PSYCHIATRIC NURSING

Types of Communication Communication is the process of conveying information verbally, through the use of words,and non-verbally, through gestures and behaviors that accompany words. Verbal Communication a individual uses verbal communication to convey contents such as ideas, thoughts or concepts to one or more listeners. FIVE LEVELS OF COMMUNICATION Level 5 (Clich Conversations) No sharing of oneself occurs during this interaction. No personal growth can occur at this level. Level 4 (Reporting of facts) - Communicating at this level reveals very little about oneself and minimal or no interaction is expected from others. No personal interaction occurs at this level. Level 3 (Revelation of Ideas and Judgments) Such communication occurs under strict censorship by the speaker, who is watching the listeners response for an indication of acceptance or approval. If the speaker is unable to read the reactions of the listeners, the speaker may revert to safer topics rather than face disapproval or rejection. Level 2 (Spontaneous here-and-now emotions) Revealing ones feelings or emotions takes courage because one faces the possibility of rejection by the listener. Level 1 ( Open, honest communication) When this type of communication occurs, two people share emotions. Open communication may not occur until people relate to each other over a period of time, getting to know and trust each other Nonverbal Communication Noneverbal communication is said to reflect a more accurate

description of ones true feelings because people have less control over nonverbal reactions. VOCAL CUES Pausing or hesitating while conversing, talking in a tense or flat tone and speaking tremulously are vocal cues that can agree or contradict a clients verbal message. PHYSICAL APPEARANCE People who are depressed may pay little attention to their appearance. They may appear unkempt and unconsciously don dark-colored clothing, reflecting their depressed feelings. GESTURES Pointing, finger-tapping, winking, handclapping, eyebrow-raising, palm rubbing, hand wringing and beard stroking a re all examples of non-verbal gestures that communicate various thoughts and feelings. DISTANCE OR SPATIAL TERRITORY Intimate zone body contact such as touching, hugging and wrestling Personal zone 1 to 4 feet; arms length; some body contact such as holding hands; therapeutic communication/touch occurs at this zone. Social zone 1 to 12 feet; formal businesses; social discourse. Public zone 12 to 25 feet; no physical contact; minimal eye contact; people remain strangers. POSITION OR POSTURE The position one assumes can designate authority, cowardice, boredom, or indifference. TOUCH Reactions to touch depend on age, sex, cultural background, interpretation of the gesture and appropriateness of the touch. FACIAL EXPRESSION

A blank stare, a startled expression, sneer, grimace, and a broad smile are examples of facial expressions denoting ones innermost feelings. Ineffective Therapeutic Communication Failure to listen Conflicting verbal and nonverbal messages A judgmental attitude Misunderstanding because of multiple meanings Giving of advice Therapeutic Communication Using Silence Giving Recognition or Acknowledging Offering Self Giving broad openings or asking open-ended questions Offering general leads or door-openers Placing the event in time or in sequence Encouraging description of perceptions Encouraging comparison Restating Reflecting Exploring Seeking clarification Presenting reality Voicing doubt Summarizing Asking direct questions Transference During the therapeutic communication, clients may distort their perceptions of others. They may relate to the nurse not on the basis of the nurses realistic attributes, but wholly or chiefly on the basis of interpersonal relationships with important figures in the clients life. Counter-Transference When the nurse responds unrealistically, to the clients behavior or interaction. Phases of a Therapeutic Relationship INITIATING OR ORIENTING PHASE

The first step of the therapeutic relationship; during this phase, the nurse sets the stage for a one-on-one relationship with the client. Building trust and rapport by demonstrating acceptance Establishing a therapeutic environment Establishing a mode of communication acceptable to both client and nurse Initiating a therapeutic contract by establishing time, place and duration for each meeting; as well as the length of time the relationship will be in effect. Assessing the clients strengths and weaknesses.

