NOTES VI - PSYCHIATRIC NURSING PART 1NOTES VI - PSYCHIATRIC NURSING PART 1

IntroductionMENTAL HEALTH balance in a persons internal life and adaptation to reality

Mental ILL Health state of imbalance characterized by a disturbance in a persons thoughts, feelings and behavior

Psychiatric nursinginterpersonal process whereby the professional nurse practitioner ,through the therapeutic use of self (art) and nursing theories (science), assist clients to achieve psychosocial well being.Core : interpersonal processRelated TermsMental hygienemeasures to promote mental health , prevent mental illness and suffering and facilitate rehabilitationMain tool: therapeutic use of selfIt requires self-awarenessMethods to increase self-awareness:IntrospectionDiscussionExperienceRole play

Assessment (psychosocial processes )Appearance , behavior or moodSpeech , thought content and thought processSensoriumInsight and judgmentFamily relationships and work habitsLevel of growth and development

Common Behavioral Signs and SymptomsDisturbances in perceptionIllusionmisinterpretation of an actual external stimuli

Hallucinationsfalse sensory perception in the absence of external stimuli

Disturbances in thinking and speechneologism coining of words that people do not understand

Circumstantiality over inclusion of inappropriate thoughts and details

Word salad incoherent mixture of words and phrases with no logical sequence

Verbigeration meaningless repetition of words and phrasesPerseveration persistence of a response to a previous questionEcholalia pathological repetition of words of othersAphasia speech difficulty and disturbanceExpressive , receptive or global

Flight of ideas- shifting of one topic from one subject to another in a somewhat related wayLooseness of association-incoherent illogical flow of thoughts (unrelated way)Clang association sound of word gives direction to the flow of thought

Delusion persistent false belief, rigidly heldDelusions of grandeur: special /important in a wayPersecutory: threatenedIdeas of reference: situation/events involve themSomatic: body reacting in a particular way

Jealous: thinking that their partner is unfaithfulErotomanic: person, usually of high status, is in love with the clientReligious: illogical ideas about God and religion exhibited by extreme or extraneous behaviorMixed: combination of above without a predominant theme

Magical thinking primitive thought process thoughts alone can change eventsAutistic thinking regressive thought process; subjective interpretations not validated with objective realityDereism unorganized thinking

Disturbances of affectInappropriate disharmony between the stimuli and the emotional reactionBlunted affect severe reduction in emotional reactionFlat affect absence or near absence of emotional reactionApathy dulled emotional tone

Depersonalization feeling of strangeness from ones selfDerealization feeling of strangeness towards environmentAgnosia lack of sensory stimuli integration

Disturbances in motor activityEchopraxia imitation of posture of othersWaxy flexibility maintaining position for a long period of timeAtaxia loss of balanceAkathesia extreme restlessness

Dystonia- uncoordinated spastic movements of the bodyTardive dyskinesia involuntary twitching or muscle movementsApraxia involuntary unpurposeful movements

Disturbances in memoryConfabulation filling of memory gapsDj vu something unfamiliar seems familiarJamais vu- something familiar seems unfamiliarAmnesia memory loss (inability to recall past events)Retrograde-distant pastAnterograde immediate pastAnomia lack of memory of items

Dynamics of Human BehaviorBehavior the way an individual reacts to a certain stimulus

Conflict situation arising from the presence of two opposing drives

Need - organismic condition that requires a certain activityDynamics of Human BehaviorPersonalitytotality of emotional and behavioral traits that characterize the person in day to day living under ordinary conditions; it is relatively stable and predictable.FORMATION OF PERSONALITYTEMPERAMENTbiological-genetic template that interacts with our environment.a set of in-built dispositions we are born withmostly unalterableour nature.CHARACTERthe outcome of the process of socialization, the acts and imprints of our environment and nurture on our psyche during the formative years (0-6 years and in adolescence).the set of all acquired characteristics we posses, often judged in a cultural-social context.Sometimes the interplay of all these factors results in an abnormal personalityTHEORIES OF PERSONALITY DEVELOPMENTFreudsPSYCHOSEXUAL THEORY

Libido inner driveParts of body focus of gratificationUnsuccessful resolution - fixationStructures of personalityId: pleasure principle-instinctEgo: controls action and perception reality principleSuperego: moral behavior - conscience

0-18 m0s ;oral mouth trust and discriminating18 mos. 3 years ; anal bowels holding on or letting goNegativism and toilet training age3 -6 years phallic ; genitals exploration and discovery ( inc. sexual tension)Gender identification and genital awarenessOedipus and Electra complexCastration anxiety and penis envy

6-12 years latency (quiet stage) sexual energy diverted to play. Institution of superego: control of instinctual impulses12 young adult genital ; reawakening of sexual drives relationshipsSexual maturationSexual identity ,ability to love and work

Eric EricksonsPSYCHOSOCIAL THEORY

0-12mos1-3y

3-66-1212-18

18-2525-60

60 and aboveTRUST vs. MISTRUSTAUTONOMY vs. SHAME & DOUBTINDUSTRY vs. INFERIORITYINITIATIVE vs. GUILTIDENTITY vs. IDENTITY CONFUSIONINTIMACY vs. ISOLATIONEGO INTEGRITY vs. STAGNATIONGENERATIVITY vs. DESPAIR

INFANCYCONSISTENT MATERNAL CHILD INTERACTION TRUSTINNER FEELING OF SELF WORTHHOPETODDLERALLOW EXPLORATIONPROVIDE FOR SAFETYNO, NO NEGATIVISMOFFER CHOICES / REVERSE PSYCHOLOGYTOILET TRAINING 18 MOS.-BOWELDAYTIME BLADDER: 2 yoNIGHTIME BLADDER: 3 yoREWARD W/ PRAISE AND AFFECTIONINDEPENDENCE

PRE-SCHOOLPROVIDE PLAY MATERIALSSATISFY CURIOSITYTEACH AND REINFORCE(HYGIENE,SOCIAL BEHAVIOR)SIBLING RIVALRYWILLPOWERSCHOOL AGEHOW TO DO THINGS WELL-SUPPORT EFFORTSCHUMS AND HOBBIESNEEDS TO EXCEL/ACCOMPLISHNEED FOR PRIVACY AND PEER INTERACTIONCOMPETENCEADOLESCENCEMAKE DECISION,EMANCIPATION FROM PARENTSBODY IMAGE CHANGESNEED TO CONFORM BUT KEEP INDIVIDUALITYSELF - AWARENESSYOUNG ADULT

