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DR. JAMES M. ALO, RN, MAN, MAP, PhD
PSYCHIATRIC NSG
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Models of Mental HealthMental health:• state of emotional, psychological & social wellness (effective coping,
(+) self-concept, emotionally stable).
Mental disorder:
•Defined generally as health conditions marked by alterations inthinking, mood or behavior taht cause distress, impair ability tofunction, or both (USDHHS, 1999).
Mental illness• Is considered a clinially significant behavioral or psychological
syndrome experienced by a person and marked by distress, disability,or loss of freedom (APA, 200).
Biomedical model
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What you see is just the tip,what lies beneath is the truth about it.
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Factors influencing mental health� INDIVIDUAL – person’s biologic make-up, autonomy and
independence, self-esteem, capacity for growth, vitality, abilityto find meaning in life, emotional resilience, sense of belonging,reality orientation and coping or stress management abilities.
� INTERPERSONAL – or relationship, may include effectivecommunication, ability to help others, intimacy, and a balance ofseparateness and connectedness.
� SOCIAL / CULTURAL or ENVIRONMENTAL - include asense of community, access to adequate resources, intolerance ofviolence, support of diversity among people, mastery of theenvironment, and a positive, yet realistic, view of one’s world.
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CONCEPT OF POSITIVE MENTAL HEALTH� 1.Attitudes toward the individual SELF� Involves aspect related to :
a. Self-acceptance - regard for oneself with arealistic concept of strengths & weaknesses.b. Self-awareness - is noticing how the self feels,thinks, behaves and senses at any given time.c. Self-concept - encompasses all what a personperceives, knows and holds to be true abouthis/her identity.
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Aspects of self-concept
BODY IMAGE
PERSONALIDENTITY
SELF-ESTEEM
ROLEPERFORMANCE
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2. Growth, Development, Self-Actualization
Is what a person does with his abilities and potentialities over a period oftime.� Future goals and investments in living are involved
3. Integrative Capacity� Core Concept : the relatedness of all processes & attributes in an
individual which influence unified or synchronized personalfunction.
� Concerns the ability of the individual to tolerate anxiety andfrustration during resistance to stress.
� Psychoanalysts view : a balance of psychic forces.(id,ego,superego)
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4. Autonomous Behavior
� individual’s ability to personally regulate hisdecision-making & actions so that these functionsrelatively independent of physical and socialinfluences.�ability to refuse to conform when to do is a social
expectation that conflicts with one’s value system.
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5. Perception of Reality� How the individual views and reacts toward the world around him .- ability to perceive reality while being free of needs which could
distort individual perceptions.
6. Mastery of One’s Environment� ability to ADAPT, ADJUST and BEHAVE appropriately in situations
and in accordance with culturally approved standards so thatsatisfactions are achieved in love, work, play and interpersonalrelations.
- ability to solve problems with expression of appropriate feelingtones and direct attack.
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HISTORICAL BACKGROUND� ANCIENT TIMES
…people believed that any sickness indicated displeasure ofthe Gods and in fact was punishment for sins and wrongdoings.… mental disorders wereviewed as either beingdivine or demonicdepending on theirbehavior.
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Renaissance (1300-1600)� People with mental illness were distinguished from criminals� Those considered harmless were allowed to wander and live in the
rural areas� Those “dangerous lunatics” were thrown in prison, chained, and
starved
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1547Hospital of St. Mary of Bethlehem, first hospital for the
insane was built
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1775visitors at the institution paid to view and ridicule the
inmates like animals
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Mentally ill patients were considered evil orpossessed and were burned at the stake
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Period of enlightenment� 1790s
– Phillippe Pinel and
Willian Tukes formulated
the concept of asylum
as a safe refuge or haven
offering protection to
mentally-ill people
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� Dorothea Dix
(1802-1887)
– began a crusade
in the USA to reform
treatment of the
mentally ill.
She opened 32 state
hospitals that offered
asylum.
