association (speaking thoughts without

censorship) and dream interpretation




• Adjunctive therapies Occupational therapy, recreational therapy, music

therapy, magnetic therapy, art therapy and hydrotherapy

Allow expression of feelings, help increase self-esteem, and promote positive interaction and reality orientation

Used in group setting or individually



• Electroconvulsive Therapy (ECT) Introduced by Ugo Cerletti and Lucio Bino in the late

1930’s Muscle relaxants and anesthesia are part of therapy

• To reduce fracture, contusion, and sprains from seizures

Treatment for depression, mania, or schizophrenia disorders that do not respond to other treatments

A very small amount of electrical current required to trigger a tonic-clonic (grand mal) seizure

• Temporary memory loss Last a few hours to a few days

• Confusion Lasts a few hours



• ECT (continued) Done as out patient treatment When used properly, it’s effectiveness is as great

or even greater than other treatment Tests before ECT

• Physical examination, blood chemistry, survey, CBC, urinalysis

To detect unsuspected conditions

• Mental examination, EEG to rule out electrical abnormalities, chest and lumbosacral spine radiography to rule out abnormalities, ECG



• ECT (continued) Nursing Interventions

• Pre-ECT Informed consent; NPO for 8 hours Baseline vital signs; void prior to treatment All jewelry, glasses, contacts, dentures, and hairpins

removed IV line inserted; pre-ECT medications given



• ECT (continued) Nursing Interventions

• Post-ECT Frequent vital signs; warm bath Constant supervision due to confusion Light meal or snack and assist in mobility Should not drive until completely confusion free



• Psychopharmacology Psychotropic (psychoactive) medications are used in

conjunction with other therapies to help modify an individual’s behavior

Use to control symptoms Nursing responsibility

• Monitor for effectiveness and side effects

• Must understand the use of these drugs (pg: 1156-1157)


Overview of Treatment Methods: PsychopharmacologyOverview of Treatment Methods: Psychopharmacology

• Antidepressants Work in different ways in brain Assist in alleviating signs and symptoms of

depression• Decreased appetite or sleep pattern disturbances,

prolonged sadness and lack of concentration Effects are seen 2 to 4 weeks before

improvement is noted Effects on depression is described as “fog lifting” Maintained for several months to a year to

prevent symptoms recurrent



• Antidepressants (cont’d) Selective serotonin reuptake inhibitors (SSRIs)

• Fluoxetine (Prozac), sertraline (Zoloft), venlafaxine (Effexor), citalopram (Celexa), paroxetine (Paxil)

Serotonin syndromeo Potentially life-threatening condition o Occurs due to an interaction between SSRI and

another serotonergic agento Occur in older adult patients taking only SSRIo SX: altered mental status, autonomic dysfunction,

and neuromuscular abnormalities

• Use is preferred due to fewer side effects



• Antidepressants (cont’d) Selective serotonin reuptake inhibitors (SSRIs)

• Serotonin syndrome Labs: elevated CPK from muscle disintegration,

elevated WBC, and transaminases, decreased serum bicarbonate level

Treatment: slowly decrease dosage of drug Sudden drug decrease leads to: dizziness, nausea,

vomiting, muscle pain, headache, fatigue, anxiety, crying spells and irritability



• Antidepressants (continued) Tricyclics

• Amitriptyline (Elavil), amoxapine (Asendin), desipramine HCl (Norpramin), imipramine HCl (Tofranil), nortriptyline HCl (Avnetyl, Pamelor)

Monoamine oxidase inhibitors (MAOIs)• Phenelzine sulfate (Nardil)

• Tranylcypromine sulfate (Parnate) Triazolopyradines

• Trazodone (Desyrel)

• Bupropion (Wellbutrin)



• Antidepressants (continued) Autonomic dysfunctions

• BP fluctuation, tachycardia, hyperthermia, mydriasis (dilated pupils), shivering, diaphoresis

Neuromuscular symptoms• Akathisia, jittery feeling inside, ataxia

(incoordination), dystonia, dyskinesia, hyperreflexia, tremors and seizures



• Antimanics Stabilizes mood and behavior of a patient with mania Therapeutic blood level required (lithium carbonate)

• May take 7-10 days to achieve Lithium carbonate (Eskalith, Lithobid)

