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BASIC CONCEPTS IN PSYCHIATRIC NURSING

MENTAL HEALTH

• Balance in a persons’ internal life and adaptation to reality.


• A state of well being in which a person is able to realize
his potentials.

Characteristics :
• attitude of self-acceptance
• growth, development and self-actualization
• integrative capacity
• autonomous behavior
• perception of reality
• environmental mastery
MENTAL ILLNESS
• A state of imbalance characterized by a disturbance
in a persons’ thoughts, feelings and behavior.
• Poverty abd abuses are major factors which increases
the risk of mental illness in the home.
PSYCHIATRIC NURSING
• Interpersonal process whereby the professional nurse
practitioner through the use of self, assist an individual
family, group or community to promote mental health, to
prevent mental illness and suffering, to participate in the
treatment and rehabilitation of the mentally ill and if
necessary to find meaning in these experiences.
• It is both Science and an Art.
Science in Psychiatric Nursing.
• the use of different theories in the practice of nursing,
serves as the science of psychiatric nursing.
Art in Psychiatric Nursing.
• The therapeutic use of self is considered as the art of
psychiatric nursing.
Core of Psychiatric Nursing.
• The interpersonal process, that is, the human to human
relationship, is the core of psychiatric nursing.
Clientele in Psychiatric Nursing.
• The individual, family, and the community, both mentally
healthy and mentally ill.
Mental Hygiene.
• It is the science that deals with measures to promote
mental health, prevent mental illness and suffering and
facilitate rehabilitation.
TH ER APE UTI C USE OF SELF
- THERAPEUTIC USE OF SELF SERVES AS THE NURSES’ MAIN
TOOL.

CO RE CO NCEPT
- It is the positive use of one’s self in the process of therapy.
- It requires self-awareness.

BA SI S O F TH ER AP EU TI C USE OF SELF
JOHARIS WINDOW

Known to self Not known to self

Known to others Public self Semi-public self


I II
Not known to Private self Area of the unknown
others III IV
METH ODS USE TO I NC RE AS E SELF
AW AR EN ESS
• INTROSPECTION
• DISCUSSION
• ENLARGING ONE’S EXPERIENCE
• ROLE PLAY

CO RE CO NCEPTS O N TH E CA RE OF
PSY CHO TI C PAT IEN T.
COMMON BEHAVIORAL SIGNS AND SYMPTOMS
9. Disturbances in perception:
Illusion – misperception of an actual external stimuli.
Hallucination – false sensory perception in the absence of external
stimuli.
12. Disturbances in thinking:
Neologism – pathological coining of new words.
Circumstantiality – over inclusion of details.
Word salad – incoherent mixture of words and phrases.
Verbigeration – meaningless reception of words or phrases.
Perseveration – persistence of a response to a previous question.
Echolalia – pathological repetition of words of others.
Flight of ideas – shifting of one topic form one subject to another in a
somewhat related way.
Looseness of association – shifting of a topic from one subject to
another in a completely unrelated way.
Clang association – the sound of the words gives direction to the flow
of thought.
Delusion –false belief which is inconsistent with one’s knowledge and
culture and cannot be corrected by reasons.

3. Disturbances of affect.
Inappropriate affect – disharmony between the stimuli and the
emotional reaction.
Flat affect – absence or near absence of emotional reaction.
Apathy – dulled emotional tone.
Blunted affect – severe reduction in emotional reaction.
Ambivalence – presence of two opposing feelings.
Depersonalization – feeling of strangeness towards one’s self
Derealization – feeling of strangeness towards the environment
4. Disturbances in motor activity
Echopraxia – the pathological imitation of posture/action of others.
Waxy flexibility – maintaining the desired position for long periods of
time without discomfort.
5. Disturbances in memory.
Confabulation – filling in memory gap.
Amnesia – inability to recall past events.
Anterograde amnesia – loss memory of the immediate past.
Retrograde amnesia – loss of memory of the distant past.
Déjà vu – feeling of having been to place which one has not yet
visited.
Jamais vu – feeling of not having been to a place which one has
visited.
COR E CON CEPTS O N TH ER APE UTI C
COM MU NI CATI ON.
Communication – refers to the reciprocal exchange of ideas between
or among persons.
Elements of Communication:
• Sender – originator of information.
• Message – information being transmitted.
• Receiver – recipient of information.
• Channel – mode of communication.
• Feedback – return response.
• Context – the setting of communication.