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Period of scientific discovery� Period of scientific study and treatment of mental illness began
with:� Sigmund Freud (1856-1939) – studied the mind, its disorders
and treatment� Emil Kraepelin (1856-1926) – classified mental disorders
according to their symptoms� Eugene Bleuler (1857-1939) – coined the term “schizophrenia”
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LINDA RICHARDSfirst American psychiatric nurse.She believed that, the mentally sickshould be at least as well cared foras the physically sick
The first training of nursesto work with persons with
mental illness was in 1882at McLean Hospital inWaverly,Mass.
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The first psychiatric nursingbook – Nursing MentalDiseases by Harriet Bailey waspublished in 1920
In 1913 John Hopkins was thefirst school of nursing toinclude a course in psychiatricnursing in its curriculum
Two early nursing theoristsshaped psychiatric nursingpractice: Hildegard Peplau andJune Mellow.
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1845first authentic book on psychiatric disorder wasreleased
1950sbirth of psychotropic drugs; first to be createdwere:
Thorazine – antipsychotic drugLithium – antimanic drug
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NEUROSCIENCE: Biology & behavior
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NeuronDendrites Receive impulses
Axon •Semd impulses away
Neuromuscularjunction(NMJ)
•Connects nerve to muscles
Glialcell/neuroglia
•Are supporting cells, they include:
üOlegodendrocytes – produce myelin in the CNSüMicroglia – phagocytes/scavengers of the CNSüAstrocytes – structural supporting cells
Myelin •Insulates axons & allow faster impulse conduction
üSchwann cell - #schwann cell myelinates #axon in the PNSüOlegodendrocyte – myelinates several axons in the CNS
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NeurotransmittersAcetylcholine (Ach)• Is both excitatory (depolarizes membranes) & inhibitory
(hyperpolarizes membranes); is used by all motorneurons, the brain, & both sympathetic, & parasympateticsystems.
• Reduced in alzheimer’s dementia & myastenia gravis.
Biogenic amines• Tyrosine" Dopamine "Norepinephrine "Epinephrine• Tryptophan "serotonin; "histidine "histamine• Metabolized by Monoamine Oxidase (MAO) & Cathecol-
O- Methyl Transferase (COMT)
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Dopamine §Excitatory, seen in midbrain for control ofcomplex movement, motivation, cognition& emotion.§$ In Parkinson’s d’s & depression§#in schizophrenia, mania, Tourette’ssyndrome
Norepinephrine(Noradrenaline)
§Excitatory, in postganglionic sympathetic neurons(figt or flight) & in the brain (attention, memory)
Epinephrine(adrenalin)
§In anxiety disorders§$in depression, low impulse control
Serotonin §Inhibitory, in brainstem, linked to impulse control§#in depression, low impulsecontrol
Histamines §Modulator, seen in hypothalamus,#in allergies
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Amino acidshaminobutyric acid(GABA)
•Primary inhibitory transmitter in CNS•$in anxiety, #by benzodiazepines &barbiturates
Glutamate •Primary excitatory transmitter in CNS•#in Huntingtons chorea, alzheimers
Glycine •Inhibitory in spinal interneurons
Nitric Oxide §Inhibitory, gas form, affects central & entericnervou system§Relaxes vascular smooth muscle causingvasodilation.
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Neuromodulators
Neuropeptides
• Enkephalins,endorphins, substance P, somatostatin,VIP, CCK, Neurotensin, ACTH, angiotensin
Alter sensitivity of synaptic membranes toneurotransmitters
• (my enhance, prolong,, or inhibit transmittereffects.
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Central Nervous System
Cerebral Cortex� Divided into 2
hemispheres:� Left: controls right side of
the body as well as logicalreasoning & analysis fxns;(reading, writing, &math).
� Right: controls left side ofthe body as well as;creative thinking, intuition,& artistic abilities.
