PSYCHIATRIC

NURSING
LECTURER:
ROSELILY COQUILLA, RN
Mental Health
• A state of well-being

• Able to recognize own potential

• Cope with normal stress

• Work productively

• Make contribution to community

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Traits of Mental Health
• Ability to
• Think rationally
• Communicate appropriately
• Learn
• Grow emotionally
• Be resilient
• Have a healthy self-esteem
• Realistic goals and reasonable function within the individual’s role

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Mental Illness
• Disorders with definable diagnosis

• Considered clinically significant when marked by

• Patient’s distress
• Disability or Risk of disability
• Loss of freedom
• Culturally defined

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Resilience
• Ability and capacity to secure resources needed to
support well-being
• Characterized by
• Optimism
• Sense of mastery
• Competence
• Essential to recovery

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Psychiatric Mental Health Nurses
• Employ purposeful use of self

• Promoting mental health through assessment, diagnosis, and

treatment of behavioral and mental disorders

• Use nursing, psychosocial, neurobiological theories and research

• Work with people throughout the life span

• Employed in a variety of settings and among varied populations

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 Concepts of the Nurse-Patient
Partnership

• Basis of all psychiatric nursing treatment

approaches
• To establish that the nurse is
• Safe
• Confidential
• Reliable
• Consistent
• Relationship with clear boundaries

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 Therapeutic Use of Self

• The nurse-patient partnership is a creative

process
• Each person brings their own uniqueness to the
relationship
• Use personality consciously and in full
awareness
• Nurse uses all the senses
• Attempt to establish relatedness
• Structure nursing interventions
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 Goals and Functions

• Facilitate communication of distressing thoughts

and feelings
• Assist patient with problem solving
• Help patient examine self-defeating behaviors
and test alternatives
• Helps patient feel understood without judgment
• Promote self-care and independence

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Therapeutic Relationships/Partnerships

• Needs of patient identified and explored

• Clear boundaries established
• Problem-solving approaches taken
• New coping skills developed
• Behavioral change encouraged

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Necessary Behaviors for Nurses

• Accountability
• Focus on patient’s needs
• Clinical competence
• Delaying judgment
• Supervision/mentorship

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 Establishing Boundaries

• Physical boundaries
• The contract
• Personal space

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 Blurring of Roles

• Transference – patient unconsciously and

inappropriately displaces onto nurse feelings and
behaviors related to significant figures in patient’s
past
• Transference intensified in relationships of authority
• The patient may say, “You remind me of…….”

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 Blurring of Roles (continued)

• Countertransference – nurse displaces feelings

related to people in nurse’s past onto patient
• Patient’s transference to nurse often results in
countertransference in nurse
• Common sign of countertransference in nurse is
overidentification with the patient

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Orientation Phase

 Establishing rapport
 Parameters of the relationship
 Formal or informal contract
 Confidentiality
 Terms of termination

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Working Phase
• Maintain relationship
• Gather further data
• Promote patient’s
• Problem-solving skills
• Self-esteem
• Use of language
• Facilitate behavioral change
• Overcome resistant behaviors
• Evaluate problems and goals
• Redefine them as necessary
• Promote practice and expression
of alternative adaptive behaviors
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Termination Phase

• Summarize goals and objectives achieved

• Discuss ways for patient to incorporate new
coping strategies learned
• Review situations of relationship
• Exchange memories

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Factors That Help
Nurse-Patient Partnership

• Consistency
• Pacing
• Listening
• Initial impressions

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Schizophrenia: A Psychotic Disorder
DSM-V Criteria: Highlights
• Two or more of the following for a significant portion
of time in 1 month:
• Delusions
• Hallucinations
• Disorganized speech
• Gross disorganization or catatonia
• Negative symptoms (diminished emotional expression or
avolition)
• Functional impairment of some kind
• Continuous disturbance for at least 6 months
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Four Main Symptom Groups of
Schizophrenia
• Positive

• Negative

• Cognitive

• Affective

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 Positive Symptoms Negative Symptoms
• Hallucinations • Blunted affect
• Delusions • Poverty of thought (alogia)
• Disorganized speech • Loss of motivation
(associative looseness) (avolition)
• Bizarre Behavior • Inability to experience
pleasure or joy
(anhedonia)