Criteria of successful communication:


• Feedback
• Appropriateness
• Flexibility
• Efficiency
Common problems in communication
• Dysfunctional communication
• Double blind communication
• Differences between the denotative and connotative meaning.
• Incongruent communication.

Common techniques in communication


To initiate conversation:
- Giving broad openiong: giving the patient an opportunity to set the
direction of the conversation.
Example: “Is there anything that you want to talk about?”
- Giving recognition: focusing on the positive aspects of the patients
personality.
Example: “I noticed that you combed your hair today.”

To establish rapport and build trust


- Giving information: responding with the needed facts.
- Use of silence: refraining from sppech to give the patient a time to
sort out thoughts and feelings.
To gather information
- Focusing: assisting a patient to explore a specific topic.
Example: Patient: “I can’t decide about…”
Nurse: “Let’s talk about that. Perhaps if we talk about it, it
will help you to decide.”
- Validating: confirming one’s observation.
Example: “Are you saying that…”
- Relflecting: directing back ideas, feelings and content.
Example: “You feel tense when you fight.”
- Restating: repeating what the patient had said.
- Summarizing: developing a concise resume of what has transpired
NURSE PATI EN T R ELA TI ONS HIP
- Series of interaction between the nurse and patient in which the
nurse assist the patient to attain positive behavioral change.

CHARACTERISTICS
• It is goal directed, focused on the needs of the patient, planned,
time limited and professional.

BASIC ELEMENTS
Trust
Rapport
Unconditional positive regard
Setting limits
Therapeutic communication

PHASES
P. PRE-INTERACTION PHASE
• Begins when the nurse is assigned to a patient.
• Phase of NPR in which the patient is excluded as an active
participant
• Nurse feels certain degree of anxiety
• Includes all of what the nurse thinks and does before interacting with
the patient
• Major task of the nurse: develop self awareness
• Data gathering, planning for first interaction

B. ORIENTATION PHASE
• Begins when the nurse and the patients interacts for the first time
• Parameters of the relationship are laid
• Nurse begins to know about the patient
• Major task of the nurse: develop a mutually acceptable contract
• Determine why the patient sought help
• Establish rapport, develop trust, assessment

C. WORKING PHASE
• It is highly individualized
• More structured than the orientation phase
• The longest and most productive phase of the NPR
• Limit setting is employed
• Major task: Identification and resolution of the patient’s problems
• Planning and implementation

D. T ERMIN AT IO N P HA SE
• It is a gradual weaning process
• It is a mutual agreement
• It involves feelings of anxiety
• It should be recognized in the orientation phase
• Major task: to assist the patient to review what he has learned and
transfer his learning to his relationship with others
• Evaluation

When to T er mina te?


• When goals have been accomplished
• When the patient is emotionally stable
• When the patient exhibits greater independence
• When the patient able to cope with anxiety separation, fear and loss
How to Ter minate?
• Gradually decreased interaction time
• Focus on future oriented topics
• Encourage expression of feelings
• Make the necessary referral

CO MMON P ROBLEM S AFFE CTING


CO MMUN ICAT IO N
• Transference – the development of an emotional attitude of the
patient either positive or negative towards the nurse
• Resistance – development of ambivalent feeling towards self-
exploration
• Counter transference – transference as experienced by the nurse

PRIN CIP LE S O F CARE IN P SYCH IAT RIC S ETTING S


• The nurse views the patient as a Holistic human being with
interdependent and interrelated needs
• The nurse accepts the patient as a unique human being with inherent
value and worth exactly as he is.
• The nurse should focus on the patient’s behavior non-judgmentally,
while assisting the patient to learn more adaptive ways of coping
• The nurse should explore the patient’s behavior for the need it is
designed to meet and the message it is communicating
• The nurse has the potential for establishing a nurse-patient
relationship with most if not all patients

• The quality of the nurse-patient relationship determines the degree of


change that can occur in the patient’s behavior.

LEVELS OF INTERVENTIONS IN PSYCHIATRIC NURSING


• Primary – interventions aimed at the promotion of mental health and
lowering the rate of cases by altering the stressors
Examples: Health education
Information dissemination
Counseling
• Secondary – Intervention that limit the severity of a disorder
Two components
1. Case finding
2. Prompt treatment
Examples: Crisis intervention
Administration of medications
Tertiary – interventions aimed at reducing the disability after a disorder
Two components
1. Prevention of complication
2. Active program of rehabilitation

Examples: Alcoholic anonymous


Occupational therapy

CH ARACT ERIS TICS O F A P SYCHI AT RIC NUR SE


• Empathy – the ability to see beyond outward behavior and sense
accurately another persons’ inner experiencing
• Genuineness/Congruence – ability to use therapeutic tools
appropriately
• Unconditional positive regard – RESPECT