COMMITMENT AND FIDELITY

RESPONSIBILITY

ACHIEVEMENT OFINDEPENDENCEMIDDLE ADULTHOODSUPPORT-PERIOD OF ROLE TRANSITIONS

MIDLIFE CRISIS

ADJUSTMENT AND COMPROMISE

MOST PRODUCTIVE AND CREATIVE

ALTRUISMLATE ADULTHOODSELF ACCEPTANCE

SELF WORTH

WISDOMJean PiagetsCOGNITIVE THEORY0-2 SENSORIMOTORREFLEXESIMITATIVE REPETITIVE BEHAVIORSENSE OF OBJECT PERMANENCE AND SELF SEPARATE FROM ENVT.TRIAL AND ERROR RESULTS IN PROBLEM SOLVING2-7Y PRE-OPERATIONALSELF-CENTERED,EGOCENTRICCANNOT CONCEPTUALIZE OTHERS VIEWANIMISTIC THINKINGIMAGINARY PLAYMATE SYMBOLIC MENTAL REPRESENTATION CREATIVITY2-4 PRE-CONCEPTUAL (PRE-LOGICAL)4-7 INTUITIVE (UNDERSTANDING OF ROLES)7-12Y CONCRETE OPERATIONALLOGICAL CONCRETE THOUGHTINDUCTIVE REASONING (SPECIFIC TO GENERAL)CAN RELATE, PROBLEM SOLVING ABILITYREASONING AND SELF-REGULATION12-ABOVE: FORMAL OPERATIONAL THOUGHTAbstract thinkingSeparation of fantasy and factReality orientedDeductive reasoningApply scientific methodHavighurstsDEVELOPMENTAL TASKS

Baby to early childhoodRight from wrong and ConscienceLate childhoodPhysical skills, wholesome attitude, social rolesConscience morality and valuesFundamental skills in academicsPersonal independence

AdolescenceSexual social rolesRelationshipsIndependenceand ideologyEarly adulthoodCareerSelecting a mateFinding Civic or social responsibility

Middle ageAchieving Civic or social responsibilityAdjusting to changesSatisfactory career performanceAdjusting to aging parentsAdjusting to parental rolesOld ageAdjusting to changesEstablishing satisfactory living arrangements and affiliations

KohlbergsMORAL DEVELOPMENT/ THINKING/ JUDGEMENT

PRE-CONVENTIONAL (0-6)PUNISHMENT AND OBEDIENCEOBEDIENCE TO RULES TO AVOID PUNISHMENTCONVENTIONAL ( 6-12 )MUTUAL INTERPERSONAL EXPECTATIONS,RELATIONSHIPS AND CONFORMITYSOCIAL SYSTEM AND CONSCIENCE MAINTENANCEBEING GOOD IS IMPORTANT SELF RESPECT OR CONSCIENCE

POST CONVENTIONAL (12 18 Y)PRIOR RIGHT OR SOCIAL CONTRACTUNIVERSAL ETHICAL PRINCIPLEABIDE FOR COMMON GOODRATIONAL PERSON-VALIDITY OF PRINCIPLES-AND BECOME COMMITTED TO THEMINNER CONTROL OF BEHAVIOR UNDERSTANDING THE EQUALITY OF HUMAN RIGHTS AND DIGNITY OF HUMAN BEINGS AS INDIVIDUALSHarry Stack SullivansINTERPERSONAL THEORY

INFANCYNEED FOR SECURITY-INFANT LEARNS TO RELY ON OTHERS TO GRATIFY NEEDS AND SATISFY WISHES, DEVELOPS A SENSE OF BASIC TRUST, SECURITY AND SELF WORTH WHEN THIS OCCURS

TODDLERHOOD / EARLY CHILDHOODCHILD LEARNS TO COMMUNICATE NEEDS THROUGH USE OF WORDS AND ACCEPTANCE OF DELAYED GRATIFICATION AND INTERFERENCE OF WISH FULFILLMENT

PRE-SCHOOLDEVELOPMENT OF BODY IMAGE AND SELF-PERCEPTIONORGANIZES AND USES EXPERIENCES IN TERMS OF APPROVAL AND DISAPPROVAL RECEIVEDBEGINS USING SELCTIVE INATTENTION AND DISASSOCIATES THOSE EXPERIENCES THAT CAUSE PHYSICAL OR EMOTIONAL DISCOMFORT AND PAINSCHOOL AGETHE PERIOD OF LEARNING TO FORM SATISFYING RELATIONSHIPS WITH PEERS-USES COMPETITION,COMPROMISE AND COOPERATIONTHE PRE-ADOLESCENT LEARNS TO RELATE TO PEERS OF THE SAME SEXADOLESCENCELEARNSINDEPENDENCEAND HOW TO ESTABLISH SATISFACTORY RELATIONSHIPS WITH MEMBERS OF THE OPPOSITE SEXYOUNG ADULTHOODBECOMES ECONOMICALLY, INTELLECTUALLY AND EMOTIONALLY SELF SUFICIENTLATER ADULTHOODLEARNS TO BE INTERDEPENDENT AND ASSUMES RESPONSIBILITY FOR OTHERSSENESCENCEDEVELOPS AN ACCEPTANCE OF RESPONSIBILITY FOR WHAT LIFE IS AND WAS AND OF ITS PLACE IN THE FLOW OF HISTORYTREATMENT MODALITIESREMOTIVATION THERAPYTREATMENT MODALITY THAT PROMOTES EXPRESSION OF FEELINGS THROUGH INTERACTION FACILITATED BY DISCUSSION OF NEUTRAL TOPICSSTEPS : climate of acceptance creating bridge to reality sharing the world we live in appreciation of works of the world climate of appreciation

MUSIC THERAPYInvolves use of music to facilitate expression of feelings, relaxation and outlet of tension

PLAY THERAPYenables patient to experience intense emotion in a safe environment with the use of playchildren express themselves more easily in play. revealing as reflection of childs situation in the familyprovide toys and materials facilitate interaction observe and help child resolve problems through playGroup therapyTreatment modality involving three or more patients with a therapist to relieve emotional difficulties, increase self esteem, develop insight , LEARN NEW ADAPTIVE WAYS TO COPE WITH STRESS and improve behavior with othersIDEAL 8 10 MEMBERSMILIEU THERAPYConsists of treatment by means of controlled modification of the patients environment to facilitate positive behavioral changeIncrease patientsAwareness of feelingsSense of responsibility andHelp return to communityclients plan social and group interactiontoken programs , open wards and self medication are doneFAMILY THERAPYA METHOD OF PSYCHOTHERAPY WHICH FOCUSES ON THE TOTAL FAMILY AS AN INTERACTIONAL SYSTEMPROBLEM IS A FAMILY PROBLEMfocus on sick members behavior as source of trouble / symptom serve a function for the familymembers develop sense of identitypoints out function of the sick member for the rest of the familyPSYCHOANALYTICfocuses on the exploration of the unconscious, to facilitate identification of the patients defensesANXIETY RESULTS BETWEEN CONFLICTS OF ID AND EGOBecomes aware of unconscious thoughts and feelings to understand anxiety and defenses

