Psychiatric nursing

Mental Health

• Balance in a person’s internal life and adaptation to reality

• State of wellbeing in which a person is able to cope with normal stresses of daily life and realize his/her potential (WHO, 2005)

• In short is the SUCCESSFUL ADAPTATION TO STRESSORS!!!

Mental Illness

• State of imbalance characterized by a disturbance in a person’s thought, feelings and behavior

• In short is the MALADAPTIVE RESPONSE TO STRESSORS!!!

• Poverty and abuse are the major factor that increase the risk of development of mental illness at home

Factors that can lead to mental disorders

• Dissatisfaction with one’s characteristics, abilities and accomplishments

• Ineffective or unsatisfying relationships• Dissatisfaction with one’s place in the world• Ineffective coping with life events• Lack of personal growth

DSM-IV-TR• Diagnostic and Statistical Manual of Mental Disorders – Fourth

Edition, Text Revision– Axis I

• Major psych disorders and other clinical disorders except those belonging to Axis II: depression, schizophrenia, anxiety and substance related d/o

– Axis II• Mental retardation and personality disorders

– Axis III• Current/General medical conditions that are potentially relevant to

understanding or managing the person’s mental disorders – Axis IV

• Psychosocial and environmental problems that may affect the diagnosis, treatment and prognosis of mental d/o

– Axis V• Global assessment of functioning w/c rates a person’s overall psychological

functioning on a scale of 0 to 100

Example of Psychiatric Diagnosis using DSM-IV

Psychiatric Diagnosis

Axis I Dysthymic Disorder

Axis II Dependent personality disorders

Axis III Hypothyroidism

Axis IV Unemployed

Axis V GAF: 60 (current)

DSM-V

DSM-5

• It has 3 sections:– Introduction and directions for usage– Diagnoses and disorders (20 disorders)– Unclassified conditions to undergo further research

• Major changes:– Direct and specific diagnosis; no more axials– From roman numeral IV to standard 5– From disorder otherwise classified to DISORDERS

NOT ELSEWHERE CLASSIFIED

THEORIES AND MODELS IN PSYCH

Psychoanalytic theory

• By Sigmund Freud• Personality Processes– Id: pleasure principle– Ego: reality principle– Superego: conscience/moral principle

Age Stage

Birth to 18 months Oral Stage

18 months to 3 years Anal

3 y/o to 6 y/o Phallic

6 y/o to 12 y/o Latency

13 to 20 years Genital

Psychoanalytic theory

Psychosocial Theory• By Erik Erikson

Stage Virtue

Trust vs. Mistrust (infant) Hope

Autonomy vs. shame & doubt (Toddler) Will

Initiative vs. Guilt (Preschool) Purpose

Industry vs. Inferiority (School Age) Competence

Identity vs. Role confusion (adolescent) Fidelity

Intimacy vs. Isolation (young adult) Love

Generativity vs. Stagnation (middle adult) Care

Integrity vs. Despair (old adult) Wisdom

• Trust vs. Mistrust– Task: to develop basic trust in the mothering figure and be able to

generalize it to others• Autonomy vs. Shame & Doubt

– To gain some self-control, ability to delay gratification and independence within the environment.

• Initiative vs. Guilt– To develop a sense of purpose and the ability to initiate and direct

own activities.• Industry vs. Inferiority

– To develop a sense of self-confidence by learning, competing, performing successfully and receiving recognition from significant others, peers and acquaintances.

Psychosocial Theory

• Identity vs. Role confusion– Task: formulating a sense of self and belonging

• Intimacy vs. Isolation– To form an intense, lasting relationship or a commitment to

another person, cause, institution or creative effort• Generativity vs. stagnation

– To achieve the life goals established for oneself, while also considering the welfare of future generation

• Integrity vs. Despair– To review one’s life and derive meaning from both positive and

negative events, while achieving a positive sense of self-worth

Psychosocial Theory

Cognitive Model• By Jean Piaget– Sensorimotor (birth-2yrs)

• Develops a sense of self. Concept of object permanence (tangible objects don’t cease to exist just because they are out of sight)

– Preoperational (2-6yrs)• Able to express self with language. Understand meaning of symbolic

gestures.– Concrete operational (6-12yrs)

• Apply logic thinking. Understand spatiality and reversibility. Increasingly social and able to apply rules, thinking is still concrete (take things literally)

– Formal operational (12-15yrs and beyond)• Child learns to think and reason in abstract terms. Further develops

logical thinking and reason and achieves cognitive maturity.