RO LE S OF T HE N URS E IN P SYCH IAT RI C


SETTIN GS
• Ward manager – creates a therapeutic environment
• Socializing agent – assists the patient to feel comfortable with others
• Counselor – listens to the patient’s verbalizations
• Parent surrogate – assists the patient in the performance of activities
• Patient advocate – enables the patient and his relatives to know their
rights and responsibilities
• Teacher – assists the patient to learn more adaptive ways of coping

• Technician – facilitates the performance of nursing procedures


• Therapist – explores the patient’s needs, problems and concerns
through varied therapeutic means
• Reality base – enables the patient to distinguish objective reality and
subjective reality
• Healthy role model – acts as a symbol of health by serving as an
example of healthful livings

BASI C CO NCEPTS ON
PSY CHO PH ARM AC OLO GY

C – heck why the medication is given and know the classification of the
drug. In other words you should know the purpose why the medication is
given.
H – ow will you know if the medicaiton is effective. What is your
assessment parameters in monitoring the effects of the drug.
E – xactly what tome should the medication be given. Some drugs are
best taken with meals, some after meals, and some on an empty
stomach. Other drugs may also be taken without regard to meals.
You should know all of these.
C – lient teaching tips. What would you tell your patient to expect. You
should be able to give instructions related to the therapeutic and
side effects of the drug.
K – eys to giving it safely. You should be able to identify interventions
to counteract the adverse/side effects of the drug.

Psychopharm acolgi c agents

G. Major tranquilizers/antipsychotic/neuroleptics
Common indication : Schizophrenia
Examples:
Haloperidol (Haldol)
Prochlorperazine (Compazine)
Fluphenazine (Prolixin)
Chlorpromazine (Thorazine)
Clozapine (Clozaril)
Olanzapine (Zyprexa)
C – Antipsychotic
H – Decreased delusions, hallucinations, and looseness of
association
E – Best taken after meals
C – Report sorethroat and avoid exposure to sunlight. Report elevated
temp. and muscle rigidity, it indicate Neurologic Malignant Syndrome.
K – check the BP, the drug causes hypotension. Observe for EPS,
check the CBC, drygs cause leukopenia

B. Anti-parkinsonian drugs
Indication: EPS (Extrapyramidal Syndrome)
Two Types:
1. DOPAMINERGIC DRUGS
Examples: Amantadine (Symmetrel)
Levodopa
Levodopa-Carbidopa (Sinemet)
2. ANTICHOLINERGIC DRUGS
Examples: Trihexylphenidyl (Artane)
Biperiden Hydrochloride (Akineton)
Benztropine Mesylate (Cogentin)
Diphenhydramine Hydrochloride (Benadryl)
C – Antiparkinsonian drug
H – Muscles become less stiff; decreased pill-rolling tremors
E – Best taken after meals
C – Avoid driving, the drug causes blurred vision
K – Check the BP, the drug may cause hypotension

C. Minor Tranquilizers/Anxiolytics
Common indication: Anxiety disorders
Examples: Diazepam (Valium)
Oxazepam (Serax)
Chlodiazepoxide (Librium)
Chlorazepate Dipotassium (Tranxene)
Alprazolam (Xanax)
C – Antianxiety; given as muscle relaxant to patient’s in traction
H – Decreased anxiety, adequate sleep
E – Best taken before meals, food in the stomach delays absorption
C – Avoid driving, intake of alcohol and caffeine containing foods,
since it alters the effect of drug
K – Administer it separately, it is incompatible with any drug
D. T ricyclic A ntidepressants
Examples: Imipramine Hydrochloride (Tofranil)
Amitriptyline (Elavil)

C – Tricyclic anti-depressant; prevents the reuptake of norepinephrine


H – Increased appetite; adequate sleep
E – Best given after meals
C – Therapeutic effects may become evident only after 2 – 3 weeks of
intake
K – Check BP, it causes hypotension, Check the heart rate, it causes
cardiac arrythmias

M. Ant idepressant MAO inhibit ors


Examples: Tranylcypromine (Parnate)
Phenelzine (Nadril)
Isocarboxazid (Marplan)

C – Antidepressant MAO inhibitors


H – Increased appetite; adequate sleep
E – Best taken after meals
C – Report headache; it indicates hypertensive crisis, avoid tyramine
containing foods like:
Avocado
Banana
Cheddar and aged cheese
Soy sauce and preserved foods
It takes 2 – 3 weeks before initial therapeutic effects become
noticeable
K – Monitor BP, There shoulb be at least a two week interval when
shifting from one antidepressant to another

