DOCUMENTATION IN PSYCHIATRIC NURSING

PROBLEM ORIENTED RECORDING

Established by Lawrence Weed in 1960s.
The data are arranged according to the problems the client has rather than the
source of the information.
Member of the health team contribute to the problem list, plan of care, and progress
notes.
FDAR
FOCUS CHARTING
A method of charting that uses key words or foci to describe what is happening to the
client.
3 COLUMNS OF RECORDING are usually used:
1. DATA and time
2.Focus
3.Progress notes
The Progress Notes are organized into: DAR
DATA
ACTION
RESPONSE
DATA
category reflects the assessment phase of the nursing process and consists of observation
of client status and behaviors, including data from flow sheet (e.g. Vital signs).
The nurse records both subjective and objective data in this section.
ACTION
Category reflects planning and implementation and includes immediate and future nursing
actions.
It also include any changes to the plan of care.
PROGRESS NOTES
RESPONSE:
Category reflects the evaluation phase of the nursing process and describes the clients
response to any nursing and medical care.
Sample Charting:
NARRATIVE RECORDING
Is a traditional part of the source-oriented record.
SOURCE-ORIENTED RECORD: is a traditional client record.
Each person or department makes notations in a separate section or sections of the
clients chart.
Ex.
The Admission Department: Admission sheet.
The physician: physicians order/Doctors order sheet.
The nurses: Nurses notes
Narrative Recording
In this type of record, information about a particular problem is distributed throughout the
record.
It consists of written notes that include routine care, normal findings, and client problems.
There is no right or wrong order to the information, although chronological order is
frequently used.

PROCESS RECORDING
Is a verbatim (word for- word) account of conversation.
It can be taped or written and includes all verbal and nonverbal interactions of both the
client and nurse.
One method of writing a process recording is to make two columns on a page.
First column: list what the nurse and client said along with the associated nonverbal
behavior.
Second column: contains an analysis about the nurses responses.

 Once a process recording has been completed, it should analyzed in terms of the content
and meaning of the interaction based on communication theory.
Each of the nurses statements is interpreted in terms of the communication skill used,
with the rationale for and effectiveness of its use.
Ex.

NURSE CLIENT RELATIONSHIP

NURSE CLIENT INTERACTION
MODULE 4
NURSE CLIENT INTERACTION (COMMUNICATION)
COMMUNICATION : is the process that people use to exchange information.
Is an interaction between two or more people that involves the exchange of information between
a sender and a receiver
Messages are simultaneously sent and received on two levels:
Verbally through the use of words
Non- verbally by behaviors that accompany the words.
THERAPEUTIC COMMUNICATION
Is an interpersonal interaction between the nurse and client during which the nurse focuses on
the clients specific needs to promote an effective exchange of information.
therapeutic communication techniques helps the nurse understand and empathize with the
clients experience.
All nurses need skills in therapeutic communication to effectively apply the nursing process and
to meet standards of care for their client.
Therapeutic Communication can help Nurses to accomplish Goals:
1. Establish a therapeutic nurse- client relationship
2. Identify the most important client concern at that moment (client centered goal).
3. Assess the clients perception of the problem as it unfolds. (the clients thoughts
and feelings about the situation, others and self).
4. Facilitate the clients expression of emotions.
5. Teach the client and family necessary self-care skills.
6. Recognize the clients needs.
7. Implement intervention designed to address the clients needs.
8. Guide the client toward identifying a plan of action to a satisfying and socially
acceptable resolution.
To have Effective Therapeutic Communication the nurse must consider:
Privacy and Respect of Boundaries
Use of Touch
Active listening and observation
1. PRIVACY AND RESPECT BOUNDARIES
Privacy is desirable but not always possible in Therapeutic Communication. ( delicate
information the nurse should know or the patient would revealed)
An interview or conference room is optimal, if the nurse believes this setting is not isolative
for interaction.
The nurse needs to evaluate whether interacting in the clients room is therapeutic.
Ex. If the client has difficulty maintaining boundaries or has been making sexual
comments, then the clients room is not the best setting.
BOUNDARIES
PROXEMICS: is the study of distance zones between people during communication.
People feel more comfortable with smaller distance when communicating with someone they
know rather than strangers.
4 Distance Zones:
1. Intimate
2. Personal
3. Social
4. Intimate
4 Distance Zones:

1. Intimate zone ( 0 to 18 inches between people) : this amount of space is comfortable for
parents with young children, people who mutually desire personal contact, or people
whispering.

invasion of this intimate zone by anyone else is threatening and produces

anxiety.
2. Personal zone (18 to 36 inches) : this distance is comfortable between family and friends
who are talking.
3. Social zone (4 to 12 feet): this distance is acceptable for communication in social, work, and
business settings.
4. Public zone (12 to 25 feet): this is acceptable distance between a speaker and an audience,
small groups, and other informal functions.
Both the client and the nurse can feel threatened, if one invades the others
personal or intimate zone, which can result tension, irritability, fidgeting
(uneasy, nervous) , or even flight.
When the nurse must invade the intimate or personal zone, the nurse should
ask the clients permission.
2. touch
AS INTIMACY INCREASES, THE NEED FOR DISTANCE DECREASES.
5 TYPES OF TOUCH:
1. Functional- Professional touch: is used in examination or procedure.
2. Social- Polite touch: is used in greetings, such as hand shake
3. Friendship- Warmth touch: hug in greeting, back slapping
4. Love- intimacy touch: tight hugs and kisses between lovers or close relatives.
5. Sexual- Arousal touch: used by lovers, specially the married couple.
3. ACTIVE LISTENING AND OBSERVATION
To receive the senders simultaneous messages, the nurse must use active listening and
active observation.
Active listening : means refraining from other internal mental activities and concentrating
exclusively on what the client says.
Active observation : means watching the speakers nonverbal action as he/ she communicates.
COMMON MISCONCEPTION OF STUDENTS learning the art of THERAPEUTIC
COMMUNICATION = is that they always must be ready with questions the instant the client has
finished speaking.
They are constantly thinking ahead regarding the next question rather than actively
listening to what the client is saying. The result can be that the nurse does not
understand the clients concerns, and the conversation is vague, superficial, and
frustrating to both participants.
Active Listening and Observation
Recognize the issue that is most important to the client at this time.
Know what further questions to ask the client.
Use additional therapeutic communication techniques to guide the client to describe his
/her perceptions fully.
Understand the clients perceptions of the issue instead of jumping to conclusions.
Interpret and respond to the message objectively.
VERBAL COMMUNICATION SKILLS
1. USING CONCRETE MESSAGES
2. USING THERAPEUTIC COMMUNICATION TECHNIQUES
1. USING CONCRETE MESSAGE
nurse should use words that are clear as possible when speaking to the client so that
the client can understand the message.
In concrete message , the words are explicit and need no interpretation.
Concrete questions, are clear, direct, and easy to understand.
Ex. "what health symptoms caused you to come to the hospital today? or
when was the last time you took your antidepressant medications?
2. USING THERAPEUTIC COMMUNICATION TECHNIQUES:
The choice of technique depends on the intent of the interaction and the clients ability to
communicate verbally. Overall , the nurse selects techniques that facilitate the
interaction and enhance communication between client and nurse.