EGO DEFENSE MECHANISM

• Compensation – overachievement in one area to offset real or perceived deficiencies in another area

• Conversion – expression of an emotional conflict through the development of a physical symptom

• Denial – failure to acknowledge an unbearable condition; failure to admit the reality of a situation

• Displacement – feelings are transferred, redirected or discharged from the appropriate person or object to less threatening person or object

• Fixation – immobilization of a portion of the personality resulting from unsuccessful completion of tasks in a developmental stage

• Identification – modeling action and opinions of influential others while searching for identity

• Intellectualization – acknowledging the facts but not the emotions

• Introjection – accepting another person’s attitudes, beliefs and values as one’s own

• Projection – unconscious blaming of unacceptable inclinations or thoughts on an external object

• Rationalization – excusing own behavior to avoid guilt, responsibility and conflict

• Reaction Formation – acting the opposite of one thinks or feels

• Regression – moving back to previous developmental stage to feel safe and have needs met

• Repression – an involuntary, automatic submerging of painful, unpleasant thoughts and feelings into the unconscious

• Suppression – conscious exclusion of unacceptable thoughts and feelings from conscious awareness

• Substitution – replacing the desired gratification with one that is more readily available

• Sublimation – substituting a socially acceptable activity for an impulse that is unacceptable

• Undoing – exhibiting acceptable behavior to make up for or negate unacceptable behavior

PATHOLOGIC BEHAVIORS

• Agnosia– Inability to recognize

objects and people• Agraphia– Loss of ability to write

• Alexia– Loss of ability to read

• Alogia– Decrease in amount

and content of speech/inability to speak

• Ambivalence– Presence of two

opposing feelings• Amnesia– Inability to recall past

events• Anhedonia– Loss of interest in

pleasurable things

• Retrograde amnesia– Loss of memory of

the distant past• Anterograde amnesia– Loss of memory of

the immediate past• Apathy– Dulled emotional

state

• Apraxia– Inability to carry out

purposeful motor activities

• Avolition– Lack of motivation

• Blunted affect– Severe reduction in

emotional reaction

• Circumstantiality– Indirect speech

characterized by over inclusion of details after which the client eventually gets through the intended purpose of his/her message

• Clang association– Association of words by

sound rather than by meaning

• Confabulation– Filling in of memory gaps

• Déjà vu– Feeling of having been to

a place w/c one has not yet visited

• Delusion– Fixed false belief that

isn’t seen in reality• Depersonalization– Feeling of strangeness

towards one’s self

• Dysarthria– Inability to articulate

• Echolalia – Echoing of phrases

• Echopraxia– Pathologic imitation of

posture/action of others

• Expressive aphasia/Broca’s aphasia– characterized by the loss of

the ability to produce language (spoken or written).

• Receptive aphasia/Wernicke’s Aphasia– have serious comprehension

difficulties and be unable to grasp the meaning of spoken words.

• Global aphasia– has difficulty speaking and

understanding words. In addition, the person is unable to read or write.