HYPNOTHERAPYVarious methods and techniques to induce a trance state where patient becomes submissive to instructionsBEHAVIOR MODIFICATIONApplication of learning principles in order to change maladaptive behaviorBelieves that psychological problems are a result of learningEverything learned can be unlearnedBEHAVIOR MODIFICATIONOPERANT CONDITIONINGUse of rewards to reinforce positive behaviorPerceived and self-reinforcement becomes more important than external reinforcement

DESENSITIZATIONSlow adjustment or exposure to feared objects (phobias)Periodic exposure until undesirable behavior disappears or lessensAVERSION THERAPYAn example of behavior modificationPainful stimulus is introduced to bring about an avoidance of another stimulusEnd view: behavioral changeOTHER THERAPIESHUMOR THERAPYTo facilitate expression and enhance interaction

ACTIVITY THERAPYGroup interaction while working on a task togetherBIOLOGICAL/ MEDICAL THEORYEMOTIONAL PROBLEM IS AN ILLNESScause may be inherited or chemical in originFOCUS OF TREATMENT IS MEDICATIONS AND ECTBIOLOGICAL THERAPYELECTROCONVULSIVE THERAPYArtificial induction of a grand mal seizure by passing a controlled electrical current through electrodes applied to one or both templesmechanism of action unclearvoltage: 70 150 voltsDuration: 0.5 2.0 seconds6 to 12 treatmentsintervals of 48 hoursindicators of effectiveness occurrence of generalized tonic clonic seizures

indications depression , mania and catatonic schizophrenias/e: confusion, disorientation, short -term memory loss, seizure (30-60 sec)NPO priorContraindicationsFever, pregnancyInc ICP, fractureretinal detachmentTB with hemoptysiscardiac d/oconsent neededReorient after, supportive care

medications given :Atropine sulfate: decrease secretionsSuccinylcholine (Anectine): promote muscle relaxationMethohexital Sodium ( Brevital ): serves as an anesthetic agentcommon complications:loss of memoryheadacheapneafracture

respiratory depression

NOTES VI - PSYCHIATRIC NURSING PART 2NOTES VI -PSYCHIATRIC NURSING PART 2

Psychopharmacologic Therapy

BenzodiazepinesIndicationsAnxietySedation/sleepMuscle spasmSeizure disorderAlcohol withdrawal syndromes

Anti-anxiety drugs Generic Trade nameAlprazolam XanaxChlordiazepoxide LibriumClorazepate TranxeneDiazepam ValiumLorazepam AtivanOxazepam SeraxBusipirone BuSparSide effectsDrowsiness/ sedationAtaxiaFeelings of detachmentIncrease irritability and hostilityAnterograde amnesiaIncreased appetite & weight gainNauseaHeadache, confusionAnti-depressantsIndicationsDepressionBipolar depressionPanic disorderBulimiaObsessive-compulsive d/oPossiblyAttention deficit/Hyperactivity d/oPost Traumatic Stress D/oConduct d/oTricyclic (TCA) Generic Trade nameAmitriptyline ElavilImipramine TofranilTrimipramine SurmontilNortriptyline PamelorTrazodone DesyrelBupropion WellbutrinSide effectsOrthostatic hypertensionAnticholinergic effectDry mouth, blurred vision, constipation, excessive sweating, urinary hesitancy/ retention, tachycardia, agitation, delirium, exacerbation of glaucomaNeurologic effectssedation, psychomotor slowing, poor concentration, fatigue, ataxia, tremorsDecrease libido and sexual performance

Monoamine Oxidase inhibitors Generic Trade nameIsocarboxazid MarplanPhenelzine NardilTranylcypromine ParnateSide effectsPostural lightheadednessConstipationDelay ejaculation or orgasmMuscle twitchingDrowsinessDry mouthDietary restrictionsCheese, esp. aged and maturedFermented or aged proteinPickled or smoked fishBeer, red wine, sherry; liquor & cognacYeastFava or broad beansBeef or chicken liverSpoiled/ overripe fruits; banana peelyogurtHypertensive CrisisSignsSudden elevation of BPExplosive headache, occipital may radiate frontallyHead & face flushedPalpitations, chest painSweating, feverNausea, vomitingDilated pupils, photophobiaIntracranial bleeding

TreatmentHold next MAO doseDont let pt. lie downIM chlorpromazine 100 mgFever: manage by external cooling techniquesSerotonin Reuptake Inhibitors Generic Trade nameFluoxetine ProzacSertraline ZoloftParoxetine PaxilVenlafaxine EffexorSide effectsNauseaDiarrheaInsomniaDry mouthNervousness

HeadacheMale sexual dysfunctionDrowsinessDizzinessSweating

Mood stabilizing drugsIndicationsAcute maniaBipolar prophylaxisPossiblyBulimiaAlcohol abuseAggressive behaviorschizoaffective

Mode of actionNormalizes the reuptake of certain neurotransmitters such as serotonin, norepinephrine, acetylcholine and dopamineReduces the release of norepinephrine thru competition with calciumEffects intracellularlyLag period: 7-10 to 14 daysLithium carbonateTrade namesEskalithLithotabsLithaneLithonateMOA: unclear; interfere with metabolism of neurotransmitters; alter Na transport in nerves and muscle cellsPrelithium workupUrinalysis (BUN and creatinine)ECG, FBC, CBCSide effectsEarlyNausea and diarrheaAnorexiaFine hand tremor (propranolol)Thirst, Polydipsia (dec. crea, inc. albumin)Metallic tasteFatigueLethargyLateWeight gainacne

ContraindicationsBrain damage/ CV diseaseEpilepsyElderly/ debilitatedThyroid and renal diseaseSevere dehydrationPregnancy (1sttrimester)