Techniques such as exploring, focusing, restating, and reflecting encourage the client to
discuss his/her feelings or concerns in more depth.
THERAPEUTIC COMMUNICATION TECHNIQUES:
1. Accepting : indicating reception
Ex. yes I follow what you said. Nodding
2. Broad opening: allowing the client to take the initiative in introducing the topic.
Ex. Is there something youd like to talk about?
Where would you like to begin?
3. Consensual validation: searching to mutual understanding, for accord in the meaning of
the words.
Ex. Tell me whether my understanding of it agrees with yours.
4. Encouraging comparison: asking that similarities and differences be noted.
Ex. Was it something like...? Have you had similar experiences?
5. Encouraging description of perceptions: asking the client to verbalize what he/ she
perceives.
Ex. Tell me when you feel anxious What is happening? What does the voice seem to be
saying?
6. Encouraging expression: asking the client to appraise the quality of his/her experiences.
Ex. What are your feelings in regard to....? Does this contribute to your distress?
7. Exploring: delving further into a subject or idea.
Ex. Tell me more about that. Would you describe it more fully?
8. Focusing: concentrating on a single point.
Ex. This point seems worth looking at more closely.
9. Formulating a plan of action: asking the client to consider kinds of behavior likely to be
appropriate in future situations.
Ex. What could you do to let your anger out harmlessly?
10. General leads: giving encouragement to continue.
Ex. Go on and then? Tell me about it.
11. Giving information: making available the facts that the client needs.
Ex. My name is.... Visiting hours are... My purpose in being here is.....
12. Giving recognition: acknowledging, indicating awareness: Good morning, Mr. S....... I
notice that youve combed your hair.
13. Making observations: verbalizing what the nurse perceives.
Ex. You appear tense. I notice youre biting your lip.
14. Offering self: making oneself available.
Ex. Ill sit with you awhile.
15. Presenting reality: offering for consideration that which is real.
Ex. Ill see no one else in the room.
16. Reflecting: directing client actions. Thoughts, and feelings back to client.
Ex. Client: do you think I should tell the doctor....? Nurse: do you think you should?
17. Restating: repeating the main idea expressed.
Ex. Client: I cant sleep. I stay awake all the night. Nurse: you have difficulty sleeping.
18. Seeking information: seeking to make clear that which is not meaningful or that which is
vague.
Ex. Im not sure that I follow. Have I heard you correctly?
AVOIDING NONTHERAPEUTIC COMMUNICATION
In contrast, there are many therapeutic techniques that nurses should avoid. These responses
cut off communication and make it more difficult for the interaction to continue.
Responses such as Everything will work out or May be tomorrow will be a better day
may be intended to comfort the client, but instead may impede the communication process.
NONTHERAPEUTIC COMMUNICATION TECHNIQUES:
1. Advising: telling the client what to do.
Ex. I think you should...
2. Agreeing: indicating accord with the client.
Ex. Thats right.
3. Belittling feelings expressed: misjudging the degree of the clients discomfort.
Ex. Client: I have nothing to live for... I wish I was dead. Nurse: Everybody gets down in the
dumps. or Ive felt that way myself.

4. Challenging: demanding proof from client.

Ex. But how can you be president of the United State? If youre dead, why is you heart
beating?
5. Defending: attempting to protect someone or something from verbal attack.
Ex. This hospital has a fine reputation. Im sure your doctor has your best interests in mind.
6. Disagreeing: opposing the clients ideas.
Ex. thats wrong.
7. Disapproving: denouncing the clients behavior or ideas.
Ex. Thats bad Id rather you wouldnt
8. Giving approval: sanctioning the clients behavior or ideas.
Ex. Thats good. Im glad that...
9. Interpreting: asking to make conscious that which is unconscious; telling the client the
meaning of his or her experience.
Ex. What you really mean is.... Unconsciously youre saying....
10. Probing: persistent questioning of the client.
Ex. Now tell me about this problem. You know I have to find out.
INTERPRETING SIGNALS OR CUES
To understand what the client means, the nurse watches and listens carefully for
cues.
CUES: are verbal or nonverbal messages that signal key words or issues for the client.
Cue words introduced by the client can help the nurse to know what to ask next or
how to respond to the client.
INTERPRETING SIGNALS OR CUES (1/2)
Ex. Client: I had a boyfriend when I was younger. Nurse: You had a boyfriend?
(reflecting, direct the clients actions, thoughts, and feelings back to client) Tell me
about you and your boyfriend. (encouraging description) How old were you when
you had this boyfriend? (placing events in time or sequences)
NONVERBAL COMMUNICATION SKILLS
Is behavior that a person exhibits while delivering verbal content.
It includes:
facial expression,
eye contact,
space ,
time,
boundaries, and
body movements.
Nonverbal communication
involves the unconscious mind acting out emotions related to the verbal content, the
situation, the environment, and the relationship between the speaker and the
listener.
1. FACIAL EXPRESSION
The human face produces the most visible, complex, and sometimes confusing nonverbal
messages.
Facial movements connect with words to illustrate meaning; this connection demonstrates the
speakers internal dialogue.
Facial expression can be categorized into:
Expressive
Impassive
Confusing
Expressive:
face portrays the persons moment- by- moment thoughts, feelings and needs.
These expression may be evident even when the person does not want to reveal his/her
emotions.
Impassive:
is frozen into an emotionless deadpan expression similar to mask.
EX. FLAT AFFECT
Confusing:
facial expression is one that is the opposite of what the person wants to convey.

A person who is verbally expressing sad or angry feelings while smiling is exhibiting a confusing
expression.
Facial expression
often affect the listeners response. The nurse should identify the facial expression and ask the
client to validate nurses interpretation of it.
Ex. youre smiling, but I sense you are very angry.
2. BODY LANGUAGE
Gesture , postures, movements, and body positions.
Is a nonverbal form of communication.
Closed Body Position
Accepting Body Position
CLOSED BODY POSITION
such as crossed legs or arms folded across the chest, indicate that interaction might threaten
the listener who is defensive or not accepting
ACCEPTING BODY POSITION
is to sit facing the client with both feet on the floor, knees parallel, hands at the sides of the
body, and legs uncrossed or crossed only at the ankle.
This open posture demonstrate unconditional positive regard, trust, care and acceptance.
The nurse indicates interest in and acceptance of the client by facing and slightly leaning
toward him or her while maintaining nonthreatening eye contact
VOCAL CUES
Are nonverbal sound signals transmitted along with the content: voice volume, tone,
pitch, intensity, emphasis, speed, and pauses augment the senders message.
Volume : the loudness of the voice, can indicate anger, fear, happiness, or deafness.
Tone: can indicate whether someone is relaxed, agitated or bored.
Pitch: varies from shrill and high to low and threatening.
Intensity: is the power, severity, and strength behind the words, indicating the
importance of the message.
Emphasis: refers to accents on words or phrases that highlight the subject or give insight
on the topic.
Speed: is number of words spoken per minute.
EYE CONTACT
The eyes have been called the mirror of the soul because they often reflect our emotions.
Looking into the other persons eyes during communication, is used to assess the other person
and the environment and to indicate whose turn it is to speak
it increases during listening but decreases while speaking.
Although maintaining good eye contact is usually desirable, it is important that the nurse doesnt
STARE at the client.
SILENCE
Or long pauses in communication may indicate many different things.
The client may be depressed and struggling to find the energy to talk.
Sometimes pauses indicate the client is thoughtfully considering the question before
responding.
At times, the client may seem to be LOST IN HIS/HER OWN THOUGHTS and not paying
attention to the nurse.
It is important to allow the client sufficient time to respond, even if it seems like
a long time.
To be continue......
THERAPEUTIC RELATIONSHIP
Therapeutic relationship
The nurses relationship with the patient consists of a series of goal-directed interactions through
which the nurse assesses patients problems, elicits patient input, selects interventions, and
evaluates the effectiveness of care.
relationship:
3 Types :
Social
Intimate

