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 OF A MENTALLY HEALTHY PERSON According to Jahoda, a mentally healthy person possesses the following: 1. Attitude of self acceptance 2. Growth, development and self actualization 3. Integrative capacity 4. Autonomous behaviour 5. Perception of reality 6. Environmental mastery Mental Health - A state of imbalance characterized by disturbance in a persons thoughts, feelings and behaviour. - Poverty and 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 therapeutic 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 a science and an art. MENTAL HYGIENE -is the science that deals with measures to promote mental health, prevent mental illness and suffering and facilitate rehabilitation. CORE CONCEPTS IN THE CARE OF PSYCHOTIC PATIENT Common behavioural signs and symptoms 1. Disturbance in perception: a. Illusion misperception of an actual external stimuli b. Hallucination false sensory perception in the absence of external stimuli 2. Disturbance in thinking a. Neologism pathological coining of new words b. Circumstantiality over inclusion of details c. Word salad incoherent mixture of words and phrases

d. e. f. g.

Verbigeration meaningless repetition 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 from one subject to another in a somewhat related way h. Looseness of association shifting of a topic from one subject to another in a completely unrelated way i. Clang association the sound of the word gives direction to the flow of thought j. Delusion false belief which is inconsistent with ones knowledge and culture. 3. Disturbance of affect a. Inappropriate affect disharmony between the stimuli and the emotional reaction b. Blunted affect severe reduction in emotional reaction c. Flat affect absence or near absence of emotional reaction d. Apathy dulled emotional tone e. Ambivalence presence of two opposing feelings f. Depersonalization feeling of strangeness towards one self g. Derealisation feeling of strangeness towards the environment 4. Disturbance in memory a. Confabulation filling in of memory gaps b. Amnesia inability to recall past events c. Anterograde amnesia loss of memory of the immediate past d. Retrograde amnesia loss of memory of the distant past e. Deja vu feeling of having been to a place which one has not yet visited f. Jamais vu feeling of not having been to a place which one has visited NURSE-PATIENT RELATIONSHIP (NPR) - Series of interaction between the nurse and the patient in which the nurse assists the patient to attain positive behavioural change CHARACTERISTICS OF THE NURSE PATIENT RELATIONSHIP: - It is goal directed, focused on the needs of the patient, planned, time limited and professional. BASIC ELEMENTS OF A THERAPEUTIC NURSE PATIENT RELATIONSHIP: 1. Trust 2. Rapport 3. Unconditional positive regard 4. Setting limits 5. Therapeutic communication

PHASES OF NURSE PATIENT RELATIONSHIP: A. 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: to develop self-awareness. - Data gathering, planning for first interaction B. ORIENTATION PHASE - Begins when the nurse and the patient interacts for the first time - Parameters of the relationship are laid - Nurse begins to know about the patient - Major task of the nurse: to develop a mutually acceptable contract. - Determine why the patient sought help - Establish rapport, develop trust, assessment C. WORKING PHASE - Is highly individualized - More structured than the orientation phase - The longest and most productive phase - Limit setting is employed - Major task: identification and resolution of the patients problems - Planning and implementation D. TERMINATION PHASE - It is a gradual weaning process It is a mutual agreement - It involves feelings of anxiety, fear and loss - 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 - Other task: evaluation WHEN TO TERMINATE THE NPR? 1. When the goal have been accomplished 2. When the patient is emotionally stable 3. When the patient exhibits greater independence 4. When the patient able to cope with anxiety, separation, fear and loss HOW TO TERMINATE: a. Gradually decrease interaction time b. Focus on future oriented topics c. Encourage expression of feelings d. Make the necessary referral

COMMON PROBLEMS AFFECTING NPR 1. Transference the development of an emotional attitude of the patient either positive or negative towards the nurse 2. Resistance development of ambivalent feelings towards self- exploration 3. Counter transference transference as experience by the nurse CHARACTERISTICS OF A PSYCHIATRIC NURSE: A. Empathy the ability to see beyond outward behaviour and sense accurately another persons inner experience B. Genuineness / Congruence ability to use therapeutic tools appropriately C. Unconditional positive regard respect ROLES OF THE NURSE IN PSYCHIATRIC SETTINGS 1. Ward manager creates a therapeutic environment 2. Socializing agent assist the patient to feel comfortable with others 3. Counsellor listens to the patients verbalizations 4. Parent surrogate assists the patient in the performance of activities of daily living 5. Patient advocate enables the patient and his relatives to know their rights and responsibilities 6. Teacher assist the patient to learn more adaptive ways of coping 7. Technician facilitates the performance of nursing procedures 8. Therapist- explores the patients needs, problems and concerns through varied therapeutic means 9. Reality base enables the patient to distinguish objective reality and subjective reality 10.Healthy role model acts as a symbol of health by serving as an example of healthful living

