Theoretical Frameworks and Developmental Stages
Kübler-Ross Stages of Death and Dying
- The five stages are denial, anger, bargaining, depression, and acceptance.
Freud's Psychoanalytic Theory
- A basic assumption is that all behavior has meaning.
- The personality operates on three levels: conscious, preconscious, and unconscious.
- The id holds instinctual drives ("i" for instinctual, "d" for drive).
- The ego controls internal demands and interacts with the outside world at the conscious, preconscious, and unconscious levels.
- The superego holds morals, values, and ethics. It evaluates thoughts and actions, rewarding good and punishing bad (the "supercop" of the unconscious).
- Between ages 12 and 20, a person is in the genital stage: learning independence, increased interest in the opposite sex, and establishing an identity.
- Per the pleasure principle, the psyche seeks pleasure and avoids unpleasant experiences regardless of consequence.
Erikson's Psychosocial Stages
- School-age child (ages 6 to 12): industry versus inferiority.
- Identity versus role confusion: ages 12 to 20.
- Generativity versus despair: generativity (investing the self in the larger community) is expressed through procreation, work, community service, and creative work.
- Older adult (age 65 or older): integrity versus despair.
- Ritualism and negativism are typical toddler behaviors, occurring during autonomy versus shame and doubt.
General Adaptation Syndrome
- The three stages are alarm, resistance, and exhaustion.
Defense Mechanisms
- Denial: refusal to acknowledge the reality of an event, or to acknowledge feelings, thoughts, desires, impulses, or external facts that are consciously intolerable.
- Projection: unconsciously assigning a thought, feeling, or action to someone or something else ("scapegoating").
- Sublimation: channeling unacceptable impulses into socially acceptable behavior.
- Repression: unconsciously pushing unacceptable or painful thoughts, impulses, or memories from consciousness.
- Reaction formation: avoiding anxiety through behavior and attitudes opposite to repressed impulses.
- Displacement: transferring unacceptable feelings to a more acceptable or less threatening object or person.
- Regression: retreating to an earlier developmental stage.
- Suppression: voluntarily excluding stress-producing thoughts from consciousness.
Common Psychiatric Terms and Concepts
- Flight of ideas: skipping rapidly from one topic to another, unrelated one.
- La belle indifférence: lack of concern for a profound disability (blindness, paralysis) seen in conversion disorder.
- Echolalia: parrotlike repetition of another person's words.
- Thought blocking: loss of one's train of thought from a defect in mental processing.
- Idea of reference: the false belief that others' statements or actions refer to oneself.
- Circumstantiality: unnecessary, minute details and digressions that delay communicating the main idea.
- Confabulation: filling memory gaps with imaginary experiences or made-up information.
- Illusion: misinterpretation of an actual environmental stimulus.
- Delusion: a fixed, false belief.
- Thought broadcasting: a delusion that one's thoughts are broadcast for the world to hear.
- Compulsion: an irresistible urge to perform an irrational act, such as repeated handwashing or a strict ritual.
- Labile affect: rapid shifts of emotion and mood.
- Amnesia: loss of memory from an organic or inorganic cause.
- Fugue: a dissociative state in which a person leaves familiar surroundings, assumes a new identity, and has amnesia for the previous one ("flight from himself").
- Dysfunctional grieving: absent or prolonged grief.
- Catharsis: expression of deep feelings and emotions.
- Free-floating anxiety: generalized apprehension and pessimism for unknown reasons.
Psychiatric Disorders
Anxiety-Related Disorders
- Moderate anxiety narrows the perceptual field. The person is selectively inattentive and less able to perceive and concentrate.
- A patient with a phobic disorder uses self-protective avoidance as an ego defense.
- Phobias are treated with desensitization, gradually exposing the patient to the feared stimulus.
- Anxiety is nonspecific; fear is specific.
- Intense anxiety can trigger the fight-or-flight reaction (alarm reflex).
- Hyperalertness and an exaggerated startle reflex characterize posttraumatic stress disorder (PTSD).
Mood Disorders (Depression and Bipolar)
- With a depressed patient, the nurse's first priority is safety because of the increased suicide risk.
- Depression is clinically significant when sadness, melancholy, dejection, worthlessness, and hopelessness are out of proportion to reality.
- Depression is the most common psychiatric disorder.