 Therapeutic
SOCIAL RELATIONSHIP
is primarily initiated for the purpose of friendship, socialization, companionship, or
accomplishment of task.
Communication, w/c may be superficial,
Usually sharing of ideas, feelings and experiences and meets basic need for people to
interact.
Advise is often given.
INTIMATE RELATIONSHIP
healthy intimate relationship involves two people who are emotionally committed to each other.
Both parties are concerned about having their individual needs met and helping each
other to meet needs as well.
The relationship may include sexual or emotional intimacy as well as sharing of mutual
goals.
THERAPEUTIC RELATIONSHIP
Differs from the social and intimate relationship in many ways because it
focuses on the needs, experiences, feelings, and ideas of the client only.
The nurse and client agree about the areas to work on and evaluate the
outcomes.
THERAPEUTIC RELATIONSHIP
The nurse uses communication skills, personal strengths, and understanding of
human behavior to interact with the client.
The nurse should not be concerned about whether or not the client likes him/her
or grateful.
The nurse must constantly focus on the clients needs not his/her own.
COMPONENTS OF A THERAPEUTIC RELATIONSHIP
Trust
Genuine interest
Empathy
Acceptance
Positive regard
Self-awareness
Therapeutic use of self
Trust
Trust develops when the client believes that the nurse will be consistent in his/her
words and actions and can be relied on to do what he or she says.
Genuine Interest
The client perceives a genuine person showing genuine interest.
A client with mental illness can detect when someone is exhibiting dishonest or artificial behavior
such as asking a question and then not waiting for the answer, talking over him or her, or
assuring him/her everything will be all right.
Empathy
Is the ability of the nurse to perceive the meaning and feelings of the client and to
communicate that understanding to the client.
It is considered one of the essential skills a nurse must develop.
Being able to put himself/herself in the clients shoes does not mean that the nurse
has had the same exact experiences as the client.
Ex. Empathy : I see you are sad.... How can I help you?
Ex. Sympathy : I feel so sorry for you.
Acceptance
The nurse who does not become upset or respond negatively to a clients outbursts,
anger, or acting out conveys acceptance to the client.
Avoiding judgment s of the person, no matter what the behavior, is acceptance.
This does not mean acceptance of inappropriate behavior but acceptance of the
person as worthy.
The nurse must set boundaries in the nurse- client relationship.
Ex. A client puts his arm around the nurses waist.

An appropriate response would be for the nurse to remove his hand and say, john,
do not place your hand on me. We are working in your relation with your girlfriend
and that does not require you to touch me. Now, lets continue.
Positive Regard
The nurse who appreciates the client as a simple worth while human being can
respect the client regardless of his or her behavior, background, or lifestyle.
Calling the client by name, spending time with the client, and listening and
responding openly are measures by which the nurse conveys respect and positive
regard to the client.
Self- Awareness
Before the nurse can begin to understand clients, the nurse must know himself
/herself.
Self awareness: is the process of developing an understanding of one owns values, beliefs,
thoughts, feelings, attitude, motivations, prejudices, strengths, and limitations and how these
qualities affect others.
Values:
are abstract standards that give a person a sense of right and wrong and
establish a code of conduct for living.
Sample values: hard work, honesty, sincerity, cleanliness,, and orderliness.
Beliefs
are ideas that one holds to be true,
Ex. if the sun is shining, it will be a good day.
Some Beliefs have objective evidence to substantiate them.
Ex. People who believe in evolution have accepted the evidence that supports this
explanation for the origin of life.
Attitudes:
are general feelings or a frame of reference around which a person organizes knowledge
about world.
Attitudes such as: hopeful, optimistic, pessimistic, positive, and negative, color how we look at
the world and people.
Therapeutic use of Self
By developing self- awareness and beginning to understand his/ her attitudes, the
nurse can begin to use aspects of his/her personality, experiences, values, feelings,
intelligence, needs, coping skills, and perceptions to establish relationships with
client.
Nurses use themselves as therapeutic tool to establish therapeutic relationships with
clients and help clients grow, change, and heal.
JOHARI WINDOW
One tool that useful in learning more about oneself.
Which creates a word portrait of a person in four areas and indicates how well that
person knows himself/ herself and communicates with others.
The Four Areas evaluated are as follows:
Quadrant 1: Open /Public self = qualities one knows about oneself and others also know.
Quadrant 2: Blind/ Unaware self = qualities know only to others.
Quadrant 3: Hidden/Private self = qualities known only to oneself.
Quadrant 4: Unknown = an empty quadrant to symbolize qualities as yet undiscovered by
oneself or others.
Johari window
3 PHASES/ STAGES OF NURSE- CLIENT RELATIONSHIP
1. ORIENTATION STAGE
2. WORKING STAGE
3. TERMINAL STAGE
ORIENTATION PHASE
Begins when the nurse and client meet and ends when the client begins to identify
problems to examine.
Before meeting the client:
The nurse reads background materials available on the client.
Becomes familiar with any medications the client is taking

 The nurse should consider his/her personal strengths and limitations in working
with this client (self assessment).
Acceptance is the foundation of all therapeutic relationship.
(orientation phase)
During the Orientation Phase:
The nurse establishes roles
The purpose of meeting and parameters of subsequent meetings
Identifies the clients problems, and clarifies expectations.
Built trust: it is the nurse responsibility to establish a therapeutic environment that
foster trust and understanding.
The nurse should share appropriate information about himself/herself at this
time, including name, reason for being on the unit, and level of schooling. (selfdisclosure)
The nurse needs to listen closely to the clients history, perceptions and
misconceptions.
The nurse needs to convey empathy and understanding.
Reality testing : is accepting the patients perception, feelings and thoughts as neither right or
wrong, but at the same time offering other options or points of view to the client in a nonargumentative manner for the purpose of helping the client arrive at more realistic conclusion.
To provide structure: is to intervene when client loses control of his feelings and behaviors by
medications, offering self, restrain, seclusion and by assessing client to observe a consistent
daily schedule.
ORIENTATION PHASE:
NURSE- CLIENT CONTRACTS
Although many clients have had prior experiences in the mental health system, the nurse must
once again outline the responsibilities of the nurse and client.
Both nurse and client agree on these responsibilities in an informal or verbal contract.
ORIENTATION PHASE: CONFIDENTIALITY, DUTY TO WARN
MEANS RESPECTING THE CLIENTS RIGHT TO KEEP PRIVATE ANY INFORMATION
ABOUT HIS/HER MENTAL AND PHYSICAL HEALTH AND RELATED CASE.
DUTY TO WARN:
The decision requires the nurse to notify intended victims and police of such
threat.
Ex. Suicidal threats, threat from the client to harm other person.
WORKING PHASE
The phase where issues are addressed,
Problems identified
Solutions explored
Nurse and client work to accomplish goals
Working exploration
/identification phase
At this point the clients problem are identified and solutions are explore, applied and
evaluated.
The focus of the assessment and of the relationship is the clients behavior and the
focus of the interaction is the clients feelings.
The nurse should realize that the clients feelings of security are developed by being
consistent at all times.
Working phase
Perception of reality, coping mechanisms and support system are identified.
The nurse assists the patient to develop coping skills, positive self concept and
independence in order to change the behavior of the client to one that is adaptive and
appropriate.
The nurse uses the techniques of communication and assumes different roles to
help the client.
THE SPECIFIC TASKS OF WORKING PHASE INCLUDE THE FF:
Maintain the relationship
Gathering more data