• Flat Affect– Absence or near absence of

emotional reaction• Flight of Ideas

– Shifting from a topic to the next in a somewhat related way

• Hallucination– False sensory perception in the

absence of external stimuli• Illusion

– Misperception of an actual external stimuli

• Inappropriate affect– Disharmony between the

stimuli and the emotional reaction

• Jamais vu– Feeling of not having

been to a place which one has visited

• Looseness of association– Shifting from one topic

to another in a completely unrelated way

• Neologism– Pathologic coining of

new words with personal meaning

• Tangentiality– Inability on the speaker

to achieve the desired goal of the communicated message

• Perseveration– Persistence of a

response to a previous question

• Verbigeration– Meaningless repetition

of words or phrases

• Word salad– Incoherent mixture of

words and phrases• Waxy flexibility– Ability to assume various

positions without resistance

ASSESSMENT

Sensory Perception

• Illusion• Hallucination– G: gustatory– O: olfactory– V: visual– A: auditory– T: tactile (common in alcohol withdrawal)

Appearance and Motor Behavior

Thought Process• Circumstantial thinking• Flight of ideas• Ideas of reference• Loose association• Tangential thinking• Thought blocking (pt. is

silent; usually seen in schizophrenic patients)

• Thought broadcasting• Thought insertion

• Thought withdrawal (false belief thought has been “taken out” of the patient)

• Word salad• Clang association• Delusion• Neologism

Mood and Affect

• Blunt affect – little or slow to respond• Broad affect – full range; exaggerated affect• Flat affect – poker face; no reaction• Inappropriate affect – incongruent • Labile affect – unpredictable, rapid change of

affect• Restricted affect – one expression

Injury towards self/others

• Suicidal ideation/plan/method/access/time & place

• Time and place: isolated places at early in the morning or during endorsement

Sensorium and intellectual process:Orientation/memory/concentration/

abstract or intellectual function

Judgment (Decision) and Insight (Lesson Learned)

Self-concept

Roles and Relationship

Physiologic, self care, hygiene

THERAPEUTIC RELATIONSHIP

Nurse-Patient Relationship (NPI)

• Involves mutual learning• A corrective emotional experience• Personal attributes (use of self) and clinical

techniques (therap comm) = change of patient’s insight and behavior

• Friendliness• Caring• Interest• Understanding• Congruency• Consistency• Treating the patient as

human being

• Suggesting without telling

• Approachability• Listening• Keeping promises• Providing schedule of

activities• Honesty

1. Trust – is built when the nurse exhibits the following behavior:

2. Genuine Interest3. Empathy – ability of the nurse to perceive the meanings and feelings of the client and to communicate that understanding to them4. Acceptance5. Positive Regards – unconditional and nonjudgmental attitude6. Self-awareness and therapeutic use of self – the nurse must know and understand his or her self

Therapeutic Nurse-Patient Relationship

• By Hildegard Peplau• Phases:

– Pre-orientation: before meeting the client– Orientation: begins when the nurse and client meets and

ends when the client begins to identify his/her problems– Identification: begins when the client works interdependently

with the nurse, expresses feelings and begins to feel stronger– Exploitation: client makes full use of the services offered– Termination/Resolution: client no longer needs professional

services and gives up dependent behavior; end of NPI

THERAPEUTIC COMMUNICATION

• Using Silence• Providing general leads• Using open-ended questions• Using touch• Restating or rephrasing• Seeking clarification (overall meaning of the

entire message)• Clarifying time or sequence

• Offering self• Giving information• Acknowledging• Listening• Presenting reality• Focusing: focus could be an idea or a feeling• Reflecting• Summarizing• Seeking consensual validation (verification of

the meaning of a specific words to patient)

NONTHERAPEUTIC COMMUNICATION

• Stereotyping• Agreeing and disagreeing• Being defensive• Challenging• Probing (ex. Is asking WHY?)• Testing

• Changing topics and subjects• Unwarranted reassurance• Passing judgment• Rejecting• Giving common advice

LEGAL ASPECTS OF PSYCHIATRIC NURSING

Exempting Circumstance

2 Types of Hospitalization

Voluntary Admission

• Client admitted himself to hospital• Discharge: initiated by patient – HAMA/DAMA• Civil rights: retained by patient• Justification: voluntarily sought out help

Involuntary Admission

• Admission: application by others• Discharge: determined by court or hospital• Civil rights: retained none, some or all• Justification: mentally ill and dangerous to

self/others, requires treatment and the patient can’t meet their own needs.

