33496209 psychiatric nursing

7/30/2019 33496209 Psychiatric Nursing

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Concerned with the promotion of mental health, prevention of mentaldisorders, and the nursing care of patients

during mental illness and rehabilitation.



Core of Psychiatric Nursing Interpersonal Process – human to human relationship (NPI)

where by the professional nurse practitioner uses of therapeutic Self

Psychiatric Nursing as Science & Art Knowledge, Skills & Attitude (KSA)

• Science – use of different theories in the practice of nursing

• Arts –

Therapeutic use of self Clientele in Psychiatric Nursing

• Individual, Family and the Community

• Mentally ill and Mentally Healthy Person



WHO definition: state of complete physical, mental,and social wellness, not merely absence of disease orinfirmity

State of emotional, psychological, and social wellnessevidenced by:

Satisfying interpersonal relationships

Effective behavior and coping

A positive self-concept

Emotional stability



Individual factors: Biologic make-up, autonomy, independence, self-esteem,

capacity for growth, vitality, ability to find meaning in life,emotional resilience or hardiness, a sense of belonging,

reality orientation, and coping or stress managementabilities Interpersonal factors: Effective communication, ability to help others, intimacy,

and a balance of separateness and connectedness Social/cultural factors: A sense of community, access to adequate resources,

intolerance of violence, support of diversity among people,mastery of the environment, and a positive, yet realistic,

view of one’s world



Historically viewed as possession by demons,punishment for religious or social transgressions,weakness of will or spirit, violation of socialnorms

Today seen as a medical problem, although somestigma from previous beliefs remains



Mental disorder is “a clinically significant

behavioral or psychological syndrome or

pattern that occurs in an individual andthat is associated with distress ordisability or with a significantly increased

risk of suffering death, pain, disability, oran important loss of freedom” (APA)



Individual factors include biologic

makeup, anxiety, worries and fears, a sense of disharmony in life, and a loss of meaning in one’s life

(Seaward, 1997) Interpersonal factors

include ineffective communication, excessive dependencyor withdrawal from relationships, and loss of emotional

control. Social and cultural factors

include lack of resources, violence, homelessness, poverty,and discrimination such as racism, classism, ageism, and

sexism.



The DSM-IV-TR® is a taxonomy published by APA

and used by all mental health professionals thatdescribes all mental disorders according tospecific diagnostic criteria

The DSM-IV-TR is based on multiaxialclassification system:

A multi-axial classification system that involvesassessment on several axes, or domains of

information, allows the practitioner to identify all the

factors that relate to a person’s condition:



► Axis I : Major psychiatric disorders except mentalretardation and personality disorders

► Axis II : Mental retardation, personality disorders,maladaptive personality features, and defensemechanisms

► Axis III : Current medical conditions

► Axis IV: Psychosocial and environmentalproblems

► Axis V: Global Assessment of Functioning (GAF)score

DSM-IV-TR (cont’d)



The ability to establish therapeuticrelationships with clients is one of themost important skills a nurse can

develop



Components include:

Trust

Genuine interest

Empathy (not sympathy)

Acceptance of person, not necessarily his orher behavior

Unconditional positive regard

Self-awareness and therapeutic use of self



Nurse Client Interaction

Direct interaction

Establishing Rapport to patient Working & Communicating to patient

Nurse Patient Relationship

Therapeutic nurse–patient relationship,which includes four phases: orientation,identification, exploitation, and resolution



Self-awareness: process of understanding one’s own

values, beliefs, thoughts, feelings, attitudes, motivations,

strengths, and limitations and how one’s thoughts and

behaviors affect others

Therapeutic use of self: the nurse uses aspects of his or her

personality, experience, values, feelings, intelligence,

needs, coping skills, and perceptions to establish

relationships with clients that are beneficial to clients



Tool that is useful in learning more aboutoneself is the Johari window (Luft, 1970),

which creates a “word portrait” of a person infour areas and indicates how well that personknows himself or herself and communicateswith others.