 Exploring perceptions of reality

Developing positive coping mechanisms
Promoting a positive self- concept
Encouraging verbalization of feelings
Facilitating behavior change
Working through resistance
Evaluating progress and redefining goals as appropriate
Providing opportunities for the client to practice new behaviors
Promoting independence
Transference : the client unconsciously to transfer to the nurse feelings he or she has for
significant others.
Countertransferrence: a similar process can occur when the nurse responds to the client
based on personal unconscious needs and conflicts.
Ex. If the nurse is the youngest in her family and often felt as if no one listened to her when she
was a child, she may respond with anger to a client who does not listen or resist her help.
TERMINATION PHASE
OR RESOLUTION PHASE: is the final stage in the Nurse- client Relationship.
It begins when the problems are resolved, and it ends when the relationship is ended.
Both nurse and client usually have feelings about ending the relationship; the client
especially may feel the termination as an impending loss.
Often the clients try to avoid termination by acting angry or as if the problem has not
been resolved.
The nurse can acknowledge the clients angry feelings and assure the client that this
response is normal to ending a relationship.
It is appropriate to tell the client that the nurse enjoyed the time spent with the client and
will remember him/he, but it is inappropriate for the nurse to agree to see the client
outside the therapeutic relationship.
Ex. Nurse Jones comes to see Mrs. Cruz for the last time.
Mrs. Cruz: is weeping quietly, oh, Ms. Jones, you have been so helpful to me. I just
know I will go back to my old self without you here to help me.
Nurse Jones: Mrs. Cruz, I think weve had a very productive time together. You have
learned so many new ways to have better relationships with your children, and I know
you will go home and be able to use those skills. When you come back for your followup visit, I will want to hear about how things have changed at home.
end

PHARMACOTHERAPEUTICS/
PSYCHOPHARCOLOGY
PREPARED BY:
MARY RUTH V. ENRIQUEZ, RN MAN
PHARMACOTHERAPEUTICS/
PSYCHOPHARCOLOGY
Drugs that treat the symptoms of mental illness, and whose actions in the brain
provides us with models to better understand the mechanism of mental disorders.
1. ANTIPSYCHOTIC DRUGS (NEUROLEPTICS)
2. ANTIDEPRESSANTS DRUGS
3. MOOD STABLIZING DRUGS
4. ANTIANXIETY DRUGS (ANXIOLYTICS)
5. STIMULANTS/PSYCHOSTIMULANTS
Antipsychotic Drugs (Neuroleptic)
Are used to alleviate psychotic symptoms (hallucination, delusions, paranoid thinking,
poor reality contact) that may occur in clients with SCHIZOPHRENIA, BIPOLAR DISORDERS
and COGNITIVE IMPAIRMENT DISORDERS.
ANTIPSYCHOTIC DRUGS CLASSIFIED into:
1. Typical
2. Atypical
Typical Antipsychotic drug
Block selected dopamine receptors in the striatal and limbic areas of the brain, an
action believe to reduce symptoms.
Dopamine: is a neuroChemical that our bodies
Contain naturally.
If overproduced or utilized
Incorrectly, it can cause
Someone to exhibit
Psychotic behavior.
Typical
Uses : treatment for schizophrenia and other acute or chronic psychotic behavior that is violent
or potentially violent.
Treat positive symptoms of schizophrenia such as hallucinations, delusions, and suspiciousness.
Side effects: Antipsychotics
Certain blood dyscrasia
Photosensitivity (especially Thorazine)
Darkening of the skin from increased pigmentation
Neuroleptic malignant syndrome
A group of side effects called Extrapyramidal side effects (EPSEs)
There is less risk of EPSEs with atypical agents.
Neuroleptic Malignant Syndrome
Is an uncommon but potentially fatal reaction to treatment with Neuroleptic medications.
Symptoms include muscle rigidity, hyperpyrexia, fluctuations in blood pressure, and altered level
of consciousness. Early recognition and immediate medical care is important.
EXTRAPYRAMIDAL SIDE EFFECTS:
Drug -induced Parkinsonism (pseudoparkinsonism):
symptoms appear 1 to 8 weeks after patient begins the medication
The major symptom is AKINESIA, manifested as shuffling gait, drooling, fatigue,
mask like facial expression, tremors, and muscle rigidity
EPSEs
AKATHISIA: symptoms appear 2 to 10 weeks after patient taking the medication.
Symptoms : agitation and motor restlessness, and seem to appear more frequently in
women. There is no absolute reason for this, but it is suggested that it may be due to
hormonal interaction with the medication.
EPSEs
Dystonia : symptoms appear 1 to 8 weeks after the patient starts taking the medication.

Symptoms manifest as bizarre distortions or involuntary movements of any muscle group.

Tongue, eyes , face, neck, or larger muscle mass can become tightened into an unnatural
position or have irregular spastic movements.
TYPES OF DYSTONIA
1. TORTICOLLIS: contracted positioning of the neck.
2. OCULOGYRIC CRISIS: contracted positioning of the eyes upward.
3. WRITERS CRAMP: fatigue spasm affecting a hand.
4. LARYNGEAL-PHARYNGEAL :constriction (potentially life-threatening)
EPSEs
Tardive dyskinesia (TD): symptoms appear within 1 to 8 weeks after the patient starts taking
the medication. The frequently seen manifestations are rhythmic, involuntary movements that
look like chewing, sucking, or licking motions (ex. Beating, spanking). Frowning and blinking
constantly are also common.
TD is irreversible
ATYPICAL ANTIPSYCHOTIC DRUG
Block dopamine receptors in the limbic system and affect serotonin receptors in the
cortical areas of the brain.
Block both dopamine and
Serotonin receptors.
ATYPICAL
Indication, contraindication and interactions are similar to those of typical antipsychotic agents.
Advantages over typical agent:
1. reduce positive symptoms of schizophrenia
( hallucination, delusions) as well as the negative symptoms (blunted affect, apathy,
and social withdrawal).
2. these agent cause decreased or no extrapyramidal effects, because they do not affect
dopamine in striated areas.
ATYPICAL
Atypical Antipsychotic Agents:
RAPID-DISSOLVING PREPARATIONS of :
OLANZAPINE (ZYPREXIA)
RISPERIDONE (RISPERAL)
They begin to dissolve with saliva and can be swallowed without water.
Contraindications: Antipsychotics Agent
Should be used carefully in patients who are hypersensitive to medications or who have brain
damage or blood dyscrasia.
Commonly used Antipsychotic Agents
Typical :
Thorazine (chlorpromazine)
Haldol (haloperidol)
Stelazine (trifluoperazine)
Mallaril (trioriazine)
Loxitane (loxapine)
Prolixin (fluphenazine)
Atypical
Risperdol (risperidone)
Clozaril (clozapine
Seroquel (quetiapine)
Zefprexa (olanzapine)
Geodone (ziprasidone)
Abilify (aripiprazole)
Nursing Considerations:
Carefully teaching by doctors and nurses can help the patient to understand that these are very
strong medications. The possibility of seizures increases in patients who require antipsychotic
medications.
Observe for any sign of EPSEs or NMS and carefully monitor blood work for abnormal results.
Nursing Considerations