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Further divided into 4 lobesFunction Impairment
Frontal lobes
Motor cortex Found in precentral gyrusFor voluntary motor activity
Mono or hemiplegia dependingon the extent
Premotor cortex Planning of movement
Contralateral head & eye turning
Bowel & bladder inhibition
Apraxis – loss of learnedmovementParalysis of head & eye toopposite sideIncontinence
Broca’s area Expression, motor for speech Expressive aphasia – can’t speakright
Prefrontal area Personality & emotion, judgment& inhibition, concentration &elaboration of thought
Personality changes: antisocialbehavior, loss ofinhibitions/impulsive, poorconcentration.
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PSCHOANALYTIC THEORYSIGMUND FREUD(1856-1939)
Father of …PsychoanalysisModern Psychiatry
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Psychoanalytic theory� Supports the notion that all human behavior is caused and can
be explained•• Supports the notion that all human behavior isSupports the notion that all human behavior iscaused and can be explainedcaused and can be explained
•• He believed that repressed sexual impulses andHe believed that repressed sexual impulses anddesires motivated much human behaviordesires motivated much human behavior
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Theory of Psychosexual Development bySigmund Freud
� Oral Phase- 1 yr. old� Greatest need- security� Greatest fear- if anger anxiety� Narcissistic- pleasure seeking
is through eating & sucking;primary narcism( self-love)
� Mouth- erogenous zone,area of satisfaction
� Insecurity in parting withbreast or bottle may cause fixation
� Tension is relieve by sucking & swallowing� Sucking need is independent of hunger satisfaction.
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� Anal phase -Primary source of pleasure iselimination/retention� This is the critical period
for toilet training� Anus- site of tension
& sexual gratification� Greatest need: power� first experience with
discipline & authority� retention & expulsion (forcing out are experienced as pleasurable
especially because these functions come under the child-control.)Child uses his new skill to please or annoy parenting adult.
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Theories of Personality� Freudian Concept
� Sigmund Freud – the father of psychoanalysis stressed that earlychildhood experiences is important in the development ofpersonality.
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Three Components of Personality
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ID� part of personality in which we are born� it is primitive, it demands immediate satisfaction� functions according to pleasure principle� unconscious part of the person which serve as the reservoir of primitive
& biologic drives & urges� reflects basic or innate desires such as pleasure seeking behavior,
aggression &sexual impulses.
� Totally self-centered� Developed during infancy� Seeks instant gratification� Impulsive, unthinking behavior� No regard for rules or social
convention
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Ego� the self or the I� known as the integrator of personality� Part of the mind which acts with the outside world, partly conscious &
partly unconscious� operates on reality- principle. If it develops it supercedes the pleasure
principles in guiding behavior� this is developed during the toddler period� conscious self. the “ I ” that deals with reality� part of personality that’s evident to the environment� Balancing or mediating force between the id and the superego.� Represents mature and adaptive behavior that allows a person to
function successfully in the world.� ANXIETY results from ego’s attempt to balance the impulsive instincts
of the id with the stringent rules of the supergo.
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Superego� the conscience� the automotive or parental directions which incorporated in the
personality as the CENSORING FORCE.� this is developed during the preschool age� Strict Superego- leads to rigid, compulsive, unhappy person� Weak/Defensive Superego – leads to antisocial behavior, hostility� reflects moral & ethical concepts, values, parental and social
expectations� controls, inhibits & regulates impulses & instincts whose
uncontrolled expression would endanger the emotional well-beingindividual & the stability of the society.
� Direct opposition to the id.
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MENTAL DISORDER
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FREUD’SPsychoanalytic/psychodynamic model
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Personality functions @ 3 levels ofawareness:
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= Neurotic benhavior is a result of childhoodtrauma or failure to complete tasks or needs ofpsychosexual development:
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Narcissistic defenses
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Anxiety/Neurotic defenses
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Anxiety/Neurotic defenses
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Immature defenses
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Mature defenses
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Examples of psychiatruc disorders &defenses used:
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ERIKSON’S Psychosocial developmentmodel
?Psychosocial growth occurs in a series of 8 developmental stages w/each stage involvinf a task w/ (+) & (-) experiences.?Completion of said task allows one to achieve life virtues.