Can augment the effects of anti-depressantsNursing considerationsTherapeutic serum level: 0.5 1.2 meq/LMaintenance level: 0.6 -1.2 meq/LToxicMild to moderate: 1.5 to 2 meq/LModerate to severe: 2 2.5 meq/LNeeds dialysis: 3 meq and aboveEarly signs of toxicityLethargy, mild nausea, vomiting, fine hand tremors, anorexia, polyuria, polydipsia, metallic taste, fatigueLate signs of toxicityAtaxia, giddiness, tinnitus, blurred vision, polyuria

Nursing considerationsLithium levels should be checked q 2-3 mosSerum drawn in the AM, 12H after last doseCommon causes of inc. levelsDec. Na intakeDiuretic therapyDec. renal functioningF&E lossMedical illnessOverdoseNSAIDSNursing considerationsDiet: adequate Na+ and fluid3g NaCl/ day6-8 glasses of H2ONo caffeineNo driving: wait for clinical effectManagementModerately severe toxicityOsmotic diuresis: urea/ mannitolAminophylline & PLR IVAdequate NaClPeritoneal/ hemodialysisSevere toxicityAssess hx quicklyHold next lithium doseCheck BP, rectal T, RR, LOC, support O2Obtain labsECGEmetic, NGT lavageHydrate: 5-6L/day c PLR; FBC-CDU

Other drugsCarbamazepine (Tegretol)Side effectsDizzinessAtaxiaClumsinessSedationDysarthriaDiplopiaNausea & GI upsetPreparation: liq, tab, chewable tab

Nursing considerationsAssess drug levels q 3-4 daysMonitor salt and fluid intakeAvoid alcohol and non-prescription drugsRefer dec. in UODont stop abruptlyC/I: pregnancyTake with mealsOther drugsValproic acid (Depakote, Depakene)Side effectsNauseaHepatoxicityNeurotoxicityHematological toxicityPancreatitisPrep: tab, cap, sprinklesMOA: inc. levels of GABA; inhibits thekindlingprocess or snoball-like effect seen in mania & seizuresNursing considerationsTherapeutic level: 50 100 ug/mLDose: 1, 000 1,500 mg/dayMonitor serum levels 12H after last doseToxic effectsSevere diarrhea, vomiting, drowsiness, mm. weakness, lack of coordinationRenal failure, coma, deathAnti-psychotic drugsIndicationsPsychotic symptoms of schizophrenia, acute mania and depressionGilles de Tourette disorderTreatment-resistant bipolar disorderHuntingtons disease and other movement disorderPossiblyParanoidChildhood psychoses

MOA: block receptors of dopamine (D2, D3, D4)If unresponsive after 6 weeks of therapy, another class is triedGeneral considerationsCalms without producing impairment of sleepHigh therapeutic indexNon addicting, no toleranceAvoided in pregnancyTYPICAL: High PotencyFluphenazine (Prolixin)Haloperidol (Haldol)Thiothexene (Navane)Trifluoperazine (Stelazine)Moderate PotencyLoxapine (Loxitane)Molindone (Moban)Perphenazine (Trilafon)Low PotencyChlopromazine (Thorazine)Chlorprothixene (Taractan)Mesoridazine (Serentil)Thioridazine (Mellaril)ATYPICALClozapine (Clozaril)Resperidone (Risperdal)Olanzapine (Zyprexa)Quetiapine (Seroquel)Sertindole (Serlect)Ziprasidone (Zeldox)

ContraindicationsCNS depression: brain damage, excess alcohol/ narcoticsParkinsons diseaseAllergyBlood dyscrasiasAcute narrow angle glaucomaBPHSide effectsHypotensionSedationDermal and ocular syndromeNeuroleptic malignant syndromeAnticholinergic syndromeMovement syndrome (Extrapyramidal Syndrome)Atropine psychosisAgranulocytosisSeizuresNeuroleptic Malignant SyndromeA potentially fatal, idiosyncratic reaction to an antipsychotic drug10-20% mortality rateSx:rigidity,high fever,autonomic instability (BP, diaphoresis, pallor, delirium, elev. CPK), confused or mute, fluctuate from agitation to stuporOccurs in the first 2 weeks of therapyRisk: high dose of high-potency drugs; dehydration, poor nx, concurrent med illnessMovement SyndromesAkathisiaDystoniaTardive dyskinesiaBradykinesiaParkinsonism

Other s/eAtropine psychosis (geriatrics)Hyperactivity, agitation, confusion, flushed skin, sluggish reactive pupilsTTT: IM physostigmineAgranulocytosis (Clozapine)Occurs 3-8 wks afterMedical emergencys/s: fever, malaise, sore throat, leukopeniaTTT: d/c, reverse iso, antibioticsSeizures (Clozapine)Occurs in 5% of patients; TTT: D/c drug

AnticholinergicsBenztropine (Cogentin)Trihexyphenidyl (Artane)Biperiden (Akineton)Procyclidine (Kemadrin)

Not withdrawn abruptlyProvide cool environment

ANTIPARKINSONIAN MEDICATIONSAdjunct to anti-psychotic agents to balance dopamine/ acetylcholine in the brains/e: glaucoma, tachycardia, HPN, cardiac dx, asthma, duodenal ulcerA/e: blurred vision, photosensitivity, drowsiness, orthostatic hypotension, CHF, hallucinations

COMMON DRUGS:Trihexyphenidyl (Artane)benztropine (Cogentin)Biperiden (Cogentin)Selegiline (Eldepryl)Pergolide (Permax)ANTIHISTAMINEDiphenhydramine HCl (BENADRYL)DOPAMINE RELEASING AGENTAmantadine (SYMMETREL)

Nursing considerationsBest taken after mealsAvoid drivingCheck BPAlcohol increases sedative effectsAvoid sudden position changeDrug is not withdrawn abruptly