PSYCHOPHARMACOLOGIC AGENTS
A. Major Tranquilizers / Antipsychotics/Neuroleptics: Common Indication: Schizophrenia Examples: Haloperidol (Haldol) Prochlorperazine (Compazine) Fluphenazine (Prolixin) Chlorpromazine (Thorazine) Clozapine (Clozaril) Olanzapine (Zyprexa) a. Antipsychotics b. Decreased delusions, hallucinations, and looseness of association c. Best taken after meals d. Report sore throat and avoid exposure to sunlight

e. Report elevated temperature and muscle rigidity, it indicates Neuroleptic Malignant Syndrome (NMS) f. Check the BP the drug causes hypotension g. Check the CBC, drugs cause leukopenia h. Assess for Extra-Pyramidal Symptoms (EPS) 1. Dystonia 2. Parkinsonism -pill-rolling tremors, flat facial expression, shuffling gait 3. Akathisia- restlessness I feel as if I have ants in my pants. 4. Tardative dyskinesia initially manifested by tongue twitching or lip smacking. i. If with EPS give anti-cholinergics ( Akineton, Artane, Benadryl, Cogentin) B. Anti-Parkinsonian Agents: 2 Types: 1. DOPAMINERGIC DRUGS Examples: Amantadine (Symmetrel) Levodopa Levodopa-Carbidopa (Sinemet) 2. ANTICHOLINERGIC DRUGS Examples: Trihexyphenidyl (Artane) Biperiden Hydrochloride (Akineton) Diphenhydramine Hydrochloride (Benadryl) Benztropine Mesylate (Cogentin)) a. Anti-parkinsonian agents b. Muscles become less stiff c. Decreased pill rolling tremors d. Best taken after meals e. Avoid driving, the drug causes blurred vision f. Check the BP, the drug may cause hypotension C. Minor Tranquilizers / Anxiolytics/Anti-Anxiety Common Indication: Anxiety disorders Examples: Benzodiazepines Non-Benzodiazepines * Diazepam (Valium) (Buspar) *Chlorazepate(Tranxene) (Miltown) * Alprazolam (Xanax) * Clonazepam ( Klonopin) *Chlordiazepoxide (Librium) * Oxazepam (Serax) *Lorazepam (Ativan) *Buspirone *Meprobamate

a. b. c. d. e.

Anti-anxiety, given as a muscle relaxant to patients in traction Decreased anxiety, adequate sleep Best taken before meals, food in the stomach delays absorption Avoid driving, intake of alcohol and caffeine, antihistamines Administer it separately, it is incompatible with any drug. Do not stop the drug abruptly. f. Rise slowly from lying or sitting position. g. Use sugar-free beverages and hard candy ( causes dry throat and mouth) h. Adequate fluids ( causes constipation). i. Report persistent restlessness, agitation and euphoria to the physician. D. Tricyclic Antidepressants (TCA) Examples: Amitriptyline (Elavil) Nortrityline (Pamelor) Desipramine (Norpramine) Anafranil Imipramine (Tofranil) Doxepin (Sinequan) a. Tricyclic anti-depressant, prevents the re-uptake of norepinephrine b. Increased appetite, adequate sleep c. Best given after meals, with adequate fluids d. Therapeutic effects may become evident only after 2 3 weeks of intake e. Check the BP, it causes orthostatic hypotension (rise slowly from sitting/lying position) f. Check the heart rate, it causes cardiac arrhythmias g. Use sugar- free beverages and hard candy ( dry mouth) h. Other s/e: dizziness, sedation, insomnia, constipation, confusion, tremors E. Anti-depressants: Selective Serotonin Re-uptake Inhibitors (SSRI) Examples: Fluoxetine ( Prozac) Citalopram(Celexa) Sertraline ( Zoloft) Escitalopram (Lexapro) Paroxetine(Paxil) a. anti-depressants, prevents re-uptake of serotonin b. administer with food, adequate fluids, in AM (if nervous) and PM ( if drowsy) c. check BP, slowly rise from sitting/lying position ( causes orthostatic hypotension) d. give sugar-free beverages and hard candy. e. side-effects: Sedation, dizziness, drowsiness, dry mouth, diarrhea, sexual dysfunction F. Anti-depressants: MAO Inhibitors (MAOI) Examples: Tranylcypromine (Parnate)

