BASIC CONCEPTS IN PSYCHIATRIC NURSING

MENTAL HEALTH

• Balance in a persons’ internal life and adaptation to reality.• A state of well being in which a person is able to realize his potentials.

Characteristics :• attitude of self-acceptance• growth, development and self-actualization• integrative capacity• autonomous behavior• perception of reality• environmental mastery

MENTAL ILLNESS • A state of imbalance characterized by a disturbance in a persons’ thoughts, feelings and behavior.• Poverty abd abuses are major factors which increases the risk of mental illness in the home.PSYCHIATRIC NURSING• Interpersonal process whereby the professional nurse practitioner through the use of self, assist an individual family, group or community to promote mental health, to prevent mental illness and suffering, to participate in the treatment and rehabilitation of the mentally ill and if necessary to find meaning in these experiences.• It is both Science and an Art.Science in Psychiatric Nursing.• the use of different theories in the practice of nursing, serves as the science of psychiatric nursing.

Art in Psychiatric Nursing.• The therapeutic use of self is considered as the art of psychiatric nursing.Core of Psychiatric Nursing.• The interpersonal process, that is, the human to human relationship, is the core of psychiatric nursing. Clientele in Psychiatric Nursing.• The individual, family, and the community, both mentally healthy and mentally ill.Mental Hygiene.• It is the science that deals with measures to promote mental health, prevent mental illness and suffering and facilitate rehabilitation.

THERAPEUTIC USE OF SELF - THERAPEUTIC USE OF SELF SERVES AS THE NURSES’ MAIN TOOL.

CORE CONCEPT - It is the positive use of one’s self in the process of therapy. - It requires self-awareness.

BASIS OF THERAPEUTIC USE OF SELFJOHARIS WINDOW

Known to self Not known to self

Known to others Public self

I

Semi-public self

II

Not known to others

Private self

III

Area of the unknown

IV

METHODS USE TO INCREASE SELF AWARENESS• INTROSPECTION• DISCUSSION• ENLARGING ONE’S EXPERIENCE• ROLE PLAY

CORE CONCEPTS ON THE CARE OF PSYCHOTIC PATIENT.

COMMON BEHAVIORAL SIGNS AND SYMPTOMS1. Disturbances in perception: Illusion – misperception of an actual external stimuli. Hallucination – false sensory perception in the absence of external

stimuli.2. Disturbances in thinking: Neologism – pathological coining of new words. Circumstantiality – over inclusion of details. Word salad – incoherent mixture of words and phrases. Verbigeration – meaningless reception of words or phrases. Perseveration – persistence of a response to a previous question.

Echolalia – pathological repetition of words of others.Flight of ideas – shifting of one topic form one subject to another in a somewhat related way.Looseness of association – shifting of a topic from one subject to another in a completely unrelated way.Clang association – the sound of the words gives direction to the flow of thought.Delusion –false belief which is inconsistent with one’s knowledge and culture and cannot be corrected by reasons.

3. Disturbances of affect. Inappropriate affect – disharmony between the stimuli and the emotional reaction. Flat affect – absence or near absence of emotional reaction. Apathy – dulled emotional tone. Blunted affect – severe reduction in emotional reaction. Ambivalence – presence of two opposing feelings. Depersonalization – feeling of strangeness towards one’s self Derealization – feeling of strangeness towards the environment

4. Disturbances in motor activity Echopraxia – the pathological imitation of posture/action of others. Waxy flexibility – maintaining the desired position for long periods of time without discomfort.5. Disturbances in memory. Confabulation – filling in memory gap. Amnesia – inability to recall past events. Anterograde amnesia – loss memory of the immediate past. Retrograde amnesia – loss of memory of the distant past. Déjà vu – feeling of having been to place which one has not yet visited. Jamais vu – feeling of not having been to a place which one has visited.

CORE CONCEPTS ON THERAPEUTIC COMMUNICATION. Communication – refers to the reciprocal exchange of ideas between or among persons.Elements of Communication:• Sender – originator of information.• Message – information being transmitted.• Receiver – recipient of information.• Channel – mode of communication.• Feedback – return response.• Context – the setting of communication.

Criteria of successful communication:• Feedback• Appropriateness• Flexibility• Efficiency

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

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

To establish rapport and build trust - Giving information: responding with the needed facts. - Use of silence: refraining from sppech to give the patient a time to sort out thoughts and feelings.