Cognitive Symptoms
• Inattention, easily Affective Symptoms
distracted • Dysphoria
• Impaired memory • Suicidality
• Poor problem-solving • Hopelessness
skills
• Poor decision-making
skills
• Illogical thinking
• Impaired judgment All Dimensions Alter
the Individual’s
•Ability to work
•Interpersonal relationships
•Self-care abilities
•Social functioning
•Quality of life

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Signs of Schizophrenia (4 As)

Affect
Associative looseness
Autism
Ambivalence
Signs of Schizophrenia (4 As)
Affect
Affect:
• The outward manifestation of a person's
feelings and emotions.

Example:
flat, blunted, inappropriate, or bizarre
Signs of Schizophrenia (4 As)

Associative looseness
 disorganized thinking, manifested as
jumbled and illogical speech and
impaired reasoning.
Signs of Schizophrenia (4 As)

Autism
• thinking is not bound to reality but
reflects the private perceptual world of
the individual.

Example:
delusions, hallucinations, and neologisms
Signs of Schizophrenia (4 As)

Ambivalence

 simultaneously holding two opposing

emotions, attitudes, ideas, or wishes
toward the same person, situation, or
object..
Potential Nursing Diagnoses
• Positive symptoms
• Disturbed sensory perception
• Formerly Disturbed Thought Process
• Risk for self-directed or other-directed violence
• Impaired verbal communication
• Negative symptoms
• Social isolation
• Chronic low self-esteem

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Intervention
• Acute phase
• Ensure safety
• Psychiatric, medical, and neurological evaluation
• Psychopharmacological treatment
• Support, psychoeducation, and guidance
• Supervision and limit setting in the milieu
• Activities and groups
• Monitor fluid intake
• Working with aggression
• Regularly assess for risk and take safety measures
• Therapeutic communication

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Interventions
• Stabilization and maintenance phases
• Medication administration/adherence
• Relationships with trusted care providers
• Community-based therapeutic services
• Teamwork and safety
• Activities and groups

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 Communication Guidelines
Therapeutic strategies for communicating with
patients with schizophrenia focus on:
•Lowering the patient’s anxiety
•Decreasing defensive patterns
•Encouraging participation in therapeutic and
social events
•Raising feelings of self-worth
•Increasing medication compliance

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 Counseling: Communication Guidelines

• Associative looseness
• Do not pretend that you understand
• Place difficulty of understanding on yourself
• Look for reoccurring topics and themes
• Emphasize what is going on in the patient's
environment
• Involve patient in simple, reality-based activities
• Reinforce clear communication of needs, feelings, and
thoughts

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Counseling: Communication Guidelines

Hallucinations
−Hearing voices (auditory hallucinations) most common
−Approach patient in nonthreatening and nonjudgmental
manner
−Assess if messages are suicidal or homicidal
−Ask directly what the voices are saying
−Do not argue or negate patient perception
−Offer your own perceptions (present reality)
−Focus on reality-based diversions
−Patient anxious, fearful, lonely, brain not processing stimuli
accurately
−Initiate safety measures if needed

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Counseling: Communication Guidelines

Delusions
−Be open, honest, matter-of-fact, and calm
−Have patient describe delusion
−Avoid arguing about content
−Interject doubt when appropriate
−Validate part of delusion that is real
−Focus on feelings the delusions generate
−Once delusion is described, do not dwell on it
−Observe events that trigger delusions

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Remember…..