- Major depressive disorder presents with depressed mood, inability to feel pleasure, sleep disturbance, appetite changes, decreased libido, and worthlessness.
- Reactive depression is a response to a specific life event.
- Always assess the depressed patient for suicidal ideation.
- Suicide is the second leading cause of death among US adolescents ages 10 to 14 (NIMH); many teens who die by suicide made a previous attempt and left warning signs.
- A patient with a chosen method and a plan to act within the next 48 to 72 hours is at high risk. A "no self-harm" contract for a specified period helps reduce that risk.
- Bipolar II disorder is characterized by at least one major depressive episode accompanied by hypomania.
- During the manic phase, nursing care aims to slow the patient down, because self-induced exhaustion or injury can be fatal. Delusional thought patterns are common in mania.
Schizophrenia and Other Psychotic Conditions
- Apathy is typical in schizophrenia.
- When a patient with schizophrenia begins to hallucinate, redirect them to here-and-now activities.
- Organic brain syndrome is the most common form of mental illness in elderly patients.
- Delusional thought patterns and hallucinations are frequent in psychotic disorders.
Neurocognitive Disorders (Alzheimer's, Dementia)
- Memory disturbance is a classic sign of Alzheimer's disease.
- Diagnosis rests on clinical findings of two or more cognitive deficits, progressive memory worsening, and neuropsychological test results.
- Early stage (2 to 4 years): inappropriate affect, transient paranoia, disorientation to time, memory loss, careless dressing, impaired judgment.
- Middle stage (4 to 7 years): profound personality changes, loss of independence, confusion, inability to recognize family, nocturnal restlessness.
- Last stage (final year of life): blank facial expression, seizures, loss of appetite, emaciation, irritability, total dependence.
- Remote memory may be impaired in late-stage dementia.
Personality Disorders
- Borderline personality disorder: demanding and judgmental in relationships, will try to "split" staff by pointing to discrepancies in the treatment plan; violent outbursts are common.
- Antisocial personality disorder: frequently confronts and challenges authority figures.
- Paranoid personality disorder: suspicion, hypervigilance, hostility.
- Dependent behavior: constantly seeking approval or assistance from staff or others.
- Manipulative behavior: a maladaptive way of meeting one's needs that disregards others. Setting limits is the most effective control.
- Passive-aggressive personality disorder: manipulative behavior and indirect resistance to demands.
Eating Disorders
- In anorexia nervosa, the highest treatment priority is correcting nutritional and electrolyte imbalances.
- Signs of anorexia nervosa include amenorrhea, excessive weight loss, lanugo, abdominal distention, and electrolyte disturbances.
- Observe patients with anorexia nervosa or bulimia during meals and for some time afterward to prevent purging.
- Provide support at mealtime and record the amount eaten.
Childhood and Adolescent Disorders (Including Abuse)
- Common causes of child abuse are poor parental impulse control and lack of knowledge of child growth and development.
- The Child Abuse Prevention and Treatment Act (CAPTA, Public Law 93-247, enacted January 31, 1974) created the federal framework under which states require reporting of suspected child abuse to child protection services (govinfo, Public Law 93-247).
- Suspect sexual abuse in a young child with blood in the feces or urine, genital trauma, or a sexually transmitted disease.
- A child who dissociates ("spacing out," separating from reality) has probably been abused.
- Methylphenidate (Ritalin) and amphetamine-based stimulants are first-line for ADHD in children. Pemoline (Cylert) was once an option but was withdrawn from the US market in 2005 for hepatotoxicity and is no longer prescribed.
- Conduct disorder shows extreme behaviors such as cruelty to animals or people.
- Autism is often diagnosed between ages 2 and 3.
Substance Abuse and Alcohol Abuse
- Alcoholics Anonymous uses a 12-step program for sobriety; Al-Anon supports families of alcoholics.
- An alcoholic who achieves sobriety is a recovering alcoholic, because no cure exists.
- Tolerance is needing increasing amounts of a substance for the same effect.
- Early signs of alcohol withdrawal (anxiety, anorexia, tremors, insomnia) may begin up to 8 hours after the last drink.
- Detoxification works best in a structured environment with supportive, nonjudgmental staff.
- Caring for the withdrawing patient: keep the environment calm, minimize intrusions, speak slowly, adjust lighting, call the patient by name, and have a friend or family member stay if possible.