F. Ant i – Manic ag ent


Lithium Carbonate
C – Anti- Manic
H – Decreased hyperactivity
E – Best taken after meals
C – Increase fluid intake (3L / day) and sodium intake (3 gm / day)
Avoid activities that increase perspiration
K – It takes 10 – 14 days before therapeutic effect becomes evident
Antipsychotic is administered during the first two weeks to
manage the acute symptoms of mania until lithium takes effect.
Monitor serum level, normal is 0.5 – 1.5 meq/L, NAUSEA, ANOREXIA
VOMITING, DIARRHEA, AND ABDOMINAL CRAMPS indicates
Lithium Toxicity, Mannitol is administered if toxicity occurs.

ELE CT RO -CO NVU LS IVE T HE RA PY


Mechanism of action: Unclear at present.
Voltage applied to the patient: 70 – 150 volts
Duration of application: 0.5 – 2 seconds
Usual number of treatments to produce
therapeutic effect: 6 – 12 treatments
Frequency of treatments: An interval of 48 hours for each treatment.
Indications of effectiveness: Generalized tonic-clonic seizure
Indication for ECT: Depression, Mania, Catatonic Schizophrenia
Contraindication to ECT: Fever, Increased ICP, Cardiac problems,
TB with history of hemorrhage, Recent fracture, Retinal detachment,
Pregnancy.
Consent needed prior to ECT: YES
Medication prior to ECT
• Atropine Sulfate – to decrease secretions
• Anectine (Succinylcholine) – to promote muscle relaxation
• Methohexital Sodium (Brevital) – serve as an anesthetic agent

COMMON COMPLICATION: Loss of memory, Headache, Apnea,


Fracture, Respiratory depression.

CO MMON P SYCH OT HE RAP EUT IC INT ERVENT ION S


• REMOTIVATION THERAPY – treatment modalitythat promotes
expression of feeling through interaction facilitated by discussion of
neutral topics.
5 Different Steps
1. Climate of acceptance
2. Creating of bridge of reality
3. Sharing the world we live in
4. Appreciation of the works of the world
5. Climate of appreciation
• MUSIC THERAPY – involves the use of music to facilitate relaxation,
expression of feelings and outlet of tension.
• PLAY THERAPY – treatment modality which enables the patient to
experience intense emotion in a safe environment with the use of play.
• GROUP THERAPY – treatment modality involving therapeutic
interactions of three or more patients with a therapist to relieve
emotional difficulties, increase self-esteem, develop insight and
improve behavior in relation with others. The minimum number of
members in a group therapy is 3, while the ideal number is 8 – 10.
• MILIEU THERAPY – consists of treatment by means of controlled
modification of the patients environment to facilitate positive behavioral
change.
• FAMILY THERAPY – a method of psychotherapy which focuses on
the total family as an interactional system.
• PSYCHOANALYSIS – a method of psychotherapy which focuses on
the exploration of the unconscious, to facilitate identification of the
patient’s defenses.
• HYPNOTHERAPY – a therapeutic modality which involves various
methods and techniques to includes a trance state where the patient
becomes submissive to instructions.
• HUMOR THERAPY – involves the use of humor to facilitate
expression of feelings and to enhance interaction.
• BEHAVIOR MODIFICATION – a therapeutic intervention involving the
application of learning principles in order to change maladaptive
behavior.
• AVERSION THERAPY – an example of behavior modification in
which a painful stimulus is introduced to bring about an avoidance of
another stimulus with the end view of facilitating change in behavior.
• TOKEN-ECONOMY – an example of behavior modification technique
which utilizes the principle of rewarding desired behavior to facilitate
change.
• DESENSITIZATION – periodic exposure of the individual to a feared
object, until the undesirable behavior disappears or is lessened.
• COGNITIVE THERAPY – short term structured therapy between the
patient and the therapist oriented towards present problems and
solutions. The main focus of cognitive therapy is depressive disorders
BAT TERED WIFE S YND ROME (BWS )
• Cycle of domestic violence characterized by wife beating by the
husband, humiliation and other forms of aggression.
• The most common trait of abusive men is low self-esteem.

• The most common trait of the abused women is dependence.

CHARACTERISTICS OF ABUSIVE HUSBANDS


• They usually come from violent family.
• They are immature, dependent and non-assertive.
• They have a strong feeling of inadequacy.