NOTES VI - PSYCHIATRIC NURSING PART 3NOTES VI - PSYCHIATRIC NURSING PART 3PSYCHIATRIC DISORDERSANXIETY DISORDERSPANIC DISORDERSSPECIFIC PHOBIASOCIAL PHOBIAOCDPTSDACUTE STRESS DISORDERGENERALIZED ANXIETY DISORDERPANIC ATTACKSDISCRETE PERIOD OF INTENSE FEAR OR DISCOMFORT IN WHICH AT LEAST 4 IF THE FF SX DEVELOP ABRUPTLY AND PEAK WITHIN 10 MINS:Palpitations, pounding heart, or accelerated HRSweatingTrembling or shakingSensations of SOB and smotheringFeeling of chokingChest pain or discomfortNausea or abd. PainFeeling dizzy, unsteady, lightheaded or faintDerealization or depersonalizationFear of losing control or going crazyFear of dyingParesthesiasChills or hot flashesSPECIFIC PHOBIA SOCIALEXCESSIVE AND UNREASONABLE CUED BY THE PRESENCE OR ANTICIPATION OF A SPECIFIC OBJECT OR SITUATIONDEFENSE MECH COMMONLY USED INCLUDE REPRESSION AND DISPLACEMENTFEAR OF SOCIAL PERFORMANCE SITUATIONS IN WHICH THE PERSON IS EXPOSED TO UNFAMILIAR PEOPLE OR TO POSSIBLE SCRUTINY BY OTHERSOBSESSION COMPULSIONRECURRENT AND PERSISTENT THOUGHTS, IMPULSES, OR IMAGES ARE EXPERIENCED DURING THE DISTURBANCE AS INTRUSIVE AND INAPPROPRIATECAUSE ANXIETY OR DISTRESSPX KNOWS THAT THESE ARE JUST PRODUCT OF ONES OWN MIND.PX FEELS DRIVEN TO PERFORM REPETITIVE BEHAVIORS OR MENTAL ACTS IN RESPONSE TO OBSESSION OR ACCORDING TO THE RULES THAT ONE DEEMS MUST BE APPLIED RIGIDLY.AIMED AT REDUCING ANXIETYOBSESSION COMPULSIONFEAR OF DIRT & GERMSFEAR OF BURGLARY OR ROBBERYWORRIES ABOUT DISCARDING SOMETHING IMPORTANTCONCERNS ABOUT CONTRACTING A SERIOUS ILLNESSWORRIES THAT THINGS MUST BE SYMMETRICAL OR MATCHINGEXCESSIVE HAND WASHINGREPEATED CHECKING OF DOOR AND WINDOW LOCKSCOUNTING AND RECOUNTING OF OBJECTS IN EVERYDAY LIFEHOARDING OF OBJECTSEXCESSIVE STRAIGHTENING, ORDERING, OR OF ARRANGING THINGSREPEATING WORDS OR PRAYERS SILENTLYPOST TRAUMATIC STRESS SYNDROMEPERSON HAS EXPERIENCED, WITNESSED OR BEEN CONFRONTED WITH AN EVENT THAT INVOLVED ACTUAL OR THREATENED DEATH OR SERIOUS INJURY, OR A THREAT TO PHYSICAL INTEGRITYPERSON REEXPERIENCES THESE IN THE MINDINVOLVES INTENSE FEAR, HELPLESSNESS, OR HORROR AND NUMBING OF GENERAL RESPONSIVENESS (PSYCHIC NUMBING)ACUTE GENERALIZED STRESS ANXIETYMEETS THE CRITERIA FOR EXPOSURE TO A TRAUMATIC EVENT AND PERSON EXPERIENCES 3 OF THE FF SX:sense of detachment,reduced awareness of ones surroundings,derealization,depersonalization,dissociated amnesiaEXCESSIVE ANXIETY OR WORRY, OCCURRING IN MORE DAYS THAN NOT FOR AT LEAST 6 MOS, ABOUT A NUMBER OF EVENTS OR ACTIVITIESFINDS IT DIFFICULT TO CONTROL THE WORRYMOOD/ AFFECTIVE DISORDERSBIPOLAR D/OBIPOLAR I: current or past experience of manic episode, lasting at least a week, that is severe enough to cause extreme impairment in social or occupational functioning.MANIA: hyperactivityDEPRESSED: extreme sadness or withdrawalMIXEDBIPOLAR II: hx of 1 or more mj depressive episodes & at least 1 hypomanic episode; no maniaMAJOR DEPRESSIVE D/O@ least 5 sx of same 2- wk period with one being either depressed mood or loss of interest or pleasure.Single episode or recurrentOther sx: wt loss, insomnia, fatigue, recurrent thoughts of death, diminished ability to think, psychomotor agitation or retardation, feelings of worthlessness.CYCLOTHYMIC D/OHx of 2 yrs of hypomania with numerous periods of abnormally elevated, expansive or irritable moods.Does not meet the criteria of mania or depression.DYSTHYMIC D/O@ least 2 yrs of usually depressed mood and at least 1 of the sx of mj depression without meeting the criteria for itSEASONAL AFFECTIVE D/ODepression that comes with shortened daylight in fall and winter that disappears during spring and summer.Dealing with Inappropriate BehaviorsAGGRESSIVE BEHAVIORASSIST THE CLIENT IN IDENTIFYING FEELINGS OF FRUSTRATION AND AGGRESSIONENCOURAGE THE CLIENT TO TALK OUT INSTEAD OF ACTING OUT FEELINGS OF FRUSTRATIONASSIST THE CLIENT IN IDENTIFYING PRECIPITATING EVENTS OR SITUATIONS THAT LEAD TO AGGRESSIVE BEHAVIORDESCRIBE THE CONSEQUENCES OF THE BEHAVIOR ON SELF AND OTHERSASSIST IN IDENTIFYING PREVIOUS COPING MECHANISMSASSIST THE CLIENT IN THE PROBLEM-SOLVING TECHNIQUES TO COPE WITH FRUSTRATION OR AGGRESSIONDEESCALATION TECHNIQUESMAINTAIN SAFETYMAINTAIN LARGE PERSONAL SPACE AND USE NONAGGRESSIVE POSTUREUSE CALM APPROACH AND COMMUNICATE WITH A CALM, CLEAR TONE OF VOICE (BE ASSERTIVE NOT AGGRESSIVEDETERMINE WHAT THE CLIENT CONSIDERS TO BE HIS OR HER NEEDAVOID VERBAL STRUGGLESPROVIDE CLEAR OPTIONS THAT DEAL WITH BEHAVIORASSIST WITH PROBLEM-SOLVING AND DECISION MAKING REGARDING THE OPTIONSMANIPULATIVE BEHAVIORSSET CLEAR, CONSISTENT, REALISTIC, AND ENFORCEABLE LIMITS AND COMMUNICATE EXPECTED BEHAVIORSBE CLEAR ABOUT CONSEQUENCES ASSOCIATED WITH EXCEEDING SET LIMITSDISCUSS BEHAVIOR IN NONJUDGMENTAL AND NONTHREATENING MANNERAVOID POWER STRUGGLESASSIST IN DEVELOPING MEANS OF SETTING LIMITS ON OWN BEHAVIORSCHIZOPHRENIACHARACTERIZED BY IMPAIRMENTS IN THE PERCEPTION OR EXPRESSION OF REALITY AND BY SIGNIFICANT SOCIAL OR OCCUPATIONAL DYSFUNCTION.ONCE CONSIDERED AS A DEADLY DISEASETHERE IS LACK OF INSIGHT IN BEHAVIORDX: LATE ADOLESCENCE AND EARLY ADULTHOOD15-25 y.o. (men); 25-35 y.o. (women)OBSOLETE TERM: DEMENTIA PRAECOX = COGNITIVE DETERIORATION EARLY IN LIFEEUGENE BLEULER: SCHIZ SPLIT; PHREN MINDRisk factorsGENETICS: IDENTICAL TWINS 50%, 15% FOR FRATERNAL TWINSBIOCHEMICAL FACTORSDopamine hypothesis: overactiveSerotonin imbalanceDecreased brain volume, enlarged ventricles, deeper fissures, and loss or underdeveloped brain tissuePSYCHOANALYTIClack of trust during the early stagesWeak egoDefenses: REPRESSION, REGRESSION, PROJECTIONENVIRONMENT INFLUENCES: POVERTY, LACK OF SOCIAL SUPPORT, HOSTILE HOME ENVIRONMENT, ISOLATION, UNSATISFACTORY HOUSING, DISRUPTION IN INTERPERSONAL RELATIONSHIPS (DIVORCE OR DEATH), JOB PRESSURE OR UNEMPLOYMENTSubtypesCATATONIC TYPEprominent psychomotor disturbances are evident. Symptoms can include catatonic stupor and waxy flexibilityDISORGANIZED TYPEwhere thought