To gather information - Focusing: assisting a patient to explore a specific topic.Example: Patient: “I can’t decide about…” Nurse: “Let’s talk about that. Perhaps if we talk about it, it will help you to decide.” - Validating: confirming one’s observation.Example: “Are you saying that…” - Relflecting: directing back ideas, feelings and content.Example: “You feel tense when you fight.” - Restating: repeating what the patient had said. - Summarizing: developing a concise resume of what has transpired

NURSE PATIENT RELATIONSHIP - Series of interaction between the nurse and patient in which the

nurse assist the patient to attain positive behavioral change.

CHARACTERISTICS• It is goal directed, focused on the needs of the patient, planned,

time limited and professional.

BASIC ELEMENTSTrustRapportUnconditional positive regardSetting limitsTherapeutic communication

PHASESA. PRE-INTERACTION PHASE• Begins when the nurse is assigned to a patient.

• Phase of NPR in which the patient is excluded as an active participant• Nurse feels certain degree of anxiety• Includes all of what the nurse thinks and does before interacting with the patient• Major task of the nurse: develop self awareness• Data gathering, planning for first interaction

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

C. WORKING PHASE• It is highly individualized• More structured than the orientation phase• The longest and most productive phase of the NPR

• Limit setting is employed• Major task: Identification and resolution of the patient’s problems• Planning and implementation

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

When to Terminate?• When goals have been accomplished• When the patient is emotionally stable• When the patient exhibits greater independence• When the patient able to cope with anxiety separation, fear and loss

How to Terminate? • Gradually decreased interaction time• Focus on future oriented topics• Encourage expression of feelings• Make the necessary referral

COMMON PROBLEMS AFFECTING COMMUNICATION• Transference – the development of an emotional attitude of the patient either positive or negative towards the nurse• Resistance – development of ambivalent feeling towards self- exploration• Counter transference – transference as experienced by the nurse

PRINCIPLES OF CARE IN PSYCHIATRIC SETTINGS• The nurse views the patient as a Holistic human being with interdependent and interrelated needs• The nurse accepts the patient as a unique human being with inherent value and worth exactly as he is.• The nurse should focus on the patient’s behavior non-judgmentally, while assisting the patient to learn more adaptive ways of coping

• The nurse should explore the patient’s behavior for the need it is designed to meet and the message it is communicating• The nurse has the potential for establishing a nurse-patient relationship with most if not all patients

• The quality of the nurse-patient relationship determines the degree of change that can occur in the patient’s behavior.

LEVELS OF INTERVENTIONS IN PSYCHIATRIC NURSING• Primary – interventions aimed at the promotion of mental health and lowering the rate of cases by altering the stressors Examples: Health education Information dissemination Counseling• Secondary – Intervention that limit the severity of a disorder Two components 1. Case finding 2. Prompt treatment Examples: Crisis intervention Administration of medications

Tertiary – interventions aimed at reducing the disability after a disorder Two components 1. Prevention of complication 2. Active program of rehabilitation

Examples: Alcoholic anonymous Occupational therapy

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

ROLES OF THE NURSE IN PSYCHIATRIC SETTINGS• Ward manager – creates a therapeutic environment• Socializing agent – assists the patient to feel comfortable with others• Counselor – listens to the patient’s verbalizations• Parent surrogate – assists the patient in the performance of activities of daily lining

• Patient advocate – enables the patient and his relatives to know their rights and responsibilities• Teacher – assists the patient to learn more adaptive ways of coping

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

BASIC CONCEPTS ON PSYCHOPHARMACOLOGY

C – heck why the medication is given and know the classification of the drug. In other words you should know the purpose why the medication is given.H – ow will you know if the medicaiton is effective. What is your assessment parameters in monitoring the effects of the drug.

E – xactly what tome should the medication be given. Some drugs are best taken with meals, some after meals, and some on an empty stomach. Other drugs may also be taken without regard to meals. You should know all of these.

C – lient teaching tips. What would you tell your patient to expect. You should be able to give instructions related to the therapeutic and side effects of the drug.

K – eys to giving it safely. You should be able to identify interventions to counteract the adverse/side effects of the drug.

Psychopharmacolgic agents

A. Major tranquilizers/antipsychotic/neuroleptics Common indication : Schizophrenia Examples: Haloperidol (Haldol) Prochlorperazine (Compazine) Fluphenazine (Prolixin) Chlorpromazine (Thorazine) Clozapine (Clozaril) Olanzapine (Zyprexa)

C – AntipsychoticH – Decreased delusions, hallucinations, and looseness of associationE – Best taken after mealsC – Report sorethroat and avoid exposure to sunlight. Report elevated temp. and muscle rigidity, it indicate Neurologic Malignant Syndrome.K – check the BP, the drug causes hypotension. Observe for EPS, check the CBC, drygs cause leukopenia