PHASES OF BWS
• Tension building phase involves minor battering incidents
• Acute battering incident more serious form of battering
• Aftermath/honeymoon stage the husband becomes loving and
gives the wife hope

PRIORITY CARE OF THE BATTERED WIFE


• Provision of shelter
CH ILD ABU SE
• Abuse – is what happens when an older adult takes advantage of his
authority over a younger child.

VIO LE NCE
• Refers to the use of force.
NEGLE CT
• Lack of provision of those things which are necessary for the child’s
growth and development
2 COMPONENTS
1. Child abandonment
2. Child neglect
PHYS ICAL AB US E
• Abuse in the form of inflicting pain
EMOT IO NAL A BUS E
• Abuse in the form of insults and undermining one’s confidence.
SEXU AL ABU SE
• Abuse in the form of unwanted sexual contact
CH ARACT ERIS TICS O F ABUS IV E P ARE NTS
• They come from violent family
• They were also abused by their parents
• They have inadequate parenting skills
• They are socially isolated because they don’t trust anyone.
• They are emotionally immature
• They have negative attitude towards the management of the abused

IN DICAT ORS OF C HILD AB US E


S – erious injuries in various stages of healing
H – ealthy hair in various length
A – pathy, No reaction
D – epression
E – xcessive knowledge of sex
S – elf esteem is low

PRIO RIT Y I N CH ILD ABU SE


• R.A. 7610, the anti child abuse law requires reporting of suspected
cases to authorities.
• Report cases to the barangay officers, DSWD personnel, police
within 48 hours.
AN XIETY
• Vague sense of impending doom
• subjective emotional response to stress.

ETIOLOGY
PSYCHOANALYTIC THEORY
• Anxiety is caused by a conflict between the Id and the Superego.
INTERPERSONAL THEORY
• Cause of anxiety is fear of interpersonal rejection
BEHAVIORAL THEORY
• Anxiety is a product of frustration.
LEARNING THEORY
• Exposure to early life fearful experiences causes anxiety.
CONFLICT THEORY
• Presence of two opposing drives, causes anxiety.
BIOLOGIC THEORY
• Anxiety may accompany physical and physiological ailments.
FAMILY STUDIES
• Anxiety can run in families.
DELIRIUM AND DEMENTIA

DELIRIUM DEMENTIA
• Disorientation Loss/impiarment of
memory
• Acute Chronic
•Involves young and old Exclusive in the elderly
• Clouded sensorium Clear sensorium
• Reversible Irreversible
• Good prognosis Poor prognosis
Alzheimer’s Disease
• a type of dementia that frequently affects the elderly.
Main Pathology
• presence of senile plaques that destroys neurons leading to decreased
acetylcholine.
Common signs and sypmtoms
Aphasia – inability to talk
Agnosia – inability to recognize objects
Apraxia – inability to perform ADL
Amnesia / Memory loss / Mnemonic disturbance
3 Phases
Forgetfulness phase – difficulty of remembering appoinments
Advance phase – difficulty of remembering past events but not recent events
Terminal phase – death occurs in 1 year.
Priority Nursing Diagnosis
Altered thought processes
Primary need of the patient
Reorientation
ALCOHOLISM
• WHO defines alcoholism as a chronic disease or a disorder characterized
by excessive intake and interference in the individuals health, interpersonal
relationship and economic functioning.
• Considered to be present when there is .1% or 10 ml for every 1000 ml of
blood.
What happens at level?
• .1 – .2% (low coordination)
• .2 -. 3% (presence of ataxia, tremors, irritability, stupor
• .3 and above (unconsciousness)
Etiological theories
Psychoanalytic theory
- due to fixation in the oral stage
Learning theory
- due to a learned behavior
Biological theory
- due to inherited traits
Socio-cultural theory
- due to effects of mass media.
Phases of progression of alcoholism
Pre-alcoholic phase – starts with social drinking
Prodromal phase – alcohol becomes a need; blackout’s occur; denial begins to
develop
Crucial phase – Cardinal symptoms of alcoholism develops (loss of control over
drinking)
Chronic phase – the person becomes intoxicated all day.
Outcomes of alcoholism
• Brain damage
• Alcoholic hallucinosis
• Death
Common behavioral problems
• Denial
• Dependency
• Demanding
• Destructive
• Domineering
Withdrawl signs and symptoms
• Halucinations, visual and tactile
• Increased vital signs
• Tremors
• Sweating and Seizure
Common defense mechanism
• Denial
• Rationalization
• Isolation
• Projection