disorder and flat affect are present togetherPARANOID TYPEwhere delusions and hallucinations are present but thought disorder, disorganized behavior, and affective flattening are absentRESIDUAL TYPEwhere positive symptoms are present at a low intensity onlyUNDIFFERENTIATED TYPEpsychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types has not been metSymptomsACCORDING TO BLEULER: 4 ASAffect is inappropriateAssociative loosenessAutistic thinkingAmbivalenceSymptomsPOSITIVE SYMPTOMSdelusions, auditory hallucinations and thought disorder and are typically regarded as manifestations of psychosis.NEGATIVE SYMPTOMSconsidered to be the loss or absence of normal traits or abilitiesE.G. flat, blunted or constricted affect and emotion, poverty of speech and lack of motivation.SymptomsSOCIAL ISOLATIONCATATONIC BEHAVIORHALLUCINATIONSINCOHERENCE (MARKED LOOSENESS OF ASSOCIATION)ZERO/ LACK OF INTEREST, ENERGY AND INITIATIVEOBVIOUS FAILURE TO ATTAIN EXPECTED LEVEL OF DEVTPECULIAR BEHAVIORHYGIENE AND GROOMING IMPAIREDRECURRENT ILLUSIONS AND UNUSUAL PERCEPTION EXPERIENCESEXACERBATIONS AND REMISSIONS ARE COMMONNO ORGANIC FACTORS ACCOUNTS FOR THE SYMPTOMSINABILITY TO RETURN TO BASELINE FUNCTIONING AFTER RELAPSEAFFECT IS INAPPROPRIATENsg Dx: Abnormal thought processBLOCKING: SUDDEN CESSATION OF A THOUGHT IN THE MIDDLE OF A SENTENCE, UNABLE TO CONTINUE THE TRAIN OF THOUGHTCIRCUMSTANTIALITY: BEFORE GETTING TO THE POINT OF ANSWERING A QUESTION, THE INDIVIDUAL GETS CAUGHT UP IN COUNTLESS DETAILS AND EXPLANATIONSCONFABULATIONLOOSENESS OF ASSOCIATIONNEOLOGISMWORD SALADInterventionsASSESS PHYSICAL NEEDSSET LIMITSMAINTAIN SAFETYINITIATE ONE-ON-ONE INTERACTION & PROGRESS TO SMALL GROUPSSPEND TIME WITH CLIENTSMONITOR FOR ALTERED THOUGHT PROCESSMAINTAIN EGO BOUNDARIES, AVOID TOUCHINGLIMIT TIME OF INTERACTIONBE NEUTRALDO NOT MAKE PROMISES THAT CANT BE KEPTESTABLISH DAILY ROUTINESDO NOT GO ALONG WITH THE CLIENTS DELUSIONS OR HALLUCINATIONSPROVIDE SIMPLE COMPLETE ACTIVITIESREORIENTSPEAK TO THE CLIENT IN SIMPLE DIRECT AND CONCISE MANNERSET REALISTIC GOALSEXPLAIN EVERYTHING THAT IS BEING DONEDECREASE STIMULIMONITOR FOR SUICIDE RISKENVIRONMENTProvide safe environmentLimit stimuliPSYCHOLOGICAL TTTBehavior therapySocial skills trainingSelf-monitoringSOCIAL TTTMilieu therapyFamily therapyGroup therapy (long-term ttt)Related psychotic disordersSCHIZOAFFECTIVE DISORDER SCHIZ + MOOD DISORDER (MANIA/ DEPRESSION)BRIEF PSYCHOTIC DISORDER SUDDEN ONSET OF PSYCHOTIC SYMPTOMS, LASTS LESS THAN 2 MOS AND CLIENT RETURNS TO PREMORBID LEVEL OF FUNCTIONINGSCHIZOPHRENIFORM DISORDER SCHIZ SX LASTING BETWEEN 1 MONTH AND 3 YEARS OF AGE) OF DEVTAL DELAYS IN LANGUAGE, SOCIAL FUNCTION AND MOTOR SKILLS; SKILLS APPARENTLY ATTAINED ARE LOSTASPERGERS D/OCHARACTERIZED BY DIFFERENCE IN LANGUAGE AND COMMUNICATION SKILLS, AS WELL AS REPETITIVE OR RESTRICTIVE PATTERNS OF THOUGHT AND BEHAVIOR.SIGNS: UNABLE TO INTERPRET OR UNDERSTAND THE DESIRES OR INTENTIONS OF OTHERS AND THEREBY ARE UNABLE TO PREDICT WHAT TO EXPECT OF OTHERS OR WHAT OTHERS MAY EXPECT OF THEMNarrow interests or preoccupation with a subject to the exclusion of other activitiesRepetitive behaviors or ritualsPeculiarities in speech and languageExtensive logical/technical patterns of thoughtSocially and emotionally inappropriate behavior and interpersonal interactionProblems with nonverbal communicationClumsy and uncoordinated motor movtsCHRONIC MOTOR/ VOCAL TICTICIS A SUDDEN, REPETITIVE, STEREOTYPED, NONRHYTHMIC, INVOLUNTARY MOVEMENT (MOTOR TIC) OR SOUND (PHONIC TIC) THAT INVOLVES DISCRETE GROUPS OF MUSCLES.CAN BE INVISIBLE TO THE OBSERVER (E.G. ABDOMINAL TENSING OR TOE CRUNCHING)TOURETTES D/OCHARACTERIZED BY THE PRESENCE OF MULTIPLE PHYSICAL (MOTOR) TICS AND AT LEAST ONE VOCAL (PHONIC) TIC; THESE TICS CHARACTERISTICALLY WAX AND WANETTT: NEUROLEPTIC MEDICATIONShaloperidol (Haldol)pimozide (Orap)ADHDINATTENTION:FAILURE TO PAY CLOSE ATTENTION TO DETAILS OR MAKING CARELESS MISTAKES WHEN DOING SCHOOLWORK OR OTHER ACTIVITIESTROUBLE KEEPING ATTENTION FOCUSED DURING PLAY OR TASKSAPPEARING NOT TO LISTEN WHEN SPOKEN TOFAILURE TO FOLLOW INSTRUCTIONS OR FINISH TASKSAVOIDING TASKS THAT REQUIRE A HIGH AMOUNT OF MENTAL EFFORT AND ORGANIZATION, SUCH AS SCHOOL PROJECTSFREQUENTLY LOSING ITEMS REQUIRED TO FACILITATE TASKS OR ACTIVITIES, SUCH AS SCHOOL SUPPLIESEXCESSIVE DISTRACTIBILITYFORGETFULNESSPROCRASTINATION, INABILITY TO BEGIN AN ACTIVITYDIFFICULTIES WITH HOUSEHOLD ACTIVITIES (CLEANING, PAYING BILLS, ETC.)DIFFICULTY FALLING ASLEEP, MAY BE DUE TO TOO MANY THOUGHTS AT NIGHTFREQUENT EMOTIONAL OUTBURSTSEASILY FRUSTRATEDEASILY DISTRACTEDHYPERACTIVITY-IMPULSIVE BEHAVIOURFIDGETING WITH HANDS OR FEET OR SQUIRMING IN SEATLEAVING SEAT OFTEN, EVEN WHEN INAPPROPRIATERUNNING OR CLIMBING AT INAPPROPRIATE TIMESDIFFICULTY IN QUIET PLAYFREQUENTLY FEELING RESTLESSEXCESSIVE SPEECHANSWERING A QUESTION BEFORE THE SPEAKER HAS FINISHEDFAILURE TO AWAIT ONE'S TURNINTERRUPTING THE ACTIVITIES OF OTHERS AT INAPPROPRIATE TIMESIMPULSIVE SPENDING, LEADING TO FINANCIAL DIFFICULTIESFREQUENTLY PRESCRIBED STIMULANTS AREMETHYLPHENIDATE (RITALIN AND CONCERTA), AMPHETAMINES (ADDERALL) AND DEXTROAMPHETAMINES (DEXEDRINE)FEINGOLD DIETWHICH INVOLVES REMOVING SALICYLATES, ARTIFICIAL COLORS AND FLAVORS, AND CERTAIN SYNTHETIC PRESERVATIVES FROM CHILDREN'S DIETS.CONDUCT D/OREPETITIVE AND PERSISTENT PATTERN OF BEHAVIOR IN WHICH THE BASIC RIGHTS OF OTHERS OR MAJOR AGE-APPROPRIATE SOCIETAL NORMS OR RULES ARE VIOLATED,AGGRESSION TO PEOPLE & ANIMALSDESTRUCTION OF PROPERTYDECEITFULNESS OR THEFTSERIOUS VIOLATIONS OF RULESBeginning before age 13OPPOSITIONAL DEFIANTCHARACTERIZED BY AN ONGOING PATTERN OF DISOBEDIENT, HOSTILE, AND DEFIANT BEHAVIOR TOWARD AUTHORITY FIGURES THAT GOES BEYOND THE BOUNDS OF NORMAL CHILDHOOD BEHAVIORSIGNSLosing temperArguing with adultsRefusing to follow the rulesDeliberately annoying peopleBlaming othersEasily annoyedAngry and resentfulSpiteful or even revengeful