B. Anti-parkinsonian drugs Indication: EPS (Extrapyramidal Syndrome) Two Types: 1. DOPAMINERGIC DRUGS Examples: Amantadine (Symmetrel) Levodopa Levodopa-Carbidopa (Sinemet) 2. ANTICHOLINERGIC DRUGS Examples: Trihexylphenidyl (Artane) Biperiden Hydrochloride (Akineton) Benztropine Mesylate (Cogentin) Diphenhydramine Hydrochloride (Benadryl)

C – Antiparkinsonian drugH – Muscles become less stiff; decreased pill-rolling tremorsE – Best taken after mealsC – Avoid driving, the drug causes blurred visionK – Check the BP, the drug may cause hypotension

C. Minor Tranquilizers/Anxiolytics Common indication: Anxiety disorders Examples: Diazepam (Valium) Oxazepam (Serax) Chlodiazepoxide (Librium) Chlorazepate Dipotassium (Tranxene) Alprazolam (Xanax)C – Antianxiety; given as muscle relaxant to patient’s in tractionH – Decreased anxiety, adequate sleepE – Best taken before meals, food in the stomach delays absorptionC – Avoid driving, intake of alcohol and caffeine containing foods, since it alters the effect of drugK – Administer it separately, it is incompatible with any drug

D. Tricyclic Antidepressants Examples: Imipramine Hydrochloride (Tofranil) Amitriptyline (Elavil)

C – Tricyclic anti-depressant; prevents the reuptake of norepinephrine H – Increased appetite; adequate sleepE – Best given after mealsC – Therapeutic effects may become evident only after 2 – 3 weeks of intakeK – Check BP, it causes hypotension, Check the heart rate, it causes cardiac arrythmias

E. Antidepressant MAO inhibitors Examples: Tranylcypromine (Parnate) Phenelzine (Nadril) Isocarboxazid (Marplan)

C – Antidepressant MAO inhibitorsH – Increased appetite; adequate sleepE – Best taken after meals

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

F. Anti – Manic agent Lithium CarbonateC – Anti- ManicH – Decreased hyperactivityE – Best taken after mealsC – Increase fluid intake (3L / day) and sodium intake (3 gm / day) Avoid activities that increase perspirationK – It takes 10 – 14 days before therapeutic effect becomes evident Antipsychotic is administered during the first two weeks to manage the acute symptoms of mania until lithium takes effect.

Monitor serum level, normal is 0.5 – 1.5 meq/L, NAUSEA, ANOREXIAVOMITING, DIARRHEA, AND ABDOMINAL CRAMPS indicatesLithium Toxicity, Mannitol is administered if toxicity occurs.

ELECTRO-CONVULSIVE THERAPYMechanism of action: Unclear at present.Voltage applied to the patient: 70 – 150 voltsDuration of application: 0.5 – 2 secondsUsual number of treatments to produce therapeutic effect: 6 – 12 treatmentsFrequency of treatments: An interval of 48 hours for each treatment.Indications of effectiveness: Generalized tonic-clonic seizureIndication for ECT: Depression, Mania, Catatonic SchizophreniaContraindication to ECT: Fever, Increased ICP, Cardiac problems,TB with history of hemorrhage, Recent fracture, Retinal detachment, Pregnancy.Consent needed prior to ECT: YES

Medication prior to ECT• Atropine Sulfate – to decrease secretions• Anectine (Succinylcholine) – to promote muscle relaxation• Methohexital Sodium (Brevital) – serve as an anesthetic agent

COMMON COMPLICATION: Loss of memory, Headache, Apnea, Fracture, Respiratory depression.

COMMON PSYCHOTHERAPEUTIC INTERVENTIONS• REMOTIVATION THERAPY – treatment modalitythat promotes expression of feeling through interaction facilitated by discussion of neutral topics. 5 Different Steps 1. Climate of acceptance 2. Creating of bridge of reality 3. Sharing the world we live in 4. Appreciation of the works of the world 5. Climate of appreciation• MUSIC THERAPY – involves the use of music to facilitate relaxation, expression of feelings and outlet of tension.

• PLAY THERAPY – treatment modality which enables the patient to experience intense emotion in a safe environment with the use of play.• GROUP THERAPY – treatment modality involving therapeutic interactions of three or more patients with a therapist to relieve emotional difficulties, increase self-esteem, develop insight and improve behavior in relation with others. The minimum number of members in a group therapy is 3, while the ideal number is 8 – 10.• MILIEU THERAPY – consists of treatment by means of controlled modification of the patients environment to facilitate positive behavioral change.• FAMILY THERAPY – a method of psychotherapy which focuses on the total family as an interactional system.• PSYCHOANALYSIS – a method of psychotherapy which focuses on the exploration of the unconscious, to facilitate identification of the patient’s defenses.• HYPNOTHERAPY – a therapeutic modality which involves various methods and techniques to includes a trance state where the patient becomes submissive to instructions.• HUMOR THERAPY – involves the use of humor to facilitate expression of feelings and to enhance interaction.