WORKING PHASE The client begins to relax, trusts the nurse, and is able to discuss mutually agreed-on goals with the nurse as the assessment process continues and a plan of care develops. Exploring the clients perception of reality Helping the client develop positive coping behaviors Identifying available support systems Promoting a positive self-concept Encourage verbalization of feelings Developing a plan of action with realistic goals Implementing the plan of action Evaluating the results of the plan of action Promoting client independence

TERMINATING PHASE The nurse terminates the relationship when the mutually agreed-on goals are reached, the client is transferred or discharged, or the nurse has finished the clinical rotation. Mutually agreed-on goals resulting in the termination of a therapeutic relationship include the clients ability to: Provide self-care or maintain his or her own environment Demonstrate independence and work interdependently with others Recognize sign of increased stress or anxiety

Cope positively when expressing feelings of anxiety, anger or hostility. Demonstrate emotional stability

Mutism refers to the refusal to speak even though the person may give indications of being aware of the environment. Variations in Content of Thought Delusions delusions are fixed false beliefs not true to fact and not ordinarily accepted by bother members of the persons culture. They cannot be corrected by an appeal to the reason of the person experiencing them. AUDITORY HALLUCINATION VISUAL HALLUCINATION GUSTATORY HALLUCINATION TACTILE HALLUCINATION Hallucinations are sensory perceptions that occur in the absence of an actual external stimulus. Illusions are misinterpretations of stimuli in which sensory stimuli is translated into other things Severity of Mental Retardation Mild IQ level of 50 to70; Can achieve social and vocational skills for minimum self-support. Educable. Can acquire academic skills up to approximately the sixth-grade level. Moderate IQ level of 35 to 55; May profit from vocational training. Can function in sheltered workshops as skilled or unskilled persons. Can acquire skills up to 2nd grade level. Trainable Severe IQ level of 25 to 35; May learn to perform simple work tasks. Can acquire skill at the preschool level. Moron Profound IQ level of below 25. Require total nursing care and highly structured environment with supervision due to self-care deficit. May learn some productive skills. Imbecile Ego Defense Mechanisms Compensation use of a specific behavior to make up for a real or imagined inability or deficiency, thus maintaining self-respect or self esteem

Types of affective responses Blunted Affect Severe reduction or limitation in the intensity of ones affective responses to a situation Flat Affect Absence or near absence of any signs of an affective response, such as an immobile face and monotonous tone of voice when conversing with others. Inappropriate affect Discordance or lack of harmony between ones voice and movements with ones speech or verbalized thoughts. Labile Affect Abnormal fluctuation or variability of ones expressions, such as repeated, rapid or abrupt shifts. Impaired Communication During assessment, clients may demonstrate impaired communication Blocking refers to a sudden stoppage in the spontaneous flow or stream of thinking or speaking for no apparent external or environmental reason. Circumstantiality with circumstantiality, the person gives much unnecessary detail that delays meeting a goal or stating a point. Perseveration the person emits the same verbal response to various questions. Perseveration is also defined as repetitive motor response to various stimuli. Verbigeration - describes the meaningless repetition of specific words or phrases. Neologism describes the use of a new word or combination of several words coined or selfinvented by a person and not readily understood by others.

Conversion Unconscious expression of a mental conflict as a physical symptom to relieve tension or anxiety Denial unconscious refusal to face thoughts, feelings, wishes, needs or reality factors that are intolerable. Displacement unconscious shifting of feelings such as Hostility or anxiety from one idea, person or object to another. Identification unconscious attempt to identify with personality traits or actions of another to preserve ones self esteem or to reach a specific goal. Introjection application of the philosophy, ideas, customs and attitudes of another person to oneself Projection unconscious assignment of unacceptable thoughts or characteristics of self to others. Rationalization justification of ones ideas, actions or feelings to maintain self-respect, prevent guilt or obtain social approval. Reaction formation demonstration of the opposite behavior, attitude or feelings of what one would normally show in a given situation. Regression retreat to the past developmental stages to meet basic needs. Sublimation rechanneling of intolerable or socially unacceptable impulses or behaviors into activities that are personally or socially acceptable. Suppression Voluntary rejection of unacceptable thoughts or feelings from conscious awareness. Undoing negation of a previous consciously intolerable action or experience. PSYCHIATRIC DISEASES AND DISORDERS Schizophrenia

is considered the most common and most disabling of the psychotic disorders. The onset of schizophrenia may occur late in adolescence or early in adulthood, usually before the age of 30. Numerous theories about the cause of schizophrenia have been developed. Some of the more common theories are described here:

GENETIC PREDISPOSITION THEORY The genetic predisposition theory suggests that the risk of inheriting Schizophrenia is 10% in those who have one immediate family member with the disease, and approximately 40% if the disease affects either parents or an identical twin. About 60% of people with schizophrenia have no close relatives with the illness. BIOCHEMICAL AND NEUROSTRUCTUAL THEORY An excessive amount of the neurotransmitter dopamine allows nerve impulses to bombard the part of the bran normally involved with arousal and motivation. Normal cell communication is disrupted, resulting in the development of hallucinations and delusions. ORGANIC OR PSYCHOPHYSIOLOGIC THEORY Schizophrenia is a functional deficit occurring in the brain caused by stressors such as viral, infection, toxins, trauma or abnormal substances. Symptoms of Schizophrenia may appear suddenly or develop gradually over time. Eugene Bleuler introduced the term Schizophrenia and cited symptoms referred to as Bleulers 4 As: Affective Disturbance, Autistic Thinking, Ambivalence, and Associative Looseness. Positive Symptoms Excess or distortion of normal functions Delusions Conceptual disorganization Hallucinations Excitement or agitation Hostility or aggressive behavior Suspiciousness, ideas of reference

Pressurized speech Bizarre dress or behavior Possible suicidal tendencies

UNDIFFERENTIATED Meets diagnostic characteristics but not the criteria for Paranoid, Disorganized or Catatonic Subtypes. RESIDUAL Absence of prominent delusions, hallucinations, disorganized speech and grossly disorganized or catatonic behavior Continuing evidence of, in attenuated form, the presence of negative symptoms or two or more symptoms of diagnostic characteristics Interventions for Agitation, Hallucinations and Delusions AGITATION Remove clients from, or avoid situations known to cause agitation Decrease stimulants such as caffeine, bright lights and loud noise or music. Avoid display of anger, discouragement or frustration when interacting with the client Avoid criticism and do not argue with the client Set limits and follow through with consequences if a violation occurs. Monitor for physical discomfort such as pain or physical illness HALLUCINATIONS Decrease environmental stimuli such as loud music, extremely bright colors or flashing lights Attempt to identify precipitating factors by asking the client what happened prior to the onset of hallucinations Monitor television programs to minimize external stimuli that may precipitate hallucinations Monitor for command hallucinations that may precipitate aggressive or violent behavior DELUSIONS Do not whisper or laugh in the presence of the client

Negative Symptoms Diminution or loss of normal functions Anergia Anhedonia Emotional withdrawal Poor eye contact Blunted affect or affective flattening Avolition Difficulty in abstract thinking Alogia Dysfunctional relationship with others

Types of Schizophrenia PARANOID Preoccupation with one or more delusions or frequent auditory hallucinations Clients tend to experience persecutory or grandiose delusions and may exhibit behavioral changes such as anger, hostility, or violent behavior. CATATONIC Motor immobility (i.e rigidity) waxy flexibility and stupor Excessive motor activity that is purposeless Extreme negativism or mutism Peculiarities of voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms or prominent grimacing Echolalia (repeats all words or phrases heard) or Echopraxia (mimics actions of others. DISORGANIZED Disorganized speech Disorganized behavior Flat or inappropriate affect

Do not argue with the client or attempt to disprove delusional or suspicious thoughts Explain all procedures and interventions, including medication management Provide for personal space and do not touch the client without warning Maintain eye contact during interactions with the client Provide consistency in care and assigned caregivers to establish trust

Significant distress or marked impairment in persons functioning, such as in social or occupational areas Symptoms not related to a medical condition or use of a substance

Bipolar Disorder Various Descriptive terms are used to describe the labile affect or mood changes of clients with the diagnosis of bipolar disorder. These terms include: Euphoria an exaggerated feeling of physical and emotional well-being Elation a state of extreme happiness, delight or excitability Mania a state characterized by excessive elation, inflated self-esteem and grandiosity. Mood that is abnormally and persistently elevated, expansive, or irritable lasting at least 1 week Inflated self-esteem or grandiosity Decrease in the need for sleep Increased talking or increased pressure to keep talking Flight of ideas or subjective feeling of racing thoughts Easily distractible Increased goal-directed activity or psychomotor agitation Excessive over-involvement in pleasurable activities usually associated with a high potential for painful consequences