Careful instruction to the patient and family regarding wearing a wide-brimmed hat, covering all
exposed skin, and using a sunscreen when in the sun , especially if the patient is using
Thorazine.
Patient should be taught to avoid alcohol.
Over -the counter (OTC) products, should not be taken w/out doctor approval.
Nursing Considerations
Instruct the patient not to alter the dose w/out first discussing it w/ the doctor.
This classification of medication should be discontinued slowly
If medication is ordered once daily, teaching the patients to take the medication 1 to 2 hours
before going to bed works well and promotes sleep.
Antacid decrease the absorption of antipsychotics, these type of medications should be taken 1
to 2 hours after oral administration of antipsychotics.
ANTIDEPRESSANTS
(MOOD ELEVATORS)
Are group of drugs generally to treat depression, including symptoms of depressed mood, loss
of interest in activities or pleasure, altered sleep patterns, and somatic complaints.
They are also used to treat anxiety disorders (especially panic attacks), phobic disorders
and obsessive-compulsive disorders
Antidepressants may be further classified based on their mechanism of action and general
usage.
Classification of Antidepressants:
Tricyclic antidepressants
Monoamine Oxidase Inhibitors
Selective Serotonin Reuptake Inhibitors
Atypical antidepressants
Serotonin Norepinephrine Reuptake Inhibitors
TETRACYCLIC ANTIDEPRESSANT
(Heterocyclic Antidepressant)
The actions, uses, contraindications, side effect and nursing considerations for the tetracyclic
antidepressants are similar for those of SSRIs and tricyclic antidepressants.
Commonly used: Ludiomil (maprotiline) , Wellbutrin or Zyban (bupropion), Remeron
(mirtazapine), Desyrel (trazodone)
MONOAMINE OXIDASE INHIBITORS
(MAOIs)
ACTION: prevents the metabolism of neurotransmitters by an enzyme, monoamine oxidase. Too
much monoamine oxidase can lead to destructive, psychotic behaviors.
Uses : generally used for patients with varied types of depression who have not been helped by
other depressants.
Nursing considerations: teach patient to avoid foods containing the amino acid tyramine, a
precursor of Norepinephrine, while taking these medications.
MAOIs
Block the metabolism of tyramine, resulting in increased Norepinephrine. A hypertensive crisis
may occur.
Foods containing significant amount of tyramine:
Aged cheese (cheddar)
Avocados
Yogurt, sour cream
Chicken and beef liver, corned beef
Bean pods
Banana, raisins
Smoke and processed meat (salami, pepperoni, and bologna)
Chocolate
Beer, red wines, caffeine
Yeast supplement
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) (Bicyclic Antidepressant)
ACTION: increase the availability of serotonin, which is decreased in the brains of depressed
individuals.
Uses: treatment of depression, anxiety, obsessive disorders, impulse control disorders.

Side effects: dependence, suicidal tendencies, sedation, dry mouth, agitation, postural
hypotension, headache, arthralgia (joint pain), dizziness, insomnia, confusion, and tremors
SSRIs
Nursing considerations: do not abruptly discontinue the medications.
Caution should be used with driving or activities that require alertness.
Alcohol and CNS depressants should be avoided
Hard , sugarless candy can be used for dry mouth
The patient should change positions slowly to avoid a sudden drop in blood pressure
Monitor the patient for suicidal ideation
Tricyclic Antidepressants
Action: these drugs increase the level of serotonin and norepinephrine, thereby increasing the
ability of the nerve cells to pass information to each other. Patients with depressive disorders
generally have decreased amounts of these two neurochemicals.
Uses : treatment symptoms of depression, including
Sleep disturbances, sexual function disturbances, changes in appetite, and cognitive changes.
Tricyclic Antidepressant
Nursing considerations:
Patients should not stop using abruptly
Medications ( including over the counter medications such as cold preparations) that
contain antihistamins, alcohol, sodium bicarbonate, benzodiazepines, and narcotic
analgesics can increase the effects of tricyclic antidepressants.
Nicotine, barbiturates, and the hypnotic chloral hydrate decrease the effect of the tricyclic
antidepressant.
SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)
ACTION: increases the availability of serotonin and norepinehrine, which are decrease in the
brains of depressed individuals
The uses, contraindications, side effects and nursing considerations are similar for those of the
SSRIs.
MOOD STABILIZERS(antimanic agents)
Are a dose of drugs that include antimanic and anticonvulsants.
Used to treat bipolar disorder by stabilizing the clients mood, preventing or
minimizing the highs and lows that characterize bipolar illness, and treating acute
episodes of mania.
Ex. Antimanic Agent: Lithium Carbonate (Eskalith, Lithane). Drug of choice for treatment
and management of bipolar mania.
Anticonvulsants Agents: Gabapentin (Neurontin), Carbamazepine (Tegretol)
ANTIANXIETY DRUGS (ANXIOLYTIC)
They are generally prescribed to treat anxiety and symptoms associated with anxiety
disorders.
BENZODIAZEPINES (BZAs): drug of choice for treatment of anxiety and sleep disorders
They are also used in ACUTE ALCOHOL, WITHDRAWAL, PREOPERATIVE SEDATION,
SEIZURE DISORDERS, SHORT-TERM TREATMENT OF ACUTE MANIA and MUSCLE
RELAXANTS.
Additional, BENZODIAZEPINES are used to treat agitation and hyperactivity in Cognitive
Impairment Disorders.
Anxiolytic Benzodiazepines Medications:
Alprazolam (Xanax)
Chlordiazepoxide (Librium)
Clonazepam (Klonopin)
Diazepam (Valium)
Psychostimulants
Hyperactivity :
ADHD: ATTENTION DEFICIT HYPEACTIVITY DISORDER (CHILDREN)
RADD: RESIDUAL ATTENTION DEFICIT DISORDER (ADULT)
STIMULANTS
Are readily available over the counter as well by prescription.
They are found over the counter in diet preparations, pills to prevent sleep, in cigarettes, and in
beverages such as coffee and soda.

They are used medically to combat narcolepsy and attention deficit disorder in children.
Amphetamines are one type of stimulant, can be abused, and they have street names,
including uppers, speed, and bennies.
STIMULANTS/
PSYCHOSTIMULANTS
Are commonly used to treat children and adult with ADHD, they also may be used to
treat NARCOLEPSY in adult.
NARCOLEPSY: a condition characterized by sudden attacks of sleep occurring repeatedly during
the day.
Excessive sleepiness characterized by repeated, irreversible sleep attacks. After 10 to 20
minutes, the person is briefly refreshed until the next asleep attack.
Psychostimulant
Detroamphetamine (Dexedrine)
Methylphenidate (Ritalin, Concerta, Addreral,)
Pemoline (Cylert)
Methamphetamine (Desoxyn)

THERAPEUTIC MODALITIES, PSYCHOSOCIAL SKILLS AND NURSING STRATEGIES

prepared by:
Mary Ruth V. ENRIQUEZ, rn man
Therapeutic Modalities
Treatment receive by mentally ill client in variety of settings.
Biophysical/Somatic Intervention
Supportive Psychotherapy
Counseling
Assertive Training
Stress Management
Behavior Modification
Cognitive Restructuring
Milieu therapy
Biophysical /Somatic Intervention
Somatic Intervention: is a tool used by psychologist to influence nervous system
regulation and therapy.
Somatoforms Disorders: characterized by multiple, recurrent physical symptoms in a
variety of bodily system that have no organic or medical basis.
ECT (ELECTRO CONVULSIVE THERAPY)
ECT (Electro Convulsive Therapy)= shock therapy
Is used primarily for treating Depression but has been used to treat MANIA,
CATATONIA, and SCHIZOPRENIA that is unresponsive to medications.
ECT
It requires consent form
May be administered 2 to 3 times per week, for total of 6 to 12 treatments.
The procedure involves inducing unconsciousness (short acting anesthesia is used), then
passing an electric current through the brain, the clients V/S, oxygenation and cardiac
functioning are carefully monitored before and after ECT.
An electric current ( 70 to 150 volts) is applied through the brain for 0.5 to 2 seconds,
producing a seizure that last for 30 to 60 seconds.
ECT
Following ECT, the client is monitored according to routine post operative protocols.
Traditionally the electrodes have been applied BILATERALLY.
Alternative electrode placements are routinely used, including: UNILATERAL AND BIFRONTAL
Electroconvulsive therapy
SUPPORTIVE PSYCHOTHERAPY
It involves interaction with the patient (not silent listening) and emphasizes a focus
on the present (not on the past).
Questioning is less challenging and critical, and the approach conveys empathy and
understanding.
Conduct:
Nurse-client relationship
Group therapy
Family therapy
Nurse Client Therapy/Individual Psychotherapy
Is a method of bringing about change in a person by exploring his/her feelings,
attitude, thinking, & behavior.
It involves a one-one relationship between therapist and the client.
Reason why people seek psychotherapy:
to understand themselves and their behavior,
To make personal changes
To improve interpersonal relationships
To get relief from emotional pain or unhappiness.
One-on one therapy
GROUP THERAPY
Client participate in sessions with a group of people.