The Johari window is aself-awareness toolthatcategorizes qualitiesof self as:

Open/public

Blind/unaware

Hidden/private

Unknown



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 known

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 byoneself or others



Social Relationship A social relationship is primarily initiated for

the purpose of friendship, socialization,companionship, or accomplishment of a task.Communication, which may be superficial,usually focuses on sharing ideas, feelings, andexperiences and meets the basic need forpeople to interact.



Intimate Relationship A healthy intimate relationship involves two

people who are emotionally committed toeach other. Both parties are concerned abouthaving their individual needs met and helpingeach other to meet needs as well. Therelationship may include sexual or emotionalintimacy as well as sharing of mutual goals.



Therapeutic Relationship

The therapeutic relationship focuses on the

needs, experiences, feelings, and ideas of theclient only. The nurse and client agree aboutthe areas to work on and evaluate theoutcomes. The nurse uses communicationskills, personal strengths, and understandingof human behavior to interact with the client.



Therapeutic relationships

are focused on the needs,

experiences, feelings, and

ideas of the client, not the

nurse The therapeutic

relationship

consists of three phases:

Orientation

Working

Termination



ORIENTATION The orientation phase begins when the nurse

and client meet and ends when the clientbegins to identify problems to examine.During the orientation phase, the nurseestablishes roles, the purpose of meeting,and the parameters of subsequent meetings;identifies the client’s problems; and clarifiesexpectations.



Nurse task is to:

Build trust

Reads background materials available on the client Becomes familiar with any medications the client is

taking

Gathers necessary paperwork

Arranges for a quiet, private, comfortable setting



Outline the responsibilities of the nurse and client. both nurse and client should agree on these

responsibilities in an informal or verbal contract. formal or written contract may be appropriate if a written contract has been necessary in the past

with the client or if the client “forgets” the agreed-on verbal contract.



The contract should state: Time, place, and length of sessions When sessions will terminate Who will be involved in the treatment plan (family

members, health team members) Client responsibilities (arrive on time, end on

time) Nurse’s responsibilities (arrive on time, end on

time, maintain confidentiality at all times,

evaluate progress with client, document sessions



Respecting the client’s right to keep private anyinformation about his or her mental and physicalhealth and related care.

The nurse must clearly state information aboutwho will have access to client assessment data andprogress evaluations.

He or she should tell the client that members of the

mental health team share appropriate informationamong themselves to provide consistent care andthat only with the client’s permission will theyinclude a family member



Revealing personal information such asbiographical information and personal ideas,

thoughts, and feelings about oneself toclients (Deering, 1999). The nurse can use self-disclosure to convey

support, educate clients, demonstrate that aclient’s anxiety is normal, and even facilitateemotional healing (Deering, 1999).



Divided into two sub phases

Problem identification

▪ the client identifies the issues or concerns causingproblems

▪ Examination of the client’s feelings and responses

Exploitation (exploration)

▪ the nurse guides the client to examine feelings andresponses and to develop better coping skills and a morepositive self-image; this encourages behavior changeand develops independence.



The specific tasks of the working phase include the following: Maintaining 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



In the working phase, the nurse must beacutely aware of 2 common elements canarise:

Transference: when clients unconsciously transfer feelings they have for significant persons in their life onto the nurse▪ Patient to nurse

Countertransference: when the nurse responds tothe client based on his or her own unconsciousneeds and conflicts▪ Nurse to patient



Begins when the client’s problems are

resolved

Ends when the relationship is ended

Deals with feelings of anger or abandonment that may occur



Inappropriate boundaries (relationshipbecomes social or intimate)

Feelings of sympathy and encouragingdependency

Nonacceptance of the client as a person

because of his or her behaviors, leading toavoidance of the client

Nurse self-awareness is the way to avoid such

problems



Teacher the nurse may teach the client new methods of coping and

solving problems. Caregiver

role in mental health settings is the implementation of thetherapeutic relationship to build trust, explore feelings, assistthe client in problem solving, and help the client meetpsychosocial needs.

Advocate In the advocate role, the nurse informs the client and then

supports him or her in whatever decision he or she makes(Kohnke, 1982).

Parent surrogate Assume the parental role as evidenced in choice of words and

nonverbal communication.

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