Common Adverse Effects of Antipsychotic Medications Dry Mouth Menstrual Irregularity Sexual Dysfunction Urinary Retention Constipation Photophobia Weight Gain MOOD DISORDERS Major Depression Depressed Mood Significant loss of interest or pleasure Marked changes in weight or significant increase or decrease in appetite Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Reduced ability to concentrate or think, or indecisiveness Recurrent thoughts of death, suicidal ideation, suicide attempt or plan of committing suicide DIAGNOSTIC CHARACTERISTICS Evidence of at least 5 clinical symptoms in conjunction with depressed mood or loss of interest or pleasure Symptoms occurring most of the day during the same 2-week period

DIAGNOSTIC CHARACTERISTICS Mood disturbance occurring in conjunction with at least 3 or more clinical symptoms Marked and significant impairment in activities or relationships with potential for self-harm or injury to others. Symptoms not related to a medical condition or a use of a substance ANXIETY

Levels of Anxiety Mild Anxiety the client has an increased alertness to inner feelings or the environment. At this level, an individual has an increased ability to learn, experiences a motivational force, may become competitive and has the opportunity to be individualistic. Feelings of restlessness may also be present, and the individual may not be able to relax. Moderate Anxiety the client experiences a narrowing of the of the ability to concentrate with the ability to focus or concentrate on only one specific thing at a time. pacing, voice tremors, increased rate of speech, physiologic changes and verbalization about expected danger occur. Severe Anxiety the ability to perceive is further reduced, and focus is on small or scattered details. Inappropriate verbalization, or the inability to communicate clearly, occurs due to increased anxiety and decreased intellectual thought processes. Lack of determination or the ability to perform occurs as the person experiences feelings of purposelessness. Physiologic responses also occur as the individual experiences a sense of impending doom. Panic state complete disruption of the ability to perceive takes place. Disintegration of the personality occurs as the individual becomes immobilized, experiences difficulty verbalizing, is unable to function normally, and is unable to focus on reality. Physiologic, intellectual and emotional changes occur as the individual experiences a loss of control. Phobias Agoraphobia fear of being alone in public places Social Phobia fear of situations in which others may criticize a person Acrophobia fear of heights Algophobia fear of pain Androphobia fear of men Astrophobia fear of storms Autophobia fear of being alone Aviophobia fear of flying

Claustrophobia fear of closed spaces Entomophobia fear of insects Hematophobia fear of blood Hydrophobia fear of water Iarrophobia fear of doctors Necrophobia fear of dead bodies Nyctophobia fear of the night Ochlophobia fear of crowds Ophidophobia fear of snakes Pathophobia fear of disease Pyrophobia fear of fire Sitophobia fear of flood Thanathophobia fear of death Topophobia fear of a particular place Zoophobia fear of animals Obsessive-Compulsive Disorder - characterized by recurrent obsessions (a persistent, painful, intrusive thought, emotion or urge that one is unable to suppress or ignore) or compulsion (the performance of a repetitious, uncontrollable, but seemingly purposeful act to prevent some future event or situation) or a combination of both, that interferes with normal daily activities. Common obsessive thoughts involve religion, sexuality, violence, the need for symmetry, and contamination. Common compulsions include hand washing, avoidance of touch, ritualistic behavior, swallowing, stretching, rocking and hoarding. Alternative and Behavioral Therapies Visual imagery Change of pace or scenery Exercise or massage Transcendental meditation Biofeedback Systematic desensitization Relaxation exercises Therapeutic Touch Healing Touch Hypnosis Implosion Therapy PERSONALITY DISORDERS Three Levels of Consciousness

Unconscious level consists of drives, feelings, ideas, and urges outside of the persons awareness. This is the most important level of behavior because of its effect on behavior. Preconscious level consists of feeling, ideals, drives and ideas that are out ones ongoing awareness but can be recalled readily. Conscious level is aware of the present and controls purposeful behavior Structure of the Personality Id unconscious reservoir of primitive drives and instincts dominated by thinking and the pleasure principle. Ego meets and interacts with the outside world as the integrator or mediator and is the executive function of the personality that operates at all three levels of consciousness Superego acts as the censoring force or conscience of the personality and is composed of morals, mores, values and ethics largely derived from ones parents Psychosexual Theory Oral Phase - (0-18 months) is a period in which pleasure is derived mainly through the mouth by the actions of sucking or biting Anal Phase - (18 mos 3 years) attention focuses on the excretory function, and the foundation is laid for the development of the superego Phallic stage (3 to7 years) a stage of growth and development, the child identifies with the parent of the same se, forms a deep attachment to the parent of the opposite sex, develops sexual identity of male or female role, and begins to experience guilt Latency phase (7 years to adolescence) the person learns to recognize, and handle reality, has a limited sexual image, develops an inner control