• Altered thought processes are generally related

to low self-esteem, powerlessness, anger or fear
• Projection is the most common defense
mechanism for the paranoid schizophrenic
• Look for the meaning

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 Reality Based Interventions
Distraction
Help-seeking
◦ Talk with friends
◦ Call therapist/mental health
◦ Listen to music worker
◦ Watch TV ◦ Go to clinic/NP/MD
Physical activity ◦ Seek family/significant other
support
◦ Exercise
Relaxation activities
◦ Sing, dance, etc.
◦ Shower, bath
Fighting back
◦ Breathing exercises
◦ Positive self –talk ◦ Relaxation techniques
◦ Yelling at voices ◦ Take PRN med
◦ Tell voices to go away

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 Patient and Family Teaching
for Schizophrenia
Learn all you can about the illness
Develop a relapse prevention plan
Participate in family, group and individual therapy
Avoid alcohol and drugs
Learn ways to address fears and losses
Learn new ways of coping
Have a plan on paper of what to do in times of increased
stress
Adhere to treatment
Maintain communication with supportive people
Stay healthy by managing stress, sleep, and diet
Balance
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Advanced Practice Interventions

• Family therapy
• Cognitive behavioral therapy (CBT)
• Individual and group therapy
• Psychoeducation
• Medication prescription and monitoring
• Cognitive remediation
• Social skills training

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Depressive Disorders

• All share symptoms of

• Sadness, emptiness, irritability, somatic
(body) concerns, and impairment of
thinking
• All impact a person’s ability to function

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Depressive Disorders Classified

• Major depressive disorder

• Others

• Persistent depressive disorder (previously dysthymia)

• Disruptive mood dysregulation disorder

• Premenstrual dysphoric disorder

• Substance/medication-induced depressive disorder

• Depressive disorder due to another medical condition

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 MDD – DSM V
 5 or more symptoms for greater than two weeks
◦ One must be either anhedonia or depressed mood
◦ Plus 4 of the following:
Weight gain/loss Inappropriate guilt
Insomnia/hypersomnia Psychomotor agitation or
retardation

Anergia (decreased Decreased

energy) or fatigue concentration/indecisivene
ss
Worthlessness Suicidal ideation
Indecisiveness

 Clear change from previous function

 Significant distress/impairment in social, occupational, or family functioning
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Persistent Depressive Disorder (dysthymia) – DSM V

• Depressed mood for most of the day, for more days

than not for at least 2 years in adults and one year in
children
• Plus two or more of the following:
Decreased or increased appetite
Insomnia or hypersomnia
Low energy or chronic fatigue
Decreased self-esteem
Poor concentration or difficulty making decisions
Feelings of hopelessness or despair
• Usually occurs before 21

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Nursing Process:
Assessment

• Safety first
• Suicide potential
• Key symptoms
• Depressed mood
• Anhedonia
• Anxiety
• Anergia
• Somatic complaints
• Vegetative signs

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Nursing Process (Cont.)

• Areas to assess
• Affect
• Thought processes
• Mood
• Feelings
• Physical behavior
• Communication
• Religious beliefs and spirituality

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Nursing Process
• Nursing diagnosis
• Risk for suicide—safety is always the highest priority
• Hopelessness
• Ineffective coping
• Social isolation
• Spiritual distress
• Self-care deficit

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Nursing Process (Cont.)
• Outcomes identification
• Recovery model
• Focus on patient’s strengths
• Treatment goals mutually developed
• Based on patient’s personal needs and values

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 Basic Level Interventions
• Observational status
• Contraband assessment/interventions
• Communication
• Counseling
• Encourage self-care activities
• Maintain therapeutic milieu
• Health teaching
• Administer medications per physician/ advanced
practice nurse
• Assess effects of medications

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 Interventions: Self-Esteem
• Promoting improved self-esteem
• Provide distraction through milieu
• 1:1 therapeutic interactions with the staff
• Activities at patient’s level
• Increase difficulty as patient progresses
• Acknowledge accomplishments without flattery or
excessive praise (matter-of-fact)
• Help patients identify own personal strengths

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Interventions: Cognitive Distortions
• Help patient question underlying assumptions and
consider alternate explanations
• Work with patient to identify cognitive distortions
• Overgeneralizations
• Self-blame
• Mind reading
• Discounting positive attributes

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 Interventions: Negativism

• Accept patient’s negative feelings but set limits on

amount of time for negative expression
• Matter-of-fact style
• Redirect to neutral topics
• Teach assertiveness techniques
• Teach how to replace negative thoughts to positive focus
• Stop “negative audiotapes”
• Cognitive reframing