• Chief drug to manage mania• Monitor for lithium toxicity

Serum level above 1.5 mEq/L Signs of toxicity: Nausea, vomiting, diarrhea,

drowsiness, muscle weakness, and ataxia, leads to seizure and death

Poor fluid intake and salt restriction in diet increases risk of toxicity



• Antipsychotics Major tranquilizers Treatment of schizophrenia, organic mental disorders

with psychosis, and the manic phase of bipolar mood disorder

Provide symptomatic control; not a cure Side effects

• Postural hypotension and sedation Consider safety measures to prevent fall

• Photosensitivity Sunscreen and hats

• Autonomic reactions Urinary retention, dry mouth, constipation, edema, weight

gain



• Antipsychotics (continued) Side effects

• Extrapyramidal symptoms Pseudoparkinsonism – tremor with rigid posture Akathisia – inability to sit still, with continuous hand,

mouth, or body movements (foot tapping) Dystonias – aberrant posturing (hand spasms) Dyskinesia – involuntary movement (lip smacking,

tongue protrusion) Tardive dyskinesia – due to reduction of medication

and can have a permanent effect



• Antipsychotics (continued) Treatment of extrapyramidal symptoms

• Reduce or stop the drug, parenteral diphenhydramine, antiparkinson drugs (trihexyphenidyl [Artane], or benztropine [Cogentin])

Example: pg 1156• Chlorpromazine (Thorazine)• Thioridazine HCl (Mellaril-S)• Trifuloperazine HCl (Stelazine)• Fluphenazine HCl (Prolixin, Permitil)• Perphenazine (Trilafon)• Thiothixene (Navane)• Haloperidol (Haldol)



• Antianxiety Minor tranquilizers Help individuals experiencing moderate to severe

anxiety Benzodiazepine sedatives like lorazepam (ativan)

• Used to relieve tension without losing motivation Drugs in this category are commonly abused



• Antianxiety Examples

• Alprazolam (Xanax)

• Busipirone (Buspar)

• Chlordiazepoxide HCl (Librium)

• Clorazepate dipotassium (Tranxene)

• Lorazepam (Ativan)

• Oxazepam (Serax)


Alternative TherapiesAlternative Therapies

• Use of natural or herbal medications has gained tremendous popularity.

• Control and manufacture of these medications do not fall under the laws of the U.S. Food and Drug Administration. Quality and quantity vary from manufacturer to

manufacturer. Claims and clinical studies are not always consistent.

• Nurse should ask about the use of herbs when obtaining drug history.



• Examples St. John’s wort (Hypernicum)

• Interacts with MAOIs and can trigger hypertension taken with allergy medication containing monoamines

or phenylalanine Taken withamino acid supplement containing tyrosine

• Used for mild depression Kava (Piper methysticum)

• Used in treating anxiety and insomnia• Proven sedative effects• S/E: scaly rash on back of hands and forearms and soles

of foot• Alcohol potentiates its effects and if taken with BNZ, can

become toxic and induce coma



• Examples Ginkgo and Ginseng

• Used to improve memory and boost energy

• Ginkgo: provide memory and cognitive improvement in treatment of early Alzheimer’s disease

Increases cerebral blood flow Potentiates anticoagulant drugs like aspirin and

warfarin which can lead to hemorrhage Affect insulin release

• Ginseng: decreases blood glucose level in diabetics



• Examples Aromatherapy

• Used to enhance or potentiate another remedy• Scented oils for massage, volatile oils to sniff or

inhale, scented candles or incense Triggers chemical activity in the brain to relieve

imbalance in the body• Citrus essences, peppermint, cedar wood,

rosemary, sandal wood, chamomile, lavander Essential oils help relieve stress and anxiety Chamomile tea, sandal wood candle, lavander bath

• Focuses on atmosphere of moment and uses body’s senses to achieve balance within

• A place in holistic care


Nursing Process ApplicationNursing Process Application

• LPN/LVN participates in nursing process as member of mental health care team that includes RN, MD, therapist

• LPN/LVN observation of patient behavior and therapeutic communications with patient Assist RN in collecting data to form nursing diagnoses Ensure appropriate patient intervention

• Health promotion interventions focus on: Prevention of relapse Management of symptom Simple, concrete, clear patient teaching is most successful


Nursing Process ApplicationNursing Process Application

• Evaluation Ongoing At intervals or when patient’s response dictates, care

plan is updated Examination of documentation and personal

observations are considerations when evaluating the plan of care

• Documentation methods: Ongoing and include assessment criteria used by

health care team Information are accurate and descriptive Avoid terms “appears depressed” and use “no eye

contact noted during conversation”

Slide 1 Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Chapter...

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