• BEHAVIOR MODIFICATION – a therapeutic intervention involving the application of learning principles in order to change maladaptive behavior.• AVERSION THERAPY – an example of behavior modification in which a painful stimulus is introduced to bring about an avoidance of another stimulus with the end view of facilitating change in behavior.• TOKEN-ECONOMY – an example of behavior modification technique which utilizes the principle of rewarding desired behavior to facilitate change.• DESENSITIZATION – periodic exposure of the individual to a feared object, until the undesirable behavior disappears or is lessened.• COGNITIVE THERAPY – short term structured therapy between the patient and the therapist oriented towards present problems and solutions. The main focus of cognitive therapy is depressive disorders

BATTERED WIFE SYNDROME (BWS)• Cycle of domestic violence characterized by wife beating by the husband, humiliation and other forms of aggression.• The most common trait of abusive men is low self-esteem.

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

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

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

PRIORITY CARE OF THE BATTERED WIFE• Provision of shelter

CHILD ABUSE• Abuse – is what happens when an older adult takes advantage of his authority over a younger child.

VIOLENCE• Refers to the use of force.NEGLECT• Lack of provision of those things which are necessary for the child’s growth and development 2 COMPONENTS 1. Child abandonment 2. Child neglectPHYSICAL ABUSE• Abuse in the form of inflicting painEMOTIONAL ABUSE• Abuse in the form of insults and undermining one’s confidence.SEXUAL ABUSE• Abuse in the form of unwanted sexual contact

CHARACTERISTICS OF ABUSIVE PARENTS• They come from violent family• They were also abused by their parents• They have inadequate parenting skills• They are socially isolated because they don’t trust anyone.• They are emotionally immature• They have negative attitude towards the management of the abused

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

PRIORITY IN CHILD ABUSE• R.A. 7610, the anti child abuse law requires reporting of suspected cases to authorities.• Report cases to the barangay officers, DSWD personnel, police within 48 hours.

ANXIETY• Vague sense of impending doom• subjective emotional response to stress.

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

DELIRIUM AND DEMENTIA

DELIRIUM DEMENTIA• Disorientation Loss/impiarment of memory • Acute Chronic•Involves young and old Exclusive in the elderly• Clouded sensorium Clear sensorium• Reversible Irreversible• Good prognosis Poor prognosis

Alzheimer’s Disease• a type of dementia that frequently affects the elderly.

Main Pathology• presence of senile plaques that destroys neurons leading to decreased acetylcholine.

Common signs and sypmtomsAphasia – inability to talkAgnosia – inability to recognize objectsApraxia – inability to perform ADLAmnesia / Memory loss / Mnemonic disturbance

3 PhasesForgetfulness phase – difficulty of remembering appoinmentsAdvance phase – difficulty of remembering past events but not recent eventsTerminal phase – death occurs in 1 year.

Priority Nursing Diagnosis Altered thought processes

Primary need of the patient Reorientation

ALCOHOLISM• WHO defines alcoholism as a chronic disease or a disorder characterized by excessive intake and interference in the individuals health, interpersonal relationship and economic functioning.• Considered to be present when there is .1% or 10 ml for every 1000 ml of blood.

What happens at level?• .1 – .2% (low coordination)• .2 -. 3% (presence of ataxia, tremors, irritability, stupor• .3 and above (unconsciousness)

Etiological theoriesPsychoanalytic theory - due to fixation in the oral stageLearning theory - due to a learned behaviorBiological theory - due to inherited traitsSocio-cultural theory - due to effects of mass media.

Phases of progression of alcoholismPre-alcoholic phase – starts with social drinking Prodromal phase – alcohol becomes a need; blackout’s occur; denial begins to developCrucial phase – Cardinal symptoms of alcoholism develops (loss of control over drinking)Chronic phase – the person becomes intoxicated all day.

Outcomes of alcoholism• Brain damage• Alcoholic hallucinosis• Death Common behavioral problems• Denial• Dependency• Demanding• Destructive• Domineering

Withdrawl signs and symptoms• Halucinations, visual and tactile• Increased vital signs• Tremors• Sweating and Seizure

Common defense mechanism• Denial• Rationalization• Isolation• Projection