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Interventions: Internal vs. External Locus of
Control
• Promote feelings of control
• Team approach
• Give patient choices & responsibility whenever
possible
• Decrease “you make me feel” terminology, replace
with “I feel _____ when ______.”
• Set short term realistic goals with the patient
• Help patient identify ways to gain control
• Identify small manageable steps

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 Communication Guidelines:
Severely Withdrawn Patients
• Technique of making observations
• Simple, concrete words
• Allow time for response
• Listen for covert messages and ask about suicide plans
• Avoid platitudes
• Sit quietly with patient

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Dependence on Medication

• Patients with many somatic

complaints often become dependent
on pain, anxiety, and sleep
medications.
• Physicians prescribe anxiolytic agents
for patients concerned about symptoms.
• Patients often return to a physician for prescription
renewal and seek treatment from many physicians.
• Nurse assessment of the medications used is important.

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Nursing Diagnoses
• Ineffective coping
• Anxiety
• Risk for loneliness
• Powerlessness, hopelessness
• Social isolation
• Pain
• Altered family processes
• Risk for suicide

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Six Key Elements for Effective Treatment
1. Provide continuity of care.
2. Avoid unnecessary procedures.
3. Provide frequent, brief, and regular visits.
4. Always conduct a physical exam.
5. Avoid disparaging comments.
6. Set reasonable therapeutic goals.

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 Trauma-Related Disorders
in Adults
• Posttraumatic stress disorder (PTSD)
• Re-experiencing of the trauma (flashbacks)
• Avoidance of stimuli associated with trauma
• Persistent symptoms of increased arousal
• Alterations in mood
• Experience of persistent numbing
of responses

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Acute Stress Disorder
• Occurs within 1 month after exposure to highly
traumatic event
• Must display at least 9 symptoms in 5 different
categories (intrusion, negative mood, dissociative
symptoms, avoidance symptoms, and arousal
symptoms)
• Cannot be diagnosed until 3 days after the event
• Resolves within 4 weeks

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Nursing Diagnoses
• Anxiety
• Ineffective coping
• Social isolation
• Insomnia
• Sleep deprivation
• Hopelessness
• Chronic low self esteem
• Self-care deficit

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PTSD: Interventions - Adults
• Priority is development of a therapeutic alliance through
nonjudgmental acceptance and empathy
• Management of arousal (relaxation techniques)
• Provide a safe, predictable environment
• Explore shattered assumptions/ideals
• Promote discussion of possible meaning of event
• Gently suggest that patient is not responsible for event,
but is responsible for coping
• Identify social support and encourage use of support
group
• Psychopharmacology

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Anxiety

• Anxiety – Apprehension, uneasiness, uncertainty, or

dread from real or perceived threat
• Fear – Reaction to specific danger
• Normal anxiety – Necessary for survival
Levels of Anxiety

• Mild anxiety

• Moderate anxiety

• Severe anxiety

• Panic

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 Mild Anxiety
• Perceptual field heightened

• Grasps what is happening

• Identifies disturbing things

• Can work toward a goal

• Can examine alternatives

• Experiences slight discomfort

• Restlessness, irritability

• Mild tension relieving behaviors

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 Moderate Anxiety

• Perceptual field narrows

• Selective inattention

• Needs to have things pointed out/ benefits from guidance

• Problem solving ability moderately impaired

• Shaky voice, concentration difficulty

• Sympathetic nervous system symptoms

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Interventions: Mild to Moderate Anxiety
Nurse remains calm
Help identify anxiety and antecedents to anxiety
Anticipate anxiety-provoking situations
Demonstrate interest
Encourage talking about feelings/concerns
Keep communication open
Broad open-ended questions, exploring, clarification
Encourage problem solving
Use role playing, modeling
Explore past coping mechanisms
Provide outlets for excess energy
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 Severe Anxiety
Perceptual field greatly reduced

Attention scattered or may only be able to focus on one detail

Self-absorbed

Can’t attend to events or see connections

Perceptions distorted

Feelings of dread or doom

Sympathetic nervous system symptoms

Confusion, purposeless activity

Cannot problem-solve or learn

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 Panic Level of Anxiety
Unable to focus on environment

Terror, emotional paralysis

Hallucinations/delusions (may lose touch with reality)