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PIAGET’s Cognitive Developmental Model= Focus of child dev’t is on genetics, envi., moral, &intellectual dev’t.
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KOHLBERG’s Moral Developmental Model= Expanded Piaget’s Moral Developmental Model
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MASLOW’s Heirarchy of Needs Model� Basic human needs are elements, shared by all people that are
necessary for human survival & health
� Certain needs are more basic than others .i.e. Some needs mustbe met before others.
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Self-actualization
Self-esteem
Love & Belonging
Safety & security: Physical &psychological
Physiologic: O2, fluids, food, temp.,elimination, shelter, sex
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PAVLOV’s & SKINNER’s Behavioral Model� Behavior is observable, predictable & controllable.
� It can be changed by a system of rewards & punishments.
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PAVLOV’s Classical Conditioning
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SKiNNER’s Operant Conditioning
Random intermittent reinforcement (reward for desired behavioronce in a while) is the slower but more permenent of increasing
desired behavior.
Continuous (+) reinforcement (reward each time behvior occurs) isthe fastest way to #a behaviors recurrence but be havior is short-
lived after after the rewards have ceased.
Behavior is learned from repeatedly reinfirced experiences
(+) reinforcement /reward � abehaviors recurrence
(-) reinforcement/ punishment $ abehaviors recurrence
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SYSTEMATIC DESENSITIZATION
EXTINGUISHED
Untill fearresponses is
EVENTUALLY
Gradual exposureto feared stimuluswhile clients are
relaxed
Application ofconditioning as
clients are helpedto overcome their
PHOBIAS
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SELYE’s Stress Adaptation ModelPhysiological response to stress correlated to anxiety level
GENERAL ADAPTATION SYNDROME (GAS)
Stage 1.Alarm Reaction (fight/flight response)• Physical; #Epinephrine & Nor-epinephgrine= sympathetis response• Psychosocial:Alert. #anxiety (1+, 2+), inefficient problem-solving
Stage 2. Ressistance (Optimal adaptation to nstress)• Physical: adrenal cortex & it’s hormones readjust, weight normalizes• Psychosocial:#Coping mechanisms, defense oriented behavior
Stage 3. EXHAUSTION (Inability to cope, depleted resources)• Physical: $immune response, hormones, weight"organ failure• Psychosocial: exaggerated behavior, disorganized thought & personality, delusions,
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PSYCHIATRIC ASSESSMENT� PSYCHIATRIC HISTORY
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MENTAL STATUS EXAMI. GENERAL DESCRIPTION
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II. EMOTIONS
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III. SPEECH – described terms of quantity, rate ofproduction & quality: ex. Talkative, non-spontaneous,hesitant, slurred
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IV. PERCEPTUAL SIDTURBANCES – process by whichphysical stimuli are brought to mental awareness
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V. THOUGHTA. Process/ form of thought – way a person puts togetherideas & assoc., form in w/c a person thinks.
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B. CONTENT OF THOUGHT – What person is actuallythinking about: beliefs, ideas, obsessions, preoccupations.
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VI. CONSCIOUSNESS (state of awarenes), SENSORIUM(awareness of special senses), & COGNITION (awareness ofthought).