The members share a common purpose and are expected to contribute to the group to benefit
others and receive benefit from others in return
Being a member of a group allows the client to learn new ways of looking at a problem or ways of
coping with or solving problems and also helps him/her to learn important interpersonal skills.
Group therapy
Ex. By interacting with other members, client often received feedback on how other
perceives and react to them and their behavior.
This is extremely important information for many clients with mental disorders, who
have difficulty with interpersonal skills.
The Therapeutic results of Group Therapy:
1. Gaining new information, or learning
2. Gaining inspiration or hope
3. Interacting with others
4. Feeling acceptance and belonging
5. Becoming aware that one is not alone and that others share the same problems
6. gaining insight into ones problems and behaviors and how they affect others.
7. Gaining of oneself for the benefit of others (ALTRUISM)
FAMILY THERAPY
A form of a group therapy which the client and his/her family members participate.
THE GOALS include:
1. Understanding how family dynamics contribute to the clients psychotherapy
2. Mobilizing the familys interest strengths and functional resources
3. Restructuring maladaptive family behavior styles.
4. Strengthening family problem-solving behavior.
Family Therapy
Can be used both to assess and treat various psychiatric disorders.
Although one family member usually is identified initially as the one who has
problems and needs help, it often becomes evident through the therapeutic
process that other family members also have emotional problems and
difficulties.
COUNSELING
COUNSELING PSYCHOLOGY: as a psychological specialty facilitates personal and
interpersonal functioning across the life span with a focus on emotional, health-related,
developmental and organizational concerns.
ex,. Group therapy
Family therapy
Group members can ventilate feelings, try out problem-solving approaches, and resolves
conflict in a rational, systematic manner.
ASSERTIVE TRAINING
Is a form of behavior therapy designed to help people stand up for themselves- to
empower themselves, in more contemporary terms.
Helps the person take more control over life situations.
Techniques help the person negotiate interpersonal situations and foster selfassurance.
They involve using I statement s to identify feelings and to communicate concerns
or needs to others.
Ex. I feel angry when you turn your back while Im talking.
dont say yes when you want to say no.
Speak up for yourself
STRESS MANAGEMENT
Is techniques intended to equip a person with psychological stress,
Stress : as a persons physiological response to an internal and external stimulus that
triggers the fight-or- flight response.
3 TECHNIQUES OF STRESS MANAGEMENT:
1. POSITIVE REFRAMING
2. DECASTROPHIZING
3.ASSERTIVE TRAINING
POSITIVE REFRAMING

Means turning negative messages to positive messages.

The therapist teaches the person to create positive messages for use during panic
episodes.
Ex. Instead of thinking, my heart is pounding. I think Im going to die!(NEGATIVE)
I can stand this. This is just anxiety. It will go away. (POSITIVE)
decastrophyzing
The technique consists of confronting the worst-case scenario of a feared event or
object, using mental imagery to examine whether the effects of the event or object
have been overestimated (magnified or exaggerated) and where the patients coping
kills have been underestimated.
Is also called the what if technique" because the worst-case scenario is confronting by asking
what if the feared event or object happened, what would occur then?
decastrophyzing
Ex.
I would make an absolute fool of myself if I say the wrong thing.
what if you say the wrong thing, what would happen then?
he might think Im weird.
Assertiveness Training
It helps the person take more control over life situations and help the person
negotiate interpersonal situations.
BEHAVIOR MODIFICATION
Is a method of attempting to strengthen a desire behavior or response by
reinforcement, either positive or negative.
TECHNIQUES OF BEHAVIOR MODIFICATION:
1. POSITIVE and NEGATIVE REINFORCEMENT
Positive reinforcement = is provided by giving a person attention and positive
feedback.
Negative reinforcement = is done by removing a stimulus after a behavior occurred to
prevent it from occurring again.
Positve and negative reinforcement
Ex.
Operant conditioning (reward & punishment)
Techniques of Behavior Modification:
2. Systematic Desensitization: it is used to help clients overcome irrational fears and
anxiety associated with a phobia.
The client is asked to make list of situations involving the phobic object, from
the least to the most anxiety- provoking.
The client learns and practices relaxation techniques to decrease and manage
anxiety.
COGNITIVE RESTRUCTURING
Is a technique useful in changing patterns of thinking by helping client to recognize
negative thoughts and feelings and to replace them with positive pattern of thinking.
TECHNIQUES OF COGNITIVE RESTRUCTURING:
1. THOUGHT-STOPPING: is a technique to alter the process of negative or self critical
thought patterns. Ex. Splashing the face with cold water.
2. POSITIVE SELF TALK: client reframes negative thoughts to positive ones
MILIEU THERAPY
Refers to the physical and social environment in which an individual is receiving
treatment.
Uses a safe environment to meet the individual clients treatment needs.
Safety is the most important priority in managing milieu.
All treatment team members are viewed as significant and valuable to the clients
successful treatment outcomes.
Elements of the Treatment Environment
For the treatment environment to managed be effectively, we consider several
interrelated elements essential.
These elements, which provide the foundation necessary for the nurse to manage the
environment effectively, include:

 Safety
Structure
Norms
Limit setting
Balance
Safety
Is the primary to all other aspects of the environment.
Safety includes both physical and psychological protection.
Physical protection: refers to safety from physical harm through the management of risks in
the environment, such as the prevention of physical aggression and the requirement of staff
supervision for patients when using potentially unsafe grooming items ( e.g. Sharps, glass items,
and plastic bags).
Safety
Psychological safety: involves the nurses active intervention to prohibit verbal abuse, ridicule,
or harassment of patients.
Structure
Refers to the physical environment, rules, and daily schedules of treatment activities.
Is an essential component of psychiatric treatment because , without it, there is no
justification for the patient being in a treatment environment, particularly if custodial
care is outmoded.
Nurses lead activities such as patient education and social skills training groups.
Teaching about medications, side effects, and after care support for both patients and
families is an important function of the psychiatric nurse in minimizing patient
noncompliance
Norms
Are specific expectations of behavior that permeate the treatment environment; they
are intended to promote safety and trust in the environment through the sanctioning
of socially acceptable behaviors and consistency about what to expect.
For ex. A norm of nonviolence provides physical and emotional security in the
environment.
Limit Setting
Is an important element of the treatment environment and is related to norms.
Limits should be set on acting-out behavior such as self destructive acts, physical
aggressiveness, and sexual behavior.
It is also sometimes necessary to set limits on behaviors such as excessive requests,
attempts to overly personalize the therapeutic relationship, and refusal to participate
in treatment activities.
Closely related to limit setting are rules.
Balance
Involves the process of gradually allowing independent behaviors and in a dependent
situation.
It might be necessary to make specific judgments about a patients readiness to
assume certain responsibilities for his/her own care versus providing assistance when
the patient might not be able to act on his/her own behalf.
Focus of Milieu Therapy
To use the physical and social environment to affect a positive change directed toward
accomplishing the clients goals.
To empower the clients through involvement in setting his/her own goals and
development purposeful relations with the staff to assist in meeting these goals.
One on one relationships with the staff are used to examine client behaviors, feelings and
interactions with the context of the therapeutic group activities.
To use community meetings, activity groups, social skills group and physical exercise
programs to accomplish treatment goals
Play therapy
Play Therapy (ADHD)
Treatment modality in which the therapist engages in play with the child.
Therapeutic play, PLAY techniques are used to understand the childs thoughts and feelings
and to promote communication. This should not be confused with play therapy.

PLAY THERAPY: a psychoanalytic technique used by therapist.