over aggressive or destructive impulses, and experiences intellectual and social growth Genital Phase (puberty or adolescence into adult life) the final stage of psychosexual development, the individual develops the capacity for object love and mature sexuality and establishes identity and independence Piagets Cognitive Development Theory Views intellectual development as a result of constant interaction between environmental influences and genetically determined attributes. Senosrimotor stage (0 2 years) the infant uses the senses to learn about the self, and the environment by exploring objects and events and imitating. The infant also develops schemata, or methods of assimilating and accommodating incoming information; these include looking schemata, hearing schemata and sucking schemata. Preoperational Stage ( 2 to 8 years) Preconceptual phase involves the childs learning to think in mental images, and the development of expressive language and symbolic play. Intuitive phase the child exhibits egocentrism. The child is unable to comprehend the ideas of others if they differ from his or her own. As a child matures, he or she realizes that other people see things differently. Concrete Operational Stage (8 to 12 years) the child is able to think more logically as the concepts of moral judgment, numbers and spatial relationships are developed Formal Operational Stage (12 years to adulthood) the person develops adult logic and is able to reason, form conclusions, plan for the future, think abstractly and build ideals. Erik Eriksons Developmental Tasks Trust vs Mistrust (Birth to 18 months)

Autonomy vs Shame and Doubt (18 months 3 yrs) Initiative vs Guilt (3 to 5 years old) Industry vs Inferiority (6 to 11 years) Identity vs Role Confusion (12 18 years) Intimacy vs Isolation (19 40 years) Generativity vs Stagnation (41 to 64 years) Ego Integrity vs Despair (65 years to death)

CLUSTER A DISORDERS: ODD, ECCENTRIC BEHAVIOR Schizoid Personality Disorder clinical symptoms include, a pervasive pattern of detachment from social relationships and a restricted range of emotional expression in interpersonal settings. The individual avoids close relationships with family or others, chooses solitary activities, has little interest in sexual experiences, does not take pleasure in activities, lacks close friends or confidants, appears indifferent to praise and criticism and exhibits emotional coldness such as detachment or flattened affect. Schizotypal personality disorder clients generally exhibit a disturbance in thought processes referred to as magical thinking, superstitiousness and telepathy. They experience ideas of reference, limit social contacts to those involved in the performance of daily tasks, describe perceptual disturbances such as illusions or depersonalization, demonstrate peculiarity in speech CLUSTER B DISORDERS: EMOTIONAL, ERRATIC, OR DRAMATIC BEHAVIOR Antisocial Personality Disorder synonyms for antisocial personality disorder include sociopathic, psychopathic and semantic disorder. Antisocial behavior isusually seen in clients between the age of 15 and 40 years. The diagnosis of conduct disorder is given to clients who exhibit clinical symptoms before the age of 18. Clients with antisocial behavior demonstrates lack of remorse or indifference to persons who one

has hurt or mistreated, expectation of immediate gratification, failure to accept social norms, repeated lying, and reckless behavior. Borderline personality disorder individuals with borderline personality disorder may exhibit impulsive, behavior related to gambling, shoplifting, sex and substance abuse. Contributing to unstable intense interpersonal relationships are inappropriate, intense anger, unstable affect reflecting depression, dysphoria or anxiety, disturbance in self-concept including gender identity, and the inability to control ones emotions. Behaviors such as paranoid ideation, severe dissociation, masochism, frantic efforts to avoid realor imagined abandonment and suicidal ideation may occur. Histrionic personality disorder is characterized by a pattern of theatrical or overly dramatic behavior. Individuals commonly display discomfort in situations in which the client is not the center of attention. The client makes use of physical appearance, inappropriate sexually seductive or provocative behavior and selfdramatization and emotional exaggeration to draw attention to self. Narcissistic personality disorder the main characteristic of a narcissistic personality disorder is an exaggerated or grandiose sense of self importance. The client requires excessive admiration and envies others, believing that they are envious of him or her. The client also displays arrogance and may display a sense of entitlement and lack of empathy as he or she exploits others.