SUBSTANCE ABUSEEXCESSIVE OR UNHEALTHY USE OF SUBSTANCES, SUCH AS ALCOHOL, TOBACCO OR DRUGS, OR USE OF PRODUCTS SUCH AS FOODTERMS:TOLERANCE: the declining effect of the same drug dose when it is taken repeatedly over timeHABITUATION: a psychological dependence of the use of a drugADDICTION: the biological and/ or psychological behaviors related to substance dependenceWITHDRAWAL SYMPTOMS: result from a biological need that develops when the body becomes adapted to having an addictive drug in the system; occurs when serum levels decreaseADDICTIONALCOHOL: BLOOD ALCOHOL LEVELS OF 0.1% (100MG ALCOHOL/DL OF BLOOD) OR HIGHERWITHDRAWALAnorexiaAnxietyEasily startledHyperalertnessHPNInsomniaIrritabilityJerky movtPossibly: hallucinations, illusions or vivid nightmaresSeizures (7-48 hrs after cessation)Tachycardiatremors

WITHDRAWAL DELIRIUMAgitationAnorexiaAnxietyDeliriumDiaphoresisDisorientation with fluctuating levels of consciousnessFever (100 to 103 F)Hallucinations and delusionsInsomniaTachycardia and HPNDisulfiram (Antabuse) therapyNursing careOBTAIN INFO ABOUT DRUG TYPE AND AMOUNT CONSUMEDASSESS V/SREMOVE UNNECSSARY OBJ FROM ENVIRONMENTPROVIDE ONE-ON-ONE SUPERVISION IF NECESSARYPROVIDE A QUIET, CALM ENVIRONMENT WITH MINIMAL STIMULIMAINTAIN ORIENTATIONENSURE SAFETYUSE RESTRAINTSPROVIDE PHYSICAL NEEDSPROVIDE FOOD AND FLUIDS AS TOLERATEDADMINISTER MEDICATIONSCOLLECT BLOOD AND URINE SAMPLES FOR DRUG SCREENINGSPOUSE ABUSEBATTERING PRECIPITATES 1:4 SUICIDE ATTEMPTS OF ALL WOMENWIVES EXPLAIN THE INJURIES AS BEING SELF-INFLICTED OR ACCIDENTALPHASESTension-building: series of small incidents that leads to beatingAcute beating phase: wife becomes object of assault behaviorLoving phase: batterer is remorseful and assures spouse that he will not harm her again. This leads to reconciliation.MYTHSThey believe that if they try not to antagonize with their husband, he will change.Efforts to coerce the wife out of the victim role can be fruitful.FACTSWomen stay in relationships with men who batter because they feel guilty or responsible of the husbands behaviorWife develops little sense of self-worth, immobilized and unable to remove self from the relationship.ASSESSMENT: INJURIES, OTHER EVIDENCEINTERVENTIONS: WITH CONSENTCHILD ABUSEPHYSICAL BATTERINGEMOTIONALSEXUALNEGLECTELDERLY ABUSEA VARIETY OF BEHAVIORS THAT THREATEN THE HEALTH, COMFORT, AND POSSIBLY THE LIVES OF THE ELDERLY, INCLUDING PHYSICAL AND EMOTIONAL NEGLECT, EMOTIONAL ABUSE, VIOLATION OF PERSONAL RIGHTS, FINANCIAL ABUSE, AND DIRECT PHYSICAL ABUSE.COMMONLY COMMITTED BY CARE GIVERS.SEXUAL ABUSECOMPONENTSSexual Misuse: inappropriate sexual activityRape: there is actual penetrationIncest: refers to the relationship between the victim and abuser blood relative or step parent roleINTERVENTIONSChildren: thru play or role playing with puppetsPrevention of further sexual abusenextCOMPLETED SUICIDESELF-INFLICTED DEATHLEVELS OF SUICIDEIdeation: thoughtAttempt: acted upon but failedCompletedCHEMICAL RESTRAINTCHEMICAL RESTRAINTS: MEDICATIONS USED TO RESTRICT THE PATIENTS FREEDOM OF MOVEMENT OR FOR EMERGENCY CONTROL OF BEHAVIOR BUT ARE NOT A STANDARD TREATMENT FOR THE PXS MEDICAL OR PSYCHIATRIC CONDITION.PHYSICAL RESTRAINTS: ARE ANY MANUAL METHOD OR PHYSICAL OR MECHANICAL DEVICE ATTACHED TO OR ADJACENT TO THE PXS BODY THAT HE OR SHE CANNOT EASILY REMOVE AND THAT RESTRICTS FREEDOM OF MOVEMENT OR NORMAL ACCESS TO ONES BODY, MATERIAL OR EQUIPMENT.SECLUTION AND RESTRAINTSSECLUTION: THE INVOLUNTARY CONFINEMENT OF A PERSON ALONE IN A ROOM FROM WHICH THE PERSON IS PHYSICALLY PREVENTED FROM LEAVING.No therapeutic evidence other than a last resort to ensure safety.Evidence suggest that it adds to further trauma and physical harmGUIDELINESAll hospital staff who have direct contact with the px should have ongoing education and training in the proper use of seclusion and restraints and other alternativesPhysician or licensed practitioner should evaluate need within 1 hour after the initiation of this intervention.Max of 4 hours for adults, 2 hours for ages 9-17, and 1 hour for children under 9 yrsOrders may be renewed for 24 hrs before another face to face evaluationContinuous assessment, monitoring and evaluation; recordedGood nursing careFor both restrained and secluded: constant monitoring face to face or by both audio and video equipment.Px should be released ASAPOTHER GUIDELINESSECLUSIONRoom should allow observation and communication with pxRemove all items that px might use to harm selfDocument: rationale, response to intervention, physical condition, nsg care, & rationale for terminationRESTRAINTSGive support & reassurancePosition in anatomical positionPrivacy is importantv/s & Circulation checkShould be released q 2hrsAvoid tying to the side rails of bedAssist in periodic change in body positionsTERMINATING THE INTERVENTIONAS SOON AS MET THE CRITERIA FOR RELEASEREVIEW WITH PX THE BEHAVIOR THAT PRECIPITATED THE INTERVENTION & PXS CAPACITY TO EXERCISE CONTROL OVER BEHAVIORDEBRIEFING: REVIEWING THE FACTS RELATED TO AN EVENT & PROCESSING THE RESPONSE TO THEM; CAN BE USED AFTER ANY STRESSFUL EVENT