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PSYCHIATRIC DIAGNOSIS
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� NANDA Accepted Nursing Diagnosis
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INTERVENTION: TherapiesTHERAPEUTIC NURSE-CLIENT REL. (Peplau)� Therapeutic use of self focus on both client-nurse needs� Has 4 PHASES:
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TECHNIQUES OF THERAPEUTIC COMMUNICATION
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PYSCHOPHARMACOLOGY
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NURSING INTERVENTION
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� STIMULANT DRUGS
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CLASSIFICATION OF MENTALDISORDERSA. Disorders usually evident in infancy, childhood & adolescence
1. MR2. PDD3. Disruptive behavior disorders4. Anxiety disorders of childhood & adolescence5. Eating disorders6. Gender identity disorders7. Tic disorders8. Elimination d’rs9. Speech dr’s
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B. Organic mental syndromes disorders1. Organic mental syndromes
a. Deliriumb. Dementia
2. OMD (dementias arising in the sensium & presensium)
a. Primary degenerative dementia (senile onset)b. Primary degnerative demntia (presenile onset)
3. Psychoactive substance use dr’s
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C. Psychoactice substance use dr'
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ANXIETY DISORDERS
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LEVELS OF ANXIETY
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ANXIETY DISORDERS
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NURSING INTERVENTIONS TO $ANXIETY
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SOMATOFORM DISORDERS
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DISSOCIATIVE DISORDERS
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FACTITIOUS DISORDERS
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ACHIZOPHRENIAS & OTHER PSYCHOTICDISORDERS
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OTHER PSYCHOTIC DISORDERS
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NURSING INTERVENTIONS FORPSYCHOTIC DISORDERS
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Mood Disorders
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Depressive DisorderA. Major Depressive D’r
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Intervention for Depressed Px
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Bipolar Disorders
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INTERVENTION FOR MANIC PX
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COGNITIVE DISORDERS
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Types of Dementia
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NURSING INTERVENTION FOR COGNITIVE D’R
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PERSONALITY DISORDERS
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DEVELOPMENTAL DISORDER
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Classification
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Elimination Disorders
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Tic Disorders
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SUBSTANCE RELATED DISORDERS
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Alcohol Abuse
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� Psychoactive Drug Abuse
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� COMMONLY ABUSE DRUGS
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EATING DISORDERS
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SEXUAL DISORDERS
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DEATH & GRIEVING
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NEXT
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ONCOLOGY NURSING� NEOPLASTIC DISEASES
� A. Characteristics1. Etiology
a) Healthy cells transformed into malignant cells upon exposure tocertain etiological agents: viruses, chemical & physical agents.
b) Failure of immune response
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2. Pathophysiologya) Rapid cell divisionb) Malignant cells metastasize
1. Extending directly into adjacent tissue2. Permeating along lympathic vessels3. Traveling through lymph system to nodes4. Entering blood circulation5. Diffusing into body cavity
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� 3. Classification of tumorsa. Accdg to type of tissue from which they evolve
1) Carcinomas begin in epithelial tissue (ex: skin, GI tract lining, lung,breast, uterus)
2) Sarcomas begin in non-epithelial tissue(ex: bone, muscle, fat, lymphsystem)
b. Type of cell in which they arise; cell types affect appearance,rate of growth & degree of malignancy.
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� 4. Staginga. Describes extent of tumorü T= primary tumorü N= regional nodesü M= metastasis
b. Describes extent of malignancy to which malignancy has # in sizeü To= no evidence of primary tumorü Ts= carcinoma in situü T1,T2,T3,T4= progressive #in tumor, size & involvementü Tx= tumor cannot be assessed
c. Involvement of regional nodesü No= regional lymph nodes not abnormalü N1-4= #degree of abnormal size
d. Metastatic dev.ü Mo= no evident of distant metastasisü M1-M3= #degree of metastasis
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� B. Manifestations > Malignant d’s (ACS 7 warning signs)1. Change in bowel/bladder movement2. Sore that does not heal3. Unusual bleeding /discharge4. Thickening/lumps in breast/ elsewhere5. Indigestion/difficulty of swallowing6. Obvious change in wart/mole7. Nagging cough/hoarseness
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� C. Cancer therapy1. Objective: to cure
1. Prevent further metastasis2. Relieve manifestations3. Maintain high quality life
2. Surgery1. Radical2. Prophylactic3. palliative
3. Chemotherapy1. Drugs interfere w/ cell division
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