CLUSTER C DISORDERS; ANXIOUS, FEARFUL BEHAVIOR Dependent personality disorder clients with this disorder lack self-confidence and are unable to function in an independent role. Such persons allow others to become responsible for their lives because they experience difficulty making everyday

decisions, disagreeing with others and initiating projects or doing things independently. Clients go to excessive lengths to obtain nurturance and support from others. Avoidant personality disorder the client with this disorder is highly sensitive to criticism, humiliation, disapproval, or shame, appearing devastated by the slightest amount of disapproval. The extreme sensitivity interferes with participation in occupational activities, development of interpersonal relationships, and the ability to take personal risks or engage in new activities. Passive-aggressive personality exhibits covert obstructionism through manipulative behavior, procrastination, stubbornness, and inefficiency due to dependency upon others. These behaviors are an expression of a passively expressed underlying aggression.

Schizoid personality: Socially distant, detached Schizotypal personality: Odd, eccentric EATING DISORDERS Anorexia Nervosa The client with anorexia nervosa refuses to maintain a normal body weight, intensely fears weight gain, and exhibits a disturbed perception about his or her body. Symptoms may include: Refusal to maintain a minimally normal weight Intense fear of gaining weight, even with preoccupation with thoughts of food Significant distortion in perception of body size and shape Amenorrhea Depressed mood Social withdrawal Insomnia Decreased interest in sex Inflexible thinking Strong need to control ones environment Bulimia Nervosa Episodic binge eating, a rapid consumption of food in less than 2 hours, is classified as bulimia nervosa. The client also has some or most of the following: Binge eating Excessive influence of body shape and weight on self-evaluation Use of self-Induced vomiting; misuse of laxatives, diuretics, fasting or excessive exercises. Low self-esteem Mood disturbance Possible stimulant use Paraphilias

Personality Disorders: Common Descriptive Behaviors* Antisocial personality: Impulsive, aggressive, manipulative Avoidant personality: Shy, timid inferiority complex Borderline personality: Impulsive, self-destructive, unstable Dependent personality: Dependent, submissive, clinging Histrionic personality: Emotional, dramatic, theatrical Narcissistic personality: Boastful, egotistical, superiority complex Obsessivecompulsive personality: Perfectionistic, rigid, controlling Paranoid personality: Suspicious, distrustful

Bestiality or Zoophilia: Sexual contact with animals serves as a preferred method to produce sexual excitement. It is rarely seen. Exhibitionism: An adult male obtains sexual gratification from repeatedly exposing his genitals to unsuspecting strangers, usually women and

children who are involuntary observers. He has a strong need to demonstrate masculinity and potency. Fetishism: Sexual contact with inanimate articles (fetishes) results in sexual gratification. Most often it is a piece of clothing or footwear. Parts of the body may also take on fetishistic significance. Its occurrence is almost exclusive to men who fear rejection by members of the opposite sex. Frotteurism: Sexual excitement is achieved by touching and rubbing against a nonconsenting person. Sexual Masochism: Sexual pleasure occurs while one is experiencing emotional or physical pain. The willing recipient of erotic whipping is considered to be masochistic. Necrophilia: Sexual arousal occurs while the person is using corpses to meet sexual needs. Pedophilia: The use of prepubertal children is needed to achieve sexual gratification. Pedophilia can be an actual sexual act or a fantasy. Sexual Sadism: Sexual gratification is experienced while the person inflicts physical or emotional pain on others. Severe forms of this behavior may be present in schizophrenia. Telephone Scatologia: Sexual gratification is achieved by telephoning someone and making lewd or obscene remarks. Transvestic Fetishism: A heterosexual male achieves sexual gratification through wearing the clothing of a woman (cross-dressing). It is a learned response due to encouragement by family members. As a child, the person was considered more attractive when dressed up as a girl. Voyeurism: The achievement of sexual pleasure by looking at unsuspecting persons who are naked, undressing, or engaged in sexual activity. Individuals engaging in voyeurism are commonly called Peeping Toms.