Isocarboxazid (Marplan) Phenelzine (Nardil) a. b. c. d. e. Anti-depressants (MAO inhibitors) Increased appetite, adequate sleep Best taken after meals (morning), adequate fluids Report headache, it indicates HYPERTENSIVE CRISIS Avoid TYRAMINE containing foods like: Avocado Banana Cheddar and aged cheese Soy sauce and preserved foods f. It takes 2 to 3 weeks before initial therapeutic effects become noticeable g. Monitor the BP, rise slowly from sitting/lying position (orthostatic hypotension) h. Two weeks interval when shifting from one anti-depressant to another.

G. Antidepressants: ATYPICAL Examples: Bupropion (Wellbutrin) Venlafaxine( Effexor) Mirtazapine ( Remeron) Duloxetine (Cymbalta) Nefazodone( Serzone) a. anti-depressant inhibits re-uptake of dopamine, serotonin, norepinephrine b. administer with food (except Serzone), adequate fluids c. use sugar-free beverages and hard candy d. monitor liver and kidney function e. s/e: hypertension, tachycardia, headache, drowsiness, dry mouth, weight gain f. Serzone alters AST, ALT, Cholesterol, Glucose and hematocrit

H. Anti-Manic Agent given for MANIA Example: Lithium Carbonate a. Anti-manic : if with reaction, use Carbamazepine b. Decreased hyperactivity c. Best taken after meals d. Increase fluid intake (3L / day) and sodium intake (3 gm/day)

e. Avoid activities that increase perspiration f. It takes 10 to 14 days before therapeutic effect becomes evident. g. Anti-psychotic is administered during the first two weeks to manage the acute symptoms of mania until lithium takes effect h. Monitor lithium serum level: normal is 0.5 to 1.5 meq/L i. Mild toxicity (1.5-2.0 mEq/L) - Nausea, vomiting, diarrhea, weakness j. Moderate toxicity ( 2-3 mEq/L) ataxia, tinnitus, confusion,slurred speech, vertigo k. Severe toxicity ( 3 mEq/L above) arrhythmia,seizures, hypotension,stupor to coma l. Mannitol is administered if toxicity occurs ELECTRO-CONVULSIVE THERAPY (ECT) a. Mechanism of action of ECT: Unclear at present b. Voltage of electrical current that is administered to the patient: 70 to 150 volts c. How long is the electrical shock applied to the patient? 0.5 to 2 seconds d. Usual number of treatment needed to produce a therapeutic effect: 6 to 12 treatments e. How frequent should the treatment be made? There should be an interval of 48 hours for each treatment f. Indicators of effectiveness of ECT: The occurrence of generalized tonic-clonic seizure g. Indications for ECT: Severe Depression, Mania, Catatonic Schizophrenia h. Contraindications to ECT: fever, Increased intracranial tumor, cardiac disease, TB with history of hemorrhage, recent fracture, retinal detachment, pregnancy i. Is consent needed prior to ECT? Yes j. Medications given to the patient prior to ECT: 1. Atropine Sulfate to decrease secretions 2. Anectine (Succinylcholine) to promote muscle relaxation 3. Methohexital Sodium (Brevital) serves as an anesthetic agent k. Common complications of ECT: 1. Loss of memory 2. Headache 3. Apnea 4. Fracture 5. Respiratory depression COMMON PSYCHOTHERAPEUTIC INTERVENTIONS A. Remotivation therapy treatment modality that promotes expression of feeling through interaction facilitated by discussion of neutral topics 5 Steps 1. Climate of acceptance