- Chlordiazepoxide (Librium) is the drug of choice for alcohol withdrawal.
- Alcohol withdrawal can precipitate seizures because alcohol lowers the seizure threshold in some people.
- In a hospitalized alcoholic, withdrawal delirium most commonly occurs 3 to 4 days after admission.
- Therapy often includes folic acid, thiamine, multivitamins, and adequate food and fluids to prevent deficiencies such as peripheral neuropathy or Wernicke-Korsakoff syndrome.
- Opiate withdrawal symptoms may appear within 12 hours of the last dose, with the most severe symptoms within 48 hours.
- Narcotic abstinence maintenance typically uses 10 to 40 mg of methadone (Dolophine) once daily, with ingestion monitored.
- Disulfiram (Antabuse) is aversion therapy for alcoholism. Drinking on disulfiram can cause severe, potentially life-threatening reactions, so the patient must also avoid hidden alcohol (cough syrups, sauces made with cooking wine).
- Do not give disulfiram with metronidazole (Flagyl); the interaction may cause a psychotic reaction.
Psychopharmacology
Lithium
- Lithium needs regular blood-level monitoring (usually monthly) because the therapeutic range is narrow.
- The therapeutic range is narrow, about 0.6 to 1.2 mEq/L for maintenance, and levels of 1.5 mEq/L and above are considered toxic (Lithium, StatPearls).
- Toxicity can occur when sodium and fluid intake are insufficient, causing the body to retain lithium.
- Signs of toxicity: diarrhea, tremors, nausea, muscle weakness, ataxia, confusion.
- For toxicity symptoms, withhold the next dose and notify the physician.
- Improved concentration signals lithium is taking effect.
- Take lithium with food, and do not restrict sodium intake unless ordered.
- Stabilized patients have levels checked 2 to 3 times weekly in the first month, then weekly to monthly during maintenance.
- Stop lithium and call the physician for vomiting, drowsiness, or muscle weakness.
Monoamine Oxidase Inhibitors (MAOIs)
- Tyramine-rich foods (aged cheese, chicken liver, avocados, bananas, salami, Chianti wine, beer) can cause severe hypertension on an MAOI and must be avoided to prevent hypertensive crisis.
- For palpitations, headache, or severe orthostatic hypotension on an MAOI, withhold the drug and notify the physician.
- Cottage cheese, cream cheese, yogurt, and sour cream are safe on an MAOI.
- Weigh the patient biweekly and monitor for suicidal tendencies.
Antipsychotics and Extrapyramidal Symptoms
- Extrapyramidal effects are common with antipsychotics: parkinsonism, dystonia, akathisia ("ants in the pants"), and tardive dyskinesia.
- Diphenhydramine (Benadryl) can relieve extrapyramidal effects.
- For muscle rigidity and tremors, give an antiparkinsonian agent (benztropine/Cogentin or trihexyphenidyl/Artane) as ordered.
- Tardive dyskinesia causes excessive blinking, unusual tongue movements, and involuntary sucking and chewing.
- A major toxic risk of clozapine (Clozaril) is blood dyscrasia (agranulocytosis). It is contraindicated in pregnancy and in severe granulocytopenia or severe CNS depression.
- Haloperidol (Haldol) adverse effects: drowsiness, insomnia, weakness, headache, extrapyramidal symptoms.
- Do not give chlorpromazine (Thorazine) to a patient who has drunk alcohol; it can cause oversedation and respiratory depression.
Antidepressants
- TCA adverse reactions: tachycardia, orthostatic hypotension, hypomania, lowered seizure threshold, tremors, weight gain, sexual dysfunction, anxiety.
- Fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) are SSRIs for depression. Prozac side effects may include diarrhea, decreased libido, weight loss, and dry mouth.
- Alcohol potentiates the effects of TCAs.
Other Notable Medications
- Methylphenidate (Ritalin) and amphetamine stimulants treat ADHD; pemoline (Cylert) is no longer marketed in the US.
- The primary purpose of psychotropic drugs is to decrease symptoms, improving function and treatment compliance.
Therapeutic Approaches and Communication
Nurse-Patient Relationship Phases
- Phase I (orientation): obtain an initial history; nurse and patient agree to a contract.
- Phase II (working): the patient discusses problems, behavioral change occurs, and self-defeating behavior is reduced.
- Phase III (termination): end the relationship and give positive feedback on accomplishments.