THERAPEUTIC IMPASSESARE BLOCKS IN THE PROGRESS OF THE NURSE-PT RELATIONSHIPPROVOKES INTENSE FEELINGS IN BOTH THE NURSE AND PATIENTRESISTANCETRANSFERENCECOUNTERTRANSFERENCEBOUNDARY VIOLATIONSRESISTANCERELUCTANCE OR AVOIDANCE OF VERBALIZING OR EXPERIENCING TROUBLING ASPECTS OF ONESELFEG: SUPPRESSION OR REPRESSION, INTENSIFICATION OF SX, SELF-DEVALUATION OR HOPELESSNESS, INTELLECTUAL INHIBITIONS, ACTING OUT OR IRRATIONAL BEHAVIOR, SUPERFICIAL TALK, INTELLECTUAL INSIGHT/ INTELLECTUALIZATION, TRANSFERENCE REACTIONS.TRANSFERENCEUNCONSCIOUS RESPONSE IN WHICH THE PX EXPERIENCES FEELINGS AND ATTITUDES TOWARD THE NURSE THAT WERE ORIGINALLY ASSOCIATATED WITH OTHER SIGNIFICANT FIGURES IN HIS OR HER LIFE.HOSTILE TRANSFERENCE: anger and hostility, resistanceDEPENDENT TRANSFERENCE: submissive, subordinate and regards the nurse as a god-like figure; views relationship as magicalWhat do you do?LISTENCLARIFYREFLECTEXPLORE/ ANALYZECOUNTERTRANSFERENCECREATED BY THE NURSES SPECIFIC EMOTIONAL RESPONSE TO THE QUALITIES OF THE PATIENT; INAPPROPRIATE IN THE CONTEXT, CONTENT AND INTENSITY OF EMOTION; NURSES IDENTIFY THE PX WITH INDIVIDUALS FROM THEIR PAST, AND PERSONAL NEEDSTYPES: REACTIONS OF INTENSElove or caringDisgust or hostilityAnxiety, often in response to resistance by the pxEG.Difficulty empathizingFeelings of depression before or after the sessionCarelessness about implementing the contractDrowsiness during the sessionsEncouragement of the pxs dependencyArguments with the pxPersonal or social involvement with the pxSexual or aggressive fantasies toward the pxTendency to focus on only one aspect or way of looking at information presented by the pxAttempts to help the px with matters not related to the identified nursing problemsFeelings of anger or impatience because of the pxs unwillingness to changeDreams about or preoccupation with the px