Muteness, severe withdrawal

Immobility or extreme agitation, severe shakiness

Disorganized, irrational thinking

Unintelligible speech, shouting, screaming

Sleeplessness
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Interventions: Severe to Panic Anxiety
Nurse maintains calm manner
Remain with patient
Minimize environmental stimuli
Use clear, simple, statements and repetition
Low pitched voice; speak slowly
Reinforce reality if distortions occur
Listen for themes
Meet physical and safety needs
Set verbal limits/physical limits
Assess need for medication or seclusion
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Interventions: Panic Anxiety
Instruct to take slow, deep breaths
Keep expectations minimal and simple
Help connect feelings with attack onset (triggers)
Help patient recognize symptoms as anxiety, not a
physical problem
Teach abdominal breathing and positive self talk (CBT)
Psychoeducation
Medications

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 Anxiety Disorders
Behaviors used to control anxiety
◦ Rigid
◦ Repetitive
◦ Ineffective
Functioning that the degree of anxiety interferes
will include
◦ The person
◦ The person's occupation
◦ The person's social interactions

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Anxiety Disorders (continued)
• Panic disorder
• Generalized anxiety disorder
• Separation anxiety disorder
• Phobias
• Specific
• Social anxiety disorder
• Agoraphobia
• Obsessive-compulsive disorder
• Body dysmorphic disorder
• Hoarding disorder
• Hair pulling and skin picking disorders
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Panic Disorder (continued)
• Physical Symptoms
• Palpitations, tachycardia, nausea, diarrhea
• Dyspnea or feelings of choking/suffocation
• Dilated pupils, face flushed
• Dizziness, feeling faint
• Sense of impending doom
• Fear of going crazy or dying

Advanced states mimic MI, mitral valve prolapse

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 Clinical Picture (continued)

• Agoraphobia
• Excessive anxiety or fear about being in places or situations
from which escape might be difficult or embarrassing
• Specific phobias

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 Clinical Picture (continued)

• Social anxiety disorder

• Severe anxiety or fear provoked by exposure to a social
or a performance situation that will be evaluated
negatively by others
• Fears humiliation, embarrassment, sounding foolish
• Can fears public speaking, interacting with superiors,
aggressive individuals

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 Clinical Picture (continued)
• Generalized anxiety disorder
• Excessive worry that lasts for months
• Pervasive and persistent anxiety
• Chronic feelings of nervousness
• Constant worry
• Insomnia, fatigue
• Twice as common in females than males

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Obsessive-Compulsive Disorders
• Obsessions
• Thoughts, impulses, or images that persist and recur, so that
they cannot be dismissed from the mind
• Compulsions
• Ritualistic behaviors an individual feels driven to perform in an
attempt to reduce anxiety

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 Nursing Diagnosis - NANDA
• Anxiety
• Fear
• Hopelessness
• Ineffective coping
• Social Isolation
• Disturbed sleep pattern
• Self-care deficit

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 Basic Level
Nursing Interventions
• Counseling
• Milieu therapy
• Promotion of self-care activities
• Pharmacological interventions
• Health teaching

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 Phobia: Interventions
• Determine type of phobia and onset

• Have patient list consequences of contacting feared

object/activity

• Identify therapies for phobias (i.e., systemic

desensitization)

• Teach relaxation techniques

• Model unafraid behavior

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OCD: Interventions
Anticipate needs, especially for information
(medication, therapy)
Focus on the patient rather than the ritual
Monitor nutrition/sleep
Encourage meals/rest
Avoid hurrying patient
Do not arbitrarily forbid rituals
Give positive reinforcement for non-ritualistic activity

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Generalized Anxiety Disorder:
Interventions
• Encourage patient to discuss preceding events
• Link patient’s behavior to feelings
• Teach cognitive therapy principles
• Anxiety is the result of a dysfunctional appraisal of a
situation
• Anxiety is the result of automatic thinking
• Ask questions that clarify and dispute illogical thinking
• Have patient give alternate interpretation
• Identify relief behaviors
• Assist to reframe situation
• Monitor own feelings (anxiety is transmittable)

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