Patient’s Rights

T– Treatment R– Refuse treatmentI – Informed consentP – Privacy & ConfidentialityL – Least restrictionE – Enter contract

C – Communicate H – Habeas corpus (immediately present the body)E – Education K – Keep personal belongings

Tarassoff’s Principle

• Duty to warn a potential victim of a person’s dangerousness

• Ex. If you as a nurse knows that a person is dangerous to others you can apply this principle by telling the authorities of such; or warning a person who can be a victim.

PSYCHOTROPIC DRUGS

Antipsychotic drugs(Neuroleptics)

• For psychosis and hallucinations seen in schizophrenia, schizoaffective disorders and manic phase of bipolar disorder

• Off label uses: for anxiety and insomnia • Mechanism of action– It blocks receptors for dopamine (decrease

dopamine)

Types(Typical & Atypical)

• Typical:– Phenothiazines:

• “azine” (Chlorpromazine – Thorazine; Fluphenazine – Prolixin – given IM)

– Thioxanthene• Thiothixene – Navane

– Butyrophenones• “dol” (Haloperidol (Haldol) & Droperidol (Inapsine))

– Dibanzazepine• Loxapine – Loxitane

– Dihydroindolone• Molindone – Moban

• Atypical– “zapine”/ “apine” & “ridone”– Clozapine (clozaril)– Risperidone (risperdal)– Olanzapine (zyprexa) note: may also be given as a

mood stabilizer– Quetiapine (seroquel)

• New Generation– Aripiprazole: Abilify

Types(Typical & Atypical)

Side effects: EPS

• Acute Dystonia• Akathisia• Bradykinesia• Pseudoparkinsonism

Other side effects

• Neuroleptic Malignant Syndrome• Tardive Dyskinesia• Anticholinergic Side effect

EPS

Acute Dystonia

• Manifestation:• Acute muscular rigidity• Dysphagia: stiff/thick

tongue• Opisthotonus: tightness in

entire body with head & back and arched neck

• Oculogyric crisis: eyes rolled back in a locked position

• Torticolis: twisted head and neck

• Occurrence:• First week of treatment• Younger than 40 years old• Males• Receiving high potency

drugs like haldol and navane

• Management:– Give anticholinergic:

Cogentin (Benztropine) -IM

– Or Benadryl – IM/IV

Akathisia

• Subjective feeling of restlessness

• S & Sx:– Restless legs– Jittery– Anxiousness– Rigid posture or gait– Lack of spontaneous

gestures– Inability to sit still and rest

• Management:– Change medication– Addition of beta-blocker

(Inderal), anticholinergic or benzodiazepene

Bradykinesia

• Slowed movement• S & Sx:– Weakness– Fatigue– Painful muscle– Anergia

• Management:– Give anticholinergic:

Cogentin or Benadryl

Pseudoparkinsonism

• Manifestation– Stooped posture– Mask-like face– Decreased arm swing– Shuffling gait– Drooling– Tremors– Bradycardia– Coarse pill-rolling

movement of thumb and fingers while at rest

• Management:– Change medication – Add oral anticholinergic– Give amantadine

(dopamine agonist)

NMS• Potentially fatal idiosyncratic

reaction to an antipsychotic drug

• Occurrence:– 1st 2 weeks of therapy– After an increase in dosage– Dehydration– Poor nutrition

• S&Sx– N: Nilalagnat– M: muscle cramps– S: sweating

• Management:– Immediately d/c meds– Treat dehydration and

hyperthermia– May change medication– DOC: Dantrium &

Parlodel– Antipsychotics should

not be adminitered at least two weeks after symtom resolution

Tardive Dyskinesia• A syndrome of permanent

involuntary movement that is most commonly caused by long term use of typical antipsychotic

• Irreversible & no tx• S & Sx

– Tongue protrution– Teeth grinding– Lip smacking– Facial twitching– Symptoms stop with sleep

• Management:– No substantial

management available.– Vitamin E helps improve

condition in minority of patients