2. Creating of bridge to reality 3. Sharing the world we live in 4. Appreciation of the works of the world 5. Climate of appreciation B. Music therapy/Art therapy (Music and Art) use of music or art or both to facilitate relaxation, expression of feelings/ outlet of tension C. Play therapy safe environment with the use of play D. 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 behaviour in relation with others. The minimum number of members in a group therapy is 3, while the ideal is 8 to 10. E. Milieu therapy consist of treatment by means of controlled modification of the patients environment to facilitate positive behavioural change. F. Family therapy a method of psychotherapy which focuses on the total family as an interactional system. G. Psychoanalysis a method of psychotherapy which focuses on the exploration of the unconscious, to facilitate identification of the patients defenses H. Hypnotherapy a therapeutic modality which involves various methods and techniques to induce a trance state where the patient becomes submissive to instructions I. Humor therapy involves the use of humor to facilitate expression of feelings and to enhance interaction J. Behavior modification a therapeutic intervention involving the application of learning principles in order to change maladaptive behaviour K. Aversion therapy an example of behaviour modification in which a painful stimulus is introduced to bring about an avoidance of another stimulus with the end view of facilitating behavioural change L. Token economy an example of behaviour modification technique which utilizes the principle of rewarding desired behaviour to facilitate change M. Desensitization periodic exposure of the individual to a feared object, until the undesirable behaviour disappears or is lessened. N. 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. O. Gestalt therapy Encourage individuals to develop a sense of awareness of feelings and behavior and its effect on environment in the present time P. Recreational therapy involves recreation to improve quality of life Q. Reminiscence therapy reviewing the events of ones life/sharing the memories of ones life R. Reality therapy problem solving method that focuses on the hereand-now to enable them

to focus on their behaviour S. Occupational therapy - uses meaningful and purposeful occupation to enable people with Impairment to participate in the activities of daily life T. Crisis Intervention problem-solving method to assist client to develop new coping skills U. Pychodrama - use of role training, actions, group dynamics to facilitate constructive changes V. Vocational training use of skills and vocational training to enable a client to have a job W. Logo therapy meaning-oriented therapy that enables a client to develop a meaningful life ANOREXIA NERVOSA Fear of gaining weight s/s amenorrhea Obviously thin but feels fat Hiding foods/collecting recipes Dx: Body image disturbance Int: monitor weight Family therapy (parents rigid/perfectionist) BULIMIA NERVOSA Binge-eating and purging Minimum of 2 binge-eating per week for 3 months Induced vomiting Abuse laxatives or diuretics Body image disturbance Monitor weight Stay with client 30mins to 1 hour after meals

SUBSTANCE ABUSE - use of substances other than legitimate purpose Substance dependence Physiological or psychological dependence with tolerance and withdrawal Tolerance declining effect of drug, there is a need to increase the amount to produce desired effect Withdrawal symptoms experienced by client when substance is reduced or stopped SUBSTANCE PHYSICAL SIGNS WITHDRAWAL STIMULANTS Amphetamine Hyperactivity, dilated Depression, irritability, (Shabu) pupils psychosis Increased VS, anorexia, euphoria Arryhtmia, repetitive behavior Cocaine Same as shabu Fatigue, hypersomnia, agitation Perforated nasal septum Depression, suicide HALLUCINOGENS

Ecstacy, LSD, PCP MARIJUANA (Cannabis)

NARCOTICS (Opioids) Morphine Meperidine (Demerol) Heroin Codein

Tachycardia, HPN, seizure, Hallucination, pyschosis Blood-shot eyes, tachycardia Dry mouth, distorted perception delirium Constricted pupils, Respiratory depression Lethargy, drowsiness, coma Impaired attention/memory Incoordination Loss of inhibitions Slurred speech, unsteady gait Impaired memory, attention Respiratory depression, Blackout (intoxication)

Cravings, flashbacks Tremors, enxiety, sweating

Lacrimation, sweating, yawning Runny nose (rhinorrhea) Restlessness, anxiety Insomnia, cravings

ALCOHOL (depressant)

(4-12 hrs) tremors, sweating, Tachycardia, HPN,insomnia DELIRIUM Tremensseizures Hallucinations KORSAKOFF PSYCHOSIS thiamine/niacin deficiency amnesia , confabulation