Therapeutic Play
Dramatic Play: is acting out an anxiety-producing situation such as allowing the child to
be a doctor or use a stethoscope or other equipment to take care of a patient (a doll).
Play Techniques: to release energy could include: pounding pegs, running, or working with
modelling clay.
Creative Play: techniques can help the children to express themselves, ex. By drawing
pictures of themselves, their family, and peers.
These techniques are especially useful when children are unable or unwilling to
express themselves verbally.
Psychosocial Intervention
Are nursing activities that enhance the clients social and psychological functioning
and improve social skills, interpersonal relationships, and communication.
Nurses often use psychosocial intervention to help meet clients needs and achieve
outcomes in all practices settings, not just mental health.
Ex. Medical-surgical nurse might need to use interventions that incorporate
behavioral principles such as limits with manipulative behavior or giving positive
feedback
Ex. A client with diabetic tells the nurse, I promise to have just one bite of cake.
Please! Its my grandsons birthday cake (manipulative behavior)
GENERAL ASSESSMENT CONSIDERATION
MODULE 3
PREPARED BY:
MARY RUTH V. ENRIQUEZ, RN MAN
General Assessment considerations
1. Principles and Techniques of the Psychiatric Nursing Interview
2. Mental Status Examination (MSE)
3. Diagnostic Examination Specific to Psychiatric Patient
PRINCIPLES and TECHNIQUES OF PSYCHIATRIC NURSING INTERVIEW
ASSESSMENT:
Is the first step of the nursing process and involves the collection , organization, and
analysis of information about the clients health.
PSYCHOSOCIAL ASSESSMENT:
Which includes a Mental Status Examination
Purposes of Psychosocial Assessment: is to construct a picture of the clients current
Emotional state, Mental capacity, and Behavioral function.
This assessment serves as the basis for developing a plan of care to meet clients needs.
Clinical baseline used to evaluate the effectiveness of treatment and interventions or a
measure of the clients progress.
FACTORS INFLUENCING ASSESSMENT
1) Client Participation/ Feedback
2) Clients Health Status
3) Clients Previous Experiences/Misconceptions about Health Care
4) Clients Ability to Understand
5) Nurses Attitude and Approach
HOW TO CONDUCT THE INTERVIEW
ENVIRONMENT
1) The nurse should conduct the psychosocial assessment in an environment that is
comfortable, private, and safe for both the client and the nurse.
2) An environment that is fairly quiet with few distractions allows the client to give his or her
full attention to the interview.
3) Conducting the interview in a place such as a conference room ensures the client that no
one will overhear what is being discussed.
4) The nurse should not choose an isolated location for interview, particularly if the client is
unknown to the nurse or has a history of any threatening behavior.
INPUT FROM FAMILY AND FRIENDS

 if family members, friends, or caregivers have accompanied the client, the nurse should
obtain their perceptions of the clients behavior and emotional state.
The nurse should then be aware that friends or family may not feel comfortable talking
about the client in his or her presence and may provide limited information.
The client may not feel comfortable participating in the assessment without family or
friends.
This may limit the amount or type of information the nurse obtains.
HOW TO PHRASE QUESTIONS
OPEN ENDED QUESTIONS : allows the client to begin as he or she feels comfortable
and also gives the nurse an idea about the clients perception of his or her situation.
Ex. Of an Open- ended questions:
What brings you here today?
Tell me what has been happening to you.
How can we help you?
CLOSED- ENDED QUESTIONS
The nurse may need to use more direct questions to obtain information.
Questions need to be clear, simple, and focused on one specific behavior or symptom;
they should not cause the client to remember several things at once.
Ex. Questions that can confuse to the client,
How are your eating and sleeping habits and have you been taking any over- the counter
medications that affect your eating and sleeping?
Ex. Closed-Ended Questions:
How many hours did you sleep last night?
Have you been thinking about suicide?
How much alcohol have you been drinking?
How well have you been sleeping?
What over-the counter medications are you taking?
The nurse should use a nonjudgmental tone and language, particularly
when asking about sensitive information such as drugs or alcohol use,
sexual behavior, abuse or violence, and childrearing practices.
Using nonjudgmental language and a matter-of-fact tone avoids giving the
client verbal cues to become defensive or to not tell the truth.
Ex. When asking a client about his or her parenting role. The nurse should
ask,
what types of discipline do you use? rather than How often do you physically
punish your child?
The first question is more likely to elicit honest and accurate information;
the second question give wrong impression that physical discipline is
wrong, and it may cause the client to respond dishonestly.
MENTAL STATUS EXAMINATION
CONTENT OF THE ASSESSMENT:
History
General Appearance and Motor Behavior
Mood and Affect
Thought Process and Content
Sensorium and Intellectual Processes
Judgmental and Insight
Self-concept
Roles and Relationships
Physiologic and Self-care concerns
1. History
Includes: clients history, age and developmental stage, cultural and spiritual beliefs, and
beliefs about health and illness.
The history of client , as well as his or her family, may provide some insight on current
situation.

Ex. Has the client experienced similar difficulties in the past? Has the client been admitted
to the hospital, and if so, what was that experience like?
A family history that is positive for alcoholism, bipolar disorder, or suicide is significant
because it increases the clients risk for these problems.
Age and developmental stage: are important factors in the psychosocial assessment.
The nurse evaluates the clients age and developmental level for congruence with
expected norms.
Ex. A client may be struggling with personal identity and attempting to achieve
independence from his or her parents. If the client is 17 years old, these are two of the
primary developmental tasks for adolescent.
If the client is 35 years old and still struggling with these issues of self-identity and
independence, the nurse need to explore the situation.
the clients age and developmental level also may be incongruent with expected
norms if the client has a developmental delay or mental retardation.
Cultural and Spiritual beliefs : the nurse must be sensitive, avoid making inaccurate
assumptions about clients psychosocial functioning.
Many cultures have beliefs and values about a persons role in society or acceptable social
or personal behavior differ from those of the nurses.
Ex. People from other cultures, such as Japan, consider such as eye contact to be
sign of disrespects.
While Western cultures consider good eye contact to be a positive characteristic
indicating self-esteem and paying attention.
2. GENERAL APPEARANCE AND MOTOR BEHAVIOR
The nurse assesses the clients overall appearance, including:
Hygiene and grooming
Appropriate dress
Posture
Eye contact
Unusual movements or mannerism
Speech (rate of the speech fast or slow, responses a minimal yes or no
without elaboration, tone audible or loud)
Specific terms used in making assessments of general appearance and motor
behavior:
Automatisms: repeated purposeless behaviors often indicative of anxiety, such as
drumming fingers, twisting locks of hair, or tapping the foot.
Psychomotor retardation: overall slowed movements
Waxy flexibility: maintenance of posture or position over time even when it is awkward
or uncomfortable.
Neologism : invented words that have meaning only for the client.
3. MOOD AND AFFECT
MOOD : refers to the clients pervasive and enduring emotional state. EXPRESSED
EMOTIONS
AFFECT : is the outward expression of the clients emotional state. FACIAL EXPRESSION
The nurse assesses for consistency among the clients mood, affect, and situation .
Ex. The client may have an angry facial expression but deny feeling angry or upset in any way.
Or the client may be talking about the recent loss of a family member while laughing and
smiling.
COMMON TERMS USED IN ASSESSING AFFECT:
BLUNTED AFFECT: showing little or a slow-to-respond facial expression.
BROAD AFFECT: displaying a full range of emotional expression.
FLAT AFFECT: showing no facial expression.
INAPPROPRIATE AFFECT: displaying a facial expression that is incongruent with mood or
situation; often silly or giddy regardless of circumstances.
RESTRICTED AFFECT: displaying one type of expression, usually serious or somber.
MOOD
May be described as: happy, sad, depressed, euphoric, anxious, or angry.