Communication and Intervention Techniques
- Open-ended questions are one of the best ways to elicit or clarify information.
- Confrontation points out discrepancies between the patient's words and behavior.
- Paraphrasing is active listening: restating what the patient just said.
- Encourage an angry patient to use a physical exercise program to ventilate feelings.
- When two psychiatric patients are in a threatening confrontation, separate them first for safety.
- Too many "why" questions overwhelm the patient and yield little information.
- Asking open-ended questions and exploring meaningful losses are key interventions with a depressed patient.
Specific Therapies
- Family therapy treats the family as a whole, reestablishing rational communication.
- Group therapy lets each participant examine interactions, practice interpersonal skills, and explore emotional conflicts.
- Psychodrama recreates life situations so participants gain insight and practice new skills.
- Behavior modification (time-outs, token economies, reward systems) is used for conditions such as ADHD.
- Stress management is a short-range goal of psychotherapy.
Seclusion, Restraints, and Safety
- Seclusion reduces overstimulation and protects against self-injury, harm to others, and property damage. Use it only after less restrictive interventions fail.
- The decision to use restraints must be based on the patient's safety needs.
- A patient admitted involuntarily loses the right to sign out against medical advice (AMA).
- Threatening a patient with an injection for refusing oral medication is assault.
Additional Nursing Care Points
- For a newly admitted psychotic patient, the primary concern is safety, followed by establishing trust.
- The patient should be able to predict the nurse's behavior and expect consistent, positive attitudes.
- When scheduling one-to-one interactions, state how long the conversation will last and hold to that limit.
Electroconvulsive Therapy
- ECT is typically used for severe depression unresponsive to drug therapy.
- Usually 6 to 12 treatments at 2 to 3 per week.
- One theory holds that ECT "resets" the brain's circuits, restoring normal function.
- Methohexital (Brevital) is the general anesthetic given beforehand; the skeletal muscle relaxant succinylcholine (Anectine) is given IV.
- Rarely, ECT can cause arrhythmias and death.
- Keep the patient NPO after midnight before ECT to prevent aspiration.
- After ECT, place the patient in the lateral position (head turned to one side) and monitor for post-shock amnesia.
Other High-Yield Points
- An alcoholic uses alcohol to cope with life's stresses.
- People with obsessive-compulsive disorder (OCD) know their behavior is unreasonable but feel powerless to stop it (ego-dystonia).
- "People who live in glass houses shouldn't throw stones" is a proverb used to test abstract thinking; a schizophrenic patient may take it literally.
Frequently Asked Questions
What is the therapeutic range for lithium, and when is it toxic?
Maintenance levels run about 0.6 to 1.2 mEq/L, and the range is narrow enough that levels of 1.5 mEq/L and above are considered toxic. Draw levels 6 to 12 hours after the last dose, hold the drug, and notify the prescriber for signs of toxicity such as diarrhea, tremor, ataxia, or confusion (Lithium, StatPearls).
What is the nurse's first priority when caring for a depressed patient?
Safety, because depression carries an elevated suicide risk. Always assess directly for suicidal ideation, a plan, and access to means before anything else.
Which foods must a patient on an MAOI avoid?
Tyramine-rich foods such as aged cheese, cured or smoked meats, chicken liver, fava beans, and red wine or beer. Combining them with an MAOI can trigger a hypertensive crisis. Cottage cheese, cream cheese, and yogurt are generally safe.
What are extrapyramidal symptoms, and how are they managed?
They are movement side effects of antipsychotics, including parkinsonism, dystonia, akathisia, and tardive dyskinesia. Acute reactions are treated with an anticholinergic such as diphenhydramine (Benadryl) or benztropine (Cogentin); tardive dyskinesia may be irreversible, so it must be caught early.
What medication is the drug of choice for alcohol withdrawal?
A benzodiazepine, classically chlordiazepoxide (Librium), given in a calm, structured setting. Thiamine, folic acid, and multivitamins are added to prevent Wernicke-Korsakoff syndrome.
Are nurses required to report suspected child abuse?
Yes. Under the framework set by the Child Abuse Prevention and Treatment Act (CAPTA, Public Law 93-247, 1974), every state names nurses as mandated reporters who must notify child protective services of reasonable suspicion of abuse or neglect (govinfo, Public Law 93-247).