 LABILE: when client exhibits unpredictable and rapid mood swings from depressed and
crying to euphoria with no apparent stimuli.
4.THOUGHT PROCESS AND CONTENT
Thought process: refers to how the client thinks.
The nurse can infer a clients thought process from speech and speech patterns.
Thought Content: is what the client actually says.
The nurse assesses whether or not the clients verbalizations make sense, that is, if ideas
are related and flow logically from one to the next.
The nurse also must determine whether the client seems preoccupied, as if talking or
paying attention to someone or something else.
When the nurse encounters clients with marked difficulties in thought process and
content, the nurse may find it helpful to ask focused questions requiring short answers.
COMMON TERMS RELATED TO THOUGHT PROCESS AND CONTENT:
Circumstantial thinking: a client eventually answer a question but only after giving
excessive unnecessary detail.
Delusion : a fixed false belief not based in reality.
Flight of ideas : excessive amount and rate of speech composed of fragmented or
unrelated ideas.
Ideas of reference: clients inaccurate interpretation that general events are personally
directed to him or her, such as hearing a speech on the news and believing the message
had personal meaning.
Loose associations: disorganized thinking that jumps from one idea to another with little
or no evident relation between the thoughts.
Tangential thinking: wandering off the topic and never providing the information
requested.
Thought blocking: stopping abruptly in the middle of a sentence or train of thought;
sometimes unable to continue the idea.
Thought broadcasting: a delusional belief that others can hear or know what the client
is thinking.
Thought insertion: a delusional belief that others are putting ideas or thoughts into the
clients head- that is, the idea are not those of the client.
Thought withdrawal: a delusional belief that others are taking the clients thoughts
away and the client is powerless to stop it.
Word salad: flow of unconnected words that convey no meaning to the listener.
Assessment of suicide or Harm toward others
The nurse must determine whether the depressed or hopeless client has suicidal ideation
or lethal plan.
The nurse does so by asking the client directly Do you have thoughts of suicide? or
what thoughts of suicide have you had?
If the client is angry, hostile, or making threatening remarks about a family member,
spouse, or anyone else, the nurse must ask if the client has thoughts or plans about
hurting that person.
The nurse does so by questioning the client directly:
What thoughts have you had about hurting (persons name)?
What is your plan?
What do you want to do to (persons name)?
When a client makes specific threats or has a plan to harm another person, health
providers are legally obliged to warn the person who is the target of the threats
or plan.
Duty to warn: legal term used.
5. SENSORIUM AND INTELLECTUAL PROCESSES
ORIENTATION
MEMORY
ABILITY TO CONCENTRATE
ABSTRACT THINKING & INTELLECTUAL ABILITIES
ORIENTATION:

 Refers to the clients recognition of person, place, and time- that is , knowing
who and where he or she is and the correct day, date , and year.
This is documented as:
Oriented x 3 : oriented
Oriented x1 : disoriented (person only)
Oriented x2 : disoriented (person and place)
When a person is disoriented: first loses track of time, then place, and finally person.
Orientation returns in reverse order: person, place, time
MEMORY:
The nurse directly assesses memory, both recent and remote by asking questions with
verifiable answers.
Ex.
What is the name of the current president?
Who was the president before that?
In what country do you live?
What is the capital of this state?
What is your social security number?
Verifiable answers : give accurate answers.
ABILITY TO CONCENTRATE:
The nurse assesses the clients ability to concentrate by asking the client to perform
certain tasks:
Spell the word WORLD backward: DLROW
Serial 7: begin with 100 subtract 7, subtract 7, again and so on.
Repeat the days of the week backward: Sunday, Saturday, Friday, Thursday, Wednesday,
Tuesday, Monday .
Perform a THREE-PART TASK, such as take a piece of paper in your right hand, fold it in
half, and put it on the floor. ( The nurse should give the instructions at one time)
ABSTRACT THINKING AND INTELLECTUAL ABILITIES:
When assessing the intellectual functioning, the nurse must consider the clients level of
formal education. Lack of formal education could hinder performance in many tasks in this
section.
The nurse assesses the clients ability to use ABSTRACT THINKING, which is associations or
interpretations about a situation or comment.
The nurse ask the client to interpret a common proverb. If the client can explain the
proverb correctly, his or her abstract thinking abilities are intact. If the client
provides a literal explanation of the proverb and cannot interpret its meaning,
abstract thinking abilities are lacking.
When the client continually gives literal translations, this is evidence of
concrete thinking.
Ex.
Proverb : A STITCH IN TIME SAVES TIME
ABSTRACT meaning: If you take the time to fix something now, youll avoid
bigger problems in the future.
LITERAL translation: Dont forget to sew up holes in your clothes (Concrete
thinking)
SENSORY- PERCEPTUAL ALTERATIONS
Some clients experience HALLUCINATIONS (false sensory perceptions or perceptual
experiences that do not really exist),
Hallucinations = can involve the five senses and bodily sensations.
Auditory hallucination: hearing voices, are the most common
Visual hallucination = seeing things dont really exist, are second most common.
Clients perceive hallucinations as real experiences, but later in the illness, they
may recognize the as hallucination.
6. JUDGMENT AND INSIGHT
JUDGMENT: refers to ability to interpret ones environment and situation correctly and
adapt ones behavior and decisions accordingly.

Problems with judgment may be evidenced as the client describes recent behavior and
activities that reflect a lack of reasonable care for self or others.
Ex. The client may spent large sums of money on frivolous items when he or she cannot
afford basic necessities such as food or clothings.
INSIGHT : is the ability to understand the true nature of ones situation and accept some
personal responsibility for that situation.
The nurse frequently can infer insight from the clients ability to describe realistically the
strengths and weaknesses of his or her behavior.
Ex. Poor insight : a client who places all blame on others for his own behavior, saying its
y wifes fault that i drink and get into fights, because she nags me all the time.
This client is not accepting responsibility for his drinking and fighting.
SELF- CONCEPT
Is the way one views oneself in terms of personal worth and dignity.
To assess clients self-concept, the nurse can ask the client to describe himself or herself
and what characteristics he or she likes and what he or she would change.
Description of self in term of Physical characteristics gives the nurse information about the
clients body image.
Emotions that client frequent experiences, such as sadness or anger, and whether or not
the client is comfortable with those emotions.
The nurse also must assess the clients coping strategies.
Ex. Questions : What do you do when you have a problem? How do you solve it?
ROLES AND RELATIONSHIP
People functioning in their community through various roles such as mother, wife, son,
daughter, teacher, secretary, or volunteer.
The nurse assesses the roles the client occupies, client satisfaction with those roles, and
whether the client believes he or she is fulfilling the roles adequately.
Relationships with other people are important to ones social and emotional health.
Relationships vary in terms of significance, level of intimacy or closeness, and intensity.
The inability to sustain satisfying relationships can result from mental health problems or
can contribute to the worsening of some problems.
The nurse must assess the relationships in the clients life, the clients satisfaction with
those relationships, or any loss of relationship.
Common questions:
Do you feel close to your family?
Do you have or want a relationship with a significant other?
Are your relationships meeting your needs for companionship or intimacy?
Can you meet your sexual needs satisfactorily?
Have you been involved in any abusive relationship?
PHYSIOLOGIC AND SELF-CARE CONSIDERATION
When doing psychosocial assessment, the nurse must include physiologic functioning.
Although a full physical health assessment may not be indicated, emotional problems
often affect some areas of physiologic function.
Emotional problems can greatly affect eating and sleeping patterns: under stress, people
may eat excessively or not at all, and may sleep up to 20 hours a day or may be unable to
sleep more than 2 or 3 hours a night.
SELF CARE CONSIDERATION:
The nurse also ask the client if he or she has any major or chronic health problems and if
he or she takes prescribed medications as ordered and follows dietary recommendations.
Noncompliance with prescribed medication is an important area. The nurse must help the
client feel comfortable enough to reveal this information.
DIAGNOSTIC PROCEDURE SPEIFIC TO PSYCHIATRIC PATIENTS